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Student and pre-registration pharmacist performance in a UK Prescribing Assessment’: room for improvement and need for curricular change Background Increasingly the global policy direction is for patient-facing pharmacist prescribers. The ‘UK Prescribing Safety Assessment’ (PSA) was developed for medical graduates to demonstrate prescribing competencies in relation to the safe and effective use of medicines. Objectives To determine PSA performance of final year undergraduate student pharmacists (year 4) and pre-registration pharmacy graduates (year 5) and explore their opinions on its suitability. Setting Scotland, UK Methods Final year undergraduates (n = 238) and pre-registration pharmacists (n = 167) were briefed and undertook the PSA. PSA questions were mapped to specific thematic areas with 30 questions over 60 min. Data was analysed using descriptive statistics. A questionnaire was completed to gauge opinions on appropriateness of the PSA. Main Outcome Measure PSA scores Results Mean total PSA score for pre-registration pharmacists (64.4, SD 10) was significantly higher than for undergraduates (51.2, SD 12.0,) (p < 0.001). Pre-registration pharmacists performed significantly better across all question areas (all p < 0.001 other than ‘adverse drug reactions’, p < 0.01). Hospital pre-registration pharmacists performed statistically significantly better than community with higher overall scores (67.4, SD 9.8 v 63.2, SD 9.8, p < 0.05). Positive views on the appropriateness of the approach and the usability of the online interface were obtained from participants. Conclusion Hospital pre-registration pharmacists performed better than the undergraduates, but there is a need to improve prescribing skills in all, most notably in diagnostic skills. The PSA is acceptable to the participants. These results will help inform pharmacy curricula development and provides a cross-disciplinary method of assessment of prescribing competence.

Medical education has historically relied on high stakes knowledge tests sat in examination centres with invigilators monitoring academic malpractice. The COVID-19 pandemic has made such examination formats impossible, and medical educators have explored the use of online assessments as a potential replacement. This shift has in turn led to fears that the change in format or academic malpractice might lead to considerably higher attainment scores on online assessment with no underlying improvement in student competence.Here, we present an analysis of 8092 sittings of the Prescribing Safety Assessment (PSA), an assessment designed to test the prescribing skills of final year medical students in the UK. In-person assessments for the PSA were cancelled partway through the academic year 2020, with 6048 sittings delivered in an offline, traditionally invigilated format, and then 2044 sittings delivered in an online, webcam invigilated format.A comparison (able to detect very small effects) showed no attainment gap between online (The finding suggests that the transition to online assessment does not affect student performance. The findings should increase confidence in the use of online testing in high-stakes assessment.

AIMS Candidates with disabilities are eligible for reasonable adjustments (RA) while undertaking the national Prescribing Safety Assessment (PSA). The PSA is a novel open-book, time-constrained, multiformat assessment that may pose challenges to candidates with dyslexia and other disabilities. METHODS Retrospective cohort analysis of 36 140 UK candidates undertaking first-sitting of the PSA (2014-2018). RESULTS Of the 36 140 candidates, 9.1% (3284) were registered for RA. The RA group had lower pass rates (absolute difference 1.94%, 95% confidence interval 1.01-2.87%; P < .001) and assessment scores (1.16 percentage marks, 95% confidence interval 0.83-1.48; P < .001) compared with the non-RA group. This absolute difference is small relative to overall variability. This difference persists after adjusting for confounding factors (medical school and paper), and was present for all 8 different question types. The attainment gap within each medical school is negatively correlated with the school's overall performance, both in terms of pass rate (P < .001) and scores (P = .01). The RA group were also less likely to perceive the PSA as an appropriate test, having easy to follow layout/presentation or clear/unambiguous questions, even after adjusting for candidate performance. CONCLUSION This analysis identifies slight differences in academic performance of candidates requiring RA in a national undergraduate assessment. The study is limited by the unavailability of data on ethnicity, sex, age, diagnosis and time of diagnosis. While further research is required to determine the cause of the attainment gap, this study emphasises the need to maintain a careful review on the fairness and validity of all aspects of the assessment.

All retroviruses encode a Gag polyprotein containing an N-terminal matrix domain (MA) that anchors Gag to the plasma membrane and recruits envelope glycoproteins to virus assembly sites. Membrane binding by the Gag protein of HIV-1 and most other lentiviruses is dependent on N-terminal myristoylation of MA by host Nmyristoyltransferase enzymes (NMTs), which recognize a six-residue “myristoylation signal” with consensus sequence: M(1)GXXX[ST]. For unknown reasons, the feline immunodeficiency virus (FIV), which infects both domestic and wild cats, encodes a non-consensus myristoylation sequence not utilized by its host or by other mammals (most commonly: M(1)GNGQG). To explore the evolutionary basis for this sequence, we compared the structure, dynamics, and myristoylation properties of native FIV MA with a mutant protein containing a consensus feline myristoylation motif (MA(NOS)) and examined the impact of MA mutations on virus assembly and ability to support spreading infection. Unexpectedly, myristoylation efficiency of MA(NOS) in E. coli by co-expressed mammalian NMT was reduced by ~70% compared to the wild-type protein. NMR studies revealed that residues of the N-terminal myristoylation signal are fully exposed and mobile in the native protein but partially sequestered in the MA(NOS) chimera, suggesting that the unusual FIV sequence is conserved to promote exposure and efficient myristoylation of the MA N-terminus. In contrast, virus assembly studies indicate that the MA(NOS) mutation does not affect virus assembly, but does prevent virus spread, in feline kidney cells. Our findings indicate that residues of the FIV myristoylation sequence play roles in replication beyond NMT recognition and Gag–membrane binding.

Aims To identify and evaluate clinical pharmacology (CP) online curricular (e-Learning) resources that are internationally available for medical students. Methods Literature searches of Medline, EMBASE and ERIC databases and an online survey of faculty members of international English language medical schools, were used to identify CP e-Learning resources. Resources that were accessible online in English and aimed to improve the quality of prescribing specific medications were then evaluated using a summary percentage score for comprehensiveness, usability and quality, and for content suitability. Results Our literature searches and survey of 252 faculty (40.7% response rate) in 219 medical schools identified 22 and 59 resources respectively. After screening and removing duplicates, 8 eligible resources remained for evaluation. Mean total score was 53% (standard deviation = 13). The Australian National Prescribing Curriculum, ranked highest with a score of 77%, based primarily on very good ratings for usability, quality and suitable content. Conclusion Using a novel method and evaluation metric to identify, classify, and rate English language CP e-Learning resources, the National Prescribing Curriculum was the highest ranked open access resource. Future work is required to implement and evaluate its effectiveness on prescribing competence.

BackgroundIncreasingly the global policy direction is for patient-facing pharmacist prescribers. The ‘UK Prescribing Safety Assessment’ (PSA) was developed for medical graduates to demonstrate prescribing competencies in relation to the safe and effective use of medicines.ObjectivesTo determine PSA performance of final year undergraduate student pharmacists (year 4) and pre-registration pharmacy graduates (year 5) and explore their opinions on its suitability. SettingScotland, UKMethodsFinal year undergraduates (n= 238) and pharmacy pre-registration graduates (n= 167) were briefed and undertook the PSA. PSA questions were mapped to specific thematic areas with 30 questions over 60 minutes. Data was analysed using descriptive statistics. A questionnaire was completed to gauge opinions on appropriateness of the PSA.Main Outcome Measure PSA scoresResultsMean total PSA score for pre-registration graduates (64.4, SD 10) was significantly higher than for undergraduates (51.2, SD 12.0,) (pConclusionHospital graduates performed better than the undergraduates, but there is a need to improve prescribing skills in all, most notably in diagnostic skills. The PSA is acceptable to the participants. These results will help inform pharmacy curricula development and provides a cross-disciplinary method of assessment of prescribing competence.

Online learning, an essential component of most traditional contact-based educational programs, must be of high quality to contribute effectively to learning. The availability of first-class web-based materials is particularly valued by both learners and educators in resource-poor nations. In this Practice article, we introduce the International Union of Basic and Clinical Pharmacology (IUPHAR) Pharmacology Education Project (PEP) (https://www.pharmacologyeducation.org/), a freely accessible online learning resource intended to support education and training in pharmacological sciences worldwide.

Background Prescribing is a complex task requiring considerable knowledge and skills. The Prescribing Safety Assessment (PSA) was developed by the British Pharmacological Society and the United Kingdom (UK) Medical Schools Council. Between February and June 2014, over 7000 final year medical students undertook the PSA, with an overall pass rate of 94%. Independent prescribing for suitably trained pharmacists was introduced in the UK in 2006. To date there has been little focus on any objective measures of prescribing safety. Objective To determine the PSA performance of a pilot group of pharmacist prescribers in Scotland relative to medical students and to test the feasibility and acceptability of running the PSA. Methods: A group of 59 pharmacist prescribers took part in ten events. The PSA consisted of 30 questions to be completed over 60 min. All questions had been used in the 2014 assessments for final year medical students. The PSA was undertaken online under invigilated conditions, mirroring the medical student assessment. One month later, participants were invited to complete an online evaluation questionnaire. Results The mean overall PSA scores (±SD) were 87.5% ± 8.7 (range 52–98) compared to a 88.5% for medical students. Based on an Angoff passmark of 76.0%, 53 pharmacists (89.8%) passed compared to an overall pass rate in PSA 2014 of 94%. Pharmacists performed equivalently to medical students in all assessment areas, with a slightly lower performance in the prescribing, drug monitoring and data interpretation questions offset by better performance in prescription review and adverse drug reactions. Feedback was positive in relation to appropriateness, relevance and level of difficulty of the PSA although several commented that they were practicing in very specific clinical areas. Conclusion These pilot events have benchmarked the PSA performance of pharmacist prescribers with final year medical students, and feedback confirmed feasibility and acceptability.

With evidence on gaps between expectations of entering residents and their performance in both medication ordering and prescription writing, our study is an attempt to document the extent to which related topics are being covered in undergraduate medical education. Results received from an online survey conducted through the American Medical Student Association found that a high percentage of clinical year students had little or no experience in writing or ordering prescriptions. Our results suggest that there is a lack of adequate coverage of these topics and this, at least partly, could explain the higher medication errors among entering residents.

The past decade of political failure on climate change has cost us all dear. It has shrunk the time left for action by two-thirds. In 2010, the world thought it had 30 years to halve global emissions of greenhouse gases. Today, we know that this must happen in ten years to minimize the effects of climate change. Incremental shifts that might once have been sufficient are no longer enough.

Background This paper seeks to contribute to a reputable evidence base for required competencies across different topics in statistics and probability (statistical topics) in preparing medical graduates for clinical practice. This is in order to inform the prioritization of statistical topics within future undergraduate medical curricula, while exploring the need for preparing tomorrow’s doctors to be producers, and not merely consumers, of statistics. Methods We conducted a comprehensive online survey from July 2013 to August 2014 for a target group of 462 medical graduates with current or prior experience of teaching undergraduate medical students of the University of Edinburgh of whom 278 (60.2%) responded. Statistical topics were ranked by proportion of respondents who identified the practice of statistics, performing statistical procedures or calculations using appropriate data, as a required competency for medical schools to provide in preparing undergraduate medical students for clinical practice. Mixed effects analyses were used to identify potential predictors for selection of the above competency and to compare the likelihood of this selection for a range of statistical topics versus critical appraisal. Results Evidence was gleaned from medical graduates’ experiences of clinical practice for the need for, not only a theoretical understanding of statistics and probability but also, the ability to practice statistics. Nature of employment and statistical topic were highly significant predictors of choice of the practice of statistics as a required competency ((F = 3.777, p Conclusions The model of medical graduates as mere consumers of statistics is oversimplified. Contrary to what has been suggested elsewhere, statistical learning opportunities in undergraduate medicine should not be restricted to development of critical appraisal skills. Indeed, our findings support development of learning opportunities for undergraduate medical students as producers of statistics across a wide range of statistical topics.

In this essay, we examine member state approaches to European development cooperation through the lens of collective action. We observe that successful collective action requires a combination of both culture and calculus. We suggest that the European debate sometimes suffers from an excess of one and a shortfall in the other – and vice-versa. We note that different perspectives can be explained by different geopolitical realities. We conclude that it is better to walk on two legs than hop along on one – and that judicious application of collective action theory can help this happen.

Prescribing medicines is the primary tool used by most healthcare systems to cure illness, relieve symptoms and prevent future disease. Prescribing is probably the most complex intellectual task required of doctors, requiring the formulation of an appropriate treatment regimen from the many thousands available, taking into account the infinite variation in the patients they encounter. Not surprisingly, suboptimal prescribing is common and represents an obvious target for quality improvement in healthcare. Common prescribing errors include omission of medicines that are indicated, selecting inappropriate drugs, choosing an incorrect dosage or frequency of administration and failures in the prescription-writing process. Factors involved in poor prescribing include the performance of prescribers themselves, the complexity of the tasks required of them and the systems in which they work. Prescribing can be improved by better education and training of prescribers, focusing on a rational approach. Other improvements should include better supervision and team-working, input from clinical pharmacists, electronic prescribing systems supported by decision support software, standardization of prescribing documentation and governance arrangements that recognize the importance of prescribing as part of good healthcare.

Objective The aim was to assess patterns in reporting of adverse drug reactions (ADRs) via the Yellow Card (YC) Scheme following a Scottish community pharmacy patient YC promotional campaign (January–February 2011).

Introduction Medical textbooks are an important teaching supplement. Few have junior doctors or medical students (‘juniors’) as primary contributors. However, the strengths of junior-led face-to-face teaching are now well-established, and we hypothesized that similar advantages would be transferrable to a textbook setting. Methods Juniors were approached to contribute to an independently published medical textbook, with senior clinicians recruited in parallel to ensure factual accuracy. Juniors directed every aspect of textbook writing and the production process. The published book stressed that it was an open collaboration with readers, inviting them to get in touch to evaluate the text and suggest ideas for new titles. Results Of 75 respondents, 93 % awarded the first textbook in the series 4 or 5 out of 5 for overall quality. Five other titles have been released, with seven more in development. Over 100 juniors are currently involved, with two students progressing from reviewers to editors after less than a year of mentorship. Conclusion Juniors can be a motivated, dynamic, innovative group, capable of significant contributions to the medical textbook literature. This initiative has generated a sustainable infrastructure to facilitate junior-led publishing, and has the capacity for expansion to accommodate new initiatives and ideas.

Effective teaching in pharmacology and clinical pharmacology and therapeutics (CPT) is necessary to make medical students competent prescribers. However, the current structure, delivery, and assessment of CPT education in the European Union (EU) is unknown. We sent an online questionnaire to teachers with overall responsibility for CPT education in EU medical schools. Questions focused on undergraduate teaching and assessment of CPT, and students' preparedness for prescribing. In all, 185 medical schools (64%) from 27 EU countries responded. Traditional learning methods were mainly used. The majority of respondents did not provide students with the opportunity to practice real-life prescribing and believed that their students were not well prepared for prescribing. There is a marked difference in the quality and quantity of CPT education within and between EU countries, suggesting that there is considerable scope for improvement. A collaborative approach should be adopted to harmonize and modernize the undergraduate CPT education across the EU.

Medical textbooks remain an integral component of the undergraduate education pathway. These texts are traditionally prepared by senior clinicians or academics, based on their long experience of the subject matter. Medical students and junior doctors are commonly asked to review these books, but often have little role in influencing the content. This article will discuss the opening of a new paradigm in medical publishing, whereby students and junior doctors (juniors) take the lead in planning and producing the content of their textbooks with senior clinicians taking the role of reviewer.

Junior doctors write the majority of hospital prescriptions but many indicate they feel underprepared to assume this responsibility and around 10% of prescriptions contain errors. Medical smartphone apps are now widely used in clinical practice and present an opportunity to provide support to inexperienced prescribers. This study assesses the contemporary range of smartphone apps with prescribing or related content. Six smartphone app stores were searched for apps aimed at the healthcare professional with drug, pharmacology or prescribing content. Three hundred and six apps were identified. 34% appeared to be for use within the clinical environment in order to aid prescribing, 14% out with the clinical setting and 51% of apps were deemed appropriate for both clinical and non-clinical use. Apps with drug reference material, such as textbooks, manuals or medical apps with drug information were the commonest apps found (51%), followed by apps offering drug or infusion rate dose calculation (26%). 68% of apps charged for download, with a mean price of £14.25 per app and a range of £0.62–101.90. A diverse range of pharmacology-themed apps are available and there is further potential for the development of contemporary apps to improve prescribing performance. Personalized app stores may help universities/healthcare organizations offer high quality apps to students to aid in pharmacology education. Users of prescribing apps must be aware of the lack of information regarding the medical expertise of app developers. This will enable them to make informed choices about the use of such apps in their clinical practice.

Aims Prescribing errors are common and inadequate preparation of prescribers appears to contribute. A junior doctor-led prescribing tutorial programme has been developed for Edinburgh final year medical students to increase exposure to common prescribing tasks. The aim of this study was to assess the impact of these tutorials on students and tutors. Methods One hundred and ninety-six tutorials were delivered to 183 students during 2010–2011. Each student completed a questionnaire after tutorial attendance which explored their previous prescribing experiences and the perceived benefits of tutorial attendance. Tutors completed a questionnaire which evaluated their teaching experiences and the impact on their prescribing practice. Student tutorial attendance was compared with end-of-year examination performance using linear regression analysis. Results The students reported increased confidence in their prescribing knowledge and skills after attending tutorials. Students who attended more tutorials also tended to perform better in end-of-year examinations (Drug prescribing: r = 0.16, P = 0.015; Fluid prescribing: r = 0.18, P = 0.007). Tutors considered that participation enhanced their own prescribing knowledge and skills. Although they were occasionally unable to address student uncertainties, 80% of tutors reported frequently correcting misconceptions and deficits in student knowledge. Ninety-five percent of students expressed a preference for prescribing training delivered by junior doctors over more senior doctors. Conclusions A ‘near-peer’ junior doctor-led approach to delivering prescribing training to medical students was highly valued by both students and tutors. Although junior doctors have relatively less clinical experience of prescribing, we believe that this can be addressed by training and academic supervision and is outweighed by the benefits of these tutorials.

Aims The aim of the study was to explore and compare junior doctors' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of those errors.

Background and aims There is little evidence about the benefits to junior doctors of participating in teaching, or how to train doctors as teachers. We explore (through South East Scotland based teaching programmes): (a) How prepared do junior doctors feel to teach? (b) What junior doctors consider to be the main challenges of teaching? (c) What motivates the junior doctors to continue teaching, and what is the perceived impact of teaching on their professional development? Methods and results ‘Questionnaire 1’, distributed at ‘tutor training days’, explored (i) attitudes towards teaching and (ii) tutors’ preparedness to teach. ‘Questionnaire 2’, distributed after completion of a teaching programme, evaluated the tutor experience of teaching. Results Seventy-six per cent of tutors reported no previous teacher training; 10% were able to teach during allocated work hours. The strongest motivation for teaching was to help students with their learning and to develop teaching skills. Ninety one per cent of tutors felt more prepared to teach by the end of the programme. Tutors also improved their clinical skills from teaching. Conclusions There is a body of junior doctors, who see teaching as an important part of their career, developing both teaching and clinical skills in the tutor. If teaching is expected of foundation doctors, rotas ought to be more flexible to facilitate both teaching and teacher training.

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.

Summary Background: There are increasing opportunities for junior doctors to deliver teaching as well as formally develop teaching skills. Near-peer teaching (NPT) programmes, like that established in South-East Scotland, not only provide additional learning opportunities for students but also have potential benefits for the teachers. Context: Achieving the multiple competencies required of both the medical school and the foundation programme poses significant challenges. Medical students have reduced exposure to bedside teaching, which may be contributing to the concerns raised regarding the clinical skills of recently graduated junior doctors. NPT increases the pool of tutors available to students, helps facilitate both practical and small group teaching and has other advantages, such as peer tutors being more approachable than senior staff. Innovation: The NPT programme in South-East Scotland was devised by a group of junior doctors keen to improve, expand and formalise NPT. It started in 2006 as one NPT programme, with 73 tutorials delivered by 18 tutors. Last year across four NPT programmes, 324 tutorials were delivered by 108 tutors, with all tutors receiving formal tutor training. In this article we describe the South-East Scotland model, and offer guidance for those interested in setting up similar programmes elsewhere. Implications: NPT, delivered by trained junior doctors, is now well established in every hospital in South-East Scotland. Our NPT model facilitates evidence-based teaching by junior doctors, is popular amongst both junior doctors and students, is sustainable and can be used as a practical example for how to generate NPT programmes elsewhere.

Falls are a major cause of morbidity and mortality in the elderly. This study examined the frequency of hospital admission for falls or fractures, and the association with a recent change in the use of cardiovascular and psychotropic medications. We conducted a retrospective case-cohort study of 39,813 patients aged >65 years from 40 Scottish general practices. Data on current prescriptions, dates of drug changes (defined as increases in dose or starting new drugs), diagnoses and clinical measurements were extracted from primary care electronic records, linked to national hospital admissions data. Multivariable logistic regression was used to model the association of change in prescribing of cardiovascular or psychotropic medication with admission to hospital for falls or fractures in the following 60 days. A total of 838 patients (2.1 %) were admitted in the 1-year study period. Following adjustment for factors including age, sex, socioeconomic deprivation, co-morbidity and current prescribing, changes in both cardiovascular and psychotropic medications were associated with subsequent admission for falls or fractures (odds ratio [OR] 1.54 [95 % confidence interval (CI) 1.17–2.03] and 1.68 [95 % CI 1.28–2.22], respectively). There was no evidence for a difference in the effect of change in medication for different cardiovascular drug types (p = 0.86), but there was evidence (p = 0.003) for variation in the association between change in different psychotropic medications and admission; the strongest associations were observed for changes in selective serotonin reuptake inhibitor (SSRI) antidepressants (OR 1.99 [95 % CI 1.29–3.08]), non-SSRI/tricyclic antidepressants (OR 4.39 [95 % CI 2.21–8.71]) and combination psychotropic medication (OR 3.05 [95 % CI 1.66–5.63]). Recent changes in psychotropic and cardiovascular medications are associated with a substantial increase in risk of hospital admission for falls and fractures. Caution should thus be taken when instigating prescribing changes in relation to these medicines, particularly in individuals already considered to be at high risk, such as those with multiple co-morbidities and the oldest old.

Many medical professionals use smartphone applications (apps) on a daily basis to support clinical decision making. Opioid switching (conversion of one opioid to another at equianalgesic dose) is common in clinical practice and often challenging for doctors. Apps providing an opioid conversion tool can therefore be a useful resource. Despite rapid growth in the use of medical apps, the lack of robust regulation and peer review to ensure the accuracy and reliability of app content is currently an area of concern. We searched major online app stores for apps providing an opioid dose conversion tool. We assessed output variability between apps in the dose calculation of seven opioid switches, as well as assessing the level of professional medical involvement in the authorship, creation and design of the apps. Of 23 different apps identified, more than half (n = 12; 52 %) had no stated medical professional involvement and only 11 (48 %) apps provided direct references to primary sources for their opioid conversion ratios. Conversion of 1 mg of oral morphine to oral codeine demonstrated the largest conversion output range (median 6.67 mg, range 3.333–12 mg). Conversion of 1 mg of oral morphine to methadone ranged from 0.05–0.67 mg, with only 44 % of methadone-converting apps (n = 4) commenting that the conversion ratio changes with magnitude of methadone dose. Overall, 35 % of apps (n = 8) did not warn the user about the standard practice of dose reduction when opioid switching. There was a statistically significant difference in the mean conversion output for hydromorphone (oral) between apps with and without medical professional involvement (0.2256 vs 0.2536; p = 0.0377). There are significant concerns with regard to the reliability of information provided by apps offering opioid dose conversion, with lack of information regarding evidence-based content and peer review in many cases. It is crucial that better regulation of medical apps is instigated in order to ensure that patient safety is maintained.

Prescribing is one of the commonest tasks expected of new doctors and is a complex process involving a mixture of knowledge, judgement and skills. Preparing graduates to be prescribers is one of the greatest challenges of modern undergraduate medical education and there is some evidence to suggest that training could be improved. The aims of this article are (i) to review some of the challenges of delivering effective prescribing education, (ii) to provide a clear statement of the learning outcomes in clinical pharmacology and prescribing that should be expected of all medical graduates and (iii) to describe a curriculum that might enable students to achieve these outcomes. We build on the previous curriculum recommendations of the British Pharmacological Society and take into account those of other key bodies, notably the General Medical Council. We have also reviewed relevant evidence from the literature and set our work in the context of recent trends in medical education. We divide our recommended learning objectives into four sections: principles of clinical pharmacology, essential drugs, essential therapeutic problems and prescribing skills. Although these will not necessarily be accepted universally we believe that they will help those who design and map undergraduate curricula to explore potential gaps and identify improvements.

Preparing medical students to prescribe is a major challenge of undergraduate education. They must develop an understanding of clinical pharmacology and acquire knowledge about drugs and therapeutics, as well as the skills to prescribe for individual patients in the face of multiple variables. The task of delivering the learning required to achieve these attributes relies upon limited numbers of teachers, who have increasingly busy clinical commitments. There is evidence that training is currently insufficient to meet the demands of the workplace. e-Learning provides an opportunity to improve the learning experience. The advantages for teachers are improved distribution of learning content, ease of update, standardization and tracking of learner activities. The advantages for learners are ease of access, greater interactivity and individual choice concerning the pace and mix of learning. Important disadvantages are the considerable resource required to develop e-Learning projects and difficulties in simulating some aspects of the real world prescribing experience. Pre-requisites for developing an e-Learning programme to support prescribing include academic expertise, institutional support, learning technology services and an effective virtual learning environment. e-Learning content might range from complex interactive learning sessions through to static web pages with links. It is now possible to simulate and provide feedback on prescribing decisions and this will improve with advances in virtual reality. Other content might include a student formulary, self-assessment exercises (e.g. calculations), a glossary and an on-line library. There is some evidence for the effectiveness of e-Learning but better research is required into its potential impact on prescribing.

Prescribing of medicines is the key clinical activity in the working life of most doctors. In recent years, a broad consensus regarding the necessary competencies has been achieved. Each of these is a complex mix of knowledge, judgement and skills. Surveys of those on the threshold of their medical careers have revealed widespread lack of confidence in writing prescriptions. A valid and reliable assessment of prescribing competence, separate from an overall assessment of medical knowledge and skill, would have many benefits for clinical governance and patient safety, and would provide a measure of the success of training programmes in therapeutics. Delivering such an assessment presents many challenges, not least of which are the difficulty in identifying a surrogate marker for competent prescribing in clinical practice and the challenge of ensuring that competence assessed in a controlled environment predicts performance in clinical practice. This review makes the case for an on-line OSCE as the most valid form of assessment and sets out the requirements for its development, scope, composition and delivery. It describes an on-going attempt to develop a national assessment of prescribing skills towards the end of undergraduate medical training in the UK.

Pharmacodynamics is the study of how drugs have effects on the body. The most common mechanism is by the interaction of the drug with tissue receptors located either in cell membranes or in the intracellular fluid. The extent of receptor activation, and the subsequent biological response, is related to the concentration of the activating drug (the agonist). This relationship is described by the dose–response curve, which plots the drug dose (or concentration) against its effect. This important pharmacodynamic relationship can be influenced by patient factors (e.g. age, disease) and by the presence of other drugs that compete for binding at the same receptor (e.g. receptor antagonists). Some drugs acting at the same receptor (or tissue) differ in the magnitude of the biological responses that they can achieve (i.e. their efficacy) and the amount of the drug required to achieve a response (i.e. their potency). Drug receptors can be classified on the basis of their selective response to different drugs. Constant exposure of receptors or body systems to drugs sometimes leads to a reduced response (i.e. desensitization).

Clinical pharmacology and therapeutics is the academic discipline that informs rational prescribing of medicines. There is accumulating evidence that a significant minority of prescriptions in the UK National Health Service contain errors. This comes at a time when the approach to and success of undergraduate education in this area has been called into question. Various stakeholders are now in agreement that this challenging area of undergraduate education needs to be strengthened. The principles that should form the basis of future educational strategy include greater visibility of clinical pharmacology and therapeutics in the curriculum, clear learning outcomes that are consistent with national guidance, strong and enthusiastic leadership, a student formulary, opportunities to practice prescribing, a robust assessment of prescribing competencies and external quality control. Important new developments in the UK are Prescribe, a repository of e-learning materials to support education in clinical pharmacology and prescribing, and the Prescribing Skills Assessment, a national online assessment designed to allow medical students to demonstrate that they have achieved the core competencies required to begin postgraduate training.

Prescribing medicines safely and effectively represents one of the greatest challenges for healthcare systems. Prescribing errors are common. A recent prospective observational study in the UK suggested that 10% of hospital prescriptions contained errors and that senior doctors were almost as frequently culpable as those who had recently graduated [1]. Avoidable adverse drug reactions are a frequent cause of consultations in primary care, admission to hospital and increased length of hospital stay [2, 3]. All healthcare providers should be striving to provide high-quality prescribing that meets the goals of being safe, effective, cost-effective and patient-centred [4]. The reasons for this failure to deliver these optimal standards of care are multiple but can be broadly divided into those that surround individuals, such as education and training and those that relate to the systems in which they work. The healthcare environment is now increasingly demanding for prescribers because of the widening choice of medicines available, expanding indications for drug treatment, greater complexity of treatment regimens and associated ‘polypharmacy’, and a more elderly and vulnerable patient cohort. The other major challenge is the pace of change in therapeutics. New evidence on effectiveness, emerging safety signals and altered costs means that what is considered good prescribing today may not necessarily be so in a year. Amidst all of these pressures it is now clear that the mid-20th century model of training prescribers in medical school and providing them with books of reference information (e.g. national or local formularies) is no longer fit for purpose. The modern day prescriber will need electronic drug information that is instantly available and in a logical format that can interface with the electronic health record and decision support systems. Bringing these three developments together has the potential to help prescribers to improve selection and dosage of drugs, make better predictions of adverse effects and interactions and will also help patients to engage more fully in the process of selecting and monitoring their own treatment. However, there is plenty of evidence to suggest that delivery of information could be improved [5, 6]. A recent report of healthcare in six European member states (Czech Republic, France, the Netherlands, Sweden, Spain and the UK) estimated that about 100 000 inpatient adverse drug events could be avoided each year in the six member states by implementing better electronic drug services [5]. This would correspond to an annual saving of €300m in bed days. The potential for improved information technology to save money and advance important political objectives such as patient safety, healthcare access and continuity of care should accelerate our efforts to develop new and user-friendly sources of drug information. So what might a new electronic system look like? It will involve several important elements including an electronic health record (EHR), a computerized physician order entry system (CPOE) and a highly developed decision support system (DSS). Each of these elements will have to be underpinned by access to an authoritative, standardized, validated and regularly updated repository of information about prescribed drugs (dosages, packages and mode of administration; Figure 1). Although many parts of the electronic prescribing vision are already in place there is still a lack of standardized electronic drug information (EDI) that can be integrated easily into DSS and EHRs. The need for standardized formats of structure, storage, visualization and communication of drug information has been highlighted in various reports [6, 7]. Figure 1 The e-SPC structure with data content can be co-ordinated with other data sources and knowledge databases, as well as electronic health records (EHR) and decision support systems (DSS), to implement a new model of electronically supported prescribing. ... How can EDI be developed? The European Medicine Agency (or the national regulatory bodies) currently require the manufacturers of all medicines to provide a summary of product characteristics (SPC) prior to the granting of a market authorization. The SPC contains detailed information about the medicinal product accumulated during the development process and regularly updated after approval and can help health professionals to use the medicinal product safely and effectively. The current SPC is a chapter-based document available only as plain free text. Each is available as a single document file and is published in portable document format running typically to between 10 and 30 pages. Its length and the fragmentation of information make them time-consuming to read and data hard to retrieve. Prescribers simply do not have the time to consult them as they make rapid ‘point of care’ decisions in clinical practice [8, 9]. Although this information provides support for health professionals as they initiate and supervise treatment safely and effectively, it falls short of the standardization and detail required to make accurate predictions on outcome. For example, adverse effects of medicines need to be described in standard terms and grouped according to frequency and body system that they affect. Dosing decisions require detailed information about pharmacokinetics in different groups of patients and drug indications should be described with specific diagnostic codes for easy linkage to patient data in EHRs. These problems emphasize the need for a detailed and carefully structured SPC that is available in a logical electronic format (e-SPC) that can complement the increasingly detailed information available in EHRs (e.g. past diseases and care episodes, current and past medicines, physiological and biochemical data). A major challenge is that a new e-SPC that offers relevant data to support complex decisions regarding, e.g. dose selection, will require information about parameters that are currently not available (or only incompletely) at the time of marketing. For example, the current SPC gives insufficient details to allow prescribers to make common dose adjustments necessitated by factors such as renal impairment or drug interactions [10, 11] and variations in pharmacokinetics are not well supported [12, 13]. Providing these details will involve not only pre-licensing studies but also careful accumulation of relevant data in the post-marketing phase. This will have to focus more clearly on parameters that will be of importance to patients who will be exposed to the drug, doctors who prescribe it and those who administer the drugs. The primary focus of future efforts with improved drug information should be to support prescribers and patients but the new e-SPC could also help other groups. These might include: (i) drug companies or clinical researchers during pre- and post-registration clinical drug development; (ii) clinical researchers who wish to combine existing EHRs with the results of prospective clinical trials to understand better how drugs produce their beneficial and adverse effects; and (iii) pharmacoepidemiologists who wish to understand safety signals derived from observational studies in large linked data sets. All of these groups would have access to carefully structured and predictable information that could be integrated into their own data sets. There will be many hurdles to overcome before rolling out the new era of EDI. The new e-SPC format needs to be specified and this will require agreement between stakeholders in the pharmaceutical industry, the regulators and healthcare providers. Another important stakeholder will be those who develop CPOE and DSS systems with which e-SPC would have to integrate. There will need to be an effective education package created, together with guidelines for use in other software systems across European healthcare institutions. It will be a major task to convert all, or even a subset of, the existing SPCs to the new format. While we strongly support the utilization of new technology to deliver extra layers of safety to the complex task of prescribing, we also readily acknowledge that such systems offer the potential to introduce new kinds of hazards [14, 15]. The introduction of CPOE and DSS systems requires close monitoring to identify potential flaws [16] and unanticipated clinical risk situations [15]. Nevertheless, prescribing-related errors and harm are so common that we should address these new challenges and not lose sight of the potential gains that the new electronic prescribing era will offer [17]. Notwithstanding all of these challenges it is clear that structured and standardized electronic drug information that can be easily accessed is vital for future clinical drug development, clinical drug research and for improving the prescribing decisions that are made at the point of patient care across Europe. Such a development will also help to enhance overall efficiency in the use of healthcare resources and will establish drug information standards that will benefit development of medical guidelines and knowledge bases by medical professional organizations and universities [18]. This development will not happen without the input of considerable effort and resource at a time when budgets are tight. However, looking at the costs currently imposed by suboptimal use of medicines in Europe the question should not be ‘Can we afford to do this?’ but rather ‘Can we afford NOT to do this?’.

AIMS Relevant and easily accessible drug information at point-of-care is essential for physicians' decision making when prescribing. However, the information available by using Clinical Decision Support Systems (CDSSs) often does not meet physicians' requirements. The Summary of Product Characteristics (SmPC) is statutory information about drugs. However, the current structure, content and format of SmPCs make it difficult to incorporate them into CDSSs and link them to relevant patient information from the Electronic Health Records. The aim of the study was to evaluate the perceived needs for drug information among physicians in Sweden. METHODS We recruited three focus group discussions with 18 physicians covering different specialities. The information from the groups was combined with a questionnaire administered at the beginning of the group discussions. RESULTS Physicians reported their needs for knowledge databases at the point of drug prescribing. This included more consistent information about existing and new drugs. They also wished to receive automatically generated alerts for severe drug-drug interactions and adverse effects, and to have functions for calculating glomerular filtration rate to enable appropriate dose adjustments to be made for elderly patients and those with impaired renal function. Additionally, features enhancing electronic communication with colleagues and making drug information more searchable were suggested. CONCLUSIONS The results from the current study showed the need for knowledge databases which provide consistent information about new and existing drugs. Most of the required information from physicians appeared to be possible to transfer from current SmPCs to CDSSs. However, inconsistencies in the SmPC information have to be reduced to enhance their utility.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Dose calculation errors are an important cause of some of the most serious medication incidents in advanced healthcare systems. • A number of small studies have shown that dose calculations are poorly performed by hospital doctors, nurses and medical students. WHAT THIS PAPER ADDS • The performance of dose calculations was highly variable amongst a large cohort of medical students from a leading UK medical school. • Calculations that involved converting concentrations expressed as percentage or calculating infusion rates were identified as major weaknesses. • The availability of an online self-assessment and education package, coupled with encouragement and twice-yearly formative assessment, led to a significant improvement in performance. AIMS Dose calculation errors can cause serious life-threatening clinical incidents. We designed eDrugCalc as an online self-assessment tool to develop and evaluate calculation skills among medical students. METHODS We undertook a prospective uncontrolled study involving 1727 medical students in years 1–5 at the University of Edinburgh. Students had continuous access to eDrugCalc and were encouraged to practise. Voluntary self-assessment was undertaken by answering the 20 questions on six occasions over 30 months. Questions remained fixed but numerical variables changed so each visit required a fresh calculation. Feedback was provided following each answer. RESULTS Final-year students had a significantly higher mean score in test 6 compared with test 1 [16.6, 95% confidence interval (CI) 16.2, 17.0 vs. 12.6, 95% CI 11.9, 13.4; n= 173, P < 0.0001 Wilcoxon matched pairs test] and made a median of three vs. seven errors. Performance was highly variable in all tests with 2.7% of final-year students scoring < 10/20 in test 6. Graduating students in 2009 (30 months' exposure) achieved significantly better scores than those in 2007 (only 6 months): mean 16.5, 95% CI 16.0, 17.0, n= 184 vs. 15.1, 95% CI 14.5, 15.6, n= 187; P < 0.0001, Mann–Whitney test. Calculations based on percentage concentrations and infusion rates were poorly performed. Feedback showed that eDrugCalc increased confidence in calculating doses and was highly rated as a learning tool. CONCLUSIONS Medical student performance of dose calculations improved significantly after repeated exposure to an online formative dose-calculation package and encouragement to develop their numeracy. Further research is required to establish whether eDrugCalc reduces calculation errors made in clinical practice.