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Redesigning hospital prescription charts to reduce prescribing errors

10th Dec 2014

Research supported by the Behavioural Insights Team has demonstrated how prescribing behaviour can be significantly improved by making simple changes to prescription charts used in NHS hospitals.

Below is a guest blog, written by Dom King, a good friend of BIT, co-author of MINDSPACE and the lead researcher on this project. The full paper is available online here

The prescription and administration of medications is the most common therapeutic intervention in the NHS. But all too often problems in the process occur that have the potential to lead to serious harm. Medication errors are common with more than 1 in every 15 of all medications prescribed in UK hospitals containing some type of error. Because most patients using NHS hospitals are taking more than one medication, it is estimated that half of all NHS inpatients will be exposed to a prescribing error during a hospital stay. Problems may include a patient being prescribed an antibiotic that they are known to be allergic to or illegibility in the prescription that can lead a nurse giving the wrong medication or dose. Fortunately most errors are picked up before actual harm occurs but substantial costs and consequences do result from prescribing behaviours across the NHS.

The Behavioural Insights Team has supported a recent programme of work undertaken at Imperial College London, in collaboration with Imperial College Healthcare NHS Trust, looking at the prescribing process from a unique perspective. Whilst most prescriptions in primary care take place electronically, the vast majority of prescribing in NHS hospitals still takes place using paper prescription charts. Efforts to improve prescribing amongst hospital doctors have tended to focus on education and training initiatives. However, these have often failed to demonstrate significant improvements in prescribing. The IDEAS project (Imperial Drug Chart Evaluation and Adoption Study) focused instead on the charts used to make prescriptions to investigate whether changes in the choice architecture (the design and content) of prescription charts could improve prescribing decisions.

The aim of IDEAS was to redesign the paper prescription chart by incorporating behavioural insights gained from research undertaken. A multidisciplinary team of physicians, pharmacists, nurses, behavioural scientists and designers conducted background research including reviews of existing charts in use through the NHS, focus groups with key stakeholders and structured observations of the prescribing process across an NHS hospital. Designers from the HELIX Centre at Imperial College London translated insights into the design of a newly designed IDEAS prescription chart. A number of ‘nudges’ towards better and safer prescribing are incorporated into the new chart:

  • Default settings are used to make sure medications and particularly antibiotics are given for the optimal duration
  • Important information boxes that are often incompletely filled in have been made more salient to prescribers
  • Prescribers are primed into more legible prescribing by replacing information based cues with an example of how a prescription should be written
  • A short checklist is used to ensure that prescribers carry out important tasks that are often forgotten about (e.g. documenting the type of reaction someone with an allergy has

The IDEAS chart has been tested through an in-situ simulation at St Mary’s Hospital in London. Junior doctors going about their normal activities were asked to prescribe a number of medications using a simulated patient case study. Half of participants filled in an existing chart whilst the other half used the new IDEAS chart. There were striking improvements in prescribing using the IDEAS chart. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber’s printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001).

The IDEAS chart can be seen here and the research has just been published in the journal BMJ Open. NHS Trusts and other health organisations are of course welcome to use the new chart design.