The Oxford AHSN supported the roll-out of PINCER – a proven pharmacist-led IT-based intervention to reduce clinically important medication errors in primary care. PINCER was one of seven programmes selected for national spread and adoption by all England’s 15 AHSNs in 2018-21. The Oxford AHSN and its partner Clinical Commissioning Groups are working with GP practices to implement PINCER. Over 200 practices did so by November 2019, with 190 pharmacists/GPs trained. After 6-12 months of pharmacist-led improvement activity. practices in the Oxford AHSN region had reduced the number of cases of potentially hazardous prescribing by more than 2,3001. Whilst the impact of the pandemic has had a negative impact on number of at-risk patients, predominantly due to routine monitoring appointments being deprioritised, PINCER and the associated QI approach embedded in practices continues to be a critical tool for primary care to improve medication safety.
AHSN Network support for PINCER was drawn to a close as of March 2021.
- Over the last 2 years we have worked closely with Oxfordshire, Berkshire West, East Berkshire and Buckinghamshire CCGs to implement PINCER
- Since April 2019, PRIMIS (which developed PINCER) and the Oxford AHSN have facilitated PINCER action learning sets across 13 localities and trained over 230 people
- As of September 2019, over 210 GP practices had implemented PINCER in their practices and were working towards reducing risks around hazardous prescribing
- As of April 2020, across the Thames Valley region there has been an 18% reduction in the number of at-risk patients identified in at least one prescribing safety indicator and a 30% reduction in the number of at-risk patients for indicators associated with a gastro-intestinal bleed equating to a reduction of over 2,300 at-risk cases.
What is PINCER?
The PINCER intervention comprises three elements:
- Conducting GP system searches to identify patients at risk from prescribing errors
- Pharmacists working with practices to develop an action plan to prevent future hazardous prescribing
- Pharmacists working with and supporting practice staff to implement action plan
PRIMIS and the University of Nottingham have developed the PINCER tool, an extension of the PRIMIS CHART Query Library that contains important PINCER prescribing safety indicators.
Why is there a need for PINCER?
- Prescribing errors in general practice are a significant and costly cause of safety incidents, morbidity and deaths.
- It has been estimated that 66 million potentially clinically significant errors occur each year, 71% of which are in primary care (EEPRU 2018).
- Serious errors affect one in 550 prescription items (Avery 2013) while hazardous prescribing in general practice contributes to around 1 in 25 hospital admissions.
What is the evidence for PINCER?
The PINCER intervention was shown to be effective at reducing medication related errors through a cluster-randomised trial published in the Lancet (Avery 2012). The trial compared two groups of GP practices using the same prescribing indicator searches. A ‘simple feedback’ group (n=36) were provided with details of patients identified in searches. The PINCER intervention group (n=36) was given similar information, but in addition, pharmacist support was assigned to work with practices on indicators and practical support to tackle recognised prescribing safety issues. The trial demonstrated at six-month follow-up hazardous prescribing was significantly lower in the PINCER group and that the intervention was likely to be cost-effective.
What has been the impact of PINCER?
- The Oxford AHSN PINCER project trained over 200 pharmacists and GPs on QI around medication safety
- PINCER was embedded and used to address medication errors in 206 practices in the Oxford AHSN, this was 96% of practices in Oxon, Bucks and Berks.
- After a single audit cycle (6-12 months) practices in the region had reduced the number of cases of hazardous prescribing by over 2,300
- The COVID-19 pandemic had a significant impact on the programme and whilst in the second audit cycle (12-18 months) the number of at-risk patients continued to fall in GI bleed indicators, the numbers at-risk of monitoring issues grew substantially, due to routine monitoring appointments no longer being prioritised in primary care.
- Nationally, Over 41% of GP practices in England have adopted the intervention. From April 2020 to the end of March 2021, more than 109,000 patients at risk of hazardous prescribing have been identified.2