Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project

Area of Science:

• Medical Safety
• Healthcare Quality Improvement
• Clinical Pharmacy

Background:

• Prescribing errors affect up to 15% of UK inpatient medication orders.
• Junior doctors report insufficient feedback on prescribing errors.
• Lack of prescriber identification on documentation hinders feedback.

Purpose of the Study:

• To reduce prescribing errors in a UK hospital.
• To improve feedback mechanisms for junior doctors regarding prescribing errors.

Main Methods:

• Implemented three interventions: name stamps for doctors, feedback training for pharmacists, and prescribing advice emails.
• Utilized plan-do-study-act cycles for intervention development.
• Compared an intervention site with a control site using process and outcome measures.

Main Results:

• The percentage of medication orders with junior doctors' names increased from 10% to 50%.
• Pharmacists' perceptions of feedback significantly improved, but doctors' perceptions did not change.
• No significant difference in weekly prescribing error rates was observed between the intervention and control sites.

Conclusions:

• The interventions improved feedback experiences for pharmacists and potentially increased doctor engagement.
• A multifaceted approach is likely necessary to achieve measurable reductions in prescribing errors.
• Feedback should be a component of broader strategies for improving medication safety.