Presentation on theme: "Medication safety - the introduction and evaluation of interventions-"— Presentation transcript:
1Medication safety - the introduction and evaluation of interventions- Bryony Dean FranklinProfessor of Medication Safety, UCL School of PharmacyDirector, Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS TrustChair, Imperial Centre for Patient Safety and Service QualityAssociate Editor, BMJ Quality and Safety
2Most common healthcare intervention… Use of medication is the most common intervention healthcare - nearly every patient admitted to hospital will be prescribed medication, and a third are prescribed anti-infectives at any one time. Two thirds of patients registered with a GP will receive at least one prescription in a year, and about 12% of these are for anti-infectives.
3But… International systematic reviews: median prescribing error rate: 7.0% of inpatient medication orders 1Median medication administration error rate: 8.0% doses, excluding wrong time errors 2Median 3.7% of unplanned hospital admissions are due to preventable adverse drug events 3Estimate that 1-2% inpatients harmed as a resultLewis et al (2009) Drug Safety 32:379-89Keers et al (2013) Ann Pharmacother 47:237-56Howard et al (2007) Br J Clin Pharmacol 63:
8Developing interventions What are the problems?Do not assume that problems (and thus solutions!) elsewhere are the same as your ownWide variation between settings and countries…Paper-based or electronic prescribing? Unit dose? Original packs? Medication preparation? Use of technology?Wide variation even within countries and settingsWhat are the problems? - internationally a particular issue with different baseline systems for prescribing, dispensing, administering medication – different driving forces, different contexts. Eg CPOE USA vs UKFormal studies eg observations, case note reviewsMcLeod et al (2014). A national survey of inpatient medication systems in English NHS hospitals. BMC HSRAhmed et al (2013). The Use and Functionality of Electronic Prescribing Systems in English Acute NHS Trusts: A Cross-Sectional Survey. PLoS ONE 8(11):
9Developing interventions Focus groupsAuditsIncident reportsFormal studiesWhat are the problems? - internationally a particular issue with different baseline systems for prescribing, dispensing, administering medication – different driving forces, different contexts. Eg CPOE USA vs UKFormal studies eg observations, case note reviews
10Developing interventions Who are the stakeholders?What are the barriers, facilitators, challenges?Plan Do Study Act (PDSA)?What are the problems? - internationally a particular issue with different baseline systems for prescribing, dispensing, administering medication – different driving forces, different contexts. Eg CPOE USA vs UKAlso finance,Who are the stakeholders? Eg EP systems in hospitals – everyone thinks about the prescribers and forget about nurses (who are the biggest users!). And even if they remember about the nurses, what about the dieticians who also have to prescribe dietary supplements. And what about the patients???What are their views on feasibility, acceptability? What are the barriers likely to be?
13What are the research questions? How to increase patient safety?What are the problems?Why do they occur?What might the solutions be?What works?What works best?Which are cost-effective?
14What are the research questions? How to increase patient safety?What are the problems?How often do they occur?Why do they occur?What might the solutions be?What works?What works best?Which are cost-effective?
15What are the research questions? How to increase patient safety?What are the problems?How often do they occur?Why do they occur?What might the solutions be?What works?What works best?Which are cost-effective?Developing interventionsEvaluating interventions
16Types of question Quantitative methods Qualitative methods How many? - Clinical outcomes- Observations- Surveys- AuditsWhy? How?Qualitative methods- Focus groups- Interviews
19Quantitative methods - important issues Define what you are countingDefine your denominatorChoice of data collection methodValidityReliabilitySampling strategyGeneralisabilityStudy design
201. Definitions Wide ranges of published error rates: Published rates of prescribing errors in England range from 1-15% of inpatient medication orders writtenInternationally, estimates of dispensing error rates in community pharmacy vary from 0.04% to 24% of dispensed items
211. DefinitionsWhat is, and what isn’t, an error??
222. Choice of data collection method Example: detection of prescribing errors in hospital Prospectivereportingby pharmacists?Retrospectivereview of medicalrecords &prescriptions ?Incidentreports?Trigger tools?
232. How do methods compare. (n = 135 errors in total; 10 2. How do methods compare? (n = 135 errors in total; 10.7% of medication orders)Retrospective Review (n = 93; 69%)Trigger Tool (n = 0)41867Data recorded byward pharmacist(n = 48; 36%)1Incident Report (n = 1; 1%)Franklin et al. Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions. Pharmacoepidemiology and Drug Safety 2009; 18: 992–999
243. Study design - what is the disadvantage of collecting data just once? Medication review intervention to reduce inpatient fallsPut into place in July56 falls logged in JuneMeasured again in October - only 15 fallsSuccess!!!
253. Study design - what is the disadvantage of collecting data just once? Mean July to Dec = 35Mean Jan to June = 35
263. Study design - what is the disadvantage of collecting data just once? Time series analysis
28Qualitative Methods Key principles of qualitative research Types of data:What people say they believe or doWhat people actually doWhat people actually believeThe context of what people say/do/believe
30Mixed methodsIntegration of qualitative and quantitative methods in the same study to answer a research questionIncrease in breadth and depthVarious ways in which the two are integratedIndependent vs interactiveEqual priority vs one weighted more than the otherTiming: concurrent vs sequential vs multi-phaseInterface: data collection vs data analysis vs data interpretationHadi et al (2013). Int J Pharm Prac 21:
34Quotes“Also for something like aspirin, I know most pharmacists would just add that on to the drug chart and PNC [prescriber not contacted], so not contact the prescriber because it’s so small you wouldn’t contact the doctor just to say, oh it should be enteric coated or, oh it should be dispersible and you didn’t write that on..A lot of the time we’ll change, we’ll add modified release and, without probably telling the doctor”. (Pharmacist)
35Quotes“And there’s another key issue here as well especially if you’re in an area where there’s a lot of doctors rotating, sometimes that phenytoin prescription is written by Doctor X, Doctor X has gone home so I have to go to Doctor Y and get them to change it and that’s fine, they learn something new, but Doctor X who wrote the prescription doesn’t know anything about it”. (Pharmacist)
38Prescribing Improvement Model AimTo develop, test the feasibility, and evaluate a practical, low-cost intervention to provide feedback to junior doctors on prescribing errors and increase patient safety.Three objectives:To encourage prescribers to identify themselves when prescribingTo increase the feedback given by pharmacists to individual prescribers on their prescribing errorsTo introduce group feedback to junior doctors on common prescribing errorsPrescribing errors happen. What doesn’t always happen is that prescribers get to know about them. Part of the problem is that prescribers routinely do not identify themselves when prescribing.The pharmacists’ emphasis is often on correcting the drug chart, which only solves the problem for that particular patient. The doctor is not told when they have made an error. We wanted to change that.Mention again the toolkit as an outcome
40And what do our patients think? “…it’s OK to screw up once but there ought to be a process that says you’ve screwed up once and we’re going to correct it so that it doesn’t happen again. What’s unforgivable is if you’ve got the ability to go on screwing up time and time again”Patient focus group participant
411. Prescriber Identification At the three intervention sites, we gave FY1s a name stamp, a set of instructions and asked them to use it.We modified the message to identify yourself when prescribing, rather than focussing on using the name-stamp per se.We also spoke to the doctors in person, mostly on an ad-hoc basis, and asked them to identify themselves when prescribing. At imperial, we gave a short presentation to them at their weekly education sessions.
42PDSA cycles Ogrinc G, Shojania KG. BMJ Qual Saf 2014;23:265–267. As a result of our PDSA cycles we added the prefix “Dr” to name-stamps, ensured we were using prescribers’ preferred names (not always the same as those held by human resources), modified our initial message from “use your name-stamp” to “state your name when prescribing”, added a label to name-stamps reminding doctors to sign their prescription, made a minor change to our inpatient drug chart and designed brief supporting information to accompany the name-stamps when distributed.
43Fortnightly dataPercentage of inpatient medication orders written FY1s where prescriber is identifiable
44Fortnightly dataPercentage of inpatient medication orders written by FY1s where prescriber is identifiableEstimate increase from 7% to 40-50%
452. Individual feedback Pharmacists asked to: Publicity and education Identify individual prescriberContact individual prescriberTell them an error madeSuggest how to avoid the errorPublicity and educationAccompanied visitsBuilding on being able to identify the prescriberError v mistake
463. “Prescribing tips” Sent fortnightly “Spot the error” Discusses one or two errors in more depthReadableCompatible with smartphonesLinks to relevant prescribing resourcesLocally relevantReferred to specialist pharmacists during development.
47Evaluation Process measures Outcome measures Weekly audit on identifiable prescribersPharmacists assessed for feedback provisionOutcome measuresPrevalence ofprescribing errorsQuestionnaireFocus groupsPrescriber identification audited on a weekly basis by the project team at Imperial, and by existing pharmacists at North West LondonPrescribing errors audited weekly by ward pharmacists at all sites, inclusive of control and intervention and North West LondonIntervention andcontrol hospitalsIntervention hospital
48FindingsWe estimate that we increased the percentage of FY1 medication orders for which the prescriber was identifiable from about 6% to 50%.Focus groups with pharmacists and FY1s suggested real benefits of our interventions and no evidence of negative unintended consequences.Attempts to produce a measureable reduction in prescribing errors are likely to need multi-faceted approach of which feedback should form part.
50The Dose-Reference Card (Dr-CARD) Development and evaluation of a pocket card to support prescribing by junior doctors in an English hospital
51The Dr-CARDFocus groups held locally: foundation year 1 (FY1) doctors perceived time pressure and lack of access to information to be sources of stress, and to potentially contribute to erroneous prescribing.Many had developed their own pocket reference guides for commonly prescribed drugs
58Publishing this work Choice of journal Appropriate checklists for study designQuality improvement workSQUIRE guidelinesContext – what kind of setting?DefinitionsWhat did you count as an error / adverse drug event / adverse drug reaction?Who or what was counted, and non-counted, in your denominator?