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ABSTRACT: The emergency care practitioner (ECP) role in the UK health service involves paramedic and nurse practitioners with advanced training to assess and treat minor illness and injury. Available evidence suggests that the introduction of this role has been advantageous in terms of managing an increased demand for emergency care, but there is little evidence regarding the quality and safety implications of ECP schemes.
The objectives were to compare the quality and safety of care provided by ECPs with non-ECP (eg, paramedic, nurse practitioner) care across three different types of emergency care settings: static services (emergency department, walk-in-centre, minor injury unit); ambulance/care home services (mobile); primary care out of hours services.
A retrospective patient case note review was conducted to compare the quality and safety of care provided by ECPs and non-ECPs across matched sites in three types of emergency care settings. Retrospective assessment of care provided was conducted by experienced clinicians. The study was part of a larger trial evaluating ECP schemes (http://www.controlled-trials.com/ISRCTN22085282).
Care provided by ECPs was rated significantly higher than that of non-ECPs across some aspects of care. The differences detected, although statistically significant, are small and may not reflect clinical significance. On other aspects of care, ECPs were rated as equal to their non-ECP counterparts.
As a minimum, care provided should meet the standards of existing service models and the findings from the study suggest that this is true of ECPs regardless of the service they are operational in.
Emergency Medicine Journal 04/2011; 29(4):327-32. · 1.44 Impact Factor
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Richard J Cooper,
Paul Bissell,
Paul Ward,
Elizabeth Murphy,
Claire Anderson,
Tony Avery,
Veronica James,
Jo Lymn,
Louise Guillaume, Allen Hutchinson,
Julie Ratcliffe
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ABSTRACT: Doctors have traditionally been viewed as the dominant healthcare profession, with the authority to prescribe medicines, but recent non-medical prescribing initiatives have been viewed as possible challenges to such dominance. Using the example of the introduction of supplementary prescribing in the UK, this study sought to explore whether such initiatives represent a challenge to medical authority. Ten case study sites in England involving primary and secondary care and a range of clinical areas were used to undertake a total of 77 observations of supplementary prescribing consultations and interviews with 28 patients, 11 doctors and nurse and pharmacist prescribers at each site. Supplementary prescribing was viewed positively by all participants but several doctors and patients appeared to lack awareness and understanding of supplementary prescribing. Continued medical authority was supported empirically in five areas: patients' and supplementary prescribers' perception of doctors as being hierarchically superior; doctors legitimation of nurses' and pharmacists' prescribing initially; doctors' belief that they could control (particularly nurses') access to prescribing training; supplementary prescribers' frequent recourse to use doctors' advice, coupled with doctors' encouragement of such 'knock on door' prescribing advice policies; doctors' denigration of most routine prescribing but claims that diagnosis was more skilled and key to medicine. Supplementary prescribing appeared to be successfully accomplished in practice in a range of clinical settings and was acceptable to all involved but did not ultimately challenge medical dominance. However, more recent nurse and pharmacist independent prescribing (involving diagnosis) may represent a more significant threat.
Health 01/2011; 16(2):115-33. · 2.10 Impact Factor
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ABSTRACT: In England, the Choose and Book service, a main component of the England National Programme for IT (NPfIT), aims at empowering patients. Little research has been performed to evaluate clinicians' perceptions of, and satisfaction with, the Choose and Book service. The aim of the research was to examine clinicians' perceptions of, and satisfaction with, the Choose and Book service. A qualitative approach, using in-depth, semi-structured interviews, was used to collect data. Framework analysis was used to analyse the data. Twenty clinicians were interviewed, including 14 general practitioners (GPs) and six hospital consultants. Although clinicians were positive about the benefits of the Choose and Book service, they were concerned about the adverse impact of the electronic referral process on their job. Paying attention to the impact of the service on clinicians' jobs, at both ends of the process, could help to improve the referral process and the use of the system.
Health Informatics Journal 10/2009; 15(3):167-78. · 1.00 Impact Factor
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ABSTRACT: The introduction of non-medical prescribing for professions such as pharmacy and nursing in recent years offers additional responsibilities and opportunities but attendant training issues. In the UK and in contrast to some international models, becoming a non-medical prescriber involves the completion of an accredited training course offered by many higher education institutions, where the skills and knowledge necessary for prescribing are learnt. Aims: to explore pharmacists' perceptions and experiences of learning to prescribe on supplementary prescribing (SP) courses, particularly in relation to inter-professional learning, course content and subsequent use of prescribing in practice.
A postal questionnaire survey was sent to all 808 SP registered pharmacists in England in April 2007, exploring demographic, training, prescribing, safety culture and general perceptions of SP.
After one follow-up, 411 (51%) of pharmacists responded. 82% agreed SP training was useful, 58% agreed courses provided appropriate knowledge and 62% agreed that the necessary prescribing skills were gained. Clinical examination, consultation skills training and practical experience with doctors were valued highly; pharmacology training and some aspects of course delivery were criticised. Mixed views on inter-professional learning were reported - insights into other professions being valued but knowledge and skills differences considered problematic. 67% believed SP and recent independent prescribing (IP) should be taught together, with more diagnostic training wanted; few pharmacists trained in IP, but many were training or intending to train. There was no association between pharmacists' attitudes towards prescribing training and when they undertook training between 2004 and 2007 but earlier cohorts were more likely to be using supplementary prescribing in practice.
Pharmacists appeared to value their SP training and suggested improvements that could inform future courses. The benefits of inter-professional learning, however, may conflict with providing profession-specific training. SP training may be perceived to be an instrumental 'stepping stone' in pharmacists' professional project of gaining full IP status.
BMC Medical Education 01/2009; 8:57. · 1.15 Impact Factor
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Proceedings of the Second International Conference on Health Informatics, HEALTHINF 2009, Porto, Portugal, January 14-17, 2009; 01/2009
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ABSTRACT: Supplementary prescribing (SP) by pharmacists and nurses in the UK represents a unique approach to improving patients' access to medicines and better utilizing health care professionals' skills. Study aims were to explore the views of stakeholders involved in SP policy, training and practice, focusing upon issues such as SP benefits, facilitators, challenges, safety and costs, thereby informing future practice and policy.
Qualitative, semi-structured interviews were conducted with 43 purposively sampled UK stakeholders, including pharmacist and nurse supplementary prescribers, doctors, patient groups representatives, academics and policy developers. Analysis of transcribed interviews was undertaken using a process of constant comparison and framework analysis, with coding of emergent themes.
Stakeholders generally viewed SP positively and perceived benefits in terms of improved access to medicines and fewer delays, along with a range of facilitators and barriers to the implementation of this form of non-medical prescribing. Stakeholders' views on the economic impact of SP varied, but safety concerns were not considered significant. Future challenges and implications for policy included SP being potentially superseded by independent nurse and pharmacist prescribing, and the need to improve awareness of SP. Several potential tensions emerged including nurses' versus pharmacists' existing skills and training needs, supplementary versus independent prescribing, SP theory versus practice and prescribers versus non-prescribing peers.
SP appeared to be broadly welcomed by stakeholders and was perceived to offer patient benefits. Several years after its introduction in the UK, stakeholders still perceived several implementation barriers and challenges and these, together with various tensions identified, might affect the success of supplementary and other forms of non-medical prescribing.
Journal of Health Services Research & Policy 11/2008; 13(4):215-21. · 1.73 Impact Factor
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ABSTRACT: This article reflects upon the introduction of nonmedical prescribing in the United Kingdom and describes the historical developments within the National Health Service over the last 2 decades, together with an assessment of the impact of this prescribing for various stakeholders, drawing upon relevant research. We argue that a number of issues are associated with the introduction and development of nonmedical prescribing, including benefits to patients, the promise of increased autonomy for professions such as nursing and pharmacy, explicit and implicit government objectives, and threats to medical dominance and autonomy.
The Journal of ambulatory care management 06/2008; 31(3):244-52.
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Jonathan Karnon,
Aileen McIntosh,
Joanne Dean,
Peter Bath, Allen Hutchinson,
Jeremy Oakley,
Nicky Thomas,
Peter Pratt,
Louise Freeman-Parry,
Ben-Tzion Karsh,
Tejal Gandhi,
Paul Tappenden
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ABSTRACT: The aim of this study is to estimate the potential costs and benefits of three key interventions (computerized physician order entry [CPOE], additional ward pharmacists and bar coding) to help prioritize research to reduce medication errors.
A generic model structure was developed to describe the incidence and impacts of medication errors in hospitals. The model follows pathways from medication error points at alternative stages of the medication pathway through to the outcomes of undetected errors. The model was populated from a systematic review of the medication errors literature combined with novel probabilistic calibration methods. Cost ranges were applied to the interventions, the treatment of preventable adverse drug events (pADEs), and the value of the health lost as a result of an ADE.
The model predicts annual health service costs of between pound 0.3 million and pound 1 million for the treatment of pADEs in a 400-bed acute hospital in the UK. Including only health service costs, it is uncertain whether any of the three interventions will produce positive net benefits, particularly if high intervention costs are assumed. When the monetary value of lost health is included, all three interventions have a high probability of producing positive net benefits with a mean estimate of around pound 31.5 million for CPOE over a five-year time horizon.
The results identify the potential cost-effectiveness of interventions aimed at medication errors, as well as identifying key drivers of cost-effectiveness that should be specifically addressed in the design of primary evaluations of medication error interventions.
Journal of Health Services Research & Policy 05/2008; 13(2):85-91. · 1.73 Impact Factor
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Richard Jason Cooper,
Claire Anderson,
Tony Avery,
Paul Bissell,
Louise Guillaume, Allen Hutchinson,
Veronica James,
Joanne Lymn,
Aileen McIntosh,
Elizabeth Murphy,
Julie Ratcliffe,
Sue Read,
Paul Ward
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ABSTRACT: Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving a tripartite agreement between independent medical prescriber, dependent prescriber and patient, enabling the dependent prescriber to prescribe in accordance with a patient-specific clinical management plan (CMP). The aim in this paper is to review, thematically, the literature on nurse and pharmacist SP, to inform further research, policy and education.
A review of the nursing and pharmacy SP literature from 1997 to 2007 was undertaken using searches of electronic databases, grey literature and journal hand searches.
Nurses and pharmacists were positive about SP but the medical profession were more critical and lacked awareness/understanding, according to the identified literature. SP was identified in many clinical settings but implementation barriers emerged from the empirical and anecdotal literature, including funding problems, delays in practicing and obtaining prescription pads, encumbering clinical management plans and access to records. Empirical studies were often methodological weaknesses and under-evaluation of safety, economic analysis and patients' experiences were identified in empirical studies. There was a perception that nurse and pharmacist independent prescribing may supersede supplementary prescribing.
There is a need for additional research regarding SP and despite nurses' and pharmacists' enthusiasm, implementation issues, medical apathy and independent prescribing potentially undermine the success of SP.
Health Policy 04/2008; 85(3):277-92. · 1.51 Impact Factor
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ABSTRACT: Care pathways can be complex, often involving multiple care providers and as such are recognised as containing multiple opportunities for error. Prospective hazard analysis methods may be useful for evaluating care provided across primary and secondary care pathway boundaries. These methods take into account the views of users (staff and patients) when determining where potential hazards may lie. The aim of this study is to evaluate the feasibility of prospective hazard analysis methods when assessing quality and safety in care pathways that lie across primary and secondary care boundaries.
Development of a process map of the care pathway for patients entering into a Chronic Obstructive Pulmonary Disease (COPD) supported discharge programme. Triangulation of information from: care process mapping, semi-structured interviews with COPD patients, semi-structured interviews with COPD staff, two round modified Delphi study and review of prioritised quality and safety challenges by health care staff.
Interview themes emerged under the headings of quality of care and patient safety. Quality and safety concerns were mostly raised in relation to communication, for example, communication with other hospital teams. The three highest ranked safety concerns from the modified Delphi review were: difficulties in accessing hospital records, information transfer to primary care and failure to communicate medication changes to primary care.
This study has demonstrated the feasibility of using mixed methods to review the quality and safety of care in a care pathway. By using multiple research methods it was possible to get a clear picture of service quality variations and also to demonstrate which points in the care pathway had real potential for patient safety incidents or system failures to occur. By using these methods to analyse one condition specific care pathway it was possible to uncover a number of hospital level problems. A number of safety challenges were systems related; these were therefore difficult to improve at care team level. Study results were used by National Health Service (NHS) stakeholders to implement solutions to problems identified in the review.
BMC Health Services Research 02/2007; 7:89. · 1.66 Impact Factor
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ABSTRACT: Abstract
Background
Care pathways can be complex, often involving multiple care providers and as such are recognised as containing multiple opportunities for error. Prospective hazard analysis methods may be useful for evaluating care provided across primary and secondary care pathway boundaries. These methods take into account the views of users (staff and patients) when determining where potential hazards may lie. The aim of this study is to evaluate the feasibility of prospective hazard analysis methods when assessing quality and safety in care pathways that lie across primary and secondary care boundaries.
Methods
Development of a process map of the care pathway for patients entering into a Chronic Obstructive Pulmonary Disease (COPD) supported discharge programme. Triangulation of information from: care process mapping, semi-structured interviews with COPD patients, semi-structured interviews with COPD staff, two round modified Delphi study and review of prioritised quality and safety challenges by health care staff.
Results
Interview themes emerged under the headings of quality of care and patient safety. Quality and safety concerns were mostly raised in relation to communication, for example, communication with other hospital teams. The three highest ranked safety concerns from the modified Delphi review were: difficulties in accessing hospital records, information transfer to primary care and failure to communicate medication changes to primary care.
Conclusion
This study has demonstrated the feasibility of using mixed methods to review the quality and safety of care in a care pathway. By using multiple research methods it was possible to get a clear picture of service quality variations and also to demonstrate which points in the care pathway had real potential for patient safety incidents or system failures to occur. By using these methods to analyse one condition specific care pathway it was possible to uncover a number of hospital level problems. A number of safety challenges were systems related; these were therefore difficult to improve at care team level. Study results were used by National Health Service (NHS) stakeholders to implement solutions to problems identified in the review.
BMC Health Services Research. 01/2007;
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ABSTRACT: Family physicians provide person-centered, continuous, comprehensive care that is accessible and available at the time of need. Although this core philosophy is shared around the world, its translation into actual practice can vary greatly with time and from place to place as family physicians adapt to local constraints and conditions. Factors driving these local variations include entrenched habits and patterns of care, funding systems, patient expectations, public policy, and the availability and quality of other critical health system components. This diversity provides both an opportunity and a challenge for family medicine research. The potential for fruitful comparisons and contrasts arising from natural experiments may require investigators to use multiple research methods capable of evaluating complex interventions and comparisons. Family medicine has the capacity to be an excellent laboratory in which research in representative populations can offer the pragmatic answers needed by practicing physicians. The nature of the research questions and interventions require the involvement of clinicians in the formulation of research questions and evaluation of the applicability of research results. The variations in implementation of the family medicine philosophy can be a potential asset because of the research opportunities they provide.
The Annals of Family Medicine 06/2004; 2 Suppl 2:S41-4. · 5.36 Impact Factor
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ABSTRACT: National Health Service (NHS) initiatives such as Clinical Governance, National Service Frameworks and the National Institute of Clinical Excellence (NICE) clinical guidelines programme create demand for tools to enable performance review by healthcare professionals. Ideally such tools should enable clinical teams to assess quality of care and highlight areas of good practice or where improvement is needed. They should also be able to be used to demonstrate progress towards goals and promote quality, while not unnecessarily increasing demand on limited resources or weakening professional control.
To formulate and evaluate a method for developing, from clinical guidelines, evidence-based review criteria that are proritised, useful and relevant to general practices assessing quality of care for the primary care management of coronary heart disease (CHD).
A two-stage study comprising, first, a review of available evidence-based guidelines for CHD and, second, the definition and prioritization of associated review criteria from the most highly rated guidelines.
Primary healthcare teams in England.
Using structured methods, evidence-based clinical guidelines for CHD were identified and appraised to ensure their suitability as the basis for developing review criteria. Recommendations common to a number of guidelines were priortszid by a panel of general practitioners to develop review criteria suitable for use in primary care.
A standardised method has been developed for constructing evidence-based review criteria from clinical guidelines. A limited, prioritized set of review criteria was developed for the primary care management of CHD. This was distributed around the NHS through the Royal College of General Practitioners for use by primary care teams across the United Kingdom.
Developing useful, evidence-based review criteria is not a straightforward process, partly because of a lack of consistency and clarity in guidelines currently available. A method was developed which accommodated these limitations and which can be applied to the development and evaluation of review criteria from guidelines for other conditions.
British Journal of General Practice 10/2003; 53(494):690-6. · 1.83 Impact Factor
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ABSTRACT: Objectives
To assess the views of the general public and general practitioners (GPs) on the General Medical Council’s Good Medical Practice.MethodsA large national consumer survey organization (MORI) was commissioned to conduct a survey of a representative sample of the general public using quota sampling methods with randomly selected sampling points across Great Britain. A similar survey was carried out of GPs across Great Britain. Questions were asked of the general public about their perceptions on medical practitioners keeping their knowledge sufficiently up to date to do their job, on complaints being properly investigated, and about doctors being removed from the General Medical Council register if they failed to perform a specifically defined duty. The GPs were asked the same questions about duties. The general public was also asked whether they worked in the National Health Service (NHS), about any recent experiences as a patient in the NHS and whether they had ever complained about a doctor.ResultsA total of 1949 people were interviewed in their homes along with 199 GPs. Over one-third either worked in the NHS or had friends or relatives who worked in the NHS. Eleven per cent felt they had reason to complain about a doctor although only 6% had made a formal or informal written or verbal complaint. The general public and GPs held similar views on reasons for doctors being removed from the register, although the public’s threshold was somewhat lower than the doctors.ConclusionsGPs and the general public have similar views on good medical practice, although the degree of concern shown by the public is greater than that registered by doctors. Both groups show similar patterns of variation in their perception of the importance of some duties compared with others.
Medical Education 11/2001; 35:52 - 59. · 3.18 Impact Factor
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The Journal of manual & manipulative therapy 12/1997; 6(3):151-153.
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ABSTRACT: Jean Peters and colleagues researched the perceptions of 97 practice nurses and 69 diabetes specialist nurses regarding their current and future role in the management of people with type 2 diabetes in the community. Issues of concern that were identified included patients, resources, training and professional responsibilities.
Nursing times 99(15):59.
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Jonathan Karnon,
Aileen McIntosh,
Joanne Dean,
Peter Bath, Allen Hutchinson,
Jeremy Oakley,
Nicky Thomas,
Peter Pratt,
Louise Freeman-Parry,
Ben-Tzion Karsh,
Tejal Gandhi,
Paul Tappenden
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ABSTRACT: Medication errors are an important problem for the UK National Health Service (NHS). The aim of this study was to implement a novel quantitative modelling method to predict rates of preventable adverse drug events (ADEs) and identify interventions with the greatest potential for reducing the burden of medication errors in secondary care. A generic model structure was developed to describe the medication process in secondary care. The model followed pathways from error points through to the outcomes of undetected errors. The model was populated using quantitative estimates and calibration methods to describe the incidence and impacts of medication errors. The effectiveness of potential interventions was estimated by describing the impact of the interventions at different stages of the medication process.The model predicts the range of preventable adverse drug events that occur annually in a 400-bed hospital in the UK to be between 200 and 700. Of the interventions evaluated, computerised physician order entry systems and increased numbers of ward pharmacists are predicted to have the greatest impact on the number of preventable ADEs. The analysis provides a relative analysis of the interventions, and indicates priorities for research allocation decisions. The model highlights the complexity of the relationship between medication errors and adverse events, and the extreme attention to detail required in the development of interventions, and in their evaluation.
Safety Science.
