Prescribing constraints: restricting prescription of high-risk medications according to doctors' seniority

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The overwhelming majority of inpatient prescribing is
undertaken by the most junior member of the team, i.e. the intern, a
fact that has previously raised concerns about the quality of prescribing.
Currently, no legal requirements exist in Ireland regarding a
pre-determined level of seniority or expertise to be attained before
doctors are allowed to prescribe high-risk medications. Consequently,
high-risk medications may legally be prescribed by the most inexperienced
prescribers—newly qualified doctors.
To develop and implement a set of prescribing constraints in
order to reduce the risk of harmful errors arising from the prescription
of high-alert medications by junior doctors.
Materials & Methods:
A set of restrictions applicable to certain
classes of medication was compiled based on published evidence of
high-alert medications and those medications which were known to
have caused serious harm in our hospital.
Four categories of constraints were proposed for high-alert
medications according to the level of risk perceived to be associated
with certain classes of medication or specific individual agents. The
constraints for the first three categories related to the seniority of
doctor required to be involved in the prescribing process. The constraints
in relation to Category 4 (treatment doses of low molecular
weight heparins) related to details which needed to be present on the
prescription before a nurse was authorised to administer against it, i.e.
dose per kg, patient weight, and total dose required.
Discussions, Conclusion:
The challenge in developing these constraints
was in balancing the drive for optimal patient safety with the
practical demands of a major teaching hospital, i.e. the flexibility
needed to manage a patient load of high complexity and turnover, and
the promotion of an environment which facilitates junior doctors in
learning to prescribe independently. The factors identified as critical
to the successful development and implementation of the initiatives
were the high level of corporate and consultant support and the
multidisciplinary approach adopted throughout the process.

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