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Donker EM, Spitaleri Timpone P, Brinkman DJ, Richir MC, Papaioannidou P, Likic R, Sanz EJ, Christiaens T, Costa JN, De Ponti F, Gatti M, Böttiger Y, Kramers C, Pandit R, van Agtmael MA, Tichelaar J. The European List of Key Medicines for Medical Education: A Modified Delphi Study. Clin Pharmacol Ther 2024; 115:515-524. [PMID: 38062784 DOI: 10.1002/cpt.3132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/29/2023] [Indexed: 12/28/2023]
Abstract
Rational prescribing is essential for the quality of health care. However, many final-year medical students and junior doctors lack prescribing competence to perform this task. The availability of a list of medicines that a junior doctor working in Europe should be able to independently prescribe safely and effectively without supervision could support and harmonize teaching and training in clinical pharmacology and therapeutics (CPT) in Europe. Therefore, our aim was to achieve consensus on such a list of medicines that are widely accessible in Europe. For this, we used a modified Delphi study method consisting of three parts. In part one, we created an initial list based on a literature search. In part two, a group of 64 coordinators in CPT education, selected via the Network of Teachers in Pharmacotherapy of the European Association for Clinical Pharmacology and Therapeutics, evaluated the accessibility of each medicine in his or her country, and provided a diverse group of experts willing to participate in the Delphi part. In part three, 463 experts from 24 European countries were invited to participate in a 2-round Delphi study. In total, 187 experts (40%) from 24 countries completed both rounds and evaluated 416 medicines, 98 of which were included in the final list. The top three Anatomical Therapeutic Chemical code groups were (1) cardiovascular system (n = 23), (2) anti-infective (n = 21), and (3) musculoskeletal system (n = 11). This European List of Key Medicines for Medical Education could be a starting point for country-specific lists and could be used for the training and assessment of CPT.
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Affiliation(s)
- Erik M Donker
- Unit Pharmacotherapy, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Pietro Spitaleri Timpone
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - David J Brinkman
- Unit Pharmacotherapy, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Milan C Richir
- Unit Pharmacotherapy, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paraskevi Papaioannidou
- Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Robert Likic
- Unit of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb and University of Zagreb School of Medicine, Zagreb, Croatia
| | - Emilio J Sanz
- School of Health Science, Universidad de La Laguna, and Hospital Universitario de Canarias (SCS), Santa Cruz de Tenerife, Spain
| | - Thierry Christiaens
- Unit of Clinical Pharmacology, Department of Fundamental and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - João N Costa
- Laboratory of Clinical Pharmacology and Therapeutics, University of Lisbon, Lisbon, Portugal
- Instituto de Medicina Molecular, Lisbon, Portugal
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Milo Gatti
- Pharmacology Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Ylva Böttiger
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Cornelis Kramers
- Department of Clinical Pharmacy, CWZ, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud University, Nijmegen, The Netherlands
| | - Rahul Pandit
- Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michiel A van Agtmael
- Unit Pharmacotherapy, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Jelle Tichelaar
- Unit Pharmacotherapy, Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
- Interprofessional Collaboration and Medication Safety at the Faculty of Health, Sports and Social Work, Inholland University of Applied Sciences, Amsterdam, The Netherlands
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Bennett RA, Fowler GE. Out-of-hours task allocation: implications for foundation training and practice. Future Healthc J 2022; 9:268-273. [PMID: 36561834 PMCID: PMC9761446 DOI: 10.7861/fhj.2022-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction The role of foundation year-1 (FY1) doctors during the out-of-hours (OOHs) period was explored, identifying areas to improve their training. Methods Data were retrospectively collected for 1 year of foundation training (2018-2019) from an electronic task system between 17:00 to 08:00, Monday to Sunday, in a 798-bed teaching hospital in Exeter, UK. Results Thirty-two thousand, two hundred and sixty OOHs jobs were requested with 21,816 (67.6%) assigned to FY1 doctors and the clinical site practitioner. Jobs were distributed with 12,044 (55.2%) for FY1 medicine, 5,739 (26.3%) for FY1 surgery and 4,033 (18.5%) for the clinical site practitioner. The three most common jobs requested were prescribing (31.1%), patient reviews (17.9%), and interpreting or taking bloods (11.6%). Procedural jobs accounted for 22.2% of all jobs. Prescribing and patient review jobs were further categorised into commonly encountered themes. Conclusion This study describes the nature of jobs performed by FY1 doctors working OOHs and identifies three areas to focus foundation doctor training. First, improving the preparedness of new graduates as guided by commonly identified jobs. Second, monitoring the appropriateness of performed jobs. Third, ensuring the evolving roles of allied health professionals and foundation doctors are clearly understood in relation to one another.
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Affiliation(s)
- Robert A Bennett
- ARoyal Devon University Healthcare NHS Foundation Trust, Exeter, UK,Address for correspondence: Dr Robert A Bennett, Royal Devon and Exeter Hospital (Wonford), Royal Devon University Healthcare NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK. Twitter: @George_Fowler1
| | - George E Fowler
- ARoyal Devon University Healthcare NHS Foundation Trust, Exeter, UK
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Richards GC, Sitkowski K, Heneghan C, Aronson JK. The Oxford Catalogue of Opioids: A systematic synthesis of opioid drug names and their pharmacology. Br J Clin Pharmacol 2021; 87:3790-3812. [PMID: 33608948 PMCID: PMC8518704 DOI: 10.1111/bcp.14786] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 12/03/2022] Open
Abstract
AIM The growing demand for analgesia, coupled with an increasing need to treat opioid dependence and overdose, has escalated the development of novel opioids. We aimed to quantify the number of opioid drugs developed and to catalogue them based on their pharmacology. METHODS We conducted a systematic search of seven sources in November 2020, including the WHO's Anatomical Therapeutic Classification index, the British National Formulary, the IUPHAR/BPS Guide to Pharmacology, the International Narcotics Control Board Index of Names of Narcotic Drugs, the WHO's International Nonproprietary Names MedNet service, Martindale's Extra Pharmacopoeia and the Merck Index, to include opioid drugs that targeted or had an effect or coeffect at one or more opioid receptors. We extracted chemical and nonproprietary names, drug stems, molecular formulas, molecular weights, receptor targets, actions at opioid receptors and classes based on their origins. We used descriptive statistics and calculated medians and interquartile ranges where appropriate. RESULTS We identified 233 opioid drugs and created an online resource (https://www.catalogueofopioids.net/). There were 10 unique drug stems, and "-fentanil" accounted for one-fifth (20%) of all opioids. Most of the drugs (n = 133) targeted mu-opioid receptors and the majority (n = 191) were agonists at one or more receptors. Most (82%) were synthetic opioids, followed by semisynthetic opioids (16%) and alkaloids (3%). CONCLUSION This catalogue centralizes and disseminates information that could assist researchers, prescribers and the public to improve the safe use of opioids.
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Affiliation(s)
- Georgia C. Richards
- Centre for Evidence‐Based Medicine, Nuffield Department of Primary Care Health SciencesUniversity of OxfordRadcliffe Observatory Quarter, Woodstock RoadOxfordOX2 6GGUK
| | - Konrad Sitkowski
- Oxford Medical School, John Radcliffe HospitalUniversity of OxfordOxfordOX3 9DUUK
| | - Carl Heneghan
- Centre for Evidence‐Based Medicine, Nuffield Department of Primary Care Health SciencesUniversity of OxfordRadcliffe Observatory Quarter, Woodstock RoadOxfordOX2 6GGUK
| | - Jeffrey K. Aronson
- Centre for Evidence‐Based Medicine, Nuffield Department of Primary Care Health SciencesUniversity of OxfordRadcliffe Observatory Quarter, Woodstock RoadOxfordOX2 6GGUK
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Insani WN, Whittlesea C, Alwafi H, Man KKC, Chapman S, Wei L. Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis. PLoS One 2021; 16:e0252161. [PMID: 34038474 PMCID: PMC8153435 DOI: 10.1371/journal.pone.0252161] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/11/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) represent a major cause of iatrogenic morbidity and mortality in patient care. While a substantial body of work has been undertaken to characterise ADRs in the hospital setting, the overall burden of ADRs in the primary care remains unclear. OBJECTIVES To investigate the prevalence of ADRs in the primary care setting and factors affecting the heterogeneity of the estimates. METHODS Studies were identified through searching of Medline, Embase, CINAHL and IPA databases. We included observational studies that reported information on the prevalence of ADRs in patients receiving primary care. Disease and treatment specific studies were excluded. Quality of the included studies were assessed using Smyth ADRs adapted scale. A random-effects model was used to calculate the pooled estimate. Potential source of heterogeneity, including age groups, ADRs definitions, ADRs detection methods, study setting, quality of the studies, and sample size, were investigated using sub-group analysis and meta-regression. RESULTS Thirty-three studies with a total study population of 1,568,164 individuals were included. The pooled prevalence of ADRs in the primary care setting was 8.32% (95% CI, 7.82, 8.83). The percentage of preventable ADRs ranged from 12.35-37.96%, with the pooled estimate of 22.96% (95% CI, 7.82, 38.09). Cardiovascular system drugs were the most commonly implicated medication class. Methods of ADRs detection, age group, setting, and sample size contributed significantly to the heterogeneity of the estimates. CONCLUSION ADRs constitute a significant health problem in the primary care setting. Further research should focus on examining whether ADRs affect subsequent clinical outcomes, particularly in high-risk therapeutic areas. This information may better inform strategies to reduce the burden of ADRs in the primary care setting.
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Affiliation(s)
- Widya N. Insani
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
- Department of Pharmacology and Clinical Pharmacy, Center of Excellence for Pharmaceutical Care Innovation, Padjadjaran University, Bandung, Indonesia
| | - Cate Whittlesea
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
| | - Hassan Alwafi
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
- Faculty of Medicine, Umm Al Qura University, Mecca, Saudi Arabia
| | - Kenneth K. C. Man
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
- Department of Pharmacology and Pharmacy, University of Hong Kong, Hong Kong, Hong Kong
| | - Sarah Chapman
- Department of Pharmacy and Pharmacology, University of Bath, Bath, United Kingdom
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom
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Donker E, Brinkman D, Richir M, Papaioannidou P, Likic R, Sanz EJ, Christiaens T, Costa J, De Ponti F, Gatti M, Böttiger Y, Kramers C, Garner S, Pandit R, van Agtmael M, Tichelaar J. European List of Essential Medicines for Medical Education: a protocol for a modified Delphi study. BMJ Open 2021; 11:e045635. [PMID: 33947736 PMCID: PMC8098946 DOI: 10.1136/bmjopen-2020-045635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/03/2021] [Accepted: 04/15/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Junior doctors are responsible for a substantial number of prescribing errors, and final-year medical students lack sufficient prescribing knowledge and skills just before they graduate. Various national and international projects have been initiated to reform the teaching of clinical pharmacology and therapeutics (CP&T) during undergraduate medical training. However, there is as yet no list of commonly prescribed and available medicines that European doctors should be able to independently prescribe safely and effectively without direct supervision. Such a list could form the basis for a European Prescribing Exam and would harmonise European CP&T education. Therefore, the aim of this study is to reach consensus on a list of widely prescribed medicines, available in most European countries, that European junior doctors should be able to independently prescribe safely and effectively without direct supervision: the European List of Essential Medicines for Medical Education. METHODS AND ANALYSIS This modified Delphi study will recruit European CP&T teachers (expert group). Two Delphi rounds will be carried out to enable a list to be drawn up of medicines that are available in ≥80% of European countries, which are considered standard prescribing practice, and which junior doctors should be able to prescribe safely and effectively without supervision. ETHICS AND DISSEMINATION The study has been approved by the Medical Ethics Review Committee of VU University Medical Center (no. 2020.335) and by the Ethical Review Board of the Netherlands Association for Medical Education (approved project no. NVMO-ERB 2020.4.8). The European List of Essential Medicines for Medical Education will be presented at national and international conferences and will be submitted to international peer-reviewed journals. It will also be used to develop and implement the European Prescribing Exam.
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Affiliation(s)
- Erik Donker
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - David Brinkman
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Milan Richir
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Paraskevi Papaioannidou
- Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Robert Likic
- University of Zagreb School of Medicine, Zagreb, Croatia
- Department of Internal Medicine, Unit of Clinical Pharmacology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Emilio J Sanz
- School of Health Science, Universidad de La Laguna, La Laguna, Tenerife, Spain
| | | | - João Costa
- Department of Pharmacology and Clinical Pharmacology, University of Lisbon, Lisbon, Portugal
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Ylva Böttiger
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Cornelis Kramers
- Department of Internal Medicine and Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sarah Garner
- Health Technologies and Pharmaceuticals Programme, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Rahul Pandit
- Department of Translational Neuroscience, University Medical Centre Utrecht Brain Centre, Utrecht, The Netherlands
| | - Michiel van Agtmael
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Jelle Tichelaar
- Department of Internal Medicine, Section Pharmacotherapy, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
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6
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Lin S, Hoffman R, Nabriski O, Moreinos D, Dummer PMH. Management of patients receiving novel antithrombotic treatment in endodontic practice: Review and clinical recommendations. Int Endod J 2021; 54:1754-1768. [PMID: 33894015 DOI: 10.1111/iej.13533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
Cardiovascular diseases are a major component of non-communicable diseases and death, with thrombosis constituting the most common underlying pathosis of the three major cardiovascular disorders: ischaemic heart disease (acute coronary syndrome), stroke and venous thromboembolism (VTE). The introduction of direct oral anticoagulants (DOACs) in recent years has necessitated a more complex approach to periprocedural and perioperative anticoagulation management and the need for revised management strategies and protocols. Currently, patients taking classic oral anticoagulants are advised to stop taking the drugs and have their INR values checked 72 h prior to dental surgery (e.g., apical surgery, tooth extraction, and periodontal surgery) and checked again 24 h prior to the procedure to ensure it is within the therapeutic range. However, the current incorporation of these novel DOACs in routine medical practice requires changes in the way patients are managed preoperatively in dentistry, and specifically in endodontic surgery. The methodology applied in this review included searching for relevant articles in the PubMed database using keywords listed in the Entree Terms databases. Articles published on human blood clotting mechanism, antithrombotic drugs, as well as treatment guidelines and recommendations for dentistry were retrieved. In addition, textbooks and guidelines that may not have surfaced in the online search were searched manually. The aim of this paper was to review the mechanisms of action of classic and novel antithrombotic medications and their impact on endodontic treatment and the management of local haemostasis in endodontics.
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Affiliation(s)
- Shaul Lin
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,The Israeli National Center for Trauma & Emergency Medicine Research, Gertner Institute, Tel Hashomer, Israel
| | - Ron Hoffman
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Omri Nabriski
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel
| | - Daniel Moreinos
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Paul M H Dummer
- School of Dentistry, College of Biomedical Sciences and Life Sciences, Cardiff University, Cardiff, UK
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Chiedozie C, Murphy ME, Fahey T, Moriarty F. How many medications do doctors in primary care use? An observational study of the DU90% indicator in primary care in England. BMJ Open 2021; 11:e043049. [PMID: 33653750 PMCID: PMC7929869 DOI: 10.1136/bmjopen-2020-043049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AIM To apply the drug utilisation 90% (DU90%) indicator (the number of unique drugs which makes up 90% of a doctor's prescribing) to general practitioner (GP) practices prescribing in England to examine time trends, practice-level variation, and relationships with practice characteristics, prescribing costs and low-value prescribing. STUDY DESIGN Retrospective cohort study. SETTING Primary care in England, using publicly available prescribing data available from the National Health Service (NHS) digital platform for 2013-2017. PARTICIPANTS All general practices in England (n=7620). PRIMARY AND SECONDARY OUTCOME MEASURES The DU90% was calculated on an annual basis for each practice based on medication British National Formulary codes. Low-value prescribing was defined using NHS 2017 guidance (including lidocaine plasters, liothyronine, omega-3 supplements). Descriptive statistics were generated per year on time trends and practice-level variation in the DU90%. Multilevel linear regression was used to examine the practice characteristics (relating to staff, patients and deprivation of the practice area). RESULTS Among 7620 practices, mean DU90% ranged from 130.0 to 131.0 across study years, and regarding variation between practices, there was a 1.4-fold difference between the lowest and highest 5% of practices. A range of medications were included in the DU90% of virtually all practices, including atorvastatin, levothyroxine, omeprazole, ramipril, amlodipine, simvastatin and aspirin. A higher volume of prescribing was associated with a lower DU90%, while having more patients, higher proportions of patients who are women or aged ≥45 years, higher number of GPs working in the practice and being in a more deprived area were associated with a higher DU90%. Practices in higher quintiles of DU90% had higher levels of low-priority prescribing and prescribing costs. CONCLUSION GP practices typically use 130 different medications in the bulk of their prescribing. Higher DU90% was associated with higher levels of low-priority prescribing and prescribing costs. Increasing use of personal formularies may enhance prescribing quality and reduce costs.
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Affiliation(s)
- Chiamaka Chiedozie
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Mark E Murphy
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
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Roche TR, Wetli DJ, Braun J, Kataife ED, Mileo FG, Spahn DR, Tscholl DW, Said S. Physicians' perceptions regarding acute bleeding management: an international mixed qualitative quantitative study. BMC Anesthesiol 2021; 21:43. [PMID: 33568050 PMCID: PMC7874660 DOI: 10.1186/s12871-021-01269-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background Acute bleeding is an omnipresent challenge for all physicians. Uncontrolled hemorrhage is the most common preventable cause of death after trauma worldwide. In different surgical disciplines, hemorrhage represents an independent risk factor for increased postoperative morbimortality, directly affecting patients’ outcomes. This study asked anesthesiologists about their personal perceived challenges when treating bleeding patients. Methods This investigator-initiated, prospective, international, dual-center, mixed qualitative and quantitative study interrogated anesthesiologists about what they found easy and what difficult in treating acutely bleeding patients. Following the template approach for qualitative research, we identified major and minor topics through free inductive coding and word count. In a second step, we derived ten statements from the participants’ answers. Using a field survey, we then asked the participants to rate their level of agreement with the derived statements. We analyzed the answers using one sample Wilcoxon test and the Mann-Whitney test. Results We included a total of 84 physicians in the qualitative interrogations and a different group of 42 anesthesiologists in the quantitative part. We identified 11 major topics and 19 associated subtopics. The main topics and the degree of agreement (here as agree or strongly agree) were as follows: “Complexity of the topic” (52.4% agreed to find the topic complex), “Cognitive aids” (92.9% agreed to find them helpful), “Time management” (64.3% agreed to feeling time pressure), “Human factors” (95.2% agreed that human factors are essential), “Resources” (95.2% agreed that resources are essential), “Experience” and “Low frequency of cases” (57.1% agreed to lack practice), “Diagnostic methods” (31.0% agreed that the interpretation of test results is difficult), “Anticoagulation” (85.7% agreed to it being difficult), “Treatment” (81.0% agreed to knowing the first therapeutic steps), and “Nothing”. Conclusions Anesthesiologists in two large tertiary care facilities in different parts of the world found coagulation management, especially in anticoagulated patients, complex. We identified the delayed diagnostic test results and their interpretation as challenges. Resources, treatment protocols and human factors such as team communication were perceived to facilitate management. Future studies should explore the challenges in smaller hospitals and other parts of the world and test new technologies addressing the identified difficulties. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01269-x.
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Affiliation(s)
- Tadzio R Roche
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Doreen J Wetli
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Ezequiel D Kataife
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Pres. Tte. Gral. Juan Domingo Peron 4190, C1199, Buenos Aires, Argentina
| | - Federico G Mileo
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Pres. Tte. Gral. Juan Domingo Peron 4190, C1199, Buenos Aires, Argentina
| | - Donat R Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - David W Tscholl
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Sadiq Said
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Linton KD, Murdoch-Eaton D. Twelve tips for facilitating medical students prescribing learning on clinical placement. MEDICAL TEACHER 2020; 42:1134-1139. [PMID: 32065546 DOI: 10.1080/0142159x.2020.1726309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Prescribing is a complex clinical skill requiring mastery by the end of basic medical training. Prescribing errors are common in newly qualified doctors, aligned with expressed anxiety about prescribing, particularly with high-risk medications. Learning about prescribing needs to start early in medical training, underpinned by regular opportunities for reflective practice. Authentic learning within the clinical work environment is more effective than lecture based learning and allows potential immediate feedback. Educational strategies should support prescribing learning underpinned by appropriate formative and summative assessments. Students should routinely be expected to use resources including an online formulary, sustained through tracking individual progress through use of their own personal formulary or 'p' drugs. Regular prescribing practice with embedded feedback during undergraduate training will help to ensure newly qualified doctors are more confident and competent prescribers.
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Affiliation(s)
- Kate D Linton
- Academic Unit of Medical Education, The Medical School, University of Sheffield, Sheffield, UK
| | - Deborah Murdoch-Eaton
- Academic Unit of Medical Education, The Medical School, University of Sheffield, Sheffield, UK
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Maida M, Sferrazza S, Maida C, Morreale GC, Vitello A, Longo G, Garofalo V, Sinagra E. Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature. World J Gastrointest Endosc 2020; 12:172-192. [PMID: 32843928 PMCID: PMC7415229 DOI: 10.4253/wjge.v12.i6.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/09/2020] [Accepted: 05/19/2020] [Indexed: 02/06/2023] Open
Abstract
Endoscopic procedures hold a basal risk of bleeding that depends on the type of procedure and patients' comorbidities. Moreover, they are often performed in patients taking antiplatelet and anticoagulants agents, increasing the potential risk of intraprocedural and delayed bleeding. Even if the interruption of antithrombotic therapies is undoubtful effective in reducing the risk of bleeding, the thromboembolic risk that follows their suspension should not be underestimated. Therefore, it is fundamental for each endoscopist to be aware of the bleeding risk for every procedure, in order to measure the risk-benefit ratio for each patient. Moreover, knowledge of the proper management of antithrombotic agents before endoscopy, as well as the adequate timing for their resumption is essential. This review aims to analyze current evidence from literature assessing, for each procedure, the basal risk of bleeding and the risk of bleeding in patients taking antithrombotic therapy, as well as to review the recommendation of American society for gastrointestinal endoscopy, European society of gastrointestinal endoscopy, British society of gastroenterology, Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy guidelines for the management of antithrombotic agents in urgent and elective endoscopic procedures.
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Affiliation(s)
- Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento 38123, Italy
| | - Carlo Maida
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Palermo 93100, Italy
| | | | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Giovanni Longo
- Cardiology Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Vincenzo Garofalo
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Istituto San Raffaele Giglio, Cefalù 90015, Italy
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11
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Gu N, Kim KJ, Lim CY, Lee JK, Rhee MY, Shin KH, Lee SH, Ahn S. Survey on the undergraduate curriculum in clinical pharmacology and interns' prescribing ability in South Korea. Transl Clin Pharmacol 2018; 26:128-133. [PMID: 32055562 PMCID: PMC6989231 DOI: 10.12793/tcp.2018.26.3.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 11/19/2022] Open
Abstract
Appropriate prescription writing is one of the critical medical processes affecting the quality of public health care. However, this is a complex task for newly qualified intern doctors because of its complex characteristics requiring sufficient knowledge of medications and principles of clinical pharmacology, skills of diagnosis and communication, and critical judgment. This study aims to gather data on the current status of undergraduate prescribing education in South Korea. Two surveys were administered in this study: survey A to 26 medical schools in South Korea to gather information on the status of undergraduate education in clinical pharmacology; and survey B to 244 intern doctors in large hospitals to gather their opinions regarding prescribing education and ability. In survey A, half of the responding institutions provided prescribing education via various formats of classes over two curriculums including lecture, applied practice, group discussions, computer-utilized training, and workshops. In survey B, we found that intern doctors have the least confidence when prescribing drugs for special patient populations, especially pregnant women. These intern doctors believed that a case-based practical training or group discussion class would be an effective approach to supplement their prescribing education concurrently or after the clerkship in medical schools or right before starting intern training with a core drug list. The results of the present study may help instructors in charge of prescribing education when communicating and cooperating with each other to improve undergraduate prescribing education and the quality of national medical care.
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Affiliation(s)
- Namyi Gu
- Department of Clinical Pharmacology and Therapeutics, Dongguk University College of Medicine and Ilsan Hospital, Goyang 10326, Korea
| | - Kyong-Jee Kim
- Department of Medical Education, Dongguk University College of Medicine, Goyang 10326, Korea
| | - Chi-Yeon Lim
- Department of Biostatistics, Dongguk University College of Medicine, Goyang 10326, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University College of Medicine and Ilsan Hospital, Goyang 10326, Korea
| | - Moo-Yong Rhee
- Department of Internal Medicine, Dongguk University College of Medicine and Ilsan Hospital, Goyang 10326, Korea
| | - Kwang-Hee Shin
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea
| | - Seung-Hwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
| | - Sangzin Ahn
- Department of Pharmacology, Inje University College of Medicine, Busan 47392, Korea
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12
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Audi S, Burrage DR, Lonsdale DO, Pontefract S, Coleman JJ, Hitchings AW, Baker EH. The 'top 100' drugs and classes in England: an updated 'starter formulary' for trainee prescribers. Br J Clin Pharmacol 2018; 84:2562-2571. [PMID: 29975799 DOI: 10.1111/bcp.13709] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/01/2018] [Accepted: 06/25/2018] [Indexed: 11/29/2022] Open
Abstract
AIMS Prescribing is a complex skill required of doctors and, increasingly, other healthcare professionals. Use of a personal formulary can help to develop this skill. In 2006-9, we developed a core list of the 100 most commonly prescribed drugs. Our aim in the present study was to update this 'starter formulary' to ensure its continued relevance for prescriber training. METHODS We analysed large contemporary primary and secondary care datasets to identify the most frequently prescribed medicinal products. Items were classified into natural groups, broadly following their British National Formulary classification. The resulting drug groups were included in the core list if they comprised ≥0.1% prescriptions in both settings or ≥0.2-0.3% prescriptions in one setting. Drugs from emergency guidelines that did not qualify by prescribing frequency completed the list. RESULTS Over 1 billion primary care items and approximately 1.8 million secondary care prescriptions were analysed. The updated list comprises 81 drug groups commonly prescribed in both settings; six from primary care; seven from secondary care; and six from emergency guidelines. Eighty-eight per cent of the formulary was unchanged. Notable changes include entry of newer anti-epileptics and dipeptidyl peptidase-4 inhibitors and exit of phenytoin and thiazolidinediones. CONCLUSIONS The relative stability of the core drug list over 9 years and the current update ensure that learning based on this list remains relevant to practice. Trainee prescribers may be encouraged to use this 'starter formulary' to develop a sound basis of prescribing knowledge and skills that they can subsequently apply more widely.
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Affiliation(s)
- Selma Audi
- Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London
| | - Daniel R Burrage
- Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London.,St George's University Hospitals NHS Foundation Trust
| | - Dagan O Lonsdale
- Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London.,St George's University Hospitals NHS Foundation Trust
| | - Sarah Pontefract
- Institute of Clinical Sciences, University of Birmingham.,University Hospital Birmingham NHS Foundation Trust
| | - Jamie J Coleman
- Institute of Clinical Sciences, University of Birmingham.,University Hospital Birmingham NHS Foundation Trust
| | - Andrew W Hitchings
- Clinical Pharmacology, Institute of Medical and Biomedical Education, St George's, University of London.,St George's University Hospitals NHS Foundation Trust
| | - Emma H Baker
- Clinical Pharmacology, Institute of Infection and Immunity, St George's, University of London.,St George's University Hospitals NHS Foundation Trust
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13
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06100] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundInterventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.ObjectivesThis study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.DesignThe review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.SettingPrimary and secondary care.ParticipantsNot applicable.InterventionsStudies related to antimicrobial prescribing for doctors in training.Main outcome measuresNot applicable.Data sourcesEMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.Review methodsClearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.ResultsA total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.LimitationsMost articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.ConclusionsThis review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.Future workMore work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.Study registrationThis study is registered as PROSPERO CRD42015017802.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Mark Pearson
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Simon Briscoe
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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14
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Brinkman DJ, Tichelaar J, Graaf S, Otten RHJ, Richir MC, van Agtmael MA. Do final-year medical students have sufficient prescribing competencies? A systematic literature review. Br J Clin Pharmacol 2018; 84:615-635. [PMID: 29315721 PMCID: PMC5867102 DOI: 10.1111/bcp.13491] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/19/2017] [Accepted: 11/26/2017] [Indexed: 01/12/2023] Open
Abstract
Aims Prescribing errors are an important cause of patient safety incidents and are frequently caused by junior doctors. This might be because the prescribing competence of final‐year medical students is poor as a result of inadequate clinical pharmacology and therapeutic (CPT) education. We reviewed the literature to investigate which prescribing competencies medical students should have acquired in order to prescribe safely and effectively, and whether these have been attained by the time they graduate. Methods PubMed, EMBASE and ERIC databases were searched from the earliest dates up to and including January 2017, using the terms ‘prescribing’, ‘competence’ and ‘medical students’ in combination. Articles describing or evaluating essential prescribing competencies of final‐year medical students were included. Results Twenty‐five articles describing, and 47 articles evaluating, the prescribing competencies of final‐year students were included. Although there seems to be some agreement, we found no clear consensus among CPT teachers on which prescribing competencies medical students should have when they graduate. Studies showed that students had a general lack of preparedness, self‐confidence, knowledge and skills, specifically regarding general and antimicrobial prescribing and pharmacovigilance. However, the results should be interpreted with caution, given the heterogeneity and methodological weaknesses of the included studies. Conclusions There is considerable evidence that final‐year students have insufficient competencies to prescribe safely and effectively, although there is a need for a greater consensus among CPT teachers on the required competencies. Changes in undergraduate CPT education are urgently required in order to improve the prescribing of future doctors.
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Affiliation(s)
- David J Brinkman
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research and Expertise Center in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jelle Tichelaar
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research and Expertise Center in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Sanne Graaf
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - René H J Otten
- Medical Library, Vrije Universiteit, Amsterdam, De Boelelaan 1105, 1081 HV, Amsterdam, The Netherlands
| | - Milan C Richir
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research and Expertise Center in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, section Pharmacotherapy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Research and Expertise Center in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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15
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McCrory RFR, Gormley GJ, Maxwell AP, Dornan T. Learning to prescribe intravenous fluids: A scoping review. PERSPECTIVES ON MEDICAL EDUCATION 2017; 6:369-379. [PMID: 29119469 PMCID: PMC5732109 DOI: 10.1007/s40037-017-0386-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Prescribing intravenous (IV) fluid therapy is a core skill expected of qualified doctors at the point of graduation, but medical graduates often feel ill-equipped to perform this task. This lack of preparedness contributes to treatment-related patient harm. This scoping review maps the current state of published evidence about how junior doctors prescribe IV fluid therapy and learn how to do it. METHODS We searched five electronic databases and grey literature from 1994 until June 2016 for articles describing any aspect of IV fluid prescribing practice or its education. A total of 63 articles were selected for analysis. Using the WHO Guide to Good Prescribing to categorize the extracted findings, our review focuses on prescribing IV fluids in adult generalist settings. RESULTS Most articles studied IV fluid prescribing from the perspective of the doctor. Junior clinicians struggled to conceptualize IV fluid prescribing as a 'whole task' in authentic work settings and lacked support. Educational interventions to improve IV fluid prescribing often focused on enhancing prescriber knowledge about fluid and electrolyte balance rather than execution of the prescribing task. CONCLUSIONS Our understanding of IV fluid prescribing as a holistic integrated skill is patchy, as is its performance. Current IV fluid prescribing education appears insufficient to foster safe and effective practice. For education to achieve the ultimate goal of safer prescribing in workplaces, we need a clearer understanding of how healthcare professionals prescribe IV fluids in real world practice.
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Affiliation(s)
- Richard F R McCrory
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK.
- Regional Nephrology Unit, Belfast City Hospital, Belfast, Northern Ireland, UK.
| | - Gerard Joseph Gormley
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK
| | | | - Tim Dornan
- Centre for Medical Education, Queens University Belfast, Belfast, Northern Ireland, UK
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16
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review. J Antimicrob Chemother 2017; 72:2418-2430. [PMID: 28859445 PMCID: PMC5890780 DOI: 10.1093/jac/dkx194] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/20/2017] [Accepted: 05/22/2017] [Indexed: 12/14/2022] Open
Abstract
Background Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Mark Pearson
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Peninsula Schools of Medicine & Dentistry, Plymouth University, Drake Circus Plymouth, Devon PL4 8AA, UK
| | - Simon Briscoe
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
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17
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Morgan SG, Li W, Yau B, Persaud N. Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada. CMAJ 2017; 189:E295-E302. [PMID: 28246223 DOI: 10.1503/cmaj.161082] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Canada's universal health care system does not include universal coverage of prescription drugs. We sought to estimate the effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada. METHODS We used administrative and market research data to estimate the 2015 shares of the volume and cost of prescriptions filled in the community setting that were for 117 drugs on a model list of essential medicines for Canada. We compared prices of these essential medicines in Canada with prices in the United States, Sweden and New Zealand. We estimated the cost of adding universal public drug coverage of these essential medicines based on anticipated effects on medication use and pricing. RESULTS The 117 essential medicines on the model list accounted for 44% of all prescriptions and 30% of total prescription drug expenditures in 2015. Average prices of generic essential medicines were 47% lower in the US, 60% lower in Sweden and 84% lower in New Zealand; brand-name drugs were priced 43% lower in the US. Estimated savings from universal public coverage of these essential medicines was $4.27 billion per year (range $2.72 billion to $5.83 billion; 28% reduction) for patients and private drug plan sponsors, at an incremental government cost of $1.23 billion per year (range $373 million to $1.98 billion; 11% reduction). INTERPRETATION Our analysis showed that adding universal public coverage of essential medicines to the existing public drug plans in Canada could address most of Canadians' pharmaceutical needs and save billions of dollars annually. Doing so may be a pragmatic step forward while more comprehensive pharmacare reforms are planned.
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Affiliation(s)
- Steven G Morgan
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Medicine (Li), University of Toronto, Toronto, Ont.; Faculty of Medicine (Yau), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Persaud), University of Toronto, Toronto, Ont.
| | - Winny Li
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Medicine (Li), University of Toronto, Toronto, Ont.; Faculty of Medicine (Yau), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Persaud), University of Toronto, Toronto, Ont
| | - Brandon Yau
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Medicine (Li), University of Toronto, Toronto, Ont.; Faculty of Medicine (Yau), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Persaud), University of Toronto, Toronto, Ont
| | - Nav Persaud
- School of Population and Public Health (Morgan), University of British Columbia, Vancouver, BC; Faculty of Medicine (Li), University of Toronto, Toronto, Ont.; Faculty of Medicine (Yau), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Persaud), University of Toronto, Toronto, Ont
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18
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Beaumont J, Chesterman J, Kellett M, Durey K. Gingival overgrowth: Part 1: aetiology and clinical diagnosis. Br Dent J 2017; 222:85-91. [DOI: 10.1038/sj.bdj.2017.71] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 12/30/2022]
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19
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Covvey JR, Al-Balushi A, Boyter AC, Gourlay Y. Antimicrobial-related medication safety incidents: a regional retrospective study in West of Scotland hospitals. J Hosp Infect 2015; 91:264-70. [PMID: 26233780 DOI: 10.1016/j.jhin.2015.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 05/05/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medication-related incidents are an important consideration in enhancing patient safety in hospital care. The wide use of antimicrobial therapy in this population renders these medications particularly vulnerable to errors and adverse events. AIM To analyse the characteristics of antimicrobial-related incident reports across a group of secondary care hospitals. METHODS Reports for antimicrobial-related incidents from April 2010 to December 2013 were obtained from a regional area of hospitals in National Health Service Scotland. Reports were analysed as a full set, and with subset analyses of incidents resulting in patient harm/injury and those included in a multi-variable regression adjusted by occupied bed-days and defined daily doses to better ascertain areas to target for antimicrobial safety. FINDINGS In total, 1345 incidents were reported at a crude rate of 0.98 reports/day [95% confidence interval (CI) 0.93-1.03 reports/day]. Penicillins (371 reports; 27.6%), aminoglycosides (358; 26.6%) and glycopeptides (210; 15.6%) were the most commonly involved classes of medications. Most incidents involved no injury/harm (514; 38.2%), but 72 reports (5.4%) did result in patient harm. The rehabilitation/assessment [relative rate (RR) 2.61, 95% CI 1.70-4.03] and women/childrens (RR 2.04, 95% CI 1.39-2.99) directorates had higher incident reporting rates compared with other directorates, likely as a function of at-risk patient populations. Among the types of incidents reported, those involving issues with administration/supply were most common (RR 2.07, 95% CI 1.51-2.84). CONCLUSION Incident reporting for antimicrobials identified several key areas for quality improvement in the hospital setting, which can guide safety efforts.
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Affiliation(s)
- J R Covvey
- Division of Clinical, Social and Administrative Sciences, Duquesne University, Mylan School of Pharmacy, Pittsburgh, PA, USA
| | | | - A C Boyter
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Y Gourlay
- NHS Greater Glasgow & Clyde, Gartnavel General Hospital, Glasgow, UK.
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20
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Angarita FA, Dueck AD, Azouz SM. Postoperative electrolyte management: Current practice patterns of surgeons and residents. Surgery 2015; 158:289-99. [DOI: 10.1016/j.surg.2015.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/15/2015] [Accepted: 02/28/2015] [Indexed: 10/23/2022]
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21
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Nazar H, Nazar M, Rothwell C, Portlock J, Chaytor A, Husband A. Teaching safe prescribing to medical students: perspectives in the UK. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2015; 6:279-295. [PMID: 25945072 PMCID: PMC4408958 DOI: 10.2147/amep.s56179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Prescribing is a characteristic role of a medical practitioner. On graduating from medical school, students are presumed to have acquired the necessary pharmacology knowledge underpinning the therapeutics and developed their personal skills and behaviors in order to write a safe and effective prescription (The Four Ps). However, there are reports of errors in medical prescribing and dissatisfied feedback from recent graduates, which evidence potential flaws in the current training in the practice of prescribing. We examine the Four Ps from a systems approach and offer scope for educators and curriculum designers to review and reflect on their current undergraduate teaching, learning, and assessment strategies in a similar manner. We also adopt a national framework of common competencies required of all prescribers to remain effective and safe in their area of practice as a more objective layer to the broader learning outcomes of the General Medical Council Tomorrow's Doctors 2009. This exercise demonstrates where standard, recognized competencies for safe prescribing can be accommodated pedagogically within existing medical curricula.
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Affiliation(s)
- Hamde Nazar
- School of Medicine, Pharmacy and Health, Durham University, UK
| | - Mahdi Nazar
- Cumberland Infirmary, North Cumbria University Hospitals NHS Trust, UK
| | | | - Jane Portlock
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, UK
| | - Andrew Chaytor
- School of Medicine, Pharmacy and Health, Durham University, UK
| | - Andrew Husband
- School of Medicine, Pharmacy and Health, Durham University, UK
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Rutkowski D, Keelan R, Warrander L, Steinke D. A simple flashcard: big impact for junior doctors! CLINICAL TEACHER 2014; 11:454-60. [PMID: 25212933 DOI: 10.1111/tct.12204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reducing prescribing errors is key to ensuring patient safety. Foundation-year doctors (FYs) have been found to be major contributors to prescribing errors, and often feel poorly prepared for prescribing by their undergraduate education. Numerous studies have reported these findings; however, few studies have introduced meaningful interventions. METHODS A questionnaire was sent to FY2s (n = 20) to determine the 15 most commonly prescribed medications on call. These medications and instructions were incorporated into a flashcard that was disseminated to new FY1s at a teaching hospital in the UK. The FY1s were asked to complete a pre- and post-flashcard questionnaire, giving instructions for 10 medications and their confidence in prescribing these medications. A control group at another teaching hospital were given the same questionnaires, but not the flashcard. RESULTS No significant difference in confidence was seen in FY1s at either hospital before the flashcard was issued. Both groups at week 4 demonstrated significant improvements in confidence in prescribing, with those who received the flashcard demonstrating a significantly higher level of confidence in a greater range of medications, compared with those who did not (p < 0.05). At week 4, 93 per cent of FY1s still used the flashcard 2.2 times per day, claiming that it saved time on call (9.2/10). DISCUSSION We have introduced an inexpensive and simple prescribing aid, which has been statistically shown to improve prescribing confidence in FY1s. Foundation-year doctors have been found to be major contributors to prescribing errors.
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Affiliation(s)
- David Rutkowski
- University Hospital of South Manchester, Wythenshawe, Manchester, UK
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Nwulu U, Hodson J, Thomas SK, Westwood D, Griffin C, Coleman JJ. Variation in cost of newly qualified doctors’ prescriptions: a review of data from a hospital electronic prescribing system. Postgrad Med J 2013; 89:316-22. [DOI: 10.1136/postgradmedj-2012-131334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
There is much variation in the implementation of the best available evidence into clinical practice. These gaps between evidence and practice are often a result of multiple individual decisions. When making a decision, there is so much potentially relevant information available, it is impossible to know or process it all (so called 'bounded rationality'). Usually, a limited amount of information is selected to reach a sufficiently satisfactory decision, a process known as satisficing. There are two key processes used in decision making: System 1 and System 2. System 1 involves fast, intuitive decisions; System 2 is a deliberate analytical approach, used to locate information which is not instantly recalled. Human beings unconsciously use System 1 processing whenever possible because it is quicker and requires less effort than System 2. In clinical practice, gaps between evidence and practice can occur when a clinician develops a pattern of knowledge, which is then relied on for decisions using System 1 processing, without the activation of a System 2 check against the best available evidence from high quality research. The processing of information and decision making may be influenced by a number of cognitive biases, of which the decision maker may be unaware. Interventions to encourage appropriate use of System 1 and System 2 processing have been shown to improve clinical decision making. Increased understanding of decision making processes and common sources of error should help clinical decision makers to minimize avoidable mistakes and increase the proportion of decisions that are better.
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Affiliation(s)
- Louise Bate
- National Institute for Health and Clinical Excellence, Medicines and Prescribing Centre, Liverpool, United Kingdom.
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Abstract
Preparing medical students to prescribe is a major challenge of undergraduate education. They must develop an understanding of clinical pharmacology and acquire knowledge about drugs and therapeutics, as well as the skills to prescribe for individual patients in the face of multiple variables. The task of delivering the learning required to achieve these attributes relies upon limited numbers of teachers, who have increasingly busy clinical commitments. There is evidence that training is currently insufficient to meet the demands of the workplace. e-Learning provides an opportunity to improve the learning experience. The advantages for teachers are improved distribution of learning content, ease of update, standardization and tracking of learner activities. The advantages for learners are ease of access, greater interactivity and individual choice concerning the pace and mix of learning. Important disadvantages are the considerable resource required to develop e-Learning projects and difficulties in simulating some aspects of the real world prescribing experience. Pre-requisites for developing an e-Learning programme to support prescribing include academic expertise, institutional support, learning technology services and an effective virtual learning environment. e-Learning content might range from complex interactive learning sessions through to static web pages with links. It is now possible to simulate and provide feedback on prescribing decisions and this will improve with advances in virtual reality. Other content might include a student formulary, self-assessment exercises (e.g. calculations), a glossary and an on-line library. There is some evidence for the effectiveness of e-Learning but better research is required into its potential impact on prescribing.
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Affiliation(s)
- Simon Maxwell
- Clinical Pharmacology Unit, University of Edinburgh, Western General Hospital, United Kingdom.
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Ross S, Maxwell S. Prescribing and the core curriculum for tomorrow's doctors: BPS curriculum in clinical pharmacology and prescribing for medical students. Br J Clin Pharmacol 2013; 74:644-61. [PMID: 22288524 DOI: 10.1111/j.1365-2125.2012.04186.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Prescribing is one of the commonest tasks expected of new doctors and is a complex process involving a mixture of knowledge, judgement and skills. Preparing graduates to be prescribers is one of the greatest challenges of modern undergraduate medical education and there is some evidence to suggest that training could be improved. The aims of this article are (i) to review some of the challenges of delivering effective prescribing education, (ii) to provide a clear statement of the learning outcomes in clinical pharmacology and prescribing that should be expected of all medical graduates and (iii) to describe a curriculum that might enable students to achieve these outcomes. We build on the previous curriculum recommendations of the British Pharmacological Society and take into account those of other key bodies, notably the General Medical Council. We have also reviewed relevant evidence from the literature and set our work in the context of recent trends in medical education. We divide our recommended learning objectives into four sections: principles of clinical pharmacology, essential drugs, essential therapeutic problems and prescribing skills. Although these will not necessarily be accepted universally we believe that they will help those who design and map undergraduate curricula to explore potential gaps and identify improvements.
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Affiliation(s)
- Sarah Ross
- Division of Medical and Dental Education, University of Aberdeen, UK.
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Abstract
The challenge to achieve safe prescribing merits the adjective 'titanic'. The organisational and human errors leading to poor prescribing (e.g. underprescribing, overprescribing, misprescribing or medication errors) have parallels in the organisational and human errors that led to the loss of the Titanic 100 years ago this year. Prescribing can be adversely affected by communication failures, critical conditions, complacency, corner cutting, callowness and a lack of courage of conviction, all of which were also factors leading to the Titanic tragedy. These issues need to be addressed by a commitment to excellence, the final component of the 'Seven C's'. Optimal prescribing is dependent upon close communication and collaborative working between highly trained health professionals, whose role is to ensure maximum clinical effectiveness, whilst also protecting their patients from avoidable harm. Since humans are prone to error, and the environments in which they work are imperfect, it is not surprising that medication errors are common, occurring more often during the prescribing stage than during dispensing or administration. A commitment to excellence in prescribing includes a continued focus on lifelong learning (including interprofessional learning) in pharmacology and therapeutics. This should be accompanied by improvements in the clinical working environment of prescribers, and the encouragement of a strong safety culture (including reporting of adverse incidents as well as suspected adverse drug reactions whenever appropriate). Finally, members of the clinical team must be prepared to challenge each other, when necessary, to ensure that prescribing combines the highest likelihood of benefit with the lowest potential for harm.
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Affiliation(s)
- Philip A Routledge
- Department of Pharmacology, Therapeutics and Toxicology, Institute of Molecular and Experimental Medicine, School of Medicine, Cardiff University, United Kingdom.
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Maxwell SRJ. How should teaching of undergraduates in clinical pharmacology and therapeutics be delivered and assessed? Br J Clin Pharmacol 2012; 73:893-9. [PMID: 22360965 PMCID: PMC3391515 DOI: 10.1111/j.1365-2125.2012.04232.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Clinical pharmacology and therapeutics is the academic discipline that informs rational prescribing of medicines. There is accumulating evidence that a significant minority of prescriptions in the UK National Health Service contain errors. This comes at a time when the approach to and success of undergraduate education in this area has been called into question. Various stakeholders are now in agreement that this challenging area of undergraduate education needs to be strengthened. The principles that should form the basis of future educational strategy include greater visibility of clinical pharmacology and therapeutics in the curriculum, clear learning outcomes that are consistent with national guidance, strong and enthusiastic leadership, a student formulary, opportunities to practice prescribing, a robust assessment of prescribing competencies and external quality control. Important new developments in the UK are Prescribe, a repository of e-learning materials to support education in clinical pharmacology and prescribing, and the Prescribing Skills Assessment, a national online assessment designed to allow medical students to demonstrate that they have achieved the core competencies required to begin postgraduate training.
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Affiliation(s)
- Simon R J Maxwell
- Clinical Pharmacology Unit, University of Edinburgh, Clinical Research Centre, Western General Hospital, Edinburgh EH4 2XU, UK.
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