Wessex Academic Health Science Network (AHSN) was an early adopter of the PINCER intervention programme and has been a strong supporter of this pharmacist-led programme which aims to make primary care prescribing even safer. All nine Clinical Commissioning Groups (CCGs) within Wessex AHSN have improved prescribing safety for their patients through the use of the PRIMIS-developed PINCER tool alongside pharmacist intervention.
The Medicines Optimisation team at West Hampshire CCG has found particular success with PINCER.
West Hampshire CCG’s practices are familiar with PRIMIS tools, as they’ve utilised many in the past including GRASP-AF, Warfarin Patient Safety (as part of a programme to optimise anticoagulation for stroke prevention in patients with atrial fibrillation) and Diabetes Care (as part of the WISDOM project to improve outcomes for patients living with Type 2 Diabetes Mellitus). So, when Wessex AHSN made PINCER freely available, West Hampshire CCG was keen to adopt the programme1.
The CCG’s Medicines Optimisation team consists of around 30 pharmacists and pharmacy technicians working in 49 practices across a wide geographical area. PINCER was rolled out as part of the Medicines Optimisation Incentive Scheme in 2018/2019.
In the spring of 2018, the team sought to obtain baseline PINCER data from all 49 practices. The activity was primarily driven by the pharmacy technicians who encouraged practices to run PINCER themselves wherever possible and either helped or ran it on their behalf (if practice staff were not yet up to speed).
Following a comprehensive review of these baseline results, the Medicines Optimisation team was able to reduce the number of people at risk across every single indicator (see Figure 1 below). This was achieved by the pharmacy technicians initially cleansing the data by identifying patients at highest risk of harm and passing them to the pharmacists for further investigation. The pharmacists in turn alerted clinicians to specific harms to individual patients and followed up remedial action. Some patients were deemed low risk or inappropriately flagged as at risk by the system, for example patients who had received a short course of NSAID and were no longer taking the medication or patients prescribed a NSAID with corneal ulceration as opposed to gastro-intestinal ulceration showing as at risk of gastro-intestinal bleeding.
Figure 1. Number of ‘at risk’ patients before (March 2018) and after (December 2018) intervention
Whilst great progress was made at reducing risk in many individual patients identified by PINCER, a re-run of the PINCER indicators in late 2018 highlighted there were still some residual patients at risk, and a new cohort of ‘at risk’ patients had emerged (see Figure 2 below). The Medicines Optimisation team discussed their next steps with Wessex AHSN to address this and ensure that previous prescribing issues are no longer repeated with new patients. As part of this ongoing approach Wessex AHSN, together with West Hampshire CCG and PRIMIS, held a root cause analysis workshop to look at quality improvement methodology, and in particular to address a sustainable change in medication risk in the practices. A number of themes were identified and incorporated into Practice/Primary Care Network (PCN)/CCG action plans for further implementation of learning outcomes from PINCER work.
Figure 2. December 2018 re-run of PINCER indicators showing a new cohort of ‘at risk’ individuals for each indicator.
The Medicines Optimisation team’s approach to the ‘at risk’ patients identified is to first look to see if a drug can be removed or reduced from a patients’ medication, rather than add a protective drug. Identifying patients ‘at risk’ on the PINCER tool provided an opportunity for pharmacist-led comprehensive medication review for the patients concerned, thereby maximising the pharmaceutical intervention and ensuring appropriate and targeted medicines optimisation.
The pharmacy technicians at West Hampshire CCG have played a fundamental role in supporting the work of the pharmacists, encouraging and assisting the practices with the PINCER clinical audits and data uploads to CHART Online and the whole Medicines Optimisation team. Liz Corteville, Locality Lead Pharmacist in the Medicines Optimisation team commented that the technicians continue to be a crucial part of the PINCER roll out. Liz explained that two pharmacy technicians in particular, Jayne Haigh and Heather Alderson, had been real champions of PINCER, encouraging and assisting the practices with the clinical audits and data uploads to CHART Online. The pharmacy technicians have also provided feedback sessions on the results and findings to GP Medicines Optimisation groups and had first sight of the results data, eliminating incorrect risks and helping the pharmacists to manage patients who need their medications reviewing with urgency. One of the pharmacy technicians also included the work undertaken with the PINCER roll out as part of her individual Leadership for Change programme participation.
What has also been identified as helpful by the CCG is the support from PRIMIS. Liz commented that it was invaluable to have the helpdesk there, even for those practices that were already well-versed in using PRIMIS tools. The support of the PRIMIS Business Implementation Leads and Wessex AHSN has helped West Hampshire CCG’s Medicines Optimisation Team to achieve a really positive ongoing outcome from the PINCER intervention programme and, ultimately, the improvement of the lives of many patients. Support and training from both Wessex AHSN and PRIMIS on Root Cause Analysis and Quality Improvement was essential as part of planning the next steps for PINCER in west Hampshire.
Clare Howard, Clinical Lead for Medicines Optimisation at Wessex AHSN and a key early adopter of the PINCER intervention programme, commented: “West Hampshire highlights how even in a CCG with a good record on medication safety, further improvements can be made by making full use of a proven tool such as PINCER. The CCG Medicines Team used the tool well, ensured one hundred percent utilisation and then looked at the results to understand where more work was needed. They are an exemplar of how to make data such as this drive improvements in care.”
PINCER is a proven pharmacist-led IT-based intervention to reduce clinically important medication errors in primary care.
The PINCER tool has been developed by PRIMIS as part of the University of Nottingham PINCER Team. The aim of the tool is to identify at-risk patients so that corrective action can be taken to reduce hazardous prescribing. Using the tool, it is possible for practices to view their results in relation to other practices within their CCG and see improvements over time.
Find out more about the PINCER intervention programme and how it is being rolled out across the AHSN Network in England with funding obtained from the Health Foundation and support from key AHSN early adopters at:
Reproduced with kind permission from Health Innovation Network South London website - see the original here.
Over the past fortnight, almost 90 GP pharmacists have taken part in training on software that aims to reduce prescribing errors. PINCER searches GP clinical systems using computerised prescribing safety indicators to identify patients at risk from complications that arise owing to being prescribed multiple medicines that don’t always work together and then acting to correct the problem. The training sessions mean that GP Pharmacists in eight south London CCGs can now use the software in their practises.
“I can’t wait to use the PINCER too, to help reduce errors and adverse reactions. This will help complement our role as clinical pharmacists.” Reena Rabheru-Dodhy, Senior Primary Care Pharmacist
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 system which acts as a risk assessment tool to identify and flag 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).
Mandeep Butt, Communities of Practice, who is part of the Health Innovation Network team coordinating the training was delighted by the response from the trainees;.
I look forward to working with the amazing practice based pharmacists and technicians we have met over the last 2 weeks. Their enthusiasm was infectious!”
Further training sessions will be happening in May and June. For more information or sign up for the training, please contact firstname.lastname@example.org
More about PINCER:
Developed by The University of Nottingham, the PINCER intervention developed as part of PRIMIS audit tools is led by primary care pharmacists and pharmacy technicians.
With funding and support from the Health Foundation and East Midlands AHSN, PINCER was rolled out to more than 360 practices across the East Midlands between September 2015 and April 2017.
The programme is one of the interventions selected for national adoption and spread across the AHSN Network and has so far demonstrated great results in a preliminary study, where there was a significant reduction in hazardous prescribing for indicators associated with gastrointestinal bleeding, heart failure and kidney injury.
Following the success of the PINCER trial, funding was obtained from The Health Foundation and East Midlands Academic Health Science Network, to roll out the intervention to 370 general practices across twelve East Midlands CCGs (September 2015 to April 2017).
Over 22,000 instances of hazardous prescribing were identified in a patient population of almost three million people following the completion of the East Midlands roll out, and you can find more details about this positive clinical impact of PINCER online.
In addition to the East Midlands roll out, since 2013 the PINCER Tool has been accessed by over 2,400 practices across 199 CCGs (30% of all practices in England) and has been delivered in other parts of the country including:
Please see more about how PINCER is being Scaled Up
PINCER is a successful, pharmacist-led IT-based intervention, for reducing important and common medication errors in general practice prescribing and has been incorporated into National Institute for Health and Care Excellence (NICE) Medicines Optimisation Clinical Guideline.
The PINCER trial, run by Professor Tony Avery and Dr Sarah Rodgers from the University of Nottingham’s School of Medicine, assess the effectiveness, cost-effectiveness and acceptability of a pharmacist-led information technology-based intervention to reduce the number of hazardous prescribing errors. The results of the trial, published in the Lancet (February 2012), showed that the PINCER intervention is an effective method for reducing a range of clinically important and commonly made medication errors in primary care.PRIMIS, in consultation with the PINCER trial team, developed the PINCER audit tool which comprises a set of prescribing safety indicators to identify patients at risk of hazardous prescribing.
Find out about the PINCER intervention
The PRoTeCT study, lead by Prof Tony Avery and the School of Medicine at the University of Nottingham, has been set up to evaluate the effectiveness and cost effectiveness of two different approaches to improving the safety of prescribing medicines in English general practices.
Expected outcomes/impacts include:
PRIMIS is delighted to support this important study through data extraction and linkage, using the PINCER indicators.
The PRoTeCT programme also aims to generate NHS policy recommendations following its conclusions. PRoTeCT has been funded by the National Institute for Health Research (NIHR) Programme Grant for Applied Research (PGfAR) until August 2021.
For more information on the PRoTeCT programme and to find out about the four work packages involved and economic evaluation please see:
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