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Biomedical subjects

Nick Barber

Publications and source records attributed to Nick Barber.

18 recordsLinked to original sources
PubMed2006

Patient-centred advice is effective in improving adherence to medicines.

OBJECTIVE: To assess the effects of pharmacists giving advice to meet patients' needs after starting a new medicine for a chronic condition. METHOD: A prospective health technology assessment including a randomised controlled trial of a pharmacist-delivered intervention to improve adherence using a centralised telephone service to patients at home in England. Patients were eligible for recruitment if they were receiving the first prescription for a newly prescribed medication for a chronic condition and were 75 or older or suffering from stroke, cardiovascular disease, asthma, diabetes or rheumatoid arthritis. MAIN OUTCOME MEASURES: Incidence of non-adherence, problems with the new medicine, beliefs about the new medicine, safety and usefulness of the interventions. RESULTS: Five hundred patients consented and were randomised. At 4-week follow-up, non-adherence was significantly lower in the intervention group compared to control (9% vs. 16%, P = 0.032). The number of patients reporting medicine-related problems was significantly lower in the intervention group compared to the control (23% vs. 34%, P = 0.021). Intervention group patients also had more positive beliefs about their new medicine, as shown by their higher score on the "necessity-concerns differential" (5.0 vs. 3.5, P = 0.007). The phone calls took a median of 12 min each. Most advice was judged by experts to be safe and helpful, and patients found it useful. CONCLUSION: Overall, these findings show benefits from pharmacists meeting patients' needs for information and advice on medicines, soon after starting treatment. While a substantially larger trial would be needed to confirm that the effect is real and sustained, these initial findings suggest the service may be safe and useful to patients.

Adult↗
PubMed2006

Systematic review of medication errors in pediatric patients.

OBJECTIVE: To systematically locate and review studies that have investigated the incidence of medication errors (MEs) in pediatric inpatients and identify common errors. METHODS: A systematic search of studies related to MEs in children was performed using the following databases: MEDLINE (1951-April 2006), EMBASE (1966-April 2006), Pharm-line (1978-April 2006), International Pharmaceutical Abstracts (1970-April 2006), Cumulative Index to Nursing and Allied Health Literature (1982-April 2006), and British Nursing Index (1994-April 2006). Studies of the incidence and nature of MEs in pediatrics were included. The title, abstract, or full article was reviewed for relevance; any study not related to MEs in children was excluded. RESULTS: Three methods were used to detect MEs in the studies reviewed: spontaneous reporting (n = 10), medication order or chart review (n = 14), or observation (n = 8). There was great variation in the definitions of ME used and the error rates reported. The most common type of ME was dosing error, often involving 10 times the actual dose required. Antibiotics and sedatives were the most common classes of drugs associated with MEs; these are probably among the most common drugs prescribed. CONCLUSIONS: Interpretation of the literature was hindered by variation in definitions employed by different researchers, varying research methods and setting, and a lack of theory-based research. Overall, it would appear that our initial concern about MEs in pediatrics has been validated; however, we do not know the actual size of the problem. Further work to determine the incidence and causes of MEs in pediatrics is urgently needed, as well as evaluation of the best interventions to reduce them.

Child↗
PubMed2006

A pilot randomised, open, uncontrolled, clinical study of two dosages of St John's wort (Hypericum perforatum) herb extract (LI-160) as an aid to motivational/behavioural support in smoking cessation.

There is an association between smoking and depression, yet the herbal antidepressant St John's wort (Hypericum perforatum L.; SJW) herb extract has not previously been investigated as an aid in smoking cessation. In this open, uncontrolled, pilot study, 28 smokers of 10 or more cigarettes per day for at least one year were randomised to receive SJW herb extract (LI-160) 300 mg once or twice daily taken for one week before and continued for 3 months after a target quit date. In addition, all participants received motivational/behavioural support from a trained pharmacist. At 3 months, the point prevalence and continuous abstinence rates were both 18%, and at 12 months were 0%. Fifteen participants (54%) reported 23 adverse events up to the end of the 3-month follow-up period. There was no statistically significant difference in the frequency of adverse events for participants taking SJW once or twice daily (p > 0.05). Most adverse events were mild, transient and non-serious. This preliminary study has not provided convincing evidence that a SJW herb extract plus individual motivational/behavioural support is likely to be effective as an aid in smoking cessation. However, it may be premature to rule out a possible effect on the basis of a single, uncontrolled pilot study, and other approaches involving SJW extract may warrant investigation.

Adolescent↗
PubMed2005

Patient-doctor decision-making about treatment within the consultation--a critical analysis of models.

This paper highlights some of the limitations of models of patient involvement in decision-making and explores the reasons for, and implications of, these limitations. Taking the three models of interpretative, shared and informed decision-making as examples, we focus on two limitations of the models: (1) neglect of which decisions the patient should be involved in (the framing problem) and (2) how the patient should be involved in decision-making (the nature of reasoning problem). Although there will inevitably be a gap between models and practice--this much is in the nature of the models--we suggest that these two issues are substantially neglected by the models and yet are fundamental to understanding patient-doctor decision-making. We also suggest that the fundamental problem that lies behind these limitations is insufficient attention to, and explicitness about, the dilemmas of professional ethics, which are played out in the professional-patient relationships that the models are supposed to represent, particularly with respect to the issue of expert and lay accountability.

Attitude of Health Personnel↗
PubMed2005

Cost-effectiveness of adherence-enhancing interventions: a quality assessment of the evidence.

OBJECTIVE: To determine whether the current cost-effectiveness evidence on adherence-enhancing interventions (AEIs) was of sufficient quality to aid in decision-making regarding medication adherence policies. DATA SOURCES: A computerized search of Embase, MEDLINE, Cinahl, Econlit, NHSEED, Psychlit, EPIC, and Cochrane databases (1980-April 2004) was performed. English-language human subject articles were identified using the key words compliance, adherence, concordance, patient assistance, therapeutic alliance, costs, economics, efficiency, resource use/utilization, cost-of-illness, cost-effectiveness, cost-minimization, cost-utility, and cost-benefit. STUDY SELECTION AND DATA EXTRACTION: Studies that appeared to assess the cost-effectiveness of medication AEIs were included. Methodologic rigor was assessed using 15 minimum quality criteria. DATA SYNTHESIS: We found 45 comparative studies in 43 publications. Asthma (14 studies) and psychiatric illness (12 studies) were most commonly investigated. In 33 studies, interventions were educational, 18 had multiple components, and 23 did not appear to be linked to proven reasons for nonadherence. Reporting of adherence and outcome results was often unclear. Cost data were poorer quality than outcome data, using average or estimated costs and omitting some cost elements. Nine studies carried out incremental economic analysis. No study met all quality criteria. CONCLUSIONS: We were not able to make definitive conclusions about the cost-effectiveness of AEIs due to the heterogeneity of the studies found and incomplete reporting of results. Important policy decisions need to be made about nonadherence; however, they are currently being made in a vacuum of adequate information. AEIs must be based on reasons for nonadherence and be evaluated using accepted clinical and economic quality criteria.

Clinical Trials as Topic↗
PubMed2005

Reimbursement decisions in health policy--extending our understanding of the elements of decision-making.

Previous theoretical and empirical work on health policy decisions about reimbursement focuses on specific rationales such as effectiveness, economic considerations and equal access for equal needs. As reimbursement decisions take place in a social and political context we propose that the analysis of decision-making should incorporate factors, which go beyond those commonly discussed. As an example we chose three health technologies (sildenafil, rivastigmine and statins) to investigate how decisions about reimbursement of medicines are made in the United Kingdom National Health Service and what factors influence these decisions. From face-to-face, in-depth interviews with a purposive sample of 20 regional and national policy makers and stakeholders we identified two dimensions of decision-making, which extend beyond the rationales conventionally cited. The first dimension relates to the role of 'subjectivity' or 'the personal' in the decisions, including personal experiences of the condition and excitement about the novelty or potential benefit of the technology-these factors affect what counts as evidence, or how evidence is interpreted, in practice. The second dimension relates to the social and political function of decision-making and broadens what counts as the relevant ends of decision-making to include such things as maintaining relationships, avoiding organisational burden, generating politically and legally defensible decisions and demonstrating the willingness to care. More importantly, we will argue that these factors should not be treated as contaminants of an otherwise rational decision-making. On the contrary we suggest that they seem relevant, reasonable and also of substantial importance in considering in decision-making. Complementing the analysis of decision-making about reimbursement by incorporating these factors could increase our understanding and potentially improve decision-making.

Decision Making, Organizational↗
PubMed2005

The frequency and potential causes of dispensing errors in a hospital pharmacy.

OBJECTIVES: To determine the frequency and types of dispensing errors identified both at the final check stage and outside of a UK hospital pharmacy, to explore the reasons why they occurred, and to make recommendations for their prevention. METHOD: A definition of a dispensing error and a classification system were developed. To study the frequency and types of errors, pharmacy staff recorded details of all errors identified at the final check stage during a two-week period; all errors identified outside of the department and reported during a one-year period were also recorded. During a separate six-week period, pharmacy staff making dispensing errors identified at the final check stage were interviewed to explore the causes; the findings were analysed using a model of human error. MAIN OUTCOME MEASURES: Percentage of dispensed items for which one or more dispensing errors were identified at the final check stage; percentage for which an error was reported outside of the pharmacy department; the active failures, error producing conditions and latent conditions that result in dispensing errors occurring. RESULTS: One or more dispensing errors were identified at the final check stage in 2.1% of 4849 dispensed items, and outside of the pharmacy department in 0.02% of 194,584 items. The majority of those identified at the final check stage involved slips in picking products, or mistakes in making assumptions about the products concerned. Factors contributing to the errors included labelling and storage of containers in the dispensary, interruptions and distractions, a culture where errors are seen as being inevitable, and reliance on others to identify and rectify errors. CONCLUSION: Dispensing errors occur in about 2% of all dispensed items. About 1 in 100 of these is missed by the final check. The impact on dispensing errors of developments such as automated dispensing systems should be evaluated.

Dosage Forms↗
PubMed2005

Can human error theory explain non-adherence?

OBJECTIVE: To apply human error theory to explain non-adherence and examine how well it fits. METHOD: Patients who were taking chronic medication were telephoned and asked whether they had been adhering to their medicine, and if not the reasons were explored and analysed according to a human error theory. RESULTS: Of 105 patients, 87 were contacted by telephone and they took part in the study. Forty-two recalled being non-adherent, 17 of them in the last 7 days; 11 of the 42 were intentionally non-adherent. The errors could be described by human error theory, and it explained unintentional non-adherence well, however, the application of 'rules' was difficult when considering mistakes. The consideration of error producing conditions and latent failures also revealed useful contributing factors. CONCLUSION: Human error theory offers a new and valuable way of understanding non-adherence, and could inform interventions. However, the theory needs further development to explain intentional non-adherence.

Drug Therapy↗
PubMed2005

The incidence of prescribing errors in hospital inpatients: an overview of the research methods.

Many different methods have been used to study the incidence of prescribing errors in hospital inpatients. The objectives of this review were to outline the methods used, highlight their strengths and limitations, and summarise the incidence of prescribing errors reported. Methods used may be retrospective or prospective and based on process or on outcome. Reported prescribing error rates vary widely, ranging from 0.3% to 39.1% of medication orders written and from 1% to 100% of hospital admissions. Unfortunately, there is no standard denominator for use when expressing prescribing error rates. It could be argued that the most meaningful is the number of medication orders written; however, it is also helpful to consider the number of medication orders written per patient stay in order to understand the risk that a given prescribing error rate poses to an individual patient. Because of wide variation in the definitions and methods used, it is difficult to make comparisons between different studies. Each method for identifying prescribing errors has advantages and disadvantages. Process-based studies potentially allow all errors to be identified, giving more scope for the identification of trends and learning opportunities, and it may be easier to collect sufficient data to show statistically significant changes in prescribing error rates following interventions to reduce them. However, studies based on process may be criticised for focusing on many minor errors that are very unlikely to have resulted in patient harm. Focusing instead on harm, as in outcome-based studies, allows efforts to reduce errors to be targeted on those areas that are likely to result in the highest impact. Therefore, the most appropriate method depends on the study's aims. However, using a combination of methods is likely to be the most useful approach if comprehensive data are required.

Drug Prescriptions↗
PubMed2004

What constitutes evidence in hospital new drug decision making?

In National Health Service hospitals in the UK the introduction of new drugs is controlled by a local Drug and Therapeutics Committee (DTC), which is expected to apply the principles of evidence-based medicine (EBM). In the light of growing expenditure on drugs, there is interest in how the decisions are made that lead to the local acceptance or rejection of a new drug. In this study the DTCs of two general hospitals were observed, tape-recorded and analysed to determine what was considered as evidence and how it was used in decision making. Evidence, as constituted by DTC members, was issues that affected the decision-making process and included: clinical trial data, cost, pre-existing prescribing of the drug, pharmaceutical company activities, decisions of other DTCs, patient demand, clinician excitement, and personality of the applicant. Debate usually started with a discussion of the scientific evidence, then the cost would be considered. Often this evidence was either inadequate or insufficient enough for a locally implementable decision and further types of evidence would be brought in to try and estimate the likely impact of adopting the new drug. EBM, while used in decision making, was supplemented by local knowledge, although decisions were accounted for in the language of scientific rationality. Both abstract scientific rationality and the local rationality of practical healthcare provision were present in the decisions of the DTCs on the adoption, or otherwise, of new drugs into local formularies and healthcare. We suggest the coming together of local and abstract in local decision-making needs to be taken into account when formulating policy and providing decision support.

Cost-Benefit Analysis↗
PubMed2004

Incidence and nature of dosing errors in paediatric medications: a systematic review.

In paediatric medicine, drug doses are usually calculated individually based on the patient's age, weight and clinical condition. Therefore, there are increased opportunities for, and a relatively high risk of, dosing errors in this setting. Consequently, a systematic literature review using several databases was conducted to investigate the incidence and nature of dosing errors in children; 16 studies were found to be relevant. Eleven of the 16 studies found that dosing errors are the most common type of medication error, three of the remaining studies found it to be the second most common type. This review of published research on medication errors therefore suggests that dosing errors are probably the most common type of error in the paediatric population. In addition, there was a great variation in the error rates reported; this is likely to be due to the differences in the medication error definitions and methodologies employed. For example, the dosing error rate determined using spontaneous reporting ranges from 0.03 per 100 admissions in the UK to 2 per 100 admissions in the US. Extrapolating this, if the under-reporting rate is about 1 in 100, then the true incidence would be around 50,000 paediatric dosing errors per year in England. The information available shows that dosing errors are not uncommon and that 10-fold overdoses caused by calculation errors have led to serious consequences. There is an urgent need to develop methods to reduce medication errors in children and dosing errors should be the first priority.

Adolescent↗
PubMed2003

Ethnographic study of incidence and severity of intravenous drug errors.

OBJECTIVES: To determine the incidence and clinical importance of errors in the preparation and administration of intravenous drugs and the stages of the process in which errors occur. DESIGN: Prospective ethnographic study using disguised observation. PARTICIPANTS: Nurses who prepared and administered intravenous drugs. SETTING: 10 wards in a teaching and non-teaching hospital in the United Kingdom. MAIN OUTCOME MEASURES: Number, type, and clinical importance of errors. RESULTS: 249 errors were identified. At least one error occurred in 212 out of 430 intravenous drug doses (49%, 95% confidence interval 45% to 54%). Three doses (1%) had potentially severe errors, 126 (29%) potentially moderate errors, and 83 (19%) potentially minor errors. Most errors occurred when giving bolus doses or making up drugs that required multiple step preparation. CONCLUSIONS: The rate of intravenous drug errors was high. Although most errors would cause only short term adverse effects, a few could have been serious. A combination of reducing the amount of preparation on the ward, training, and technology to administer slow bolus doses would probably have the greatest effect on error rates.

Confidence Intervals↗
PubMed2003

Self-treatment and its discussion in medical consultations: how is medical pluralism managed in practice?

Recent policy changes in the UK such as deregulation of prescribed medicines and the introduction of telephone helpline services are intended to promote self-treatment. Drawing on interviews with, and consultations between, 35 patients and 20 general practitioners, we use Kleinman's (Patients and Healers in the context of culture: an exploration of the Borderland between Anthropology, Medicine and Psychiatry, University of California Press Ltd., London) model of the three sectors of health care in order to examine the range of self-treatments people use and the discussion of these treatments in medical consultations. We argue that despite the availability of a range of treatment options and policy changes advocating greater use of self-treatment, patients are inhibited from disclosing prior self-treatment, and disclosure is affected by patients' perceptions of the legitimacy of self-treatment. The findings are in keeping with Cant and Sharma's (A New Medical Pluralism, Alternative Medicines, Doctors, Patients and the State, UCL Press, London) contention that although there has been a pluralisation of "legitimate" providers of health care and a restructuring of expertise, biomedicine itself remains dominant.

Attitude of Health Personnel↗
PubMed2003

Developing and using quantitative instruments for measuring doctor-patient communication about drugs.

Previous qualitative work has identified communication problems between doctors and patients in general practice consultations, particularly in relation to prescribing. This study aimed to develop quantitative measures to extend the research and provide instruments for both researchers and practitioners to use in monitoring communication and prescribing. Questionnaires were developed from existing instruments. When used with patients and doctors in a variety of general practices, the instruments appeared to be acceptable and had high response rates. While many consultations were satisfactory in terms of patients' expectations and their experiences with medicines, only 38% did not have any poor outcome. The results using quantitative instruments were similar to but less striking compared to our previous qualitative work. The research was developmental and findings suggest that unnecessary prescribing and problems in communication are more likely to lead to poor outcomes in terms of non-adherence and patients having barriers to using their medication.

Communication↗
PubMed2003

Understanding the role of "the hidden curriculum" in resource allocation--the case of the UK NHS.

In this paper we want to briefly illustrate the ways in which technical, ethical and political judgements of various kinds are interwoven in the processes of healthcare decision-making in the UK. Drawing upon the research for the "Choices in Health Care" project we will borrow the notion of the hidden curriculum from education to illuminate the nature of resource allocation decision processes. In particular we will indicate some of the fundamental but largely hidden political factors in play in these processes and the importance of the inchoate and implicit notion of "NHS values" in shaping UK resource allocation policies. We suggest that these more diffuse, holistic and system level value judgements are both central to understanding priority setting and at the same time difficult to reduce or abstract out into lists of single values/principles.

Costs and Cost Analysis↗
PubMed2002

Causes of prescribing errors in hospital inpatients: a prospective study.

BACKGROUND: To prevent errors made during the prescription of drugs, we need to know why they arise. Theories of human error used to understand the causes of mistakes made in high-risk industries are being used in health-care. They have not, however, been applied to prescribing errors, which are a great cause of patient harm. Our aim was to use this approach to investigate the causes of such errors. METHODS: Pharmacists at a UK teaching hospital prospectively identified 88 potentially serious prescribing errors. We interviewed the prescribers who made 44 of these, and analysed our findings with human error theory. FINDINGS: Our results suggest that most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. Doctors identified many risk factors-work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organisational factors were also identified, and included inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors. INTERPRETATION: To reduce prescribing errors, hospitals should train junior doctors in the principles of drug dosing before they start prescribing, and enforce good practice in documentation. They should also create a culture in which prescription writing is seen as important, and formally review interventions made by pharmacists, locum arrangements, and the workload of junior doctors, and make doctors aware of situations in which they are likely to commit errors.

Attitude of Health Personnel↗
PubMed2002

The validation of an existing method of scoring the severity of medication administration errors for use in Germany.

OBJECTIVE: The aim of this study was to assess the validity and reliability of an existing method of scoring the severity of medication administration errors, developed in the United Kingdom (UK), for use in Germany. METHOD: 10 doctors, 10 nurses, and 10 pharmacists from German hospitals were asked to score the potential clinical significance of 49 cases of medication administration errors on a visual analogue scale. MAIN OUTCOME MEASURE: Generalisability theory was used to determine the minimum number of judges required to obtain a reliable mean score, Validity was assessed by comparing the mean scores given by the judges to the known outcome of the errors for a subset of the cases. German results were compared to original UK data. RESULTS: The scores of 27 judges could be used (nine from each profession). At least three health professionals, one from each profession, were required to achieve a generalisability coefficient of 0.86, indicating acceptable reliability. The mean scores were found to be valid indicators of the potential severity of the errors German scores were significantly below UK scores for the same cases. CONCLUSION: The mean score calculated from scores given by one doctor, one nurse and one pharmacist from the population of German health professionals was a valid and reliable measure of the potential clinical significance of medication administration errors. That German health professionals see cases as less dangerous than their UK counterparts is worthy of further investigation.

Germany↗