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See Bayram and Litvan (doi:10.1093/brain/awaa287) for a scientific commentary on this article. Patients with diabetes appear to be at increased risk of Parkinson’s disease. In a longitudinal study of approximately 100,000 patients with diabetes, Brauer et al. reveal a lower risk of incident Parkinson’s disease in those treated with GLP-1 mimetics or DPP-4 inhibitors compared to users of other oral antidiabetic drugs., The elevated risk of Parkinson’s disease in patients with diabetes might be mitigated depending on the type of drugs prescribed to treat diabetes. Population data for risk of Parkinson’s disease in users of the newer types of drugs used in diabetes are scarce. We compared the risk of Parkinson’s disease in patients with diabetes exposed to thiazolidinediones (glitazones), glucagon-like peptide-1 (GLP-1) receptor agonists and dipeptidyl peptidase 4 (DPP4) inhibitors, with the risk of Parkinson’s disease of users of any other oral glucose lowering drugs. A population-based, longitudinal, cohort study was conducted using historic primary care data from The Health Improvement Network. Patients with a diagnosis of diabetes and a minimum of two prescriptions for diabetes medications between January 2006 and January 2019 were included in our study. The primary outcome was the first recording of a diagnosis of Parkinson’s disease after the index date, identified from clinical records. We compared the risk of Parkinson’s disease in individuals treated with glitazones or DPP4 inhibitors and/or GLP-1 receptor agonists to individuals treated with other antidiabetic agents using a Cox regression with inverse probability of treatment weighting based on propensity scores. Results were analysed separately for insulin users. Among 100 288 patients [mean age 62.8 years (standard deviation 12.6)], 329 (0.3%) were diagnosed with Parkinson’s disease during the median follow-up of 3.33 years. The incidence of Parkinson’s disease was 8 per 10 000 person-years in 21 175 patients using glitazones, 5 per 10 000 person-years in 36 897 patients using DPP4 inhibitors and 4 per 10 000 person-years in 10 684 using GLP-1 mimetics, 6861 of whom were prescribed GTZ and/or DPP4 inhibitors prior to using GLP-1 mimetics. Compared with the incidence of Parkinson’s disease in the comparison group (10 per 10 000 person-years), adjusted results showed no evidence of any association between the use of glitazones and Parkinson’s disease [incidence rate ratio (IRR) 1.17; 95% confidence interval (CI) 0.76–1.63; P = 0.467], but there was strong evidence of an inverse association between use of DPP4 inhibitors and GLP-1 mimetics and the onset of Parkinson’s disease (IRR 0.64; 95% CI 0.43–0.88; P

AIMS The aim of this study was to investigate the initial cardiovascular prescription patterns in patients after their first cardiovascular events, and to identify factors associated with cardiovascular polypharmacy. METHODS This was a cross-sectional study including patients aged ≥ 45 years with the first record of coronary heart disease (CHD) or stroke between 2007 and 2016 using The Health Improvement Network database. This study investigated the patterns of cardiovascular drugs prescribed during the first 90 days after the first cardiovascular events. Logistic regression was used to examine the association between patients' baseline characteristics and cardiovascular polypharmacy (≥5 cardiovascular drugs). RESULTS A total of 121,600 (59,843 CHD and 61,757 stroke) patients were included in the study. The mean age was 69.5 ± 11.9 years. The proportion of patients who were prescribed 0-1, 2-3, 4-5 drugs and ≥6 drugs were 11.0%, 29.8%, 38.6% and 20.5%, respectively. Factors associated with cardiovascular polypharmacy were sex (female: OR 0.74, 95% CI 0.72-0.76 vs male), age (75-84 years old: OR 0.50, 0.47-0.53 vs 45-54 years old), smoking status (current smoking: OR 1.29, 1.15-1.24 vs never), body mass index (obesity: OR 1.38, 1.34-1.43 vs normal), deprivation status (most deprived: OR 1.09, 1.04-1.14 vs least deprived) and Charlson comorbidity index (index ≥5: OR 1.25, 1.16-1.35 vs index 0). CONCLUSION Multiple cardiovascular drugs treatment was common in patients with CVD in the UK. High-risk factors of CVD were also associated with cardiovascular polypharmacy. Further studies are warranted to assess the impact of cardiovascular polypharmacy and its interaction on CVD recurrence and mortality.

ObjectivesChlamydia testing among young people in community pharmacies in North East England has been low compared with other remote settings offering testing for the past few years. To understand why this may be, to maximise service provision, the perceptions of young men and women about pharmacy testing and possible chlamydia treatment were gathered and interpreted.DesignIndepth, semistructured interviews.SettingFour youth centres in North East England.ParticipantsThe study included 26 young people aged 16–23. The sample of participants comprised those with a history of chlamydia testing as well as those never tested.InterviewsFace-to-face interviews were conducted between October 2018 and May 2019. The interview schedule covered young people’s perceptions of sexually transmitted infections, provision of pharmacy sexual and reproductive health and chlamydia testing, and potential chlamydia treatment. Data from the interviews were subjected to thematic analysis.ResultsThe geographical accessibility and long opening times of community pharmacies in North East England were perceived benefits of the service. However, young people had concerns about being judged by pharmacy staff or overheard by customers when requesting the test. Men did not want to be seen by their peers accessing the pharmacy. These barriers were associated with a perceived stigma of chlamydia. Despite this, young people thought that pharmacist advice on the test kit would be important to ensure they complete it correctly. Those never tested favoured how the kit could be taken home to complete the urine sample. The option of including chlamydia treatment was reported to be convenient and comforting.ConclusionSupporting pharmacies in North East England to offer a confidential chlamydia testing service is necessary to overcome young people’s perceived barriers to testing. Delivering testing as an integrated sexual health package with other pharmacy services, together with treatment where suitable, will increase acceptance for testing and timely access to treatment.

Objectives To investigate the rounding of prescribed drug doses for paediatric administration. Methods A cross-sectional medication chart review was conducted at a UK paediatric hospital. Proposed administration dose volumes were calculated for prescribed doses using available manufactured liquids measured with oral and intravenous syringes. Resulting percentage deviations in doses administered were calculated. Results Of 2031 doses observed, 524 (25.8%) required rounding. The majority of which were for children aged 1–12 months. Twenty-seven rounded doses deviated from the prescribed dose by more than 10%. Conclusion This study highlights the impact of dose-rounding in paediatrics and the need for standardisation.

Background Adverse drug reactions (ADRs) represent a major cause of iatrogenic morbidity and mortality in patient care. While a substantial body of work has been undertaken to characterise ADRs in the hospital setting, the overall burden of ADRs in the primary care remains unclear. Objectives To investigate the prevalence of ADRs in the primary care setting and factors affecting the heterogeneity of the estimates. Methods Studies were identified through searching of Medline, Embase, CINAHL and IPA databases. We included observational studies that reported information on the prevalence of ADRs in patients receiving primary care. Disease and treatment specific studies were excluded. Quality of the included studies were assessed using Smyth ADRs adapted scale. A random-effects model was used to calculate the pooled estimate. Potential source of heterogeneity, including age groups, ADRs definitions, ADRs detection methods, study setting, quality of the studies, and sample size, were investigated using sub-group analysis and meta-regression. Results Thirty-three studies with a total study population of 1,568,164 individuals were included. The pooled prevalence of ADRs in the primary care setting was 8.32% (95% CI, 7.82, 8.83). The percentage of preventable ADRs ranged from 12.35–37.96%, with the pooled estimate of 22.96% (95% CI, 7.82, 38.09). Cardiovascular system drugs were the most commonly implicated medication class. Methods of ADRs detection, age group, setting, and sample size contributed significantly to the heterogeneity of the estimates. Conclusion ADRs constitute a significant health problem in the primary care setting. Further research should focus on examining whether ADRs affect subsequent clinical outcomes, particularly in high-risk therapeutic areas. This information may better inform strategies to reduce the burden of ADRs in the primary care setting.

Background Alcohol is challenging to discuss, and patients may be reluctant to disclose drinking partly because of concern about being judged. This report presents an overview of the development of a medications review intervention co-produced with the pharmacy profession and with patients, which breaks new ground by seeking to give appropriate attention to alcohol within these consultations. Methods This intervention was developed in a series of stages and refined through conceptual discussion, literature review, observational and interview studies, and consultations with advisory groups. In this study we reflect on this process, paying particular attention to the methods used, where lessons may inform innovations in other complex clinical consultations. Results Early work with patients and pharmacists infused the entire process with a heightened sense of the complexity of consultations in everyday practice, prompting careful deliberation on the implications for intervention development. This required the research team to be highly responsive to both co-production inputs and data gathered in formally conducted studies, and to be committed to working through the implications for intervention design. The intervention thus evolved significantly over time, with the greatest transformations resulting from patient and pharmacist co-design workshops in the second stage of the process, where pharmacists elaborated on the nature of the need for training in particular. The original research plans provided a helpful structure, and unanticipated issues for investigation emerged throughout the process. This underscored the need to engage dynamically with changing contexts and contents and to avoid rigid adherence to any early prescribed plan. Conclusions Alcohol interventions are complex and require careful developmental research. This can be a messy enterprise, which can nonetheless shed new insights into the challenges involved in optimising interventions, and how to meet them, if embraced with an attitude of openness to learning. We found that exposing our own research plans to scrutiny resulted in changes to the intervention design that gained the confidence of different stakeholders. Our understanding of the methods used, and their consequences, may be bounded by the person-centred nature of this particular intervention.

Background Alcohol interventions are important to the developing public health role of community pharmacies. The Medicines and Alcohol Consultation (MAC) is a new intervention, co-produced with community pharmacists (CPs) and patients, which involves a CP practice development programme designed to integrate discussion of alcohol within existing NHS medicine review services. We conducted a pilot trial of the MAC and its delivery to investigate all study procedures to inform progression to a definitive trial. Methods This cluster pilot RCT was conducted in 10 community pharmacies in Yorkshire, UK, with a CP from each who regularly conducted Medicine Use Review (MUR) and New Medicine Service (NMS) consultations. Randomisation was conducted using a secure remote randomisation service. Intervention CPs (n = 5) were trained to deliver the MAC in MUR/NMS consultations. Control CPs (n = 5) provided these services as usual. Consecutive MUR/NMS patients were asked by CPs to participate, screened for eligibility (consumption of alcohol at least twice per week), and baseline data collected for those eligible. A two-month follow-up telephone interview was conducted. Blinding of CPs was not possible, but patients were blinded to the alcohol focus of the trial. Primary outcomes were total weekly UK units (8 g of ethanol per unit) of alcohol consumption in the week prior to follow-up, and confidence in medications management. Trial procedures were assessed by recruitment, attrition, and follow-up rates. Results 260 patients were approached by CPs to take part in the trial, 68% (n = 178) were assessed for eligibility and 30% (n = 54) of these patients were eligible. Almost all eligible patients (n = 51; 94%) consented to participate, of whom 92% (n = 47) were followed-up at 2 months; alcohol consumption was lower in the intervention arm and confidence in medication management reduced slightly for both groups. Exploration of recall issues at follow-up showed a high level of agreement between a two-item quantity/frequency measure and 7-day guided recall of alcohol consumption. Conclusions The pilot trial demonstrates the feasibility of implementing the MAC in community pharmacy and trial recruitment and data collection procedures. However, decommissioning of MURs means that it is not possible to conduct a definitive trial of the intervention in this service. Trial registration ISRCTN57447996

Introduction\ud Community pharmacies have an increasingly prominent public health function. This includes addressing alcohol, but guidance on delivery of alcohol interventions in this setting is lacking. We have developed an intervention that integrates attention to alcohol within existing community pharmacy medicine review services. This paper examines the experiences of community pharmacists (CPs) in conducting a pilot trial of the intervention, including the acceptability of the trial patient recruitment procedures, and the training and support provided by the research team. \ud \ud \ud Method\ud The pilot trial was conducted in 10 community pharmacies in Yorkshire, England. One CP from each pharmacy was recruited via a multi-stage process to assess motivation, commitment and capacity to participate. Each CP attended a research training day and received on-going research support to conduct the trial. Semi-structured audio-recorded face-to-face interviews (lasting 40-105 minutes) were conducted with all the CPs at the end of the trial. Data were also available from three direct observations conducted during trial support visits. Data were analysed thematically. \ud \ud Results\ud The CPs were supportive of research in community pharmacy but had little direct experiences of research themselves. They valued the training and support provided, which had quickly identified areas where CPs were deviating from the study recruitment protocol. In some instances, the boundaries between research and practice became blurred with CPs making changes to their usual routines and interactions with patients to accommodate the research.\ud \ud Conclusions\ud The trial procedures were acceptable to CPs, in part because of the training and support provided. There are also identifiable areas where CPs’ readiness for research could be enhanced to facilitate participation in future trials in this setting.

Background To manage the risk factors and to improve clinical outcomes, patients with stroke commonly receive multiple cardiovascular medications. However, there is a lack of evidence on the optimum combination of medication therapy in the primary care setting after ischemic stroke. Therefore, this study aimed to investigate the effect of multiple cardiovascular medications on long-term survival after an incident stroke event (ischemic stroke or transient ischemic attack (TIA)). Methods This study consisted of 52,619 patients aged 45 and above with an incident stroke event between 2007 and 2016 in The Health Improvement Network database. We estimated the risk of all-cause mortality in patients with multiple cardiovascular medications versus monotherapy using a marginal structural model. Results During an average follow-up of 3.6 years, there were 9230 deaths (7635 in multiple cardiovascular medication groups and 1595 in the monotherapy group). Compared with patients prescribed monotherapy only, the HRs of mortality were 0.82 (95% CI 0.75–0.89) for two medications, 0.65 (0.59–0.70) for three medications, 0.61 (0.56–0.67) for four medications, 0.60 (0.54–0.66) for five medications and 0.66 (0.59–0.74) for ≥ six medications. Patients with any four classes of antiplatelet agents (APAs), lipid-regulating medications (LRMs), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers, diuretics and calcium channel blockers (CCBs) had the lowest risk of mortality (HR 0.51, 95% CI 0.46–0.57) versus any one class. The combination containing APAs, LRMs, ACEIs/ARBs and CCBs was associated with a 61% (95% CI 53–68%) lower risk of mortality compared with APAs alone. Conclusion Our results suggested that combination therapy of four or five cardiovascular medications may be optimal to improve long-term survival after incident ischemic stroke or TIA. APAs, LRMs, ACEIs/ARBs and CCBs were the optimal constituents of combination therapy in the present study.

Patients with Type 2 diabetes mellitus (T2DM) have an increased risk of atrial fibrillation (AF). The current study aimed to investigate the prevalence and treatment of AF in patients with T2DM, assess the impact of direct oral anticoagulants (DOACs) introduction on oral anticoagulant (OACs) prescribing rates, and factors associated with OAC initiations in patients with T2DM and AF. The Health Improvement Network (THIN) database (2001–2016), was used to examine the annual prevalence and treatment of AF in T2DM. The impact of DOACs introduction on OAC prescribing rates were investigated using interrupted time series analysis (ITS). Factors associated with OAC initiations were also identified using multivariate logistic regression. The prevalence of AF increased from 2.7 [95% confidence intervals (CI) 2.5–2.8] in 2001 to 5.0 (4.9–5.1) in 2016 per 100 persons. OACs prescribing within 30-days of AF diagnosis increased from 21.5% in 2001 to 56.8% in 2016. ITS analysis showed that OAC prescribing increased after DOAC introduction (P P = 0.29). T2DM patients with AF, aged 60–79, male gender and BMI ≥ 25 were more likely to receive OAC, adjusted OR 1.3 (1.2–1.5) for aged 60–79, 1.3 (1.2–1.4) for male gender and 2.0 (1.9–2.2) for BMI ≥ 25, respectively. This study highlighted an increase in prevalence of AF in patients with T2DM during the study period. Further studies are warranted to investigate factors contributing to the underuse of OAC in patients with T2DM and AF.

Objectives Although pharmacist-led medicines use reviews (MURs) are effective for medicines management, little is understood about patients’ experiences of alcohol-related advice delivered therein. Sampling a population at high risk for misuse (within an area of socio-economic deprivation), we explored patient experiences of alcohol-related MURs. Methods Two focus groups were conducted with patients who had discussed alcohol in an MUR in the preceding 3 months (n = 9). Data were analysed thematically. Key findings and conclusion Patients were open to discussing alcohol in the MUR context. The absence of practitioner-patient power asymmetry and pharmacists’ sensitivity to cultural contexts were critical to patient engagement.

Pharmacists have been employed in UK general practice for many years. Their numbers are now expanding and their roles developing. Clinical pharmacists are expected to alleviate workload pressures on GPs. Notwithstanding the COVID-19 vaccination programme, a new Structured Medication Review (SMR) service has been introduced in Primary Care Networks (PCNs). The long term drivers are clear: addressing problematic polypharmacy in the NHS, reducing avoidable hospitalisations, and delivering better value from medicines spending. SMRs are intended to improve the quality of prescribing, delivering improvements to patient care and outcomes.

Feasibility study Objectives:Refine a bespoke enhanced support intervention (ESI) (including self-help materials, intervention manual and training) for implementation by community pharmacy (CP) staff to people with sub-threshold depression and long-term conditions (LTCs) based upon evidence-supported interventions in primary careDevelop and refine study procedures (recruitment strategies and set up, screening, participant recruitment, assessment, suitability of outcome measures and data collection procedures) for testing in the pilot study phase Design: A case series/qualitative study Setting: UK community pharmacy Population: Adults with long-term health conditions who screen-positive for depression but who do not reach the threshold for DSM IV Moderate Depressive disorder Intervention: Enhanced support intervention (ESI) delivered by an appropriately trained community pharmacy team member involving four to six sessions over four months. ESI is a modified form of an intervention within the collaborative care framework for sub-threshold depression validated in previous studies in UK primary care which appears suitable for implementation in community settings. Sample size: 20–30 participants Outcomes: Study implementation (recruitment and attrition rates), quality of data collection at baseline and 4 months and ESI adherence (number of contacts, DNA and drop out) as per objectives 1a/b Qualitative evaluation: Semi-structured interviews with up to 10 participants and ESI facilitators and focus group(s) (range of pharmacy staff n = 8–10) will be conducted to explore the acceptability of the intervention and feasibility of the study, training and study procedures. External pilot study Objectives:Quantify the flow of participants (eligibility, recruitment and follow-up rate)Evaluate proposed recruitment, assessment and outcome measure collection methodsExamine the delivery of the enhanced support intervention in a community pharmacy setting (intervention uptake, retention and dose) to inform process evaluationProcess evaluation, using semi-structured interviews with participants across a range of socio-economic settings, and pharmacy staff to explore the acceptability of the ESI within community pharmacy, elements of the intervention that were considered useful (or not) and appropriateness of study procedures Design: Pilot randomised controlled trial, including a prospective economic and qualitative evaluation Setting: As above Population: As above Intervention: As above with adaptations post feasibility study Comparator: Usual care Sample size: 100 participants Outcomes: Data will be used to estimate recruitment, intervention delivery and study completion rates as per objectives 2a–d. Definitive estimates of the effectiveness of ESI will not be made. Primary outcome: Depression severity (Patient Health Questionnaire 9) at four months. Secondary outcomes: Patient acceptance, uptake and attrition. ICD10 depression status, anxiety (GAD 7), health-related quality of life (SF-12v2) and health-state utility (EQ5D 3L) will be measured at four months. Economic evaluation: The incremental cost per QALY will be calculated from both the NHS and societal perspective. Process evaluation: Using mixed methods, potential mediators/moderators of the intervention, the acceptability (to participants and pharmacy staff), barriers and facilitators to the use of ESI in community pharmacy, and impact on usual practice will be examined. Semi-structured interviews with approximately 30 study participants, 20 pharmacy staff and eight GPs near participating pharmacies will be conducted. Trial registration ISRCTN: ISRCTN11290592 Protocol version number: Version 4.1 (dated 16th January 2018) Study Sponsor Tees Esk and Wear Valleys NHS Foundation Trust Electronic supplementary material The online version of this article (10.1186/s40814-019-0457-y) contains supplementary material, which is available to authorized users.

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.

Background: Medicines Use Reviews (MURs) and the New Medicine Service (NMS) are services\ud delivered by UK community pharmacists to improve adherence, improve patient understanding of\ud their medicines and reduce medicines wastage.\ud Aim: In this scoping review we aim to identify, map and critically examine the nature of existing\ud empirical evidence in peer reviewed journals relating to MUR and NMS consultations.\ud Method: Systematic searches identified the available MUR and NMS empirical literature. We sought\ud data on barriers and facilitators to conducting MUR or NMS consultations, the perceptions of\ud pharmacists and patients, the conduct of consultations, and outcomes of consultations. Searches\ud from 2005 (when MURs were introduced) to May 2018 were conducted in MEDLINE, PsycINFO,\ud Embase and Scopus databases. Data were extracted into Excel for examination of study\ud characteristics, participant characteristics, type of intervention/services delivered and key study\ud quantitative and/or qualitative findings.\ud Results: Forty-one papers from 37 studies met the inclusion criteria: 28 papers were of MURs, 10 of\ud NMS and 3 for both services. Studies focused on the introduction and implementation of these\ud services, with little attention to outcomes for patients; effectiveness was not evaluated beyond in a\ud single NMS RCT. Observational data indicated that pharmacists and patients view MURs and the\ud NMS positively, despite challenges implementing these services and apparent lack of communication\ud between pharmacists and GPs. Consultations were reported to be short, typically 10-12 minutes,\ud characterised by limited engagement with patients and their health problems. The extent and\ud nature of advice on health behaviours during consultations or other content was rarely examined.\ud Conclusion: The research literature on MURs and the NMS has developed slowly. There is much\ud scope for further research attention to developing more patient-centred care.

Background & Aims: To undertake the first randomised controlled trial to evaluate the effectiveness of a brief intervention delivered by community pharmacists to reduce hazardous or harmful drinking. Design: This parallel group individually randomised trial, allocated participants to brief alcohol intervention (n=205) or a leaflet-only control condition (n=202), with follow-up study after 3 months. Setting: 16 community pharmacies in one London borough, UK. Participants: 407 pharmacy customers (aged 18 or over) with AUDIT scores 8-19 inclusive. Intervention: A brief motivational discussion of approximately 10 minutes duration for which 17 pharmacists received a half-day of training. Measurements: Hazardous or harmful drinking was assessed using the Alcohol Use Disorders Identification Test (AUDIT) administered by telephone by a researcher blind to allocation status. The two primary outcomes were: 1) change in AUDIT total scores and 2) the proportions no longer hazardous or harmful drinkers (scoring

BackgroundPreventing hypoglycaemia is an essential component of diabetes self-management that is affected by patients' attitudes and perceptions. This study aimed to explore the hypoglycaemia problem-solving ability of patients who have diabetes mellitus and factors that determine their attitudes and perceptions towards their previous events.MethodologyA cross-sectional study was conducted between October 2017 and May 2018 in three Arab countries (Jordan, Saudi Arabia and Kuwait) in patients with diabetes mellitus, who were prescribed antidiabetic therapy and had experienced hypoglycaemic events in the past six months. The Hypoglycaemia Problem-Solving Scale was used in this study. This scale contains two subscales, problem orientation (six questions) and problem-solving skills (eighteen questions), using a five-point Likert scale (range 0-4). Multiple linear regression analysis was used to identify predictors of hypoglycaemia problem-solving abilities.ResultsA total of 895 patients participated in this study from the three countries (300 in Jordan, 302 in Saudi Arabia, and 293 in Kuwait). The average age of the patients was 53.5 years (standard deviation = 13.7) and 52.4% (n = 469) were males. Patients had moderate overall problem-solving ability with a median score of 63.00 (interquartile range = 13.00). Patients' problem-solving skills score (68.1%) was better than their problem-orientation skills score (58.3%). The highest sub-scale scores were for detection control, setting problem-solving goals, and evaluating strategies, 75.0%. The lowest sub-scale score was for problem-solving perception and immediate management, 50.0%. Older age, being educated, being married, having T2DM, prescribed insulin therapy, and not having been admitted to hospital for hypoglycaemia were important predictors of patients' problem-solving ability (p < 0.05).ConclusionsHealthcare professionals are advised to provide more education to patients on how to self-manage hypoglycaemic events. Specifically, they should focus on the overall problem-solving perception of hypoglycaemia and its immediate management.

Background Medication incidents (MIs) account for 11.3 % of all reported patient-safety incidents in England and Wales. Approximately one-third of inpatients are prescribed an antibiotic at some point during their hospital stay. The WHO has identified incident reporting as one solution to reduce the recurrence of adverse incidents. Objectives The aim of this study was to determine the number and nature of reported antibiotic-associated MIs occurring in inpatients and to use defined daily doses (DDDs) to calculate the incident rate for the antibiotics most commonly associated with MIs at each hospital. Setting Two UK acute NHS teaching hospitals. Methods Retrospective quantitative analysis was performed on antibiotic-associated MIs reported to the risk management system over a 2-year period. Quality-assurance measures were undertaken before analysis. The study was approved by the clinical audit departments at both hospitals. Drug consumption data from each hospital were used to calculate the DDD for each antibiotic. Main outcome measures The number of antibiotic-related MIs reported and the incident rate for the 10 antibiotics most commonly associated with MIs at each hospital. Results Healthcare staff submitted 6,756 reports, of which 885 (13.1 %) included antibiotics. This resulted in a total of 959 MIs. Most MIs occurred during prescribing (42.4 %, n = 407) and administration (40.0 %, n = 384) stages. Most common types of MIs were omission/delay (26.3 %, n = 252), and dose/frequency (17.9 %, n = 172). Penicillins (34.5 %, n = 331) and aminoglycosides (16.6 %, n = 159) were the most frequently reported groups with co-amoxiclav (16.8 %, n = 161) and gentamicin (14.1 %, n = 135) the most frequently reported drugs. Using DDDs to assess the incident rate showed that cefotaxime (105.4/10,000 DDDs), gentamicin (25.7/10,000 DDDs) and vancomycin (23.7/10,000 DDDs) had the highest rates. Conclusions This study highlights that detailed analysis of data from reports is essential in understanding MIs and developing strategies to prevent their recurrence. Using DDDs in the analysis of MIs allowed determination of an incident rate providing more useful information than the absolute numbers alone. It also highlighted the disproportionate risk associated with less commonly prescribed antibiotics not identified using MI reporting rates alone.

Background Administering nurse/patient controlled analgesia (N/PCA) to children requires complex dose calculations and multiple manipulations to prepare morphine solutions in 50 mL syringes for administration by continuous infusion with additional boluses. Objective To investigate current practice and accuracy during preparation of morphine N/PCA infusions in hospital theatres and wards at a UK children’s hospital. Methods Direct observation of infusion preparation methods and morphine concentration quantification using UV–Vis spectrophotometry. The British Pharmacopoeia specification for morphine sulphate injection drug content (±7.5 %) was used as a reference limit. Results Preparation of 153 morphine infusions for 128 paediatric patients was observed. Differences in preparation method were identified, with selection of inappropriate syringe size noted. Lack of appreciation of the existence of a volume overage (i.e. volume in excess of the nominal volume) in morphine ampoules was identified. Final volume of the infusion was greater than the target (50 mL) in 33.3 % of preparations. Of 78 infusions analysed, 61.5 % had a morphine concentration outside 92.5–107.5 % of label strength. Ten infusions deviated by more than 20 %, with one by 100 %. Conclusions Variation in morphine infusion preparation method was identified. Lack of appreciation of the volume overage in ampoules, volumetric accuracy of different syringe sizes and ability to perform large dilutions of small volumes were sources of inaccuracy in infusion concentration, resulting in patients receiving morphine doses higher or lower than prescribed.

Objectives - To demonstrate the contribution of community pharmacy from NHS 111 referrals out of hours (OOH) for emergency supply repeat medication requests via presentation of service activity, community pharmacist feedback and lean thinking transformation.Design - Descriptive service evaluation using routine service activity data over the pilot period; survey of community pharmacists, and service redesign through lean thinking transformation.Setting - North East of England NHS 111 provider and accredited community pharmacies across the North East of England.Participants - Patients calling the North East of England NHS 111 provider during OOH with emergency repeat medication supply requests.Interventions - NHS 111 referral to community pharmacies for assessment and if appropriate, supply of emergency repeat medication.Main outcome measures - Number of emergency repeat medication supply referrals, completion rates, reasons for rejections, time of request, reason for access, medication(s), pharmaceutical advice and services provided. Secondary outcomes were community pharmacist feedback and lean thinking transformation of the patient pathway.Results - NHS 111 referred 1468 patients to 114 community pharmacies (15/12/2014–7/4/2015). Most patients presented on Saturdays, with increased activity over national holidays. Community pharmacists completed 951 (64.8%) referrals providing 2297 medications; 412 were high risk. The most common reason for rejecting referrals was no medication in stock. Community pharmacists were positive about the provision of this service. The lean thinking transformation reduced the number of non-added value steps, waits and bottlenecks in the patient pathway.Conclusions - NHS 111 can redirect callers OOH from urgent and emergency care services to community pharmacy for management of emergency repeat medication supply. Existing IT and community pharmacy regulations allowed patients to receive a medication supply and pharmaceutical advice. Community pharmacists supported integration into the NHS OOH services. Adopting lean thinking provided a structured framework to evaluate and redesign the service with the aim to improve effectiveness and efficiency.

Aims: This qualitative process study, nested within a randomised controlled trial evaluating community\ud pharmacist brief alcohol intervention delivery, aims to explore participants’ engagement with the trial,\ud so as to identify whether research participation effects may explain why the brief intervention was not\ud found to be effective.\ud Method: Qualitative interviews were conducted with 24 randomly selected participants approximately\ud one month after the end of the trial. Semi structured Interviews were conducted by telephone in which\ud participants were asked to give a chronological account of their trial participation, leading to a discussion\ud of possible impacts. These were digitally recorded, transcribed verbatim, and analysed using the\ud Framework method.\ud Results: A range of motivations for taking part in the trial were identified, including pharmacy visitors\ud wanting to obtain an assessment of their drinking. Participants in both arms of the trial spoke of the\ud potent effect that screening had on them. All participants were exposed to discussions about alcohol with\ud empathic pharmacists and, as this is an integral intervention component, this constitutes contamination.\ud Participants’ pre-existing ideas about the nature of alcohol problems had an important bearing on how\ud relevant they thought the intervention was to them.\ud Conclusion: A detailed appreciation of participant engagement with the trial can provide a strong basis for\ud interpretation of trial outcome data, and in this instance does help explain the null finding. Other findings also indicate the need for dedicated studies of public understanding of the nature of alcohol problems,\ud and their implications for receptivity to brief interventions.

ObjectivesTo determine the common stages and strategies involved in the dispensing accuracy-checking process used by pharmacy staff and to determine the training activities used by these staff to gain the knowledge and skills for accuracy checking.MethodFace-to-face tape-recorded ethnographic interviews (n = 28) were undertaken in 2009–2010 at two large teaching hospitals with a purposive sample of pharmacists and accredited checking technicians qualified to undertake the final accuracy check on dispensed medicines. Participants described their accuracy-checking process, strategies used to aid checking using anonymised prescriptions and accurate dispensing of medicines to aid discussion. The range of training activities undertaken to develop this skill were discussed. Qualitative data were analysed in accordance with the principles of grounded theory to identify themes.Key findingsThe accuracy-checking process was described as a cognitive and systematic process. The order in which accuracy checking was executed was found to follow two pathways, with all participants checking the prescription first before verifying either the label or dispensed product. Various physical and sensory aids were used to assist in this verification process. There were inconsistencies in the level of accuracy-checking training received by pharmacists and accredited checking technicians, with many pharmacists reporting no training.ConclusionAlthough an important medication-error prevention strategy, until this study little was known about the process used by pharmacy staff when verifying the accuracy of dispensed medicines. Accuracy checking is a complex cognitive task involving verification of the product and label with the prescription. Strategies obtained during past experience and in training were used to aid checking. The study highlighted that pharmacy staff training to undertake this task was variable. Application of strategies identified in this study may allow individuals to adopt further safeguards to improve patient safety.

Objectives To determine the effect of installing an original-pack automated dispensing system (ADS) on dispensary workload and prevented dispensing incidents in a hospital pharmacy. Methods Data on dispensary workload and prevented dispensing incidents, defined as dispensing errors detected and reported before medication had left the pharmacy, were collected over 6 weeks at a National Health Service hospital in Wales before and after the installation of an ADS. Workload was measured by non-participant observation using the event recording technique. Prevented dispensing incidents were self-reported by pharmacy staff on standardised forms. Median workloads (measured as items dispensed/person/hour) were compared using Mann–Whitney U tests and rate of prevented dispensing incidents were compared using Chi-square test. Spearman's rank correlation was used to examine the association between workload and prevented dispensing incidents. A P value of ≤0.05 was considered statistically significant. Key findings Median dispensary workload was significantly lower pre-automation (9.20 items/person/h) compared to post-automation (13.17 items/person/h, P < 0.001). Rate of prevented dispensing incidents was significantly lower post-automation (0.28%) than pre-automation (0.64%, P < 0.0001) but there was no difference (P = 0.277) between the types of dispensing incidents. A positive association existed between workload and prevented dispensing incidents both pre- (ρ = 0.13, P = 0.015) and post-automation (ρ = 0.23, P < 0.001). Dispensing incidents were found to occur during prolonged periods of moderate workload or after a busy period. Conclusion Study findings suggest that automation improves dispensing efficiency and reduces the rate of prevented dispensing incidents. It is proposed that prevented dispensing incidents frequently occurred during periods of high workload due to involuntary automaticity. Prevented dispensing incidents occurring after a busy period were attributed to staff experiencing fatigue after-effects.

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.

Objective Determine the effect of installing an original pack automated dispensing system (ADS) on staff experience of occupational stressors. Methods Pharmacy staff in a National Health Service hospital in Wales, UK, were administered an anonymous occupational stressor questionnaire pre- (n = 45) and post-automation (n = 32). Survey responses pre- and post-automation were compared using Mann–Whitney U test. Statistical significance was P ≤ 0.05. Four focus groups were conducted (two groups of accredited checking technicians (ACTs) (group 1: n = 4; group 2: n = 6), one group of pharmacists (n = 17), and one group of technicians (n = 4) post-automation to explore staff experiences of occupational stressors. Focus group transcripts were analysed according to framework analysis. Key findings Survey response rate pre-automation was 78% (n = 35) and 49% (n = 16) post-automation. Automation had a positive impact on staff experience of stress (P = 0.023), illogical workload allocation (P = 0.004) and work–life balance (P = 0.05). All focus-group participants reported that automation had created a spacious working environment. Pharmacists and ACTs reported that automation had enabled the expansion of their roles. Technicians felt like ‘production-line workers.’ Robot malfunction was a source of stress. Conclusion The findings suggest that automation had a positive impact on staff experience of stressors, improving working conditions and workload. Technicians reported that ADS devalued their skills. When installing ADS, pharmacy managers must consider the impact of automation on staff. Strategies to reduce stressors associated with automation include rotating staff activities and role expansions.

Objectives To compare dispensary workload, determined using the Welsh benchmarking event recording technique and the direct time technique, at two district general UK National Health Service hospitals within different university local health Boards (hospital A – manual dispensing system; hospital B – automated dispensing system). Methods Data on dispensary workload were collected, over a period of 6 weeks (hospital A: 8 May–18 June 2007; hospital B: 1 October–11 November 2007), by a non-participant observer using two simultaneous methods of workload measurement: direct time and event recording. Direct time technique involved timing each task involved in dispensing a sample of prescriptions from receipt to issue of dispensed medicines to patients. Welsh benchmarking event recording involved continuously logging staff activities that deviated from the dispensary rota on a data collection form to enable calculation of total staff time involved in dispensing activities. Data on number of items dispensed were obtained from the pharmacy computer system and also by manual counting of prescription items. The mean dispensary workloads were calculated as the number of items dispensed per person per hour. Two-sample t-tests were used to compare dispensary workload measurements determined using direct time and event recording technique reported by each individual hospital. Mean workloads for hospitals A and B were compared using a two-sample t-test. Statistical significance was taken as P ≤ 0.05. Key findings Hospital A was associated with a lower workload (direct time: 7.27 ± 7.16 items per person per hour; event recording: 9.57 ± 10.6 items per person per hour). In contrast, hospital B gave a higher workload (direct time: 11.93 ± 8.3 items per person per hour; event recording: 12.6 ± 8.80 items per person per hour). There was a significant difference between workload (direct time: P < 0.01; event recording: P < 0.01) reported for both hospitals. The direct time and event recording techniques produced consistent results at each hospital (hospital A: t = 0.02, P = 0.99; hospital B: t = 0.004, P = 0.1). Conclusion The direct time and Welsh benchmarking event recording techniques produced consistent results at both hospitals. Thus the Welsh benchmarking event recording technique is a valid and reproducible method of measuring dispensary workload. Hospital B (automated) had a higher workload than hospital A (manual). Further work is required to investigate the impact of automation on dispensary workload.

Objective To determine potential predisposing factors to medication errors involving confusion between drug names, strengths and dosage forms. Methods The study analysed medication errors reported over the period January 2005 to December 2008 from the two main dispensaries of a 1200-bed NHS Foundation Hospital Trust in London. Dispensing incidents considered for analysis included all incidents involving drug name, strength and dosage label and content errors. Statistical analyses were performed using Statistica. Dispensing frequencies of the prescribed and wrongly dispensed drugs were compared by means of Wilcoxon signed-rank test, and the extent of correlation between dispensing frequency and error frequency was assessed using Spearman's rank correlation coefficient. Key findings The Trust recorded a total of 911 dispensing errors between 2005 and 2008. The most significant category, which accounted for 211 (23.2%) of the reported errors, involved errors in drug selection. Drug-selection errors were not random events because the plot of error frequency against the average yearly dispensing frequency for the 1000 most issued drugs showed little evidence of association (r = 0.19, P(α) = 0.03). There was, however, an increased likelihood of drug-selection errors occurring when the prescribed drug was dispensed with relatively low frequency and shows a significant orthographic similarity to another drug which has a higher dispensing frequency. Conclusion The majority of drug-selection errors would seem to be caused by insufficient attention paid to the specified drug strength. Dispensing frequency is an important factor influencing the likelihood of a drug-selection errors occurring, but it is also shown here that a large proportion of the drug-selection errors involved specifications exhibiting high orthographic similarity.

Objectives To compare the rate, error type, causes and clinical significance of unprevented and prevented dispensing incidents reported by Welsh National Health Service (NHS) hospital pharmacies. Methods Details of all unprevented and prevented dispensing incidents occurring over 3 months (September–December 2005) at five district general hospitals across Wales were reported and analysed using a validated method. Rates of unprevented and prevented dispensing incidents were compared using Mann–Whitney U test. Reported error types, contributory factors and clinical significance of unprevented and prevented incidents were compared using Fisher's exact test. Key findings Thirty-five unprevented and 291 prevented dispensing incidents were reported amongst 221 670 items. The rate of unprevented (16/100 000 items) and prevented dispensing incidents (131/100 000 items; P = 0.04) was significantly different. There was a significant difference in the proportions of prevented and unprevented dispensing incidents involving the wrong directions/warnings on the label (prevented, n = 100, 29%; unprevented, n = 4, 10%; P = 0.02) and the wrong drug details on the label (prevented, n = 15, 4%; unprevented, n = 6, 14%; P = 0.01). There was a significant difference in the proportions of prevented and unprevented dispensing incidents involving supply of the wrong strength (prevented, n = 46, 14%; unprevented, n = 2, 5%; P = 0.02) and issue of expired medicines (prevented, n = 3, 1%; unprevented, n = 5, 12%; P = 0.002). Conclusion The use of prevented dispensing incidents as a surrogate marker for unprevented incidents is questionable. There were significant differences between unprevented and prevented dispensing incidents in terms of rate and error types. This is consistent with the medication error iceberg. Care must be exercised when extrapolating prevented dispensing incident data on error types to unprevented dispensing incidents.

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 …

Aims and objectives The study aimed to evaluate the causes of prevented dispensing incidents reported by hospitals using the critical incident technique developed by key-informant interviews, focus group and observation. Setting All Welsh NHS hospitals (n = 20) were invited to participate in the study. Sixteen hospitals agreed to take part; 10 hospitals reported incidents, four hospitals did not report any incidents and two hospitals withdrew from the study. Method In June 2005 three key-informant interviews and a focus group were conducted to determine dispensary workflow, which was then validated by a piloted non-participant observational study at three Welsh hospitals. Self-reported critical incident forms were then developed to collect dispensing-incident data involving drugs at high risk of dispensing incidents. Sixteen Welsh hospitals participated in the 4-month study (January-August 2006). Key findings Dispensary workflow encompassed the following events: prescription receipt, validating patient information, log of prescription, technical check, clinical check, label generation, stock selection, medicines assembly, product labelling, completion of registers, self-checking/endorsing and final accuracy check. Twenty-four incidents were reported by 10 hospitals involving paediatrics (n = 9, 38%), morphine sulphate (n = 5, 21%), insulin (n = 5, 21%), angiotensin-converting enzyme inhibitors (n = 3, 13%) and nifedipine (n = 2, 8%). Incidents commonly occurred at label generation (n = 9, 43%) and stock selection (n = 9, 43%), caused by error-producing conditions, active and latent failures. Active failures involved dispensing the wrong quantity of medication, interchanging different formulations, and computer and stock-selection errors. Error-producing conditions were reported as high workload, complex prescriptions and interruptions. Latent conditions were inadequate staffing/ skill mix, unclear drug computer selection lists and the storage of drugs on dispensary shelves. Conclusion The critical incident technique provided an in-depth understanding of the causes of dispensing incidents. Dispensing incidents arose because of organisational pathologies, error producing conditions and active failures such as inadequate staffing, high workload, interruptions, and computer and drug-selection errors.

Objective To monitor unprevented dispensing incidents in NHS hospitals by identifying incident types, drugs involved and factors that may have contributed to the occurrence of incidents. Setting All 20 Welsh NHS hospitals (15 district general; 2 teaching; 2 psychiatric and 1 other specialist hospital). Method Unprevented dispensing incidents that occurred between January 2003 and December 2004 were reported and analysed using a validated method. Incident rate was calculated for those hospitals that provided both incident and issue data. Incident rate was compared with previous research using a two-sample t-test. Reported incident types and contributory factors were compared with previous research using chi-square analysis. Key findings A total of 1005 unprevented dispensing incidents were reported by 20 hospitals. The overall incident rate, based on data from 17 hospitals, was 16 incidents per 100000 items dispensed (range 0.2–46 incidents per 100000 items dispensed). The overall dispensing incident rate was less than previously reported (18 incidents per 100000 items dispensed).This finding was not statistically significant (t = 0.421, P = 0.676). The most common incidents reported were dispensing the wrong strength of drug (n = 241, 24%), wrong drug (n = 168, 17%), wrong form (n = 134, 13%) and printing the wrong warnings/directions on the label (n = 112, 11%). A statistically significant finding was that fewer incidents involving dispensing the wrong drug were reported by Welsh hospitals (17%) compared to previous research in the UK (23%; P = 0.01). Drugs most commonly involved in incidents were insulin (n = 34; 6 incidents per 10000 issues of insulin), nifedipine (n = 16; 10 incidents per 10000 issues of nifedipine) and carbamazepine (n = 10; 5 incidents per 10000 issues of carbamazepine). Conclusion The overall unprevented dispensing incident rate was less than previously reported. Dispensing the wrong strength of the correct drug is a problem. Staff should be aware of the risk of dispensing incidents involving insulin, nifedipine and carbamazepine. Strategies for minimising dispensing incidents include using shelf labels to highlight different strengths or formulations of the same drug, and educating staff about easily confused drugs.

Objective The aim was to evaluate the potential causes of dispensing-label errors at a hospital. Methods The study took place at a 1200-bed NHS Foundation Trust with two main pharmacy dispensaries (one manual and one automated). Face-to-face interviews were conducted with staff involved in label-generation errors to obtain in-depth understanding of dispensing-label errors. Interviews were tape-recorded, transcribed and analysed with the aid of Nvivo into themes. Key findings Factors suggested as causing label-generation errors were illegible handwriting, lack of knowledge, hurrying through tasks, distractions, interruptions and the use of past medical records in generating labels. Self-checking every stage of the labelling process was suggested as the key to detecting and preventing errors. Conclusions The study highlights the vulnerability of the label-generation process to errors, with potential causes linked to organisational, environmental, task, team and individual factors.

During a 17-month study to determine if community pharmacists have access to sufficient appropriate and relevant information to complete adverse drug reaction reports, 21 out of 98 pharmacies submitted 49 ADR reports. Each report required 31 fields of information. Between 15 and 30 fields were completed on each report. Twelve reports covered “new” medicines (identified in the British National Formulary by a black triangle), 19 “established” medicines, nine generic medicines and nine pharmacy only (P) medicines. Evaluation of the reports by a panel of six pharmacists revealed total agreement that 16 of the reports (33 per cent) were ADRs but one was not. A further 16 (33 per cent) reports were considered by all but one panel member to be ADRs. There was a varying level of agreement over the remaining 17 (35 per cent) reports. Eight months into the study, the participating pharmacists evaluated the scheme by postal questionnaire. The replies indicated that submitting reports to both the Committee on Safety of Medicines (CSM) and the patient's general medical practitioner were the preferred route of 87 per cent and 75 per cent of respondents, respectively, for reporting ADRs to new and established prescription only medicines, while 59 per cent favoured direct submission to the CSM alone for ADRs to medicines purchased over the counter. The results demonstrate that the pharmacist has appropriate knowledge and access to sufficient information to identify and submit ADR reports.

Previous studies have shown that community-pharmacy– based screening and brief intervention (SBI) for risky alcohol use is feasible. However, few studies have reported significant reductions in alcohol use following pharmacy-delivered BI. In this study, trained pharmacists (N = 29) at 28 community pharmacies in London, UK, offered BI from February-July 2010. Customers seeking alcohol-related medication and/or advice were targeted. Participating pharmacists used Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scores (≥3 for women and ≥4 for men), a seven-day drinking diary, and feedback on a readiness to change form to identify people with risky drinking and to inform appropriate advice and feedback. One in four community pharmacy customers (n = 246) offered the alcohol BI were initially interested, and half of these (n = 134, 87 of whom were men) received the intervention. Of the 128 customers whose alcohol use was recorded, 16% (n = 21) were classified as high-risk drinkers, 56% (n = 72) as increasingrisk drinkers, and 27% (n = 35) as low-risk drinkers. Three months following BI, low- and increasing-risk drinkers were contacted by a member of the study team to obtain a post-BI AUDIT-C score and to assess past seven-day alcohol consumption. High-risk drinkers were contacted to ascertain whether they had accessed specialty alcohol services. Seventy-five customers were available for follow-up (response rate, 56%). Of the high-risk drinkers, 91% (n = 10) had seen their general practitioner (GP) and/or accessed specialty alcohol services. Increasing-risk drinkers were found to have significantly reduced their weekly consumption (average decrease, 84%; p = 0.004) and number of drinking days (p = 0.05), however, no significant change in AUDIT-C score was observed. As anticipated, no significant differences in consumption were observed for low-risk drinkers. In this study, community-pharmacy–based alcohol SBI was effective in reducing weekly alcohol use among increasing-risk drinkers and facilitated contact between high-risk drinkers and their GPs and/or specialty alcohol treatment services.

Background Studies indicate that community pharmacy-based alcohol brief intervention (BI) is feasible. However, few studies report significant reductions in post-BI alcohol consumption and customer experience. Cost-effectiveness has not been previously examined. Objectives This 5 month study adopted a single group pre- and post-experimental design to: (1) assess uptake of the community pharmacy alcohol BI service; (2) establish post-BI changes in alcohol consumption for hazardous drinkers; (3) report the acceptability of the service to customers who received it; and (4) undertake a preliminary economic evaluation of the service through establishing whether pharmacy-based alcohol BI affected health and social care costs, including lost employment costs, and whether it was cost-effective. Setting 26 community pharmacies in south London, UK. Method Trained pharmacists used the AUDIT-C and a retrospective 7-day Drinking Diary to identify risky drinkers and inform feedback and advice. Harmful drinkers were referred to their general practitioner and/or specialist alcohol services. A confidential service feedback questionnaire was completed by alcohol BI recipients. Baseline and 3-month follow-up telephone interviews were conducted with hazardous and low risk drinkers to assess post-BI alcohol use change and service cost-effectiveness. Main outcome measures AUDIT-C, 7-day alcohol unit consumption, drinking days, cost utilisation data. Results Of the 663 eligible customers offered alcohol BI, 141 (21 %) took up the service. Three-quarters of customers were identified as risky drinkers. Follow-up interviews were conducted with 61 hazardous/low risk drinkers (response rate = 58 %). Hazardous drinkers were found to significantly reduce their 7-day alcohol unit consumption and drinking days, but not AUDIT-C scores. The majority of harmful drinkers (91 %, n = 10) who were contactable post-BI had accessed further alcohol related services. Customer feedback was generally positive. Over 75 % of customers would recommend the service to others. The cost of delivering the service was estimated to be £134. The difference in service costs pre-BI and post-BI was not statistically significant and remained non-significant when calculated on 500 customers receiving the intervention. Conclusion Community pharmacy-based alcohol BI is a low cost service that may not have immediate beneficial impact on health and social service use, but can be effective in reducing drinking in hazardous drinkers.

Objectives To identify, review and evaluate the published literature on the incidence, type and causes of dispensing errors in community and hospital pharmacy. Method Electronic databases were searched from 1966 to February 2008. This was supplemented by hand-searching the bibliographies of retrieved articles. Analysis of the findings explored the research methods, operational definitions, incidence, type and causes of dispensing errors. Key findings Sixty papers were identified investigating dispensing errors in the UK, US, Australia, Spain and Brazil. In general, the incidence of dispensing errors varied depending on the study setting, dispensing system, research method and operational definitions. The most common dispensing errors identified by community and hospital pharmacies were dispensing the wrong drug, strength, form or quantity, or labelling medication with the incorrect directions. Factors subjectively reported as contributing to dispensing errors were look-alike, sound-alike drugs, low staffing and computer software. High workload, interruptions, distractions and inadequate lighting were objectively shown to increase the occurrence of dispensing errors. Conclusions Comparison of the reviewed studies was confounded by differences in study setting, research method and operational definitions for dispensing errors, error rate and classification of error types. The World Health Organization is currently developing global patient safety taxonomy. Such a standardized taxonomy for dispensing errors would facilitate consistent data collection and assist the development of error-reduction strategies.

Ensuring the competence of healthcare professionals’ is core to undergraduate and post-graduate education. Undergraduate pharmacy students and pre-registration graduates are required to demonstrate competence at dispensing and accuracy checking medicines. However, competence differs from understanding. This study determined the competence and understanding of undergraduate students and pharmacists at accuracy checking dispensed medicines. Third year undergraduate pharmacy students and first year post-graduate diploma pharmacists participated in the study, which involved an accuracy checking task and concept mapping exercise. Participants accuracy checked eight medicines which contained 13 dispensing errors and then constructed a concept map illustrating their understanding of the accuracy checking process. The error detection rates and types of dispensing errors detected by undergraduates and pharmacists were compared using Mann–Whitney and chi-square, respectively. Statistical significance was p ≤ 0.05. Concept maps were qualitatively analysed to identify structural typologies. Forty-one undergraduates and 78 pharmacists participated in the study. Pharmacists detected significantly more dispensing errors (85%) compared to the undergraduates (77%, p ≤ 0.001). Only one undergraduate and seven pharmacists detected all dispensing errors. The majority of concept maps were chains (undergraduates = 46%, n = 19; pharmacists = 45%, n = 35) and spokes (undergraduates = 54%, n = 22; pharmacists = 54%, n = 42) indicating surface learning. One pharmacist, who detected all dispensing errors in the accuracy checking exercise, created a networked map characteristic of deep learning. Undergraduate students and pharmacists demonstrated a degree of operational competence at detecting dispensing errors without fully understanding the accuracy checking process. Accuracy checking training should be improved at undergraduate and post-graduate level so that pharmacists are equipped with the knowledge and understanding to accurately check medicines and detect dispensing errors, thereby safeguarding patient safety.

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.

Pharmacy-based alcohol brief intervention (BI) has the potential to identify risky drinkers in the general population, but the opinions of users regarding the service remain relatively unexplored. Alcohol BI was offered to customers by trained pharmacists (n = 29) at 28 London, UK, community pharmacies between February and July 2010. Customers requiring alcohol-use related medication and/or advice were targeted. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), a drinking diary, and a readiness to change assessment were used by pharmacists to assess and provide appropriate feedback regarding alcohol use. Customers also received written information, including a UK Department of Health “Units and You” booklet. Following BI, customers were given a confidential service evaluation questionnaire to complete and return to the project team using a prepaid envelope. This invited responses to closed- and open-format questions regarding their initial reason for visiting the pharmacy, why they took up the BI service, and their levels of satisfaction with the service delivery and environment. Of the 134 customers who received a BI, 58% (n = 78) returned the questionnaire. Bringing a prescription for dispensing was the most common reason for the pharmacy visit (55%, n = 43). Wishing to find out about alcohol use and concerns for personal health were the two most reported reasons for taking up the service. Almost one-quarter of customers (n = 18) reported that they liked having increased their alcohol-related awareness, and 18% (n = 14) indicated that they liked the informative written information. The privacy (74%, n = 57), confidentiality (77%, n = 59), and quietness (70%, n = 54) of consulting rooms was rated as good, with 77% (n = 60) of customers reporting they would recommend this service to others. In line with past primary care BI studies, customers were generally positive about the experience of receiving BI in community pharmacies and would recommend it to others.

Background There is strong evidence to support the effectiveness of Brief Intervention (BI) in reducing alcohol consumption in primary healthcare. Methods and design This study is a two-arm randomised controlled trial to determine the effectiveness of BI delivered by community pharmacists in their pharmacies. Eligible and consenting participants (aged 18 years or older) will be randomised in equal numbers to either a BI delivered by 17 community pharmacists or a non-intervention control condition. The intervention will be a brief motivational discussion to support a reduction in alcohol consumption and will take approximately 10 minutes to deliver. Participants randomised to the control arm will be given an alcohol information leaflet with no opportunity for discussion. Study pharmacists will be volunteers who respond to an invitation to participate, sent to all community pharmacists in the London borough of Hammersmith and Fulham. Participating pharmacists will receive 7 hours training on trial procedures and the delivery of BI. Pharmacy support staff will also receive training (4 hours) on how to approach and inform pharmacy customers about the study, with formal trial recruitment undertaken by the pharmacist in a consultation room. At three month follow up, alcohol consumption and related problems will be assessed with the Alcohol Use Disorders Identification Test (AUDIT) administered by telephone. Discussion The UK Department of Health’s stated aim is to involve community pharmacists in the delivery of BI to reduce alcohol harms. This will be the first RCT study to assess the effectiveness of BI delivered by community pharmacists. Given this policy context, it is pragmatic in design. Trial registration Current Controlled Trials ISRCTN95216873

The UK Department of Health’s aim is to involve community pharmacists in the delivery of alcohol brief intervention (BI). This possibility extends the settings in which BIs have been delivered and has attracted international attention. The objective of this study was to assess the effectiveness of BI delivered by community pharmacists in a randomised controlled trial (RCT) in London. A two-arm RCT was conducted to determine the effectiveness of BI delivered by community pharmacists. Pharmacists and their support staff were trained in the trial procedures. Pharmacy support staff (N = 23) approached and informed customers about the study, to support formal recruitment by the community pharmacist (N = 17). Eligible and consenting pharmacy customers (aged≥18 years) at the 16 community pharmacies were randomised in equal numbers to either BI delivered by a community pharmacist or a non-intervention control condition, conducted in the pharmacy consultation room. The intervention was a brief motivational discussion of approximately 10 minutes duration. Participants randomised to the control arm were given an alcohol information leaflet with no opportunity for discussion. At 3-month follow up, alcohol consumption and related problems were assessed with the Alcohol Use Disorders Identification Test (AUDIT) administered by telephone. Of the 1440 customers approached, 541 (38%) consented to participate. Of those who consented, 409 were identified as hazardous/harmful drinkers (AUDIT 8-19), 94 as low risk drinkers (AUDIT≤7), and 38 as possibly dependent drinkers (AUDIT≥20), with the latter two groups excluded from the trial. The 409 trial participants were followed up at three months (follow-up rate ≥80%). Data analysis is under way and the preliminary main trial results are presented here. This is the first presentation of trial outcomes from this internationally significant study.