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.

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.

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.

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.

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.

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.

Realist evaluation of public engagement and involvement in data-intensive health research.

BACKGROUND: High quality public engagement and involvement (PEI) in data-intensive health research is seen as one way of ensuring that social legitimacy, i.e. a social license, is conferred through public acceptance of the need for research use of their data. This is a complex research area, and portfolios of involvement have been suggested, but not yet evaluated, to support the role of public contributors. The study aim was to evaluate if and how membership of a data-intensive research public forum can act as a mechanism for enhancing members' personal development. Our objective was to understand the circumstances and mechanisms that help to explain how, why and for whom involvement with a public forum enhanced those members' personal development. METHOD: Qualitative data were collected from 15 current and previous members, via semi-structured interviews, notes from meetings, and consultations with and feedback from members. Data were critically compared, contrasted and reviewed until no new themes could be discerned and then condensed into context-mechanism-outcome (CMO) configurations. Realist evaluation was used to generate a theoretical and empirical appreciation of the contextual circumstances and mechanisms which help to explain the extent to which involvement with a public forum would enhance members' personal development and, if so, how, why, and for whom. RESULTS: Three CMO configurations were identified. All of them showed that using the portfolio facilitated growth in forum members' personal development, but only where the members valued using the portfolio. This was particularly so for female members. Members valued the portfolio in one or more of three ways: as a tool to record and evidence activities, to facilitate reflective practice or as a guiding framework. CONCLUSIONS: Data analysis and consideration of the three CMO configurations suggests a refined middle range theory that 'The use of a portfolio as a framework for learning in a public forum will facilitate members' personal development if they value its use as a framework for learning'. Further work is needed to confirm these findings both elsewhere in data-intensive health research and in other complex research areas using public forums for PEI. PLAIN ENGLISH SUMMARY: Public engagement and involvement in health research is now well established and makes a valuable contribution to the research process. However, little is known about its impact on participants. This article investigates how involvement in a data-intensive health research public forum impacts on public forum members, rather than the research process. Personal involvement portfolios were used to support their involvement work and help evaluate if and how involvement in research activities enhanced members' personal development. Taking a realist evaluation approach, 'Context-Mechanism-Outcome' configurations were used to explore how membership of a public forum might enhance public forum members' personal development. The Context-Mechanism-Outcome configuration refers to an exploration of what influences the extent to which an intervention is successful or unsuccessful in producing positive outcomes and tries to identify the reasons why it is successful for some and unsuccessful for others. However, evidence from this realist evaluation recommends that engagement and involvement should always be underpinned by procedures which ensure that public contributors receive ongoing and tailored guidance and support throughout the process.

Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement.

BACKGROUND: To protect children from harm, clinicians, educators, and patient safety champions need information to direct improvement efforts. Critical incident data could provide this but are often disregarded as a source of evidence because under-reporting makes them an inaccurate measure of error rates. OBJECTIVE: Our aim was to identify key targets for pediatric healthcare quality improvement. The objective was to evaluate the types, characteristics, and areas of risk within reported medication errors in pediatric patients. METHODS: We conducted a retrospective study of a large regional dataset of 1522 pediatric medication errors reported from secondary care between 2011 and 2015, including all hospitals and community pediatric settings in Northern Ireland. The following characteristics were included: error severity, patient age, drug involved, error type, and area of practice. Two academic pediatricians, a senior medicines governance pharmacist, a Reader in Pharmacy Practice, and a Professor of Medical Education analyzed the data. Validity checks included comparing the findings against key published literature and discussion by a practitioner panel representing five multidisciplinary stakeholder groups. RESULTS: Neonates, particularly in intensive care, were implicated in 19% of all errors. The medications most represented in risk were antimicrobials, paracetamol, vaccines, and intravenous fluids. The error types most implicated were dosing errors (32%) and omissions (21%). CONCLUSIONS: Incident reports identified neonates, a shortlist of drugs, and specific error types, associated with modifiable behaviors, as priority improvement targets. These findings direct further study and inform intervention development, such as specific training in calculations to prevent dosing errors. Involving experienced practitioners both endorsed the findings and engaged the practice community in their future implementation. The utility of incident reports to direct improvement efforts may offset the limitations in their representativeness.

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.

Readiness to prescribe: Using educational design to untie the Gordian Knot.

INTRODUCTION: Junior residents routinely prescribe medications for hospitalised patients with only arms-length supervision, which compromises patient safety. A cardinal example is insulin prescribing, which is commonplace, routinely delegated to very junior doctors, difficult, potentially very dangerous, and getting no better. Our aim was to operationalise the concept of 'readiness to prescribe' by validating an instrument to quality-improve residents' workplace prescribing education. METHODS: Guided by theories of behaviour change, implementation, and error, and by empirical evidence, we developed and refined a mixed-methods 24-item evaluation instrument, and analysed numerical responses from Foundation Trainees (junior residents) in Northern Ireland, UK using principal axis factoring, and conducted a framework analysis of participants' free-text responses. RESULTS: 255 trainees participated, 54% women and 46% men, 80% of whom were in the second foundation year. The analysis converged on a 4-factor solution explaining 57% of the variance. Participants rated their capability to prescribe higher (79%) than their capability to learn to prescribe (69%; p<0.001) and rated the support to their prescribing education lower still (43%; p<0.001). The findings were similar in men and women, first and second year trainees, and in different hospitals. Free text responses described an unreflective type of learning from experience in which participants tended to 'get by' when faced with complex problems. DISCUSSION: Operationalising readiness to prescribe as a duality, comprising residents' capability and the fitness of their educational environments, demonstrated room for improvement in both. We offer the instrument to help clinical educators improve the two in tandem.

Meeting patient expectations: Development of an Emergency Department Pharmacist Practitioner service specification.

BACKGROUND: Emergency Department Pharmacist Practitioners (EDPPs) undertake both 'traditional' clinical pharmacy work, e.g. check prescriptions, and 'practitioner' work, e.g. perform clinical examinations. A recent study found a large variation in the extent and type of care provided. Whilst variation allows services to be tailored to local needs, it is important that care meets the minimum standards that are safe, effective, patient-centred, timely, efficient, and equitable. OBJECTIVE(S): To develop an EDPP service specification based on views of professional and patient stakeholders, primarily to support providers with delivery of high quality services. METHODS: Patients, ED pharmacists and other ED healthcare professionals developed standards guided by the Institute of Medicine's quality domains. A panel of six ED pharmacists suggested and agreed on themes that should be included in the service specification. Additional themes were identified through interviews with eight patients who had been cared for by EDPPs as to their expectations of the service. Finally, a multidisciplinary expert panel of healthcare professionals and researchers reviewed and refined the service specification. RESULTS: ED pharmacists developed 36 themes with consensus achieved for 25. Additional themes from the patient interviews concerned the communication and behaviour of EDPPs rather than specific clinical activities undertaken. Whilst patients were happy to be cared for by an EDPP working within their competence, for certain conditions (e.g. major trauma) they wanted a doctor as their main care provider. An evidence-based EDPP service specification of 52 criteria grouped into 4 categories was produced: direct patient care (29); other activities (10); general approach (10); and service structures (3). CONCLUSIONS: As the product of both patient and expert input, EDs could align existing or newly developed services to the specification. Whether or not the specification actually improves the quality of EDPP services requires investigation, as does the absolute quality impact of services.

An exploration of the perceptions of non-medical prescribers, regarding their self-efficacy when prescribing, and their willingness to take responsibility for prescribing decisions.

BACKGROUND: In the UK, non-medical prescribers (NMPs) are a significant part of the healthcare workforce. Little is known about their self-efficacy when prescribing, and their willingness to take responsibility for prescribing decisions. OBJECTIVE: To explore the perceptions of NMPs regarding their self-efficacy in prescribing and responsibility for prescribing decisions. METHODS: Cross-sectional survey of a purposive sample of NMPs on acute medical units (AMUs) across the UK. Bandura's Social Cognitive Theory informed the self-efficacy aspect of the questionnaire. Participants' views were also sought on responsibility for prescribing decisions. For quantitative data descriptive statistics were calculated. Hierarchical multiple linear regressions determined whether five independent variables improved the prediction of self-efficacy in aspects of prescribing: NMP's profession; length of time qualified as a healthcare professional and as an NMP; the number of items prescribed and hours worked per week on an AMU. Framework analysis was used to analyse the qualitative data. RESULTS: Ninety-nine valid responses were obtained. Self-efficacy overall was high. The longer the participant had been qualified as an NMP was associated with increased self-efficacy in certain aspects of prescribing. All physiotherapists, and more nurses than pharmacists were responsible for prescribing decisions. Where participants were not fully responsible, the responsibility was partial or shared. CONCLUSIONS: Self-efficacy of NMPs when prescribing is influenced by several factors. The variables within this study appear to account for only a small part of this self-efficacy. Self-efficacy in prescribing appears to contribute to NMPs' willingness to take responsibility for prescribing decisions; further influenced by their job role and the prescribing this entails. Stakeholders need to appreciate the full range of factors that influence the self-efficacy of NMPs when prescribing, and the association of this to take responsibility for prescribing decisions. This knowledge will assist in maximising the benefits of non-medical prescribing within the healthcare system.

Commercial use of health data-A public "trial" by citizens' jury.

INTRODUCTION: Surveys suggest a dichotomy in how citizens view research for public benefit and research for commercial gain. Therefore, a research initiative, such as a learning health system, which works for both public and commercial benefit, may be controversial and lower public trust. METHODS: This study aimed to investigate what informed citizens considered to be appropriate uses of health data in a learning health system and why they made those decisions. Two-paired 4-day juries were run, with different jurors but the same purpose, expert witnesses, and facilitators. Overall, 694 people applied; 36 jurors were selected to match criteria based on demographics and privacy views. Jurors considered whether and why eight exemplars of anonymised patient data were acceptable. The exemplars were either planned initiatives to improve care pathways (Planned Examples) or possible commercial data uses (Potential Examples). RESULTS: These citizens' juries found that all Planned and two of the Potential Examples were considered appropriate by most, but not all, jurors because they could deliver public benefit. In general, positive health outcomes for patients were more acceptable than improved efficiency of services for the NHS, although they recognised that the latter also improved health. Jurors had concerns about whether improving efficiency would lead to inequitable distribution or closure of services, based on their existing understanding from media reports. Commercial gain that accrued secondary to this benefit was acceptable, with some jurors becoming more accepting of commercial uses as they understood them better. Prioritising profit, however, was unacceptable, regardless of any governance arrangements. CONCLUSIONS: Jurors tended to be more accepting of data sharing to both private and public sectors after the jury process. Many jurors accept commercial gain if public benefit is achieved. Some were suspicious of data sharing for efficiency gains. Juries elicited more informed and nuanced judgement from citizens than surveys.

What causes prescribing errors in children? Scoping review.

OBJECTIVES: (1) Systematically assemble, analyse and synthesise published evidence on causes of prescribing error in children. (2) Present results to a multidisciplinary group of paediatric prescribing stakeholders to validate findings and establish how causative factors lead to errors in practice. DESIGN: Scoping review using Arksey and O'Malley's framework, including stakeholder consultation; qualitative evidence synthesis. METHODS: We followed the six scoping review stages. (1) Research question-the research question was 'What is known about causes of prescribing error in children?' (2) Search strategy-we searched MEDLINE, EMBASE, CINAHL (from inception to February 2018), grey literature and reference lists of included studies. (3) Article selection-all published evidence contributing information on the causes of prescribing error in children was eligible for inclusion. We included review articles as secondary evidence to broaden understanding. (4) Charting data-results were collated in a custom data charting form. (5) Reporting results-we summarised article characteristics, extracted causal evidence and thematically synthesised findings. (6) Stakeholder consultation-results were presented to a multidisciplinary focus group of six prescribing stakeholders to establish validity, relevance and mechanisms by which causes lead to errors in practice. RESULTS: 68 articles were included. We identified six main causes of prescribing errors: children's fundamental differences led to individualised dosing and calculations; off-licence prescribing; medication formulations; communication with children; and experience working with children. Primary evidence clarifying causes was lacking. CONCLUSIONS: Specific factors complicate prescribing for children and increase risk of errors. Primary research is needed to confirm and elaborate these causes of error. In the meantime, this review uses existing evidence to make provisional paediatric-specific recommendations for policy, practice and education.

Prevalence, nature and risk factors for medication administration omissions in English NHS hospital inpatients: a retrospective multicentre study using Medication Safety Thermometer data.

OBJECTIVE: To determine the prevalence, nature and predictors of patients having medication administration omissions in hospitals. METHODS: All medication administration omissions data collected using the standardised methodology of the Medication Safety Thermometer in January 2015 were examined. Hospital inpatients prescribed at least one medication were included in the analysis. Multilevel logistic regression models ascertained the effects of patients' gender, age, number of prescribed medicines, ward specialty and medicines reconciliation initiation status on the likelihood of having omissions. Valid clinical reasons (VCRs) were excluded from regression models. A sensitivity analysis, excluding patient refusal (PR) omissions, was also conducted. RESULTS: The final study sample included 5708 patients from 320 wards in 37 hospitals. Excluding VCRs, 30% of patients had medication administration omissions (95% CI 29 to 30). Approximately half of patients with omissions had refused medicines (51%, 95% CI 49 to 53). Univariable analysis suggested that all variables were significantly associated with omissions. However, in the multivariable model, significant differences were only observed regarding the numbers of medicines patients were prescribed and their ward specialty. Patients prescribed more than 20 medications were approximately five times more likely to have had omissions than patients prescribed one to four medications (OR 4.99, 95% CI 3.22 to 7.73). Patients on surgical wards were also more likely to have had omissions than those on medical wards (OR 1.58, 95% CI 1.14 to 2.18, p=0.006), but there was no significant difference when PRs were excluded (OR 0.5, 95% CI 0.27 to 1.22, p=0.473). CONCLUSION: Medication administration omissions are a substantial problem that affect many hospital patients, and certain patient groups are at higher risk. Specific interventions are required targeting the underlying reasons for medication omissions for different patient subgroups.

Prescribing errors by junior doctors- A comparison of errors with high risk medicines and non-high risk medicines.

INTRODUCTION: Prescribing errors in hospital are common. However, errors with high-risk-medicines (HRMs) have a greater propensity to cause harm compared to non-HRMs. We do not know if there are differences between the causes of errors with HRMs and non-HRMs but such knowledge might be useful in developing interventions to reduce errors and avoidable harm. Therefore, this study aims to compare and contrast junior doctors' prescribing errors with HRMs to non-HRMs to establish any differences. METHODS: A secondary analysis of fifty-nine interviews with foundation year doctors, obtained from three studies, was conducted. Using a Framework Analysis approach, through NVivo software, a detailed comparison was conducted between the unsafe acts, error-causing-conditions (ECCs), latent conditions, and types of errors related to prescribing errors with HRMs and non-HRMs. RESULTS: In relation to unsafe acts, violations were described in the data with non-HRMs only. Differences in ECCs of HRMs and non-HRMs were identified and related to the complexity of prescribing HRMs, especially dosage calculations. There were also differences in the circumstances of communication failures: with HRMs ineffective communication arose with exchanges with individuals outside the immediate medical team while with non-HRMs these failures occurred with exchanges within that team. Differences were identified with the latent conditions: with non-HRMs there was a reluctance to seek seniors help and with HRMs latent conditions related to the organisational system such as the inclusion of trade names in hospital formularies. Moreover, prescribing during the on-call period was particularly challenging especially with HRMs. CONCLUSION: From this secondary analysis, differences in the nature and type of prescribing errors with HRMs and non-HRMs were identified, although further research is needed to investigate their prevalence. As errors with HRMs have the potential to cause great harm it may be appropriate to target limited resources towards interventions that tackle the underlying causes of such errors. Equally concerning, however, was the sense that doctors regard the prescribing of non-HRMs as 'safe'.

Understanding the causes of prescribing errors from a behavioural perspective.

INTRODUCTION: While many attempts have been made to reduce prescribing errors (PEs), they persist. PE is not in itself a behaviour, but a consequence of a prescribing behaviour. Interventions aimed at prescribers should focus on understanding prescribers' behaviours. OBJECTIVES: The aim of this study was to use the capability, opportunity, motivation - behaviour (COM-B) model to explore the behaviours that could have caused PEs made by senior doctors in a speciality paediatric inpatient ward. METHODS: A qualitative approach was used to investigate prescribers' behaviours in a 26-bed paediatric oncology ward. Error data were collected over a two-month period and were presented during focus groups with prescribers, which were audio-recorded and transcribed verbatim. Thematic analysis was used to identify contributory factors to errors, which was used to identify sources of behaviours using the COM-B model. RESULTS: Behaviours related to prescribers' capabilities were: prescribers' improper use of the software because of insufficient skills, and prescribers' inability to prescribe correctly because of lack of knowledge. Behaviours related to opportunities in the environment were: prescribers' inability to make an informed decision because of poor access to patient information, inability to properly complete a task because of heavy workload and interruption, and having to re-check doses frequently because of frequent change in patients' weight and surface area. Those related to motivation were: prescribers unquestioningly following recommendations and not communicating with other specialists because they over-trusted them or feared a negative reaction, and prescribers inability to complete a task because of other competing and preferable tasks at the same time. CONCLUSION: Employing COM-B helped in identifying causes of PEs from a new perspective. Future work could focus on mapping identified sources of behaviour and errors against appropriate intervention functions and policies in order to design more successful interventions.

A formative evaluation of the implementation of a medication safety data collection tool in English healthcare settings: A qualitative interview study using normalisation process theory.

BACKGROUND: Reducing medication-related harm is a global priority; however, impetus for improvement is impeded as routine medication safety data are seldom available. Therefore, the Medication Safety Thermometer was developed within England's National Health Service. This study aimed to explore the implementation of the tool into routine practice from users' perspectives. METHOD: Fifteen semi-structured interviews were conducted with purposely sampled National Health Service staff from primary and secondary care settings. Interview data were analysed using an initial thematic analysis, and subsequent analysis using Normalisation Process Theory. RESULTS: Secondary care staff understood that the Medication Safety Thermometer's purpose was to measure medication safety and improvement. However, other uses were reported, such as pinpointing poor practice. Confusion about its purpose existed in primary care, despite further training, suggesting unsuitability of the tool. Decreased engagement was displayed by staff less involved with medication use, who displayed less ownership. Nonetheless, these advocates often lacked support from management and frontline levels, leading to an overall lack of engagement. Many participants reported efforts to drive scale-up of the use of the tool, for example, by securing funding, despite uncertainty around how to use data. Successful improvement was often at ward-level and went unrecognised within the wider organisation. There was mixed feedback regarding the value of the tool, often due to a perceived lack of "capacity". However, participants demonstrated interest in learning how to use their data and unexpected applications of data were reported. CONCLUSION: Routine medication safety data collection is complex, but achievable and facilitates improvements. However, collected data must be analysed, understood and used for further work to achieve improvement, which often does not happen. The national roll-out of the tool has accelerated shared learning; however, a number of difficulties still exist, particularly in primary care settings, where a different approach is likely to be required.

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.