Improving prescription quality in an in-patient mental health unit: three cycles of clinical audit

AIMS AND METHOD

We undertook three cycles of clinical audit of prescriptioncharts to improve the quality of the prescriptions writtenin an in-patient unit. Pharmacy and medical staff revieweda total of 1466 prescriptions on 242 prescription charts againstlocal guidelines and provided feedback to medical staff. Thepharmacist also regularly reviewed prescription charts on thewards between audits.

RESULTS

After three cycles of audit, 99.5% of prescriptions writtenwere legible. The recording of drug allergies, section 58 statusand patient age remained poor.

CLINICAL IMPLICATIONS

A combination of clinical audit and continual pharmacist reviewof prescription charts can improve the quality of prescriptionswritten by medical staff in an in-patient unit.

Introduction

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Introduction

Prescription writing is a basic clinical skill for all doctors,but errors in prescriptions are believed to be one of the mostcommon forms of medical error. Prescription errors may leadto harm in a number of ways, including sub-therapeutic dosage,potential overdose or unintended polypharmacy. This type oferror may occur for a number of reasons: some relatively complex,such as short-comings in medical training, and others moremundane, such as fatigue, interruptions, or being asked tocover unfamiliar patients (Dean et al, 2000). One study ofprescriptions in a psychiatric unit for older people found that 20% were illegible and one-third contained missing information (Nirodi & Mitchell, 2002). Clinical audit is a commonlyused quality improvement process which measures clinical practiceagainst agreed standards and introduces change where this is indicated (National Institute for Clinical Excellence, 2002).Coventry Teaching Primary Care Trust published guidelines forthe completion of prescriptions in May 2001. We used a series of clinical audits in the period June 2001 to February 2006in an attempt to improve the quality of prescriptions writtenat the Caludon Centre, a 70-bed in-patient unit in Coventry.

Method

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Method

A prospective clinical audit was based on the trust prescriptionwriting guidelines. This was then used by the pharmacist andjunior medical staff to conduct three cycles of prospectiveclinical audit of the prescription records of patients admittedto adult wards at the Caludon Centre. The first audit was completedin June 2001, the second in March 2004 and the third in February 2006. Minor adjustments were made to the audit tool in 2004and the size of the 2006 audit was increased by the inclusionof a newly opened ward. Results were fed back to trust staffat postgraduate medical education meetings. The pharmacistalso conducted regular review of the prescription charts onthe wards between the audits and highlighted errors to theappropriate medical team.

Results

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Results

A total of 1466 prescriptions on 242 prescription charts werereviewed during the three cycles of audit, 67 records in 2001,57 in 2004 and 118 in 2006. The recording of patient informationon prescription charts improved after the first cycle of auditbut declined after the second (Table 1). Although overall legibilityimproved, the recording of drug allergies, section 58 statusand age remained especially poor throughout the audit period.

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Table 1. Recording of patient information on drug records

The quality of regular prescriptions showed a consistent improvementover the audit period (Table 2). Prescription cancellationsimproved over the audit period, but the recording of frequencyto be given remained poor.

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Table 2. Completeness of regular prescriptions

The overall quality of ‘as required’ prescriptionsalso showed consistent improvement (Table 3). Recording ofreason for administration improved, as did prescription cancellations.

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Table 3. Completeness of ‘as required’ prescriptions

Discussion

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Discussion

The results of this study suggest that clinical audit and feedbackcombined with pharmacist intervention at ward level can improvethe quality of prescriptions in an in-patient setting. Theoverall legibility of prescriptions reviewed improved to apoint where 99.5% of all prescriptions reviewed were consideredlegible. Specific aspects of prescription writing that hadbeen poor in 2001 also showed improvement, most noticeably theproper cancelling of ‘as required’ and regularprescriptions. However, some basic aspects of prescriptionwriting, such as using block capitals for drug names, onlyimproved slightly and the recording of drug allergies remainedvery poor throughout the audit period. This is a cause for concern, although the actual risk it represents is difficult to assess.Although drug allergies are believed to occur in 14–17%of all patients, the most common are to antibiotics and non-steroidalanti-inflammatory drugs (Vervloet & Durham, 1998), bothof which are not widely prescribed in our unit. However, recordingdrug allergies remains the responsibility of the prescriberand other audits have shown allergy recording rates of 75%or more are achievable (Tuthill et al, 2004).

Continuous quality assurance requires ongoing data collection,review of that data and action. Various strategies have beensuggested to improve the quality and safety of hospital prescribing,including systems analysis (Hronek & Bleich, 2002), electronicprescribing systems (Fowlie et al, 2000) and applying humanerror theory (Dean et al, 2000). Barber et al (2003) advocatea three-part strategy aimed at reducing prescribing errors.This is based on improving individual prescriber’s competence,controlling the prescribing environment and changing organisationalculture to allow open discussion of errors. Clinical pharmacistscan have a positive impact on prescribing practice, outcomesand resource use (Finley et al, 2003), and we believe thatclinical pharmacist review on the wards was the most effectiveelement of this audit. Medicines are given because it is believed that the benefits will outweigh any associated risks, but trustsneed appropriate controls to ensure that these risks are minimised (Healthcare Commission, 2007). The involvement of clinicalpharmacy staff in caring for in-patients is a service thatprovides such controls and safety measures.

Acknowledgments

We thank Drs Padmapriya Musunuri and Karthik Modem for helpwith data collection.

References

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