Exploring the challenges faced by foundation doctors when prescribing high risk medicines safely during the on-call period: A qualitative study.

AIMS: Errors with prescribing high-risk medicines (HRMs) have a greater propensity to cause harm than with non-HRMs. Prescribing errors arise due to multiple factors and it can be particularly challenging for junior doctors to prescribe safely during the on-call period. Knowledge regarding the challenges of prescribing HRM during the on-call period would be useful to target preventative interventions. The aim of this study was to explore the challenges encountered by foundation doctors (doctors who have graduated medical school within the last 2 years) when prescribing specific HRMs (anticoagulants, insulin and opioids) safely during the on-call period. METHODS: Six focus groups exploring the challenges of prescribing HRMs safely during the on-call period were conducted, 3 with foundation year 1 and 3 with foundation year 2 doctors from across 3 different hospitals. A thematic framework analysis based on the London Protocol was conducted. RESULTS: Doctors described multiple challenges to prescribing HRMs safely during the on-call period including a lack of prescribing support, nursing pressure, complex prescribing tasks, unknown patients as well as individual factors such as lack of knowledge and tiredness. Many of these factors exist to some extent during the day, yet the nature of the on-call period as a fast-paced environment heightened the challenges that prescribers faced. CONCLUSION: There are multiple challenges experienced by foundation doctors when prescribing HRMs during the on-call period. The potentially devastating consequences of errors with HRMs means that closer attention and more concern from healthcare professionals, researchers and policymakers is required to improve safe prescribing of HRMs in hospitals.

Public preferences regarding data linkage for research: a discrete choice experiment comparing Scotland and Sweden.

BACKGROUND: There are increasing examples of linking data on healthcare resource use and patient outcomes from different sectors of health and social care systems. Linked data are generally anonymised, meaning in most jurisdictions there are no legal restrictions to their use in research conducted by public or private organisations. Secondary use of anonymised linked data is contentious in some jurisdictions but other jurisdictions are known for their use of linked data. The publics' perceptions of the acceptability of using linked data is likely to depend on a number of factors. This study aimed to quantify the preferences of the public to understand the factors that affected views about types of linked data and its use in two jurisdictions. METHOD: An online discrete choice experiment (DCE) previously conducted in Scotland was adapted and replicated in Sweden. The DCE was designed, comprising five attributes, to elicit the preferences from a representative sample of the public in both jurisdictions. The five attributes (number of levels) were: type of researcher using linked data (four); type of data being linked (four); purpose of the research (three); use of profit from using linked data (four); who oversees the research (four). Each DCE contained 6 choice-sets asking respondents to select their preferred option from two scenarios or state neither were acceptable. Background questions included socio-demographics. DCE data were analysed using conditional and heteroskedastic conditional logit models to create forecasts of acceptability. RESULTS: The study sample comprised members of the public living in Scotland (n = 1004) and Sweden (n = 974). All five attributes were important in driving respondents' choices. Swedish and Scottish preferences were mostly homogenous with the exception of 'who oversees the research using linked data', which had relatively less impact on the choices observed from Scotland. For a defined 'typical' linked data scenario, the probability (on average) of acceptance was 85.7% in Sweden and 82.4% in Scotland. CONCLUSION: This study suggests that the public living in Scotland and Sweden are open to using anonymised linked data in certain scenarios for research purposes but some caution is advisable if the anonymised linked data joins health to non-health data.

Foundation year one and year two doctors' prescribing errors: a comparison of their causes.

OBJECTIVE: Junior doctors have the highest rates of prescribing errors, yet no study has set out to understand the differences between completely novice prescribers (Foundation year one (FY1) doctors) and those who have gained some experience (Foundation year two (FY2) doctors). The objective of this study was to uncover the causes of prescribing errors made by FY2 doctors and compare them with previously collected data of the causes of errors made by FY1 doctors. DESIGN: Qualitative interviews, using the critical incident technique, conducted with 19 FY2 doctors on the causes of their prescribing errors and compared with interviews previously conducted with 30 FY1 doctors. Data were analysed using a constant comparison approach after categorisation of the data using Reason's model of accident causation and the London protocol. RESULTS: Common contributory factors in both FY1 and FY2 doctors' prescribing errors included working on call, tiredness and complex patients. Yet, important differences were revealed in terms of application of prescribing knowledge, with FY1 doctors lacking knowledge and FY2 misplacing their knowledge. Due to the rotation of foundation doctors, both groups are faced with novel prescribing contexts, yet the previous experience that FY2 doctors gained led to misplaced confidence when caution would have been expedient. CONCLUSIONS: Differences in the contributory factors of prescribing errors should be taken into account when designing interventions to improve the prescribing of foundation doctors. Furthermore, careful consideration should be taken when inferring expertise in FY2 doctors, who are likely to prescribe in contexts in which their experience is little different to an FY1 doctor.

Investigating the Extent to Which Patients Should Control Access to Patient Records for Research: A Deliberative Process Using Citizens' Juries.

BACKGROUND: The secondary use of health data for research raises complex questions of privacy and governance. Such questions are ill-suited to opinion polling where citizens must choose quickly between multiple-choice answers based on little information. OBJECTIVE: The aim of this project was to extend knowledge about what control informed citizens would seek over the use of health records for research after participating in a deliberative process using citizens' juries. METHODS: Two 3-day citizens' juries, of 17 citizens each, were convened to reflect UK national demographics from 355 eligible applicants. Each jury addressed the mission "To what extent should patients control access to patient records for secondary use?" Jurors heard from and questioned 5 expert witnesses (chosen either to inform the jury, or to argue for and against the secondary use of data), interspersed with structured opportunities to deliberate among themselves, including discussion and role-play. Jurors voted on a series of questions associated with the jury mission, giving their rationale. Individual views were polled using questionnaires at the beginning and at end of the process. RESULTS: At the end of the process, 33 out of 34 jurors voted in support of the secondary use of data for research, with 24 wanting individuals to be able to opt out, 6 favoring opt in, and 3 voting that all records should be available without any consent process. When considering who should get access to data, both juries had very similar rationales. Both thought that public benefit was a key justification for access. Jury 1 was more strongly supportive of sharing patient records for public benefit, whereas jury 2 was more cautious and sought to give patients more control. Many jurors changed their opinion about who should get access to health records: 17 people became more willing to support wider information sharing of health data for public benefit, whereas 2 moved toward more patient control over patient records. CONCLUSIONS: The findings highlight that, when informed of both risks and opportunities associated with data sharing, citizens believe an individual's right to privacy should not prevent research that can benefit the general public. The juries also concluded that patients should be notified of any such scheme and have the right to opt out if they so choose. Many jurors changed their minds about this complex policy question when they became more informed. Many, but not all, jurors became less skeptical about health data sharing, as they became better informed of its benefits and risks.

A qualitative study exploring how pharmacist and nurse independent prescribers make clinical decisions.

AIM: The aim of this study was to explore how secondary care pharmacist and nurse independent prescribers clinically reason when making prescribing decisions. BACKGROUND: Clinical reasoning is a central component of prescribers' competence and professional autonomy when reaching a clinically appropriate decision. Like doctors, pharmacist and nurse independent prescribers in the UK have extensive prescribing rights, but little is known about their clinical reasoning. DESIGN: A qualitative approach using a think-aloud methodology and semi-structured interviews. METHODS: Eleven nurse and 10 pharmacist independent prescribers were asked to think-aloud about validated clinical vignettes prior to interview, between March - December 2015. Data were analysed using a constant-comparative approach. RESULTS: A strong link between clinical knowledge, grounded in previous experience and clinical reasoning was found. Despite prescribers approaching the clinical vignettes holistically, their focus varied according to professional background and job role. Nurses were more likely to describe interacting with patients, compared with pharmacists who were more focused on medical notes and laboratory results. Think-aloud protocol analysis revealed a distinct pattern in the process undertaken to reach a clinical decision. This is presented as a decision-making model, encompassing case familiarization, generating hypotheses, case assessment, final hypotheses and decision-making stages, which oscillated throughout the model. CONCLUSION: This is the first study to explore the clinical reasoning processes of secondary care pharmacist and nurse independent prescribers. The resultant decision-making model shows clinical reasoning as a complex and dynamic process. This model can inform the training of independent prescribers to become accurate problem solvers and continue making clinically appropriate decisions.

Factors influencing secondary care pharmacist and nurse independent prescribers' clinical reasoning: An interprofessional analysis.

In the United Kingdom, pharmacist and nurse independent prescribers are responsible for both the clinical assessment of and prescribing for patients. Prescribing is a complex skill that entails the application of knowledge, skills, and clinical reasoning to arrive at a clinically appropriate decision. Decision-making is influenced and informed by many factors. This study, the first of its kind, explores what factors influence pharmacist and nurse independent prescribers during the process of clinical reasoning. A think-aloud methodology immediately followed by a semi-structured interview was conducted with 11 active nurse and 10 pharmacist independent prescribers working in secondary care. Each participant was presented with validated clinical vignettes for the think-aloud stage. Participants chose the clinical therapeutic areas for the vignettes, based on their self-perceived competencies. Data were audio-recorded, transcribed verbatim, and a constant-comparative approach was used for analysis. Influences on clinical reasoning were broadly categorised into themes: social interaction, intrinsic, and contextual factors. These themes showed that intrinsic, sociocultural, and contextual aspects heavily influenced the clinical reasoning processes of prescribers. For example, prescribers were aware of treatment pathways, but chose to refer patient cases to avoid making the final prescribing decision. Exploration of this behaviour in the interviews revealed that previous experience and attitudes such as confidence and cautiousness associated with responsibility were strong influencers within the decision-making process. In addition, strengthening the professional identity of prescribers could be achieved through collaborative work with interprofessional healthcare teams to orient their professional practice from within the profession. Findings from this study can be used to inform the education, training, and practice of independent prescribers to improve healthcare services by improving their professional and interprofessional development.

Rasch analysis of the Antimicrobial Self-Assessment Toolkit for National Health Service (NHS) Trusts (ASAT v17).

OBJECTIVES: The Antimicrobial Self-Assessment Toolkit for National Health Service (NHS) Trusts (ASAT) was developed to evaluate hospital-based antimicrobial stewardship programmes. Iterative validity investigations of the ASAT were used to produce a 91-item ASAT v17 utilizing qualitative methodology. Rasch analysis was used to generate question (item) behaviour estimates and to investigate the validity of ASAT v17. METHODS: In 2012, the partial credit model (PCM) was used to analyse ASAT responses from 33 NHS Trusts within England. WINSTEPS® outputs such as fit statistics and respondent/item maps were examined to determine unidimensionality, item discrimination and item hierarchy. Ordinary least squares regression modelling was used to determine the predictive validity using NHS Trust ability estimates generated from the PCM and corresponding Clostridium difficile rates. RESULTS: Each domain contained items that were misfitting the PCM (with INFIT MNSQ <0.7 or >1.3), except Domain 3. Subsequent iterative item removal had a negligible effect on the fit indices within most ASAT domains. Scale analysis demonstrated that most items were productive for measurement (n = 81). Respondent/item maps showed ceiling effects (n = 3) and floor effects (n = 1) within ASAT domains. Ordinary least squares regression modelling identified that there was limited predictive validity due to the small positive correlation between the predictor and outcome variables for participating hospitals (ρ = 0.146; P = 0.418). CONCLUSIONS: Rasch analysis was an effective measurement technique for evaluating the validity of ASAT v17 by providing evidence that each sub-scale and the overall scale demonstrated unidimensionality (construct validity). Improved item targeting may be required to improve item discrimination within the toolkit.

Learning from the design, development and implementation of the Medication Safety Thermometer.

QUALITY ISSUE: Approximately 10% of patients are harmed by healthcare, and of this harm 15% is thought to be medication related. Despite this, medication safety data used for improvement purposes are not often routinely collected by healthcare organizations over time. INITIAL ASSESSMENT: A need for a prospective medication safety measurement tool was identified. CHOICE OF SOLUTION: The aim was to develop a tool to allow measurement and aid improvement of medication safety over time. The methodology used for the National Health Service (NHS) Safety Thermometer was identified as an approach. The resulting tool was named the 'Medication Safety Thermometer'. IMPLEMENTATION: The development of the Medication Safety Thermometer was facilitated by a multidisciplinary steering group using a Plan, Do, Study, Act (PDSA) method. Alpha and beta testing occurred over a period of 9 months. The tool was officially launched in October 2013 and continued to be improved until May 2016 using ongoing user feedback. EVALUATION: Feedback was gained through paper and online forms, and was discussed at regular steering group meetings. This resulted in 16 versions of the tool. The tool is now used nationally, with over 230 000 patients surveyed in over 100 NHS organizations. Data from these organizations are openly accessible on a dedicated website. LESSONS LEARNED: Measuring harm from medication errors is complex and requires steps to measure individual errors, triggers of harm and actual harm. PDSA methodology can be effectively used to develop measurement systems. Measurement at the point of care is beneficial and a multidisciplinary approach is vital.

Pharmacist-led feedback workshops increase appropriate prescribing of antimicrobials.

OBJECTIVES: To investigate whether and how structured feedback sessions can increase rates of appropriate antimicrobial prescribing by junior doctors. METHODS: This was a mixed-methods study, with a conceptual orientation towards complexity and systems thinking. Fourteen junior doctors, in their first year of training, were randomized to intervention (feedback) and 21 to control (routine practice) groups in a single UK teaching hospital. Feedback on their antimicrobial prescribing was given, in writing and via group sessions. Pharmacists assessed the appropriateness of all new antimicrobial prescriptions 2 days per week for 6 months (46 days). The mean normalized prescribing rates of suboptimal to all prescribing were compared between groups using the t-test. Thematic analysis of qualitative interviews with 10 participants investigated whether and how the intervention had impact. RESULTS: Data were collected on 204 prescriptions for 166 patients. For the intervention group, the mean normalized rate of suboptimal to all prescribing was 0.32 ±â€Š0.36; for the control group, it was 0.68 ±â€Š0.36. The normalized rates of suboptimal prescribing were significantly different between the groups (P = 0.0005). The qualitative data showed that individuals' prescribing behaviour was influenced by a complex series of dynamic interactions between individual and social variables, such as interplay between personal knowledge and the expectations of others. CONCLUSIONS: The feedback intervention increased appropriate prescribing by acting as a positive stimulus within a complex network of behavioural influences. Prescribing behaviour is adaptive and can be positively influenced by structured feedback. Changing doctors' perceptions of acceptable, typical and best practice could reduce suboptimal antimicrobial prescribing.

Prevalence and appropriateness of psychotropic medication prescribing in a nationally representative cross-sectional survey of male and female prisoners in England.

BACKGROUND: Mental illness is highly prevalent among prisoners. Although psychotropic medicines can ameliorate symptoms of mental illness, prescribers in prisons must balance clinical needs against risks to safety and security. Concerns have been raised at the large number of prisoners reportedly receiving psychotropic medicines in England. Nonetheless, unlike for the wider community, robust prescribing data are not routinely available for prisons. We investigated gender-specific patterns in the prevalence and appropriateness of psychotropic prescribing in English prisons. METHODS: We studied 6052 men and 785 women in 11 prisons throughout England. This represented 7.9 % of male and 20.5 % of female prisoners nationally. Using a cross-sectional design, demographic and prescription data were collected from clinical records of all prisoners prescribed psychotropic medicines, including hypnotic, anxiolytic, antipsychotic, anti-manic, antidepressant and Central Nervous System stimulant medications. Percentages and 95 % CIs were used to estimate the prevalence of prescribing. The Prescribing Appropriate Indicators tool was used to determine appropriateness. Prevalence Ratios (PR) were generated to make age-adjusted comparisons between prisoners and the general population using a dataset supplied by the Clinical Practice Research Datalink. RESULTS: Overall, 47.9 % (CI 44.4-51.4) of women and 16.9 % (CI 16.0-17.9) of men in prison were prescribed one or more psychotropic medicines. Compared with the general population, age-adjusted prescribing prevalence was six times higher among women (PR 5.95 CI 5.36-6.61) and four times higher among men (PR 4.02 CI 3.75-4.30). Undocumented or unapproved indications for prescriptions, not listed in the British National Formulary, were recorded in a third (34.7 %, CI 32.5-37.0) of cases, most commonly low mood and personality disorder. CONCLUSIONS: Psychotropic medicines were prescribed frequently in prisons, especially among women, and for a wider range of indications than are currently recommended. These findings raise questions about whether the prescribing of psychotropic medicines in prisons is wholly appropriate and proportionate to the level of clinical need. Prisons need to develop a wider array of treatment responses, other than medicines, to effectively tackle mental illness, challenging behaviours and distress.

Preparing to prescribe: How do clerkship students learn in the midst of complexity?

Prescribing tasks, which involve pharmacological knowledge, clinical decision-making and practical skill, take place within unpredictable social environments and involve interactions within and between endlessly changing health care teams. Despite this, curriculum designers commonly assume them to be simple to learn and perform. This research used mixed methods to explore how undergraduate medical students learn to prescribe in the 'real world'. It was informed by cognitive psychology, sociocultural theory, and systems thinking. We found that learning to prescribe occurs as a dynamic series of socially negotiated interactions within and between individuals, communities and environments. As well as a thematic analysis, we developed a framework of three conceptual spaces in which learning opportunities for prescribing occur. This illustrates a complex systems view of prescribing education and defines three major system components: the "social space", where the environmental conditions influence or bring about a learning experience; the "process space", describing what happens during the learning experience; and the intra-personal "cognitive space", where the learner may develop aspects of prescribing expertise. This conceptualisation broadens the scope of inquiry of prescribing education research by highlighting the complex interplay between individual and social dimensions of learning. This perspective is also likely to be relevant to students' learning of other clinical competencies.

Association between Clostridium difficile infection and antimicrobial usage in a large group of English hospitals.

AIMS: This study aimed to determine the association between the reduction in the number of Clostridium difficile infection (CDI) cases reported by the English National Health Service (NHS) hospitals and concurrent antimicrobial use. METHODS: A retrospective ecological study for January 2005 to December 2008 was conducted using data from 26 of the 29 NHS trusts (i.e. a trust manages one or more hospitals) located in the North West Strategic Health Authority of England. Antimicrobial use data, for patients of all ages, were provided by IMS Health, and CDI case data for patients aged ≥65 years were provided by the Health Protection Agency. Antimicrobial use was converted into defined daily doses (DDDs). The overall association between antimicrobial use and CDI for the trusts was investigated using multilevel models. RESULTS: Our study shows a positive significant association between the CDI cases and the use of the following antimicrobials: 'third-generation cephalosporins' [11.62 CDI cases per 1000 DDDs; 95% confidence interval (CI), 5.92­17.31]; 'fluoroquinolones' (4.79 CDI cases per 1000 DDDs; 95% CI, 2.83­6.74); and 'second-generation cephalosporins' (4.25 CDI cases per 1000 DDDs; 95% CI, 1.66­6.83). The strength of this association was not significantly different (95% CI) among the antimicrobial groups. CONCLUSIONS: This study shows that the reduction in the number of CDI cases reported by the English NHS hospitals is associated with concurrent reductions in antimicrobial use. This means that the number of CDI cases over time decreased in a similar fashion to the usage of various antimicrobials.

Exploring the causes of junior doctors' prescribing mistakes: a qualitative study.

AIMS: Prescribing errors are common and can be detrimental to patient care and costly. Junior doctors are more likely than consultants to make a prescribing error, yet there is only limited research into the causes of errors. The aim of this study was to explore the causes of prescribing mistakes made by doctors in their first year post graduation. METHODS: As part of the EQUIP study, interviews using the critical incident technique were carried out with 30 newly qualified doctors. Participants were asked to discuss in detail any prescribing errors they had made. Participants were purposely sampled across a range of medical schools (18) and hospitals (15). A constant comparison approach was taken to analysis and Reason's model of accident causation was used to present the data. RESULTS: More than half the errors discussed were prescribing mistakes (errors due to the correct execution of an incorrect plan). Knowledge-based mistakes (KBMs) appeared to arise from poor knowledge of practical aspects of prescribing such as dosing, whereas rule-based mistakes (RBMs) resulted from inappropriate application of knowledge. Multiple error-producing and latent conditions were described by participants for RBMs and KBMs. Poor/absent senior support and a fear of appearing incompetent occurred with KBMs. Following erroneous routines or seniors' orders were major contributory factors in RBMs. CONCLUSIONS: Although individual factors such as knowledge and expertise played a role in prescribing mistakes, there were many perceived interrelated factors contributing to error. We conclude that multiple interventions are necessary to address these and further research is essential.

What do emergency department pharmacist practitioners know and understand about patient safeguarding? A qualitative study.

BACKGROUND: Pharmacists with additional clinical skills now work in UK emergency departments. Known as Emergency Department Pharmacist Practitioners, the role was developed in response to a shortage of physicians and nurses. They carry out activities typical of traditional hospital pharmacists, but also novel 'practitioner' activities such as examining patients, and acting as designated care provider. The role includes a responsibility to safeguard patients from harm. Professional competence, i.e. to safeguard patients, is underpinned by knowledge of the subject, but also knowledge application. AIM: To investigate what Emergency Department Pharmacist Practitioners know and understand about safeguarding vulnerable children and adults. METHOD: Thirteen Emergency Department Pharmacist Practitioners were interviewed to explore their knowledge and understanding of safeguarding. Interview questions were developed from review of relevant literature, as were vignettes with variables identified and altered to produce different scenarios. Template analysis was used to code data to a priori themes for each of the stages of the initial safeguarding process, and new themes that emerged throughout the process. RESULTS: Six themes were identified in addition to the four a priori themes. Overall, participants frequently described how safeguarding concerns are both recognised and responded to, but seemed more comfortable when responding to medicines related concerns. Factors thought to influence the safeguarding process included: resources and setting; and education, training and experiential learning; and culture. CONCLUSION: While Emergency Department Pharmacist Practitioners interviewed were aware of the safeguarding process, there were some misconceptions as to the roles of different healthcare workers in this process.

Prescribing errors in hospital practice.

Prescribing errors that occur in hospitals have been a source of concern for decades. This narrative review describes some of the recent work in this field. There is considerable heterogeneity in definitions and methods used in research on prescribing errors. There are three definitions that are used most frequently (one for prescribing errors specifically and two for the broader arena of medication errors), although many others have also been used. Research methods used focus primarily on investigating either the prescribing process (such as errors in the dose prescribed) or the outcomes for the patient (such as preventable adverse drug events). This complicates attempts to calculate the overall prevalence or incidence of errors. Errors have been reported in handwritten descriptions of almost 15% and with electronic prescribing of up to 8% of orders. Errors are more likely to be identified on admission to hospital than at any other time (usually failure to continue ongoing medication) and errors of dose occur most commonly throughout the patients' stay. Although there is evidence that electronic prescribing reduces the number of errors, new types of errors also occur. The literature on causes of error shows some commonality with both handwritten and electronic prescribing but there are also causes that are unique to each. A greater understanding of the prevalence of the complex causal pathways found and the differences between the pathways of minor and severe errors is necessary. Such an understanding would underpin theoretically-based interventions to reduce the occurrence of prescribing errors.

Pharmacy users' expectations of pharmacy encounters: a Q-methodological study.

BACKGROUND: Pharmacy practice is evolving according to general health-care trends such as increased patient involvement and public health initiatives. In addition, pharmacists strive to find new professional roles. Clients' expectations of service encounters at pharmacies is an under-explored topic but crucial to understanding how pharmacy practice can evolve efficiently. OBJECTIVE: To identify and describe different normative expectations of the pharmacy encounter among pharmacy clients. METHODS: Q methodology, an approach to systematically explore subjectivity that retains complete patterns of responses and organizes these into factors of operant subjectivity. SETTING AND PARTICIPANTS: Eighty-five regular prescription medication users recruited at Swedish community pharmacies and by snowballing. RESULTS: Seven factors of operant subjectivity were identified, and organized into two groups. Factors that emphasized the physical drug product as the central object of the pharmacy encounter were labelled as independent drug shopping; logistics of drug distribution; and supply of individual's own drugs. Factors that emphasized personal support as desirable were labelled competence as individual support; individualist professional relations, just take care of me; and practical health-care and lifestyle support. DISCUSSION AND CONCLUSIONS: The systematic Q-methodological approach yielded valuable insights into how pharmacy clients construct their expectations for service encounters. They hold differentiating normative expectations for pharmacy services. Understanding these varying viewpoints may be important for developing and prioritizing among efficient pharmacy services. Clients' expectations do not correspond with trends that guide current pharmacy practice development. This might be a challenge for promoting or implementing services based on such trends.

Prescriber behaviours that could be targeted for change: An analysis of behaviours demonstrated during prescription writing in children.

BACKGROUND: The prescribing process for children with cancer is complex, and errors can occur at any step. As a result, many interventions have been used to reduce errors. However, few of them have been designed based on an understanding of the prescriber behaviour that can lead to errors. In order to design effective behaviour change interventions, it is important first to understand the prescribing process and identify prescriber behaviours that could be targeted for change. OBJECTIVES: To describe the prescribing process in a paediatric oncology ward and to identify prescriber behaviours during prescription writing that could be targeted to reduce errors. METHODS: This study employed two sequential phases. First, the prescribing process was observed and then described using the hierarchical task analysis (HTA) method. Second, prescriber tasks identified from the HTA were analysed using the behaviour change wheel (BCW) approach to identify promising behaviours for change. These identified behaviours were prioritised based on information collected from four focus groups with prescribers and chart review of errors made in the ward. RESULTS: The prescribing process was complex and involved multiple tasks performed in varying orders. Applying the BCW identified thirty-two candidate behaviours for potentially reducing prescribing errors. However, after prioritization, only two emerged as promising candidate behaviours for intervention: writing drug indications at the time of prescribing and using a pre-written order when ordering medications through electronic prescribing. CONCLUSIONS: This research suggests that two behaviours could be promising in reducing errors. Having identified these behaviours, future work could explore what needs to change with respect to individuals and their work environments to achieve the desired change in these identified behaviours.

Development of the adult complexity tool for pharmaceutical care (ACTPC) in hospital: A modified Delphi study.

BACKGROUND: Hospital pharmacists play an essential role in patient care; however, a lack of resources means pharmacists are unable to review all patients daily. Consequently, there is a demand for reliable screening tools to allocate care to patients with urgent and/or complex pharmaceutical needs. Several tools have been developed, but no broad consensus exists on the design of a screening tool to be used in the adult hospital setting. OBJECTIVE: To obtain expert consensus on the design of a pharmaceutical care complexity screening tool for use on admission to hospital. METHODS: Two Delphi studies were conducted: the first sought to gain consensus from experts including pharmacists, academics and physicians on the components of a pharmaceutical complexity tool, the second to achieve consensus from UK chief pharmacists and clinical service pharmacy managers on the clinical appropriateness and practicality of the tool. Tool components and Delphi statements were identified and refined from our previous systematic review, UK survey and interview study of prioritisation tools. A valid definition for consensus was used. RESULTS: Over 300 components were extracted from the interview data and systematic review and then refined for inclusion in the first Delphi study. Thirty-three experts completed Delphi One and consensus was reached on 92 components. Components were grouped into demographic, clinical and medication components and condensed to 33 items, which were included in the first draft of the Adult Complexity Tool for Pharmaceutical Care (ACTPC). The tool stratified patients into highly, moderately or least complex. Forty expert panellists completed Delphi Two and consensus was reached on review frequency and experience of pharmacy practitioner at each level. These decisions were incorporated into the final version of the ACTPC. CONCLUSIONS: The ACTPC is the first systematically designed and internationally agreed tool for use on medical admission to hospital. It has potential to enable the delivery of targeted patient-centred pharmaceutical care.

Patient prioritisation for hospital pharmacy services: current approaches in the UK.

OBJECTIVES: To survey and explore current approaches to deployment of pharmaceutical care prioritisation tools in acute hospitals in the UK. METHODS: A national online survey was circulated electronically to chief pharmacists of hospitals to determine if they use a prioritisation tool or process. Where such mechanisms exist, respondents were invited to participate in a semistructured telephone interview to explore the development, evaluation and application of their tool and share relevant documentation. Interviews were transcribed and thematically analysed. RESULTS: Seventy hospitals (70/130) used a tool or process to prioritise clinical pharmacy services. Thirty-six interviews were conducted, and two were excluded. The majority of tools had been developed in-house. Few hospitals had undertaken formal evaluations of their prioritisation tool. Pharmacy prioritisation tools ranged in complexity and often included a combination of pharmacy service prioritisation, such as medicines reconciliation, and a section to assign an individual patient prioritisation level. Determining the priority of a patient based on the identification of set indicators instilled confidence in pharmacists by ensuring they were not missing high-risk patients. Electronic prioritisation tools were especially useful at retrieving real-time data to prioritise workload, improving workflow and ensuring continuity in patient care. Drawbacks of using prioritisation tools included lack of tool sensitivity across certain specialties and time spent using the tool if not all information was accessible. CONCLUSIONS: Prioritisation tools were seen to be useful for prioritising workload and ensuring the right patients are seen at the right time. As few hospitals had formally evaluated their tools, it is important to rigorously and systematically develop an evidence-based prioritisation tool that is both useable and acceptable. Further research to evaluate such tools would be needed to ensure it improves patient health outcomes and efficiency in pharmacy services.

Trading off accuracy and explainability in AI decision-making: findings from 2 citizens' juries.

OBJECTIVE: To investigate how the general public trades off explainability versus accuracy of artificial intelligence (AI) systems and whether this differs between healthcare and non-healthcare scenarios. MATERIALS AND METHODS: Citizens' juries are a form of deliberative democracy eliciting informed judgment from a representative sample of the general public around policy questions. We organized two 5-day citizens' juries in the UK with 18 jurors each. Jurors considered 3 AI systems with different levels of accuracy and explainability in 2 healthcare and 2 non-healthcare scenarios. Per scenario, jurors voted for their preferred system; votes were analyzed descriptively. Qualitative data on considerations behind their preferences included transcribed audio-recordings of plenary sessions, observational field notes, outputs from small group work and free-text comments accompanying jurors' votes; qualitative data were analyzed thematically by scenario, per and across AI systems. RESULTS: In healthcare scenarios, jurors favored accuracy over explainability, whereas in non-healthcare contexts they either valued explainability equally to, or more than, accuracy. Jurors' considerations in favor of accuracy regarded the impact of decisions on individuals and society, and the potential to increase efficiency of services. Reasons for emphasizing explainability included increased opportunities for individuals and society to learn and improve future prospects and enhanced ability for humans to identify and resolve system biases. CONCLUSION: Citizens may value explainability of AI systems in healthcare less than in non-healthcare domains and less than often assumed by professionals, especially when weighed against system accuracy. The public should therefore be actively consulted when developing policy on AI explainability.