Intended for healthcare professionals


Using drugs safely

BMJ 2002; 324 doi: (Published 20 April 2002) Cite this as: BMJ 2002;324:930

Undergraduates must be proficient in basic prescribing

  1. Simon Maxwell, senior lecturer,
  2. Tom Walley, professor,
  3. Robin E Ferner, director
  1. Clinical Pharmacology Unit, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU
  2. Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool L69 3GF
  3. West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH

    The recent Audit Commission report A Spoonful of Sugar was grim reading.1 The report suggested that nearly 1100 people died last year in England and Wales as a result of medication errors or adverse reactions to medicines and that the number had increased fivefold in just 10 years. This alarming increase may be an overestimate inflated by changes in defining and reporting causes of death and cannot all be attributed to a true deterioration in prescribing. However, studies elsewhere also hint at high rates, 2 3 although the definitions and data have been questioned.3 The Audit Commission failed to distinguish clearly between medication errors, inevitable adverse reactions, and potentially preventable adverse reactions. Since strategies for minimising each are different, we need data that tell us where problems lie.

    There are several reasons why drug errors might have risen (see box). In addition, human error is most likely when inexperienced and overworked staff, in a stressful environment, struggle with unfamiliar problems, competing tasks, and incompatible goals—which precisely characterises junior doctors in hospitals.4 Senior doctors in primary and secondary care are not excluded from such problems either.

    Some factors that could increase the rate of medication errors

    • More rapid throughput of patients

    • New drug developments, extending medicines into new areas

    • Increasing complexity of medical care

    • Increased specialisation

    • Increased use of medicines generally

    • Sicker and older patients, more vulnerable to adverse effects

    Whatever their cause and precise frequency, medication errors in primary and secondary care lead to great personal misery and injury, diminish public confidence, and are expensive and wasteful for the National Health Service.5 The Audit Commission, in part reflecting the bias of its advisory panel, sees the solution in clinical pharmacy and new information systems. The report gives no information on how effective such solutions might be in preventing the most serious errors (most studies have identified potential errors, rather than harm), nor how much they would cost—astonishing for an organisation whose primary function is to ensure that public funds are well spent.

    A concern mentioned only briefly in the report is that current undergraduate medical courses “do not provide a thorough knowledge of safe medicines prescribing and administration” for junior doctors. As well as improving systems to avoid prescribing errors, there is a pressing need to improve the training of prescribers at all levels.

    Tomorrow's Doctors from the General Medical Council6 emphasised closer integration between subjects, reduced factual burden, greater student choice, and problem based learning. This has changed undergraduate education for the better in many ways but has marginalised individual disciplines, even disciplines like clinical pharmacology and therapeutics that teach skills that all doctors require. Although the council identified the principles of therapy as a key component of any undergraduate core curriculum,6 few courses ensure that undergraduates are taught and tested on how to prescribe and give drugs safely. A firm grounding in the principles of therapeutics is essential in undergraduate education, so that tomorrow's doctors know how to weigh up the potential benefits and hazards of treatment, monitor drug effects, understand the reasons for variability in drug response, base prescribing choices on sound evidence, and keep up to date in the future.7

    Assessment drives and consolidates learning: although examination in individual disciplines is now discouraged, prescribing and administering drugs-which are central to almost all medical care—are different. Together they are essential skills for the newly qualified doctor. Proficiency could be demonstrated in many ways,8 for instance as part of an objective structured clinical examination, but students should not be able to compensate for a poor performance in this high risk clinical activity by good performances in other areas.

    Undergraduate education has to be supported by induction programmes for junior doctors that can address specific issues in each hospital and by continuing education programmes. But these can be effective only if they build on a firm foundation. We have described here education of medical students, but the same issues apply to other professions as they acquire prescribing rights within the NHS. Current programmes for training nurse prescribers (25 days of theory, and two months' supervised prescribing practice) might be looked at enviously in many medical schools.

    A report from the United States about medication errors suggests strongly that identifying competency in this key area of patient safety should be the responsibility of the professional licensing body.3 The General Medical Council is currently in consultation about a revised version of Tomorrow's Doctors. We hope that it will respond to these concerns by providing clear directions to the United Kingdom's medical schools about the need for the learning and assessment of the skills needed to use drugs safely, effectively, and cost effectively. The Audit Commission is right to worry about medication errors, but preventing them is likely to be difficult and should not concentrate on pharmacists or computers to the exclusion of those who prescribe and give drugs.


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