title: Redesigning the 'choice architecture' of hospital prescription charts: a mixed methods study incorporating in situ simulation testing.
abstract: OBJECTIVE
  To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors.
  
  
  METHODS
  A mixed-methods approach was taken in the development phase of the project; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart.
  
  
  METHODS
  A London teaching hospital.
  
  
  METHODS
  A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation.
  
  
  RESULTS
  Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber's printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001). Antiinfective indication (28/28 vs 17/29; p<0.0001) and duration (26/28 vs 15/29; p<0.0001) were more likely to be completed using the IDEAS chart.
  
  
  CONCLUSIONS
  In a simulated context, the IDEAS prescription chart significantly reduced a number of common prescribing errors including dosing errors and illegibility. Positive behavioural change was seen without prior education or support, suggesting that some common prescription writing errors are potentially rectifiable simply through changes in the content and design of prescription charts.
authors.affiliation: Imperial College London, St Mary's Hospital, London, UK.
authors.forename: Dominic
authors.initials: D
authors.lastname: King
authors.affiliation: School of Pharmacy, University College London, London, UK.
authors.forename: Ali
authors.initials: A
authors.lastname: Jabbar
authors.affiliation: Centre for Infection Prevention and Management, Imperial College London, London, UK.
authors.forename: Esmita
authors.initials: E
authors.lastname: Charani
authors.affiliation: Imperial College London, St Mary's Hospital, London, UK.
authors.forename: Colin
authors.initials: C
authors.lastname: Bicknell
authors.affiliation: Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Zhe
authors.initials: Z
authors.lastname: Wu
authors.affiliation: Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Gavin
authors.initials: G
authors.lastname: Miller
authors.affiliation: Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Mark
authors.initials: M
authors.lastname: Gilchrist
authors.affiliation: Imperial College London, St Mary's Hospital, London, UK.
authors.forename: Ivo
authors.initials: I
authors.lastname: Vlaev
authors.affiliation: Centre for Medication Safety, Imperial College Healthcare NHS Trust and UCL School of Pharmacy, London, UK.
authors.forename: Bryony Dean
authors.initials: BD
authors.lastname: Franklin
authors.affiliation: Imperial College London, St Mary's Hospital, London, UK.
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
mesh_terms: D003198:Computer Simulation; D011307:Drug Prescriptions / Q000592:standards*; D006784:Hospitals, Teaching / Q000592:standards*; D006801:Humans; D007297:Inpatients; D008131:London; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital / Q000592:standards*; D010607:Pharmacy Service, Hospital / Q000592:standards*; D010865:Pilot Projects; D055656:Prescriptions / Q000592:standards*
keywords: EDUCATION & TRAINING (see Medical Education & Training)