Support systems: how the Royal Pharmaceutical Society is investing in the future of safe prescribing

Medication errors are one of the leading causes of preventable harm in paediatric patients, affecting around 13% of prescriptions for this patient group. Results from a systematic literature review of 16 studies, published in Drug Safety in 2004, indicated that dosing errors are the most common type of error^​1​. 

Dosing calculations for paediatric patients is an area fraught with risk in healthcare, largely owing to the need for ‘individualised dosing’ calculations. These require a prescriber to accurately measure a child’s weight, age and clinical condition to generate the correct dose for that patient. 

With all of these variables at play, clinicians writing in the BMJ Open in 2019 recommended “paediatric-specific electronic prescribing, electronic health records and clinical decision support tools” be introduced to help mitigate these errors^​2​.

Dosium’s Touchdose — a patient-specific dosage clinical decision support system (CDSS), funded in part by the Royal Pharmaceutical Society (RPS), which also publishes The Pharmaceutical Journal — is on the way towards meeting this need. 

Touchdose is an indication-based prescribing system that calculates the correct dosage of the drug for the individual patient and indication — including frequency, duration and route of administration. The patient’s details are pulled from the medical record and the system filters by characteristics, such as age and weight, to suggest only relevant treatment options. It then calculates the correct doses. 

Touchdose provides a real-time link with the British National Formulary (BNF) and BNF for Children (BNFC) — both published by the RPS – and where appropriate, other local guidelines. This makes it different to most existing CDSSs, which are reactive and only throw alerts if potential prescribing errors are detected. Touchdose has been developed to support clinicians to make the correct decision in the first instance.

The system is currently active in West London Children’s Healthcare, an amalgam of children’s services across Imperial College Healthcare NHS Trust and Chelsea and Westminster Hospital NHS Foundation Trust.

Richard Daniels, a senior paediatric register at St Mary’s Hospital, which is part of Imperial, uses the system and says the integration with local trust guidelines means he can see different prescribing options, where they differ and why.

“For example, we’ve got a big paediatric infectious disease team, so we’ve got robust antimicrobial, anti-infective guidelines and learning,” he says, which “changes hospital to hospital, and they will change their first-line preferences and their doses and so on”.

“It doesn’t always sit exactly as the BNF lists it — so, for something like that, it’s really useful,” he adds.

Ian Maconochie, consultant in paediatric emergency medicine and senior responsible officer for the project across West London Children’s Healthcare, says that another advantage of the system is that “you can actually look at prescribing practice”.

“One of the things we’re finding is, as we’re looking at all the guidelines where medication may be required across the different trusts, there’s variation in them. That is also then leading to reconciliation of those different recommended doses.

“We get much more uniform prescribing, which is obviously a good thing for pharmacists and also for patients,” he adds.

Benefits of clinical decision support systems

Research has confirmed that CDSSs do reduce errors and unwarranted variation in care and can be applied across different care settings using a range of information resources.

Touchdose in particular has been found to reduce the number of prescribing errors by more than 80%, compared with standard clinical practice, according to a small simulation study published in BMJ Quality and Safety in November 2024^​3​. The researchers asked prescribers working at West London Children’s Healthcare to complete five simulated prescribing tasks with, and five without, access to Touchdose. Results showed that Touchdose reduced the number of prescribing errors by 84% and using the system also made the process of prescribing 20% quicker.

“Further real-world evaluation and development of the system to meet the needs of more diverse patient groups, users and healthcare settings is now required,” the study says.

In addition to the patient and prescriber benefits, an economic evaluation of the system carried out by Dosium also revealed financial benefits, potentially saving the NHS £178.3m per year if it were rolled out across all of NHS secondary care.

The system’s significant potential is what drew the RPS to invest in Dosium in 2024. Announcing the move in August 2024, a statement from the Society said the investment “underscores the RPS’s belief in the company’s potential to revolutionise CDSSs in the UK and increase patient safety”.

“Our decision to collaborate with Dosium was driven by our shared core value of a dedication to improving patient safety,” says Karen Baxter, managing director of Pharmaceutical Press and deputy chief executive of the RPS.

“Creating impactful and effective clinical decision support is very difficult. Aside from ensuring the necessity for strict data accuracy, it takes time, patience and commitment to create a product, and particularly a user experience, that supports the clinician most effectively,” she adds. 

“The additional challenge of making that service patient-specific requires an extra level of dedication. Dosium impressed us by the commitment to doing the right thing for the clinician over and above the easy and quick thing for them. This is demonstrated by them choosing to tackle paediatrics first, where impact was most needed.”

Bridging the gap

Despite the clear benefits, a large-scale roll-out of any CDSS is challenging. NHS England guidance on using CDSSs, published in August 2024, says: “The uptake of CDSSs remains inconsistent and there are many barriers to widespread adoption.”

Nicholas Appelbaum, chief executive of Dosium, says the biggest barrier to scaling up CDSS use “is the belief that current CDSS approaches are ‘good enough’”.

“As long as trusts continue relying on outdated reactive solutions” — those which send alerts when a prescription is written, but before dispensing, rather than guiding users to the best prescribing solution initially — “and seek validation through frameworks… real progress will remain elusive”, he explains. 

“We need to redefine what’s possible and raise our expectations of ‘what good looks like’.”

Touchdose includes BNF and BNFC integration, which supports safer prescribing for clinicians. The system is also designed to help trusts address efficiency challenges with their “highly configured” electronic prescribing and medicines administration (EPMA) systems.

“We have built, for the very first time, a live connection between the BNF and electronic prescribing systems on the front line,” says Appelbaum, but he adds that these systems have “lots of data and rules built into them” that are currently manually input by EPMA teams.

“So, we have this emergent role of the ‘electronic pharmacist’ who configures databases, but they’re configuring these databases whilst the BNF exists as the best database in the world,” he explains.

“We bridge that gap by allowing the electronic configuration [of the EPMA] to be driven by the RPS, rather than hundreds — and it actually is hundreds — of EPMA teams across the country.”

Calendra Feather, implementation lead and clinical safety officer at Dosium, says this will “hugely reduce” the overheads of EPMA pharmacy teams “in terms of the need to duplicate a lot of the work that the BNF have already done”.

“Now that we have made it feasible to integrate with this computer readable BNF, it should reduce that need for the local hospitals nationwide to have to be transcribing the BNF into their system. So, [users] can focus more on patients,” she adds.

While the Department of Health and Social Care plans for all trusts in England to have EPMA systems in place by 2025, it is unclear how many currently do have such a system in place. However, Touchdose can also run independently of EPMAs on hospital IT systems and the clinician can enter patient details — including age, weight and height — to guide dose recommendations.

End-user focused

The RPS’s involvement with Dosium is not just a one-off investment. Feather notes that the RPS team uses the system daily as they update content, providing live feedback to the developers.

India Smith, lead writer for the Dosium project within Pharmaceutical Press — publisher of the BNF and BNFC — explains that her team assesses and updates BNF/C content for use not only in Touchdose, but across all its existing digital and print outputs.

“It requires a deep understanding of our content, structural requirements and clinical context, as well as technical and product considerations,” she says. “Throughout our work, patient safety is our top priority.”

Currently only used in paediatrics, Touchdose is part of a broader ambition. “[Dosium’s] vision is for indication-based prescribing to be the foundation of a more proactive approach to decision support,” says Appelbaum. 

“Whether it’s in paediatrics or in adult medicine, I think the benefits of getting it right first time are relevant across the board,” he adds.

Daniels puts it simply: why has no one done this before?

“I’ve worked in lots of places and do wish, ten years ago, someone had given me something like [Touchdose],” he reflects.

“If I was rotating around to a new job in another trust in six months or a year, I would be very strongly advocating my team there to have a look at it.”