Providing feedback to hospital doctors about prescribing errors; a pilot study.
OBJECTIVE
To assess the feasibility and acceptability of obtaining data on prescribing error rates in routine practice, and presenting feedback on such errors to medical staff.


METHODS
One clinical directorate of a London teaching trust.


METHODS
Ward pharmacists recorded all prescribing errors identified in newly written medication orders on one day each fortnight between February and May 2005. We examined prescribing errors reported on the trust's medication incident database for the same period.


METHODS
Prescribing errors identified and recorded by ward pharmacists, prescribing errors reported as incident reports; prescribing error rates per clinical specialty; lead consultants' views on receiving feedback on errors for their specialty.


RESULTS
During eight data collection days, 4,995 new medication orders were examined. Of these, 462 (9.2%; 95% confidence interval 8.5 -10.1%) contained at least one prescribing error. There were 474 errors in total. Pharmacists indicated that they would have reported 19 (4%) of the prescribing errors as medication incidents. Eight prescribing errors were reported for the entire four-month study period on non-data collection days. Feedback was presented to lead clinicians of 10 clinical specialties. This included graphical summaries showing how the specialty compared with others, and a list of errors identified. This information was well-received by clinicians.


CONCLUSIONS
Prescribing errors identified by ward pharmacists can be systematically fed back at the level of the clinical specialty; this is acceptable to the consultants involved. Incident report data is subject to gross under-reporting. Routinely providing feedback for each consultant team or for individual prescribers will require more focussed data collection.
Franklin
Bryony Dean
BD
Academic Pharmacy Unit, Hammersmith Hospitals NHS Trust, London, UK. bdean@hhnt.nhs.uk
O'Grady
Kara
K
Paschalides
Christos
C
Utley
Martin
M
Gallivan
Steve
S
Jacklin
Ann
A
Barber
Nick
N
D003625:Data Collection / Q000379:methods*; D004282:Documentation; D005246:Feedback; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D008131:London; D008508:Medication Errors; D010595:Pharmacists; D010820:Physicians; D010865:Pilot Projects; D010818:Practice Patterns, Physicians' / Q000592:standards*