Search

ObjectivesTo explore patient views and perspectives of current management of chronic rhinosinusitis (CRS) in primary and secondary care.DesignSemistructured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic RhinOsinusitis).SettingPrimary care and secondary care ear, nose and throat outpatient clinics in the UK.ParticipantsTwenty-five patients consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis.ResultsCRS has a significant impact on patients’ quality of life, affecting their ability to work effectively, their social interactions and daily living. Patients seek help when symptoms become unmanageable, but can become frustrated with the primary care system with difficulties obtaining an appointment, and lack of continuity of care. Patients perceive that general practitioners can be dismissive of CRS symptoms, and patients often prioritise other concerns when they consult. Health system barriers and poor communication can result in delays in accessing appropriate treatment and referral. Adherence to intranasal steroids is a problem and patients are uncertain about correct technique. Nasal irrigation can be time-consuming and difficult for patients to use. Secondary care consultations can appear rushed, and patients would like specialists to take a more ‘holistic’ approach to their management. Surgery is often considered a temporary solution, appropriate when medical options have been explored.ConclusionsPatients are frustrated with the management of their CRS, and poor communication can result in delays in receiving appropriate treatment and timely referral. Patients seek better understanding of their condition and guidance to support treatments decisions in light of uncertainties around the different medical and surgical options. Better coordinated care between general practice and specialist settings and consistency of advice has the potential to increase patient satisfaction and improve outcomes.

Objectives The aim was to explore and describe community pharmacists' current and potential place in the cancer pain pathway. Objectives were to describe pharmacists' role in advising patients and their carers on optimum use of opioid drugs for pain relief, identify elements of medicines management that could be modified and identify opportunities for improved communication with patients and other professionals. Methods Semi-structured interviews were conducted with 25 community pharmacists in three areas of England. Data were analysed using the Framework method. Key findings Pharmacists had no reliable method to identify patients with cancer and no access to disease stage and treatment plan information. There was little evidence of any routine communication with other professionals about patient care. Contact with patients was limited. Access to palliative care medicines could be problematic for patients and medicines use reviews (MURs) were rarely done. Interview data suggested variable levels of knowledge about optimal opioid use in cancer pain or awareness of patients' priorities. For some pharmacists, proactive involvement appeared to be inhibited by fear of discussing emotional and wider social aspects and accounts showed that a wide range of issues and concerns were raised by family members, indicating considerable unmet need. Pharmacists tended to assume information had already been provided by others and felt isolated from other care team members. Many felt that their potential contribution to cancer pain management was constrained but aspired to do more. Conclusions There is significant scope for improving access to and interaction with, community pharmacists by people with cancer pain and their families. Finding ways to embed pharmacists within palliative care teams could provide a starting point for a greater contribution to cancer pain management.

INTRODUCTION: Older people in care homes are at increased risk of medication errors and adverse drug events. The effect of formulation on administration errors is not known, that is whether the medicine is a tablet or capsule, liquid or device such as an inhaler. Also, the impact on administration errors of monitored dosage systems (MDS), commonly used in UK care homes to dispense tablets and capsules, is not known. This study investigated the influence of formulation and MDS on administration errors. METHODS: Administration errors were identified by pharmacists (using validated definitions) observing two drug rounds of residents randomly selected from a purposive sample of UK nursing and residential homes. Errors were classified and analysed by formulation and medicine delivery system. RESULTS: The odds of administration errors by formulation, when compared with tablets and capsules in MDS, were: liquids 4.31 (95% CI 2.02 to 9.21; p = 0.0002); topicals/transdermals/injections 19.61 (95% CI 6.90 to 55.73; p < 0.0001); inhalers 33.58 (95% CI 12.51 to 90.19; p < 0.0001). The odds of administration errors for tablets and capsules not in MDS were double those that were dispensed in MDS (adjusted OR 2.14, 95% CI 1.02 to 4.51; p = 0.04). CONCLUSIONS: Inhalers and liquid medicines were associated with significantly increased odds of administration errors. Training of staff in safe administration of these formulations needs implementing. Although there was some evidence that MDS reduced the odds of an administration error, the use of MDS impacts on other aspects of medicines management. Because of this, and as the primary topic of our study was not MDS, a prospective trial specifically designed to evaluate the overall impact of MDS on medicine management in care homes is needed.

Background Diclofenac is commonly used for acute pain in children, but is not licensed for this indication in all age groups. Objectives 1) Assess the efficacy of diclofenac for acute pain in children. 2) Assess the safety of diclofenac for short-term use in children. 3) Identify gaps in the evidence to direct future research. Search strategy Seventeen databases indexing clinical trial reports were searched in February 2005 (with an update search as part of this first review in May 2008). A hand search of Paediatric Anaesthesia was undertaken and summaries obtained of adverse reaction reports from the UK Yellow Card Scheme and World Health Organization (WHO) Monitoring Centre. The reference lists of included studies were also searched. Selection criteria Any published report, in any language, involving the administration of diclofenac to a patient aged 18 years or younger for acute pain and detailing either monitoring of efficacy or safety. Data collection and analysis Two review authors independently assessed study quality and extracted the data. Authors were contacted where necessary. Review Manager version 5 was used for analysis. Main results 1) Efficacy: randomised controlled trials (RCTs) comparing diclofenac with placebo/any other treatment by using pain scores (assessed or reported), or need for rescue analgesia. 2) Safety: any type of study seeking adverse events (regardless of cause). An adverse event was defined as any reported adverse or untoward happening to a patient being treated with diclofenac for acute pain. Seven publications on diclofenac efficacy and 79 on safety (74 studies plus five case reports) were included in the final analysis. Compared with placebo/no treatment, diclofenac significantly reduced need for post-operative rescue analgesia (relative risk [RR] 0.6; number needed to treat to benefit [NNT] 3.6; 95% confidence interval [CI] 2.5 to 6.3). Compared with any other non-NSAID, patients receiving diclofenac suffered less nausea or vomiting, or both (RR 0.6; NNT 7.7 [5.3 to 14.3]). There appeared to be no increase in bleeding requiring surgical intervention in patients receiving diclofenac in the peri-operative period. Serious diclofenac adverse reactions occurred in fewer than 0.24% of children treated for acute pain. The types of serious adverse reactions were similar to those reported in adults. Authors' conclusions Diclofenac is an effective analgesic for perioperative acute pain in children. It causes similar types of serious adverse reactions in children as in adults, but these are rare. More research on optimum dosing and safety in asthmatic children is required. PLAIN LANGUAGE SUMMARY Diclofenac for pain relief in children Diclofenac is commonly used for short-term pain relief in children, particularly around the time of surgery. There is good evidence that diclofenac is effective for pain relief in adults, and side effects such as stomach upset are well known. However, developmental differences mean that children may sometimes react differently to medicines than adults do. It is important to assess whether diclofenac is also effective in children, and to understand the type and frequency of adverse reactions that diclofenac causes in children. This review has found that, as with adults, diclofenac is effective for the relief of pain after an operation. If it is given at the time of an operation, it will halve the number of children needing extra pain relief. Diclofenac seems to be twice as effective as paracetamol (acetaminophen) for surgical pain, and this is also true for adults. Diclofenac appears to cause similar types of serious adverse reactions (such as bleeding of the stomach and allergic-type reactions), but these are rare and occur in fewer than 3 in 1000 children who take the drug. We had hoped to investigate whether diclofenac made children with asthma more wheezy, but there was not enough information for us to do this. The main conclusions of this review are that diclofenac is effective for relief of acute pain arising from operations in children, with a low risk of serious adverse reactions. Intramuscular injections of diclofenac should be avoided, due to risk of injection site problems. The main questions still to be answered are: What is the best dose to give and should diclofenac be avoided in children with asthma?

Purpose To compare four methods of detecting prescribing errors (PE) in the same patient cohorts before and after an intervention (computerised physician order entry; CPOE) and to determine whether the impact of CPOE is identified consistently by all methods. Methods PEs were identified using (1) prospective detection by ward pharmacist; (2) retrospective health record review; (3) retrospective use of a trigger tool and (4) spontaneous reporting over two separate 4-week periods on one surgical ward in a UK teaching hospital. Results We reviewed 93 patients pre- and 114 post-CPOE. Using all four methods, we identified 135 PE (10.7% of all medication orders) pre-CPOE, and 127 (7.9%) post-CPOE. There was little overlap in PE detected by the different methods: prospective detection identified 48 (36% of all PE) pre- and 30 (24%) post-CPOE; retrospective review (RR) revealed 93 (69%) pre- and 105 (83%) post-CPOE, trigger tool 0 pre- and 2 (2%) post-CPOE and spontaneous reporting 1 (1%) pre- and 1 (1%) post-CPOE. The calculated relative reduction in risk of PE was 50% using prospective data, 12% with RR and 26% using data from all four methods. Conclusions In this study, each method predominantly identified different PE. A combination of methods may be required to understand the true effectiveness of different interventions. Copyright © 2009 John Wiley & Sons, Ltd.

Aim The identification of medication-monitoring errors requires a validated definition. This paper describes the development and validation of a definition which includes criteria for specific medicines to determine whether a medication-monitoring error has occurred in the care home setting. Setting Criteria were developed for older people (aged 65 years or older) living in care homes. Methods Criteria were developed by two clinical pharmacists using published guidelines. The criteria were divided into those relating to initiation of therapy and maintenance monitoring. The study steering group, made up of clinical pharmacists, a general practitioner (GP) and pharmacy academics, then reviewed the criteria and a consensus was achieved. The criteria were then reviewed by a sample of 21 GPs and 11 clinical pharmacists. The threshold for acceptance for each criterion was set at 70% by agreement of all participants. Key findings The definition of a medication-monitoring error was accepted as ‘when a prescribed medicine is not monitored in the way which would be considered acceptable in routine general practice. It includes the absence of tests being carried out at the frequency listed in the criteria for each medicine, with tolerance of +50%’. Seventy per cent agreement was reached on all criteria for the initiation of therapy, except warfarin (69%), and on all criteria for maintenance monitoring, except penicillamine (63%) and potassium (63%). Conclusions To our knowledge, this is the first study to define a medication-monitoring error, and to determine and validate specific criteria to identify such errors in older people living in care homes.

(a) To compare metered dose inhaler (MDI) technique in users with poor English and fluent English, (b) to evaluate two interventions: a translated patient information leaflet (PIL) plus support from an translator (PIL + verbal) and a multimedia touch screen system (MTS) using video clips and own-language instruction.(a) Inhaler technique was videotaped and key steps rated blind for 105 fluent English-speakers (FE) and 69 Turkish-speakers with poor English (EP). (b) The EP group was randomised to receive information by MTS (n = 34) or PIL + verbal (n = 35). Inhaler technique was videotaped before and after information.(a) Global inhaler technique; (b) breathing-in time; (c) co-ordination of inspiration and inhaler actuation.Global technique, co-ordination and breath-holding were all significantly worse in MDI users with poor English. Only 17% of that group had adequate technique compared to over half (62%) of FE. The EP group were significantly less likely than the FE group to report ever seeing the practice nurse about their asthma. After information, global technique was rated as improved in 50% of the MTS group compared to 28% of those given a translated PIL. A further six people (17%) in the PIL group improved after subsequent verbal advice in their own language. Both information methods significantly increased inhaler shaking and mouthpiece checking, but co-ordination only improved in a small number of people.The study suggests that Turkish-speaking MDI users with poor English may be disadvantaged in terms of access to medicines information in the UK. The acceptability of pharmacy-based support services for this, and other specific language groups should be explored. Multimedia offers an alternative to a translator for brief explanations, particularly for first-time users, but improving poor co-ordination requires individualised "hands on" teaching from health professionals.

BACKGROUND Metered dose inhalers (MDIs) are not easy to use well. Every MDI user receives a manufacturer's patient information leaflet (PIL). However, not everyone is able or willing to read written information. Multimedia offers an alternative method for teaching or reinforcing correct inhaler technique. OBJECTIVE The aim of this study was to compare the effects of brief exposure to the same key information, given by PIL and multimedia touchscreen computer (MTS). METHODS A single-blind randomized trial was conducted in 105 fluent English speakers (53% female; 93% White) aged 12-87 years in London general practices. All patients had had at least one repeat prescription for a bronchodilator MDI in the last 6 months. Inhaler technique was videotaped before and after viewing information from a PIL (n = 48) or MTS (n = 57). Key steps were rated blind using a checklist and videotape timings. The main outcome measures were a change in (i) global technique; (ii) co-ordination of inspiration and inhaler actuation; (iii) breathing-in time; and (iv) information acceptability. RESULTS Initially, over a third of both groups had poor technique. After information, 44% (MTS) and 19% (PIL) were rated as improved. Co-ordination improved significantly after viewing information via MTS, but not after PIL. Breathing-in time increased significantly in both groups. Half the subjects said they had learned 'something new'. The MTS group were more likely to mention co-ordination and breathing. CONCLUSIONS Short-term, multimedia is as least as effective as a good leaflet, and may have advantages for steps involving movement. MTS was acceptable to all age groups. The method could be used more widely in primary care.

The 9th Health Services Research and Pharmacy Practice Conference was hosted by the clinical and practice research group at the School of Pharmacy, Queen's University Belfast, Northern Ireland, on April 14 and 15, 2003. The opening plenary address focused on the influence that social environment has on health. Imogen Savage reports on this and on some of the other research presented at the conference.

Objective To describe and evaluate the training and support provided to the first cohort of community pharmacists to supply progestogen-only emergency contraception (POEC) under a Patient Group Direction (PGD) in Lambeth, Southwark and Lewisham, London. Design The study comprised (a) a systematic analysis of written and oral data from pharmacists before and during training, and at 5 and 13-14 months after launch; (b) analysis of telephone calls to clinical support and (c) analysis of written pharmacy records. Subjects A total of 20/22 pharmacists in the first training cohort; 6/23 pharmacists who applied but were not accepted were also followed up. Results A formal course with role-play was a successful training method, and the course also served as a team-building exercise. Subsequent interviews demonstrated that pharmacists had understood the concept of client confidentiality and gained confidence over time in the use of the PGD. The on-call consultants received 152 calls in the first 12 months of the scheme. Over 80% of the calls concerned clinical criteria (notably including 22% that were queries about oral contraceptives). Frequency ranged from one to eight calls per week with 28% made at weekends. In over half (60%) of the calls the pharmacist was subsequently able to make a supply. Queries over client management resulted in several changes in the protocol. The primary expressed concern for all pharmacists at all time points was how clients might 9misuse9 or 9abuse9 the service, and this remained a concern despite the fact that it also applies to other routes of supply of POEC. However, the PGD cohort was more positive on local benefits than pharmacists who were not selected. Conclusions Training and support have enabled this often-underused group of professionals to participate in an extended reproductive health service. Mobile phones are an essential support tool.

PACT (prescribing analysis and cost tabulation) data is a national data set which analyses prescribing data in terms of cost and number of items (volume). At an organizational level, PACT is used to monitor and control prescribing cost and to set prescribing budgets. At individual practitioner level, it is used as an educational and audit tool. The Prescription Pricing Authority (PPA) has sent general practitioners (GPs) quarterly summary reports of their own prescribing since 1988. From 2000 prescriptions written by nurse prescribers have been added to the national PACT data set, and health authorities, practices and trusts will now be analysing both nurse and GP prescribing quality. Because of differences in the way they work, nurse prescribers will not automatically receive individual reports of their own prescribing. However they should be able to access this information on request through their local health authority prescribing advisers and primary care group pharmacists. Based on GP experience, nurse prescribers should find PACT data a useful learning resource for individual and team practice development.

Objective To explore and describe patients' views of the value of brown bag medication reviews. Method Semi-structured, tape-recorded interviews were conducted with 20 patients who had participated in a brown bag medication review scheme. Setting A health authority area in south-east inner London. Key findings Patients perceived the following benefits from brown bag reviews: clinical problems resolved; better understanding of their medications, leading to increased confidence; and appreciation that an interest was being taken in their health care. Reviews had given patients a sense of empowerment, and had made them realise that they had a right to information about their medical treatment and medication. As a result they were likely to be more proactive in seeking information in future. Reviews had made patients realise that pharmacists were knowledgeable about medicines, where previously many had thought that only doctors had sufficient knowledge. Reviews had enhanced relationships between patients and pharmacists. However, some patients still perceived their doctor as the authoritative source of information about medicines. Patients' accounts indicated that much of the information provided by the pharmacist was new, raising the issue of what information was routinely being provided by pharmacists. Conclusions Brown bag reviews were regarded by patients as beneficial and they wanted them to be available in the future. Patients' perceptions of pharmacists as health professionals and providers of information on medicines were enhanced by brown bag reviews.

Objectives To determine whether the professional policy shift away from dispensing towards patient-focused care is reflected in the way community pharmacists actually use their time. Method Retrospective comparison, using data from five observational work sampling studies employing the same methodology. The percentage of time spent on manipulative dispensing (defined as creating labels and physically preparing prescription items) and health-related customer communication was monitored. Setting Fifteen independent practices (8.7 prescriptions/hour; London, England, 1993); 40 urban/rural pharmacies (7.8 prescriptions/hour; Dublin, Eire, 1985); 28 independents (9.1 prescriptions/hour; Sydney, Australia, 1985); one traditional multiple (9.6 prescriptions/hour; Nova Scotia, Canada, 1980); 20 traditional multiples (8.1 prescriptions/hour; eastern United States, 1973). Key findings Despite full computerisation, English pharmacists in 1993 spent as much time creating dispensing labels (8.8 per cent) as they did on health-related customer talk (7.2 per cent), and twice as much time preparing prescription items (14.2 per cent). Of their total time, 6.5 per cent was spent on simple redispensing (mostly counting tablets, pouring liquids and cutting blister strips). The time spent on extemporaneous preparation was extremely low. In Eire, pharmacists spent nearly twice as much time (5.8 per cent) on health-related talk as on counting, pouring and compounding (3.8 per cent) and in Australia nearly three times as much time (6.6 per cent vs 2.3 per cent). In Eire, two-thirds of pharmacists had qualified dispensing help of a type not found in other countries. In Australia, most products were ready to issue. Conclusion The proportion of pharmacist time spent on customer communication has increased three-fold since 1973. However, this has not been mirrored by a decline in time spent on manipulative dispensing. Keeping the study limitations in mind, it is suggested that, in Britain, the reprofessionalisation process may be hampered by the continued need for redispensing and the limited availability and use of trained support staff.

Dispensary workload is widely perceived by pharmacists as limiting the time available for customer contact. This study compared pharmacist work patterns at two neighbouring independent pharmacies, one without (A) and one with (B) a trained dispensing technician, using fixed interval activity sampling. Pharmacists were observed at work over two weeks; six half-day observation sessions (A = 1,181 observations; B=1,348) could be matched for incoming dispensing workload. Data on 505 prescription issues and 74 over-the-counter events (advice requests, advised sales, and health information) were collected. Pharmacy B dispensed a greater proportion of antibiotics (19 per cent v 11 per cent, P

With 116 participants from 21 countries, the 8th Social Pharmacy Workshop, held at Humboldt university in former East Berlin in June, was a truly international event. This year, there were participants from Bulgaria, Czech Republic, Slovakia and Slovenia, and a large British contingent, which matched that of the host country. We publish here a summary of some of the research presented.

With the new National Patient Safety Agency starting to roll out its “error and near miss” reporting system across the UK National Health Service, the 8th Health Services Research and Pharmacy Practice conference, held in Leeds on April 11–12, provided a timely introduction to the science of human error, as Imogen Savage reports

This paper reports a study undertaken in the UK to gather lessons learned from hospital sites that have implemented electronic prescribing systems. The work was commissioned by NHS Connecting for Health, the UK Department of Health agency responsible for the implementation of the National Programme for Information Technology. The aim was to capture front-line experience of the project and systems implementation, and to share it with staff who will in the future participate in other implementations. Data were drawn from detailed interviews with staff and a survey in 13 hospitals in England, as well as a review of published studies of implementations. The study output is a report and six user-facing briefing documents targeted at key stakeholder groups; nurses, pharmacist, doctors, senior executives, implementation team members and IMT staff.

Background Quantitative prospective methods are widely used to evaluate the impact of new technologies such as electronic prescribing (eP) on medication errors. However, they are labour-intensive and it is not always feasible to obtain pre-intervention data. Our objective was to compare the eP medication error picture obtained with retrospective quantitative and qualitative methods. Methods The study was carried out at one English district general hospital approximately two years after implementation of an integrated electronic prescribing, administration and records system. Quantitative: A structured retrospective analysis was carried out of clinical records and medication orders for 75 randomly selected patients admitted to three wards (medicine, surgery and paediatrics) six months after eP implementation. Qualitative: Eight doctors, 6 nurses, 8 pharmacy staff and 4 other staff at senior, middle and junior grades, and 19 adult patients on acute surgical and medical wards were interviewed. Staff interviews explored experiences of developing and working with the system; patient interviews focused on experiences of medicine prescribing and administration on the ward. Interview transcripts were searched systematically for accounts of medication incidents. A classification scheme was developed and applied to the errors identified in the records review. Results The two approaches produced similar pictures of the drug use process. Interviews identified types of error identified in the retrospective notes review plus two eP-specific errors which were not detected by record review. Interview data took less time to collect than record review, and provided rich data on the prescribing process, and reasons for delays or non-administration of medicines, including "once only" orders and "as required" medicines. Conclusions The qualitative approach provided more understanding of processes, and some insights into why medication errors can happen. The method is cost-effective and could be used to supplement information from anonymous error reporting schemes.

Imogen Savage reports on some of the highlights from the sixth Health Services Research and Pharmacy Practice conference, held in Aberdeen from April 13–14

Background Diclofenac is commonly used for acute pain in children, but is not licensed for this indication in all age groups. Objectives 1) Assess the efficacy of diclofenac for acute pain in children. 2) Assess the safety of diclofenac for short‐term use in children. 3) Identify gaps in the evidence to direct future research. Search methods Seventeen databases indexing clinical trial reports were searched in February 2005 (with an update search as part of this first review in May 2008). A hand search of Paediatric Anaesthesia was undertaken and summaries obtained of adverse reaction reports from the UK Yellow Card Scheme and World Health Organization (WHO) Monitoring Centre. The reference lists of included studies were also searched. Selection criteria Any published report, in any language, involving the administration of diclofenac to a patient aged 18 years or younger for acute pain and detailing either monitoring of efficacy or safety. Data collection and analysis Two review authors independently assessed study quality and extracted the data. Authors were contacted where necessary. Review Manager version 5 was used for analysis. Main results 1) Efficacy: randomised controlled trials (RCTs) comparing diclofenac with placebo/any other treatment by using pain scores (assessed or reported), or need for rescue analgesia. 2) Safety: any type of study seeking adverse events (regardless of cause). An adverse event was defined as any reported adverse or untoward happening to a patient being treated with diclofenac for acute pain. Seven publications on diclofenac efficacy and 79 on safety (74 studies plus five case reports) were included in the final analysis. Compared with placebo/no treatment, diclofenac significantly reduced need for post‐operative rescue analgesia (relative risk [RR] 0.6; number needed to treat to benefit [NNT] 3.6; 95% confidence interval [CI] 2.5 to 6.3). Compared with any other non‐NSAID, patients receiving diclofenac suffered less nausea or vomiting, or both (RR 0.6; NNT 7.7 [5.3 to 14.3]). There appeared to be no increase in bleeding requiring surgical intervention in patients receiving diclofenac in the peri‐operative period. Serious diclofenac adverse reactions occurred in fewer than 0.24% of children treated for acute pain. The types of serious adverse reactions were similar to those reported in adults. Authors' conclusions Diclofenac is an effective analgesic for perioperative acute pain in children. It causes similar types of serious adverse reactions in children as in adults, but these are rare. More research on optimum dosing and safety in asthmatic children is required.

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Diclofenac is frequently used off-label in children for acute pain, but little information is available on diclofenac adverse drug reactions in this population. WHAT THIS STUDY ADDS • The common adverse drug reactions of diclofenac for acute pain in children are of a similar type to those seen in adults. • Serious adverse reactions occur in 1% of patients) adverse reactions caused by diclofenac when given to children for acute pain. METHODS A prospective observational study was undertaken on paediatric surgical patents aged ≤12 years at Great Ormond Street and University College London Hospitals. All adverse events were recorded, and causality assessment used to judge the likelihood of them being due to diclofenac. Prospective recruitment meant not all patients were prescribed diclofenac, allowing an analysis of utilization. Causality of all serious adverse events was reviewed by an expert panel. RESULTS Children prescribed diclofenac were significantly older, and stayed in hospital for shorter periods than those who were not. Diclofenac was not avoided in asthmatic patients. Data on 380 children showed they suffer similar types of nonserious adverse reactions to adults. The incidence (95% confidence interval) of rash was 0.8% (0.016, 2.3); minor central nervous system disturbance 0.5% (0.06, 1.9); rectal irritation with suppositories 0.3% (0.009, 1.9); and diarrhoea 0.3% (0.007, 1.5). No serious adverse event was judged to be caused by diclofenac, meaning the incidence of serious adverse reactions to diclofenac in children is

To compare four methods of detecting prescribing errors (PE) in the same patient cohorts before and after an intervention (computerised physician order entry; CPOE) and to determine whether the impact of CPOE is identified consistently by all methods.PEs were identified using (1) prospective detection by ward pharmacist; (2) retrospective health record review; (3) retrospective use of a trigger tool and (4) spontaneous reporting over two separate 4-week periods on one surgical ward in a UK teaching hospital.We reviewed 93 patients pre- and 114 post-CPOE. Using all four methods, we identified 135 PE (10.7% of all medication orders) pre-CPOE, and 127 (7.9%) post-CPOE. There was little overlap in PE detected by the different methods: prospective detection identified 48 (36% of all PE) pre- and 30 (24%) post-CPOE; retrospective review (RR) revealed 93 (69%) pre- and 105 (83%) post-CPOE, trigger tool 0 pre- and 2 (2%) post-CPOE and spontaneous reporting 1 (1%) pre- and 1 (1%) post-CPOE. The calculated relative reduction in risk of PE was 50% using prospective data, 12% with RR and 26% using data from all four methods.In this study, each method predominantly identified different PE. A combination of methods may be required to understand the true effectiveness of different interventions.

AIMS: To develop a population pharmacokinetic model for a new diclofenac suspension (50 mg 5 ml -1) in adult volunteers and paediatric patients, and recommend a dose for acute pain in children. METHODS: Blood samples were drawn at the start and end of surgery, and on removal of the venous cannula from 70 children (aged 1 to 12 years, weight 9 to 37 kg) who received a preoperative oral 1 mg kg -1 dose; these were pooled with rich (14 post-dose samples) data from 30 adult volunteers. Population pharmacokinetic modelling was undertaken with NONMEM. The optimum adult dose of diclofenac for acute pain is 50 mg. Simulation from the final model was performed to predict a paediatric dose to achieve a similar AUC to 50 mg in adults. RESULTS: A total of 558 serum diclofenac concentrations from 100 subjects was used in the pooled analysis. A single disposition compartment model with first order elimination and dual absorption compartments was used. The estimates of CL/F and V D/F were 53.98 l h -1 70 kg -1 and 4.84 l 70 kg -1 respectively. Allometric size models appeared to predict adequately changes in CL and V D with age. Of the simulated doses investigated, 1 mg kg -1 gave paediatric AUC (0,12 h) to adult 50 mg AUC (0,12 h) ratios of 1.00, 1.08 and 1.18 for ages 1-3, 4-6 and 7-12 years respectively. CONCLUSIONS: This study has shown 1 mg kg -1 diclofenac to produce similar exposure in children aged 1 to 12 years as 50 mg in adults, and is acceptable for clinical practice; patients are unlikely to obtain further benefit from higher doses. © 2008 The Authors., link_to_subscribed_fulltext

The biennial social pharmacy workshops provide a forum for practice research from around the world. This report of the 10th meeting, held in Leuven, Belgium, from August 25 to 28, is a British view of some of the work underway in other countries. Sadly, the Russian pharmacists who had intended to present work on economic aspects of rational medicines use were not, after all, able to attend. But with delegates from 13 other countries, there was still more than enough to whet the international appetite.

Most of us wonder what pharmacy practice will look like as the millenium comes round. But how can we study what is happening in our profession? “Researching change” was the theme of the 9th Social Pharmacy Workshop, held at the University of Wisconsin-Madison in America, from August 10 to 14. This report summarises some of the research methods discussed at the conference.

Aim To investigate pharmacists' views and experiences of supplying emergency hormonal contraception (EHC) via a group prescribing protocol in community pharmacies in the UK. Design Qualitative study using depth interviews. Setting Community pharmacists in Manchester, Salford and Trafford (Greater Manchester), and Lambeth, Southwark and Lewisham (London) Health Action Zones in the UK. Participants Forty-four community pharmacists supplying EHC in Manchester, Salford and Trafford, and Lambeth, Southwark and Lewisham (London). Results Pharmacists were broadly very positive about their experiences supplying EHC via the group prescribing protocol. Pharmacists identified many benefits of the EHC schemes for clients, in particular, improved access to EHC at no cost to clients. The confidential nature of the scheme was also seen as an advantage as was the scope for referral to other service providers. Pharmacists also believed that the scheme had benefits for the profession in terms of enhanced professional standing. However, their concerns included the extent of repeated use of EHC, the possible impact on contraceptive behaviors and sexually transmitted infections and its impact on male coercive sexual behavior. Conclusions Although pharmacy supply of EHC may improve access for some clients and is perceived as a popular service, research into the implications of the schemes as identified in this study need to be conducted.

People with chronic illness are being encouraged to become more involved in their care. For this, they need to be well informed about their medicines, and more written medicines information is becoming available. However, there is little data about its effectiveness and impact. This study examined the patient perspective of medicines information through focus groups of people with asthma. Most participants actively sought medicines information from a variety of professional and lay sources. There were some positive experiences but many examples of partial or total information failure. Individualised information was valued and medicine leaflets were generally seen as less helpful than face-to-face advice. Some felt strongly that patients with long experience should be involved in the development of medicine information leaflets. We conclude that medicine information leaflets do not currently meet the needs of users and that people who take medicines should be involved in their development and testing.

Focal points Patient information leaflets are mandatory, but highly standardised A sample of mainly white English-speaking inhaler-users aged 12 to 87 was asked for their views on the white male models used in a widely used patient information leaflet (n = 48) and a multimedia touch-screen program (n = 57) Of 75 people expressing an opinion, a third (25) said the choice of model mattered to them, and 13 (17 per cent) thought it might matter to some people There were differences between the two methods in terms of engaging information; there was an association between interest in the information and global change in inhaler technique Multimedia enables users to personalise the way information is presented; this could increase acceptability and make information more effective

Focal points □ Pharmacists have been supplying emergency hormonal contraception via patient group direction in two health action zone areas since late 1999 and early 2000 □ This paper presents qualitative interview data on participating pharmacists' views of the service □ Pharmacists were in general extremely positive about supplying EHC via patient group direction in the pharmacy, citing the chief benefits to users as including greatly improved access at no financial cost □ Participants also noted that the scheme also enhanced the professional standing of community pharmacy and demonstrated its worth as a sexual health resource □ There were concerns about use of EHC as a “regular” form of contraception and that widened availability might increase the number of episodes of unprotected sexual intercourse and consequently, sexually transmitted infections