Preventing prescribing errors with PINCER

SUMMARY 

 Prescribing errors in general practice are an expensive, preventable cause of safety incidents, illness, hospitalisations and even deaths. Serious errors affect one in 550 prescription items, while hazardous prescribing in general practice contributes to around 1 in 25 hospital admissions. 

 Outcomes of a trial published in the Lancet showed a reduction in error rates of up to 50% following adoption of PINCER – a pharmacist-led IT intervention for reducing clinically important errors in general practice prescribing. 

These original PINCER indicators have been incorporated into National Institute for Health and Care Excellence (NICE) Medicines Optimisation Clinical Guideline (May 2015). 

The PINCER intervention is led by primary care pharmacists and pharmacy technicians. It involves searching GP clinical systems using computerised prescribing safety indicators to identify patients at risk from their medications and then acting to correct the problem. 

PINCER was established as one of the AHSN Network’s national programmes in 2018, and with the support of KSS AHSN, more than 400 GP practices have used the approach in Kent, Surrey and Sussex. 

While national funding for PINCER ended in 2020, KSS AHSN continued to support the project up to March 2022.

The following report gives an overview of KSS AHSN’s approach to supporting the use of PINCER, the programme’s benefits and the next steps for the initiative in our region.  

KSS AHSN PINCER Delivery  

KSS AHSN has been working to increase the use of PINCER in general practice since 2018.  

A PINCER Progress Report was published in September 2020 giving an overview of the first 18 months of the national rollout of the programme which can be found here.  

More than 400 GP practices have used  the approach across Kent, Surrey, and Sussex. In addition to securing funds to support the programme following the end of the initial national commission with access to the software and PINCER resources, the AHSN also provided training for those wanting to use the intervention and approach in practice. 

KSS AHSN worked with key stakeholders from the region’s medicine optimisation teams, including but not limited to CCGs, ICSs, Primary care teams, GPs and pharmacists, to drive engagement with the initiative across Kent, Surrey and Sussex. A key partner in this approach was the CCG medicines management teams. 

Given the clear patient safety benefit and potential economic savings that could be realised by using PINCER in primary care, KSS AHSN particularly engaged with CCG medicines management teams across the region. Working with them, it was able to tailor the national programme to meet regional needs, ensuring that the approach benefitted all partners.  

KSS AHSN provided project management support to bring together partners from across the region to develop and deliver a collaborative project. 

With innovation funding from NHS England, KSS AHSN was able to support the initial roll out of PINCER, and then funded the project locally during the COVID pandemic, when the initial national funding ended.  

Through its approach, KSS AHSN was able to offer the following elements to the region’s health system:  

• Licenses for all practices in the region, with KSS AHSN signing an individual contract with PRIMIS,  who led the development and testing of PINCER intervention from the University of Nottingham 

• Action learning PINCER training for nominated practitioners  

• Engagement events with PRIMIS support 

• Cover the cost of venues for training and engagement events. Also set up of virtual training during the pandemic. 

Benefits of programme:  

• Reduction in serious medication-related adverse effects and a significant improvement in prescribing safety in primary care    

• Cost saving of approximately £2,600 per practice. If implemented across the entire KSS AHSN region this would be approximately £1,430,000 over a 5-year horizon  

• Additional savings made by preventing any hospital admission related to an adverse effect 

• Improved patient outcomes by supporting the PCN DES and IIF indicators  

• PINCER supports prioritising patients eligible for Structured Medication Reviews (SMRs) and Medicines Optimisation 

• Identifying and improving prescribing behaviours within general practices through RCA and QI cycles 

• Avoidance of future harm by proactively searching for patients at-risk of medication errors. During the national rollout of PINCER (2019-2021), more than 20,000 at-risk patients were identified in KSS AHSN helping to reduce patient harm and/or potential hospital admissions  

•  PINCER QI training also supports GPhC revalidation through CPD submission  

• The PINCER programme also supports with CQC visits as the audits are patient safety focussed.  

Long term impact 

As well as identifying existing medication related errors, the PINCER programme was also able to stop similar incidents from happening with subsequent patients. For example, where a GP practice was able to identify those two medicines that were commonly prescribed caused an adverse effect, they would be able to change their standard operating procedure to avoid future errors.  

A key secondary impact of the initiative relates to the upskilling of the. As part of their PINCER programme staff undertook three Action Learning Sets that looked at a range of topics, from how to analyse the data delivered by PINCER to the change methodology.  

As a result there is now a cohort of the workforce with enhanced skills needed to identify patient safety concerns, and with the knowledge and skills to implement an effective change programme.  

Appendices 

The PINCER approach 

• PINCER has been shown, in a large cluster randomised controlled trial published in The Lancet, to reduce medication error rates by up to 50%i.  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)ii and an overall reduction in costs of £2,679 per practice. 

• The pharmacists involved in delivering PINCER: 

• Use software (PRIMIS – PINCER tool) to interrogate the GP clinical system to identify patients at risk of potentially hazardous prescribing, typically uploading results to a centralised system. 

• Review the patient notes with GPs to assess the risk and the appropriate actions needed to address the issues identified, 

• Apply root cause analysis to identify the circumstances that led to the patient being put at risk and then feedback findings to the practice, 

• Work with the practice to build an action plan to protect those patients at risk and work on rectifying any system issues which resulted in those risks occurring. 

National PINCER Delivery  

• Successes since 2018 in the national roll out of PINCER 

• PINCER rolled out to over 2,800 (41%) GP practices in England  

• 2,350 health care professionals (including 1,785 primary care pharmacists) trained to deliver the PINCER intervention 

• Just over 27 million patient records have been searched to identify instances of potentially hazardous prescribing using 13 evidence-based prescribing safety indicators 

• 220,981 patients have been identified as being at risk in at least one indicator at baseline. 

• Analysis of follow-up data has shown reductions in numbers of patients at risk of medication error for a range of indicators, particularly for those indicators associated with GI bleeding, a common cause of medication-related hospital (18,935 fewer patients at risk; a 32.7% reduction)