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

OBJECTIVE: The authors sought to identify ways in which the use of general practice computer systems could be improved to enhance safety in primary care. DESIGN: Qualitative study using semistructured interviews. PARTICIPANTS: Thirty one participants, representing a broad range of relevant disciplines and interest groups. Participants included clinicians, computer system and drug database suppliers, academics with interests in health informatics and members of governmental, professional and patient representative bodies. SETTING: UK. RESULTS: Participants identified deficiencies in current systems that pose serious threats to patient safety. To bring about improvements, providers need to supply clinicians with safe, accurate and accessible information for decision support; be aware of the importance of human ergonomics in the design of hazard alerts; consider the value of audit trails and develop mechanisms to allow for the accurate transfer of information between clinical computer systems. These improvements in computer systems will be most likely to occur if mandated through regulations. Individual practices are in need of improved education and training which focuses, in particular, on providing support with recording data accurately and using call, recall and reminders effectively. CONCLUSION: There are significant opportunities for improving the safety of general practice computer systems. Priorities include improving the knowledge base for clinical decision support, paying greater attention to human ergonomics in system design, improved staff training and the introduction of new regulations mandating system suppliers to satisfy essential safety requirements.

Feasibility study to inform the design of a UK multi-centre randomised controlled trial of prophylactic antibiotics for the prevention of recurrent cellulitis of the leg.

BACKGROUND: This paper describes the results of a feasibility study for a randomised controlled trial (RCT). METHODS: Twenty-nine members of the UK Dermatology Clinical Trials Network (UK DCTN) expressed an interest in recruiting for this study. Of these, 17 obtained full ethics and Research & Development (R&D) approval, and 15 successfully recruited patients into the study. A total of 70 participants with a diagnosis of cellulitis of the leg were enrolled over a 5-month period. These participants were largely recruited from medical admissions wards, although some were identified from dermatology, orthopaedic, geriatric and general surgery wards. Data were collected on patient demographics, clinical features and willingness to take part in a future RCT. RESULTS: Despite being a relatively common condition, cellulitis patients were difficult to locate through our network of UK DCTN clinicians. This was largely because patients were rarely seen by dermatologists, and admissions were not co-ordinated centrally. In addition, the impact of the proposed exclusion criteria was high; only 26 (37%) of those enrolled in the study fulfilled all of the inclusion criteria for the subsequent RCT, and were willing to be randomised to treatment. Of the 70 participants identified during the study as having cellulitis of the leg (as confirmed by a dermatologist), only 59 (84%) had all 3 of the defining features of: i) erythema, ii) oedema, and iii) warmth with acute pain/tenderness upon examination. Twenty-two (32%) patients experienced a previous episode of cellulitis within the last 3 years. The median time to recurrence (estimated as the time since the most recent previous attack) was 205 days (95% CI 102 to 308). Service users were generally supportive of the trial, although several expressed concerns about taking antibiotics for lengthy periods, and felt that multiple morbidity/old age would limit entry into a 3-year study. CONCLUSION: This pilot study has been crucial in highlighting some key issues for the conduct of a future RCT. As a result of these findings, changes have been made to i) the planned recruitment strategy, ii) the proposed inclusion criteria and ii) the definition of cellulitis for use in the future trial.

Identifying and establishing consensus on the most important safety features of GP computer systems: e-Delphi study.

Our objective was to identify and establish consensus on the most important safety features of GP computer systems, with a particular emphasis on medicines management. We used a two-round electronic Delphi survey, completed by a 21-member multidisciplinary expert panel, all from the UK. The main outcome measure was percentage agreement of the panel members on the importance of the presence of a number of different safety features (presented as clinical statements) on GP computer systems. We found 90% or greater agreement on the importance of 32 (58%) statements. These statements, indicating issues considered to be of considerable importance (rated as important or very important), related to: computerised alerts; the need to avoid spurious alerts; making it difficult to override critical alerts; having audit trails of such overrides; support for safe repeat prescribing; effective computer-user interface; importance of call and recall management; and the need to be able to run safety reports. The high level of agreement among the expert panel members indicates clear themes and priorities that need to be addressed in any further improvement of safety features in primary care computing systems.

A randomized controlled trial of the effect of providing information on accidental injury admissions and their costs to Primary Care Groups and Trusts.

BACKGROUND: Primary Care Groups and Trusts (PCG/Ts) are responsible for improving the health of local populations, but there is little evidence of their strategic involvement in accident prevention. OBJECTIVE: To determine the effect of providing information on local accidental injuries to PCG/Ts on the development of accident prevention strategies. METHODS: The study is a randomized controlled trial in PCG/Ts in the former Trent Region. Intervention PCG/Ts were sent profiles containing PCG/T specific information on hospital admissions for accidental injury and their costs and on accident prevention interventions. Health promotion leads were surveyed at baseline and three and fifteen months. The primary outcome was whether the PCG/T had a written accident prevention strategy. Secondary outcome measures included other accident prevention activities, prioritization of accident prevention, and knowledge and attitudes towards accident prevention. RESULTS: At three months 38% of PCG/Ts in the intervention arm had a written accident prevention strategy, compared with 42% in the control arm [difference -4%, 95% confidence interval (CI) -31% to 25%]. At fifteen months these values were 55% in the intervention arm and 50% in the control arm (difference 5%, CI -24% to 33%). There were no statistically significant differences between the groups for any outcome measures. CONCLUSIONS: Providing profiles containing information on accidental injuries to PCG/Ts did not significantly increase the development of accident prevention strategies, however this study only had sufficient power to detect substantial changes. Larger national studies would be required to detect moderate effects of tailored packages in changing PCG/T behaviour.

Accidental injury: a neglected area within Primary Care Groups and Trusts?

Our objective was to assess accidental injury prevention activity within Primary Care Groups/Trusts (PCG/Ts), and current knowledge and attitudes towards accidental injuries and their prevention amongst PCG/T board members. We used a cross-sectional postal questionnaire survey design. Participants were board members of 51 PCG/Ts in Trent. The main outcome measures were prioritization of accidental injury prevention and factors influencing prioritization, perceptions of the accidental injury rates in the population served by the PCG/T, accidental injury prevention activity undertaken by the PCG/T, attitudes towards accidental injury prevention and towards the PCG/Ts involvement in accidental injury prevention, knowledge of accidental injury mortality, and beliefs in the effectiveness of interventions. Many (66%) PCG/T board members see accident prevention as the least important of the priority areas in the Government's health strategy for England. Half the PCG/Ts (49%) had formally discussed accidents at a PCG/T meeting, 34% had taken action and 29% had written an accident prevention strategy. The median number of agencies PCG/Ts were working with on accident prevention was 2. GPs held less positive attitudes about accident prevention than other board members (Z = -10.01, P < 0.001), but had a greater knowledge about injury mortality (Z = -3.92, P < 0.001). Health promotion leads had more positive attitudes towards accident prevention than other board members (Z = -3.70, P < 0.001). There were misconceptions amongst health promotion leads about the effectiveness of some accident prevention interventions. We conclude that there is little evidence of prioritization of accidents as an area for health improvement. Although some PCG/Ts are undertaking accidental injury prevention, a minority have demonstrated strategic planning with respect to accident prevention or collaboration with a wide range of agencies. Accident prevention and the PCG/Ts role within this are not viewed positively by all board members. Gaps in knowledge about accidents and their prevention are apparent. PCG/Ts will need help and support to fully develop their potential in preventing accidental injuries.

Improving the safety features of general practice computer systems.

General practice computer systems already have a number of important safety features. However, there are problems in that general practitioners (GPs) have come to rely on hazard alerts when they are not foolproof. Furthermore, GPs do not know how to make best use of safety features on their systems. There are a number of solutions that could help to improve the safety features of general practice computer systems and also help to improve the abilities of healthcare professionals to use these safety features.