Guidance on Checking MI Enquiries

On this page

• Background
• What is meant by a “check”?
• When should checks be considered?
• Who should check?
• Assessment of competence
• Checking environment
• Giving Feedback
• Sample table for recording checking requirements

Background

Medicines Information Services are generally managed by a senior pharmacist who will manage and supervise other permanent or rotational staff assigned to their team. It is acknowledged that each individual registered professional takes responsibility for the work they do, including the advice they provide to other health care professionals and to patients/carers. However, it is reasonable to assume that the Senior Pharmacist in Medicines Information could also be expected to share some responsibility for the work that others do under their management. This is particularly the case with regards to unregistered staff, including Trainee Pharmacists and Pharmacy Technicians, inexperienced staff, or those who are undergoing training.

Reports submitted via the UKMi incident reporting process continue to demonstrate that a lack of robust checking procedures, or failure of an existing checking process, contribute to adverse incidents in which incorrect or incomplete information or advice is given to enquirers. Although some of these errors involved inexperienced staff, this was not always the case, indicating that the requirement for a check is not confined to staff with little experience in medicines information.

Systems need to be in place for the supervision of the work of MI team members so that the Senior MI Pharmacist managing the service is able to provide the necessary level of assurance of its quality and safety. This assurance will comprise a number of components, many of which are captured by the UKMi Audit Standards (under review), and cover things such as staff training, resources, user experience etc. Most systems also include a degree of checking of enquiries. This guidance identifies the situations in which MI enquiry checking is most likely to reduce the risk of incorrect or incomplete information leaving the department, and how a check might be completed. Local MI Service Managers should find this guidance useful in determining their local working procedures.

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What is meant by a “check”?

A check is any one of several processes in which a second person (the checker) looks through enquiry documentation in order to ascertain that all is as it should be.

A check may be carried out prospectively in “real time”, at key points in the process or on final answers. Ideally enquiries needing a check should be checked prospectively (before the answer is given out). However, in certain circumstances checks may be carried out retrospectively (after the answer is given out) depending on the staff in the unit or on the nature of the enquiry, at the end of the working day, week or on the return of the service manager from a period of leave.

A check can be carried out at a range of levels. It isn’t possible in this guidance to specify the level of check required for each enquiry as that depends on the level of expertise of the person preparing an answer, together with the level of clinical risk that may arise from incorrect advice. Therefore, it is up to the person checking the enquiry to determine the type of check required.

MiDatabank has functionality that prevents enquiries from being completed by members of staff who require a check, through its authorisation function.

Full check

A full check means that each component of the enquiry answering process – documentation, analysis, coverage and answer – is independently assessed. The actual process of conveying the answer may also be checked, e.g. by listening to the conversation or by checking a written reply before it is sent.

Note: in the case of a telephone conversation, this should involve the reviewer/checker being able to listen to both sides of the conversation (using a speaker phone, a training adapter/splitter or similar technology) and the enquirer should be aware that another person is also listening for training/audit purposes. It is unlikely that many enquirers would object to this.

For trainees a full check may be needed, depending on their level of experience. If there are concerns that a trainee has not used the resources correctly, each source cited in preparing the answer may need to be reviewed to check that all details have been accurately extracted.

An example of a full checking procedure is given in Checklist for staff in training.

Final check

A final check involves a review of the overall approach taken in preparing an answer together with a check to see that the answer is clear and reasonable.

Retrospective check

Retrospective checks are those checks conducted after the answer has been given. They will not prevent any very immediate consequences of an error, but they may still prevent less immediate consequences depending on how soon after the advice has been conveyed they are undertaken.

Retrospective checks have value in assuring that the service is being provided to a satisfactory level and may provide useful information for appraisal, peer review and audit.

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When should checks be considered?

It is not possible, and neither is it desirable or necessary, for every component of every MI enquiry to be checked routinely by a second person. An exception may be enquiries completed by very inexperienced trainees. Situations in which a check is valuable fall into several categories:

• Complex or high risk enquiries.
• Enquiries completed by trainees or inexperienced staff.
• Written answers, as these are frequently more complex and there is no opportunity for clarification of misunderstanding by the enquirer.
• Calculations, even when the calculation is very simple.
• Enquiries with ‘political’ implications.
• Any enquiry where a member of staff feels that a check would be beneficial.

The checking requirements for each enquiry and staff group in an MI centre are at the discretion of the Medicines Information Manager. However, a sample table is provided below, that offers suggestions from QRMG regarding checking requirements for a variety of grades and types of staff working within Medicines Information. These suggestions are ‘generic’ in nature; an MI centre may choose to increase or decrease the checking requirements for each enquiry type/staff group dependent on location-specific factors such as (but not limited to):

• Experience level of staff (e.g. if permanent staff are very experienced, fewer checks may be required).
• Types of enquiry received (e.g. a specialist centre may routinely deal with more complex enquiries requiring more checks).
• Usual mode of enquiry received (e.g. if a centre routinely receives simple enquiries by email, it is unlikely to be appropriate to have all written answers checked).

It is important to note that these recommendations may additionally need to be adapted to suit the abilities of individual practitioners.

Please also note that whilst the aforementioned table may suggest that a check is required for a specific enquiry type, this does not imply that the enquiry type is suitable for completion by that member of staff. It may be more appropriate for a more experienced member of staff to complete the enquiry, or the staff member may need additional support during the enquiry answering process in addition to a final check. This should be a professional decision made on an individual basis.

A blank version of the table for adaptation/completion by the local centre is attached below.

Trainees and Inexperienced Staff

The level of check required on the work of trainees/inexperienced staff will vary both with the level of training and level of experience of the staff member concerned, and with the type of enquiry itself. There are no absolute rules for which staff require a check on their enquiries, what level of check, and for how long. However, consider the following points:

• Staff with little or no experience of MI work are likely to need a full check of all of their enquiries regardless of job role. This includes experienced pharmacists/technicians who are transferring into MI from other roles. Although their clinical/technical knowledge is likely to be good, their knowledge of MI processes and resources is likely to be limited.
• Different staff will learn at different rates, or have different levels of competence/comfort with different types of enquiry. It is likely that staff will progress through having a full check of their enquiry, through having a final check, and then possibly only a retrospective check on all/some of their enquiries. There is no set timetable for this; the senior MI pharmacist should use their professional judgement regarding when a member of staff has reached an appropriate level of competence/comfort with particular types of enquiry to allow the checking requirement to be relaxed or removed.
• You may also wish to check the work of experienced MI staff who are new to your department, although in this case it is more likely to be to ensure that they are aware of local procedures and conform to your ‘house style’ or are competent in dealing with particular specialities.

Complex or High Risk Enquiries

• These enquiries are those where an error is either more likely (complex enquiries) or where the consequences of an error could be serious (high risk). Complexity includes not only complexity of question, but also enquiries where multiple sources must be consulted and the information must be evaluated and then formulated into an answer, possibly involving the exercise of professional judgement.
• Although most of the ‘high risk’ enquiries will be those where the risk is clinical, and refers to potential adverse health consequences to a patient, the risk may also be ‘political’, as in enquiries involving a complaint, or a disagreement between two parties as to the correct course of action. This is particularly true of enquiries where legal action is in progress or is being considered.
• Enquiries with ethical implications are also more likely to benefit from a check. When checking complex or high risk enquiries, good practice would be to also briefly review the search strategy, in particular reviewing any search terms/ subheadings / limits used for bibliographical databases.

Written Answers

A written answer includes any answer where information is taken from one or more sources and summarised to be conveyed in writing. Written answers are worthy of consideration for routine checking for the following reasons:

• Most written answers are used for more complex enquiries.
• Spelling mistakes and/or grammatical errors reflect badly on the service.
• When a written answer is sent out, there is usually no opportunity for discussion or clarification with the enquirer. Thus, it is imperative to ensure that written answers are clear and complete, including the implications of tone and phrasing. For instance, although the following phrases may all be correct, they carry different implications:
  • “X is used in the treatment of Y.”
  • “X may be used in the treatment of Y.”
  • “X has been used in the treatment of Y.”
  • “There is some evidence for the use of X in the treatment of Y.”

Many centres have a policy of checking all written answers; this may be appropriate as long as it is not at the expense of checks being carried on more relevant enquiries answered by telephone or if it introduces clinically relevant delays.

Calculations

Calculations – even very simple ones – are a common source of error. There are several points at which an error can be made in a calculation, including:

• Copying error, e.g. if the formula itself is copied wrongly into enquiry documentation, or the answer copied wrongly into the enquiry answer.
• Input. If the wrong values are put into a calculation (e.g. the wrong blood results or patient weight) the answer will be wrong.
• Mathematical error, where the formula is correct, the input is correct – but an error is made in the working out.

It is advisable, where possible, to have all calculations checked by a second person. This person does not have to be a member of MI staff or even fully trained. Any member of staff can check a calculation, even if they would not be able to check any other part of the enquiry. If no-one is available locally, a calculation check should be requested from the enquirer themselves.

The member of staff undertaking the second check should:

• Ensure the correct formula has been used, checking from the resource.
• Double check the calculation’s answer without being aware of the original answer.
• Check the final answer is practical in the case of doses.
• Consider the safety of the final dose with regards to patient characteristics, e.g. renal function, liver function, age.

Any enquiry where a member of staff requests a check

Any member of MI staff should feel able to request a second check on any enquiry they deal with. There are a number of reasons why a member of staff who does not usually require a check may feel one is necessary, including:

• Workload. This may relate to either high workload or interruptions; both of these situations are known to increase the risk of error.
• Unfamiliarity with the subject of the enquiry.
• Professional judgement. Even the most senior person may sometimes feel the need to talk through an enquiry, or get a second opinion on whether they are following the right path or have made the correct decision. Knowing the limits of one’s own knowledge and expertise is the mark of the professional; it is not a sign of weakness or incompetence.

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Who should check?

Enquiries should be checked by a person with the appropriate skill, experience or training relevant to the enquiry type. This will usually be the most senior medicines information pharmacist, but this need not always be the case. It is necessary only that the checking member of staff have the knowledge and experience necessary to perform the check. Thus, a suitably experienced rotational pharmacist or MI technician may also perform a check on certain enquiries.

Non-MI staff such as a clinical pharmacist may also perform checks under certain circumstances. These may include (but are not limited to):

• Calculation checks.
• ‘Sense check’ either for legibility and readability of the answer, or in the clinical sense.
• Where the non-MI checker has specialist knowledge of the subject of the enquiry.

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Assessment of competence

Individual competence

The requirements for assessment of competence will be defined at a local level, and are likely to include both training requirements and demonstration of the required standard of practice.

Training requirements may include satisfactory completion of the sections of MiCAL and Medicines Learning Portal that are appropriate to the staff member’s role and grade. Centres dealing with particular specialities are likely to have additional training requirements.

Methods of assessment may also vary according to local practice. e.g. checklists that need completion before a trainee is formally signed off as competent.

The final judgement on whether a member of staff may answer enquiries without a check will, however, be a professional one made by the senior MI pharmacist.

Competence to check

Individual centres may have a specific procedure for determining when an individual is competent to check other staff members. This may involve a period of ‘double checking’ whereby the trainee checker is double checked by another checker. It is recognised that this may not be possible or practical in smaller, local medicines information centres. In this instance it should be a professional decision undertaken by the Medicines Information Manager, or the individual themselves if they do not have one, to determine the suitability of the staff member to undertake checks.

As with all areas of practice, even after being designated as competent to check, the individual must use their own professional judgement to ensure that they work within their area of competence and expertise.

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Checking environment

In order to reduce risk of error, it is important to ensure that sufficient time is allowed for the checker to check the enquiry carefully, and for the person answering the enquiry time to undertake any additional research or modification of the answer in response to the checker’s feedback. It is also important that the checker is able to check the enquiry in an environment free from distraction.

Individual centres may wish to consider negotiating a ‘checking deadline’ with the member of staff who is answering the enquiry. This may be done on an individual or query specific basis, or there may be a standard timeframe agreed within the department e.g. half a day, or a full day in advance of the enquiry deadline.

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Giving Feedback

After checking an enquiry, the checker should provide feedback to staff in an appropriate manner, e.g. comments in the drafted answer, verbal discussion. The functionality ‘Control M’ in MiDatabank should be used to identify feedback/data provided by checker.

After checking an enquiry, indicate whether or not the checked enquiry needs to be re-checked before sending, and who will do this (if not the allocated checker).

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Sample table for recording checking requirements

This sample table offers suggestions from QRMG regarding checking requirements for a variety of staff working within Medicines Information. These recommendations may need to be adapted to suit the abilities of individual practitioners, and the resources of the individual Medicines Information centre. This should be a professional decision made on an individual basis. Individuals should also use their professional judgement to request a check or second opinion for any specific enquiry that they feel appropriate, based on their own competence and expertise.

Key:

• X = check not routinely required
• P = prospective check (i.e. in-process and before answer is given)
• R = retrospectively (i.e. within a defined period of time after the answer is given)
• R/P = retrospective check acceptable if prospective check not possible in time frame for providing advice to enquirer

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