Standards for the design of hospital in-patient prescription charts

Helping to reduce prescribing errors by developing standards for the design of hospital in-patient prescription charts

Medication errors (particularly prescribing errors) are common, can be serious and sometimes result in deaths. An Audit Commission report estimated that medication errors may have been associated with more than 150 fatalities each year in England and Wales between 1996 and 2000 ¹

More recently, The EQUIP study (commissioned by the General Medical Council) examined 124,260 medication orders on seven ‘census days’ in 19 acute hospital trusts in North-west England and found a mean prescribing error rate of 8.9% by doctors and nurses.²The errors most often occurred at the time of patients’ admission to hospital and potentially lethal errors made up 193 (1.74%) of the 11077 medication errors in the study period. All grades of doctor (including consultants) made prescribing errors, although the highest error rate (10.3%) occurred in prescriptions written by foundation year 2 doctors. In this observational study, almost all errors were intercepted by pharmacists before they could affect patients.

The authors of the EQUIP study believed that the design of prescription charts was one of several primary causes of prescribing errors. Their first of six recommendations under the heading of clinical working environments was that a standard drug chart should be introduced throughout the NHS. The NHS in Wales have had a single standardised national in-patient medication administration chart since 2004, accompanied by nationally agreed prescription writing standards and supported by an e-learning programme.^3,4 This has enabled effective and efficient training of staff at undergraduate level in Wales, as well as delivering the EQUIP recommendation designed to reduce the risk of prescribing errors after qualification. The movement of doctors between hospitals within the NHS is now substantial and hospital-based non-medical prescribers are also beginning to move around the UK. This only makes an even stronger case for moving from independently developed prescription charts to a common approach.

Sir Bruce Keogh, the NHS Medical Director, commissioned the Academy of Medical Royal Colleges to work together with the Royal Pharmaceutical Society (RPS) and Royal College of Nursing (RCN) to produce a report on standards for the design of hospital in-patient prescription charts. The report, together with relevant reference documents, can be found on the Academy’s Website.⁵ The Academy wishes to promote these standards throughout the NHS. We want to ensure that they are considered in the design of future in-patient prescription charts in either paper or electronic form.

The standards were developed by an inter-professional group of doctors, pharmacists and nurses drawn from the medical Royal Colleges, the RPS and the RCN, who reviewed hospital prescription charts from a variety of sources, examined the scientific publications in the area and consulted widely with colleagues in their own organisations and in the NHS using an extensive iterative approach before finalising the recommendations outlined in the report.

At present very few hospitals have a fully implemented electronic prescribing system (although more are in the process of implementation) so that the vast majority are still using paper prescription charts. However, we believe that the standards are equally applicable to paper and electronic charts, although a number of standards could of course be automatically embedded into an electronic chart.

The Academy of Medical Royal Colleges believes that adoption of these standards into an electronic chart is urgently required to improve patient safety both through embedding these standards in an electronic chart and through such software decreasing errors in dosages and durations of treatment and flagging up potential drug interactions. The Academy also commend these standards to the private health-care sector.

A letter from Professor Sir Bruce Keogh, NHS Medical Director, Dame Christine Beasley, Chief Nursing Officer, and Dr Keith Ridge Chief Pharmaceutical Officer has been sent to all Trust Chief Executives and Medical Directors in England with a link to Academy report to promote greater awareness of the need to ensure that in-patient prescribing systems meet agreed standards across the NHS.

Professor Sir Neil Douglas
Chairman
Academy of Medical Royal Colleges

References

“A Spoonful of sugar: medicines management in NHS hospitals” Audit Commission 2001. available at http://www.audit-commission.gov.uk/nationalstudies/health/other/Pages/aspoonfulofsugar.aspx
Dornan et al 2009. The EQUIP Study available at http://www.gmc-uk.org/FINALReport prevalence and causes of prescribing errors.pdf 28935150.pdf
New all-Wales drug chart looks set to increase patient safety. Hosp Pharm 2004; 12:185
All Wales Medicines Strategy Group: available at http://www.wales.nhs.uk/sites3/Documents/371/All%20Wales%20Prescription%20Chart%20Sep%2009.pdf
The Academy of Medical Royal Colleges. Standards for the design of hospital in-patient prescription charts http://www.aomrc.org.uk/publications/reports-guidance.html