Teaching of junior doctors

Many UK paediatric departments run their own teaching sessions on prescribing for children. There has been little published regarding their format or content and most centres work independently without sharing resources or expertise. There are no central recommendations for either such teaching of new doctors or ongoing training of paediatricians. In our trust we run a 1 h teaching session for senior house officers (SHOs) within 1 month of their starting in paediatrics and a 2 h session for all F2 doctors within their teaching program. These sessions include a lecture on the differences between paediatric and adult prescribing, mention the importance of continued drug research, highlight risks of paediatric medication errors and provide examples of common mistakes. Scenarios are presented and the doctors are asked to practice prescribing on drug charts followed by a discussion. There is no formal assessment of individual doctor’s prescribing. At ward level, pharmacists and nurses play an important role in detecting and rectifying mistakes, and provide advice and support to medical staff in their prescribing practice. A study in our trust identified 139 clinical interventions by pharmacists and nurses to correct or clarify prescriptions in a 6-week study period.6

Assessment of competency

It is difficult to determine what impact our teaching has on prescribing competency or if it is typical of that throughout the UK. A Cardiff study looked at whether paediatric junior doctors given ideal circumstances would prescribe correctly.7 The study consisted of a test conducted during an interactive session for paediatric SHOs at induction. Only 31% (10/32) answered all four questions correctly. One doctor answered all four incorrectly. Experience did not improve prescribing skills, in fact it apparently did the reverse. Six of nine doctors with no paediatric experience answered all questions correctly compared to only four of 23 with previous paediatric experience. Other studies have suggested that clinical experience has little to do with making calculation errors, but that the necessary skills for calculations are obtained earlier in education.8 ,9 A national competency based assessment in prescribing for children/neonates has been recommended, which could be embedded within the postgraduate MRCPCH exam.7 It is difficult, however, to establish the best format and timing that competency assessment should take. Ideally practical paediatric prescribing should be addressed at all levels in medical education and competence to prescribe should be assessed BEFORE prescribing begins for real patients. In light of the above studies, training and validation of competency should then continue throughout a doctor’s career.

Canadian research examined the numeracy skills of 34 paediatric residents by anonymous testing.8 Seven trainees committed 10-fold errors in their calculations. There was no correlation between length of training and likelihood of making a mistake. Rowe et al recommended screening residents before starting paediatric practice to identify those who may need increased supervision and training. To our knowledge, few UK centres routinely do this, with most doctors just expected to start work in a new specialty and prescribe as necessary. Prescribing error rates have been seen to double when new doctors start work on paediatric wards.10 In comparison, nurses are required to pass a test prior to being allowed to administer drugs and pharmacy staff prior to checking dispensed items, although admittedly this may not necessarily guarantee competence. Mistakes in dispensing and drug administration are still common and less likely to be detected prior to reaching the patient as they are further down the medicines management pathway.

Further work

While the GMC research project into the prevalence and causes of prescribing errors in new doctors is welcomed, the challenges in paediatrics are specifically different to those in adults. It would be prudent to investigate further what measures are being taken currently for the teaching of paediatric prescribing in the UK and any assessment of competency that follows this. It is essential for our national organisations, such as the RCPCH and Neonatal and Paediatric Pharmacists Group, to become involved in the development of national standards. Electronic prescribing is anticipated by some to be the answer to all these problems and has been suggested to reduce prescribing error rates. However, it is proving to be a challenge to introduce it into the UK and with paediatric prescribing systems requiring even more complex support than those for adults it is unlikely to be widely available for neonates and children for some years yet.

Conclusion

The safety and well-being of the patient need to be the first concern of any healthcare professional, regardless of that patient’s age. Prescribing for children does however have its own specific challenges. Doctors entering the paediatric setting and those in training need therefore to have ongoing teaching and supervision. In the UK we have no formal training for prescribing, nor a validated tool for assessing the competence of prescribing in any age group. These are essential to avoid the regular errors which occur. If we are going to assess competency, we also need to have mechanisms in place to support failing prescribers. We will need mechanisms for reassessment in the future and resources to cope with the implications that this may bring if prescribers fail. These will be challenges for all paediatricians, pharmacists and other non-medical prescribers in the future.