- Clinical indications on hospital prescriptions can improve patient safety, but will increase the length of time healthcare professionals (HCPs) spend prescribing.
- Overall, 23% of responding NHS trusts do not mandate clinical indications on hospital prescriptions.
- Governance issues and patient confidentiality were considered a barrier to incorporating a clinical indication on a prescription.
- Documenting medicines prescribed on admission were considered more of a transcribing process than a prescribing process, where accuracy may be an issue.
- Differences in functionality between prescribing systems affected HCP completion rates; paper-based systems were reported as superior to electronic prescribing and medicines administration systems (where a mandatory field was not used).
- Including clinical indications for newly initiated medicines could be more achievable.
Prescriptions should communicate information in an effective, succinct, timely and legible manner so that the intended treatment is correctly given to the patient,
. When prescribing for hospital inpatients, the details of the medicine are typically entered onto paper or an electronic prescribing and medicines administration (EPMA) system. The structured format of the prescription/EPMA form prompts the prescriber to include all relevant details
. The prescription then becomes the basis for further prescribing, medicine review, supply and administration.
A lack of written documentation and the poor quality of information about prescribing decisions in medical notes have been identified as contributing to prescribing errors
. Furthermore, poor communication when patients are transferred between wards or care settings can lead to confusion among healthcare professionals (HCPs), potentially causing patient harm
Communication between HCPs may be improved by adding a space on the prescription chart/system for clinical indications, as recommended by the Academy of Medical Royal College’s standards, and in line with Australian and Welsh national inpatient prescription charts,,,
. Clinical indications inform why a medicine is prescribed; however, they are not always clearly recorded or easy to locate within patients’ medical records, making the appropriateness of the medicine difficult to assess,,
. The inclusion of a clinical indication is particularly important when a new treatment is initiated within a hospital environment, where the intended reason for prescribing the medicine needs to be succinct
. For example, recording the clinical indication for antibiotics is a major part of antimicrobial stewardship; visibility on the prescription and in the medical notes means HCPs are aware of both why the patient requires the antibiotic and the appropriate length of the course,
. Similarly, the inclusion of an indication for warfarin prescribing is recommended in guidelines for oral anticoagulation
. One recommendation for the design of hospital inpatient prescription charts is the inclusion of a space for the clinical indication of all regular and ‘as required’ (PRN) medicines
. With the growth in polypharmacy, the specific indication of why a patient is receiving a particular drug, rather than a general list of potential indications described in a patient information insert, is important for both patients and the HCPs delivering their care
However, there is currently no standardised, national, paper-based inpatient prescription chart in England; local NHS trusts and regions have developed their own, each with varying standards regarding the inclusion of clinical indications,,
. With a widespread move towards EPMA in secondary care, important safety-related features that should be present within such systems have been outlined, but these guidelines do not specifically mention the inclusion of clinical indications
This study reports aspects of a larger study examining the impact of EPMA on the quality of healthcare provision, particularly focusing on prescribing and medicines management processes
, and explores the impact of including clinical indications for prescribed medicines, in paper and electronic prescribing systems, in acute hospitals in England.
Approval from the Institutional Research Ethics Committee was obtained prior to recruitment. This mixed-methods study involved three elements: semi-structured telephone interviews with chief pharmacists; focus group discussions with multidisciplinary healthcare teams (MDTs); and a review of medical documentation for patients who were under the care of the focus groups’ MDTs. The study used published standards for the design of hospital inpatient charts
and trust policies were used as the standard against which clinical indication records were measured.
All data were anonymised before they were entered into a study database for analysis. A mixed-methods approach of concurrent data analysis
was undertaken; the quantitative analysis of written documentation expanded on the initial understanding gained from the descriptive qualitative analysis. Triangulation of the data was used, allowing development of a more complete picture
Semi-structured telephone interviews
Audio-recorded, semi-structured telephone interviews were conducted with chief pharmacists of acute hospital NHS trusts across England. At the time of data collection (between January and February 2012), there were 146 non-specialist acute trusts within England; 65 (45%) of the 146 chief pharmacists (who were initially contacted by letter) agreed to participate in the study. This provided an executive perspective on the use of clinical indications within the prescription chart design, as well as the type of prescribing system being used.
The semi-structured interview involved both open and closed questions that covered the use of clinical indications on prescription charts/systems (see Supplementary File). Tick boxes were used to record answers to the closed questions; responses to open questions were transcribed from the recording. Qualitative thematic analysis was carried out on the transcriptions and quantitative data were transferred into a Microsoft Excel document for analysis.
Thematic analysis of the semi-structured interviews and focus group data were completed by KS, a registered pharmacist, using a constant comparative approach
, and independently reviewed by CWM, a professor of pharmacy, prior to discussion to reach consensus on the coding framework. Constant comparison is the data-analytic process whereby each interpretation and finding is compared with existing findings as it emerges from the data analysis.
NHS trust selection
The three acute NHS trust sites (termed Hospitals A, B and C) were selected based on the following criteria to capture the diversity of the prescribing systems across England:
- The type of prescribing system used;
- When the system was implemented;
- The size of the trust;
- The location of the trust.
Hospital A was a district general hospital in England that only used the MeditechÂ® (Medical Information Technology Incorporated, London) EPMA system. Hospital B was a teaching hospital in England that used a hybrid of paper and an EPMA system supplied by JACÂ® (JAC Computer Services, Essex). Hospital C was a district general hospital in England that only used a paper prescribing system.
Focus group discussions
Focus group discussions involved MDTs from hospitals A, B and C. The discussions explored the MDTs’ opinions and experiences of using clinical indications on prescriptions.
Overall, 11 MDTs (7 from medical and 4 from surgical specialities) across the three hospitals participated in the study, with each focus group comprising of 5–9 participants. Group discussions took place between September 2012 and May 2013, with an average duration of 60 minutes (range 30–80 minutes). Overall, there were 73 participants: 28 doctors, 25 nurses and 20 pharmacists. The gender mix was 49 (67%) female to 24 (33%) male. Illustrative quotations were taken verbatim from the transcripts. Quotes were documented using the hospital letter and the focus group session number (e.g. A3 = Hospital A, focus group 3). The professional role of the speaker was also provided (e.g. nurse).
Review of medical documentation
Review of medical documentation was undertaken at the three acute NHS trusts between May and July 2013. All three hospitals had policies stating that antibiotic therapy and PRN medicines must have a clinical indication specified on the prescription. Therefore, documentation of patients who started a new antibiotic or PRN medicine while under the care of the MDTs was reviewed retrospectively. This focused on the clarity and accuracy of the clinical indication recorded on the paper or electronic prescription and/or in the medical notes. Clarity, for the purposes of this study, is a factor that relates to the ease with which the correct meaning of a prescription can be interpreted by the HCPs.
The documents reviewed included: patient-specific, hospital-based healthcare records; medical notes; nursing notes; pharmacy notes; and prescription charts relating to selected patients over a specified period. Reviews were carried out using content analysis and the recording unit, which consisted of each medical note entry made about newly initiated medicine. This was rated by KS using a five-point scale (see Table 1), termed the Medical Entry Score (MES). The MES, based on General Medical Council standards
, graded the depth of written communication around newly prescribed medicines. The MES rated the clarity and accuracy of the written content provided in each recording unit, similar to previous studies
. An MES of 1–2 required the entry to show a clear clinical indication of the drug that was connected to the new medicine, whereas an MES of 3–5 did not. However, it must be noted that the MES is not a validated tool.
| Table 1: The definition and meaning of the Medical Entry Score|
|1||Clear and accurate direction||The standard of clarity and accuracy is such that the reason for initiation is clearly provided, along with the medicine details (dose and frequency), and so may be acted on with confidence.|
|2||Implied direction||The standard of clarity is such that there is a reason for initiating a new medicine, along with the medicine name; however, no specific medicine details are provided.|
|3||Implied but no clear direction||There is mention of a possible indication within the entry but no specific connection is made between the medicine and the indication.|
|4||No clear direction||The new medicine is documented as a “group” of medicines, with or without an indication given.|
|5||No direction||There is no documentation of indication or new medicine.|
The themes that emerged after triangulation of the results included clinical workflow, practicality, accuracy, regulation and patient safety.
Chief pharmacists’ perspectives
In total, 65 (45%) of the 146 chief pharmacists contacted agreed to participate and came from a range of acute trusts. However, one of these chief pharmacists did not provide any information. Therefore, of those providing information, 72% (n=46/64) reported that a clinical indication must be included on inpatient prescriptions for antibiotics and 39% (n=25/64) for warfarin. Overall, 23% (n=15/64) of trusts did not require an indication for any medicine on their prescription charts (see Table 2).
Only 12 (18%) chief pharmacists stated that their trust had EPMA in place or were actively implementing an EPMA for use on some or all inpatient wards, while the remainder used a paper-based system.
The antibiotic stewardship national policy
was the motive for introducing clinical indications on prescriptions by 63% (n=31/49) of chief pharmacists. It should be noted that only 49 chief pharmacists responded to this question as some were not aware of the policy at the time. Other circumstances where the clinical indication was required included unlicensed medicines, ‘Payment by Results’-excluded medicines
, National Institute for Health and Care Excellence (NICE)-approved drugs, proton pump inhibitors, low-molecular-weight heparins, anticoagulants, chemotherapeutic agents and immunoglobulins.
|Table 2: Breakdown of acute hospital NHS trusts (n=64) requiring a clinical indication on the prescription for a specific medicine|
|Clinical indication required on the prescription||Number of acute hospital trusts|
|Paper prescribing||Electronic prescribing||Total|
|‘As required’ medicines||15||1||16|
Note: chief pharmacists’ responses to the questions were obtained, but they were not specifically asked for the policy in place at the trust.
Overall, 49 trusts required an indication for a medicine to be included on inpatient prescription charts; of these, 29 (59%) stated that the indication was completed “all the time” or “most of the time”. Only seven trusts using EPMA required an indication on the prescription; of these, two stated that they were completed “all the time”, while three stated this was done “most of the time”. However, discussion with a participant from one of the EPMA trusts (see Quote 1) indicated that the completion of a clinical indication on the prescription on their system was actually less enforceable compared with the paper prescribing system.
“[The clinical indication] was always for antibiotics when we had a paper system, but it’s quite difficult to impose that with our elecronic prescribing system because you have to put it in as a note — so that’s not compulsory … it’s a disadvantage really.”
Incorporating an indication onto electronic prescriptions was perceived as supporting and improving control and feedback on the prescribing process and it was seen as facilitating governance (see Quote 2; note: primary care trusts no longer exist — alternative organisations now control budgets).
“The primary care trusts (PCTs) are requiring more and more information from us around Payment by Results (PBR)-excluded medicines and cancer therapy. So we do, by the end of this financial year, need to be providing the PCT with the clinical indication for PBR-excluded meds.”
Governance issues and patient confidentiality were considered a limitation to incorporating an indication on the prescription. It was felt that patient confidentiality could be compromised if an indication was provided on a paper prescription chart and visitors were to view this (see Quote 3).
“So my personal view is if we get around the issues to do with … concerns over patient confidentiality then it would be a nice standard to have.”
The words “helpful” or “useful” were used by 23 chief pharmacists to explain the use of a clinical indication on the prescription, suggesting that it is beneficial (see Quote 4) in assisting HCPs’ communication and clinical workflow around the prescribing process, along with providing information to patients.
“[I am] very pro [clinical indication], because I think it helps prescribers — it certainly helps pharmacists when checking the prescriptions — and also it assists with the information that we are now supposed to be sharing with patients.”
The inclusion of an indication within paper-based and electronic prescribing systems was considered to facilitate the transfer of patients, clarify the prescription, establish the clinical appropriateness of medicines and, from the viewpoint of patient safety, confirm that the prescription was correct (see Quote 5).
“[The clinical indication] gives you a lot more understanding that the drug which has been prescribed is correct, that the dose is correct and also that the actual treatment length is right.”
However, a range of opinions were expressed about the accuracy of the indication, compliance in completing the indication and whether the indication would improve patient safety. Views about which medicine should have an indication documented on the prescription varied from all medicines to just the newly initiated. One rationale given for not putting an indication on all medicines concerned junior doctors’ abilities to find the indication of a patient’s existing medicines during admission (see Quote 6). Several comments were made regarding medicines prescribed on admission being more of a transcribing process than a prescribing process and, therefore, prescribers would not know the indication of each medicine.
“I think that for certain things, [including the clinical indication] a good idea — but I think for particularly some of the regular medicines, I would be concerned that actually the junior doctors wouldn’t know and would therefore guess. Then you have actually got inaccurate information, because they won’t know when they write that drug up on admission what the clinical indication for everything is [sic].”
Making the input of an indication mandatory on a prescription was considered problematic, as it was not deemed realistic unless some degree of support was provided within an electronic prescribing system. By support, it was suggested that the electronic prescribing system could automatically provide the indications for the medicine prescribed and that the prescriber could then pick the appropriate indication.
Multidisciplinary team’s perspectives
In contrast to the chief pharmacists’ perspective that a clinical indication on an antibiotic prescription could be enforced once an EPMA system had been implemented, discussion in the focus groups indicated that this was not always possible. This is owing to the differences in functionality between different EPMA systems, which can affect the completion rate of clinical indications (see Quote 7).
“I think [it] depends if [an antibiotic prescription] was forced or if it wasn’t forced, but you have to put a reason in before you moved on or whether it was optional. If it was good practice, it probably wouldn’t get done; the things that you get done … all get done because there’s a money incentive.” (Pharmacist; B3)
The EPMA system in Hospital A forced prescribers to complete the indication. Participants questioned the prescribers provide the indication was long and had no logical order; therefore, there was a perception that HCPs were not necessarily picking the correct indication or were putting “I don’t know” (see Quote 8).
“I think that that’s very useful for the patient … I would say it is more useful in primary care but, on the e-prescription for antibiotics it’s very difficult often to find the indication that you want from the drop-down menu, so having to find it for every single medicine the patient is on and then having to find a thing to say ‘I don’t know’.” (Doctor; A3)
All focus groups agreed that an indication on all prescriptions, as proposed for the design of inpatient charts
, would be too time consuming and unrealistic in practice. As a compromise, many focus groups considered that an indication for newly initiated medicines would be beneficial for communication between HCPs and the patient, especially on discharge.
Discussions exposed how NHS trust clinical indication policies forced within the electronic system had other repercussions. Each focus group explained that, on admission, the HCPs would not necessarily know why the patient was already on medicines and, without being able to confirm with the GP, HCPs would not want to provide an indication in case it was incorrect (see Quote 9).
“I was thinking that it wouldn’t be as time consuming if, when a patient came in, you could select as a clinical indication ‘GP continuation’. Then if you did prescribe something new, you could put an indication in.” (Pharmacist; A1)
A consensus across all focus groups was that they could provide an indication for a newly initiated medicine in hospital, which would facilitate communication with GP surgeries following discharge. A comment was made about communication being reciprocal and that GP surgeries should provide an indication with the list they provide of patient medicines (see Quote 10).
Doctor: “I think there’s a case [for clinical indications] for new things; I don’t think you could ask somebody who’s clerking in the patient, who’s potentially confused and really unwell, to go through all of their medicines and say why they’re taking them — particularly when things have got multiple uses. But I think if you’re starting something new, I think that’s probably quite good practice just say why.” (B2)
Nurse: “It would also be good when patients are transferred between wards.” (B2)
Medical documents were reviewed for 89 patients under the care of the MDTs participating in the focus groups, with around 30 patients from each hospital for whom antibiotics or PRN medicines were initiated during their inpatient stay. The methods of recording the clinical indications on prescriptions for antibiotic therapy and PRN medicines varied for each hospital (see Table 3).
|Table 3: The method of recording the clinical indication on the prescription for antibiotics and ‘as required’ medicines for each hospital|
|Hospital A||The electronic prescribing and medicines administration (EPMA) system forced the prescriber to document the clinical indication of the stipulated medicines by not allowing them to continue with the prescribing process unless the information was provided.|
|Hospital B||The clinical indication of stipulated medicines was done by completing a “note” within the EPMA system, which was not compulsory and therefore the system did not enforce the prescriber to provide this information.|
|Hospital C||On the paper drug chart, there was a specific box requiring the clinical indication to be written.|
In Hospital A (which had an EPMA-based system), there was 100% (n=81) completion of the clinical indication being written, owing to the field being mandatory. However, when the accuracy of the recorded clinical indications was reviewed, only nine (47%) of the antibiotic entries could be confirmed as accurate from entries made in the medical notes (see Table 4) and eight (13%) of the PRN medicine entries.
In Hospital B (which had a hybrid paper-based and EPMA system), the indication in some PRN medicine cases was already populated within the electronic prescription because it was part of an “order set”. Of the 19 new antibiotic prescriptions, 8 (42%) had a clinical indication, and of the 41 new PRN medicine prescriptions, 22 (54%) had a clinical indication given.
In Hospital C (which had a paper-based system), the general term ‘antibiotics prescribed’ was used within the medical note entries on a number of occasions to signify that a new antibiotic had been initiated. Of the 35 new antibiotic prescriptions, 20 (57%) had a clinical indication, and of the 24 new PRN medicine prescriptions, 16 (67%) had a clinical indication given.
The completion rate of the clinical indications in Hospital C was, therefore, superior to that of Hospital B where the EPMA system did not force the prescriber into completing the information. However, the accuracy of the indication in Hospital C (35% and 12%) showed that the indication might be completed, but that it is not necessarily accurate, replicating the finding in Hospital A (47% and 13%).
The clarity of a prescription is enhanced by having a clinical indication for PRN or antibiotic drugs. However, this clarity can be compromised and the accuracy disputed if the indication on the prescription is incorrect or not completed (see Table 4).
|Table 4: The number of newly initiated antibiotic medicines and ‘as required’ medicines with a completed clinical indication on the prescription and the accuracy of the clinical indication provided from the medical note entries for 89 inpatients at three hospitals|
|Category|| Number per hospital|
|Hospital A||Hospital B||Hospital C|
|New antibiotic prescriptions||19||19||35|
|New antibiotic prescriptions with a clinical indication provided||19 (100%)||8 (42%)||20 (57%)|
|New antibiotic prescriptions with a clinical indication provided and a Medical Entry Score (MES) of 1 or 2 (confirming accuracy of the clinical indication)||9 (47%)||6 (75%)||7 (35%)|
|New antibiotic prescriptions with an MES of 3–5 (did not clearly connect the reason for initiation with the medicine)||10 (53%)||2 (25%)||13 (65%)|
|New ‘as required’ prescriptions||62||41||24|
|New ‘as required’ prescriptions with a clinical indication provided||62 (100%)||22 (54%)||16 (67%)|
|New ‘as required’ prescriptions with a clinical indication provided and a MES of 1 or 2||8 (13%)||0 (0%)||2 (12%)|
|New PRN prescriptions with an MES of 3–5||54 (87%)||22 (100%)||14 (87%)|
Note: No statistical comparison was made across hospitals as there was a limited data pool.
The data collected from the chief pharmacists, MDTs and patient records were triangulated, which enhanced valid and robust outcomes
. These data were used to explore the use of indications from a variety of different viewpoints. The themes that emerged after triangulation
included clinical workflow, practicality, accuracy, regulation and patient safety.
The ability to check that a prescription is appropriate for a patient by having a clinical indication on the prescription was perceived by chief pharmacists and the MDTs to speed up the medication review process. The inclusion of clinical indications was also considered “helpful” or “useful” in assisting the prescribing, prescription review and administration process in comparison with typical practice where clinical indications seem to be rarely documented.
Lack of clarity or difficulty in locating a clinical indication in medical notes has led to prescribing errors,
. However, frontline staff from the focus groups considered that to ask prescribers to provide a clinical indication on all medicines, in line with Australian standards
, would be unduly time consuming and not realistic in practice. Chief pharmacists and the MDTs agreed that junior doctors might struggle to provide an accurate clinical indication for pre-admission medicines and that it is more of a transcribing process rather than prescribing. Therefore, the consensus was that it would be achievable to provide an indication for newly initiated medicines and facilitate communication with GP surgeries following discharge.
Quantitative data from the telephone interviews showed that very few trusts required a clinical indication on all prescriptions. By contrast, nearly a quarter of trusts did not require an indication for any medicines on their prescription charts (see Table 2). Mandatory input of an indication in EPMA was considered problematic and not realistic unless some degree of electronic support was given. Therefore, consideration should be given for the reverse workflow, where the clinical indication is entered and suggested medicines for the indication of choice are provided.
National prescribing policies, such as those for antibiotic stewardship
and financial audits, were cited by chief pharmacists to be key drivers for including an indication on the prescription. However, reservations about including this information included governance issues (e.g. patient confidentiality), accuracy and poor completion rates.
The telephone interviews showed that the requirement for clinical indications on prescriptions varied across NHS trusts. Medicines where indications were required were antimicrobial therapies, followed by warfarin and PRN medicines. Very few hospitals required an indication on every prescribed medicine. Effective good practice requires guidelines, policies and procedures to be followed; in Australia, the completion rates of a clinical indication on a prescription were assessed and found to be 11.3% of all medicines
. Chief pharmacists in the UK study believed that the indication was completed all the time or most of the time in 59% of cases; however, our documentation review showed that, for newly initiated antibiotics or PRN medicines, completion rates ranged from 42–100%, depending on the prescribing system used.
Although the use of mandatory fields within an EPMA system achieved 100% completion rates, the accuracy of the information could not be verified. The effectiveness of EPMA in forcing policies, such as a requirement for an indication, is variable owing to the different functionalities available in the inpatient prescribing system and the ingenuity of staff to work around mandatory fields
. Healthcare IT software providers must consider how user-friendly their prescribing systems are and embrace user-centred design in order to support HCPs in their work, rather than creating new opportunities for error
The documentation in the medical notes of an indication was not clear on a number of occasions, possibly leading to miscommunication between members of the MDT. A distinction between pre-admission medicine on the prescription (medicines the patient is already taking prior to being admitted to hospital) and newly initiated medicine would facilitate the use of an indication on the prescription and communication between primary and secondary care.
Such inconsistencies reinforce the need for published NICE guidelines, such as ‘Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes’, which asks for communication of the clinical indication and provides additional evidence
. Although based on a relatively small sample size from three hospitals, the data suggest that vague or incomplete entry of clinical indications may be made, leading to wider clinical implications, especially when antimicrobial resistance is of great concern globally (see Table 4).
The limitations of this study exploring the accuracy of the clinical indications are owing to the lack of detailed entries in the medical notes. It does not mean that the clinical indication was conclusively wrong or inaccurate if there is no corresponding medical entry. However, the researcher cannot decisively say if the clinical indication was 100% accurate, which would also reflects a ‘real-world’ scenario. Further prospective research into the clarity and accuracy of clinical indications on the prescription is required.
Further research is also required to appreciate if a clinical indication should only be required in the hospital setting for newly initiated medicines, owing to the opinion provided by HCPs during the study. The use of a clinical indication on the prescription chart uncovered different perspectives and working practices. Therefore, it would be beneficial to further investigate the use of a clinical indication on the inpatient prescription, since access to patient data has changed; data can now be accessed through the summary care record.
This study identified different perspectives and working practices on including clinical indications for prescribed medicines — in paper and electronic prescribing systems — in acute hospitals in England. Key themes emerging from the data were practicality and reliability of information, plus clinical workflow and patient safety. Requiring an indication on hospital prescriptions improves patient safety but increases the HCPs’ time dedicated to prescribing; however, 23% of responding trusts did not mandate this practice.
Chief pharmacists whose trusts did not require a clinical indication on prescriptions considered governance issues and patient confidentiality as a barrier. Detailing medicines prescribed on admission were considered more of a transcribing process than a prescribing process, where accuracy of the clinical indication may be an issue. This resulted in a consensus that an indication for newly initiated medicines would be more achievable.
Documentation in medical notes of a clinical indication was unclear on a number of occasions, probably leading to miscommunication between members of the MDT. Chief pharmacists and frontline practitioners recognised both the risks and benefits of including the indication on the prescription, but approaches that force prescribers to document indication may be counterproductive.
Given the differences in current systems and the transcribing process on admission, a seamless national system that transports the information across systems, in terms of both care setting and IT, is required. This would, in theory, mean that the newly initiated clinical indications are the only ones which would need to be recorded. A complete redesign and approach to how a medicine is prescribed electronically may make it easier for prescribers to capture this important information from the very beginning, once the decision to prescribe a medicine is made.
Financial and conflicts of interest disclosure
The authors have no relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in this manuscript. No writing assistance was used in the production of this manuscript.
 General Medical Council. Good practice in prescribing and managing medicines and devices. 2013. Available at: https://www.gmc-uk.org/guidance/ethical_guidance/14316.asp (accessed January 2019)
 Goundrey-Smith S. Principles of Electronic Prescribing. London: Springer London; 2008
 Franklin BD, Reynolds M, Shebl NA et al. Prescribing errors in hospital inpatients: a three-centre study of their prevalence, types and causes. Postgrad Med J 2011;87(1033):739–745. doi: 10.1136/pgmj.2011.117879
 Specialist Pharmacy Service. Collaborative audit on the quality of medication related information provided when transferring patients from secondary care to primary care and the subsequent medicines reconciliation in primary care reports and tools. 2017. Available at: https://www.sps.nhs.uk/articles/a-collaborative-audit-on-the-quality-of-medication-related-information-provided-when-transferring-patients-from-secondary-care-to-primary-care-and-the-subsequent-medicines-reconciliation-in-primary-c/ (accessed January 2019)
 Australian Commission on Safety and Quality in Health Care. National inpatient medication chart 2011: National audit report. 2012. Available at: https://www.safetyandquality.gov.au/wp-content/uploads/2014/01/NIMC-2011-National-Audit-Report-PDF-1.02MB.pdf (accessed January 2019)
 Quality and Safety Group of Welsh Chief Pharmacists Committee. All Wales prescription writing standards. 2014. Available at: http://www.awmsg.org/docs/awmsg/medman/All%20Wales%20Prescription%20Writing%20Standards.pdf (accessed January 2019)
 Public Health England. Antimicrobial stewardship: Start smart — then focus. 2015. Available at: https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus (accessed January 2019)
 Public Health England. Antimicrobial prescribing and stewardship competencies. 2013. Available at: https://www.gov.uk/government/publications/antimicrobial-prescribing-and-stewardship-competencies (accessed January 2019)
 Academy of Medical Royal Colleges, Royal Pharmaceutical Society & Royal College of Nursing. Standards for the design of hospital inpatient prescription charts. 2011. Available at https://www.aomrc.org.uk/wp-content/uploads/2016/05/Standards_design_hospital_prescription_charts_0411.pdf (accessed January 2019)
 Academy of Medical Royal Colleges. Guy’s and St Thomas’ NHS FT Inpatient Medication Administration Record. 2011. Originally available at: http://www.aomrc.org.uk/projects/standards-for-the-design-of-hospital-inpatient-prescription-charts.html. Cited at: http://www.aomrc.org.uk/reports-guidance/standards-design-hospital-prescription-charts-0411/ (accessed January 2019)
 Academy of Medical Royal Colleges. The Leeds Teaching Hospitals Prescription Chart and Administration Record. 2011. Originally available at: http://www.aomrc.org.uk/projects/standards-for-the-design-of-hospital-inpatient-prescription-charts.html. Cited at: http://www.aomrc.org.uk/reports-guidance/standards-design-hospital-prescription-charts-0411/ (accessed January 2019)
 Academy of Medical Royal Colleges. University Hospitals of Leicester Adult Inpatient Medication Administration Record. 2011. Originally available at: http://www.aomrc.org.uk/projects/standards-for-the-design-of-hospital-inpatient-prescription-charts.html. Cited at: http://www.aomrc.org.uk/reports-guidance/standards-design-hospital-prescription-charts-0411/ (accessed January 2019)
 Slee A & Cousins D. Guidelines for hazard review of ePrescribing systems. 2008. Available at: http://webarchive.nationalarchives.gov.uk/20130503111545/http://www.connectingforhealth.nhs.uk/systemsandservices/eprescribing/hazard_framework.pdf (accessed January 2019)
 Shemilt K, Morecroft CW, Ford JL et al. Inpatient prescribing systems used in NHS Acute trusts across England: a managerial perspective. Eur J Hosp Pharm 2016;24(4):213–217. doi: 10.1136/ejhpharm-2016-000905
 Teddlie C & Tashakkori A. Foundations of Mixed Methods Research. Los Angeles: SAGE Publications; 2009
 Public Health England. Payment by Results in the NHS: A simple guide. 2013. Available at: https://www.gov.uk/government/publications/simple-guide-to-payment-by-results (accessed January 2019)
 Robson C. Flexible designs. In: Robson C. Real World Research. 3rd ed. London: Wiley; 2011
 NHS Commissioning Board. Commissioning for quality and innovation (CQUIN): 2013/14 guidance: Draft — December 2012. 2012. Available at: https://www.england.nhs.uk/wp-content/uploads/2012/12/cquin-guidance.pdf (accessed January 2019)
 Watcher RM. Making IT work: Harnessing the power of health IT to improve care in England. 2016. Available at: https://www.england.nhs.uk/digitaltechnology/info-revolution/wachter-review/ (accessed January 2019)
 National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE guideline [NG5]. 2015. Available at: https://www.nice.org.uk/guidance/ng5 (accessed January 2019)