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BackgroundDespite recommendations, documentation of indication on prescriptions and inpatient medication orders is not routinely practised. There has been a recent systematic review of indication documentation for antimicrobials, but not for interventions relating to indication documentation for medication more broadly. Our aims were to 1) identify, describe and synthesise the literature relating to effectiveness of interventions aimed at improving indication documentation and/or indication-based prescribing in both primary and secondary healthcare; 2) synthesise participant perspectives to identify barriers and facilitators to these interventions; and 3) make recommendations for both practice and research.MethodsA systematic literature search was conducted using Medline, Embase and CINAHL using two search concepts: electronic prescribing systems, and indication documentation and/or indication-based prescribing. Qualitative, quantitative and mixed-methods studies were included; outcome measures and results were extracted to produce a narrative synthesis. Quality appraisal by two independent reviewers was undertaken using the Mixed Methods Appraisal Tool.ResultsWe identified 21 studies evaluating interventions to aid indication documentation. Indication documentation was either via free-text, selection from a list, or by use of pre-defined indication-based order sentences for individual medications. For a number of outcomes, there was a mostly positive impact, including appropriateness of the medication order (6 of 8 studies), rates of prescribing error (2/2) and some less commonly reported clinical (2/4) and workflow-related outcomes (2/3). There was a less favourable impact on accuracy of indication documentation and rates of medication use, highlighting some unintended consequences that may occur when implementing new interventions. Participant insights from prescribers and other healthcare professionals complemented quantitative study results, highlighting both facilitators and barriers to indication documentation and the associated interventions. For example, barriers included long drop-down lists and the need to use workarounds to navigate approval systems due to time or knowledge constraints. Facilitating factors included the perceived benefits of indication documentation on communication among the healthcare team and with the patient.ConclusionIndication documentation has the potential to improve appropriate prescribing and reduce prescribing errors. However, further benefits to the prescriber, multidisciplinary team and patient may only be realised by developing methods of indication documentation that integrate more efficiently with prescriber workflows.PROSPERO registration numberCRD42021278495.

It is widely accepted that electronic health records, computerised provider order entry (CPOE) and electronic-prescribing systems represent a way forward for patient safety. Even relatively basic electronic-prescribing systems have been shown to improve patient safety by eliminating the ‘technical’ prescription writing errors of clarity and completion, such as those related to poor handwriting or missing information.1 2 However, reductions in errors relating to clinical decisions are likely to require more advanced systems incorporating clinical decision support systems (CDSS), which may also be linked to patient-specific information. A recent overview highlights that CDSS ‘…is comprised of software designed to be a direct aid to clinical-decision making, in which the characteristics of an individual patient are matched to a computerised clinical knowledge base and patient-specific assessments or recommendations are then presented to the clinician for a decision’.3 Within electronic-prescribing and CPOE systems, such recommendations are often presented to the user as interruptive pop-up alerts, including those relating to allergies, drug–drug interactions and potentially inappropriate doses. The systematic review by Cerqueira and colleagues4 in this issue of BMJ Quality & Safety focuses on the effectiveness of such interruptive alerts on prescribing behaviour in outpatient and ambulatory care settings. The review specifically excluded other types of CDSS as well as non-interruptive alerts. The authors identified only nine comparative studies of interruptive alerts that met their inclusion criteria, of which three were randomised controlled trials, with randomisation at either the level of the practice or the prescriber. Eight of the nine studies were from North America. The effectiveness of interruptive alerts on prescriber behaviour was conceptualised as prescriber acceptance of the alerts leading to changes in prescribing practices, medication costs and/or prescribing errors. The authors conclude that seven of the nine studies demonstrated significant provider behaviour …

Background Governance of controlled drugs (CDs) in hospitals is resource intensive but important for patient safety and policy compliance. Objectives To explore whether and how storing CDs in an automated dispensing cabinet (ADC) in a children’s hospital intensive care unit (ICU) contributes to the effectiveness and efficiency of CD governance. Methods We conducted a mixed-methods exploratory study, comprising observations, interviews and audits, 3 months after ADC implementation. We observed 54 hours of medications activities in the ICU medication room (with 42 hours of timed data); interviewed nurses (n=19), management (n=1) and pharmacy staff (n=3); reviewed 6 months of ICU incident reports pertaining to CD governance; audited 6 months of CD register data and extracted logs of all ADC transactions for the 3 months following implementation. Data analysis focused on four main CD governance activities: safekeeping/controlling access, documenting use, monitoring, and reporting/investigating. Results Nurses and pharmacists perceived spending less time on CD governance tasks with the ADC. The ADC supported CD governance through automated documentation of CD transactions; ‘blind counts’; automated count discrepancy checks; electronic alerts and reporting functionalities. It changed quality and distribution of governance tasks, such as removing the requirement for ‘nurses with keys’ to access CDs, and allowing pharmacists to generate reports remotely, rather than reviewing registers on the ward. For CDs in the ADC, auditing and monitoring appeared to be ongoing rather than periodic. Such changes appeared to create positive reinforcing loops. However, the ADC also created challenges for CD governance. Most importantly, it was not suitable for all CDs, leading to workarounds and parallel use of a safe plus paper registers. Conclusions ADCs can significantly alter CDs governance in clinical areas. Effects of an ADC on efficiency and effectiveness of governance tasks appear to be complex, going beyond simple time savings or more stringent controls.

IntroductionThe lack of evidence for drug dosing in pregnancy represents a large unmet need for pregnant women and their unborn child. This study examines Dutch stakeholders’ perceptions of model-informed dosing in pregnancy as part of an effort to build a model-informed pregnancy formulary (MIPF).MethodsOnline focus groups and individual interviews were conducted with health care practitioners (HCPs) from various specialties (gynecology, pharmacy, general medicine, midwifery and other medical specialties) and with currently or recently pregnant women. The perceived barriers and facilitators for implementing a MIPF were identified using a hybrid thematic analysis.Results30 HCPs and 10 pregnant women participated in nine focus groups and three interviews. The awareness of pharmacokinetic changes in pregnancy varied across focus group participants. While a majority of HCPs and pregnant women found a MIPF to be a relevant innovation, several participants across both groups indicated that the lack of information on fetal safety constituted another important gap to address. The information needs of HCPs in order to be willing to apply model-informed dosing recommendations varied. A majority of participants indicated that they preferred model predictions to be clinically verified for the concerned drug. HCPs expressed different preferences with regards to the most appropriate website for publishing model-informed dosing advice. Several pregnant women indicated that they wanted to be informed on the evidence behind model-informed dosing recommendations.ConclusionsStakeholders’ views on the barriers and facilitators for relying on model-informed dosing in pregnancy will be further investigated through an online survey and will inform the design of a MIPF.

BackgroundPatients often carry medication lists to mitigate information loss across healthcare settings. We aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use.MethodsWe used a mixed-methods design comprising two focus groups with patients and carers, 16 semistructured interviews with healthcare professionals, 60 semistructured interviews with people carrying medication lists, a quantitative features analysis of tools available for patients to record their medicines and usability testing of four tools. Findings were triangulated using thematic analysis. Distributed cognition for teamwork models were used as sensitising concepts.ResultsWe identified a wide range of mechanisms through which carrying medication lists can improve medication safety. These included improving the accuracy of medicines reconciliation, allowing identification of potential drug interactions, facilitating communication about medicines, acting as an aide-mémoire to patients during appointments, allowing patients to check their medicines for errors and reminding patients to take and reorder their medicines. Different tools for recording medicines met different needs. Of 103 tools examined, none met the core needs of all users. A key barrier to use was lack of awareness by patients and carers that healthcare information systems can be fragmented, a key facilitator was encouragement from healthcare professionals.ConclusionOur findings suggest that patients and healthcare professionals perceive patient-held medication lists to have a wide variety of benefits. Interventions are needed to raise awareness of the potential role of these lists in enhancing patient safety. Such interventions should empower patients and carers to identify a method that suits them best from a range of options and avoid a ‘one size fits all’ approach.

ObjectivesTo explore the views of junior doctors towards (1) electronic prescribing (EP) training and feedback, (2) readiness for receiving individualised feedback data about EP errors and (3) preferences for receiving and learning from EP feedback.DesignExplanatory sequential mixed methods study comprising quantitative survey (phase 1), followed by interviews and focus group discussions (phase 2).SettingThree acute hospitals of a large English National Health Service organisation.Participants25 of 89 foundation year 1 and 2 doctors completed the phase 1 survey; 5 participated in semi-structured interviews and 7 in a focus group in phase 2.ResultsFoundation doctors in this mixed methods study reported that current feedback provision on EP errors was lacking or informal, and that existing EP training and resources were underused. They believed feedback about prescribing errors to be important and were keen to receive real-time, individualised EP feedback data. Feedback needed to be in manageable amounts, motivational and clearly signposting how to learn or improve. Participants wanted feedback and better training on the EP system to prevent repeating errors. In addition to individualised EP error data, they were positive about learning from general prescribing errors and aggregated EP data. However, there was a lack of consensus about how best to learn from statistical data. Potential limitations identified by participants included concern about how the data would be collected and whether it would be truly reflective of their performance.ConclusionsJunior doctors would value feedback on their prescribing, and are keen to learn from EP errors, develop their clinical prescribing skills and use the EP interface effectively. We identified preferences for EP technology to enable provision of real-time data in combination with feedback to support learning and potentially reduce prescribing errors.

Objective To examine the effectiveness and cost-effectiveness of the community pharmacy New Medicine Service (NMS) at 26 weeks. Methods Pragmatic patient-level parallel randomised controlled trial in 46 English community pharmacies. 504 participants aged ≥14, identified in the pharmacy when presenting a prescription for a new medicine for predefined long-term conditions, randomised to receive NMS (n=251) or normal practice (n=253) (NMS intervention: 2 consultations 1 and 2 weeks after prescription presentation). Adherence assessed through patient self-report at 26-week follow-up. Intention-to-treat analysis employed. National Health Service (NHS) costs calculated. Disease-specific Markov models estimating impact of non-adherence combined with clinical trial data to calculate costs per extra quality-adjusted life-year (QALY; NHS England perspective). Results Unadjusted analysis: of 327 patients still taking the initial medicine, 97/170 (57.1%) and 103/157 (65.6%) (p=0.113) patients were adherent in normal practice and NMS arms, respectively. Adjusted intention-to-treat analysis: adherence OR 1.50 (95% CI 0.93 to 2.44, p=0.095), in favour of NMS. There was a non-significant reduction in 26-week NHS costs for NMS: −£104 (95% CI −£37 to £257, p=0.168) per patient. NMS generated a mean of 0.04 (95% CI −0.01 to 0.13) more QALYs per patient, with mean reduction in lifetime cost of −£113.9 (−1159.4, 683.7). The incremental cost-effectiveness ratio was −£2758/QALY (2.5% and 97.5%: −38 739.5, 34 024.2. NMS has an 89% probability of cost-effectiveness at a willingness to pay of £20 000 per QALY. Conclusions At 26-week follow-up, NMS was unable to demonstrate a statistically significant increase in adherence or reduction in NHS costs, which may be attributable to patient attrition from the study. Long-term economic evaluation suggested NMS may deliver better patient outcomes and reduced overall healthcare costs than normal practice, but uncertainty around this finding is high. Trial registration number NCT01635361, ISRCTN23560818, ISRCTN23560818, UKCRN12494.

BackgroundFew studies have applied a systems approach to understanding the causes of specific prescribing errors in the context of hospital electronic prescribing (EP). A comprehensive understanding of underlying causes is essential for developing effective interventions to improve prescribing safety. Our objectives were to explore prescribers’ perspectives of the causes of errors occurring with EP and to make recommendations to maximise benefits and minimise risks.MethodsWe studied a large hospital using inpatient EP. From April to June 2016, semistructured interviews were conducted with purposively sampled prescribers involved with a prescribing error. Interviews explored prescribers’ perceived causes of the error and views about EP; they were audio-recorded and transcribed verbatim. Data were thematically analysed against a framework based on Reason’s accident causation model, with a focus on identifying latent conditions.ResultsTwenty-five interviews explored causes of 32 errors. Slips and rule-based mistakes were the most common active failures. Error causation was multifactorial; environmental, individual, team, task and technology error-producing conditions were all influenced by EP. There were three broad groups of latent conditions: the EP system’s functionality and design; the organisation’s decisions around EP implementation and use; and prescribing behaviours in the context of EP.ConclusionsErrors were associated with the design of EP itself and its integration within the healthcare environment. Findings suggest that EP vendors should focus on revolutionising interface design and usability issues, bearing in mind the wider healthcare context in which such software is used. Healthcare organisations should draw upon human factors principles when implementing EP. Consideration of work environment, infrastructure, training, prescribing responsibilities and behaviours should be considered to address local issues identified.

IntroductionMany countries are launching large-scale, digitally enabled change programmes as part of efforts to improve the quality, safety and efficiency of care. We have been commissioned to conduct an independent evaluation of a major national change programme, the Global Digital Exemplar (GDE) Programme, which aims to develop exemplary digital health solutions and encourage their wider adoption by creating a learning ecosystem across English National Health Service (NHS) provider organisations.Methods and analysisThis theoretically informed, qualitative, longitudinal formative evaluation comprises five inter-related work packages. We will conduct a combination of 12 in-depth and 24 broader qualitative case studies in GDE sites exploring digital transformation, local learning and mechanisms of spread of knowledge within the Programme and across the wider NHS. Data will be collected through a combination of semistructured interviews with managers, implementation staff (clinical and non-clinical), vendors and policymakers, plus non-participant observations of meetings, site visits, workshops and documentary analysis of strategic local and national plans. Data will be analysed through inductive and deductive methods, beginning with in-depth case study sites and testing the findings against data from the wider sample and national stakeholders.Ethics and disseminationThis work is commissioned as part of a national change programme and is therefore a service evaluation. We have ethical approval from the University of Edinburgh. Results will be disseminated at six monthly intervals to national policymakers, and made available via our publicly accessible website. We will also identify lessons for the management and evaluation of large-scale evolving digital health change programmes that are of international relevance.

Objectives To conduct a pilot study to compare the upper limb disorder (ULD) risk associated with manual and automated cytotoxic compounding, and comment on the suitability of using the UK Health and Safety Executive Assessment of Repetitive Tasks (ART) tool for this purpose. Methods The ART tool comprised 12 domains, each scored on an ordinal scale. An overall ULD exposure score was calculated and categorised using the tool as low, medium or high risk. 21 manual and four automated sessions were observed in a UK hospital pharmacy aseptic unit; a smaller sample of automated sessions were used as these showed little variation in exposure score. The following were compared: (1) median (IQR) overall exposure scores; (2) overall exposure level categories; and (3) median (IQR) risk scores for each of the 12 domains. Practicalities of using the ART tool were documented. Results Manual sessions were associated with a higher median ULD exposure score (9.8 (IQR 8.8 to 12.0)) than automation (1.0 (0.9 to 1.3)). 14 manual sessions were low risk and seven were medium risk. All automated sessions were low risk. Overall, eight domains scored higher in the manual sessions than automated session; four domains scored the same. The largest difference in median exposure score was for domains regarding ‘force’, ‘arm movement’ and ‘arm posture’. Conclusions Automated compounding was associated with a lower ULD exposure score than manual compounding in our aseptic unit. The ART tool was useful for comparing ULD risk of manual and automated cytotoxic compounding.

Failure mode and effects analysis (FMEA) is a structured prospective risk assessment method that is widely used within healthcare. FMEA involves a multidisciplinary team mapping out a high-risk process of care, identifying the failures that can occur, and then characterising each of these in terms of probability of occurrence, severity of effects and detectability, to give a risk priority number used to identify failures most in need of attention. One might assume that such a widely used tool would have an established evidence base. This paper considers whether or not this is the case, examining the evidence for the reliability and validity of its outputs, the mathematical principles behind the calculation of a risk prioirty number, and variation in how it is used in practice. We also consider the likely advantages of this approach, together with the disadvantages in terms of the healthcare professionals' time involved. We conclude that although FMEA is popular and many published studies have reported its use within healthcare, there is little evidence to support its use for the quantitative prioritisation of process failures. It lacks both reliability and validity, and is very time consuming. We would not recommend its use as a quantitative technique to prioritise, promote or study patient safety interventions. However, the stage of FMEA involving multidisciplinary mapping process seems valuable and work is now needed to identify the best way of converting this into plans for action.

This is the final article in the series on the epistemology of patient safety research, and considers the selection of study design and end points during the planning of an evaluation. The key message of this series is that “one size does not fit all”: the nature of the evaluation will depend on logistical and pragmatic constraints, a priori assessment of the probability of benefits and harms, the plausible scale of these effects and the target audience for the results. This paper also discusses the advantages of mixed method designs. The strength of any conclusions can be increased if different end points concur and the authors therefore advocate assessment of the effect of the intervention on different end points across the generic causal chain linking structure, process and outcome. The use of both qualitative and quantitative methods is also advocated to help explain findings, generate theory and help contextualise results. We show how a bayesian framework can be used to synthesise evidence from a number of different sources and why this approach may be particularly appropriate for the evaluation of patient safety interventions.

This is the first of a four-part series of articles examining the epistemology of patient safety research. Parts 2 and 3 will describe different study designs and methods of measuring outcomes in the evaluation of patient safety interventions, before Part 4 suggests that "one size does not fit all". Part 1 sets the scene by defining patient safety research as a challenging form of service delivery and organisational research that has to deal (although not exclusively) with some very rare events. It then considers two inter-related ideas: a causal chain that can be used to identify where in an organisation's structure and/or processes an intervention may impact; and the need for preimplementation evaluation of proposed interventions. Finally, the paper outlines the authors' pragmatist ontological stance to patient safety research, which sets the philosophical basis for the remaining three articles.

This is the second in a four-part series of articles detailing the epistemology of patient safety research. This article concentrates on issues of study design. It first considers the range of designs that may be used in the evaluation of patient safety interventions, highlighting the circumstances in which each is appropriate. The paper then provides details about an innovative study design, the stepped wedge, which may be particularly appropriate in the context of patient safety interventions, since these are expected to do more good than harm. The unit of allocation in patient safety research is also considered, since many interventions need to be delivered at cluster or service level. The paper also discusses the need to ensure the masking of patients, caregivers, observers and analysts wherever possible to minimise information biases and the Hawthorne effect. The difficulties associated with masking in patient safety research are described and suggestions given on how these can be ameliorated. The paper finally considers the role of study design in increasing confidence in the generalisability of study results over time and place. The extent to which findings can be generalised over time and place should be considered as part of an evaluation, for example by undertaking qualitative or quantitative measures of fidelity, attitudes or subgroup effects.

This article builds on the previous two articles in this series, which focused on an evaluation framework and study designs for patient safety research. The current article focuses on what to measure as evidence of safety and how these measurements can be undertaken. It considers four different end points, highlighting their methodological advantages and disadvantages: patient outcomes, fidelity, intervening variables and clinical error. The choice of end point depends on the nature of the intervention being evaluated and the patient safety problem it has been designed to address. This paper also discusses the different methods of measuring error, reviewing best practice and paying particular attention to case note review. Two key issues with any method of data collection are ensuring construct validity and reliability. Since no end point or method of data collection is infallible, the present authors advocate the use of multiple end points and methods where feasible.

Background: Medication administration errors (MAEs) occur in 3–8% of all non-intravenous drug doses given in UK hospitals; higher rates have been reported for intravenous drugs. Educational interventions are often advocated as one way of reducing these rates. However, group education sessions are often not practical. We developed internet-based educational modules on drug safety, and evaluated their effect on MAEs. Methods: 11 modules were developed on different aspects of drug safety and delivered via commercially available software. All nursing staff on one ward were encouraged to participate. MAEs were identified using observation; the denominator used to calculate MAE rates was the number of opportunities for error. We aimed to observe 56 drug rounds before and after asking staff to complete the package. Results: The 19 nurses who administered drugs on the study ward all agreed to participate. Of these, 12 (63%) nurses completed all 11 modules. Pre-education, 82 (6.9%) errors were identified in 1188 opportunities for error. Afterwards, 66 (5.0%) errors were identified in 1397 opportunities for error (95% confidence interval (CI) for the difference −3.8% to 0%). The MAE rate for non-intravenous drugs was 6.1% pre-education and 4.1% afterwards (95% CI for the difference −3.8% to −0.2%). Most errors with regard to intravenous doses were due to fast administration of bolus injections. Conclusions: An interactive educational package focusing on patient safety was developed, with a high rate of uptake among nursing staff on the study ward. A reduction in non-intravenous MAEs was observed after the use of the package, but no significant change was seen in the overall error rate.

IntroductionThe emergence of patient and public involvement (PPI) in healthcare in the UK can be traced as far back as the 1970s. More recently, campaigns by harmed patients and their relatives have emerged as a result of clinical failings in the NHS, challenging paternalistic healthcare, which have led to a new focus on PPI in quality and safety, nationally and internationally. Evidence suggests that PPI within patient safety is often atheoretical and located within a biomedical discourse. This review will explore the literature on PPI across patient safety, healthcare and social care to identify theory, barriers and enablers that can be used to develop PPI in patient safety.Methods and analysisSystematic searches of three electronic bibliographic databases will be conducted, using both MeSH and free-text terms to identify empirical literature published from database inception to May 2017. The screening process will involve input from at least two researchers and any disagreement will be resolved through discussion with a third reviewer. Initial inclusion and exclusion criteria have been developed and will be refined iteratively throughout the process. Data extraction from included articles will be conducted by at least two researchers using a data extraction form. Extracted information will be analysed using a narrative review approach, which synthesises data using a descriptive method.Ethics and DisseminationNo ethical approval is required for this review as no empirical data were collected. We believe that the findings and recommendations from this review will be particularly relevant for an audience of academics and policymakers. The findings will, therefore, be written up and disseminated in international peer-reviewed journals and academic conferences with a health focus. They will also be disseminated to leading health policy organisations in the NHS, such as NHS England and NHS Improvement and national policy bodies such as the Health Foundation.

Objectives: To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors. Design: A mixed-methods approach was taken in the development phase of the project; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart. Setting: A London teaching hospital. Interventions/methods: A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation. Results: Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber’s printed name (163/164 vs 0/174; p

Medication error research typically focuses on just one stage of the medication use process: prescribing, transcribing, dispensing, administration or monitoring. Such simplification is required so that manageable boundaries can be set around the research, and to make it easier to specify error definitions, methods and denominators. However, this is clearly very simplistic, and from the patient's perspective it is a somewhat arbitrary and meaningless distinction. In addition, many quantitative studies present the numbers of doses, drugs or patients with one or more errors, which makes it easy to miss the fact that multiple errors can occur together. While studies of adverse drug events (ADEs) typically include a wider range of sources of harm, some analyses include only the first ADE identified for each patient. Collectively, this means we may miss the opportunity to explore how multiple errors may occur together in the same patient. And yet detailed investigations into catastrophic medication errors typically reveal a whole concatenation of errors and failed defences, involving multiple stages of the medication use process.1 ,2 We therefore need to better understand how errors are related across the whole medication process. A paper presented by Carayon et al 3 explores this very issue in two US adult critical care units, shedding new light on the complexities surrounding medication use in the hospital setting. While the critical care setting is likely to be particularly complex, with patients prescribed high numbers of medications, particularly intravenously, the principles are likely to apply much more widely. Carayon et al took the novel approach of analysing errors both by group (where more than one error occurs for the same medication order at the same …

Introduction Prescribing in the elderly population is a complex process and the prevalence of inappropriate prescribing is high, with potentially severe consequences. Care home residents are particularly vulnerable to inappropriate prescribing. With a growing ageing population, strategies to improve prescribing are essential. The aim of this systematic review was to collect and interpret the results of controlled trials of interventions to reduce inappropriate prescribing in care homes, to determine the most effective strategies. Method Databases searched were MEDLINE, EMBASE, international pharmaceutical abstracts and the Cochrane library. Search items included “nursing home”, “residential home”, “inappropriate prescribing”, “education”, “staff education”, “MDT”, “pharmacist”, “computer”. The search strategy retrieved 16 articles that met the inclusion criteria. Two independent reviewers undertook screening and methodological quality assessment, using the Downs and Black rating scale. A meta-analysis could not be done due to heterogeneity of the outcome measures used in the different studies. Results Four intervention strategies were indentified: education, multidisciplinary team (MDT) meetings, clinical pharmacist reviews and computerised clinical support systems. Educations interventions was the most studied area, with six studies showing an improvement in inappropriate prescribing. Mixed results were found for the pharmacist interventions, possibly due to the inappropriate choice of outcome measures used for assessing prescribing quality. Computerised decision support systems were evaluated in two studies, with one showing a significant increase in the final appropriate drug orders. Two of the three studies examining MDT meetings found an overall improvement in quality of prescribing. Conclusion Results from various interventional strategies are mixed; a multi-faceted approach, clearer policy guidelines and standardised measurements for measuring inappropriate prescribing are required to improve prescribing practices for these vulnerable patients.

Objectives To conduct an independent evaluation of the first phase of the Health Foundation’s Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals.\ud \ud Design Mixed method evaluation involving five substudies, before and after design.\ud \ud Setting NHS hospitals in the United Kingdom.\ud \ud Participants Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals.\ud \ud Intervention The SPI1 was a compound (multi-component) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change.\ud \ud Results Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P

The reported error rates in Valentin and colleagues’ study on errors in administration of parenteral drugs in intensive care units are likely to underestimate the true incidence of errors.1 Firstly, errors were identified using self reporting by hospital staff. Only about 1 in 100 prescribing errors and 1 in 1000 administration …