Main disease area impacted
Primary care
Project overview
Improving medication safety is a core objective for health care systems worldwide, and was recently identified by the World Health Organization (WHO) as the theme for the third Global Patient Safety Challenge. Medication safety research and quality improvement have traditionally focused on hospital-based settings, but there is clear evidence that medication errors are very common also in primary care and contribute to patient harm, despite the fact that individual items carry low risk. The sheer volume of primary care prescribing (over one billion prescription items supplied in the community in England each year) means that medication errors in primary care contribute to more than seven times more avoidable deaths than secondary care (627 versus 85). We have previously found that 5% of patients who are managed in general practices in the UK are exposed to potentially hazardous prescribing, and about 12% had no record of appropriate monitoring.
Information technology has long been recognised as having the potential to increase patient safety. Previous research conducted by the University of Nottingham demonstrated that medication safety in primary care can be improved by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners in a pharmacist-led intervention (the “PINCER” intervention). However, when based on a single feedback cycle, the effect of these interventions tends to wane over time. For this reason, we have developed a web-based, interactive dashboard application, called the Safety Medication dASHboard (SMASH) that delivers this audit and feedback intervention in a continuous fashion.
This work was conducted by the NIHR Greater Manchester Patient Safety Translational Research Centre (GM PSTRC).
START: 2014
END: Ongoing
Funded by:
NIHR Greater Manchester Patient Safety Translational Research Centre; NIHR Applied Research Collaboration Greater Manchester
Data Sources
The SMASH dashboard interrogates the electronic health record (EHR) database of general practices to identify patients who have been precribed a potentially hazardous drug (or combination of drugs), or who have been prescribed a drug and are subsequently not adequately monitored via blood tests. The dashboard was designed in collaboration with various stakeholders (pharmacists, GPs and a patient).
Overall, the SMASH intervention comprises three components. First, clinical pharmacists work in general practices as members of the practice team. They are trained to deliver the intervention and apply root cause analysis techniques to identify, explore, resolve and prevent medication errors in partnership with general practice staff. Many pharmacists work across several practices. Second, pharmacists and practice staff are given access to the dashboard which provides them with feedback on potentially hazardous prescribing and inadequete monitoring. The dashboard also provides practice-level summary data as well as educational material. Dashboard content (numbers and graphs) for each indicator are updated on a daily basis. Third, pharmacists review individual patients that trigger the indicators, and initiate remedial actions (e.g. ordering laboratory tests) or advise GPs on action plans (e.g. discontinuing medication; co-prescribing protective medication).
Methodology
Since 2015, the SMASH intervention has been deployed in all but one (n=43) general practices in Salford (population size, 251,300). All these practices are still using it. Thirty-six pharmacists were trained in delivering the intervention to practices. There are over 100 registered users of the dashboard, including pharmacists, GPs; GP staff; and CCG staff (in particular the medications management team at Salford CCG).
General practices received the intervention at different points in time, depending on the availability of trained pharmacists to help deliver this within the practices. Once a pharmacist was available, the practice controlled the precise date at which they would start the intervention. We used an interrupted time-series design to evaluate the impact of the intervention on medication safety in this “natural experiment”. We also interviewed pharmacists, GPS, and practice staff, and observed how they worked with the system, and we analysed usage logs of the SMASH dashboard.
In 2018, it was decided to roll out SMASH across all >500 general practices in Greater Manchester. This roll-out is led by Health Innovation Manchester and evaluated by the NIHR Applied Research Collaboration Greater Manchester (ARC-GM).
Benefits
Potentially, any patient in a practice that uses SMASH can benefit from the intervention, because it may prevent that they are prescribed a harmful drug (or combination of drugs), or not adequately monitored for the effects of drugs in their body.
Findings and outcomes
The intended outcome is sustained deployment of SMASH in all general practices across Greater Manchester, as well as clear evidence of its effectiveness. Furthermore, we aim to use SMASH to drive further improvement in medication safety in primary care in the future, by introducing new indicators in the dashboard.
Initially, Salford practices interacted with the dashboard 12 times per month, on average, to identify and resolve potential medication safety hazards, typically starting with the most prevalent hazards or those they perceived to be most serious. Having observed a potential hazard, pharmacists and practice staff worked together to resolve that in a sequence of steps (1) verifying the dashboard information, (2) reviewing the patient’s clinical records, and (3) deciding potential changes to the patient’s medicines. Over time, dashboard use transitioned towards regular but less frequent checks to identify and resolve new cases. The frequency of dashboard use was higher in practices with a larger number of iniitial at-risk patients. In 24 (56%) practices only pharmacists used the dashboard; in 12 (28%) use by other practice staff increased as pharmacist use declined after the initial intervention period; and in 7 (16%) there was mixed use by both pharmacists and practice staff over time.
The overall prevalence (proportion of patients with at least one medication safety hazard) in Salford primary care has dropped from 1979 (1st Jan 2015) to 882 (1st Oct 2018). For instance, the number of patients over 65 years that was prescribed an NSAID with co-presciption of gastro-protective medication, has dropped from 775 to 205. This is likely to have led to a reduction of a hospital admissions for gastro-intestinal bleeds. Detailed analyses are underway to estimated the precise reduction of hazardous prescribing and inadequeate blood-test monitoring over time, adjusting for existing trends.
The results from our qualitative evaluation have shown that SMASH has helped to establish and develop the role of clinical pharmacists in general practice. Pharmacists have become integrated into practice teams and the dashboard has built confidence and understanding of the value of clinical pharmacists’ professional role in general practice. Pharmacists felt the system helped to build respect and trust between themselves and GPs. Overall, this has provided pharmacists with new career opportunities.
Publications
Williams R, Keers R, Gude WT, Jeffries M, Davies C, Brown B, Kontopantelis E, Avery AJ, Ashcroft DM, Peek N. SMASH! The Salford medication safety dashboard. J Innov Health Inform. 2018;25(3):183–193.
https://pubmed.ncbi.nlm.nih.gov/30398462/
Jeffries M, Keers RN, Phipps DL, Williams R, Brown B, Avery AJ, et al. (2018) Developing a learning health system: Insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care. PLoS ONE 13 (10): e0205419.
https://pubmed.ncbi.nlm.nih.gov/30365508/
Jeffries M, Gude WT, Keers RN, Phipps DL, Williams R, Kontopantelis E, Brown B, Avery AJ, Peek N, Ashcroft DM. Understanding the utilisation of a novel interactive electronic medication safety dashboard in general practice: a mixed methods study. BMC Med Inform Decis Mak. 2020 Apr 17;20(1):69. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164282/
Researchers involved
Mr Richard Williams, Dr Louise Laverty,
Prof Darren Ashcroft, Dr Richard Keers,
Prof Niels Peek, Dr Ben Brown,
Dr Mark Jeffries, Dr Wouter Gude,
Prof Tony Avery, Prof Evangelos Kontopantelis,
Dr Denham Phipps