ObjectiveTo synthesise qualitative studies that explore prescribers’ perceived barriers and enablers to minimising potentially inappropriate medications (PIMs) chronically prescribed in adults.DesignA qualitative systematic review was undertaken by searching PubMed, EMBASE, Scopus, PsycINFO, CINAHL and INFORMIT from inception to March 2014, combined with an extensive manual search of reference lists and related citations. A quality checklist was used to assess the transparency of the reporting of included studies and the potential for bias. Thematic synthesis identified common subthemes and descriptive themes across studies from which an analytical construct was developed. Study characteristics were examined to explain differences in findings.SettingAll healthcare settings.ParticipantsMedical and non-medical prescribers of medicines to adults.OutcomesPrescribers’ perspectives on factors which shape their behaviour towards continuing or discontinuing PIMs in adults.Results21 studies were included; most explored primary care physicians’ perspectives on managing older, community-based adults. Barriers and enablers to minimising PIMs emerged within four analytical themes: problem awareness; inertia secondary to lower perceived value proposition for ceasing versus continuing PIMs; self-efficacy in regard to personal ability to alter prescribing; and feasibility of altering prescribing in routine care environments given external constraints. The first three themes are intrinsic to the prescriber (eg, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (eg, patient, work setting, health system and cultural factors). The PIMs examined and practice setting influenced the themes reported.ConclusionsA multitude of highly interdependent factors shape prescribers’ behaviour towards continuing or discontinuing PIMs. A full understanding of prescriber barriers and enablers to changing prescribing behaviour is critical to the development of targeted interventions aimed at deprescribing PIMs and reducing the risk of iatrogenic harm.

Objective: To identify and analyse factors underlying intern prescribing errors to inform development of specific medication‐safety interventions. Design: A prospective qualitative study that involved face‐to‐face interviews and human‐factor analysis. Setting: A tertiary referral teaching hospital, Brisbane, Queensland, February–June, 2004. Participants: Fourteen intern prescribers involved in 21 errors. Method: A structured questionnaire was used to identify factors causing the errors. Transcripts were analysed on the basis of human‐error theory to identify underlying themes. Main outcome measures: Factors underlying prescribing errors. Results: Errors were multifactorial, with a median of 4 (range, 2–5) different types of performance‐influencing factors per error. Lack of drug knowledge was not the single causative factor in any incident. The factors in new‐prescribing errors included team, individual, patient and task factors. Factors associated with errors in represcribing were environment, task and number of weeks into the term. Defences against error, such as other clinicians and guidelines, were porous, and supervision was inadequate or not tailored to the patient, task, intern or environment. Factors were underpinned by an underlying culture in which prescribing is seen as a repetitive low‐risk chore. Conclusion: To reduce the risk of prescribing errors, a range of strategies addressing patient, task, individual, team and environment factors must be introduced.

Objectives: To evaluate the effects of a Medication Liaison Service (MLS) on quality of medication‐related information associated with hospital admission, risk of drug misadventure and other patient outcomes, and health resource utilisation. Method: Patients were randomly selected from eight acute wards (servicing 12 medical and five surgical units) and an orthopaedic pre‐admission clinic at two major hospitals. Subjects were randomly assigned to an intervention (MLS) or control group. For each patient in the MLS group a clinical pharmacist attached to the MLS contacted the general practitioner and community pharmacist in order to prepare a comprehensive medication history. Prior to discharge, the MLS clinical pharmacist, in consultation with the hospital medical staff, prepared a discharge communication which included a list of medications on admission and discharge, corresponding therapy changes, intended duration of therapy, sources of supply, allergies and adverse drug reactions, new therapeutic devices, medication‐related problems and actions required by the general practitioner. This information was forwarded to the patient's general practitioner and community pharmacist within 24 hours of discharge. Patient outcomes were evaluated 30 days after discharge using a mailed questionnaire and review of medical files. Results: Of 240 patients recruited, 113 were randomised to the MLS group and 127 to the control group. During hospital admission a significantly greater proportion of MLS subjects experienced a clinical pharmacist intervention (MLS 68% vs control 44%) and more subjects had at least one change to their therapy (MLS 97% vs control 90%), with more interventions (mean MLS 1.43 [SD 1.5] vs control 0.77 [SD 1.1]) and more medication changes per subject (mean MLS 3.75 [SD 2.6] vs control 3.10 [SD 2.3]). There was no significant effect on length of stay or mortality. In the 30 days following discharge there were fewer réadmissions per subject in the MLS group (mean 0.12 [SD 0.4] vs 0.46 [SD 1.9]) but this difference did not quite reach statistical significance (p = 0.055). The MLS group had significantly fewer healthcare professional visits per subject (mean MLS 7.54 [SD 7.4] vs control 9.94 [SD 10]). In an assessment of functional health status, MLS subjects improved for 7 of 8 factors (significantly so for two), and tended to improve more than controls in all factors except vitality. Conclusion: MLS was associated with improved patient outcomes and a greater number of inpatient clinical pharmacy interventions and medication changes intended to optimise therapy. There was also a tendency for reduced readmissions, a significant decrease in community healthcare professional visits, and significant improvements in functional health status score.

Inappropriate polypharmacy in older patients imposes a significant burden of decreased physical functioning, increased risk of falls, delirium and other geriatric syndromes, hospital admissions and death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed medications. Deprescribing is the process of tapering or stopping drugs, with the goal of minimising polypharmacy and improving outcomes. Barriers to deprescribing include underappreciation of the scale of polypharmacy-related harm by both patients and prescribers; multiple incentives to overprescribe; a narrow focus on lists of potentially inappropriate medications; reluctance of prescribers and patients to discontinue medication for fear of unfavourable sequelae; and uncertainty about effectiveness of strategies to reduce polypharmacy. Ways of countering such barriers comprise reframing the issue to one of highest quality patient-centred care; openly discussing benefit-harm trade-offs with patients and assessing their willingness to consider deprescribing; targeting patients according to highest risk of adverse drug events; targeting drugs more likely to be non-beneficial; accessing field-tested discontinuation regimens for specific drugs; fostering shared education and training in deprescribing among all members of the health care team; and undertaking deprescribing over an extended time frame under the supervision of a single generalist clinician.

The medicines management pathway describes the cognitive and physical steps involved in the use of medicines, with a focus on the consumer. There are 9 steps and 3 background processes. The steps and processes are interdependent and influence each other. Documentation of the pathway provides a framework to identify how the steps are related, the potential for any errors and safety system improvements. The pathway is applicable to all medicines, independent of the setting, health professionals involved and funding source. An understanding of the pathway and human factors associated with each step are necessary to ensure safe, effective and efficient use of medicines. The pathway can assist consumers and health professionals to understand their role and how their actions can improve medicine safety. Hospital pharmacists have an established role at all steps. With more professional services being offered via community and other pharmacy practice settings, the medicines management pathway concept will play an increasingly greater role across the continuum of care.

Introduction of a standard revised medication chart significantly reduced the frequency of prescribing errors, improved ADR documentation and decreased the potential risks associated with warfarin management. The standard chart has enabled uniform training in medicine management.

At the end of medical school education and prior to assuming responsibility for prescribing, students felt unprepared and perceived that negative outcomes would result if they were involved in errors. These findings indicate that much more work is needed to prepare doctors to prescribe safely, improve the safety of prescribing systems and address the issue of blame.

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