Exploring the effectiveness of prescribing error feedback in an acute hospital setting

Background: Prescribing errors (PEs) are problematic within healthcare creating workflow inefficiencies and potentially compromising patient safety 1. Various strategies have been employed in an attempt to reduce error rates yet PEs remain a concern. Feedback has been proposed as one potential intervention 2 with prescribers welcoming PE feedback 3 but evidence in its use and application for prescribing in hospital settings is limited. The purpose of this study was to determine the impact of a pharmacist-led constructive feedback on prescribing error rates in a hospital setting. Methodology: Baseline PE data was collected prospectively over a five day period on sixteen wards in a UK hospital. Wards were assigned into control and intervention groups with 41 prescribers on control wards and 37 prescribers on intervention wards. All prescriber grades were included. Prescribers in the intervention group received written and verbal feedback on their prescribing from ward pharmacists including error rates, stage of prescription, severity and examples of both good and suboptimal prescribing. This was followed by further feedback on any PE intercepted and classified as significant or above. Pharmacists working on the intervention wards were trained in the principles of effective feedback 4,5. This was to ensure timely delivery of constructive feedback that facilitated reflection, encouraged identification of error causation and was actionable. PE data collection was repeated following three months of the intervention. Data were analysed using chisquared, Spearman’s rank and independent t-tests. Results: For the intervention group, there was a mean increase of 23.7% (95% CI, 15.6 to 31.8, SD 24.00) in error free prescriptions, compared to a 5.8% reduction (95% CI, -14.4 to 2.9, SD 27.4) in the control group, a statistically significant difference of 29.5% (95% CI, 17.7 to 41.2, SD 5.9), t(75) = 4.978, p = 0.005. Effect size (d) = 1.14. Overall PE rates were statistically significantly lower in the intervention group (mean change of -18.3%) compared to the control group (mean change of +5.5%) with a mean difference of 23.8% (SD 3.5, 95% CI, -30.6 to -16.8), t(75) = -6.849, p Discussion: Audit and feedback, combined with on-going feedback on significant PEs, produces statistically significant 3 / 7 reductions in PE rates with PE feedback now part of routine clinical practice in the study hospital. These results are consistent with empirical evidence 6 and show promise for wider application in hospital settings where clinical pharmacists can be utilised as facilitators of PE feedback. Further work is necessary to determine the most effective method of feedback alone and in combination with other PE reduction strategies. Additionally, exploring the impact of feedback on prescribing behaviour could highlight why feedback works to inform prescribing pedagogy and feedback delivery further. References: 1. Bertels J, Almoudrais AM, Cortoos PJ, Jacklin A, franklin BD. Feedback on prescribing errors to junior doctors: exploring views, problems and preferred methods. Int J Clin Pharm (2013):35;332-338 2. Lloyd M, Watmough SD, O’Brien SV, Furlong N, Hardy K. Exploring Attitudes and Opinions of Pharmacists towards delivering Prescribing Error Feedback: A Qualitative Case Study using focus group interviews. Research in Social and Administrative Pharmacy, 2016;12(3):461-74. doi: 10.1016/j.sapharm.2015.08.012 3. Lloyd M, Watmough SD, O’Brien SV, Furlong N, Hardy K. A pilot study exploring doctor attitudes and opinions to receiving formalised prescribing error feedback from hospital pharmacists. British Journal of Hospital Medicine 2015;76(12):713-8 4. Lloyd M, Watmough SD, O’Brien SV, Furlong N, Hardy K. How to give and receive constructive feedback. The Pharmaceutical Journal, 2016; Vol 296, No 7887, online | DOI: 10.1211/PJ.2016.20200756 5. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment Medical teacher 2012; 34: 787–791 6. Ivers N, Jamtvedt G, Flottorop S, Young JM, Odgaard-Jensen J, French SD, et al: Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012, 6:CD000259. http:// onlinelibrary.wiley.com/doi/10.1002/14651858.CD000259.pub3/pdf/standard