Date Published: January 31, 2019
Publisher: Public Library of Science
Author(s): Mahdi A. Alanazi, Mary P. Tully, Penny J. Lewis, Melissa T. Baysari.
Prescribing errors in hospital are common. However, errors with high-risk-medicines (HRMs) have a greater propensity to cause harm compared to non-HRMs. We do not know if there are differences between the causes of errors with HRMs and non-HRMs but such knowledge might be useful in developing interventions to reduce errors and avoidable harm. Therefore, this study aims to compare and contrast junior doctors’ prescribing errors with HRMs to non-HRMs to establish any differences.
A secondary analysis of fifty-nine interviews with foundation year doctors, obtained from three studies, was conducted. Using a Framework Analysis approach, through NVivo software, a detailed comparison was conducted between the unsafe acts, error-causing-conditions (ECCs), latent conditions, and types of errors related to prescribing errors with HRMs and non-HRMs.
In relation to unsafe acts, violations were described in the data with non-HRMs only. Differences in ECCs of HRMs and non-HRMs were identified and related to the complexity of prescribing HRMs, especially dosage calculations. There were also differences in the circumstances of communication failures: with HRMs ineffective communication arose with exchanges with individuals outside the immediate medical team while with non-HRMs these failures occurred with exchanges within that team. Differences were identified with the latent conditions: with non-HRMs there was a reluctance to seek seniors help and with HRMs latent conditions related to the organisational system such as the inclusion of trade names in hospital formularies. Moreover, prescribing during the on-call period was particularly challenging especially with HRMs.
From this secondary analysis, differences in the nature and type of prescribing errors with HRMs and non-HRMs were identified, although further research is needed to investigate their prevalence. As errors with HRMs have the potential to cause great harm it may be appropriate to target limited resources towards interventions that tackle the underlying causes of such errors. Equally concerning, however, was the sense that doctors regard the prescribing of non-HRMs as ‘safe’.
Prescribing errors are said to occur when “as a result of a prescribing decision or prescription writing process, there is an unintentional significant reduction in the probability of treatment being timely and effective or increase in the risk of harm when compared with generally accepted practice”. Such errors are the most frequent type of error in the medication use process[2, 3] and can double patients’ length of hospital stay and cost of care, as well as increasing their mortality rate.[4–6] With all types of medication, hospital prescribing errors are common occurring with 7% of medication orders, 2% of patient days and 50% of hospital admission. Seventy percent of hospital prescriptions are prescribed by Foundation Year 1 (FY1) and Foundation Year 2 (FY2) junior doctors. Nonetheless they have twice the prescribing error rate compared to consultants. Not all prescribing errors necessarily have the same consequences; about 41% are considered to be minor. High Risk Medicines (HRMs) have a greater ability to cause devastating harm when they are used in error compared to regular medicines.
Forty-seven out of the fifty-nine interviews were included in the analysis. The remaining 12 interviews were excluded because they did not mention any prescribing errors (n = 7), did not provide the name or type of medication in which the error occurred (n = 1), or because the prescribing error occurred outside hospital settings such as in general practice settings (n = 4). The 47 interviews contained descriptions of 108 prescribing errors; 39 errors with HRMs, for example, Low Molecular Weight Heparins (LMWH), insulin, narcotics and opioids, and antibiotic related allergy; and 69 with non-HRMs, for example, Non- Steroidal Anti- Inflammatory Drugs (NSAIDs), paracetamol, statins, and Proton Pump Inhibitors (PPIs).
This study is the first to explore and compare the causes of prescribing errors and violations with HRMs and non-HRMs. We found that violations were not linked to HRMs and were only reported in prescribing errors with non-HRMs. This finding could be explained by the heightened risk of harmful consequences with HRMs in comparison to non-HRMs which may lead prescribers to avoid violations with HRMs. Although violations are intentional deviations from safe practice or the written rules of the working place, the violations described in this study with non-HRMs were intended to ensure patient benefit and to overcome workplace complexity. This finding is similar to previous findings that most violations are well-intended. As well, our results confirmed that time pressures, leading to prescribers being in a hurry, high workload and lack of resources could lead to violations.
The differences between HRMs and non-HRMs reflect the nature of the prescribed medication class and the attitude of the prescribers toward the prescribed medication. Prescribers’ confidence with non-HRMs and the reduced sense of risk could lead to breaking the rules or reluctance to seek help. HRM related errors were illustrative of the complexity of the prescribing task with HRMs or additional rules regarding HRM prescriptions (e.g. controlled medication). Furthermore, medication class had an influence on communication as non-HRMs were associated with different types of communication failures than HRMs. In conclusion, these findings highlighted some of the areas that could be targeted by future interventions to reduce prescribing errors and increase patient safety, with both HRMs and non-HRMs.