Rachel Spencer

Development of prescribing-safety indicators for GPs using the RAND Appropriateness Method.

BACKGROUND In the UK, a process of revalidation is being introduced to allow doctors to demonstrate that they meet current professional standards, are up-to-date, and fit to practise. Given the serious risks to patients from hazardous use of medicines it will be appropriate, as part of the revalidation process, to assess the safety of prescribing by GPs. AIM To identify a set of potential prescribing-safety indicators for the purposes of revalidation of individual GPs in the UK. DESIGN AND SETTING The RAND Appropriateness Method was used to identify, develop, and obtain agreement on the indicators in UK general practice. METHOD Twelve GPs from across the UK with a wide variety of characteristics assessed indicators for appropriateness of use in revalidation. RESULTS Forty-seven safety indicators were considered appropriate for assessing the prescribing safety of individual GPs for the purposes of revalidation (appropriateness was defined as an overall panel median score of ≥ 7 (on a 1-9 scale), with no more than three panel members rating the indicator outside the 3-point distribution around the median]. After removing indicators that were variations on the same theme, a final set of 34 indicators was obtained; these cover hazardous prescribing across a range of therapeutic areas, hazardous drug-drug combinations, prescribing with a history of allergy, and inadequate laboratory-test monitoring. CONCLUSION This study identified a set of 34 indicators that were considered, by a panel of 12 GPs, to be appropriate for use in assessing the safety of GP prescribing for the purposes of revalidation. Violation of any of the 34 indicators indicates a potential patient-safety problem.

Identification of an updated set of prescribing-safety indicators for GPs

BACKGROUND Medication error is an important contributor to patient morbidity and mortality and is associated with inadequate patient safety measures. However, prescribing-safety tools specifically designed for use in general practice are lacking. AIM To identify and update a set of prescribing-safety indicators for assessing the safety of prescribing in general practice, and to estimate the risk of harm to patients associated with each indicator. DESIGN AND SETTING RAND/UCLA consensus development of indicators in UK general practice. METHOD Prescribing indicators were identified from a systematic review and previous consensus exercise. The RAND Appropriateness Method was used to further identify and develop the indicators with an electronic-Delphi method used to rate the risk associated with them. Twelve GPs from all the countries of the UK participated in the RAND exercise, with 11 GPs rating risk using the electronic-Delphi approach. RESULTS Fifty-six prescribing-safety indicators were considered appropriate for inclusion (overall panel median rating of 7-9, with agreement). These indicators cover hazardous prescribing across a range of therapeutic indications, hazardous drug-drug combinations and inadequate laboratory test monitoring. Twenty-three (41%) of these indicators were considered high risk or extreme risk by 80% or more of the participants. CONCLUSION This study identified a set of 56 indicators that were considered, by a panel of GPs, to be appropriate for assessing the safety of GP prescribing. Twenty-three of these indicators were considered to be associated with high or extreme risk to patients and should be the focus of efforts to improve patient safety.

Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method

BackgroundThe majority of patient contacts occur in general practice but general practice patient safety has been poorly described and under-researched to date compared to hospital settings. Our objective was to produce a set of patient safety tools and indicators that can be used in general practices in any healthcare setting and develop a ‘toolkit’ of feasible patient safety measures for general practices in England.MethodsA RAND/UCLA Appropriateness Method exercise was conducted with a panel of international experts in general practice patient safety. Statements were developed from an extensive systematic literature review of patient safety in general practice. We used standard RAND/UCLA Appropriateness Method rating methods to identify necessary items for assessing patient safety in general practice, framed in terms of the Structure-Process-Outcome taxonomy. Items were included in the toolkit if they received an overall panel median score of ≥7 with agreement (no more than two panel members rating the statement outside a 3-point distribution around the median).ResultsOf 205 identified statements, the panel rated 101 as necessary for assessing the safety of general practices. Of these 101 statements, 73 covered structures or organisational issues, 22 addressed processes and 6 focused on outcomes.ConclusionsWe developed and tested tools that can lead to interventions to improve safety outcomes in general practice. This paper reports the first attempt to systematically develop a patient safety toolkit for general practice, which has the potential to improve safety, cost effectiveness and patient experience, in any healthcare system.

Prescribing errors in general practice and how to avoid them

This article is a summary and update for prescribing clinicians and primary care managers who are interested in medication error in general practice. It summarizes the state of primary care prescribing in the UK and reviews areas in which there is potential for error. Practical solutions and methods to mitigate the impact of error are presented alongside potential prescribing problems throughout the article.

Undertaking effective medication reviews

In the General Medical Council-funded PRACtICe study around half the prescribing and monitoring errors identified involved repeat prescriptions. This suggests a need to improve the effectiveness of medication reviews in order to ensure that any errors are detected and corrected. In this article we focus on identifying the elements of an effective medication review; providing examples of medication reviews, and identifying and tackling adherence issues. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Providing the right dose instructions

The General Medical Council -funded PRACtICe study investigated the prevalence and causes of prescribing errors in general practices. The results showed that around one in three of the prescribing errors detected were associated with incomplete information on the prescription whilst around one in 10 involved giving a medicine at the wrong time. In this article we focus on achieving clear and unambiguous dosing instructions including how clinical computer systems can help to alleviate the problem. We also look at the cautionary and advisory labels added during the dispensing process. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Providing the right medication monitoring

In order for medication to be prescribed effectively and safely, many medications require monitoring. Medication monitoring may involve blood tests but can also include other monitoring such as blood pressure, weight or electrocardiograms. Monitoring can be required before initiating medication, soon after starting, or regularly over the course of treatment. Ensuring that this monitoring has been undertaken is an important part of medication review involving repeat prescribing. The General Medical Council-funded PRACtICe study looked at prescribing and monitoring errors in primary care. Out of the 302 errors identified, 55 (18%) were monitoring errors. Of those drugs that required blood test monitoring, 7% of prescriptions contained a monitoring error. This article gives the reader opportunities to reflect upon different scenarios that involve medication that requires monitoring decisions and how monitoring could be managed in primary care. There are also suggestions for additional continuing professional development activities.

Selecting the right dose

Around one in six of the prescribing errors detected in the General Medical Council-funded PRACtICe study involved either the wrong dose or the wrong strength of medication. Around one in 10 of the prescribing errors involved giving a medicine at the wrong time. In this article we focus on the factors that need to be taken into consideration when selecting the right dose for an individual patient. We also highlight the importance of selecting the right timing for particular medicines. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Avoiding hazardous prescribing

Around one in 13 of the prescribing errors detected in the General Medical Council-funded PRACtICe study involved either contraindications or hazardous drug-drug combinations In this article we focus on these issues and also cover the problem of selecting the wrong drug, or drug strength, from computer-based drop-down menus. The article gives the reader opportunities to reflect upon different scenarios involving hazardous prescribing, and there are also suggestions for additional continuing professional development activities.

Selecting the right drug

Around 1 in 10 of the prescribing errors detected in the General Medical Council-funded PRACtICe study involved incorrect drug selection or unnecessary prescriptions. In this article we focus on the principles involved in selecting the right drug for individual patients. We also highlight the usefulness of prescribing formularies and explain when it is appropriate to prescribe generically and when it is necessary to prescribe by brand. The article gives the reader opportunities to reflect upon different scenarios involving prescribing decisions, and there are also suggestions for additional continuing professional development activities.