Exploring the impact of formalised prescribing error feedback

Simon Watmough

Research output: Chapter in Book/Report/Conference proceedingConference proceeding (ISBN)peer-review


Background: Prescribing errors (PEs) are an endemic problem in healthcare with prevalence estimated at up to 50%. Error causation is complex with lack of PE feedback considered a contributing latent condition. The aims of this research are to explore the views of Pharmacists towards PE feedback and the impact of feedback on PE rates and Prescribers. Summary of Work: Prospective prescribing audits were completed at the beginning and end of a three month prescriber rotational period for control and intervention wards. Prescribers received feedback on PEs in-between audit periods. PE data were analysed using an independent t-test. 24 Pharmacists were recruited into one of four focus groups. Twenty prescribers who had received feedback were interviewed individually. Interviews were transcribed and analysed using a thematic framework approach. Summary of Results: Mean PE rates were significantly lower in the intervention group following feedback (mean difference 19.7%, p<0.05, d=0.7). Pharmacists 3 / 7 recognised that feedback on PEs was essential to learn from mistakes and reduce PEs. However, delivery of feedback appeared to be inconsistent and mainly directive with communication anxieties with prescribers also reported. Prescribers welcomed and valued feedback, advocating its role in facilitating reflection and supporting their development. Pharmacists were considered credible facilitators of feedback. Discussion: The work has involved a change in hospital practice and in some cases a change of culture, but it seems these changes are worthwhile. If this is to be taken further then pharmacists may need to have more training in giving feedback and more time allowed for giving and receiving feedback. Conclusion: Early results are promising with positive impacts on PE rates and prescribers themselves. Further work is necessary to determine reproducibility, sustainability and the impact of feedback on specific error types and Pharmacists who deliver the structured feedback. Take Home Messages: Allowing pharmacists to give feedback to prescribers can reduce prescribing error rates.
Original languageEnglish
Title of host publicationNot Known
Publication statusAccepted/In press - 1 May 2016
EventAssociation for Medical Education in Europe (AMEE) Conference - Edinburgh International Conference Centre, Edinburgh, United Kingdom
Duration: 5 Sept 20048 Sept 2004


ConferenceAssociation for Medical Education in Europe (AMEE) Conference
Country/TerritoryUnited Kingdom


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