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Objective The aim of the study was to investigate the effectiveness of user testing for improving healthcare professionals' retrieval and comprehension of information in medicines guidelines. Methods The United Kingdom's Injectable Medicines Guide was selected as a case study. This gives guidance to nurses on preparing and administering intravenous medicines on hospital wards, in line with standard UK practice. Three rounds of user testing were completed with 10 hospital nurses per round, using the Injectable Medicines Guide for voriconazole and aminophylline. Participants used the guidelines to answer 17 questions related to the administration of these medicines. Answers were scored for "finding" and "understanding" the required information. Semistructured interviews explored participants' opinions of guideline content, design, and wording, with responses analyzed thematically. The guidelines were revised between rounds. Results In round 1, 8 of 17 questions were answered correctly by all participants. Participants had difficulty with dose, dilution, administration rate, and adverse effects questions. Revisions included new subsections and increased calculation support. In round 2, 14 of 17 questions were answered correctly by all participants. Difficulty persisted with dose and administration rate questions and further revisions made. In round 3, 15 of 17 questions were answered correctly by all participants. Across all rounds, participants considered appropriate subheadings and information order as important for fast location of information. Specific, detailed, and practical instructions were perceived as important to improve understandability and usefulness. Conclusions Key information in medicines guidelines may not be found and/or understood by healthcare professionals. User testing increased information retrieval and comprehension and could have an important role in improving the safety of medicines use.

Background The Global Digital Exemplar (GDE) Programme is a national initiative to promote digitally enabled transformation in English provider organizations. The Programme applied benefits realization management techniques to promote and demonstrate transformative outcomes. This work was part of an independent national evaluation of the GDE Programme. Aims We explored how benefits realization management was approached and conceptualized in the GDE Programme. Methods We conducted a series of 36 longitudinal case studies of provider organizations participating in the GDE Programme, 12 of which were in depth. Data collection included a combination of 628 interviews (with implementation staff in provider organizations, national programme management staff, and suppliers), 499 documents (of national and local implementation plans and lessons learned), and 190 nonparticipant observations (of national and local programme management meetings to develop insights into the broader context of benefits realization activities, tensions arising, and how these were negotiated). Data were coded drawing on a sociotechnical framework developed in related work and thematically analyzed, initially within and then across cases, with the help of NVivo 11 software. Results Most stakeholders broadly agreed with the rationale of benefits realization in the GDE Programme to show due diligence that public money was appropriately spent, and to develop an evidence base supporting the value of digitally enabled transformation. Differing national and local reporting purposes, however, created tensions. Central requirements, for progress reporting and tracking high-level benefits, had limited perceived local value and were seen to impose an unnecessary burden on provider organizations. This was accentuated by the lack of harmonization of reporting requirements to different stakeholders (which differed in content and timing). There were tensions between the desire for early evidence of outcomes and the slow processes of infrastructural change (which created problems of attribution of benefits to causes as benefits emerged gradually and over long timeframes), and also between reporting immediately visible local changes and showing how these flowed through to high level organization wide benefits (eg, in terms of health outcomes or cost savings/return on investment). The attempt to fulfill these diverging agendas and informational needs within a single reporting tool had limited success. These difficulties were mitigated by efforts to simplify reporting requirements and to support targeted collection of key national outcome measures. Although progress was hampered by an initial lack of benefits realization expertise in provider organizations, some providers subsequently retained these skills for their own change management purposes. Conclusions There is a need to recognize the limitations and cost of benefits realization management practices in the context of healthcare digitalization where benefits may materialize over long timeframes and in unanticipated ways. Although diverse stakeholder information needs may create tensions, prior agreement about rationales for collecting information and a targeted approach to tracking local and high-level benefits may enhance local relevance, reduce perceived reporting burdens, and improve acceptance/effectiveness. A single integrated reporting mechanism is unlikely to fulfill both national and local requirements.

OBJECTIVES The aims of the study were to describe medication administration incidents reported in England and Wales between 2007 and 2016, to identify which factors (reporting year, type of incident, patients' age) are most strongly related to reported severity of medication administration incidents, and to assess the extent to which relevant information was underreported or indeterminate. METHODS Medication administration incidents reported to the National Reporting & Learning System between January 1, 2007, and December 31, 2016 were obtained. Characteristics of the data were described using frequencies, and relationships between variables were explored using cross-tabulation. RESULTS A total of 517,384 incident reports were analyzed. Of these, 97.1% (n = 502,379) occurred in acute/general hospitals, mostly on wards (69.1%, n = 357,463), with medicine the most common specialty area (44.5%, n = 230,205). Medication errors were most commonly omitted doses (25.8%, n = 133,397). The majority did not cause patient harm (83.5%, n = 432,097). When only incidents causing severe harm or death (n = 1,116) were analyzed, the most common type of error was omitted doses (24.1%). Most incidents causing severe harm or death occurred in patients aged 56 years or older. For the 10-year period, the percentage of incidents with “no harm” increased (74.1% in 2007 to 86.3% in 2016). For some variables, data were often missing or indeterminate, which has implications for data analysis. CONCLUSIONS Medication administration incidents that do not cause harm are increasingly reported, whereas incidents reported as severe harm and death have declined. Data quality needs to be improved. Underreporting and indeterminate data, inaccuracies in reporting, and coding jeopardize the overall usefulness of these data.

Background\ud \ud Local services in the United Kingdom National Health Service enable autonomous provision of medication by nurses, supporting individual nurses to gain prescribing qualifications or by introducing local patient group directions.\ud Aim\ud \ud To compare nurse prescribing and patient group directions about clinic processes, patients' experiences, and costs from the perspectives of providers, nurses, and patients.\ud Design\ud \ud Mixed methods, comparative case study in five urban sexual health services in the United Kingdom.\ud Methods\ud \ud Data were collected from nurse prescribers, patient group direction users and their patients July 2015 to December 2016. Nurse questionnaires explored training (funding and methods). Nurses recorded consultation durations and support from other professionals in clinical diaries. Patient notes were reviewed to explore medication provision, appropriateness and safety; errors were judged by an expert panel. Patients completed satisfaction questionnaires about consultations and information about medications.\ud Results\ud \ud Twenty-eight nurse prescribers and 67 patient group directions users took part; records of 1682 consultations were reviewed, with 1357 medications prescribed and 98.5% therapeutically appropriate. Most medication decisions were deemed safe (96.0% nurse prescribers, 98.7% patient group directions, Fisher's Exact Test p = .55). Errors were predominantly minor (55.6% nurse prescribers, 62.4% patient group directions) and related to documentation omissions (78.0%); no patients were harmed. Consultation durations and unplanned re-consultations were similar for both groups. Nurse prescribers sought assistance from colleagues less frequently (chi-squared = 46.748, df = 1, p < .001) but spent longer discussing cases. Nurse prescribing training required more resources from providers and nurses, compared with patient group directions. Nurse prescribers were on higher salary bands. Patient satisfaction was high in both groups (>96%).\ud Conclusions\ud \ud Nurse medication provision by both nurse prescribers and patient group direction users is safe and associated with high patient satisfaction; effects on clinic processes and costs are similar. Undertaking the prescribing qualification involves independent study but may bring longer-term career progression to nurses.

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 …

Aim In the UK, injectable medicines are often prepared and administered by nurses following the Injectable Medicines Guide (IMG). Our earlier study confirmed a higher frequency of correct administration with user-tested versus standard IMG guidelines. This current study aimed to model the cost-effectiveness of user-testing. Methods The costs and cost-effectiveness of user-testing were explored by modifying an existing probabilistic decision-analytic model. The adapted model considered administration of intravenous voriconazole to hospital inpatients by nurses. It included 11 error types, their probability of detection and level of harm. Model inputs (including costs) were derived from our previous study and other published data. Monte Carlo simulation using 20,000 samples (sufficient for convergence) was performed with a 5-year time horizon from the perspective of the 121 NHS trusts and health boards that use the IMG. Sensitivity analyses were undertaken for the risk of a medication error and other sources of uncertainty. Results The net monetary benefit at £20,000/quality-adjusted life year was £3,190,064 (95% credible interval (CrI): −346,709 to 8,480,665), favouring user-testing with a 96% chance of cost-effectiveness. Incremental cost-savings were £240,943 (95% CrI 43,527–491,576), also favouring user-tested guidelines with a 99% chance of cost-saving. The total user testing cost was £6317 (95% CrI 6012–6627). These findings were robust to assumptions about a range of input parameters, but greater uncertainty was seen with a lower medication error risk. Conclusions User-testing of injectable medicines guidelines is a low-cost intervention that is highly likely to be cost-effective, especially for high-risk medicines.

Background Effective, integrated and coordinated communication is essential in providing high quality patient care. There has been limited research detailing the impact of electronic prescribing and medication administration (ePMA) systems on healthcare professionals’ (HCPs’) communication. We aimed to explore hospital pharmacists’, doctors’ and nurses’ perceptions of how ePMA systems have affected, or are expected to affect, the way they communicate with each other in an inpatient setting.MethodsThis was a qualitative study in three English NHS hospitals: two used different inpatient ePMA systems, and one used paper-based prescribing. We conducted focus groups with pharmacists, and semi-structured individual interviews with doctors and nurses. Transcribed data were analysed inductively using thematic analysis. ResultsNine focus groups, three at each hospital, were conducted with pharmacists with different levels of seniority (58 pharmacists in total). Fourteen doctors and twelve nurses took part in individual interviews. Four themes were identified: modes of communication, reduced pharmacist visibility, system limitations, and future aspirations for ePMA. Whether working with ePMA or paper-based systems, all participants preferred to communicate face-to-face to facilitate collaborative discussions regarding patient care. Participants perceived that ePMA reduced contact time with patients. Pharmacists perceived that both their physical ward presence and their written communication on medication charts had reduced since introduction of ePMA. Doctors felt they were now less likely to ask pharmacists questions due to pharmacists’ reduced physical presence on the ward. Hardware and software limitations were identified by all HCPs, with suggestions made for future developments to better support communication.Conclusion ePMA does not necessarily support communication among HCPs. Pharmacists and doctors were also concerned that ePMA reduces communication between themselves and their patients. Hospital managers should ensure sufficient hardware for HCPs, including pharmacists, to conduct their work in clinical areas, and work with ePMA system suppliers to develop ways of enhancing, rather than inhibiting, communication.

Avoidable harm associated with medication is a persistent problem in health systems and the use of preprogrammed infusion devices (‘smart pumps’) and data monitoring is seen as a core approach to mitigating and reducing the incidence of these harms. However, smart pumps are costly to procure, configure and maintain (in both human and financial terms) and are often poorly implemented. Variation in the manner in which medicines are prepared and used within complex modern healthcare systems exacerbates these challenges, and a strategic human-centred approach is needed to support their implementation. A symposium of 36 clinical and academic medication safety experts met virtually to discuss the current ‘state of the art’ and to propose strategic recommendations to support the implementation of medication administration technology to improve medication safety. The recommendations were that health systems (1) standardise infusion concentrations to facilitate the development of ready-to-administer formulations of frequently used medicines, and support ‘out of the box’ programming of infusion devices; (2) develop and implement drug libraries using human-centred approaches and the aforementioned standard concentrations, with a theoretical understanding of how devices are used in practice; (3) develop standardised metrics and outcomes to support the interpretation of data produced by infusion devices; (4) involve all stakeholders in the development of drug libraries and metrics to ensure broad understanding of the devices, their benefits and limitations; and (5) leverage input into device design, working with manufacturers and users. Using this strategic approach, it is then possible to envisage and plan real-world implementation studies using a uniform approach to quantify improvements in safety, efficiency and cost effectiveness.

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.

Objectives: Errors in medication administration are common, with many interventions suggested to reduce them. For intravenous infusion–related errors, “smart infusion devices” incorporating dose error reduction software are widely advocated. Our aim was to explore the role of smart infusion devices in preventing or contributing to medication administration errors using retrospective review of 2 complementary data sets that collectively included a wide range of errors with different levels of actual or potential harm. Methods: We reviewed 216 medication administration errors identified from an observational study in clinical practice and 123 medication incidents involving infusion devices reported to a national reporting system. The impact of smart infusion devices in preventing or contributing to these errors was assessed by the research team and an expert panel. Results: The data suggest that use of any infusion device rather than gravitational administration may have prevented 13% of observed errors and 8% of reported incidents; additional reductions may be possible with standalone smart infusion devices, and further potential reductions with smart infusion devices integrated with electronic prescribing and barcode administration systems. An estimated 52% to 73% of errors that occurred with traditional infusion pumps could be prevented with such integrated smart infusion devices. In the few cases where smart infusion devices were used, these contributed to errors in 2 of 58 observed errors and 7 of 8 reported incidents. Conclusions: Smart infusion devices not only prevent some medication administration errors but can also contribute to them. Further evaluation of such systems is required to make recommendations for policy and practice.

Objectives Our study aimed to explore to what extent the priority areas and domains of the World Health Organization (WHO)'s third Global Patient Safety Challenge were being addressed in a sample of hospital organizations. Methods A qualitative approach was taken using a combination of focus groups, semistructured interviews, and documentary analysis in 4 UK teaching hospital organizations. A purposive sampling strategy was adopted with the aim of recruiting health care professionals who would be likely to have knowledge of medication safety interventions that were being carried out at the hospital organizations. Medication safety group meeting notes from 2017 to 2019 were reviewed at the hospital organizations to identify interventions recently implemented, those currently being implemented, and plans for the future. A content analysis was undertaken using the WHO's third Global Patient Safety Challenge priority areas and domains as deductive themes. Results All the domains and priority areas of the WHO Medication Safety Challenge were being addressed at all 4 sites. However, a greater number of interventions focused on "health care professionals" and "systems and practices of medication management" than on "patients and the public." In terms of the priority areas, the main focus was on "high-risk situations," particularly high-risk medicines, with fewer interventions in the areas of "transitions of care" and "polypharmacy." Conclusions More work may be needed to address patient and public involvement in medication safety and the priority areas of transitions of care and polypharmacy. Comparative global studies would help build an international picture and allow shared learning.

Background Attempts to achieve digital transformation across the health service have stimulated increasingly large-scale and more complex change programmes. These encompass a growing range of functions in multiple locations across the system and may take place over extended timeframes. This calls for new approaches to evaluate these programmes. Main body Drawing on over a decade of conducting formative and summative evaluations of health information technologies, we here build on previous work detailing evaluation challenges and ways to tackle these. Important considerations include changing organisational, economic, political, vendor and markets necessitating tracing of evolving networks, relationships, and processes; exploring mechanisms of spread; and studying selected settings in depth to understand local tensions and priorities. Conclusions Decision-makers need to recognise that formative evaluations, if built on solid theoretical and methodological foundations, can help to mitigate risks and help to ensure that programmes have maximum chances of success.

Objective Hospital pharmacy is undergoing a period of rapid change, with pharmacists needing to focus where they add most value. Our aim was to identify where pharmacists have potential for greatest impact by analysing data on clinically relevant medication-related problems (MRPs). Methods We included consecutive admissions from adult medical wards at two UK hospitals between April and November 2016. MRPs were identified by pharmacists at the study sites as part of their routine daily patient assessments, validated and assessed for preventability and severity. Descriptive analyses were performed on clinically relevant (moderate or severe preventable) MRPs to establish the stage of inpatient stay where identified and their types/categories (overall and by stage of inpatient stay). Key findings Among 1503 eligible admissions, 2614 validated MRPs were identified, of which 1153 were moderate or severe, and preventable. Over 70% of these clinically relevant MRPs were identified during/before the first ward-based pharmacy review of patients. The most frequent MRP subcategory was ‘indication not treated/missing therapy’, accounting for 46% of clinically relevant MRPs. Dose selection issues were the next most common, accounting for 24%. The subcategory ‘indication not treated/missing therapy’ was identified more frequently at admission and discharge (53% and 45% of MRPs, respectively) compared with during the inpatient stay (14%), P < 0.001. Conclusions This research suggests patients are at greatest need of pharmacist input in terms of identification/resolution of clinically relevant MRPs during early stages of inpatient stay; however, clinically relevant MRPs continue to occur throughout their stay, suggesting need for ongoing pharmacy review.

Background Intravenous (IV) medication administration has traditionally been regarded to be error-prone with high potential for harm. A recent US multisite study revealed surprisingly few potentially harmful errors despite a high overall error rate. However, there is limited evidence about infusion practices in England and how they relate to prevalence and types of error. Objectives To determine the prevalence, types and severity of errors and discrepancies in infusion administration in English hospitals, and to explore sources of variation in errors, discrepancies and practices, including the contribution of smart pumps. Design Phase 1 comprised an observational point-prevalence study of IV infusions, with debrief interviews and focus groups. Observers compared each infusion against the medication order and local policy. Deviations were classified as either errors or discrepancies based on their potential for patient harm. Contextual issues and reasons for deviations were explored qualitatively during observer debriefs, and analytically in supplementary analyses. Phase 2 comprised in-depth observational studies at five of the participating sites to better understand causes of error and how safety is maintained. Workshops were held with key stakeholder groups, including health professionals and policy-makers, the public and industry. Setting Sixteen English NHS hospital trusts. Results Point-prevalence data were collected from 1326 patients and 2008 infusions. In total, 240 errors were observed in 231 infusions and 1489 discrepancies were observed in 1065 infusions. Twenty-three errors (1.1% of all infusions) were considered potentially harmful; one might have resulted in short-term patient harm had it not been intercepted, but none was judged likely to prolong hospital stay or result in long-term harm. Types and prevalence of deviations varied widely among trusts, as did local policies. Deviations from medication orders and local policies were sometimes made for efficiency or to respond to patient need. Smart pumps, as currently implemented, had little effect. Staff had developed practices to manage efficiency and safety pragmatically by working around systemic challenges. Limitations Local observers may have assessed errors differently across sites, although steps were taken to minimise differences through observer training, debriefs, and review and cleaning of data. Each in-depth study involved a single researcher, and these were limited in scale and scope. Conclusions Errors and discrepancies are common in everyday infusion administration but most have low potential for patient harm. Findings are best understood by viewing IV infusion administration as a complex adaptive system. Better understanding of performance variability to strategically manage risk may be more helpful for improving patient safety than striving to eliminate all deviations. Future work There is potential value in reviewing policy around IV infusion administration to reduce unnecessary variability, manage staff workload and engage patients, while retaining the principle that policy has to be fit for purpose, contextualised to the particular ward situation and treatment protocol, and sensitive to the risks of different medications. Further work on understanding infusion administration as a complex adaptive system might deliver new insights into managing patient safety. Funding This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 7. See the NIHR Journals Library website for further project information.

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.

Missed medication doses can affect patient safety in hospitals. The use of automated dispensing cabinets (ADC) in clinical areas may reduce the occurrence of medications being unavailable at the time of need by alerting pharmacy to replenish stock. However, workarounds in ADC use can affect this capability. We studied nurses' use of an ADC in a paediatric intensive care unit with 54 hours of observation, semi-structure interviews (19 nurses; 4 pharmacy/management staff) and review of reported incidents. We found running out of medication a recurrent problem despite the ADC. Contributing factors affecting data entry in the ADC, and therefore replenishment alerts to pharmacy, included: the organisation of medication activities in the ward, nurses' information needs, patients' medication needs, and ADC design. Running out of medications was a 'tragedy of the commons'. Effective solutions may require going beyond user training and directives for accurate data entry, to work process redesign.

Evidence is limited of automated dispensing cabinets (ADCs) impact on effectiveness and efficiency of controlled drugs' (CDs) governance processes. We carried out a mixed-methods study of an ADC in an intensive care unit. We found ADC improved effectiveness and efficiency of governance of CDs through secure storage, alerts and automated recording of transactions. Limitations were associated with ADC design and 'fit' between ADC and some types of CDs.

Aim To compare the satisfaction of patients managed by independent nurse prescribers with that of patients managed by nurses using PGDs with respect to experience of the consultation and information received about the medication. Design Survey. Methods Patients receiving medications from nurses in five urban sexual health services in the United Kingdom completed validated questionnaires immediately after the consultation, September 2015-August 2016. Scores of independent nurse prescribers and nurses using patient group directions were compared about consultation experience (5 items) Satisfaction with Information about Medicines (SIMS 16 items scale). Results Of 808 patients receiving medications, 393 (48.6%) received questionnaires and 380 were returned (independent nurse prescribers 180 of 198, 90.9%; patient group directions 173 of 195, 88.7%). Patients in both groups reported high levels of satisfaction. About the consultation experience, patients found nurses friendly/ approachable (>99%), instilling confidence and trust (>99%) and explaining reasons for medications clearly (97%). Satisfaction with medication information: Of 348 (92%) respondents completing SIMS, the overall mean score was 13.4 of maximum 16 (no difference between groups, t-test, p = .63). Conclusions Patients were highly satisfied with nurse consultations and information around medications regardless of whether they were managed by independent nurse prescribers or nurses using patient group directions. Impact Findings provide evidence in support of autonomous provision of medications by nurses in sexual health clinics.

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.

Objectives To determine the frequency of clinical decision support system (CDSS) medication-related alerts generated, accepted, or overridden, to assess appropriateness of alert display and overrides, and to characterise the documentation of clinician justification for these overrides in an academic medical centre in Saudi Arabia. Materials and methods System-generated CDSS reports for the period June 2015 to December 2017 were retrospectively reviewed and analysed. Alerts were classified into different types, and rates of alert overrides calculated as percentages of all generated alerts. A subset of 307 overridden alerts was assessed for appropriateness of display and override by two clinical pharmacists. Physician documentation of reasons for overriding alerts were categorised. Results A total of 4,446,730 medication-related alerts were generated from both inpatient and outpatient settings, and 4,231,743 (95.2%) were overridden. The most common alert type was ‘duplicate drug’, accounting for 3,549,736 (79.8%) of alerts. Of 307 alerts assessed for appropriateness, 246 (80%) were judged to be appropriately displayed and 244 (79%) were overridden appropriately. New drug allergy and drug allergy alerts had the highest percentage of being judged as inappropriately overridden. For 1,594,313 alerts (37.7%), ‘no overridden reason selected’ was chosen from the drop-down menu. Conclusions The alert generation and override rate were higher than reported previously in the literature. The small sample size of 307 alerts assessed for appropriateness of alert display and override is a potential limitation. Revision of the CDSS rules for alerts (focusing on specificity and relevance for the local context) is now recommended. Future research should prospectively assess providers’ perspectives, and determine patient harm associated with overridden alerts.

Nonadherence to medicines is widespread and can adversely affect health outcomes. Previous research has identified that patients develop their own strategies to assist with adherence. However, such research has not focused on how the helpfulness of these strategies may change in response to changes in patients’ circumstances. This study aimed to explore resilience of medication adherence to life changes. It involved secondary thematic analysis of the verbatim transcripts of 50 semi-structured interviews that were conducted with adults who were advised to shield or were over the age of 70 during the first wave of the COVID-19 pandemic in the UK. Interview data suggested that resilience of medication adherence varied between participants. Participants either reported that they had not used any specific strategies to remind them to take their medicines prior to the pandemic, that the strategies that they had employed prior to the pandemic remained effective during the pandemic, that they had needed to make some adjustments to the strategies used, or that the strategies they had used were no longer effective. In addition, beliefs about medicines and motivation to take them were altered for some participants. These findings suggest that challenges associated with medication adherence do not always remain stable over time and that healthcare professionals need to continue to monitor and support medication adherence long-term.

Objectives To explore home medicine practices and safety for people shielding and/or over the age of 70 during the COVID-19 pandemic and to create guidance, from the patient/carer perspective, for enabling safe medicine practices for this population. Methods Semi-structured interviews were carried out with 50 UK participants who were shielding and/or over the age of 70 and who used medicines for a long-term condition, using telephone or video conferencing. Participants were recruited through personal/professional networks and through patient/carer organisations. Participants were asked about their experiences of managing medicines during the pandemic and how this differed from previous practices. Data were analysed using inductive thematic analysis. Key findings Patients’ and their families’ experiences of managing medicines safely during the pandemic varied greatly. Analysis suggests that this was based on the patient’s own agency, the functioning of their medicines system pre-pandemic and their relationships with family, friends, community networks and pharmacy staff. Medicine safety issues reported included omitted doses and less-effective formulations being used. Participants also described experiencing high levels of anxiety related to obtaining medicines, monitoring medicines and feeling at risk of contracting COVID-19 while accessing healthcare services for medicine-related issues. Effects of the pandemic on medicines adherence were reported to be positive by some and negative by others. Conclusions Pharmacy staff have a key role to play by establishing good relationships with patients and their families, working with prescribers to ensure medicines systems are as joined up as possible, and signposting to community networks that can help with medicines collection.

Objectives Infusion safety is a recognised concern internationally. While few observational studies explore the causes of the errors that occur, even fewer describe how safety is maintained in routine practice. We sought to understand safety around infusion devices. Methods An ethnographic study of infusion device use was conducted on a haematology ward. This included observations of 51 infusions, plus their preparation where possible, during 120 h of ward observation over 11 days. Field notes were transcribed and analysed using deductive coding informed by distributed cognition. A further inductive thematic analysis highlighted new themes for making sense of the data. Results The distributed cognition analysis highlighted how infusion treatment was affected by interactions distributed across artefacts, tasks, social networks, physical space and time. These interactions occurred close to and away from the infusion: at micro, meso and macro levels according to distance from the actual process. The inductive analysis highlighted three new interdependent themes that account for how safety is constructed and compromised: structure, agency and performance variability. Discussion and conclusion Safety is constructed through the co-evolution of sociotechnical structure and agency whereby structure shapes and influences people’s behaviour and people reproduce and create structures. Everyday performance variability emerges from these interactions, including deviations in processes and outcomes (e.g. incidents, near misses and opportunities). Studies of everyday safety can explore interactions between four points of a sociotechnical structuration model: structure, agency, and satisfactory and unsatisfactory performance.

Background The aim of this systematic review was to synthesise peer-reviewed literature assessing the impact of electronic prescribing (eP) systems on the working practices of healthcare professionals (HCPs) in the inpatient setting and identify implications for practice and research. Methods We searched PubMed, Medline, Embase, Cochrane and the Cumulative Index to Nursing Allied Health Literature databases for studies published from inception to November 2018. We included controlled, uncontrolled, observational and descriptive studies that explored the effect of eP on HCPs’ working practices in an inpatient setting. Data on setting, eP system and impact on working practices were extracted. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Emergent themes were identified and subjected to narrative synthesis. The protocol was registered with PROSPERO (registration CRD42017075804). Results Searches identified 1301 titles and abstracts after duplicate removal. 171 papers underwent full-text review. A total of 25 studies met the inclusion criteria, from nine different countries. Nineteen were of commercial eP systems. There were a range of study designs; most (n = 14) adopted quantitative methods such as cross-sectional surveys, ten adopted qualitative approaches and a further one used mixed methods. Fourteen of the 25 studies were deemed to be of high quality. Four key themes were identified: communication, time taken to complete tasks, clinical workflow, and workarounds. Within each theme, study findings differed as to whether the effects of eP on HCPs’ working practices were positive or negative. Conclusion There is a lack of consensus within the literature on the impact of eP on HCPs’ working practices. Future research should explore the strategies resulting in a positive impact on HCPs’ working practices and learn from those that have not been successful.

Background Medication administration errors may contribute to patient mortality, thus additional understanding of such incidents is required. Objectives To analyse medication administration errors reported in acute care resulting in death, to identify the drugs concerned, and to describe medication administration error characteristics (location of error, error type, patient's age) by drug group. Methods Medication administration errors reported in acute care in 2007 2016 (n = 517,384) were obtained from the National Reporting and Learning System for England and Wales. Incidents reported as resulting in death (n = 229) were analysed. Drugs were classified by two researchers using the British National Formulary. Drug categories were described by medication administration errors' year, location, patient age, and error category based on the incidents’ original classification. Results Errors were most often reported on wards (66.4%, n = 152), and in patients aged over 75 years (41.5%, n = 95). The most common error category was omitted medicine or ingredient (31.4%, n = 72); most common drug groups were cardiovascular (20.1%, n = 46) and nervous system (10.0%, n = 23). Most errors in patients under 12 years concerned drugs to treat infection; cardiovascular drugs were most common among other age groups. Conclusions In order to prevent these most serious of medication administration errors, interventions should focus on avoiding dose omissions, and administration of drugs for patients over 75 years old, as well as safe administration of parenteral anticoagulants and antibacterial drugs.

Background: The administration of medication or fluids via the intravenous route is a common intervention for many hospital inpatients. However, little research has explored the safety and quality of intravenous therapy from the patient’s perspective, despite the role of the patient in patient safety receiving increased attention in recent years. Objective: To explore patients’ perspectives on the perceived quality and safety of intravenous infusions and identify implications for practice. Method: Qualitative semistructured interviews were conducted with 35 hospital patients receiving intravenous infusions in critical care, oncology day care, general medicine, and general surgery areas within 4 National Health Service hospitals in England. Data were analyzed thematically. Results: Four underlying and interlinked themes were identified: knowledge about intravenous infusions, challenges associated with receiving intravenous infusions, the role of health-care professionals, and patients’ attitudes toward receiving infusions. Conclusions: Patients were generally satisfied with receiving infusions; however, factors that contributed to decreased feelings of quality and safety were identified, suggesting areas for intervention. Issues to do with infusion pump alarms, reduced mobility, cannulation, and personal preferences for information, if given more attention, may improve patients’ experiences of receiving intravenous infusions.

Most studies evaluating the impact of electronic prescribing on prescribing safety have used comparatively weak study designs such as uncontrolled before-and-after studies. This study aimed to apply a more robust naturalistic stepped wedge study design to compare the prevalence and types of prescribing errors for electronic prescribing and paper prescribing. Data were collected weekly during a phased electronic prescribing implementation across 20 wards in a large English hospital. We identified 511 (7.8%) erroneous orders in 6523 paper medication orders, and 312 (6.0%) in 5237 electronic prescribing orders. Logistic regression suggested no statistically significant effect of electronic prescribing use or of study week; patient and ward had significant effects. Errors involving incorrect doses and illegible or incomplete orders were less common with electronic prescribing; those involving duplication, omission, incorrect drug and incorrect formulation were more common. Actions are needed to mitigate these error types; future studies should give more consideration to the effects of patient and ward.

Data sharing: The data used to inform this policy paper can be made able, upon reasonable request from Esmita Charani, e.charani@imperial.ac.uk. Copyright © 2021 The Author(s). Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security. Wellcome Trust; Economic and Social Research Council (ESRC); National Institute for Health Research ASPIRES project (Antibiotic use across Surgical Pathways: Investigating, Redesigning and Evaluating Systems) (https://www.imperial.ac.uk/arc/aspires/); National Institute for Health Research, UK Department of Health [HPRU-2012-10047] in partnership with Public Health England.

BACKGROUND The Global Digital Exemplar (GDE) Programme is a national initiative to promote digitally-enabled transformation in English provider organisations. The Programme applied benefits realisation management techniques to promote and demonstrate transformative outcomes. This work was part of an independent national evaluation of the GDE Programme. OBJECTIVE We explored how benefits realisation management was approached and conceptualised in the GDE Programme. METHODS We conducted a series of 36 longitudinal case studies of provider organisations participating in the GDE Programme, 12 of which were in depth. Data collection included a combination of 563 semi-structured interviews (with implementation staff in provider organisations, national programme management staff, and suppliers), 389 documents (of national and local implementation plans and lessons learned), and 217 non-participant observations (of national and local programme management meetings). Data were coded drawing on a sociotechnical framework developed in related work and thematically analysed, initially within and then across cases, with the help of NVivo 11 software. RESULTS Most stakeholders broadly agreed with the rationale of benefits realisation in the GDE Programme to show due diligence that public money was appropriately spent, and to develop an evidence base supporting the value of digitally-enabled transformation. Differing national and local reporting purposes however created tensions. Central requirements for progress reporting and tracking high-level benefits had limited perceived local value and were perceived to impose an unnecessary burden on provider organisations. This was accentuated by the lack of harmonisation of reporting requirements to different stakeholders (which differed in content and timing). There were tensions between the desire for early evidence of outcomes and the slow processes of infrastructural change (which created problems of attribution) also between reporting immediately visible local changes and showing how these flowed through to high level organisation wide benefits (e.g. in terms of health outcomes or cost savings/return on investment). The attempt to fulfil these diverging agendas and informational needs within a single reporting tool had limited success. These difficulties were mitigated by efforts to simplify reporting requirements and to support targeted collection of key national outcome measures. Although progress was hampered by an initial lack of benefits realisation expertise in provider organisations, some providers subsequently retained these skills for their own change management purposes. CONCLUSIONS There is a need to recognise the limitations and cost of benefits realisation management practices. Prior agreement about rationales for collecting information and a more targeted approach to tracking local and high level benefits may enhance local relevance, reduce perceived reporting burdens and improve acceptance/effectiveness.

The UK's response to the pandemic The UK has recorded one of the highest death rates associated with COVID-19 globally, whether measured as deaths that are directly attributable to COVID-19 or by excess mortality. The reasons for this high rate are complex and not yet fully understood, but elements of the UK Government response have been criticised, including delayed implementation of physical distancing measures, poor coordination with local authorities and public health teams, a dysfunctional track and trace system, and an absence of consultation with devolved nations. The role of the National Health Service (NHS) and relevant national executive agencies in relation to testing capacity, availability of personal protective equipment (PPE), the cancellation and postponement of many aspects of routine care, and decisions around discharge from hospital to care homes should also be critically examined. Conversely, aspects of the response by the NHS and relevant national executive agencies deserve recognition. In only a few weeks, capacity for critical care was massively expanded, many thousands of staff were reallocated, and services were reorganised to reduce transmission of SARS-CoV-2. The NHS also collaborated with academic institutions to share knowledge about clinical characteristics of the disease and to establish world-leading clinical trials on vaccines and treatments. The response to COVID-19 brings to attention some of the chronic weaknesses and strengths of the UK's health and care systems and real challenges in society to health. Failures in leadership, an absence of transparency, poor integration between the NHS and social care, chronic underfunding of social care, a fragmented and disempowered public health service, ongoing staffing shortfalls, and challenges in getting data to flow in real time were all important barriers to coordinating a comprehensive and effective response to the pandemic. More positively, the high amount of financial protection that was provided by the NHS and an allocation of resources that explicitly accounted for differing geographical needs have, to some extent, mitigated the already substantial effect of the pandemic on health inequalities. The London School of Economics and Political Science–Lancet Commission on the future of the NHS This UK-wide London School of Economics and Political Science (LSE)–Lancet Commission on the future of the NHS provides the first analysis of the initial phases of the COVID-19 response as part of a uniquely comprehensive assessment of the fundamental strengths of and challenges that are faced by the NHS. The NHS has long been regarded as one of the UK's greatest achievements, providing free care at the point of delivery for over 66 million people from birth to death. Against this backdrop, and considering international evidence, this Commission sets out a long-term vision for the NHS: working together for a publicly funded, integrated, and innovative service that improves health and reduces inequalities for all. This Commission makes seven recommendations, and associated subrecommendations, for both the short term and long term, with a 10-year timeline. First, increase investment in the NHS, social care, and public health. This Commission proposes that yearly increases in funding of at least 4%, in real terms, are needed for health, social care, and public health. Second, improve resource management across health and care at national, local, and treatment levels. Third, develop a sustainable, skilled, and fit for purpose health and care workforce to meet changing health and care needs. Fourth, strengthen prevention of disease and disability and preparedness to protect against major threats to health. Fifth, optimise diagnosis to improve outcomes and reduce inequalities. Sixth, develop the culture, capacity, and capability to become a so-called learning health and care system (ie, in which data-enabled infrastructures are routinely used to support policy and planning, public health, and personalisation of care). Finally, improve integration between health care, social care, and public health and across different providers, including the third sector (ie, charity and voluntary organisations). Central to the argument of this Commission is that an ongoing increase in funding for the NHS, social care, and public health is essential to ensure that the health and care system can meet demand, rebuild after the pandemic, and develop resilience against further acute shocks and major threats to health. This funding should be targeted towards increased investment in capital, workforce, preparedness, prevention, diagnosis, health information technology (HIT), and research and development. Furthermore, the NHS should develop new ways of working with patients and citizens. This Commission sets a vision of transformation to meet changing health and care needs of the UK population but rejects any calls for reorganisation of the NHS on a large scale. Past experiences have taught us that reorganisation on a large scale is often a disruptive process without any evidence of benefit.1 We argue instead that the foundations of the NHS can be strengthened through further investment and integration of pre-existing operational institutions. The COVID-19 pandemic has reinforced the economic case to invest in health, which is crucial for fiscal sustainability and enhancing societal wellbeing.2 However, we acknowledge that committing to increased investment in the NHS, social care, and public health will be challenging in economically and geopolitically uncertain times. To implement the funding recommendations, this Commission estimates that total expenditure would need to increase by around £102 billion in real terms, or 3·1% of gross domestic product (GDP) in 2030–31. Taxation reforms would be required to increase funding and we provide an indicative analysis of the amount of potential change that would be required to personal income tax, national insurance contributions, and value-added tax. This Commission serves as a call to action. We argue that, similar to the establishment of the NHS after World War 2, after the COVID-19 pandemic and leaving the EU, the UK faces a once-in-a-generation opportunity to invest in the health of all its population and secure the long-term future of the NHS. Failure to re-lay the foundations of the NHS (ie, strengthen through increased investment and commitment to its founding principles) risks a continued deterioration in service provision, worsening health outcomes and inequalities, and an NHS that is poorly equipped to respond to future major threats to health.

Background: In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs). Objective: The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice ( discrepancies) that contributed to large-magnitude and/or clinically significant MAEs. Methods: Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study. Results: In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs. Conclusion and Relevance: Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.

Objective To identify concerns related to the use of medicines for adults with complex needs and explore whether these differed between healthcare professionals and patients/carers, in order to inform development of interventions to increase medication adherence. Methods A quantitative secondary analysis of a database of healthcare professionals’ and patients’/carers’ healthcare concerns, related to adults with complex needs. Categories of concerns related to medicines use were identified and concerns related to medication use coded against these. Data were analysed descriptively, and a Chi-square test conducted to test for differences in responses from healthcare professionals versus patients/carers. Results There was a significant difference in the types of medication concern raised by healthcare professionals versus those raised by patients/carers. Patients/carers expressed more concerns about side effects and interactions; healthcare professionals identified more concerns related to patient support and carers’ knowledge/training. Conclusion Healthcare professionals had significantly different concerns about medicines to patients; this may be a potential barrier to medication adherence. Practice implications Healthcare professionals may need to adopt an approach to non-adherence that goes beyond education and counselling and adopts a wider patient perspective. Findings suggest that a greater focus on addressing side effects and interactions may be beneficial in increasing medication adherence.

IntroductionThose who are staying at home and reducing contact with other people during the COVID-19 pandemic are likely to be at greater risk of medication-related problems than the general population. This study aims to explore household medication practices by and for this population, identify practices that benefit or jeopardise medication safety and develop best practice guidance about household medication safety practices during a pandemic, grounded in individual experiences.Methods and analysisThis is a descriptive qualitative study using semistructured interviews, by telephone or video call. People who have been advised to ‘cocoon’/‘shield’ and/or are aged 70 years or over and using at least one long-term medication, or their caregivers, will be eligible for inclusion. We will recruit 100 patient/carer participants: 50 from the UK and 50 from Ireland. Recruitment will be supported by our patient and public involvement (PPI) partners, personal networks and social media. Individual participant consent will be sought, and interviews audio/video recorded and/or detailed notes made. A constructivist interpretivist approach to data analysis will involve use of the constant comparative method to organise the data, along with inductive analysis. From this, we will iteratively develop best practice guidance about household medication safety practices during a pandemic from the patient’s/carer’s perspective.Ethics and disseminationThis study has Trinity College Dublin, University of Limerick and University College London ethics approvals. We plan to disseminate our findings via presentations at relevant patient/public, professional, academic and scientific meetings, and for publication in peer-reviewed journals. We will create a list of helpful strategies that participants have reported and share this with participants, PPI partners and on social media.

On 1 September 2020, we took on the roles of co-editors-in-chief for BMJ Quality and Safety , and want to take this opportunity to introduce ourselves and our vision for the journal. We represent two different continents, two different professions and two different sets of research expertise. What we have in common is a passion for conducting and publishing high-quality research and quality improvement work to benefit the quality and safety of patient care, as well as encouraging others to do likewise. We assume leadership of the journal during a major worldwide crisis brought on by the COVID-19 pandemic, which has affected almost every aspect of society. Response to the pandemic is requiring engagement from every part of our health care systems—government policy, public health, ambulatory care, inpatient and long-term care, every type of healthcare worker, and of course patients and …

Barcode medication administration (BCMA) is advocated as a technology that reduces medication errors relating to incorrect patient identity, drug or dose. Little is known, however, about the impact it has on nursing workflow. Our aim was to investigate the impact of BCMA on nursing activity and workflow. A comparative study was conducted on two similar surgical wards within an acute UK hospital. We observed nurses during drug rounds on a non-BCMA ward and a BCMA ward. Data were collected on drug round duration, timeliness of medication administration, patient identification, medication verification and general workflow patterns. BCMA appears not to alter drug round duration, although it may reduce the administration time per dose. Workflow was more streamlined, with less use of the medicines room. The rate of patient identification increased from 74% (of 47) patients to 100% (of 43), with 95% of 255 scannable medication doses verified using the system. This study suggests that BCMA does not affect drug round duration, further research is required to determine the impact it has on timeliness of medication administration. There was reduced variability in the medication administration workflow of nurses, along with an increased patient identification rate and high medication scan rate, representing potential benefits to patient safety.

Background Hospitals worldwide are developing ambitious digital transformation programs as part of broader efforts to create digitally advanced health care systems. However, there is as yet no consensus on how best to characterize and assess digital excellence in hospitals. Objective Our aim was to develop an international agreement on a defined set of technological capabilities to assess digital excellence in hospitals. Methods We conducted a two-stage international modified electronic Delphi (eDelphi) consensus-building exercise, which included a qualitative analysis of free-text responses. In total, 31 international health informatics experts participated, representing clinical, academic, public, and vendor organizations. Results We identified 35 technological capabilities that indicate digital excellence in hospitals. These are divided into two categories: (a) capabilities within a hospital (n=20) and (b) capabilities enabling communication with other parts of the health and social care system, and with patients and carers (n=15). The analysis of free-text responses pointed to the importance of nontechnological aspects of digitally enabled change, including social and organizational factors. Examples included an institutional culture characterized by a willingness to transform established ways of working and openness to risk-taking. The availability of a range of skills within digitization teams, including technological, project management and business expertise, and availability of resources to support hospital staff, were also highlighted. Conclusions We have identified a set of criteria for assessing digital excellence in hospitals. Our findings highlight the need to broaden the focus from technical functionalities to wider digital transformation capabilities.

BACKGROUND The English Global Digital Exemplar (GDE) program is one of the first concerted efforts to create a digital health learning ecosystem across a national health service. OBJECTIVE This study aims to explore mechanisms that support or inhibit the exchange of interorganizational digital transformation knowledge. METHODS We conducted a formative qualitative evaluation of the GDE program. We used semistructured interviews with clinical, technical, and managerial staff; national program managers and network leaders; nonparticipant observations of knowledge transfer activities through attending meetings, workshops, and conferences; and documentary analysis of policy documents. The data were thematically analyzed by drawing on a theory-informed sociotechnical coding framework. We used a mixture of deductive and inductive methods, supported by NVivo software, to facilitate coding. RESULTS We conducted 341 one-on-one and 116 group interviews, observed 86 meetings, and analyzed 245 documents from 36 participating provider organizations. We also conducted 51 high-level interviews with policy makers and vendors; performed 77 observations of national meetings, workshops, and conferences; and analyzed 80 national documents. Formal processes put in place by the GDE program to initiate and reinforce knowledge transfer and learning have accelerated the growth of informal knowledge networking and helped establish the foundations of a learning ecosystem. However, formal networks were most effective when supported by informal networking. The benefits of networking were enhanced (and costs reduced) by geographical proximity, shared culture and context, common technological functionality, regional and strategic alignments, and professional agendas. CONCLUSIONS Knowledge exchange is most effective when sustained through informal networking driven by the mutual benefits of sharing knowledge and convergence between group members in their organizational and technological setting and goals. Policy interventions need to enhance incentives and reduce barriers to sharing across the ecosystem, be flexible in tailoring formal interventions to emerging needs, and promote informal knowledge sharing. CLINICALTRIAL

Automated dispensing cabinets in clinical wards may contribute to improving safety by reducing the likelihood of medications not being available when needed. However, achieving this safety benefit is dependent on a 'back office' sociotechnical infrastructure that combines semi-automated processes with mindful, resilient work practices.

BackgroundThere are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies.MethodsWe conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n = 10), nurses (n = 6), a pharmacist, and oncology CPOE team members (n = 2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive).ResultsIncident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and ‘no go’ contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients’ treatments: life-long, the whole regimen, and the ‘here and now’. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the ‘here and now’ better than a life-long or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice.ConclusionsWithin oncology, CPOE appears to move the ‘mix’ of risk strategies towards ultra-safe models of safety and protocol-mandated care. However, in order to operate ultra-safe strategies embedded in CPOE and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use. CPOE design can be advanced by better consideration of mechanisms to support interdependencies.

Background User interface (UI) design features such as screen layout, density of information, and use of colour may affect the usability of electronic prescribing (EP) systems, with usability problems previously associated with medication errors. To identify how to improve existing systems, our aim was to explore prescribers’ perspectives of UI features of a commercially available EP system, and how these may affect patient safety. Methods Two studies were conducted, each including ten participants prescribing a penicillin for a test patient with a penicillin allergy. In study 1, eye-gaze tracking was used as a means to explore visual attention and behaviour during prescribing, followed by a self-reported EP system usability scale. In study 2, a think-aloud method and semi-structured interview were applied to explore participants’ thoughts and views on prescribing, with a focus on UI design and patient safety. Results Study 1 showed high visual attention toward information on allergies and patient information, allergy pop-up alerts, and medication order review and confirmation, with less visual attention on adding medication. The system’s usability was rated ‘below average’. In study 2, participants highlighted EP design features and workflow, including screen layout and information overload as being important for patient safety, benefits of EP systems such as keeping a record of relevant information, and suggestions for improvement in relation to system design (colour, fonts, customization) and patient interaction. Conclusions Specific UI design factors were identified that may improve the usability and/or safety of EP systems. It is suggested that eye-gaze tracking and think-aloud methods are used in future experimental research in this area. Limitations include the small sample size; further work should include similar studies on other EP systems.

Background and importance Studies suggest that in the hospital setting, prescribing errors are most common at admission, largely due to challenges of medication reconciliation. Problems are also common following transfer from hospital into the community and when attending outpatient appointments. Many patients who take medications use patient held information about medication (PHIMed) to improve transfer of medication related information across care settings. However, it is not known how PHIMed is used in practice and the extent to which PHIMed tools available meet the needs of patients and healthcare professionals. Discussion with patients and carers highlighted this as a priority for research. Aim and objectives To identify how PHIMed is used in practice, barriers and facilitators to its use, and its role in supporting medication safety. Material and methods We used a mixed methods design comprising two focus groups with patients and carers, 16 semi-structured interviews with healthcare professionals, 60 semi-structured interviews with PHIMed users, a quantitative features analysis of PHIMed solutions available in the UK and usability testing of four PHIMed tools. Participants were identified and recruited in Greater London in 2018, using advertisements on social media, our professional networks and face to face recruitment in outpatient clinics. Findings were triangulated using thematic analysis using distributed cognition for teamwork (DiCoT) models as sensitising concepts. NHS ethics approval was obtained. Results We found that PHIMed was viewed positively by patients and carers using it and healthcare professionals. We identified a wide range of mechanisms through PHIMed improved medication safety, such as identification of potential drug interactions. However, a key barrier to use was lack of awareness by patients and carers that healthcare information systems are often fragmented, which meant that they had not identified a need for PHIMed. Different PHIMed tools met different needs, with no ‘one size fits all’ solution. No tools currently meet the core needs of all users. Conclusion and relevance Healthcare professionals should raise awareness among patients and carers of the potential safety benefits of carrying and using PHIMed, encourage its use during consultations and be able to signpost to some of the tools and features available. PHIMed tool developers should modify their tools in order to meet all core user requirements. References and/or acknowledgements No conflict of interest.

Background and importance User interface design features, such as screen layout, density of information, position of messages and use of colour, may affect the usability of electronic prescribing (EP) systems, with usability problems previously associated with medication errors. Aim and objectives To explore users’ perspectives of the on-screen design features of a commercially available EP system and how these are perceived to affect patient safety. Material and methods The study was conducted at a large London teaching hospital during 2018–2019. Participants were recruited via adverts on the intranet; all prescribers with experience using the EP system were eligible to participate. We used a mixed qualitative approach. First, prescribers were asked to conduct a prescribing task for a simulated patient using a think aloud approach. Second, we conducted a semi-structured interview with each participant to explore their views in more detail, with a focus on patient safety. Interview questions were developed based on the literature and then piloted. Think aloud and interview transcripts were analysed inductively using a thematic approach. Ethics approval was obtained. Results Ten participants took part (three registrars, three foundation year 1 doctors, two foundation year 2 doctors and two pharmacist prescribers). Key themes from the think aloud and interview transcripts included: (1) EP design features and process flow; (2) benefits of EP systems; and (3) suggestions for improvement. For instance, design features such as screen features and layout were discussed with regards to impact on workflow, as well as ‘information overload’. Suggestions for improvement were made in relation to embedding trust guidelines and making changes to system design (eg, colour, fonts, customisation) to increase information visibility and enhance overall attention. Lastly, a need was expressed for better support for interacting with patients while using the system, as well as making drug–drug interaction alerts more targeted to support medication safety while also avoiding alert fatigue. Conclusion and relevance We identified specific interface design factors that may improve the usability and/or safety of EP systems, which can be used to inform future experimental research in this area. Limitations include the small sample size; further work should include similar studies on other EP systems. References and/or acknowledgements Conflict of interest Corporate sponsored research or other substantive relationships: I supervise a PhD student who is partly funded by a supplier of a commercial electronic prescribing system.

Background and importance User interface design can have a significant impact on interactions with online systems. Eye tracking is generally accepted as a useful method to study performance in areas such as interpretation of medical imaging. However, there is little evidence of its use to study user interactions with electronic prescribing (EP) systems, an area in which failure to see and act on key information is particularly critical. Aim and objectives To explore the feasibility of using eye tracking to study EP users’ visual attention and behaviour, with a focus on safe prescribing. Material and methods The study took place at a London teaching hospital from 2018 to 2019. Participants were recruited via the organisation’s intranet. Any prescriber with experience of the EP system was eligible to participate. We used Tobii Pro X3-120 integrated screen monitor trackers in a simulation setting. Participants were asked to complete a prescribing task for a test patient, which included prescribing penicillin for a patient with a penicillin allergy. Data collected included videos of the screen showing the participant’s scan paths. We segmented the data according to when the user switched screens, and calculated percentage of time spent looking in each of the four quadrants of the screen for each. The study was approved as a service evaluation. Results Ten prescribers participated. Overall, the highest percentages of fixation points were at the top left and right corners of the screen, where information is provided on allergies and patient information, respectively. However, each prescriber initially prescribed a penicillin and was stopped only by a pop-up alert. The highest number of fixation points was observed during review of the prescription and final signature, followed by review of the allergy alert and the search for drug names and dosages. Conclusion and relevance Eye tracking is a feasible method for studying EP interactions. The findings will be used to plan a larger evaluation, with the aims of understanding how screen design can help or hinder patient safety, and how type and positioning of decision support information influences the likelihood of it being acted on. Limitations include small sample size; further work should also explore how gaze patterns may differ between novices and experts. References and/or acknowledgements Conflict of interest Corporate sponsored research or other substantive relationships: I supervise a PhD student who is part funded by a supplier of a commercial electronic prescribing system.

Background A previous census of electronic prescribing (EP) systems in England showed that more than half of hospitals with EP reported more than one EP system within the same hospital. Our objectives were to describe the rationale for having multiple EP systems within a single hospital, and to explore perceptions of stakeholders about the advantages and disadvantages of multiple systems including any impact on patient safety. Methods Hospitals were selected from previous census respondents. A decision matrix was developed to achieve a maximum variation sample, and snowball sampling used to recruit stakeholders of different professional backgrounds. We then used an a priori framework to guide and analyse semi-structured interviews. Results Ten participants, comprising pharmacists and doctors and a nurse, were interviewed from four hospitals. The findings suggest that use of multiple EP systems was not strategically planned. Three co-existing models of EP systems adoption in hospitals were identified: organisation-led, clinician-led and clinical network-led, which may have contributed to multiple systems use. Although there were some perceived benefits of multiple EP systems, particularly in niche specialities, many disadvantages were described. These included issues related to access, staff training, workflow, work duplication, and system interfacing. Fragmentation of documentation of the patient’s journey was a major safety concern. Discussion The complexity of EP systems’ adoption and deficiencies in IT strategic planning may have contributed to multiple EP systems use in the NHS. In the near to mid-term, multiple EP systems may remain in place in many English hospitals, which may create challenges to quality and patient safety. Electronic supplementary material The online version of this article (10.1186/s12913-018-3750-1) contains supplementary material, which is available to authorized users.

Background The risks of poor information transfer across healthcare settings are well documented, particularly for medication. Various patient-held tools have been designed to hold information about patients’ medicines to improve information transfer. Anecdotal evidence suggests some are more widely implemented than others, but there has been little research exploring the reasons why. Our objectives were to explore the facilitators and barriers to implementation of patient handheld medication information from the perspective of pharmacy staff, to understand why some tools are more widely implemented than others and to make recommendations as appropriate. Method Semi-structured interviews were conducted with 15 pharmacists and pharmacy technicians working in wards and/or dispensary of a London hospital organisation. Participants were recruited using convenience sampling. We asked about six purposefully selected tools designed to be carried by patients to provide information about their medicines, including both national and local tools, and those that were new and established. Interviews were audio-recorded and transcribed verbatim. We used framework analysis, based on a theory of behavioural change. Results The majority of participants expressed the view that older tools, such as the steroid card and warfarin booklet, were used more often than newer tools such as a medication passport and a specific insulin passport. Interview data suggested that pharmacy staff did not have enough information and training about the proper use of the newer tools and therefore lacked confidence in providing them to their patients. In addition, they perceived that they were not integrated into policies and procedures with a lack of guidance regarding their use. Conclusion We identified the main barriers to effective implementation of tools to increase patient safety across healthcare settings to be lack of guidance and training for newer tools. Making a tool available is not sufficient to ensure its use. Recommendations include clarifying guidance within the hospital organisation to standardise use of all tools and raising awareness and providing training to both healthcare professionals and patients about their use.

Background: Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries. Methods: A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included. Results: Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5–16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists’ interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists’ recommendations. Conclusions: Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required. Keywords: Medication error, Adverse drug event, Drug related problem, Medication safety, Gulf Cooperation Council