Year of Publication

2013

College

Martin School of Public Policy and Administration

Degree Name

Master of Public Administration

Executive Summary

A previous study, EQUIP 2009, found the rate of in-hospital prescription errors in 19 hospitals across Manchester, England, to be nearly nine percent. Prescription errors have been shown to contribute to adverse drug events, prolonged hospital stay, increased morbidity and mortality, and increased cost. The aim of this pilot study is to determine if constructive feedback by consultants (senior physicians) to junior physicians on their prescribing errors changes their attitudes toward prescribing safety. The hope is that feedback sessions will help solidify a deeper understanding of both the situation and individual actions on errors and more effectively impact future actions.

The study was conducted in July 2012 with 9 junior physicians, graduate doctors in training, from Wythenshawe Hospital, England. Two of the nine originally identified physicians were unable to participate in feedback due to one having a conflict of schedule and the other leaving the hospital. A questionnaire was given to junior physicians before and after the feedback session to identify attitudes toward prescribing errors. I used discharge prescriptions before and after feedback to determine the prescribing error rate and severity of errors; a senior physician from the ward provided the feedback within two weeks. The Hewson and Little’s Feedback Model was used as a guide for the sessions to ensure non-threatening and objective feedback. Outcome measures include changes in error prevalence, attitudes before and after, and evaluating the usefulness of feedback as a learning tool. Analysis includes descriptive statistics and Fisher’s exact tests on data collected from survey response and medication discharge lists.

There was a 71% response rate to all three surveys (pre-intervention, post-intervention, and feedback). Survey responses revealed that physicians felt they had made fewer errors after receiving feedback. Analysis of discharge medication lists of all nine physicians showed a decrease in rate of prescribing errors from pre- to post-intervention (15.5% and 13.5% respectively). Following elimination of the two physicians excluded from feedback, the difference in rate of prescribing errors was greater between pre- and post-intervention (17% and 10.2% respectively).

The majority of physicians did not feel this experience altered their ways of prescribing. However, all physicians who provided responses to the feedback survey questionnaire indicated that they were happy with pharmacy collecting information about their prescribing errors. They were not pleased that consultant physicians instead of pharmacists conveyed these errors to them. Four out of the five physicians said they would recommend this program to their colleagues. Physicians also expressed the desire for more of their discharge medication lists to be evaluated and on a more frequent basis.

Results of this study show that the use of feedback sessions was widely accepted by physicians. Future programs should consider pharmacists as the providers of feedback based on survey responses.

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