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

BACKGROUND: Medication 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. METHODS: In 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 researchers and statisticians involved in processing and analysing the data. The allocation was not masked to general practices, pharmacists, patients, or researchers who visited practices to extract data. [corrected]. 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; ß 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. FINDINGS: 72 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 ß 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. INTERPRETATION: The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. FUNDING: Patient Safety Research Portfolio, Department of Health, England.

Information in general medical practices: the information processing model.

BACKGROUND: The need for effective communication and handling of secondary care information in general practices is paramount. OBJECTIVE: To explore practice processes on receiving secondary care correspondence in a way that integrates the information needs and perceptions of practice staff both clinical and administrative. METHODS: Qualitative study using semi-structured interviews with a wide range of practice staff (n = 36) in nine practices in the Northwest of England. Analysis was based on the framework approach using N-Vivo software and involved transcription, familiarization, coding, charting, mapping and interpretation. RESULTS: The 'information processing model' was developed to describe the six stages involved in practice processing of secondary care information. These included the amendment or updating of practice records whilst simultaneously or separately actioning secondary care recommendations, using either a 'one-step' or 'two-step' approach, respectively. Many factors were found to influence each stage and impact on the continuum of patient care. CONCLUSION: The primary purpose of processing secondary care information is to support patient care; this study raises the profile of information flow and usage within practices as an issue requiring further consideration.

Satisfaction predictors and attitudes towards electronic prescribing systems in three UK hospitals.

OBJECTIVE: Measuring satisfaction of technology users, along with satisfaction determinants, is important to enhance system utilisation and identify potential problems. The aim of this study was to investigate pharmacists' and doctors' attitudes towards e-prescribing systems, and assess the predictors of their satisfaction. METHOD: A cross-sectional survey was conducted, with 67 pharmacists and 335 doctors in three English hospitals completing a pre-piloted, postal questionnaire. RESULTS: The majority of pharmacists and doctors agreed that their e-prescribing system improved the efficiency of prescribing, and reduced dosage regimen errors. However, the majority did not believe that the system created more time for near-patient clinical activities, or sped up patient discharge. More pharmacists than doctors believed that the system improved the quality of patient care. Doctors were more likely to perceive that the e-prescribing system reduced formulation and omission errors. Doctors and pharmacists from the same hospital had similar opinions about the strengths and weaknesses of the e-prescribing system. Nine variables (out of 29 potential independent variables), seven of which were related to e-prescribing system efficiency, were significant predictors of user satisfaction. CONCLUSION: Overall, respondents were satisfied with the systems; however, pharmacists were generally more satisfied than doctors. The number of satisfaction predictors related to the feelings about e-prescribing system efficiency was larger than those predictors related to the quality of patient care. IMPLICATIONS FOR PRACTICE: These findings contribute to better understanding of how pharmacists and doctors perceive e-prescribing systems, and also have implications for system development, training, and how an e-prescribing system can be most effectively 'marketed' to different user groups.

The prescribing of specialist medicines: what factors influence GPs' decision making?

BACKGROUND: As Governments worldwide strive to integrate efficient health care delivery across the primary-secondary care divide, particular significance has been placed on the need to understand GPs' prescribing of specialist drugs. OBJECTIVE: To explore the factors which influence GPs' decision-making process when requested to prescribe specialist drugs. METHODS: A qualitative approach was used to explore the perspectives of a wide range of practice-, primary care trust-, strategic health authority-level staff and other relevant stakeholders in the North-West of England. All semi-structured interviews (n = 47) were analysed comprehensively using the five-stage 'framework' approach. RESULTS: Six diverse factors were identified as having a crucial bearing on how GPs evaluate initial requests and subsequently decide whether or not to prescribe. These include GPs' lack of knowledge and expertise in using specialist drugs, the shared care arrangement, the influence of a locally agreed advisory list, financial and resource considerations, patient convenience and understanding and GPs' specific areas of interest. CONCLUSION: This exploration of GPs' decision-making process is needed to support future integrated health care delivery.

Health information-seeking behaviour in adolescence: the place of the internet.

The internet is one of a range of health information sources available to adolescents. It is recognised that young people have difficulties accessing traditional health services; in theory, the internet offers them confidential and convenient access to an unprecedented level of information about a diverse range of subjects. This could redress adolescents' state of relative health 'information poverty', compared to adults. This paper seeks to explore United Kingdom (UK) and United States (US) adolescents' perceptions and experiences of using the internet to find information about health and medicines, in the context of the other health information sources that are available to them. The study involved a series of 26 single-gender focus groups with 157 English-speaking students aged 11-19 years from the UK and the US. Many students reported that the internet was their primary general information source. Information sources were defined during analysis in terms of previous experience of the source, saliency of the available information, and credibility of the source (defined in terms of expertise, trustworthiness and empathy). Most focus group participants had extensive personal experience with the internet and some information providers therein (notably search engines). Internet health information was regarded generally as salient. Its saliency was increased through active searching and personalisation. Perceived credibility of the internet varied because expertise and trustworthiness were sometimes difficult to determine, and empathy could be facilitated through online communities but the individual could control disclosure. The internet combines positive features of traditional lay and professional, personal and impersonal sources. Although it is unlikely to supplant the role of trusted peers and adults, the internet has found an important place among adolescents' repertory of health information sources.

Insights into creation and use of prescribing documentation in the hospital medical record.

RATIONALE, AIMS AND OBJECTIVES: Extraction of prescribing data from medical records is a common, albeit flawed, research method. Yet little is known about the processes that result in those data. This study explores the creation and use of prescribing documentation in the medical record, from the perspective of the hospital doctors who both create and use it. METHODS: Thirty-six hospital doctors were purposely selected for qualitative interviews, giving a maximum variability sample of grades of doctors across the range of major medical specialty areas and medical teams at a large teaching hospital in England. RESULTS: The findings suggest a number of reasons why hospital doctors fail to record prescribing decisions in the medical record. There was no set standard, record keeping was not formally taught and the hurried environment of the ward gave little time for documentation. The doctors also acknowledged that there was no need for completeness, as colleagues would be able to 'fill in the gaps' via an inferential process. Assumptions were made and although this was not seen as ideal, it was recognized as necessary if work was to be done efficiently. CONCLUSION: These results reinforce the suggestion that, despite the large number of potential users, the medical record is created for those with the right privileged knowledge. This has profound implications for those without that insider knowledge who are using medical records for research purposes. FUNDING: This work was funded by a North West Regional National Health Service Postdoctoral Fellowship.

Automated quality checks on repeat prescribing.

BACKGROUND: Good clinical practice in primary care includes periodic review of repeat prescriptions. Markers of prescriptions that may need review have been described, but manually checking all repeat prescriptions against the markers would be impractical. AIM: To investigate the feasibility of computerising the application of repeat prescribing quality checks to electronic patient records in United Kingdom (UK) primary care. DESIGN OF STUDY: Software performance test against benchmark manual analysis of cross-sectional convenience sample of prescribing documentation. SETTING: Three general practices in Greater Manchester, in the north west of England, during a 4-month period in 2001. METHOD: A machine-readable drug information resource, based on the British National Formulary (BNF) as the 'gold standard' for valid drug indications, was installed in three practices. Software raised alerts for each repeat prescribed item where the electronic patient record contained no valid indication for the medication. Alerts raised by the software in two practices were analysed manually. Clinical reaction to the software was assessed by semi-structured interviews in three practices. RESULTS: There was no valid indication in the electronic medical records for 14.8% of repeat prescribed items. Sixty-two per cent of all alerts generated were incorrect. Forty-three per cent of all incorrect alerts were as a result of errors in the drug information resource, 44% to locally idiosyncratic clinical coding, 8% to the use of the BNF without adaptation as a gold standard, and 5% to the inability of the system to infer diagnoses that, although unrecorded, would be 'obvious' to a clinical reading the record. The interviewed clinicians supported the goals of the software. CONCLUSION: Using electronic records for secondary decision support purposes will benefit from (and may require) both more consistent electronic clinical data collection across multiple sites, and reconciling clinicians' willingness to infer unstated but 'obvious' diagnoses with the machine's inability to do the same.

'Health repertories': an understanding of lay management of minor ailments.

Data from a programme of research exploring information channels about health and medicines used by young adults (16-24 years old) in the UK were considered, in the light of existing schema and memory theory, to provide a concept of 'health repertories' for self-medication of minor ailments. Focus groups comprising a total of 48 young adults were conducted, followed by structured interviews with 76 young adults who visited a community pharmacy to purchase non-prescription medicines or to ask for advice, and case studies from this cohort. We propose that young adults develop a dynamic 'health repertory' of information for management of minor illness episodes, comprising a number of 'entries', and that these repertories are consistent with schema theory. Each 'repertory' includes description/labelling of symptoms, one or more self-medication strategies, and contingency plans (including formal health care intervention), if these strategies fail. Information in the repertory is drawn from both lay and professional channels.

Validating reasons for medication discontinuation in electronic patient records at hospital discharge.

RATIONALE, AIMS AND OBJECTIVES: The accuracy of health care professionals in reporting safety events determines their usefulness for both system improvement and research. The study objectives were to: (1) validate (assess the accuracy of) the reasons recorded by doctors and pharmacists for discontinuing medication orders at discharge in a hospital's electronic patient records (EPR); (2) investigate the causes of any detected recording inaccuracy; and (3) collect preliminary data on the frequency and types of medication discontinuation. METHODS: This was a validation study in one English hospital. The study comprised two steps: extraction of discontinued medication orders from the EPR followed by short structured interviews with doctors and pharmacists who made the discontinuation. A total of 104 discontinued orders were discussed during 15 face-to-face and six telephone interviews. The software package spss was used for data analysis. RESULTS: Duplication of therapy (27, 25.2%), omission of drug (23, 21.5%) and dosage regimen change (19, 17.8%) were the three most frequent reasons given for discontinuing medications. The majority of recorded discontinuation reasons were correct (100, 96.2%) and complete (101, 97.1%), and hence were judged accurate (97, 93.3%). The difference in accurate recording between doctors (15, 88.2%) and pharmacists (82, 94.3%) was not statistically significant. Potential causes of recording inaccuracy included: slip or lapse, lack of training, carelessness and electronic system rigidity. CONCLUSION: This study showed that doctors and pharmacists recorded accurate reasons for the majority of the discontinued medication orders. It also showed that utilizing pharmacists' recorded reasons during clinical interventions using EPR was beneficial in understanding and characterizing prescribing errors. Although they require further research, the reasons identified present preliminary data about the most prevalent types of pharmacists' interventions during hospital discharge.

Shared care arrangements for specialist drugs in the UK: the challenges facing GP adherence.

OBJECTIVE: To explore the challenges facing GPs' adherence to shared care arrangements for specialist drugs. DESIGN: A qualitative study using semistructured interviews; data analysed using the 'framework' approach aided by QSR N-Vivo 2.0. SETTING: Three Primary Care Trusts (PCTs) within one Strategic Health Authority (SHA) in the North West of England. PARTICIPANTS: 47 semistructured interviews were conducted with a range of Practice, PCT and SHA staff and other relevant stakeholders. RESULTS: GPs faced multiple challenges in adhering to shared care arrangements for specialist drugs. Psychiatric patients were given as an example where such arrangements were perceived as particularly difficult to maintain, with patient non-compliance a contributory factor. GP uncertainty and confusion surrounded the sharing of test results between primary and secondary care, and was felt to give rise to test duplication and omission. Of particular concern to GPs was the lack of compliance of practice and hospital colleagues with these arrangements, and the dependence they placed on specialists' responses to requests for advice. CONCLUSION: This study provides evidence of the numerous challenges facing GP adherence to shared care arrangements. Such challenges need to be overcome if the issues of test duplication and omission are to be addressed, and GPs' future acceptance of shared care arrangements encouraged.

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.

BACKGROUND: Pharmacists have an essential role in improving drug usage and preventing prescribing errors (PEs). PEs at the interface of care are common, sometimes leading to adverse drug events (ADEs). This was the first study to investigate, using a computerized search method, the number, types, severity, pharmacists' impact on PEs and predictors of PEs in the context of electronic prescribing (e-prescribing) at hospital discharge. METHOD: This was a retrospective, observational, 4-week study, carried out in 2008 in the Medical and Elderly Care wards of a 904-bed teaching hospital in the northwest of England, operating an e-prescribing system at discharge. Details were obtained, using a systematic computerized search of the system, of medication orders either entered by doctors and discontinued by pharmacists or entered by pharmacists. Meetings were conducted within 5 days of data extraction with pharmacists doing their routine clinical work, who categorized the occurrence, type and severity of their interventions using a scale. An independent senior pharmacist retrospectively rated the severity and potential impact, and subjectively judged, based on experience, whether any error was a computer-related error (CRE). Discrepancies were resolved by multidisciplinary discussion. The Statistical Package for Social Sciences was used for descriptive data analysis. For the PE predictors, a multivariate logistic regression was performed using STATA 7. Nine predictors were selected a priori from available prescribers', patients' and drug data. RESULTS: There were 7920 medication orders entered for 1038 patients (doctors entered 7712 orders; pharmacists entered 208 omitted orders). There were 675 (8.5% of 7920) interventions by pharmacists; 11 were not associated with PEs. Incidences of erroneous orders and patients with error were 8.0% (95% CI 7.4, 8.5 [n = 630/7920]) and 20.4% (95% CI 18.1, 22.9 [n = 212/1038]), respectively. The PE incidence was 8.4% (95% CI 7.8, 9.0 [n = 664/7920]). The top three medications associated with PEs were paracetamol (acetaminophen; 30 [4.8%]), salbutamol (albuterol; 28 [4.4%]) and omeprazole (25 [4.0%]). Pharmacists intercepted 524 (83.2%) erroneous orders without referring to doctors, and 70% of erroneous orders within 24 hours. Omission (31.0%), drug selection (29.4%) and dosage regimen (18.1%) error types accounted for >75% of PEs. There were 18 (2.9%) serious, 481 (76.3%) significant and 131 (20.8%) minor erroneous orders. Most erroneous orders (469 [74.4%]) were rated as of significant severity and significant impact of pharmacists on PEs. CREs (n = 279) accounted for 44.3% of erroneous orders. There was a significant difference in severity between CREs and non-CREs (χ2 = 38.88; df = 4; p < 0.001), with CREs being less severe than non-CREs. Drugs with multiple oral formulations (odds ratio [OR] 2.1; 95% CI 1.25, 3.37; p = 0.004) and prescribing by junior doctors (OR 2.54; 95% CI 1.08, 5.99; p = 0.03) were significant predictors of PEs. CONCLUSIONS: PEs commonly occur at hospital discharge, even with the use of an e-prescribing system. User and computer factors both appeared to contribute to the high error rate. The e-prescribing system facilitated the systematic extraction of data to investigate PEs in hospital practice. Pharmacists play an important role in rapidly documenting and preventing PEs before they reach and possibly harm patients. Pharmacists should understand CREs, so they complement, rather than duplicate, the e-prescribing system's strengths.

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.

BACKGROUND: Medication errors are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. METHODS: RESEARCH SUBJECT GROUP: "At-risk" patients registered with computerised general practices in two geographical regions in England. DESIGN: Parallel group pragmatic cluster randomised trial. INTERVENTIONS: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. PRIMARY OUTCOME MEASURES: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs; - with a computer-recorded diagnosis of asthma being prescribed beta-blockers; - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. SECONDARY OUTCOME MEASURES; These relate to a number of other examples of potentially hazardous prescribing and medicines management. ECONOMIC ANALYSIS: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. QUALITATIVE ANALYSIS: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. SAMPLE SIZE: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. DISCUSSION: At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken.

Pharmacists' changing views of their supplementary prescribing authority.

OBJECTIVE: To investigate the views and experiences of pharmacists in England before and after they registered as supplementary prescribers. METHOD: Eight pharmacists were recruited from training courses; seven from secondary care and one from primary care and interviewed during training and again after registration. In the first interviews, topics included previous experience, views on current roles, responsibilities and accountability for prescribing and how these might change. In the second interviews, the pharmacists discussed how these had actually changed after gaining supplementary prescribing authority, how their role worked in practice and how they saw it developing in the future. MAIN OUTCOME MEASURE: Descriptions of anticipated and actual changes in their roles, responsibilities and accountability before and after registration as supplementary prescribers RESULTS: The pharmacists anticipated that training would legitimise their current 'informal' prescribing practices, with increased legal responsibility and accountability, but experienced many procedural delays in implementing their new role. Pharmacists who were already heavily involved with prescribing were more likely to work as prescribers, but not necessarily within the clinical management plan framework. The desire to maintain the efficiency of their existing clinical services impacted negatively on the pharmacists' ability or willingness to prescribe in this legally approved manner. CONCLUSION: Clear and realistic expectations need to be set by the pharmacists as to what is achievable and greater attention needs to be paid to minimising delays between the end of training and the beginning of practice, to minimise reduction in motivation and redeployment of staff.

[Preventable drug-related morbidity: determining valid indicators for primary care in Portugal].

Preventable drug-related morbidity (PDRM) indicators are operational measures of therapeutic risk management. These clinical indicators, which cover a wide range of drugs, combine process and outcome in the same instrument. They were developed in the US and have been validated for primary care settings in the US, UK and Canada. This study is part of a research programme; it aimed to determine a valid set of PDRM indicators for adult patients in primary care in Portugal. Face validity of 61 US and UK-derived indicators translated to Portuguese was preliminarily determined by means of a postal questionnaire using a purposive sample of four Portuguese pharmacists with different backgrounds. Preliminary content validity of indicators approved in the previous stage was determined by cross-checking each definition of PDRM with standard drug information sources in Portugal. Face and content validity of indicators yielded by preliminary work were then established by a 37 expert panel (20 community pharmacists and 17 general practitioners) using a two-round Delphi survey. Data were analysed using SPSS release 11.5. Nineteen indicators were ruled out in preliminary validation. Changes were made in the content of eight of the remaining 42 indicators; these were related to differences in the drugs being marketed and patterns of drug monitoring between countries. Thirty-five indicators were consensus approved as PDRM for adult patients in Portuguese primary care by the Delphi panel.

The validity of explicit indicators of prescribing appropriateness.

OBJECTIVE: To assess, from the perspective of UK hospital doctors, the content validity and operational validity of a set of 14 previously developed explicit indicators of the appropriateness of long-term prescribing started during a hospital admission. METHOD: A combination of data extraction from medical records and qualitative interviews with a maximum variability sample of hospital doctors. PARTICIPANTS: The indicators were applied to 132 new prescriptions, intended for long-term use, prescribed for 61 patients; 36 doctors, of various grades, were purposively selected for interview. RESULTS: Appropriate prescribing was viewed as prescribing that was indicated, necessary, evidence based (using a broad meaning of 'evidence') and of acceptable cost and risk-benefit ratio. These concepts applied to individual drugs for individual patients, rather than at a more general, public health level. Where drugs had failed an indicator, rationales were explored. Often, it was missing data in the medical notes that had resulted in the drug failing the indicator. CONCLUSIONS: The 14 indicators were considered to have content validity, reflecting all aspects of appropriate prescribing discussed by the doctors. Their operational validity was less clear-cut, due to the lack of necessary data in the medical notes. This has implications for the use of explicit indicators for assessing prescribing appropriateness, as these hospital doctors did not consider that the data required for objective, systematic assessment of prescribing would ever be recorded in hospital medical notes.

Inter-rater reliability of explicit indicators of prescribing appropriateness.

OBJECTIVE: To assess the inter-rater reliability of 14 explicit indicators of appropriate long-term prescribing. METHOD: All available data required for the assessment of 59 long-term prescriptions started during a hospital admission for 25 patients were transcribed from the patients' medical records. These transcripts were presented in a standardised format and random order to four raters (two doctors and two pharmacists) who used the indicators to judge the appropriateness of each prescription. Debriefing interviews were held with each rater. An a priori level of acceptable agreement between the raters was set at a weighed kappa of 0.70. RESULTS: There was no apparent difference between pharmacists and doctors for all findings, so data were combined. Two indicators showed poor agreement, three showed moderate agreement, and nine showed substantial or near perfect agreement, exceeding a weighted kappa of 0.70. There was excellent positive agreement as to which prescriptions were judged appropriate by the indicators, but much worse negative agreement as to which prescriptions were judged to be inappropriate. In the interviews, the raters remarked on the difficulty of applying explicit indicators when they routinely made implicit judgements about data in the medical records. CONCLUSION: Nine of the indicators achieved the required level of reliability and the negative agreement levels showed that this was the area that required greater improvement in future developments of the indicators. Further work needs to be conducted to investigate ways of the improving instructions on how to make explicit judgements and reducing the need for implicit or subjective assessments.

Development and face validity of explicit indicators of appropriateness of long term prescribing.

OBJECTIVES: To develop a set of explicit and operationalisable indicators of appropriate prescribing and assess their face validity using clinical pharmacists practising in secondary and primary care. METHOD: Appropriateness indicators were derived from the literature, applied to data in the hospital clinical records of all newly prescribed long-term drugs for 50 randomly selected patients, further refined and then applied to another 25 randomly selected patients. A pre-piloted postal questionnaire was sent to 200 hospitals and primary care pharmacists, asking them to assess the indicators as to their importance for the assessment of appropriateness of long-term prescribing initiated in hospitals. RESULTS: Fourteen indicators were developed and piloted. Of the 16 original indicators, 5 were discarded, as they were unable to be operationalised, and 2 were subdivided to reflect the routinely available data. Eighty-six pharmacists with individual patient-focussed clinical duties took part in the assessment of the face validity (response rate 43%). Eleven indicators achieved a median importance rating of 1 (very important), and three indicators a median importance rating of 2 on a 5-point scale. The three most important indicators overall were "indication included in discharge summary", "questionable high-risk therapeutic combination" and "hazardous drug-drug combination". CONCLUSION: It was possible to develop and operationalise 14 indicators of the appropriateness of long-term prescribing commenced in hospital practice, all of which were considered to have face validity by an expert panel of clinical pharmacists. The development of these explicit indicators highlighted the incompleteness of the patient's record. Further work is needed to assess their validity and reliability, before their use in research or audit can be recommended.

The Internet: a window on adolescent health literacy.

PURPOSE: Adolescents are well served by the Internet through school access, but they will only derive maximum benefit from this information resource if they are able to search for, evaluate, and use its online information effectively. Internet use, however, requires significant literacy skills, and little is known about the health literacy of adolescents. The aim of this paper is to describe functional, critical, and interactive health literacy challenges experienced by adolescent students when using the Internet for online health information. METHODS: Twenty-six focus groups with 157 adolescent students, aged 11-19, conducted within a convenience sample of middle and high schools in diverse geographical and socioeconomic settings in the United Kingdom (UK) and United States of America (US) between May 2001 and May 2002. RESULTS: Many students cited difficulties in accessing health information online. Functional health literacy challenges included, for example, spelling medical terms correctly and being able to construct questions describing symptoms accurately. Critical challenges included discerning relevance of information retrieved by search engines and knowing which sites to trust. Interactive challenges included the appropriate application of health information to address personal health concerns within their local neighborhood. CONCLUSIONS: Exploring the challenges faced when adolescents search for online health information indicates deficiencies regarding health literacy skills. Difficulties regarding functional, critical, and interactive skills were all present. The Internet may offer opportunities for identifying such deficiencies and building better health literacy skills among adolescents, as part of health curriculum interventions to improve the population's future health.

Exploring the domains of appropriateness of drug therapy, using the Nominal Group Technique.

OBJECTIVE: To explore the domains encompassed within the assessment of the appropriateness of prescribing for an individual patient. METHOD: The Nominal Group Technique was used to address the question "How can we assess inappropriate drug therapy of individual patients that is responsive to pharmaceutical care?" The group participants were a self-selected group of nine pharmacists and one pharmacologist attending an international working conference on the Outcomes of Pharmaceutical Care. Item generation was followed by discussion for clarification and operationalization. Voting achieved a consensus, defined as > or = 70%, agreement on the importance of items for inclusion in an instrument to assess appropriateness. RESULTS: Sixty-seven items were initially generated. During discussion, similar items were combined and items were grouped into domains. Items that considered the patient's perspective were commonly suggested, but many were discarded after discussing their operationalization. Consensus was obtained that eighteen items, in seven domains, should be included in the instrument. The domains were indication and drug choice (5 items), effectiveness (2), risks and safety (2), dosage (3), interactions (1), practical use (4), and monitoring (1). CONCLUSION: It is hoped that, with adequate testing, these indicators of appropriateness of prescribing can be used by pharmacists to begin to routinely assess the impact of pharmaceutical care on the quality of prescribing for patients under their care.

The nature of informal pain questioning by nurses--a barrier to post-operative pain management?

OBJECTIVE: The aim of this study was to explore the nature of nurses' informal pain-related questioning. METHODS: Non-participant observations were performed on one vascular and one urology surgery ward, involving 26 nurses in 402 patient contacts on eight days (total observation time: 39 hours). A questionnaire survey of 180 (of 335 = 53.7% response rate) nurses working on the same two types of surgery wards in 14 UK hospitals was also undertaken. Instruments (observation sheet & questionnaire) were based on initial qualitative work and developed alongside each other to enable complementation of data. RESULTS: Both methods identified routine drug administration rounds as the predominant time for informal pain questioning. Observed nurses asked about one third of patients at those times. The majority of pain questions were closed, and interactions were generally brief and task-orientated, often involving one question. CONCLUSION: This study has shown the need for a more systematic way to assess patients' pain in routine practice. Suggestions are made about how pain questioning could be improved even if it continues to take place during drug rounds. These may provide a good opportunity for efficient pain questioning within a work environment acknowledging pressures of time and workload. Furthermore, within the current climate of increased multidisciplinary collaboration, the relevance of this study to medicines management and pharmacy are discussed.