title: Understanding the implementation and adoption of a technological intervention to improve medication safety in primary care: a realist evaluation.
abstract: Monitoring for potentially hazardous prescribing is increasingly important to improve medication safety. Healthcare information technology can be used to achieve this aim, for example by providing access to prescribing data through surveillance of patients' electronic health records. The aim of our study was to examine the implementation and adoption of an electronic medicines optimisation system that was intended to facilitate clinical audit in primary care by identifying patients at risk of an adverse drug event. We adopted a sociotechnical approach that focuses on how complex social, organisational and institutional factors may impact upon the use of technology within work settings.
  
  
  
  We undertook a qualitative realist evaluation of the use of an electronic medicines optimisation system in one Clinical Commissioning Group in England. Five semi-structured interviews, four focus groups and one observation were conducted with a range of stakeholders. Consistent with a realist evaluation methodology, the analysis focused on exploring the links between context, mechanism and outcome to explain the ways the intervention might work, for whom and in what circumstances.
  
  
  
  Using the electronic medicines optimisation system could lead to a number of improved patient safety outcomes including pre-emptively reviewing patients at risk of adverse drug events. The effective use of the system depended upon engagement with the system, the flow of information between different health professionals centrally placed at the Clinical Commissioning Group and those locally placed at individual general practices, and upon variably adapting work practices to facilitate the use of the system. The use of the system was undermined by perceptions of ownership, lack of access, and lack of knowledge and awareness.
  
  
  
  The use of an electronic medicines optimisation system may improve medication safety in primary care settings by identifying those patients at risk of an adverse drug event. To fully realise the potential benefits for medication safety there needs to be better utilisation across primary care and with a wider range of stakeholders. Engaging with all potential stakeholders and users prior to implementation of such systems might allay perceptions that the system is owned centrally and increase knowledge of the potential benefits.
authors.affiliation: Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, University of Manchester, Manchester, UK. mark.jefferies@manchester.ac.uk.|NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK. mark.jefferies@manchester.ac.uk.
authors.forename: Mark
authors.initials: M
authors.lastname: Jeffries
authors.affiliation: Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, University of Manchester, Manchester, UK.|NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.
authors.forename: Denham L
authors.initials: DL
authors.lastname: Phipps
authors.affiliation: Research Pharmacist, Isle of Wight, UK.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Howard
authors.affiliation: Division of Primary Care, University of Nottingham, Nottingham, UK.
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Avery
authors.affiliation: Division of Primary Care, University of Nottingham, Nottingham, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Rodgers
authors.affiliation: Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, University of Manchester, Manchester, UK.|NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.
authors.forename: Darren M
authors.initials: DM
authors.lastname: Ashcroft
mesh_terms: D054869:Clinical Audit; D064420:Drug-Related Side Effects and Adverse Reactions / Q000517:prevention & control*; D057286:Electronic Health Records; D004739:England; D005069:Evaluation Studies as Topic; D058006:General Practice / Q000379:methods* / Q000458:organization & administration / Q000592:standards; D006282:Health Personnel; D006801:Humans; D061214:Patient Safety / Q000592:standards; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011320:Primary Health Care / Q000379:methods*; D058996:Quality Improvement
keywords: Information technology; Medication safety; Prescribing; Primary care; Realist evaluation; Sociotechnical