Children offer specific challenges for prescribers as drug doses must be calculated individually and children are particularly vulnerable to errors.1 2 Faulty prescribing skills may result from inadequate medical education; the quality of the teaching of clinical therapeutics and prescribing to UK students has been debated.3 4 Little research exists regarding the teaching of prescribing skills or competency assessment, although the General Medical Council (GMC) hopes to examine junior doctor’s errors.5 Most F1 doctors feel inadequately trained to prescribe at graduation6 and less than a third of final year medical students are aware of drugs for anaphylaxis and chest infections.7

Inadequate mathematical skills may cause dosing errors.8 US paediatric residents scored less than 70% on average when mathematical and prescribing skills were tested9 and only 31% of UK junior doctors answered all questions correctly in a prescribing test despite calculators and references being provided.10

Methodology

The study aimed to identify interventions to reduce errors in drug dose calculations using a systematic literature review of published interventions and a questionnaire survey to identify unpublished interventions.11 12 The questionnaire was sent to:

• paediatric clinical directors via the Royal College of Paediatrics and Child Health,

• the Neonatal and Paediatric Pharmacists Group,

• US and EU paediatric health professionals and medication error researchers.

Respondents mentioning educational interventions were contacted to establish further details. Interviews and observations were performed at three centres which used competency assessment. Ethical approval was obtained for this part of the study.

RESULTS

Literature review

Two highly relevant papers were identified. One described an intervention where medical trainees took an in-service dose calculation test.13 A significant decrease in subsequent errors was found, but it was impossible to determine the contribution of the test as several other interventions had been introduced.

The second assessed the impact of a combined risk management/ward based clinical pharmacist led education programme in a neonatal intensive care unit.14 Monthly medication errors fell significantly after it was introduced although again it was difficult to know which intervention had had the biggest impact.

Questionnaire survey

A total of 319 out of 559 questionnaires were returned (57%). Thirty-four, all from the UK, described teaching methods. Fifteen centres sent us further details. Table 1 summarises this information.

Presentations

Thirteen centres provided a presentation by paediatric pharmacists which lasted 30–60 min, usually at doctors’ induction. The content is shown in fig 1. Eleven taught correct drug chart completion and seven discussed common prescribing errors. One hospital used a computerised prescribing programme to teach drug calculations and included a formative assessment. Ten centres provided doctors with an induction pack containing medicine codes, drug charts, example errors, policies, descriptions of cases and calculation examples.

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Figure 1 Content of presentations.

Workbooks

Three centres provided a workbook. Each followed a similar format (advice about completing drug charts, handwriting, date, time, route, drug and signature) and each contained calculation questions, unit conversions, charts with errors to identify and charts to complete. One workbook was self marked and pharmacists or consultants marked the others. In one case if a doctor performed poorly, their supervisor was informed.

Practice questions

Four centres provided practice questions. One distributed these before with answers discussed at induction, one was distributed at induction with ideal answers discussed, and two were handed out afterwards for future practice. Three contained questions on unit conversions, dose calculations, route, regimen and infusion rates. The other contained four questions, each with patient information to calculate drug doses and frequency.

Assessment of competency

Three centres tested prescribing competency. One had four questions10: the child’s age, weight and drug were given and required calculation of the dosing regimen. This test was marked during the session and answers were discussed. Any doctor performing badly was required to resit the test. Doctors failing every question were subsequently not allowed to prescribe independently until they passed the test. The other tests (at sites A and C) are detailed below.

Interviews and observations

Site A

All junior doctors were required to undertake training and pass an exam on the hospital intranet as part of a national modular training scheme. The exam was devised by a pharmacist based on common errors. It contained 10 scenarios and questions with true/false options. Students were expected to achieve at least 70%. If they did not, individual training was provided. Once the test was submitted, it was computer marked. The trainee could access the results/pass mark and go through each question to identify errors.

Advantages reported included:

• the module could be accessed from home,

• it was a good assessment tool giving baseline understanding of prescribing issues,

• it was flexible,

• it was easy for staff to monitor whether students had completed the test.

Reported disadvantages included:

• online training does not replace practical teaching,

• there were some ambiguous questions.

Site B

Junior medical staff were expected to complete a 1-day workshop covering general prescribing issues including calculations before beginning their placement. The workshop was considered to provide an opportunity for doctors to meet pharmacy staff, but not all had access to it as it only ran once a year.

Site C

Doctors completed calculations which were returned to a pharmacist who provided individual feedback. Extra support was given to doctors failing to meet the 100% pass rate. The programme was said to:

• reduce dose calculation errors,

• provide staff with opportunities to become familiar with protocols and formulary,

• provide substantial support to staff with problems,

• fulfil college requirements,

• give other staff confidence in doctors’ competence,

• standardise practice.

The main problems were:

• arranging lectures and workshops to suit medical and pharmacy staff,

• the large amount of information to absorb,

• the 2-week return for completed calculations was difficult,

• errors possibly made due to workload and not lack of knowledge,

• problems when a doctor was not deemed competent.

DISCUSSION

Little is known about how we teach and assess prescribing competency. GMC guidelines and a suggested medical student teaching curriculum exist, but these are not comprehensive.15 No guidelines concerning the knowledge base or assessment of paediatric prescribing are available.

The information we collected provides an insight into current UK teaching. Paediatric pharmacists teach doctors using presentations during induction. Some consolidate this with practice questions, workbooks or tests. The main topics covered include differences from adult prescribing, common errors and their effects, and how to calculate doses using age and weight. Many provide practical teaching on how to complete a drug chart. Computerised teaching and assessment systems are also used.

Prescribing is assessed using workbooks, questions during lectures or formal testing. No validated tool exists. Previous studies have shown the potential for calculation errors8 9 and advised assessment prior to prescribing being undertaken. Others describe errors and the devastating effects they can cause.16

Suggestions have been made for assessment of prescribing competency to be built into postgraduate paediatric exams.10 However, this would miss junior prescribers and those in other specialities also prescribing for children. Any assessment or revalidation must have a mechanism to identify and support failing individuals.

We acknowledge that this study is not a comprehensive review of all teaching and assessment taking place. It is possible that many questionnaire respondents did not recognise education as an intervention to reduce errors. However, we have gained some information on what is happening and hope this will prompt further comprehensive examination of what is currently taking place. Evaluation and determination of the best teaching methods and competency assessments is needed, as is research to establish whether education does indeed reduce prescribing errors. No centre could provide us with evidence that it does. A validated competency assessment tool is required before this can take place. National standards of prescribing teaching practice and competency assessment could then be developed.

Conclusion

Teaching for paediatric prescribing is taking place in some centres, usually in the form of presentations with or without questions and workbooks during doctors’ induction periods. There is little formal assessment or feedback from this teaching. Further work is needed to evaluate its impact, to develop competencies and to validate assessment methods.