Comprehensive Guide to the Prescribing Safety Assessment

What is the Prescribing Safety Assessment?

The Prescribing Safety Assessment (PSA) is a collaborative effort between the British Pharmacological Society and MSC Assessment.

This online assessment is a pass/fail evaluation that gauges the prescribing skills of final-year medical students. It aligns with the competencies defined by the General Medical Council (GMC) in their "Outcomes for Graduates" document.

These competencies encompass essential tasks, including:

• Writing Prescriptions
• Calculating drug doses
• Recognising and preventing adverse reactions
• Medication errors
• Reviewing medicines
• Tailoring prescriptions to individuals

The assessment's questions focus on medical conditions and medications commonly encountered by new doctors in their first year of the Foundation Programme.

Why is the PSA Necessary?

Prescribing is a pivotal responsibility for Foundation Year 1 doctors, who routinely issue and review numerous prescriptions. This role involves a multifaceted skill set, demanding knowledge of medicines, their applications in treating diseases, careful assessment of risks and benefits, and meticulous attention to detail.

Prescribing comes with inherent risks, with research supported by the GMC revealing that 9% of hospital prescriptions contain errors. It is also a challenging aspect for recent medical graduates, as underscored by various studies. Interestingly enough, some studies have shown a higher error rate for FY2 doctors than FY1 doctors.

The Prescribing Safety Assessment serves as a means for candidates to showcase their proficiency in the safe and effective use of medications, ensuring they meet the requisite competencies.

The PSA plays a crucial role in the successful completion of your Foundation Year 1 and is a fundamental requirement for a favourable outcome in your Annual Review of Competence Progression (ARCP).

Who Should Take the Exam?

The Prescribing Safety Assessment is primarily designed for final-year medical students and international graduates who are on the path to becoming Foundation Year 1 Doctors.

If candidates have not taken it earlier or did not pass it, they have the opportunity to complete it during their Foundation Year 1 (FY1) training.

How Much Does it Cost?

Here's the sweet deal: The PSA is absolutely free.

Yep, you read that right. No need to break the bank for this assessment.

About the Exam

Structure & Domains Covered

The Prescribing Safety Assessment Blueprint outlines eight different question types that can be related to seven different clinical domains:

• Medicine
• Surgery
• Elderly Medicine
• Paediatrics
• Psychiatry
• Obstetrics & Gynaecology
• General Practice

The exam is structured into 8 different sections (questions involve a mix of domains above):

• Prescribing
• Prescription Review
• Planning Management
• Providing Information
• Calculation Skills
• Adverse Drug Reactions
• Drug Monitoring
• Data Interpretation

The PSA consists of 8 sections worth a total of 200 marks and has a time limit of 120 minutes (2 hours).

Quick Guide to Each Domain

• Prescribing:

  You'll face scenarios like treating acute and chronic conditions, fluid prescriptions, and pain management.

  Search for drug information or treatment summaries in the BNF when unsure.

• Prescription Review:

  Review 6-10 medications, and identify issues like dosing errors or interactions.

  Prior knowledge of common medication effects and interactions helps.

  Use "Ctrl F" to find specific side effects or interactions in the BNF.

• Planning Management:

  Decide on the best treatment option for clinical scenarios.

  Tailor treatments to individual patients.

  Consider non-drug therapies.

• Communicating Information:

  Select crucial information to provide to patients.

  Find important safety info, patient advice, or monitoring requirements on BNF

• Calculation Skills:

  Calculate medication doses or rates.

  Double-check your calculations.

  Be familiar with unit conversions.

• Adverse Drug Reactions:

  Identify common adverse drug reactions (ADRs) and how to manage them.

  Use the BNF to find ADRs and solutions.

  Pick the most common drug for a particular ADR.

• Drug Monitoring:

  Choose appropriate monitoring for newly started medications.

  Know whether it's for beneficial or harmful effects.

  Check "monitoring requirements" in the BNF.

• Data Interpretation:

  Analyze clinical scenarios and test results.

  Decide whether to adjust, withdraw, or continue medication.

  Be familiar with common scenarios for effective decision-making.

Timing Guide

Because the PSA is time-sensitive, effective time management is crucial. Here's a guide from Mind The Bleep on how much time to allocate to each section based on their importance:

Sections	Number of Questions x Marks	Timing guide
Prescribing	8 x 10 marks (5 for drug choice, 5 for choice of dose/route/frequency)	48 minutes
Prescription review	8 x 4 marks	19 minutes 12 seconds
Planning management	8 x 2 marks	9 minutes 36 seconds
Providing information	6 x 2 marks	7 minutes 12 seconds
Calculation skills	8 x 2 marks	9 minutes 36 seconds
Adverse drug reactions	8 x 2 marks	9 minutes 36 seconds
Drug monitoring	8 x 2 marks	9 minutes 36 seconds
Data interpretation	6 x 2 marks	7 minutes 12 seconds

High-Yield Medications

Expect the Prescribing Safety Assessment to have at least two questions about these drugs, so make sure you know them reasonably well:

• Insulin.

  Includes short, intermediate, and long-acting insulin, as well as mixed formulations and prescription of variable (e.g. for nil-by-mouth diabetics) and fixed-rate (e.g. for DKA) intravenous infusions.

• Anticoagulants

  This can include warfarin (particularly for patients who have conditions in which newer anticoagulants are unlicensed) as well as the more common DOACs.

• Painkillers

  It's important to know how to prescribe common painkillers such as paracetamol and ibuprofen, and contraindications for these. You should also be able to safely prescribe opioids, and know how to prescribe for breakthrough pain in those taking long-acting opioids.

• Intravenous fluids

  IV fluids are one of the most common medications you'll be asked to prescribe as a foundation doctor. Make sure you know how to correctly prescribe fluids with and without additions (such as KCL for supplementary potassium).

• Antibiotics

  Learn how to prescribe antibiotics using formularies, and make sure you can reference prescribing guidance to make sure you don't prescribe the wrong antibiotic to someone who is allergic or contraindicated.

Other common drugs to be aware of:

• Antidepressants
• Antiepileptics
• Antihypertensives
• Antiplatelets
• Antipsychotics
• Bisphosphonates
• Contraceptives
• Corticosteroids
• Hypoglycaemics
• Inhalers
• Laxatives
• NSAIDs
• Statins

Question Types in the PSA

Each Prescribing Safety Assessment question follows a set structure. You are given a clinical scenario and then asked a question to do with this scenario. There are four types of questions you could be asked:

Note: These example PSA questions are just examples to demonstrate how questions may typically be presented.

1. Single Best Answer Questions

The key here is "best" - you are likely to be given at least two options which are reasonable, but must choose the most appropriate answer for each case. This is used when planning medicines management, dealing with drug reactions, and interpreting data and drug monitoring.

2. Prescribing Questions

You will be asked to prescribe a medication, including the drug, dose, route, and frequency, using best practice.

3. Select Answers From a List - Prescription Review

This will likely be in a review of prescriptions, in which you will have to select one or more drugs from a list of medications.

4. Written Answers - Calculations

For answering questions to do with dose calculation.

Prescribing Safety Assessment Exam Dates

The PSA exam is taken at the end of the final year of medical school across the UK, but is not a requirement to start practising. Dates for "1st attempts" of UK graduates will be given to you by your medical school.

If you don't pass on this attempt, or you are an International Medical Gratuate, you still have a chance to pass at a later date.

For those current foundation doctors who are yet to pass, the PSA dates for 2024 are:

• Tuesday 12th March 2024, 1pm
• Tuesday 23rd April 2024, 1pm

Success Rate and Pass Mark

The passing score for the PSA is determined using the Modified Angoff method. In the Modified Angoff Method, the passing score for the exam is calculated using expert opinion on how many questions a "borderline" candidate (expected to just scrape a pass) should answer correctly, taking biases into account.

The specific passing score isn't disclosed in advance because it may need adjustments based on variations in test difficulty and any item-related problems identified after the test. Although the PSA test may seem challenging, most test-takers pass it, with the typical median score being approximately 75%, and the passing score often roughly 62-63%.

Preparing for the Exam

Revision Resources I found useful

2. Practice Papers on the PSA Website

• Considered the gold standard for PSA preparation
• Closely mirrors the actual exam, providing an authentic practice experience
• Highly recommended to be done multiple times for effective preparation.tice Papers on PSA website

3. Mind The Bleep PSA Course

• Offers valuable tips, revision guidance, and teaching videos.
• Comprehensive coverage of all domains of the PSA exam.
• Free!

Using the BNF (British National Formulary)

During the assessment, you can use the online BNF as your go-to resource for Prescribing Safety Assessment questions. The BNF is a rich source of information about medicines and is available on the NICE website or Medicines Complete. However, keep in mind that the PSA is a time-sensitive exam, so while the BNF is your "Best Nifty Friend," you'll still need some prior knowledge about prescribing to do well.

Since the BNF is electronic, you can quickly find specific information by using the CTRL+F to quickly search for the keyword you're looking for.

In order to make the best use of the BNF on the day of the PSA, make sure you can use it to quickly:

• Look up medications
• Find the appropriate indication and dose
• Search for interactions using the drug interaction tool
• View contraindications and common side effects
• Use drug monitoring advice and directions for administration
• Make use of treatment summaries in common conditions

Before the Exam

Registering and Activating Your Account

Your medical school will send a list of students taking the PSA about four weeks before the test. They'll create accounts and tell the school when it's done.

Your school's PSA leader will let you know when you can activate your account. If you haven't heard from them, just ask your school's PSA leader.

Preparing

You should log in to your account and test your access to the PSA interface and the BNF before the exam day. On the exam day, laptops will be provided by the venue.

The team will set them up in the morning to ensure they work with both of these sites. It's a good idea to arrive 45 minutes early to make sure you can log in without any problems.

On the Day

On the exam day, make sure to:

• Bring your ID (like your passport or driver's license)
• Know your registered PSA email address
• Remember your PSA Account password
• If you want to take notes, bring a pen or pencil (they provide extra paper)
• Bring a BNF and calculator if you don't want to use the versions available within the exam interface

Remember, you won't be allowed to use any personal electronic devices during the assessment, and you can't use a calculator that's part of another device, like a phone.

Remember - Life Happens

One important thing to note: If you can't make it to your PSA sitting, please let them know as soon as possible, but no later than two working days before the PSA date.

If something comes up on the day of the exam, you must submit an extenuating circumstances form no later than one working day after the test.

Moment of Truth… Results Day

Your PSA results will be ready for you to check out when you log into the PSA website.

Just head to the "My Profile" section, and you'll find your Assessment Feedback around two weeks after the test.

You'll also get an email from the foundation school to let you know when your results are ready.

When you're looking at your results, make sure to download and save a copy of your certificate. Keep in mind that accounts get disabled at the end of the academic year. So, after that time, you won't be able to access your certificate anymore.

Top Five Tips

• Familiarise yourself with the BNF

  The BNF is the main resource you'll be using during the exam. It's important to not only use it accurately, but as you're on a timer you need to be able to use it effieciently.

• Ctrl+F (your best friend)

  Using Ctrl+F makes it so much easier to find the correct information on the online BNF.

• Practice the timing

  This will help you get a feel for how much time you can allocate to each question and section. Keep in mind that some questions may require more time than others, so finding the right balance is key.

• Pay attention to the clock

  It's easy to lose track of time when you're engrossed in answering questions, but you must stay aware of how much time you have left for each section. If you find yourself spending too much time on a single question, consider moving on and coming back to it later if time allows.

• Choose a focus

  Focus on the first two sections as they are the heaviest in terms of marks

You’ve got this!

In a nutshell, when prepping for the PSA, practice is your best buddy. You've got to get cozy with the BNF and dive into practice questions before the actual deal.

Why? Well, practice builds your confidence and sharpens your skills for handling different scenarios and question types. So, when it comes to gearing up for the PSA, keep it simple: Practice, practice, practice. It's the name of the game for acing this assessment!

If you don't pass on your first attempt, don't worry. You can give it another shot on the upcoming test dates mentioned earlier. Just make sure to pass it before the end of your FY1.