Br. J. clin. Pharmac. (1975), 2, 389-390
EDI TORI ALS
389
ERRORS OF DRUG PRESCRIBING Although medical and administrative problems associated with hospital drug prescribing must have existed since the first prescription was written in the first hospital, it is only in recent years that they have claimed our attention and attempts have been made to identify and quantify them (Crooks, Weir, Coull, McNab, Calder, Barnett & Caie, 1967; Vere, 1967). The main reason for this has been the rapidly increasing number of pharmacologically active drugs used in clinical medicine coupled with the persistence of hospital drug handling systems designed in an era when effective drug treatment, and therefore, the number of drugs prescribed, was limited. Apart from the effect of the increase of work load on the traditional hospital procedures for prescribing and administering drugs, three other factors have added to the problem-firstly the failure of communication between the various components of the hospital team, especially doctor and nurse (how many doctors have ever accompanied a nurse on a medicine round?); secondly the medical profession's reluctance to accept managerial, as well as clinical responsibility; and lastly, staff shortages in all sections of the hospital team, doctors, nurses and pharmacists. In response to the awareness that a problem existed, many hospitals in this country and elsewhere have adopted standardized methods of prescribing and administering drugs, but such is the nature of human behaviour that a variety of 'standardized' methods have resulted, furthermore, such systems require to be kept under review but this necessary step is often ignored. Apart from ensuring that patients actually receive the drugs prescribed, the increasing number of drugs available has produced an information explosion which increases the possibility of inappropriate prescribing on the basis of indications, doseage required, drug interactions, etc. (Crooks et al., 1967). The report in this issue (Tesh, Beeley, Clewett & Walker, 1975, p. 403) of an investigation of these two problem areas of hospital prescribing is therefore welcome. The study covers 7526 prescriptions written for 840 patients in three medical wards of the Queen Elizabeth Hospital, Birmingham. As might be expected in a medical unit of a teaching hospital, with a special interest in drug treatment, the number of prescriptions which were judged to be inappropriate was small, approximately 3%. On the basis that this level of
inappropriate drug prescribing will often be exceeded, the results point to the need for the prescriber to develop a compact drug armamentarium with which he is thoroughly familiar. This is particularly relevant today when therapeutically active drugs are so numerous and their presentations so varied. While no doctor can claim (nor is there need for) full knowledge about all drugs, in case of doubt it is essential to check all relevant information required for the prescribing of any given drug before commitment in writing. Problems facing the prescriber may be illustrated by 25 different preparations containing phenobarbitone that are currently marketed-a similar number of preparations contain other barbiturates. Many of these are presented as multiple ingredient medications where the barbiturate component may be easily overlooked. These drugs afford an unncessarily wide scope for the prescriber and increase the possibilities of drug interaction. The Birmingham study showed that in 38 instances involving 31 patients, the concurrent prescribing of two drugs could have led to a potentially serious interaction. This was determined on the basis of drug combinations considered to be capable of giving rise to clinically important reactions. Such a selection was probably responsible for the relatively small numbers, although a greater awareness of drug-drug interaction possibilities is to be expected in an active teaching hospital centre. It should be emphasized, however, that there is a deficiency of information concerning the clinical importance of many suggested drug interactions, although the incidence is probably much less than originally anticipated (Leading Article, Lancet, 1975). The usefulness of evaluating the performance of any hospital procedure is shown by the Birmingham study in which errors in prescription writing occurred with surprisingly high frequency, involving 30% of all prescriptions and in 79% of the patients studied. While many of the writing errors were trivial, it was felt that they could have resulted in overdose or in under-treatment. As mentioned above, drug prescribing systems often differ from hospital to hospital and a newly appointed Junior Medical Officer may be expected to be prone to making errors until he becomes familiar with existing routines. Also, the rate of rotation of hospital staff within and between hospitals is highest at the level of Junior Medical Officers who probably write the most prescrip-
390
EDITORIALS
tions. These factors predispose towards errors in prescription writing. Assistance in this respect may be given by means of a standard instructional programme on the policy of individual hospitals in drug handling, accompanied by adequate in-service training for new hospital staff. The relatively high use of approved names in the Birmingham study (90% of prescriptions) probably reflects the practice in a medical ward with an interest in therapeutics, since in a study of over 7000 prescriptions from a complete hospital group, approved names were only used in 48% (Crooks et al., 1967). In order to reduce proliferation of drug names which refer to the same active agent, the use of approved names where possible, as followed by the Birmingham Centre, is probably the most acceptable in hospital prescribing. If needed, the indentification of a particular brand is usually possible at the Pharmacy level. Consideration, however, should also be given to the brand of drug with which a patient will be maintained when at home, since formulation differences may occasionally affect bioavailability as with digoxin, certain steroids and phenytoin. It may be appropriate now to make a plea for the institution of a common system of drug prescribing and administration in hospitals in the United Kingdom. Nowadays, movement of medical and nursing staff is common from one hospital to another, especially within health authority regions, as part of in-service training programmes. Such movement could be achieved without prejudicing the safe use of drugs if hospital routines in the prescribing and
administration of drugs could be standardized. An added advantage would be the possibility of the utilization of hospital drug data on a regional or even national basis for research purposes. The role of the computer in the development of such systems remains to be established but it has begun to make a contribution by stimulating the Birmingham Group to examine their manual system critically. Ideally, one aims for a simple and practical drug handling system in which the roles of the doctor, pharmacist, and nurse are well identified and one which includes a regular assessment of overall efficiency. But, even when this is achieved it is the responsibility of the prescribing doctor to choose the most appropriate drug in terms of indications, contraindications, and dosage regime-and to write the prescription unambiguously and legibly; i.e. to be suitably trained in prescribing. While the emphasis in medicine up to the present has been traditionally the area of diagnosis, it is becoming more evident that the scalpel of drug therapy should be more precisely used and perhaps we could benefit from the example of our surgical colleagues who owe much of their success to the uniformly high quality of training in the delivery of surgical therapy. The responsibility for emulating the achievements of the surgeons lies squarely with the emerging speciality of clinical pharmacology.
J. CROOKS Department of Pharmacology and Therapeutics, Nirewells Hospital, Dundee DD2 I UD
References CROOKS, J., WEIR, R.D., COULL, D. McNAB, J.W., CALDER, G., BARNETT, J.W., & CAIE, H.B. (1967). Evaluation of a method of prescribing drugs in hospital and a new method of recording their administration. Lancet, i, 668-671. Lancet (1975). Drug interactions, Leading article. Lancet, i, 904-905.
TESH, DOROTHY E., BEELEY, LINDA, CLEWETT, A.J. & WALKER, G.F. (1975). Errors of drug pre-
scribing. Br. J. clin. Pharmac., 2, 403409. VERE, D.W. (1967). Prescribing systems in hospital. J.
Roy. Coll. Phys. Lond., 1, 244-253.
EDI TORI ALS
389
ERRORS OF DRUG PRESCRIBING Although medical and administrative problems associated with hospital drug prescribing must have existed since the first prescription was written in the first hospital, it is only in recent years that they have claimed our attention and attempts have been made to identify and quantify them (Crooks, Weir, Coull, McNab, Calder, Barnett & Caie, 1967; Vere, 1967). The main reason for this has been the rapidly increasing number of pharmacologically active drugs used in clinical medicine coupled with the persistence of hospital drug handling systems designed in an era when effective drug treatment, and therefore, the number of drugs prescribed, was limited. Apart from the effect of the increase of work load on the traditional hospital procedures for prescribing and administering drugs, three other factors have added to the problem-firstly the failure of communication between the various components of the hospital team, especially doctor and nurse (how many doctors have ever accompanied a nurse on a medicine round?); secondly the medical profession's reluctance to accept managerial, as well as clinical responsibility; and lastly, staff shortages in all sections of the hospital team, doctors, nurses and pharmacists. In response to the awareness that a problem existed, many hospitals in this country and elsewhere have adopted standardized methods of prescribing and administering drugs, but such is the nature of human behaviour that a variety of 'standardized' methods have resulted, furthermore, such systems require to be kept under review but this necessary step is often ignored. Apart from ensuring that patients actually receive the drugs prescribed, the increasing number of drugs available has produced an information explosion which increases the possibility of inappropriate prescribing on the basis of indications, doseage required, drug interactions, etc. (Crooks et al., 1967). The report in this issue (Tesh, Beeley, Clewett & Walker, 1975, p. 403) of an investigation of these two problem areas of hospital prescribing is therefore welcome. The study covers 7526 prescriptions written for 840 patients in three medical wards of the Queen Elizabeth Hospital, Birmingham. As might be expected in a medical unit of a teaching hospital, with a special interest in drug treatment, the number of prescriptions which were judged to be inappropriate was small, approximately 3%. On the basis that this level of
inappropriate drug prescribing will often be exceeded, the results point to the need for the prescriber to develop a compact drug armamentarium with which he is thoroughly familiar. This is particularly relevant today when therapeutically active drugs are so numerous and their presentations so varied. While no doctor can claim (nor is there need for) full knowledge about all drugs, in case of doubt it is essential to check all relevant information required for the prescribing of any given drug before commitment in writing. Problems facing the prescriber may be illustrated by 25 different preparations containing phenobarbitone that are currently marketed-a similar number of preparations contain other barbiturates. Many of these are presented as multiple ingredient medications where the barbiturate component may be easily overlooked. These drugs afford an unncessarily wide scope for the prescriber and increase the possibilities of drug interaction. The Birmingham study showed that in 38 instances involving 31 patients, the concurrent prescribing of two drugs could have led to a potentially serious interaction. This was determined on the basis of drug combinations considered to be capable of giving rise to clinically important reactions. Such a selection was probably responsible for the relatively small numbers, although a greater awareness of drug-drug interaction possibilities is to be expected in an active teaching hospital centre. It should be emphasized, however, that there is a deficiency of information concerning the clinical importance of many suggested drug interactions, although the incidence is probably much less than originally anticipated (Leading Article, Lancet, 1975). The usefulness of evaluating the performance of any hospital procedure is shown by the Birmingham study in which errors in prescription writing occurred with surprisingly high frequency, involving 30% of all prescriptions and in 79% of the patients studied. While many of the writing errors were trivial, it was felt that they could have resulted in overdose or in under-treatment. As mentioned above, drug prescribing systems often differ from hospital to hospital and a newly appointed Junior Medical Officer may be expected to be prone to making errors until he becomes familiar with existing routines. Also, the rate of rotation of hospital staff within and between hospitals is highest at the level of Junior Medical Officers who probably write the most prescrip-
390
EDITORIALS
tions. These factors predispose towards errors in prescription writing. Assistance in this respect may be given by means of a standard instructional programme on the policy of individual hospitals in drug handling, accompanied by adequate in-service training for new hospital staff. The relatively high use of approved names in the Birmingham study (90% of prescriptions) probably reflects the practice in a medical ward with an interest in therapeutics, since in a study of over 7000 prescriptions from a complete hospital group, approved names were only used in 48% (Crooks et al., 1967). In order to reduce proliferation of drug names which refer to the same active agent, the use of approved names where possible, as followed by the Birmingham Centre, is probably the most acceptable in hospital prescribing. If needed, the indentification of a particular brand is usually possible at the Pharmacy level. Consideration, however, should also be given to the brand of drug with which a patient will be maintained when at home, since formulation differences may occasionally affect bioavailability as with digoxin, certain steroids and phenytoin. It may be appropriate now to make a plea for the institution of a common system of drug prescribing and administration in hospitals in the United Kingdom. Nowadays, movement of medical and nursing staff is common from one hospital to another, especially within health authority regions, as part of in-service training programmes. Such movement could be achieved without prejudicing the safe use of drugs if hospital routines in the prescribing and
administration of drugs could be standardized. An added advantage would be the possibility of the utilization of hospital drug data on a regional or even national basis for research purposes. The role of the computer in the development of such systems remains to be established but it has begun to make a contribution by stimulating the Birmingham Group to examine their manual system critically. Ideally, one aims for a simple and practical drug handling system in which the roles of the doctor, pharmacist, and nurse are well identified and one which includes a regular assessment of overall efficiency. But, even when this is achieved it is the responsibility of the prescribing doctor to choose the most appropriate drug in terms of indications, contraindications, and dosage regime-and to write the prescription unambiguously and legibly; i.e. to be suitably trained in prescribing. While the emphasis in medicine up to the present has been traditionally the area of diagnosis, it is becoming more evident that the scalpel of drug therapy should be more precisely used and perhaps we could benefit from the example of our surgical colleagues who owe much of their success to the uniformly high quality of training in the delivery of surgical therapy. The responsibility for emulating the achievements of the surgeons lies squarely with the emerging speciality of clinical pharmacology.
J. CROOKS Department of Pharmacology and Therapeutics, Nirewells Hospital, Dundee DD2 I UD
References CROOKS, J., WEIR, R.D., COULL, D. McNAB, J.W., CALDER, G., BARNETT, J.W., & CAIE, H.B. (1967). Evaluation of a method of prescribing drugs in hospital and a new method of recording their administration. Lancet, i, 668-671. Lancet (1975). Drug interactions, Leading article. Lancet, i, 904-905.
TESH, DOROTHY E., BEELEY, LINDA, CLEWETT, A.J. & WALKER, G.F. (1975). Errors of drug pre-
scribing. Br. J. clin. Pharmac., 2, 403409. VERE, D.W. (1967). Prescribing systems in hospital. J.
Roy. Coll. Phys. Lond., 1, 244-253.
