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Randomized Controlled Trial
. 2018 Jul 19;19(1):120.
doi: 10.1186/s12875-018-0808-4.

The impact of a prescription review and prescriber feedback system on prescribing practices in primary care clinics: a cluster randomised trial

Wei Yin Lim  1 , Amar Singh Hss  2   3 , Li Meng Ng  4 , Selva Rani John Jasudass  5 , Sondi Sararaks  6 , Paranthaman Vengadasalam  7 , Lina Hashim  2 , Ranjit Kaur Praim Singh  8
Affiliations
Randomized Controlled Trial

The impact of a prescription review and prescriber feedback system on prescribing practices in primary care clinics: a cluster randomised trial

Wei Yin Lim et al. BMC Fam Pract. .

Abstract

Background: To evaluate the effectiveness of a structured prescription review and prescriber feedback program in reducing prescribing errors in government primary care clinics within an administrative region in Malaysia.

Methods: This was a three group, pragmatic, cluster randomised trial. In phase 1, we randomised 51 clinics to a full intervention group (prescription review and league tables plus authorised feedback letter), a partial intervention group (prescription review and league tables), and a control group (prescription review only). Prescribers in these clinics were the target of our intervention. Prescription reviews were performed by pharmacists; 20 handwritten prescriptions per prescriber were consecutively screened on a random day each month, and errors identified were recorded in a standardised data collection form. Prescribing performance feedback was conducted at the completion of each prescription review cycle. League tables benchmark prescribing errors across clinics and individual prescribers, while the authorised feedback letter detailed prescribing performance based on a rating scale. In phase 2, all clinics received the full intervention. Pharmacists were trained on data collection, and all data were audited by researchers as an implementation fidelity strategy. The primary outcome, percentage of prescriptions with at least one error, was displayed in p-charts to enable group comparison.

Results: A total of 32,200 prescriptions were reviewed. In the full intervention group, error reduction occurred gradually and was sustained throughout the 8-month study period. The process mean error rate of 40.7% (95% CI 27.4, 29.5%) in phase 1 reduced to 28.4% (95% CI 27.4, 29.5%) in phase 2. In the partial intervention group, error reduction was not well sustained and showed a seasonal pattern with larger process variability. The phase 1 error rate averaging 57.9% (95% CI 56.5, 59.3%) reduced to 44.8% (95% CI 43.3, 46.4%) in phase 2. There was no evidence of improvement in the control group, with phase 1 and phase 2 error rates averaging 41.1% (95% CI 39.6, 42.6%) and 39.3% (95% CI 37.8, 40.9%) respectively.

Conclusions: The rate of prescribing errors in primary care settings is high, and routine prescriber feedback comprising league tables and a feedback letter can effectively reduce prescribing errors.

Trial registration: National Medical Research Register: NMRR-12-108-11,289 (5th March 2012).

Keywords: Feedback; League tables; P-chart; Prescribers; Prescribing errors; Prescription review; Primary care; Statistical process control chart.

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Conflict of interest statement

Ethics approval and consent to participate

The study had waiver of informed consent from the Medical Research & Ethics Committee (MREC), Ministry of Health Malaysia ((2) dlm.KKM/NIHSEC/08/0804/P12–186) as data in the study were routinely collected prescription data and identifying information was not disclosed. This cluster randomised trial was not registered with the International Clinical Trials Registry as the purpose of this trial was to examine the effect of the intervention only on the prescribers (healthcare providers) and not patients, in compliance with the International Committee of Medical Journal Editors (ICMJE) guidelines on clinical trial registration. The trial is registered with the National Medical Research Registry (NMRR-12-108-11,289), Ministry of Health Malaysia as per guidelines of the MREC.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Summary of trial methodology flow chart
Fig. 2
Fig. 2
Prescriptions screened and prescribers evaluated in each study group
Fig. 3
Fig. 3
p-charts illustrating the percentage of prescriptions with error over the 8-month study period. The line with data markers represents the percentage of prescriptions with error at each time point. The central line corresponds to the process mean (average percentage of prescriptions with errors). The control limits (dotted lines) were calculated based on a normal approximation of the binomial distribution, and positioned at a distance of three standard deviations (SD) around the central line. The upper control limit was calculated by adding three times the SD to the process mean. The lower control limit was calculated by subtracting three times the SD from the process mean. The control limits for each time point was calculated based on its specific sample size (number of prescriptions), and drawn in stair-steps to reflect the changes in sample size over time. Data points within the control limits suggest common-cause variation, and data points outside the control limits suggest special-cause variation. There was a delay in the delivery of prescribing performance feedback in September and November 2012. Prescribing performance feedback reports for September 2012 and November 2012 were delivered together with the reports for October 2012 and December 2012, respectively
Fig. 4
Fig. 4
Line graphs comparing the percentage of prescriptions with error between study groups. The lines with data markers represent the percentage of prescriptions with drug error (a), information error (b), and administrative error (c) at each time point. Error bars indicate 95% confidence intervals
See this image and copyright information in PMC

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