Primary care is a unique healthcare environment, distinct from other aspects of the health system, with its own scope of challenges and risks. Primary care systems are structured in a manner where care is coordinated and communicated via a number of health professionals, services and family members, which presents multiple opportunities for error (Australian Commission on Safety and Quality in Healthcare, 2009). Medication management becomes particularly challenging in the primary care setting: patients come into contact with the system at different times and places, may use more than one doctor, clinic or pharmacy and generally administer their own medications (Olaniyan et al, 2015). Medication discrepancies and errors are a global problem, affecting low-, middle- and highincome countries, with errors occurring commonly at care transition in all economic environments (World Health Organization, 2016).
Preventable and non-preventable adverse events related to medication use in primary care significantly contribute to unplanned hospital admissions and mortality (Khalil et al, 2017). Tudor Car et al (2015) identified three top-ranked problems that lead to medication errors: unreconciled medication lists at handover, inadequate patient education on how to manage medications and poor discharge summaries. Stewart and Lynch (2014) showed that medication reconciliation and patient education are effective interventions to reduce medication discrepancies and errors, although they note that it was challenging to implement an effective organisation-wide medication review program.
Objective
The objective of the Cochrane review by Khalil et al (2017) was to assess the effectiveness of structural, organisational and professional interventions to reduce preventable medication errors (resulting in hospital admission, emergency department visits and/or mortality) by primary healthcare professionals. These interventions were compared to standard care practices.
Methods
The authors of the Cochrane review included randomised controlled trials for review and did not impose any restrictions on the language or country of the study. Studies included organisations providing primary care in community settings, including general practice, community pharmacy, nursing homes and residential homes. All health professionals authorised to manage medication, including prescribing, administering and selling medications, were included. Interventions were categorised as professional, organisational or structural.
Professional interventions included the use of health information technologies to identify patients at risk of medication problems (computer-generated care suggestions, electronic drug notification systems, educational interventions on drug use, etc.).
Organisational interventions included health professionalled initiatives, such as medication review by pharmacists or home care visits by a health professional.
Structural interventions included social, economic and political interventions and wider quality monitoring systems.
Primary outcomes were measured in the number of hospital admissions and the number of people admitted to hospital. Secondary outcomes included emergency department visits and mortality. The authors searched seven databases using keywords and controlled vocabulary terms, with no restriction on time limits. A grey literature search was conducted, as well as a search of trial registries.
Results
From an initial identification of 14 604 titles for review, Khalil et al found 30 relevant papers reporting on 30 trials. They found that professional, structural and organisational interventions in primary care make little or no difference to the number of people admitted to hospital or the number of hospitalisations, emergency department visits or mortality rate. However, the certainty of the evidence was low to moderate. Most interventions took place in high-income countries, such as the UK and the US, with low- to middle-income countries as well as disadvantaged populations in high-income countries underrepresented. This may affect the generalisability of the results. Studies with a high risk of bias were removed in the sensitivity analysis, but this did not affect the overall outcome.
Conclusion
The authors of the review concluded that interventions conducted to reduce preventable medication errors in primary care may not have any benefit in reducing hospital admissions, emergency department visits or mortality. Healthcare professionals need to be aware that evidence to support these interventions is limited, with further large-scale studies required. Nonetheless, Khalil et al acknowledged that the interventions included in the review were ‘complex and generally multifaceted’, meaning the results should be treated with caution due to potential inconsistency. They also alluded to the fact that interventions may vary when accounting for different background practices, settings, healthcare systems or delivery of an intervention. Primary care nurses appreciate the diversity and complexity of medication management within the healthcare setting and understand the need for a flexible and patient-centred approach to reducing medication errors.
Recommendations for practice
Nurses play an important role in the management and quality use of medications within primary care. Clinics and other facilities that store medications for patient use require robust systems to ensure medications are stored appropriately and securely onsite. Clinics must provide nurses with access to pharmacology reference guides as well as regularly updated policies and procedures to reflect current practice. Primary care nurses can opportunistically identify patients at risk of medication errors during any patient interaction. This may include identifying polypharmacy, patients with a significant change in their condition or those for whom quality use of medications may be an issue. These patients can be referred to a pharmacist for review. Nurses are excellent at holistic assessment and care and may be able to identify potential compliance issues as well as provide supportive education to patients to assist them in taking their medications correctly. Primary health clinics can support nursing staff to routinely ask about over-the-counter and complementary medicine use when any discussions about medications occur. Documenting this information and working with clinical staff to ensure a reconciled medication list promotes continuity of care. Nurses could also substantially contribute to the safe and quality use of medicines within primary care by conducting further research in this area.