REVISiTing GPs in training prescribing to improve medication safety

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:

• receiving a prescription for a medicine is a common way to manage illness, with figures from 2017 showing that an estimated 1,105.8 million prescription items were dispensed in England alone
• Prescribing errors have the potential to cause significant illness and even, rarely, death.

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.

Understanding patient views of online discussion forums to help improve patient safety

by Sally Giles

A new study exploring patient views on using online discussion forums, to find information relating to side effects from medication, will begin shortly. It is hoped the findings will lead to new ways of improving patient safety.  We know many people with long-term conditions use online discussion forums to share experiences and support. The free-text information from online discussions could provide a valuable source of information about side effects from medication.  However, the experiences of those using online forums varies considerably depending on which long-term condition(s) they may suffer from.

In light of this, it is important to understand the views of different groups of patients in relation to sharing information about medication side effects from online discussion forums.  The plan is to conduct 5 focus groups with patients from 5 of the online communities in Health Unlocked, including patients with lung conditions, thyroid disorders, fibromyalgia, mental health issues and rheumatoid arthritis.  We also have a patient and public involvement (PPI) advisory group. This group consists of 6 members of the public who are part of the five online communities. Their role will be to contribute to the design of the study and its materials, as well as involvement in focus group facilitation and analysis. The PPI group will also play a key part in the dissemination of the findings and development of any future work.

If you would like more information about this study, please contact Sally Giles.

Self-harm in older people

by Carly Rolfe

Self-harm in older people predominantly takes the form of self-poisoning, usually by medication overdose. A recent study by the NIHR Greater Manchester PSTRC found that older people who self-harm are 145 times more likely to die by suicide than older people who don’t self-harm.

From patient medical records, 2854 older people aged over 65 years who had harmed themselves and had at least one year of follow up were identified.  Only 12% were subsequently referred to mental health services following a self-harm episode. 59% were prescribed antidepressants, with 12% being a tricyclic antidepressant, a form of the medication which is known to be potentially dangerous in overdose.

Dr Cathy Morgan, from The University of Manchester, lead-author on the study paper recently published in Lancet Psychiatry, says:

“We emphasise the need for early intervention, careful alternative prescribing, and increased support when older adults consult after an episode of self-harm and with other health conditions.”

With there being limited studies in this area of research, interest in the work has been high, with 148 media outlets covering the findings in the paper’s first day of publication, including BBC Breakfast as well as national radio stations and press.

If a computer gives you a diagnosis, should it also give you an explanation?

Jurors from previous Citizens’ Juries

by Malcolm Oswald

Artificial intelligence (AI) plays an increasing role in our daily lives. Computers are being trained how to do many things, including making medical diagnoses. For example, AI can diagnose skin cancer from skin images as reliably as dermatologists, and this clever software is only going to get better. But how do we know whether a diagnosis we get is accurate? If we are given it by a human doctor, we can ask for an explanation. However, the most advanced AI systems are very complex and do not just act according to pre-defined rules, but continue to “learn”, and it may not be possible to explain to a patient how the computer reached its diagnosis.

If you were given a diagnosis by a computer, and were given the choice, would you always prefer to be given an explanation of how the computer reached its diagnosis even if that meant the computer’s diagnosis was likely to be a little less accurate?

That is one question being put to two “citizens’ juries” being commissioned by the NIHR Greater Manchester Patient Safety Translational Research Centre (Greater Manchester PSTRC) in early 2019. Citizens Juries c.i.c. will recruit 18 people from around Manchester – chosen to represent a cross-section of the public – to come together for five days to hear expert evidence and tackle difficult questions concerning how AI should be used within healthcare. The process will then be repeated with 18 different people from around Coventry to see whether they reach the same conclusions.

The Greater Manchester PSTRC is collaborating on this project with the Information Commissioner’s Office which has the challenging task of regulating the use of AI. The results of the juries will feed directly into national guidance that the Information Commissioner’s Office has to produce on citizens’ rights to an explanation when decisions that affect people are made using AI.

For more information about citizens’ juries, see the Citizens Juries c.i.c. website, or if you have a specific enquiry about this project, email Dr Malcolm Oswald or the principal investigator, Prof Niels Peek.

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

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

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.

Using Artificial Intelligence to help primary care triage

by Ben Brown

Researchers at The University of Manchester and Spectra Analytics are developing an Artificial Intelligence (AI) system to help support GP practices triage requests for appointments – the Patient Automated Triage and Clinical Hub Scheduling (PATCHS) system.

It’s often difficult to get an appointment with a GP, and it’s estimated that over a quarter of GP appointments could have been dealt with in an alternative way, for example by another clinician (such as a nurse) or through patient self-care. One solution may therefore be to allocate GP appointments to patients that really need them.

While receptionists at GP practices can direct patients to the most appropriate care provider, not all practices do this, and often patients are unwilling to disclose their problems to them. PATCHS plans to tackle this by providing an online tool that will efficiently direct patients to the right place, 24 hours a day. Patients will input their reasons for requesting a GP appointment, and PATCHS will analyse this request, taking into account the patient’s medical history, in addition to other factors such as the weather, to come to a triage decision. It is hoped the system could ultimately be integrated into practice websites and medical records, ensuring effective triage at the beginning of a patient’s care pathway.

The project is funded by Innovate UK and is currently in the development stage: PATCHS is currently learning from existing data about how patients are triaged when booking a GP appointment. However, the team are looking for volunteers – both patients and doctors – to participate in the project. If you’d like to know more please contact Dr Ben Brown on benjamin.brown@manchester.ac.uk.