3.9 Implications for practice
An important factor identified in the present research was the perceived
dearth of trusted medication history resulting in doctors understandably
lacking confidence in making prescribing decisions based upon absent or
inaccurate data. An inadequate medication history represents a
significant shortcoming in the context of encouraging safe prescribing.
Electronic patient medication records (ePMR) with alert systems are now
routinely used in pharmacies and act as a safety-net prior to dispensing
in pharmacies. Although ePMR are effective in alerting users of
potential clinical hazards and errors, problems of false alerts and
inconsistencies in alert management still persist.25There remains, therefore, an on-going need to sit with the patient and
take a traditional drug history to ensure not only prescribed medicines
are included but also that alternative therapies, treatments or
lifestyle medicines that have been purchased from pharmacies, or bought
over the internet, are also included. The perceived value of
pharmacists, as experts in taking a medication history, lends support to
an argument for pharmacists to be present on the AMU out of hours in
order to provide support for medical staff in the medicines
reconciliation process.
Pressure from patients, relatives or carers may result in uncomfortable
prescribing decisions by hospital prescribers, 26 but
stress within the work environment has not yet been acknowledged in
relation to prescribing decisions. The finding that there are competing
priorities encountered by doctors on the AMU implies that it is
unrealistic to assume an effective medication review can be completed
immediately prior to a patient being discharged. A suggested way forward
would be to allocate staff with protected time to overcome these
challenges. Alternatively, proven schemes could be expanded, such as
those in Scotland 23 and Cornwall24, where the value of community pharmacists reviewing
medicines of patients who have recently been discharged from hospital
has been demonstrated. The AMU is recognised as being a high-pressure
working environment owing to the clinical urgency of patients’
admissions as well as the need to maintain patient flow through the
hospital. If doctors feel under pressure, they may focus principally on
the primary diagnosis, prescribing medicines that are efficacious in
relation to symptoms associated with the cause of admission rather than
to plan the discharge prescription in the context of avoiding
longer-term inappropriate polypharmacy. Such an approach may ultimately
increase the likelihood of patients experiencing an adverse drug event
in primary care as outlined by Slight et al.27Moreover, perceived workplace pressure may legitimise hospital
prescribers, underpinned by recent UK guidance to assign accountability
to the GP for the continuation or modification of medicines that were
not initiated in hospital. 28
Prescribing tools such as Beers and STOPP/START criteria have been
available for over a decade and have been integrated into computerised
clinical decision support systems (CDSS). Prescribing tools have been
successfully deployed to quantify the incidence of inappropriate
prescribing but several studies over recent years, in a variety of
clinical settings, have demonstrated that there is insufficient evidence
of their clinical or economic impact.14,29,30,31,32,33The failure of prescribing tools such as STOPP/START to reduce the
incidence of inappropriate prescribing suggests that an alternative
approach may be worthy of consideration. Hence, we propose that a
greater understanding of factors that directly influence doctors during
routine practice at the point of prescribing may help point the way
towards providing better support for prescribers, including CDSS
support, to ensure prescribing guidance translates into patient benefit.