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Proactive pharmacist feedback cuts prescribing errors

Electronic health record data key to simple and cheap intervention

Caroline White

Tuesday, 21 February 2012

Active feedback from pharmacists, using electronic health record data, can cut prescribing errors in primary care, and is cheap and easy to implement, indicates a study published online in The Lancet today.

The authors assessed whether PINCER—a pharmacist-led, information technology-based intervention—was better than simple feedback at cutting the number of potentially harmful prescribing errors and inadequate monitoring of medicines over a period of six months.

They looked at three common and potentially serious types of prescribing/monitoring error. These were non-steroidal anti-inflammatory drugs (NSAIDs) prescribed without a proton-pump inhibitor (PPI) to patients with a history of peptic ulcer; β blockers prescribed to patients with a history of asthma; and long-term prescription of angiotensin-converting-enzyme (ACE) inhibitors or loop diuretics to those aged 75 years above whose urea and electrolytes had not been assessed in the preceding 15 months.

Seventy two UK general practices with a combined patient list size of 480 942 patients were randomly assigned to either the PINCER intervention or simple feedback.

The practices allocated to receive simple feedback were provided with computerised feedback on patients at risk of medication errors, and given brief written information on the importance of each type of error.

The practices allocated to the PINCER intervention were provided with the same information, but they also met with a pharmacist to discuss the problems picked up by the feedback and to agree on an action plan.

The pharmacist then spent roughly two days a week over the next 12 weeks helping to implement the action plan, including inviting patients into the surgery for a prescription review or blood test, as appropriate.

After six months, patients in the PINCER group were 42% less likely to have been prescribed a non-selective NSAID without a PPI; 27% less likely to have been given a β blocker if they had asthma; and around half as likely to have been prescribed an ACE inhibitor or loop diuretic without appropriate monitoring.

The cost worked out at £75 per error avoided, which, the authors say, is extremely likely to be cost-effective.

“This trial shows that a pharmacist-delivered information technology intervention substantially reduced the frequency of a range of clinically important prescription and medication monitoring errors,” they comment.

“Because of the pressing need to reduce errors in healthcare, PINCER offers an effective method for reducing a range of medication errors in general practice,” they add.

But they go on to say that electronic health records are essential for reducing prescribing errors.

“The intervention that we have developed will be suitable for implementation in the increasing number of countries where clinical records are now computerised and where the roles of pharmacists to monitor proactively for clinically important medication errors can be extended.”

In a linked Comment, doctors from the Division of General Medicine and Primary Care, at Brigham and Women’s Hospital, Boston, conclude: “The PINCER trial is important because it shows how the elements necessary for a successful medication safety intervention can be combined on a large scale.

Further research is needed so as to understand better how to successfully implement such interventions as broadly as possible, and the potential tradeoffs inherent in focusing efforts on certain measurable quality and safety goals, possibly at the expense of less measurable ones.”

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