Tag Archives: publication

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.

A Patient Safety Toolkit for general practice

15 Mar


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

Patient Safety: Blame the Patient?

12 Aug

by Gavin Daker-White, Research Fellow, NIHR Greater Manchester PSTRC, The University of Manchester

Cause and effect are never divided between two people
(Max Frisch, I’m Not Stiller)

Part One - Blame the patient-

According to the World Health Organisation, “Patient Safety” can be defined as the “reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.” This is the first of 3 blogs that discuss the results of a review of qualitative studies of patient safety in primary care as undertaken by researchers at the NIHR Greater Manchester PSTRC and NUI Galway. The review, published in August 2015 (and available here) examined 48 reports of studies grouped into 5 topic areas:

1. Patients’ perspectives around safety (8 articles)
2. Staff perspectives on safety (14 articles)
3. Medication safety (10 articles)
4. Organisational or management issues (7 articles)
5. Care transitions between primary care and hospitals (9 articles)

The findings of the review were seen to boil down to those that blamed patients for safety failures, those that blamed doctors and those which explained safety failures by shortfalls in clinical systems or the organisation of care. This blog looks at the role of patients in their own safety.

From the first of the 8 published studies concerned with patients’ perceptions of patient safety, it was noted how “trivial insults could eventually lead to more serious problems” (Kuzel et al., 2004). Thus, in another study the authors were explicitly concerned with the kinds of actions or processes that could be seen to maximise the impact of harm once an error had occurred (Elder et al. 2005). For example, if a patient became angry following an encounter with a health professional who refused to refer them on to a specialist, that might affect trust in doctors or future use of services.

Technology is increasingly a feature of health care. A study concerned with patient preferences regarding the notification of test results found that “privacy” and “assured confidentiality” were important concerns which could lead to suspicions around the use of new technologies (Baldwin et al., 2005). Similarly, another study showed how a kind of blind faith in Electronic Health Records (EHRs) could represent a safety risk given the awareness that “patient information in the EHR was scattered, incomplete, or inaccurate” (Baran et al., 2011).

One message that derived from this group of studies was that when patients had more experience of health services they were better equipped to identify potential risks and take steps to avoid or reduce harm. In this context, patient safety appeared as a ‘feeling’ engendered through successful relationships and encounters with health professionals.

In the 14 studies concerned with the perspectives of health service staff, the characteristics or behaviour of patients appeared as important factors seen to impact on safety. These factors also appeared important in the 10 studies focused on medication errors. Both groups of findings pointed to the difficulties encountered in consultations with patients with multiple health conditions (so-called ‘multimorbidity’) or problems related to hearing, comprehension and memory. So far as medications were concerned, some patient’s characteristics were seen to limit the likelihood of adherence to drug regimens and also created challenges for receptionists in understanding older patients’ prescription requests (Hesselgreaves et al., 2009).

In sum, the findings suggested that the following characteristics or behaviours of patients appear as threats to patient safety in primary care:

• Disadvantages (physical, educational, level of comprehension and understanding)
• Complex symptoms
• Problematic presentation
• Lack of health literacy and self-management skills
• Social circumstances (e.g. living alone)

By extension, individual patients could promote their own safety by becoming more actively involved in their own care, by taking more responsibility for their own care, by becoming better informed about their health conditions and skilled in the self-management of their symptoms. This was especially evident in research that had looked at safety around hospital discharge. However, the findings around becoming more active in health care encounters in other groups of studies (e.g. medications) were sometimes contradictory which suggests the need for further research about what works in this context. It was also clear that patients can help minimize the risks in health care by being adaptable in response to system requirements.

There is a tension evident in the findings concerning the safety ‘risks’ associated with patients, however. For example, somebody who faces disadvantages, complex symptoms or lacks social support might find it harder to manage their conditions or become more actively involved in their own care. These are issues we are exploring in ongoing research within the Multimorbidity research theme of the NIHR Greater Manchester PSTRC. In one study we are following people over time to learn about threats to safety and what patients might be able to do about them (“MAXIMUM”). In a video study for the website healthtalk.org we will explore the health care dilemmas faced by people with multiple health conditions and how they cope with health conditions in different ways.

The findings of our review can be used to inform patients more generally about how to enhance their safety in healthcare. Of course some patient characteristics that can be seen to affect safety (e.g. being cognitively impaired or living in particular social or economic circumstances) are less easy for people to do anything about themselves. However, this points to situations or circumstances in which it could be beneficial to make use of advocates or carers for maintaining safety vigilance. Alternatively, instances where staff or services need to monitor cases or processes with extra detail or care are highlighted.

The influences of health care staff on patient safety will form the next blog in this 3-part series.


Baldwin D, Quintela J, Duclos C, Staton E, Pace W (2005) Patient preferences for notification of normal laboratory test results: A report from the ASIPS Collaborative. BMC Family Practice 6: 1-7.

Baran SD, Lapin JA, Beasley JW, Smith PD, Karsh B-T (2011) Identifying Hazards in Primary Care: The Elderly Patient’s Perspective. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 55: 1130-1134.

Elder NC, Jacobson CJ, Zink T, Hasse L (2005) How experiencing preventable medical problems changed patients’ interactions with primary health care. Ann Fam Med 3: 537-544.

Hesselgreaves H, Lough M, Power A (2009) The perceptions of reception staff in general practice about the factors influencing specific medication errors. Educ Prim Care 20: 21-27.

Kuzel AJ, Woolf SH, Gilchrist VJ, Engel JD, LaVeist TA, et al. (2004) Patient reports of preventable problems and harms in primary health care. Ann Fam Med 2: 333-340.

Tsang C, Majeed A, Aylin P (2012) Consultations with general practitioners on patient safety measures based on routinely collected data in primary care. JRSM Short Rep 3: 5.