Evaluation of a pharmacist-led actionable audit and feedback intervention for improving medication safety in UK primary care: An interrupted time series analysis.

Darren M Ashcroft,Sean Patrick Macbride-Stewart,Niels Peek,Benjamin Brown,Wouter T Gude,Anthony J Avery,Denham L Phipps,Richard N Keers,Mark Jeffries,Richard Williams,Evangelos Kontopantelis

doi:10.1371/journal.pmed.1003286

Abstract

We evaluated the impact of the pharmacist-led Safety Medication dASHboard (SMASH) intervention on medication safety in primary care. SMASH comprised (1) training of clinical pharmacists to deliver the intervention; (2) a web-based dashboard providing actionable, patient-level feedback; and (3) pharmacists reviewing individual at-risk patients, and initiating remedial actions or advising general practitioners on doing so. It was implemented in 43 general practices covering a population of 235,595 people in Salford (Greater Manchester), UK. All practices started receiving the intervention between 18 April 2016 and 26 September 2017. We used an interrupted time series analysis of rates (prevalence) of potentially hazardous prescribing and inadequate blood-test monitoring, comparing observed rates post-intervention to extrapolations from a 24-month pre-intervention trend. The number of people registered to participating practices and having 1 or more risk factors for being exposed to hazardous prescribing or inadequate blood-test monitoring at the start of the intervention was 47,413 (males: 23,073 [48.7%]; mean age: 60 years [standard deviation: 21]). At baseline, 95% of practices had rates of potentially hazardous prescribing (composite of 10 indicators) between 0.88% and 6.19%. The prevalence of potentially hazardous prescribing reduced by 27.9% (95% CI 20.3% to 36.8%, p < 0.001) at 24 weeks and by 40.7% (95% CI 29.1% to 54.2%, p < 0.001) at 12 months after introduction of SMASH. The rate of inadequate blood-test monitoring (composite of 2 indicators) reduced by 22.0% (95% CI 0.2% to 50.7%, p = 0.046) at 24 weeks; the change at 12 months (23.5%) was no longer significant (95% CI -4.5% to 61.6%, p = 0.127). After 12 months, 95% of practices had rates of potentially hazardous prescribing between 0.74% and 3.02%. Study limitations include the fact that practices were not randomised, and therefore unmeasured confounding may have influenced our findings. The SMASH intervention was associated with reduced rates of potentially hazardous prescribing and inadequate blood-test monitoring in general practices. This reduction was sustained over 12 months after the start of the intervention for prescribing but not for monitoring of medication. There was a marked reduction in the variation in rates of hazardous prescribing between practices.

Highlights

Improving medication safety is a core objective for healthcare systems worldwide, and was recently identified by the World Health Organization (WHO) as the theme for the Third Global Patient Safety Challenge [1]
The Safety Medication dASHboard (SMASH) intervention was associated with reduced rates of potentially hazardous prescribing and inadequate blood-test monitoring in general practices
Stocks et al [6] found that 5% of patients who are managed in general practices in the UK are exposed to potentially hazardous prescribing, and about 12% had no record of appropriate monitoring

Summary

Introduction

Improving medication safety is a core objective for healthcare systems worldwide, and was recently identified by the World Health Organization (WHO) as the theme for the Third Global Patient Safety Challenge [1]. While most medications are prescribed, dispensed, and administered in ambulatory care settings, research and quality improvement have traditionally focused on hospital-based settings. There is clear evidence that medication errors are very common in ambulatory care and contribute to iatrogenic morbidity [4], despite the fact that individual items carry low risk. The sheer volume of ambulatory care prescribing (over 1 billion prescription items supplied in the community in England each year) means that avoidable deaths in primary care due to medication errors are 7 times likely than in secondary care (627 versus 85) [5]. Variation in the prevalence of potentially high-risk prescribing and lack of appropriate monitoring tests between practices was high, even after adjustment for patient- and practice-level variables. We evaluated the impact of the pharmacist-led Safety Medication dASHboard (SMASH) intervention on medication safety in primary care

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