Adam J. Mackridge

An analysis of returned medicines in primary care

Objective: The number of pharmaceutical items issued on prescription is continually rising and contributing to spiralling healthcare costs. Although there is some data highlighting the quantity, in terms of weight of medicines returned specifically to community pharmacies, little is known about the specific details of such returns or other destinations for wasted medications. This pilot study has been designed to investigate the types and amounts of medicines returned to both general practices (GPs) and associated local community pharmacies determining the reasons why these medicines have been returned.Method: The study was conducted in eight community pharmacies and five GP surgeries within East Birmingham over a 4-week period.Main outcome Measure: Reason for return and details of returned medication.Results: A total of 114 returns were made during the study: 24 (21.1) to GP surgeries and 90 (78.9) to community pharmacies. The total returns comprised 340 items, of which 42 (12.4) were returned to GPs and 298 (87.6) to pharmacies, with the mean number of items per return being 1.8 and 3.3, respectively. Half of the returns in the study were attributed to the doctor changing or stopping the medicine; 23.7 of returns were recorded as excess supplies or clearout often associated with patients’ death and 3.5 of returns were related to adverse drug reactions. Cardiovascular drugs were most commonly returned, amounting to 28.5 of the total drugs returned during the study.Conclusions: The results from this pilot study indicate that unused medicines impose a significant financial burden on the National Health Service as well as a social burden on the United Kingdom population. Further studies are examining the precise nature of returned medicines and possible solutions to these issues.

A community pharmacy-based cardiovascular screening service: views of service users and the public

Objectives  To determine whether pharmacy‐based cardiovascular disease (CVD) screening reached the desired population, the local populations awareness of pharmacy screening and the views of service users and the general public about CVD screening.

Involving the public and other stakeholders in development and evaluation of a community pharmacy alcohol screening and brief advice service

OBJECTIVES To explore the views of community pharmacy staff, the general public and other stakeholders towards pharmacy-based alcohol screening and advice services. To involve all relevant stakeholders in designing an acceptable and feasible pharmacy-based alcohol screening and advice service. To evaluate a pilot service from the user perspective. STUDY DESIGN Mixed methods study involving a range of populations, designed to explore multiple perspectives and enable triangulation of results, to develop an optimal service design, prior to service commissioning. METHODS Telephone interviews were conducted with relevant stakeholders and a street survey undertaken with the public to explore views on the desirability and feasibility of pharmacy-based alcohol services. Following this, a stakeholder working group was held, involving a nominal group technique, to develop and refine the service design. Finally a pilot service was evaluated from the user perspective through telephone interviews and direct observations by a trained researcher. RESULTS All stakeholder groups (pharmacy staff, public, commissioners, alcohol treatment service staff) viewed pharmacy-based alcohol screening services as acceptable and feasible with the potential for integration and/or combination with existing public health services. Privacy was the main concern of the public, but 80% were comfortable discussing alcohol in a pharmacy. These views were not influenced by drinking status age or gender, but people recruited in areas of high deprivation were more likely to accept a pro-active approach or alcohol-related advice from a pharmacist than those from areas of low deprivation. Stakeholder groups were in agreement on the acceptability of a pharmacy screening service, but alcohol treatment service staff viewed direct referral to alcohol support services less beneficial than other stakeholders. Posters in pharmacies and GP surgeries were viewed as most likely to encourage uptake of screening. Involvement of non-pharmacist pharmacy staff was seen as essential. The working group considered accessibility of pharmacies as the key facilitator for alcohol services, but agreed that an optimal service must ensure that poor pharmacy environment did not create a potential barrier, that clear information about the services availability was necessary. Plus good use of quiet areas. Use of AUDIT-C as a prescreening tool by pharmacy staff, followed when appropriate by completion of full AUDIT by the pharmacist in a private room/quiet area was agreed as optimal to ensure accessibility plus privacy. Direct referral was viewed as desirable. Five pharmacies piloted this service for two months and recruited 164 people for alcohol screening, of whom 113 were low risk (AUDIT score 0-7), 24 increasing risk (8-19) and 28 high risk/possibly dependent drinkers (20 or above). Observations showed that pharmacy support staff were involved in proactively approaching customers, that 20 of the 72 customers observed (28%) during two hours in each pharmacy were invited for screening and that 14 (19%) accepted screening. Promotion of the service was variable dependent on company policies, but was shown to have a positive effect, as two of the ten service users interviewed requested screening. The environment was judged suitable for alcohol services in all pharmacies, but some quiet areas were not audibly discrete. Ten service users interviewed all considered the experience positive and all would recommend the service, but most wanted the service to be delivered in a private area. CONCLUSION The methodology enabled the development of pharmacy-based alcohol screening to be assessed for acceptability and feasibility from multiple perspectives, prior to full service commissioning. Results suggest that the pharmacy environment and concerns about privacy need to be recognized as potential barriers to service delivery. Good promotion is required to maximize service uptake and pharmacy staff need to be involved in both this and in service delivery.

Prescribing errors on admission to hospital and their potential impact: a mixed-methods study

Background Medication errors are an important cause of morbidity and mortality and adversely affect clinical outcomes. Prescribing errors constitute one type of medication error and occur particularly on admission to hospital; little is known about how they arise. Aim This study investigated how doctors obtain the information necessary to prescribe on admission to hospital, and the number and potential impact of any errors. Setting English teaching hospital—acute medical unit. Methods Ethics approval was granted. Data were collected over four 1-week periods; November 2009, January 2010, April 2010 and April 2011. The patient admission process was directly observed, field notes were recorded using a standard form. Doctors participated in a structured interview; case notes of all patients admitted during study periods were reviewed. Results There were differences between perceived practice stated in interviews and actual practice observed. All 19 doctors interviewed indicated that they would sometimes or always use more than one source of information for a medication history; a single source was used in 31/68 observed cases. 7/12 doctors both observed and interviewed indicated that they would confirm medication with patients; observations showed they did so for only 2/12 patients. In 66/68 cases, the patient/carer was able to discuss medication, 14 were asked no medication-related questions. Of 688 medication charts reviewed, 318 (46.2%) had errors. A total of 851 errors were identified; 737/851 (86.6%) involved omission of a medicine; 94/737 (12.8%) of these were potentially significant. Conclusions Although doctors know the importance of obtaining an accurate medication history and checking prescriptions with patients, they often fail to put this into practice, resulting in prescribing errors.

Experiences, attitudes and training needs of pharmacy support staff providing services to drug users in Great Britain: A qualitative study

Community pharmacies play an important role in providing services to drug users, having provided needle exchange and substitution therapy services for a number of years. Previous studies of these services and the problems faced in implementing them have focused on the attitude and experiences of pharmacists. However, with the increasing use of pharmacy support staff in a range of expanded roles, it is also appropriate to consider this group. This article aims to qualitatively explore the experiences, attitudes, and training needs of pharmacy support staff involved in providing services to drug users. Copies of the questionnaire were issued to a 10% sample of community pharmacies and distributed to up to five support staff working in the pharmacy. The questionnaire asked open questions regarding training needs, personal experiences and attitudes. Data were transcribed and thematically analysed according to Grounded Theory in NVivo v7. 454 respondents made qualitative comments. The data demonstrated a strong desire among some support staff to be further involved in support services. However, many expressed negative attitudes towards drug users and some considered pharmacies as inappropriate venues for providing services to this group. Identified training needs focused on four key areas: advising and working with drug users; the nature of drug use; treatment services and their availability; and clinical and legal detail. Knowledge gaps were evident in some of the responses, most notably a misunderstanding of service aims and intended outcomes. All those involved in designing and delivering pharmacy services to drug users should ensure that they take account of and involve support staff when developing training.

Meeting the health needs of problematic drug users through community pharmacy: A qualitative study

Background: Community pharmacies are established service providers for problematic drug users (PDUs). PDUs have many unmet health needs, which pharmacists may be able to help resolve. This paper aims to qualitatively explore the feasibility and desirability of further developing community pharmacy services to meet the wider health needs of problematic drug users. Methods: Semi-structured interviews and focus group discussions were used to explore current and future pharmacy service provision to PDUs. Views were sought from 20 PDUs, 12 staff from community pharmacies, and seven stakeholders and commissioners from relevant agencies. Data were thematically analyzed and potential services including possible barriers identified. Results & Discussion: Data highlighted variability in current services in the study area in terms of availability and quality. Good rapport between users and regular staff was highlighted as an important factor in good quality services. Pharmacies were consistently identified as having key opportunities to make useful health interventions within a range of therapeutic areas including nutrition, dentistry, wound care, and infectious diseases. The most widely supported roles were based around information provision and signposting. However, there was support for direct interventions to be delivered within the pharmacy, by a regular member of staff or a visiting specialist.

General public's views on pharmacy public health services: current situation and opportunities in the future

OBJECTIVES To explore the experience of and willingness to use seven pharmacy public health services related to cardiovascular risk among the general public in England. STUDY DESIGN Mixed-methods study. METHODS A mixed-methods study, involving a cross-sectional survey using multiple distribution methods followed by a focus group discussion (FGD) with a sample of survey respondents. RESULTS From 3596 approachable individuals, 908 questionnaires were completed (response rate 25.3%). Few respondents (2.1-12.7%) had experienced any of the seven pharmacy public health services. About 40% stated they would be willing to use health check services, fewer (9.3-26.3%) were willing to use advisory services. More females, frequent pharmacy users and those in good health were willing to use services in general (P < 0.05). Smokers, overweight individuals and those with alcohol-related problems were most willing to use specific advisory services supporting their problems (P < 0.05). FGD identified barriers to service use; for example, frequent staff changes, seeing pharmacist as medicines suppliers and concerns about competence for these services. CONCLUSION The general public are receptive to pharmacy public health services. Pharmacists must consider barriers if uptake of services is to increase.

Pharmacy support staff involvement in, and attitudes towards, pharmacy-based services for drug misusers

Objective This study aimed to examine involvement of pharmacy support staff in delivering services to drug misusers; to quantify their participation in related training; and to examine relationships between attitudes, practice experience and training.

Involving community pharmacists in pharmacy practice research: experiences of peer interviewing.

Background Translation of interest in research into active engagement of community pharmacists as research partners/co-researchers remains a challenge. Involving pharmacists in specific research techniques such as peer interviewing, however, may enhance validity of the results. Objective To enhance community pharmacists’ involvement in pharmacy practice research through peer interview training. Method A subgroup of participants in a multi-phase pharmacy practice research project trained to do peer interviews. These pharmacist interviewers attended a workshop and were mentored. Comments from their feedback forms and ongoing engagement with the Research Associate were thematically analysed. Results Positive themes from five interviewers included the importance of the topic and their wish to learn skills beyond their everyday role. The small group format of the training day helped to build confidence. Interviewers felt their shared professional background helped them to capture relevant comments and probe effectively. There were challenges, however, for interviewers to balance research activities with their daily work. Interviewers experienced difficulty in securing uninterrupted time with interviewees which sometimes affected data quality by ‘rushing’. Conclusion Community pharmacists can be engaged as peer interviewers to the benefit of the volunteers and research team, but must be well resourced and supported.

Use and diversion of illicit methadone – under what circumstances does it occur, and potential risks associated with continued use of other substances

Background: Concerns about prescribed methadone diversion are ongoing. This research investigated motivations for methadone diversion and continued use of street-sourced substances. Methods: Questionnaires completed with 886 past year users of methadone recruited in and out of prescribing agencies. Topics covered included current prescribing, obtaining/providing methadone, reasons for using illicit methadone and other substance use. Results: Missing appointments (prescription pick-up or reviews) were the most common reasons for use of diverted methadone but the most common course of action in these circumstances was to use other street-sourced substances. Topping up dosage levels was also a common reason for obtaining illicit methadone. The most common reason diverting methadone was to “help another substance user out”. Concurrent and simultaneous use of a variety of substances whilst prescribed methadone was common. Conclusion: Reasons for using diverted methadone are primarily related to service use and provision. Treatment services will need to consider their role in reducing demand for diverted methadone. Unlike previous work the diversion of prescribed methadone appears to be most often motivated by altruism. Simultaneous and concurrent polysubstance use increases health risks, and with the extent of these risks not fully understood, individuals are “gambling” with their usage patterns.