The Effective Prescribing Insight for the Future (EPIFFany) project used a blended learning approach to increase prescribing competence, performance and safety behaviours of junior doctors. The components of the education included eLearning, simulation, clinical decision support and personalised teaching with feedback from pharmacists and clinicians.
The project summary video is available here: http://www.youtube.com/watch?v=5eimkmMsfVU
The problemA GMC study conducted across 19 hospitals in North-west England found there were 8.9 medication errors every 100 prescriptions made by healthcare professionals. Local data suggests the problem occurred at a similar rate in the East Midlands however the GMC study also concluded that junior doctors made twice as many prescribing errors compared to consultants, nurses or pharmacists over the 7 day period.
Medicines cost the NHS over £12.9 billion in 2011, yet avoidable harm from medication cost an extra £750 million. There are currently few effective interventions for reducing prescription errors; therefore developing one that can change the prescribing knowledge, skills and safety behaviours is a priority.
Proposed education interventionThe ‘aggregation of marginal gains ’ was used as the guiding principle for improving the prescribing competence, performance and safety behaviours through education. The education was personalised to the individual needs of each junior doctor using a developmental learning approach.
There were four components to the education delivered across a 4-month job rotation:
• A simulated ‘ward round’ at the start and end of the placement
• Face-to-face teaching in a dedicated ‘feedback clinic’ delivered by pharmacists and clinicians
• Clinical decision support made available on mobile devices
• Computer-based eLearning to practice complex problem-solving and decision-making involving medication
The effectiveness of the education for improving prescribing competence was measured by assessing the change in drug chart quality produced by junior doctors at the end of the simulations between the start and end of the rotation.
The effectiveness of the intervention for reducing prescribing errors was evaluated by comparing prescribing error rate, severity and type of error among individuals who received the education with similar data obtained from a control group of 16 junior doctors who rotated through the renal unit four-months previously.
Benefit to PatientsThere was a 50% reduction from baseline in the number of prescribing errors made after the intervention was delivered to the junior doctors. The severity of medication errors made by prescribers was also reduced with no lethal errors whilst the intervention was received by junior doctors.
The intervention taught junior doctors how to talk to patients about medication and patients noticed the difference in the way doctors in the intervention group treated them. The former chair of the local Kidney Patients Association said doctors in this group "seemed better at greeting and goodbyes" and more able to have conversations with "a beginning, a middle and an end".
Benefits to serviceePIFFany resulted in a significant increase in the prescribing competence, performance and safety behaviours of junior doctors who received the intervention.
• Performance gains among FY1 and FY2 doctors’ equivalent to gaining an extra 12-months experience. FY1 doctors who received the education were prescribing as well as FY2 doctors in the control group and FY2 doctors who received the education were prescribing as well as CT (core-training) doctors in the control group.
• Sustained confidence, enthusiasm and positive well-being in the workplace: Many doctors experience a loss of confidence and enthusiasm in their early placements and this observation was confirmed by individuals in control group. However, junior doctors who received the education remain engaged with the intervention and experienced no drop in enthusiasm about their job at the end of the rotation.
The Next Stage Review (2008) emphasises the NHS ‘will have quality at its heart’ and a reduction in medication errors would be evidence of this commitment to quality improvement . A reduction in medication errors is also a marker of effective healthcare delivery; therefore this project demonstrates commitment to clinical and quality governance through an innovative educational intervention.
A total of £48,939 was provided for the project by Health Education East Midlands, with an additional £29,367 in co-funding from NHS Midlands and East, University Hospitals of Leicester NHS Trust and an Educational Project Grant from our industry partner, Pfizer. In return, ePIFFany resulted in a potential cost avoided of £308,928 with a total of 489 bed days. ePIFFany also led to an extra 13.3 Quality Adjusted Life Years (QALY) improvement in health for patients from avoiding the harm of medications at a cost of £2739.77 per QALY.
Productivity and impactMedicines are the single largest item of healthcare spending after pay or salary costs. Medication error can also have a significant impact on staff confidence and morale. Furthermore, society bears the cost of medication errors, in terms of lost worker productivity and lower levels of population health status.
From an organisational perspective, medication errors increase the risk of litigation for clinical negligence. This theory-driven and evidence-based educational intervention may reduce some of these problems and prevent a significant proportion of errors from medicines within the East Midlands.
Dr Rakesh Patel
Title: NIHR Academic Clinical Lecturer in Medical Education/Honorary Specialist Registrar in Nephrology
Tel: 0116 252 3668