PINCER is a pharmacist-led, IT-based intervention (PINCER) to reduce clinically important medication errors in primary care, developed and tested by researchers.
Need for innovation
The World Health Organisation (WHO) has identified ‘Medication Without Harm’ as the theme for their 3rd Global Patient Safety Challenge, which aims to reduce severe avoidable medication-related harm by 50% globally in the next five years.
Prescribing errors in general practice are an important and expensive preventable cause of safety incidents, morbidity, hospitalisations and deaths. A recent large-scale study in English general practices identified prescribing errors in 5% of prescription items, with one in 550 items containing a severe (potentially life threatening) error; this equates to approximately 1.8 million serious prescribing errors each year.
Further studies have shown hazardous prescribing in general practices to be a contributory cause of around one in 25 hospital admissions. The annual hospital admission costs in England for adverse drug events are £650 million (at 2013 prices).
The intervention comprises of 3 core elements:
- An integrated search on GP computer systems to identify patients at risk of potentially hazardous prescribing using a national set of 14 evidence based validated prescribing safety indicators. Searches allow for stratification and prioritisation of patients at highest risk, identifying patients who are at more than one type of risk.
- Pharmacists and Pharmacy Technicians, specifically trained to deliver the intervention provide an educational outreach intervention, where they meet with GPs and other practice staff to implement an agreed action plan for patients identified at high risk. The intervention uses academic detailing and root cause analysis (RCA) to minimise future risk, thereby improving prescribing and medication monitoring systems.
- Access to comparative analysis of prescribing safety data called CHART ONLINE, allowing practices to compare results from baseline to post PINCER intervention. Practices can quickly identify trends and cause for action; by uploading non patient identifiable data at 6-12 monthly intervals. Analysis at practice, CCG, STP, regional and national level allows benchmarking, monitoring and comparison.
PINCER has been rolled out across the West Midlands region in 252 practices across the region. The was largest and quickest uptake of PINCER across the country and the project overachieved its 2 year target in 1 year.
The effectiveness of the PINCER intervention was shown in a large cluster randomised controlled trial published in The Lancet, to reduce medication error rates by up to 50%. An economic analysis showed introducing PINCER was cost effective, demonstrating an increased quality of life for patients (0.81 Quality Adjusted Life Years per practice) and an overall reduction in costs of £2,679 per practice. An evaluation of the rollout of PINCER in 370 general practices (94%) across 12 East Midlands CCGs between 2015 and 2017, identified over 21,000 instances of hazardous prescribing in a patient population of over 2.9 million people. Over 10,500 patients received an active intervention resulting in safer care as a direct benefit of implementing the intervention. Results show significant reduction in hazardous prescribing between the beginning and end of the study period for indicators associated with: gastrointestinal bleeding; heart failure and kidney injury.