Mindful organizing in patients' contributions to primary care medication safety

Patient Participation in Medication Safety for Noncommunicable Diseases: A Qualitative Study of General Practitioners, Pharmacists, and Outpatients' Perspectives in Beijing

Purpose

Our study aimed to explore the current status of patient participation in medication safety from the perspectives of general practitioners (GPs), pharmacists, and outpatients in Beijing, China.

Patients and Methods

A qualitative study using semi-structured in-depth individual interviews with GPs, pharmacists, and outpatients. Subjects were identified by purposive sampling until code saturation. Semi-structured qualitative interviews were conducted with GPs, pharmacists, and patients from community health service centers in three urban districts of Beijing, China. The interviews were transcribed verbatim and the text was analysed using thematic analysis techniques including familiarising with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.

Results

A total of eight GPs, seven pharmacists, and 18 outpatients were interviewed. Data analysis led to the generation of five key themes: (1) mutual trust between patient and GP, (2) communication with healthcare professionals, (3) acquisition of knowledge about medication safety, (4) implementation of medication self-management at home, and (5) different attitudes toward participation in medication decisions. Patients participated in medication safety in multiple ways. However, insufficient knowledge about medication safety, lack of awareness of the patient's role in ensuring medication safety, shortage of consultation lengths, and being misled by some information were problems with patient participation in medication safety.

Conclusion

This exploratory study contributes to our initial understanding of patient participation in medication safety. There were still many issues and barriers in the process of patient participation. Appropriate policies and measures, such as providing various forms of patient education, ensuring sufficient physician-patient communication, giving full play to the role of pharmacists, and making judicious use of digital health tools should be taken to improve medication safety by fully utilising the role of patients.

Towards understanding and improving medication safety for patients with mental illness in primary care: A multimethod study

INTRODUCTION

Medication safety incidents have been identified as an important target to improve patient safety in mental healthcare. Despite this, the causes of preventable medication safety incidents affecting patients with mental illness have historically been poorly understood, with research now addressing this knowledge gap through a healthcare professional lens. However, patients and carers can also provide complimentary insight into safety issues, and as key stakeholders in healthcare, it is vital to consider their needs when designing effective interventions.

METHODS

A two-stage approach was adopted by (i) conducting three focus groups (FG) comprising 13 patients with mental illness and their carers to develop a holistic picture of medication safety in primary care with extraction of themes guided by the P-MEDS framework; (ii) conducting two separate nominal group consensus workshops with seven patients with mental illness/carers and seven healthcare professionals to identify priority areas for targeted interventions.

RESULTS

Seven themes were identified in the FGs: communication; trust, involvement and respect; continuity and support; access; the healthcare professional; the patient and carer; and the organisation. Priority areas identified for intervention by key stakeholders included improving communication within and between clinical services, enhancing patient support with holistic continuity of care, maximising shared decision-making and empowerment, ensuring timely access to medicines and services, strengthening healthcare professional knowledge regarding mental illnesses and associated medications, and increasing patient dignity and respect.

CONCLUSION

This study has developed a holistic picture of contributors to medication safety incidents affecting patients with mental illness in primary care. This theory was then used by key stakeholders to inform and generate priority recommendations for targeted interventions. These findings can be used to inform future intervention research, as they consider the needs of those who access or work within primary care services.

PATIENT OR PUBLIC CONTRIBUTION

An advisory group consisting of three expert patients with lived experience of mental illness was consulted on the design of both stages of this study. Patients with mental illness and/or their carers were recruited and participated in both stages of this study. Patients/carers aided with data analysis and interpretation during the patient/carer nominal group consensus workshop.

unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study

Background

It is estimated that 237 million medication errors occur in England each year with a significant number occurring in the community. Our understanding of the causes of preventable medication errors and adverse drug events (ADE) affecting patients with mental illness is limited in this setting. Better understanding of the factors that contribute to errors can support the development of theory-driven improvement interventions.

Methods

Remote qualitative semi-structured interviews with 26 community-based healthcare professionals in England and Wales were undertaken between June-November 2022. Recruitment was undertaken using purposive sampling via professional networks. Interviews were guided by the critical incident technique and analysed using the framework method. Any data that involved speculation was not included in the analysis. Independent analysis was carried out by the research team to extract themes guided by the London Protocol.

Results

A total of 43 medication errors and 12 preventable ADEs were discussed, with two ADEs having an unknown error origin. Prescribing errors were discussed most commonly (n = 24), followed by monitoring errors (n = 8). Six contributory factor themes were identified: the individual (staff); the work environment; the teams/interfaces; the organisation and management; the patient; and the task and technology. The individual (staff) factors were involved in just over 80% of all errors discussed. Participants reported a lack of knowledge regarding psychotropic medication and mental illnesses which accompanied diffusion of responsibility. There were difficulties with team communication, particularly across care interfaces, such as ambiguity/brevity of information being communicated and uncertainty concerning roles which created confusion amongst staff. Unique patient social/behavioural contributory factors were identified such as presenting with challenging behaviour and complex lifestyles, which caused difficulties attending appointments as well as affecting overall clinical management.

Conclusion

These findings highlight that the causes of errors are multifactorial with some unique to this patient group. Key areas to target for improvement include the education/training of healthcare professionals regarding neuropharmacology/mental illnesses and enhancing communication across care interfaces. Future research should explore patient perspectives regarding this topic to help develop a holistic picture. These findings can be used to guide future intervention research to ameliorate medication safety challenges for this patient group.

Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising

BACKGROUND

Our aim was to understand actions by primary care teams to improve medication safety.

METHODS

This was a qualitative study using one-on-one, semistructured interviews with the questions guided by concepts from collaborative care and systems engineering models, and with references to the care of older adults. We interviewed 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in Southwest US during 2019-2020. We used thematic analysis with a combination of inductive and deductive coding. First, codes capturing safety actions were incrementally developed and revised iteratively by a team of multidisciplinary analysts using the inductive approach. Themes that emerged from the coded safety actions taken by primary care professionals to improve medication safety were then mapped to key principles from the high reliability organisation framework using a deductive approach.

RESULTS

Primary care teams described their actions in medication safety mainly in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. Most of the actions required customisation at the individual level, such as limiting the supply of certain medications prescribed and simplifying medication regimens in certain patients. Primary care teams enacted high reliability organisation principles by anticipating and mitigating risks and taking actions to build resilience in patient work systems. The primary care teams' actions reflected their safety organising efforts as responses to many other agents in multiple settings that they could not control nor easily coordinate.

CONCLUSIONS

Primary care teams take many actions to shape medication safety outcomes in community settings, and these actions demonstrated that primary care teams are a reservoir of resilience for medication safety in the overall healthcare system. To improve medication safety, primary care work systems require different strategies than those often used in more self-contained systems such as hospital inpatient or surgical services.

A Multisite Qualitative Analysis of Perceived Roles in Medication Safety: Older Adults' Perspectives

Older adults and caregivers play an essential role in medication safety; however, self-perception of their and health professionals' roles in medication safety is not well-understood. The objective of our study was to identify the roles of patients, providers, and pharmacists in medication safety from the perspective of older adults. Semi-structured qualitative interviews were held with 28 community-dwelling older adults over 65 years who took five or more prescription medications daily. Results suggest that older adults' self-perceptions of their role in medication safety varied widely. Older adults perceived that self-learning about their medications and securing them are critical to avoiding medication-related harm. Primary care providers were perceived as coordinators between older adults and specialists. Older adults expected pharmacists to inform them of any changes in the characteristics of medications to ensure medications were taken correctly. Our findings provide an in-depth analysis of older adults' perceptions and expectations of their providers' specific roles in medication safety. Educating providers and pharmacists about the role expectations of this population with complex needs can ultimately improve medication safety.

Factors Contributing to Best Practices for Patient Involvement in Pharmacovigilance in Europe: A Stakeholder Analysis

Introduction

Involving patients in decision making adds value in the context of pharmacovigilance (PV). This added value goes beyond participation in spontaneous reporting systems for adverse drug reactions. However, there is a gap between allowing patients to report and actual patient involvement. Views regarding best practices from regulators, patient organizations and pharmaceutical companies could help increase and improve patient involvement in PV.

Objective

The aim of this study was to investigate the factors contributing to best practices for patient involvement in PV and to develop a definition of patient involvement based on a qualitative multistakeholder study across Europe.

Methods

A literature review was conducted to map the field of study and obtain insights for the elaboration of an interview guide. Subsequently, patient representatives, members of the pharmaceutical industry and regulators were invited to participate in interviews. These interviews were analyzed using NVIVO^® software and employing reflective thematic analysis.

Results

A total of 20 interviews were conducted with representatives at both the national and European levels. The best practices identified were engagement from the start, face-to-face communication, a full circle of feedback, same-level partners, structured involvement and guidelines, establishing common goals, patient education and empowerment, and developing trust and balance. These activities can be implemented via deep collaboration among stakeholders. A definition of patient involvement was constructed in accordance with the input of all stakeholder groups, which reflects the involvement of all types of patients at all levels of the decision-making process.

Conclusion

In this study, we developed a definition for patient involvement based on qualitative interviews. The factors contributing to best practices for patient involvement were mentioned across stakeholder groups and aimed to stimulate patient involvement in PV. Patients are eager to become equal partners and to engage effortlessly in the same manner as other stakeholders.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-022-01222-y.

Patient-Nurse Partnerships to Prevent Medication Errors: A Concept Development Using the Hybrid Method

Medication safety is the most patient-centered aspect of nursing, and the medication process needs patients' active participation to effectively prevent medication errors. The aim of this study was to develop the concept of a patient-nurse partnership for medication safety activities. The study design used the three-phase hybrid model for concept analysis: the theoretical phase, fieldwork phase, and final phase for integration. The results of a study define the concept of patient-nurse partnership for medication safety as "a fair cooperative relationship of mutual responsibility in which patients and nurses share information and communicate with each other through mutual trust." Seven attributes were derived: mutual trust, mutual respect, mutual sharing, mutual communication, mutual responsibility, fair relationship, and mutual cooperation. The conclusion of the study of patient-nurse partnerships for medication safety was that it is necessary to ensure a balance in power between patient and nurse. This balance can be established through patient-centered nursing by implementing the active transfer of authority from nurses as professionals to patients.

Post-discharge medicines management: the experiences, perceptions and roles of older people and their family carers

Background

Multiple changes are made to older patients’ medicines during hospital admission, which can sometimes cause confusion and anxiety. This results in problems with post‐discharge medicines management, for example medicines taken incorrectly, which can lead to harm, hospital readmission and reduced quality of life.

Aim

To explore the experiences of older patients and their family carers as they enacted post‐discharge medicines management.

Design

Semi‐structured interviews took place in participants’ homes, approximately two weeks after hospital discharge. Data analysis used the Framework method.

Setting and participants

Recruitment took place during admission to one of two large teaching hospitals in North England. Twenty‐seven participants aged 75 plus who lived with long‐term conditions and polypharmacy, and nine family carers, were interviewed.

Findings

Three core themes emerged: impact of the transition, safety strategies and medicines management role. Conversations between participants and health‐care professionals about medicines changes often lacked detail, which disrupted some participants’ knowledge and medicines management capabilities. Participants used multiple strategies to support post‐discharge medicines management, such as creating administration checklists, seeking advice or supporting primary care through prompts to ensure medicines were supplied on time. The level to which they engaged with these activities varied.

Discussion and conclusion

Participants experienced gaps in their post‐discharge medicines management, which they had to bridge through implementing their own strategies or by enlisting support from others. Areas for improvement were identified, mainly through better communication about medicines changes and wider involvement of patients and family carers in their medicines‐related care during the hospital‐to‐home transition.

Mindful organizing in patients' contributions to primary care medication safety

Background

There is a need to ensure that the risks associated with medication usage in primary health care are controlled. To maintain an understanding of the risks, health‐care organizations may engage in a process known as “mindful organizing.” While this is typically conceived of as involving organizational members, it may in the health‐care context also include patients. Our study aimed to examine ways in which patients might contribute to mindful organizing with respect to primary care medication safety.

Method

Qualitative focus groups and interviews were carried out with 126 members of the public in North West England and the East Midlands. Participants were taking medicines for a long‐term health condition, were taking several medicines, had previously encountered problems with their medication or were caring for another person in any of these categories. Participants described their experiences of dealing with medication‐related concerns. The transcripts were analysed using a thematic method.

Results

We identified 4 themes to explain patient behaviour associated with mindful organizing: knowledge about clinical or system issues; artefacts that facilitate control of medication risks; communication with health‐care professionals; and the relationship between patients and the health‐care system (in particular, mutual trust).

Conclusions

Mindful organizing is potentially useful for framing patient involvement in safety, although there are some conceptual and practical issues to be addressed before it can be fully exploited in this setting. We have identified factors that influence (and are strengthened by) patients’ engagement in mindful organizing, and as such would be a useful focus of efforts to support patient involvement.