It’s 1947. The Labour Government is planning a new National Health Service, and Nye Bevan announces that each hospital in the country will have its own unique prescription chart and all general practitioners their own distinct outpatient prescription sheets. Not. That would have been foolish.
So why, when GPs’ prescription sheets are uniform, are hospital prescription charts all different? At every stage in the history of hospital charts the need for standardization has been apparent.
A historical perspective
Prescription charts didn’t exist in the 1940s. Hospital doctors wrote their prescriptions in patients’ notes, and a nurse, usually the ward sister, transcribed them on to a sheet called a medicine list. At that time few medicines were used, and nurses could be expected to know a great deal about their beneficial and harmful actions; changes in treatment were infrequent and it was simple to make out new medicine lists. However, in 1958, highlighting problems with what were called “dangerous drugs”, the Central Health Services Council recommended that medicine lists should be abolished, and in 1959 Fowler noted that they had become totally inadequate. Patients were often receiving four or five different medications at the same time, changes in treatment were frequent, and the rate of patient turnover was increasing.
Medicines had become more dangerous, and a single dose omitted or doubled could have serious results. Fowler listed the disadvantages of the medicine list: alterations could be made only by deleting an entry and adding the new treatment above it; movements of patients in the hospital were difficult to record and errors from mistaken identification could result; the task of compiling new medicine lists was time-consuming; new lists tended to be made from old ones and errors were thus perpetuated.
Fowler proposed a new system involving a flat-folding file, of the type later known as a Kardex, in which each patient’s prescription chart was filed, and he discussed possible variations: writing the prescription directly on to the patient’s sheet in the file; providing a column for the prescribing doctor to countersign the nurse’s entry; having the nurse sign for each dose of medicine administered; combining the medicines files with the similar file kept for special nursing requirements.
In 1965 clinical pharmacologists in London and Aberdeen studied the rates of medication errors in their wards. The latter described a new drug chart that they suggested would reduce the error rate. Hospital prescription charts were subsequently introduced nationwide, but without standardization.
Evidence of benefit
A national uniform prescription chart would reduce medication errors in hospitals.
In 1967 the Aberdeen group reported on the use of their new chart, after 18 months of experience. Nursing time spent in administering medicines was nearly halved and the rate of errors was reduced from 12% to 4%. In London, the introduction of a prescription chart reduced the error rate from 15% to 4%.
A national prescription chart for Australian hospitals, first suggested in 2003, was adopted in 2004. It was instituted throughout the country, with some local variations; improvements were later suggested. In Queensland, the introduction of a uniform chart reduced prescription errors from 20% of orders per patient before to 15.8% after. In addition, the documentation of adverse drug reactions improved and the potential risks associated with management of warfarin therapy were reduced. When the chart was introduced throughout Australia, prescription errors fell by almost one-third , from 6383 errors in 15 557 orders, a median (range) of 3 (0–48) per patient to 4293 in 15 416 orders, 2 (0–45) per patient.[link 10]
The UK experience
A uniform chart was introduced into Welsh hospitals in 2004. It is supported by nationally agreed prescription writing standards and an e-learning training program. There are versions for acute in-patient use, for long-stay in-patient use, and for paediatric use. The charts are updated regularly, and are used in conjunction with several supplementary charts (e.g. for the use of anticoagulants).
In a report prepared for Sir Bruce Keogh, Medical Director of the NHS, the Academy of Medical Royal Colleges in collaboration with the Royal Pharmaceutical Society and Royal College of Nursing recommended the adoption of a uniform prescription chart throughout the UK. A separate initiative is in progress in Scotland.
Most recently, a group from Imperial College, London, have devised a prescription chart, the use of which, assessed by in situ simulation testing, significantly reduced a number of common prescribing errors, including dosing errors and illegibility.
Medication errors are more likely to be made when a doctor starts to work in an unfamiliar hospital; familiarity with a standard chart would, given the evidence, reduce such errors. A standard chart would also facilitate prescribing education; in Wales, a separate (differently coloured and watermarked) student chart is used for training purposes. A single prescription format would also facilitate medicines reconciliation, particularly at time of discharge, and national electronic prescribing.
The national prescription form used by general practitioners (the FP10 in England and Wales, the EC10 in Scotland) has been standard for many years. The time has come to introduce a standard UK national hospitals prescription chart.