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Purpose of study Initiatives to standardise hospital paper-based prescription charts are underway in various countries in an effort to reduce prescribing errors. The aim of this study was to investigate the extent to which prescribing error rates are influenced by prescription chart design and familiarity. Study design In this prospective, randomised, cross-over study, Foundation Year 1 doctors working in five Scottish National Health Service (NHS) Boards participated in study sessions during which they were asked to prescribe lists of medications for five fictional patients using a different design of paper prescription chart for each patient. Each doctor was timed completing each set of prescriptions, and each chart was subsequently assessed against a predefined list of possible errors. A mixed modelling approach using three levels of variables (design of and familiarity with a chart, prescribing speed and individual prescriber) was employed. Results A total of 72 Foundation Year 1 doctors participated in 10 data-collection sessions. Differences in prescription chart design were associated with significant variations in the rates of prescribing error. The charts from NHS Highland and NHS Grampian produced significantly higher error rates than the other three charts. Participants who took longer to complete their prescriptions made significantly fewer errors, but familiarity with a chart did not predict error rate. Conclusions This study has important implications for prescription chart design and prescribing education. The inverse relationship between the time taken to complete a prescribing task and the rate of error emphasises the importance of attention to detail and workload as factors in error causation. Further work is required to identify the characteristics of prescription charts that are protective against errors.

OBJECTIVE: To investigate the possibility that uric acid (UA) can impair endothelial function, an important surrogate for atherosclerosis.DESIGN: UA was administered locally or systemically to healthy adult men and women in a series of randomised placebo controlled studies. This temporarily raised serum UA concentrations, so that the potential effects of hyperuricaemia on mechanisms of cardiovascular disease could be studied.MAIN OUTCOME MEASURES: The effects of UA administration on basal blood flow and responses to locally administered acetylcholine, sodium nitroprusside, and L-N(G)-monomethylarginine were studied in the forearm vascular bed with venous occlusion plethysmography. The effects of hyperuricaemia on systemic vascular resistance, large artery compliance, and baroreflex sensitivity were examined by validated non-invasive techniques.RESULTS: UA administration caused a twofold increase in serum concentrations. However, there were no acute effects on haemodynamic variables, basal forearm blood flow, or nitric oxide dependent endothelial function.CONCLUSION: Unlike other risk factors associated with endothelial dysfunction, acute exposure to high concentrations of UA does not impair cardiovascular function in healthy men. These findings do not support a causal link between hyperuricaemia and atherosclerosis.

How long someone has to live intuitively seems important in rationing decisions. Incorporating it into economic assessments, as described here, could make decisions fairer Explicit rationing—decisions not to fund certain treatments—has become a fact of life in many healthcare systems.1–4 Health economic assessments often underpin rationing decisions, although it remains unclear whether society's values are well reflected by the utilitarian approach of maximising the units of health attainable from available resources.5 6 Health economic assessments are used to determine the additional cost per unit of health gain for different treatment options. Cost effectiveness analysis is the most common method of assessment7 8 and, for life shortening conditions, primarily focuses on the additional cost per life year gained. We propose that prognosis without treatment is an important contextual modifier of life years gained in evaluating treatments for life shortening conditions. We present initial data supporting this hypothesis and describe resource allocation strategies that use this information. Life years gained represent the extra life expectancy resulting from a treatment. By definition, the comparison is with the life expectancy associated with an established standard of care for the condition. Depending on the condition, the established standard of care may be interventional or supportive. Using life years gained in health economic assessments has several problems. The first is that they are inapplicable to treatments that do not prolong life. Most of the other problems relate to the fact that a year of life in a particular clinical setting may not have the same value as a year of life in a different clinical setting. Initial attempts at improving the fairness of life years gained resulted in the development of quality adjusted life years (QALYs). In a QALY, each unit of time in a health state is weighted by both …

Acute ascent to high altitude causes illness ranging from relatively trivial symptoms of acute mountain sickness (AMS) to rapidly fatal conditions including high altitude pulmonary oedema (HAPE) and high altitude cerebral oedema (HACE).1 HAPE, HACE, and oedema in other tissues at altitude may have a common pathogenesis in increased vascular permeability. There is some evidence that this increased permeability may be caused by oxidative stress.2 In conducting a trial of antioxidant supplementation in healthy adults acutely exposed to high altitude, we unexpectedly found small pericardial effusions in many subjects at high altitude. This has not been reported elsewhere. The study was approved by the Lothian Research Ethics Committee. Eighty three lowlanders (median age 21 years, range 18–30, 44 men) participated in a randomised, placebo controlled, double blind trial of antioxidant supplementation. Subjects flew to La Paz, Bolivia (3650 m) and after 4–5 days’ acclimatisation ascended over 90 minutes to the Chacaltaya laboratory (5200 m) by off road vehicle. The antioxidant group (41 subjects) received 1 g l-ascorbic acid, 400 IU α tocopherol acetate, and 600 mg α lipoic acid/day in four divided doses starting five days before ascent to 5200 m. The primary objective of the trial was to determine whether antioxidant supplementation could reduce the symptoms of AMS. A secondary …

Is the goal, but prescribers still need education, experience, and common sense E vidence based medicine has been defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”1 Few areas of medical practice have felt the effects of this movement more clearly than prescribing. Until recently doctors could prescribe medicines without worrying that their choices might be judged against evidence accumulated in the world's literature. Now, prescribers are increasingly expected to back up their decisions with evidence.2 Enthusiasm for evidence based prescribing is welcome and should lead to safer and more effective use of medicines. But it also poses some real problems for prescribers. Reliable information to underpin everyday prescribing decisions at the point of prescription is hard to find. One solution is to provide modern information technology systems in the consulting room or at the bedside.3 But even these may deliver too much unfiltered information including some original research, some guidance derived from research, …

The potential dangers of hyperoxia need to be recognised Oxygen is cheap, widely available, and used in a range of settings and conditions to relieve or prevent tissue hypoxia. Since its discovery by Scheele and Priestley in the 1770s, it has remained one of the most effective therapeutic agents available. However, as a result of poor prescribing and monitoring, inappropriate doses are often given.1 Oxygen is most commonly delivered by devices with variable performance such as face masks and nasal cannulae. These can produce unexpectedly high concentrations of inspired oxygen, particularly when ventilation is depressed.2 In addition, masks that incorporate a reservoir bag are often used in emergencies, following the widespread adoption of advanced trauma life support style (or ATLS) guidelines. These appliances can produce systemic hyperoxia that is generally assumed to be harmless. However, emerging evidence suggests that for some patients with acute medical conditions, hyperoxia may be harmful. Oxygen therapy is often …

The Joint British Societies’ (JBS) charts use a “traffic lights” system to emphasise different categories of cardiovascular risk.1 They were published in 2005 in conjunction with the societies’ guidelines2 and are reproduced biannually in the BNF . We recently observed that the green (

How do you go about minimising the harmful effects of prescription drugs? Rachel Green and Simon Maxwell discuss

In the second part of our series on prescribing skills, Kate Wilkinson and Simon Maxwell explain how to write safe and effective prescriptions

EDITOR—An editorial should bring an important topic to readers' attention and engage their interest, provoke a reaction, and trigger debate. We are delighted that the recent editorial on poor prescribing in the United Kingdom seems to have done all of these things.1 We did not give a thorough account of all the evidence, but we are surprised that Rubin thinks that we provided no evidence at all.2 We cited …

Clinical pharmacology and therapeutics is a relatively young specialty borne out of the rapidly increasing contribution that drug treatments have made to medical practice in the second half of the century. This, in turn, has been driven by a thriving pharmaceutical industry, much of which is UK based. Its development has been underpinned by the recognition that newly available drugs must be assessed in unbiased controlled clinical trials designed, conducted, and analysed to the highest possible standards. Meanwhile, improved measurement techniques of both drugs and their metabolites, and the body's response to them, have increased understanding of pharmacokinetics and pharmacodynamics. Understanding of the potential mechanisms of drug action has increased, increasing the number of target sites for new drug development. Drugs are also used as tools to understand physiological and pathophysiological processes. The arrival of molecular genetics with mapping of the human genome is set to revolutionise the specialty in the next century. The latest scientific techniques will lead to the discovery of many hitherto unknown target sites and, subsequently, to the design of specific drugs modelled to interact with them. Doctors can expect new, highly specific drugs to progressively replace the blunter pharmacological approaches of past decades. The next generation of clinical pharmacologists will be involved in developing methods to measure the effects of these new drugs in patients. Training in clinical pharmacology provides the opportunity to develop a career in many different areas of medical practice, with all clinical pharmacologists sharing the traits of enthusiasm and expertise in the development, evaluation, and use of drugs. As well as practising medicine in the NHS, clinical pharmacologists also fulfil a wide variety of other roles (see box). Traditionally, clinical pharmacologists have combined their specialist interest with a commitment to general internal medicine, usually in a teaching hospital. However, the future …