A Systems Approach to Identify Factors Influencing Adverse Drug Events in Nursing Homes

Using Systems Engineering and Implementation Science to Design an Implementation Package for Preoperative Comprehensive Geriatric Assessment Among Older Adults Having Major Abdominal Surgery: Protocol for a 3-Phase Study

BACKGROUND

Older Americans, a growing segment of the population, have an increasing need for surgical services, and they experience a disproportionate burden of postoperative complications compared to their younger counterparts. A preoperative comprehensive geriatric assessment (pCGA) is recommended to reduce risk and improve surgical care delivery for this population, which has been identified as vulnerable. The pCGA optimizes multiple chronic conditions and factors commonly overlooked in routine preoperative planning, including physical function, polypharmacy, nutrition, cognition, mental health, and social and environmental support. The pCGA has been shown to decrease postoperative morbidity, mortality, and length of stay in a variety of surgical specialties. Although national guidelines recommend the use of the pCGA, a paucity of strategic guidance for implementation limits its uptake to a few academic medical centers. By applying implementation science and human factors engineering methods, this study will provide the necessary evidence to optimize the implementation of the pCGA in a variety of health care settings.

OBJECTIVE

The purpose of this paper is to describe the study protocol to design an adaptable, user-centered pCGA implementation package for use among older adults before major abdominal surgery.

METHODS

This protocol uses systems engineering methods to develop, tailor, and pilot-test a user-centered pCGA implementation package, which can be adapted to community-based hospitals in preparation for a multisite implementation trial. The protocol is based upon the National Institutes of Health Stage Model for Behavioral Intervention Development and aligns with the goal to develop behavioral interventions with an eye to real-world implementation. In phase 1, we will use observation and interviews to map the pCGA process and identify system-based barriers and facilitators to its use among older adults undergoing major abdominal surgery. In phase 2, we will apply user-centered design methods, engaging health care providers, patients, and caregivers to co-design a pCGA implementation package. This package will be applicable to a diverse population of older patients undergoing major abdominal surgery at a large academic hospital and an affiliate community site. In phase 3, we will pilot-test and refine the pCGA implementation package in preparation for a future randomized controlled implementation-effectiveness trial. We anticipate that this study will take approximately 60 months (April 2023-March 2028).

RESULTS

This study protocol will generate (1) a detailed process map of the pCGA; (2) an adaptable, user-centered pCGA implementation package ready for feasibility testing in a pilot trial; and (3) preliminary pilot data on the implementation and effectiveness of the package. We anticipate that these data will serve as the basis for future multisite hybrid implementation-effectiveness clinical trials of the pCGA in older adults undergoing major abdominal surgery.

CONCLUSIONS

The expected results of this study will contribute to improving perioperative care processes for older adults before major abdominal surgery.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59428.

Instruments and Warning Signs for Identifying and Evaluating the Frequency of Adverse Events in Intermediate and Long-Term Care Centres: A Narrative Systematic Review

INTRODUCTION

There is a lack of data about adverse events (AE) in intermediate and long-term care centers (ILCC). We aimed to synthesize the available scientific evidence on instruments used to identify and characterize AEs. We also aimed to describe the most common adverse events in ILCCs.

MATERIAL AND METHODS

A narrative systematic review of the literature was conducted according to Prisma recommendations. The PubMed database was searched for articles published between 2000 and 2021. Two reviewers independently screened and reviewed the studies through blind and independent review. We evaluated bias risk with Cochrane's risk of bias tool. Disagreements were resolved by consensus. Discrepancies that were not resolved by discussion were discussed with a third reviewer. Descriptive data was extracted and qualitative content analysis was performed.

RESULTS

We found 2191 articles. Based on the inclusion and exclusion criteria, 272 papers were screened by title and abstract, and 66 studies were selected for full review. The instruments used to identify AEs were mostly tools to identify specific AEs or risks of AEs (94%), the remaining 6% were multidimensional. The most frequent categories detected medication-related AEs (n=26, 40%); falls (n=7, 11%); psychiatric AEs (6.9%); malnutrition (4.6%), and infections (4.6%). The studies that used multidimensional tools refer to frailty, dependency, or lack of energy as predictors of AEs. However, they do not take into account the importance of detecting AEs. We found 2-11 adverse drug events (ADE) per resident/month. We found a prevalence of falls (12.5%), delirium (9.6-89%), pain (68%), malnutrition (2-83%), and pressure ulcers (3-30%). Urinary tract infections, lower respiratory tract infections, skin and soft tissue infections, and gastroenteritis were the most common infections in this setting. Transitions between different care settings (from hospitals to ILCC and vice versa) expose AE risk.

CONCLUSION

There are many instruments to detect AEs in ILCC, and most have a specific approach. Adverse events affect a significant proportion of patients in ILCC, the nurse-sensitive outcomes, nosocomial infections, and adverse drug events are among the most common. The systematic review was registered with Prospero, ID: CRD42022348168.

Medication administration in aged care facilities: A mixed-methods systematic review

AIM(S)

To synthesize aged care provider, resident and residents' family members' perspectives and experiences of medication administration in aged care facilities; to determine the incidence of medication administration errors, and the impact of medication administration on quality of care and resident-centredness in aged care facilities.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

CRD42023426990.

DATA SOURCES

The AMED, CINAHL, MEDLINE, EMBASE, EMCARE, PsycINFO, Scopus and Web of Science core collection databases were searched in June 2023.

REVIEW METHODS

Included studies were independently screened, selected and appraised by two researchers. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was followed, with the Mixed Methods Appraisal Tool was used for critical appraisal. Convergent synthesis of data, thematic synthesis and meta-analysis were performed.

RESULTS

One hundred and twenty-eight studies were included (33 qualitative, 85 quantitative and 10 mixed-methods). Five themes were formulated, including 1) Staffing concerns, 2) The uncertain role of residents, 3) Medication-related decision-making, 4) Use of electronic medication administration records and 5) Medication administration errors. Educational interventions for aged care workers significantly reduced medication administration errors, examined across five studies (OR = 0.37, 95%CI 0.28-0.50, p < .001).

CONCLUSIONS

Medication administration in aged care facilities is challenging and complex on clinical and interpersonal levels. Clinical processes, medication errors and safety remain focal points for practice. However, more active consideration of residents' autonomy and input by aged care workers and providers is needed to address medication administration's interpersonal and psychosocial aspects. New directions for future research should examine the decision-making behind dose form modification, aged care workers' definitions of medication omission and practical methods to support residents' and their family members' engagement during medication administration.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

It is important that medication administration in aged care facilities be more clearly acknowledged as both a clinical and interpersonal task. More attention is warranted regarding aged care workers clinical decision-making, particularly concerning dose form modification, covert administration and medication omissions. Resident-centred care approaches that support resident and family engagement around medication administration may improve adherence, satisfaction and quality of care.

IMPACT

What Problem Did the Study Address? Medication administration in aged care facilities is a complex clinical and interpersonal activity. Still, to date, no attempts have been made to synthesize qualitative and quantitative evidence around this practice. There is a need to establish what evidence exists around the perspectives and experiences of aged care workers, residents and resident's family members to understand the challenges, interpersonal opportunities and risks during medication administration. What Were the Main Findings? There is a lack of empirical evidence around resident-centred care approaches to medication administration, and how residents and their families could be enabled to have more input. Dose form modification occurred overtly and covertly as part of medication administration, not just as a method for older adults with swallowing difficulties, but to enforce adherence with prescribed medications. Medication administration errors typically included medication omission as a category of error, despite some omissions stemming from a clear rationale for medication omission and resident input. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: The findings of this systematic review contribute to aged care policy and practice regarding medication administration and engagement with older adults. This review presents findings that provide a starting point for aged care workers in regards to professional development and reflection on practice, particularly around clinical decision-making on dose form modification, medication administration errors and the tension on enabling resident input into medication administration. For researchers, this review highlights the need to develop resident-centred care approaches and interventions, and to assess whether these can positively impact medication administration, resident engagement, adherence with prescribed medications and quality of care.

REPORTING METHOD

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution to this systematic review.

Prevalence of Opioid Use in Nursing Homes Over the Last Decade: A Systematic Literature Review

Background: Despite global concerns of an opioid epidemic, there is no systematic literature review on how frequently these drugs are used in nursing home (NH) populations, including those living with dementia. Objective: This systematic review aims to describe the prevalence and incidence of opioid use in NHs. A secondary objective is to describe the use of these drugs in a subset of NH residents, namely among persons living with dementia. Methods: A systematic literature review was carried out using MEDLINE and Scopus (PROSPERO registration number CRD42021254210). Screening of title and abstract was carried out by 2 persons independently for studies published between January 1, 2011 and May 19, 2021. The main outcomes were annual prevalence, period prevalence, and duration of opioid use. Results: From a total of 178 identified studies, 29 were considered eligible for inclusion. The annual prevalence of any opioid use among all NH residents without any selection criteria ranged from 6.3% to 50% with a median annual prevalence of 22.9% (Q25-Q75: 19.5%-30.2%), based on 17 studies. Five studies measured the annual prevalence in NH residents living with dementia, finding that this ranged from 10% to 39.6%. Conclusions: More evidence is needed quantifying opioid use in NH, especially among persons living with dementia. Given that opioid use in NH is still a problem, implementation of a pain management protocol in NH or nationally would help improve clinical outcomes.

Patient Safety in Nursing Homes From an Ecological Perspective: An Integrated Review

OBJECTIVES

The aims of the study were to identify the systemic factors affecting the characteristics and safety of older adults living in nursing homes and the resulting resident outcomes and to explore the relationship between them through an integrated literature review.

METHODS

A literature search was conducted from April 22 to May 6, 2021, in the PubMed, Embase, Cochrane CENTRAL, CIHNAL, RISS, NDL, and KoreaMed databases. The following key words and MeSH terms were used for the search: "nursing home," "skilled nursing facility," "long-term care facility," and "patient safety" or "safety."

RESULTS

Forty-seven qualifying articles were finally selected. Three domains were derived as personal factors, 12 as facility factors, and one as a policy factor. The interrelationships between them could result in positive or negative resident outcomes. The relationship between them was also reconstructed from an ecological perspective.

CONCLUSIONS

The results demonstrated that the safety and quality of life of older adults living in nursing homes were affected by both individual and institutional factors.

Long-term Care Facility Staff's Experience of Safety Activities: A Qualitative Study

BACKGROUND

Ensuring the safety and quality of care is paramount in long-term care facilities due to residents' vulnerability.

OBJECTIVE

We explored the experiences of long-term care facility staff (eg, registered nurses [RNs], certified nursing assistants [CNAs], care workers, social workers, and physical therapists) in safety activities, aiming to understand their meaning and nature.

METHODS

We conducted qualitative focus group interviews with 25 participants, specifically addressing safety issues in long-term care facilities through the use of open-ended questions. We transcribed the data and conducted thematic analysis.

RESULTS

Participants engaged in discussions about various challenges, including assisting residents in maintaining physical comfort, managing behavioral and psychological symptoms of dementia, ensuring medication safety, implementing infection control practices, and providing adequate training on fire prevention, evacuation, and response protocols. Themes identified were "physical comfort," "managing dementia symptoms," "drug administration," "infection control," and "fire prevention."

CONCLUSIONS

The staff emphasized the safety of residents as their highest priority. Considering the lack of registered nurses in long-term care facilities, ongoing training and supervision are necessary to ensure that other long-term care facility staff can perform safety activities.

Changes in chronic disease medications after admission to a Geriatric Health Services Facility: A multi-center prospective cohort study

Older adults often receive polypharmacy, including some medications for chronic diseases. Nutritional management after admission to a nursing home may enable to deprescribe some chronic disease medications. This study aimed to investigate the status of deprescribing of chronic disease medications among nursing home residents, and to assess the appropriateness based on changes of laboratory test values and nutritional status. A multi-center prospective cohort study was conducted in 6 Geriatric Health Services Facilities, a major type of nursing homes in Japan. Newly admitted residents aged ≥ 65 years who took ≥1 medication for hypertension, diabetes, or dyslipidemia at admission were recruited. Participants who stayed for 3 months were included in the analysis. Medications at admission and 3 months after admission and situations for deprescribing were investigated. Changes in body mass index, blood pressure, laboratory tests (e.g., cholesterol and hemoglobin A1c levels), energy intake, and International Classification of Functioning, Disability and Health staging were evaluated. Sixty-nine participants (68% female, 62% aged ≥ 85 years) were included. At admission, 60 participants had medications for hypertension, 29 for dyslipidemia, and 13 for diabetes. Those receiving lipid-modifying drugs (mainly statins) decreased from 29 to 21 (72%; P = .008), since their cholesterol levels was within the normal range or was low at admission, and they had no history of cardiovascular events. However, there were no statistically significant changes in the frequencies of antihypertensive drugs (60 to 55; 92%; P = .063) or antidiabetic drugs (13 to 12; 92%; P = 1.000). During the 3-month observation, body mass index and diastolic blood pressure decreased, while energy intake and serum albumin level increased. Nutritional management after admission to a ROKEN may facilitate appropriate deprescribing of lipid-modifying drugs, by offseting the effects of discontinuation of these drugs.

Prevalence and Preventability of Adverse Medicine Events in a Sample of Australian Aged-Care Residents: A Secondary Analysis of Data from the ReMInDAR Trial

BACKGROUND

Aged care residents are vulnerable to the harmful effects of medicines; however, data on the prevalence and preventability of adverse medicine events in aged care residents are scarce.

AIM

To determine the prevalence and preventability of adverse medicine events in Australian aged care residents.

METHODS

A secondary analysis of data from the Reducing Medicine-Induced Deterioration and Adverse Reactions (ReMInDAR) trial was conducted. Potential adverse medicine events were identified and independently screened by two research pharmacists to produce a short-list of potential adverse medicine events. An expert clinical panel reviewed each potential adverse medicine to determine the likelihood that the event was medicine related (based on the Naranjo Probability Scale criteria). The clinical panel assessed preventability of medicine-related events using Schumock-Thornton criteria.

RESULTS

There were 583 adverse events due to medicines, involving 154 residents (62% of the 248 study participants). There was a median of three medication-related adverse events (interquartile range [IQR] 1-5) per resident over the 12-month follow-up period. The most common medication-related adverse events were falls (56%), bleeding (18%) and bruising (9%). There were 482 (83%) medication-related adverse events that were preventable, most commonly falls (66% of preventable adverse medicine events), bleeding (12%) and dizziness (8%). Of the 248 residents, 133 (54% of the cohort) had at least one preventable adverse medicine event, with a median of 2 (IQR 1-4) preventable adverse medicine events per resident.

CONCLUSION

In total, 62% of aged care residents in our study had an adverse medicine event and 54% had a preventable adverse medicine event in a 12-month period.

Actual drug-related harms in residential aged care facilities: a narrative review

INTRODUCTION

Older people in residential aged care facilities (RACFs) have a high risk of safety issues and concerns about the potential quality of care received. This narrative review investigates the types of actual drug-related harms, their prevalence, reporting of any standard definitions for these harms, and their identification methods.

AREAS COVERED

The authors conducted a systematic search on Ovid Embase, Ovid Medline, and PubMed from March 2001 to March 2021. This narrative review included all types of studies targeting aged care residents aged 65 years and above with actual drug-related harms.

EXPERT OPINION

The prevalence of actual drug-related harms in residents ranged from 0.07% to 63.0%. Falls, drug-drug interactions, neuropsychiatric symptoms, anaphylaxis, urinary tract infection, hypoglycemia, hypokalaemia, and acute kidney injury are the most common drug-related harms in older residents. Psychotropic drugs are the most common drug class implicated in these harms. Evidence related to the association between individual psychotropic drugs and injury, or harm is also lacking. Due to the variation in study duration, reported prevalence, identification methods, and absence of a definition for actual drug-related harms in most studies, further research is mandated to understand the prevalence and clinical implications of drug-related harms in older residents.

Communication Disparities between Nursing Home Team Members

Optimal care in nursing home (NH) settings requires effective team communication. Certified nursing assistants (CNAs) interact with nursing home residents frequently, but the extent to which CNAs feel their input is valued by other team members is not known. We conducted a cross-sectional study in which we administered a communication survey within 20 Utah nursing home facilities to 650 team members, including 124 nurses and 264 CNAs. Respondents used a 4-point scale to indicate the extent to which their input is valued by other team members when reporting their concerns about nursing home residents. We used a one-way ANOVA with a Bonferroni correction. When compared to nurses, CNAs felt less valued (CNA mean = 2.14, nurse mean = 3.24; p < 0.001) when reporting to physicians, and less valued (CNA mean = 1.66, nurse mean = 2.71; p < 0.001) when reporting to pharmacists. CNAs did not feel less valued than nurses (CNA mean = 3.43, nurse mean = 3.37; p = 0.25) when reporting to other nurses. Our findings demonstrate that CNAs feel their input is not valued outside of nursing, which could impact resident care. Additional research is needed to understand the reasons for this perception and to design educational interventions to improve the culture of communication in nursing home settings.

Working Dynamics of Licensed Nurses and Nurse Aides in Nursing Homes: A Scoping Review

Collaboration between licensed nurses (LNs) and nurse aides (NAs) is critical in the provision of quality care for residents living in nursing homes (NHs). The current scoping review explores how working dynamics between LNs and NAs in the NH setting are researched and described in the literature. Thirty-five articles were identified and reviewed that address the LN/NA relationship in the context of (a) the LN role as a supervisor and leader; (b) variation in structure; (c) expanding, understanding, and supporting staff roles; and (d) communication. We found that the LN/NA relationship has been primarily explored through the LN lens and often studied in the context of role expansion and revision associated with new models of care. Our contribution to the literature includes the following main points: efforts to improve LN/NA collaboration may be hindered without substantial structural change; collaboration may be limited within the hierarchal LN/NA relationship; LNs and NAs in NHs need greater support, recognition, and empowerment; and NAs require a representative voice. [Journal of Gerontological Nursing, 48(5), 27-34.].

Effect of an ongoing pharmacist service to reduce medicine-induced deterioration and adverse reactions in aged-care facilities (nursing homes): a multicentre, randomised controlled trial (the ReMInDAR trial)

Objective

To assess the effectiveness of a pharmacist-led intervention using validated tools to reduce medicine-induced deterioration and adverse reactions.

Design and setting

Multicenter, open-label parallel randomised controlled trial involving 39 Australian aged-care facilities.

Participants

Residents on ≥4 medicines or ≥1 anticholinergic or sedative medicine.

Intervention

Pharmacist-led intervention using validated tools to detect signs and symptoms of medicine-induced deterioration which occurred every 8 weeks over 12 months.

Comparator

Usual care (Residential Medication Management Review) provided by accredited pharmacists.

Outcomes

Primary outcome was change in Frailty Index at 12 months. Secondary outcomes included changes in cognition, 24-hour movement behaviour by accelerometry, grip strength, weight, adverse events and quality of life.

Results

248 persons (median age 87 years) completed the study; 120 in the interventionand, 128 in control arms. In total 575 pharmacist, sessions were undertaken in the intervention arm. There was no statistically significant difference for change in frailty between groups (mean difference: 0.009, 95% CI: −0.028, 0.009, P = 0.320). A significant difference for cognition was observed, with a mean difference of 1.36 point change at 12 months (95% CI: 0.01, 2.72, P = 0.048). Changes in 24-hour movement behaviour, grip strength, adverse events and quality of life were not significantly different between groups. Point estimates favoured the intervention arm at 12 months for frailty, 24-hour movement behaviour and grip strength.

Conclusions

The use of validated tools by pharmacists to detect signs of medicine-induced deterioration is a model of practice that requires further research, with promising results from this trial, particularly with regards to improved cognition.

Is medication administration in the elderly influenced by nurses’ demographics in South Africa?

Background

Globally, nurses are increasingly employed post-retirement, with task-shifting to nurses with lower competencies, a lack of knowledge being a barrier, all of which could lead to medication errors.

Aim

To describe the impact of nurses’ age, experience, training, and skill mix on the medication administration processes in long-term care facilities (LTCFs).

Setting

Nurses (N=123) working in 28 LTCFs in the Western Cape province, South Africa.

Methods

A quantitative non-experimental, cross-sectional descriptive design was used. The LTCFs were divided into funded (state-subsidised) and private (for profit) facilities using a stratified sampling method and each stratum thereafter randomised to obtain equal samples from each stratum. Self-administered questionnaires with close-ended statements were used, and statistical software (SPSS version 27) to perform descriptive and inferential analyses.

Results

Respondents, (27%), had more than nine years of experience, with 15.8% aged 61-70 years; and 3.5% aged 71-80 years. Some were ‘very inexperienced’ in computer use (29.3%), 35% received medication training longer than five years ago, and n=28 nurses administered medication outside their scope of practice. The highest sources of job pressure were an increase in workloads (75.6%), being under stress (42.3%), and being overworked (39.0%).

Conclusion

The aging nursing workforce, although experienced, found the job demands, paperwork, and technology barriers. Outdated training and delegating medication administration to lower categories of nurses can lead to medication errors.

Contribution

This study’s findings can serve as a guideline for creating succession plans, recruiting procedures, development, and training of nurses, and improving clinical practices.

Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective

BACKGROUND

Hospitals in various countries such as the Netherlands investigate and analyse serious adverse events (SAEs) to learn from previous events and attempt to prevent recurrence. However, current methods for SAE analysis do not address the complexity of healthcare and investigations typically focus on single events on the hospital level. This hampers hospitals in their ambition to learn from SAEs. Integrating human factors thinking and using a holistic and more consistent method could improve learning from SAEs.

AIM

This study aims to develop a novel generic analysis method (GAM) to: (1) facilitate a holistic event analysis using a human factors perspective and (2) ease aggregate analysis of events across hospitals.

METHODS

Multiple steps of carefully evaluating, testing and continuously refining prototypes of the method were performed. Various Dutch stakeholders in the field of patient safety were involved in each step. Theoretical experts were consulted, and the prototype was pretested using information-rich SAE reports from Dutch hospitals. Expert panels, engaging quality and safety experts and medical specialists from various hospitals were consulted for face and content validity evaluation. User test sessions concluded the development of the method.

RESULTS

The final version of the GAM consists of a framework and affiliated questionnaire. GAM combines elements of three methods for SAE analysis currently practised by Dutch hospitals. It is structured according to the Systems Engineering Initiative for Patient Safety model, which incorporates a human factors perspective into the analysis. These eases aggregated analysis of SAEs across hospitals and helps to consider the complexity of healthcare work systems.

CONCLUSION

The GAM is a valuable new tool for hospitals to learn from SAEs. The method can facilitate a holistic aggregate analysis of SAEs across hospitals using a human factors perspective, and is now ready for further extensive testing.

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

Relationship Between Working Conditions, Worker Outcomes, and Patient Care: A Theoretical Model for Frontline Health Care Workers

Despite the integral role that frontline health care workers play in providing care to older adults and those with chronic conditions and disabilities, few studies have examined the relationships between the working conditions endured by this workforce, the quality of the care they deliver, and the outcomes of patients for whom they care. Thus, the authors: (1) developed a novel conceptual framework that highlights these relationships and (2) performed a comprehensive search and analysis of the literature (PubMed, AgeLine, Cumulative Index to Nursing and Allied Health Literature (CINAHL), JSTOR, Scopus, Web of Science) to assess the relationships proposed in the framework. A total of 31 studies were included. The results suggest that working conditions affect workers themselves, the care they deliver, and their patients' outcomes. Additional studies, as well as policy solutions, are needed to address the issues faced by this workforce in order to improve health care delivery.

Organization factors influencing nurse ability to prevent and detect adverse drug events in public hospitals using a patient safety model

The objective of this study was to measure organization factors that can influence the ability of nursing staff to prevent and detect ADEs in public hospitals using Systems Engineering Initiative for Patient Safety (SEIPS) model.

METHODS

This was a multi-center cross-sectional study. The study included a self-administered paper-based survey which was distributed and collected between October through December 2019. The study participants were nurses from 11 public hospitals located in two Iraqi provinces. Binary logistic regression was used to measure the relationship between the independent SEIPS factors (persons, organizations, tools, tasks, and environments) and the incidence of ADEs (outcome variable).

RESULTS

The study recruited 603 nurses (68.3% men) from 11 public hospitals across two provinces. Less than half (48.8%) of the nurses received enough training to detect ADEs, 43.1% had adequate experience to detect ADEs, and 69.8% had to report ADEs in a special record. More than three-quarters (78.4%) believed that their jobs need fast work. Two of the five SEIPS model domains had significant negative association with the incidence of ADEs including organization (nurse-physician collaboration) and nurse experience in ADE detection.

CONCLUSIONS

Nursing staff face several challenges to prevent and minimize ADEs including shortages in nurses, inadequate nurse experience in ADE detection, no training for ADE detection was received, fear of reporting ADEs, and a lack in monitoring equipment. Increasing nurse/patient ratio and providing more monitoring equipment and training courses can minimize ADEs and enhance their detection.

Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students

Background: Although access to accurate patient documentation is recognized as a prerequisite for delivering of safe and continuous municipal elderly care, healthcare professionals often fail to provide comprehensive clinical information in an accurate and timely manner. The aim of this study was to understand the perceptions of healthcare professionals and healthcare students regarding existing barriers to patient safety through the performance of documentation practices.

Methods: Using a qualitative, exploratory design, this study conducted six focus group interviews with nurses and social educators (n = 12) involved in primary care practice and nursing and social educator bachelor’s degree students from a University College (n = 11). Data were analyzed using qualitative content analysis.

Results: Four themes emerged from the analysis, which described barriers to patient safety and quality in documentation practices: “Individual factors,” “Social factors,” “Organizational factors,” and “Technological factors.” Each theme also included several sub-themes.

Conclusion: According to the findings, several barriers negatively influenced documentation practices and information exchange, which may place primary care patients in a vulnerable and exposed situation. To achieve successful documentation, increased awareness and efforts by the individual professional are necessary. However, primary care services must facilitate the achievement of these goals by providing adequate resources, clear mission statements, and understandable policies.

Utilization of drugs for the management of cardiovascular diseases at intermediate care facilities for older adults in Japan

OBJECTIVES

No established approaches exist for the pharmacological management of cardiovascular diseases (CVDs) in residents of long-term care facilities (LTCFs). This study aimed to evaluate the use of drugs for CVD prevention and treatment (CVD-related drugs) in a major type of LTCF in Japan.

METHODS

This study included 1318 randomly selected residents at 349 intermediate care facilities for older adults (called Roken). Prescriptions were investigated at admission and two months after admission according to therapeutic categories. Logistic regression was used to identify residents' characteristics that were associated with prescriptions of CVD-related drugs.

RESULTS

Prescriptions of all types of drugs and CVD-related drugs decreased in 36 % and 16 % of residents, respectively. Half of the residents received antihypertensives, a quarter received antiplatelets and diuretics, whereas one-tenth received antidiabetics, oral anticoagulants, and lipid-modifying drugs. The prevalence of most of individual drug categories were similar among residents with different physical or cognitive function, except for fewer antihypertensive and lipid-modifying drugs in those with severe cognitive disability. Adjusted analyses for prescriptions at two months after admission revealed that bedridden residents were more likely to be prescribed diuretics but less likely to be prescribed antihypertensives, antiplatelets, or lipid-modifying drugs. Residents with severe cognitive disability were less likely to be prescribed antihypertensives or lipid-modifying drugs. A known history of cardiovascular events was associated with greater use of CVD-related drugs.

CONCLUSION

CVD-related drugs were commonly prescribed for Roken residents, including those with low physical and cognitive functions. Deprescribing may contribute to the optimization of pharmacotherapy in LTCF residents.