Around 237 million medication errors occur in England each year. When patients transition between primary and secondary care, they are at significant risk of experiencing unintended changes to their medication. One approach to reduce these errors is the adoption of technology, including electronic prescribing.
In September 2017, Bradford Teaching Hospitals NHS Foundation Trust implemented Cerner, an electronic prescribing system, which replaced the traditional paper medical records and chart. Inadvertently, it resulted in a loss of the paper pharmaceutical care plan (PCP), which was used by pharmacy staff as a form of communication to the medical team for drug monitoring and pharmaceutical issues.
Pharmacists’ feedback from meetings post implementation of Cerner was that they perceived their workload had increased since the loss of the PCP. This meant that they had to review the patients’ entire medical notes from admission when completing clinical reviews.
A pharmacist-led quality improvement project team was established and included eight pharmacists of differing years of experience, a Cerner specialist and an academic practitioner. Their aim was to establish a robust proforma and guideline to electronically document a PCP for patients using Cerner and to improve patient care by December 2019. The ‘plan-do-study-act’ (PDSA) continuous improvement method was chosen as it allowed one to use cycles of iterative change. The main outcome measure was pharmacists’ satisfaction with the electronic PCP in relation to improving patient care. Coinciding with this was a reduction in the time taken to review discharge prescriptions post implementation of the electronic PCP.
To investigate the current problem, baseline data was prospectively collected on 18 November 2019 for two weeks (Monday to Friday) from pharmacists covering five wards, including older people, medical and surgical specialities. They were specifically chosen to determine if the intervention would work universally prior to a trust-wide roll out. Pharmacists completed data collection forms (see supplement 1) that captured information on the time taken to review a new patient, a transfer patient with a completed review, and to review a discharge prescription. Pharmacists anonymously completed a satisfaction survey with the current patient handover process.
Baseline data showed that the mean time taken by pharmacists to review new patients was 17.5 minutes versus 12.6 minutes to review a transfer patient. Pharmacists reviewed discharge prescriptions for patients who had been under their care in 13.0 minutes, versus 15.5 minutes for patients unknown to them.
The electronic PCP was produced through three PDSA cycles, which were undertaken over a three-week period (November/December 2019) (see supplement 2). It was based on feedback after each PDSA cycle from the anonymously completed pharmacist satisfaction survey. The survey asked pharmacists’ to rate on a scale of 1 to 10 (where 1 was least satisfied and 10 highly satisified) how satisfied they were with the current handover process, as well as improvements they would like to see made. The mean score was 3/10 at baseline from the pharmacist satisfaction survey. The common themes that emerged from the qualitative data were inconsistencies with the current handover process and informal documentation of pharmaceutical issues. Pharmacists found it challenging to establish what happened to the patient when they were transferred between wards owing to variable documentation. Thus, making the task of clinically reviewing a patient more difficult and time consuming, as it was unclear why medicines had been discontinued or initiated.
Pharmacists on the selected wards completed data collection forms as those completed at baseline (Monday to Friday) recording the time taken to complete pharmacist tasks. Information about the project was disseminated to key stakeholders, including Cerner, and the remaining pharmacy team to allow for wider staff engagement. This enabled sustainability and scalability of the project in the future.
Overall improvements in pharmacists’ satisfaction with the intervention were observed after each PDSA cycle. The baseline mean satisfaction score was 3/10 with the handover process, this increased to 8/10 after 3 PDSA cycles. Qualitative data suggested that pharmacists were more satisfied with the new electronic PCP, as it allowed pharmaceutical issues to be documented formally. During the first PDSA cycle pharmacists requested the project team to produce a guideline on information to be included in the electronic PCP, as well as the process to create the PCP using the Cerner system. This was to improve consistency in documentation.
Data showed that pharmacists became more efficient in completing tasks after each PDSA cycle. There was a 53.6% (n= 5.1 minutes) reduction in the mean time taken to review a transfer patient. A predictable consequence of the intervention was the increased time taken to complete the electronic PCP. However, the mean time taken reduced from 7.2 minutes after PDSA cycle 1, to 5 minutes after PDSA cycle 2, which could have been a result of user familiarity with the new form.
The increase in time was discussed with the project team, as well as reviewing comments made by pharmacists in the satisfaction survey. It was evident that the increase in time was justified, as there was an overall benefit in delivering patient care. Overall, there was strong feedback from the pharmacist satisfaction survey that the electronic PCP should be rolled out trust wide.
The project was a success owing to the early involvement of key stakeholders in the design of the intervention. Any potential bias created by the Hawthorne effect that may have altered participants behaviour was minimised by anonymising the data collection forms.
A paperless NHS is the future with healthcare professionals having to adapt their working practices owing to implementation of electronic prescribing programmes. The results showed more pharmacist satisfaction since the adoption of the electronic PCP, with improved patient care and robust pharmacist communication. The overall mean time taken for pharmacists to undertake daily tasks reduced since the introduction of the electronic PCP. The mean time taken to review a new patient at baseline was 17.8 minutes this reduced to 16.8 minutes. The mean time take to review a transfer patient at baseline was 12.6 minutes this reduced to 7.5 minutes. The mean time taken to review a discharge prescription for a patient under the pharmacist care reduced from taking 13 minutes to 9.8 minutes. The mean time taken to review a discharge prescription for a patient not known to the pharmacist reduced from 15.5 minutes to 10 minutes (see Supplement 3).
The next stage of continuous measurement would be to review the number of safety incidents pre and post electronic PCP. This would further demonstrate sustainability and intervention success.
The considerable improvement observed from the intervention has resulted in the project being scaled up next year, and the electronic PCP will be rolled out across the trust.
For further information, see supplementary PDF.
Amna Khan-Patel, lead pharmacist for renal services, Bradford Teaching Hospitals NHS Foundation Trust.
A K-P would like to acknowledge the assistance of Gemma Quinn, academic supervisor; Penny Daynes for producing the electronic PCP on Cerner; and Katherine Cullen for supervisory project support.
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