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Objectives: Transition of care when a patient moves between healthcare locations is a risk factor for medication errors and medicines-related preventable harm. The aims of this retrospective service evaluation were to understand, by classifying and quantifying, the nature of interventions made by community pharmacy when receiving a discharge medicines service referral from a secondary care hospital, with a focus on two groups of high-risk medicines supplied at discharge-oral anticoagulants and weak opioids following hip or knee surgery., Methods: Records made on the PharmOutcomes™ platform by community pharmacists in response to referral for the NHS England discharge medicines service were analysed and summarized. This analysis was exploratory and interpretative in nature and used a convenience sample of patients who had consented for the service over 12 months from May 2022 to April 2023., Key Findings: During 12 months, 6811 referrals occurred, of which 71% were recorded as having different stages of the service completed on PharmOutcomes™. Medicines reconciliation, first-prescription review, and consultation stages decreased as patients progressed through the service. Slightly greater rates of completion were observed for patients receiving oral anticoagulants and for codeine or dihydrocodeine following hip and knee surgery, although overall referrals were low for this latter cohort., Conclusions: Through this service, community pharmacists are well placed to support the safe and effective use of medicines including oral anticoagulants and weak opioids posthospital discharge and potentially reduce incidents of avoidable harm. The variations in recorded completion rates across the three stages of the service and the apparent greater finalization rates for the high-risk medicines studied require further investigation., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objectives: We aimed to assess the appropriateness of penicillin allergy (PenA) assessment conducted by clinical teams and to review the safety of subsequent exposure of these patients to penicillin., Methods: Opportunistic, prospective observational study of usual clinical care, between 16 May 2023 and 14 August 2023, of inpatients with a PenA and requiring antibiotics, in a 750-bed hospital in England. To assess the appropriateness of management, PenA patients prescribed penicillins were grouped into risk categories using a validated antibiotic allergy assessment tool: eligible for de-label on history alone (direct de-label; DDL), eligible for direct oral challenge (DOC), high risk or unable to obtain history., Results: Of the 123 patients admitted with a PenA (or sensitivity record) and exposed to a penicillin, data were collected for 50. Their PenA records were grouped follows: eligible for DDL 34 (68%), eligible for DOC 11 (22%), high risk 4 (8%) and unable to obtain history 1 (2%). In 14/50 (28%) patients there was no evidence of a current PenA assessment in the medical notes., Conclusions: Using the allergy risk tool, most patients with PenA records were exposed to penicillin appropriately. However, patients meeting high-risk criteria were also exposed to penicillin when the tool excluded them. PenA assessment needs to be carried out with appropriate training and governance structures in place., Competing Interests: Declaration of competing interest NP & JS have NIHR funding to explore how to best deliver penicillin allergy de-labelling. The work presented here was undertaken as part of usual work and is not funded., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Competing interests: None declared. Refer to the online supplementary files to view the ICMJE form(s).

Objectives: Penicillin allergy records are common, often incorrect and are associated with broad spectrum antibiotic use. We piloted a pharmacist-led multidisciplinary penicillin allergy de-labelling daily ward round to determine the opportunity for penicillin allergy de-labelling in a UK hospital., Methods: A daily ward round, delivered by antibiotic pharmacists or junior doctors, identified adult medical and surgical patients between 7 November 2022 and 31 January 2023 with a penicillin allergy record that was preventing first-line penicillin use. An allergy history was taken before risk stratifying likelihood of future harm from penicillin re-exposure and an allergy testing method was determined (direct de-label on history alone or after direct drug provocation testing). After successful allergy de-label, the antibiotic was switched to a penicillin antibiotic., Results: Of 7214 inpatients during the study period, 1133 (15.7%) had a penicillin allergy record. Of 285 allergy histories taken, 105 (36.8%) met high-risk criteria, 45 (15.8%) met low-risk criteria eligible for direct de-label and 73 (25.6%) met criteria eligible for direct drug provocation testing. We were unable to obtain a history for 61 (21.4%) patients. Of 45 low-risk patients eligible for direct de-label, 40 (88.9%) were de-labelled of whom 24 (53.3%) were switched to a penicillin antibiotic. Of 73 patients with a low-risk allergy history eligible for direct drug provocation testing, 16 (21.9%) received direct drug provocation testing, of whom 9 were switched to a penicillin antibiotic. Two direct de-label patients experienced harm (thrush within 5 days and delayed skin reaction after day 5); none of the direct drug provocation testing patients had a reaction by day 5. The switches resulted in reduced alternative antibiotic use by 173 Daily Defined Doses (DDDs)., Discussion: Penicillin allergy de-labelling patient pathway delivered by pharmacists and junior doctors was safe and effective and well accepted by patients and the wider clinical teams., (Copyright © 2023 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background Medication errors can occur because of incomplete or poorly communicated information at the transition from hospital to community. Following an audit in 2016, a project was undertaken to determine if pharmacists could improve the quality of medication information in discharge summaries by introducing a discharge medication reconciliation process. Pharmacists recorded any changes to the patient's medication in the electronic prescribing system during their inpatient stay and summarised these changes on discharge. Objective To compare medication information in discharge summaries with recognised standards for the clinical structure and content of patient records, and to assess the impact of the pharmacist process on compliance with certain elements of these standards. Setting A 750 bed teaching district general hospital in England. Method A retrospective observational study examining all patient discharge summaries over a 1 week period for compliance to national standards. Main outcome measure The main outcome measures were compliance with standards for medication started, stopped or changed in hospital and any differences between extent of recording this information by doctors and pharmacists. Results Data were collected and analysed for 243 patients, of whom 94 (38.7%) attracted a discharge medicines reconciliation process by a pharmacist. Discharge summaries were compliant with basic standards for changed medication in 42% of patients or 51.4% with the input of a pharmacist. This increase of 9.4% was statistically significant (p = 0.0365). At an enhanced level, pharmacists increased compliance from 39.1 to 46.5%, this did not represent a significant increase (p = 0.0989). Conclusion Pharmacists undertaking a discharge medication reconciliation process significantly improves the quality of discharge summaries., (© 2021. Crown.)

In England, the prescribing of antidepressants, primarily the newer generation antidepressant classes, has steadily increased over recent years. There is ongoing debate about how the efficacy of these drugs is viewed, their place in therapy and the harms associated with stopping them. Much of the evidence of their efficacy comes from short-term placebo-controlled trials which tend not to include outcomes that are of greatest relevance to patients, such as social functioning or quality of life, but rather restrict outcomes narrowly to symptom measures. On such measures these studies do not demonstrate clinically significant differences from placebo for depression. A range of adverse effects are also recognised, often greater in naturalistic studies of long-term antidepressants users than those measured in short-term efficacy studies, including emotional numbing, sexual difficulties, fatigue and weight gain. There is increasing recognition that withdrawal symptoms from antidepressants are common and that these symptoms can be severe and long-lasting in some patients. Recent guidance on how to stop antidepressants in a tolerable way has been presented by the Royal College of Psychiatrists. We believe that increasing awareness about the difficulty that some patients have in stopping antidepressants should lead to more cautious prescribing practice, with antidepressants given to fewer patients and for shorter periods of time. This article discusses the perceived benefits and harms of antidepressant use., Competing Interests: Competing interests: None declared. Refer to the online supplementary files to view the ICMJE form(s)., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared. Refer to the online supplementary files to view the ICMJE form(s).

Competing Interests: Competing interests: None declared. Refer to the online supplementary files to view the ICMJE form(s).

Objectives: Approximately 10% of the general population are reported to have a penicillin allergy, but more than 90% of these patients are able to tolerate penicillins after formal assessment. Patients with penicillin allergy labels have poorer health outcomes and incorrect labels impact negatively on healthcare systems. Identifying patients with incorrect penicillin allergy labels (those who can safely take penicillin) has the potential to benefit patients and healthcare systems. This study explores barriers and enablers towards identifying and removing incorrect penicillin allergy labels in inpatients ('delabelling')., Methods: Two focus groups were completed with a total of 17 doctors, nurses and pharmacists at a 750-bed district general hospital in England., Results: Thematic analysis identified four main themes: managing penicillin allergic patients, environmental barriers, education for patients and staff and a future delabelling process. Staff reported that identifying and delabelling incorrect penicillin allergy records was a complex task and not a priority during the acute presentation. Participants felt confident removing erroneous allergy records if the patient was able to describe the reaction. Balancing time to confirm and delabel with competing duties was felt to be a challenge. Revisiting the discussion with the patient when time was less pressured was offered as a solution to the problem. The lack of provision to translate uncertainty about allergy status in the electronic health record was mentioned as a barrier to accurate documentation of allergy history. Ensuring all patient records were amended to reflect the new allergy status was identified as a challenge. A delabelling process involving nurses, doctors and pharmacist was discussed., Conclusions: Delabelling patients with erroneous penicillin allergy labels was recognised as a complex problem. A patient pathway involving nurses, doctors and pharmacist is likely to be the optimal method to safely delabel patients., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared. Refer to the online supplementary files to view the ICMJE form(s).

Competing Interests: Competing interests: None declared. Refer to the online supplementary files to view the ICMJE form(s).

Objectives: The purpose of this study was to determine any benefit from a discharge transfer of care service from hospital to community pharmacy., Method: A cross-sectional cohort design was used to compare actioned and non-actioned transfers of care., Key Findings: Of the 1130 transfers of care referrals to pharmacies in 2017, 365 patients received an actioned community pharmacy service after discharge. The 30-day readmission rate was 8.5% (31/365) in those who received an actioned community pharmacist service compared to 23.3% (178/765) in those who did not. Odds ratio for readmission at 30 days was 3.26 (95% CI 2.04 to 4.59, P < 0.0001), significantly higher in those not receiving an actioned transfer of care service., Conclusion: Involving community pharmacy at patient discharge appears to contribute to lower rates of readmission., (© 2020 Royal Pharmaceutical Society.)

Competing Interests: Competing interests: None declared. Refer to the online supplementary files to view the ICMJE form(s).

Competing Interests: Competing interests: None declared. Disclosure of conflicts of interest form(s) are published online as supplementary files.

Objectives: To ascertain the views, beliefs and attitudes of hospital staff to incorrect penicillin allergy records in order to determine healthcare worker motivation for the implementation of a penicillin de-labelling antibiotic stewardship intervention at the study hospital., Methods: An electronic questionnaire (SurveyMonkey) was distributed to medical, nursing and pharmacy staff at a 750-bed teaching district general hospital with no specialist allergy service., Results: 193 staff responded (58% medical, 31% nursing and 11% pharmacy). Virtually all staff had encountered patients who believed themselves to be penicillin allergic, but felt the patient's belief to be erroneous. The potential negative consequences of an incorrectly assigned penicillin allergy label were acknowledged by the majority of respondents. In total, 188/190 (99%) of staff thought patients having an incorrect allergy status to penicillin was a problem and required a solution. Staff reported they would feel confident using a validated evidence-based question tool to de-label patients incorrectly labelled as penicillin allergic if the process was supported by Trust management, although many still felt apprehensive about de-labelling patients for fear of patient harm through inappropriate de-labelling., Conclusions: A penicillin allergy de-labelling intervention would be well supported by healthcare workers at the study hospital, demonstrating a receptive environment for this behavioural change intervention. Further exploration of the barriers and levers to introducing an intervention is required using behavioural change methodology in order to design a successful de-labelling intervention., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared. Disclosure of conflicts of interest form(s) are published online as supplementary files.

Objectives: Our aim was to determine the views of nurses and midwives in an acute hospital regarding a potential role in an antimicrobial stewardship programme., Methods: An online survey about antimicrobial stewardship was distributed to nursing and midwifery staff at the Royal Cornwall Hospitals NHS Trust. Descriptive statistics were used for analysis., Results: Eighty responses were received. Forty-three (54%) claimed to have heard the term antimicrobial stewardship. Only seven (9%) had cause to look at the hospital's antimicrobial guidelines at least once a week. Between 47 (60%) and 68 (87%) respondents agreed they should be involved in a range of stewardship roles. Constraints of time and workload, lack of knowledge and lack of adequate staff training were the three main perceived challenges to a wider role., Conclusions: Staff in this survey recognise the potential for wider antimicrobial stewardship roles. They also identify challenges to undertaking these roles. Some of these barriers could be overcome by provision of education and support; hospital pharmacists may be able to assist with this role development., Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Background: There are potential conflicts between authorities and companies to fund new premium priced drugs especially where there are safety and/or budget concerns. Dabigatran, a new oral anticoagulant for the prevention of stroke in patients with non-valvular atrial fibrillation (AF), exemplifies this issue. Whilst new effective treatments are needed, there are issues in the elderly with dabigatran due to variable drug concentrations, no known antidote and dependence on renal elimination. Published studies have shown dabigatran to be cost-effective but there are budget concerns given the prevalence of AF. There are also issues with potentially re-designing anticoagulant services. This has resulted in activities across countries to better manage its use., Objective: To (i) review authority activities in over 30 countries and regions, (ii) use the findings to develop new models to better manage the entry of new drugs, and (iii) review the implications for all major stakeholder groups., Methodology: Descriptive review and appraisal of activities regarding dabigatran and the development of guidance for groups through an iterative process., Results: There has been a plethora of activities among authorities to manage the prescribing of dabigatran including extensive pre-launch activities, risk sharing arrangements, prescribing restrictions, and monitoring of prescribing post-launch. Reimbursement has been denied in some countries due to concerns with its budget impact and/or excessive bleeding. Development of a new model and future guidance is proposed to better manage the entry of new drugs, centering on three pillars of pre-, peri-, and post-launch activities., Conclusion: Models for introducing new drugs are essential to optimize their prescribing especially where there are concerns. Without such models, new drugs may be withdrawn prematurely and/or struggle for funding.

Background: Medication errors are a potential major threat to patient's health, and allergic reactions occurring in patients with known allergies are an important preventable form of adverse drug event. The use of penicillin antibiotics in patients who are allergic to penicillin, in particular, is a major concern., Aim: To survey staff attitudes and beliefs to incidents involving penicillin allergic patients who are prescribed and administered penicillin antibiotics., Setting: A 650 bed teaching hospital in England., Method: Using individual and (focus) group interview proceedings with a purposive sample of doctors, nurses and pharmacists, an electronic questionnaire was administered hospital wide to all clinical staff. No reminders were issued., Main Outcome Measures: Clinical staff's views on the causes of penicillin medication errors., Results: The electronic survey was completed by 235 members of the clinical staff. Half the respondents definitely considered themselves knowledgeable about which antibiotics contain penicillin medicines, though approximately 90 % of respondents considered that misinformation or lack of knowledge on which antibiotics contain penicillin medicines was an issue for some or most colleagues. Various organisational issues such as the use of red wrist bands, the wearing of red tabards by the nurse during the medicines round, and a busy work environment were recurrently highlighted as systems factors that could be improved upon., Conclusion: Our study elucidated concerns amongst clinical staff relating to the scenario of a penicillin allergic patient receiving a penicillin antibiotic. The resulting local learning and feedback about staff beliefs pertaining to this one specific type of error will be used to consider the nature and type of local action to be taken to help improve patient safety.

Objective: This study aimed to investigate inpatients' and outpatients' need for information about medication, to what extent those needs were addressed and patient attitudes regarding pharmaceutical services., Method: Self-administered questionnaires were distributed to a sample of outpatients and inpatients in a UK district general hospital. Themes included satisfaction with information given about medication, potential confusion over medication prescribed by the general practitioner and by the hospital, access to a member of the pharmacy team and preferences on how information on medication should be given., Key Findings: Ninety-one outpatient and 126 inpatient questionnaires were available for analysis. All outpatients who responded acknowledged that they were told how long they might need to wait for their medicines to be dispensed, although approximately one-fifth felt they had to wait a long time. Nearly three-quarters of outpatients felt there was an opportunity to ask medication-related questions of the pharmacy team. Nearly three-quarters of inpatients reported they were encouraged to bring into any hospital any medication they were taking at home. Twenty-eight per cent of 95 inpatients reported that some of their existing medication was stopped while in hospital. For the inpatients who received information about new medication, this was explained to the patient verbally (76%) and both verbally and in writing (22%). Forty-two per cent of inpatients (and 36% of outpatients) expressed a preference to receive information about medication both verbally and in writing. Thirty-five (32%) of 110 inpatients were not aware that a pharmacy team had a presence on the ward., Conclusions: Overall the majority of both in- and outpatients appeared to be receiving appropriate pharmaceutical services. There is a need to raise the profile of the pharmacy team in regards to provision of medication advice for inpatients. Consideration needs to be given to better provision of written information about medication for patients., (© 2011 The Authors. IJPP © 2011 Royal Pharmaceutical Society.)

Objectives: To explore existing mechanism to ensure quality assurance of medicine use reviews (MURs), and to identify those parameters of an MUR that community pharmacists consider as indicators of quality., Setting: Community pharmacists undertaking MURs in Cornwall, United Kingdom., Method: A questionnaire was developed to investigate pharmacists' attitudes towards MURs and towards quality assurance of MURs. Questionnaires were distributed during December 2008 to a sample of pharmacists in Cornwall accredited to provide the service. Main outcome measures Community pharmacists' attitudes towards quality assurance of MURs., Results: Fifty completed questionnaires were returned, a third of which were from locum pharmacists. The most frequently reported determinant for undertaking an MUR was the pharmacist's judgement. Company policy to deliver MURs was acknowledged as a potential indicator of a sub-optimal MUR. Pharmacists shared a common sense of what constitutes a "poor" MUR but not what defines a quality one., Conclusion: For peer review to operate as an effective mechanism to assure quality of MURs, pharmacists need to develop an effective forum to share their practice experiences.

Objective: To study the pattern of use of medicines that may contribute to, or protect against, falls and fractures in the setting of a UK residential home population, and to compare the results with a similar study conducted in 2001., Setting and Method: A cross-sectional survey was conducted in 2003 in 18 residential homes. A trained community pharmacist visited the homes to retrieve information about use of medicines whilst demographic details were provided by the residential home staff., Main Outcome Measure: The proportion of patients who were prescribed medicines with a potential positive benefit in preventing fractures, and medicines that may cause elderly people to fall., Results: The study population consisted of 581 residents. Compared to the 2001 study, the use of both calcium and vitamin D had increased significantly (8.3% versus 2.1%). Although, the overall prescribing of psychotropics in 2003 was relatively low, there was a trend for increased prescribing of these medicines which have been identified as risk factors for falling., Conclusion: In a residential home setting in the UK, the use of psychotropic drugs is not uncommon, whereas there is limited use of drugs that have the potential for preventing morbidity associated with falls.

Objective: To review whether oral terbinafine, used for fungal nail infections, is prescribed appropriately by general practitioners., Method: Cross-sectional survey of forty volunteer practices. Prescribing systems were searched to identify patients who had been prescribed a course of oral terbinafine during 1998. The clinical records of five such patients in each practice were examined for additional information regarding appropriate diagnostic tests., Results: Five hundred sixty-nine patients (0.25% of the population aged 12 and over) were reported to have received a course of oral terbinafine. Sixty-four percent had been treated empirically without any recorded diagnostic test., Conclusion: Treatment of onychomycosis with terbinafine is commonly undertaken without diagnostic confirmation. This empirical treatment does not comply with locally recommended good practice.