Why reducing prescribing errors?
Prescribing errors, resulting from inappropriately prescribed medication, can cause iatrogenic patient harm, prolonged hospitalization and hospital readmission (1-3). These events are associated with an increased risk of morbidity, mortality and increased healthcare costs. Recent estimations show that 5–7% of all hospital admissions in economically developed countries are medication related. Approximately 66% are due to inappropriate prescribed medication. Associated worldwide costs are estimated at 42 billion USD each year (1, 4) and are therefore a worldwide topic of awareness (5).
In the Netherlands, the HARM study showed that 2.4% of all hospital admissions and 5.6% of all acute admissions in Dutch hospitals were related to medication errors (6). Almost half (46%) of these admissions were potentially preventable. One or more prescribing errors were detected in most (71%) of the preventable admissions.
In response, over the past decades, several strategies aiming to reduce in-hospital PEs and related patient harm have been developed, including programmes with a focus on specific medications and their harmful ADEs (e.g. nonsteroidal anti‐inflammatory drugs and antiplatelet drugs causing gastrointestinal tract bleeding (6, 7), medication reconciliation (8) and the implementation of computerized physician order entry (CPOE) systems, often in combination with clinical decision support systems (CDSS). Nonetheless, ADEs still occur and numbers are not declining (9, 10). A recent report, commissioned by the Dutch government (10), revealed a rise of 26% in (the absolute number of) medication‐related hospital admissions between 2008 and 2013. This is in line with international publications (9), underscoring the need for more effective strategies.
How to reduce prescribing errors in the in-hospital setting?
Due to the increasing complexity of hospital-admitted patients (e.g. multimorbidity, polypharmacy, multiple prescribers involved, older age); the demanding work environment; hard to find or conflicting protocols; a heavy workload, in-hospital prescribers are challenged in prescribing appropriately. To prevent and reduce medication-related harm, new strategies are urgently needed. In this new strategy, we hypothesize that a multidisciplinary team (‘Pharmacotherapy team’) including a clinician and a hospital pharmacist, working together with local stakeholders, e.g. (junior) prescribers, nurses, medical managers, can make a valuable contribution to reduce prescribing errors.
Since September 2015, this Pharmacotherapy team is operational inAmsterdam University Medical Centers -location VUmc. Between mid 2015 and mid 2018 we developing a multifaceted strategy, using Participatory Action Research (PAR). Participatory action research is characterized by the involvement of relevant stakeholders in the analysis of complex problems and in leading the change process (11). Stakeholders are empowered to identify the problem's root causes as well as opportunities to improve, develop and implement a tailored plan of improvement. This process should result in sustainable improvement as stakeholders place value on an intervention they partially created, the IKEA effect (12). This study was recently published and led to several hospital-wide interventions.
Based on the results of the individual wards, hospital-wide interventions are developed including:
- Consultation of the Pharmacotherapy team, involving clinical pharmacologists, clinical pharmacist and medical doctors,in daily clinical practice.
- eLearning covering important prescribing topics (e.g. pain/fluid management, anticoagulation) for junior doctors;
- ‘App-ification and optimization of hospital guidelines for drug prescribing.
Eversince, the Pharmacotherapy team is inbedded in daily in-hospital practice. Future research will focuss on in-dept research of facilitators and protective barriers to in-hospital prescribing errors and how to use this information in developing a more effective multifaceted strategy to sustainably reduce prescribing errors in the in-hospital setting.
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