It is recognised the risk of prescribing specialist immune modifying drugs (IMDs) in an unsafe manner is increased due to lack of functionality within GP electronic patient record (EPR), systems are heavily reliant upon non-clinical staff to support the process. In many cases the next opportunity to resolve any problems only presents when a further prescription is requested. In response to patient safety incidents in North Tyneside (NT) NECS MO team audited IMDs in line with SC guidance. Numerous errors were identified including knowledge, rules-based errors, omissions and action-based failures of skill such as technical slips or memory-based lapses. Such errors have a high probability of reoccurrence mirroring the findings of an observational study.1 The audit identified a signed SCA was absent from 17% of patients' records and many with a SCA but not for the currently prescribed IMD. The audit concluded primary and secondary care should be integrally linked to improve communication and to mitigate observed variation in practice & develop a centralised monitoring team (CMT) to provide a consistent and thorough approach to address other recognised issues with SC. To address the dearth of EPR functionality and provide a vehicle to bridge the communication interface between primary and secondary care NT commissioned beetrootCOMMUNITY®️ a digital risk management clinical decision support system (CDSS) with functionality to ensure blood monitoring is undertaken, results are correctly interpreted to identify abnormals and deteriorating trends in line with BSR recommendations2 and the SCA provide assurance IMDs can be prescribed safely by creating a time sensitive digital certificate identifying the IMD is safe to prescribe, To date the CMT has successfully onboarded 14% of the eligible patients into the CDSS, managed 568 reported exceptions & addressed many issues related to the SC process, such as absence of a signed SCA for the current IMD, those lost to follow up and liaising with specialist teams to manage interruptions in treatment. The system has issued 328 'safe prescribing digital certificates' automatically issued and delivered to practice EPRs.
A close working relationship has developed with the specialist team in Rheumatology, Northumbria Healthcare NHS FT (NHCFT) that is facilitating discussion to improve the processes governing SC, and together with the CMT have co-produced a communication process for managing reported exceptions. The specialist team values the role of the CMT, and it has helped reduce their workload as they now do not see the need to continue to monitor patients whose care has transferred to primary care in NT as they are confident and reassured by the CMT managed process. Implementation of beetrootCOMMUNITY®️ is progressing & it is fully operational in 2 PCNs, partially in a third with the remaining PCN to be onboarded when there is clarity as to their pathology provider to allow an electronic feed from pathology to be received by the CDSS.
All members of the NECS MO NT team are involved in the CMT and they have responded magnificently to this challenging work and meet weekly to discuss challenging cases and suggest process improvements. The process of taking on beetrootCOMMUNITY®️ has required the CMT to develop a broader understanding of IMD monitoring and how to manage the system.
1. Improving specialist drug prescribing in primary care using task and error analysis: an observational study N Chana, T Porat, C Whittlesea and B Delaney Br J Gen Pract 2017
2. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs J Ledingham, N Gullick, K Irving, R Gorodkin, M Aris, Jn Burke, P Gordon, D Christidis, S Galloway, E Hayes: Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868
