{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T05:03:09Z","timestamp":1788930189170,"version":"build-2803163510"},"reference-count":35,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2026,5,3]],"date-time":"2026-05-03T00:00:00Z","timestamp":1777766400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,5,3]],"date-time":"2026-05-03T00:00:00Z","timestamp":1777766400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Health Expectations"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The prison population in England and Wales exceeds 88,000, with a high turnover \u2013 47% of sentenced admissions in 2023 served less than 12 months. Transitions from prison to the community are recognised as high\u2010risk periods for medication\u2010related harm, driven by complex health needs, short custodial stays, and fragmented healthcare systems. While national and international guidance exists to support safe medication management, implementation during prison\u2010community transitions remains inconsistent, and evidence on both the drivers of unsafe medication practices and potential solutions is limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>This study explored the human, organisational, and environmental factors influencing medication safety during transitions from prison to the community, as well as potential solutions for improvement, from the perspective of staff involved in these transitions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Qualitative semi\u2010structured interviews were conducted with 12 staff members working in roles relevant to transitions from prison to the community, including general practitioners, pharmacists, and prison officers. Participants were recruited through professional networks and snowball sampling. Data were thematically analysed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Five main factors impacting medication safety during transitions were identified: release practices, care coordination and communication issues, staffing shortages, IT system limitations, and patient\u2010related factors. Key findings highlighted risks associated with immediate releases, discontinuity in medication regimens, insufficient staffing for discharge planning, and poor information transfer between prison and community healthcare providers. These challenges were further compounded by patient\u2010level issues such as low health literacy, substance use, and housing instability. Staff proposed several improvements to enhance medication safety during prison\u2010to\u2010community transitions, including electronic prescribing for timely access to medication, improved information transfer, dedicated discharge teams to ensure medication follow\u2010up, early discharge planning to address medication needs, and multi\u2010disciplinary meetings to coordinate complex care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Medication safety during transitions from prison to community healthcare requires coordinated efforts to address organisational challenges, including short\u2010notice releases and inadequate information transfer, as well as human factors such as communication barriers and staffing constraints. Improvements that clarify roles, enhance processes and technology, and foster cross\u2010system collaboration are essential to ensuring continuity of care and medication safety.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patient or Public Contribution<\/jats:title>\n                    <jats:p>Two people, one with lived experience of care transitions and one carer, contributed to study design, recruitment strategies, participant materials, and the analysis plan through quarterly input. Findings were shared with a wider group of lived experience representatives, carers, professionals, and policy makers, who informed interpretation and dissemination. While PPI members did not directly participate in coding or analysing the data, their input ensured that the study design and interpretation were informed by real\u2010world perspectives.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/hex.70684","type":"journal-article","created":{"date-parts":[[2026,5,4]],"date-time":"2026-05-04T05:41:24Z","timestamp":1777873284000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Exploring Medication Safety in Transitions From Prison to Community: A Qualitative Study"],"prefix":"10.1111","volume":"29","author":[{"given":"Claire","family":"Planner","sequence":"first","affiliation":[{"name":"NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK"},{"name":"NIHR Greater Manchester Patient Safety Research Collaboration University of Manchester Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard N.","family":"Keers","sequence":"additional","affiliation":[{"name":"NIHR Greater Manchester Patient Safety Research Collaboration University of Manchester Manchester UK"},{"name":"Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK"},{"name":"Optimising Outcomes with Medicines (OptiMed) Research Unit Pennine Care NHS Foundation Trust Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denham","family":"Phipps","sequence":"additional","affiliation":[{"name":"Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ozlem Eylem van","family":"Bergeijk","sequence":"additional","affiliation":[{"name":"NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8257-1090","authenticated-orcid":false,"given":"Natasha","family":"Tyler","sequence":"additional","affiliation":[{"name":"NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK"},{"name":"NIHR Greater Manchester Patient Safety Research Collaboration University of Manchester Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"Shaw","sequence":"additional","affiliation":[{"name":"Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Darren","family":"Ashcroft","sequence":"additional","affiliation":[{"name":"NIHR Greater Manchester Patient Safety Research Collaboration University of Manchester Manchester UK"},{"name":"Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7153-5745","authenticated-orcid":false,"given":"Maria","family":"Panagioti","sequence":"additional","affiliation":[{"name":"NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK"},{"name":"NIHR Greater Manchester Patient Safety Research Collaboration University of Manchester Manchester UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,5,3]]},"reference":[{"key":"e_1_2_11_2_1","unstructured":"Ministry of Justice. Prison population bulletin: weekly 20 October 2023. London: Ministry of Justice;2023."},{"key":"e_1_2_11_3_1","unstructured":"Ministry of Justice. Prison population projections 2022 to 2027 England and Wales. London: Ministry of Justice;2023.https:\/\/assets.publishing.service.gov.uk\/media\/63f62718e90e077baea173c1\/Prison_Population_Projections_2022_to_2027.pdf."},{"key":"e_1_2_11_4_1","volume-title":"Prison Mental Health Services in England","author":"Durcan G.","year":"2023"},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.58248\/PB58"},{"key":"e_1_2_11_6_1","doi-asserted-by":"publisher","DOI":"10.1093\/bmb\/ldx052"},{"key":"e_1_2_11_7_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.j1378"},{"key":"e_1_2_11_8_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12913-022-08209-6"},{"key":"e_1_2_11_9_1","unstructured":"Ministry of Justice. Safety in Custody Statistics England and Wales: Deaths in Prison Custody to June 2023 Assaults and Self\u2010Harm to March 2023. London: Ministry of Justice;2023 https:\/\/www.gov.uk\/government\/statistics\/safety-in-custody-quarterly-update-to-march-2023\/safety-in-custody-statistics-england-and-wales-deaths-in-prison-custody-to-june-2023-assaults-and-self-harm-to-march-2023."},{"key":"e_1_2_11_10_1","volume-title":"Alcohol and Drug Treatment in Secure Settings 2020 to 2021: report","year":"2022"},{"key":"e_1_2_11_11_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11524-018-0276-0"},{"key":"e_1_2_11_12_1","doi-asserted-by":"publisher","DOI":"10.1111\/eos.12972"},{"key":"e_1_2_11_13_1","first-page":"43","volume-title":"Global Burden of Preventable Medication\u2010Related Harm in Health Care: A Systematic Review","author":"Panagioti M.","year":"2024"},{"key":"e_1_2_11_14_1","doi-asserted-by":"publisher","DOI":"10.1111\/bcp.15107"},{"key":"e_1_2_11_15_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(17)31047-4"},{"key":"e_1_2_11_16_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0275907"},{"key":"e_1_2_11_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(23)00152-4"},{"key":"e_1_2_11_18_1","doi-asserted-by":"publisher","DOI":"10.12968\/pnur.2017.28.9.386"},{"key":"e_1_2_11_19_1","doi-asserted-by":"publisher","DOI":"10.1111\/hsc.12445"},{"key":"e_1_2_11_20_1","unstructured":"NHS England. Ensuring GP Practices and Community Pharmacy Are Ready to Support Individuals Being Released Early From Prison as Part of the Initiative to Help Tackle Prison Pressures. London: NHS England;2024 https:\/\/www.england.nhs.uk\/long-read\/ensuring-gp-practices-and-community-pharmacy-are-ready-to-support-individuals-being-released-early-from-prison\/."},{"key":"e_1_2_11_21_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjph-2023-000735"},{"key":"e_1_2_11_22_1","doi-asserted-by":"publisher","DOI":"10.31389\/jltc.161"},{"key":"e_1_2_11_23_1","volume-title":"Safer Prescribing in Prisons: Guidance for Clinicians","author":"Royal College of General Practitioners","year":"2019"},{"key":"e_1_2_11_24_1","doi-asserted-by":"publisher","DOI":"10.3310\/GRFV4068"},{"key":"e_1_2_11_25_1","doi-asserted-by":"publisher","DOI":"10.1177\/13634593231195785"},{"key":"e_1_2_11_26_1","doi-asserted-by":"publisher","DOI":"10.1177\/01410768231166138"},{"key":"e_1_2_11_27_1","article-title":"The Incidence of Avoidable Healthcare\u2010Associated Harm in Prisons in England: A Retrospective Case Note Review","author":"McFadzean I. 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