Introduction
The World Health Organization (WHO) launched a patient safety challenge in 2017, Medication Without Harm,1 with an ambition to "reduce severe avoidable medication related harm globally by 50% in the next five years".2 The covid-19 pandemic disrupted the delivery of primary care services within the National Health Service (NHS) in the UK from mid-March 2020, with a reduction of 30% in general practitioner (GP) consultations, 74% in routine referrals, and 43% in urgent cancer referrals, compared with precovid baselines.3 4 The extent of disruption varied by clinical context,5–7 although most primary care services were restored by September 2020.8 9 The disruption during this time might have contributed towards increased rates of harm related to medication, with 34% of an estimated 66 million potentially clinically significant errors occurring in primary care prescribing in England annually, as estimated by NHS dispensing statistics in 2015-16.10
As part of its response to WHO's challenge, PRIMIS at the University of Nottingham led on the national roll-out of PINCER (pharmacist-led information technology intervention for medication errors) in collaboration with the Academic Health Science Networks.11 The PINCER intervention is a proven programme of activities for reducing hazardous prescribing in general practices (more information provided in online supplemental text).12 Briefly, the intervention involves training pharmacists working in general practice to provide feedback, educational outreach, and dedicated support, systematically focusing on patients who are identified to be at risk of harm from medications. These patients are identified using prespecified and quality assured analytical indicators in the Systematized Nomenclature of Medicine Clinical Terms SNOMED-CT code classification system used by general practice systems in England. PINCER includes 13 indicators of hazardous prescribing of high risk medications prescribed in primary care that: (1) can cause gastrointestinal bleeds; (2) are cautioned against in specific conditions (heart failure, asthma, and chronic renal failure); or (3) require blood test monitoring (box 1). These indicators have been developed from collaboration between academics from the University of Nottingham and made available to pharmacists in practices participating in the PINCER programme (online supplemental text).
The 13 PINCER indicators (shortened terms used hereafter)
Prescribing indicators associated with gastrointestinal bleeding
Oral non-steroidal anti-inflammatory drug (NSAID), without co-prescription of an ulcer healing drug, to a patient of ≥65 years (age ≥65 years and NSAID)
Oral NSAID, without co-prescription of an ulcer healing drug, to a patient with a history of peptic ulceration (peptic ulceration and NSAID)
Antiplatelet drug, without co-prescription of an ulcer healing drug, to a patient with a history of peptic ulceration (peptic ulceration and antiplatelet)
Warfarin or direct oral anticoagulants (DOAC) in combination with an oral NSAID (warfarin or DOAC and NSAID)
Warfarin or DOAC and an antiplatelet drug, without co-prescription of an ulcer healing drug (warfarin or DOAC)
Aspirin in combination with another antiplatelet drug, without co-prescription of an ulcer healing drug (aspirin and other antiplatelet)
Prescribing indicators associated with cautioned medication in other conditions
Oral NSAID to a patient with heart failure (heart failure and NSAID)
Non-selective beta blocker to a patient with asthma (asthma and beta blocker)
Oral NSAID to a patient with estimated glomerular filtration rate of <45 (chronic renal failure and NSAID)
Prescribing indicators associated with blood test monitoring
Long term prescription of angiotensin-converting enzyme inhibitor or a loop diuretic to patients aged ≥75 years who have not had a computer recorded check of their renal function and electrolytes in the previous 15 months (angiotensin-converting enzyme inhibitor or a loop diuretic, no blood tests)
Methotrexate treatment for at least three months in people who have not had a recorded:
Full blood count within the previous three months (methotrexate and no full blood count); or
Liver function test within the previous three months (methotrexate and no liver function test)
Lithium treatment for at least three months in people who have not had a recorded check of their lithium concentrations in the previous three months (lithium and no level recording)
Amiodarone treatment for at least six months who have not had a thyroid function test within the previous six months (amiodarone and no thyroid function test)
OpenSAFELY is a secure analytics platform for electronic patient records built by our group with the approval of NHS England to deliver urgent academic13 and operational NHS service research14 15 on the direct and indirect effects of the pandemic. Analyses can use patients’ full, raw, pseudonymised primary care records at 95% of English general practices (55% use EMIS software, and 40% use TPP software) with patient level linkage to various sources of secondary care data. All code and analysis is shared openly for inspection and re-use.
The PINCER indicators created by PRIMIS are typically implemented for single practices, or groups of practices, through various technical methods (online supplemental materials) in different settings to monitor compliance for practices that are participating in the PINCER programme. We aimed to implement the full suite of PINCER codelists, methods, and indicators in OpenSAFELY to allow monitoring of compliance on all prescribing safety indicators at a population level. Additionally, we aimed to describe changes in compliance after the disruption induced by covid-19 to primary care services in England.