Improving general practice computer systems for patient safety: qualitative study of key stakeholders

Structured yet simple approaches to primary care data quality improvements can indeed strike gold

General practice data provide important opportunities for both population health and within-practice initiatives to improve health. Despite its promise, a lack of accuracy affects the use of such data. The Sentinel Practices Data Sourcing (SPDS) project is a structured chronic disease surveillance and data quality improvement strategy in general practice. A mixed-methods approach was used to evaluate data quality improvement in 99 participating practices over 12 months. Quantitative data were obtained by measuring performance against 10 defined indicators, whereas 48 semi-structured interviews provided qualitative data. Aggregated scores demonstrated improvements in all indicators, ranging from minor to substantially significant improvements. Participants reported positively on levels of support provided, and acquisition of new knowledge and skills relating to data entry and cleansing. This evaluation provides evidence of the effectiveness of a structured approach to improve the quality of primary care data. Investing in this targeted intervention has the potential to create sustained improvements in data quality, which can drive clinical practice improvement.

Never events in general practice: a focus group study exploring the views of English and Scottish general practitioners of 'never events'

OBJECTIVES

To examine general practitioner (GP) understanding of the never event (NE) concept in general practice, and to identify potential enablers and barriers to implementation in UK general practice.

DESIGN

Qualitative study using focus groups. The data were analysed thematically and were informed by the normalisation process theory.

SETTING

General practice in Northwest England and Southwest Scotland.

PARTICIPANTS

25 GPs took part in five focus groups. 13 GPs were female and 12 male with an age range of 28-60.

RESULTS

The NE approach of avoiding serious preventable adverse outcomes from healthcare fitted with participants expectations of the delivery of care but the implementation of strategies to prevent the specific NE was considered complex and variable. The main themes identified participants' understandings and perceived limitations of the NE concept; the embedded layers of responsibility to implement NE within practices and the work required for implementation within general practices. Participants' accounts highlighted the differential nature of work in general practice and that the implementation of initiatives to address specific NE should be situated within a learning and systems approach to implementation. Some NEs were considered more relevant and amenable to simple solutions than others which could influence implementation.

CONCLUSIONS

The NE concept was considered overall an important approach to help address key primary care patient safety issues. The utility of individual NEs may vary depending on the complexity of the initiatives that would be needed to manage related risks to as low as reasonably practicable.

Understanding the implementation and adoption of a technological intervention to improve medication safety in primary care: a realist evaluation

Background

Monitoring for potentially hazardous prescribing is increasingly important to improve medication safety. Healthcare information technology can be used to achieve this aim, for example by providing access to prescribing data through surveillance of patients’ electronic health records. The aim of our study was to examine the implementation and adoption of an electronic medicines optimisation system that was intended to facilitate clinical audit in primary care by identifying patients at risk of an adverse drug event. We adopted a sociotechnical approach that focuses on how complex social, organisational and institutional factors may impact upon the use of technology within work settings.

Methods

We undertook a qualitative realist evaluation of the use of an electronic medicines optimisation system in one Clinical Commissioning Group in England. Five semi-structured interviews, four focus groups and one observation were conducted with a range of stakeholders. Consistent with a realist evaluation methodology, the analysis focused on exploring the links between context, mechanism and outcome to explain the ways the intervention might work, for whom and in what circumstances.

Results

Using the electronic medicines optimisation system could lead to a number of improved patient safety outcomes including pre-emptively reviewing patients at risk of adverse drug events. The effective use of the system depended upon engagement with the system, the flow of information between different health professionals centrally placed at the Clinical Commissioning Group and those locally placed at individual general practices, and upon variably adapting work practices to facilitate the use of the system. The use of the system was undermined by perceptions of ownership, lack of access, and lack of knowledge and awareness.

Conclusions

The use of an electronic medicines optimisation system may improve medication safety in primary care settings by identifying those patients at risk of an adverse drug event. To fully realise the potential benefits for medication safety there needs to be better utilisation across primary care and with a wider range of stakeholders. Engaging with all potential stakeholders and users prior to implementation of such systems might allay perceptions that the system is owned centrally and increase knowledge of the potential benefits.

Perceptions of primary care staff on a regional data quality intervention in Australian general practice: a qualitative study

Background

Technological advances in clinical data capturing and storage systems have led to recent attempts at disease surveillance and region specific population health planning through regularly collected primary care administrative clinical data. However the accuracy and comprehensiveness of primary care health records remain questionable.

Methods

We aimed to explore the perceptions and experiences of general practice staff in maintaining accurate patient health data within clinical software used in primary care settings of regional NSW. Focus groups were conducted with general practitioners, practice nurses and practice administrative staff from 17 practices in the Illawarra-Shoalhaven region of the state of New South Wales (NSW) in Australia that had participated in the Sentinel Practices Data Sourcing (SPDS) project - a general practice based chronic disease surveillance and data quality improvement study. A total of 25 respondents that included 12 general practitioners (GPs) and 13 practice staff participated in the 6 focus groups. Focus groups were audio-recorded and transcribed verbatim. Thematic analysis of the data was undertaken.

Results

Five key themes emerged from the data. Firstly, the theme of resourcing data management raised issues of time constraints, the lack of a dedicated data management role and the importance of multidisciplinary involvement, including a data champion. The need for incentives was identified as being important to motivate ongoing commitment to maintaining data quality. However, quality of software packages, including coding issues and software limitations and information technology skills were seen as key barriers. The final theme provided insight into the lessons learnt from the project and the increased awareness of the importance of data quality amongst practice staff.

Conclusion

The move towards electronic methods of maintaining general practice patient records offers significant potential benefits in terms of both patient care and monitoring of health status and health needs within the community. However, this study has reinforced the importance of human factors in the maintenance of such datasets. To achieve optimal benefits of electronic health and medical records for patient care and for population health planning purposes, it is extremely essential to address the barriers that clinicians and other staff face in maintaining complete and correct primary care patient electronic health and medical information.

Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports

OBJECTIVE

To identify the categories of problems with information technology (IT), which affect patient safety in general practice.

DESIGN

General practitioners (GPs) reported incidents online or by telephone between May 2012 and November 2013. Incidents were reviewed against an existing classification for problems associated with IT and the clinical process impacted.

PARTICIPANTS AND SETTING

87 GPs across Australia.

MAIN OUTCOME MEASURE

Types of problems, consequences and clinical processes.

RESULTS

GPs reported 90 incidents involving IT which had an observable impact on the delivery of care, including actual patient harm as well as near miss events. Practice systems and medications were the most affected clinical processes. Problems with IT disrupted clinical workflow, wasted time and caused frustration. Issues with user interfaces, routine updates to software packages and drug databases, and the migration of records from one package to another generated clinical errors that were unique to IT; some could affect many patients at once. Human factors issues gave rise to some errors that have always existed with paper records but are more likely to occur and cause harm with IT. Such errors were linked to slips in concentration, multitasking, distractions and interruptions. Problems with patient identification and hybrid records generated errors that were in principle no different to paper records.

CONCLUSIONS

Problems associated with IT include perennial risks with paper records, but additional disruptions in workflow and hazards for patients unique to IT, occasionally affecting multiple patients. Surveillance for such hazards may have general utility, but particularly in the context of migrating historical records to new systems and software updates to existing systems.

Monitoring patient safety in primary care: an exploratory study using in-depth semistructured interviews

OBJECTIVES

To explore how information and data are used to monitor patient safety and quality of primary care by professionals working in, or supporting, primary healthcare.

DESIGN

Qualitative study of semistructured interviews with a directed content analysis of transcripts.

SETTING

North-West London, UK.

PARTICIPANTS

21 individuals from various levels of the primary healthcare system were recruited, including general practitioners, practice nurses, practice managers, members of Clinical Commissioning Group (CCG) governing bodies, and senior members of regional patient safety teams.

RESULTS

Participants described being overwhelmed with complicated data which lacked any meaningful analyses about safety and quality. There was also a lack of clarity over which patient safety events are expected to be reported or monitored. Participants also reported uncertainty on whose responsibility it was to act on patient safety information or concerns. At the practice level, there was a range of disincentives for responding to and acting on safety issues and concerns, with few reported benefits. Participants made recommendations to improve future monitoring.

CONCLUSIONS

There is a need for clearer information in the form of specific guidelines, policies and procedures with regard to who monitors patient safety in primary care, what is monitored and how it should be monitored.

The evolution of the market for commercial computerized physician order entry and computerized decision support systems for prescribing

Objective To understand the evolving market of commercial off-the-shelf Computerized Physician Order Entry (CPOE) and Computerized Decision Support (CDS) applications and its effects on their uptake and implementation in English hospitals.

Methods Although CPOE and CDS vendors have been quick to enter the English market, uptake has been slow and uneven. To investigate this, the authors undertook qualitative ethnography of vendors and adopters of hospital CPOE/CDS systems in England. The authors collected data from semi-structured interviews with 11 individuals from 4 vendors, including the 2 most entrenched suppliers, and 6 adopter hospitals, and 21 h of ethnographic observation of 2 user groups, and 1 vendor event. The research and analysis was informed by insights from studies of the evolution of technology fields and the emergence of generic COTS enterprise solutions.

Results Four key themes emerged: (1) adoption of systems that had been developed outside of England, (2) vendors’ configuration and customization strategies, (3) localized adopter practices vs generic systems, and (4) unrealistic adopter demands. Evidence for our over-arching finding concerning the current immaturity of the market was derived from vendors’ strategies, adopters’ reactions to the technology, and policy makers’ incomplete insights.

Conclusions The CPOE/CDS market in England is still in an emergent phase. The rapid entrance of diverse products, triggered by federal policy initiatives, has resulted in premature adoption of systems that do not yet adequately meet the needs of hospitals. Vendors and adopters lacked understanding of how to design and implement generic solutions to meet diverse user needs.

Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

Objective

Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.

Method

Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.

Results

Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.

Conclusion

Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.

Challenges to and the future of medication safety in Saudi Arabia: A qualitative study

BACKGROUND

Medication safety is a global concern among healthcare providers. However, the challenges to and the future of medication safety in Saudi Arabia have not been explored.

OBJECTIVES

We explored the perspectives of healthcare practitioners on current issues about medication safety in hospitals and community settings in Saudi Arabia in order to identify challenges to improving it and explore the future of medication safety practice.

METHODS

A total of 65 physicians, pharmacists, academics and nurses attended a one-day meeting in March 2010, designed especially for the purpose of this study. The participants were divided into nine round-table discussion sessions. Three major themes were explored in these sessions, including: major factors contributing to medication safety problems, challenges to improving medication safety practice, and participants' suggestions for improving medication safety. The round-table discussion sessions were videotaped and transcribed verbatim and analyzed by two independent researchers.

RESULTS

The round-table discussions revealed that major factors contributing to medication safety problems included unrestricted public access to medications from various hospitals and community pharmacies, communication gaps between healthcare institutions, limited use of important technologies such as computerized provider order entry, and the lack of medication safety programs in hospitals. Challenges to current medication safety practice identified by participants included underreporting of medication errors and adverse drug reactions, multilingualism and differing backgrounds of healthcare professionals, lack of communication between healthcare providers and patients, and high workloads. Suggestions for improving medication safety practices in Saudi Arabia included continuous education for healthcare professionals and competency assessment focusing on medication safety, development of a culture that encourages medication error and adverse drug reactions reporting, use of technology proven to decrease medication errors, and promotion and implementation of national patient safety initiatives.

CONCLUSIONS

Healthcare professionals have identified major challenges and opportunities for medication safety in Saudi Arabia. Policy makers and practitioners should consider these factors when designing future programs aimed at improving the safe use of medications.

The causes of prescribing errors in English general practices: a qualitative study

BACKGROUND

Few detailed studies exist of the underlying causes of prescribing errors in the UK.

AIM

To examine the causes of prescribing and monitoring errors in general practice and provide recommendations for how they may be overcome.

DESIGN AND SETTING

Qualitative interview and focus group study with purposive sampling of English general practices.

METHOD

General practice staff from 15 general practices across three PCTs in England participated in a combination of semi-structured interviews (n = 34) and six focus groups (n = 46). Thematic analysis informed by Reason's Accident Causation Model was used.

RESULTS

Seven categories of high-level error-producing conditions were identified: the prescriber, the patient, the team, the working environment, the task, the computer system, and the primary-secondary care interface. These were broken down to reveal various error-producing conditions: the prescriber's therapeutic training, drug knowledge and experience, knowledge of the patient, perception of risk, and their physical and emotional health; the patient's characteristics and the complexity of the individual clinical case; the importance of feeling comfortable within the practice team was highlighted, as well as the safety implications of GPs signing prescriptions generated by nurses when they had not seen the patient for themselves; the working environment with its extensive workload, time pressures, and interruptions; and computer-related issues associated with mis-selecting drugs from electronic pick-lists and overriding alerts were all highlighted as possible causes of prescribing errors and were often interconnected.

CONCLUSION

Complex underlying causes of prescribing and monitoring errors in general practices were highlighted, several of which are amenable to intervention.

Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method

Background

The majority of patient contacts occur in general practice but general practice patient safety has been poorly described and under-researched to date compared to hospital settings. Our objective was to produce a set of patient safety tools and indicators that can be used in general practices in any healthcare setting and develop a ‘toolkit’ of feasible patient safety measures for general practices in England.

Methods

A RAND/UCLA Appropriateness Method exercise was conducted with a panel of international experts in general practice patient safety. Statements were developed from an extensive systematic literature review of patient safety in general practice. We used standard RAND/UCLA Appropriateness Method rating methods to identify necessary items for assessing patient safety in general practice, framed in terms of the Structure-Process-Outcome taxonomy. Items were included in the toolkit if they received an overall panel median score of ≥7 with agreement (no more than two panel members rating the statement outside a 3-point distribution around the median).

Results

Of 205 identified statements, the panel rated 101 as necessary for assessing the safety of general practices. Of these 101 statements, 73 covered structures or organisational issues, 22 addressed processes and 6 focused on outcomes.

Conclusions

We developed and tested tools that can lead to interventions to improve safety outcomes in general practice. This paper reports the first attempt to systematically develop a patient safety toolkit for general practice, which has the potential to improve safety, cost effectiveness and patient experience, in any healthcare system.

A qualitative evaluation of general practitioners' views on protocol-driven eReferral in Scotland

Background

The ever increasing volume of referrals from primary care to specialist services is putting considerable pressure on resource-constrained health services while effective communication across fragmented services remains a substantial challenge. Previous studies have suggested that electronic referrals (eReferral) can bear important benefits for cross-organisational processes and patient care management.

Methods

We conducted 25 semi-structured interviews and 1 focus group with primary care providers to elucidate General Practitioners’ (GPs) perspectives on information management processes in the patient pathway in NHSScotland, 1 focus group with members of the Scottish Electronic Patient Record programme and one interview with a senior architect of the Scottish Care Information national eReferral System (SCI Gateway). Using Normalisation Process Theory, we performed a qualitative analysis to elucidate GPs’ perspectives on eReferral to identify the factors which they felt either facilitated or hindered referral processes.

Results

The majority of GPs interviewed felt that eReferral substantially streamlined communication processes, with the immediate transfer of referral documents and the availability of an electronic audit trail perceived as two substantial improvements over paper-based referrals. Most GPs felt that the SCI Gateway system was reasonably straightforward to use. Referral protocols and templates could be perceived as useful by some GPs while others considered them to be cumbersome at times.

Conclusion

Our study suggests that the deployment and adoption of eReferral across the NHS in Scotland has been achieved by a combination of factors: (i) a policy context – including national mandatory targets for eReferral – which all NHS health-boards were bound to operationalise through their Local Delivery Plans and also (ii) the fact that primary care doctors considered that the overall benefits brought by the deployment of eReferral throughout the patient pathway significantly outweigh any potential disbenefits.

Comparative evaluation of different medication safety measures for the emergency department: physicians' usage and acceptance of training, poster, checklist and computerized decision support

Background

Although usage and acceptance are important factors for a successful implementation of clinical decision support systems for medication, most studies only concentrate on their design and outcome. Our objective was to comparatively investigate a set of traditional medication safety measures such as medication safety training for physicians, paper-based posters and checklists concerning potential medication problems versus the additional benefit of a computer-assisted medication check. We concentrated on usage, acceptance and suitability of such interventions in a busy emergency department (ED) of a 749 bed acute tertiary care hospital.

Methods

A retrospective, qualitative evaluation study was conducted using a field observation and a questionnaire-based survey. Six physicians were observed while treating 20 patient cases; the questionnaire, based on the Technology Acceptance Model 2 (TAM2), has been answered by nine ED physicians.

Results

During field observations, we did not observe direct use of any of the implemented interventions for medication safety (paper-based and electronic). Questionnaire results indicated that the electronic medication safety check was the most frequently used intervention, followed by checklist and posters. However, despite their positive attitude, physicians most often stated that they use the interventions in only up to ten percent for subjectively “critical” orders. Main reasons behind the low usage were deficits in ease-of-use and fit to the workflow. The intention to use the interventions was rather high after overcoming these barriers.

Conclusions

Methodologically, the study contributes to Technology Acceptance Model (TAM) research in an ED setting and confirms TAM2 as a helpful diagnostic tool in identifying barriers for a successful implementation of medication safety interventions. In our case, identified barriers explaining the low utilization of the implemented medication safety interventions - despite their positive reception - include deficits in accessibility, briefing for the physicians about the interventions, ease-of-use and compatibility to the working environment.

An ethnographic exploration of influences on prescribing in general practice: why is there variation in prescribing practices?

Background

Prescribing is a core activity for general practitioners, yet significant variation in the quality of prescribing has been reported. This suggests there may be room for improvement in the application of the current best research evidence. There has been substantial investment in technologies and interventions to address this issue, but effect sizes so far have been small to moderate. This suggests that prescribing is a decision-making process that is not sufficiently understood. By understanding more about prescribing processes and the implementation of research evidence, variation may more easily be understood and more effective interventions proposed.

Methods

An ethnographic study in three Scottish general practices with diverse organizational characteristics. Practices were ranked by their performance against Audit Scotland prescribing quality indicators, incorporating established best research evidence. Two practices of high prescribing quality and one practice of low prescribing quality were recruited. Participant observation, formal and informal interviews, and a review of practice documentation were employed.

Results

Practices ranked as high prescribing quality consistently made and applied macro and micro prescribing decisions, whereas the low-ranking practice only made micro prescribing decisions. Macro prescribing decisions were collective, policy decisions made considering research evidence in light of the average patient, one disease, condition, or drug. Micro prescribing decisions were made in consultation with the patient considering their views, preferences, circumstances and other conditions (if necessary).

Although micro prescribing can operate independently, the implementation of evidence-based, quality prescribing was attributable to an interdependent relationship. Macro prescribing policy enabled prescribing decisions to be based on scientific evidence and applied consistently where possible. Ultimately, this influenced prescribing decisions that occur at the micro level in consultation with patients.

Conclusion

General practitioners in the higher prescribing quality practices made two different ‘types’ of prescribing decision; macro and micro. Macro prescribing informs micro prescribing and without a macro basis to draw upon the low-ranked practice had no effective mechanism to engage with, reflect on and implement relevant evidence. Practices that recognize these two levels of decision making about prescribing are more likely to be able to implement higher quality evidence.

Using the computer in the clinical consultation; setting the stage, reviewing, recording, and taking actions: multi-channel video study

BACKGROUND AND OBJECTIVE

Electronic patient record (EPR) systems are widely used. This study explores the context and use of systems to provide insights into improving their use in clinical practice.

METHODS

We used video to observe 163 consultations by 16 clinicians using four EPR brands. We made a visual study of the consultation room and coded interactions between clinician, patient, and computer. Few patients (6.9%, n=12) declined to participate.

RESULTS

Patients looked at the computer twice as much (47.6 s vs 20.6 s, p<0.001) when it was within their gaze. A quarter of consultations were interrupted (27.6%, n=45); and in half the clinician left the room (12.3%, n=20). The core consultation takes about 87% of the total session time; 5% of time is spent pre-consultation, reading the record and calling the patient in; and 8% of time is spent post-consultation, largely entering notes. Consultations with more than one person and where prescribing took place were longer (R(2) adj=22.5%, p<0.001). The core consultation can be divided into 61% of direct clinician-patient interaction, of which 15% is examination, 25% computer use with no patient involvement, and 14% simultaneous clinician-computer-patient interplay. The proportions of computer use are similar between consultations (mean=40.6%, SD=13.7%). There was more data coding in problem-orientated EPR systems, though clinicians often used vague codes.

CONCLUSIONS

The EPR system is used for a consistent proportion of the consultation and should be designed to facilitate multi-tasking. Clinicians who want to promote screen sharing should change their consulting room layout.

A study of general practitioners' perspectives on electronic medical records systems in NHSScotland

BACKGROUND

Primary care doctors in NHSScotland have been using electronic medical records within their practices routinely for many years. The Scottish Health Executive eHealth strategy (2008-2011) has recently brought radical changes to the primary care computing landscape in Scotland: an information system (GPASS) which was provided free-of-charge by NHSScotland to a majority of GP practices has now been replaced by systems provided by two approved commercial providers. The transition to new electronic medical records had to be completed nationally across all health-boards by March 2012.

METHODS

We carried out 25 in-depth semi-structured interviews with primary care doctors to elucidate GPs' perspectives on their practice information systems and collect more general information on management processes in the patient surgical pathway in NHSScotland. We undertook a thematic analysis of interviewees' responses, using Normalisation Process Theory as the underpinning conceptual framework.

RESULTS

The majority of GPs' interviewed considered that electronic medical records are an integral and essential element of their work during the consultation, playing a key role in facilitating integrated and continuity of care for patients and making clinical information more accessible. However, GPs expressed a number of reservations about various system functionalities - for example: in relation to usability, system navigation and information visualisation.

CONCLUSION

Our study highlights that while electronic information systems are perceived as having important benefits, there remains substantial scope to improve GPs' interaction and overall satisfaction with these systems. Iterative user-centred improvements combined with additional training in the use of technology would promote an increased understanding, familiarity and command of the range of functionalities of electronic medical records among primary care doctors.

Investigating and learning lessons from early experiences of implementing ePrescribing systems into NHS hospitals: a questionnaire study

BACKGROUND

ePrescribing systems have significant potential to improve the safety and efficiency of healthcare, but they need to be carefully selected and implemented to maximise benefits. Implementations in English hospitals are in the early stages and there is a lack of standards guiding the procurement, functional specifications, and expected benefits. We sought to provide an updated overview of the current picture in relation to implementation of ePrescribing systems, explore existing strategies, and identify early lessons learned.

METHODS

A descriptive questionnaire-based study, which included closed and free text questions and involved both quantitative and qualitative analysis of the data generated.

RESULTS

We obtained responses from 85 of 108 NHS staff (78.7% response rate). At least 6% (n = 10) of the 168 English NHS Trusts have already implemented ePrescribing systems, 2% (n = 4) have no plans of implementing, and 34% (n = 55) are planning to implement with intended rapid implementation timelines driven by high expectations surrounding improved safety and efficiency of care. The majority are unclear as to which system to choose, but integration with existing systems and sophisticated decision support functionality are important decisive factors. Participants highlighted the need for increased guidance in relation to implementation strategy, system choice and standards, as well as the need for top-level management support to adequately resource the project. Although some early benefits were reported by hospitals that had already implemented, the hoped for benefits relating to improved efficiency and cost-savings remain elusive due to a lack of system maturity.

CONCLUSIONS

Whilst few have begun implementation, there is considerable interest in ePrescribing systems with ambitious timelines amongst those hospitals that are planning implementations. In order to ensure maximum chances of realising benefits, there is a need for increased guidance in relation to implementation strategy, system choice and standards, as well as increased financial resources to fund local activities.

Consultations with general practitioners on patient safety measures based on routinely collected data in primary care

OBJECTIVES

To gauge the opinions of doctors working, or interested, in general practice on monitoring patient safety using administrative data. The findings will inform the development of routinely collected data-based patient safety indicators in general practice and elsewhere in primary care.

DESIGN

Non-systematic participant recruitment, using personal contacts and colleagues' recommendations.

SETTING

Face-to-face consultations at participants' places of work, between June 2010 and February 2011.

PARTICIPANTS

Four general practitioners (GPs) and a final year medical student. The four clinicians had between eight to 34 years of clinical practice experience, and held non-clinical positions in addition to their clinical roles.

MAIN OUTCOME MEASURES

Views on safety issues and improvement priorities, measurement methods, uses of administrative data, role of administrative data in patient safety and experiences of quality and safety initiatives.

RESULTS

Medication and communication were the most commonly identified areas of patient safety concern. Perceived safety barriers included incident-reporting reluctance, inadequate medical education and low computer competency. Data access, financial constraints, policy changes and technology handicaps posed challenges to data use. Suggested safety improvements included better communication between providers and local partnerships between GPs.

CONCLUSIONS

The views of GPs and other primary care staff are pivotal to decisions on the future of English primary care and the health system. Broad views of general practice safety issues were shown, with possible reasons for patient harm and quality and safety improvement obstacles. There was general consensus on areas requiring urgent attention and strategies to enhance data use for safety monitoring.

Planned implementations of ePrescribing systems in NHS hospitals in England: a questionnaire study

Objectives

To describe the plans of English NHS hospitals to implement ePrescribing systems.

Design and setting

Questionnaire-based survey of attendees of the National ePrescribing Forum.

Participants

A piloted questionnaire was distributed to all NHS and non-NHS hospital-based attendees. The questionnaire enquired about any completed or planned implementation of ePrescribing systems, the specific systems of interest, and functionality they offered.

Main outcome measures

Estimate of the number of NHS Trusts planning to implement ePrescribing systems.

Results

Ninety-one of the 166 questionnaires distributed to NHS hospital-based staff were completed and returned. Of those, six were incomplete, resulting in a total usable response rate of 51% (n = 85). Eighty-two percent (n = 46) of the 56 Trusts represented at the Forum were either ‘thinking of implementing’ or ‘currently implementing’ an ePrescribing system, such as Ascribe (13%, n = 7) and JAC (20%, n = 11). Forty percent (n = 22) of respondents specified other systems, including those procured by NHS Connecting for Health e.g. RiO, Lorenzo and Cerner. Knowledge support, decision support and computerized links to other elements of patients’ individual care records were the functionalities of greatest interest.

Conclusion

There is considerable reported interest and activity in implementing ePrescribing systems in hospitals across England. Whether such developments have the desired impact on improving the safety of prescribing is however, yet to be determined.

Computerized clinical decision support for prescribing: provision does not guarantee uptake

There is wide variability in the use and adoption of recommendations generated by computerized clinical decision support systems (CDSSs) despite the benefits they may bring to clinical practice. We conducted a systematic review to explore the barriers to, and facilitators of, CDSS uptake by physicians to guide prescribing decisions. We identified 58 studies by searching electronic databases (1990-2007). Factors impacting on CDSS use included: the availability of hardware, technical support and training; integration of the system into workflows; and the relevance and timeliness of the clinical messages. Further, systems that were endorsed by colleagues, minimized perceived threats to professional autonomy, and did not compromise doctor-patient interactions were accepted by users. Despite advances in technology and CDSS sophistication, most factors were consistently reported over time and across ambulatory and institutional settings. Such factors must be addressed when deploying CDSSs so that improvements in uptake, practice and patient outcomes may be achieved.

What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians

OBJECTIVES

To identify potential barriers and facilitators to implementing computerized decision support systems (CDSSs) in health care as perceived by clinicians.

METHODS

We carried out a qualitative focus group study with primary and secondary health care settings in six areas of Finland. A total of 39 interviewed physicians, of whom 22 practised in primary care and 17 in secondary care. The main outcome measures physicians' expectations, preconceived barriers and facilitators were explicitly identified by the participants during the interviews.

RESULTS

Identified barriers were earlier experience of dysfunctional computer systems in health care, potential harm to doctor-patient relationship, obscured responsibilities, threats to clinician's autonomy and potential extra workload due to excessive reminders. Identified facilitators were self-control of frequency and contents of CDSS and noticeable help of CDSS in clinical practice. It was easy for the physicians to think of applications and clinical topics for CDSS that could help them to avoid mistakes and improve work processes.

CONCLUSIONS

Physicians had relatively positive attitudes towards the idea of CDSS. They expected flexibility, individuality and reliability of the CDSS. The rather high level of computerized practices and wide use of electronic guidelines probably have paved the way for the CDSS in Finland.

Medication errors in older people with mental health problems: a review

OBJECTIVE

To review and summarise published data on medication errors in older people with mental health problems.

METHODS

A systematic review was conducted to identify studies that investigated medication errors in older people with mental health problems. MEDLINE, EMBASE, PHARMLINE, COCHRANE COLLABORATION and PsycINFO were searched electronically. Any studies identified were scrutinized for further references. The title, abstract or full text was systematically reviewed for relevance.

RESULTS

Data were extracted from eight studies. In total, information about 728 errors (459 administration, 248 prescribing, 7 dispensing, 12 transcribing, 2 unclassified) was available. The dataset related almost exclusively to inpatients, frequently involved non-psychotropics, and the majority of the errors were not serious.

CONCLUSIONS

Due to methodology issues it was impossible to calculate overall error rates. Future research should concentrate on serious errors within community settings, and clarify potential risk factors.

A mixed method study of the merits of e-prescribing drug alerts in primary care

OBJECTIVES

The objective of this paper was to describe primary care prescribers' perspectives on electronic prescribing drug alerts at the point of prescribing.

DESIGN

We used a mixed-method study which included clinician surveys (web-based and paper) and focus groups with prescribers and staff.

PARTICIPANTS

Prescribers (n = 157) working in one of 64 practices using 1 of 6 e-prescribing technologies in 6 US states completed the quantitative survey and 276 prescribers and staff participated in focus groups.

MEASUREMENTS

The study measures self-reported frequency of overriding of drug alerts; open-ended responses to: "What do you think of the drug alerts your software generates for you?"

RESULTS

More than 40% of prescribers indicated they override drug-drug interactions most of the time or always (range by e-prescribing system, 25% to 50%). Participants indicated that the software and the interaction alerts were beneficial to patient safety and valued seeing drug-drug interactions for medications prescribed by others. However, they noted that alerts are too sensitive and often unnecessary. Participant suggestions included: (1) run drug alerts on an active medication list and (2) allow prescribers to set the threshold for severity of alerts.

CONCLUSIONS

Primary care prescribers recognize the patient safety value of drug prescribing alerts embedded within electronic prescribing software. Improvements to increase specificity and reduce alert overload are needed.