Background to the SPARS Project

Prescribing errors

Prescribing errors are common. Many are minor, but some can be serious and even result in deaths. The recent EQUIP study (commissioned by the General Medical Council) found a prescribing error rate of 8.9% among 125,000 prescriptions written by doctors and nurses in the hospitals of North West England [1]. This observational study showed that all grades of doctor (including consultants) were prone to making prescribing errors, but the highest error rate of 10.3% occurred in prescriptions written by foundation year 2 doctors. Almost all errors observed in the EQUIP study were intercepted by pharmacists before they could affect patients. The PROTECT study group recently found a similar prescribing error rate (7%) in Scottish hospitals [2]. The causes of error were varied but many involved poor use of the prescribing documentation that was available.

History of prescription charts

From the outset, the National Health Service accepted that all general practitioners should use a single form for prescribing so that all doctors and pharmacists would be familiar with it and it has remained largely unchanged. However, individual hospitals were left to create their own charts to address the more complex requirements of hospital prescribing. The result has been the development of a wide variety of styles of documentation.

The call to unify prescribing charts was made by the British Pharmacological Society some years ago [3] and is has more recently been supported by Medical Royal Colleges, the Medical Schools Council, the Royal Pharmaceutical Society and the Royal College of Nursing. These organisations recently published a joint report calling for harmonization of prescribing documentation and setting out the standards that they thought should be included [4].

The NHS in Wales, advised by the All Wales Medicines Strategy Group, introduced a single chart in the autumn of 2004 [5]. It has continued evolving in response to feedback from users and safety alerts, refining the content and design, all healthcare workers in secondary care have been able to be trained for the use of a chart with which they are familiar. The Welsh chart has subsequently been endorsed and proposed by the Royal College of Physicians as a suitable national chart for England although this proposal is yet to be ratified by other stakeholders.

In Scotland, a number of projects related to the unification of prescription documents are underway. The Single Prescription and Administration Record for Scotland (SPARS) project is addressing the possible harmonization of adult in-patient prescription forms. A parallel project run by the Scottish Diabetes Group is developing a national chart for the prescribing of insulin, known as the Insulin Prescription and Administration Record (IPAR), based at Ninewells Hospital, Dundee.

Justification for unified prescribing documentation

There is intuitive common sense to the proposal that prescribing documentation should be harmonised. There is no clinical justification for variation in prescription charts within a national service that delivers standard care based on national and international guidance on best practice. The NHS relies on a mobile workforce; most prescribers will move hospitals many times during a career. Each move currently involves re-orientating themselves to a new layout and completion rules. A single chart offers the prospect that all Scottish healthcare professionals will always be familiar with a fundamental clinical tool of their work. Furthermore, it would also mean that all medical, nursing and pharmacy schools can train and assess their students effectively to ensure that they are confident in the use of the chart at the outset of their careers.

More broadly, many of the advances in the standards of care for NHS patients have been made by standardization of practices drawing on evidence from the literature as well as audit, feedback and improvement cycles. The SPARS Group intends to apply these principles to the development of a single adult in-patient prescription and administration record for Scotland.

Evidence from elsewhere

The introduction of a standard revised medication chart in a Queensland hospital was associated with a significant reduction in the frequency of prescribing errors, improved ADR documentation and a decrease in the potential risks associated with warfarin management [6]. The chart was subsequently piloted nationally and went on to become the Australian National Inpatient Medication Chart.

 

1. The EQUIP Study available at:
http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf

2. Ryan C, Davey P, Francis J, Johnston M, Ker J, Lee AJ, MacLeod MJ, Maxwell S, McKay G, McLay J, Ross S, Webb D, Bond C. The prevalence of prescribing errors amongst junior doctors in Scotland. Basic and Clinical Pharmacology and Toxicology 2011;109:35.

3. Aronson JK. A prescription for better prescribing. Br J Clin Pharmacol 2006;61:487–491.

4. Academy of Medical Royal Colleges 2011. Standards for the design of hospital in-patient prescription charts. Available at http://www.aomrc.org.uk/publications/reports-a-guidance.html

5. Routledge P. A national in-patient prescription chart: the experience in Wales 2004–2012. Br J Clin Pharmacol 2012;74:561–565.

6. Coombes ID, Stowasser DA, Reid C, Mitchell CA. Impact of a standard medication chart on prescribing errors: a before and after audit. Qual Saf Health Care 2009;18:478-485.
Available at http://qualitysafety.bmj.com/content/18/6/478