An e-Delphi study to obtain expert consensus on the level of risk associated with preventable e-prescribing events.

AIMS: We aim to seek expert opinion and gain consensus on the risks associated with a range of prescribing scenarios, preventable using e-prescribing systems, to inform the development of a simulation tool to evaluate the risk and safety of e-prescribing systems (ePRaSE). METHODS: We conducted a two-round e-Delphi survey where expert participants were asked to score pre-designed prescribing scenarios using a five-point Likert scale to ascertain the likelihood of occurrence of the prescribing event, likelihood of occurrence of harm and the severity of the harm. RESULTS: Twenty-four experts consented to participate with 15 pand 13 participants completing rounds 1 and 2, respectively. Experts agreed on the level of risk associated with 136 out of 178 clinical scenarios with 131 scenarios categorised as high or extreme risk. CONCLUSION: We identified 131 extreme or high-risk prescribing scenarios that may be prevented using e-prescribing clinical decision support. The prescribing scenarios represent a variety of categories, with drug-disease contraindications being the most frequent, representing 37 (27%) scenarios, and antimicrobial agents being the most common drug class, representing 28 (21%) of the scenarios. Our e-Delphi study has achieved expert consensus on the risk associated with a range of clinical scenarios with most of the scenarios categorised as extreme or high risk. These prescribing scenarios represent the breadth of preventable prescribing error categories involving both basic and advanced clinical decision support. We will use the findings of this study to inform the development of the e-prescribing risk and safety evaluation tool.

Patients' perceptions and experiences of patient safety in primary care in England.

BACKGROUND: One of the most remarkable features of patient safety research in primary care is the sparse attention paid to patients' own experiences. OBJECTIVE: To explore patient's perceptions and experiences of patient safety in primary care in England. METHODS: We conducted a qualitative study in the South of England with an opportunistic sample of 27 primary care users. Information was obtained from four patient focus groups. A thematic content analysis was conducted by three analysts and consensus reached within the research team on the key themes that emerged. RESULTS: Participants' conceptualizations of patient safety referred to high standards of health care delivery within a relationship of trust. Participants identified four main factors that they believed could potentially affect patient safety. These included factors related to (i) the patient (attitudes, behaviours and health literacy); (ii) the health professional (attitudes, behaviours and accuracy of diagnoses); (iii) the relationship between patients and health professionals (communication and trust); and (iv) the health care system (workload, resources, care coordination, accessibility, interdisciplinary teamwork and accuracy of health care records). Confidentiality, continuity of care and treatment-related safety emerged as cross-cutting major threats to patient safety. CONCLUSIONS: The exploration of participants' perceptions and experiences allowed the identification of a wide variety of themes that were perceived to impact on patient safety in primary care. The findings of this study could be used to enrich current frameworks that are exclusively based on professional or health care system perspectives.

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement.

OBJECTIVES: To evaluate how often and why providers overrode drug allergy alerts in both the inpatient and outpatient settings. DESIGN: A cross-sectional observational study of drug allergy alerts generated over a 3-year period between 1 January 2009 and 31 December 2011. SETTING: A 793-bed tertiary care teaching affiliate of Harvard Medical School and 36 primary care practices. PARTICIPANTS: Drug allergy alerts were displayed for a total of 29 420 patients across both settings. MAIN OUTCOME MEASURES: Proportion of drug allergy alerts displayed and overridden, proportion of appropriate overrides, proportion of overrides in each medication class, different reasons for overriding and types of reactions overridden. RESULTS: A total of 158 023 drug allergy alerts were displayed, 131 615 (83%) in the inpatient setting and 26 408 (17%) in the outpatient setting; 128 157 (81%) of which were overridden. A random sample of inpatient (n=200, 0.19%) and outpatient (n=50, 0.25%) alert overrides were screened for appropriateness, with >96% considered appropriate. Alerts for some drug classes, such as 'non-antibiotic sulfonamides', were overridden for >81% of prescriptions in both settings. The most common override reason was patient has taken previously without allergic reaction. In the inpatient setting alone, 70.9% of alerts that warned against the risk of anaphylaxis were overridden. CONCLUSIONS: The information contained in patients' drug allergy lists needs to be regularly updated. Most of the drug allergy alerts were overridden, with the majority of alert overrides in the subsample considered appropriate. Some of the rules for these alerts should be carefully reviewed and modified, or removed. Further research is needed to understand providers' overriding of alerts that warned against the risk of 'anaphylaxis', which are more concerning with respect to patient safety.

How safe is primary care? A systematic review.

IMPORTANCE: Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care. OBJECTIVE: We investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm. EVIDENCE REVIEW: We searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised. FINDINGS: Nine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2-3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patient's well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm. CONCLUSIONS AND RELEVANCE: Millions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm. SYSTEMATIC REVIEW REGISTRATION: This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42012002304).

Meaningful Use of Electronic Health Records: Experiences From the Field and Future Opportunities.

BACKGROUND: With the aim of improving health care processes through health information technology (HIT), the US government has promulgated requirements for "meaningful use" (MU) of electronic health records (EHRs) as a condition for providers receiving financial incentives for the adoption and use of these systems. Considerable uncertainty remains about the impact of these requirements on the effective application of EHR systems. OBJECTIVE: The Agency for Healthcare Research and Quality (AHRQ)-sponsored Centers for Education and Research in Therapeutics (CERTs) critically examined the impact of the MU policy relating to the use of medications and jointly developed recommendations to help inform future HIT policy. METHODS: We gathered perspectives from a wide range of stakeholders (N=35) who had experience with MU requirements, including academicians, practitioners, and policy makers from different health care organizations including and beyond the CERTs. Specific issues and recommendations were discussed and agreed on as a group. RESULTS: Stakeholders' knowledge and experiences from implementing MU requirements fell into 6 domains: (1) accuracy of medication lists and medication reconciliation, (2) problem list accuracy and the shift in HIT priorities, (3) accuracy of allergy lists and allergy-related standards development, (4) support of safer and effective prescribing for children, (5) considerations for rural communities, and (6) general issues with achieving MU. Standards are needed to better facilitate the exchange of data elements between health care settings. Several organizations felt that their preoccupation with fulfilling MU requirements stifled innovation. Greater emphasis should be placed on local HIT configurations that better address population health care needs. CONCLUSIONS: Although MU has stimulated adoption of EHRs, its effects on quality and safety remain uncertain. Stakeholders felt that MU requirements should be more flexible and recognize that integrated models may achieve information-sharing goals in alternate ways. Future certification rules and requirements should enhance EHR functionalities critical for safer prescribing of medications in children.

Can the London 2012 Olympics 'inspire a generation' to do more physical or sporting activities? An overview of systematic reviews.

OBJECTIVE: To examine if there is an increased participation in physical or sporting activities following an Olympic or Paralympic games. DESIGN: Overview of systematic reviews. METHODS: We searched the Medline, Embase, Cochrane, DARE, SportDISCUS and Web of Knowledge databases. In addition, we searched for 'grey literature' in Google, Google scholar and on the International Olympic Committee websites. We restricted our search to those reviews published in English. We used the AMSTAR tool to assess the methodological quality of those systematic reviews included. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was evidence for an increased participation in physical or sporting activities. Secondary outcomes included public perceptions of sport during and after an Olympic games, barriers to increased sports participation and any other non-sporting health benefits. RESULTS: Our systematic search revealed 844 citations, of which only two matched our inclusion criteria. The quality of these two reviews was assessed by three independent reviewers as 'good' using the AMSTAR tool for quality appraisal. Both reviews reported little evidence of an increased uptake of sporting activity following an Olympic Games event. Other effects on health, for example, changes in hospital admissions, suicide rates and drug use, were cited although there was insufficient evidence to see an overall effect. CONCLUSION: There is a paucity of evidence to support the notion that hosting an Olympic games leads to an increased participation in physical or sporting activities for host countries. We also found little evidence to suggest other health benefits. We conclude that the true success of these and future games should be evaluated by high-quality, evidence-based studies that have been commissioned before, during and following the completion of the event. Only then can the true success and legacy of the games be established.