Exploratory Research in Clinical and Social Pharmacy 6 (2022) 100143

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Exploratory Research in Clinical and Social Pharmacy

journal homepage: www.elsevier.com/locate/rcsop

Changes to primary care delivery during the COVID-19 pandemic

and perceived impact on medication safety: A survey study
Laura L. Gleeson a, Aoife Ludlow a, Emma Wallace b, Rob Argent a, Claire Collins c, Barbara Clyne b, Lisa Mellon d,
James W. Barlow e, Benedict Ryan a, Aoife De Brún f, Alice Holton a, Muriel Pate g, Ciara Kirke g,
Michelle Flood a,1, Frank Moriarty a,1,
⁎
a
School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
b
Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Ireland
c
Research Unit, Irish College of General Practitioners, Dublin, Ireland
d
Division of Population Health Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
e
Department of Chemistry, RCSI University of Medicine and Health Sciences, Dublin, Ireland
f
UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery & Health Systems, University College Dublin,
Ireland
g
National Medication Safety Programme, National Quality and Patient Safety Directorate, Health Service Executive, Ireland

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The COVID-19 pandemic has had a profound impact on the delivery of primary care around the world. In
COVID-19 Ireland, the use of technologies such as virtual consultations and the electronic transfer of prescriptions became wide-
Primary care spread in order to deliver care to patients while minimising infection risk. The impact of these changes on medication
Community pharmacy safety is not yet known.
General practice
Objectives: The aims of this survey study were to investigate 1) the changes that have occurred in Irish primary care
Medication safety
since the start of the COVID-19 pandemic and 2) the impact of these changes on medication safety.
Methods: Anonymous, online surveys were distributed to general practitioners (GPs) and pharmacists from August–
September 2021. Surveys contained quantitative (multiple-choice, Likert scale) and qualitative (free-text) questions
concerning workflow changes, medication safety incidents and near misses, and GP/pharmacist perspectives on med-
ication safety and COVID-19. Reported medication safety incidents and near misses were categorised according to the
WHO Conceptual Framework for the International Classification for Patient Safety.
Results: In total, there were 251 responses to the survey, comprising of 211 pharmacists and 40 GPs. The most signif-
icant workflow changes during the pandemic were the widespread use of a secure clinical email service (Healthmail)
that facilitates electronic prescription transfer and communication (75.3% of respondents) and the increased use of
telephone consultations (49%). Overall, Healthmail was widely perceived to have had a positive impact on medication
safety. Most GPs did not perceive a change in the frequency of medication safety incidents during the pandemic, while
most pharmacists reported a slight increase in incidents. Survey participants highlighted pressure, patient expecta-
tions, and patient monitoring as significant challenges encountered during the pandemic.
Conclusions: During the pandemic, a number of significant changes occurred in primary care in Ireland, particularly in-
volving communication of healthcare information, with varying impacts on workflow and medication safety. Future
research should focus on the optimisation of electronic prescribing and telemedicine services in Ireland, patient per-
spectives on the changes in primary care, and interventions to improve medication safety in primary care.

1. Introduction management of medicines around the world.2 In Ireland, supported by leg-

islative and policy amendments, technologies such as virtual consultations
Medicines are the most common intervention used to maintain and im- and the electronic transfer of prescriptions, and services such as the home
prove health in primary care.1 The COVID-19 pandemic has had a profound delivery of medicines, became widely used to reduce the spread of
impact on the long-established practices of safe prescribing, dispensing and COVID-19 in healthcare settings.3,4 While these changes served an

⁎ Corresponding author.
E-mail address: frankmoriarty@rcsi.ie (F. Moriarty).
1
Denotes joint senior authorship

http://dx.doi.org/10.1016/j.rcsop.2022.100143
Received 21 February 2022; Received in revised form 27 April 2022; Accepted 27 April 2022
2667-2766/© 2022 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
L.L. Gleeson et al. Exploratory Research in Clinical and Social Pharmacy 6 (2022) 100143

important and timely role in reducing spread of the virus, they reduced and influenza and pneumococcal vaccinations.13 This scope of practice
opportunities for traditional face-to-face interaction and informal commu- was formally extended to dispense prescriptions transferred electroni-
nication between patients and healthcare professionals about safe medi- cally via Healthmail, apply professional judgement to dispense a pre-
cines use.5 scription up to 9 months after its date of issue (compared to the
In 2017, the World Health Organisation announced its third Global Pa- previous validity of 6 months) and administer COVID-19 vaccines
tient Safety Challenge, ‘Medication without Harm’, which aims to reduce the from July 2021.
worldwide level of severe, avoidable harm related to medications by 50%
over 5 years.6 However, despite increased awareness and an increased
2.3. Data collection
focus on patient safety research in recent years as recently as 2019, the
WHO estimated that 1 in every 300 patients dies due to a preventable med-
A specific survey was designed for each participant group to investigate
ical accident, and that up to 4 in 10 patients suffer an adverse event while
their attitudes and experiences regarding the impact of the COVID-19 pan-
receiving primary or ambulatory care.7 Medication safety incidents, de-
demic on medication safety in primary care (Appendices 1 and 2). Informed
fined as any preventable event that may cause or lead to inappropriate med-
consent was obtained from respondents in the first page of the survey,
ication use or patient harm, can occur at any stage during the prescribing,
where they were presented with study information, and at the end, asked
compounding, dispensing, administration, education, monitoring and use
to tick several boxes to confirm they consented to participate (see Appendi-
of medicines.8
ces 1 and 2). Surveys were developed with input from pharmacist and GP
An early finding of patient safety research was the need to adopt a pro-
members of the research group, including piloting. Each survey was deliv-
active approach to safety in healthcare, rather than reacting every time a
ered via SurveyMonkey® and consisted of four sections containing a com-
medication safety incident occurs.9 Risk management should be an integral
bination of multiple-choice, Likert scale and free-text questions:
part of the work of a healthcare organisation and members should always
be aware of risks that could occur. The delivery of primary care in Ireland 1. Demographics
and other countries changed rapidly at the start of the COVID-19 pandemic; 2. Workflow Changes and COVID-19
however the impact of these changes on medication safety is not yet clear.10 3. Medication Safety Incidents and Near Misses
Many of these changes may persist as the COVID-19 pandemic continues 4. Opinions on Medication Safety and COVID-19
and potentially beyond, hence it is important to examine and understand
The following demographic information was collected in Section 1: gen-
their impact. The aims of this survey study were: 1) to investigate how
der, age group, and practice/pharmacy location. In Section 2, respondents
Irish primary care has changed since the start of the COVID-19 pandemic
were asked what new services/technologies were introduced into their
and 2) to examine the perceived impact these changes could have on med-
practice during the pandemic, e.g., home delivery of medicines, electronic
ication safety.
transmission of prescriptions and video or telephone consultations, and
the perceived impact on medication safety. In Section 3, respondents
2. Methods
were given definitions for medication safety incidents and near misses,
asked whether they had been involved in either in the past 8 weeks and,
2.1. Study design and participants
if so, to provide details. Finally, in Section 4, Likert-scaled and free-text
questions assessed the perceived impact of the COVID-19 pandemic on
This was a cross-sectional study of community pharmacists and general
medication safety. ‘Not applicable’ and ‘Don't know’ options were included
practitioners (GPs) using an online anonymous survey. Ethical approval for
for all questions, and no mandatory responses were required. Key differ-
the study was granted by the Research Ethics Committee of the Royal Col-
ences between the GP and pharmacist surveys were that GPs were addition-
lege of Surgeons in Ireland (REC No. 202105021). Electronic copies of the
ally asked about the impact of the COVID-19 pandemic on laboratory and
surveys were shared on social media (Twitter and LinkedIn) over a four-
other monitoring relating to patients' medications, with other questions re-
week period in August and September 2021, inviting community pharma-
lating to services and technologies tailored to the practice setting i.e. only
cists and GPs to take part. There are approximately 6800 pharmacists and
pharmacists were asked about home delivery of medicines.
2500 GPs in Ireland currently. An invitation to the survey was also distrib-
uted to community pharmacists via the Pharmaceutical Society of Ireland
(PSI) email list. Eligibility criteria were being a registered pharmacist/ 2.4. Data analysis
physician and being in active practice as a community pharmacist/GP in
Ireland since January 2020 (to ensure participants had experience of pri- Quantitative data analyses were conducted using Stata version 17
mary care practice prior to the introduction of the COVID-19 public health (StataCorp, College Station, Texas, USA). Descriptive statistics were gener-
measures in March 2020). Participants confirmed their eligibility and pro- ated for all quantitative survey questions, separately for pharmacist and GP
vided consent at the outset of the survey. Participation in the survey was respondents. The medication safety incidents and near misses reported by
voluntary, with no incentive offered, and an indicative time for completion respondents in Section 3 were categorised according to the WHO Concep-
of 10 min was given to participants. tual Framework for the International Classification for Patient Safety
(ICPS).14
2.2. Concepts and definitions No hypothesis testing was specified a priori. As a post-hoc analysis,
Spearman's rank correlation and Kendall's tau correlation were computed
For the purposes of this paper, the term ‘telemedicine’ will refer to to assess the relationship between answers to the question ‘In your opinion,
the use of technology to deliver healthcare at a distance, the term ‘vir- how have the number of medication safety incidents in your practice changed
tual consultations’ will refer to the use of telephone and video consulta- since the COVID-19 pandemic?’ and responses to the following two state-
tions to deliver care to patients, and ‘primary care’ refers to general ments: 1) ‘In this practice/pharmacy, we are open to embracing new technologies
practice and community pharmacy. ‘Healthmail’ refers to a secure clin- in our work processes’ and 2) ‘In this practice/pharmacy, we are open to embrac-
ical email service which was introduced in Ireland in 2014 to transfer ing workflow changes to improve medication safety’. The responses to each of
patient information. Healthmail did not become widely used until these questions were 5-point Likert scales. For the purposes of these tests,
2020, when legislative changes allowed prescriptions to be transferred the responses for pharmacists and GPs were combined and a significance
electronically for the first time, via the service, and it was integrated level of p ≤ 0.05 was adopted.
into GP prescribing software.11,12 Prior to the pandemic, community Using conventional content analysis, responses to free-text survey ques-
pharmacist practice in Ireland included reviewing, reconciliation and tions were reviewed and grouped into categories reflecting the attitudes of
dispensing medications, patient counselling, managing minor ailments, survey respondents towards the impact of COVID-19 on medication safety.

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2.5. Patient and public involvement by GPs during the COVID-19 pandemic were ‘Electronic transmission of pre-
scriptions via Healthmail’ and ‘Phone consultations for COVID-19 screening’,
Patients provided input in identifying and prioritising the focus of the each of which were introduced by 77.5% of GP respondents (n = 31).
project at the design stage through short interviews with a small number Fig. 1 shows the effect of new services on medication safety, as per-
of patients, designed to gather information to guide study priorities and en- ceived by pharmacist and GP respondents. The service that was perceived
hance potential impact for patients. This initial work identified that people's by most pharmacists who used it to have a positive effect on medication
usual routines for engaging with primary care had been significantly safety was ‘Healthmail, for electronic prescription transfer and/or HCP commu-
disrupted by logistical changes and feeling fearful about exposure to nications’ (n = 96, 45.1%), while the service most perceived to have a neg-
COVID-19 when in healthcare facilities. It was noted that while some im- ative effect was ‘Telephone Consultations’ (n = 13, 6.2%). Similarly for GPs,
pacts have been positive e.g. medicines delivery for regular prescriptions, ‘Healthmail, for electronic prescription transfer and/or HCP communications’
there were concerns about how to access information about medicines and was perceived by the highest percentage of respondents who introduced
supplements. This helped to shape the research questions of this study in it to have a positive effect on medication safety (n = 27, 67.5%), while
focusing on changes to primary care delivery and medication safety. the service most perceived to have a negative effect was ‘Email Consulta-
tions’ (n = 5, 12.5%).
3. Results Table 2 presents a selection of survey respondents' comments on the im-
pact of the most widely introduced changes, Healthmail and virtual consulta-
3.1. Demographics tions, on medication safety. Participants reported that Healthmail had a
significant impact on pharmacists' workflow, allowing prescriptions to
In total, there were 251 responses to the survey, comprising of 211 phar- be prepared in advance of the patient arriving at the pharmacy, and both
macists and 40 GPs. Demographic information about survey respondents pharmacists and GPs agreed that Healthmail had a positive impact on interpro-
are presented in Table 1. The majority of respondents were female (n = fessional communication. However, pharmacists also commented that paper-
162, 64.5%), aged 30–49 (n = 170, 67.8%), and based in a town (popula- work associated with Healthmail could increase their workload, and that
tion 1500-49,999) (n = 130, 51.8%). Most GPs worked in a group practice Healthmail lacked the advantages of a fully integrated electronic prescribing
(n = 34, 85%), while most pharmacists worked in an independent system. Similarly, while there were advantages to virtual consultations, espe-
pharmacy (n = 93, 44.1%). cially during a pandemic, both GPs and pharmacists acknowledged that they
could not substitute face-to-face care, due to a lack of physical examinations
and visual cues.
3.2. Workflow changes
3.3. Medication safety incidents and near misses
The most widely introduced workflow change across both subgroups
was the use of Healthmail (n = 182, 72.5%), followed by telephone consul-
Of 211 pharmacist respondents, 73 (34.6%) reported being involved in
tations (n = 123, 49%). Detailed results regarding the categories and sub-
a medication safety incident in the past 8 weeks of their practice, while 114
categories of new services introduced during the COVID-19 pandemic are
(53.3%) reported being involved in a near miss. Three GP respondents
presented in Appendix 3. The most common new service introduced by
(7.5%) reported being involved in a medication safety incident in the past
pharmacists was ‘Electronic receipt of prescriptions via Healthmail’ (n = 151,
8 weeks of their practice, and ten (25.0%) reported being involved in a
71.6%), followed by ‘Communication with other healthcare professionals via
near miss.
Healthmail’ (n = 147, 60.7%). The most common new services introduced
In total, 92 pharmacists provided information on the type of medication
safety incident or near miss in which they were involved. Two incidents in-
Table 1
volved more than one type of error, therefore 94 incident types were
Demographics.
categorised according to the ICPS (Fig. 2). ‘Wrong Dose/Strength/
Pharmacist Pharmacist GP GP Total Total
Frequency’ was the incident type most commonly reported by pharmacists
(n = 211) (%) (n = 40) (%) (n = 251) (%)
(n = 39, 41.5%), followed by ‘Wrong Drug’ (n = 27, 28.7%). Only eight
Gender
GPs provided information on the type of medication safety incident or
Male 68 32.2 17 42.5 85 33.9
Female 140 66.4 22 55.0 162 64.5
near miss in which they were involved; these results were not analysed
Non-Binary or due to the small sample size.
3 1.4 1 2.5 4 1.6
Prefer not to saya

Age
3.4. Medication safety and COVID-19
<30 13 6.2 1 2.5 14 5.6
30–39 71 33.6 14 35.0 85 33.9 When asked ‘In your opinion, how has the number of medication safety in-
40–49 73 34.6 12 30.0 85 33.9 cidents in your practice changed since the COVID-19 pandemic?’, 39.3% of
50–59 37 17.5 11 27.5 48 19.1
pharmacists (n = 83) felt there had been an increase in medication safety
>60 17 8.1 2 5.0 19 7.6
incidents, 31.8% felt that there had been no change (n = 67), and 16.1%
Location felt there had been a decrease (n = 34). More than one third of GPs
City 68 32.2 19 47.5 87 34.7
(35.0%, n = 14) felt there had been an increase in medication safety inci-
Town 116 55.0 14 35.0 130 51.8
Village 27 12.8 7 17.5 34 13.5 dents, while 27.5% felt there had been no change (n = 11), and 20.0%
felt there had been a decrease (n = 8) (Fig. 3).
Practice type
Fig. 4 shows the responses of GPs to the questions ‘To what extent has the
Single-handed 5 12.5
Group 34 85.0 COVID-19 pandemic impaired the ability to ensure appropriate laboratory mon-
Other 1 2.5 itoring relating to your patients’ medications?’ and ‘To what extent has the
COVID-19 pandemic impaired the ability to appropriately conduct other moni-
Pharmacy type
Independent 93 44.1 toring (e.g. blood pressure monitoring) relating to your patients' medications?’.
Small Group 29 13.7 Most GP respondents reported some degree of impairment to monitoring,
Large Group 49 23.2 with nearly half (n = 19, 47.5%), reporting that the COVID-19 pandemic
Chain 27 12.8 had moderately impaired laboratory monitoring of patients' medications,
Other 13 6.2
while 37.5% (n = 15) felt that other types of monitoring had been moder-
a
Categories combined for reporting due to low numbers in sub-groups. ately impaired.

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L.L. Gleeson et al. Exploratory Research in Clinical and Social Pharmacy 6 (2022) 100143

Healthmail 42 51 96 5

Text service 2 14 4 25 5

Phone Consultaon 13 15 37 18 8

Video Consultaon 4 33 6 6

Online Ordering 5 21 27 42 6

Delivery 9 42 52 32 23

0 30 60 90 120 150 180 210

No. of Pharmacist Respondents

Negave Effect No Effect Posive and Negave Effects Posive Effect Don't Know/No Response

Email consultaons 5 2 1 2

Healthmail 2 27 3

Text service 3 2 8 2

Phone Consultaon 4 6 14 4 4

Video Consultaon 1 10 6 1 5

Online Ordering 1 6 5 3

0 5 10 15 20 25 30 35 40
No. of GP Respondents

Negave Effect No Effect Posive and Negave Effects Posive Effect Don't Know/No Response

Fig. 1. Perceived effects of new services on medication safety reported by pharmacists and GPs.

Both pharmacists and GPs indicated that they were open to implementing responded that their practice/pharmacy was more open to new technologies
new measures to improve medication safety; 55.0% (n = 116) and 65.0% than they were before COVID-19.
(n = 26) respectively agreed with the statement ‘In this pharmacy/practice, In post-hoc analysis, there was a small, but statistically significant, asso-
we are open to implementing new measures to improve medication safety’. Similarly, ciation between a perceived increase in the number of medication safety in-
more than two thirds of both pharmacists (n = 142, 67.3%) and GPs (n = 29, cidents since the onset of the COVID-19 pandemic, and openness to
72.5%) agreed with the statement ‘In this pharmacy/practice, we are open to im- embracing new technologies in work processes (r (182) = 0.167, p =
plementing new technologies in our work processes’ (Fig. 5). When asked whether 0.024, τb = 0.151, p = 0.022). However, no statistically significant corre-
their attitudes towards new technologies had changed since the COVID-19 lation was identified between the number of medication safety incidents
pandemic, 57.5% of GPs (n = 23) and 46.9% of pharmacists (n = 99) and openness to embracing new workflow changes, although the sample

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L.L. Gleeson et al. Exploratory Research in Clinical and Social Pharmacy 6 (2022) 100143

Table 2 pressure, patient expectations, and patient monitoring. Illustrative com-

Illustrative comments on the perceived impact of workflow changes on medication ments in relation to several themes are shown in Table 3.
safety.
Healthmail • ‘We are now rarely preparing a prescription for someone who is waiting 4. Discussion
in store for it. This means that we are continuously and steadily busy
but never under severe pressure’ (P30)
• ‘Healthmail has been positive in many aspects but it is not true e- The aims of this survey study were to investigate 1) the changes that oc-
-prescribing, so many downfalls’ (P77) curred in Irish primary care because of the COVID-19 pandemic and 2) the
• ‘It does increase the workload as the pharmacy must print the prescrip- perceived impact of these changes. Increased adoption of telehealth may
tions’ (P7)
have improved access for people who had challenges attending healthcare
• ‘Healthmail has been really helpful during the pandemic, however
patients often have unrealistic expectations that their prescription
settings in person, and electronic prescription transfer (via Healthmail) re-
should be ready for collection as soon as the Dr presses send on his/her duced the need for patients to visit pharmacies. However these changes also
computer’ (P85) affected the opportunities for patient-health professional communication.
• ‘It should be easy to reply to the prescription with a query but replies Overall, use of Healthmail was the workflow change most widely re-
are seldom received resulting in having to phone surgery to clarify
ported by respondents; it was also the change most widely perceived to
issues resulting in delays in patients receiving medications’ (P40)
Virtual • ‘Patients can check what medicine they have at home and have access have had a positive impact on medication safety by both subgroups. In
consultations to what they are taking but missing visual aspect of consultation can be the free-text comments, pharmacists reported that Healthmail had a signif-
problematic’ (GP8) icant, mostly positive impact on pharmacy workflow, allowing prescrip-
• “Hard to read a patients understanding over a phone without the usual tions to be prepared in advance of patients' arrival at the pharmacy, and
visible signs” (P7)
• “Patients' contact with their GPs seems to have decreased significantly.
both GPs and pharmacists reported that Healthmail had a positive impact
Patients are not having their medicines reviewed regularly because they on interprofessional communication, allowing queries and messages to be
haven't been attending their doctors as often. Repeat prescriptions are transferred more quickly and easily.
just sent via healthmail without a health check from the doctor or a While both electronic prescription transfer and integrated electronic pre-
medication review, which could lead to medication safety issues” (P2)
scribing systems have been widely used in countries such as England,
• ‘Patients would email at all hours of the day and night and expect an
instant answer’ (GP2) Denmark and the United States for several years, legislation for the electronic
transfer of prescriptions was not introduced in Ireland until April 2020.4,15,16
Countries with integrated e-prescribing systems have benefitted from safer
who responded to this latter question was smaller (r (143) = 0.109, p = and more streamlined medicines management processes.15,17 In 2021, the
0.196, τb = 0.095, p = 0.19). Irish Medication Safety Network published a report outlining the disadvan-
tages of the Healthmail system, including a lack of integration within
existing electronic systems, impact on current workflow practices, the risk of
3.5. Views on medication safety and COVID-19 selecting an inappropriate prescription recipient, and the risk of poor quality
documentation.18 Although some of these disadvantages were highlighted in
Responses to open-ended questions asking about the most significant the survey findings, most notably the impact on workflow, Healthmail was
changes to pharmacy and general practice, contained in Section 4 of the generally perceived positively by survey respondents. The widespread use of
survey, were subjected to conventional content analysis. Respondents Healthmail in Ireland represents a significant step forward from paper-based
most often mentioned Healthmail, virtual consultations and COVID-19 prescriptions, yet it remains an electronic prescription transfer system, which
safety measures such as social distancing as significant changes relating to lacks the advantages of a fully integrated electronic prescribing system. The
medication safety. With respect to challenges, respondents highlighted National eHealth (electronic health) Strategy, published in 2013, advocates

50
Percetnage of Reported Incident Types

41.5
40

28.7
30

20

8.5
10 6.4
4.3 3.2 3.2
0.0 1.1 1.1
0

Fig. 2. Types of Medication Safety Incidents Reported by Pharmacists.

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L.L. Gleeson et al. Exploratory Research in Clinical and Social Pharmacy 6 (2022) 100143

40
34.1 Pharmacist
31.8
GP

Percentage of Repondents
30 27.5
25.0

20
15.0
12.3 12.5
10.0
10 7.6
5.0 5.2 5.2 5.0
3.8

Fig. 3. Reported Impact of COVID-19 on Medication Safety Incidents.

50 47.5
Laboratory Monitoring
Percentage of GP Respondents

Other Monitoring
40 37.5

30
25.0
22.5
20
15.0
12.5 12.5 12.5
10.0
10
2.5 2.5
0.0
0

Fig. 4. GP reported impact of COVID-19 on patient monitoring relating to medications.

for the implementation of an eHealth system eHealth (Electronic Health) to conduct telephone consultations after deliver medicines to patients'
involving ‘the integration of all information and knowledge sources involved in homes. A survey of members of the Irish College of General Practitioners
the delivery of healthcare via information technology-based systems’, however an (ICGP) found that there was a significant decrease in the number of face-
updated strategy has yet to be published.19 to-face consultations, and a significant increase in the number of virtual
The other major change noted in the survey was the increased use of vir- consultations, between February and June 2020, as well as a decrease in
tual consultations in primary care. At the beginning of the pandemic in consultations for non-COVID related symptoms.21 While these changes
Ireland, the general advice to the public was to reduce social interactions.20 were necessary to prevent COVID-19 infection in healthcare settings,
Although the practical implementation of this advice varied across pharma- many survey respondents reported concerns regarding the lack of face-to-
cies and general practice clinics, survey results indicate that telephone con- face contact with patients, including the increased likelihood of misdiagno-
sultations were widely introduced by GPs, and that many pharmacies began ses and reduced opportunities for patient monitoring.

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L.L. Gleeson et al. Exploratory Research in Clinical and Social Pharmacy 6 (2022) 100143

50
Pharmacist
40.0 GP 40.3
40
Percentage of Respondents

36.0
32.5

30
25.0

19.0
20

10
2.8 2.5
0.5 0.0 0.5 0.0 0.9 0.0
0

50
Pharmacist
GP
40 37.4 37.5
Percentage of Respondents

35.0

29.9
30
24.2 25.0

20

10
4.3
2.8 2.5
1.4
0.0 0.0 0.0 0.0
0

Fig. 5. Level of respondent agreement on the openness within their Pharmacy/Practice to implementing new measures to improve medication safety (top) and to
implementing new technologies in their work processes (bottom).

The widespread use of telephone and video consultations is a relatively of learning and adaptation was required before telemedicine could be
new phenomenon in Ireland, however studies on the safety and efficacy of successfully implemented in a healthcare organisation, and a 2018 study,
telemedicine and virtual consultations have been conducted in recent years conducted in the United Kingdom, found that while virtual consultations
in other countries. A 2010 review of systematic reviews found mixed evi- are safe, effective, and practical for certain patients, there are challenges
dence for the effectiveness of telemedicine, and highlighted a lack of evi- associated with embedding the service within routine practice.23,24
dence regarding patient satisfaction with telemedicine and its impact on The increase in telemedicine occurred quickly in Ireland, with little im-
relationships between patients and healthcare professionals.22 A 2017 plementation research or guidance for patients and healthcare profes-
study on the use of telemedicine in Norway reported that a long process sionals. The Irish Medical Council has produced guidance for doctors

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L.L. Gleeson et al. Exploratory Research in Clinical and Social Pharmacy 6 (2022) 100143

Table 3 improve medication and patient safety. Research conducted in countries

Illustrative comments on the perceived significant changes and challenges faced in where telemedicine and electronic prescribing have been in place for sev-
primary care during the COVID-19 pandemic. eral years may provide important insights for the future of Irish primary
Remote care • ‘Healthmail has had massive benefits from making it easier to query care. Finally, qualitative research may be helpful in exploring some of the
and fix issues we have clinically and administratively with a direct issues arising in this paper in more depth, as well as patient perspectives
connection to the Dr thereby greatly improving medication safety’ on the changes in primary care.
(P163)
• “Not having patients in the practice and not being able to fully clinically
examine them means that medication safety has been compromised e.g. 4.1. Strengths and limitations
sometimes leads to over/mis/under-prescribing of medications” (GP24)
• “Prescriptions arriving from GPs do not always replicate what changes To the best of our knowledge, this is the first study to examine the
were made from the hospital” (P7)
impact of the COVID-19 pandemic on workflow and medication safety in
Patient • ‘Heathmail is brilliant except for the fact that patients walk in straight
expectations from their appointment next door in the surgery and expect their pre- primary care internationally. The survey design provided detailed insights
scription to be dispensed and ready to collect instantly’ (P5) into the experiences of GPs and community pharmacists during the pan-
• ‘Customers unrealistic expectations of how prescriptions are prepared demic, and the anonymous nature of the data collection allowed partici-
leads to increased pressure’ (P49)
pants to report experiences and opinions they may not otherwise have
• ‘Patients are rushing to get in and out of the pharmacy quickly trying to
hurry the dispensing process up’ (P8)
disclosed. Nonetheless, this study has a number of limitations. The low re-
Safety • ‘Implementing a 24 h rule for repeat scripts’ (P7) spondent numbers limit the generalisability of the results. Considerably
strategies • ‘Taking a break, organising prescriptions by priority, increasing the more pharmacists responded to the survey than GPs, therefore it is possible
waiting time for the patient, trying to control anxiety’ (P12) that the study conclusions are focussed on issues that affected pharmacists
• ‘Protected time slots to complete Rx’ (GP24)
more than GPs. This discrepancy in response rates could be due to differing
data collection methods between the two groups. However, results are
presented by professional group to ensure this does not skew the findings.
conducting phone and video consultations during COVID-19, which states As the pandemic is ongoing, attitudes towards workflow and medication
that ‘doctors are responsible for determining the appropriateness of telemedicine safety may change with time. We relied on healthcare professionals' reports
to support the best outcome for their patients, considering their patients’ context on the perceived impact on medication safety, and were unable to collect
and symptoms'; no formal guidance on telemedicine has been produced for objective outcome measures. There was also a risk of recall bias since re-
pharmacists.3 The results of this study indicate that patient monitoring spondents were recalling the pre-pandemic period (approximately 18
and counselling was impaired during the COVID-19 pandemic; 75% and months previous). However questions were phrased to ask about the cur-
85% of GPs, reported that laboratory monitoring and other types of moni- rent situation, relative to before the pandemic, as a measure to mitigate
toring, respectively, had been impaired to some degree, while pharmacists this.
regularly mentioned in the free text comments that checking patient under-
standing during telephone consultations was difficult due to a lack of visual 5. Conclusion
cues. In the survey of ICGP members, it was noted that while the use of tele-
medicine was invaluable in the continuation of care during the pandemic, This survey study investigated the changes that occurred in Irish pri-
patients who are digitally disadvantaged, and therefore less likely to engage mary care during the COVID-19 pandemic and the impact of these changes
in telemedicine, are often from populations already at greater risks of on medication safety. A number of changes occurred in primary care during
adverse health outcomes, such as older people and those in lower socioeco- the pandemic, the most significant being the introduction of electronic pre-
nomic classes21; however, a report from the US National Poll for Healthy scription transfer via Healthmail and the increased use of virtual consulta-
Ageing found that telemedicine acceptability amongst older adults tions. Both pharmacists and GPs perceived an increase in medication
increased substantially during the first year of the pandemic.21,25 Telemed- safety incidents during the pandemic. Future research should focus on
icine can be a safe and effective tool in the provision of medical care to methods to improve medication safety in primary care, including the opti-
certain patients; however, its implementation requires significant planning misation of electronic prescribing and telemedicine services in Ireland.
and resources, and it cannot act as a blanket substitute for face-to-face care.
Given the numerous ways in which GP and pharmacist workflows Funding
changed during the pandemic, it could be expected that the frequency
of medication safety incidents would increase; this was supported by This study was funded by the Health Research Board (Ireland) via the
the survey results. Survey respondents reported managing patient ex- CONNECTS project grant (RCSPS-2020-032).
pectations, longer wait times for prescriptions, and generally ‘managing
stress’ as important safety strategies they had introduced during the
pandemic, and also indicated their openness to introducing new tech- Declaration of Competing Interest
nologies and strategies to improve medication safety. The high levels
of stress and burnout experienced by frontline workers in Ireland and ☒ The authors declare that they have no known competing financial in-
the UK during the pandemic have been widely reported.26–28 Introduc- terests or personal relationships that could have appeared to influence the
ing such methods to relieve pressure and stress in healthcare organisa- work reported in this paper.
tions could have a positive impact on patient safety and medication ☐The authors declare the following financial interests/personal rela-
incident rates. The pandemic has seen extensive developments of the tionships which may be considered as potential competing interests:
role of community pharmacists internationally, and during this time,
GPs have also increasingly taken on the care and treatment of patients Appendix A. Supplementary data
previously managed in hospital.29,30 It will also be important to consider
how the workload and burden associated with these expanded roles Supplementary data to this article can be found online at https://doi.
could potentially impact patient and medication safety. org/10.1016/j.rcsop.2022.100143.
This survey study has elucidated the many changes that occurred in
Irish primary care during the COVID-19 pandemic, and the impact of References
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