Realising the potential of shared digital medication records

A systems approach to the safety and efficiency of prescribing at the primary-secondary care interface

The interface between primary and secondary care represents a highly complex and heterogeneous system that continues to pose risks to the safety and quality of care. Many issues relate to prescribing activities, and suboptimal information sharing between stakeholders can lead to avoidable harm events and system inefficiencies that increase workload. The framework of a systems approach is used to structure four key interface issues: medicines reconciliation, prescribing at secondary care outpatient appointments, shared records, and quality of communication. We outline opportunities for improved safety and efficiency, and identify key barriers that need to be addressed. Significant further development is required for the measures discussed. We recommend the use of a systems approach to methodologically support this process, particularly due to the inherent system-wide understanding of problems that it generates. We argue such understanding is essential to ensure that risks and workload are not shifted around a system, without overall gain.

Defining avoidable healthcare-associated harm in prisons: A mixed-method development study

BACKGROUND

Reducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons.

METHODS

Using a sequential mixed methods study design we first characterised and reached consensus on the types and avoidability of patient harm in prison healthcare involving analysis of 151 serious prison incidents reported to the Strategic Executive Information System (StEIS) followed by in-depth nominal group (NG) discussions with four former service users and four prison professionals. Findings of the NG discussions and StEIS analysis were then synthesised and discussed among the research team and study oversight groups to develop an operational definition of avoidable harm in prison healthcare which was subsequently tested and validated using prison patient safety incident report data derived from the National Reporting and Learning System (NRLS).

RESULTS

Analysis of StEIS incident reports and NG discussions identified important factors influencing avoidable harm which reflected the unique prison setting, including health care delivery issues and constraints associated with the secure environment which limited access to care. These findings informed the development of a new working two-tier definition of avoidable harm using appropriate and timely intervention, which included an additional assessment of harm avoidability taking into the account the prison regime and environment. The definition was compatible with the NRLS incident report narratives and illustrated how the prison environment may influence identification of avoidable harm and judgements of avoidability.

CONCLUSIONS

We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement.