Improving patient safety is a priority in healthcare, and reducing prescribing errors and identifying factors that predispose risk can help to achieve this (Royal et al, 2006). While prescribing remains one of the most common interventions by the NHS, the impact of drug errors on patients, the prescriber and organisations is increasing (Barber et al, 2003). There is also a significant financial cost associated with medication errors, which is estimated to be $42 billion worldwide (Department of Health and Social Care, 2018). Furthermore, prescribing errors can result in pain or disability for the patient, or negative feelings experienced by staff such as shame, guilt and depression (Department of Health (DH), 2000).
Non-medical prescribing does have advantages for the patient, which Courtenay et al (2011) identify as being an increasingly central element of nursing practice in many clinical areas, while also making improved use of the nursing skills, knowledge and experience.
Background
Prescribing legislation in the UK is some of the most liberal worldwide (Kroezen et al, 2011), requiring robust safeguards to ensure patient safety is not compromised. Errors in prescribing are preventable, yet remain a reported cause of harm to patients (Williams, 2007) and one of the most common adverse events in healthcare (Ghaleb et al, 2006; Berdot et al, 2012). This prevalence of errors has led to an increase in morbidity and mortality (Basey et al, 2014). A root cause of these errors has been attributed to human factors with more prescribing errors occurring in the first year following qualification as a prescriber than any other (Lesar et al, 1990).
It is pertinent that this an area that should be given appropriate attention, the current focus from the World Health Organization's (WHO) (2017)Third Global Patient Safety Challenge is to reduce the global burden of iatrogenic medication-related harm by 50% within 5 years. This identifies tools for practitioners to use in managing the risks of medication error at all stages, including the act of prescribing. This can be achieved by focusing on high-risk situations, such as the role of polypharmacy and transitions of care and the impact on medicines safety.
However, initiatives such as this rely on commitment from ministers and leaders of healthcare systems that guide and develop these strategies, to ensure patient safety remains at the centre of safe and appropriate prescribing. In support of WHO, the Department of Health and Social Care commissioned a review of the evidence in this area (2018), that made a number of recommendations and identified many priorities, including development of strategies in electronic prescribing, cultural changes and better reporting systems to improve medication safety.
Medication errors are complex, with elements in some areas, such as paediatrics that predispose the population to an increased level of prescribing errors compared to adult prescribing (Wong et al, 2004; Ghaleb et al, 2010). Challenges in paediatric prescribing include calculations based on weight and body surface area, as well as the additional consideration of off-label or unlicensed medication.
Although errors can happen at all stages of prescribing (ie dispensing, administration and monitoring), most mistakes are due to poor prescribing practice (Fortescue et al, 2003; Simpson et al, 2004). By identifying where errors occur within the prescribing process, improvements in medication safety can be made by targeting resources and interventions, with the additional benefit of educational improvements within paediatric prescribing (Kaushal et al, 2001). Errors can have many contributing elements, developing a knowledge of human factors allows for an increased understanding of adverse events in prescribing and an awareness that human risk can be moderated, but not eliminated.
Human factors
There are many definitions of human factors, the Clinical Human Factors Group (2016) believed it is an enhancement of clinical performance that understands the effects of various factors including effective teamwork, type of tasks, available equipment and the workspace environment and the impact on behaviour patterns, while also acknowledging the cultural and organisational components. There are several elements that can contribute to prescribing errors, and they are not only the result of a deficit of knowledge or skills, but have many facets that combine to result in poor prescribing (Tully et al, 2009). This agrees with the human factors view that predicts how prescribers develop the safety mechanisms to function within a complex sociotechnical system (Dekker, 2003).
There are principles seen in aviation, described as black box safety, which some argue can be applied to healthcare scenarios (Kapur et al, 2015). If the fatalities that occur from prescribing errors were to happen in aviation, Sullenberger (2013) believed that airlines would stop flying. The same principles have been applied in other industries; in the UK, a safety toolkit was introduced following railway accidents. These accidents were highlighted from the public enquiries undertaken following the Southhall (2000) and Ladbroke Grove (2001) rail crashes. Key features were identified that are central to managing human factors including leadership; communication strategies; involvement of employees and the organisations; learning culture; and attitude towards blame (Health and Safety Executive, 2005), all areas that are applicable to the healthcare setting.
In the NHS, there continues to be an institutional fear of speaking out accompanied by a lack of accountability when errors occur, perpetuating the culture of blame (Francis, 2015). As Timmons et al (2015) argues, without an organisation that is accommodating to the recognition of human factors and a commitment to implementing strategies to overcome error, initiatives will fail.
Prescribing and human factors
The process of prescribing has several stages each linking in to the prescribing pyramid (Figure 1). While Huynh et al (2016) believed there is the potential for error to occur in one or more steps of the process, Butler et al (2013) is of the opinion that the highest potential for error happens during the writing of the prescription, increasing the likelihood of adverse drug events occurring.
There can be many situations that affect prescribing, such as failures in communication, conditions that are clinically critical where there is a loss of situational awareness, and complacency or corner cutting (Carthey et al, 2001). Mayo and Duncan (2004) identified that these may all contribute to lapses in judgment, where the practitioner has the right intention or idea, but executes the task incorrectly. Complacency such as this becomes more apparent in situations where seemingly experienced prescribers become overconfident and then make mistakes.
Poor staffing, fatigue or inexperience are other latent factors identified by Dornan et al (2009) that can contribute to errors. While these technical and non-technical factors may affect prescribing, an increased awareness of patient safety and errors has been used in other areas, such as in surgery, to enhance practice (Arora et al, 2008; Gordon et al, 2011). Transfer of some of these elements into prescribing practice have been used with some success. Safe prescribing relies on attention to all the areas mentioned, but some of the main components are communication and collaborative working with other members of the multidisciplinary team, such as pharmacists.
‘Without the effective reporting of incidents and prescribing errors, a false representation of error rates among prescribers is portrayed’
Pharmacists often prevent the majority of medication errors from reaching the patient. These ‘near misses’ or ‘saves’ are not always appropriately communicated or recorded. Without the effective reporting of incidents and prescribing errors, a false representation of error rates among prescribers is portrayed. Ferner et al (2011) believed that this prevents the prescriber from being fully aware of making errors and perpetuates a continuation of automatic thinking and failure to check a prescription if there was uncertainty.
Although pharmacists provide a level of safety-netting for the prescribing process, there needs to be more ownership from the individual prescriber to check their work and adopt their own safe prescribing procedures. Dean et al (2002) highlighted how some clinicians believe that the act of writing a prescription is unimportant, and they have a low self-awareness of making errors, which further perpetuates the problem if reporting is not encouraged in an organisation.
There are influences that can have an effect on a professional's responsibility to prescribe safely, such as being faced with poor role models in practice or undue pressure from peers. This may lead to irresponsible prescribing and a decreased awareness of risk, with each influencing the other. Positive role models can provide a sense of professional responsibility and lead to improved prescribing, with risk assessment strategies allowing new prescribers to demonstrate the behaviours needed. Having a heightened professional responsibility can improve situational awareness and knowledge of error. A prescriber needs a deep understanding of how their performance can be influenced or affected by context in which they work.
Communication
Failures in communication are more likely to occur in prescribing situations as distractions, and interruptions remain common in the clinical areas. For prescribing to be safe, effective communication is paramount, both between the clinical teams and the patients or carers. As prescribers do not work in isolation, there needs to be a shared organisational responsibility to promote safe practice. Episodes of poor communication or a lack of cooperation can occur frequently in the complex prescribing process. While there should be recognition of the importance of respecting the contributions of others, poor practice needs to be challenged to enable safe prescribing and provide an open culture to feedback, promoting a willingness to seek help and challenge others (Dornan et al, 2009).
There is a historically hierarchical environment in healthcare that Lyndon (2006) highlighted as creating barriers towards assertiveness. Questioning the advice or directions given by peers can be difficult, and although there needs to be acceptance of leadership, the patient's needs and safety should be kept central to the care delivered. This, at times, will involve the questioning of instructions others may give during the prescribing process.
Drug errors can stem from inaccurate information surrounding the drug or patient, as a non-medical prescriber, there is a responsibility to carry out a clinical assessment of the patient, obtaining a full and comprehensive medical history, allergies, intolerances and medication reconciliation. The pharmacological knowledge for the patient needs to be holistic, guided by the patient's pathophysiology and linked to their specific situation. From this, a diagnosis can be established and a clinical plan formulated. This includes prescribing where necessary and ensuring the prescription is appropriate (Luker et al, 1998). Patient education, side-effects and interactions with other medication, and maintaining the patient centred context all contribute to this decision-making process.
Failures in these steps can result in error, Tam et al (2005) showed how many prescribing errors can be traced to incomplete medication histories being completed at the time of hospital admission. Alongside these examples of verbal communication, poor non-verbal communication has also been recognised by Dean et al (2002) as a contributing factor in prescribing error, with a lack of agreed standards in prescription writing compounding this.
The EQUIP study (Dornan et al, 2009) stated that this was a contributing factor in prescribing errors alongside the design of the drug chart. It also demonstrated that non-medical prescribers were as safe as senior doctors in the process of prescribing. Electronic prescribing, while not universally adopted, can provide a safety net to address the inconsistencies found in standards of prescribing, but it may highlight new risks in this process, and while suitable in some areas, is not always adapted appropriately (Caldwell and Power, 2012).
Promoting good practice
Although prescribers should be individually accountable for their own actions, there are other contributing factors that lie outside of their control. There has been evidence of sources (eg written communication, medication procedures, the working environment, training and education) linked to avoidable harm and death in prescribing identified as early as the 1960s by Chapanis (1960). These remain relevant today, Dornan et al (2009) recommended five key targets towards improving the safety of prescribing. Among these were an improvement in the clinical work environment, leadership in promoting good prescribing practice, acceptable working conditions and a robust safety culture.
‘Pharmacists often prevent the majority of medication errors from reaching the patient. These ‘near misses’ or ‘saves’ are not always appropriately communicated or recorded’
Anthony et al (2010) suggested the introduction of non-interruption zones to facilitate safe prescribing, which has had some success in clinical practice. However, consideration of clinical priorities and the needs of others who feel interruptions may be justified should be taken into account. Colligan et al (2012) recommend targeted physical barriers to improve safe prescribing scenarios, with others endorse applying the idea of the ‘sterile cockpit’ to medication, where do not disturb signs or tabards are visible during medication rounds to limit the number of distractions (Federwisch et al, 2014). Interruptions have been attributed increasing prescribing errors, linking the high frequency of distractions and interruptions to reduced patient safety (Sevdalis et al, 2014).
Other studies have recommended the use of checklists to provide a form of ‘time-out’ within an established routine. Caldwell (2010) designed a consultant-led checklist and correct ward round checklist to deliver real time feedback and to direct the doctors focus on patient's prescriptions. There are examples of these being used in areas such as surgery and infection control (WHO, 2008; Haynes et al 2015); however, Clay-Williams and Colligan (2015) argued that having an over-reliance on checklists could distract from the implementation of other forms of safety improvement.
Education
Lesar (2002) identified how, when decisions regarding prescribing are formulated, prescribers can be reliant on behaviours that have become routine instead of using knowledge that is based in evidence and research. Although the experience of prescribing can often be best gained by practice, using memory alone to recall drug doses is not considered to be a reliable method and has the potential to cause harm. Woods (2001) further believed that doses should be looked up to ensure accuracy rather than committing them to memory and risking error.
Demonstrating an enhanced knowledge of medications contributes to the reduction of the risk of prescribing errors (Aronson, 2006). The Nursing and Midwifery Council (NMC) standard 36 also acknowledges that possessing knowledge in the management of adverse drug events, adverse drug reactions, prescribing and administration errors and the potential repercussions for safety is a requirement for safe practice (NMC, 2010). This follows the guidance in the NMC Code (2018) that has the requirements for professionals to maintain the knowledge and skills required to demonstrate safe and effective practice. It is recommended that to reach this goal there is a need for ongoing professional development in the areas of pharmacology and therapeutics alongside improvements in the working environment and a positive safety culture in the organisation that demonstrates reductions in cases of poor prescribing. Support for prescribers can be supplemented by guidelines, both local and national, and these should be readily available. This does not remove the need for a strong foundation in pharmacology, which is needed to demonstrate a commitment to deliver the highest standards of prescribing behaviour (Avery et al, 2013).
Conclusion
Skills are needed to enable safe prescribing and increased responsibility surrounding medication errors from all members of the healthcare team to appropriately address the impact of human factors (Coombes et al, 2007). This requires the development of an environment where prescribing errors are discussed constructively, and learning undertaken at all levels (Dean et al, 2002). By demonstrating a heightened awareness of error and being able to reflect on negative behaviours and the subsequent impact this may have provides guidance on how non-medical prescribers can alter their practice. The non-medical prescribing preparation, which provides the foundations in learning and teaching, leading to clinical and academic assessment supported by an appropriate medical practitioner with experience in this area and evidenced in a reflective learning in practice portfolio enables evidence of this continued commitment to development in the clinical area.
Key Points
- Medication errors are common
- Procedures can be implemented to lessen the chances of errors occurring
- Changes need to made at an organisational level to support staff to improve safety and lessen the negative impact human factors can have on prescribing practice
CPD reflective questions
- How can you support your organisation to embed human factors awareness?
- Reflect on a time when your prescribing practice has been affected by human factors. What did you learn from it?
- How do human factors apply to your prescribing practice, what could you do to be more aware of these and improve the safety of your patient population?