How to pass the Prescribing Safety Assessment (PSA)…
All you need to know about the ever-dreaded PSA 2024. How scoring works, exam format, question types, common scenarios and our top tips!
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What is the PSA?
The prescribing safety assessment (PSA) is a UK-based, online national examination for medical students and some foundation year one doctors that has been designed to test competencies around safe and effective prescribing.
The PSA was developed by the Medical Schools Council (MSC) and British Pharmacology Society (BPS) with roll-out across medical schools in the UK during 2014.
Newly qualified FY1 doctors will write and review many prescriptions each day, however, prescribing is often considered one of the most challenging areas. In addition, prescription errors are commonly observed in practice. Therefore, the PSA was introduced to ensure junior doctors are safe prescribers with the aim to improve clinical practice and reduce the number of prescribing errors.
The PSA is undertaken by medical students in the early spring of their final year. It is an online exam that lasts for two hours and comprises 60 questions across eight-question formats. The total number of marks available is 200. Each medical school is allowed to choose whether or not they interpret the PSA as a summative assessment towards their medical degree.
If the assessment is formative, candidates who do not pass the PSA will be given two further opportunities during FY1 to pass the assessment to be awarded the Foundation Year 1 Certificate of Completion (F1CC). Non-UK medical students applying to the foundation programme will be expected to take the PSA within their foundation school doing their FY1.
While the test may be daunting, the majority of those sitting the PSA will pass with the median score being ~75% and the pass mark frequently around ~63% (Determined by the Standard-Setting Group). It is important to remember that the PSA will help you prepare to prescribe in clinical practice – it’s not just an exam!
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What makes up the PSA?
The PSA is an online, two hour assessment that includes a total of 200 marks across 60 questions. The PSA is divided into eight distinct sections that test different aspects of prescribing across a range of clinical contexts.
These sections include:
- Writing a prescription
- Prescription review
- Planning management
- Providing information
- Calculation skills
- Adverse drug reactions
- Drug monitoring
- Data interpretation
During the assessment, you will have access to an online version of the British National Formulary (BNF) that can be considered the ‘ultimate arbiter’ for writing and answering PSA questions. The BNF aims to provide prescribers, pharmacists, and other healthcare professionals with up-to-date information about the use of medicines. It is a wealth of information. It can be used as frequently as needed during the exam via the online BNF on the NICE website or Medicines Complete.
However, remember the PSA is a time-sensitive examination – you will not be able to look up every answer, so having some background knowledge around prescribing is essential.
British National Formulary (BNF)...
The BNF is a joint publication by the British Medical Association and the Royal Pharmaceutical Society. It provides healthcare professionals with up-to-date information about the use of medicines.
PSA questions are predominantly based on information that can be found within the BNF. This includes: drug dose, drug route, drug frequency, side effects, adjustments in renal impairment, monitoring requirements and so on. It has a wealth of information beyond simply drug dosing, including interactions and treatment summaries.
Due to the electronic nature of the publication, it can be quickly searched for key information by conducting a CRTL+F function.
The BNF can be used at any point during the PSA examination. Therefore, it is absolutely vital that candidates are confident with using the BNF prior to the exam.
We strongly recommend:
- You look up common drug choices (e.g. inhalers, anti-hypertensives, contraceptives)
- You are comfortable with the drug monograph
- You can extract information within the monograph subtitles (e.g. side-effects)
- You can use the interactions tool to check drug-drug interactions
- You have used the treatment summaries for the medical management of common conditions (e.g. Asthma)
- You are comfortable interpreting ‘drug monitoring’ and ‘directions for administration’ sections
What sort of content makes up the PSA?
The PSA is primarily based on SEVEN clinical settings. These include:
- Medicine
- Surgery
- Elderly care
- Paediatrics
- Psychiatry
- Obstetrics & Gynaecology
- General practice
Questions within the PSA will be focused on one of these clinical settings. Therefore, you will need to be comfortable prescribing in children and prescribing in specific situations (e.g. pregnancy).
The PSA is likely to contain at least two items on the following five high-risk prescribing areas:
- Insulin
- Anticoagulants
- Opioids
- IV fluids
- Antibiotics
You need to ensure you have a reasonable understanding of the use of each of these classes of drugs. Therefore, make sure you brush up on the general principles of prescribing IV fluids! For an excellent summary of IV fluids, check out our FREE notes: Fluid prescribing.
There is a standard structure for each PSA question. This will include the stem that gives the ‘CLINICAL PRESENTATION’, which is followed by the ‘LEAD-IN’ that refers to the actual question being asked.
Following this, there will be the answer section. The format of the answer will change depending on the subject domain. In general, there are four answer types:
- Single-best answer – planning management, providing information, adverse drug reactions, drug monitoring, data interpretation
- Write on a prescription chart (i.e. drug, dose, route and frequency): prescription
- Selecting the correct answers from a list of 6-10 drugs (i.e. choose 1-3 correct answers): prescription review
- Write in a blank box: drug dose calculation
We’re now going to talk about each of the eight major sections mentioned above in detail…
Domain 1: Prescribing
The prescribing section is arguably the hardest and worth the most amount of marks. It is worth a whopping 40% of the total marks, so it’s really important to excel in this section.
You will be asked to choose an appropriate drug or intravenous fluid with its corresponding dose, route, and frequency.
The treatment summaries can help in this section if you are not sure what drug should be used. However, having a good basic understanding of most conditions allows you to focus on looking up the appropriate drug based on your prior understanding which helps save time.
Each question is out of 10, but you will quickly lose marks for incorrect answers. It is absolutely vital you choose the correct drug. The maximum amount you can score for dose, route and frequency is what you scored for the choice of drug. You choose answers by selecting from drop-down menus (e.g. >1000 different medicines, > 20 different routes and 30 different frequencies).
Remember, at least two of the questions will be on fluids!
Questions: 8
Marks: 80 (5 for the drug choice, 5 for the dose, route and frequency)
Timing: ~6 minutes per question
Structure: Choose an appropriate prescription (drug, dose, route, frequency) using drop-down menu
You will be tested on one of three areas:
- Safe & effective prescription
- Managing medical emergencies
- Planning therapy for common indications
Common scenarios:
- Prescribing IV fluid (e.g. maintenance, resuscitation),
- Acute conditions (e.g. anaphylaxis)
- Chronic conditions (e.g. asthma)
- Important symptoms (e.g. constipation, pain).
Top tip: Remember, there may be more than one correct answer!
Domain 2: Prescription Review
Prescription review tests your ability to identify inappropriate, unsafe or ineffective scripts. You essentially need to identify prescription errors from a list of prescribed medications that can include between 6 and 10 drugs.
In this section, you will not have time to look up side effects or interactions for every drug listed. Therefore, having a good understanding of basic prescribing errors will help you save time in the exam.
Remember, the BNF should have all the information on side effects, contraindications, prescribing in pregnancy, renal impairment, hepatic impairment and interactions.
Questions: 8
Marks: 32
Timing: ~2.5 minutes per question
Structure: Each question has a part A and part B. Choose 1-3 correct answers from a list of 6-10 medications
You will be tested on one of four areas:
- Contra-indications
- Adverse drug reactions
- Interactions
- Dose errors
Common scenarios:
- ACE inhibitors
- Anticoagulation
- NSAIDs
- Analgesia
- P450 enzymes
- Penicillins
Top tip: Learn common side effects and contraindications – you won’t have time to look up everything!
Domain 3: Planning management
Planning management involves the identification of the most appropriate management option. It will test you ability to manage commonly encountered conditions with the use of an appropriate medication.
Questions: 8
Marks: 16
Timing: ~1 minute per question
Structure: Single best answer (Best of five)
You will be tested on three main areas:
- Symptom control
- Acute conditions
- Chronic conditions
Common scenarios:
- Anaphylaxis
- Asthma
- Hypertension
- Diabetes
- Infections
Top tip: If you get stuck, the BNF has a really good section of treatment summaries for many conditions!
Domain 4: Providing information
Providing information assesses your ability to give important and relevant advice. Giving the correct information to patients about how they need to take their drug, any side-effects to monitor, or what they should do if they miss a dose is all really vital information.
Most information needed for this domain can be found in the ‘Patient and carer advice’, ‘directions for administration’ or ‘dispensing information’ sections of the BNF.
Questions: 6
Marks: 12
Timing: ~1.25 minutes per question
Structure: Single best answer (Best of five)
Common scenarios:
- Breastfeeding
- Contraception
- Antibiotics
- Pregnancy
- Side effects (e.g. immunosuppression)
Top tip: Multiple answers may be ‘correct’, so think about what is relevant to the patient in question!
Domain 5: Calculation skills
This domain requires you to complete basic drug calculation skills in response to a question. This may be working out the correct dose, the correct rate of administration or even the correct conversion of units.
The calculation skills will not be overly complex in the exam and there are three basic skills you need to be able to do:
- Calculate based on weight (e.g. 50 mg/kg)
- Calculate dilations (e.g. dilute 10 mg/mL -> 1 mg / mL)
- Calculate frequencies or rates (e.g. 75 mL/hour)
Questions: 8
Marks: 16
Timing: ~1.25 minutes per question
Structure: Fill in the blank box (units are provided)
Common scenarios:
- Weight-based calculations
- Volume-based calculations
- Frequencies
- Percentage in a solution
Top tip: All the information you need will be in the question, although sometimes there is distracting information!
Domain 6: Adverse drug reactions
Adverse drug reactions test your ability to identify an abnormal reaction/interaction or how you would manage an adverse drug reaction in practice. These questions will be based on well recognised adverse reactions.
Having a good foundation about common drug interactions and side-effects will really help you speed through this section.
Questions: 8
Marks: 16
Timing: ~1.25 minutes per question
Structure: Single best answer (Best of five)
Common scenarios:
- NSAIDs
- Diuretics
- Opioids
- Insulin
- Analgesics
- Anticoagulation
You will be tested on four main areas:
- Identifying likely adverse reactions
- identifying a drug causing a specific reaction
- Identifying a drug interaction
- Managing adverse reactions
Top tip: If you are unsure, always check an interaction in the BNF using the ‘interactions’ section and CTRL+F look-up strategy
Domain 7: Drug monitoring
Drug monitoring is about how you how may demonstrate that treatment with a drug has been a success or a failure. A lot of drug monitoring requirements are about watching out for the development of adverse effects (e.g. deranged thyroid function tests) or monitoring plasma levels.
Be ready to answer questions on drugs that require monitoring of their plasma levels (e.g. phenytoin, digoxin, lithium).
The majority of the information in the BNF is found in the ‘drug monitoring’ section
Questions: 8
Marks: 16
Timing: ~1.25 minutes per question
Structure: Single best answer (Best of five)
Common scenarios:
- Antibiotics (gentamicin, vancomycin)
- Acute infusions (phenytoin, aminophylline)
- Long-term medications (digoxin, lithium)
Top tip: Make sure you read the question carefully and know the exact time point they are asking about (e.g. at baseline, at 3 months or at 12 months)
Domain 8: Data interpretation
This domain requires you to decide on the most appropriate course of action based on the clinical scenario. In this section, you may need interpret clinic information such as a graph, thyroid function tests or drug plasma levels.
In this section, there is less emphasis on the BNF and more on your clinical reasoning skills that can be applied to the question. Don’t worry, if you find this hard it is only a short section!
Questions: 6
Marks: 12
Timing: ~1.25 minutes per question
Structure: Single best answer (Best of five)
Common scenarios:
- Thyroid function tests
- Plasma drug concentrations
- Chest x-rays
- ECGs
Top tip: Make sure you have a general idea of how to adjust medications based on plasma drug levels!
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How do I prepare for the PSA?
Get used to the BNF! The PSA is essentially an ‘open book’ exam because you have full access to the BNF. However, it is a fast paced exam, so you will not have enough time to look up everything.
The most important thing is being comfortable with using the BNF that includes using it to look up drugs, check interactions, look-ip treatment summary and find useful information on broad topics such as contraceptives and peri-operative management.
Revise common drugs
Having a good foundation about the indication for certain drugs, how they work, common side-effects, interactions and how they should be monitored will help you to quickly find the answer in the BNF and allow you to answer questions without having to double check them.
Make sure you know these common groups well:
- Analgesia
- Antibiotics
- Anticoagulants
- Antidepressants
- Antiepileptics
- Antihypertensives
- Antiplatelets
- Antipsychotics
- Bisphosphonates
- Contraceptives
- Corticosteroids
- Hypoglycaemics
- Inhalers
- Insulin
- Intravenous fluids
- Laxatives
- NSAIDs
- Statins
Practice, Practice, Practice...
It’s really important that you get used to the question format of the exam and go over practice questions before you sit the exam.
You will have access to practice papers once you activate your PSA account ahead of the exam and at Pulsenotes we have > 100 practice questions and hours of online lectures to get you up to speed and ready for the exam!
Our Top tips for the PSA...
We summarise our ten top tips for passing the PSA!