Of snarks, boojums and national drug charts

There have been frequent suggestions over the last few years that a national inpatient drug chart is needed for the UK NHS. Here we draw on The Hunting of the Snark, Lewis Caroll’s nonsense poem, described by Caroll as ‘An Agony, in Eight Fits’, to critique this movement, where Agony is used ‘in the old sense of a struggle that involves great anguish, bodily pain or death.’ In most UK hospitals, medicines are prescribed on a paper drug chart, a proforma on which doctors prescribe, pharmacists annotate and nurses record administration of medicines. The drug chart was developed in the late 1960s, and shown to be safer than the previous system of nurse transcription onto medicine cards. Some variant of the drug chart has been at the end of beds in English and Welsh wards ever since; Scotland and Northern Ireland have a similar document, the Kardex, usually kept centrally on the ward. The stimulus for the current movement to create a national chart was the excellent EQUIP study of prescribing errors made by hospital doctors. The study, funded by the General Medical Council (GMC), the regulator for the medical profession in the UK, found the prevalence of prescribing errors in inpatient and discharge medication orders to be 8.9%, unacceptably high. The GMC, in a press release which accompanied the launch of the report, called for a national drug chart to improve safety. Others have echoed the call. Here, in eight Fits, we explore and critique the case supporting this initiative. The first three Fits summarize the commonly used arguments for a national chart, and our critiques of them; the remainder represent additional arguments against a national chart. Fit the first: The EQUIP study suggested that differences between drug charts predispose to error. How strong is this evidence? First, drug chart design was not actually a major cause of error. In this study, the investigators studied the causes of error by inviting doctors to come to interview prepared to talk about a case in which they had made an error in the past. There were only two of 85 errors in which interviewees felt that the variation in drug chart designs was a contributing factor. For three other errors, poorly designed drug charts were also mentioned, but good design and standardization are not the same. Second, the methodology may have biased the causes of errors reported. We know that prescribers are not aware of most errors that they make, and suggest that to understand causation, people need to be interviewed about their errors soon after they are made. We previously interviewed doctors within 96 hours of making a serious prescribing error which they were not aware of at the time, and variation in drug charts never emerged as a cause. Finally, if you knew you had made errors in the past, would you be tempted to describe one in which you had been culpable (and may look foolish or ignorant), or describe one in which the fault could be laid elsewhere? In our view the methodology might over-represent errors in which unfamiliarity with the drug chart was the cause. Fit the Second: Two studies from Australia suggest that standardization of drug charts, in combination with education, reduces error. The first study, oft cited in support of drug chart standardization, showed that when five hospitals adopted a standard drug chart, the prevalence of prescribing error reduced from 24 to 19 errors per 100 medication orders. An Australia-wide pilot of a national chart then reported a reduction from 41 to 28 errors per 100 medication orders – both DECLARATIONS