Protocol for the PINCER trial: a cluster randomised trial comparing the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Avery, Anthony J; Rodgers, Sarah; Ja, Cantrill; Armstrong, Sarah; Elliott, Rachel A.; Howard, Rachel; Kendrick, Denise; Morris, Caroline; Murray, Scott; Prescott, R. J.; Cresswell, Kathrin; Sheikh, Aziz

doi:10.1186/1745-6215-10-28

Cited by 36 publications

(54 citation statements)

References 30 publications

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“…Further details of the methods are available in the trial protocol 19 . We chose a cluster design because the intervention was applied by the general practice.…”

Section: Methodsmentioning

confidence: 99%

“…Interventions included review of patients' medical records; discussions with family doctors to decide on actions to be taken; invitation of patients to be reviewed or to have blood tests; and working with members of the practice team to improve local safety systems. Details are provided in the trial protocol 19 . All general practices had access to some computerised decision support, such as drug interactions, for prescription.…”

Section: Methodsmentioning

confidence: 99%

“…Characteristics of practices and participants were recorded at baseline and compared informally between treatment groups 19 . The prevalences of primary and secondary outcomes were measured at each timepoint by allocation group, at the level of the patient, using the numerator, denominator and percentage.…”

Section: Methodsmentioning

confidence: 99%

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

Avery

Rodgers²,

et al. 2012

The Lancet

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357

450

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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.

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“…Further details of the methods are available in the trial protocol 19 . We chose a cluster design because the intervention was applied by the general practice.…”

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

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

Avery

Rodgers²,

et al. 2012

The Lancet

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357

450

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“…[10][11][12][13] Research on repeat prescribing has been largely quantitative, comprising retrospective surveys of conditions, drugs, authorisation dates, clinicians' views, 2 14-17 and experimental or quasi-experimental studies of interventions aimed at improving efficiency or safety. [18][19][20][21][22] One small qualitative study explored general practitioners' perceptions of the causes of preventable drug related admissions to hospital. 11 Another reported that continuous quality improvement in one practice reduced the percentage of repeat prescriptions needing records to be checked by the doctor.…”

Section: Introductionmentioning

confidence: 99%

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study

Swinglehurst

Greenhalgh

Russell

et al. 2011

BMJ

118

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Objective To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality.Design Ethnographic case study.Setting Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing.Participants 395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally.Main outcome measures Potential threats to patient safety and characteristics of good practice.Methods Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies.Results Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as "exceptions" by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients. ConclusionReceptionists and administrative staff make important "hidden" contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety. IntroductionRepeat prescriptions are traditionally understood to be those issued without a consultation between clinician and patient. 1 With electronic records, the de facto definition became "prescriptions printed by a practice computer from its repeat prescribing program." 2 Repeat prescribing accounts for up to three quarters of all drugs prescribed and four fifths of drug costs in U...

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“…6,7 It was calculated that if a similar prevalence of prescribing errors were to be found in the present study, 3750 prescription items needed to be reviewed, in order to report this with a two-sided 95% confidence interval (CI) and accuracy of ±1.6%. This allowed for the clustered design and assumed a total of 15 practices, an intra-class correlation coefficient of 0.01 (based on the authors' previous studies), 10 and an average cluster size of 250 prescription items reviewed per practice.…”

Section: Sample Size Calculationmentioning

confidence: 99%

The prevalence and nature of prescribing and monitoring errors in English general practice: a retrospective case note review

Avery¹,

Ghaleb²,

Barber³

et al. 2013

Br J Gen Pract

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124

103

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Protocol for the PINCER trial: a cluster randomised trial comparing the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Abstract: Background: Medication errors are an important cause of morbidity and mortality in primary care.

Cited by 36 publications

References 30 publications

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

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

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study

The prevalence and nature of prescribing and monitoring errors in English general practice: a retrospective case note review

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