IMPROVING PRESCRIPTION-WRITING SKILLS INA FAMILY PRACTICE RESIDENCY AllenF. Shaughnessy, Frank D'Amico, and Ronald O. Nickel
ABSTRACf: The objectiveof this study was to evaluatea novelmethod of physician educationthat uses copiesof prescriptions written by study participantsto providefeedbackon their prescription-writing skills. A prospective, blind, completelyrandom before-afterdesign wasused, with observation,intervention, and postintervention periods, each lastingfour months. The study group comprised 20 family practiceresidents,stratifiedby year of trainingand randomlyassigned to treatment or controlgroups. Copiesof all prescriptions written by participating residentswereevaluatedfor prescription-writing errors. Duringthe intervention phase, prescriptioncopies with errors were returnedto the treatmentgroup residentswith a tactfulcomment pointingout the error and suggestingchanges. Over the three time periods, there was a continuousdecline in the rate of prescriptionwritingerrors in the treatmentgroup, but not in the controlgroup. A significant numberof physicianswho receivedthe feedbackimproved theirprescriptionwriting (p50 prescriptions per time period.
Dlep, The Annals ofPharmacotherapy •
1991 January, Volume 25 •
19
back. Lastly, the results may have been influenced by the residents' response to the evaluator, rather than to the feedback. Some residents receiving feedback may have viewed the evaluation of their prescriptions by a nonphysician as offensive or threatening. Feedback methods that use a fellow physician providing face-to-face feedback have met with the greatest success. IS However, feedback via trained clinical pharmacists ("counter-detailing") has also been very successful. 9 This method of feedback requires little time, and the only special materials needed are prescription forms with attached carbonless copies (available from most business form printers) and a spindle or box for collecting the completed copies. During the course of the study, the evaluation and feedback took the evaluating pharmacist only about 20 minutes a week to evaluate the prescriptions written by 20 residents, and a few minutes of a secretary's time to sort and distribute the copies to the original prescriber. Thus, this method of feedback could be easily incorporated into the daily activities of a clinical pharmacist teaching in a family practice or other residency program. Reviewing copies of prescriptions written can also be helpful in formally or informally assessing the prescribing habits of the residents. The criteria used in this study may appear strict and unimportant; however, the need for clear, complete, and accurate prescriptions cannot be overly stressed. Minor details that are omitted or unclear on prescriptions are important to the dispensing pharmacist, who often is required to make assumptions and decisions based on inadequate information. Because it is not practical or possible to contact the prescriber each time a prescription is written incorrectly, the pharmacist may unintentionally dispense or label a prescription in a manner not intended by the prescriber. Thus, every effort should be made to assure the development of proper prescription-writing habits during residency training. Summary
In this study, written feedback on copies of prescriptions resulted in a small decrease in prescription-writing errors (p>0.05). In addition, the biggest effect of the intervention was experienced by the second-year residents during the intervention time period, continuing through the postintervention period. This method provides the clinical pharmacist teaching in family practice or in other residency programs an easy way to monitor prescribing practices and prescription-writing habits with a minimum of time, effort, and materials required. Further study may reveal other uses for this type of instruction. ~
References I. American College of Physicians. Improving medical education in therapeutics. Ann Intern Med 1988;108: 145-7. 2. LITTLE TL, LAYTON RH. Prescribing patterns in a family medicine residencyprogram. 1 Fam Pract 1979;8:1161-6. 3. ANASTASIO GD, WHITE TR, FRIES rc. Computerized prescription inventory program for the education of residents (PIPER). 1 Fam Pract 1986;23:598-600. 4. WALSON PD, HAMMEL M. MARTIN R. Prescription-writing by pediatric house officers. 1 Med Educ 1981;56:423-8. 5. HIRSCHMAN SZ, MEYERS BR. BRADBURY K, MEHL B, GENDELMAN S, KIMMELBLATT B. Use of antimicrobial agents in a university
teaching hospital. Evolution of a comprehensive control program. Arch Intern Med 1988;148:2001-7.
20
•
D/CP, The Annals ofPharmacotherapy
•
6. NES TJ, FREY JJ, FURR SJ, BENTZ EJ. Effectof an education intervention on oral cephalosporin use in primary care. Arch Intern Med 1987; 147:44-7.
7. FENDLER KJ, GUMBHIR AK, SALL K. The impactof drug bulletinson physicianprescribinghabits in a health maintenance organization. Drug Intell Clin Pharm 1984;18:627-31. 8. RAY WA, BLAZER DG, SCHAFFNER W, FEDERSPIEL CF, FINK R.
Reducing long-termdiazepamprescribingin officepractice.A controlled trial of educational visits. lAMA 1986;256:2536-9. 9. AVORN J, SOUMERAI SB. Improving drug-therapy decisions through educational outreach.A randomized controlledtrialof academically based "detailing." N Engl 1 Med 1983;308:1457-63. 10. KLEIN LE, CHARACHE p. JOHANNES RS. Effectof physician tutorials on prescribingpatternsof graduatephysicians. 1 Med Educ 1981 ;56: 504-11.
II. CARTER BL, HELLING DK, JONES ME, MOESSNER H, WATERBURG CA Jr. Evaluation of family physicianprescribing: influence of the clinical pharmacist. Drug Intell Clin Pharm 1984;18:817-21. 12. BROWN OJ, HELLING DK, JONES ME. Evaluation of clinicalpharmacist consultation in a familypracticeoffice. Am 1 Hosp Pharm 1979; 36:912-5. 13. SCHAFFNER W, RAY WA, FEDERSPIEL CF, MILLER wo. Improving antibiotic prescribing in office practice. A controlledtrial of three educational methods. lAMA 1983;250:1728-32. 14. CHRISCHILLES EA, HELLING DK, ASCHOFF CR. Effect of clinical pharmacyservices on the quality of family practice physician prescribing and medication costs. DICP Ann Pharmacother 1989;23: 417-21. 15. AVORN J. SOUMERAI SB, TAYLOR W, WESSELS MR, JANOUSEK J. WEINER M. Reduction of incorrectantibioticdosingthrougha structured educational order form. Arch Intern Med 1988;148:1720-4. 16. GEHLBACH SH, WILKINSON WE, HAMMOND WE, et al. Improving drug prescribing in a primary care practice. Med Care 1984;22: 193-201. 17. SHAUGHNESSY AF, NICKEL RO. Prescription-writing patterns and errors in a family medicineresidency program. 1 Fam Pract 1989; 29:290-5. 18. EISENBERG JM. Physician utilization. The state of research about physicians' practice patterns. Med Care 1985;23:461-83.
EXTRACTO
Las 6rdenes medicaspor escrito son el principalrnetodode comunicaci6nentre el personalmedico y el farrnaceutico, La mejor decisi6n terapeuticapuede ser inefectivasi la prescripci6n no comunica en forma completa y precisa la intenci6ndel que prescribey si no informaal paciente sobre el uso adecuadodel medicamentoordenado. Una prescripci6n escrita incorrectarnente puede resultaren perdidade tiempo del personaly el paciente,en un tratarniento inadecuado 0 en toxicidadrelacionadaa la farmacoterapia. Se han utilizadodiferentes estrategiaspara educar 0 reeducar al personalmedico en la redacci6nde prescripciones. En este estudio se presentala evaluaci6nde un metodo nuevo de educaci6nal personalmedico medianteel uso de las copias de prescripci6ndonde se provefaretroalimentaci6n sobre las destrezas relacionadasa la redacci6nde 6rdenes medicas, Este estudio se llev6 a cabo en un centro ambulatoriode medicinade familia,afiliadoa una universidad. El rnismofue prospectivo, ciego, aleatorioantes y durante los diferentesperfodosdel estudio:observaci6n, intervenci6n, y postintervenci6n. En el estudio participaron 20 residentes de medicina de familia,los cuales fueron estratificados segiinel aiio de adiestrarniento y asignadosal azar al grupo de control 0 experimental. Durante el penodo de intervenci6ntodas las copias de las prescripciones de los residentesevaluadosfueron analizadaspara erroresen la redacci6n. Estos errores se clasificaronen problemasde ornisi6n, error en la dosis 0 instrucciones; cantidadesno especificadas con claridade incumplirniento con los requerirnientos legales,entre otros. Las copias de las prescripciones con errores fueron devueltasal grupo experimental con un comentarioseiialando el error y sugiriendocambios. Durantelos tres perfodosse encontr6 una reducci6ncontinuaen la frecuenciade errores en el grupo experimental, pero no asf en el grupo control.Un mimerosignificativo de los residentesque recibieronel insumo (9/10) mejoraronsu redacci6nde la prescripci6n (pO.05). Estudios por perfodosmas prolongadospodrfandemostrarun mayor impacto en mejorarestos patrones. MIRZA D. MARTINEZ
RESUME
L'infonnation communiqueepar I'ordonnance ecrite du medecinau pharmaciense doit d'etre complete dans Ie but d'eviter toute confusion ou fausse interpretation. Cene etude prospective a simple-insuevaluait les habitudesde prescriptionde 20 residentsen medecinefarniliale, randornises au groupe controle ou au groupe intervention. Chaque duplicatad' ordonnanceetait revise selon des criteresbien etablis
pendant trois periodesde quatre mois chacune (observation, intervention et postintervention). Durant la deuxierneperiode,Ie duplicataetait retourneau rnedecin emetteur,randomiseau groupe intervention, avec une petite note detaillant(I) omissionset erreurs quant aI'infonnation contenuesur I'ordonnancede rnemeque (2) methodessuggereespour ameliorerla qualite de celle-ci. Aucun resident n'etait au courantde l'etude et tout commentairesur certainesordonnancesleur avait ete expliquecomme etant un outil pedagogique, De facon generate,une diminutiondans Ie nombre d'erreurs et d'ornissions fut remarque uniquementchez Ie groupe intervention. Les residentsqui recurentdes commentairesameliorerentsignificativement leur facon de prescrire durant la periode postintervention (p' several case reports'" have implied that there is potential for a clinically significant drug interaction between these two medications. The following case report further substantiates the possibility of ranitidine reducing theophylline clearance in certain patients, to the extent of inducing theophylline toxicity. CASE REPORT A 63-year-oldwoman was admitted to the hospitalfor a cystocele and rectocele repair. The patient, having a previous history of chronic obstructive pulmonary disease (asthma and emphysema), was being treated for this condition with sustained-release theophylline300 mg q4h (Constant-T as an outpatient, Thea-Our as an inpatient), terbutaline 5 mg q4h, and prednisone 10 mg/d. Postoperative medications were many and varied, and included
D/CP, The Annals ofPharmacotherapy •
/99/ January, Volume 25 •
21
ABSTRACf: The objectiveof this study was to evaluatea novelmethod of physician educationthat uses copiesof prescriptions written by study participantsto providefeedbackon their prescription-writing skills. A prospective, blind, completelyrandom before-afterdesign wasused, with observation,intervention, and postintervention periods, each lastingfour months. The study group comprised 20 family practiceresidents,stratifiedby year of trainingand randomlyassigned to treatment or controlgroups. Copiesof all prescriptions written by participating residentswereevaluatedfor prescription-writing errors. Duringthe intervention phase, prescriptioncopies with errors were returnedto the treatmentgroup residentswith a tactfulcomment pointingout the error and suggestingchanges. Over the three time periods, there was a continuousdecline in the rate of prescriptionwritingerrors in the treatmentgroup, but not in the controlgroup. A significant numberof physicianswho receivedthe feedbackimproved theirprescriptionwriting (p50 prescriptions per time period.
Dlep, The Annals ofPharmacotherapy •
1991 January, Volume 25 •
19
back. Lastly, the results may have been influenced by the residents' response to the evaluator, rather than to the feedback. Some residents receiving feedback may have viewed the evaluation of their prescriptions by a nonphysician as offensive or threatening. Feedback methods that use a fellow physician providing face-to-face feedback have met with the greatest success. IS However, feedback via trained clinical pharmacists ("counter-detailing") has also been very successful. 9 This method of feedback requires little time, and the only special materials needed are prescription forms with attached carbonless copies (available from most business form printers) and a spindle or box for collecting the completed copies. During the course of the study, the evaluation and feedback took the evaluating pharmacist only about 20 minutes a week to evaluate the prescriptions written by 20 residents, and a few minutes of a secretary's time to sort and distribute the copies to the original prescriber. Thus, this method of feedback could be easily incorporated into the daily activities of a clinical pharmacist teaching in a family practice or other residency program. Reviewing copies of prescriptions written can also be helpful in formally or informally assessing the prescribing habits of the residents. The criteria used in this study may appear strict and unimportant; however, the need for clear, complete, and accurate prescriptions cannot be overly stressed. Minor details that are omitted or unclear on prescriptions are important to the dispensing pharmacist, who often is required to make assumptions and decisions based on inadequate information. Because it is not practical or possible to contact the prescriber each time a prescription is written incorrectly, the pharmacist may unintentionally dispense or label a prescription in a manner not intended by the prescriber. Thus, every effort should be made to assure the development of proper prescription-writing habits during residency training. Summary
In this study, written feedback on copies of prescriptions resulted in a small decrease in prescription-writing errors (p>0.05). In addition, the biggest effect of the intervention was experienced by the second-year residents during the intervention time period, continuing through the postintervention period. This method provides the clinical pharmacist teaching in family practice or in other residency programs an easy way to monitor prescribing practices and prescription-writing habits with a minimum of time, effort, and materials required. Further study may reveal other uses for this type of instruction. ~
References I. American College of Physicians. Improving medical education in therapeutics. Ann Intern Med 1988;108: 145-7. 2. LITTLE TL, LAYTON RH. Prescribing patterns in a family medicine residencyprogram. 1 Fam Pract 1979;8:1161-6. 3. ANASTASIO GD, WHITE TR, FRIES rc. Computerized prescription inventory program for the education of residents (PIPER). 1 Fam Pract 1986;23:598-600. 4. WALSON PD, HAMMEL M. MARTIN R. Prescription-writing by pediatric house officers. 1 Med Educ 1981;56:423-8. 5. HIRSCHMAN SZ, MEYERS BR. BRADBURY K, MEHL B, GENDELMAN S, KIMMELBLATT B. Use of antimicrobial agents in a university
teaching hospital. Evolution of a comprehensive control program. Arch Intern Med 1988;148:2001-7.
20
•
D/CP, The Annals ofPharmacotherapy
•
6. NES TJ, FREY JJ, FURR SJ, BENTZ EJ. Effectof an education intervention on oral cephalosporin use in primary care. Arch Intern Med 1987; 147:44-7.
7. FENDLER KJ, GUMBHIR AK, SALL K. The impactof drug bulletinson physicianprescribinghabits in a health maintenance organization. Drug Intell Clin Pharm 1984;18:627-31. 8. RAY WA, BLAZER DG, SCHAFFNER W, FEDERSPIEL CF, FINK R.
Reducing long-termdiazepamprescribingin officepractice.A controlled trial of educational visits. lAMA 1986;256:2536-9. 9. AVORN J, SOUMERAI SB. Improving drug-therapy decisions through educational outreach.A randomized controlledtrialof academically based "detailing." N Engl 1 Med 1983;308:1457-63. 10. KLEIN LE, CHARACHE p. JOHANNES RS. Effectof physician tutorials on prescribingpatternsof graduatephysicians. 1 Med Educ 1981 ;56: 504-11.
II. CARTER BL, HELLING DK, JONES ME, MOESSNER H, WATERBURG CA Jr. Evaluation of family physicianprescribing: influence of the clinical pharmacist. Drug Intell Clin Pharm 1984;18:817-21. 12. BROWN OJ, HELLING DK, JONES ME. Evaluation of clinicalpharmacist consultation in a familypracticeoffice. Am 1 Hosp Pharm 1979; 36:912-5. 13. SCHAFFNER W, RAY WA, FEDERSPIEL CF, MILLER wo. Improving antibiotic prescribing in office practice. A controlledtrial of three educational methods. lAMA 1983;250:1728-32. 14. CHRISCHILLES EA, HELLING DK, ASCHOFF CR. Effect of clinical pharmacyservices on the quality of family practice physician prescribing and medication costs. DICP Ann Pharmacother 1989;23: 417-21. 15. AVORN J. SOUMERAI SB, TAYLOR W, WESSELS MR, JANOUSEK J. WEINER M. Reduction of incorrectantibioticdosingthrougha structured educational order form. Arch Intern Med 1988;148:1720-4. 16. GEHLBACH SH, WILKINSON WE, HAMMOND WE, et al. Improving drug prescribing in a primary care practice. Med Care 1984;22: 193-201. 17. SHAUGHNESSY AF, NICKEL RO. Prescription-writing patterns and errors in a family medicineresidency program. 1 Fam Pract 1989; 29:290-5. 18. EISENBERG JM. Physician utilization. The state of research about physicians' practice patterns. Med Care 1985;23:461-83.
EXTRACTO
Las 6rdenes medicaspor escrito son el principalrnetodode comunicaci6nentre el personalmedico y el farrnaceutico, La mejor decisi6n terapeuticapuede ser inefectivasi la prescripci6n no comunica en forma completa y precisa la intenci6ndel que prescribey si no informaal paciente sobre el uso adecuadodel medicamentoordenado. Una prescripci6n escrita incorrectarnente puede resultaren perdidade tiempo del personaly el paciente,en un tratarniento inadecuado 0 en toxicidadrelacionadaa la farmacoterapia. Se han utilizadodiferentes estrategiaspara educar 0 reeducar al personalmedico en la redacci6nde prescripciones. En este estudio se presentala evaluaci6nde un metodo nuevo de educaci6nal personalmedico medianteel uso de las copias de prescripci6ndonde se provefaretroalimentaci6n sobre las destrezas relacionadasa la redacci6nde 6rdenes medicas, Este estudio se llev6 a cabo en un centro ambulatoriode medicinade familia,afiliadoa una universidad. El rnismofue prospectivo, ciego, aleatorioantes y durante los diferentesperfodosdel estudio:observaci6n, intervenci6n, y postintervenci6n. En el estudio participaron 20 residentes de medicina de familia,los cuales fueron estratificados segiinel aiio de adiestrarniento y asignadosal azar al grupo de control 0 experimental. Durante el penodo de intervenci6ntodas las copias de las prescripciones de los residentesevaluadosfueron analizadaspara erroresen la redacci6n. Estos errores se clasificaronen problemasde ornisi6n, error en la dosis 0 instrucciones; cantidadesno especificadas con claridade incumplirniento con los requerirnientos legales,entre otros. Las copias de las prescripciones con errores fueron devueltasal grupo experimental con un comentarioseiialando el error y sugiriendocambios. Durantelos tres perfodosse encontr6 una reducci6ncontinuaen la frecuenciade errores en el grupo experimental, pero no asf en el grupo control.Un mimerosignificativo de los residentesque recibieronel insumo (9/10) mejoraronsu redacci6nde la prescripci6n (pO.05). Estudios por perfodosmas prolongadospodrfandemostrarun mayor impacto en mejorarestos patrones. MIRZA D. MARTINEZ
RESUME
L'infonnation communiqueepar I'ordonnance ecrite du medecinau pharmaciense doit d'etre complete dans Ie but d'eviter toute confusion ou fausse interpretation. Cene etude prospective a simple-insuevaluait les habitudesde prescriptionde 20 residentsen medecinefarniliale, randornises au groupe controle ou au groupe intervention. Chaque duplicatad' ordonnanceetait revise selon des criteresbien etablis
pendant trois periodesde quatre mois chacune (observation, intervention et postintervention). Durant la deuxierneperiode,Ie duplicataetait retourneau rnedecin emetteur,randomiseau groupe intervention, avec une petite note detaillant(I) omissionset erreurs quant aI'infonnation contenuesur I'ordonnancede rnemeque (2) methodessuggereespour ameliorerla qualite de celle-ci. Aucun resident n'etait au courantde l'etude et tout commentairesur certainesordonnancesleur avait ete expliquecomme etant un outil pedagogique, De facon generate,une diminutiondans Ie nombre d'erreurs et d'ornissions fut remarque uniquementchez Ie groupe intervention. Les residentsqui recurentdes commentairesameliorerentsignificativement leur facon de prescrire durant la periode postintervention (p' several case reports'" have implied that there is potential for a clinically significant drug interaction between these two medications. The following case report further substantiates the possibility of ranitidine reducing theophylline clearance in certain patients, to the extent of inducing theophylline toxicity. CASE REPORT A 63-year-oldwoman was admitted to the hospitalfor a cystocele and rectocele repair. The patient, having a previous history of chronic obstructive pulmonary disease (asthma and emphysema), was being treated for this condition with sustained-release theophylline300 mg q4h (Constant-T as an outpatient, Thea-Our as an inpatient), terbutaline 5 mg q4h, and prednisone 10 mg/d. Postoperative medications were many and varied, and included
D/CP, The Annals ofPharmacotherapy •
/99/ January, Volume 25 •
21
