Success in scaling up improvement

In April, our Scaling Up Improvement funding programme opens for applications. The programme supports teams to take successful health care improvement interventions and deliver them at a larger scale. PINCER is ‘A pharmacist-led information technology intervention to reduce medication errors in general practice’. The PINCER project set out to scale up a pharmacist-led intervention to 150 GPs in the East Midlands. We spoke to Project Manager Tony Panayiotidis to find out more.

What is the PINCER intervention?

PINCER aims to reduce prescribing errors in general practice – ultimately reducing medication-related hospital admissions. Under the PINCER programme, around 2.9 million patient records have been analysed for prescribing errors – it’s working on a huge scale.

This type of analysis can be done through clinical audits and in general practice most are run by GPs or administrative staff. But this intervention is led by local teams of primary care pharmacists and pharmacy technicians.

A search is run on the GP clinical system looking at 11 indicators that can help to determine if prescribing is safe. The search identifies potentially hazardous prescribing. The pharmacists then review the patient notes using their clinical judgement to assess the risk and the appropriate actions needed to address the issues identified. The next steps are key to the success of the intervention. The pharmacists apply root cause analysis which helps to identify the circumstances that led to the potential risk and then feedback their findings to the practice. Together with the practice, they build an action plan to protect those patients at risk and work on any system issues which resulted in those risks occurring.

For example, the pharmacist might identify a patient, John, who is at risk of a gastro-intestinal bleed, because he is over the age of 65 and taking a long-term NSAID (non-selective non-steroidal anti-inflammatory drug), but hasn’t been prescribed anything to protect his stomach. They can then talk to the practice about what to do to protect John and the systems that need to be in place to prevent this from happening from anyone else.

The pharmacists are using information technology tools designed by PRIMIS, a business unit at the University of Nottingham. The search tool used within the practice can also populate comparison charts which allow clinical commissioning groups (CCGs) to see the changes in the numbers of patients at risk over time and the impact of the pharmacist intervention.

Before we started the roll out, we had already demonstrated, in a paper published in The Lancet, that the intervention reduced the numbers of patients at risk of medication errors and that it was cost-effective and acceptable to practices and pharmacists.

You planned to roll out the intervention to around 150 general practices in the East Midlands. How did it go?

We have made excellent progress and the project has exceeded its original aim to roll out PINCER to at least 150 practices in the East Midlands, while evaluating its implementation and effects on prescribing safety.

Since September 2015, PINCER has been implemented in 362 practices in 12 CCGs which is equivalent to 93% of eligible practices. We expect practice uptake to increase further by end of the project.

The pharmacy teams and general practices have worked effectively to implement PINCER, balancing their other duties and priorities, and sharing learning through existing structures such as the East Midlands Medicines Management Group.

What do you think made the programme so successful?

Firstly, the pharmacists have really taken it on board. They love the PINCER intervention because it’s about patient safety and allows them to use their clinical skills. The GPs like it because they’re getting the support from the pharmacists to both improve patient safety and the safety systems within their practice

The CCGs are supportive because the intervention is evidence-based and they are able to clearly see improvements in patient safety across their practices. We also had early engagement with the CCGs, along with the East Midlands Academic Health Science Network.

The primary care pharmacist teams have worked collaboratively across the participating CCGs, sharing their learning and experience with each other, while the implementation team has provided ongoing support and information.

What are the next steps for PINCER?

The people on board – the CCGs, the practices and the pharmacists – are happy to continue using PINCER and we are taking steps to make it happen. We are also exploring different models for further scale and spread. We plan to hold a show case event in October this year for those involved in the project and those who might be interested in PINCER

We have further grant money from the National Institute for Health Research for a more detailed evaluation of the implementation to see whether PINCER leads to reduced hospital admissions and death.

You can find out more about the PINCER project on the PRIMIS website.

Applications for the next round of our Scaling Up Improvement funding programme open on 3 April 2017.