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1.  Using human error theory to explore the supply of non‐prescription medicines from community pharmacies 
Quality & Safety in Health Care  2006;15(4):244-250.
Background
The importance of theory in underpinning interventions to promote effective professional practice is gaining recognition. The Medical Research Council framework for complex interventions has assisted in promoting awareness and adoption of theory into study design. Human error theory has previously been used by high risk industries but its relevance to healthcare settings and patient safety requires further investigation. This study used this theory as a framework to explore non‐prescription medicine supply from community pharmacies. The relevance to other healthcare settings and behaviours is discussed.
Method
A 25% random sample was made of 364 observed consultations for non‐prescription medicines. Each of the 91 consultations was assessed by two groups: a consensus group (stage 1) to identify common problems with the consultation process, and an expert group (stages 2 and 3) to apply human error theory to these consultations. Paired assessors (most of whom were pharmacists) categorised the perceived problems occurring in each consultation (stage 1). During stage 2 paired assessors from an expert group (comprising patient safety experts, community pharmacists and psychologists) considered whether each consultation was compliant with professional guidelines for the supply of pharmacy medicines. Each non‐compliant consultation identified during stage 2 was then categorised as a slip/lapse, mistake, or violation using human error theory (stage 3).
Results
During stage 1 most consultations (n = 75, 83%) were deemed deficient in information exchange. At stage 2, paired assessors varied in attributing non‐compliance to specific error types. Where agreement was achieved, the error type most often selected was “violation” (n = 27, 51.9%, stage 3). Consultations involving product requests were less likely to be guideline compliant than symptom presentations (OR 0.30, 95% CI 0.10 to 0.95, p = 0.05).
Conclusions
The large proportion of consultations classified as violations suggests that either pharmacy staff are unaware of professional guidelines and thus do not follow them (therefore these acts would not be violations), or that they knowingly violate the guidelines due to reasons that need further research. The methods presented here could be used in other healthcare settings to explore healthcare professional behaviour and to develop strategies to promote patient safety and effective professional practice.
doi:10.1136/qshc.2005.014035
PMCID: PMC2564009  PMID: 16885248
non‐prescription medicines; evidence based practice; human error theory; community pharmacy services
2.  Factors predicting the guideline compliant supply (or non‐supply) of non‐prescription medicines in the community pharmacy setting 
Background
The reclassification of prescription only medicines to pharmacy and general sales list medicines (also known as non‐prescription medicines) provides the public with greater access to medicines that they can purchase for self‐care. There is evidence that non‐prescription medicines may be associated with inappropriate supply. This study investigated factors predicting evidence‐based (guideline compliant) supply or non‐supply of non‐prescription medicines.
Method
Secondary analysis of results from a randomised controlled trial of educational interventions to promote the evidence based supply of non‐prescription medicines. Ten actors made simulated patient (customer) visits to 60 community pharmacies using seven scenarios reflecting different types of presentations. The dependent variable was appropriate (guideline compliant) supply of antifungal medication for treatment of vaginal candidiasis.
Results
No significant association was shown between guideline compliant behaviour and pharmacy type or location, or with the actor making the visit. The likelihood of guideline compliant outcome was significantly greater with symptom presentations than with condition or product presentations (p<0.001). The likelihood of a guideline compliant outcome increased (a) as more information was exchanged (p<0.001), (b) with the use of WWHAM (a mnemonic frequently used by medicine counter assistants during consultations for non‐prescription medicines) (p<0.001); (c) when specific WWHAM questions were used (including “description of symptoms” (p<0.001) and “whether other medication was currently being used” (p<0.001); and (d) in consultations involving solely pharmacists compared with those involving only medicine counter assistants (p = 0.017). After adjustment for presentation type, a significant association persisted between appropriate outcome and consultations with WWHAM scores of 2 and ⩾3, respectively.
Conclusions
The nature and extent of information exchange between pharmacy staff and customers has a strong influence on the guideline compliant supply of non‐prescription medicines. Future interventions to promote the safe and effective use of non‐prescription medicines should address the apparent deficit in communication between pharmacy staff in general, and medicine counter assistants in particular, which may reflect both pharmacy staff skills and customer expectations.
doi:10.1136/qshc.2005.014720
PMCID: PMC2564005  PMID: 16456211
communication; community pharmacy services; evidence based practice; non‐prescription medicines
3.  A pharmaceutical needs assessment in a primary care setting. 
BACKGROUND: As part of a reconfiguration of its general medical services, Ardach Health Centre has integrated a community pharmacist into the centre to provide pharmaceutical care. In order to systematically identify areas of 'pharmaceutical need', a needs assessment was carried out during October 1997. AIM: To prioritize and assist the planning of pharmaceutical care provision within the centre, such that maximum gain could be achieved from inevitable limited resources. METHOD: A four-stage pharmaceutical needs assessment method was created around a selection of techniques: gap analysis, the nominal group technique, and rapid participatory appraisal. This was then applied to a random sample of people drawn from the patient register of Ardach Health Centre and all the health care professionals associated with their care. RESULTS: Through the four-stage process, a pharmaceutical service priority league table was constructed to reflect the unmet pharmaceutical needs of patients and their primary health care providers. The table provided a structured framework around which pharmaceutical service provision within the health centre could be planned. CONCLUSION: We have developed a pragmatic, systematic method of identifying the prevalence of unmet pharmaceutical needs of a community. The assessment assisted service selection, balancing what should be done with what could be done and what could be afforded.
PMCID: PMC1313624  PMID: 10750204
5.  Limited list: limited effects? 
During the first month after the limited National Health Service drug list came into effect 17 cooperative general practitioners recorded the actions taken when a now prohibited drug would formerly have been prescribed. An average of 6% of direct surgery contacts with patients and 8% of indirect contacts with patients were affected by the new regulations, but in 2% and 4% of cases respectively the patient received the same pharmacological substance under a different (generic or approved) name. Where a real change in pharmacological constitution or formulation had been required four fifths of these substitutes were considered by the doctors to result in less effective treatment. In 1% of contacts no drug was issued or recommended where one would formerly have been given.
PMCID: PMC1416495  PMID: 3928035
6.  Over the counter drugs. The interface between the community pharmacist and patients. 
BMJ : British Medical Journal  1996;312(7033):758-760.
Pharmacists play an important part in primary health care, and their accessibility is a key factor. Their NHS payments relate predominantly to the dispensing of prescribed medicines; to recognise the service element of their advisory role, an NHS funded professional fee could be built into the cost structure for pharmacy medicines. The increased number of medicines available over the counter has highlighted the need for training for counter assistants; it will become compulsory in July 1996, and some family health services authorities are providing this. The shift to care in the community could mean that pharmacists will have an even greater role in the primary health care team. Encouraging the public to seek advice from the community pharmacist may lead to a greater proportion of visits to doctors resulting from referrals from the pharmacist. Joint development by pharmacists and doctors of guidelines for advice on, and recommendation of, over the counter medicines is needed.
PMCID: PMC2350455  PMID: 8605465
7.  Hormone replacement therapy: a study of women's knowledge and attitudes. 
Hormone replacement therapy can successfully treat menopausal symptoms. A postal questionnaire was used to investigate the knowledge of and attitudes to hormone replacement therapy of an age-stratified, computer-generated, representative sample of 1500 women living in the Grampian region of Scotland. A response rate of 78% was achieved. Comparisons were made between women of differing age, educational background and their current or past experience of hormone replacement therapy. The questionnaire also assessed their knowledge of osteoporosis, including the possible beneficial role of hormone replacement therapy. The results showed that women had a poor knowledge of the potential risks and benefits of oestrogen, lack of knowledge being greatest in the less educated and older women. The majority of women agreed with the view that because the menopause is brought on by diminished hormone levels, it should be viewed as a medical condition and treated as such, and also that a woman who experiences distressing menopausal symptoms should take hormone replacement therapy. Despite this, relatively few postmenopausal women were currently taking hormone replacement therapy (9%) or had taken the treatment in the past (7%), although many had experienced menopausal symptoms for over six months. The most common reason for postmenopausal women never having taken hormone replacement therapy was that they had never considered the treatment (70%) and had not discussed it with a doctor (79%).(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1372520  PMID: 8251232
8.  Change in the established prescribing habits of general practitioners: an analysis of initial prescriptions in general practice. 
The aim of this study was to describe the types of drugs prescribed by general practitioners in a sample of initial (rather than repeat) prescriptions, the additions and deletions made to a doctor's repertory and the factors influencing these changes. The method used here enabled repeat prescriptions to be excluded as these are an inaccurate reflection of the current habits of the prescriber. A total of 201 (74%) of the principal general practitioners in the Grampian region participated. Data were obtained by substituting special prescription pads containing duplicate forms which allowed additional data to be recorded at the time of prescribing, including perceived influences that had resulted in changes from established choices of drug therapy. A sample of 100 forms were collected on seven occasions from each doctor over a one year sample period. Prescribers on average selected a preparation that they had only started to use within the last 12 months (that is newly adopted to their repertory) in 5.4% of initial prescriptions. These changes mostly involved antibiotics and analgesics and were occasioned mainly by the influence of the 'limited list' regulations, pharmaceutical company representatives and hospital specialists. We conclude that general practitioners were not unduly influenced by commercial sources of information, and that their prescribing habits were stable and conservative. The paper presents a case for the separate analysis of initial and repeat prescriptions as an essential step in producing more informative data on prescribing.
PMCID: PMC1371588  PMID: 1817480

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