David Phillip Alldred

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Clinical medication review by a pharmacist of elderly people living in care homes: pharmacist interventions

Objectives To describe the rate and nature of pharmacist interventions following clinical medication review of elderly people living in care homes.

A combined nurse-pharmacist managed pain clinic: joint venture of public and private sectors

Chronic pain has become one of the most prevalent problems in primary care. The management of chronic pain is complex and often requires a multidisciplinary approach. The limited capacity of general practitioners to manage chronic pain and long waiting time for secondary care referrals further add to the complexity of chronic pain management. Restricted financial and skilled human capital make it hard for healthcare systems across the world to establish and maintain multidisciplinary pain clinics, in spite of their documented effectiveness. Affordability and accessibility to such multidisciplinary pain clinics is often problematic for patients. The purpose of this paper is to share our experience and relevant research evidence of a community based combined nurse-pharmacist managed pain clinic. The pain clinic serves as an example of public–private partnership in healthcare.

Mixed-methods research in pharmacy practice: basics and beyond (part 1).

This is the first of two papers which explore the use of mixed‐methods research in pharmacy practice. In an era of evidence‐based medicine and policy, high‐quality research evidence is essential for the development of effective pharmacist‐led services. Over the past decade, the use of mixed‐methods research has become increasingly common in healthcare, although to date its use has been relatively limited in pharmacy practice research. In this article, the basic concepts of mixed‐methods research including its definition, typologies and advantages in relation to pharmacy practice research are discussed. Mixed‐methods research brings together qualitative and quantitative methodologies within a single study to answer or understand a research problem. There are a number of mixed‐methods designs available, but the selection of an appropriate design must always be dictated by the research question. Importantly, mixed‐methods research should not be seen as a ‘tool’ to collect qualitative and quantitative data, rather there should be some degree of ‘integration’ between the two data sets. If conducted appropriately, mixed‐methods research has the potential to generate quality research evidence by combining strengths and overcoming the respective limitations of qualitative and quantitative methodologies.

Mixed-methods research in pharmacy practice: recommendations for quality reporting (part 2)

This is the second of two papers that explore the use of mixed‐methods research in pharmacy practice. This paper discusses the rationale, applications, limitations and challenges of conducting mixed‐methods research. As with other research methods, the choice of mixed‐methods should always be justified because not all research questions require a mixed‐methods approach. Mixed‐methods research is particularly suitable when one dataset may be inadequate in answering the research question, an explanation of initial results is required, generalizability of qualitative findings is desired or broader and deeper understanding of a research problem is necessary. Mixed‐methods research has its own challenges and limitations, which should be considered carefully while designing the study. There is a need to improve the quality of reporting of mixed‐methods research. A framework for reporting mixed‐methods research is proposed, for researchers and reviewers, with the intention of improving its quality. Pharmacy practice research can benefit from research that uses both ‘numbers’ (quantitative) and ‘words’ (qualitative) to develop a strong evidence base to support pharmacy‐led services.

Development of a core outcome set for effectiveness trials aimed at optimising prescribing in older adults in care homes

BackgroundPrescribing medicines for older adults in care homes is known to be sub-optimal. Whilst trials testing interventions to optimise prescribing in this setting have been published, heterogeneity in outcome reporting has hindered comparison of interventions, thus limiting evidence synthesis. The aim of this study was to develop a core outcome set (COS), a list of outcomes which should be measured and reported, as a minimum, for all effectiveness trials involving optimising prescribing in care homes. The COS was developed as part of the Care Homes Independent Pharmacist Prescribing Study (CHIPPS).MethodsA long-list of outcomes was identified through a review of published literature and stakeholder input. Outcomes were reviewed and refined prior to entering a two-round online Delphi exercise and then distributed via a web link to the CHIPPS Management Team, a multidisciplinary team including pharmacists, doctors and Patient Public Involvement representatives (amongst others), who comprised the Delphi panel. The Delphi panellists (n = 19) rated the importance of outcomes on a 9-point Likert scale from 1 (not important) to 9 (critically important). Consensus for an outcome being included in the COS was defined as ≥70% participants scoring 7–9 and <15% scoring 1–3. Exclusion was defined as ≥70% scoring 1–3 and <15% 7–9. Individual and group scores were fed back to participants alongside the second questionnaire round, which included outcomes for which no consensus had been achieved.ResultsA long-list of 63 potential outcomes was identified. Refinement of this long-list of outcomes resulted in 29 outcomes, which were included in the Delphi questionnaire (round 1). Following both rounds of the Delphi exercise, 13 outcomes (organised into seven overarching domains: medication appropriateness, adverse drug events, prescribing errors, falls, quality of life, all-cause mortality and admissions to hospital (and associated costs)) met the criteria for inclusion in the final COS.ConclusionsWe have developed a COS for effectiveness trials aimed at optimising prescribing in older adults in care homes using robust methodology. Widespread adoption of this COS will facilitate evidence synthesis between trials. Future work should focus on evaluating appropriate tools for these key outcomes to further reduce heterogeneity in outcome measurement in this context.

Prescribing for older people in nursing homes: strategies to improve prescribing and medicines use in nursing homes

Interventions to improve prescribing in the nursing home environment are many and varied. The critical literature review presented in Paper 1 (Parsons et al., 2011, International Journal of Older People Nursing 6, 45-54) in this series discussed the main issues repeatedly identified as problematic, and this paper summarises the main approaches which have been used to attempt to improve prescribing. These include national legislation which demands documented justification for the prescribing of medicines, medication review, approaches to reducing medication errors, improving communication across care boundaries and assessment teams and alternative service models. It is difficult to make global recommendations as some of these approaches are country specific or have been delivered in different ways, involving different professionals. However, a series of prompt questions have been provided which may assist nursing home staff in deciding whether prescribing is optimal in a resident or if an intervention is required which may lead to an overall improvement in outcomes.

Development and validation of criteria to identify medication-monitoring errors in care home residents

Aim The identification of medication‐monitoring errors requires a validated definition. This paper describes the development and validation of a definition which includes criteria for specific medicines to determine whether a medication‐monitoring error has occurred in the care home setting.

The recording of drug sensitivities for older people living in care homes

AIMS The aims of this study were to determine the recording of drug sensitivities of elderly care home residents, to describe the nature of sensitivities and to identify and describe discrepancies in the documentation of drug sensitivity status in general practices, pharmacies and care homes. METHODS A random sample of residents within a purposive sample of care homes (nursing and residential) was selected. A clinical pharmacist inspected the GP medical record, the medicines administration record, and the care home record for each resident to identify drug sensitivities and discrepancies between records and to describe the nature of the recorded sensitivities. RESULTS The records of 121 residents in 31 care homes were studied. Thirty-one (26%) residents had at least one documented drug sensitivity in one of the sources inspected, with 48 sensitivities in total recorded. There was no description of the nature of the sensitivities recorded in 39/48 (81%) cases. The number of sensitivities recorded on the medicines administration record, care home record and the GP record were 3 (6%), 29 (60%) and 35 (73%), respectively. Only two sensitivities were simultaneously recorded on all three records. CONCLUSIONS It was of concern that over 90% of drug sensitivities were not recorded on the medicines administration record which is the final checking document when administering medication. The reason for this was that the dispensing pharmacy was responsible for generating the medicines administration record; however, drug sensitivity status is seldom shared between the GP and the dispensing pharmacy. Printing sensitivities on prescriptions would help to resolve this.

'Treated as a number, not treated as a person': a qualitative exploration of the perceived barriers to effective pain management of patients with chronic pain

Objectives To identify barriers to effective pain management encountered by patients with chronic pain within the UK’s National Health Service (NHS). Design Secondary analysis of face-to-face, semistructured qualitative interviews using thematic analysis. Setting A community-based chronic pain clinic jointly managed by a nurse and pharmacist located in the North of England. Participants Nineteen adult (>18 years) patients with chronic pain discharged from a pain clinic, with the ability to understand and speak the English language. Results In general, patients were highly disappointed with the quality of pain management services provided both within primary and secondary care, and consequently were willing to seek private medical care. Barriers to effective pain management were divided into two main themes: healthcare professional-related and health systems-related. Three subthemes emerged under healthcare professionals-related barriers, namely (1) healthcare professionals’ lack of interest and empathy, (2) general practitioners’ (GP) lack of specialised knowledge in pain management and (3) lack of communication between healthcare professionals. Three subthemes emerged under health system-related barriers: (1) long waiting time for appointments in secondary care, (2) short consultation times with GPs and (3) lack of an integrated multidisciplinary approach. Conclusions The patients expressed a clear desire for the improved provision and quality of chronic pain management services within the NHS to overcome barriers identified in this study. An integrated holistic approach based on a biopsychosocial model is required to effectively manage pain and improve patient satisfaction. Future research should explore the feasibility, effectiveness and cost-effectiveness of integrated care delivery models for chronic pain management within primary care.