Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

A retrospective audit of medicines use review forms

The medicines use review (MUR) service was introduced in England and Wales in 2005 to improve patients’ knowledge and use of medicines through a private, patient–pharmacist consultation. The pharmacist completes a standard form as a record of the MUR consultation and the patient receives a copy. The 2008 White Paper, Pharmacy in England[1] notes some MURs are of poor or questionable quality and there are anecdotal reports that pharmacists elect to conduct ‘easy’ MURs with patients on a single prescribed medicine only.[2] In 2009, the Royal Pharmaceutical Society of Great Britain (RPSGB) launched a multi-disciplinary audit template to review the effectiveness of MURs and improve their quality.[3] Prior to this, we conducted a retrospective MUR audit in a 1-month period in 2008. Our aims were to report on findings from this audit and the validity of using MUR forms as data for audit.

How is the language of medicines use review leaflets symbolising the service?

Introduction The medicines use review (MUR), a new community pharmacy ‘service’, was launched in England and Wales to improve patients’ knowledge and use of medicines through a private, patient–pharmacist appointment. After 18 months, only 30% of pharmacies are providing MURs; at an average of 120 per annum (maximum 400 allowed).1 One reason linked to low delivery is patient recruitment.2 Our aim was to examine how the MUR is symbolised and given meaning via printed patient information, and potential implications. Method The language of 10 MUR patient leaflets, including the NHS booklet,3 and leaflets from multiples and wholesalers was evaluated by discourse analysis. Results and Discussion Before experiencing MURs, patients conceivably ‘categorise’ relationships with pharmacists based on traditional interactions.4 Yet none of the leaflets explicitly describe the MUR as ‘new’ and presuppose patients would become involved in activities outside of their pre-existing relationship with pharmacists such as appointments, self-completion of charts, and pharmacy action plans. The MUR process is described inconsistently, with interchangeable use of formal (‘review meeting‘) and informal (‘friendly’) terminology, the latter presumably to portray an intended ‘negotiation model’ of interaction.5 Assumptions exist about attitudes (‘not understanding’; ‘problems’) that might lead patients to an appointment. However, research has identified a multitude of reasons why patients choose (or not) to consult practitioners,6 and marketing of MURs should also consider other barriers. For example, it may be prudent to remove time limits to avoid implying patients might not be listened to fully, during what is for them an additional practitioner consultation.

What is the new medicines use review ‘patient survey’ attempting to capture in the context of existing patient satisfaction with pharmacy questionnaires and a new conceptual framework?

The community pharmacy service medicines use review (MUR) was introduced in 2005 ‘to improve patient knowledge, concordance and use of medicines’ through a private patient–pharmacist consultation. The MUR presents a fundamental change in community pharmacy service provision. While traditionally pharmacists are dispensers of medicines and providers of medicines advice, and patients as recipients, the MUR considers pharmacists providing consultation-type activities and patients as active participants. The MUR facilitates a two-way discussion about medicines use. Traditional patient–pharmacist behaviours transform into a new set of behaviours involving the booking of appointments, consultation processes and form completion, and the physical environment of the patient–pharmacist interaction moves from the traditional setting of the dispensary and medicines counter to a private consultation room. Thus, the new service challenges traditional identities and behaviours of the patient and the pharmacist as well as the environment in which the interaction takes place. In 2008, the UK government concluded there is at present too much emphasis on the quantity of MURs rather than on their quality.[1] A number of plans to remedy the perceived imbalance included a suggestion to reward ‘health outcomes’ achieved, with calls for a more focussed and scientific approach to the evaluation of pharmacy services using outcomes research. Specifically, the UK government set out the main principal research areas for the evaluation of pharmacy services to include ‘patient and public perceptions and satisfaction’as well as ‘impact on care and outcomes’. A limited number of ‘patient satisfaction with pharmacy services’ type questionnaires are available, of varying quality, measuring dimensions relating to pharmacists’ technical competence, behavioural impressions and general satisfaction. For example, an often cited paper by Larson[2] uses two factors to measure satisfaction, namely ‘friendly explanation’ and ‘managing therapy’; the factors are highly interrelated and the questions somewhat awkwardly phrased, but more importantly, we believe the questionnaire excludes some specific domains unique to the MUR. By conducting patient interviews with recent MUR recipients, we have been working to identify relevant concepts and develop a conceptual framework to inform item development for a Patient Reported Outcome Measure questionnaire bespoke to the MUR. We note with interest the recent launch of a multidisciplinary audit template by the Royal Pharmaceutical Society of Great Britain (RPSGB) in an attempt to review the effectiveness of MURs and improve their quality.[3] This template includes an MUR ‘patient survey’. We will discuss this ‘patient survey’ in light of our work and existing patient satisfaction with pharmacy questionnaires, outlining a new conceptual framework as a basis for measuring patient satisfaction with the MUR. Ethical approval for the study was obtained from the NHS Surrey Research Ethics Committee on 2 June 2008. References 1. Department of Health (2008). Pharmacy in England: Building on Strengths – Delivering the Future. London: HMSO. www. official-documents.gov.uk/document/cm73/7341/7341.pdf (accessed 29 September 2009). 2. Larson LN et al. Patient satisfaction with pharmaceutical care: update of a validated instrument. JAmPharmAssoc 2002; 42: 44–50. 3. Royal Pharmaceutical Society of Great Britain (2009). Pharmacy Medicines Use Review – Patient Audit. London: RPSGB. http:// qi4pd.org.uk/index.php/Medicines-Use-Review-Patient-Audit. html (accessed 29 September 2009).

On the use of headline indices to link environmental quality and income at the level of the nation state

This paper deconstructs the relationship between the Environmental Sustainability Index (ESI) and national income. The ESI attempts to provide a single figure which encapsulates environmental sustainability' for each country included in the analysis, and this allied with a 'league table' format so as to name and shame bad performers, has resulted in widespread reporting within the popular presses of a number of countries. In essence, the higher the value of the ESI then the more 'environmentally sustainable' a country is deemed to be. A logical progression beyond the use of the ESI to publicise environmental sustainability is its use within a more analytical context. Thus an index designed to simplify in order to have an impact on policy is used to try and understand causes of good and bad performance in environmental sustainability. For example the creators of the ESI claim that ESI is related to GDP/capita (adjusted for Purchasing Power Parity) such that the ESI increases linearly with wealth. While this may in a sense be a comforting picture, do the variables within the ESI allow for alternatives to the story, and if they do then what are the repercussions for those producing such indices for broad consumption amongst the policy makers, mangers, the press, etc.? The latter point is especially important given the appetite for such indices amongst non-specialists, and for all their weaknesses the ESI and other such aggregated indices will not go away. (C) 2007 Elsevier Ltd. All rights reserved.

Quality of medicines stored together in multi-compartment compliance aids

Background and Objective: Dispensing medicines into compliance aids is a common practice in pharmacy contrary to manufacturers’ advice and studies have shown the appearance of light-sensitive tablets is compromised by such storage; we previously found evidence of reduced bioavailability at elevated temperature and humidity. Our objective was to examine the physicochemical stability of two generic atenolol tablets in different compliance aids and with aspirin co-storage at room temperature and at 40 °C/75% relative humidity. Methods: The physicochemical stability of atenolol tablets was evaluated after 28 days of storage and compared with controls by examining visual appearance, weight, disintegration, dissolution, friability and hardness to accepted standards and using a previously validated HPLC method for chemical assay. Results and Discussion: The response to storage was brand-dependent and not straightforward. With one make of atenolol (Alpharma), storage in compliance aids even at room temperature impacted on physical stability, reducing tablet hardness, with storage in Dosett® exerting a greater impact than storage in Medidos® (t-test P < 0·001). Co-storage at elevated temperature and humidity also impacted on the appearance of non-coated aspirin tablets (Angette™). The chemical stability of atenolol was not affected and we did not find evidence of changes to bioavailability with either make. Certainly data for one atenolol make (CP Pharmaceuticals) co-stored with aspirin (Angette™ and Nu-Seals) in both compliance aids at room temperature provided evidence of short-term stability. But medicines are dispensed into compliance aids in multi-factorial ways so our study highlights not only the lack of evidence but also a realization that evidence to support real practice may not be accomplished through research. Conclusion: Reassuring practitioners of the continued stability of medicines in compliance aids under the countless condition in which they are dispensed in practice may requires a different approach involving medical device regulators and more definitive professional guidance.

Biodiversity of Collembola in urban soils and the use of Folsomia candida to assess soil 'quality'

The effects of metal contamination on natural populations of Collembola in soils from five sites in the Wolverhampton area ( West Midlands, England) were examined. Analysis revealed that metal concentrations were elevated above background levels at all sites. One location in particular (Ladymoor, a former smelting site) was highly contaminated with Cd, Cu, Pb and Zn at more than 20 times background levels. Biodiversity indices ( Shannon - Weiner, Simpson index, Margalef index, alpha index, species richness, Shaneven ( evenness) and Berger - Parker dominance) were calculated. Of these indices, estimates of species richness and evenness were most effective at highlighting the differences between the Collembola communities. Indeed, the highest number of species were found at the most contaminated site, although the Collembola population also had a comparatively low evenness value, with just two species dominating. The number of individuals per species were allocated into geometric classes and plotted against the cumulative number of species as a percentage. At Ladymoor, there were more geometric classes, and the slope of the line was shallower than at the other four sites. This characteristic is a feature of polluted sites, where a few species are dominant and most species are rare. The Ladymoor soil also had a dominance of Isotomurus palustris, and was the only site in which Ceratophysella denticulata was found. Previous studies have shown that these two species are often found in sites subject to high metal contamination. Survival and reproduction of the "standard'' test springtail, Folsomia candida (Willem), were determined in a 4 week exposure test to soils from all five sites. Mortality was significantly increased in adults and reproduction significantly lower in the Ladymoor soil in comparison to the other four sites. This study has shown that severe metal contamination can be related to the population structure of Collembola in the field, and performance of F. candida ( in soils from such sites) in the laboratory.

Biodiversity of Collembola in urban soils and the use of Folsomia candida to assess soil 'quality'

The effects of metal contamination on natural populations of Collembola in soils from five sites in the Wolverhampton area ( West Midlands, England) were examined. Analysis revealed that metal concentrations were elevated above background levels at all sites. One location in particular (Ladymoor, a former smelting site) was highly contaminated with Cd, Cu, Pb and Zn at more than 20 times background levels. Biodiversity indices ( Shannon - Weiner, Simpson index, Margalef index, alpha index, species richness, Shaneven ( evenness) and Berger - Parker dominance) were calculated. Of these indices, estimates of species richness and evenness were most effective at highlighting the differences between the Collembola communities. Indeed, the highest number of species were found at the most contaminated site, although the Collembola population also had a comparatively low evenness value, with just two species dominating. The number of individuals per species were allocated into geometric classes and plotted against the cumulative number of species as a percentage. At Ladymoor, there were more geometric classes, and the slope of the line was shallower than at the other four sites. This characteristic is a feature of polluted sites, where a few species are dominant and most species are rare. The Ladymoor soil also had a dominance of Isotomurus palustris, and was the only site in which Ceratophysella denticulata was found. Previous studies have shown that these two species are often found in sites subject to high metal contamination. Survival and reproduction of the "standard'' test springtail, Folsomia candida (Willem), were determined in a 4 week exposure test to soils from all five sites. Mortality was significantly increased in adults and reproduction significantly lower in the Ladymoor soil in comparison to the other four sites. This study has shown that severe metal contamination can be related to the population structure of Collembola in the field, and performance of F. candida ( in soils from such sites) in the laboratory.

Differences in perceived risks and benefits of herbal, over-the-counter conventional, and prescribed conventional, medicines, and the implications of this for the safe and effective use of herbal products

Objectives: To investigate people's views about the efficacy and specific risks of herbal, over-the-counter (OTC) conventional, and prescribed conventional medicines, and their likelihood of taking a second (herbal or OTC conventional) product in addition to a prescribed medicine. Methods: Experiment 1 (1 factor within-participant design); Experiment 2 (1 factor between-participant design). Convenience samples of general population were given a hypothetical scenario and required to make a number of judgements. Results: People believed herbal remedies to be less effective, but less risky than OTC and prescribed conventional medicines. Herbal medicines were not seen as being safer simply because of their easier availability. Participants indicated that they would be more likely to take a herbal medicine than a conventional OTC medicine in addition to a prescribed medicine, and less likely to consult their doctor in advance. Conclusion: People believe that herbal medicines are natural and relatively safe and can be used with less caution. People need to be given clear information about the risks and benefits of herbal medicines if they are to use such products safety and effectively. (c) 2006 Elsevier Ltd. All rights reserved.

Comparison of two methods of presenting risk information to patients about the side effects of medicines

Objective: To determine whether the use of verbal descriptors suggested by the European Union (EU) such as "common" (1-10% frequency) and "rare" (0.01-0.1%) effectively conveys the level of risk of side effects to people taking a medicine. Design: Randomised controlled study with unconcealed allocation. Participants: 120 adults taking simvastatin or atorvastatin after cardiac surgery or myocardial infarction. Setting: Cardiac rehabilitation clinics at two hospitals in Leeds, UK. Intervention: A written statement about one of the side effects of the medicine (either constipation or pancreatitis). Within each side effect condition half the patients were given the information in verbal form and half in numerical form (for constipation, "common" or 2.5%; for pancreatitis, "rare" or 0.04%). Main outcome measure: The estimated likelihood of the side effect occurring. Other outcome measures related to the perceived severity of the side effect, its risk to health, and its effect on decisions about whether to take the medicine. Results: The mean likelihood estimate given for the constipation side effect was 34.2% in the verbal group and 8.1% in the numerical group; for pancreatitis it was 18% in the verbal group and 2.1% in the numerical group. The verbal descriptors were associated with more negative perceptions of the medicine than their equivalent numerical descriptors. Conclusions: Patients want and need understandable information about medicines and their risks and benefits. This is essential if they are to become partners in medicine taking. The use of verbal descriptors to improve the level of information about side effect risk leads to overestimation of the level of harm and may lead patients to make inappropriate decisions about whether or not they take the medicine.

Informing people about the risks and benefits of medicines: implications for the safe and effective use of medicinal products

Providing effective information about drug risks and benefits has become a major challenge for health professionals, as many people are ill equipped to understand, retain and use the information effectively. This paper reviews the growing evidence that people’s understanding (and health behaviour) is not only affected by the content of medicines information, but also by the particular way in which it is presented. Such presentational factors include whether information is presented verbally or numerically, framed positively or negatively, whether risk reductions are described in relative or absolute terms (and baseline information included), and whether information is personalized or tailored in any way. It also looks at how understanding is affected by the order in which information is presented, and the way in which it is processed. The paper concludes by making a number of recommendations for providers of medicines information, about both the content and presentation of such information, that should enhance safe and effective medicines usage.

Combined use of satellite estimates and rain gauge observations to generate high-quality historical rainfall time series over Ethiopia

Climate data are used in a number of applications including climate risk management and adaptation to climate change. However, the availability of climate data, particularly throughout rural Africa, is very limited. Available weather stations are unevenly distributed and mainly located along main roads in cities and towns. This imposes severe limitations to the availability of climate information and services for the rural community where, arguably, these services are needed most. Weather station data also suffer from gaps in the time series. Satellite proxies, particularly satellite rainfall estimate, have been used as alternatives because of their availability even over remote parts of the world. However, satellite rainfall estimates also suffer from a number of critical shortcomings that include heterogeneous time series, short time period of observation, and poor accuracy particularly at higher temporal and spatial resolutions. An attempt is made here to alleviate these problems by combining station measurements with the complete spatial coverage of satellite rainfall estimates. Rain gauge observations are merged with a locally calibrated version of the TAMSAT satellite rainfall estimates to produce over 30-years (1983-todate) of rainfall estimates over Ethiopia at a spatial resolution of 10 km and a ten-daily time scale. This involves quality control of rain gauge data, generating locally calibrated version of the TAMSAT rainfall estimates, and combining these with rain gauge observations from national station network. The infrared-only satellite rainfall estimates produced using a relatively simple TAMSAT algorithm performed as good as or even better than other satellite rainfall products that use passive microwave inputs and more sophisticated algorithms. There is no substantial difference between the gridded-gauge and combined gauge-satellite products over the test area in Ethiopia having a dense station network; however, the combined product exhibits better quality over parts of the country where stations are sparsely distributed.

Training on the use of a bespoke continuing professional development framework improves the quality of CPD records

BACKGROUND: Using continuing professional development (CPD) as part of the revalidation of pharmacy professionals has been proposed in the UK but not implemented. We developed a CPD Outcomes Framework (‘the framework’) for scoring CPD records, where the score range was -100 to +150 based on demonstrable relevance and impact of the CPD on practice. OBJECTIVE: This exploratory study aimed to test the outcome of training people to use the framework, through distance-learning material (active intervention), by comparing CPD scores before and after training. SETTING: Pharmacy professionals were recruited in the UK in Reading, Banbury, Southampton, Kingston-upon-Thames and Guildford in 2009. METHOD: We conducted a randomised, double-blinded, parallel-group, before and after study. The control group simply received information on new CPD requirements through the post; the active intervention group also received the framework and associated training. Altogether 48 participants (25 control, 23 active) completed the study. All participants submitted CPD records to the research team before and after receiving the posted resources. The records (n=226) were scored blindly by the researchers using the framework. A subgroup of CPD records (n=96) submitted first (before-stage) and rewritten (after-stage) were analysed separately. MAIN OUTCOME MEASURE: Scores for CPD records received before and after distributing group-dependent material through the post. RESULTS: Using a linear-regression model both analyses found an increase in CPD scores in favour of the active intervention group. For the complete set of records, the effect was a mean difference of 9.9 (95% CI = 0.4 to 19.3), p-value = 0.04. For the subgroup of rewritten records, the effect was a mean difference of 17.3 (95% CI = 5.6 to 28.9), p-value = 0.0048. CONCLUSION: The intervention improved participants’ CPD behaviour. Training pharmacy professionals to use the framework resulted in better CPD activities and CPD records, potentially helpful for revalidation of pharmacy professionals. IMPACT: • Using a bespoke Continuing Professional Development outcomes framework improves the value of pharmacy professionals’ CPD activities and CPD records, with the potential to improve patient care. • The CPD outcomes framework could be helpful to pharmacy professionals internationally who want to improve the quality of their CPD activities and CPD records. • Regulators and officials across Europe and beyond can assess the suitability of the CPD outcomes framework for use in pharmacy CPD and revalidation in their own setting.

The use of computer-based learning tools for teaching and clinical purposes: Interactive computing strategy for Iraq

Medical universities and teaching hospitals in Iraq are facing a lack of professional staff due to the ongoing violence that forces them to flee the country. The professionals are now distributed outside the country which reduces the chances for the staff and students to be physically in one place to continue the teaching and limits the efficiency of the consultations in hospitals. A survey was done among students and professional staff in Iraq to find the problems in the learning and clinical systems and how Information and Communication Technology could improve it. The survey has shown that 86% of the participants use the Internet as a learning resource and 25% for clinical purposes while less than 11% of them uses it for collaboration between different institutions. A web-based collaborative tool is proposed to improve the teaching and clinical system. The tool helps the users to collaborate remotely to increase the quality of the learning system as well as it can be used for remote medical consultation in hospitals.

Blended learning approach to include the innovative use of vodcasts (video-podcasts) to enrich students learning experience in structures laboratory

Students may have difficulty in understanding some of the complex concepts which they have been taught in the general areas of science and engineering. Whilst practical work such as a laboratory based examination of the performance of structures has an important role in knowledge construction this does have some limitations. Blended learning supports different learning styles, hence further benefits knowledge building. This research involves the empirical studies of how an innovative use of vodcasts (video-podcasts) can enrich learning experience in the structural properties of materials laboratory of an undergraduate course. Students were given the opportunity of downloading and viewing the vodcasts on the theory before and after the experimental work. It is the choice of the students when (before or after, before and after) and how many times they would like to view the vodcasts. In blended learning, the combination of face-to-face teaching, vodcasts, printed materials, practical experiments, writing reports and instructors’ feedbacks benefits different learning styles of the learners. For the preparation of the practical laboratory work, the students were informed about the availability of the vodcasts prior to the practical session. After the practical work, students submit an individual laboratory report for the assessment of the structures laboratory. The data collection consists of a questionnaire completed by the students, and the practical reports submitted by them for assessment. The results from the questionnaire were analysed quantitatively, whilst the data from the assessment reports were analysed qualitatively. The analysis shows that students who have not fully grasped the theory after the practical were successful in gaining the required knowledge by viewing the vodcasts. Some students who have understood the theory may choose to view it once or not at all. Their understanding was demonstrated by the quality of their explanations in their reports. This is illustrated by the approach they took to explicate the results of their experimental work, for example, they can explain how to calculate the Young’s Modulus properly and provided the correct value for it. The research findings are valuable to instructors who design, develop and deliver different types of blended learning, and beneficial to learners who try different blended approaches. Recommendations were made on the role of the innovative application of vodcasts in the knowledge construction for structures laboratory and to guide future work in this area of research.