Modelling the expected net benefits of interventions to reduce the burden of medication errors.

OBJECTIVES: The aim of this study is to estimate the potential costs and benefits of three key interventions (computerized physician order entry [CPOE], additional ward pharmacists and bar coding) to help prioritize research to reduce medication errors. METHODS: A generic model structure was developed to describe the incidence and impacts of medication errors in hospitals. The model follows pathways from medication error points at alternative stages of the medication pathway through to the outcomes of undetected errors. The model was populated from a systematic review of the medication errors literature combined with novel probabilistic calibration methods. Cost ranges were applied to the interventions, the treatment of preventable adverse drug events (pADEs), and the value of the health lost as a result of an ADE. RESULTS: The model predicts annual health service costs of between pound 0.3 million and pound 1 million for the treatment of pADEs in a 400-bed acute hospital in the UK. Including only health service costs, it is uncertain whether any of the three interventions will produce positive net benefits, particularly if high intervention costs are assumed. When the monetary value of lost health is included, all three interventions have a high probability of producing positive net benefits with a mean estimate of around pound 31.5 million for CPOE over a five-year time horizon. CONCLUSIONS: The results identify the potential cost-effectiveness of interventions aimed at medication errors, as well as identifying key drivers of cost-effectiveness that should be specifically addressed in the design of primary evaluations of medication error interventions.

Nurse and pharmacist supplementary prescribing in the UK--a thematic review of the literature.

OBJECTIVES: Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving a tripartite agreement between independent medical prescriber, dependent prescriber and patient, enabling the dependent prescriber to prescribe in accordance with a patient-specific clinical management plan (CMP). The aim in this paper is to review, thematically, the literature on nurse and pharmacist SP, to inform further research, policy and education. METHODS: A review of the nursing and pharmacy SP literature from 1997 to 2007 was undertaken using searches of electronic databases, grey literature and journal hand searches. RESULTS: Nurses and pharmacists were positive about SP but the medical profession were more critical and lacked awareness/understanding, according to the identified literature. SP was identified in many clinical settings but implementation barriers emerged from the empirical and anecdotal literature, including funding problems, delays in practicing and obtaining prescription pads, encumbering clinical management plans and access to records. Empirical studies were often methodological weaknesses and under-evaluation of safety, economic analysis and patients' experiences were identified in empirical studies. There was a perception that nurse and pharmacist independent prescribing may supersede supplementary prescribing. CONCLUSIONS: There is a need for additional research regarding SP and despite nurses' and pharmacists' enthusiasm, implementation issues, medical apathy and independent prescribing potentially undermine the success of SP.

Developing primary care review criteria from evidence-based guidelines: coronary heart disease as a model.

BACKGROUND: National Health Service (NHS) initiatives such as Clinical Governance, National Service Frameworks and the National Institute of Clinical Excellence (NICE) clinical guidelines programme create demand for tools to enable performance review by healthcare professionals. Ideally such tools should enable clinical teams to assess quality of care and highlight areas of good practice or where improvement is needed. They should also be able to be used to demonstrate progress towards goals and promote quality, while not unnecessarily increasing demand on limited resources or weakening professional control. AIM: To formulate and evaluate a method for developing, from clinical guidelines, evidence-based review criteria that are proritised, useful and relevant to general practices assessing quality of care for the primary care management of coronary heart disease (CHD). DESIGN OF STUDY: A two-stage study comprising, first, a review of available evidence-based guidelines for CHD and, second, the definition and prioritization of associated review criteria from the most highly rated guidelines. SETTING: Primary healthcare teams in England. METHODS: Using structured methods, evidence-based clinical guidelines for CHD were identified and appraised to ensure their suitability as the basis for developing review criteria. Recommendations common to a number of guidelines were priortszid by a panel of general practitioners to develop review criteria suitable for use in primary care. RESULTS: A standardised method has been developed for constructing evidence-based review criteria from clinical guidelines. A limited, prioritized set of review criteria was developed for the primary care management of CHD. This was distributed around the NHS through the Royal College of General Practitioners for use by primary care teams across the United Kingdom. CONCLUSION: Developing useful, evidence-based review criteria is not a straightforward process, partly because of a lack of consistency and clarity in guidelines currently available. A method was developed which accommodated these limitations and which can be applied to the development and evaluation of review criteria from guidelines for other conditions.

Managing care in the community for patients with type 2 diabetes.

Jean Peters and colleagues researched the perceptions of 97 practice nurses and 69 diabetes specialist nurses regarding their current and future role in the management of people with type 2 diabetes in the community. Issues of concern that were identified included patients, resources, training and professional responsibilities.

A structured judgement method to enhance mortality case note review: development and evaluation.

BACKGROUND: Case note review remains a prime means of retrospectively assessing quality of care. This study examines a new implicit judgement method, combining structured reviewer comments with quality of care scores, to assess care of people who die in hospital. METHODS: Using 1566 case notes from 20 English hospitals, 40 physicians each reviewed 30-40 case notes, writing structured judgement-based comments on care provided within three phases of care, and on care overall, and scoring quality of care from 1 (unsatisfactory) to 6 (very best care). Quality of care comments on 119 people who died (7.6% of the cohort) were analysed independently by two researchers to investigate how well reviewers provided structured short judgement notes on quality of care, together with appropriate care scores. Consistency between explanatory textual data and related scores was explored, using overall care score to group cases. RESULTS: Physician reviewers made informative, clinical judgement-based comments across all phases of care and usually provided a coherent quality of care score relating to each phase. The majority of comments (83%) were explicit judgements. About a fifth of patients were considered to have received less than satisfactory care, often experiencing a series of adverse events. CONCLUSIONS: A combination of implicit judgement, explicit explanatory comment and related quality of care scores can be used effectively to review the spectrum of care provided for people who die in hospital. The method can be used to quickly evaluate deaths so that lessons can be learned about both poor and high quality care.

Barriers to patient information provision in primary care: patients' and general practitioners' experiences and expectations of information for low back pain.

BACKGROUND: As patient involvement in health-care increases, the role of information is crucial, especially in conditions where self-management is considered an integral part of care. However, the suitability and applicability of much patient information has not been appraised in terms of how far it meets patients' information needs. AIMS: To ascertain patients' and clinicians' experiences and expectations of information in low back pain in order to suggest a suitable 'patient-centred' content for a patient information pack to be used in a primary care setting. METHODS: A qualitative study using semi-structured interviews with General Practitioners (GPs) (n = 15) and focus groups comprising patients with low back pain (n = 37). RESULTS: Barriers to information-giving for low back pain in primary care exist. Patients are dissatisfied with the information they receive from their GPs, especially regarding diagnosis and treatment. Patients tend to access information from a variety of other sources, which is often contradictory, conflicts with research evidence and leads to unreasonable expectations. GPs have varying views regarding the value of patient information and are equivocal about their roles as information providers. Although The Back Book is generally acceptable as a patient information leaflet for low back pain, attention to the tone of the text is required. CONCLUSIONS: Barriers exist to patient information provision, both generally and for low back pain, which need to be addressed in order to close the gap between strategy and implementation. Improving clinician communication skills and involving patients in developing information materials which meet their needs are crucial to this process.