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Background: Hospital pharmacists play an essential role in patient care; however, a lack of resources means pharmacists are unable to review all patients daily. Consequently, there is a demand for reliable screening tools to allocate care to patients with urgent and/or complex pharmaceutical needs. Several tools have been developed, but no broad consensus exists on the design of a screening tool to be used in the adult hospital setting.Objective: To obtain expert consensus on the design of a pharmaceutical care complexity screening tool for use on admission to hospital.Methods: Two Delphi studies were conducted: the first sought to gain consensus from experts including pharmacists, academics and physicians on the components of a pharmaceutical complexity tool, the second to achieve consensus from UK chief pharmacists and clinical service pharmacy managers on the clinical appropriateness and practicality of the tool. Tool components and Delphi statements were identified and refined from our previous systematic review, UK survey and interview study of prioritisation tools. A valid definition for consensus was used.Results: Over 300 components were extracted from the interview data and systematic review and then refined for inclusion in the first Delphi study. Thirty-three experts completed Delphi One and consensus was reached on 92 components. Components were grouped into demographic, clinical and medication components and condensed to 33 items, which were included in the first draft of the Adult Complexity Tool for Pharmaceutical Care (ACTPC). The tool stratified patients into highly, moderately or least complex. Forty expert panellists completed Delphi Two and consensus was reached on review frequency and experience of pharmacy practitioner at each level. These decisions were incorporated into the final version of the ACTPC.Conclusions: The ACTPC is the first systematically designed and internationally agreed tool for use on medical admission to hospital. It has potential to enable the delivery of targeted patient-centred pharmaceutical care. [ABSTRACT FROM AUTHOR]

Background: The prescribing process for children with cancer is complex, and errors can occur at any step. As a result, many interventions have been used to reduce errors. However, few of them have been designed based on an understanding of the prescriber behaviour that can lead to errors. In order to design effective behaviour change interventions, it is important first to understand the prescribing process and identify prescriber behaviours that could be targeted for change.Objectives: To describe the prescribing process in a paediatric oncology ward and to identify prescriber behaviours during prescription writing that could be targeted to reduce errors.Methods: This study employed two sequential phases. First, the prescribing process was observed and then described using the hierarchical task analysis (HTA) method. Second, prescriber tasks identified from the HTA were analysed using the behaviour change wheel (BCW) approach to identify promising behaviours for change. These identified behaviours were prioritised based on information collected from four focus groups with prescribers and chart review of errors made in the ward.Results: The prescribing process was complex and involved multiple tasks performed in varying orders. Applying the BCW identified thirty-two candidate behaviours for potentially reducing prescribing errors. However, after prioritization, only two emerged as promising candidate behaviours for intervention: writing drug indications at the time of prescribing and using a pre-written order when ordering medications through electronic prescribing.Conclusions: This research suggests that two behaviours could be promising in reducing errors. Having identified these behaviours, future work could explore what needs to change with respect to individuals and their work environments to achieve the desired change in these identified behaviours. [ABSTRACT FROM AUTHOR]

Background: Emergency Department Pharmacist Practitioners (EDPPs) undertake both 'traditional' clinical pharmacy work, e.g. check prescriptions, and 'practitioner' work, e.g. perform clinical examinations. A recent study found a large variation in the extent and type of care provided. Whilst variation allows services to be tailored to local needs, it is important that care meets the minimum standards that are safe, effective, patient-centred, timely, efficient, and equitable.Objective(s): To develop an EDPP service specification based on views of professional and patient stakeholders, primarily to support providers with delivery of high quality services.Methods: Patients, ED pharmacists and other ED healthcare professionals developed standards guided by the Institute of Medicine's quality domains. A panel of six ED pharmacists suggested and agreed on themes that should be included in the service specification. Additional themes were identified through interviews with eight patients who had been cared for by EDPPs as to their expectations of the service. Finally, a multidisciplinary expert panel of healthcare professionals and researchers reviewed and refined the service specification.Results: ED pharmacists developed 36 themes with consensus achieved for 25. Additional themes from the patient interviews concerned the communication and behaviour of EDPPs rather than specific clinical activities undertaken. Whilst patients were happy to be cared for by an EDPP working within their competence, for certain conditions (e.g. major trauma) they wanted a doctor as their main care provider. An evidence-based EDPP service specification of 52 criteria grouped into 4 categories was produced: direct patient care (29); other activities (10); general approach (10); and service structures (3).Conclusions: As the product of both patient and expert input, EDs could align existing or newly developed services to the specification. Whether or not the specification actually improves the quality of EDPP services requires investigation, as does the absolute quality impact of services. [ABSTRACT FROM AUTHOR]

Background: In the UK, non-medical prescribers (NMPs) are a significant part of the healthcare workforce. Little is known about their self-efficacy when prescribing, and their willingness to take responsibility for prescribing decisions.Objective: To explore the perceptions of NMPs regarding their self-efficacy in prescribing and responsibility for prescribing decisions.Methods: Cross-sectional survey of a purposive sample of NMPs on acute medical units (AMUs) across the UK. Bandura's Social Cognitive Theory informed the self-efficacy aspect of the questionnaire. Participants' views were also sought on responsibility for prescribing decisions. For quantitative data descriptive statistics were calculated. Hierarchical multiple linear regressions determined whether five independent variables improved the prediction of self-efficacy in aspects of prescribing: NMP's profession; length of time qualified as a healthcare professional and as an NMP; the number of items prescribed and hours worked per week on an AMU. Framework analysis was used to analyse the qualitative data.Results: Ninety-nine valid responses were obtained. Self-efficacy overall was high. The longer the participant had been qualified as an NMP was associated with increased self-efficacy in certain aspects of prescribing. All physiotherapists, and more nurses than pharmacists were responsible for prescribing decisions. Where participants were not fully responsible, the responsibility was partial or shared.Conclusions: Self-efficacy of NMPs when prescribing is influenced by several factors. The variables within this study appear to account for only a small part of this self-efficacy. Self-efficacy in prescribing appears to contribute to NMPs' willingness to take responsibility for prescribing decisions; further influenced by their job role and the prescribing this entails. Stakeholders need to appreciate the full range of factors that influence the self-efficacy of NMPs when prescribing, and the association of this to take responsibility for prescribing decisions. This knowledge will assist in maximising the benefits of non-medical prescribing within the healthcare system. [ABSTRACT FROM AUTHOR]

Introduction: While many attempts have been made to reduce prescribing errors (PEs), they persist. PE is not in itself a behaviour, but a consequence of a prescribing behaviour. Interventions aimed at prescribers should focus on understanding prescribers' behaviours.Objectives: The aim of this study was to use the capability, opportunity, motivation - behaviour (COM-B) model to explore the behaviours that could have caused PEs made by senior doctors in a speciality paediatric inpatient ward.Methods: A qualitative approach was used to investigate prescribers' behaviours in a 26-bed paediatric oncology ward. Error data were collected over a two-month period and were presented during focus groups with prescribers, which were audio-recorded and transcribed verbatim. Thematic analysis was used to identify contributory factors to errors, which was used to identify sources of behaviours using the COM-B model.Results: Behaviours related to prescribers' capabilities were: prescribers' improper use of the software because of insufficient skills, and prescribers' inability to prescribe correctly because of lack of knowledge. Behaviours related to opportunities in the environment were: prescribers' inability to make an informed decision because of poor access to patient information, inability to properly complete a task because of heavy workload and interruption, and having to re-check doses frequently because of frequent change in patients' weight and surface area. Those related to motivation were: prescribers unquestioningly following recommendations and not communicating with other specialists because they over-trusted them or feared a negative reaction, and prescribers inability to complete a task because of other competing and preferable tasks at the same time.Conclusion: Employing COM-B helped in identifying causes of PEs from a new perspective. Future work could focus on mapping identified sources of behaviour and errors against appropriate intervention functions and policies in order to design more successful interventions. [ABSTRACT FROM AUTHOR]

Background: Doctors at all levels make prescribing errors which can prolong patients' hospital stay, increase the risk of death, and place a significant financial burden on the health system. Doctors have previously reported receiving little or no feedback on their prescribing errors. The effectiveness of feedback in modifying future practice varies widely, depending on how feedback is delivered. To date there is little evidence about why and how feedback interventions do or do not work. Behavioural theories can be used to evaluate this process and provide explanatory accounts to inform recommendations for future interventions.Objective: To explore the experiences of prescribers receiving different methods of feedback about their prescribing errors. Perceptual Control Theory (PCT) was used as a theoretical framework to explain which aspects of feedback were most likely to influence prescribing behaviour.Methods: A secondary analysis of 31 semi-structured qualitative interviews with junior doctors who had taken part one of three studies in which they received feedback on their prescribing errors. A hybrid approach to analysis involved inductive thematic analysis, and deductive a priori template of codes using PCT as a framework to guide data analysis and interpretation.Results: Feedback was most useful for learning and most likely to influence future prescribing behaviour when it was timely, and provided a comprehensive, contextualised benchmark to which participants could compare their prescribing behaviours and current level of knowledge. Group discussions and completing directly-observed prescribing event forms were thought most likely to impact future prescribing; email feedback alone was perceived as least effective in changing prescribing behaviour.Conclusion: Feedback has the potential to change future prescribing behaviour. Behaviour change can only take place if prescribers are made aware of these discrepancies, either via providing appropriate reference values or benchmarks before mistakes are made, or by providing timely and comprehensive feedback after mistakes are made. [ABSTRACT FROM AUTHOR]

Background: Prescribing is a complex and error-prone task that demands expertise. McLellan et al.'s theory of expertise development model ("the model"), developed to assess medical literature on prescribing by medical students, proposes that in order to develop, individuals should deliberately engage their knowledge, skills and attitudes within a social context. Its applicability to independent prescribers (IP) is unknown.Aim: A systematic review was conducted to explore whether the model is applicable to non-medical independent prescribing and to assess the factors underpinning expertise development reported in the literature.Method: Six electronic databases (EMBASE, Medline, AMED, CINAHL, IPA and PsychInfo) were searched for articles published between 2006 and 2016, reporting empirical data on pharmacist and nurse IPs education or practice. Data were extracted using themes from the model and analysed using framework analysis.Results: Thirty-four studies met the inclusion criteria. Knowledge, pre-registration education, experience, support and confidence were some of the intrinsic and extrinsic factors influencing IPs. Difficulty in transferring theory to practice was attributed to lack of basic pharmacology and bioscience content in pre-registration nursing rather than the prescribing programme. Students saw interventions using virtual learning or learning in practice as more useful with long-term benefits e.g. students were able to use their skills in history taking following the virtual learning intervention 6-months after the programme. All studies demonstrated how engaging knowledge and skills affected individuals' attitude by, for example, increasing professional dignity. IPs were able to develop their expertise when integrating their competencies in a workplace context with support from colleagues and adherence to guidelines.Conclusion: This is the first study to synthesize data systematically on expertise development from studies on IPs using the model. The model showed the need for stronger foundations in scientific knowledge amongst some IPs, where continuous workplace practice can improve skills and strengthen attitudes. This could facilitate a smoother transfer of learnt theory to practice, in order for IPs to be experts within their fields and not merely adequately competent. [ABSTRACT FROM AUTHOR]

Background: There is evidence that the transfer of information on medication changes on patient discharge summaries is poor. By considering the completion of an electronic discharge summary as a behavior, the various components of the behavior can be targeted to improve their completion so that they consistently include information on medication changes.Objectives: Study objectives were to identify the barriers and facilitators to junior doctors completing information on medication changes on electronic discharge summaries, including why these occurred.Methods: In this qualitative study, 12 semi-structured interviews were conducted with junior doctors. An interview topic guide based around the COM-B model (Capability, Opportunity, Motivation, Behavior) within the Behavior Change Wheel (BCW) was used. Transcripts of the interviews were analyzed using framework analysis to identify key categories emerging from the data. Barriers and facilitators to completing information on medication changes on discharge summaries were identified. These were then mapped to behavioral components within the COM-B model to help design tailored interventions to affect change.Results: Nine categories were identified that encompassed the identified barriers and facilitators. The identified barriers and facilitators influenced all aspects of the COM-B model.Conclusions: Use of the BCW as a theoretical lens for this study enabled interventions to be identified that targeted specific components of behavior. It is the implementation of all these interventions that may be required to influence behavior change and ensure all electronic discharge summaries contain information on medication changes. All intervention functions were relevant but key functions were education, enablement and persuasion. Other institutions can use the BCW and the COM-B model to develop their own tailored interventions to achieve these functions. [ABSTRACT FROM AUTHOR]

Background The use of electronic patient records (EPR) and electronic prescribing systems (such as electronic patient medication and administration records (EPMAR)) have many benefits. Changes and problems can result, however. Anecdotally, how pharmacists respond to system introduction varies greatly; there is very little information regarding pharmacists' experience in the literature. Objectives This study aimed to establish the changes that electronic systems afforded to hospital pharmacists' working practices and to investigate how and why they had responded to EPR and EPMAR. Methods Four semi-structured focus groups were conducted with pharmacists with different levels of seniority, with 4–6 participants in each. The focus groups were held 8 months after implementation of EPR and EPMAR were complete, and each focus group met once. Transcripts were analyzed manually using thematic analysis and data interpreted through the application of Actor Network Theory (ANT) and human activity systems as described in Engestrom's Expansive Learning Theory (ELT). Results The three main overarching themes identified involved reduced patient contact, professional representation in the clinical environment and documentation in the EPR. Pharmacists felt less visible to, and had poorer relationships with, patients as they no longer saw them when they checked prescriptions. Interprofessional relationships changed as pharmacists provided informal EPMAR training for doctors and spoke more often with nurses to relay important information. Changes in whether, what and how pharmacists recorded information also were seen, particularly between pharmacists of different generations and years of working at the hospital. Analysis of the changes afforded by electronic systems using ANT and ELT suggest that pharmacists develop individual working practices in response to changes that electronic systems provide. Conclusion For implementation success of EPR and EPMAR systems, pharmacists need to be taught not just the practicalities of system use, but also how to ensure that patients remain the focus of care, in response to the professional changes that may well occur following computerization. [ABSTRACT FROM AUTHOR]

Abstract: Background: A shared electronic medical record (EMR) can improve communication between primary and secondary care. A consideration of the contents using Data-Information-Knowledge-Wisdom (DIKW) hierarchy could help inform further development of such systems regarding communication about prescribed medication. Objectives: To investigate primary and secondary care doctors' experiences of the shared EMR in Uppsala, Sweden, focusing on the creation, use and cross-sector transfer of data, information, knowledge and wisdom about individual patients' prescribed medication. Method: Nine focus groups were held with hospital doctors, of different grades and medical specialties, working at a single large teaching hospital in Uppsala, Sweden and primary care doctors worked in the same geographical area, in urban and rural primary care centers. The transcribed data were analyzed used the constant comparative method, based on data from the participants and application of the DIKW hierarchy. Results: The doctors were very positive about accessing and using the shared EMR. Data and information in the system were efficiently retrieved and combined with newly collected data and information to create further knowledge. However, they also described a data and information overload, where it was difficult to get a general overview of what had happened over time, coupled with the frequent lack of knowledge being created and shared by other healthcare providers. Doctors were, instead, either explicitly asked or implicitly expected to read and interpret all available data and information and recreate knowledge themselves. Conclusions: This study highlighted the differences between access to data and information and access to knowledge in a shared EMR. In rolling out such a system, an increased availability of data and information should not be at the expense of a reduced availability of knowledge. [Copyright &y& Elsevier]

Abstract: Background: The influence of patient expectations and demands on the decisions of prescribers in general practice has been associated with irrational prescribing and lack of evidence-based practice. However, to our knowledge, no one has investigated patient pressure to prescribe in secondary care. Objectives: To investigate the influences on hospital prescribers'' decisions by exploring what they found uncomfortable when prescribing. Methods: Qualitative interviews with 48 prescribers of varying seniority from 4 hospitals were conducted. Interviews were based on the critical incident technique, and prescribers were asked, before an interview, to remember any uncomfortable prescribing decisions that they had made; these were then discussed in detail during an interview. This approach allowed the interviewer to explore the more general influences on the decision to prescribe. Interviews were tape recorded and transcribed verbatim. A grounded theory approach to data analysis was taken. Results: Prescribers discussed various factors that could provoke feelings of discomfort when prescribing. Pressure on the prescribing decision from patients, relatives, or carers was a major theme, and more than half of interviewees discussed discomfort caused by such perceived pressure on the prescribing decision. How prescribers dealt with this pressure varied with seniority and the type of relationship that they had fostered with the patient. Nearly half of all incidents of patient pressure resulted in the patient being prescribed the medication they requested. Yet, many of these requests were deemed inappropriate by the prescriber. Their reasons for capitulation varied but included maintaining a good prescriber-patient relationship and avoiding conflict in the wider health care team. Conclusions: Pressure from patients, relatives, or carers was an uncomfortable influence on these hospital prescribers'' prescribing decisions. Increasingly consumer-driven health care will intensify these issues in the future. We advocate further research, focusing on managing patient demands and improving prescribers'' coping strategies. [Copyright &y& Elsevier]

Abstract: Background: Qualitative research has shown that gaining control of medicine treatment and increased feelings of safety and empowerment are central concepts in patients'' perceptions of a pharmaceutical care (PC) service provided in Sweden. However, little is known about any unique differences among patients receiving PC versus standard pharmacy services (SSs) and the impact of these services on patient-perceived outcomes. Objective: To describe and compare patients who had previously received a PC service and patients who had received a SS with regard to their perceptions of medicine use and the pharmacy encounter. Methods: Cross-sectional survey design comparing matched groups of patients who were previously elected to receive a PC service or who had received SS. Patients who were 60 years or older and used 5 or more prescription medicines concomitantly were included in the survey. Questionnaires included questions about perceptions of safety in drug therapy, general health, drug-related problems (DRPs), medication beliefs, adherence, and experiences of pharmacy encounters. Results: Patients receiving the PC service used more prescription medicines, reported poorer self-reported health, and less perceived safety in their medicine therapy than did patients in SS. PC patients reported that they felt safer with medications, felt a genuine interest from the pharmacist, received important information, and felt more prepared to see the doctor after having spoken to the pharmacist than did patients in SS. DRPs reported to a greater extent by patients receiving the PC service included difficulties opening containers, worries about side effects, experiences of side effects, worries about drug-drug interactions, and inadequate treatment effects. Adherence and medication beliefs showed no statistical difference between groups. Conclusion: Patients receiving a PC service are a worried, vulnerable, and information-seeking group. When compared with patients receiving SS, the PC patients are more insecure about their medicine therapy, although talking to a pharmacist increased their self-reported feelings of safety and provided better preparation for visits to the doctor. [Copyright &y& Elsevier]

Abstract: Background: There is a need for evidence to support expanded pharmacist services, especially regarding subjective outcomes experienced by patients. However, it is unclear what aspects of life are actually affected by such services. Objectives: The aims of this study are to identify patients'' perceptions of both an expanded pharmacist service and its impact on subjective outcomes such as health and quality of life, and to elicit variables that may be targeted in future evaluation of the impact of such services. Methods: In-depth interviews were performed with 12 respondents receiving a patient medication record service. The interviews were analyzed using a qualitative constant comparative method. Results: The service was perceived very differently by unique respondents in regards to its purpose and content, as well as its outcomes. It was difficult for respondents to describe the service as separate from other health care experiences. Gaining control of drug treatment and a perceived feeling of increased safety were central concepts in patients'' description of the service. Talking spontaneously about health effects of the service carried no meaning for the respondents. Conclusions: The value of enhanced patient consultation, empowerment, the feeling of safety, and increased drug knowledge are important to patients receiving this kind of service and should be central in choosing outcome measures when studying such services. [Copyright &y& Elsevier]

Abstract: Background: The existing appropriateness measures for prescribing used in the United States and the United Kingdom use clinical attributes. Treatment and care from a patient''s perspective need to be evaluated in terms of whether they are more likely to lead to an outcome of a life worth living, in social, psychological, and physical terms. However, it is unclear whether patients specifically evaluate their prescribed medication and treatment. If so, do they use only clinical attributes or a combination of clinical and nonclinical attributes? Objectives: The aim of this study was to explore if patients evaluated their hypertension management, and if they did, investigate what attributes were involved in the evaluation. Methods: Semistructured interviews, which focused on personal experiences of hypertension and its management were undertaken with patients (n=28). The aim of the interviews was to obtain, in a narrative format, the experiences, beliefs, and information that patients considered important when discussing the management of hypertension. Data analysis used a constant comparative method. Results: All patients considered their hypertension management regimen appropriate, but were able to mention only 2 categories of attributes to justify their decision (the relationship with their General Practitioner and lowering of their blood pressure). Further series attributes were mentioned by the patient during the course of their interview; these attributes were considered to be involved in their evaluation. These implicit attributes were categorized as anxieties and concerns regarding treatment and diagnosis, explanation of the consequences of treatment, choice of antihypertensives, and the side effects experienced. Conclusions: Patient''s evaluation of appropriateness was constructed from both explicit and implicit attributes. Implicit attributes, those not consciously known to the patient still, could be involved in the process of evaluating hypertension, its treatment, and care. Although the nonmedical attributes that are considered by patients can be categorized, it has to be remembered that it is the inherent meaning held by each individual patient involved when an evaluation is made. [Copyright &y& Elsevier]