Barriers to managing medications appropriately when patients have restrictions on oral intake

Medication management in general surgical patients made nil by mouth perioperatively: A quality improvement study

Perioperative medication management in patients who are nil by mouth for surgery or endoscopy is often suboptimal. Inappropriate medication management can prolong postoperative recovery and increase morbidity and mortality. This quality improvement study, carried out in general surgical patients at an 800-bed general hospital, aimed to improve perioperative medication management in accordance with the recommendations of the UK Clinical Pharmacy Association Handbook of Perioperative Medicine. Increasing awareness and educating general surgical team members, including doctors and non-medical prescribers, about perioperative medication management led to a non-significant improvement in medication management. However, a statistically significant improvement was achieved when nursing staff were also included. This study highlights the importance of involving different members of the multidisciplinary team in perioperative medication management.

Impact of a policy to improve the management of oral medications when patients are fasting before a procedure: an interrupted time series analysis

Background

Managing medications inappropriately when patients have oral intake restrictions can cause patient harm. This study evaluated the impact of a medication policy separating fasting from nil by mouth with respect to giving oral medications in patients fasting before a diagnostic or interventional procedure.

Methods

The policy stipulated that ‘fasting’ means oral medications should be given with a sip of water up to 1 hour before a procedure, unless there is a clinical reason to withhold, while ‘nil by mouth’ means nothing to be given orally, including medications.

The policy was implemented in Surgical areas in February 2015 and Medical areas in March 2015 at a tertiary referral hospital in Melbourne, Australia, and included bedside signs, clinical champions and education sessions.

The study was conducted in 2020. Admission and medication records were matched for non-elective procedure patients from January 2014 to May 2016. The monthly proportion of doses omitted inappropriately and overall omissions pre/post-policy implementation were compared using segmented regression.

Results

Pre-implementation, the proportion of doses withheld inappropriately and total omissions in medical areas were 18.1% and 28.0%, respectively. Post-implementation, an absolute reduction of 13.4% (95% CI 9.0% to 17.7%) and 11.1% (95% CI 2.6% to 19.6%), respectively, was seen. Post-implementation linear trend showed a 0.3% (95% CI 0.0% to 0.6%) increase in inappropriate omissions but not overall omissions.

In Surgical areas, pre-implementation proportions for inappropriate and overall omissions were lower than Medical areas’. Post-implementation, there was an absolute decrease in doses withheld inappropriately (8.3%, 95% CI 0.8% to 15.7%, from 11.9% pre-implementation) but not total omissions.

Conclusions

Distinguishing fasting from nil by mouth appeared to provide clarity for some staff: a reduction in inappropriate omissions was seen post-implementation. Although the small increase in post-implementation linear trend for inappropriate omissions in Medical areas suggests sustainability issues, total omissions were sustained. The policy’s concepts require verification beyond our institution.

Care Coordination Strategies and Barriers during Medication Safety Incidents: a Qualitative, Cognitive Task Analysis

BACKGROUND

Medication errors are prevalent in healthcare institutions worldwide, often arising from difficulties in care coordination among primary care providers, specialists, and pharmacists. Greater knowledge about care coordination surrounding medication safety incidents can inform efforts to improve patient safety.

OBJECTIVES

To identify strategies that hospital and outpatient healthcare professionals (HCPs) use, and barriers encountered, when they coordinate care during a medication safety incident involving an adverse drug reaction, drug-drug interaction, or drug-renal concern.

DESIGN

We asked HCPs to complete a form whenever they encountered these incidents and intervened to prevent or mitigate patient harm. We stratified incidents across HCP roles and incident categories to conduct follow-up cognitive task analysis interviews with HCPs.

PARTICIPANTS

We invited all physicians and pharmacists working in inpatient or outpatient care at a tertiary Veterans Affairs Medical Center. We examined 24 incidents: 12 from physicians and 12 from pharmacists, with a total of 8 incidents per category.

APPROACH

Interviews were transcribed and analyzed via a two-stage inductive, qualitative analysis. In stage 1, we analyzed each incident to identify decision requirements. In stage 2, we analyzed results across incidents to identify emergent themes.

KEY RESULTS

Most incidents (19, 79%) were from outpatient care. HCPs relied on four main strategies to coordinate care: cognitive decentering; collaborative decision-making; back-up behaviors; and contingency planning. HCPs encountered four main barriers: role ambiguity and constraints, breakdowns (e.g., delays) in care, challenges related to the electronic health record, and factors that increased coordination complexity. Each strategy and barrier occurred across all incident categories and HCP groups. Pharmacists went to extra effort to ensure safety plans were implemented.

CONCLUSIONS

Similar strategies and barriers were evident across HCP groups and incident types. Strategies for enhancing patient safety may be strengthened by deliberate organizational support. Some barriers could be addressed by improving work systems.