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Introduction As of 2015, as part of the implementation of the Welsh Government primary care plan and primary care clusters, the Welsh Government has encouraged non-medical healthcare professionals working in primary care to train as independent prescribers (IPs).Objectives This research aimed to identify the number of NMIPs in primary care in Wales and describe their prescribing trend of items between 2011 and 2018, in order to compare their prescribing pattern before and after the implementation of primary care clusters for Wales.Design Retrospective secondary data analysis and interrupted time series analysis in order to compare prescribing by non-medical independent prescribers (NMIPs) preimplementation and postimplementation of primary care clusters across Wales.Results Over the study period, 600 NMIPs (nurses n=474 and pharmacists n=104) had prescribed at least one item. The number of nurse IPs increased by 108% and pharmacists by 325% (pharmacists had the largest increase between July 2015 and March 2018). The number of items prescribed by NMIPs increased over time by an average of 1380 per month (95% CI 904 to 1855, p

Background: Lithium is a drug with a narrow therapeutic range and has been associated with a number of serious adverse effects. This study aimed to characterise primary care lithium-related patient safety incidents submitted to the National Reporting and Learning System (NRLS) database with respect to incident origin, type, contributory factors and outcome. The intention was to identify ways to minimise risk to future patients by examining incidents with a range of harm outcomes. Methods: A mixed methods analysis of patient safety incident reports related to lithium was conducted. Data from healthcare organisations in England and Wales were extracted from the NRLS database. An exploratory descriptive analysis was undertaken to characterise the most frequent incident types, the associated chain of events and other contributory factors. Results: A total of 174 reports containing the term ‘lithium’ were identified. Of these, 41 were excluded and, from the remaining 133 reports, 138 incidents were identified and coded. Community pharmacies reported 100 incidents (96 dispensing related, two administration, two other), general practitioner (GP) practices filed 22 reports and 16 reports originated from other sources. A total of 99 dispensing-related incidents were recorded, 39 resulted from the wrong medication dispensed, 31 the wrong strength, 8 the wrong quantity and 21 other. A total of 128 contributory factors were identified overall; for dispensing incidents, the most common related to medication storage/packaging ( n = 41), and ‘mistakes’ ( n = 22), whereas no information regarding contributory factors was provided in 41 reports. Conclusion: Despite the established link between medication packaging and the risk of dispensing errors, our study highlighted storage and packaging as the most commonly described contributory factors to dispensing errors. The absence of certain relevant data limited the ability to fully characterise a number of reports. This highlighted the need to include clear and complete information when submitting reports. This, in turn, may help to better inform the further development of interventions designed to reduce the risk of incidents and improve patient safety. Lay Summary A characterisation of lithium-related patient safety incidents in primary care Lithium is an effective treatment for certain mental illnesses, but has a number of harmful side effects. Safety incidents related to medicines in the UK are reported to the National Reporting and Learning System database (NRLS), and concerns relating to lithium have previously been highlighted. This study aimed to characterise lithium incidents reported to the NRLS that occurred in a primary care setting. Reports relating to lithium and submitted between 2002 and 2013 were reviewed, and the information coded. A total of 174 reports containing the term ‘lithium’ were identified. Of these, 41 were excluded and, from the remaining 133 reports, 138 incidents were identified and coded with respect to incident origin, type, contributory factors and outcome. A total of 100 incidents were reported by community pharmacies (96 of which related to medicine dispensing), general practitioner (GP) practices filed 22 reports and 16 reports originated from other sources. Of the dispensing-related incidents, 39 resulted from the wrong medication dispensed, 31 the wrong strength, 8 the wrong quantity and 21 other. A total of 128 contributory factors were identified overall; for dispensing incidents, the most common related to medication storage/packaging ( n = 41), and ‘mistakes’ ( n = 22) whereas no information regarding contributory factors was provided in 41 reports. Despite the established link between medication packaging and the risk of dispensing errors, our study highlighted storage and packaging as the most commonly cited contributory factors to dispensing errors. The absence of certain relevant data limited the ability to fully characterise a number of reports. This highlighted the need to include clear and complete information when submitting reports. This, in turn, may help to better inform the further development of interventions designed to reduce incident numbers and improve patient safety.

Background: Data suggest that approximately 50,000 adults with learning disabilities (LDs) in England and Wales are currently prescribed antipsychotic medication. Illness in this population is common, including significant rates of challenging behaviour and mental illness, but there is particular concern over the use of antipsychotics prescribed for reasons other than the treatment of psychosis. Control of challenging behaviour is the primary reason why such medications are prescribed despite the absence of good evidence for any therapeutic effect for this purpose. Objectives: To assess the feasibility of recruitment and retention and to explore non-efficacy-based barriers to a blinded antipsychotic medication withdrawal programme for adults with LDs without psychosis compared with treatment as usual. A secondary objective was to compare trial arms regarding clinical outcomes. Design: A two-arm individually randomised double-blind placebo-controlled drug reduction trial. Setting: Recruitment was through community learning disability teams (CLDTs) in south Wales and south-west England. Participants: Adults with LDs who are prescribed risperidone for treatment of challenging behaviour with no known current psychosis or previous recurrence of psychosis following prior drug reduction. Intervention: A double-blind drug reduction programme leading to full withdrawal within 6 months. Treatment in the intervention group was gradually reduced over a 6-month period and then maintained at the same level for a further 3 months, still under blind conditions. In the control group, the baseline level of medication was maintained throughout the 9-month period. The blind was broken at 9 months, following final data collection. Main outcome measures: Feasibility outcomes were (1) the number and proportion of general practices/CLDTs that progressed from initial approach to recruitment of participants and (2) the number and proportion of recruited participants who progressed through the various stages of the study. Trial arms were also compared regarding clinical outcomes, the Modified Overt Aggression Scale, the Aberrant Behaviour Checklist, the Psychiatric Assessment Schedule for Adults with Developmental Disability checklist, the Antipsychotic Side-effect Checklist, the Dyskinesia Identification System Condensed User Scale, the Client Service Receipt Inventory, use of other interventions to manage challenging behaviour, use of as-required (pro re nata) medication and level of psychotropic medication use. Results: Of the 22 participants randomised (intervention, n = 11; control, n = 11), 13 (59%) achieved progression through all four stages of reduction. Follow-up data at 6 and 9 months were obtained for 17 participants (intervention, n = 10; and control, n = 7; 77% of those randomised). There were no clinically important changes in participants’ levels of aggression or challenging behaviour at the end of the study. There were no expedited safety reports. Four adverse events and one serious adverse event were reported during the trial. Limitations: Recruitment was challenging, which was largely a result of difficulty in identifying appropriate persons to consent and carer concerns regarding re-emergence of challenging behaviour. Reduced recruitment meant that the full trial became an exploratory pilot study. Conclusions: The results indicate that drug reduction is possible and safe. However, concerns about taking part were probably exacerbated by limited availability of alternative (behavioural) interventions to manage behaviour; therefore, focused support and alternative interventions are required. The results of the qualitative study provide important insights into the experiences of people taking part in drug reduction studies that should influence future trial development. Future work: We recommend that further work focuses on support for practitioners, carers and patients in reducing antipsychotic medication. Trial registration: Current Controlled Trials ISRCTN38126962. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 47. See the NIHR Journals Library website for further project information.