Electronic prescribing: Different professions, similar problems.

November 09, 2020


Our research group has a new paper (Open Access) looking at the experiences of multi-professional prescribers using an electronic prescribing system. We suspected some differences between the professional groups (nurses, pharmacists, and doctors), but they all reported similar experiences. The pharmacists had some differing perspectives because of their monitoring role in prescribing, but their own experiences matched those of the other professions. Not entirely unexpected given what we know about human cognitive bias.

We present an analysis of six major interacting themes involved in the production of a prescription. Many of these echo areas found in other studies.

Conceptual figure of the interaction of the six major themes leading to the production of a prescription

We conclude that:

Medical and non-medical prescribers have similar experience of prescribing errors when using CPOE, with the broad areas of concern aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. Solutions focused on a single factor, such as system design or training, may only result in only limited impact on prescribing errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical and environmental aspects of practice remain important.

Alshahrani, F., Marriott, J.F. & Cox, A.R. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Int J Clin Pharm (2020). https://doi.org/10.1007/s11096-020-01192-0

Photo by National Cancer Institute

Medicines Safety Week: Special Medication Safety Edition of the International Journal of Pharmacy Practice

November 06, 2020


Over the past year I’ve been working on a Special Edition of the International Journal of Pharmacy Practice on focused on medication safety with some colleagues from Cardiff University. It’s been a long haul, but we have just got it out for medication safety week 2020. It has been an interesting process of filtering and reviewing papers, but I think we have an interesting mix of papers, that fit around the WHO’s global patient safety challenge.

We also have an editorial in the issue, which gives a whistle stop tour of the papers and how they fit with the WHO framework. It concludes as follows.

This Safety edition illustrates the breadth and diversity of pharmacist involvement in research on patient safety from an international perspective. A recent report from the International Pharmaceutical Federation (FIP) entitled Pharmacists’ role in ‘Medication without harm’ summarises the evidence base for pharmacists’ contributions to patient and medication safety and concludes that ‘all pharmacists may consider themselves as medication safety pharmacists — advocates for safety within the healthcare system and for each individual patient’. The contributions in the Medication Safety Special Edition aim to add positively to the evidence base for medication safety, and we hope that the increasingly important role of pharmacists in medication safety and related research is demonstrated by the range of papers included from around the world.

Medicines Safety Week: Finding Needles in Haystacks

November 02, 2020

Needle in a haystack

It’s Medicines Safety week. The twitter hashtag #medsafetyweek shows a lot of international activity to encourage awareness of the harms of medicines, with a special emphasis on the importance of everybody playing their part in reporting suspected side effects of medicines. Every report counts.

The MHRA’s Yellow Card Scheme has been established since 1964 and has just reached the milestone of having a million reports submitted. When you make a single report, you might think it won’t have great impact, but it can. The MHRA as part of today’s celebrations have highlighted the case of a single patient reporting, leading to a change in medicine information. I think this sort of story telling about the reporting of side effects is so important to encourage further reporting. It’s great to see the MHRA doing this.

However, it isn’t the only story. You might think once an individual report of a suspected side effect has been analysed, it just disappears into the haystack of reports where we are looking for those valuable needles. However, because of the way in which we find side effects in databases such as the Yellow Card Scheme, through signals of disproportionality, every existing card also helps find side effects from new reports that are submitted.

Disproportionality analysis is primarily a tool to generate hypotheses on possible causal relations between drugs and adverse effects, to be followed up by clinical assessment of the underlying individual case reports. It is based on the contrast between observed and expected numbers of reports, for any given combination of drug and adverse event.

Unlike trying to find a needle in a haystack, where the haystack is in the way, finding an adverse effect in a database requires the haystack of previously submitted reports to find a possible link between a drug and a side effect.

Those million reports continue to serve a purpose.

Every report counts. Twice.

Photograph: Photo by Idella Maeland

World Patient Safety Day

September 17, 2020


It’s patient safety day. If you go to twitter and look at the hashtag #WorldPatientSafetyDay there’s lots of interesting and valuable material that can be used to make healthcare a safer place for both patients and healthcare staff.

But there is one easy small thing you can do to have huge impact.

This year make a commitment to spend 5 minutes on one thing that adds to global patient safety.

You can definitely do it if you are a health professional.

You might be able to do it if you are a patient or a carer, but I hope you don’t need to.

You can report a suspected adverse reaction (side effect) to your country’s regulatory system.

We don’t know much about the real-world safety of new drugs and vaccines when they first come to market. We can predict what might happen from the studies that got the drug or vaccine licensed, but when they are used in the wider population new side effects might become apparent. Sometimes even mild side effects may be indicative of a more serious issue in other patients.

Therefore every report of suspected adverse drug reactions that regulators receives adds a little knowledge. That knowledge accumulates. And over time that aggregation of data can give a signal of possible harm. And that helps regulators keep us all safe by focusing where they need to look.

So if you take a medicine or a vaccine this year, please let regulators know if you suffer a side effect.

You probably won’t.

You might even think the side effect is from something else. But you only have to suspect, not be sure. And each one helps other patients by ensuring we know a drug or vaccine is safe, or alternatively allowing us to find a problem that can be prevented in others.

If you are a health professional, just reporting one of the many suspected adverse drug reactions you see a year will make you better than average reporter.

And it will take you 5 minutes.

Once a year.

Photograph: Photo by James Yarema

Science Fictions

August 10, 2020

Pro-Science Rally, Washington DC, 2017

About 15 years ago the skeptic movement on the internet was in full throat, pushing back against anti-vaccine activists, homeopaths, and poor science reporting in the media. Before social media, this network of blogs focused on quackery, framed as an issue outside of science itself. Alongside quacks, the media was seen as particular problem, with journalists making unfounded claims about scientific papers. If you were lucky, they might put a caveat in paragraph 19 of a news report.

But what if the problem isn’t with media reporting, but the science itself?

Science Fictions is a new book by Stuart Ritchie, a psychologist and researcher, which makes this claim. Described in his twitter bio as a ‘startled hedgehog’, like the hedgehog in Isaiah Berlin’s Fox and the Hedgehog, he has focused on one important thing.


In some ways Science Fictions follows on from Ben Goldacre’s excellent Bad Science, and his later book Bad Pharma. When covering the same, or similar cases, of bad science Ritchie keeps the focus on the incentive structures surrounding science, rather than the individual issues themselves.

The book consists of three main parts. Firstly, how science ought to work and its value, and inevitably the replication crisis in psychology. It then takes on the some of the main faults in science: fraud, bias, negligence, and hype. Finally, it deals with the perverse incentives that create the climate which allow the flaws in science to flourish, with some suggestions for fixing them.

Goldacre argued in Bad Pharma that the total contribution of fraud to in the medical literature was marginal when compared to the ‘routine, sophisticated and - more than anything - plausibly deniable everyday methodological distortions.’ Ritchie makes a stronger case that fraud has a more insidious effect on science as a whole, damaging careers, diverting scare resources into fruitless areas and investigations, and poisoning the scientific record (as retracted papers continue to be unwittingly cited despite being retracted). His gathering of some of the worse cases, and the fact much may remain undetected, gives it a greater weight than when you read about them as isolated cases in the news. However, again this is dwarfed by the other issues in science such as multiple forms of bias, clear negligence (some of which are genuinely shocking failures), and hype (scientists are as guilty as the media).

The discussion of these issues is clear, easy to read, and would be an excellent primer for anyone about to take an undergraduate science degree, or for that matter someone about to undertake a PhD. I imagine scientists may be familiar with controversies in their own areas, but not the wider picture he describes. However, the last chapter on the incentives that drive science suggests another group of readers.

the scientific incentive system engenders an obsession not just with certain kinds of papers, but with publication itself. The system incentivises scientists not to practise science, but simply to meet its own perverse demands. These incentives are at the root of so many of the dubious practices that undermine our research.

Ritchie, Stuart. Science Fictions (p. 177). Random House. Kindle Edition.

As Steven Pinker noted in Enlightenment Now, science is under attack from both the right and left of politics, and where it intersects with religion, humanities, and the arts. Yet science is possibly the greatest achievement of the human race. Science, and the application of reason, is the best way we have to try to understand the universe we live in, and even to defeat a tiny virus which has turned the world upside down (Ritchie’s book includes discussion of preprint culture in a time of Covid, unexpected given the book publication process).

Science Fictions is clearly written by someone who loves science, and while it could be seen as a condemnation of science, it is not. Science is a process that includes humans and all their fallibilities. Ritchie’s concern with the incentives that lead to poor decisions around statistics, the lack of openness of data, the culture of publications, the metrics that drive academic success, and how grant money is allocated is about strengthening the core tenets of science, rather than a destructive assault on science as a concept.

This is why, while I would recommend the book to undergraduate or graduate students, this book should be read by leaders in science, by those running funding bodies, by those involved in senior managerial positions, and also by politicians who can have a system wide influence on incentive structures. It’s not enough for individual scientists to push back against perverse incentives. Although Ritchie provides sound advice that all should follow, some of the incentives themselves also have to change. That requires either a long wait as a new generation of researchers battle through the existing system, or a top down examination from those who can effect system wide change now. The strength of his argument suggests the latter is needed. Whether that is possible during a period of unprecedented pressures on Universities is another question.

Photograph: Photo by Vlad Tchompalov