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Warunek LN, Gruver B, Bartko L, Blair J. Assessing intradisciplinary pharmacy communication related to transitions of care. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 14:100438. [PMID: 38646470 PMCID: PMC11026837 DOI: 10.1016/j.rcsop.2024.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/29/2024] [Accepted: 04/03/2024] [Indexed: 04/23/2024] Open
Abstract
Background Pharmacists play an important role in transitions of care, where successful communication is vital. The primary objective of this study was to assess the extent of intradisciplinary communication between pharmacists during patient transitions of care. Secondary objectives were to evaluate pharmacist communication practices and to explore the potential barriers and facilitators to effective health communications. Methods A twenty item online survey was administered by email to all pharmacists practicing within a multisite regional healthcare system in central and northeastern Pennsylvania. Statistical analysis consisted of descriptive statistics for multiple choice, select all that apply, and Likert-type questions. Themes were summarized for open ended questions. Results A total of 132 (32%) pharmacists responded to the survey of which 90 responses were included in the analysis. The majority of pharmacists felt either extremely comfortable (53.3%) or somewhat comfortable (33.3%) reaching out to another pharmacist within the same health system. However, most contacted other pharmacy disciplines within the health system ≤25% of their work week. The ability to reach the pharmacist was the most important factor to pharmacist comfort (extremely important n = 56, somewhat important n = 27). Not knowing who to contact was the biggest barrier (44.8%). The electronic messaging systems Microsoft Teams (almost always n = 33, often n = 25) and TigerText (almost always n = 17, often n = 23) were the forms of communication utilized most often. Conclusions Pharmacists feel comfortable communicating with pharmacists across different entities within the health system, however, intradisciplinary communication related to transitions of care activities is limited. Improving awareness of system-wide pharmacist directories (34.2%) and distribution of pharmacist schedules (18.4%) were identified as tools that may improve communication.
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Affiliation(s)
- Letitia N. Warunek
- Wilkes University, Nesbitt School of Pharmacy, 84 W. South Street, Wilkes-Barre, PA 18766, United States of America
| | - Brenda Gruver
- Wilkes University, Nesbitt School of Pharmacy, 84 W. South Street, Wilkes-Barre, PA 18766, United States of America
| | - Liam Bartko
- Wilkes University, Nesbitt School of Pharmacy, 84 W. South Street, Wilkes-Barre, PA 18766, United States of America
| | - Jaycee Blair
- Wilkes University, Nesbitt School of Pharmacy, 84 W. South Street, Wilkes-Barre, PA 18766, United States of America
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Vellonen M, Härkänen M, Välimäki T. Flow of information contributing to medication incidents in home care-An analysis considering incident reporters' perspectives. J Clin Nurs 2024; 33:664-677. [PMID: 37803812 DOI: 10.1111/jocn.16896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
AIM To describe the contributing factors and types of reported medication incidents in home care related to the flow of information in different phases of the medication process, as reported by multi-professional healthcare groups. DESIGN This descriptive, qualitative study used retrospective data. METHODS An incident-reporting database was used to collect 14,289 incident reports from 2017 to 2019 in a city in Finland. We used this data to select medication incidents (n = 1027) related to the flow of information in home care and between home care and hospitals. Data were divided into five groups based on the medication phase: (1) prescribing, (2) dispensing, (3) administration, (4) documentation and (5) self-administration. In addition, the types of medication-related incidents were described. The data were examined using abductive content analysis. The EQUATOR SRQR checklist was used in this report. RESULTS Four main categories were identified from the data: (1) issues related to information management, (2) cooperation issues between different actors, (3) work environment and lack of resources and (4) factors related to healthcare workers. Cooperation issues contributed to medication-related incidents during each phase. Incomplete communication was a contributing factor to medication incidents. This occurred between home care, remote care, hospital, the client and the client's relatives. Specifically, a lack of information-sharing occurred in repatriation situations, where care transitioned between different healthcare professionals. CONCLUSION Healthcare professionals, organisations, clients and their relatives should focus on the efficient and safe acquisition of medications. Specifically, the use of electronic communication systems, together with oral reports and checklists for discharge situations, and timely cooperation with pharmacists should be developed to manage information flows. RELEVANCE TO CLINICAL PRACTICE These findings demonstrate that healthcare professionals require uniform models and strategies to accurately and safely prescribe, dispense and administer medications in home care settings. No patient or public contributions.
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Affiliation(s)
- Marja Vellonen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
- Laurea University of Applied Sciences, Vantaa, Finland
| | - Marja Härkänen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Tarja Välimäki
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
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Syyrilä T, Vehviläinen-Julkunen K, Mikkonen S, Härkänen M. Measuring health professionals' perceptions of communication contributing to medication incidents in hospitals - scale development and primary results of weekly perceived communication challenges. BMC Nurs 2023; 22:285. [PMID: 37626368 PMCID: PMC10463788 DOI: 10.1186/s12912-023-01455-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Communication challenges are one of the main contributors for medication incidents in hospitals, but health professionals' perceptions about variety of the contributing communication factors and the factors' occurrence frequencies are studied little. This cross-sectional descriptive study aimed to (1) operationalize a literature-based framework into a scale for measuring health professionals' perceptions of communication factors, which contribute to medication incidents either directly or indirectly in hospitals, (2) to measure the construct validity and internal consistency of the scale and (3) to describe the primary results of the measured weekly perceived communication challenges. METHODS The structured online questionnaire with 82 communication related items was developed based on a framework in literature. A content validity index of expert panelists' answers was used for item reduction. Data was collected between November 1st, 2019, and January 31st, 2020, by convenience sampling. The study sample (n = 303) included multiple health professional groups in diverse specialties, unit types and organizational levels in two specialized university hospital districts in Finland. Exploratory factor analysis with Maximum Likelihood method and Oblique rotation produced a six factors scale consisting of 57 items and having acceptable construct validity and internal consistency. RESULTS The six communication factors contributing to medication incidents concerned (1) medication prescriptions, (2) guidelines and reporting, (3) patient and family, (4) guideline implementation,5) competencies and responsibilities, and 6) attitude and atmosphere. The most frequently perceived communication challenges belonged to the Medication prescription related factor. Detailed item frequencies suggested that the most usual weekly challenges were: (1) lack or unclarity of communication about medication prescriptions, (2) missing the prescriptions which were written outside of the regular physician-ward-rounds and (3) digital software restricting information transfer. CONCLUSIONS The scale can be used for determining the most frequent detailed communication challenges. Confirmatory factor analysis of the scale is needed with a new sample for the scale validation. The weekly perceived communication challenges suggest that interventions are needed to standardize prescribing documentation and to strengthen communication about prescriptions given outside of regular ward-rounds.
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Affiliation(s)
- Tiina Syyrilä
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), PO Box 1627, Kuopio, 70211, Finland.
| | - Katri Vehviläinen-Julkunen
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), PO Box 1627, Kuopio, 70211, Finland
- Kuopio University Hospital (KUH), Kuopio, Finland
| | - Santtu Mikkonen
- Department of Environmental and Biological Sciences, University of Eastern Finland (UEF), Kuopio, Finland
- Department of Technical Physics, Faculty of Science, Forestry and Technology, University of Eastern Finland (UEF), Kuopio, Finland
| | - Marja Härkänen
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), PO Box 1627, Kuopio, 70211, Finland
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Paul P, Era N, Paul UK. Need for implementation of safe medication practice to avoid medication errors - A journey through case series. J Family Med Prim Care 2023; 12:1464-1467. [PMID: 37649763 PMCID: PMC10465052 DOI: 10.4103/jfmpc.jfmpc_2016_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/21/2023] [Accepted: 04/26/2023] [Indexed: 09/01/2023] Open
Abstract
Patient safety is seriously threatened by medication errors. Pharmacological therapy aims to accomplish particular therapeutic objectives that improve patient quality of life while reducing patient risk. To develop a clear plan for minimizing medication errors and establishing safe and effective medication practices, the study's major goal is to identify the key locations at which medication errors usually occur. The five scenarios presented here demonstrate the frequent errors that took place, including communication problems, technical errors, rule-based errors, and knowledge-based errors. Patients' quality of life must be improved by educating both patients and healthcare workers on safe medication practices. This involves monitoring for and recognizing errors, reporting them in a blame-free environment, analyzing their root causes, changing procedures on the lessons learned, and ongoing monitoring.
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Affiliation(s)
- Pritama Paul
- Department of Pharmacology, Mata Gujri Memorial Medical College, Kishanganj, Bihar, India
| | - Nikhil Era
- Department of Pharmacology, Mata Gujri Memorial Medical College, Kishanganj, Bihar, India
| | - Uttam K. Paul
- Department of Medicine, MGM Medical College, Kishanganj, Bihar, India
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Al Jabri F, Kvist T, Turunen H. Core competencies of healthcare professionals in Oman: Research and evidence-based practice needs attention. Nurs Open 2023; 10:2053-2065. [PMID: 36323624 PMCID: PMC10006615 DOI: 10.1002/nop2.1453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 05/14/2022] [Accepted: 10/11/2022] [Indexed: 11/05/2022] Open
Abstract
AIM The aim of the study was to examine (1) the perceptions on core competencies of healthcare professionals working at clinical settings in Oman and (2) which demographic characteristics explain the overall core competency. DESIGN A cross-sectional design. METHODS Healthcare Professional Core Competency Instrument, consisting of 11 sub-scales with 81 items, was distributed to healthcare professionals (n = 1,543; 826 nurses and 717 physicians) who worked at primary, secondary and tertiary healthcare institutions. Descriptive statistics, t-test, ANOVA and linear regression were used for data analysis. RESULTS Altogether 1,078 healthcare professionals (628 nurses and 450 physicians) responded representing 70% overall response rate. Healthcare professionals perceived their overall core competence as excellent, safety being the highest, and research and evidence-based practice was the lowest. The multiple linear regression analysis revealed that ethnicity, gender and years of working experience were the characters that explained the overall core competence, where expatriate senior professionals reported higher competency levels compared with counterparts.
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Affiliation(s)
- Fatma Al Jabri
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Tarja Kvist
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Hannele Turunen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
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Syyrilä T, Vehviläinen-Julkunen K, Härkänen M. Healthcare professionals' perceptions on medication communication challenges and solutions - text mining and manual content analysis - cross-sectional study. BMC Health Serv Res 2021; 21:1226. [PMID: 34774044 PMCID: PMC8590289 DOI: 10.1186/s12913-021-07227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 10/27/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Communication challenges contribute to medication incidents in hospitals, but it is unclear how communication can be improved. The aims of this study were threefold: firstly, to describe the most common communication challenges related to medication incidents as perceived by healthcare professionals across specialized hospitals for adult patients; secondly, to consider suggestions from healthcare professionals with regard to improving medication communication; and thirdly, to explore how text mining compares to manual analysis when analyzing the free-text content of survey data. METHODS This was a cross-sectional, descriptive study. A digital survey was sent to professionals in two university hospital districts in Finland from November 1, 2019, to January 31, 2020. In total, 223 professionals answered the open-ended questions; respondents were primarily registered nurses (77.7 %), physicians (8.6 %), and pharmacists (7.3 %). Text mining and manual inductive content analysis were employed for qualitative data analysis. RESULTS The communication challenges were: (1) inconsistent documentation of prescribed and administered medication; (2) failure to document orally given prescriptions; (3) nurses' unawareness of prescriptions (given outside of ward rounds) due to a lack of oral communication from the prescribers; (4) breaks in communication during care transitions to non-communicable software; (5) incomplete home medication reconciliation at admission and discharge; (6) medication lists not being updated during the inpatient period due to a lack of clarity regarding the responsible professional; and (7) work/environmental factors during medication dispensation and the receipt of verbal prescriptions. Suggestions for communication enhancements included: (1) structured digital prescriptions; (2) guidelines and training on how to use documentation systems; (3) timely documentation of verbal prescriptions and digital documentation of administered medication; (4) communicable software within and between organizations; (5) standardized responsibilities for updating inpatients' medication lists; (6) nomination of a responsible person for home medication reconciliation at admission and discharge; and (7) distraction-free work environment for medication communication. Text mining and manual analysis extracted similar primary results. CONCLUSIONS Non-communicable software, non-standardized medication communication processes, lack of training on standardized documentation, and unclear responsibilities compromise medication safety in hospitals. Clarification is needed regarding interdisciplinary medication communication processes, techniques, and responsibilities. Text mining shows promise for free-text analysis.
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Affiliation(s)
- Tiina Syyrilä
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), Yliopistonranta 1c, P.O. Box 1627, 70211, Kuopio, Finland.
- University of Helsinki, Helsinki University Hospital (HUS), Meilahti Tower Hospital, building 1, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, HUS, Finland.
| | - Katri Vehviläinen-Julkunen
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), Yliopistonranta 1c, P.O. Box 1627, 70211, Kuopio, Finland
- Kuopio University Hospital (KUH), Puijonlaaksontie 2, 70210, Kuopio, Finland
| | - Marja Härkänen
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland (UEF), Yliopistonranta 1c, P.O. Box 1627, 70211, Kuopio, Finland
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Manias E, Street M, Lowe G, Low JK, Gray K, Botti M. Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit. BMC Health Serv Res 2021; 21:1025. [PMID: 34583681 PMCID: PMC8480109 DOI: 10.1186/s12913-021-07033-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/02/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Efforts to ensure safe and optimal medication management are crucial in reducing the prevalence of medication errors. The aim of this study was to determine the associations of person-related, environment-related and communication-related factors on the severity of medication errors occurring in two health services. METHODS A retrospective clinical audit of medication errors was undertaken over an 18-month period at two Australian health services comprising 16 hospitals. Descriptive statistical analysis, and univariate and multivariable regression analysis were undertaken. RESULTS There were 11,540 medication errors reported to the online facility of both health services. Medication errors caused by doctors (Odds Ratio (OR) 0.690, 95% CI 0.618-0.771), or by pharmacists (OR 0.327, 95% CI 0.267-0.401), or by patients or families (OR 0.641, 95% CI 0.472-0.870) compared to those caused by nurses or midwives were significantly associated with reduced odds of possibly or probably harmful medication errors. The presence of double-checking of medication orders compared to single-checking (OR 0.905, 95% CI 0.826-0.991) was significantly associated with reduced odds of possibly or probably harmful medication errors. The presence of electronic systems for prescribing (OR 0.580, 95% CI 0.480-0.705) and dispensing (OR 0.350, 95% CI 0.199-0.618) were significantly associated with reduced odds of possibly or probably harmful medication errors compared to the absence of these systems. Conversely, insufficient counselling of patients (OR 3.511, 95% CI 2.512-4.908), movement across transitions of care (OR 1.461, 95% CI 1.190-1.793), presence of interruptions (OR 1.432, 95% CI 1.012-2.027), presence of covering personnel (OR 1.490, 95% 1.113-1.995), misread or unread orders (OR 2.411, 95% CI 2.162-2.690), informal bedside conversations (OR 1.221, 95% CI 1.085-1.373), and problems with clinical handovers (OR 1.559, 95% CI 1.136-2.139) were associated with increased odds of medication errors causing possible or probable harm. Patients or families were involved in the detection of 1100 (9.5%) medication errors. CONCLUSIONS Patients and families need to be engaged in discussions about medications, and health professionals need to provide teachable opportunities during bedside conversations, admission and discharge consultations, and medication administration activities. Patient counselling needs to be more targeted in effort to reduce medication errors associated with possible or probable harm.
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Affiliation(s)
- Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Maryann Street
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia
| | - Grainne Lowe
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia
| | - Jac Kee Low
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia
| | - Kathleen Gray
- Centre for Digital Transformation of Health, The University of Melbourne, Grattan Street, Parkville, Victoria, 3010, Australia
| | - Mari Botti
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia
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Shiima Y, Malik M, Okorie M. Medication Without Harm: Developing optimal medication error reporting systems. Curr Drug Saf 2021; 17:7-12. [PMID: 33902416 DOI: 10.2174/1574886316666210423115029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/29/2020] [Accepted: 02/16/2021] [Indexed: 11/22/2022]
Abstract
Medication errors are amongst the most frequently occurring health care related incidents and have the potential to lead to life-threatening harm to patients. An incident reporting system is a traditional approach to improvement of patient safety and entails the retrieval of information from incident reports. This not only provides a better understanding of causes and contributing factors but also enables the collection of data on the severity of incidents, system deficiencies and the role of human factors in safety incidents. Medication error reporting systems are often developed as a part of larger incident reporting systems which deal with other types of incidents. Although a rise in the prevalence of medication errors has led to an increased demand for medication error reporting, little is known about characteristics and limitations of medication error reporting systems. The authors broach the subject of medication error reporting systems and propose a more robust and standardized approach.
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Affiliation(s)
- Yuko Shiima
- Brighton and Sussex Medical School, Falmer, Brighton, UK; 2 Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Muzaffar Malik
- Brighton and Sussex Medical School, Falmer, Brighton, UK; 2 Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Michael Okorie
- Brighton and Sussex Medical School, Falmer, Brighton, UK; 2 Brighton and Sussex University Hospitals, Brighton, United Kingdom
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Corrigendum. J Clin Nurs 2020; 30:306. [PMID: 33539592 DOI: 10.1111/jocn.15526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Härkänen M, Franklin BD, Murrells T, Rafferty AM, Vehviläinen-Julkunen K. Factors contributing to reported medication administration incidents in patients' homes - A text mining analysis. J Adv Nurs 2020; 76:3573-3583. [PMID: 33048380 PMCID: PMC7702090 DOI: 10.1111/jan.14532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/03/2020] [Accepted: 08/10/2020] [Indexed: 11/29/2022]
Abstract
AIMS To describe the characteristics of medication administration (MA) incidents reported to have occurred in patients' own homes (reporters' profession, incident types, contributing factors, patient consequence, and most common medications involved) and to identify the connection terms related to the most common contributing factors based on free text descriptions. DESIGN A retrospective study using descriptive statistical analysis and text mining. METHODS Medication administration incidents (N = 19,725) reported to have occurred in patients' homes between 2013-2018 in one district in Finland were analysed, describing the data by the reporters' occupation, incident type, contributing factors, and patient consequence. SAS® Text Miner was used to analyse free text descriptions of the MA incidents to understand contributing factors, using concept linking. RESULTS Most MA incidents were reported by practical (lower level) nurses (77.8%, N = 15,349). The most common category of harm was 'mild harm' (40.1%, N = 7,915) and the most common error type was omissions of drug doses (47.4%, N = 9,343). The medications most commonly described were Marevan [warfarin] (N = 2,668), insulin (N = 811), Furesis [furosemide] (N = 590), antibiotic (N = 446), and Panadol [paracetamol] (N = 416). The contributing factors most commonly reported were 'communication and flow of information' (25.5%, N = 5,038), 'patient and relatives' (22.6%, N = 4,451), 'practices' (9.9%, N = 1,959), 'education and training' (4.8%, N = 949), and 'work environment and resources' (3.0%, N = 598). CONCLUSION There is need for effective communication and clear responsibilities between home care patients and their relatives and health providers, about MA and its challenges in home environments. Knowledge and skills relating to safe MA are also essential. IMPACT These findings about MA incidents that have occurred in patients' homes and have been reported by home care professionals demonstrate the need for medication safety improvement in home care.
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Affiliation(s)
- Marja Härkänen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Bryony Dean Franklin
- Centre for Medication Safety and Service Quality, Imperial College London Healthcare NHS Trust, London, UK.,UCL School of Pharmacy, London, UK
| | - Trevor Murrells
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Katri Vehviläinen-Julkunen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland.,Kuopio University Hospital, Kuopio, Finland
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