“PINCER is a really worthwhile intervention. It has led to complex reviews being carried out by GP’s facilitated by practice pharmacists, which will ultimately improve patient safety.”
Medicines Management Team

EMAHSN imageOverview

Prescribing errors in general practices are not common – but when they happen they can be expensive cause of safety incidents, illness, hospitalisation and even deaths.

Errors happen for a number of reasons but main causes include ‘contraindications’ (different drugs used together when they shouldn’t be), failure to take action on computer warnings, lack of appropriate monitoring and breakdown of safety systems.

A pharmacist-led information technology intervention for reducing clinically important errors in general practice prescribing (PINCER) was shown in a trial published in The Lancet to reduce error rates by up to 50%.  An economic analysis showed introducing PINCER was cost effective.

Following Health Foundation and EMAHSN funding and support PINCER has been scaled-up to general practices in the East Midlands using a large-scale Quality Improvement Collaborative (QIC) to implement and spread the intervention across Clinical Commissioning Groups (CCGs) resulting in safer prescribing in participating practices. This phase has been called PINCER 3, the main focus of which is to avoid harm by stopping or adding therapy to a patient’s prescription.

The PINCER scale-up so far has identified an estimated 21,636 instances of potentially dangerous prescriptions across 11 prescribing indicators – enabling action to be taken.

Challenge / problem identified

General practice prescribing error rates are estimated to be 5%, with serious errors affecting 1 in 500 of all prescription items.

Errors happen for a number of reasons but the main causes include ‘contraindications’ (different drugs used together when they shouldn’t be), failure to take action on computer warnings, lack of appropriate monitoring and breakdown of safety systems.

Actions taken

pincerThe teams involved review patients’ medication lists where potential prescribing errors have been identified, undertake root cause analysis to identify reasons why these may have occurred and implement changes in practice prescribing systems to prevent these potential errors recurring. This is done via PINCER.

Local teams of primary care pharmacists and pharmacy technicians:

  • Use software (PRIMIS*) to run a search on the GP clinical system to identify patients at risk of potentially hazardous prescribing.
  • Review the patient notes with GPs, using clinical judgement to assess the risk and the appropriate actions needed to address the issues identified.
  • Apply root cause analysis to identify the circumstances that led to the potential risk and then feedback 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.

*PRIMIS is a leading organisation in extracting knowledge and value from primary care data, helping to achieve better health outcomes across the UK. www.nottingham.ac.uk/primis/tools-chart/index.aspx  

EMAHSN have supported the scaling up of PINCER, along with the Health Foundation in order to evaluate the large-scale rollout of PINCER across the East Midlands over an 18 month period. The process has used a stepped-wedge study design – a form of randomised controlled trial that involves sequential but random rollout of an intervention over multiple time periods.

The QIC approach was used to implement the intervention whereby an expert team, using structured activities, engaged clinicians and pharmacy teams to effect improvement in specific areas of practice.

Support was provided in the form of education, feedback and opportunities for shared learning.  Improvement was measured using anonymised routinely recorded data from general practices collected retrospectively, at 3 monthly time points.

The data formed the basis of statistical process control charts which were used to provide feedback at both CCG and practice level.

Impacts / outcomes

  • Pharmacists and pharmacy technicians have worked with over 350 (approximately 95%) East Midlands GP practices in 12 CCGs to implement PINCER.
  • 2.9m patient records have been searched and 21,636 instances of potentially hazardous prescribing have been identified using 11 prescribing indicators – it is estimated that approximately half of these needed an intervention to avoid harm, cases that could otherwise have been missed.
  • For most participating CCGs, improvements have been noted for 8 of the 11 indicators; for 2 of the indicators all participating CCGs have improved.
  • Quarterly analysis of the data indicates that improvements to the safety systems are sustained by the practices, beyond the time of the pharmacy team intervention.
  • Economic analysis has shown the cost-effectiveness of the intervention. It’s demonstrated an overall reduction in costs of £2,679 per practice and an increase in quality of life of patients (0.81 Quality Adjusted Life Years per practice).
  • PINCER has now been incorporated into national guidelines to support medicines optimisation by NICE and NHS England.
  • The PINCER intervention has now rolled out to GP practices in other areas including:
    – 235 in Wessex
    – 82 in Wigan Borough
    – 32 in Southampton
    – 30 in Newscastle and Gateshead
    – 25 in Salford

East Midlands PINCER (002)

 “We are delighted that there has been such a strong take-up of the PINCER interventions by general practices in the East Midlands, and based on the initial findings we are confident this will in lead to improvements in patient safety.”
Professor Anthony J Avery, Dean and Head of School, School of Medicine, The University of Nottingham and Niro Siriwardena, Professor of Primary & Pre-Hospital Health Care, University of Lincoln

Plans for the future

  • The intention is to include all those practices that have implemented the PINCER intervention in the qualitative evaluation (n=361) – excluding those in NHS Rushcliffe CCG from the quantitative evaluation (n=11) due to the fact that they were involved in the piloting of the PINCER Query Library.
  • The PINCER team have engaged with the East Midlands Medicines Management forum which has widespread pharmacy team representation to discuss continuing PINCER.
  • With support from EMAHSN participating CCGs will gain extended access to the PINCER toolkit for a period of 12 months. Support from the Universities of Lincoln and Nottingham will also continue.
  •  Wessex AHSN are implementing the original PINCER 1 intervention (across 237 GP practices) and with the PINCER team and PRIMIS have delivered a series of training workshops to the Centre for Pharmacy Postgraduate Education (CPPE). The next phase for Wessex is to be an early adopter of PINCER 3.
  • 19 practices in Northern Ireland have also implemented PINCER 1.
  • Following discussions, several other AHSNs keen to take up PINCER and the team, supported by EMAHSN are sharing experiences and learning from this project to facilitate spread.
  • Conduct more detailed evaluation of PINCER rollout as part of 2.43m NIHR Programme Grant for Applied Research: Avoiding patient harm through the application of prescribing safety indicators in English general practices (PRoTeCT)

Which national clinical or policy priorities does this example address?

  • Care and Quality
  • Funding and Efficiency
  • Health and Well Being

Start and end dates

August 2015 – Ongoing

Contact us for help and advice

Tony Panayiotidis, Training Consultant and Account Manager
M: 07740 924 787
E: tony.panayiotidis@nottingham.ac.uk

Chris Taylor, East Midlands Academic Health Science Network
E: chris.taylor@nottingham.ac.uk

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