This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Two information technology (IT)-based interventions, which aim to improve prescribing safety in primary care, have been rolled out across England over the past few years. Researchers identified 5 strategies which could help ensure that the systems continue to have an impact over the longer term.
The first system (computerised decision support, or CDS) raises a warning when a clinician is about to prescribe a medicine that could increase a patient’s risk of harm. The second method (PINCER) is led by pharmacists; it searches people’s medical notes to identify potential errors that have already happened. Pharmacists, GPs and other clinicians work together to investigate and correct any errors.
The research team examined documents, interviewed relevant professionals and carried out workshops which also involved members of the public. They identified strategies that could help ensure that these systems have an ongoing impact in primary care.
This study is part of the wider PRoTeCT study, which aims to improve the safety of prescribing in general practice. It is examining the impact of these two IT-based interventions on medication safety and on NHS costs.
5 strategies for long-term success
- Ensure a good fit with current practice and priorities through ease of use and integration into IT systems
- Engage hearts and minds through leadership and alignment with professional values
- Build resilience with a team approach involving all staff members
- Align prescribing safety guidelines with secondary care through shared IT infrastructure and communication
- Consider using PINCER and CDS together; share data for best practice.
The issue: prescribing safety
Medication errors have been estimated to cost the NHS £98 million and cause 1700 avoidable deaths every year in England; primary care is an important contributor to this burden. Medication errors include errors in prescribing, dispensing, drug administration or monitoring.
Prescribing errors are the most common medication error in primary care, and may affect 1 in 20 patients. Most do not cause harm, but children, older adults and people with multiple long-term conditions may be more at risk of experiencing these errors.
IT-based systems have been shown to improve the safety prescribing in general practice, and to protect people from these errors. Two approaches, CDS and PINCER, are now being used in GP practices across England.
Both methods were shown in initial studies to improve the safety of prescribing. However, longer-term study is necessary to understand how to ensure that safe prescribing continues beyond the initial roll-out phase. In this study, researchers explored factors which could help ensure that the prescribing interventions have a long-term impact.
What’s new?
The team analysed 48 academic and professional documents on prescribing safety in general practice. From this they developed the themes to be explored. The researchers then interviewed 27 professionals who had experience of PINCER and CDS or could influence their adoption at local or national levels. They ran 2 workshops for 20 people in all, which included some of the same interviewees, PINCER users, and patients and members of the public.
The researchers identified 5 strategies to increase the long-term success of the prescribing interventions:
- A good fit with current practice and priorities. The intervention has to be easy for the practice team to use, and not disrupt workflow; it needs to be integrated into existing computer systems and align with local and national priorities: “Anything that slows the consultation down isn’t often welcomed.”
- Engage hearts and minds. ‘Champions’ could promote the interventions; but strong leadership is needed to ensure that all levels buy in to the idea. Benefits need to be made explicit and align with professional values: “Clinicians have to be convinced that it is worth their while having it there and the irritations that it causes… If it is improving the quality of prescribing well let’s see the evidence of that.”
- Build Resilience. Pharmacists’ specialist knowledge is valued, but teamwork involving all staff members helped embed the interventions in everyday practice. This requires resources and training but could enhance impact, otherwise: “.. when the pharmacist is away, it all defaults back to the GPs again and then we have almost got deskilled to some extent.”
- Align with secondary care. IT systems that are shared with secondary care, and open lines of communication, are needed to ensure that the same prescribing safety guidelines are followed in primary and secondary care. Educational bodies, higher education institutes, and healthcare providers need to be involved in education and training; patients also need to be involved in discussions about prescribing safety.
- Complementary use of PINCER and CDS. The two systems work in different ways to improve prescribing safety. PINCER is used for periodic overviews while CDS “…is your dashboard.. to tell you in the moment where your issues are and what is happening.” Participants said that publishing prescribing safety data would help share learning and best practice between practices and regions.
Fitting with current priorities (strategy 1) could influence whether the systems were adopted. The other 4 strategies were to maintain the impact of the systems, once in place.
Why is this important?
These 5 strategies are based on studying the early and longer-term implementation of PINCER and CDS across England. They were developed to help implement and sustain the impact of IT-based interventions to improve prescribing safety in primary care.
At their heart is the importance of alignment of services, a team approach across the healthcare system, and sharing information. The need for resources and training was emphasised, along with support from local and national organisations, and advocacy of the interventions by key healthcare leaders.
The impact of new interventions or ways of working depends on how successfully they are introduced and embedded into clinical practice. The strategies developed in this research form the basis of a toolkit local managers and clinicians can use to get the most out of these interventions to improve prescribing safety. The researchers say that they can pick and choose the strategies that best fit their local situation.
The study has some limitations. The patient and public groups that took part had a particular interest in medication safety. Similarly, many of the clinicians involved had worked directly with medication safety and were likely to understand the burden of drug-related harm. The participants may therefore not represent the wider views of other clinicians and members of the public.
What’s next?
GPs and regional teams may adapt these strategies to change their working patterns. Since PINCER and CDS are IT systems, they may also offer opportunities for teams to track the impact of any changes they make to their working patterns on prescribing safety. They might use acceptance rates for CDS alerts, for example, and PINCER indicator data.
The PRoTeCT research team is continuing to analyse the impact (and economic impact) of PINCER and CDS on patient safety.
You may be interested to read
This Alert is based on: Shamsuddin A, and others: Strategies supporting sustainable prescribing safety improvement interventions in English primary care: a qualitative study. BJGPOpen. 2021;5(5).
A previous Alert on the SMASH system, which is based on PINCER.
The wider PRoTeCT study.
Scaling up PINCER in clinical practice: Rodgers S, and others: Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: Multiple interrupted time series study. PLoS Med. 2022;19(11): e1004133.
Funding: The PRoTeCT Programme is funded by the NIHR Programme Grants for Applied Research Programme.
Conflicts of Interest: Several authors hold positions with NIHR, NHS England, and with academic publications. Full disclosure on the original paper.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
