Engineering care transitions: Clinician perceptions of barriers to safe medication management during transitions of patient care

The Macro Impact of Microtransitions in Post-acute and Long-Term Care

The care transitions concept emerged in medical literature more than 40 years ago, with an exponential rise in publications dedicated to its exploration since that time. It is generally accepted that older patients are particularly vulnerable during care transitions because of complex medical comorbidity, frailty, cognitive dysfunction, and the fragmented nature of health care. A care transition is defined as the movement of patients from one health care setting to another as their care needs change during acute or chronic illness. Easily recognizable examples include the discharge of a patient from the hospital to a skilled nursing facility or an admission to the hospital after a patient is evaluated in the emergency department. These macrotransitions are marked by major changes in clinical condition and span days to weeks. This discussion examines a new term coined by the authors: microtransitions, which are care transitions characterized by movement of a patient between health care settings or within a given setting, usually over shorter periods (less than 24 hours) and accompanied by changes in clinical or custodial responsibility for a patient. Although often unrecognized as formal care transitions, these microtransitions, if not handled appropriately, can lead to poor outcomes, including clinical deterioration and the need for macrotransition. The authors propose formal recognition of microtransitions, standardization of processes related to them, and practical considerations for implementation.

Barriers and Facilitators of Communication in the Medication Reconciliation Process during Hospital Discharge: Primary Healthcare Professionals' Perspectives

The WHO established that medication errors are the most common and preventable errors and represent an expenditure of 42 billion U.S. dollars annually. The risk of medication errors increases in transitions between levels of care, mainly from hospital care to primary healthcare after hospital discharge. In this context, communication is a key element in the safety of the medication reconciliation process. The aim of this paper was to describe the barriers to, and facilitators of, effective communication during the medication reconciliation process at hospital discharge in people over 65 years of age, from the perspective of primary healthcare professionals. A qualitative descriptive study was designed, and in-depth interviews were conducted with 21 individuals, of whom 13 were nurses and 8 were physicians. This study was carried out with healthcare professionals belonging to primary healthcare centres in Huelva (Spain). Following content analysis of the discourses we identified 19 categories, grouped into three areas: interlevel communication, communication between primary healthcare professionals, and communication between healthcare professionals and patients/caregivers. The barriers found mainly relate to the adequacy and use of technological tools, time available, workload and the level of collaboration of patients/caregivers. Facilitating elements for communication in medication reconciliation included technologies, such as computerized medical history, protocolization of clinical sessions, the presence of case management nurse and interdisciplinary teamwork.

Understanding Hazards for Adverse Drug Events Among Older Adults After Hospital Discharge: Insights From Frontline Care Professionals

OBJECTIVES

Care transitions pose a high risk of adverse drug events (ADEs). We aimed to identify hazards to medication safety for older adults during care transitions using a systems approach.

METHODS

Hospital-based professionals from 4 hospitals were interviewed about ADE risks after hospital discharge among older adults. Concerns were extracted from the interview transcript, and for each concern, hazard for medication-related harms was coded and grouped by its sources according to a human factors and systems engineering model that views postdischarge ADEs as the outcome of professional and patient home work systems.

RESULTS

Thirty-eight professionals participated (5 hospitalists, 24 nurses, 4 clinical pharmacists, 3 pharmacy technicians, and 2 social workers). Hazards were classified into 6 groups, ranked by frequencies of hazards coded: (1) medication tasks related at home, (2) patient and caregiver related, (3) hospital work system related, (4) home resource related, (5) hospital professional-patient collaborative work related, and (6) external environment related. Medications most frequently cited when describing concerns included anticoagulants, insulins, and diuretics. Top coded hazard types were complex dosing, patient and caregiver knowledge gaps in medication management, errors in discharge medications, unaffordable cost, inadequate understanding about changes in medications, and gaps in access to care or in sharing medication information.

CONCLUSIONS

From the perspective of hospital-based frontline health care professionals, hazards for medication-related harms during care transitions were multifactorial and represented those introduced by the hospital work system as well as defects unrecognized and unaddressed in the home work system.

Personalized and Self-Management: Systematic Search and Evaluation Quality Factors and User Preference of Drug Reference Apps in Taiwan

Background: Drug reference apps promote self-management and improve the efficiency and quality of work for physicians, nurses, pharmacists, and patients. This study aimed to describe a systematic and stepwise process to identify drug reference apps in Taiwan, assess the quality of these apps, and analyze the influential factors for user ratings. Methods: A two-step algorithm (KESS) consisting of keyword growing and systematic search was proposed. Seven independent reviewers were trained to evaluate these apps using Mobile App Rating Scale (MARS). A logistic regression model was fitted and average marginal effects (AME) were calculated to identify the effects of factors for higher user ratings. Results: A total of 23 drug reference apps in Taiwan were identified and analyzed. Generally, these drug reference apps were evaluated as acceptable quality with an average MARS score of 3.23. Higher user engagement, more functionality, better aesthetics, and more information associated with higher user ratings. Navigation is the most influential factor on higher user ratings (AME: 13.15%) followed by performance (AME: 11.03%), visual appeal (AME: 10.87%), credibility (AME: 10.67%), and quantity of information (AME: 10.42%). Conclusions: User experience and information clearly affect user ratings of drug reference apps. Five key factors should be considered when designing drug reference apps.