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UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Medication safety - the introduction and evaluation of interventions- Bryony Dean Franklin Professor of Medication.

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Presentation on theme: "UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Medication safety - the introduction and evaluation of interventions- Bryony Dean Franklin Professor of Medication."— Presentation transcript:

1 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Medication safety - the introduction and evaluation of interventions- Bryony Dean Franklin Professor of Medication Safety, UCL School of Pharmacy Director, Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust Chair, Imperial Centre for Patient Safety and Service Quality Associate Editor, BMJ Quality and Safety

2 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Most common healthcare intervention…

3 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE But… International systematic reviews: –median prescribing error rate: 7.0% of inpatient medication orders 1 –Median medication administration error rate: 8.0% doses, excluding wrong time errors 2 –Median 3.7% of unplanned hospital admissions are due to preventable adverse drug events 3 1.Lewis et al (2009) Drug Safety 32: Keers et al (2013) Ann Pharmacother 47: Howard et al (2007) Br J Clin Pharmacol 63:

4 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE

5 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE So what are we going to do about it?

6 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Objectives To highlight key issues in developing, evaluating and publishing on interventions to enhance medication safety

7 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE DEVELOPING INTERVENTIONS

8 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Developing interventions What are the problems? –Do not assume that problems (and thus solutions!) elsewhere are the same as your own –Wide 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 settings McLeod et al (2014). A national survey of inpatient medication systems in English NHS hospitals. BMC HSR Ahmed et al (2013). The Use and Functionality of Electronic Prescribing Systems in English Acute NHS Trusts: A Cross-Sectional Survey. PLoS ONE 8(11):

9 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Developing interventions Focus groups Audits Incident reports Formal studies

10 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Developing interventions Who are the stakeholders? What are the barriers, facilitators, challenges? Plan Do Study Act (PDSA)?

11 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE EVALUATING INTERVENTIONS

12 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE What are the research questions?

13 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE What 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?

14 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE What 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?

15 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE What 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

16 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Types of question Quantitative methods - Audits - Surveys - Observations - Clinical outcomes How many? Qualitative methods - Observations - Interviews - Focus groups Why? How?

17 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Quantitative v qualitative characteristics QUANTITATIVE Measuring/counting Hypothesis testing Random sampling Scientific empiricism Statistical analysis QUALITATIVE Exploring/qualifying Generates hypotheses Purposive sampling Naturalistic Eg. Content analysis, framework analysis

18 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE QUANTITATIVE METHODS

19 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Quantitative methods - important issues Define what you are counting Define your denominator Choice of data collection method –Validity –Reliability Sampling strategy –Generalisability Study design

20 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 1. Definitions Wide ranges of published error rates: –Published rates of prescribing errors in England range from 1-15% of inpatient medication orders written –Internationally, estimates of dispensing error rates in community pharmacy vary from 0.04% to 24% of dispensed items

21 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 1. Definitions What is, and what isn’t, an error? ?

22 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 2. Choice of data collection method Example: detection of prescribing errors in hospital Prospective reporting by pharmacists? Retrospective review of medical records & prescriptions ? Incident reports? Trigger tools?

23 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 2. How do methods compare? (n = 135 errors in total; 10.7% of medication orders) Retrospective Review (n = 93; 69%) Data recorded by ward pharmacist (n = 48; 36%) Incident Report (n = 1; 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 Trigger Tool (n = 0)

24 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 3. Study design - what is the disadvantage of collecting data just once? Medication review intervention to reduce inpatient falls Put into place in July 56 falls logged in June Measured again in October - only 15 falls

25 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 3. Study design - what is the disadvantage of collecting data just once? Mean Jan to June = 35 Mean July to Dec = 35

26 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 3. Study design - what is the disadvantage of collecting data just once? Time series analysis

27 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE QUALITATIVE METHODS

28 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Qualitative Methods Key principles of qualitative research Types of data: –What people say they believe or do –What people actually do –What people actually believe –The context of what people say/do/believe

29 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE MIXED METHODS

30 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Mixed methods Integration of qualitative and quantitative methods in the same study to answer a research question –Increase in breadth and depth Various ways in which the two are integrated –Independent vs interactive –Equal priority vs one weighted more than the other –Timing: concurrent vs sequential vs multi-phase –Interface: data collection vs data analysis vs data interpretation Hadi et al (2013). Int J Pharm Prac 21:

31 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE SOME EXAMPLES

32 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Improving patient safety through providing feedback to junior doctors on prescribing errors The Prescribing Improvement Model Study (PIMs)

33 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE First... identify root causes 33

34 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Quotes “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) 34

35 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Quotes “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) 35

36 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Is this the problem?

37 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE

38 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Prescribing Improvement Model Aim To 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: 1.To encourage prescribers to identify themselves when prescribing 2.To increase the feedback given by pharmacists to individual prescribers on their prescribing errors 3.To introduce group feedback to junior doctors on common prescribing errors

39 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Focus group - foundation year 1 doctors (FY1s)

40 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE “…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 And what do our patients think?

41 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 1. Prescriber Identification 41

42 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE PDSA cycles Ogrinc G, Shojania KG. BMJ Qual Saf 2014;23:265–267.

43 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Fortnightly data 43 Percentage of inpatient medication orders written FY1s where prescriber is identifiable

44 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Fortnightly data 44 Percentage of inpatient medication orders written by FY1s where prescriber is identifiable

45 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 2. Individual feedback Pharmacists asked to: –Identify individual prescriber –Contact individual prescriber –Tell them an error made –Suggest how to avoid the error Publicity and education Accompanied visits

46 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE 3. “Prescribing tips” Sent fortnightly “Spot the error” Discusses one or two errors in more depth Readable Compatible with smartphones Links to relevant prescribing resources

47 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Evaluation Process measures Weekly audit on identifiable prescribers Pharmacists assessed for feedback provision Outcome measures Prevalence of prescribing errors Questionnaire Focus groups Intervention and control hospitals Intervention hospital

48 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Findings We 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.

49 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Hopefully...

50 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Development and evaluation of a pocket card to support prescribing by junior doctors in an English hospital The Dose- Reference Card (Dr-CARD)

51 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE The Dr-CARD Focus 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

52 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Dr-CARD

53 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE

54 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE

55 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE

56 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE PUBLISHING

57 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Publishing this work

58 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Publishing this work Choice of journal Appropriate checklists for study design Quality improvement work –SQUIRE guidelines Context – what kind of setting? Definitions –What did you count as an error / adverse drug event / adverse drug reaction? –Who or what was counted, and non-counted, in your denominator?

59 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE The right tools for the job

60 UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE


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