Strategies supporting sustainable prescribing safety improvement interventions in English primary care: a qualitative study.

Azwa Shamsuddin,Richard N Keers,Aziz Sheikh,Libby Laing,Anthony J Avery,Justin Waring,Antony Chuter,Nde-Eshimuni Salema,Mark Jeffries

doi:10.3399/bjgpo.2021.0109

Abstract

BackgroundWhile the use of prescribing safety indicators (PSI) can reduce potentially hazardous prescribing, there is a need to identify actionable strategies for the successful implementation and sustainable delivery of PSI-based interventions in general practice.AimTo identify strategies for the successful implementation and sustainable use of PSI-based interventions in routine primary care.Design & settingQualitative study in primary care settings across England.MethodAnchoring on a complex pharmacist-led IT-based intervention (PINCER) and clinical decision support (CDS) for prescribing and medicines management, a qualitative study was conducted using sequential, multiple methods. The methods comprised documentary analysis, semi-structured interviews, and online workshops to identify challenges and possible solutions to the longer-term sustainability of PINCER and CDS. Thematic analysis was used for the documentary analysis and stakeholder workshops, while template analysis was used for the semi-structured interviews. Findings across the three methods were synthesised using the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework.ResultsForty-eight documents were analysed, and 27 interviews and two workshops involving 20 participants were undertaken. Five main issues were identified, which aligned with the adoption and maintenance dimensions of RE-AIM: fitting into current context (adoption); engaging hearts and minds (maintenance); building resilience (maintenance); achieving engagement with secondary care (maintenance); and emphasising complementarity (maintenance).ConclusionExtending ownership of prescribing safety beyond primary care-based pharmacists, and achieving greater alignment between general practice and hospital prescribing safety initiatives, is fundamental to achieve sustained impact of PSI-based interventions in primary care.

Highlights

Prescribing and medication errors are common in primary care
Previous studies have shown the following to be important: availability of resources; simplifying the use of interventions; avoiding alert fatigue; pharmacist embedment; and improving the specificity of prescribing safety indicators (PSI). This qualitative study synthesises findings from a documentary analysis, interviews, and workshops with local, regional, and national primary care stakeholders, to draw lessons from the implementation of a complex PINCER and clinical decision support (CDS). This results in five strategies centering around engagement with the primary care team and alignment of policies to achieve sustainable use of PSI-b ased interventions
PINCER is a pharmacist-led intervention that involves a search of patient records to identify those at risk of potentially hazardous prescribing and/or monitoring errors based on PSIs built into the software, and an educational outreach programme for general practice staff

Summary

Introduction

Prescribing and medication errors are common in primary care. many are not serious, they overall — as a function of the substantial volume of prescribing in this setting — are responsible for considerable potentially avoidable harm.[1]. There is evidence from the authors' work and others that focusing on PSI offers an opportunity to reduce the frequency of these errors, which may translate into improved health outcomes.[2,3]. These indicators have been embedded in technology-enabled interventions to improve prescribing safety in primary care such as CDS and PINCER,[4] both of which have demonstrated positive impact in reducing the rate of potentially hazardous prescribing in primary care.[2,4,5]. CDS systems are often used in primary care for support in decision making for prescribers at the point of prescribing They provide patient-related information and clinical knowledge to enhance patient care, and may reduce medication error or the potential prescribing of inappropriate medications. While the use of prescribing safety indicators (PSI) can reduce potentially hazardous prescribing, there is a need to identify actionable strategies for the successful implementation and sustainable delivery of PSI-based interventions in general practice

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Discussion

Conclusion