Improving patient safety through feedback on prescribing errors Imperial College Healthcare NHS Trust

The Imperial College Healthcare NHS Trust project aimed to improve patient safety by reducing prescribing errors made by foundation year 1 (FY1) doctors in the hospital setting.

Specific goals included:

• increasing the proportion of FY1s providing their name on inpatient medication orders, to enable personal feedback on any errors
• supporting hospital pharmacists to provide clear and constructive feedback on prescribing errors
• developing an approach to sharing common or serious errors among FY1s and pharmacists to facilitate shared learning.

The team developed the Prescribing Improvement Model (PIM) toolkit - a low-cost intervention that built on hospital pharmacists’ existing practice. The toolkit featured:

• personalised name stamps for FY1s to use when adding medication orders to inpatient drug charts
• training for pharmacists on how to give effective feedback
• fortnightly emails discussing a common or serious prescribing error in detail, including how to prevent it happening.

Who was involved

The intervention involved pharmacists and doctors at Charing Cross Hospital. St. Mary’s Hospital acted as the control site.

Outcomes

• The percentage of identifiable medication orders written by FY1 doctors increased from 6% to 50%.
• The introduction of individual feedback from pharmacists led to a small but significant difference in the rate of reduction in prescribing errors. 
• There was no overall difference in error rates between the sites - the team concluded that as there are multiple causes of prescribing errors, improving feedback alone was unlikely to significantly reduce their prevalence.
• The toolkit was rolled out to St Mary's Hospital and Hammersmith Hospital.

Challenges

While there was excellent engagement from FY1 doctors, the team found it harder to engage with more senior doctors.