Non-dispensing pharmacist integrated in the primary care team: effect on the quality of physician's prescribing, a non-randomised comparative study.

Background Especially in elderly with polypharmacy, medication can do harm. Clinical pharmacists integrated in primary care teams might improve quality of pharmaceutical care. Objective To assess the effect of non-dispensing clinical pharmacists integrated in primary care teams on general practitioners' prescribing quality. Setting This study was conducted in 25 primary care practices in the Netherlands. Methods Non-randomised, controlled, multi-centre, complex intervention study with pre-post comparison. First, we identified potential prescribing quality indicators from the literature and assessed their feasibility, validity, acceptability, reliability and sensitivity to change. Also, an expert panel assessed the indicators' health impact. Next, using the final set of indicators, we measured the quality of prescribing in practices where non-dispensing pharmacists were integrated in the team (intervention group) compared to usual care (two control groups). Data were extracted anonymously from the healthcare records. Comparisons were made using mixed models correcting for potential confounders. Main outcome measure Quality of prescribing, measured with prescribing quality indicators. Results Of 388 eligible indicators reported in the literature we selected 8. In addition, two more indicators relevant for Dutch general practice were formulated by an expert panel. Scores on all 10 indicators improved in the intervention group after introduction of the non-dispensing pharmacist. However, when compared to control groups, prescribing quality improved solely on the indicator measuring monitoring of the renal function in patients using antihypertensive medication: relative risk of a monitored renal function in the intervention group compared to usual care: 1.03 (95% CI 1.01-1.05, p-value 0.010) and compared to usual care plus: 1.04 (1.01-1.06, p-value 0.004). Conclusion This study did not demonstrate a consistent effect of the introduction of non-dispensing clinical pharmacists in the primary care team on the quality of physician's prescribing.This study is part of the POINT-study, which was registered at The Netherlands National Trial Register with trial registration number NTR-4389.

Association Between Workarounds and Medication Administration Errors in Bar Code-Assisted Medication Administration: Protocol of a Multicenter Study.

BACKGROUND: Information technology-based methods such as bar code-assisted medication administration (BCMA) systems have the potential to reduce medication administration errors (MAEs) in hospitalized patients. In practice, however, systems are often not used as intended, leading to workarounds. Workarounds may result in MAEs that may harm patients. OBJECTIVE: The primary aim is to study the association of workarounds with MAEs in the BCMA process. Second, we will determine the frequency and type of workarounds and MAEs and explore the potential risk factors (determinants) for workarounds. METHODS: This is a multicenter prospective study on internal medicine and surgical wards of 4 Dutch hospitals using BCMA systems to administer medication. We will include a total of 6000 individual drug administrations using direct observation to collect data. RESULTS: The project was funded in 2014 and enrollment was completed at the end of 2016. Data analysis is under way and the first results are expected to be submitted for publication at the end of 2017. CONCLUSIONS: If an association between workarounds and MAEs is established, this information can be used to reduce the frequency of MAEs. Information on determinants of workarounds can aid in a focused approach to reduce workarounds and thus increase patient safety. TRIAL REGISTRATION: Netherlands Trial Register NTR4355; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4355 (Archived by WebCite at http://www.webcitation.org/6pqTLxc6i).

Risk analysis and user satisfaction after implementation of computerized physician order entry in Dutch hospitals.

BACKGROUND: Computerized physician order entry (CPOE) in hospitals is widely considered to be important for patient safety, but implementation is lagging behind and user satisfaction is often low. Risk analysis methods may improve the implementation process and thus user satisfaction. Objective The aim of our study was to determine the association of performing risk analysis with user satisfaction after implementation of CPOE. Setting All hospitals in the Netherlands. METHOD: A cross-sectional study using a questionnaire was performed. All Dutch hospital pharmacies were asked about the extent of implementation of CPOE in the hospitals they served, the performance of (retrospective or prospective) risk analysis and the satisfaction with CPOE of doctors, nurses and pharmacists. Only hospitals that had implemented inpatient CPOE on at least 70 % of the wards were included in the primary analysis. MAIN OUTCOME MEASURE: The primary outcome measure was the proportion of hospital pharmacists with a satisfaction level of 4 or 5 (i.e. 'satisfied'). The secondary outcome measure was the proportion of medical doctors and nurses with a satisfaction level of 4 or 5 (i.e. satisfied). The main determinant was the performance of a formal method of prospective or retrospective risk analysis. RESULTS: The questionnaire was sent to all 79 Dutch hospital pharmacies. Questionnaires were returned by 70 hospital pharmacies, serving 72 separate hospitals. In 40 hospitals the CPOE was implemented on at least 70 % of the wards. The association of risk analysis with the proportion of satisfied users was determined within this group of 40 hospitals. For hospital pharmacists we found that the performance of risk analysis showed a statistically non-significant trend towards an association with satisfaction [OR 3.3 (95 % CI 0.8-14.1)]. For medical doctors the performance of risk analysis was associated with satisfaction [OR 10.0 (95 % CI 1.8-56.0)]. Also a statistically non-significant trend towards an association with satisfaction was found for nurses [OR 4.5 (95 % CI 0.8-24.7)]. CONCLUSION: Although not statistically significant, the user satisfaction with CPOE seems to be associated with the performance of risk analysis during the implementation of CPOE. This suggests that the CPOE implementation process can be optimized by performing risk analysis before and/or after implementation.

Preventing hospital admissions by reviewing medication (PHARM) in primary care: design of the cluster randomised, controlled, multi-centre PHARM-study.

BACKGROUND: Medication can be effective but can also be harmful and even cause hospital admissions. Medication review or pharmacotherapy review has often been proposed as a solution to prevent these admissions and to improve the effectiveness and safety of pharmacotherapy. However, most published randomised controlled trials on pharmacotherapy reviews showed no or little effect on morbidity and mortality. Therefore we designed the PHARM (Preventing Hospital Admissions by Reviewing Medication)-study with the objective to study the effect of the total pharmaceutical care process on medication related hospital admissions and on adverse drug events, survival and quality of life. METHODS/DESIGN: The PHARM-study is designed as a cluster randomised, controlled, multi-centre study in an integrated primary care setting. Patients with a high risk of a medication related hospital admission are included in the study with randomisation at GP (general practitioner) level. We aim to include 14200 patients, 7100 in each arm, from at least 142 pharmacy practices.The intervention consists of a patient-centred, structured, pharmaceutical care process. This process consists of several steps, is continuous and occurs over multiple encounters of patients and clinicians. The steps of this pharmaceutical care process are a pharmaceutical anamnesis, a review of the patient's pharmacotherapy, the formulation and execution of a pharmaceutical care plan combined with the monitoring and follow up evaluation of the care plan and pharmacotherapy. The patient's own pharmacist and GP carry out the intervention. The control group receives usual care.The primary outcome of the study is the frequency of hospital admissions related to medication within the study period of 12 months of each patient. The secondary outcomes are survival, quality of life, adverse drug events and severe adverse drug events. The outcomes will be analysed by using mixed-effects Cox models. DISCUSSION: The PHARM-study is one of the largest controlled trials to study the effectiveness of the total pharmaceutical care process. The study should therefore provide evidence as to whether such a pharmaceutical care process should be implemented in the primary care setting. TRIAL NUMBER: NTR 2647.