Active-learning intervention for medication prescription writing in undergraduate medical education: a quasi-experimental study

Abstract

Background

Medication prescription errors remain a major patient safety concern, while undergraduate training in prescription writing is still inconsistently addressed in medical curricula.

Aim

To evaluate changes in medication prescription writing quality following an active educational intervention among undergraduate medical students.

Design and setting

Quasi-experimental before-and-after study conducted with 40 third-semester medical students from a public university in Brazil.

Methods

The intervention consisted of eight stages involving simulated prescription activities, collaborative discussion, and feedback sessions. Prescription quality was assessed using the QualiPresc instrument at baseline, immediately after the intervention, and at a 15-day follow-up. Repeated measures were analyzed using the Friedman test, considering a significance level of 5%.

Results

The intervention was associated with significant improvements in prescription quality scores, particularly for the indicators “date of birth,” “allergy record,” “pharmaceutical form,” “route of administration,” and “non-pharmacological recommendations” (p < 0.001).

The mean total prescription quality score increased from 73.47 at baseline to 95.34 immediately after the intervention and remained higher than baseline at the 15-day follow-up (87.80), suggesting partial retention of learning.

Conclusion

The active teaching method was associated with improvements in medication prescription writing quality among undergraduate medical students, with partial retention of learning after 15 days. Although causal inferences cannot be established due to the absence of a control group, the findings suggest that this educational strategy may represent a promising approach for prescription safety education.

Introduction

Concerns about the quality of medication prescriptions are reflected in initiatives promoted by the World Health Organization (WHO), particularly within the Global Patient Safety Action Plan 2021–2030, which highlights “health worker education, skills, and safety” as a strategic priority [1]. Medication errors—beginning during prescription writing, extending through pharmacy dispensing, and culminating in medication administration by nursing staff—may negatively affect both patients and healthcare systems [2]. Prescribing medications is therefore considered a critical clinical competency, as it involves not only therapeutic decision-making but also the accurate documentation of patient identification, medication specifications, and prescriber information [3].

Despite advances in patient safety policies, the occurrence of nonconformities in medication prescriptions remains high. Observational studies conducted in primary and tertiary healthcare settings have identified prescription errors related to medication details, prescriber identification, and patient information in a substantial proportion of prescriptions analyzed [4–8]. In this context, the implementation of pedagogical strategies aimed at developing prescribing competence and safe medication practices among future healthcare professionals is essential [9, 10]. Nevertheless, many health-related curricula still fail to systematically incorporate prescription-writing training into undergraduate education, resulting in persistent gaps in professional preparation [11, 12]. Conversely, some medical curricula have progressively incorporated early prescribing education through active-learning and simulation-based approaches.

Educational strategies for prescription training have included structured prescribing exercises, simulation-based learning, case-based discussions, supervised feedback, and paper-based clinical scenarios [13]. Although these approaches may contribute to improving prescribing skills, many interventions remain fragmented, lack standardized assessment tools, or fail to integrate collaborative and reflective learning components into the educational process.

In response to this educational gap, faculty members from the Escola Multicampi de Ciências Médicas do Rio Grande do Norte (EMCM), Universidade Federal do Rio Grande do Norte (UFRN), developed a teaching-learning methodology entitled Teaching Good Practices in Medication Prescription Writing [14]. The intervention was designed to strengthen prescribing competence through active-learning strategies involving simulated prescription activities, collaborative discussion, reflective feedback, and structured assessment. Initially developed for undergraduate medical education, the methodology also presents potential applicability in undergraduate and postgraduate programs across other health professions, considering the legal and institutional frameworks regulating prescribing practices [14].

Improving prescribing competence during undergraduate medical education remains an important challenge for patient safety and healthcare quality. Previous educational interventions have frequently focused on isolated prescribing exercises or non-standardized evaluation methods, limiting comparability and reproducibility across studies. Unlike previous studies centered primarily on nursing education or fragmented prescribing activities, the present study evaluated a structured eight-stage active-learning intervention applied to undergraduate medical students using a validated prescription quality assessment instrument and follow-up evaluation.

The aim of this study was to evaluate changes in medication prescription writing quality following an active educational intervention among undergraduate medical students.

Methods

Study design

This was a quantitative quasi-experimental before-and-after study without a control group, conducted according to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND Statement) guidelines [15].

Study setting and participants

The study was conducted at the Multicampus School of Medical Sciences of Rio Grande do Norte, Federal University of Rio Grande do Norte (UFRN), Brazil, with third-semester undergraduate medical students enrolled in the module Pain, Skills, and Community Axis (MDM4007).

A convenience sample was used, consisting of all students regularly enrolled in the module during the study period. Students were eligible if they participated in all stages of the intervention and signed the informed consent form. Students who were absent during the intervention or failed to complete any assessment stage were excluded.

A total of 40 students participated in the study. No formal sample size calculation was performed because the study included all eligible students enrolled during the study period.

Educational intervention

The intervention consisted of the active teaching-learning methodology entitled Teaching Good Practices in Medication Prescription Writing [14, 16], designed to improve prescription-writing competencies related to patient safety and rational medication use.

The educational strategy was structured into eight sequential stages:

1. Organization of groups and presentation of the trigger case;

2. Initial individual prescription writing;

3. Group discussion and development of a collective prescription;

4. Individual feedback;

5. Collective feedback;

6. Presentation and discussion of the key answer;

7. Repetition of the process using a second trigger case;

8. Final discussion and closure.

The pedagogical objective of the intervention was to improve students’ competencies in safe medication prescription writing, including patient identification, medication description, administration instructions, and non-pharmacological recommendations.

The intervention incorporated active-learning principles, including case-based learning, collaborative problem-solving, reflective feedback, and deliberate practice through simulated prescribing activities.

Students were initially divided into three large operational groups and subsequently subdivided into small groups containing four to five students. These subdivisions were used exclusively for pedagogical organization during the intervention and were not considered independent comparison groups for experimental purposes.

The intervention was designed as a focused short-duration educational workshop lasting approximately 40 min.

Data collection

Data collection occurred in three stages:

Pre-test

Participants individually completed a simulated medication prescription based on a fictional clinical case within 10 min.

Immediate post-test

Immediately after the intervention, participants completed a new individual prescription using the same clinical case to evaluate short-term learning gains. The same clinical case was intentionally refused to allow direct comparison of prescription quality across assessment moments.

Delayed follow-up

Fifteen days after the intervention, participants completed another simulated prescription to assess short-term retention of learning.

All prescriptions were evaluated using the QualiPresc instrument [13], a validated tool developed to assess the quality of medication prescription writing in healthcare education and clinical practice. The instrument evaluates indicators related to patient identification, prescriber identification, medication description, administration instructions, and non-pharmacological recommendations, using operational definitions for each item. Previous validation studies demonstrated satisfactory evidence of validity, reliability, and usability for prescription quality assessment [13]. The instrument generates quantitative scores reflecting the quality and completeness of prescription writing.

The primary outcome of this study was the total prescription quality score across the three assessment moments. Figure 1 presents the flow of the study procedures and participant follow-up.

Fig. 1.

Flow diagram of study procedures and participant follow-up. Note: All students (n=40) completed the three assessment moments. N o losses to follow-up occured

All prescriptions were independently assessed by trained researchers using the QualiPresc instrument according to the operational definitions established in the validation study.

Data analysis

Data were entered into Microsoft Excel and analyzed using R software (version 2024.12.0 Build 467, Posit Software).

Descriptive statistics were used to characterize participants according to sociodemographic variables. Prescription quality scores were analyzed across the three evaluation periods (pre-test, immediate post-test, and delayed follow-up).

The Friedman test was applied to compare repeated measures of prescription quality scores over time, considering a significance level of 5% and a 95% confidence interval. The Friedman test was selected due to the repeated-measures design and the nonparametric distribution of prescription quality scores.

Given the exploratory and non-randomized nature of the study, findings were interpreted cautiously, emphasizing associations between the intervention and observed changes rather than causal inferences.

Ethical considerations

This study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte (CEP/UFRN) under approval number 7.031.169, in accordance with Resolution No. 466/2012 of the Brazilian National Health Council and the Declaration of Helsinki.

All participants received information regarding the study objectives, procedures, and potential risks and provided written informed consent before participation. Clinical trial registration was not applicable.

Results

A total of 40 undergraduate medical students participated in the study. Most participants were male (57%), aged between 21 and 23 years (47%), self-identified as white (60%), and reported higher household income levels (57%). In addition, 60% reported previous experience with medication prescription training.

The educational intervention was associated with a substantial improvement in the overall quality of prescription writing. The total mean score increased from 73.47 at baseline to 95.34 immediately after the intervention and remained elevated at 87.80 during the delayed follow-up (p < 0.001), suggesting partial retention of the acquired competencies over time.

Significant improvements were observed in several prescription quality indicators addressed during the intervention, including “date of birth,” “allergy record,” “pharmaceutical form,” “route of administration,” and “non-pharmacological recommendations” (p < 0.05).

Despite the overall positive results, the indicator “instructions for medication use” demonstrated a marked decline during the delayed follow-up. Changes in prescription quality scores across the three assessment periods are presented in Table 1.

Table 1.

Mean scores of individual prescription quality indicators across follow-up periods (n = 40)

Indicator	Pre-test mean	Immediate post-test mean	Late follow-up mean	P-value
Date of birth	0.00	6.40	5.92	< 0.001
Prescriber identification	3.05	3.67	3.46	0.078
Allergy record	0.00	5.42	6.30	< 0.001
Pharmaceutical form	5.78	8.23	8.68	< 0.001
Route of administration	6.67	7.59	8.97	0.004
Non-pharmacological recommendations	0.00	5.30	5.17	< 0.001
Total prescription quality score	73.47	95.34	87.80	< 0.001

Friedman test; significance level of 5%

Evolution of mean total prescription quality scores across the three evaluation periods. A substantial increase was observed immediately after the educational intervention, followed by partial retention of learning at the 15-day follow-up (Fig. 2).

Fig. 2.

Evolution of total prescription quality scores over time

Discussion

The sociodemographic profile of the participants partially reflects national trends among Brazilian medical students, particularly regarding socioeconomic characteristics and previous exposure to prescription training [17, 18]. The high proportion of students reporting prior experiences related to medication prescription writing may reflect the growing incorporation of active-learning approaches into undergraduate medical curricula [19].

The findings of this study demonstrated that the educational intervention was associated with improvements in overall prescription-writing quality among undergraduate medical students. Significant increases were observed in the total prescription quality score and in several QualiPresc indicators, particularly those related to patient identification, allergy documentation, pharmaceutical form, route of administration, and non-pharmacological recommendations. In addition, although a reduction in scores was observed during the delayed follow-up, follow-up values remained substantially higher than baseline values, suggesting partial retention of the competencies acquired throughout the intervention.

The observed improvements may be partially explained by active-learning principles emphasizing deliberate practice, collaborative problem-solving, and reflective feedback.

These educational mechanisms are considered essential for the development of prescribing competence and patient safety skills in health professions education. The structured combination of simulated prescription activities, peer discussion, and immediate feedback may have contributed to reinforcing cognitive processing and facilitating short-term retention of safe prescribing practices.

The active teaching method was initially tested in a pilot study involving undergraduate medical students by Batista et al. [16]. In that investigation, participants demonstrated persistent difficulties in prescription-writing indicators such as “allergy record,” “instructions for medication use,” “non-pharmacological recommendations,” and “treatment duration,” even after receiving operational guidance for each item [16]. In the present study, however, most of these indicators demonstrated significant improvement, except for “instructions for medication use,” which showed reduced performance during follow-up assessment.

Similar findings observed in undergraduate nursing education suggest that the educational strategy may be transferable across different health professions training contexts [11, 12]. In a previous quasi-experimental study conducted with nursing students, the same active-learning intervention was associated with improvements in most prescription-writing indicators across multiple follow-up periods, in addition to positively influencing student motivation [11, 12].

These convergent findings reinforce the educational applicability of the intervention beyond a single professional category.

The findings of this study are also consistent with those reported by Batista et al. [20], who evaluated medication prescriptions written by primary care physicians using the QualiPresc instrument. The authors identified low conformity rates for indicators such as “allergy record,” “non-pharmacological recommendations,” and “instructions for medication use” [20]. In the present study, these same indicators showed substantial improvement following the educational intervention, reinforcing the relevance of structured educational strategies for promoting safer prescribing practices during undergraduate training.

Furthermore, the decline observed in some indicators over time aligns with learning retention theories emphasizing the importance of deliberate practice, systematic review, and periodic reinforcement for long-term knowledge consolidation [21]. Although partial retention was observed after 15 days, the reduction in follow-up scores suggests that isolated educational interventions may be insufficient to ensure long-term maintenance of prescribing competence. These findings support the adoption of continuous educational strategies, including periodic review sessions, supervised practice, and ongoing feedback processes in medical education [22].

Despite these limitations, this study contributes to the literature by evaluating a structured active-learning intervention using a validated prescription quality assessment instrument and follow-up evaluation among undergraduate medical students. The study also expands the discussion regarding prescribing competence and patient safety education in undergraduate healthcare training.

The main limitation of this study lies in the absence of a control group, which restricts the ability to establish direct causal relationships between the intervention and the observed outcomes. Additionally, the use of a convenience sample from a single institution may limit the generalizability of the findings. Another relevant limitation concerns the short follow-up period, which restricts conclusions regarding medium- and long-term knowledge retention.

Finally, the reuse of the same clinical case during post-test assessments may have introduced familiarity or testing effects capable of influencing participant performance independently of the intervention itself.

Conclusion

This study demonstrated that the active teaching intervention was associated with improvements in prescribing competence and prescription-writing quality among undergraduate medical students, with partial retention of learning observed after 15 days.

Although causal inferences cannot be established due to the absence of a control group, the findings suggest that the educational strategy may represent a promising approach for promoting safe prescribing practices in undergraduate medical education.

Future studies should incorporate longer follow-up periods, controlled and multicenter designs, and qualitative or mixed-methods approaches to better understand knowledge retention, transfer to clinical practice, and learners’ perceptions regarding prescription training.

Authors' contributions

M.V.D.S.: Conceptualization, Methodology, Formal Analysis, Investigation, Writing - Original Draft; F.A.S.S.: Writing - Original Draft, Visualization; R.R.O.C.: Conceptualization, Supervision; S.M.M.: Writing - Original Draft, Visualization; A.M.B.: Conceptualization, Project Management, Supervision.

Funding

The Article Processing Charge (APC) for the publication of this research was funded by the Coordination for the Improvement of Higher Education Personnel – CAPES (ROR ID: 00 × 0ma614). For the purposes of open access, the authors have assigned a Creative Commons CC BY license to any accepted version of the article.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Federal University of Rio Grande do Norte (No:7,031,169). Written informed consent was obtained from all participants prior to their enrollment in this study. All participants were fully informed of the study’s objectives, procedures, and potential risks. Written informed consent was obtained from all the participants prior to enrolment in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.