Exploring the impact and effectiveness of prescribing error feedback in an acute hospital setting

• Main Author: Lloyd, M.
• Published: University of Liverpool 2017
• Online Access: https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.733809

Background: Prescribing errors (PEs) are prevalent and a prominent cause of patient safety incidents. Feedback has the potential to improve prescribing with pharmacists potential facilitators of PE feedback. However, evidence supporting PE feedback in a hospital setting is limited. Aims: The aims of this thesis were to explore the effectiveness and impact of feedback on prescribing, prescribing behaviour, and the feedback participants: prescribers and pharmacists. Methods: A mixed methodology was adopted. Focus groups were used to explore pharmacist experiences of delivering PE feedback prior to the intervention. A pilot study was then undertaken with prescribers on two wards receiving constructive PE feedback, and two wards continuing with existing practice. Prescribing was audited over a five-day period before delivery of PE feedback verbally, and in writing. Prescribing was re-audited after 3-months. A larger controlled study across 16 wards was then repeated. Change in PE rates were compared between groups. Semi-structured interviews were used to explore prescriber’s and pharmacist’s experiences of receiving and delivering feedback and the impact on prescribing behaviour. All interviews and focus groups were analysed thematically using a framework approach. Results: Twenty-four pharmacists were recruited to one of four focus groups. Prior to the intervention, PE feedback was delivered inconsistently. Ward-based pharmacists were considered suitable facilitators of PE feedback, but expressed concern that the process may adversely affect prescriber- pharmacist relationships. Ten and eleven prescribers were included in the pilot intervention and control groups. There was a mean reduction in overall PE rates of 11.5% in the intervention group and an increase of 5.9% in the control group, a significant change in PE rates of 17.4% (p < 0.05) between groups. Thirty-six and forty-one prescribers were included in the intervention, and control groups for the larger cohort study. PE rates reduced by 18.3% in the intervention group and increased by 5.4% in the control group, a significant change in PE rates of 23.7% (p < 0.05) between groups. Eighteen pharmacists and ten prescribers were interviewed to explore their experiences of the intervention. Feedback was valued, considered sustainable, and pharmacist’s credible facilitators. Increased information and feedback-seeking behaviours were noted from prescribers with raised discretionary efforts and prioritisation of prescribing tasks. Feedback is an educational process benefiting both facilitator and recipient. Enhanced rapport was noted with pharmacists also reporting improved self-worth and self-efficacy. Thirty-eight interviews were conducted with twenty-three prescribers to explore the impact of feedback on prescribing behaviour. Feedback is an educational process but benefits extend beyond knowledge-based improvements, with a range of adaptive prescribing behaviours reported. These included more mindful prescribing and engagement with prescribing tasks. Feedback facilitates reflection, increases self-awareness and informs self-regulation of prescribing behaviour. Prescribers reported greater situational and error awareness and improvements in their prescribing. Conclusions: PE feedback is valued, considered sustainable and positively influences prescribing. However, it is a complex intervention with potential benefits extending beyond PE reduction with pharmacists working less in parallel, and more integrated within clinical teams. Feedback supports prescribing practice with changes in prescriber behaviour resonating with non-technical prescribing skills. Feedback can develop the situational-awareness for prescribers to reflect-in-action and adapt their behaviour to the clinical environment. Contextualised inter-professional and non-technical skills training could enhance prescribing education further.