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.