title: A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.
abstract: BACKGROUND
  Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention.
  
  
  METHODS
  In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to researchers and statisticians involved in processing and analysing the data. The allocation was not masked to general practices, pharmacists, patients, or researchers who visited practices to extract data. [corrected]. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-effectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299.
  
  
  RESULTS
  72 general practices with a combined list size of 480,942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38-0·89); a β blocker if they had asthma (0·73, 0·58-0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34-0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months.
  
  
  CONCLUSIONS
  The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records.
  
  
  BACKGROUND
  Patient Safety Research Portfolio, Department of Health, England.
authors.affiliation: Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK. tony.avery@nottingham.ac.uk
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Avery
authors.forename: Sarah
authors.initials: S
authors.lastname: Rodgers
authors.forename: Judith A
authors.initials: JA
authors.lastname: Cantrill
authors.forename: Sarah
authors.initials: S
authors.lastname: Armstrong
authors.forename: Kathrin
authors.initials: K
authors.lastname: Cresswell
authors.forename: Martin
authors.initials: M
authors.lastname: Eden
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Elliott
authors.forename: Rachel
authors.initials: R
authors.lastname: Howard
authors.forename: Denise
authors.initials: D
authors.lastname: Kendrick
authors.forename: Caroline J
authors.initials: CJ
authors.lastname: Morris
authors.forename: Robin J
authors.initials: RJ
authors.lastname: Prescott
authors.forename: Glen
authors.initials: G
authors.lastname: Swanwick
authors.forename: Matthew
authors.initials: M
authors.lastname: Franklin
authors.forename: Koen
authors.initials: K
authors.lastname: Putman
authors.forename: Matthew
authors.initials: M
authors.lastname: Boyd
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
mesh_terms: D000319:Adrenergic beta-Antagonists; D000638:Amiodarone; D000806:Angiotensin-Converting Enzyme Inhibitors; D000889:Anti-Arrhythmia Agents; D000894:Anti-Inflammatory Agents, Non-Steroidal; D018692:Antimanic Agents; D001249:Asthma / Q000453:epidemiology; D003157:Community Pharmacy Services / Q000191:economics* / Q000458:organization & administration; D003278:Contraceptives, Oral, Hormonal; D000075202:Contraindications; D003362:Cost-Benefit Analysis; D004346:Drug Information Services / Q000191:economics* / Q000458:organization & administration; D016903:Drug Monitoring; D004573:Electrolytes / Q000032:analysis; D004739:England / Q000453:epidemiology; D005194:Family Practice; D030141:Feedback, Psychological; D006801:Humans; D007166:Immunosuppressive Agents; D018020:Lithium Compounds; D008508:Medication Errors / Q000191:economics / Q000517:prevention & control*; D008727:Methotrexate; D010437:Peptic Ulcer / Q000188:drug therapy / Q000453:epidemiology; D010595:Pharmacists / Q000191:economics*; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D012044:Regression Analysis; D049994:Sodium Potassium Chloride Symporter Inhibitors; D014508:Urea / Q000032:analysis
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000889:Anti-Arrhythmia Agents; D000894:Anti-Inflammatory Agents, Non-Steroidal; D018692:Antimanic Agents; D003278:Contraceptives, Oral, Hormonal; D004573:Electrolytes; D007166:Immunosuppressive Agents; D018020:Lithium Compounds; D054328:Proton Pump Inhibitors; D049994:Sodium Potassium Chloride Symporter Inhibitors; D014508:Urea; D000638:Amiodarone; D008727:Methotrexate