DEMANDA REGIONAL

There was a wide variety in terms of design and content between the 15 different NHS prescription charts examined (Appendix 3.1). Most charts used a booklet format; these ranged from six to twelve pages. All charts examined – including the ICHT chart - failed on at least one of the AoMRC standards for the design of hospital prescription charts.

A review of 40 completed prescription charts at ICHNT revealed that demographic information about the patient was generally completed to a high standard. Allergies were documented in 10 (10%) patients although the complete type of reaction was only fully completed for 3 (30%) of these. Overall, 22 of the 350 (6.3%) of the ‘regular’ medication orders and 10 of the 101 (9.9%) ‘as required’ medications reviewed were deemed illegible by the physician reviewers. In 313 (89.4%) of regular medication orders and 92 (91.1%) of as required medications, the prescriber could not be identified. Antibiotics were prescribed for 18 (45%) of the patients at some point during their inpatient stay. The indication was only documented for 21 of the 40 (52.5%) antibiotic orders prescribed and the length of course specified for only 8 (20%) of these orders (Appendix 3.2).

In our two focus groups, recurring themes included an explicit dislike across the professions for multiple different charts being used for the same patient. All professional groups felt that incomplete and barely legible medication orders were often ‘tolerated’ and that medications were

occasionally administered even if key details were missing. Doctors in the group felt that pharmacists would spot and rectify mistakes before any harm was caused. When the groups were asked for reasons underlying poor prescribing it was suggested that an important factor was that prescriptions were often completed by junior medical staff. Some prescribers commented that the format of the prescription chart made it difficult to enter all the details requested. For possible solutions, a checklist was seen as a good idea although opinions varied on what the individual components should be. It was widely agreed that more attention should also be directed at the design of the charts.

Insight gathering through the shadowing of prescribers, nursing staff and pharmacists in different clinical areas found that prescribers often appeared in a rush as they completed drug charts. Nursing and pharmacy staff were commonly observed having difficulty in identifying who was responsible for individual medication orders and then getting in touch with them with any queries.

Phase 2: Design of IDEAS prescription chart

Findings from phase 1 led to some specific design specifications for the IDEAS chart that complemented recommendations from the AoMRC report.

While some UK drug charts are in a fold-out format, it was clear from the observations that prescription charts were often used ‘on the move’ and so fold-out sections were not considered an appropriate design for the users. This was confirmed by a preference across the professional groups for a booklet format in our focus groups. All professional groups also disliked multiple and supplementary charts and the need for new charts to be written if patients stayed longer than a certain number of days. As a consequence of these findings, it was decided that the IDEAS chart would be in booklet format and be of sufficient length to avoid supplementary charts and repetitive transcriptions.

Prescription charts in use across the NHS have a range of colour schemes. The focus group explored participants’ views of different colour schemes and it was generally felt that a blue background with white boxes was ‘easiest on the eyes’. It was therefore decided that the IDEAS chart would have a blue background and white boxes leading to a ‘writing in the white’ principle.

There was no consensus among existing UK drug charts in terms of the ordering of the different sections (e.g. for regular, when required, once only medication and so on). Focus group participants across the different professional groups generally supported the use of separate sections but felt that little thought had been put into their ordering in charts they had worked with. It was decided for the IDEAS prescription chart that there should be an intuitive layout with separate sections for oxygen, anti-infectives and intravenous fluids also included. A cut out index was used so that people using the chart could quickly navigate to the relevant sections.

Mindspace interventions

A working group of clinicians, behavioural scientists and designers was established to think about how Mindspace could be applied to improving prescription chart design. It was agreed to incorporate the following element based interventions.

Salience

It is essential that certain parts of the prescription chart are completed fully and correctly and this may be achieved by increasing the salience of specific parts of the chart. One example is the completion of the allergies/sensitivities section. Clinicians are asked on prescription charts to enter both the allergy (e.g. penicillin) and the type of reaction (e.g. anaphylaxis) but often fail to do the latter. Allergy boxes on many prescription charts can make this difficult. In Figure 6.3, taken from an existing prescription chart, the prescriber is asked to enter the allergy and a description of

reaction but is given very little space to do so. The allergy box in the IDEAS chart is made more salient and encourages clinicians to enter both the allergy and the reaction type.

Many current prescription charts in use have ‘all in one’ boxes where prescribers are expected to enter a number of details together (e.g name/signature/contact number). All professional groups felt it was a good idea to provide more salient individual boxes for these details and this was incorporated across the IDEAS chart (Figure 6.4). Nursing staff and pharmacists described how they were often left to decipher unclear instructions such as the dose and units of the medications prescribed. There was general support for a system in which ambiguity was made difficult and prescribers were helped to ‘go with the flow’. It was decided that the IDEAS chart should provide clear, well spaced out data entry boxes that facilitate legible prescriptions and reduced the potential for ambiguity.

Figure 6.3: Standards for safe prescribing that completed charts were evaluated

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Figure 6.4: Individual data entry boxes in the IDEAS prescription chart

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Priming

Human behaviour is greatly influenced by subconscious cues. Prescription charts in current use tend to provide clinicians with a long list of instructions as to how they should safely prescribe and administer medications. It was evident from our focus groups that these were rarely read. In the IDEAS prescription chart, traditional information based cues have been replaced with an example of how a prescription entry should look at the start of the regular prescription section with the aim of priming subsequent prescribing behaviour (Figure 6.5).

Figure 6.5: Instructions on prescribing found on an existing chart compared to

‘priming’ instruction from the IDEAS chart that encompasses all instructions

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Defaults

It is well recognised that default settings have a powerful impact on our behaviour as people often go with the preset option (35). An area of significant concern where defaults may have an important influence is in the prescribing of anti-infectives. Once prescribed, anti-infectives can often continue for days after the optimum duration of treatment as a consequence of prescribers not actively stopping them. Excessive administration of antibiotics increases the likelihood of drug resistant infections (19). A separate section for antibiotic prescribing was incorporated into the IDEAS chart, with the default changed from one in which antibiotics continue to be given to one in which they will only be given if a clinician confirms that this is appropriate every 3 days (figure 6.6).

Figure 6.6: The anti-infective section of the IDEA chart where prescribers need to confirm every 3 days that the antibiotic should continue to be given

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Commitment devices/Prescription checklist

Checklists have a long history of use across many high risk industries and a safe surgery checklist has been successfully implemented in hospital operating rooms (20). Checklists incorporate some of the key features of commitment devices and salience to provide checks and balances for safe prescribing. In the IDEAS chart, we have placed a checklist on the front page and have restricted it to three domains to ensure it does not cause an excessive burden on those completing it (Figure 6.7). The three areas the checklist focuses on problem areas that have been identified as being endemic in hospital based prescribing. They include a failure to complete the following: (1) reaction type of any allergy (2) suggested duration and indication for antibiotic courses (3) thromboembolism risk assessment and prescription of prophylactic treatment.

Figure 6.7: The checklist found on the front of the IDEAS chart

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