Improving prescribing safety in general practices in the East Midlands through the PINCER intervention: a qualitative evaluation

Problem

A pharmacist-led information technology intervention for reducing clinically important errors in medicines management (PINCER) in general practices continues to attract users following its proven effectiveness in a cluster randomised trial published in the Lancet. Subsequently, questions about the fidelity with which PINCER is being used and its effectiveness when rolled out at scale are of ongoing interest. Using principles of quality improvement collaboratives, a mixed method service evaluation of scaling up the PINCER intervention in the East Midlands aims to qualitatively evaluate the contextual factors for implementation of the PINCER intervention; PINCER’s acceptability and feasibility in a range of settings; and what factors enhance its effects.

Approach

Twenty-five semi-structured interviews, two focus groups (n=10) and an observation (n=6), were conducted between April and November 2017 to engage the views of policy and practice stakeholders who were involved in the process of implementing the PINCER intervention. The Damschroder’s framework was used to guide the interview and focus group discussions and the subsequent thematic analysis of the data. Interviews and focus groups were audio recorded and transcribed verbatim, while field notes were taken for the observation. NVivo was used to aid data organisation. Participants were not paid to take part in this study.

Findings

Engaging support from policymakers, CCG and practice teams was as an important aspect to the implementation of PINCER. The fact that PINCER was considered to contribute to patient safety made it appealing to participants. Having trust in the intervention resulted in confidence to use it in practice. As cost-saving pressures hindered the use of PINCER, being able to demonstrate a cost-saving effect of PINCER was believed would enable the intervention to be supported more consistently. Incorporating PINCER into the prescribing quality scheme and knowing that other CCGs/practices were using the intervention helped the uptake of PINCER. Pharmacists were keen proponents of the intervention as they found it to be rewarding and viewed working on PINCER as an appropriate use of their training and skills. Receiving training on the intervention, and involving pharmacists in many aspects of PINCER, were cited as factors contributing to the successful implementation of PINCER. Participants shared the strategies they used to overcome different challenges they faced when using PINCER. The importance of practices taking ownership for the intervention and using a system-level approach to resolving problems was considered necessary for PINCER to have long-lasting effect.

Consequences

Implementing PINCER has relied on effectively engaging the support of both policy and practice stakeholders, training, and recognising the key ways pharmacists contribute to the success of the intervention. Ongoing efforts to understand challenges faced as part of the implementation process and working to identify solutions will be important for future efforts to roll-out PINCER.