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Q: I need references about hospital pharmacists teaching doctors prescribing skills ( Answered 4 out of 5 stars,   0 Comments )
Subject: I need references about hospital pharmacists teaching doctors prescribing skills
Category: Reference, Education and News > Teaching and Research
Asked by: dani2000-ga
List Price: $100.00
Posted: 08 Feb 2004 01:40 PST
Expires: 09 Mar 2004 01:40 PST
Question ID: 304638
Dear researchers,

I am a clinical pharmacist and I am about to undertake an MSc project
re: hospital pharmacists teaching junior doctors prescribing skills.
As you well know, unlike in the US junior doctors ("interns"?)in the
UK are required to prescribe, but unfortunately this is one of the
main reasons for medication errors. The aim of my project is trying to
evaluate whether the contribution of a pharmacist at each stage of
prescribing would reduce/prevent such errors.

Is there any literature available all over the world? Can I have some relevant 
references/bibliography/links regarding the subject?


Daniela Webbe
Subject: Re: I need references about hospital pharmacists teaching doctors prescribing skills
Answered By: nancylynn-ga on 09 Feb 2004 22:05 PST
Rated:4 out of 5 stars
Hello Daniela:

There is no question that junior doctors (or "interns" or "residents"
here in the USA) benefit from the guidance of, and interaction with,

Virtually all of the sources I cited for you have footnotes which will
lead you to even more resources. Just take care to look at the bottom
of the page for each online article I've cited, and you'll almost
always see a bibliography.

I've also found some abstracts from medical journals, such as "The
Pharmaceutical Journal" and "The British Medical Journal." While you
may not  be able to read the articles in full online, these journals
are likely to be archived in your school's library, and I've taken
care to provide you with the issue dates and volume numbers for the
journals I've cited.

I've divided these references into general background;
suggestions/ideas for improving prescribing skills; examples and case
studies of clinical pharmacists working closely with doctors/junior
doctors; curricula models, and an extensive bibliography/reference

Also, some of the studies I found pertained to pharmacists working
with fully licensed doctors (not medical students or "junior
doctors"), but the principle remains the same: patients benefit when
pharmacists and doctors use a team approach.


The article "Comment: Time to review prescribing in hospitals by
preregistration house officers," by Keith Farrar, from the
Pharmaceutical Journal (Vol 268 No 7183 p136, 2 February 2002):
"Estimates of prescribing errors are difficult to make but a series of
studies in the United States and Australia has estimated that the
medication error rate is between 5 and 17 per cent. . . . The risk is
often greater when the doctor in training is working outside of
"office hours" with minimal support from peers or other clinical
support staff. . . ."

"Anecdotal reports suggest that interventions by pharmacists increase
during August and February as junior doctors either join the hospital
or change discipline and are required to take on the burden of
prescribing. The, perhaps subjective, feeling of many pharmacy and
nursing staff is that the majority of doctors in training learn about
therapeutics and prescribing by doing it."
Long before the infamous "Spoonful of Sugar" report was released, the
April 11,1998 British Medical Journal published "Framework for
analysing risk and safety in clinical medicine":

This article is an overview of "incidents in which a patient is
unintentionally harmed by medical treatment."

"Adverse events usually originate in a variety of systemic features
operating at different levels the task, the team, the work
environment, and the organisation. We present a framework that aims to
encompass the many factors influencing clinical practice. It can be
used to guide the investigation of incidents, to generate ways of
assessing risk, and to focus research on the causes and prevention of
adverse outcomes."

Among the factors the article weighs: "The confidence and assurance of
staff may be of considerable importance, especially where junior staff
are concerned; risk is attached to being nervous and unsure, and also
to being
overconfident and arrogantly self assured."

The article goes on to stress the importance of team work:
"Verbal communication
 Communication between junior and senior staff
Communication between professions
Communication between specialties and departments Adequate handover"

"A Survey of Junior Doctors' Attitudes Toward Pharmacists and How
Their Interactions Can Be Improved," published in the Feb. 1, 2003
issue (Vol: 270) of The Pharmaceutical Journal:

This survey found that junior doctors are very amenable to more
interaction with, and supervision by, pharmacists. Still, there were
some caste system conflicts: " . . . some [junior doctors] believed
that pharmacists challenged their authority."

But, overall, interns made clear they rely on pharmacists monitoring
their prescriptions, and would appreciate more training time and
interaction with pharmacists. One junior doctor told the authors of
the study that pharmacists should even join junior doctors on ward

The study recommends that "newly qualified doctors undertake formal
prescribing training similar" to programs pharmacy students are
required to take.


The April 2002 "Science Blog" has an abstract from "The Lancet" of the
article "Junior doctors need training to reduce prescribing errors":
"Bryony Dean and colleagues from the School of Pharmacy, University of
London . . . . interviewed staff who made 44 potentially serious
prescribing errors identified by hospital pharmacists, and analysed
their findings with human-error theory.

"Bryony Dean comments: 'To reduce prescribing errors, hospitals should
train junior doctors in the principles of drug dosing before they
start prescribing, and enforce good practice in documentation. They
should also create a culture in which prescription writing is seen as
important, and formally review interventions made by pharmacists,
locum arrangements, and the workload of junior doctors, and make
doctors aware of situations in which they are likely to commit
errors.' "

The Feb, 2 2002 issue of "The Pharmaceutical Journal" (Vol 268 No 7183 p136,
2 February 2002) includes Clare Bellingham's article "How pharmacists
can help to reduce new junior doctors' prescribing errors":

"A strong suspicion exists that rates of medication errors increase in
February and August: the times that junior doctors begin new jobs.
However, there is a lack of data to prove this. Pharmacists tend to
agree that they make more interventions in these months than at other
times of the year, but again there are no hard data to demonstrate it.
. . .

"Pharmacists are trained to spot prescribing errors and so prevent
patients receiving the wrong medication. But is there more they can
do? And how else can errors be prevented? The introduction of clinical
governance means that health care professionals can no longer ignore
the existence of prescribing errors but need to find ways to prevent
them from happening . . . .

"So what roles can pharmacists play in preventing errors? Dr Lannigan
says that pharmacists should be involved in:

*Education of staff
*Working as part of the team to influence the quality of prescribing
*Policy writing to set up systems to ensure safe use of medicines
*Monitoring and auditing of prescribing

Professor Walley identifies ward pharmacists as having an important
role in error prevention. 'Ward pharmacists are key. They provide the
continuity that junior doctors need and are a resource of
information.' He adds: 'We need more ward pharmacists. The role of the
ward pharmacist should not be seen as a service role but rather as an
educational role for both doctors and nurses . . . .'

" 'It would be ideal if it happened at an undergraduate level but
schools of pharmacy and medicine are often not located close together.
Therefore, a better time might be at the induction of house officers.'

See a report from an international conference: "Challenges Of Rational
Drug Use In Hospitals":

If you have Power Point you can read that report at this link: 

"Pharmaceutical Journal Online" has this article "Improving
prescribing practice needs culture change" at:
Click on "(more)" to bring up:,2,3,4,10&journalcode=qhc
At upper right, click "Full Text of this Article." 

Find out how to order this issue of volume 4 of "Education For Primary Care," at:
That issue contains the article "The educational challange of
improving prescribing," by Tom Walley and John Bligh.

Article summary: "Changing prescribing habits is a complex activity
which requires a carefully planned and integrated educational

The May 2002 issue (vol: 256) of "Medicine Digest," from North West
Medical Services Information (UKMI), contains this recommendation:
"The authors recommend that hospitals should train doctors in the
principles of drug dosing before they start prescribing and enforce
good practice in documentation in order to reduce prescribing errors.
They should also create a culture in which prescription writing is
seen as important. Formal review of interventions made by pharmacists,
the workload of junior doctors, and bringing to the attention of
doctors situations in which they are likely to make errors should also
be considered.


New Zealand's Otago Board of Health is utilizing a new computer
program, MedChart, to reduce errors. But just as key, pharmacists are
now more involved in drug management.

See this (undated) article "Electronic Prescribing System -- Otago
District Health Board," from "Ministry of Health" magazine:

" . . . junior doctors (who actually do the electronic prescribing)
are the key to the project's success. They are often computer literate
and willing to make changes in their work practices.

"Dunedin hospital's information services staff provided a very high
level of support to the junior doctors until they built up confidence.
Initially they prescribed electronically for one patient only. As they
gained confidence and increased their speed in prescribing they could
increase the number of patients . . . . The drugs available for
prescribing can be modified at any time by the hospital pharmacist."

Results from "The Physician and Pharmacist Team" study (I'm not sure
where the study was conducted) were reported in the "Journal of
General Internal Medicine" (Volume 12 Issue 3; March 1997).

You can see an abstract from the study at Blackwell Publishing's Synergy site:

The purpose of the study was to "assess the effect of a program that
encourages teamwork between physicians and pharmacists on attempts to
lower total cholesterol levels and to meet recommended goals proposed
by the National Cholesterol Education Program (NCEP). . . .

"Equal numbers of patients were randomly assigned to a control arm in
which standard medical care was received and an intervention arm which
implemented close interaction between physicians and pharmacists. . .
. The rate of success in achieving NCEP goals in the intervention arm
was double the rate in the control arm (43% vs 21%, p< .05)."

Obviously, the team work's excellent results in this trial suggest
such a setup can be applied to any manner of illnesses and
corresponding treatments.

I can't find the full article online, but you may want to check for
this issue at your school's archives.

Another trial case study:

"Effect of an Educational Program on the Treatment of RSV
Lower-Respiratory-Tract Infection," from The American Journal of
Health-System Pharmacy by Kevin Purcel and Jaime Fergie (Posted
05/08/2003 on
" . . . educational programs targeting physicians have been effective
in changing physician prescribing habits and improving rational drug
therapy, especially those using face-to-face personal educational
visits with pharmacist or physician experts (academic detailing). . .
." (To read the remainder of the article, you can register at Medscape
-- it's free.)

"Medical residents, interns benefit from easy access to physicians and
pharmacists" from Seton Net's "Good Health," July/Aug/Sept 2003 issue:
This profile of Emily Sandbach, MD, who is doing her residency at
Brackenridge Hospital in Texas, also details how Brackenridge's team
approach helps doctors -- and their patients.

"Dr. Sandbach explains that because each and every patient has a
unique set of circumstances and body makeup, there is no set formula
for the best course of drug treatment for an individual. 'That is why
it is so valuable to have pharmacists rounding with us while we see
patients. Each patient is unique. Many have several medical problems
affecting different organ systems and many are already on multiple
medications, each with different mechanisms of action and side
effects. The clinical pharmacist's knowledge of the intricacies of
medicines, interactions and side effects in a particular patient is
precious information.' "

Also read "Team approach in hospital takes mystery out of medicine,"
the companion article from that same issue. This feature focuses on
Brackenridge's pharmacists:

See an abstract "A Drug Utilisation Review At A Psychiatric Hospital," at:

Among the recommendations: "To establish a team approach between the
pharmacists and the psychiatrists to achieve more rational and
effective drug use."

" . . . junior doctors say that standardisation of treatment would
make them feel more confident in difficult situations. The
participants said they preferred having guidelines for particular
disorders and side-effects as shown in Table 1 (in this case, three of
the respondents failed to rank in order of preference ticking only one
of the options). . . ."

You may also want to look up the March/April 2002 issue of "Dialogue,"
published by the College Of Physicians & Surgeons of Ontario. That
includes an article on the school's "Prescribing Skills Course." 

The University of Manchester's "Research and Development site:

At left, click on "16 Central Manchester & Manchester Children's,"
which corresponds to "Improvement of safe and effective prescribing
skills for health professionals." That will bring up this very brief

"The project is intended to address the education and training needs
around safe and effective prescribing by the multi-professional team,
in order to improve the quality of prescribing and consequently the
quality of care given to patients who are prescribed with medicines.

It may be worth contacting the university for more information on this
research project:
University of Manchester
Gateway House, Piccadilly South
Manchester M60 7LP, UK
Telephone: + 44 (0) 161 237 2045  


From the April 20, 2002, of the "British Medical Journal" comes this
editorial written by Simon Maxwell, and the aforementioned Tom Walley
(who appears to be contradicting what he told "The Pharmaceutical
Journal"), and Robin E. Ferner:

"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. . . .

"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."


On February 4, 2002, The University of Georgetown Medical Center
Released this statement:

"Although studies have reported that adverse drug reactions may cause
more than 100,000 deaths annually in the United States, only a small
percentage of the curriculum at many medical schools is dedicated to
recognizing and reporting adverse drug reactions, according to a study
conducted at Georgetown University Medical Center and published in the
current issue of 'Clinical Pharmacology & Therapeutics.'

"The study also found that residents?newly minted physicians in
specialty training?receive only a modest amount of education in this
area. 'The lack of time dedicated to clinical pharmacology and adverse
drug reactions curriculum seems out of proportion to their importance
to society and health care,' the study noted."

So, like their British counterparts, American medical authorities and
institutions have also been tackling the issue of reducing
prescription errors.

Here are some examples of U.S. programs designed to increase
interaction between pharmacists and medical students:

"Curriculum for MUSC [Medical University of South Carolina] General
Medicine Inpatient Rotation"

"The GEM team consists of a PGY 2 or 3 resident, two PGY1 residents, a
4th year medical student, two 3rd year medical students, and the
attending physician.  Discharge planners and clinical pharmacists
round with the team as well. The upper level resident directly
supervises the interns and the medical students.  The upper level
resident leads rounds and helps formulate the care plan.  The interns
perform the H and P, writes progress notes and writes orders under the
upper level residents' supervision.  All patient care encounters are
directly supervised by the attending physician. "

"The Interprofessional Curriculum To Improve Patient Safety,"
established by the University of Colorado Health Sciences Center, has
developed a team approach to treating patients:

"The proposal is to improve patient safety in primary and long-term
care by targeting the current generation of healthcare professionals
at the graduate level with a new way of thinking about patient care

According to Marie Miller, RN, PhD, Director of the Colorado AHEC
System: " 'This proposal would heighten awareness of potential
problems by teaching medicine and nursing students to work
collaboratively from the very beginning . . . 'These students will
build the skills needed to think critically, define patient safety
problems and intervene long before they can adversely affect the

"Those patient safety problems run the gamut from falling injuries to
faulty prescription dosing. The hope is healthcare providers will
become part of a collaborative approach to patient care and bridge the
separate practice cultures of medicine and nursing by expanding the
number of professionals in both disciplines who are trained to work in

The University of California at San Diego is now integrating medical
and pharmaceutical students in several courses and programs:
" Illustrating the interdisciplinary culture, UCSD pharmacy and
medical students will develop a foundation in the biomedical sciences
in common classes and shared volunteer community clinical


The National Patient Safety Foundation (in Chicago) has great
bibliography & abstract resources:

Just type in "prescribing errors" or "prescribing skills" or another
applicable search term. That will bring up abstracts with information
on which journal they appeared in and that journal's volume
number/publication date.

Some of the abstracts I found by clicking "bibliography" and typing in
my search terms, include:

"Dean B, Schachter M, Vincent C, Barber N. 'Causes of prescribing
errors in hospital inpatients: a prospective study.' Lancet. 2002;
359:1373-1378. This study at a teaching hospital focuses on the errors
made in prescribing medications . . .  ."

"Scobie SD, Lawson M, Cavell G, Taylor K, Jackson SH, Roberts TE.
Meeting the challenge of prescribing and administering medicines
safely: structured teaching and assessment for final year medical
students. Med Educ. 2003;37(6):434-437.
This structured teaching program involved five practical teaching
stations covering seven skills. This produced an overall improvement
in performance and identified skills for which a single session is
necessary and those for which additional practice is needed."

Or you can go their MED page ("articles that discuss adverse drug
events and pharmaceutical care issues":
and search from there.

NPSF also has an extensive list of, and links to, medical journals, at: 

The site can be a little confusing. You might want to read the "Search Help" page:
You can search for abstract ("bibliography"), or click "the entire
site," then type in your search terms; that will bring up abstracts
and corresponding URLs.

I was also able to find valuable conference syllabuses (or is it
syllabi?!) at NPSF's "Publications" page:

There, I scrolled down through conferences and found Enhancing Patient
Safety and Reducing Errors in Health Care Conference Proceedings
November 8-10, 1998. I then clicked the link "1998 conference site".
That brought up the main page from that conference:
At left I clicked "Conference Syllabus," which brought up this page:

You can then choose whether to read the syllabus in Word, WordPerfect,
or RTF formats. If a syllabus's highlights intrigue you enough, you
click "Conference Audio Tapes" (in menu at left) to order the tape of
that lecture. Most audio tapes range from $10-15.

You may be interested in this article in which clinical pharmacology
is pushed to a new level:

"Hospital pharmacist prescribing: a pilot study," by Sheila Woolfrey,
PhD, MRPharmS, Catherine Dean, BSc, MRPharmS, and Helen Hall, MSc, RN,
from the Pharmaceutical Journal Vol 265, No 7, July 15, 2000:

"Potential problems with drug therapy are identified from examination
of the drug Kardex, patient's notes and discussion with nursing staff,
the patient or a relative. Discussion with the appropriate junior
doctor takes place and it is the junior doctor's responsibility to
amend the drug Kardex. Unfortunately, this does not always occur and
so the patient does not always receive the optimal therapy. The junior
doctors are not on site all the time, which has resulted in delays in
optimising patients' therapy.

"We have developed a model whereby medical staff and pharmacists
worked in partnership to improve patient care. . . .

"Junior medical staff Interviews were particularly valuable as all the
junior doctors had worked on other wards as well as the study wards,
and were ideally placed to comment on the difference. This entire
group felt that there was more discussion and interaction between the
pharmacist and the doctor on the study wards. . . .The study was felt
to have been excellent and useful, and made for teamwork,
communication and education."

The Flip Side:

Some American pharmacology schools are now requiring that their
students complete a one-year residency program in hospitals:

"A new residency program at the University of Rochester [NY] Medical
Center and Strong Memorial Hospital will better prepare pharmacists
for the complexities of providing drug therapy to hospital patients. .
. .'Once they?ve completed a residency, pharmacists are better
qualified to interact with patients and play a more vital role on the
patient care team . . .'"

Search Strings:

"teaching prescribing skills"
" 'junior doctors' AND effect AND pharmacist AND supervising"
"interns AND pharmacists"
"pharmacists train interns"
"interns AND 'prescription errors' "
"doctors AND pharmacists AND "prescription errors"
" 'reducing prescription errors' AND interns"
"reducing prescription errors by junior doctors"
"pharmacists teach interns OR residents"
"pharmacists AND interns AND mistakes"
"hospital pharmacists teach interns"
"hospital pharmacists teach junior doctors [or "medical interns"]"
"prescription drug training for doctors"
" 'junior doctors' [or "medical residents"] AND study AND drugs AND dosing"
" 'medical residents' AND programs AND prescribing"
"clinical pharmacists teach medical students"
" 'clinical pharmacists' AND "medical students' "
" 'junior doctors' AND pharmacists AND team OR train"
"junior doctors increased interaction with pharmacists"
"curriculum AND 'clinical pharmacists' AND 'medical students'"

I hope my research is of help to you.

Please post a "Request For Clarification" if you need help navigating
any of the above links, or if you feel I misunderstood your question
and you require further information and/or clarification.

Best of luck pursuing your Master's degree!

dani2000-ga rated this answer:4 out of 5 stars
Thanks a lot! The answer was very satisfying and the links suggested
were useful. I now have enough material to be able to proceed with my


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