Process evaluation of PINCER
Research type
Research Study
Full title
Generating recommendations for national roll-out and sustainable use of prescribing safety indicator based interventions using longitudinal process evaluation and a consolidated learning exercise
IRAS ID
212446
Contact name
Anthony J Avery
Contact email
Sponsor organisation
University of Nottingham
Duration of Study in the UK
3 years, 9 months, days
Research summary
Prescribing errors in general practice are an important and expensive cause of preventable safety incidents, illness, hospitalisations and deaths.
Many errors can be detected using ‘prescribing safety indicators’ (PSIs, otherwise known as ‘indicators of potentially inappropriate prescribing’). These indicators, used in conjunction with general practice (GP) computer systems, can identify patients at risk of hazardous prescribing (e.g. probable prescribing errors, whereby risks are likely to strongly outweigh any potential benefits). Prescribing safety indicators can be used in two complementary ways to identify patients at risk of harm and take corrective action:
• The first involves computerised decision support (CDS) alerts when a prescribing decision is being made, with the aim of preventing a hazardous prescription. We know that this approach is moderately successful, but prescribers often override these alerts, and
• The second involves searching GP computer systems to identify patients at on-going risk from their prescriptions, and then acting to correct the problem. The latter is the approach we used in the pharmacist-led information technology intervention for medication errors (PINCER) trial where pharmacists working with general practice teams successfully reduced hazardous prescribing.To justify further investment in these two approaches, we need robust evidence to determine whether the interventions prevent serious harm in a cost-effective way, and how best to support their implementation, roll-out and sustainable use across the NHS.
This study will evaluate PINCER through observations, interviews and questionnaires and inform future rollout through focus groups and development workshops.
Summary of Results:
What was the question?
We wanted to find out what might help health professionals and patients to successfully introduce and use two approaches to improve safe prescribing of medicines in general practices over longer time periods. This was important as most of what we knew already from research studies about these approaches was either from hospitals or from only a few places in England. The first approach was called Clinical Decision Support, and involved the use of computer alerts which warned staff before prescribing medicines that could risk harming the patient. The second approach (the focus of this report) was called PINCER, and involved running computer searches of health records to find patients who may already be prescribed medicines that could increase the risk of harm, and with a pharmacist looking at the search results and working with the staff in the general practice to try and reduce the number of patients affected by these risks.
What did we do?
Our research was done in three stages. We have reported what we did in relation to Clinical Decision Support as well as PINCER as there was some overlap in the responses. In stage one, we interviewed 33 health care and IT staff from two areas of England about their experiences using Clinical Decision Support and what they thought of it. This included 11 of these people who we interviewed again 6-12 months after their first interview to see how they were using Clinical Decision Support in the longer term. In the second stage, we gathered the experiences and views of health care staff across England towards PINCER using interviews and an online survey. We also spoke to 46 patients with long term health conditions about their experiences of medication reviews (an important part of PINCER) and what they thought of PINCER using interviews and focus groups. Finally, in stage three we held workshops with health professionals, managers and members of the pubic to find what was most important to successfully introduce and PINCER and Clinical Decision Support to improve safe prescribing of medicines in general practices over longer time periods.
What did we find?
For stage one, health care staff said although they understood that clinical decision support could be very helpful in keeping patients safe with their medicines, it was important that the use of clinical decision support was balanced against what they knew about the patient to help them make decisions. They also thought it was important to carefully control what ‘alerts’ the system gave to staff when prescribing medicines, so that people continued to like and use it over the longer term. In stage two, staff said that PINCER could help with the safe prescribing of medicines and found ways to help use it over the longer term, but workload and getting training right were seen as important to make sure people used it. Patients also thought that PINCER could help make the prescribing of medicines safer, but said that it would be important for the public to get better access to medication review and to know more about the role of pharmacists in general practice to give PINCER the best chance of succeeding. In stage three, five important issues were found that helped general practices to successfully introduce the prescribing safety approaches, which included working together in general practice and with hospitals and making sure they ‘fit’ with how people work and what is important to them. The project also helped us to think about how best to run workshops online in future.
What does this mean?
Our results support NHS policies to promote Clinical Decision Support and approaches such as PINCER, so that patients can be prescribed medicines as safely as possible. For example, early findings from the research helped inform the national rollout of the PINCER intervention across England.REC name
East Midlands - Nottingham 2 Research Ethics Committee
REC reference
18/EM/0016
Date of REC Opinion
5 Feb 2018
REC opinion
Favourable Opinion