What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?

ABSTRACT (IMRAD)

Introduction- The medication process present with the paper based prescription system faced significant threats in relation to the patient’s safety and hence the current research evaluated the effectiveness of eprescription system with the relevance of PINCER and BCMA.  The aim of the research is ‘’ how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level.’’

Methods- It used PRISMA to filter research journal articles from (CINAHL, MEDLINE, APA PsycINFO, Dementia journal, Gerontology, and Cochrane) and five articles were chosen. It is a secondary research that helped to capture prevalent practices on research phenomenon in real life, and synthesize its outcomes to gain insights using thematic analysis.

Results- Results showed BCMA achieving 100% patient satisfaction in surgical settings and PINCER interventions to reduce hazardous prescription workflow methods and processes thereby significantly urging the nursing fraternity to be compliant in a techno social environment that is high water pressure requiring 100% patient safety.

Analysis- It is evident that the success of E prescription system is an institutional demand that is dependent upon different IT systems and a higher system of clinical decision support platform that synthesizes real time data in creating alerts and adding human decisions for overcoming the socio-technical barriers and help nurses for workarounds

Discussion- It can be concluded that electronic interventions in a healthcare system are able to significantly reduce the drug adversity drug dosage mismatch chances enhancing patient safety and yet the benefits can erode overtime, if the practices from nursing perspective is not meeting the continuous learning process and compliance adherence.

Key words:  PINCER, BCMA, eprescription, nursing, healthcare

Chapter One

1.INTRODUCTION

In the health institutions, designing a healthcare system comprises of the patients nurses, doctors, and IT system which is able to ease clinical operations and its management efficiently and effectively. However, any system has dimension of errors or defects, that cause extended period of patient stay, harm to the patient, and adding on to the financial burdens (Clifford,  2025). In the context of UK, the NHS ‘National Health Service’ has protocol based medication administering practices, which is aligned with the doctor prescribing, and the medication dispensing, that has adopted electronic interventions for patients linking the pharmaceutical supply chain (Colin et al. 2025). The concept of BCMA or ‘bar code medication administration’ has emerged strongly in last decade, thereby, facilitating the electronic prescribing systems impacting the hospital as organisation, the doctor, the patient, nurses, impacting the paper prescription process to be digitalized (Williams et al. 2022). The implication of the above, has led to aspects of drug matching as per patient diagnosis, and also the pharmacy leading to close the gaps of human errors, matching records, decision making and oversight. Eprescription system however, offers a digitalised environment of records, involving multiple technologies for a 100% clinical decision support system. However, research studies show that technologies are designed, to eliminate human error, workflow efficiency to enhance the patient safety, have been compromised, challenged in terms of the practical and real-life incidents (Wissal, 2025).  The vital question remains about the resource constraint, staff training, and systems integration, for barcode medication administration across institutions (hospitals and pharmacies), that exposes the gap illustrated in the literature review secondary research (Shiima et al. 2022). The critical insight about the limitations and the impact, thereby, contributing towards the current research topic. This raises the central question: What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?”‘

1.1. BACKGROUND AND SIGNIFICANCE

1.1.1. Aim of the Literature Review

A literature review contributes to diverse dimensions of the research phenomenon to understand the research topic deeply (Aveyard & Bradbury-Jones, 2019).  The literature review in any research, helps to establish the past findings in relation to the research phenomenon and thereby, demonstrate the dimensions (Holloway & Galvin, 2023). The current research shows how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level.

1.1.2 Electronic prescribing system

The electronic prescribing systems are designed to replace the age-old handwritten doctor prescriptions for the patients, thereby, reducing the human transcription errors (Goodman & Miller, 2021). Understanding the system characteristics and the ability to reduce the medication errors or defects in prescribing system (Adeyemi et al. 2024) is critical, as it helps to measure ensure the pathway of improvement process, in electronic communication formats (Elshayib  & Pawola, 2020). The communication modalities between the pharmacist and the drug prescriber, defines failsafe pathway (Strauven et al. 2020), that impacts the institutional workforce efficiency, impacting the quality dimension in patient care safety (Cahill et al. 2025) and patient satisfaction outcomes (Farre et al. 2019). While the manual prescribing practice had illegibility in the prescription, incomplete information, the structure and process centric electronic prescribing system is also facing the challenges (Tantray et al. 2024), that of ‘system downtime’, the ‘user resistance’ recurring continuous training to show its adoption and prevalence in healthcare institutions (Penati, 2024).

1.1.3 Barcode medication administration system

The second dimension is ‘barcode medication administration system’ which ensures how the right patient, with the right medication, with the right dose and on-time dosage administration, has led to intelligent prescription system (Owens et al. 2020) (Zheng et al,.2021) offering nursing autonomy (Hong et al. 2021). In this context, the patient perception about the medication, the packaging have embedded scanning barcodes along with the prescription offers cost-effort-time savings, which is the literature review shows automation in eprescription as evidence (Jessurun et al. 2021). However, in order to remove the administration error reduction, a standard compliance based process and improving outcome in the medical environment requires guidelines (van der Veen et al. 2020).

1.1.4. Why Is This Important in Nursing?

Between the patient, nurse and doctor relationship, the institutional role to safeguard medication safety for the patient satisfaction involves multiple stakeholders (Shapovalov, 2023), like the pharmacy and nurses, that forms the last and final checkpoint before the drug administration process happens (Ahmed & Tamim, 2025). Any error act any stage have serious impact on the patient treatment outcomes (Nurmeksela et al. 2021), which directly points to the healthcare institution professional accountability (Bhati et al. 2023). Therefore, the BAMS is an electronic intervention in the hospital operations management environment, where  pharmacist led IT as e-tool, that aligns with multiple stakeholders in the institution, is reducing the clinician cognitive load, standardizing workprocesses and streamlining the process of eprescription communication in the digital format (Mohiuddin, 2019) impacting patient-provider improvement in healthcare (Drossman, & Ruddy, 2020). This offers a real-time safeguard to the patients against the human mistakes (Vaismoradi et al. 2020). The effectiveness is crucial for safeguarding the patient safety upholding the ethics of nursing practice, physician practices, adopting integrated IT system, for seamless communication offering autonomy in decision making, building brand credibility of the healthcare institution (Molina-Mula & Gallo-Estrada, 2020). Therefore, the current research contributes to understanding the tools which help the nurses and the evolution of the healthcare technology that strengthens the process given approach in providing safe high quality healthcare to the patients.

1.2 DEFINITIONS

To conduct a thorough analysis, it is essential to clearly define key terms.

1.2.1. BCMA

This is defined as a technology which uses barcode and specifically used in medical sector, with drug, dose, dosage implementation to right patient at right time.

1.2.2. e-prescribing

The process through which the doctor uses a digital platform in order to recommend the prescribed drugs for the patient treatment outcomes. It reduces the aspect of hand written prescriptions, reducing probability of errors, stolen/lost, legibility issues.

1.2.3. CDS

Clinical decision support

This uses the IT based platform to give the clinicians electronic format of output, guiding them with alerts, reminder to nurses and/or patients offering transparent evidence based guidance.

Chapter 2 (Methodology)

The research methodology section gives a justification of the steps to be followed to find relevant literature, to answer the research question and achieve the research objectives (Snyder, 2019). The literature review that is based on a systematic research approach entails the development of a purposeful research question, systematic manner of searching right articles, appraising each one by one (Pollock & Berge, 2018), and then finally evaluating the published results. Although Bramer et al. (2018) argued that a quality literature review uses a systematic method while searching and analysing the literature, it might not be considered as a thorough as a systematic review.

Developing the review question:

Coming up with a review question is the initial step in a literature review (Rodgers & Yee, 2023) is a first step towards understanding. The purpose of this review is to answer ‘’ What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?’. In order to formulate a clear focused question depending on the above chosen topic, the tools PICO (Population, Intervention, Comparison, and Outcome) (Kloda et al. 2020), and SPIDER uses (sample, phenomenon of the interest in researcher, design, evaluation, and research type) which is predominantly for qualitative and mixed research (van der Waldt, 2025). Even though PICO is an effective tool in the development of research questions, it is specific to quantitative studies. Thus, SPIDER was applied, which is intended to be applied in qualitative research in table 1, but Cooke, Smith, & Booth,  (2012) argued that SPIDER tool can fail to identify the relevant papers during literature searching because it is specific.

Qualitative approach:

The qualitative research approach was used in order to respond to the question, ‘’ What is the effectiveness of electronic interventions including electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools in reducing medication errors in NHS settings in England?’’  Bettany-Saltikov & McSherry, (2024) and (Polanin et al. 2019) highlight that the structure of a literature review must be closely consistent with the questions which were asked during the review. Qualitative research will seek to investigate the phenomena of humans that give detailed descriptions and theoretical elaborations (Bazen, Barg & Takeshita, 2021). This method puts depth at the forefront, with the views of the participants being the centre of attention (Lim, 2025). Although it has been criticized that qualitative literature reviews might not be systematic,

Table 1: Formulation of the research question

resulting in less reliable evidence being obtained by chance and not by rigorous methods (Oranga & Matere, 2023) emphasize that rigour, sometimes known as trustworthiness, can be obtained through transparency and by reporting the systematic process followed

Search strategy:

A systematic search is used to identify the research study variables which describe its overall research phenomenon, which is relevant to the review question (MacFarlane, Russell-Rose, & Shokraneh, 2022). It included searching by keywords that are embedded in the topic, and a combination of variables, that correspond to the review question.

Table 2:  Keywords

This helped the researcher to make sure that the output of selected literature is exhaustive, avoids selectivity or a tendency to cherry-pick research studies (Harari et al. 2020). The Boolean operators and truncation (asterisk,) were used together with the research keywords, to find the required literature (Salvador-Oliván, Marco-Cuenca, & Arquero-Avilés, 2019). Preliminary scoping search was conducted to evaluate the presence of qualitative literature on the selected topic with the help of such keywords as – electronic interventions, electronic prescribing system, barcode medication administration (BCMA), pharmacist-led IT tools, in combination with phrases like reducing medication errors, NHS. Although this search produced a few indirectly relevant literature, new keywords were found, including by permutation and combination of words-phrases, that was included in the search procedure (see Table 2), which helped to find more relevant literature. Maltseva, & Batagelj, (2020) suggest using the keywords identified to include various representations of the topic of the review. Search concepts were effectively combined using Boolean operators “AND” and “OR” (Grames et al. 2019), and a search concept was broadened with the use of truncation (Sivakumar, & Sivakumar, 2025)) although with a risk of retrieving irrelevant articles.

Database searched:

In order to maintain its focus and select the unbiased literature review, bibliographic databases were used. The general search engines available in the market such as Google, Yahoo, which may provide an abundance of varied information output can be unreliable. The databases which were deployed in this research like – MEDLINE, PsycINFO, CINAHL, APA and Academic search complete was preferred due to their capability in producing subject area specific articles (Gusenbauer & Haddaway, 2020).

CINAHL offers diverse nursing literature, and is a searching tool in that domain, that can successfully locate qualitative research. It offers useful research articles in the context of UK even with North American bias the output are credible (Hopia & Heikkilä, 2020). On the other hand, the MEDLINE search offers diverse medical and nursing information. Similarly, the APA PsycINFO provides access peer-reviewed journals around to 98% are specifically on psychological care in nursing area (Sirois, & Owens, 2021). Academic search is complete therefore, is a multidisciplinary database, which expands the range of available scholarly articles. Limiters were used to narrow the search to only English language publications published in the past 2015-2025, which could potentially filter out some potential studies of interest.

Inclusion and Exclusion criteria:

To achieve a systematic search strategy, it is important to have clear inclusion and exclusion criteria (see Table 3) in order to select only those studies that are directly related to the review question (Krnic Martinic et al. 2019).In this instance the studies that were prioritised were the ones that

Table 3: Xyz

examine the experiences of nurses in relation to the ‘electronic prescribing systems, barcode medication administration (BCMA), and pharmacist-led IT tools’ in NHS England. Cochrane systematic reviews are believed to be the gold standard; however, they lacked inclusion because their focus was on healthcare interventions, which are not the focus of this review (Moore, Fisher, & Eccleston, 2022). Rather, qualitative research by peers was selected due to its credibility and high-quality assessment. Non-UK studies were filtered out to prevent the occurrence of discrepancies due to differences in healthcare systems to make them relevant to UK nursing practice. Even though, it is possible to learn much on the basis of their experience of other countries, and the specified aspect remains underdeveloped in other countries in particular to cite in this research. These criteria narrowed the search process and made sure that only those studies that were applicable directly to the review question were included in the search.

Study selection:

The process of selecting the studies explains how the literature that is directly related to the review question was identified, and the PRISMA diagram by Page et al. (2021) provides a clear idea of this process (see figure 1). The extraction of duplicates left 545 results, 299 of which were irrelevant articles filtered out by reviewing titles and abstracts, this process allows concentrating on the studies related to the review question. Another screening process against inclusion criteria reduced the number of articles to 36 further exclusions.

Critical Appraisal

The procedure of critical appraisal for any research study have their respective strength and weaknesses in terms of its evaluation power and the quality and relevance of the article selection in respect to the research question. The CASP checklist is designed for qualitative research studies and in the current appraisal process, (Long, French, & Brooks, 2020). Recommend its importance in the specificity of the tools that have checklists which show the qualitative research to show ‘rigour’, where the ‘decisional quality’ of including the study for analysis. It needs to eliminate research self-selection bias, and adopt a thorough assessment guided by professional standards.

Critical Appraisal: Barakat & Franklin (2020): Nursing Workflow and BCMA

The research overview and background by Barakat & Franklin (2020) explores barcode medication administration (BCMA) advocated for reducing medication errors. This area of study and its effect on the nursing process is not well studied. This research aimed to evaluate the impact of BCMA, when included to the existing electronic prescribing and medication administration (ePMA) system over the nursing practices in UK teaching hospital. The researchers used research approach that comprised of comparative study, on two similar surgical wards. This process consisted of using direct observation at 8 AM each day for 10 consecutive weekdays in each ward especially during the drug rounds. Data gathered were on drug round time, where the aspect of punctuality, identification of patient, and the last one was on medication cross verification. The study identified and determined that there was no significant difference in the overall time per round of drugs, and that this time was about 68 minutes per round on both wards. The mean time per dose however was significantly lower on the BCMA ward (2.3 minutes) than the non-BCMA ward (4.2 minutes). Importantly, patient identification checks went from 74% to 100% with the use of BCMA.

The strengths of the research method included the direct observation by a single observer which can help in the consistency of finding and can minimize the limitations of self-reports. The study, which involved observation of nurses in an actual context, allowed to record nuanced patterns of their workflow-workaround, for instance walking paths, with spaghetti diagrams while an integrative view as per (Fraczkowski, Matson, & Lopez, 2020) findings was not done. This approach provided a visual comparison of the activities streamlined through the use of BCMA, and demonstrated there was consistently less walking to the medicines room overall on the BCMA ward. Moreover, if BCMA is compared to an existing ePMA system rather than a paper-based system, the assessment would be more relevant for modern NHS trusts where there is already a digital system in place while its application in different medical fields (Vanderveen, & Husch, 2015) could have given more insights.

When critiquing research methods, it was found that a major drawback in conducting the study was the fact that the study was carried out in two wards as opposed to a single ward before and after implementation but it missed, where (Vanderboom et al. 2016) showed interdisciplinary team feedback to BCMA success was acheived. Nursing leadership, culture, and patient acuity were also different by wards, and may cause bias in this physically similar surgical units while (Giraldo et al. 2018) captured their perception about mobile apps based interventions in workprocesses. The data collection on the BCMA ward was only four days after implementation, and staff may not have had the opportunity to become acquainted with the system which could have influenced the results. Moreover, there was no quantitative assessment of the various categories of nursing activities, which restricts the thoroughness of the research workflow data capture and data analysis while the research missed on quality tools (FMEA failure mode effective analysis) as described by (Thompson et al. 2018) in reduction of errors, or the BCMA transition experience of nurses using eprescription in electronic health record system as per (Reale et al. 2023).

Twenty drug rounds were sampled, 10 at each of the two wards. This study looked at the administration of 47 patients on the non-BCMA ward and 43 patients on the BCMA ward, whereas other longitudinal studies analyzed 613,868 administrations. The number of different nurses observed in each ward was low (7 or 8), and may not have been representative of the broader nursing profession. There is a relatively small number of subjects and the study involves only one institution so it is hard to extrapolate the results to other institutions that may have different methods of medication giving, while it missed out on nurses treating inpatient-outpatient using BCMA effectiveness as highlighted (Post et al. 2023) study.

Results indicate that BCMA standardizes and harmonizes the way medicine is administered without putting additional time pressure on the nurses. A big safety success is the 100% patient identification rate, though the researchers noticed some workarounds, such as nurses scanning a patient’s barcode sticker on their notes rather than on patient wrist bands in side rooms, while (van der Veen et al. 2020) showed factors important for workaround methods for nursing while the behavioural dimensions of nurses (Grailey et al. 2023). This means that although the system is in place to check for identity, there can be counterproductive practices due to environmental barriers such as tethered scanners. The less time per dose, may be an opportunity for more timeliness if drug rounds are started on time.

Critical Appraisal- Fisher et al. (2023): Medication Safety during COVID-19

Following the COVID-19 pandemic which caused massive disruption to UK Primary Care, a study by Fisher et al. (2023) study on ‘Medication Safety During COVID-19′ raised concerns about hazardous medication prescribing. The aims of this study was to check the use of ‘OpenSAFELY’ platform to describe how the pandemic is affecting medication safety indicators. The researchers based their study on 57 million patients, in NHS and applied a population-based, retrospective cohort design. They adopted 13 ‘PINCER’ (Pharmacist-led Information Technology Intervention for Medication Errors) indicators, which determine the risks for gastrointestinal bleeding among others and required monitoring via blood tests. Concerning this study, it was determined that hazardous prescribing had not undergone major alterations throughout the pandemic. Monitoring in October 2021 slightly deteriorated for blood ACE inhibitors (from 5.16% to 12.14%), with recovery of most indicators by September 2021 while it has missed the controlled trail for cost effectiveness (Avery et al. 2012).

In this study, the researchers used federated analytics – a way of high-security analysing pseudonymised primary care records from 95% of the English population, without data being moved. This means it is 100% transparent, reproducible: all of the code used for analysis is publicly available on GitHub. The study covered the entire national scale, which was not possible in past manual audits, because of running the same code in both environments. This approach values patient confidentiality both as patients and as public health reports and encourages near real-time status updates on key public health challenges. However, it does not capture (Avery et al. 2012) cost effectiveness of workmethods in institutional.

Critique of research methods did however, reveal that the findings are largely descriptive and that the researchers did not attempt to statistically examine the significance of the changes that were made apparent. Long-term seasonal trends in the rates of indicators could not be taken into account because of the study period, especially the time prior to the pandemic. In addition, only prescriptions and tests done in primary care were captured; those communicated via hospital letter and telephone were not captured as structured data. This could lead to an overestimation of the lack of monitoring in some patient groups.

No study has captured such a large sample size – of around 56.8 million patients across 6,367 GP practices. This huge data set allowed the identification of 1,813,058 patients who were at risk of experiencing at least one potentially hazardous prescribing event during the 2 years of this study. This extent of a population – at National level – removes sampling error to a level of virtual extinction and gives a complete picture of medication safety within different populations and areas of England.

The study suggests that, concerning medication safety, the NHS primary care system was very resilient during the pandemic. Some hazardous indicators, such as NSAID prescribing among the elderly may not reflect deliberate safety measures, but may instead reflect fewer acute presentations. The lengthy timeframe associated with ACE inhibitor monitoring, however, does reflect the focus primary care clinicians had toward practicing higher risk monitoring (e.g, methotrexate) when resources were limited. They illustrate that federated analytics can help guide policy decisions regarding which services we should try to provide focused recovery assistance following systemic shocks.

Critical Appraisal- Rodgers et al. (2022): Scaling-up the PINCER Intervention

Research overview scaling-up the PINCER intervention by Rodgers et al. (2022) showed that medication errors in general practice contribute significantly to hospital admissions and avoidable deaths. This study sought to investigate whether the PINCER intervention—a pharmacist-led IT system that identifies at-risk patients—remained effective when rolled out at scale. Using a multiple interrupted time series design, the researchers tracked the intervention across 343 general practices in the East Midlands. The study measured 11 prescribing safety indicators over 16 quarterly periods. Findings showed a 16.7% reduction in hazardous prescribing at 6 months and a 15.3% reduction at 12 months post-intervention. The most significant improvements were seen in indicators for gastrointestinal (GI) bleeding risk, which fell by 23.9%.

The interrupted time series (ITS) design is a robust method for evaluating large-scale interventions where randomisation is not possible due to logistical or commissioning constraints which (Danda, 2026) research using informatics. By including calendar time as a covariate, the researchers accounted for secular trends toward safer prescribing that might have occurred regardless of the intervention which is an advantages of research methods. The use of logistic mixed models allowed for within-practice correlations and provided adjusted odds ratios that enhance the reliability of the findings. Furthermore, involving PPI representatives in the design ensured that the research remained focused on patient safety and welfare while factors was identified by (Laing et al. 2022).

As an observational study, the findings may have been influenced by unknown confounding factors or behavioural changes unrelated to PINCER. The researchers were unable to collect follow-up data for all practices; by 12 months, the number of contributing practices dropped from 343 to only 70. This significant attrition could introduce selection bias if only the most engaged practices continued to upload data. Additionally, the term “without co-prescription” was kept in the denominator, which might have underrepresented the true effectiveness of adding protective medications like proton pump inhibitors while (Elliott et al. 2013) research highlighted pharmacist based economic impact in medicine management.

The study initially searched 2.97 million patient records at baseline, making it one of the largest evaluations of a medication safety intervention in primary care. While the 12-month follow-up was limited to 70 practices, the sensitivity analysis showed that the characteristics of these practices remained comparable to the original 343. The large initial sample size provided enough power to detect small but clinically significant changes in hazardous prescribing across multiple drug groups, while (Daniel, 2013) findings found how this was assessed in emergency departments managed by nurses.

The results strongly support the national rollout of PINCER in England. The sustained reduction in GI bleeding risk indicators suggests that the intervention is most effective when it prompts a straightforward clinical action, such as prescribing an ulcer-healing drug. However, the study found no reduction in hazards related to asthma or stroke, speculating that these changes are more difficult for pharmacists to implement due to complex patient indications. This highlights that IT interventions need to be coupled with clinical support to address more nuanced prescribing challenges.

Critical Appraisal- Sheikh et al. (2022): ePrescribing Systems in Hospitals

Sheikh et al. (2022) study on ePrescribing Systems in Hospitals stated background errors in hospitals in everyday operations are common. This eventually leads to avoidable morbidity and mortality. This multimethods research programme was sought to describe the implementation of ePrescribing systems for estimating their effectiveness and cost-effectiveness in the operations while (Cresswell et al. 2013) study found that early interventions help to reduce errors. Six longitudinal case studies across diverse hospital sites was carried out, combining 242 interviews with 32.5 hours of ePrescribing systems observation in this research. The researchers also developed ‘IMPACT tool’ via an eDelphi exercise, in order to track the list of 80 high-risk prescribing errors. The study found that while implementation of ‘ePrescribing systems’, was difficult due to integration issues, ePrescribing was associated with a significant reduction in error rates. The earlier scores from 5.0% was reduced to 4.0%, at two of the three sites, where effectiveness was measured.

The theoretically the authors tried to ascertain the naturalistic evaluation method that offered a rich, context-heavy understanding as to why any systems are failing or succeeding while (Williams et al. 2020) where optimising hospital eprescription was found with planned interventions succeeding in NHS hospitals shown by (Crowe et al. 2010) research. By using a Bayesian framework in the research approach that was used for health economic analysis the researchers synthesized the aggregate expert opinions (priors) with empirical study data. This helped to generate meaningful posterior distributions. It is advantageous for “upstream” outcomes as the research on the clinical errors, where a minute incident or chances of error, leads to higher case of mortality was tackled. It was found that the online ePrescribing Toolkit was a tangible evidence for connecting all stakeholders in NHS.

Implementation delays forced the researchers to abandon their planned stepped-wedge design in favour of a less rigorous pre- and post-implementation design. This limited their ability to make a clear causal inferences existing ‘online ePrescribing Toolkit’ systems’ impacts. The researchers faced data access and data capture in regards to the economic factor ‘cost data’ from the hospitals. This forced them “headroom” approach that helped them to maximise the justifiable prices over the direct cost-effectiveness. Small number of case study made it difficult for the researchers, in order to generalize the findings throughout the NHS.

Researchers were able to use qualitative sample that included 242 interviews. This research approach to sampling offered to capture a broad range of stakeholder perspectives from clinical implementation teams to end user patients. The use of the drug charts from 2,422 patients were reviewed for the safety analysis which had 28,526 medication orders. The current research did show large dataset, enough to identify significant reductions in common procedural errors. The study detected a 1.5% reduction in errors in ‘online ePrescribing Toolkit’ systems’. However, there were limited number of hospitals (only three went live during the study) implies the between-site variance could not be reliably estimated while (Heeney et al. 2023) used qualitative approach for ‘why’ and ‘how’ about interoperatability of eprescribing systems while (Bell et al. 2019) used mixed method to understand CDS in eprescription in UK. .

Findings showed that ePrescribing is a complex organisational intervention. It is simply not just a technical one. The outcomes of the research benefits showed -improved legibility and completeness are common but (Cresswell et al. 2017) study offered workaround for nurses in eprescription systems adoption. However, the study warned that ‘online ePrescribing Toolkit’ systems’ introduces a new risks if not properly configured. Authors found that only few hospitals, which used restrictive clinical decision support (CDS) saw specific errors eliminated. But again (Pontefract et al. 2018) showed that there is a general reluctance by the institutions for commercial viability skepticism, to fully deploy CDS. The pre-post study, due to fears high degree of stakeholder involvement to ascertain the errors, and associated effort fatigue. Alagiakrishnan et al. (2005) showed how it is important to reduce and remove inappropriate medication in the healthcare system where CDS plays a key role. It is a system beyond human optimization, using data driven analysis and output helping internal stakeholders to adopt, culture of continuous learning that are essential to realizing long-term patient safety benefits.

Critical Appraisal- Williams et al. (2025): Longitudinal BCMA Adoption and Safety

Williams et al. (2025): Longitudinal BCMA Adoption and Safety BCMA systems are touted as a method to provide the “five rights” of medication administration, and they must be adopted by users to be effective, as noted in Longitudinal BCMA Adoption and Safety by Williams et al. (2025). This was a retrospective longitudinal study looking at the BCMA use and the barriers and enablers in a London NHS Trust over a 16 month period. Five wards provided 613,868 administrations and this data was analysed along with prospective clinical observations. The study showed a high range of rates of wards scanning medicine from 5.6% to 67%. There was a fall in compliance over the years in most areas, with one ward (N1) that had a quality improvement (QI) initiative showing an increase. There were “safety catches” with 37% of mismatch alerts leading to an adjustment of user action in total.

One of the benefits is that it is a longitudinal study, and compliance is tracked over the course of 16 months, shedding light on compliance after adoption has taken place for more than 16 months. When the researchers blended big data from EHRs with observations made from a contextual inquiry, they were able to gain insight into the “why” behind the numbers. For example, observations were made to explain that common reason codes such as “barcode unreadable” were in many instances simply a method of popping the system when under pressure for time. However, study of (Svandova, & Smutny, 2026) stated that minimising workaround needs to ascertain deviation of work paths or methods, uncovering specific factors, such as medication formulation, nurse behaviour, technical fault, that have a significant impact on the rate of scanning.

The study took place in one trust with significant digital maturity, therefore results may not apply to other less maturing trusts. Data was collected in the time of COVID19 pandemic which did undoubtedly affect clinical workflow and limited the frequency of observations for the researchers. Also, the safety catch data analysis period was only one month, and the extent to which this is representative of long-term safety effects is unknown. The study also indicated that non-error events (e.g., two half dose tablets) cause trigger alerts. However, it did not capture a home based drug administration by (Shore et al. 2024), which could be overestimating the safety benefits of holistic healthcare delivery system.

The number of administrators in the data-based sample was huge (613,868), giving the regressions a lot of power to determine the relationship outcomes in variables. But the clinical observations were performed only once in each area, and included only eight areas. The majority of the wards where retrospective data were relied on were different than the wards, where the observations were carried out, and thus some of the qualitative data may not fully account for the quantitative data across the five over-arching wards studied.

The influence of contextual factors, like specialist ward type or workload of nurses, on the success of BCMA, is shown. Grailey et al. (2023) capture the barriers and faciliators in their study, especially in the fast-paced work environments which required to understand behavioural capability along with CDA and eprescription. Previously  unsustainable for scanning on the acute medical unit, as evidenced by the speedy drop in AMU scanning. In contrast, the high scanning levels in Ward N1 shows that nurse-led QI projects and ongoing commitment can help to maintain high levels of scanning. The results highlighted that BCMA systems are not “set and forget” technologies, while it supported earlier study of (Popat et al. 2024) set in NHS, and that they need continuous monitoring in order to keep them effective as safety barriers.

Chapter 4.0: Synthesis

Theme 1: Social and technical barriers in workflow process

The first theme that emerges strongly across the research journal shows the emphasis of the use of electronic interventions in the healthcare management process and especially when the adoption of digital systems requiring to align with the clinical practice the workflow work around needs to be categorically instituted (Williams et al. 2025). The author argued that ward management by hour, is necessary to check dosage omissions, which represents micro-macro dimensions of workflowprocess to be improved as workaround, in real time. This theme also calls for BCMA context the aspect of changing workarounds in existing workflow process needs for example linking barcode sticker of patient with patient notes bypassing primary safety check of patient identity as per (Barakat & Franklin, 2020). A change in the eprescription settings shows lack of integration between the workflow methods, the modules, the prescribing methods as highlighted by (Lundhaug et al. 2025), that is forcing the clinicians to do repetitive tasks (multiple times) alternating between using paper based intermediaries and digital which is creating new risks in patient safety which was also found in Saudi Arabia hospitals (Alharthi, 2024). Rodrigues et al. (2024) argued this to be a multidimensional construct for the workarounds in relation to the hardware limitation (in the rooms or ward), the software immaturity. The human factor of time based workload pressure in a formalized job setting, which is doing potential harm by increasing the risk factor (Sheikh et al. 2022). From the patient perspective introduction of technology in the healthcare management process and the patient involvement has caused removal of paper based medication information to digitalization of new form of eprescriptions, which is a continuous learning process for the ‘patient-clinician-doctor’ (Sheikh et al. 2022). While implementation success is dependent on ‘culture of use’ by frontline staff, system configuration, bringing iterative optimisation overcoming technical limitations in formal practice as discussed by (Williams et al. 2025).

Theme 2: Longitudinal compliance in BCMA

The second theme that emerges strongly is about the barcode medication administration system rule that request to verify the five rights the scanning the patient wristband the medication documentation barcode making it user compliant in the clinical context as highlighted by (Williams et al. 2025). The longitudinal nature of the research showed how systematically scan mismatch alerts have captured wrong patient order, discontinued/expired order drug and wrong patient wristband, scanned to be eliminated. The longitudinal study showed how medication scanning has reduced the workflow process time lines improve the accuracy rate and eliminated the risks as the frontline workers were becoming stressed (Williams et al. 2025) that was evident with (Sheikh et al. 2022) developing ‘critical error types’ IMPACT tool systematically reducing errors over time (reducing 21138 opportunities of error), improving cost effectiveness across eprescription lifecycle implementation to system optimisation. Evidence from the study showed a high of 67% medication scanning rate in acute medical units in a high work pressure environment to yield error as low as 5.6% is testimony of longitudinal iteration based improvement. The longitudinal implication of using BCMA guidelines have shown a change within the stakeholders especially users in action and capturing the ‘safety catch’ in errors especially the wrong patient respond or expiry orders of medicine (Williams et al. 2025). Additionally decline in compliance was also noted in a logistical barrier perspective when there was malfunctioning of the medical hardware software and barcodes that are unreadable or unavailability of the scanners which proves how environment and system improvement is a longitudinal effort in medical quality management. Evidence from these studies show micro level locally laid quality improvement practices in real time that captured the frontline employee feedback and with able nursing leadership across the words helped the system to sustain and improve the scanning rates in eprescriptions thereby proving BCMA technology and compliance to be beneficial.

Theme 3: Institutional eprescribing decision and CDS

The third theme that emerges strongly is a evaluation of the NHS hospitals that have primarily accepted hospital eprescription as a system and incorporating the clinical decision support system along with computerized provider order entry CPOE (Sheikh et al. 2022). Eprescribing impact on the work methods eliminated the human errors, in existing paper system and associated issues of incomplete orders, illegible handwriting and inappropriate drug administration dosage to patients, but  (Schmidt et al. 2026) stated the continous challenges of serious configuration with systems, alerting humans is technology induced error reduction system across the health institution still remained which was found in Swedish health care study by (Rahman Jabin, & Hammar, 2022). It is evident technology use in prescribing underwent a transition, that has been prolonged and challenging from institutional perspective, with implementation delay in error defects identification, defect reduction in specific task area, that has helped the hospitals to standardize the process. While the aspect of nursing perception (Jaber et al. 2025), significant reduction across wards/departments in the hospital but equally important IT system, system design and information system design, which has helped CDS to aid the human fatigue. The applicability of the system output, eliminating the probability of potential error types, in the patient management system was found by military hospital (Alanazi et al. 2024) expanding scope of the findings. The institution faced challenges in implementation, optimizing and standardizing, the ‘commercial off the shelf’ (COTS) products into an adaptable home grown system. Findings match with (Khan et al. 2022) who argued that it required the contribution of the internal stakeholders, apply wireless technology for easy integration within medical devices. It needed to focus on the alignment of the system and the clinical workflow against the existing job descriptions, to match and be effective. As institution, the hospitals had resource and technology challenges, and which (Wu et al. 2022) argued in terms of maximizing human efficiency, automate workflow process efficiency. This is achieved through design, architecture, and data analysis in order to realize the full potential in reducing the patient term by adopting a long-term system optimization approach.

Theme 4: Pharmacist led IT interventions

Across the research studies the last thing that emerges strongly is in relation to the pharmacy within the healthcare institution and how large scale evaluation system PINCER (Pharmacist lady information technology intervention for medication errors was developed and applied as an effective tool to reduce the hazardous prescribing workflow methods in primary healthcare setting (Fisher et al. 2023).   This team have shown that usage of pharmacy technology caregivers and the patients have an equal role to play in order to identify the probability of risk, risk types, and eliminate the chances of ‘risk of harm ‘through an educational outreach embraced by the stakeholders.  The studies prove that pincer associated with the healthcare institutions decreased hazardous prescribing workflow methods within six months from 15.3% decrease over one year, post-intervention and from disease perspective (gastro-intestinal GI bleeding) using drugs decreased to 24% levels in patients due to NSAID hazardous drug prescription tracing system (Rodgers et al. 2022). Open supply platform have shown the resilience of the platforms, against the external shocks, like COVID19 pandemic that disrupted the primary care services, from institutional perspective, thereby, focusing how pharmacy and its role in high risk medications. It matched with a Czech study (Berger et al. 2023) set in COVID19 on eprescription system, as the required technology centric interventions to scope out the risks and achieve performance in the institution (Fisher et al. 2023). The application of pharmacy related IT tools therefore, captured the pharmacy supply chain ‘end to end’ creating a robust framework, of continuous safety monitoring practices on pharmacy workflow, nursing workflow (Yu et al. 2025) echoed the findings which is changing the human habits and translating to shift towards an automated risk detection system, helping in sustain clinical improvement environment (Rodgers et al. 2022).

4.1 Discussion

The above result synthesis help us to understand that electronic prescribing system, and the dimension of barcode medication administration, at the institutional level especially, for the health care sector that has significantly enhanced the institutional capability and frontline employee delivery efficiency directly impacting the patient safety. The mix of technology, information capture, information processing, systematically have helped the institutions, to reduce the rate of medication errors, which are clinically vital for the organization to prove its operational efficiency. The synthesis of the multi-method research in the above topic, have specifically shown how NHS hospitals demonstrated a transition from a paper based prescription system to an electronic or eprescription system over the months and years by systematically overcoming the challenges in implementation.  The internal stakeholders have you illustrated you have understood the paper and digital platform the dimension of errors and the implications of the typology of risk that impact the clinical delivery efficiency and the institutional commitment to patient safety system. Even though the technology reduces the adversity of the prescription drugs, the pharmacy involvement in capturing data of the supply chain, and the work method and workaround processes have reduced the chances or adversity of mismatch prescription drugs probability and its outcome on the patient health safety. Similarly, the technology accessed by the institutions which had procedural errors previously like incomplete drug orders inappropriate dosages and illegible handwriting have been eliminated completely with the aid of clinical decision support system (CDS).  It can be concluded that the role of technology across the length and breadth of clinical management in the healthcare industry, cannot be ignored though the internal stakeholders have to reconfigure information technology (IT), information systems (TI), databases, to understand the source of errors, error types, cost-time impact on the degree of hazardous liability on the institution and on the patients. The above evidence of focused on -anticoagulants, antiplatelets and NSAIDs, where epharmacy role, now enabled tools and platforms, with electronic interventions, that have helped preventable medication related hospital treatment and admissions.

From the nurse nursing perspective application of BCMA has provided a important and critical safety layer, where the point of care complied with the ‘five rights’ verification which is indirectly resulted in active patient identification 100%. Legacy work method and work process in paper based prescription have shown mismatch of data that was overcome by bcma system which changed with the digital shift in the frontline user action and the higher level information technology algorithm that acted as safety catch in identifying and determining the error from the perspective of expired medication in the system or tracking a wrong patient order. It is evident that the studies reflect long term trend by the internal stakeholders in improving the existing workflow method system and trying to comply with high pressure work environment with zero error delivery in departments/ wards, where longitudinal quality improvement practices have helped to standardize the system capability and frontline delivery. The role of nurses embracing E prescription technology therefore has improved the legacy work methods to a new workflow to work around system reducing the time eliminating the errors and also achieving cost efficiency in serving per patient from institutional context.

The ever results also help to emphasise on the technology which has played a huge roll in reducing the drug adversity and its impact on the patients from healthcare service delivery perspective. All the interventions of the tools platforms any prescription system was off the shelf but have been implemented and adopted by the healthcare institutions with significant iterative system optimization happening in each department and ward. This adoption and adoption is a supportive organizational culture by the internal stakeholders as regular feedback from the patients from the nurses with that have helped the healthcare organization to clinically adhere with the high compliance KPIs and prevent the existing system of patient safety benefits erosion. The role of nurses with pincer automated computer platform technology that searches hazardous prescription in post intervention have shown the power of technical framework to catch errors aiding the human decision making process in ensuring the nursing role in patient safety and also integrating the technology with the clinical new workflow methods. Their role has also been critical in utilizing technology and human judgment to mitigate the diverse risks in their task areas and the safety threats in the old workflow method and also in the transitional period of workflow method changing from traditional paper base prescription to eprescription process.

4.2: Limitations

Firstly, the studies of (Roger et al. 2022) and (Fisher et al. 2023) acknowledge that observational research method to ascertain the confounding factors and determine the causal inferences is a methodological limitation while (Sheikh et al. 2022) and (Rogers et al. 2020) had to abandon the stepped wedge design in research due to delays and it’s robust people’s research comparison. From geographical perspective the studies in the region of East Midlands or in London may not represent the entirety of picture of NHS healthcare organization as the inability to understand the transparency of cost data remained a hurdle for bringing about the change in relation to the research topic (Sheikh et al. 2022). Many studies like (Barakat & Franklin 2020) and (Williams et al. 2025) have captured short observation windows as defaced the attrition in follow-up data in the health care institution, while Rogers et al.(2022) had to complete all the research method within a year, with 70 practices captured as a baseline. More recent studies in 2026, in relation to eprescriptions and sociotechnical workaround, required to be captured, for understanding the involvement of artificial intelligence (Ai), and human decision fatigue, that the above studies have not fully captured and discussed.

Chapter 5.0: Conclusion

The current study aim to understand ‘how patient safety is impacted by technology usage and how it reduces the adversity of prescription drugs, using electronic prescribing system at institutional level’. The results in the last chapter have shown that there is a significant impact of multiple information technology systems generated for internal stakeholders in healthcare organization, which has significantly improved the work methods, work processes and enabled him to improvise on new work approaches. It can be concluded that electronic interventions in eprescribing systems like BCMA and pharmacist led IT platform based tools like PINCER have helped healthcare organizations significantly to improve and enhance the patient safety levels by systematically adopting quality interventions an iterative reduction of medication risk. The outcome showed BCMA compliance helping nurses, in achieving over 100% patient identification eliminating mismatch cases and preventing errors at 37% of instances and 16.7% reduction in PINCER based hazardous prescribing even during COVID-19. There is high degree of socio- technical alignment, which was required to maximize the effectiveness of the organizational throughput in meeting the compliance, which was found to decline overtime in a high pressure word in the healthcare institution. The involvement of CDs clinical decision support system helping the humans in the healthcare system have helped technical power to identify error track the error offer real time restricted alerts aiding the success of the workflow around through iterative optimization process. It can be concluded that the transitional journey from paper to digital shift in prescription requires the what methods the culture to show digital maturity, in achieving a set goal or clinical outcome while installing technical software and aligning the ‘culture of safety’ in everyday work process.

5.1: Implications for Practice

The above research showed the transitional journey to be a challenging for the healthcare institution from top-level view, against the frontline nurses and their work around methods at micro level to be a key element, from a reactive-error correction and pro-active risk removal perspective. It showed that the system design in the clinical workflow, requires integration, alignment and collaboration, from multiple departments/wards, IT-IS from task perspective. This helps the practice followed to embrace, eliminating the legacy system and implementing IT based workaround which requires normalizing, standardizing to achieve 100% patient safety identification, amidst high pressure work conditions.

   5.2: Recommendations:

1. Suggestions include to expand PINCER integration to 100% automated pharmacist led supply chain information system, at national level and focus on implementing high risk drug group patients to be threat free.
2. Institutional prioritising of restrictive CDS and sharing the data with multiple organizations would help to eliminate the procedural and system based clinical errors entirely in case of extreme risk based prescriptions.
3. The alignment of hardware software accessibility at institutional level is required to enable collaboration between the healthcare organisations a nursing data for a top level perspective of eprescription effectiveness across nations.
4. Ergonomic medical scanning devices that are wireless for the nurses is required to remove the physical barriers preventing bedside workarounds in side rooms.

#UK, #nursing, #academicwriting, #dissertation, #Bachelors, #Masters, #Ireland, #Scotland, #Healthcare, #Publichealth 

 In adult patients receiving end-of-life care in community settings, how effective are anticipatory medication-based pain management approaches, including clinician- and carer-led administration, in improving pain relief and symptom control compared to usual care?

Abstract

I- The pain management especially for the patients with the end of life remains a clinical challenge presenting a critical dimension where anticipated prescription with injectable medication to be I mean best practice followed in UK, New Zealand, Australia for symptom control.  The background research contributes to a diverse research studies and effectiveness of clinician LED administration while the question remains about Kerala administration of pain relief outcomes for palliative care in adult patients in residential care settings that is yet to be researched. The main aim of this research is systemically examine in order to evaluate how anticipatory medication approaches health pain relief in adults for symptom control compared to the usual hospital care.

M-The current research followed a systematic secondary research reviewing the articles is in different databases like midline Cochrane Library within 2015 to 2024 timeline the use of PRIMSA and synthesis through ‘thematic analysis’, have helped inclusion exclusion criteria to narrow down into select journals meeting the end of life adult population criteria, community setting, measurable pain and symptom outcomes.

R-The studies met the inclusion criteria and using different research method like -mixed method of design, qualitative research, it was found that anticipatory medication prescribed to 5165% of adult dying patient reflected moderate effectiveness in terms of symptom relief. But there was significant delay in the administration in the home environment that was captured which points to carer efficiency when compared to hospital based system raising the concern of training adequacy resource availability and the psychological readiness .

A- The thematic analysis diverged into  streams ‘’ Rapid Innovation and Systemic Adaptation During Global Crisis, Professional Decision-Making: The GP as Gatekeeper and Consultant, Patterns of Frequency, Timing, and Clinical Predictors, The “Simultaneously Reassuring and Unsettling” Patient Experience, Barriers to Medication Administration and Caregiver Burden, Economic Inefficiency and the Paradox of Standardised Wastage, Safety Concerns and the Risks of Advance Prescribing’’.

D-The prescribing patterns from the above research showed standardized approach rather than individualized that could have generated paradoxical economic waste of time and effort leading to unmet clinical needs. The patients and the caregivers have experienced existential distress but the caregiver burden intensified when successive barriers emerged in the process especially ‘out of hour’ period.  The advanced prescribing for the patient safety risk please tell me the clinical oversight and the need for adopting, person centric anticipatory care framework especially when each patient condition differs .

CHAPTER One

BACKGROUND AND SIGNIFICANCE

In community‑based end‑of‑life care, pain management can be complex (Saunders et al. 2019). First, the growing need for community‑based palliative care reflects a preference for home‑based care and the need to ease hospital pressures (Dadich et al. 2023). Second, the reported gaps in timely and effective symptom relief when usual care involves reactive prescribing (Shaw et al. 2023), in which patients and families are unable to access needed medications, is a factor (Manias et al. 2019). Third, the increasing focus on anticipatory prescribing underlines the need for proactive medication planning, allowing clinicians and families to administer pain relief as needed (Bowers et al. 2019). Finally, increasing involvement of family carers in medication administration raises issues about safety, education and support (Gil-Hernández et al. 2024), and Mouna Sawan et al. (2025) argued that it is important to consider the balance of clinician‑led and family carer‑led approaches to medication administration in improving patient quality of life, dignity and comfort. Anticipatory medication‑based pain relief strategies include prescribing and preparing key medications in anticipation of common symptoms in end‑of‑life care (Bowers et al. 2024). This approach guarantees timely access to analgesics and other symptom‑relieving drugs for patients in the community, avoiding delays associated with reactive prescribing (Bowers & While, 2019). Anticipatory medication management strategies provide clinicians and carers with prescriptions, reducing the need for hospital visits and improving home‑care comfort (Kiiski et al. 2025). Clinician‑led administration offers expert oversight and ensures safe administration and protocol adherence, while carer‑led administration allows families, informal carers to administer immediate relief, promoting patient‑centred care (Alkhaldi et al. 2025). This research focusses on the end of life adult patients in the community care settings, and the effectiveness of the anticipatory medication based pain management approaches for pain control and relief.

Aim of the Literature Review          

The purpose of this literature review is to analyse current research about the effectiveness of research variable related to each other to lead to academic gap. In the current study, the literature review examines, anticipatory medication‑based pain management strategies in adults with advanced illness and end‑of‑life care in the community. The review aims to draw on peer‑reviewed research to highlight best practice, limitations and areas for improvement.

Literature review

Anticipatory Prescribing and Pain Management in End‑of‑Life Care

Anticipatory prescribing involves anticipating a patient’s needs for vital medications, preventing a delay in providing pain relief. Research indicates early access to prescribed analgesics enhances comfort and prevents emergency care in the community (Bowers et al., 2023; Bowers, Pollock, & Barclay, 2021). It also promotes coordinated care through patient‑centred care and palliative care standards as evident in England and Wales (Goodrich et al., 2026).

Clinician‑Led vs Carer‑Led Administration Approaches

Clinician‑administered doses offer professional oversight, leading to precise dose administration and adherence to safety protocols, potentially reducing medication errors (Bowers et al., 2021). In contrast, carer‑administered medication empowers families to provide timely symptom relief, promoting patient‑centred care and comfort (Quigley & McCleskey, 2021). Recent studies compare approaches and identify advantages and disadvantages, with clinicians providing safe care and carers facilitating responsive care and family support . (Bowers et al., 2023).

Community‑Based End‑of‑Life Care Models and Usual Care Comparisons

Community‑based care focuses on anticipatory prescribing and shared decision-making, compared to reactive approaches in usual care (Antunes et al. 2022). Evidence shows that anticipatory care decreases hospitalisations and enhances quality of life by addressing pain and distress early (Martin et al. 2019). These models show improved adherence to palliative care principles when compared to usual care, helping maintain dignity and autonomy in end‑of‑life care (Nnate, 2021).

Why Is This Important in Nursing?

Nurses are integral to end‑of‑life care, especially in the community where they are often the linchpin between individuals, families and the health system. Advance prescribing and administration of medications impact nurses’ roles in pain and symptom management and overall care. Nurses benefit from insights into the impact of clinician‑ or carer‑led strategies by individualising care, supporting families, and promoting medication safety. This empowers nurses, supports comfort and dignity for the patient, and provides support for family carers – leading to better palliative care in community settings.

1.2.  DEFINITIONS

End of life care-This is a 360 degree approach where the patients facing the final stages of their life cycle curve need a holistic care.

Clinician led administration- It is about medication delivery offered by trained certified professional staff who are categorized as healthcare professionals working in an organization.

Carer led administration- It is the procedure of medication offered to the patient by the nearest family members or informal caregivers.

Anticipatory prescribing – It is a method of proactive method of provisioning the medication even before the symptoms in the patients escalate.

Community based palliative care- Any procedure of care delivered outside the medical hospital setting which emphasizes a broader community support with home environment facility.

Pain management – Strategies and methods in the form of interventions that help patients to relieve the degree of pain in the body.

Chapter 2: Methodology

The methodology section provides a justification of the procedures to be followed to locate pertinent literature, to answer the research question and fulfil the research objectives. The systematic research-based literature review involves the formulation of a purposeful research question, systematic way of searching appropriate articles, evaluating each article individually and finally assessing the published outcomes (Houghton, Hunter, & Meskell, 2012). A quality literature review may not be a comprehensive as a systematic review, although it deploys a systematic approach when searching and analysing the literature.

Formulating the review question:

A literature review as defined by Lame, (2019) is a first step towards understanding, in which the first thing is to come up with a review question. This nursing review aims to respond to the following question: ‘’ In adult patients receiving end-of-life care in community settings, how effective are anticipatory medication-based pain management approaches, including clinician- and carer-led administration, in improving pain relief and symptom control compared to usual care?” ’. Therefore in order to develop a concise focused question based on the topic selected above, the PICO (Population, Intervention, Comparison, and Outcome) (Schiavenato, & Chu, 2021), and SPIDER tools were chosen to use in the study (Munhall, 2012). Although PICO is a powerful instrument in formulating research questions, it is quantitative in nature.

Qualitative approach:

Only the qualitative research method was applied to answer the question, which is, ‘’ In adult patients receiving end-of-life care in community settings, how effective are anticipatory medication-based pain management approaches, including clinician- and carer-led administration, in improving pain relief and symptom control compared to usual care?”  and Kilpatrick et al. (2023), emphasize the fact that the framework of a literature review has to be very similar to the questions that were posed when conducting a literature review. The qualitative research will aim at exploring the phenomena of humans that provide descriptions and an elaboration of these phenomena in a detailed way (Choi et al. 2022). The approach places depth in the forefront with the perspectives of the participants as the centre stage (Bettany-Saltikov & McSherry, 2024). Though it has been criticized that qualitative literature reviews may lack being systematic,

Table1: Formulation of the research question

leaving behind less reliable evidence found by chance and not by rigorous means Patterson et al. (2023) highlight that rigour, sometimes called trustworthiness, may be achieved through transparency and reporting of the systematic procedure adhered to.

Search strategy:

The research study variables, i.e. describe the overall phenomenon of the research, which is pertinent to the review question, were identified using a systematic search. It involved search using embedded in the topic keywords, and combination of variables, which are related to the review question (Chigbu et al. 2023).

Table 2: Keywords

This assisted the researcher to ensure that the output of the selected literature is exhaustive, it is not selective or it does not have a cherry-picking research studies . The research keywords were combined with the Boolean operators and truncation (asterisk,) to locate the necessary literature (Caponnetto et al. 2024). To determine the availability of qualitative literature on the chosen topic, preliminary scoping search was performed through the assistance of such keywords as – adult end of life care, anticipatory medication, community care, pain reflef approaches. Despite this search yielding a couple of indirectly relevant literature, new keywords were discovered, such as moral distress, treatment cessation and emotional impact, and were added to the search procedure (see Table 2), which assisted in locating more relevant literature. Inclusion: propose the use of the identified keywords to incorporate different variations of the topic of the review. The Boolean operators of ‘AND’ and ‘OR’ were used successfully to combine search concepts (, ) and to make a search concept broader with the help of truncation (,) at the risk of retrieving irrelevant articles.

Database searched:

Bibliographic databases were employed in order to sustain the focus and choose the unbiased literature review. The general search engines present in the market like Google search engine, which can be extremely fruitful in giving a variety of information output can prove to be unreliable (Azarian et al. 2023). The databases that were implemented in this study such as MEDLINE (Heintz et al. 2023, CINAHL (Hopia & Heikkilä, 2020), PsycINFO (Leclercq et al. 2019), APA and Academic search (Rahaman, Taru, & Prajapat, 2023) complete were of choice because they had the ability of retrieving subject area specific articles.

CINAHL is a variety of nursing literature, and search tool in that field, that is capable of finding qualitative research. It provides practical research articles in the setting of UK despite the USA bias the production are plausible (Bettany-Saltikov, & McSherry, 2024). Conversely, MEDLINE search has a variety of information on medicine and nursing. Likewise, to 98% of peer-reviewed journals available on the APA PsycINFO focus on psychological care in nursing area (Ravi et al. 2022). Academic search is complete thus, is a multidisciplinary database, which widens the scope of the available scholarly articles (Höglander et al 2023). The search was also limited to the English language using limiters which narrowed the search to publications published in the last 2018-2025, which might have excluded the possible existence of studies of interest.

Inclusion and Exclusion criteria:

A systematic search strategy requires having clear inclusion and exclusion criteria (Randles, & Finnegan, 2023), (see Table 3) that would allow only the studies that are directly related to the review question to be selected. In this case the prioritised studies were those that examine the experiences of end of life care in community settings, in relation to the ‘.anticipatory medication-based pain management approaches, including clinician- and carer-led administration.’ . The use of Cochrane systematic reviews is said to be the gold standard but they were not included since they focused on healthcare interventions, not the subject of this review. Instead, peer qualitative research was chosen based on its credibility and quality assessment (Johnson, Adkins, & Chauvin, 2020). Although, it can be based on their experience of other countries a lot, and the given aspect is not developed in other countries in particular in order to refer to it in the given research. These criteria helped to cut down the search and ensure that only the applicable studies to the review question were included in the search.

Study selection:

The studies selection process elaborates how the literature which is directly related to the review question was selected and the PRISMA diagram by Page et al. (2021) gives a clear picture about the process (see figure 1). The removal of the duplicates resulted in 421 results across 4 databases (110 MEDLINE, 120 CINHAL, 130 APA, 61 Others ) totalling 360 of which were irrelevant studies 230 filtered out by reading their titles and abstracts, and the given procedure enables focusing on the studies that are connected with the review question. Further exclusions added to 36 more articles were caused by another screening process against inclusion criteria.

PRISMA

Critical Appraisal

Critical appraisal of any research study procedures possess their own strength and weaknesses in the evaluation power as well as the quality and relevance of the article selection with regard to the research question (Brignardello-Petersen, Santesso, & Guyatt, 2025). The CASP checklist is appropriate to qualitative research studies and in the present process of appraisal, the authors suggest its significance in the mythology specific tools that have checklists to demonstrate the qualitative research to demonstrate rigour (Frias-Goytia et al. 2024). The qualitative research to demonstrate the quality of the decision to include the study in the analysis and to adopt comprehensive assessment based on the professional guiding standards.

Chapter 3: Critical Appraisal

Study1: Anticipatory prescribing in community end- of- life care in the UK and Ireland during the COVID-19 pandemic: online survey [Antunes, 2020]

Research Issue, Aim and Objectives-The COVID-19 pandemic has drastically raised the death rates at home and in care homes in the UK and Ireland. This generated acute stress on the already existing practice of anticipatory prescribing (AP) – the pre-emptive dispensing of injectable drugs to relieve symptoms in the last few days of life. There were fears of drug shortages, decreased nurse and doctor supply to give subcutaneous injections and the necessity to rapidly adapt prescribing instructions. The research fills an urgent evidence gap on the ground on the transformation of AP practice in response to these pressures. The overall objective was to explore the experience of change in AP practice among UK and Ireland clinicians during the COVID-19 pandemic and to elicit their suggestions of how the change can be improved. The four targeted research questions inquired what practitioners reported about: (1) drug prescription changes; (2) drug administration changes; (3) support structures of AP; and (4) additional practice, policy and legislative changes.

Research Appraisal-The study is a cross-sectional online survey study conducted in mixed methods, i.e., quantitative (descriptive statistics of the categorical responses) and qualitative (inductive analysis of the themes of the free-text responses) ways. One of the main methodological strengths is its timeliness: data were gathered April 2020, when the practice is being carried out in the acute period of COVID19 pandemic which captured unique perspectives (Schroeder et al. 2020. The geographic coverage in UK and Ireland regions and the size of the sample (n=261) further enhances representativeness. Methodological rigour is demonstrated by the use of ‘CHERRIES’ checklist, which is used to report internet surveys (Torrejón-Guirado et al. 2024). Nevertheless, a number of shortcomings are recognized. Snowball sampling means that a response rate cannot be calculated, and it brings about self-selection bias (Kubiciel-Lodzińska, 2021). The sample was selected based on professional contacts that have already been involved in AP (e.g., workshop attendees, members of palliative medicine), so the sample might be biased toward specialist and not generalist practitioners which was also found by (Jones et al. 2021). Moreover, this was also an initial analysis of a preliminary dataset, and the authors planned to conduct a more thorough follow-up analysis.

Sampling and Selection-It was first conducted as purposive sampling, whereby the delegates of AP national workshops of 2019 and the representatives of the corresponding professional organisations such as the ‘’Association for Palliative Medicine of Great Britain and Ireland’’, the ‘NICE Medicines Associate Programme’, the ‘Resilient GP Facebook Group’ and the ‘Queen Nursing Institute’ were targeted. This was propagated via the snowball sampling method in which recipients were requested to share the survey link in case of interested workmates which was also found in the study of (Artioli et al. 2019). The survey was open 813 April 2020 (to be distributed) and responses received by 19 April 2020. The respondents were over a group of professional roles – the majority of them (37 percent) were palliative medicine consultants and GPs (24 percent) which (Clark et al. 2023) found in their research, with various working environments, low resource setting, within the community, hospice, hospital and care home.

Research Ethics-The ethics committee of the University of Cambridge Psychology Research reviewed and gave the study approval (reference: PRE.2019.013). It was a voluntary participation, all fields were obligatory to complete the data, but the answers were anonymous by default meeting the ethical procedures (EL Barbi et al. 2024). Contact details were provided by the respondents at their own discretion and could only be used as a factor in considering the respondent to be contacted to complete further interviews by telephone, hence, the respondents were clearly separated between taking part in the anonymous survey which without additional participation added to rigour in health research (Koo, & Yang, 2025). No formal patient consent requirements are mentioned in the study, which was correct considering that the survey was focused solely on the clinicians and not on patients. The ‘NIHR Applied Research Collaboration East of England’ funded the study with a clear disclaimer that the opinions were that of the authors only.

Study2: GPs’ decisions about prescribing end-of-life anticipatory medications: Bowers et al. (2020)

Research Issue, Aim and Objectives-Anticipatory prescribing (AP) of injectable drugs is a longstanding aspect of community end-of-life care in the UK, Australia, and New Zealand, which is aimed at the timely control of symptoms during the last days of life. Although the central prescribing authority was in the hands of GPs, there was minimal research studies that investigated their decision making processes in the context of AP. Rae, (2024) stated that the literature previously had been overly focused on the views of nurses, and while (McNab, 2022) found that it has tended to depict nurses as the instigators of prescribing requests and GPs as reluctant or reactive prescribers. There were still critical gaps in terms of how GPs construct AP discussions with patients and families, when prescribing, and the responsibility of drug administration after prescription which (Morris et al. 2021) used realist research phenomenon to prove patient role in AP. The research fills this underexplored view in a field of considerable clinical and ethical dilemma. The purpose of the stated aim was to investigate how GPs make decisions regarding prescribing and use of anticipatory medications to patients towards the end of life. Although there are no officially stated objectives, the study implicitly aimed to investigate three lines of inquiry: the reasons behind why GPs choose to prescribe (when and whether); how GPs discuss the issue of AP with patients and families; and how GPs cope with the continued responsibility of the prescriptions they make, especially in their relationship with community nurses in their delegation of care.

Research Appraisal-It is a qualitative study, interpretive descriptive and semi-structured in-depth interviews with an analysis in a six-phase thematic analysis framework by Braun and Clarke in nursing study (Ahmed et al. 2025). The interpretive descriptive design is suitable to its goals, as it produces detailed, contextually detailed information about professional practice and decision-making and not testing hypotheses that (Duff et al. 2020) stated as interpretative based representation of healthcare practice. The inductive method enabled us to identify three subtle themes that would naturally arise out of the data: *something we can do, getting the timing right and delegating care but retaining responsibility. Ryder, Jacob, & Hendricks, (2019) as the aspect of rigour was improved by a series of analytical lenses: one of the public contributors coded the first three transcripts independently, a second researcher coded six transcripts, and (Klooster et al. 2022) highlighted the importance of analytical decisions were discussed in an iterative manner. Reflexivity was directly discussed and the lead researcher had previously worked as a community palliative care nurse and therefore a positionality that which (Moralli, 2024) argued to have facilitated both rapport and necessitated direct control to prevent interpretive bias. Another weakness is that data are based on GPs self-report of practice, as opposed to observed behaviour, and thus social desirability bias can occur which was argued by (Bailey & Wundersitz, 2019). Direct generalizability is also constrained by the single-county sampling frame though the authors propose analytical transferability between UK settings because of the combination of urban and rural practices.

Sampling and Selection-Purposive sampling was used to sample GPs who had a broad spectrum of views and experience which (Ibrahim, Barry, & Hughes, 2023) argued to guide research to adopt qualitative study. Potential participants were found through publicly available GP practice websites in one English county. Letters to thirty two GPs were sent; sixteen of them were interested and thirteen were finally interviewed in the course of June to December 2017 in thirteen separate GP surgeries. The last sample consisted of ten GP principals and three salaried GPs, five of whom worked out-of-hours. There was intention to find diversity in terms of sex, place of practice (urban/rural), full-time/part time and interest in palliative care. Information saturation was achieved successfully after eleven interviews, and two more interviews were held on the purpose to guarantee an appropriate variety of insight which was highlighted by (Braun & Clarke, 2021), and which is in line with the information power principles in qualitative sampling.

Research Ethics-The research was ethically approved twice: by ‘Cambridge University Psychology Research Ethics Committee’ (reference number PRE.2017.028) and NHS Health Research Authority (HRA IRAS reference 225853). Informed consent was obtained beforehand by all participants and respondents were interviewed with their knowledge and consent which was audio-recorded though (Sindhuri & Dongre, 2023) highlighted challenges remain in obtaining informed consent in healthcare setting. The published findings make use of pseudonyms to ensure anonymity of participants. The ‘NIHR Applied Research Collaboration East of England’ and the ‘NIHR School for Primary Care Research’ funded it, and a typical disclaimer that opinions are those of the authors only. None of the authors indicated any competing interests.

Study3: Unwelcome memento mori or best clinical practice? Community end of life anticipatory medication prescribing practice: A mixed methods observational study Bowers et al. (2021)

Research Issue, Aim and Objectives-Although anticipatory prescribing (AP) has been extensively advocated and practised in the UK, Australia, Canada, Norway and New Zealand, there was strikingly little empirical data available. Zhang, Méndez & Scott, (2019) study confirmed findings, on the frequency of AP medication prescribing, the time of illness course when the prescription occurred, and the clinical contexts within which prescription choices were made. The published rates of prescribing were quite different, between 14-16 percent of foreseeable deaths in primary care groups, to 63 percent among those receiving specialist palliative care, but were based on heterogeneous and methodologically weak sources. There were serious issues arising on patient safety and especially where medications were prescribed well before they were expected to be needed (Bates et al. 2023) while (Ocloo et al. 2021) where they were administered by clinicians who were not familiar with the patient. The lack of evidence relating to patient and family engagement in prescribing decisions was also prominent and this was of great concern which was highlighted by (Manias et al. 2024), to the issue of informed consent and person-centred care in community end-of-life practice. The mentioned objective was to conduct research on the frequency, timing and documented conditions of injectable end-of-life anticipatory medicine prescribing to both home and residential care patients. The aim of the study was to determine: how frequently AP medications were prescribed in a varied sample of GP practices; the fluctuation and distribution of time between prescription and death; what clinical contexts and decision-making process were recorded in patient records; and how much patient and family engagement were recorded in prescribing decisions.

Research Appraisal-It is a retrospective mixed methods observational study, which relies on the GP and community nursing clinical record on the basis of which a social constructionist paradigm is applicable since it acknowledges that clinical records represent selective accounts by clinicians, rather than objective data. The mixed methods design is well adapted to the objective, allowing quantitative examination of the prescribing frequency, timing and patient characteristics, and inductive examination of described contexts, language and interactions within prescribing choices. Descriptive statistics, chi-square and Fisher exact tests, as well as multivariate logistic regression were used, with a priori computation of sample size (Madadizadeh, Soodejani, & Bahariniya, 2026). Constant comparison incident-to-incident analysis through NVivo 12 was employed in qualitative coding (Chun Tie, Birks, & Francis, 2019). Rigour was aided by thematic refinement through iteration with co-investigators and two Patient and Public Involvement (PPI) groups which is important for validation of data and findings (Vellani et al. 2024), the Cambridge Positive Ageing group and the Cambridge Palliative and End of Life Care group, who helped in prioritising research and its interpretation. One of the limitations is that clinical records only provide a partial record of clinical interactions, especially, patient and family discussions as (Brooks, Manias, & Bloomer, 2024) argued that the results on decision-making involvement might not reflect practice. Cohabitation and opioid misuse risk, socioeconomic status were not routinely measured, which constrained the ability to adjust confounding variables. The purposive maximum diversity sampling method and sequential deaths identification methodology enhance generalisability (Safari, McKenna, & Davis, 2023).

Sampling and Selection-Purposive sampling was used to select 11 GP practices and two related NHS Community Trusts across two English counties to maximise variation in the size of patient lists (range 5,50043,000), geographic location (urban, rural, outer London) and socioeconomic status (third most deprived to least deprived decile). This meets the findings of (Parsaeian et al. 2021) as quality and cost of research effort needs to be explored and sampling is critical. Each practice identified the 30 most recent expected adult deaths of patients who had lived at home or in residential care at least one day in their last month and died of any cause other than trauma, sudden death or suicide between March 2017 and September 2019. Nursing homes with on-site trained nurses were included and the patients who had not participated in the research were excluded. This produced a final study population of 329 dead patients. The sample was mainly aged 75 and above (65.7%), mainly male (51.4) and mostly dying of non-cancer causes (58.7).

Research Ethics-The South Cambridgeshire Research Ethics Committee (reference: 19/EE/0012) gave full ethical approval. Since the research study implied retrospective access to the clinical records of deceased patients and the absence of their personal consent, further consent of the Confidentiality Advisory Group of the Health Research Authority (reference: 19/CAG/0014) was obtained that permitted the processing of confidential patient information under the condition that data were anonymised as soon as possible. The two PPI groups recommended the ethical acceptability of the access to the records of deceased patients without consent. Tadros, Carley, & Lucassen, (2020) argued that bringing a community voice to the sensitive decision, which has been an issue especially in COVID19 time period as well (Schoch-Spana et al. 2020). No conflicts of interest were reported. The NIHR School of Primary Care Research, NIHR Applied Research Collaboration East of England, and RCN Foundation Professional Bursary Scheme funded it.

Study4: Simultaneously reassuring and unsettling:a longitudinal qualitative study of community anticipatory medication prescribing for older patients Bowers et al. (2022)

Research Issue, Aim and Objectives-Although the notion of anticipatory prescribing (AP) is widely established as a good clinical practice in the UK as well as internationally, the views of patients and informal caregivers had virtually been missing in the evidence base. The overwhelming premise that AP was based on, namely, the effect of medications being available in the house reassures everyone involved, allows the symptomatic relief to occur promptly and avoid unnecessary crises hospitalization, as (Majumder, 2024) argued it was based more on beliefs conveyed by clinicians, as opposed to patient or family experience. Only a single previous study had investigated the opinions of patients, with the results indicating that prescriptions were considered as a sign of impending death which (Krikoria et al. 2020) stated to be a key contributor for medical audit and review. Three other studies had examined the experiences of bereaved caregivers retrospectively, expressing concerns regarding insufficient explanations, ambivalence regarding effectiveness and concerns regarding drug safety where families withdrawing from treatment was also reported (Korsah, Schmollgruber, & Abukari, 2025). More importantly, no prospective study had investigated the experiences of older patients and their informal caregivers with regard to AP as it occurred in the real-time or how they coped with the practical and emotional challenges of obtaining and self-administering prescribed drugs, which (van der Zijpp et al. 2022) argued to focus on relationships, medication dispensing system narratives to be captured. This is a big gap considering that older patients are the largest number of those who die in the community and the main beneficiaries of AP. The objective of the study was to get insights into the perceptions and experiences of older patients, informal caregivers and clinicians regarding the prescription and use of anticipatory medications in the community. The implicit aims were to: investigate the experience of prescribing conversations with patients and their families; study the emotional and practical reactions to medication in the home over time; investigate how informal caregivers and nursing staff negotiated the decision to administer medications; and identify the invisible work that families do to manage AP care.

Research Appraisal- Particular methodological strength is the longitudinal case-based design, which permits the perspectives to be recorded at several times – after prescribing, after the first administration, and two- to four-month follow-up. Elsahn et al. (2020) argued that not always methodological rigor is captured through technology and research management, so that the changes in understanding and experience can be monitored over time. Constant comparison techniques were used to conduct thematic analysis, and initial line-by-line coding in NVivo 12 and independent coding (Humble & Mozelius, 2022). Five transcripts by a second researcher was used to enhance analytical rigour and reflexivity. Important interpretative choices were narrowed down after a series of debates involving all three authors and the Patient and Public Involvement (PPI) groups. One of the clear weaknesses was the fact that it was not always possible to interview the patient and two cases did not involve patients. Morris et al. (2020) attributed it because of fluctuating cognitive impairment which biased some of the analysis to caregivers and clinician perspectives. The sample was also purely white and English speaking which constrained generalization to other communities. Notably, all nurses that were engaged in the administration of medications refused to take part in the study, and an essential professional voice was missing in the dataset. The COVID-19-induced data collection implied that interviews were carried out remotely, which (Bandini et al. 2022) argued have been less in-depth than face-to-face, as well as put into perspective some of the remote prescribing practices identified.

Sampling and Selection-Purposive sampling strategy was used to select participants who were diverse. Ames, Glenton, & Lewin, (2019) stated that diversity in respondents in terms of age, living arrangements, terminal conditions and geographical setting, in two English counties. Six GP practices, two community nursing organisations and three community palliative care teams were used to facilitate recruitment. They used to first assess the appropriateness of approaching potential participants because the context was sensitive and then provide study invitation letters which requires researcher to decide on survey or interview based on access (Klar & Leeper, 2019). Among the 34 patients and informal caregivers who showed interest, 16 were willing and available to participate on being contacted. Patient and caregiver participants nominated twelve clinicians who were approached by letter and six agreed. The last sample included 11 patient cases but included six patients (65-94 years old) as well as nine informal caregivers and six clinicians- three GPs and three nurses. Information power led to the end of data collection wherein 11 cases were taken based on the information power where rich multi-perspective longitudinal data was deemed adequate to answer the research objective. A total of 28 interviews were carried out.

Research Ethics-The study was approved by the South Cambridgeshire Research Ethics Committee (reference: 19/EE/0361). Ethical approval was fully informed, and continued approval was expressly re-established before each subsequent interview, in light of the possibly dynamic ability and desires of a dying population. Initial recruitment by clinical teams to ensure vulnerable patients and caregivers, are not overburdened or put at a disadvantage by undue stress. The two PPI groups Cambridge Positive Ageing and Cambridge Palliative and End of Life Care were involved in the research design. Nii Laryeafio & Ogbewe, (2023) argued that the recruitment procedures, the words to use as interview guide and interpretation of the findings, thus integrating the lay perspectives in the research process. No conflicts of interest were reported. The NIHR School of Primary Care Research, NIHR Applied Research Collaboration East of England and the RCN Foundation Professional Bursary Scheme funded it.

Study 5: The financial costs of anticipatory prescribing: A retrospective observational study of prescribed, administered and wasted medications using community clinical records- Morgan et al. (2023)

Research Issue, Aim and Objectives–Anticipatory prescribing (AP) of injections at the end of life is strongly advised in a variety of states and has become the norm of community palliative care. However, although it was extensively used, the financial implications of this intervention had come under a very minimal serious examination. Past cost estimates were done using partial data – usually estimating the price of two three days worth of the four most commonly used pharmaceuticals, arriving at figures of between 22.12 and 30.26 in regard to prescription and 10.00 and 14.61 in regard to the unused drugs. These estimates did not take into consideration the entire spectrum of drugs actually prescribed, as (Benhamou et al. 2024) argued about the changes in quantities issued, foreseen syringe driver prescriptions or real rates of medication dispensing and wastage. Parallel evidence was also arising that standardised prescribing as opposed to individualised prescribing was routine, often with predetermined amounts of vials irrespective of the specific patient symptom as reported by (Andersson, 2023). It caused apprehension over wasteful spending and the squandering of medication (Penati, 2024). As AP costs are thought to have an insignificant role in the policy and clinical discussion, there was a gap in the financial evidence base that needed systematic investigation with complete and patient-level clinical data (Sturmberg et al. 2024). The purpose of the stated aim was to determine the costs of anticipatory medications dispensed, administered and not used to patients at the end of life at home and in residential care. The implicit objectives of the study were to: compute total costs of prescription per patient at patient level and drug level, compute percentage of prescribed medications that were actually used and that were wasted, compute specific drugs that contributed the most to the unused medications and it was also to see whether patient characteristics that included anticipatory syringe driver prescriptions, GP practice, cause of death and timing of prescription were statistically significant in difference of prescription, usage and wastage costs.

Research Appraisal-It is a retrospective, observational study based on GP and community nursing electronic and paper clinical records, and is a secondary analysis of data gathered previously to conduct the Bowers et al. (2021) mixed methods study. The research adopts a stringent quantitative methodology, and the costs were systematically calculated (Abu, Shafie & Chandriah, 2023). This was done at both patient and drug level based on a standardised reference of costs at British National Formulary tariff prices. The statistical analysis was well-specified, with non-parametric Kruskal-Wallis H tests in univariate analysis due to non-normally distributed cost data, with multivariate linear regression with bootstrapping to control confounding variables, such as gender, age, cause of death and GP practice. One of the strongest methodological aspects is the administration of complete paper and electronic records to allow real administration data to be captured (Zeleke et al. 2021), which is not regularly available in large-scale primary care data as medication usage is not logged in a systematic manner. The biggest weakness is that non-medication costs are not included, such as the time spent by community nurses making visits, GPs prescribing time and family carer input, so the actual economic cost of AP is probably understated (Lam et al. 2022). The two counties in England where the study was carried out were relatively well off thus restricting the generalisability to poorer and more ethnically diverse societies. Prices of drug tariffs can also be a local issue because of negotiations with suppliers, but the prices of BNF are an example of a standard and generally accepted benchmark.

Sampling and Selection-The sample size was the same as Bowers et al. (2021), and included patients enlisted in eleven GP practices and two related NHS Community Trusts in two English counties. Each of the practices selected the 30 most recent eligible deaths, and a pre-determined sample size of 330 patients was used to allow sufficient statistical power. The patients inclusion criteria was that they had to be aged 18 or more, lived at home or in a residential care home at least one day during their last month of life and they had to die between March 2017 and September 2019 due to any cause other than trauma, sudden death or suicide. On-site nursing care nursing home residents were excluded. Out of 167 patients taking anticipatory drugs, 164 were not left out of the cost analysis as they had full records and only three were left out because of incomplete records. The GP practices were chosen purposefully to achieve a maximum distribution of diversity in terms of practice size list, geographical location and socioeconomic variables.

Research Ethics-The South Cambridgeshire Research Ethics Committee (reference: 19/EE/0012) gave its ethical approval. Since the research was based on retrospective access to the clinical records of deceased patients without the direct consent of the patients, the Confidentiality Advisory Group of the Health Research Authority (reference: 19/CAG/0014) granted permission to process confidential patient information on the condition that it would be anonymised as soon as possible. There were no conflicts of interest that were declared. The Wellcome trust, NIHR School of primary care research and NIHR Applied Research collaboration East of England funded it, but a typical disclaimer that opinions are those of the authors only.

Chapter 4: Synthesis

4.1 Discussion

This is an analysis of the research findings of five fundamental research papers on anticipatory prescribing (AP) in community palliative care, mainly in the United Kingdom and Ireland. Such sources are a national survey of clinicians in the COVID-19 pandemic (Antunes et al., 2020), a qualitative investigation of the process of General Practitioner (GP) decision-making (Bowers et al., 2020), a retrospective observational study of the frequency and timing of prescribing (Bowers et al., 2021), a longitudinal qualitative study of patient. Also the chosen research analysis gave perspectives of caregiver experiences (Bowers et al., 2022), new dimension of economic analysis of medication (Morgan et al., 2023) which gave a new dimension to research. The aggregate study synthesis, showed collectively, for the unravelling of the complex landscape, that points to the aspects of the clinical necessity, need for the professional autonomy, framework for patient psychological wellbeing mapping, and maintaining institutional economic efficiency and the management operations conflict.

Theme 1. Rapid Innovation and Systemic Adaptation During Global Crisis

The COVID-19 pandemic acted as a stimulus to drastic and swift changes in AP practice. The national survey by Antunes et al. (2020) indicates that clinicians noted significant changes in routes of administration (47%), the type of drugs prescribed (38%), and the overall volumes dispensed (35%). The crisis required a shift to remote patient evaluations through telephone or video (63%) to reduce the risk of infection. One of the notable innovations was the greater focus on non-injectable routes, including buccal, sublingual, and transdermal delivery, especially in cases where there were limited healthcare professional (HCP) resources. It was also during this time, that there was a marked change toward family caregiver administration of medications (37%), which was very uncommon in the UK but hastened by the fear of nurse shortages while (Husted, & Dalton, 2021) argued not to show resource scarcity. Another policy that was promoted by clinicians was legislative reforms that could allow used and unused medications to be repurposed and recycled in care homes, that (Makki et al. 2019) findings supported, in order to counter the possibility of running out of stock and minimizing waste.

Theme 2. Professional Decision-Making: The GP as Gatekeeper and Consultant

The AP process heavily depends on the role of the GP but their reasoning can be informed by the necessity to cope with clinical uncertainty. Bowers et al. (2020) found that GPs perceive AP as something we can do when no longer appropriate active medical options apply. The medications are frequently prescribed by GPs as an insurance policy to avoid out of hours crises, despite the fact that they may end up being unused at all. Interestingly, although most GPs are actively on the forefront of such decisions, they also perform the role of a medical consultant (Bi & Liu, 2023), by passing the everyday evaluation and administration to the nurses in the community. This delegation is significantly dependent on the history of relationships based on trust, which is increasingly becoming tense as a result of organisational transformations that have divided communication between centralised nursing hubs and GP surgeries (Rudebeck, 2019). In addition, the presence of AP medications in a home is a frequently used sympathetic indicator by GPs to warn other clinicians who come to the home that it is no longer the primary goal of care, but the management of terminal symptoms (Andrews et al. 2020).

Theme 3. Patterns of Frequency, Timing, and Clinical Predictors

The retrospective observational data by Bowers et al. (2021) offers a statistical map of AP prevalence in detail. About half of potentially predictable deaths patients received AP medications (50.8%). These prescriptions were dispensed approximately 1,212 days before death and with a median of 17 days, with the highest prescriptions date being the day of death and the lowest being 1,212 days before death. Other important predictors of being an AP prescription recipient were specialist palliative care involvement (OR 7) and a recorded preferred place of death (OR 34). Of the patients, the data indicates that in 66.5 percent of the cases, AP was not a dynamic process but a one-size-fits-all intervention that was documented and ordered in conjunction with the other end-of-life planning forms such as DNACPR forms that was also reported in findings of (Pereira et al. 2020). This implies as (Majumder, 2024) argued that it is overdependent on electronic templates that can easily bureaucratise terminal care instead of personalising it.

Theme 4. The “Simultaneously Reassuring and Unsettling” Patient Experience

AP is a very sensitive and at times emotional experience to the patient and his/her informal caregivers. Bowers et al. (2022) referred to the intervention as both reassuring and unsettling. Although the drugs give a feeling of safety that the pain would be under control, their delivery is a sign of impending death and a physical reminder of the terminal condition of the patient. There is a coping process of living in the present used by many patients and care givers, which also reported in (Zhang et al. 2023) who used field study in order to attempt to put thoughts of death aside despite having already made plans. Discussions about AP were frequently identified to be unclear or professional-focused, with families being given the bag of medicines that (Palapar et al. 2023) findings showed to create documentation and dialogue, without much or no sense-making at all. As a result, a large number of care givers turn to the internet to find out the role played by the drugs administered to them.

Theme 5. Barriers to Medication Administration and Caregiver Burden

There is a very serious disconnection between the act of prescribing drugs and their actual taking. Bowers et al. (2022) discovered that informal caregivers frequently have a hard time convincing nurses to administer the prescribed medications. Giving more emphasis to the clinical evaluation of the nurses, rather than to the information provided by the family, is a common problem of nurses that may cause certain delays in relieving the symptoms, causing a lot of distress to the caregiver who is to act on behalf of the patient. Moreover, caregivers also do considerable work behind the scenes, such as organization of pharmaceuticals, checking prescription orders, and integration of services provided in a disjointed manner which (Ashimwe, & Davoody, 2024) found to be meeting similar results . This burden of treatment may turn overwhelming to flimsy support systems which was shown by (Linzer et al. 2022) how they feel, particularly where there is the breakdown of professional promises of timely care in practice.

Theme 6. Economic Inefficiency and the Paradox of Standardised Wastage

Morgan et al. (2023) present a financial analysis that shows that there is an important economic paradox in AP practice. Whereas the average cost of an AP prescription is fairly low at £43.17, 85% of this amount is wasted. The average price of drugs actually dispensed to a patient is just £2.16, which implies that most of the dispensed drugs ended being destroyed. The disproportionate contribution of specific drug classes to this waste includes anti-emetic drugs (Haloperidol and Cyclizine) and anti-secretory drugs (Glycopyrronium Bromide) that produce 64% of the total costs of wastage. The research proposes that the prevalent norm of ordering five vials of each drug that (Cruz et al. 2019) argued on knowledge-attitude and practice, irrespective of the symptom profile of a particular patient, contributes to the unjustified wastes. Individualised prescribing or even three initial vials of some drugs to help save money which (Fabian-Therond, 2024) findings argued without jeopardizing care has a definite range.

Theme 7. Safety Concerns and the Risks of Advance Prescribing

The resources all indicate issues related to patient safety, especially when the drugs are ordered months or years before they are needed. According to research of Bowers et al. (2021) and Bowers et al. (2020), the longer the strong opioids and midazolam are kept in a home, the higher the chances are, of abuse or diversion. Moreover, the availability of such drugs may trigger the decrease in clinical reviews; the clinician will be less motivated to visit the patient with the presence of the already available in case box, which may result in failure to identify the reversible symptoms. The inquiry into the “Gosport War Memorial Hospital” is quoted as a warning of the dangers of prescribing to anticipatory syringe drivers with large dose ranges, that (Bowers et al. 2019) findings initiated at the will of third parties, (Au et al. 2022 who may have unknown skills to the prescriber.

Conclusion

The cumulative evidence of all the above studies shows that as much as anticipatory prescribing is pillar in UK community palliative care, it is an intervention that is complex, full of clinical, psychological and economic friction. However, it is an anxiety and clinical uncertainty management instrument, but its standard use in practical life, does not commonly consider the particular requirements and preparedness of the patients and their families. AP needs to support end of life, by better incorporating the professional judgment with the professional lived experience of the informal caregivers.

5. Conclusion

The five studies discussed together shed light on a dynamic and diverse landscape of anticipatory prescribing (AP) in end-of-life care in communities. It has always been shown that AP is a frequent practice with around 50-65% of patients with foreseeable deaths given prescriptions, but that its clinical efficacy has never been sufficiently supported. Antunes et al. (2020) disclosed the COVID-19 pandemic increased the rate of innovation, opening up new drug routes and caregiver administration opportunities beyond the traditional conventions. Bowers et al. (2020) have shown that GPs consider AP as a concrete measure to deal with uncertainty, but prescribe largely on professional intuition instead of solid clinical evidence, many weeks or months before it is expected. Bowers et al. (2021) affirmed the jarring variation in prescription timing, 0-12 days preceding death, and emphasised that standardised, as opposed to individualised, prescribing prevails in practice and poses a substantial amount of safety concern. The longitudinal patient/caregiver perspective presented by Bowers et al. (2022) was the first to present AP as a reassuring and disturbing experience, where informal caregivers often bear unidentified responsibilities in advocacy around timely drug administration. Morgan et al. (2023) determined that 85% of the money spent on prescribed medications was wasted, and Haloperidol, Cyclizine and Glycopyrronium made up a disproportionate portion of wasted money. Throughout the five studies, one common thread is evident: patient and family voice continues to be marginalized in prescribing, levels of administration set by nurses pose limitations to timely symptom management, and the evidence behind this popular practice is not robust enough to warrant the unthinking standardisation.

5.1 Implications for Practice

The results of these studies have significant implications in clinical practice in the end-of-life care in the community. To begin with, the pre-eminence of standardised AP – prescribing set amounts of four drugs irrespective of their likelihood of symptoms in a person – needs to be radically redefined. The NICE guidance proposes individualised prescribing, but clinical records and cost information continue to demonstrate a template-based, one-size-fits-all practice that creates a lot of medication wastage and possible safety risks to patients. In the case of antiemetics, clinicians should be more proactive in adjusting the prescription based on the expected symptom profile of a particular patient to minimize unnecessary antiemetic prescribing of Haloperidol and Cyclizine when nausea is not expected.

Second, the prescribing conversations need to be enhanced immediately in terms of its quality and depth. Bowers et al. (2022) established that patients and caregivers were often provided with ambiguous, clinician-directed conversations that were framed with the use of minimising language and the families looked up the information about medications online. Frank, compassionate discussions of dying, expected symptoms and the place of individual drugs is a clinical and ethical requirement, reconsidered as situations evolve.

Third, the direction of care to community nurses should be supported by the strong inter-professional communication system. GPs noted an increasing dependency on fragmented centralised contact systems at the expense of direct nurse relationships, which underlie safe AP. It is important to re-establish routine interdisciplinary team meetings and open lines of communication between GPs and community nurses. Lastly, the under-the-radar strain imposed on informal caregivers in terms of advocacy of drug administration, prescription logistics and symptom monitoring should be officially recognized and established with specific carer education, concise written instructions regarding the requirements to adhere to when administering drugs and available professional contact points that can be reached at any time of the day or night.

5.2 Recommendations

Hospital perspective: Hospitals must have strong discharge planning which includes timely AP prescribing when patients leave hospital environments to their communities, and share of electronic care plans across services. It is advisable that anticipatory syringe driver prescription is only issued after due individualised clinical evaluation considering evidence of safety risks and increased costs of wastage.

Nursing point of view: Community nurses should treat informal caregivers as skilled collaborators in care and use their observations of patient distress to make administration decisions – especially when patients are unable to self-report symptoms. Clinical assessment of the end-of-life should be regularly trained to the nurses to standardise administration thresholds and minimise differences in care quality. There should be regular provision of clear and written symptom criteria and ‘out of hours’ palliative care support lines.

Carer perspective: Informal caregivers need to be talked to proactively, honestly and repeatedly about the dying process, what to expect and the anticipated symptoms when medicines are given. Guidance on requesting drug administration, when and how to do so, and a named clinical contact would significantly decrease the navigational load that families are now bearing. Provision of emotional support in the aftermath of bereavement especially in cases where drugs were not administered or care was not provided systematically.

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