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LETTERS: Jeffrey K Aronson, David B Barnett, Robin E Ferner, Albert Ferro, Graeme Henderson, Simon R Maxwell, Michael D Rawlins, and David J Webb Poor prescribing is continual BMJ 2006; 333: 756-b [Full text]

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Evidence needed to inform debate

Professor Peter Rubin   (9 October 2006)

NPSA supports debate on safer prescribing

Richard Thomson, David Cousins   (16 October 2006)

Learning needs of established prescribers should be considered too

Neal Maskrey   (23 October 2006)

Getting postgraduate junior doctors to prescribe at all can be a “problem”-Australian experience.(Oct 2006)

Phillip J. Colquitt   (25 October 2006)

Evidence needed to inform debate 9 October 2006
Professor Peter Rubin, Chairman, GMC Education Committee NW1 3JN Send response to journal: Re: Evidence needed to inform debate	I am pleased that Aronson et al recognise the need for evidence to inform the debate over prescribing and I note that they have broadened their interest to include postgraduate education. The General Medical Council Education Committee already has a good deal of information relating to the undergraduate phase and is collecting more through its ongoing research into how well its requirements, described in Tomorrow’s Doctors, prepare new graduates for the Foundation Programme and beyond. However, there is a paucity of evidence relating to factors that could improve the quality of prescribing in later stages of a doctor’s training and career. There is a growing risk that this debate will escalate in the wider media, where the underlying issues are not widely understood, with resulting alarm to patients and the public about their safety. It is essential that this perception does not become entrenched. The GMC therefore strongly supports the value of acquiring such evidence and will convene a meeting of interested parties to take this important matter forward. Professor Peter Rubin Chairman, GMC Education Committee Competing interests: None declared
NPSA supports debate on safer prescribing 16 October 2006
Richard Thomson, Director of Epidemiology and Research National Patient Safety Agency, 4-8 Maple Street, London W1T 5HD, David Cousins Send response to journal: Re: NPSA supports debate on safer prescribing	Editor - We read with considerable interest the editorial on medical student teaching for better prescribing (1) and the subsequent letter from the authors (2) which has set a challenge to a number of agencies to consider practical measures to address the perceived problems. Aronson and colleagues suggest that there should be joint commissioning by interested parties of an independent systematic review of the evidence relevant to prescribing and its teaching and assessment of both graduates and undergraduates, and included the National Patient Safety Agency as one of the interested parties. It is indeed the case that the NPSA holds valuable data and information relevant to medication safety within its National Reporting and Learning System and has also actively contributed to the implementation of safety within both undergraduate and post graduate curricula. We would be delighted to contribute to any further discussion and debate on this issue and to share any relevant data that might help address it, including to the meeting to be convened by the GMC(3). In terms of commissioning an independent systematic review, we suggest that the Health Technology Assessment Programme of NHS R&D National Institute for Health Research could take a lead on commissioning this. Alternatively, this is a topic that could be addressed through the Campbell Collaboration(4). Professor Richard Thomson Director of Epidemiology & Research Professor David Cousins Head of Safer Medication Practice (1) Aronson JK, Henderson G,Webb DJ, Rawlins MD. A prescription for better prescribing. BMJ 2006;333:459-60 (2) Aronson JK, Barnett DB,Ferner RE, Ferro A, Henderson G, Maxwell SR, Rawlins MD, Webb DJ. Poor prescribing is continual. BMJ 2006;333:756 (3) Rubin P. Rubin P. A prescription for better prescribing. BMJ 2006;333:601 (4) http://www.campbellcollaboration.org/ Competing interests: None declared
Learning needs of established prescribers should be considered too 23 October 2006
Neal Maskrey, Director of Evidence Based Therapeutics National Prescribing Centre, 70 Pembroke Place, Liverpool. L69 3GF Send response to journal: Re: Learning needs of established prescribers should be considered too	Editor, I agree that the recent debate about the undergraduate teaching of clinical pharmacology, therapeutics, and prescribing is timely, and that the suggestion in terms of a 'stocktake' from Aronson et al is in principle worth exploring. However, the present and future learning needs of existing postgraduate prescribers, both medical and non-medical, are also in need of consideration. Whilst an evidence-based approach is now an established foundation of practice, clinicians face an information explosion, a constant battle to recognise and then minimise their own cognitive biases which may adversely affect their own perceptions of the evidence, a rapidly changing health care environment with increasingly informed patients and public and the inevitability of a finite set of health care resources. The recent publication of the GP Curriculum by the Royal College of General Practitioners may in hindsight be seen as a watershed. Is it possible to define the curriculum for clinical pharmacology, therapeutics, and prescribing at undergraduate and postgraduate level? And as a result establish a competency based approach? The National Prescribing Centre would be a willing party to discussions to establish feasibility. Yours sincerely Competing interests: None declared
Getting postgraduate junior doctors to prescribe at all can be a “problem”-Australian experience.(Oct 2006) 25 October 2006
Phillip J. Colquitt, Technician/RN Independent Comment Send response to journal: Re: Getting postgraduate junior doctors to prescribe at all can be a “problem”-Australian experience.(Oct 2006)	Cutting down on medication errors, is one of the end points(presumably) of better prescribing, yet almost impossible to achieve if nurses administering intravenous medications have to beg for scripts from doctors. Problems seemed to start a few years ago in synchrony with; the almost complete departure of consultants from wards, the change from a six year medical degree to a four year postgraduate one, and the latest version of themselves demonstrated by pharmacists, nurses, dieticians and sundry health care associates. Briefly, the RN has, several times in each shift, to call(page) the ward call(junior doctor) to prescribe things like daily dose IV Gentamicin for the infected patient, IV Heparin for the usually Warfarinised patient, oral once daily Warfarin for the previously intravenously Heparinised patient, oral Calcium supplementation for the postoperative thyroid patient, and so on. For reasons unknown junior doctors are incapable of using modern communication systems(computers/printers) to pass on/handover the names and locations of those of their patients in the above categories to other doctors. The problem seems to “worsen” as follows. Because doctors are no longer allowed to use “standing IV fluid orders” – by that I mean repeating the previous flask of fluid from the same prescription- for nil by mouth patients, they now have to be asked(paged) to “take an interest” in the what mixture of crystalloids they would like the patient to have next. And the doctors now seem willing to prescribe almost anything over the phone without actually knowing the patient.And when I ask them, they swear they are across the situation. Competing interests: None declared