Transcript Presentation slides

A national prescribing exam
The Prescribing Safety Assessment
PSA
July 2015
Patricia McGettigan
Clinical Senior Lecturer in Clinical
Pharmacology
Today
• GMC requirements in respect of clinical
pharmacology, therapeutics and prescribing
• PSA background – summary
• PSA structure, topics, domains
• Question templates & examples
• Clinical Pharmacology & Therapeutics (CPT)
during Years 3-5, Barts and The London
• PSA experience at Barts and The London
Tomorrow’s Doctors 2009
Clinical pharmacology, therapeutics, prescribing
outcomes
The doctor as a scholar and a scientist
Outcome 8f
The graduate will be able to demonstrate knowledge
of drug actions therapeutics and pharmacokinetics; drug
side effects and interactions, including for multiple
treatments, longterm conditions and non-prescribed
medication; and also including effects on the population,
such as the spread of antibiotic resistance.
The doctor as a practitioner
Outcome 17. Able to Prescribe drugs safely, effectively and economically
(a) Establish an accurate drug history, covering both prescribed and
other medication.
(b) Plan appropriate drug therapy for common indications, including pain
and distress.
(c) Provide a safe and legal prescription.
(d) Calculate appropriate drug doses and record the outcome accurately.
(e) Provide patients with appropriate information about their medicines.
(f) Access reliable information about medicines.
(g) Detect and report adverse drug reactions.
(h) Demonstrate awareness that many patients use complementary and
alternative therapies, and awareness of the existence and range of
these therapies, why patients use them, and how this might affect
other types of treatment that patients are receiving.
Drugs as risk factors in patient well-being
PSA BACKGROUND
EQUIP Study 2009 GMC
• 11,077 errors were detected in 124,260
medication orders checked on seven ‘census
days’ in 19 acute hospital trusts
• FY1 and FY2 doctors write most hospital
prescriptions
– FY1 doctors write 40% of hospital prescriptions (50k)
– FY2: write 28%
– Consultants: write just 3%
• Prescribing is risky: Errors in 8%-11% of FY1 &
FY2 prescriptions
On-line: 24 stations; Prescribing has 8 stations; other sections have 2-4 questions each
BNF is the only reference permitted
https://prescribingsafetyassessment.ac.uk/aboutpsa
PSA Design
8 question types
7 domains
• Prescribing
• Prescription review
• Planning management
• Communicating
information
• Drug dose calculation
• Adverse drug reactions
• Drug monitoring
• Data interpretation
•
•
•
•
•
•
•
Medicine
Surgery
Elderly care
Paediatrics
Psychiatry
Obs & Gyn
General Practice
PSA Question Section and Domain grid
https://prescribingsafetyassessment.ac.uk/aboutpsa
Question writing and
standard setting
• Question writing
–
–
–
–
Initial author
Editors review (2)
Peer-review (groups of 8)
Exam board review (groups of 6)
• Standard Setting
• January each year – groups of 10 reviewers – mixed skills
• MSC Assessment oversight
Templates With thanks to Dr Fu Ng
https://prescribingsafetyassessment.ac.uk/aboutpsa
SOME QUESTION EXAMPLES
CAL – Calculation
• Examples include
–
–
–
–
Correct number of tablets to achieve required dose
Dose adjustments based on weight or body surface area
Diluting a drug for administration in infusion pump.
Convert different expressions of drug doses and
concentrations.
• 1, 2, 3 or very rarely 4 step calculations.
ID
Calculation Skills Item
CAL000
Case presentation
A [age]-year-old [man/woman/child] presents to [location and
situation] complaining of [symptom that might be used as the focus
for one of the questions] etc. You are required to give a dose of
...etc. The patient weighs …
[The case presentations should be fairly brief – 2 or 3 sentences]
Calculation
What [total amount/volume/duration/total dose etc.] should the
patient [be given, etc.] …… ?
(Write your answer in the box below)
Answer
This item is worth 2 marks
You may use a
calculator at any
time
Answer box
Correct answer
Write the correct answer with units in this box
Working
Write a brief justification of the answer in this box, sufficient to explain how to
calculate the correct answer
unit
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.
ID
Calculation Skills Item
CAL000
Case presentation
A 45-year-old man with type 2 diabetes
mellitus attends his GP. His weight has been
problematic; consideration is being given to
an anti-obesity drug.
Eligibility for treatment depends on his body
mass index (BMI).
His weight is 97.2 kg and height is 1.8 m.
This item is worth 2 marks
Answer box
Correct answer
Write the correct answer with units in this box
Working
Write a brief justification of the answer in this box, sufficient to explain how to
calculate the correct answer
Calculation
What is his body mass index based on
these measurements?
Answer
You may use a
calculator at any
time
unit
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.
DAT – Data interpretation
• Interpreting data in light of clinical scenario and deciding most
appropriate action, may involve
–
–
–
–
–
Withdrawing a medicine
Reducing dose
No change
Increasing dose
Prescribing new medicine.
• Examples might include
–
–
–
–
Drug concentrations
Drug effects (e.g. INR / TFT / Chol / BP)
Drug side effects (e.g. U+E, FBC, CK)
Nomograms (e.g. paracetamol)
Data Interpretation Item
ID
This item is worth 2 marks
DAT000
Case presentation
A [age]-year-old [man/woman/child] presents to [location and
situation] complaining of [symptom that might be used as the focus
for one of the questions] etc. PMH. She/he has suffered from ….
[describe any past medical history relevant to the scenario]. DH.
She/he normally takes …. [list any current prescriptions]. SH.
[include any relevant social history]
[Authors should try to adhere to this general layout but there is
room for flexibility – the presentations should be fairly brief but
identify the treatment for which a decision is required, the
therapeutic indication and sufficient information about the patient
to for the candidate to be able to identify the best decision option]
Question
Select the most appropriate decision option with regard to [the
xxxx prescription/the treatment of xxxxxx] based on these data.
(mark it with a tick)
You may use the
BNF at any time
DECISION OPTIONS
Identify the correct
answer by placing a
tick in the column
on the right
A
Option A
B
Option B
C
Place
Option
C 5 plausible options
D
E
in the boxes provided,
Option D
describing each with
Option E
clarity
Answer box
Option A
Justification
Write a brief justification in this box
Option B
Justification
Write a brief justification in this box
Option C
Justification
Option D
Justification
Option E
Justification
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.
☐
☐
☐
☐
☐
TDM – Drug monitoring
• Involves making judgement about the impact of
ongoing / planned treatments.
• Duration of effects; Beneficial and harmful effects
• ‘Culprit’ drugs
• Monitoring (and correct timing) including
– Clinical symptoms & signs; Investigations
• Examples requiring monitoring
– Digoxin for atrial fibrillation
– Inhaled corticosteroids for asthma
– Thyroxine for hypothyroidism
Drug Monitoring Item
ID
This item is worth 2 marks
TDM000
Case presentation
A [age]-year-old [man/woman/child] presents to [location and
situation] complaining of [symptom that might be used as the focus
for one of the questions] etc. PMH. She/he has suffered from ….
[describe any past medical history relevant to the scenario]. DH.
She/he normally takes …. [list any current prescriptions]. SH.
[include any relevant social history]
[Authors should try to adhere to this general layout but there is
room for flexibility – the presentations should be fairly brief but
identify the treatment that is being started, the therapeutic
indication and sufficient information about the patient for the
candidate to be able to identify the best monitoring option]
Question
Select the most appropriate monitoring option to assess the
[beneficial/adverse] effects of this treatment.
(mark it with a tick)
You may use the
BNF at any time
MONITORING OPTIONS
A
Option A
B
Option B
C
Option C
D
Option D
E
Option E
Identify the correct
answer by placing a
tick in the column
on the right
Justification
Write a brief justification in this box
Option B
☐
☐
Place 5 plausible
monitoring options in the
boxes provided,
describing each with
clarity
Answer box
Option A
☐
Justification
Write a brief justification in this box
Option C
Justification
Option D
Justification
Option E
Justification
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.
☐
☐
Answer
• Plasma HIV RNA
• (Viral load)
• Strategic Timing of AntiRetroviral Treatment
(START) study,
• May 27, 2015
• http://www.niaid.nih.gov/news/QA/Pages/ST
ARTqa.aspx
REV – Prescribing review
• Involves interpreting list of medicines in light of a
clinical problem
– Spotting important drug interactions
– Serious dosing errors
– Suboptimal prescriptions
• Total list of medicines for each question item ≥6.
• Some knowledge of common effects, adverse
reactions and interactions will be assumed.
• Dosing errors
• Interactions
Prescription Review Item
ID
REV000
Case presentation
A [age]-year-old [man/woman/child] presents to [location and
situation] complaining of [symptom that might be used as the focus
for one of the questions] etc. PMH. She/he has suffered from ….
[describe any past medical history relevant to the scenario]. DH.
She/he normally takes …. [list any current prescriptions]. SH.
[include any relevant social history] His current regular medicines
are listed (right).
[Authors should try to adhere to this general layout but there is
room for flexibility – the presentations should be fairly brief]
You may use the
BNF at any time
This question item is worth 4 marks
CURRENT PRESCRIPTIONS
Drug name
Dose
Route
Freq.
A
B
Drug 1
xx mg
IV
daily
☐
☐
Drug 2
xx mg
ORAL
12-hrly
☐
☐
Drug 3
xx mg
☐
☐
Drug 4
xx mg
☐
☐
xx mg
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Drug 5
Question A
Select the [ONE/TWO/THREE prescription/prescriptions] that
[is/are] [most likely to be a cause of/contains a serious dosing
error/interact/is contra-indicated, etc.].
(mark [it/them] with a tick in column A)
Drug 6
Question B
Select the [ONE/TWO/THREE prescription/prescriptions] that
[is/are] [contra-indicated/most likely to be a cause of/contains a
serious dosing error/interact/, etc.].
(mark [it/them] with a tick in column B)
Drug 7
Use between 5 and 10 rows to
xx mg
create the list
of drugs that will form
the focusxxofmg
Questions A and B
Drug 8
xx mg
Drug 9
xx mg
Drug 10
xx mg
Identify the correct answer(s)
☐ justify
☐
on columns A and B and
in the answer box below
Answer box
Question A
Marks per correct tick
[1 or 2]
Write a brief justification in this box
Question B
Marks per correct tick
Write a brief justification in this box
Prescribing Skills Assessment – Prescription Review Question Item Example
[1 or 2]
PWS - Prescribing
• Acute and chronic conditions or symptoms
• Deciding between different drugs, formulations,
routes, doses and frequencies
• Typical prescriptions: high-risk (e.g. anticoagulants,
opioids, insulin); common (e.g. antibiotics); special
dosing; fluids.
• The likely differential diagnosis should be clear from
the scenario (but not necessarily be identified).
Prescribing Item
ID
PWS003
Case presentation
A 68-year-old woman attends her GP after a recent manipulation
under anaesthetic for a left Colles’ fracture. PMH. Recent diagnosis
of osteoporosis. DH. Calcichew D3 Forte two tablets orally daily.
Pharmacy Stamp
Age
Title, Forename, Surname & Address
0yr 0mths
Patient Name
Address Line 1
Address Line 2
Town Postcode
D.o.B.
00/00/0000
Please don’t stamp over age box
Number of days’ treatment
N.B. Ensure dose is stated
On examination
Left forearm in plaster cast.
You may use the
BNF at any time
This item is worth 10 marks
28
Drug Name
Dose
Frequency
Endorsements
Investigations
DEXA scan confirms osteoporosis.
Prescribing request
Write a prescription for ONE drug will help reduce the risk of
further fractures.
(use the general practice prescription form provided)
Signature of Prescriber
Date
Signature
00/00/0000
For
Dispenser
No. of
Prescns.
on form
Xxxxx Health Authority
Dr
Address
Town Postcode
Tel: 00000 000 000
FP10NC0105
Created by Department of Clinical Pharmacology, QMUL
Prescribing Item
A. Drug choice
1
Alendronic Acid
ID
Answer Page
Score
4
PWS000
Feedback/justification
1st
BNF recommended line for post menopausal,
secondary prevention of osteoporotic fractures
You may use the
BNF at any time
This item is worth 10 marks
B. Dose and Posology
Score
70mg ORAL once-weekly or 10mg once-daily
4
Feedback/justification
Recommended dose
2
10mg ORAL once-weeky
2
Too low
3
70mg ORAL daily
1
Danger of toxicity
4
Other doses
0
(not readily available)
5
Risedronate
3
2nd line for post menopausal, secondary prevention
of osteoporotic fractures
Correct doses of weekly/daily dose of
Risedronate (ORAL 35mg weekly or 5mg
daily)
3
Recommended dose
6
5mg ORAL weekly
1
Too low
7
35mg ORAL daily
0
Danger of toxicity
8
Other doses
0
(not readily available)
9
Strontium ranelate
Raloxifene
2
3rd line for post menopausal, secondary prevention
of osteoporotic fractures
Correct doses of strontium (ORAL 2g daily),
raloxifene (ORAL 60mg daily)
2
10
Teriparatide
1
4th line for post menopausal, secondary prevention
of osteoporotic fractures
20 micrograms SC daily
1
11
Any other drugs
0
Not indicated
12
Other bisphosphonates
2
Not recommended for osteoporosis orally
Correct dose of other bisphosphonates
2
13
HRT
Calcitriol
1
Recommended for corticosteroid induced
osteoporosis as 2nd line to bisphosphonates
Correct dose of HRT/calcitriol
1
Correct doses (any other dose = 0 marks
as not readily available)
Marking
guide for A and B. Candidates should be given 4 marks for an optimal answer that can’t be improved. They should get 3 marks for an answer that
14
is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide
15
benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit.
16
C. Timing. Candidates will also be given 1 mark for
18
correctly dating (and timing) the prescription
17
D. Signature. Candidates will also be given 1 mark for
signing the prescription
19
20
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.
Prescribing Item
ID
PWS002
Case presentation
A 13-year-old boy is assessed on the paediatric day unit for severe
aural pain that has not improved despite 72 hours of treatment
with simple analgesia. PMH. None. DH. Paracetamol 1 g orally as
required. Allergic to penicillin.
On examination
T 37.7 oC; HR 100/min; BP 100/68 mmHg. Otoscopy reveals intact
red drum, bulging on right side.
This question item is worth 10 marks
Date
Time
Drug (Approved name)
Dose
Route
Prescriber – sign + print
Start date
Notes
Pharmacy
Prescribing request
Write a prescription for ONE drug that will treat his infection.
(use the hospital ‘regular medicines’ prescription chart provided)
Created by Department of Clinical Pharmacology, QMUL
6
8
12
14
18
22
You may use the
BNF at any time
Prescribing Item
A. Drug choice
1
Clarithromycin
ID
Answer Page
Score
4
PWS000
Feedback/justification
BNF recommended
1st
line for penicillin allergy
You may use the
BNF at any time
This item is worth 10 marks
B. Dose and Posology
Score
Feedback/justification
250 mg 12-hrly orally
4
Recommended dose/posology
2
500mg 12-hrly orally
3
Usually reserved for severe infections
3
500mg 12-hrly iv
2
Parenteral reserved for serious or
systemic upset
4
Any other dose/timing/routh
0
5
Beta lactam antibiotic
0
POTENTIALLY LIFE-THREATENING
Any dose of beta-lactam
0
6
Other macrolide
(erythromycin,
azithromycin)
2
Likely to be effective, but not first line
Correct dose timing length other macrolide
2
POTENTIALLY LIFE-THREATENING
7
8
9
10
11
12
13
14
15
16
17
18
Marking guide
for A and B. Candidates should be given 4 marks for an optimal answer that can’t be improved. They should get 3 marks for an answer that
is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide
19
benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit.
20
C. Timing. Candidates will also be given 1 mark for
correctly dating (and timing) the prescription
D. Signature. Candidates will also be given 1 mark for
signing the prescription
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.
PSA at Barts & The London
2012 - 2015
• Formative: 2012-2014
• Summative component of Finals 2015
• Exam on 27th February 2015
• Major IT problem at PSA – slow/broken connection to online
BNF
• Extraordinary ‘First sit’ resit offered to 9 students with
scores under ‘satisfactory’ score
• All but one passed
• PSA practice focus in Year 5 but PSA topics mean
that attention during Year 4 is needed
• Increasing attention during Year 4 placements
Mean category score as % of possible: Year 5 students 2012-15
Year
PWS (80
marks)
REV (32
marks)
MAN (16
marks)
COM (12
marks)
CAL (16
marks)
ADR (16
marks)
TDM (16
marks)
DAT (12
marks)
Mean
Score
Pass Rate
2012
75.6%
71.0%
71.0%
85.7%
79.6%
76.6%
42.8%
80.2%
73.9%
86%
2013
84.8%
69.2%
55.0%
86.6%
82.7%
63.6%
68.6%
71.6%
76.1%
92.72%
2014 A
84.3%
80.5%
74.3%
89.3%
80.6%
75.0%
57.6%
85.8%
80.7%
92.78%
2014 B
87.8%
77.5%
67.7%
87.3%
88.3%
70.8%
68.0%
86.3%
81.9%
93%
2015
83.5%
79.3%
64.6%
80.6%
81.5%
85.1%
74.1%
76.8%
80.0%
97.35%
(99.7%)
CPT / Prescribing in Years 3 & 4
Year 3
• Lecture series CPT
• Prescribing workshops
• Formative exam
Year 4
• Specialty placements – each to include relevant therapeutics
• CPT lectures (September, March, July) – overview / common
themes / principles of prescribing
• SCRIPT Principles of Prescribing on-line modules –
mandatory coursework over 11 weeks Feb-March
• QMUL on-line resources – core drugs list, history/
therapeutics template, therapeutics exercises
• Log Books – new requirement to include prescription writing
(just two/placement but it’s a start!)
Year 4, April 2015
•
•
•
•
Mock PSA for Year 4 students
Exam conditions
On-line 1-hour exam
Q type proportions were the same as in the
Year 5 PSA 2-hour exam
• No ‘pass’ score set
– On my experience, likely around 65%
Score summary
PSA Score Range
65%79%
60%64%
55%59%
50%54%
40%49%
39% or
less
31
114
51
32
23
13
3
12%
43%
19%
12%
9%
5%
1%
QMUL
>/=80%
Candidates
267
Rounded %
54%
31%
15%
PSA section score detail
PSA Section
Max score for
section
Students with
scores of 0 in
the section
Prescribing
40
0
Review
16
0
Score <20: 37 students.
34/37 had scores <65%
Score <8; 5 students
Calculation
8
41
32/41 had PSA Score <65%
TDM
Adverse Events
Management
Data
Communication
8
9
8
3
8
5
6
50
6
1
Alerts
37/50 had PSA Score <65%
Year 4 in context of Year 5
performance
Mean category score as % of possible: Year 5 students 2012-15
Year
PWS (80
marks)
REV (32
marks)
MAN (16
marks)
COM (12
marks)
CAL (16
marks)
ADR (16
marks)
TDM (16
marks)
DAT (12
marks)
Mean
Score
Pass Rate
2012
75.6%
71.0%
71.0%
85.7%
79.6%
76.6%
42.8%
80.2%
73.9%
86%
2013
84.8%
69.2%
55.0%
86.6%
82.7%
63.6%
68.6%
71.6%
76.1%
92.72%
2014 A
84.3%
80.5%
74.3%
89.3%
80.6%
75.0%
57.6%
85.8%
80.7%
92.78%
2014 B
87.8%
77.5%
67.7%
87.3%
88.3%
70.8%
68.0%
86.3%
81.9%
93%
2015
83.5%
79.3%
64.6%
80.6%
81.5%
85.1%
74.1%
76.8%
80.0%
97.35%
(99.7%)
Year 4
Mock
66.4%
77.4%
57.3%
83.8%
55.8%
77.4%
57.6%
40.2%
66.2%
54%*
*As s ume pa s s s core 65%
What do Year 5 do to prepare for the PSA
& for FY1 work?
Percentage of students using CPT activity
2014-2015
2013-2014
Total respondents = 137.
Total respondents = 47
SCRIPT (required)
100% (137)
100% (47)
QMUL exam (required)
96% (132)
96% (45)
Pharmacist (required)
100% (137)
91% (43)
Lectures
96% (132)
91% (43)
Workshops
69% (95)
68% (32)
Case series
N/A
57% (27)
QMplus
50% (69)
43% (20)
PRESCRIBE (PSA website)
94% (129)
26% (12)
Drug SMD
43% (59)
21% (10)
Survey by Dr Claire Calderwood during PfP week; 137 respondents (41% Year 5 cohort)
Ranking of resources
Q3: Ranking of CPT Resources
30
% Respondents
Ranking
1
2
3
4
5
6
7
8
9
10
20
10
0
100
Compulsory
Optional
50
0
Workshops
PSA
website
Internal
SPE
SCRIPT
MRP
Shadowing
SCRIPT Pharmacist-led Lectures
(optional) teaching
QMPlus
e-learning
Drugs SMD
e-modules
Year 5: Preparedness for FY1
1. Do you feel prepared for your first day of work as an FY1 doctor?
2. Do you feel that there has been an improvement in your prescribing
skills compared to one year ago?
Q1: Self-assessment of prescribing skills
Preparedness
3%
57%
Improvement
30%
8%
31%
66%
Definitely not
Mostly not
Unsure
Mostly yes
Definitely yes
1%
2% 1%
% Respondents
Q1: Self-assessment of prescribing skills
Preparedness (SEP)
Preparedness (GEP)
Improvement (SEP)
Improvement (GEP)
1%
57%
9%
30%
58%
65%
70%
% Respondents
11%
1%
30%
3%
32%
2% 1%
27%
3%
Definitely not
Mostly not
Unsure
Mostly yes
Definitely yes
Self-evaluation of prescribing skills
Claire Calderwood questions based on prior survey by Simon Maxwell)
Q2: Self-evaluation of prescribing skills
I know where to find advice when making
decisions about medications
35%
I can write a legally correct prescription
for a common medicine
27%
31%
I can perform common drug dosage calculations
29%
19%
I can explain to patients how they should
take their medications
10%
17%
26%
26%
11%
18%
26%
Score
1 = I cannot do this
10 = Always Agree
5%
6%
8%
12%
25%
16%
5%
Score
I can decide on and prescribe a medication to treat a
common acute medical problem (e.g. acute asthma)
I can review a patient’s regular prescriptions when they
are admitted to hospital, and amend these if needed
12%
9%
I can recognise a likely adverse drug event
8%
I can amend medications in light of drug levels
or other monitoring tests
6%
I know when monitoring tests are required for
common drug therapies (e.g. certain antibiotics)
30%
14%
35%
16%
8%
11%
30%
23%
25%
20%
25%
10%
19%
28%
5%
17%
15%
28%
% Respondents
5%
7%
9%
18%
7%
6%
5%
1
2
3
4
5
6
7
8
9
10
Resources
• PSA Website
https://prescribingsafetyassessment.ac.uk/aboutpsa
• Books
– Pass the PSA by Will Brown & others; February
2014; Churchill Livingstone ISBN: 978-0-70205518-8 (£30 approx)
– Top 100 Drugs by Andrew Hitchings & others;
2014; Churchill Livingstone; ISBN: 0702055166
(£15 approx)
– Prescribing Scenarios at a Glance by Emma Baker
& others; July 2014, Wiley-Blackwell (£26
approx)
• Library has some copies of all