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Redesign of NHS Trust Prescription Chart

Imperial College asked us to work on a project funded via the Behavioural Insight Team at the Cabinet Office looking at redesigning the Imperial College NHS Prescription Chart.

Each patient that gets admitted to hospital in the NHS is allocated a prescription chart. The chart accompanies the patient as they go through their care in the various departments (such as A&E) and onto the ward. It is both a record of drugs and treatments given and an instruction on what is to be given. Consultants, doctors and others prescribe on the chart, and nurses administer drugs accordingly. Although the data is entered to a digital system for archive purposes, the active information is centered on a paper chart, as it is reliable, cost effective, and staff universally know how it works. Although tablet computers pave the way for a fully digitised system in the future, there is a very long way to go until we can do away with paper charts.

However, there are significant shortcomings to paper charts… they rely on handwriting and they are prone to being filled in incorrectly due to either complacency or poor graphic design. Appropriate signatures can be hard to trace, and an ‘information creep’ in their design iterations often leads to an excess of confusing text and layouts.

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A selection of existing and old prescription charts from a range of NHS trusts

Furthermore, every trust designs its own chart, so when clinical staff move from one hospital to the next they have to relearn the layout of each chart. Although this project never intended to create a ‘universal chart’, it was hoped that we could inspire and inform one if the project was successful.

Medication error is the cause of huge problems in any healthcare system, having serious impact on the patients’ well-being, but also costing the NHS huge sums of money in liability payouts, consequencial care and lengthened hospital stays.

We were asked to assess and improve the prescription chart layout, with the aim of increasing accountability and reducing error. We aimed to make the chart easier and more elegant to use by making cleaner layouts, a more intuitive graphical scheme, resetting the information hierarchy and removing ineffective clutter.

We spent several sessions shadowing clinicians in A&E and on wards, and saw first-hand some of the shortcomings of the current design. We reviewed a collection of anonymised completed prescription charts, and compared them to a wider statistical study of used charts by the Imperial College researchers on the team.

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Ideas sketched on to an prototype chart during a feedback session

We then came up with some new ideas on improvements that we presented to a working group of clinicians before producing a prototype chart for clinical studies on the ward.

Resulting Design Principles

As you can imagine with the chart, the devil is in the detail, and this project was about detail. We improved the chart along the following principles:

We strictly enforced a colour scheme where every area of ‘white’ on the form was a data entry area, and all other areas including instructions and labels were on a light blue coloured background*. This creates a clean, clear and intuitive chart. We also made section headings very clear with a reverse white on dark blue format.

*with the exception of occasional use of red, reserved only for the most important sections.

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We used block letter fields where handwriting can potentially lead to error such as medicine names, dose information and patient statistics.

We craftfully added space between sections to make the chart as a whole more readable and attractive to use.

We made the layout more spacious by using faint background text inside input fields rather than labels to the side or top of the field.

We made full use of ‘multiple choice’ fields allowing users to circle commonly used units units, intervals, etc.

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We included an example field that demonstrates how the main elements of the form should be correctly filled in.

And there are many specific improvements we made to specialist sections within the chart.

We also proposed a few further developments such as including smart phone links (QR codes) to up-to-date information resources on transient local policies such as use of antibiotics, and a user guide and feedback site.

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Although this project has not been our most photogenic project it has been a really exciting process as it has highlighted how the detail of a graphic layout can have a significant impact on people’s lives. It is possible that ideas within our design could go on to save lives, and we find that an exciting and rewarding idea.

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Behavioural Insight Team