New research published Online First by The Lancet shows that a pharmacist-led, information technology-based intervention reduces errors in prescribing of drugs in primary care and is cheap and easy to implement, costing GBP75 for each error avoided at six months. The Article is by Professor Anthony J Avery, Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK, and colleagues.
Medication errors are an important cause of potentially avoidable morbidity and mortality in primary and secondary care, and reports from the USA, UK, and elsewhere have shown the urgent need to reduce the risk of occurrence of these errors. In this study, the authors tested whether a pharmacist-led, information technology-based intervention (PINCER) was more effective than simple feedback in reducing the number of patients at risk of hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. Three clinically important, commonly made errors were analysed: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; and long-term prescription of angiotensin-converting-enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months.
GP practices allocated to receive simple feedback were provided with computerised feedback on patients at risk from medication errors, and the practices were given brief written information on the importance of each type of error. GP practices allocated to the PINCER intervention were also provided with computerised feedback on patients at risk from medication errors. In addition, they met with a pharmacist to discuss the problems identified from the computerised feedback and to agree on an action plan. The pharmacist then spent roughly 2 days a week for the next 12 weeks dealing with the problems and working to improve safety systems. The types of activities undertaken by the pharmacists included inviting patients into the surgery for a prescription review or blood test with the aim of correcting the errors that had been identified.
72 general practices in the UK with a combined patient list size of 480 942 were randomised to receive either the PINCER intervention or simple feedback. At 6 months' follow-up, patients in the PINCER group were 42% less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection; 27% less likely to be given a β blocker if they had asthma; and around half as likely to be prescribed an ACE inhibitor or loop diuretic without appropriate monitoring. The authors add that provided general practices are prepared to pay GBP75 per error avoided, the PINCER intervention was extremely likely to be cost-effective.
The authors say: "This trial shows that a pharmacist-delivered information technology intervention substantially reduced the frequency of a range of clinically important prescription and medication monitoring errors."
They conclude: "Because of the pressing need to reduce errors in health care, PINCER offers an effective method for reducing a range of medication errors in general practice. An essential prerequisite is the use of electronic health records, which effectively reduces errors. The intervention that we have developed will be suitable for implementation in the increasing number of countries where clinical records are now computerised and where the roles of pharmacists to monitor proactively for clinically important medication errors can be extended."
In a linked Comment, Dr Jeffrey L Schnipper and Dr Jeffrey M Rothschild, Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA, conclude: "The PINCER trial is important because it shows how the elements necessary for a successful medication safety intervention can be combined on a large scale. Further research is needed so as to understand better how to successfully implement such interventions as broadly as possible, and the potential tradeoffs inherent in focusing efforts on certain measurable quality and safety goals, possibly at the expense of less measurable ones."
Professor Anthony J Avery, Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK. T) 44-115-8230209 E) tony.avery@nottingham.ac.uk
Dr Jeffrey M Rothschild, Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. T) 617-732-4825 E) jrothschild@partners.org
Journal
The Lancet