Tag Archives: General Practice

Making prescribing safer with PINCER

16 Mar

Pharmacist

Recent news reports brought home the importance of reducing medication errors in healthcare. The news coverage highlighted that research, conducted by university academics in Manchester, Sheffield and York estimated 230,000 errors each year in the administering of medication in the NHS, contributing to 22,000 deaths. While the majority of these errors are spotted (and corrected) at the point of error, or do not threaten patient safety, a drastic reduction in the number of errors is now being called for. A change from the current culture of blame to a learning culture is one solution being discussed, but there are other, more practical interventions already in existence.

Once such intervention, called PINCER, is a pharmacist-led intervention developed at the Universities of Nottingham, Manchester and Edinburgh. PINCER has been shown to be an effective method for reducing a range of clinically important and commonly made medication errors in primary care.  Using a set of ‘prescribing safety indicators’ which identify common, but potentially harmful, medication prescribing errors, the intervention involves:

  •         Running searches on GP computer systems to identify patients at risk from common and important prescribing and drug monitoring errors
  •         Pharmacists – trained in the PINCER approach – working with individual general practices to develop an action plan to address the issues identified
  •         Pharmacists (and pharmacy technicians) working with and supporting general practice staff to implement the action plan.

With funding from the Health Foundation and East Midlands Academic Health Science Network, PINCER has been rolled out to 360 practices across the East Midlands since September 2015.  Over 2.9 million patient records have been searched, identifying over 21,000 instances of hazardous prescribing. Applying trends from data collected as part of the evaluation of the rollout, it is estimated that over 10,500 patients have received an active intervention resulting in safer care as a direct benefit of implementing the intervention.

The PINCER intervention has been incorporated into national guidelines to support medicines optimisation by NICE and a more detailed evaluation of the rollout in the East midlands is being done as part of a new NIHR funded programme grant called PRoTeCT to explore whether implementing PINCER reduces avoidable medication-related harm and hospital admissions.

A Patient Safety Toolkit for general practice

15 Mar

Patient-Safety-Toolkit_Banner2

The development and testing of a Patient Safety Toolkit for general practice has taken place over a number of years by a partnership of researchers at the Greater Manchester PSTRC in Nottingham (including Tony Avery, Brian Bell, Sarah Rodgers, Ndeshi Salema, Rachel Spencer) and Manchester (including Stephen Campbell, Kathy Perryman) the NIHR School for Primary Care Research at the Universities of Birmingham, Keele, Oxford and Southampton, as well as the University of Exeter.

The Patient Safety Toolkit is hosted on the Royal College of General Practitioners (RCGP) website. The RCGP is a network of over 52,000 family doctors. The Toolkit is important in preventing patients from being harmed. It is designed to be used by any general practice in the UK and covers the following topics:

  • safe systems
  • safety culture
  • communication
  • patient reported problems
  • diagnostic safety
  • prescribing safety

This range of topics addresses the fact that patient safety is complex and multidimensional. Improving patient safety requires preventing, identifying and addressing issues using practical and actionable information. The collection of tools is hosted on a single platform, which makes it easy to use and enables general practices to identify safety deficits. They can then review and change procedures to improve their patient safety across a key set of patient safety issues.

The research team has published a summary paper, which has been published in the Journal of Patient Safety: A Patient Safety Toolkit for Family Practices

Introducing…Safer Care Transitions

1 Jun

by Justin Waring (University of Nottingham) and Harm van Marwijk (University of Manchester)

Safer Care Transitions will be one of the research themes in the NIHR PSTRC Greater Manchester which will run from 1 August 2017 until 31 July 2022.

Safer Care Transitions blog icon

Patient journeys are full of care transitions. By transitions, we mean that the responsibility for patient care is transferred or handed over from one team, department or organisation to another.

If we think about someone who experiences an accident at work, they might be seen at first by a paramedic before being transported by ambulance to their local hospital’s emergency department. There they might receive urgent care before being admitted into the hospital for follow-up care. When recovered, the patient will then be discharged home or to community setting where they could receive rehabilitation, nursing care, social care and follow-up treatments by their GP, under the primary medical responsibility of the GP.  The GPs’ medical records can follow most of such transitions and provide an overarching view, but others (patients) cannot access such data now. GPs would be seen to have an overarching responsibility to facilitate seamless management between settings but little work has been done on this.

Transitions are common to virtually all patient journeys, because healthcare services are provided by specialists and professionals who work in different clinics, surgeries and hospitals. Although there is now better understanding of what makes for safer care within each of these care settings, there is less of a clear picture about what makes for safer care transitions between these care settings, and how to develop problem-based records that capture transitions and are accessible to more than GP practices.

There is mounting evidence from around the world that care transitions are a high-risk stage in the patient journey. Research from the US, for example, suggests that as many as two out of every ten hospital discharges will experience some form of safety incident. These safety incidents take the form of incorrect medicines, missing equipment, or inappropriate care planning.  Research within the NHS suggests that it is often difficult to coordinate the involvement of different professionals and specialists because of common communication breakdowns and the difficulties of finding time to work together to identify solutions to common problems or work from a shared and validated record. A recent Healthwatch report highlighted the enormous suffering and anxiety experienced by patients as they approach hospital discharge, often because of the uncertainties about when they will go home, who will look after them, and how they will cope. Current resources constraints within the health and social care sectors have seemed to make these problems worse, with limits on the availability of social care to support safe hospital discharge.

The Patient Safety Translational Research Centre Greater Manchester is leading a programme of research that will develop new learning about what makes for safer care transitions. It will look to ways of working and technological breakthroughs in other sectors to learn lessons for the NHS. For example, many courier and supply chain services use advanced technologies to track their deliveries. There is also greater scope to empower patients to coordinate their own care through developing smart technologies that enable them to manage and share their own records with different healthcare professionals. There is also much healthcare services could learn from other industries about ensuring continuous accountability for care, so that someone is always there to speak up for and protect the safety of patients, and ways to develop such support for the most vulnerable trajectories such as around cancer and frail older people.

The projects developed in this theme will address the safety of care transitions in primary and secondary care, in mental health services, in chronic conditions, cancer care, and end of life care, to ensure learning and innovations are shared across the health and social care sectors.

Further information:

Healthwatch (2016) Safely Home, London: Healthwatch. http://www.healthwatch.co.uk/safely-home

Waring, J., Bishop, S., & Marshall, F. (2016). A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service. BMC health services research, 16(1), 297.

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1568-2

Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of internal medicine, 138(3), 161-167.

Keep taking the tablets: part one

11 Apr

by Max Scott

Part six of the blog series “The desperate fight to be heard, and supported, when living with the invisible struggles of Multimorbidity”

Introduction to the blog series is here

MaxScottMedsBox_photo_blogApr16

Regular (daily) medications:

VENTOLIN EVOHALER 10 micrograms (µg) as needed

SYMBICORT TURBOHALER 200µg, two puff morning and night

LEVOTHYROXINE TABLETS 50 µg, one every morning

LEVOTHYROXINE TABLETS 25µg, one every morning

OMEPRAZOLE TABLETS 20 milligrams (mg), one morning and night

TESTOSTERONE GEL 50 mg, one sachet each morning

FLUOXETINE 40mg, by way of two 20mg tablets every morning

PRAVASTATIN TABLETS, 20mg, one every night

GENOTROPHIN GROWTH HORMONE INJECTIONS, 5.3mg, one every night

PREGABALIN CAPSULES 300mg, one at night (for sleep disorders)

PREGABALIN CAPSULES 150mg, one in the morning (for meralgia paresthetica and back pain)

CLONAZEPAM TABLETS, 0.5mg, progressing to 1mg tablet and to be gradually raised to 2mg, at night

FOLIC ACID TABLETS 5mg, one at night


Other (sometimes taken) medicines:

MICOLETTE MICRO-ENEMAS, approx once a week

PARACETAMOL TABLETS 500mg, one-two when needed

CO CODAMOL TABLETS 8/500mg, one-two when needed

CODEINE TABLETS 30mg, one-two when needed

TRAMADOL TABLETS 50mg, rarely

DIAZEPAM TABLETS 5mg, when needed

ANUSOL SUPPOSITORIES, when needed (for haemorrhoids)

Various creams, intermittently, not regularly


So far in this series, I have concentrated on the many experiences and difficulties of living with multimorbidity, and somehow making sure that you are listened to, believed, and respected by medical professionals. By the very nature of the condition, professionals will be faced with a patient who is complex and will, more than likely, have conditions which are invisible to the eye, making trust that much more important.  I will continue on this theme in the future, but for this article I am going to focus more on an inevitable price to pay for having multimorbidity – and that is having to take multiple medications.

I am presently on thirteen regular daily medications for my varied health issues, and I have to take several more intermittently when the need arises. Let me explain some of the problems this can cause. Firstly, for me, the patient. Then (in part two) with the GPs and Consultants.

The Patient

The first of my present medications I ever took were my asthma inhalers, and I have been on these for longer than I can remember. Taking them became a way of life many years ago. Later, gastritis led to me taking Omeprazole. These were joined by the odd Diazepam here and there for anxiety, and sometimes I needed to use a nasal spray for rhinitis. All fairly straightforward at this stage. Then came my Pituitary surgery in 2005. Along with my life in general, that is when taking medications became more complex. I have included a list of my medications above but, to clarify, the ones I take as a result of my tumour removal/hypopituitarism are Levothyroxine 50 and 25 mg, Testosterone gel, and nightly injections of Genotrophin Growth Hormone. Hydrocortisone tablets have been needed on occasion, but this remains an ambiguity of extreme curiousness, which I shall raise again later in this blog. Such things as foot operations; pain from trapped nerves, osteoarthritis, slipped discs etc; and complex sleep disorders have all added to the list.

It’s not just about the amount of medications that I am now on, but the amount of tablets I have to take, when, and how. Remember, anyone who has seen any of my other blogs on here, I have short term memory loss, plus cognitive and executive disorders, which make it all the more easy to make mistakes. I have had to get various “Daily Pill Boxes”, example photo also included here, which should give you an idea of the sheer amount.

I mentioned a moment ago about making mistakes. Well, the drug companies do not make things any easier by manufacturing capsule shells, containing different medications, that look so similar. For example, two of my medications – one for my gastritis, the other an anticonvulsant medication also used for pain and sleep disorders – are both contained in a small, totally white capsule. How ridiculous, and potentially hazardous, is this?  This may be one thing when still in their original boxes (which, incidentally, chop and change their designs and colours so that you never build up a familiarity with them, often seemingly copying the packaging of other drug brands) but when separated into my “daily pill box” can become a nightmare…I have to put my strongest reading glasses on, to find some tiny dark lettering on one of them, and that is the only way I can tell these two, radically different, medications apart. So, basically, I am now on so many medications that just taking the tablets, at the right time, and making sure they are the right ones, has become an art-form all unto itself!

A final point in this part one, and it is a very strange one. One medication that I have not had to take following the Pituitary surgery has been Hydrocortisone, needed when there is a deficiency of ACHC, the hormone that stimulates the production of hydrocortisone by the Adrenal Gland. This hormone often does need to be replaced with patients who have had Pituitary surgery, and, as so much of the after-effects of my Pituitary surgery has been severe, life-changing chronic fatigue, it would have been logical to expect me to be deficient in this. But not so. That is until recently, when I had a series of blood samples taken later in the day than usual: after mid-day, when I am really beginning to flounder as my body and mind wind down towards my afternoon sleep.  THIS time, my hydrocortisone level was found to be very low, and an emergency phone call came that I must start taking hydrocortisone tablets IMMEDIATELY. Ahh, an answer to a problem, I thought. But no. A couple of weeks later, I had another series of tests, which astonishingly showed that I do NOT need to take Hydrocortisone after all. The last test was taken earlier in the morning than the other one. Relevant? Well, all I can say is that there are times like this when I begin to feel like a human guinea-pig!

Can computer software programmes be used to help clinicians with their diagnoses?

23 Jun

by Rahul Alam, Research Associate in General Practice theme

Isabel screenshot

Figure 1 Screenshot of a differential diagnosis list

General Practitioners (GPs) and nurse practitioners in general practice are required to recall a large number of illnesses and diseases as well as a large number of tests and drugs that can be ordered and prescribed. Given such breadth, arriving at the correct diagnoses can be a difficult task, particularly when patients present with unusual symptoms. As a result, diagnostic errors can, and do, occur. One potential resource for helping clinicians to make the correct diagnoses are specialised computer software programmes, otherwise known as differential diagnosis (DDx) generators. They are aimed at helping clinicians with the diagnostic process to reduce the possibility of clinicians missing, delaying or making incorrect diagnoses. In principle, clinicians can enter the patient’s clinical symptoms and the DDx generator produces a list of potentially relevant diagnoses the clinician might want to consider (please see figure 1). This information may be utilised by clinicians as part of the differential diagnostic process to whittle the potential diagnoses down to those most likely. Isabel is one such commercially available web-based DDx generator.

However, little is known about how DDx generators will be viewed and whether they can be used by clinicians in routine practice.  There is also limited evidence on how accurate programmes like Isabel are. In order to ascertain the potential feasibility and utility (benefits) of using this program, we are conducting a small one-practice study divided into two separate components.

The first component of the study will investigate the diagnostic ‘accuracy’ of Isabel in relation to cases of diagnostic uncertainty. Two situations that are likely to involve elements of diagnostic uncertainty relate to referrals to secondary care for follow-up investigations and people who frequently attend the practice (those whose attendance rate is in the top 3% of the practice). Two GPs will review and select all cases of diagnostic uncertainty and the patient details will be entered into Isabel and compared to the final discharge diagnosis from the hospital or the final recorded diagnosis to determine Isabel’s accuracy rate.

In the second component we aim to ascertain the feasibility of clinician’s using Isabel in routine practice when diagnosing patients. We have conducted 11 interviews with 9 GPs and 2 nurse practitioners to ascertain their views and experiences of using a differential diagnosis tool such as Isabel.  We then trained all clinical staff at the practice to use Isabel and they have now had a 6-month opportunity to use Isabel. A remote monitoring system captured wider data such as usage rates, links accessed and time taken to use. We are now conducting post-use interviews with the clinicians to obtain their feedback and opinions on Isabel as a diagnostic aide in routine general practice.

We hope that the findings of the two components of this study can help assess the diagnostic accuracy of Isabel in UK general practice as well provide useful insights in to the feasibility of utilising Isabel in routine clinical practice.

Missed Diagnostic Opportunities: we need your help

22 Jan

gp2 - we want you

Researchers in the General Practice theme are conducting a large review of patient records to estimate the rate of missed diagnostic opportunities (MDOs) in general practice in England.

What are MDOs?  Researchers are looking at cases where something different could have been done to make the correct diagnosis earlier or where a diagnosis was incorrect.

Identifying, measuring and understanding MDOs in general practice is the first step in developing policies and interventions (e.g. educational resources for GPs) to reduce harm and improve patient safety in this area.  At present there is no reliable estimate of diagnostic error in English general practice with which to formulate any such policies or interventions, hence the need for this work.

General practices: study opportunity

If your practice agrees to participate you are simply agreeing to provide access and space for our study team to conduct the study in your practice.

Specifically, we will provide a specialist administrator who will identify 100 patient records (meeting certain inclusion criteria) from your system which will be retained on-site.  Two GP reviewers will visit the practice on separate occasions at your convenience, to independently work through the list generated by the administrator.

The reviewers will use a structured data collection tool and will not collect any patient identifiable information other than age and gender. They will specifically look at information within the electronic health record to ascertain the underlying diagnostic process. The study will require approximately five days of access for the study team and we will compensate each practice for their participation.

Participation from a large number of practices across Greater Manchester is required – if you and your practice are interested in being involved in this study, please contact Rebecca Morris on 0161 275 0748.