A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis

Abstract

SummaryBackgroundMedication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention.MethodsIn this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to general practices, patients, pharmacists, researchers, and statisticians. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-effectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299.Findings72 general practices with a combined list size of 480 942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38–0·89); a β blocker if they had asthma (0·73, 0·58–0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34–0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months.InterpretationThe PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records.FundingPatient Safety Research Portfolio, Department of Health, England.

A Patient Safety Toolkit for Family Practices

“…The eight prescribing safety indicators identified 1435 instances of potentially hazardous prescribing or lack of recommended monitoring in a total population of 92,649 patients. Compared with findings from the PINCER Trial, 21 the proportion of patients identified at risk for each of the prescribing safety indicators was similar or lower, with the exception of the indicator relating to the monitoring of patients receiving warfarin, which was higher.…”

Behind the screens: Clinical decision support methodologies – A review

“…Randomized Controlled Trials where results arising from the testing phase of a specific CDSS are reported without any technical details about the system [8][9][10][11][12] ; 2. Systematic Reviews, which summarize previously published Randomized Controlled Trials and assess the impact and potential of CDSSs in clinical practice 7,13,14 ; 3.…”

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

“…[3][4][5][6][7][8][9][10][11] Most of the indicator sets developed specifically for primary care originated in the UK. [12][13][14][15][16][17] Other methods of analysing prescribing also exist, for example, prescribing analysis and cost tabulation (PACT) data and the Medication Appropriateness Index (MAI). 18,19 There are obvious limitations with PACT data because of a lack of linkable clinical information, and the MAI is a time-consuming process involving detailed medical records analysis.…”