A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system

Background Computerised Physician Order Entry (CPOE) is considered to enhance the safety of prescribing. However, it can have unintended consequences and new forms of prescribing error have been reported. Objective The aim of this study was to explore the causes and contributing factors associated with prescribing errors reported by multidisciplinary prescribers working within a CPOE system. Main Outcome Measure Multidisciplinary prescribers experience of prescribing errors in an CPOE system. Method This qualitative study was conducted in a hospital with a well-established CPOE system. Semi-structured qualitative interviews were conducted with prescribers from the professions of pharmacy, nursing, and medicine. Interviews analysed using a mixed inductive and deductive approach to develop a framework for the causes of error. Results Twenty-three prescribers were interviewed. Six main themes influencing prescribing were found: the system, the prescriber, the patient, the team, the task of prescribing and the work environment. Prominent issues related to CPOE included, incorrect drug name picking, default auto-population of dosages, alert fatigue and remote prescribing. These interacted within a complex prescribing environment. No substantial differences in the experience of CPOE were found between the professions. Conclusion Medical and non-medical prescribers have similar experiences of prescribing errors when using CPOE, aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical, and environmental aspects of practice remain important. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11096-020-01192-0) contains supplementary material, which is available to authorized users

An investigation of healthcare professionals’ experiences of training and using electronic prescribing systems: four literature reviews and two qualitative studies undertaken in the UK hospital context

Electronic prescribing (ePrescribing) is the process of ordering medicines electronically for a patient and has been associated with reduced medication errors and improved patient safety. However, these systems have also been associated with unintended adverse consequences. There is a lack of published research about users’ experiences of these systems in UK hospitals. The aim of this research was therefore to firstly describe the literature pertaining to the recent developments and persisting issues with ePrescribing and clinical decision support systems (CDS) (chapter 2). Two further systematic literature reviews (chapters 3 and 4) were then conducted to understand the unintended consequences of ePrescribing and clinical decision support (CDS) systems across both adult and paediatric patients. These revealed a taxonomy of factors, which have contributed to errors during use of these systems e.g., the screen layout, default settings and inappropriate drug-dosage support. The researcher then conducted a qualitative study (chapters 7-10) to explore users’ experiences of using and being trained to use ePrescribing systems. This study involved conducting semi-structured interviews and observations, which revealed key challenges facing users, including issues with using the ‘Medication List’ and how information was presented. Users experienced benefits and challenges when customising the system, including the screen display; however, the process was sometimes overly complex. Users also described the benefits and challenges associated with different forms of interruptive and passive CDS. Order sets, for instance, encouraged more efficient prescribing, yet users often found them difficult to find within the system. A lack of training resulted in users failing to use all features of the ePrescribing system and left some healthcare staff feeling underprepared for using the system in their role. A further literature review (chapter 5) was then performed to complement emerging themes relating to how users were trained to use ePrescribing systems, which were generated as part of a qualitative study. This review revealed the range of approaches used to train users and the need for further research in this area. The literature review and qualitative study-based findings led to a follow-on study (chapter 10), whereby the researcher conducted semi-structured interviews to examine how users were trained to use ePrescribing systems across four NHS Hospital Trusts. A range of approaches were used to train users; tailored training, using clinically specific scenarios or matching the user’s profession to that of the trainer were preferred over lectures and e-learning may offer an efficient way of training large numbers of staff. However, further research is needed to investigate this and whether alternative approaches such as the use of students as trainers could be useful. This programme of work revealed the importance of human factors and user involvement in the design and ongoing development of ePrescribing systems. Training also played a role in users’ experiences of using the system and hospitals should carefully consider the training approaches used. This thesis provides recommendations gathered from the literature and primary data collection that can help inform organisations, system developers and further research in this area

Pharmacist-Physician Communications in a Highly Computerised Hospital:Sign-Off and Action of Electronic Review Messages

<div><p>Background</p><p>Some hospital Computerized Physician Order Entry (CPOE) systems support interprofessional communication. The aim of this study was to investigate the effectiveness of pharmacist-physician messages sent via a CPOE system.</p><p>Method</p><p>Data from the year 2012 were captured from a large university teaching hospital CPOE database on: 1) review messages assigned by pharmacists; 2) details of the prescription on which the messages were assigned; and 3) details of any changes made to the prescription following a review message being assigned. Data were coded for temporal, message and prescription factors. Messages were analysed to investigate: 1) whether they were signed-off; and 2) the time taken. Messages that requested a measurable action were further analysed to investigate: 1) whether they were actioned as requested; and 2) the time taken. We conducted a multivariable analysis using Generalised Estimating Equations (GEE) to account for the effects of multiple factors simultaneously, and to adjust for any potential correlation between outcomes for repeated review messages on the same prescription. All analyses were performed using SPSS 22 (IBM SPSS Inc., Chicago, IL, USA), with p<0.05 considered significant.</p><p>Results</p><p>Pharmacists assigned 36,245 review messages to prescriptions over the 12 months, 34,506 of which were coded for analysis after exclusions. Nearly half of messages (46.6%) were signed-off and 65.5% of these were signed-off in ≤ 48 hours. Of the 9,991 further analysed for action, 35.8% led to an action as requested by the pharmacist and just over half of these (57.0%) were actioned in ≤ 24 hours. Factors predictive of an action were the time since the prescription was generated (p<0.001), pharmacist grade (p<0.001), presence of a high-risk medicine (p<0.001), messages relating to reconciliation (p = 0.004), theme of communication (p<0.001), speciality, (p<0.001), category of medicine (p<0.001), and regularity of the prescription (p<0.001).</p><p>Conclusion</p><p>In this study we observed a lower rate of sign-off and action than we might have expected, suggesting uni-directional communication via the CPOE system may not be optimal. An established pharmacist-physician collaborative working relationship is likely to influence the prioritisation and response to messages, since a more desirable outcome was observed in settings and with grades of pharmacists where this was more likely. Designing systems that can facilitate collaborative communication may be more effective in practice.</p></div

Impact of an inpatient electronic prescribing system on prescribing error causation: a qualitative evaluation in an English hospital

BACKGROUND: Few studies have applied a systems approach to understanding the causes of specific prescribing errors in the context of hospital electronic prescribing (EP). A comprehensive understanding of underlying causes is essential for developing effective interventions to improve prescribing safety. Our objectives were to explore prescribers' perspectives of the causes of errors occurring with EP and to make recommendations to maximise benefits and minimise risks. METHODS: We studied a large hospital using inpatient EP. From April to June 2016, semistructured interviews were conducted with purposively sampled prescribers involved with a prescribing error. Interviews explored prescribers' perceived causes of the error and views about EP; they were audio-recorded and transcribed verbatim. Data were thematically analysed against a framework based on Reason's accident causation model, with a focus on identifying latent conditions. RESULTS: Twenty-five interviews explored causes of 32 errors. Slips and rule-based mistakes were the most common active failures. Error causation was multifactorial; environmental, individual, team, task and technology error-producing conditions were all influenced by EP. There were three broad groups of latent conditions: the EP system's functionality and design; the organisation's decisions around EP implementation and use; and prescribing behaviours in the context of EP. CONCLUSIONS: Errors were associated with the design of EP itself and its integration within the healthcare environment. Findings suggest that EP vendors should focus on revolutionising interface design and usability issues, bearing in mind the wider healthcare context in which such software is used. Healthcare organisations should draw upon human factors principles when implementing EP. Consideration of work environment, infrastructure, training, prescribing responsibilities and behaviours should be considered to address local issues identified

Electronic Prescribing In Children (EPIC): an evaluation of implementation at a children’s hospital.

Medication errors are common and can cause significant mortality and morbidity. Electronic prescribing (EP), with or without clinical decision support systems (CDSS), is a complex intervention that has been proposed as a solution. US studies indicate that there may be a reduction in medication errors as well as adverse events, but equally new errors may be introduced. There is a paucity of studies assessing the use and impact of EP in the UK hospital setting, especially those involving paediatric patients. The aim of this thesis was to investigate and evaluate the implementation of an EP system at a children's hospital in the UK. The objectives were to assess the effect on prescribing errors, to explore the level of CDSS available and in use within the system, to identify any changes in practice and workflow patterns of healthcare professionals, and to determine the views of patients and users. Mixed qualitative and quantitative methods were used within an evaluation framework (the Cornford framework). The results show an overall reduction in prescribing errors directly as a result of more complete and legible prescriptions after EP. Outpatient errors decreased from 1219/1574 (77.4%) to 33/648 (5.1%), a 72.3% reduction [95% confidence interval (CI) -74.6% to -69.3%]. The number of outpatient visits that were error free increased from 185/883 (21%) to 225/250 (90%), 95% Cl of difference in proportions, 64% to 73.4%. Inpatient errors decreased from 85/1267 (6.7%) to 96/ 2079 (4.6%), 95% CI of difference in proportions, -3.4% to -0.5% There was an increase in discharge prescription errors from 839/1098 (76.4%>) to 1777/2057 (86.4%), 95% CI of difference in proportions, 7.88% to 12.94%. The dosing error rate in all types of prescriptions was lower after EP: 88/3939 (2.2%) vs. 57/4784 (1.2%), 95% CI of difference in proportions, -1.6% to -0.5%, but there was no statistically significant change in severity ratings of dosing errors. New types of errors, such as selection errors, were seen due to EP. Although principles of the medicines use process remained the same, the practical approach to tasks was altered. The system was accepted by users and patients, but there was a desire for further improvements, especially in the level of clinical decision support available to the end user. In conclusion, the EP system was implemented successfully. The benefits in medication safety appear to be the results of effective interaction between system functionality and usability, user acceptance and organisational infrastructure

The impact of electronic prescribing on pharmacists’ communication in UK inpatient settings: a mixed methods study

Background: Electronic prescribing and medication administration (ePMA) systems are becoming widely adopted across the UK. System users, researchers and patients are now questioning the profound nature through which these systems affect the ways in which healthcare professionals (HCPs) communicate with each other. Aim: The overall aim of this PhD was to explore the impact of ePMA systems on pharmacists’ communication with other HCPs and identify areas of improvement. Method: A systematic review explored the impact of electronic prescribing systems on HCPs’ working practices. Focus groups and semi-structured interviews were conducted with hospital pharmacists, doctors and nurses to explore their perceptions of how ePMA systems have affected, or are expected to affect, the way they communicate with each other. Observations, collecting both quantitative and qualitative data, were carried out to study how pharmacists communicated with other HCPs at two sites with established ePMA systems and one with paper-based prescribing. Results: The systematic review identified four areas of working practices affected by ePMA. The focus group and interview study suggested that ePMA systems were not being used to facilitate communication among HCPs. Doctors felt that the written and physical presence of the pharmacist had reduced since ePMA systems were introduced. Participants suggested ways their current ePMA systems could improve and streamline communication. The observational study revealed differences in pharmacists’ working practices; factors included differences in pharmacy services, organisational cultures and prescribing systems. More medication charts were reviewed by the pharmacists at the ePMA sites, but a lower percentage of patients were reviewed face-to-face. This may be indicative of a potentially negative impact of ePMA on pharmacist-patient relationships. Conclusion: Practical challenges faced by HCPs working with ePMA systems were identified. Recommendations were made for clinical practice, ePMA providers and future researchers. A recommendation made to the hospitals was to consider updating their pharmacy clinical guidelines to incorporate ePMA into their working practice

Qualitative study exploring the phenomenon of multiple electronic prescribing systems within single hospital organisations

BACKGROUND: A previous census of electronic prescribing (EP) systems in England showed that more than half of hospitals with EP reported more than one EP system within the same hospital. Our objectives were to describe the rationale for having multiple EP systems within a single hospital, and to explore perceptions of stakeholders about the advantages and disadvantages of multiple systems including any impact on patient safety. METHODS: Hospitals were selected from previous census respondents. A decision matrix was developed to achieve a maximum variation sample, and snowball sampling used to recruit stakeholders of different professional backgrounds. We then used an a priori framework to guide and analyse semi-structured interviews. RESULTS: Ten participants, comprising pharmacists and doctors and a nurse, were interviewed from four hospitals. The findings suggest that use of multiple EP systems was not strategically planned. Three co-existing models of EP systems adoption in hospitals were identified: organisation-led, clinician-led and clinical network-led, which may have contributed to multiple systems use. Although there were some perceived benefits of multiple EP systems, particularly in niche specialities, many disadvantages were described. These included issues related to access, staff training, workflow, work duplication, and system interfacing. Fragmentation of documentation of the patient's journey was a major safety concern. DISCUSSION: The complexity of EP systems' adoption and deficiencies in IT strategic planning may have contributed to multiple EP systems use in the NHS. In the near to mid-term, multiple EP systems may remain in place in many English hospitals, which may create challenges to quality and patient safety.Peer reviewe

Improving antibiotic prescribing for adults with community acquired pneumonia: Does a computerised decision support system achieve more than academic detailing alone? – a time series analysis

BACKGROUND: The ideal method to encourage uptake of clinical guidelines in hospitals is not known. Several strategies have been suggested. This study evaluates the impact of academic detailing and a computerised decision support system (CDSS) on clinicians' prescribing behaviour for patients with community acquired pneumonia (CAP). METHODS: The management of all patients presenting to the emergency department over three successive time periods was evaluated; the baseline, academic detailing and CDSS periods. The rate of empiric antibiotic prescribing that was concordant with recommendations was studied over time comparing pre and post periods and using an interrupted time series analysis. RESULTS: The odds ratio for concordant therapy in the academic detailing period, after adjustment for age, illness severity and suspicion of aspiration, compared with the baseline period was OR = 2.79 [1.88, 4.14], p < 0.01, and for the computerised decision support period compared to the academic detailing period was OR = 1.99 [1.07, 3.69], p = 0.02. During the first months of the computerised decision support period an improvement in the appropriateness of antibiotic prescribing was demonstrated, which was greater than that expected to have occurred with time and academic detailing alone, based on predictions from a binary logistic model. CONCLUSION: Deployment of a computerised decision support system was associated with an early improvement in antibiotic prescribing practices which was greater than the changes seen with academic detailing. The sustainability of this intervention requires further evaluation