An investigation into the clinical checking of prescriptions in community pharmacies

Abstract

Abstract Medication-Related Harm (MRH) remains a significant challenge to healthcare systems globally, despite multiple interventions aimed at its reduction. Approximately 1 billion prescriptions are dispensed annually by community pharmacies in the UK, where pharmacists must ensure their legal compliance, accuracy, and clinical appropriateness. Community Pharmacists (CPs), being the last point-of-contact with prescriptions before they reach patients, are well-positioned to intervene and minimise MRH. The process by which pharmacists determine clinical appropriateness, known as clinical checking, is perceived to play a crucial role in minimising MRH. However, little is known about how clinical checking is carried out in practice and its contribution to reducing MRH. This PhD aimed to explore how CPs perform clinical checking in practice and to identify the priorities for improving this process. Four studies were conducted to achieve these aims: three focused on a thorough investigation of clinical checking, and the fourth on identifying priorities for improving the clinical screening of prescriptions. Study One utilised semi-structured interviews to understand how clinical checking is carried out in practice. Pharmacists reported a trade-off between thorough examination and prescription throughput due to pressure, assumptions about medicine safety, lack of information, and challenging workplace conditions. The study concluded that clinical checking is complex, variable and somewhat environment-dependent. Study Two focused on investigating CPs' decision-making when checking prescriptions. Pharmacists clinically checked three virtual prescriptions while providing verbal accounts of their thoughts, revealing that checking is a multi-staged process with several co-existing concerns. CPs varied considerably in recognising and responding to these concerns. They mainly used pattern recognition but switched to an analytical approach for atypical situations, showing consistency in cue processing but variability and hesitancy in taking actions. Acknowledging the consistent variations observed in studies One and Two, a multi-method study (Study Three) was carried out to analyse clinical checking SOPs, CPs' compliance, and the reasons for variations between CPs practice and standardised protocols. The study revealed that CPs deviate frequently from SOPs due to patient factors, work conditions, exercising professional judgment and relying on others. Finally, Study Four involved a Delphi exercise where CPs were tasked with rating the importance of thirty recommendations, achieving consensus on sixteen, covering continuous education, access to patient information, technology integration, workflow optimisation, and environmental improvements. Participants also emphasised documentation, financial incentives, feedback, reduced interruptions, and better communication with prescribers. These findings collectively provide an understanding of clinical checking in community pharmacies and offer actionable recommendations to enhance this procedure. The research uncovered multiple facets of vulnerability within the clinical checking practice, showing that, by current definitions and operational standards, the process of clinical checking is falling short of its intended objectives. These shortcomings are multifaceted, stemming from various environmental and organisational barriers, as delineated in Studies 1 and 3, and from the complexity of pharmacists' decision-making, as portrayed in Study 2. Such findings underscore the need for a holistic approach to enhance the clinical screening of prescriptions—one that transcends mere enhancements to education or training. Study 4 suggested that improvements in clinical checking necessitate a systemic overhaul that enhances the accessibility of information, supports CPs’ decision-making, and potentially entails significant restructuring of the current design and traditional workflow within pharmacies

Date of Award	19 Feb 2025
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Denham Phipps (Main Supervisor) & Jason Hall (Co Supervisor)