Summary of the example
Prescribing safety indicators (PSI) describe scenarios where there is potentially inappropriate and unsafe prescribing. Based on a project commissioned by the Royal College of General Practitioners (RCGP) a set of prescribing safety indicators has been developed for use in general practices based on the consensus of a varied sample of GPs in the UK.
Based on these same PSIs and work developed by the NHSBSA, searches have been created in SystmOne (S1) to actively identify potentially harmful scenarios. Prompt action can then be taken to minimise risk to patients and optimise medication regimens.
These searches are carried out on a monthly basis at both Her Majesty’s Prison (HMP) Wymott and HMP Garth. The patients highlighted as potentially at risk are reviewed by the Clinical Pharmacist. The patients medication regime is then either optimised by the pharmacist or referred to the GP for review. Following referral, this medication is optimised and communicated to the patient or GP appointments booked for discussion.
Results and trends from these searches that highlight unsafe or less robust practices have been discussed with the heads of healthcare and the clinical director.
These findings form the basis for further and more detailed prescribing audits (example attached).
Why we think it’s important
After joining HMP Wymott and HMP Garth in April 2019, I was tasked with auditing medication and prescribing trends.
Prior to my introduction to the role, no formal prescribing audits were taking place. From April 2019, I started completing monthly audits on specific prescribing criteria e.g. Metformin prescribing and eGFR results or Clopidogrel and PPI co-prescribing. Although these were comprehensive audits, they were limited in terms of only providing a snapshot of results at a specific period of time. When conducted these audits I was always able to identify patients where prescribing could be optimised. However, I also found that conducting one extensive audit at a time would leave many other areas unaudited for a long period, as developing and implementing detailed audits was time consuming.
I researched other approaches, such as PINCER and several PSI documents and started to adapt these scenarios to S1 searches to review, collate and analyse the data. With this approach I believe I have introduced a more flexible and agile way of identifying risk, as once the PSI searches have been created, they’re always available on S1, giving a real time view of any patient that might potentially be at risk of inappropriate prescribing.
Learn more about the example
Aims and objectives of the work
- Improve medicines optimisation and minimize risk to patients by identifying and reviewing hazardous prescribing.
- Review prescribing standards and practice.
- Introduce regular prescribing auditing and PSI review
- Run PSI searches on S1 to identify hazardous prescribing
- Capture and collate data obtained from searches
- Review and analyse data obtained from searches
- Identify patients at risk of hazardous prescribing and minimise this risk by optimising their medication
- Review prescribing trends and service delivery (such as blood clinics and blood recalls)
Based on the Patient Safety Toolkit and the RCGP’s PSI consensus document, local computer searches have been created on SystmOne (S1) to identify these potentially harmful scenarios.
PSIs not relevant to adult males have been excluded.
Prescribing Safety Indicators are grouped according to risk as per the RCGP consensus document (see full list of PSIs in attached document):
- Extreme Risk e.g. Metformin prescribed to a patient with an eGFR ≤30ml/min.
- High Risk e.g. DMARD prescribed with no FBC blood test in the previous 12 weeks.
- Moderate Risk e.g. Allopurinol without baseline urea, electrolytes, creatinine and eGFR.
- Optimization (local optimization searches) e.g. Clopidogrel co-prescribed with omeprazole or esomeprazole.
Searches of PSIs were created on S1. Using the metformin and eGFR PSI as an example, one search was created to identify all patients currently prescribed metformin and a second search was created to identify all patients with a read code for eGFR and a recorded value ≤30ml/min. Another search was then produced to tie these two together to identify patients being prescribed metformin with an eGFR ≤30ml/min.
Searches are run at least monthly.
Following identification of patients that fall under these PSIs, each patient is reviewed by the clinical pharmacist who makes recommendations for medicines optimisation to the doctor on duty.
In addition, these PSIs also form the basis for future audits based on the risk category they fall under, the frequency of occurrence and the potential risk to patients and the service. This data also gives an insight into prescribers’ habits and prescribing trends, which help to identify possible areas of concern for review by the Clinical Director.
Outcomes of these PSI searches and subsequent optimisation examples are shared with the multidisciplinary team at the monthly medicines management meetings.
Results (from searches):
173 patients were identified and reviewed:
- 2 possible Extreme Risk
- 69 possible High Risk
- 102 optimization opportunities identified and reviewed
- 2 Extreme Risk situations identified related to concomitantly prescribing antimicrobials and warfarin. Upon reviewing both records it was apparent that INRs were completed at appropriate times
- Risk of myopathy has been reduced in 7 patients by optimizing statin treatment.
- Antiplatelet treatment outcome improved in 5 patients by optimizing co-prescribing of PPIs e.g. switching from omeprazole to lansoprazole in a patient taking clopidogrel.
- Risk of bleeding minimized in 4 patients by prescribing gastro-protection e.g. in patients prescribed NSAIDs who were already on an antiplatelet drug.
- Risk minimized in 133 patients on DMARDS, metformin, ACE inhibitors or olanzapine where blood tests were arranged as they were overdue.
Key findings indicate that:
- No prescribing was identified in the extreme risk PSI category that hadn’t already been considered by the prescriber over the reviewed period, which is indicative of safe prescribing practices in the monitored areas.
- Several patients were late for their blood monitoring and there was poor follow up of patient non-attendance at blood test appointments, indicating that the current system wasn’t robust which was reported to the head of healthcare and clinical director for review.
- Results from searches highlighted areas of concern which would later be the focus of more detailed audits e.g. it was identified that several diabetic patients were late for blood monitoring, therefore a detailed audit was conducted on the prescribing of metformin and eGFR monitoring (see attached).
Future work will involve further development of these PSIs and production of procedures to allow for more frequent searches and reviews (e.g. daily or weekly). Results from searches reviewed daily, would allow the service to immediately identify any prescribing concerns and act promptly to improve patient safety.
- List of prescribing safety indicators (PSI) used to produce searches in S1 (attached)
- Metformin and eGFR monitoring audit developed following identified weaknesses in our service from the review of PSIs (attached)
National guidance, data and publications
- Patient Safety Toolkit for General Practice. https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/patient-safety.aspx
- Medication Safety -Indicators Specification, NHSBSA, 2019. https://www.nhsbsa.nhs.uk/sites/default/files/2019-08/Medication%20Safety%20-%20Indicators%20Specification%20%28Aug19%29.pdf
- Identification of an updated set of prescribing-safety indicators for GPs. British Journal of General Practice, 2014. https://bjgp.org/content/61/589/e526
- Developing consensus on hospital prescribing indicators of potential harms amenable to decision support. British Journal of Clinical Pharmacology, 2013. https://www.ncbi.nlm.nih.gov/pubmed/23362926