OBJECTIVES:Specialised hospital pharmacists, integrated in medical teams on the ward, can improve medication safety. When a specialised hospital pharmacist is temporarily not available, the pharmaceutical care will be conducted by a substitute hospital pharmacist with less specific knowledge about that patient population. Our objective was to compare the resolution rate of prescribing errors between specialised hospital pharmacists and their substitutes. Furthermore, we investigated whether other characteristics of the pharmacists, the prescriber, patient, drug or intervention itself were associated with the resolution rate. METHODS:A retrospective cross-sectional study was conducted to assess the resolution of prescribing errors, based on the analysis of electronic prescriptions. A prescribing error was defined as an alert that required intervention of the pharmacist to prevent harm or to optimise therapy. To identify prescribing errors, a medical doctor and hospital pharmacist analysed all alerts that were retained to be checked by a pharmacist. Resolution of a prescribing error was defined as resolution of the error within 24 hours after detection. RESULTS:In total, 145 574 medication prescriptions were analysed and 448 prescribing errors were detected. Of these prescribing errors, 94.0% were resolved within 24 hours. No differences were found between the resolution rate of prescribing errors after advice from a specialised hospital pharmacists and their substitutes (94.4% vs 91.9%, p=0145 (χ2 test)). Administrative prescribing errors, prescribing errors for patients aged >80 years and prescribing errors handled during weekends showed a relatively low-resolution rate. No other characteristics of the pharmacist, prescriber, patient, the drug involved or the intervention itself were associated with the resolution of the prescribing error. CONCLUSIONS:In the temporarily absence of a specialised hospital pharmacist, the resolution rate of prescribing errors remains high when advice about prescribing errors is provided by a substitute hospital pharmacist.

Introduction The Dutch National Pharmacotherapy Assessment (DNPA) was introduced in 2013 to improve clinical pharmacology and therapeutics (CPT) education. This study investigated final-year medical students’ perceived motivation and level of preparation for the DNPA in different scenarios: mandatory vs. non-mandatory, and traditional high-stakes assessment programme vs. programmatic assessment programme. Methods In this survey study, students from four Dutch medical schools participated. In two medical schools the DNPA is a mandatory assessment in a programmatic assessment programme, and in two schools it is a mandatory, high-stakes assessment in a traditional assessment programme. The questionnaire included six 5-point Likert-type questions, and one open-ended question. Results A total of 142 final-year medical students completed the survey. Their overall satisfaction with and current preparation for the DNPA was good (both median scores were 4 out of 5), without differences between students with a traditional or programmatic assessment programme. The majority of the students said they would be more (or much more) motivated (62.7%) and prepared (59.2%) if the DNPA were a high-stakes assessment rather than a programmatic assessment; the non-mandatory or mandatory nature of the assessment would only modestly affect their motivation and preparation (62.7% of the students would be less or similar motivated, 74.6% less or similar prepared). Students opined that the DNPA should be given earlier in the curriculum, together with more dedicated CPT education. Conclusion While students expressed a greater motivation and preparation when having a high-stakes assessment, and almost a similar motivation and preparation for mandatory and non-mandatory assessments, there were no notable differences in their current perceived motivation and preparation across medical schools with different assessment programmes. This suggests that students appreciate the importance of the DNPA assessment, being almost similarly motivated to prepare for the assessment regardless of whether it is mandatory or non-mandatory or a programmatic or high-stakes assessment.

BACKGROUND:The Dutch National Pharmacotherapy Assessment (DNPA), which focuses on assessing medication safety and essential drug knowledge, was introduced to improve clinical pharmacology and therapeutics education in the Netherlands. This study investigated how the performance of final-year medical students on the DPNA was affected by the assessment programme (traditional with summative or formative assessment, and programmatic assessment). METHODS:This multicentre retrospective longitudinal observation study (2019-2023) involved final-year medical students from four medical schools in the Netherlands. The DNPA was used in different ways - either as a summative or formative assessment in a traditional assessment programme or as a non-high-stakes assessment in a programmatic assessment programme. Three medical schools changed from assessment programme over time. RESULTS:This study involved 1894 students. Summative assessment resulted in significantly higher scores and pass rates than formative assessment in a traditional assessment programme (mean score of 84.3% vs. 67.5%, and pass rate of 60.4% vs. 5.9%). In contrast, slightly lower scores were obtained when the assessment was non-high-stakes as part of a programmatic assessment programme rather than a summative assessment in a traditional assessment programme (mean score of 81.% vs. 84.3%, pass rate of 51.8% vs. 60.4%). In curricula where the assessment became summative instead of formative, scores and pass rates significantly improved (mean increase of +14.4% and 42.3%, respectively), when the assessment programme changed from traditional with summative assessment to programmatic with non-high-stakes assessment, scores and pass rates modestly decreased (decrease of 3.3% and 14.2%, respectively). CONCLUSION:Integrating the DNPA within a traditional assessment programme is most effective when assessed summatively, as it results in significantly higher scores compared to formative assessment. In the context of a programmatic assessment programme, the scores may be slightly lower. Changing assessment programmes within a medical school influences DNPA scores. Scores increase when the assessment is summative rather than formative within a traditional assessment programme. Conversely, scores mildly decrease when the assessment programme shifts from traditional with summative assessment to non-high-stakes programmatic assessment.

•Upon diagnosing a patient, an initial automatic response arises based on pattern recognition through therapy scripts (type 1 thinking). At some point, this response is evaluated by the reflective mind using metacognition (which plays an important role in type 2a thinking), and if found to be incorrect or incomplete, an alternative response is formulated through a slower, more analytical, and deliberative process, known as type 2b thinking. This process is shown in the European Model of Therapeutic Reasoning.•Metacognition monitors the reasoning process and helps a person to form new therapy scripts after choosing the right therapy.•Experienced physicians have more and richer therapy scripts than inexperienced physicians, based not only on their knowledge but also on their expertise and appreciation of the relevance of enabling conditions, such as patient characteristics. Therefore their type 1 response is more often correct.•There are significant differences between diagnostic and therapeutic reasoning, raising questions about their comparability, and therefore more research is needed.•It is recommended that all steps of the reasoning process in clinical pharmacology and therapeutics be optimized. This can be done, among other things, by providing structure , stimulating metacognition through reflection, increasing motivation, and providing context-rich education to develop rich therapy scripts early in professional training. However, because these teaching methods are mainly based on diagnostic reasoning, they should be tested in practice for therapeutic reasoning as well, and adjusted if necessary.

Abstract Background Despite efforts to improve undergraduate clinical pharmacology & therapeutics (CPT) education, prescribing errors are still made regularly. To improve CPT education and daily prescribing, it is crucial to understand how therapeutic reasoning works. Therefore, the aim of this study was to gain insight into the therapeutic reasoning process. Methods A narrative literature review has been performed for literature on cognitive psychology and diagnostic and therapeutic reasoning. Results Based on these insights, The European Model of Therapeutic Reasoning has been developed, building upon earlier models and insights from cognitive psychology. In this model, it can be assumed that when a diagnosis is made, a primary, automatic response as to what to prescribe arises based on pattern recognition via therapy scripts (type 1 thinking). At some point, this response may be evaluated by the reflective mind (using metacognition). If it is found to be incorrect or incomplete, an alternative response must be formulated through a slower, more analytical and deliberative process, known as type 2 thinking. Metacognition monitors the reasoning process and helps a person to form new therapy scripts after they have chosen an effective therapy. Experienced physicians have more and richer therapy scripts, mostly based on experience and enabling conditions, instead of textbook knowledge, and therefore their type 1 response is more often correct. Conclusion Because of the important role of metacognition in therapeutic reasoning, more attention should be paid to metacognition in CPT education. Both trainees and teachers should be aware of the possibility to monitor and influence these cognitive processes. Further research is required to investigate the applicability of these insights and the adaptability of educational approaches to therapeutic reasoning.

AimsThis randomized controlled pilot study aimed to assess the differences in the frequency, type and severity of prescribing errors made by medical students when assessed in an electronic (e‐)prescribing system compared to a traditional prescribing method (e.g., typing out a prescription).MethodsFourth year medical students in the period of 1 November to 31 July 2023, were asked to participate in this single‐centre prospective, randomized, controlled intervention study. Participants performed a prescribing assessment in either an e‐prescribing system (intervention group) or in a more traditional prescribing platform (control group). The prescriptions were checked for errors, graded and categorized. Differences in prescribing errors, error categories and severity were analysed.ResultsOut of 334 students, 84 participated in the study. Nearly all participants (98.8%) made 1 or more prescribing errors, primarily involving inadequate information errors. In the intervention group, more participants made prescribing errors involving the prescribed amount (71.4 vs. 19.0%; P < .01), but fewer involving administrative errors (2.4 vs. 19.0%; P = .03). Prescribing‐method‐specific errors were identified in 4.8 and 40.5% of the intervention and control group, respectively, with significant differences in overlapping errors as well.ConclusionThis pilot study shows the importance of training e‐prescribing competencies in medical curricula, in addition to traditional prescribing methods. It identifies prescribing‐method‐specific prescribing errors and emphasizes the need for further research to define e‐prescribing competencies. Additionally, the need for an accessible real‐life‐like e‐prescribing environment tailored to educators and students is essential for effective learning and incorporation of e‐prescribing into medical curricula.

AimsPrescribing errors among junior doctors are common in clinical practice because many lack prescribing competence after graduation. This is in part due to inadequate education in clinical pharmacology and therapeutics (CP&T) in the undergraduate medical curriculum. To support CP&T education, it is important to determine which drugs medical undergraduates should be able to prescribe safely and effectively without direct supervision by the time they graduate. Currently, there is no such list with broad-based consensus. Therefore, the aim was to reach consensus on a list of essential drugs for undergraduate medical education in the Netherlands. MethodsA two-round modified Delphi study was conducted among pharmacists, medical specialists, junior doctors and pharmacotherapy teachers from all eight Dutch academic hospitals. Participants were asked to indicate whether it was essential that medical graduates could prescribe specific drugs included on a preliminary list. Drugs for which >= 80% of all respondents agreed or strongly agreed were included in the final list. ResultsIn all, 42 (65%) participants completed the two Delphi rounds. A total of 132 drugs (39%) from the preliminary list and two (3%) newly proposed drugs were included. ConclusionsThis is the first Delphi consensus study to identify the drugs that Dutch junior doctors should be able to prescribe safely and effectively without direct supervision. This list can be used to harmonize and support the teaching and assessment of CP&T. Moreover, this study shows that a Delphi method is suitable to reach consensus on such a list, and could be used for a European list.

PurposeFormative assessments can help motivate students and ease students' learning through feedback. There is a pressing need for improvement of clinical pharmacotherapy (CPT) education since junior doctors make many prescribing errors. The aim of this study was to determine whether a formative assessment with personalized narrative feedback helps medical students to increase their prescribing skills.MethodsThis retrospective cohort study was conducted among masters' medical students at Erasmus Medical Centre, The Netherlands. Students made a formative and a summative skill-based prescription assessment, both during clerkships as part of their regular curriculum. Errors in both assessments were categorized by type and possible consequence and compared with each other.ResultsA total of 388 students made 1964 errors in the formative assessment and 1016 in the summative assessment. Most improvements after the formative assessment were seen for mentioning the weight of a child on the prescription (n = 242, 19%). Most new and repeated errors in the summative assessment were missing usage instructions (n = 82, 16% and n = 121, 41%).ConclusionsThis formative assessment with personalized and individual narrative feedback has helped students to increase the technical correctness of their prescriptions. However, errors repeated after the feedback were predominantly errors showing that only one formative assessment has not yet enhanced the clinical prescribing enough.

Purpose The primary aim of this study was to investigate the effect of including the Dutch National Pharmacotherapy Assessment (DNPA) in the medical curriculum on the level and development of prescribing knowledge and skills of junior doctors. The secondary aim was to evaluate the relationship between the curriculum type and the prescribing competence of junior doctors. Methods We re-analysed the data of a longitudinal study conducted in 2016 involving recently graduated junior doctors from 11 medical schools across the Netherlands and Belgium. Participants completed three assessments during the first year after graduation (around graduation (+ / − 4 weeks), and 6 months, and 1 year after graduation), each of which contained 35 multiple choice questions (MCQs) assessing knowledge and three clinical case scenarios assessing skills. Only one medical school used the DNPA in its medical curriculum; the other medical schools used conventional means to assess prescribing knowledge and skills. Five medical schools were classified as providing solely theoretical clinical pharmacology and therapeutics (CPT) education; the others provided both theoretical and practical CPT education (mixed curriculum). Results Of the 1584 invited junior doctors, 556 (35.1%) participated, 326 (58.6%) completed the MCQs and 325 (58.5%) the clinical case scenarios in all three assessments. Junior doctors whose medical curriculum included the DNPA had higher knowledge scores than other junior doctors (76.7% [SD 12.5] vs. 67.8% [SD 12.6], 81.8% [SD 11.1] vs. 76.1% [SD 11.1], 77.0% [12.1] vs. 70.6% [SD 14.0], p < 0.05 for all three assessments, respectively). There was no difference in skills scores at the moment of graduation ( p = 0.110), but after 6 and 12 months junior doctors whose medical curriculum included the DNPA had higher skills scores (both p < 0.001). Junior doctors educated with a mixed curriculum had significantly higher scores for both knowledge and skills than did junior doctors educated with a theoretical curriculum ( p < 0.05 in all assessments). Conclusion Our findings suggest that the inclusion of the knowledge focused DNPA in the medical curriculum improves the prescribing knowledge, but not the skills, of junior doctors at the moment of graduation. However, after 6 and 12 months, both the knowledge and skills were higher in the junior doctors whose medical curriculum included the DNPA. A curriculum that provides both theoretical and practical education seems to improve both prescribing knowledge and skills relative to a solely theoretical curriculum.

OBJECTIVES:Prescribing errors can lead to inconvenience, morbidity and mortality. It is therefore crucial to educate doctors to prescribe safely, efficiently and effectively. To create an effective educational programme, it is essential to understand which errors are made and by whom. The aim of this study is to explore if the experience level of the doctor influences how many and which prescribing errors are made in a European academic teaching hospital, where a computerised physician order entry system (CPOE) with a clinical decision support system (CDSS) is exclusively used. METHODS:Prescriptions for all inpatients in an academic teaching hospital were collected in June 2021. All prescriptions with an alert generated by the CDSS which could not be handled by a pharmacy technician according to local protocol were checked for errors. Identified errors were categorised by type and severity. RESULTS:A total of 130 538 prescriptions were newly made or altered by doctors. Of these prescriptions, 1914 (1.5%) were retained for a check by the pharmacist. These contained 430 prescribing errors (0.3% of total prescriptions). Doctors not in specialty training and those in specialty training made more prescribing errors than consultants (0.5% and 0.5% vs 0.1%; p<0.001). Doctors in specialty training made relatively more drug-drug interaction errors than consultants (n=31 (16%) vs n=3 (3%), p<0.05). No significant difference was found regarding the severity of the errors. CONCLUSIONS:Doctors not in specialty training and doctors in specialty training, who are the less experienced doctors, make more prescribing errors than consultants, even with the use of a CPOE combined with CDSS. The type of errors differ between doctors of different experience levels. This finding provides a solid basis for specific additional education to medical students, doctors not in specialty training and doctors in specialty training.

Aims Prescribing errors occur frequently, especially among junior doctors. Our aim was to investigate prescribing errors made by final-year medical students. Information on these errors can help to improve education on and assessment of clinical pharmacotherapy (CPT). Methods This was a retrospective cohort study amongst final-year medical students at Erasmus Medical Centre, The Netherlands. Errors made in the final prescribing assessment were analysed. Errors were categorized by type, possible consequence and possibility of reaching the patient in real life. Results A total of 381 students wrote 1502 analysable prescriptions. Forty per cent of these contained at least one error, and 54% of errors were of the inadequate information type. The rating of prescriptions for children was lower than for other question categories (P = <.001). Fifty per cent of errors were classified as "would have reached the patient but would not have had the potential to cause harm". In total, 253 (29%) errors would not have been intercepted by an electronic prescribing system or a pharmacist. Ten (4%) of these would probably have caused harm in the patient. Conclusions There is a high rate of errors in prescriptions written by final-year medical students. Most errors were of the inadequate information type, indicating that students had difficulties determining the content and amount of information needed to make treatment successful. Prescriptions for children contained most errors. Curricula could be improved by offering more case-based CPT education, focusing on the practical issues of prescribing, especially for paediatric cases, and offering more practice time for prescribing during clerkships.

The relationship between race and biology is complex. In contemporary medical science, race is a social construct that is measured via self-identification of study participants. But even though race has no biological essence, it is often used as variable in medical guidelines (e.g., treatment recommendations specific for Black people with hypertension). Such recommendations are based on clinical trials in which there was a significant correlation between self-identified race and actual, but often unmeasured, health-related factors such as (pharmaco)genetics, diet, sun exposure, etc. Many teachers are insufficiently aware of this complexity. In their classes, they (unintentionally) portray self-reported race as having a biological essence. This may cause students to see people of shared race as biologically or genetically homogeneous, and believe that race-based recommendations are true for all individuals (rather than reflecting the average of a heterogeneous group). This medicalizes race and reinforces already existing healthcare disparities. Moreover, students may fail to learn that the relation between race and health is easily biased by factors such as socioeconomic status, racism, ancestry, and environment and that this limits the generalizability of race-based recommendations. We observed that the clinical case vignettes that we use in our teaching contain many stereotypes and biases, and do not generally reflect the diversity of actual patients. This guide, written by clinical pharmacology and therapeutics teachers, aims to help our colleagues and teachers in other health professions to reflect on and improve our teaching on race-based medical guidelines and to make our clinical case vignettes more inclusive and diverse.

AimThe aim of this study was to investigate how the prescribing knowledge and skills of junior doctors in the Netherlands and Belgium develop in the year after graduation. We also analysed differences in knowledge and skills between surgical and nonsurgical junior doctors.MethodsThis international, multicentre (n = 11), longitudinal study analysed the learning curves of junior doctors working in various specialties via three validated assessments at about the time of graduation, and 6 months and 1 year after graduation. Each assessment contained 35 multiple choice questions (MCQs) on medication safety (passing grade ≥85%) and three clinical scenarios.ResultsIn total, 556 junior doctors participated, 326 (58.6%) of whom completed the MCQs and 325 (58.5%) the clinical case scenarios of all three assessments. Mean prescribing knowledge was stable in the year after graduation, with 69% (SD 13) correctly answering questions at assessment 1 and 71% (SD 14) at assessment 3, whereas prescribing skills decreased: 63% of treatment plans were considered adequate at assessment 1 but only 40% at assessment 3 (P < .001). While nonsurgical doctors had similar learning curves for knowledge and skills as surgical doctors (P = .53 and P = .56 respectively), their overall level was higher at all three assessments (all P < .05).ConclusionThese results show that junior doctors' prescribing knowledge and skills did not improve while they were working in clinical practice. Moreover, their level was under the predefined passing grade. As this might adversely affect patient safety, educational interventions should be introduced to improve the prescribing competence of junior doctors.

AimsJunior doctors write most hospital prescriptions, yet are more than twice as likely to make an error in their prescriptions compared to senior doctors. A possibility to enhance pharmacotherapy education is through the use of e‐learning modules. The aim of this study was to determine whether P‐scribe, as the chosen e‐learning resource, helps students in passing their pharmacotherapy assessments.MethodsThis retrospective study was undertaken in the Erasmus Medical Center, the Netherlands. All 270 medical students who started their master's curriculum in the academic session of 2017–2018 were included. Data were analysed to identify the frequency of student's use per e‐learning module, total time students spent on e‐learning modules and timing of the use of e‐learning modules in relation to their assessments. The results of the assessments were analysed to identify possible correlations between the time students spent using P‐scribe, their timing of use and their assessment results.ResultsStudents who passed their knowledge‐based assessment first time had a mean practice time of five more hours than students who did not pass first time (P < .05, 95% CI: 3.4–6.6). These students practised on average six e‐learning modules more (P < .05, 95% CI: 4.1–7.0) than students who failed their first attempt. Students who passed their skill‐based prescription test first time, practised on average five more e‐learning modules (P = .006, 95% CI: 1.4–8.3) than students who failed their first attempt.ConclusionStudents who passed their pharmacotherapy assessments first time spent more time, and practised more frequently, with e‐learning modules.

CONTEXT. Pediatric and intensive care patients are particularly at risk for medication errors. Computerized physician order entry systems could be effective in reducing medication errors and improving outcome. Effectiveness of computerized physician order entry systems has been shown in adult medical care. However, in critically ill patients and/or children, medication prescribing is a more complex process, and usefulness of computerized physician order entry systems has yet to be established. OBJECTIVE. To evaluate the effects of computerized physician order entry systems on medication prescription errors, adverse drug events, and mortality in inpatient pediatric care and neonatal, pediatric or adult intensive care settings. METHODS. PubMed, the Cochrane library, and Embase up to November 2007 were used as our data sources. Inclusion criteria were studies of (1) children 0 to 18 years old and/or ICU patients (including adults), (2) computerized physician order entry versus no computerized physician order entry as intervention, and (3) randomized trial or observational study design. All studies were validated, and data were analyzed. RESULTS. Twelve studies, all observational, met our inclusion criteria. Eight studies took place at an ICU: 4 were adult ICUs, and 4 were PICUs and/or NICUs. Four studies were pediatric inpatient studies. Meta-analysis showed a significant decreased risk of medication prescription errors with use of computerized physician order entry. However, there was no significant reduction in adverse drug events or mortality rates. A qualitative assessment of studies revealed the implementation process of computerized physician order entry software as a critical factor for outcome. CONCLUSIONS. Introduction of computerized physician order entry systems clearly reduces medication prescription errors; however, clinical benefit of computerized physician order entry systems in pediatric or ICU settings has not yet been demonstrated. The quality of the implementation process could be a decisive factor determining overall success or failure.