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IntroductionIncreasing collaborative and integrated working between General practice (GP) and Community pharmacy (CP) is a key priority of the UK National Health Service and has been proposed as a solution to reducing health system fragmentation, improving synergies and coordination of care. However, there is limited understanding regarding how and under which circumstances collaborative and integrated working between GP and CP can be achieved in practice and how regulatory, organisational and systemic barriers can be overcome.Methods and analysisThe aim of our review is to understand how, when and why working arrangements between GP and CP can provide the conditions necessary for optimal communication, decision-making, and collaborative and integrated working. A realist review approach will be used to synthesise the evidence to make sense of the complexities inherent in the working relationships between GP and CP. Our review will follow Pawson’s five iterative stages: (1) finding existing theories; (2) searching for evidence (our main searches were conducted in April 2022); (3) article selection; (4) data extraction and (5) synthesising evidence and drawing conclusions. We will synthesise evidence from grey literature, qualitative, quantitative and mixed-methods research. The research team will work closely with key stakeholders and include patient and public involvement and engagement throughout the review process to refine the focus of the review and the programme theory. Collectively, our refined programme theory will explain how collaborative and integrated working between GP and CP works (or not), for whom, how and under which circumstances.Ethics and disseminationFormal ethical approval is not required for this review as it draws on secondary data from published articles and grey literature. Findings will be widely disseminated through: publication in peer-reviewed journals, seminars, international conference presentations, patients’ association channels, social media, symposia and user-friendly summaries.PROSPERO registration numberCRD42022314280.

ObjectivesTo investigate the perception and experience of patients and the public (PP) about community pharmacy (CP) services and other primary care services after hospital discharge back home.Design and settingA rapid review and qualitative study exploring PP perceptions of primary care, focusing on CP services in the UK.MethodsA mixed-methods approach was adopted including a rapid review undertaken between 24 April and 8 May 2019 across four databases (MEDLINE, EMBASE, PsycINFO and CINAHL). Semistructured interviews were then conducted investigating for shifts in current PP perception, but also nuanced opinion pertaining to CP services. A convenience sampling technique was used through two online PP groups for recruitment. Thematic framework analysis was applied to interview transcripts.ParticipantsAny consenting adults ≥18 years old were invited regardless of their medical condition, and whether they had used post-discharge services or not.ResultsTwenty-five studies met the inclusion criteria. Patients were generally supportive and satisfied with primary care services. However, some barriers to the use of these services included: resource limitations; poor communication between healthcare providers or between patient and healthcare providers; and patients’ lack of awareness of available services. From the 11 interviewees, there was a lack of awareness of CP post-discharge services. Nevertheless, there was general appreciation of the benefit of CP services to patients, professionals and wider healthcare system. Potential barriers to uptake and use included: accessibility, resource availability, lack of awareness, and privacy and confidentiality issues related to information-sharing. Several participants felt the uptake of such services should be improved.ConclusionThere was alignment between the review and qualitative study about high patient acceptance, appreciation and satisfaction with primary care services post-discharge. Barriers to the use of CP post-discharge services identified from interviews resonated with the existing literature; this is despite developments in pharmacy practice in recent times towards clinical and public health services.

Introduction In the UK half of all pregnancies are unplanned and half of teenage pregnancies terminated. Southwark and Lambeth have the highest teenage conception rates in London. In 2009, many teenage pregnancies in Southwark led to terminations. A contraception service was established where qualified pharmacists supplied oral contraception (OC) using a patient group direction (PGD). This service evaluation aimed to assess this service delivered in five community pharmacies. Methods Monthly data were submitted by each pharmacy to the Primary Care Trust on consultations, pills supplied, initial or subsequent supply and client referral. For specified periods consultation time was collected and a clinical notes audit undertaken. Client satisfaction was determined using a structured questionnaire returned to the pharmacy. Mystery shoppers were employed to assess the service. Results A total of 741 consultations were undertaken by seven pharmacists at five community pharmacies (October 2009–June 2011) with many (45.5%) occurring following emergency contraception supply. The mean consultation time was 19 minutes . Combined OC was most commonly supplied with nearly half (46.1%) of initial supplies to first-time pill users. Most consultations (92.2%) were with women aged under 30 years, with 22.5% aged under 20. Most consultations were with black or black British clients. Of the 99 women who completed the satisfaction questionnaires, most clients were very satisfied or satisfied with the service and felt comfortable talking to the pharmacist about contraception. Conclusions Trained pharmacists were clinically competent and provided OC in community pharmacy according to a PGD. This service was accessed by the target population; young women using emergency hormonal contraception who had not previously used OC. Clients were largely very satisfied with the service.

Opioid infusions are essential therapy for children in severe pain. Patient controlled analgesia (PCA) is an attractive treatment option because of the multiple benefits it provides: immediate and effective pain relief, titration of analgesia and empowerment of the patient (or nurse) to have a degree of control over their pain which helps to retain autonomy and decrease anxiety. However, opioid infusions for children carry a high risk of medication error. Risks include the complexity in calculating dosages, the manipulation of small volumes to prepare individual infusions and the necessity to deliver the infusion with precision at low flow rates (down to 0.1 mL/h). During PCA additional boluses on top of the baseline infusion rate add to the pharmaceutical and therapeutic complexity. The severe side effects of opioids, including hypoventilation, hypotension and sedation, exacerbate the risk and raise great concern in hospitals, plus limiting the use of PCA in community and hospice settings. At present there is no international standard practice or guideline on the way that PCA is administered. This commentary highlights problems with current practices of preparing and administering PCA in hospitalised children in the UK. Additionally, we advocate a system management approach which we are piloting to address the problems of opioid-based PCA for children in a large (200-bed) hospital, the Evelina London Children's Hospital, in the hope of developing safer practices for the delivery of opioid analgesia. Intravenous infusions are an important means of administering therapy, yet the technical process is complex with multiple error-prone steps. The errors associated with preparing and administering intravenous infusions in paediatrics (eg, low volume at low flow rate) make drug delivery by infusion a particularly high risk,1 but continuous infusions of opioid are crucial to achieve effective analgesia and avoid uncontrolled pain in neonates and children with conditions such as sickle …

OBJECTIVES: Service and stakeholder evaluation of an NHS-funded service providing out-ofhours (OOH) emergency repeat medications to patients self-presenting at community pharmacies.SETTING: Community pharmacies across the North East of England accredited to provide this service.PARTICIPANTS: Patients self-presenting to community pharmacies during OOH periods with emergency repeat medication supply requests.INTERVENTION: Community pharmacists assessed each request for clinical appropriateness and when suitable provide an emergency repeat medication supply, with additional pharmaceutical advice and services if required.PRIMARY OUTCOMES: Number of emergency repeat medication supplies, time of request, reason for access, medication(s), pharmaceutical advice and services provided. Secondary outcomes were community pharmacist and patient satisfaction.RESULTS: A total of 2485 patients were managed across 227 community pharmacies (15 December 2014 to 7 April 2015). Most patients presented on Saturdays, with increased activity over national holidays. Older age was associated with increased service use. Of the 3226 medications provided, 439 were classified as high risk. Patients found this service easy to access and were willing to access the community pharmacy in the future for medication-related issues. In the absence of this service, 50% of patients would have missed their medication(s) until they saw their doctor and a further 46% would have accessed an alternative service. The cost of National Health Service (NHS) service(s) for patients who would have accessed an alternative OOH service was estimated as 37 times that of the community pharmacy service provided. Community pharmacists were happy to provide this service despite increased consultation times and workload.CONCLUSIONS: Community pharmacists were able to manage patients' OOH requests for emergency repeat medication and patients were happy with the service provided. Since the service cost was favourable when compared with alternative OOH services, it would be a viable option to reduce the workload on the wider NHS.

Objectives: Gentamicin and vancomycin are narrowtherapeutic-index antibiotics with potential for high toxicity requiring dose individualisation and continuous monitoring. Clinical decision support (CDS) tools have been effective in reducing gentamicin and vancomycin dosing errors. Online dose calculators for these drugs were implemented in a London National Health Service hospital. This study aimed to evaluate the impact of these calculators on the accuracy of gentamicin and vancomycin initial doses. Methods: The study used a pre–postintervention design. Data were collected using electronic patient records and paper notes. Random samples of gentamicin and vancomycin initial doses administered during the 8 months before implementation of the calculators were assessed retrospectively against hospital guidelines. Following implementation of the calculators, doses were assessed prospectively. Any gentamicin dose not within ±10% and any vancomycin dose not within ±20% of the guideline-recommended dose were considered incorrect. Results: The intranet calculator pages were visited 721 times (gentamicin=333; vancomycin=388) during the 2-month period following the calculators’ implementation. Gentamicin dose errors fell from 61.5% (120/195) to 44.2% (95/215), p

Aim Opiate infusions are essential therapy for children with severe pain, but have been associated with serious medication errors.1–4 These infusions require complex dose calculations, multiple manipulations and complicated administration rate adjustments. The project aimed to minimise the risk of medication errors in nurse- or patient-controlled analgesia (N/PCA) for children. Method A system management approach was developed to minimise complex calculations and individualised medicine manufacture by providing standard dose-banded concentrations of morphine infusion, manufactured aseptically, for N/PCA administration using pre-programmed safety pumps. The new system was implemented in three phases: 1. Pre-implementation: Direct observation in theatres and wards of current practice; analysis of individually prepared syringes; focus groups (ward nurses, recovery nurses, and anaesthetists) on the current practice; Product design: packaging and labelling; Failure mode & effect analysis. 2. Implementation: Reconfiguration of the smart pumps with the new morphine standardised concentrations protocols; production of new colour-coded protocols, labels and standard operating procedures for ward/theatres use; evaluation of storage of the new product in different areas. 3. Post-implementation: direct observation of administration process of morphine standardised prefilled syringe (PFS); focus groups on the new system (morphine PFS); 6-month follow up study after full roll out. Results Observation of morphine infusions (153) prepared by healthcare professionals for 128 children (7.5±5.6 years; mean±SD) identified major differences in preparation methods. Analysis of the individually prepared infusions (78) identified that 61.5% deviated from the target concentration by greater than the pharmacopoeial limit (±7.5%), of which 75% (36/48) were in excess with 28% (10/36) deviating by more than +20%. A variety of preparation practices led to the out-of-specification results, including lack of appreciation of the overage in morphine ampoules; “Say I9ve got 27 kg child, and you have to put 27 mg in. I9ll always put the 20 mg, all of the ampoules in, as I opposed to drawing it up in a syringe I will be losing some and I want to make sure that I get what I think in my head is 27, so the first 2 will get the full ampoule and only the last 7 mg that I will draw up in a 1 mL syringe.” (Anaesthetist). Three standardised concentrations of morphine were established: 3 mg/50 mL glucose 5% for weight ≤3.99 kg 10 mg/50 mL sodium chloride 0.9% for weight ≥4 kg – 19.9 kg 50 mg/50 mL sodium chloride 0.9% for weight ≥20 kg Pilot implementation of standardised morphine infusions (35 to date) was well-received by anaesthetists and nurses. Colour coded protocols and labels were regarded as lowering the risk of wrong selection. Conclusion The project addressed the unacceptable variation identified in individually prepared medicines and simplified their administration. Whilst it is known that standard concentration morphine infusions can be utilised in paediatrics, we have demonstrated for the first time that it is possible to use them for N/PCA. Limits of accuracy for the pumps were quantified and accommodated in defining the weight-concentration relationships to verify reliable delivery of continuous infusions and boluses.