•
•
•
•
•
•

The doctor as a scholar and a scientist
The graduate will be able to demonstrate knowledge of drug actions therapeutics and pharmacokinetics; drug side effects and interactions, including for multiple treatments, longterm conditions and non-prescribed medication; and also including effects on the population, such as the spread of antibiotic resistance.

The doctor as a practitioner
Outcome 17. Able to Prescribe drugs safely, effectively and economically
(a) Establish an accurate drug history, covering both prescribed and other medication.
(b) Plan appropriate drug therapy for common indications, including pain and distress.
(c) Provide a safe and legal prescription.
(d) Calculate appropriate drug doses and record the outcome accurately.
(e) Provide patients with appropriate information about their medicines.
(f) Access reliable information about medicines.
(g) Detect and report adverse drug reactions.
(h) Demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and range of these therapies, why patients use them, and how this might affect other types of treatment that patients are receiving.

Drugs as risk factors in patient well-being

• 11,077 errors were detected in 124,260 medication orders checked on seven ‘census days’ in 19 acute hospital trusts
• FY1 and FY2 doctors write most hospital prescriptions
– FY1 doctors write 40% of hospital prescriptions (50k)
– FY2: write 28%
– Consultants: write just 3%
• Prescribing is risky: Errors in 8%-11% of FY1 &
FY2 prescriptions

On-line: 24 stations; Prescribing has 8 stations; other sections have 2-4 questions each
BNF is the only reference permitted https://prescribingsafetyassessment.ac.uk/aboutpsa

• Prescribing
• Prescription review
• Planning management
• Communicating information
• Drug dose calculation
• Adverse drug reactions
• Drug monitoring
• Data interpretation
•
•
•
•
•
•
•

PSA Question Section and Domain grid
https://prescribingsafetyassessment.ac.uk/aboutpsa

• Question writing
– Initial author
– Editors review (2)
– Peer-review (groups of 8)
– Exam board review (groups of 6)
• Standard Setting
• January each year – groups of 10 reviewers – mixed skills
• MSC Assessment oversight

With thanks to Dr Fu Ng https://prescribingsafetyassessment.ac.uk/aboutpsa

• Examples include
– Correct number of tablets to achieve required dose
– Dose adjustments based on weight or body surface area
– Diluting a drug for administration in infusion pump.
– Convert different expressions of drug doses and concentrations.
• 1, 2, 3 or very rarely 4 step calculations.

Calculation Skills Item ID CAL000
Case presentation
A [ age ]-year-old [ man/woman/child ] presents to [ location and situation ] complaining of [ symptom that might be used as the focus for one of the questions ] etc. You are required to give a dose of
...etc. The patient weighs …
[ The case presentations should be fairly brief – 2 or 3 sentences ]
Calculation
What [ total amount/volume/duration/total dose etc.
] should the patient [ be given, etc.
] …… ?
(Write your answer in the box below)
Answer unit
This item is worth 2 marks
You may use a calculator at any time
Answer box
Correct answer
Write the correct answer with units in this box
Working
Write a brief justification of the answer in this box, sufficient to explain how to calculate the correct answer
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Calculation Skills Item ID CAL000
Case presentation
A 45-year-old man with type 2 diabetes mellitus attends his GP. His weight has been problematic; consideration is being given to an anti-obesity drug.
Eligibility for treatment depends on his body mass index (BMI).
His weight is 97.2 kg and height is 1.8 m.
This item is worth 2 marks
You may use a calculator at any time
Answer box
Correct answer
Write the correct answer with units in this box
Working
Write a brief justification of the answer in this box, sufficient to explain how to calculate the correct answer
Calculation
What is his body mass index based on these measurements?
Answer unit
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

• Interpreting data in light of clinical scenario and deciding most appropriate action, may involve
– Withdrawing a medicine
– Reducing dose
– No change
– Increasing dose
– Prescribing new medicine.
• Examples might include
– Drug concentrations
– Drug effects (e.g. INR / TFT / Chol / BP)
– Drug side effects (e.g. U+E, FBC, CK)
– Nomograms (e.g. paracetamol)

Data Interpretation Item ID DAT000
Case presentation
A [ age ]-year-old [ man/woman/child ] presents to [ location and situation ] complaining of [ symptom that might be used as the focus for one of the questions ] etc. PMH. She/he has suffered from ….
[ describe any past medical history relevant to the scenario ]. DH.
She/he normally takes …. [ list any current prescriptions ]. SH.
[ include any relevant social history ]
[ Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief but identify the treatment for which a decision is required, the therapeutic indication and sufficient information about the patient to for the candidate to be able to identify the best decision option ]
Question
Select the most appropriate decision option with regard to [ the xxxx prescription / the treatment of xxxxxx ] based on these data.
(mark it with a tick)
This item is worth 2 marks
You may use the
BNF at any time
A Option A
DECISION OPTIONS
Identify the correct answer by placing a tick in the column on the right
B Option B
C Place 5 plausible options
D in the boxes provided, describing each with
E Option E clarity
☐
☐
☐
☐
☐
Answer box
Option A Justification
Write a brief justification in this box
Option B Justification
Write a brief justification in this box
Option C Justification
Option D Justification
Option E Justification
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

• Involves making judgement about the impact of ongoing / planned treatments.
• Duration of effects; Beneficial and harmful effects
• ‘Culprit’ drugs
• Monitoring (and correct timing) including
– Clinical symptoms & signs; Investigations
• Examples requiring monitoring
– Digoxin for atrial fibrillation
– Inhaled corticosteroids for asthma
– Thyroxine for hypothyroidism

Drug Monitoring Item ID TDM000
Case presentation
A [ age ]-year-old [ man/woman/child ] presents to [ location and situation ] complaining of [ symptom that might be used as the focus for one of the questions ] etc. PMH. She/he has suffered from ….
[ describe any past medical history relevant to the scenario ]. DH.
She/he normally takes …. [ list any current prescriptions ]. SH.
[ include any relevant social history ]
[ Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief but identify the treatment that is being started, the therapeutic indication and sufficient information about the patient for the candidate to be able to identify the best monitoring option ]
Question
Select the most appropriate monitoring option to assess the
[ beneficial/adverse ] effects of this treatment.
(mark it with a tick)
This item is worth 2 marks
You may use the
BNF at any time
A Option A
B Option B
MONITORING OPTIONS
Identify the correct answer by placing a tick in the column on the right
☐
☐
C Option C ☐
D Option D
E Option E
Place 5 plausible monitoring options in the boxes provided, describing each with clarity
☐
☐
Answer box
Option A Justification
Write a brief justification in this box
Option B Justification
Write a brief justification in this box
Option C Justification
Option D Justification
Option E Justification
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

•
•
•
•
•

• Involves interpreting list of medicines in light of a clinical problem
– Spotting important drug interactions
– Serious dosing errors
– Suboptimal prescriptions
• Total list of medicines for each question item ≥6.
• Some knowledge of common effects, adverse reactions and interactions will be assumed.
• Dosing errors
• Interactions

Prescription Review Item ID REV000
Case presentation
A [ age ]-year-old [ man/woman/child ] presents to [ location and situation ] complaining of [ symptom that might be used as the focus for one of the questions ] etc. PMH. She/he has suffered from ….
[ describe any past medical history relevant to the scenario ]. DH.
She/he normally takes …. [ list any current prescriptions ]. SH.
[ include any relevant social history ] His current regular medicines are listed (right).
[ Authors should try to adhere to this general layout but there is room for flexibility – the presentations should be fairly brief ]
Question A
Select the [ ONE/TWO/THREE prescription/prescriptions ] that
[ is/are ] [ most likely to be a cause of/contains a serious dosing error/interact/is contra-indicated, etc.
].
(mark [ it/them ] with a tick in column A)
Question B
Select the [ ONE/TWO/THREE prescription/prescriptions ] that
[ is/are ] [ contra-indicated/most likely to be a cause of/contains a serious dosing error/interact/, etc.
].
(mark [ it/them ] with a tick in column B)
This question item is worth 4 marks
You may use the
BNF at any time
CURRENT PRESCRIPTIONS
Drug name
Drug 1
Drug 2
Drug 3
Drug 4
Drug 5
Drug 6
Drug 7
Drug 8
Drug 9
Drug 10
Dose Route Freq.
xx mg IV daily xx mg ORAL 12-hrly xx mg xx mg xx mg
Use between 5 and 10 rows to create the list of drugs that will form xx mg xx mg xx mg
A
☐
☐
☐
☐
☐
☐
☐
☐
☐ in the answer box below
☐
☐
☐
☐
☐
☐
☐
Identify the correct answer(s) on columns A and B and justify
B
☐
☐
Answer box
Question A Marks per correct tick
Write a brief justification in this box
[1 or 2]
Question B Marks per correct tick
Write a brief justification in this box
[1 or 2]
Prescribing Skills Assessment – Prescription Review Question Item Example

• Acute and chronic conditions or symptoms
• Deciding between different drugs, formulations, routes, doses and frequencies
• Typical prescriptions: high-risk (e.g. anticoagulants, opioids, insulin); common (e.g. antibiotics); special dosing; fluids.
• The likely differential diagnosis should be clear from the scenario (but not necessarily be identified).

Prescribing Item ID PWS003
Case presentation
A 68-year-old woman attends her GP after a recent manipulation under anaesthetic for a left Colles’ fracture. PMH. Recent diagnosis of osteoporosis. DH. Calcichew D3 Forte two tablets orally daily.
On examination
Left forearm in plaster cast.
Investigations
DEXA scan confirms osteoporosis.
This item is worth 10 marks
You may use the
BNF at any time
Pharmacy Stamp
Please don’t stamp over age box
Age
0yr 0mths
D.o.B.
00/00/0000
Number of days’ treatment
N.B. Ensure dose is stated
Endorsements Drug Name
Dose
Frequency
28
Title, Forename, Surname & Address
Patient Name
Address Line 1
Address Line 2
Town Postcode
Prescribing request
Write a prescription for ONE drug will help reduce the risk of further fractures.
(use the general practice prescription form provided)
Signature of Prescriber
Signature
For
Dispenser
No. of
Prescns.
on form
Xxxxx Health Authority
Dr
Address
Town Postcode
Tel: 00000 000 000
Date
00/00/0000
FP10NC0105
Created by Department of Clinical Pharmacology, QMUL

Prescribing Item
2
3
4
1
A. Drug choice
Alendronic Acid
5 Risedronate
Answer Page
Score
4
Feedback/justification
BNF recommended 1 st line for post menopausal, secondary prevention of osteoporotic fractures
3
ID PWS000
2 nd line for post menopausal, secondary prevention of osteoporotic fractures
This item is worth 10 marks
B. Dose and Posology
70mg ORAL once-weekly or 10mg once-daily
You may use the
BNF at any time
Score
4
Feedback/justification
Recommended dose
10mg ORAL once-weeky
70mg ORAL daily
Other doses
2
1
0
Too low
Danger of toxicity
(not readily available)
Correct doses of weekly/daily dose of
Risedronate (ORAL 35mg weekly or 5mg daily)
5mg ORAL weekly
3
1
Recommended dose
Too low 6
7
8
9 Strontium ranelate
Raloxifene
10 Teriparatide
11 Any other drugs
2
1
0
3 rd line for post menopausal, secondary prevention of osteoporotic fractures
4 th line for post menopausal, secondary prevention of osteoporotic fractures
Not indicated
35mg ORAL daily
Other doses
Correct doses of strontium (ORAL 2g daily), raloxifene (ORAL 60mg daily)
20 micrograms SC daily
0
0
2
1
Danger of toxicity
(not readily available)
Correct doses (any other dose = 0 marks as not readily available)
12 Other bisphosphonates
13 HRT
Calcitriol
2
1
Not recommended for osteoporosis orally
Recommended for corticosteroid induced osteoporosis as 2 nd line to bisphosphonates
Correct dose of other bisphosphonates
Correct dose of HRT/calcitriol
2
1 is good but is suboptimal on some grounds (e.g. cost-effectiveness, likely adherence). They should get 2 marks for an answer that is likely to provide
15 benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit.
16
D. Signature. Candidates will also be given 1 mark for
signing the prescription
19
20 Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

Prescribing Item ID PWS002
Case presentation
A 13-year-old boy is assessed on the paediatric day unit for severe aural pain that has not improved despite 72 hours of treatment with simple analgesia. PMH. None. DH. Paracetamol 1 g orally as required. Allergic to penicillin.
On examination
T 37.7 o C; HR 100/min; BP 100/68 mmHg. Otoscopy reveals intact red drum, bulging on right side.
This question item is worth 10 marks
Drug (Approved name)
Dose
Prescriber – sign + print
Notes
Route
Start date
Pharmacy
Date
Time
6
8
12
14
18
22
You may use the
BNF at any time
Prescribing request
Write a prescription for ONE drug that will treat his infection.
(use the hospital ‘regular medicines’ prescription chart provided)
Created by Department of Clinical Pharmacology, QMUL

3
Prescribing Item
1
2
A. Drug choice
Clarithromycin
9
14
15
16
17
10
11
12
13
7
8
4
5
6
Beta lactam antibiotic
Other macrolide
(erythromycin, azithromycin)
Answer Page ID PWS000
Score
4
Feedback/justification
BNF recommended 1 st line for penicillin allergy
0
2
POTENTIALLY LIFE-THREATENING
Likely to be effective, but not first line
This item is worth 10 marks
B. Dose and Posology
250 mg 12-hrly orally
500mg 12-hrly orally
You may use the
BNF at any time
Score
4
3
Feedback/justification
Recommended dose/posology
Usually reserved for severe infections
500mg 12-hrly iv 2 Parenteral reserved for serious or systemic upset
Any other dose/timing/routh
Any dose of beta-lactam
Correct dose timing length other macrolide
0
0
2
POTENTIALLY LIFE-THREATENING benefit but is clearly suboptimal for more than one reason. They should get 1 mark for an answer that has some justification and deserves some credit.
20
C. Timing. Candidates will also be given 1 mark for
correctly dating (and timing) the prescription
D. Signature. Candidates will also be given 1 mark for
signing the prescription
Slide compilation © 2012 The British Pharmacological Society & Medical Schools Council. All rights reserved.

• Formative: 2012-2014
• Summative component of Finals 2015
• Exam on 27 th February 2015
• Major IT problem at PSA – slow/broken connection to online
BNF
• Extraordinary ‘First sit’ resit offered to 9 students with scores under ‘satisfactory’ score
• All but one passed
• PSA practice focus in Year 5 but PSA topics mean that attention during Year 4 is needed
• Increasing attention during Year 4 placements

Year
2012
2013
2014 A
2014 B
2015
PWS (80 marks)
75.6%
84.8%
84.3%
87.8%
83.5%
REV (32 marks)
71.0%
Mean category score as % of possible: Year 5 students 2012-15
MAN (16 marks)
71.0%
COM (12 marks)
85.7%
CAL (16 marks)
79.6%
ADR (16 marks)
76.6%
TDM (16 marks)
42.8%
DAT (12 marks)
80.2%
69.2%
80.5%
77.5%
55.0%
74.3%
67.7%
86.6%
89.3%
87.3%
82.7%
80.6%
88.3%
63.6%
75.0%
70.8%
68.6%
57.6%
68.0%
71.6%
85.8%
86.3%
Mean
Score
73.9%
76.1%
80.7%
81.9%
79.3% 64.6% 80.6% 81.5% 85.1% 74.1% 76.8% 80.0%
Pass Rate
86%
92.72%
92.78%
93%
97.35%
(99.7%)

Year 3
• Lecture series CPT
• Prescribing workshops
• Formative exam
Year 4
• Specialty placements – each to include relevant therapeutics
• CPT lectures (September, March, July) – overview / common themes / principles of prescribing
• SCRIPT Principles of Prescribing on-line modules – mandatory coursework over 11 weeks Feb-March
• QMUL on-line resources – core drugs list, history/ therapeutics template, therapeutics exercises
• Log Books – new requirement to include prescription writing
(just two/placement but it’s a start!)

•
•
•
•
•
– On my experience, likely around 65%

QMUL
Candidates
>/=80%
65%-
79%
267 31 114
PSA Score Range
60%-
64%
55%-
59%
50%-
54%
51 32 23
40%-
49%
39% or less
13 3
Rounded %
12%
54%
43% 19%
31%
12% 9% 5%
15%
1%

PSA Section
Prescribing
Review
Calculation
TDM
Adverse Events
Management
Data
Communication
Max score for section
Students with scores of 0 in the section
40 0
16
8
8
8
8
6
6
0
41
9
3
5
50
1
Alerts
Score <20: 37 students.
34/37 had scores <65%
Score <8; 5 students
32/41 had PSA Score <65%
37/50 had PSA Score <65%

Year
2012
2013
2014 A
2014 B
2015
Year 4
Mock
PWS (80 marks)
75.6%
84.8%
84.3%
87.8%
83.5%
66.4%
REV (32 marks)
71.0%
Mean category score as % of possible: Year 5 students 2012-15
MAN (16 marks)
71.0%
COM (12 marks)
85.7%
CAL (16 marks)
79.6%
ADR (16 marks)
76.6%
TDM (16 marks)
42.8%
DAT (12 marks)
80.2%
69.2%
80.5%
77.5%
55.0%
74.3%
67.7%
86.6%
89.3%
87.3%
82.7%
80.6%
88.3%
63.6%
75.0%
70.8%
68.6%
57.6%
68.0%
71.6%
85.8%
86.3%
Mean
Score
73.9%
76.1%
80.7%
81.9%
79.3% 64.6% 80.6% 81.5% 85.1% 74.1% 76.8% 80.0%
77.4% 57.3% 83.8% 55.8% 77.4% 57.6% 40.2%
*As s ume pa s s s core 65%
66.2%
Pass Rate
86%
92.72%
92.78%
93%
97.35%
(99.7%)
54%*

SCRIPT (required)
QMUL exam (required)
Pharmacist (required)
Lectures
Workshops
Case series
QMplus
PRESCRIBE (PSA website)
Drug SMD
Percentage of students using CPT activity
2014-2015
Total respondents = 137.
100% (137)
2013-2014
Total respondents = 47
100% (47)
96% (132)
100% (137)
96% (132)
96% (45)
91% (43)
91% (43)
69% (95)
N/A
50% (69)
94% (129)
43% (59)
68% (32)
57% (27)
43% (20)
26% (12)
21% (10)
Survey by Dr Claire Calderwood during PfP week; 137 respondents (41% Year 5 cohort)

Q3: Ranking of CPT Resources
30
20
10
100
50
0
0
Workshops PSA website
Internal
SPE
SCRIPT
MRP
Shadowing SCRIPT
(optional)
Pharmacist-led teaching
Lectures QMPlus e-learning
Drugs SMD e-modules
Ranking
8
7
6
5
4
3
2
1
9
10
Compulsory
Optional

1. Do you feel prepared for your first day of work as an FY1 doctor?
2. Do you feel that there has been an improvement in your prescribing skills compared to one year ago?
Q1: Self-assessment of prescribing skills
Preparedness
3%
Improvement
57%
66%
30%
31%
% Respondents
Q1: Self-assessment of prescribing skills
8% 1%
2% 1%
Definitely not
Mostly not
Unsure
Mostly yes
Definitely yes
Preparedness (SEP)
1%
Preparedness (GEP)
Improvement (SEP)
Improvement (GEP)
9%
57%
65%
58%
70%
% Respondents
30%
30%
11% 1%
3%
32%
27%
2% 1%
3%
Definitely not
Mostly not
Unsure
Mostly yes
Definitely yes

Claire Calderwood questions based on prior survey by Simon Maxwell)
Q2: Self-evaluation of prescribing skills
Score
1 = I cannot do this
10 = Always Agree
I know where to find advice when making decisions about medications
I can write a legally correct prescription for a common medicine
I can perform common drug dosage calculations 19%
35%
31%
26%
27%
29%
26%
I can explain to patients how they should take their medications
I can decide on and prescribe a medication to treat a common acute medical problem (e.g. acute asthma)
I can review a patien t’s regular prescriptions when they are admitted to hospital, and amend these if needed
17%
12%
9% 14%
I can recognise a likely adverse drug event 8%
I can amend medications in light of drug levels or other monitoring tests
I know when monitoring tests are required for common drug therapies (e.g. certain antibiotics)
6% 8%
11%
16%
26%
30%
20%
25%
25%
35%
28%
25%
28%
30%
19%
% Respondents
10%
18%
23%
15%
11% 5%
12%
16%
10% 5%
17%
18%
8%
5%
7%
9% 7%
6% 5%
6%
5%
Score
5
6
7
8
9
10
1
2
3
4

• PSA Website https://prescribingsafetyassessment.ac.uk/aboutpsa
• Books
– Pass the PSA by Will Brown & others; February
2014; Churchill Livingstone ISBN: 978-0-7020-
5518-8 (£30 approx)
– Top 100 Drugs by Andrew Hitchings & others;
2014; Churchill Livingstone; ISBN: 0702055166
(£15 approx)
– Prescribing Scenarios at a Glance by Emma Baker
& others; July 2014, Wiley-Blackwell (£26 approx)
• Library has some copies of all