Preparation for the Canadian Prescribing Safety Assessment
Concerns about prescribing competence are not isolated to North American medical graduates. The EQUIP study in England reviewed 124,260 medication orders finding an error rate as high as 10.3% amongst junior housestaff. In response to this study and a series of serious medication safety incidents, education leaders in clinical pharmacology and the British Pharmacological Society instituted the Prescribing Safety Assessment (PSA), an online exam that final year medical students must pass prior to their licensing exams. The full PSA consists of 60 questions and lasts for two hours, drawing on a large database of validated questions. Students participate in the PSA at the end of medical school a few months before their medical licensure examinations, and are encouraged to prepare using practice resources.(14) Approximately 53,000 students have completed the exam in the last five years, with very positive feedback on fairness and the helpfulness of the exam to their competence to practice. These students expressed appreciation for the initiative taken to address the prescription competency concerns, for increased their confidence when prescribing as a first year resident, and for making them aware of key prescribing resources such as formularies.
The Canadian PSA is a 30-question, 1 hour exam modified by Dr Holbrook from the British PSA. It has been tried consistently at McMaster University and sporadically at other Ontario medical schools over a 7-year period, with very good face validity. The exam is meant to be a formative assessment near the end of medical school as a measure of readiness for residency. Practice exams are made available for the Transitions to Clerkship period.
Recommendations to prepare for the PSA exam include:
- Review the exam format, time available, open book resources allowed. There are 8 domains tested in the PSA.
Table 1: Prescribing Safety Assessment Question Domains
| Prescription Writing | Writing a prescription requiring decisions regarding specific drug, dose, route and frequency based on clinical circumstances and supplementary information. |
| Prescription Review | Deciding which components of the current prescription list are inappropriate, unsafe, or ineffective based on clinical circumstances. |
| Planning Management | Deciding which combination of therapies would be the most appropriate to manage a particular clinical situation. |
| Providing Information | Deciding which are the important pieces of information that should be provided to patients to allow them to choose whether to take the medication, or to enhance its safety and effectiveness. |
| Calculation Skills | Making an accurate drug dosage calculation based on numerical information. |
| Adverse Drug Reactions | Identifying likely adverse reactions of specific drugs, drugs that are likely to be causing specific adverse drug reactions, potentially dangerous drug interactions and deciding on the best approach to managing a clinical presentation that results from the adverse effects of a drug. |
| Drug Monitoring | Deciding on how to monitor the beneficial and harmful effects of medicines. |
| Data Interpretation | Deciding on the meaning of the results of investigations as they relate to decisions about on-going drug therapy. |
- Since the Canadian PSA is open book, decide on resources that you want to use during the exam, for example, UptoDate, Lexicomp, RxTx, ODB formulary, etc.
- Take time to do all of the practice exams allowed.
References:
- Holbrook A, Liu JT, Rieder M, Gibson M, Levine M, Foster G, et al. Prescribing competency assessment for Canadian medical students: a pilot evaluation. Canadian Medical Education Journal. 2019;10(1):e103-e110.
- Liu J, Wong S, Foster G, Holbrook A. Prescribing Competency of Medical Students: National Survey of Medical Education Leaders. Journal of Population Therapeutics and Clinical Pharmacology January 2018; doi 10.22374/1710-6222.25.1.2.