What has changed in the experiences of people with mental health problems during the COVID-19 pandemic: a coproduced, qualitative interview study.

PURPOSE: We sought to understand how the experiences of people in the UK with pre-existing mental health conditions had developed during the course of the COVID-19 pandemic. METHODS: In September-October 2020, we interviewed adults with mental health conditions pre-dating the pandemic, whom we had previously interviewed 3 months earlier. Participants had been recruited through online advertising and voluntary sector community organisations. Semi-structured qualitative interviews were conducted by telephone or video-conference by researchers with lived experience of mental health difficulties, and, following principles of thematic analysis, were analysed to explore changes over time in people's experience of the pandemic. RESULTS: We interviewed 44 people, achieving diversity of demographic characteristics (73% female, 54% White British, aged 18-75) and a range of mental health conditions and service use among our sample. Three overarching themes were derived from interviews. The first theme "spectrum of adaptation" describes how participants reacted to reduced access to formal and informal support through personal coping responses or seeking new sources of help, with varying degrees of success. The second theme describes "accumulating pressures" from pandemic-related anxieties and sustained disruption to social contact and support, and to mental health treatment. The third theme "feeling overlooked" reflects participants' feeling of people with mental health conditions being ignored during the pandemic by policy-makers at all levels, which was compounded for people from ethnic minority communities or with physical health problems. CONCLUSION: In line with previous research, our study highlights the need to support marginalised groups who are at risk of increased inequalities, and to maintain crucial mental and physical healthcare and social care for people with existing mental health conditions, notwithstanding challenges of the pandemic.

Acceptability of a technology-supported and solution-focused intervention (DIALOG+) for chronic depression: views of service users and clinicians.

BACKGROUND: Treating chronic depression represents a significant burden for the NHS, yet there is a lack of evidence-based interventions and research specifically focused on this condition. DIALOG+, a technology-assisted and resource-oriented intervention found effective for people with psychosis, may improve care for this service user group. The aim of this study was to explore the acceptability and relevance of DIALOG+ for the treatment of chronic depression in community-based settings. METHODS: A convenience sample of 16 mental health professionals and 29 service users with chronic depression tested the DIALOG+ intervention in routine community care appointments for 3 months across 3 different mental health NHS Trusts in England. Of these, 15 clinicians and 19 service users were individually interviewed about their experiences. Interview transcripts were analysed using thematic analysis by an analytic team which included a service user researcher. RESULTS: Analysis of the combined dataset identified five overarching themes: DIALOG+ Structure; Therapeutic Communication; Reflecting and Monitoring; Empowerment and Powerlessness; and The Impact of Technology. Overall, service users and clinicians were interested in the continued use of DIALOG+ as part of routine care. CONCLUSIONS: DIALOG+ was viewed as acceptable by both service users with chronic depression and their clinicians who work in community care settings, albeit with some caveats. Clinician training required significant improvements to address the issues that were referenced, most notably around support with using technology.

Early impacts of the COVID-19 pandemic on mental health care and on people with mental health conditions: framework synthesis of international experiences and responses.

PURPOSE: The COVID-19 pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. We aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these. METHODS: We searched for relevant material in the public domain published before 30 April 2020, including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. Search languages were English, French, German, Italian, Spanish, and Mandarin Chinese. Relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach. RESULTS: We found 872 eligible sources from 28 countries. Most documented observations and experiences rather than reporting research data. We found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. Immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. We summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future. CONCLUSION: Our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the COVID-19 pandemic in several countries. We identify potential foci for service planning and research.

Influences on participation in a programme addressing loneliness among people with depression and anxiety: findings from the Community Navigator Study.

BACKGROUND: Loneliness is associated with negative outcomes, including increased mortality and is common among people with mental health problems. This qualitative study, which was carried out as part of a feasibility trial, aimed to understand what enables and hinders people with severe depression and/or anxiety under the care of secondary mental health services in the United Kingdom to participate in the Community Navigator programme, and make progress with feelings of depression, anxiety and loneliness. The programme consisted of up to ten meetings with a Community Navigator and three optional group sessions. METHODS: Semi-structured interviews were carried out with participants (n = 19) shortly after programme completion. A co-produced two-stage qualitative approach, involving narrative and reflexive thematic analysis, was undertaken by members of the study's working group, which included experts by experience, clinicians and researchers. RESULTS: The narrative analysis showed that individuals have varied goals, hold mixed feelings about meeting other people and define progress differently. From the thematic analysis, six themes were identified that explained facilitators and challenges to participating in the programme: desire to connect with others; individual social confidence; finding something meaningful to do; the accessibility of resources locally; the timing of the programme; and the participant's relationship with the Community Navigator. CONCLUSIONS: We found that people with severe depression and/or anxiety supported by secondary mental health services may want to address feelings of loneliness but find it emotionally effortful to do so and a major personal challenge. This emotional effort, which manifests in individuals differently, can make it hard for participants to engage with a loneliness programme, though it was through facing personal challenges that a significant sense of achievement was felt. Factors at the individual, interpersonal and structural level, that enable or hinder an individual's participation should be identified early, so that people are able to make the best use out of the Community Navigator or other similar programmes.

A national survey of inpatient medication systems in English NHS hospitals.

BACKGROUND: Systems and processes for prescribing, supplying and administering inpatient medications can have substantial impact on medication administration errors (MAEs). However, little is known about the medication systems and processes currently used within the English National Health Service (NHS). This presents a challenge for developing NHS-wide interventions to increase medication safety. We therefore conducted a cross-sectional postal census of medication systems and processes in English NHS hospitals to address this knowledge gap. METHODS: The chief pharmacist at each of all 165 acute NHS trusts was invited to complete a questionnaire for medical and surgical wards in their main hospital (July 2011). We report here the findings relating to medication systems and processes, based on 18 closed questions plus one open question about local medication safety initiatives. Non-respondents were posted another questionnaire (August 2011), and then emailed (October 2011). RESULTS: One hundred (61% of NHS trusts) questionnaires were returned. Most hospitals used paper-based prescribing on the majority of medical and surgical inpatient wards (87% of hospitals), patient bedside medication lockers (92%), patients' own drugs (89%) and 'one-stop dispensing' medication labelled with administration instructions for use at discharge as well as during the inpatient stay (85%). Less prevalent were the use of ward pharmacy technicians (62% of hospitals) or pharmacists (58%) to order medications on the majority of wards. Only 65% of hospitals used drug trolleys; 50% used patient-specific inpatient supplies on the majority of wards. Only one hospital had a pharmacy open 24 hours, but all had access to an on-call pharmacist. None reported use of unit-dose dispensing; 7% used an electronic drug cabinet in some ward areas. Overall, 85% of hospitals had a double-checking policy for intravenous medication and 58% for other specified drugs. "Do not disturb" tabards/overalls were routinely used during nurses' drug rounds on at least one ward in 59% of hospitals. CONCLUSIONS: Inter- and intra-hospital variations in medication systems and processes exist, even within the English NHS; future research should focus on investigating their potential effects on nurses' workflow and MAEs, and developing NHS-wide interventions to reduce MAEs.

Interventions to optimise prescribing for older people in care homes.

BACKGROUND: There is a substantial body of evidence that prescribing for care home residents is suboptimal and requires improvement. Consequently, there is a need to identify effective interventions to optimise prescribing and resident outcomes in this context. OBJECTIVES: The objective of the review was to determine the effect of interventions to optimise prescribing for older people living in care homes. SEARCH METHODS: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library (Issue 11, 2012); Cochrane Database of Systematic Reviews, The Cochrane Library (Issue 11, 2012); MEDLINE OvidSP (1980 on); EMBASE, OvidSP (1980 on); Ageline, EBSCO (1966 on); CINAHL, EBSCO (1980 on); International Pharmaceutical Abstracts, OvidSP (1980 on); PsycINFO, OvidSP (1980 on); conference proceedings in Web of Science, Conference Proceedings Citation Index - SSH & Science, ISI Web of Knowledge (1990 on); grey literature sources and trial registries; and contacted authors of relevant studies. We also reviewed the references lists of included studies and related reviews (search period November 2012). SELECTION CRITERIA: We included randomised controlled trials evaluating interventions aimed at optimising prescribing for older people (aged 65 years or older) living in institutionalised care facilities. Studies were included if they measured one or more of the following primary outcomes, adverse drug events; hospital admissions;mortality; or secondary outcomes, quality of life (using validated instrument); medication-related problems; medication appropriateness (using validated instrument); medicine costs. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. A narrative summary of results was presented. MAIN RESULTS: The eight included studies involved 7653 residents in 262 (range 1 to 85) care homes in six countries. Six studies were cluster-randomised controlled trials and two studies were patient-randomised controlled trials. The interventions evaluated were diverse and often multifaceted. Medication review was a component of seven studies, three studies involved multidisciplinary case-conferencing, two studies involved an educational element for care home staff and one study evaluated the use of clinical decision support technology. Due to heterogeneity, results were not combined in a meta-analysis. There was no evidence of an effect of the interventions on any of the primary outcomes of the review (adverse drug events, hospital admissions and mortality). No studies measured quality of life. There was evidence that the interventions led to the identification and resolution of medication-related problems. There was evidence from two studies that medication appropriateness was improved. The evidence for an effect on medicine costs was equivocal. AUTHORS' CONCLUSIONS: Robust conclusions could not be drawn from the evidence due to variability in design, interventions, outcomes and results. The interventions implemented in the studies in this review led to the identification and resolution of medication-related problems, however evidence of an effect on resident-related outcomes was not found. There is a need for high-quality cluster-randomised controlled trials testing clinical decision support systems and multidisciplinary interventions that measure well-defined, important resident-related outcomes.

English community pharmacists' experiences of using electronic transmission of prescriptions: a qualitative study.

BACKGROUND: The Electronic Prescription Service Release 2 (EPS2) in England has been designed to provide electronic transmission of digitally-signed prescriptions between primary care providers, with the intent on removing the large amounts of paper currently exchanged. As part of a wider evaluation of the EPS service, we wished to explore pharmacists' experience with the new system and their perceptions of its benefits and any associated problems. METHODS: We conducted semi-structured telephone interviews with community pharmacists using EPS2. We used a purposive sampling technique to obtain views from pharmacists working in pharmacies with a range of sizes and locations and to include both independent pharmacies and multiples. Interviews were transcribed verbatim and coded using grounded theory to identify the main factors that have influenced deployment and implementation in the eyes of respondents. QSR Nvivo was used as to aid in this process. RESULTS: It became apparent from the analysis that respondents perceived a wide range of advantages of EPS including improved safety, stock control, time management and improved relationships between pharmacy and General Practice staff. Respondents did not perceive a large difference in terms of work processes or development of their professional role. A large number of problems had been experienced in relation to both the technology itself and the way it was used by General Practices. It became apparent that work-around procedures had been developed for dealing with these issues but that not all these problems were perceived as having been addressed sufficiently at source. This sometimes had implications for the extent of EPS2 use and also limited some of the potential advantages of the EPS2 system, such as reduced effort in the management of prescription reimbursement. Respondents made suggestions for future improvements to EPS2. While interview data demonstrated that there were some feedback procedures in place, these were not regarded as being sufficient by the majority of respondents. CONCLUSIONS: Whilst pharmacists perceived a wide range of benefits of EPS, a large number of problems had been experienced. Despite these difficulties, no pharmacists expressed an overall negative view.

Selection of medicines in Chilean public hospitals: an exploratory study.

BACKGROUND: There is a growing interest in high income countries to control expenditure on medicines by improving the rationale for their selection. However, in middle income countries with differing priorities and needs, little attention has been paid to this issue. In this paper we explore the policies and processes for the selection and use of medicines in a group of hospitals in Chile, a middle income country which has recently joined the OECD. METHODS: A combination of qualitative and quantitative methods was used. A national survey questionnaire was distributed to investigate the role and operation of PTCs (Pharmacy and Therapeutics Committees). Interviews were conducted with key actors in the selection of medicines in large urban public hospitals. RESULTS: The national survey had an overall response rate of 42% (83 out of 196), whilst 7 out of 14 hospitals participated in the qualitative study. High complexity hospitals are large urban hospitals; all of which claim to have a working PTC. The pharmacy offices are mainly involved in dispensing medicines with little involvement in clinical duties.The interviews conducted suggest that the formulary of all the hospitals visited is no more than a stock list. PTCs are unable to influence the prescribing practices of doctors. Members do not feel prepared to challenge the opinions of specialists requesting a certain drug, and decisions are based primarily on costs. The inclusion of medicines in the clinical practice of hospitals is as a result of doctors bypassing the PTC and requesting the purchase of exceptional items, some of which are included in the formulary if they are widely used. CONCLUSIONS: There is an urgent need to develop medicine policies in hospitals in Chile. The procedures used to purchase medicines need to be revised. Central guidance for PTCs could help ensure a more rational use of medicines. PTCs need to be empowered to design formularies which cover all the clinical needs of doctors, training members in the analysis of scientific evidence beyond their own specialities. An influential PTC can take the appropriate measures and design workable policies to enforce a cost effective-use of resources.

Exploring the experiences of loneliness in adults with mental health problems: A participatory qualitative interview study.

BACKGROUND: Loneliness is associated with many mental health conditions, as both a potential causal and an exacerbating factor. Richer evidence about how people with mental health problems experience loneliness, and about what makes it more or less severe, is needed to underpin research on strategies to help address loneliness. METHODS: Our aim was to explore experiences of loneliness, as well as what helps address it, among a diverse sample of adults living with mental health problems in the UK. We recruited purposively via online networks and community organisations, with most interviews conducted during the COVID-19 pandemic. Qualitative semi-structured interviews were conducted with 59 consenting participants face-to-face, by video call or telephone. Researchers with relevant lived experience were involved at all stages, including design, data collection, analysis and writing up of results. FINDINGS: Analysis led to identification of four overarching themes: 1. What the word "lonely" meant to participants, 2. Connections between loneliness and mental health, 3. Contributory factors to continuing loneliness, 4. Ways of reducing loneliness. Central aspects of loneliness were lack of meaningful connections with others and lack of a sense of belonging to valued groups and communities. Some drivers of loneliness, such as losses and transitions, were universal, but specific links were also made between living with mental health problems and being lonely. These included direct effects of mental health symptoms, the need to withdraw to cope with mental health problems, and impacts of stigma and poverty. CONCLUSIONS: The multiplicity of contributors to loneliness that we identified, and of potential strategies for reducing it, suggest that a variety of approaches are relevant to reducing loneliness among people with mental health problems, including peer support and supported self-help, psychological and social interventions, and strategies to facilitate change at community and societal levels. The views and experiences of adults living with mental health problems are a rich source for understanding why loneliness is frequent in this context and what may address it. Co-produced approaches to developing and testing approaches to loneliness interventions can draw on this experiential knowledge.

Randomised controlled trial of the Community Navigator programme to reduce loneliness and depression for adults with treatment-resistant depression in secondary community mental health services: trial protocol.

BACKGROUND: New treatments are needed for people with treatment-resistant depression (TRD), who do not benefit from anti-depressants and many of whom do not recover fully with psychological treatments. The Community Navigator programme was co-produced with service users and practitioners. It is a novel social intervention which aims to reduce loneliness and thus improve health outcomes for people with TRD. Participants receive up to 10 individual meetings with a Community Navigator, who helps them to map their social world and set and enact goals to enhance their social connections and reduce loneliness. Participants may also access group meet-ups with others in the programme every 2 months, and may be offered modest financial support to enable activities to support social connections. METHODS: A researcher-blind, multi-site, 1:1 randomised controlled trial with N = 306 participants will test the effectiveness of the Community Navigator programme for people with TRD in secondary community mental health teams (CMHTs). Our primary hypothesis is that people who are offered the Community Navigator programme as an addition to usual CMHT care will be less depressed, assessed using the PHQ-9 self-report measure, at 8-month, end-of-treatment follow-up, compared to a control group receiving usual CMHT care and a booklet with information about local social groups and activities. We will follow participants up at end-of-treatment and at 14 months, 6 months after end-of-treatment follow-up. Secondary outcomes include the following: loneliness, anxiety, personal recovery, self-efficacy, social network, social identities. We will collect data about health-related quality of life and service use to investigate the cost-effectiveness of the Community Navigator programme. DISCUSSION: This trial will provide definitive evidence about the effectiveness and cost-effectiveness of the Community Navigator programme and whether it can be recommended for use in practice. The trial is due to finish in August 2025. TRIAL REGISTRATION: Prospectively registered on 8th July 2022 at: ISRCTN13205972.

The socio-technical organisation of community pharmacies as a factor in the Electronic Prescription Service Release Two implementation: a qualitative study.

BACKGROUND: The introduction of a new method of transmitting prescriptions from general practices to community pharmacies in England (Electronic Prescription Service Release 2 (EPS2)) has generated debate on how it will change work practice. As EPS2 will be a key technical element in dispensing, we reviewed the literature to find that there were no studies on how social and technical elements come together to form work practice in community pharmacies. This means the debate has little point of reference. Our aim therefore was to study the ways social and technical elements of a community pharmacy are used to achieve dispensing through the development of a conceptual model on pharmacy work practice, and to consider how a core technical element such the EPS2 could change work practice. METHOD: We used ethnographic methods inclusive of case-study observations and interviews to collect qualitative data from 15 community pharmacies that were in the process of adopting or were soon to adopt EPS2. We analysed the case studies thematically and used rigorous multi-dimensional and multi-disciplinary interpretive validation techniques to cross analyse findings. RESULTS: In practice, dispensing procedures were not designed to take into account variations in human and technical integration, and assumed that repetitive and collective use of socio-technical elements were at a constant. Variables such as availability of social and technical resources, and technical know-how of staff were not taken into account in formalised procedures. Yet community pharmacies were found to adapt their dispensing in relation to the balance of social and technical elements available, and how much of the social and technical elements they were willing to integrate into dispensing. While some integrated as few technical elements as possible, some depended entirely on technical artefacts. This pattern also applied to the social elements of dispensing. Through the conceptual model development process, we identified three approaches community pharmacies used to appropriate procedures in practice. These were 'technically oriented', 'improvising' or 'socially oriented'. CONCLUSION: We offer a model of different work approaches community pharmacies use to dispense, which suggests that when adopting a core technical element such as the EPS2 system of dispensing there could be variations in its successful adoption. Technically oriented pharmacies might find it easiest to integrate a similar artefact into work practice although needs EPS2 to synchronise effectively with existing technologies. Pharmacies adopting an improvising-approach have the potential to improve how they organise dispensing through EPS2 although they will need to improve how they apply their operating procedures. Socially oriented pharmacies will need to dramatically adapt their approach to dispensing since they usually rely on few technical tools.

Failure mode and effects analysis outputs: are they valid?

BACKGROUND: Failure Mode and Effects Analysis (FMEA) is a prospective risk assessment tool that has been widely used within the aerospace and automotive industries and has been utilised within healthcare since the early 1990s. The aim of this study was to explore the validity of FMEA outputs within a hospital setting in the United Kingdom. METHODS: Two multidisciplinary teams each conducted an FMEA for the use of vancomycin and gentamicin. Four different validity tests were conducted: Face validity: by comparing the FMEA participants' mapped processes with observational work. Content validity: by presenting the FMEA findings to other healthcare professionals. Criterion validity: by comparing the FMEA findings with data reported on the trust's incident report database. Construct validity: by exploring the relevant mathematical theories involved in calculating the FMEA risk priority number. RESULTS: Face validity was positive as the researcher documented the same processes of care as mapped by the FMEA participants. However, other healthcare professionals identified potential failures missed by the FMEA teams. Furthermore, the FMEA groups failed to include failures related to omitted doses; yet these were the failures most commonly reported in the trust's incident database. Calculating the RPN by multiplying severity, probability and detectability scores was deemed invalid because it is based on calculations that breach the mathematical properties of the scales used. CONCLUSION: There are significant methodological challenges in validating FMEA. It is a useful tool to aid multidisciplinary groups in mapping and understanding a process of care; however, the results of our study cast doubt on its validity. FMEA teams are likely to need different sources of information, besides their personal experience and knowledge, to identify potential failures. As for FMEA's methodology for scoring failures, there were discrepancies between the teams' estimates and similar incidents reported on the trust's incident database. Furthermore, the concept of multiplying ordinal scales to prioritise failures is mathematically flawed. Until FMEA's validity is further explored, healthcare organisations should not solely depend on their FMEA results to prioritise patient safety issues.

Developing the Diagnostic Adherence to Medication Scale (the DAMS) for use in clinical practice.

BACKGROUND: There is a need for an adherence measure, to monitor adherence services in clinical practice, which can distinguish between different types of non-adherence and measure changes over time. In order to be inclusive of all patients it needs to be able to be administered to both patients and carers and to be suitable for patients taking multiple medications for a range of clinical conditions. A systematic review found that no adherence measure met all these criteria. We therefore wished to develop a theory based adherence scale (the DAMS) and establish its content, face and preliminary construct validity in a primary care population. METHODS: The DAMS (consisting of 6 questions) was developed from theory by a multidisciplinary team and the questions were initially tested in small patient populations. Further to this, patients were recruited when attending a General Practice and interviewed using the DAMS and two other validated self-reported adherence measures, the Morisky-8 and Lu questionnaires. A semi-structured interview was used to explore acceptability and reasons for differences in responses between the DAMS and the other measures. Descriptive data were generated and Spearman rank correlation tests were used to identify associations between the DAMS and the other adherence measures. RESULTS: One hundred patients completed the DAMS in an average of 1 minute 28 seconds and reported finding it straightforward to complete. An adherence score could not be calculated for the 4(4%) patients only taking 'when required' medication. Thirty six(37.5%) of the remaining patients reported some non-adherence. Adherence ratings of the DAMS were significantly associated with levels of self reported adherence on all other measures Spearman Rho 0.348-0.719, (p < 0.01). Differences in trends could generally be explained by qualitative data. CONCLUSION: The DAMS has been developed for routine monitoring of adherence in clinical practice. It was acceptable to patients taking single or multiple medication and valid when tested against other adherence measures. However, 'when required' medication needs to be excluded. Further tests of the DAMS against objective measures such as MEMS are in progress and reliability needs to be established. Further investigation of the carers' version of the DAMS is required.

Suitability of measures of self-reported medication adherence for routine clinical use: a systematic review.

BACKGROUND: There is a recognised need to build primary care medication adherence services which are tailored to patients' needs. Continuous quality improvement of such services requires a regular working method of measuring adherence in order to monitor effectiveness. Self report has been considered the method of choice for clinical use; it is cheap, relatively unobtrusive and able to distinguish between intentional and unintentional non-adherence, which have different underlying causes and therefore require different interventions. A self report adherence measure used in routine clinical practice would ideally be brief, acceptable to patients, valid, reliable, have the ability to distinguish between different types of non-adherence and be able to be completed by or in conjunction with carers where necessary. METHODS: We systematically reviewed the literature in order to identify self report adherence measures currently available which are suitable for primary care and evaluate the extent to which they met the criteria described above. We searched the databases Medline, Embase, International Pharmaceutical Abstracts, Pharmline, CINAHL, PsycINFO and HaPI to identify studies reporting the development, validation or reliability of generic adherence measures. One reviewer screened all abstracts and assessed all relevant full text articles obtained and a second reviewer screened/assessed 10% to check reliability. RESULTS: Fifty eight measures were identified. While validation data were presented in support of the vast majority of self reported measures (54/58), data for a relatively small number of measures was presented for reliability (16/58) and time to complete (3/58). Few were designed to have the ability to be completed by or in conjunction with carers and few were able to distinguish between different types of non-adherence, which limited their ability be used effectively in the continuous improvement of targeted adherence enhancing interventions. The data available suggested that patients find it easier to estimate general adherence than to report a specific number of doses missed. Visual analogue scales can be easier for patients than other types of scale but are not suitable for telephone administration. CONCLUSIONS: There is a need for a measure which can be used in the routine continual quality monitoring of adherence services.

Republished error management: Paediatric dosing errors before and after electronic prescribing.

OBJECTIVE: To compare the incidence and severity rating of dose prescribing errors before and after the implementation of a commercially available electronic prescribing system at a tertiary care children's hospital. METHODS: Dose errors were identified using prescription review to detect errors. Severity rating was determined by five judges using a validated, reliable scoring tool. The mean score for each error was used as an index of severity. RESULTS: Dose prescribing errors occurred in 88 of the 3939 (2.2%) items prescribed for outpatients and inpatients, and on discharge prescriptions prior to the implementation of electronic prescribing (EP). After EP, there were 57 dose errors in 4784 (1.2%) items prescribed (1% absolute reduction (p<0.001 χ(2) test; 95% CI of difference in proportions -1.6% to -0.5%)). A decrease in the severity rating of dose errors was also seen: dose errors with potentially minor outcomes 35/3939 (0.89%) pre vs 21/4784 (0.44%) post (95% CI of difference in proportions -0.8% to -0.11%, p=0.009 χ(2) test); moderate outcome 46/3939 (1.17%) pre vs 33/4784 (0.69%) post (95% CI of difference in proportions -0.91% to -0.08, p=0.019, χ(2) test); severe outcome: 7/3939 (0.18%) pre vs 3/4784 (0.06%) post (95% CI of difference in proportions -0.31% to +0.04, p=0.11, χ(2) test). CONCLUSION: Electronic prescribing appears to reduce rates of dosing errors in paediatrics, but larger studies are required to assess the effect on the severity of these errors and in different settings.

Medication errors with electronic prescribing (eP): Two views of the same picture.

BACKGROUND: Quantitative prospective methods are widely used to evaluate the impact of new technologies such as electronic prescribing (eP) on medication errors. However, they are labour-intensive and it is not always feasible to obtain pre-intervention data. Our objective was to compare the eP medication error picture obtained with retrospective quantitative and qualitative methods. METHODS: The study was carried out at one English district general hospital approximately two years after implementation of an integrated electronic prescribing, administration and records system. QUANTITATIVE: A structured retrospective analysis was carried out of clinical records and medication orders for 75 randomly selected patients admitted to three wards (medicine, surgery and paediatrics) six months after eP implementation. QUALITATIVE: Eight doctors, 6 nurses, 8 pharmacy staff and 4 other staff at senior, middle and junior grades, and 19 adult patients on acute surgical and medical wards were interviewed. Staff interviews explored experiences of developing and working with the system; patient interviews focused on experiences of medicine prescribing and administration on the ward. Interview transcripts were searched systematically for accounts of medication incidents. A classification scheme was developed and applied to the errors identified in the records review. RESULTS: The two approaches produced similar pictures of the drug use process. Interviews identified types of error identified in the retrospective notes review plus two eP-specific errors which were not detected by record review. Interview data took less time to collect than record review, and provided rich data on the prescribing process, and reasons for delays or non-administration of medicines, including "once only" orders and "as required" medicines. CONCLUSIONS: The qualitative approach provided more understanding of processes, and some insights into why medication errors can happen. The method is cost-effective and could be used to supplement information from anonymous error reporting schemes.

Testing a trigger tool as a method of detecting harm from medication errors in a UK hospital: a pilot study.

OBJECTIVES: The aim was to adapt a US adverse drug event (ADE) trigger tool for UK use, and to establish its positive predictive value (PPV) and sensitivity in comparison to retrospective health record review for the identification of preventable ADEs, in a pilot study on one hospital ward. METHODS: An established US trigger tool was adapted for UK use. We applied it retrospectively to 207 patients' health records, following up positive triggers to identify any ADEs (both preventable and non-preventable). We compared the preventable ADEs to those identified using full health record review. KEY FINDINGS: We identified 168 positive triggers in 127 (61%) of 207 patients. Seven ADEs were identified, representing an ADE in 3.4% of patients or 0.7 ADEs per 100 patient days. Five were non-preventable adverse drug reactions and two were due to preventable errors. The prevalence of preventable ADEs was 1.0% of patients, or 0.2 per 100 patient days. The overall PPV was 0.04 for all ADEs, and 0.01 for preventable ADEs. PPVs for individual triggers varied widely. Five preventable ADEs were identified using health record review. The sensitivity of the trigger tool for identifying preventable ADEs was 0.40, when compared to health record review. CONCLUSIONS: Although we identified some ADEs using the trigger tool, more work is needed to further refine the trigger tool to reduce the false positives and increase sensitivity. To comprehensively identify preventable ADEs, retrospective health record review remains the gold standard and we found no efficiency gain in using the trigger tool.

Learning lessons from electronic prescribing implementations in secondary care.

This paper reports a study undertaken in the UK to gather lessons learned from hospital sites that have implemented electronic prescribing systems. The work was commissioned by NHS Connecting for Health, the UK Department of Health agency responsible for the implementation of the National Programme for Information Technology. The aim was to capture front-line experience of the project and systems implementation, and to share it with staff who will in the future participate in other implementations. Data were drawn from detailed interviews with staff and a survey in 13 hospitals in England, as well as a review of published studies of implementations. The study output is a report and six user-facing briefing documents targeted at key stakeholder groups; nurses, pharmacist, doctors, senior executives, implementation team members and IM&T staff.

'New Medicine Service': supporting adherence in people starting a new medication for a long-term condition: 26-week follow-up of a pragmatic randomised controlled trial.

OBJECTIVE: To examine the effectiveness and cost-effectiveness of the community pharmacy New Medicine Service (NMS) at 26 weeks. METHODS: Pragmatic patient-level parallel randomised controlled trial in 46 English community pharmacies. 504 participants aged ≥14, identified in the pharmacy when presenting a prescription for a new medicine for predefined long-term conditions, randomised to receive NMS (n=251) or normal practice (n=253) (NMS intervention: 2 consultations 1 and 2 weeks after prescription presentation). Adherence assessed through patient self-report at 26-week follow-up. Intention-to-treat analysis employed. National Health Service (NHS) costs calculated. Disease-specific Markov models estimating impact of non-adherence combined with clinical trial data to calculate costs per extra quality-adjusted life-year (QALY; NHS England perspective). RESULTS: Unadjusted analysis: of 327 patients still taking the initial medicine, 97/170 (57.1%) and 103/157 (65.6%) (p=0.113) patients were adherent in normal practice and NMS arms, respectively. Adjusted intention-to-treat analysis: adherence OR 1.50 (95% CI 0.93 to 2.44, p=0.095), in favour of NMS. There was a non-significant reduction in 26-week NHS costs for NMS: -£104 (95% CI -£37 to £257, p=0.168) per patient. NMS generated a mean of 0.04 (95% CI -0.01 to 0.13) more QALYs per patient, with mean reduction in lifetime cost of -£113.9 (-1159.4, 683.7). The incremental cost-effectiveness ratio was -£2758/QALY (2.5% and 97.5%: -38 739.5, 34 024.2. NMS has an 89% probability of cost-effectiveness at a willingness to pay of £20 000 per QALY. CONCLUSIONS: At 26-week follow-up, NMS was unable to demonstrate a statistically significant increase in adherence or reduction in NHS costs, which may be attributable to patient attrition from the study. Long-term economic evaluation suggested NMS may deliver better patient outcomes and reduced overall healthcare costs than normal practice, but uncertainty around this finding is high. TRIAL REGISTRATION NUMBER: NCT01635361, ISRCTN23560818, ISRCTN23560818, UKCRN12494.

The Community Navigator Study: Results from a feasibility randomised controlled trial of a programme to reduce loneliness for people with complex anxiety or depression.

BACKGROUND: Loneliness is common among people with mental health problems and predicts poorer recovery from depression and anxiety. Needs for support with loneliness and social relationships are often under-addressed in mental health services. The Community Navigator programme was designed to reduce loneliness for adults (aged 18 and above) with complex depression or anxiety who were using secondary mental health services. Acceptability and feasibility of the programme and a trial evaluation were tested in a feasibility randomised controlled trial with qualitative evaluation. METHODS: Forty participants with depression or anxiety using secondary mental health services were recruited from mental health services in two London sites and randomised to receive: the Community Navigator programme over six months in addition to routine care (n = 30); or routine care (n = 10). Measures of loneliness, depression, other clinical and social outcomes and service use were collected at baseline and six-months follow-up. Levels of engagement in the programme and rates of trial recruitment and retention were assessed. Programme delivery was assessed through session logs completed by Community Navigators. The acceptability of the programme was explored through qualitative interviews (n = 32) with intervention group participants, their family and friends, programme providers and other involved staff. RESULTS: Forty participants were recruited in four months from 65 eligible potential participants asked. No one withdrew from the trial. Follow-up interviews were completed with 35 participants (88%). Process records indicated the programme was delivered as intended: there was a median of seven meetings with their Community Navigator (of a maximum ten) per treatment group participant. Qualitative interviews indicated good acceptability of the programme to stakeholders, and potential utility in reducing loneliness and depression and anxiety. CONCLUSIONS: A definitive, multi-site randomised controlled trial is recommended to evaluate the effectiveness and cost-effectiveness of the Community Navigator programme for people with complex anxiety and depression in secondary mental health services.