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Understanding how Community Pharmacists complete tasks in practice

30 Jan

community pharmacists sorting meds_banner

by Ahmed Ashour, PhD Fellow in the NIHR Greater Manchester PSTRC

The World Health Organization set its 3rd Global Patient Safety Challenge in 2017 to reduce severe avoidable medication-related harm by 50%, globally in five years (1). This led researchers to publish a new report investigating how often medication errors happen and the cost to the NHS in England (2). This renewed the focus on reducing errors and particularly errors occurring within primary care. Internationally, and specifically within the UK, the majority of healthcare interactions will occur with a primary care healthcare professional. One of the ways medication errors can be reduced is by using the scientific discipline of Human Factors and Ergonomics, which uses a number of tools to help reduce human error.

Human Factors and Ergonomics (HFE) aims to understand how individuals are affected by and affect factors around them, and the consequences of their actions. One of the tools used by Human Factors experts is Hierarchical Task Analysis (HTA). HTAs presents the sub-tasks involved in completing a task in a step-by-step form, accompanied by plans that describe the order and context in which the sub-tasks take place (3).

Within community pharmacy practice, pharmacies are required to have in place procedures describing how they should deal with the sale and supply of medicines and for specific services related to patients (4). However, it has been reported that under certain circumstances these Standard Operating Procedures (SOPs) are not always followed (5).

Ahmed Ashour’s PhD will aim to identify and develop the non-technical skills that community pharmacists require in practice. He will use the HTA tool to describe the tasks community pharmacists complete in practice. As part of the work of the Community Pharmacy Patient Safety Collaborative, which was set up by the NIHR Greater Manchester Patient Safety Translational Research Centre (GM PSTRC), participants were trained by a process expert in how to conduct an HTA before being asked to prepare an HTA for a specific task. These HTAs were then discussed in a focus group consisting of between 5 and 7 community pharmacists. Participants were encouraged to share the differences in how they completed the sub-tasks. The HTAs will be used as a basis for observations in community pharmacies. Differences will be documented and an analysis between the HTAs produced by the focus groups and those observed in practice, will be conducted.

There are a number of error-predicting tools that can be applied to HTAs to identify potential errors ahead of time and suggest solutions. One such tool is the Systematic Human Error Reduction and Prediction Approach (SHERPA), which is a method used to identify potential failures. The SHERPA tool can be used to design tasks in a way that minimises the possibility of potentially serious errors. By applying such methods to tasks that community pharmacists do, more specific training can be developed which will help to reduce the number of errors that occur.

Error prediction is not the only use for HTAs. HTAs provide an accurate description of how tasks are completed in practice, which can help to better understand the skills required to complete the tasks. It can also be used as a basis for discussing best practice and sharing information on the barriers to effectiveness. By producing this collection of HTAs, an important resource will be available to HFE researchers and others, to improve how tasks are carried out within community pharmacy.

The validated HTAs will also be published online for use by researchers. If you would like to get involved or for more information, you can contact Ahmed Ashour.

1.       https://www.who.int/patientsafety/medication-safety/medication-without-harm-brochure/en/

2.       Elliot R, Camacho E, Campbell F, Jankovic D, Martyn M, Kaltenthaler E, Wong R, Sculpher M, Faria R. Prevalence and economic burden of medication errors in the NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. 2018.

3.       Stanton N. Hierarchical task analysis: Developments, applications, and extensions. Applied Ergonomics. 2006;37(1): 55-79, ISSN 0003-6870, https://doi.org/10.1016/j.apergo.2005.06.003.

4.       Royal Pharmaceutical Society. Developing and implementing standard operating procedures for dispensing, 2007:1–13.

5.       Thomas C, Phipps D, Ashcroft D. When procedures meet practice in community pharmacies: qualitative insights from pharmacists and pharmacy support staff. BMJ Open. 2016.

REVISiTing GPs in training prescribing to improve medication safety

16 Nov

Pharmacist_small

by Ndeshi Salema

In 2012, the PRACtICe study, funded by the General Medical Council, set out to determine the prevalence and nature of prescribing and monitoring errors in general practices in England. The PRACtICe study found that prescribing errors occur in around one in twenty, or about 5% of the prescriptions. This is important because:

The PRACtICe study also highlighted that, as a group, GPs in training may benefit from further support in prescribing. Further exploratory work took place to identify possible ways to support GPs in training with their prescribing, which resulted in the development of an educational intervention, called REVISiT.

The REVISiT intervention involves:

  • a retrospective review of GPs in training prescribing, which is completed by a pharmacist, followed by
  • individualised feedback on the results of this review in the form of a report, which is discussed in a face-to-face meeting setting.

A small feasibility study of the REVISiT intervention (a retrospective review of approximately 100 prescriptions prescribed by 10 GPs in training) found that 9% of the prescriptions by GPs in training contained an error. The percentage of errors made by GPs in training was much higher than the percentage that was found in the PRACTiCE study, which may be due to the relative inexperience of GPs in training. It also indicated some benefits of the REVISiT intervention in improving the knowledge, skills and attitudes of GPs in training towards prescribing.

Interviews with a variety of stakeholders (healthcare professionals, policymakers, and members of the public) have shown that there is support for REVISiT as an educational intervention that can help improve prescribing, not only for GPs in training but for all types of prescribers. This will enhance the safety of healthcare received by patients.

With funding from the NIHR Greater Manchester PSTRC, the REVISiT intervention is being further developed and tested, in preparation for a trial in the future.

A new career in patient safety…thanks to the Community Pharmacy Patient Safety Collaborative!

13 Nov

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by David Mehdizadeh

Joining the Community Pharmacy Patient Safety Collaborative for me was to gain new insights and new experience in healthcare. I have always had a passion for improving systems and reducing errors, and this collaborative within the NIHR Greater Manchester PSTRC allowed me to take this one step further. This project certainly took me out of my comfort zone as a community pharmacist, and I relished the opportunity to explore and gain new skills!

Meeting regularly with fellow community pharmacists, and researchers within the Greater Manchester PSTRC at The University of Manchester was a rewarding and unique experience. As healthcare professionals, we all have a responsibility of caring for patients safely, and therefore it was refreshing that we could spend protected time solely on patient safety within our practice. This involved learning elements of “improvement science” for improving work systems, sharing and discussing real life patient safety incidents and reflecting on our experiences, all within a non-judgmental and supportive environment.

One of my highlights was being trained up to develop “safety cases” for our individual pharmacies; identifying problem areas which could lead to patient safety incidents and subsequently targeting areas for improvement. Members of my pharmacy team were really supportive of this, and identified areas for improvement in our dispensing of high risk opioid products. This led to higher quality dispensing in this area, but ultimately changed the culture amongst the team, and encouraged the team to prioritise patient safety, and continually reflect on their practice. This was a real success for our pharmacy, and changed the safety culture for the better.

I would highly recommend other community pharmacists and technicians to get involved with the Community Pharmacy Patient Safety Collaborative. You never know what doors this could open for you!

For me, it gave me a platform to explore patient safety further, and to re-evaluate my career goals. This led to me pursue a career in patient safety, and in October 2018 I will be commencing a full-time NIHR PhD studentship at the University of Bradford (in partnership with the NIHR Yorkshire and Humber PSTRC), with the title “Digital Decision Support for Safer Prescribing.” My experience in the collaborative was instrumental in developing a strong application for this PhD programme, and I am grateful to the team at the Greater Manchester PSTRC for providing me with this opportunity.

Safer medicines after hospital discharge

29 Oct

Involvement opportunity_small

by Mark Jeffries

Salford Royal NHS Foundation Trust (SRFT) is introducing an electronic system which will enable hospital pharmacists to refer patients to community pharmacists when they leave hospital, in order to receive advice about their medicine taking.  It is hoped these patients (or their carers) will be able to discuss their medicines with their community pharmacist and that this might resolve potential medication related issues, as well as improving patient knowledge and understanding about their medicines. This may help with the avoidance of errors and may help patients better understand any changes in their medicines. A positive outcome of this initiative is hoped to be patients taking their medicines more safely after spending time in hospital.

As part of our planned evaluation of the service we hope to talk to patients (and carers) about their experiences of using the electronic system and their interactions with the community pharmacists.

We are looking for a patient representative who could be involved in the project and might provide the research team with help and guidance at the different stages of project design, recruitment, data collection and data analysis. If you are interested, or would like more information, please contact Mark Jeffries at mark.jefferies@manchester.ac.uk.

What can we learn from North America about the role of community pharmacy teams in suicide awareness and prevention?

10 Sep
Hayley Gorton_Pharmacy trip photo

Hayley Gorton (r) with Bloom pharmacist Melissa at Haliburton Pharmacy, Antigonish

by Hayley Gorton

It is the NIHR Greater Manchester PSTRC I have to thank for starting the metaphorical journey that is my study of community pharmacy teams in suicide prevention. I joined the original Greater Manchester PSTRC in 2014 to undertake, and later complete, a PhD in the epidemiology of suicide and self-harm (epidemiology looks at how often and where diseases or healthcare events happen). Throughout my time, I was acutely aware of my profession and practice as a community pharmacist: “how would I help someone with thoughts or actions of suicide or self-harm in my pharmacy practice?” I didn’t know, but made it my mission to find out.

This summer, I spent a month in the USA and Canada exploring this question, thanks to a fellowship from the Winston Churchill Memorial Trust (WCMT) and support from the Greater Manchester PSTRC. There is too much to cover in one short blog, but you can find out about each leg of my trip by reading my own blog series. I’ve been back for a month and only now getting some clarity on which (of my many) research questions to pursue, fostering collaborations with those people I met en route and looking at how I can inform UK policy and practice with my WCMT findings. It was a brilliant experience in chronological order from grassroots research to mandatory training.

NHS 70: celebrating pharmacy and looking to the future

2 Aug
NHS 70 Pharmacy event group photo_small

Members and organisers of the Pharmacy Collaborative l-r: James Hind, Edward Teggart, Melinda Lyons, Lauren Worrall

by Lauren Worrall and Melinda Lyons

This year, to celebrate 70 years of the NHS, the Local Professional Network for Pharmacy in Greater Manchester held a conference to recognise how pharmacy professionals had contributed to the NHS and looking forward to how pharmacists expect their role to change to serve the needs of the NHS in the future. The conference involved exploring current issues impacting on pharmacy practice. As part of this, the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative gave a workshop in Manchester on their continuing research into improving patient safety.

Co-chaired by Lauren Worrall and Melinda Lyons from the PSTRC, previous translational research was presented demonstrating how some techniques used in high hazard industries could be applied to pharmacy practice.  These included looking at errors, as well as trying to manage distractions and interruptions. There was also insight from the pharmacy collaborative members on how involvement in the research has influenced their practice and provided them with new approaches to improve patient safety in their pharmacy teams.  Collaborative member Edward Teggart presented his approach to managing error risk in practice and James Hind presented his award winning work on managing distractions.

To get the audience of pharmacists really engaged and learn about risk management decision making, the delegates took part in a team game where their risk management decisions could result in them maintaining lucrative service contracts or going bankrupt in the blink of an eye!

The workshop concluded with a question and answer session which led to a lively discussion about safety in practice. The delegates shared the issues that impact upon their work on a day-to-day basis.  In the relatively unexplored area of risk management research in community pharmacy, questions were posed about the potential avenues and future direction of their research. Whilst everyone agreed that patient safety is critical to their practice, there was also agreement that it is often difficult to share good ideas and learning. The concept of the community pharmacy collaborative was something that all agreed enhanced patient safety and could be used in other geographical areas.

Refer-to-Pharmacy: improving medicines safety and reducing medicines wastage

2 Aug
Jane Ferguson

Jane Ferguson, lead author on the Refer-to-Pharmacy paper

by Jane Ferguson

Transition between care settings is a time of high risk for preventable medication errors. Poor communication about medication changes on discharge from hospital can result in adverse drug events and medicines-related readmissions. Refer-to-Pharmacy is an electronic referral system which allows hospital pharmacy staff to refer patients to their community pharmacist for post-discharge medicines support, or to update a patient’s pharmacy record with medication changes.

Better communication between settings has the potential to improve medicines safety and adherence and reduce cost and wastage. Despite input from hospital pharmacy staff, many patients, once they leave hospital, are unsure about how and why they should take medicines introduced or changed during their hospital stay, meaning that they may end up taking wrong or old medicines. Refer-to-Pharmacy means that community pharmacists can contact patients soon after they leave hospital and provide them with advice and support on their medicines. Through Refer-to-Pharmacy, hospital pharmacists can send an electronic copy of the discharge information to the community pharmacist – enabling them to identify and highlight medication discrepancies and avoid potential adverse drug events. Furthermore, when patients are admitted to hospital, community pharmacists are usually unaware and can continue to dispense their patients’ regular medicines, which are likely to change during their hospital stay, meaning that these medicines are then wasted. Refer-to-Pharmacy notifies community pharmacies of hospital admission for particular patient groups so they can stop dispensing and reduce wasted medicines.

Refer-to-Pharmacy is now routine in East Lancashire Hospitals NHS Trust where it was first established, with high acceptance rates from local community pharmacies. There is much interest in spreading the development into other health economies. The aim of this study was to examine factors that promoted or inhibited the implementation of Refer-to-Pharmacy in hospital and community settings. This information will be useful to other health economies wishing to adopt this service.

We carried out twenty six interviews with hospital pharmacists, hospital technicians, and community pharmacists to understand the implementation of the technology, as part of their normal routine.[1] This study is the first to examine perspectives from community and hospital pharmacists about the Refer-to-Pharmacy scheme at an important time in the development of transfer of care initiatives.[2] Previous research has highlighted that use of new technologies is dependent on the successful integration into existing practices combined with the collective effort of those involved.[1, 3] This study has extended this understanding by detailing the early stages of the implementation of Refer-to-Pharmacy in a hospital trust and community pharmacies.

Shared views on the perceived benefits of Refer-to-Pharmacy and ease of integration into existing work practices were key factors that promoted the implementation of the scheme in both the community and hospital pharmacy settings. Barriers to implementation were more evident in the community setting where it was more challenging to promote and legitimise the scheme due to the different types of community pharmacy.  An important message for health economies interested in adopting this service is to prepare community and hospital pharmacists and organisational leaders at the earliest opportunity – who will then need to work individually and collectively if Refer-to-Pharmacy is to become more widely embedded across healthcare settings.

The full paper can be read in BMC Health Services Research.

  1. May, C. and T. Finch, Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory. Sociology 2009. 43 p. 535-554.
  2. Royal Pharmaceutical Society, Keeping patients safe when they transfer between care providers – getting the medicines right. 2012: London.
  3. Black, A.D., et al., The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview. PLOS Medicine, 2011. 8(1): p. e1000387.