UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Medication safety - the introduction and evaluation of...

UCL SCHOOL OF PHARMACYBRUNSWICK 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

Most common healthcare intervention…

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 32:379-892. Keers et al (2013) Ann Pharmacother 47:237-563. Howard et al (2007) Br J Clin Pharmacol 63: 136-147

So what are we going to do about it?

Objectives

• To highlight key issues in developing, evaluating and publishing on interventions to enhance medication safety

DEVELOPING INTERVENTIONS

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):

Focus groups

• Who are the stakeholders?• What are the barriers, facilitators, challenges?• Plan Do Study Act (PDSA)?

EVALUATING INTERVENTIONS

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?

What are the

problems?

How often do

they occur?

Why do they occur?

What might the solutions

What works?

What works best?

What are the

problems?

How often do

they occur?

Why do they occur?

What might the solutions

What works?

What works best?

Developing interventions Evaluating interventions

Types of questionQuantitative methods

- Audits- Surveys- Observations- Clinical outcomes

How many?

Qualitative methods

- Observations- Interviews- Focus groups

Why? How?

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

QUANTITATIVE METHODS

Quantitative methods- important issues

• Define what you are counting• Define your denominator• Choice of data collection method

– Validity– Reliability

• Sampling strategy– Generalisability

• Study design

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

1. Definitions

What is, and what isn’t, an error?

2. Choice of data collection methodExample: detection of prescribing errors in hospital

Prospective reporting by pharmacists?

Retrospective review of medical records & prescriptions ?

Incident reports?

Trigger tools?

2. How do methods compare?(n = 135 errors in total; 10.7% of medication orders)

86 417

Retrospective Review (n = 93; 69%)

Data recorded byward pharmacist (n = 48; 36%)

Incident 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

Trigger Tool (n = 0)

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

Success!!!

January February March April May June July August September October November December0

Number of patient falls per month

Mean Jan to June = 35

Mean July to Dec = 35

Time series analysis

QUALITATIVE METHODS

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

MIXED METHODS

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: 341-45

SOME EXAMPLES

Improving patient safety through providing feedback to junior doctors on prescribing errors

The Prescribing Improvement Model Study (PIMs)

First... identify root causes

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)

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)

Is this the problem?

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

Focus group - foundation year 1 doctors (FY1s)

“…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?

1. Prescriber Identification

PDSA cyclesOgrinc G, Shojania KG. BMJ Qual Saf

2014;23:265–267.

Fortnightly data

• Percentage of inpatient medication orders written FY1s where prescriber is identifiable

Fortnightly data

• Percentage of inpatient medication orders written by FY1s where prescriber is identifiable

2. Individual feedback

• Pharmacists asked to:– Identify individual prescriber– Contact individual prescriber– Tell them an error made– Suggest how to avoid the

• Publicity and education• Accompanied visits

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

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

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.

Hopefully...

Development and evaluation of a pocket card to support prescribing by junior doctors in an English hospital

The Dose-Reference Card (Dr-CARD)

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

Dr-CARD

PUBLISHING

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?

The right tools for the job

UCL SCHOOL OF PHARMACY BRUNSWICK SQUARE Medication safety - the introduction and evaluation of...

Documents

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