Gaps, traps, bridges and props: a mixed-methods study of resilience in the medicines management system for patients with heart failure at hospital discharge

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.

Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes

BACKGROUND

Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients' perspectives of their medications from hospital to two months after discharge.

METHODS

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

RESULTS

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

CONCLUSIONS

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients' difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients' needs, increase their safety, and standardize physicians', pharmacists', and nurses' roles and responsibilities.

Identifying, categorising, and mapping actors involved in resilience in healthcare: a qualitative stakeholder analysis

BACKGROUND

Resilience in healthcare is the capacity to adapt to challenges and changes to maintain high-quality care across system levels. While healthcare system stakeholders such as patients, informal carers, healthcare professionals and service managers have all come to be acknowledged as important co-creators of resilient healthcare, our knowledge and understanding of who, how, and in which contexts different stakeholders come to facilitate and support resilience is still lacking. This study addresses gaps in the research by conducting a stakeholder analysis to identify and categorise the stakeholders that are key to facilitating and sustaining resilience in healthcare, and to investigate stakeholder relationships relevant for the enactment of resilient healthcare systems.

METHODS

The stakeholder analysis was conducted using a sample of 19 empirical research projects. A narrative summary was written for 14 of the projects, based on publicly available material. In addition, 16 individual interviews were undertaken with researchers from the same sample of 19 projects. The 16 interview transcripts and 14 narratives made up the data material of the study. Application of stakeholder analysis methods was done in three steps: a) identification of stakeholders; b) differentiation and categorisation of stakeholders using an interest/influence grid; and c) investigation and mapping of stakeholder relationships using an actor-linkage matrix.

RESULTS

Identified stakeholders were Patients, Family Carers, Healthcare Professionals, Ward/Unit Managers, Service or Case Managers, Regulatory Investigators, Policy Makers, and Other Service Providers. All identified stakeholders were categorised as either 'Subjects', 'Players', or 'Context Setters' according to their level of interest in and influence on resilient healthcare. Stakeholder relationships were mapped according to the degree and type of contact between the various groups of stakeholders involved in facilitating resilient healthcare, ranging from 'Not linked' to 'Fully linked'.

CONCLUSION

Family carers and healthcare professionals were found to be the most active groups of stakeholders in the enactment of healthcare system resilience. Patients, managers, and policy makers also contribute to resilience to various degrees. Relationships between stakeholder groups are largely characterised by communication and coordination, in addition to formal collaborations where diverse actors work together to achieve common goals.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review

BACKGROUND

Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management.

OBJECTIVES

To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio.

METHODS

Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) 'Key Components of an Ideal Transfer of Care', (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored.

RESULTS

Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support.

CONCLUSION

The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.

Characterizing barriers to closing cross-institutional referral loops: Workflow and information flow analysis

The specialty referral process consists of primary care clinicians referring patients to specialty consultants. This care transition requires effective care coordination and health information exchange between care teams; however, breakdowns in workflow and information flow impede "closing the referral loop" and delay or prevent referrers from receiving the consultant's "visit notes," particularly in cross-institutional referrals. This study aimed to describe and map the referral process as it occurs in clinics and identify and characterize work system barriers affecting its performance. Referrers and consultants were interviewed about their perceived workflows, barriers, and clinical outcomes to inform a workflow analysis.

Views on sharing mental health data for research purposes: qualitative analysis of interviews with people with mental illness

BACKGROUND

Improving the ways in which routinely-collected mental health data are shared could facilitate substantial advances in research and treatment. However, this process should only be undertaken in partnership with those who provide such data. Despite relatively widespread investigation of public perspectives on health data sharing more generally, there is a lack of research on the views of people with mental illness.

METHODS

Twelve people with lived experience of mental illness took part in semi-structured interviews via online video software. Participants had experience of a broad range of mental health conditions including anxiety, depression, schizophrenia, eating disorders and addiction. Interview questions sought to establish how participants felt about the use of routinely-collected health data for research purposes, covering different types of health data, what health data should be used for, and any concerns around its use.

RESULTS

Thematic analysis identified four overarching themes: benefits of sharing mental health data, concerns about sharing mental health data, safeguards, and data types. Participants were clear that health data sharing should facilitate improved scientific knowledge and better treatments for mental illness. There were concerns that data misuse could become another way in which individuals and society discriminate against people with mental illness, for example through insurance premiums or employment decisions. Despite this there was a generally positive attitude to sharing mental health data as long as appropriate safeguards were in place.

CONCLUSIONS

There was notable strength of feeling across participants that more should be done to reduce the suffering caused by mental illness, and that this could be partly facilitated by well-managed sharing of health data. The mental health research community could build on this generally positive attitude to mental health data sharing by following rigorous best practice tailored to the specific concerns of people with mental illness.

Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

BACKGROUND

Hospital discharge is a complex process encompassing multiple interactions and requiring coordination. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aims of this study were to 1) map coordination and team collaboration across healthcare and social care organisations, 2) describe interdependencies and system variability in the discharge process for older people with complex care needs, and 3) evaluate the alignment between discharge planning and the needs in the home.

METHODS

Data were collected through participant observations, interviews, and document review in a region of southern Sweden. The Functional Resonance Analysis Method (FRAM) was used to model the discharge process and visualise and analyse coordination of care across healthcare and social care organisations.

RESULTS

Hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals' performance is constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in health and social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. Flexibility and appropriate resources enable for handling variability and responding to uncertainties in care after discharge.

CONCLUSIONS

Mapping hospital discharge using the FRAM reveals couplings and interdependencies between various individuals, teams, and organisations and the most vulnerable point, when the patient arrives at home. Resilient performance in responding to unexpected events and variations during the first days after the return home requires a system allowing flexibility and facilitating successful adaptation of discharge planning.

Patient and public co-creation of healthcare safety and healthcare system resilience: The case of COVID-19

INTRODUCTION

Healthcare system resilience is a conceptual approach that seeks to explore how health services adapt and respond to variability in demand and resources. As has been witnessed since the beginning of the COVID-19 pandemic, healthcare services have undergone many reconfigurations. One understudied aspect of how the 'system' is able to adapt and respond is the contribution of key stakeholders-patients and families, and in the context of the pandemic, the general public as a whole. This study aimed to understand what people were doing during the first wave of the pandemic to protect the safety of their health, and the health of others from COVID-19, and the resilience of the healthcare system.

METHODS

Social media (Twitter) was used as a method of recruitment due to its ability for social reach. Twenty-one participants took part in 57 semistructured interviews over three time points from June to September 2020. The included an initial interview and invitation to two follow-up interviews after 3 and 6 weeks. Interviews were conducted virtually using Zoom-an encrypted secure video conferencing software. A reflexive thematic analysis approach to analysis was used.

RESULTS

Three themes, each with its own subthemes were identified in the analysis: (1) A 'new safety normal'; (2) Existing vulnerabilities and heightened safety and (3) Are we all in this together?

CONCLUSION

This study found that the public had a role in supporting the resilience of healthcare services and systems during the first wave of the pandemic by adapting their behaviour to protect themselves and others, and to avoid overwhelming the National Health Service. People who had existing vulnerabilities were more likely to experience safety gaps in their care, and be required to step in to support their safety, despite it being more difficult for them to do so. It may be that the most vulnerable were previously required to do this extra work to support the safety of their care and that the pandemic has just illuminated this issue. Future research should explore existing vulnerabilities and inequalities, and the heightened safety consequences created by the pandemic.

PATIENT AND PUBLIC CONTRIBUTION

The National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC), Patient and Public Involvement and Engagement Research Fellow and NIHR Yorkshire and Humber PSTRC Patient Involvement in Patient Safety theme lay leader are involved in the preparation of a lay version of the findings within this manuscript.

Unpacking the Cinderella black box of complex intervention development through the Partners at Care Transitions (PACT) programme of research

INTRODUCTION

Complex intervention development has been described as the 'Cinderella' black box in health services research. Greater transparency in the intervention development process is urgently needed to help reduce research waste.

METHODS

We applied a new consensus-based framework for complex intervention development to our programme of research, in which we developed an intervention to improve the safety and experience of care transitions for older people. Through this process, we aimed to reflect on the framework's utility for intervention development and identify any important gaps within it to support its continued development.

FINDINGS

The framework was a useful tool for transparent reporting of the process of complex intervention development. We identified potential 'action' gaps in the framework including 'consolidation of evidence' and 'development of principles' that could bracket and steer decision-making in the process.

CONCLUSIONS

We consider that the level of transparency demonstrated in this report, aided through use of the framework, is essential in the quest for reducing research waste.

PATIENT OR PUBLIC CONTRIBUTION

We have involved our dedicated patient and public involvement group in all work packages of this programme of research. Specifically, they attended and contributed to co-design workshops and contributed to finalizing the intervention for the pilot evaluation. Staff also participated by attending co-design workshops, helping us to prioritize content ideas for the intervention and supporting the development of intervention components outside of the workshops.

What Do Patients and Their Carers Do to Support the Safety of Cancer Treatment and Care? A Scoping Review

BACKGROUND

Cancer patients and their carers face a multitude of challenges in the treatment journey; the full scope of how they are involved in promoting safety and supporting resilient healthcare is not known.

OBJECTIVE

The study aimed to undertake a scoping review to explore, document, and understand existing research, which explores what cancer patients and their carers do to support the safety of their treatment and care.

DESIGN

This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. Five online databases were searched from 2000 to 2021 to identify primary literature exploring perspectives on patient and caregiver involvement in maintaining their safety during cancer care. Narrative synthesis was then conducted on the included literature.

RESULTS

Of the 1582 results generated from the initial search, 16 studies were included in the review. Most consisted of qualitative semistructured interviews with patients, as well as carers and healthcare professionals (HCP). Four narrative themes were identified: patient perception of safety and their involvement; patients take charge of their own care and well-being; safety as a dynamic collective responsibility; and carers are an undersupported asset. Patients and their carers involve themselves in a variety of behaviors in physical care, well-being, communication, and care coordination to ensure safety and support system resilience. This review adds a novel perspective on cancer patient and caregiver involvement in supporting resilient healthcare.

CONCLUSIONS

Patients and their carers play an important role in promoting safe cancer care and healthcare system resilience. Further research is recommended to realize the full extent of the system gaps encountered and mediated by patients and their carers.

A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home

BACKGROUND

The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient-friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post-discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention.

METHODS

This was a qualitative formative evaluation involving three wards from one hospital. We recruited 25 patients aged 75 years and older. Ward staff supported intervention delivery. Data were collected in wards and patients' homes, through semi-structured interviews, observation, and documentary analysis. Data were analysed inductively and iteratively with findings sorted according to the research aims.

RESULTS

Patients and staff felt there was a need for, and understood the purpose of, the PACT intervention. Most patients read the booklet but other components were variably used. Implementation challenges included time, awareness, and balancing intervention benefits against risks. Changes to the intervention and implementation included clarifying the booklet's messages, simplifying the discharge letter to reduce staff burden, and using prompts and handouts to promote awareness.

CONCLUSION

The PACT intervention offers a promising new way to improve care transitions for older people by supporting patient involvement in their care. After further development of the intervention and implementation package, it will undergo further testing.

PATIENT OR PUBLIC CONTRIBUTION

This study regularly consulted a panel representing the local patient community, who supported the development of this intervention and its implementation.

Experiences of patients with heart failure with medicines at transition intervention: Findings from the process evaluation of the Improving the Safety and Continuity of Medicines management at Transitions of care (ISCOMAT) programme

BACKGROUND

Medicines are often suboptimally managed for heart failure patients across the transition from hospital to home, potentially leading to poor patient outcomes. The Improving the Safety and Continuity Of Medicines management at Transitions of care programme included: understanding the problems faced by patients and healthcare professionals; developing and co-designing the Medicines at Transitions of care Intervention (MaTI); a cluster randomized controlled trial testing the effectiveness of a complex behavioural MaTI aimed at improving medicines management at the interface between hospitals discharge and community care for patients with heart failure; and a process evaluation. The MaTI included a patient-held My Medicines Toolkit; enhanced communication between the hospital and the patient's community pharmacist and increased engagement of the community pharmacist postdischarge. This paper reports on the patients' experiences of the MaTI and its implementation from the process evaluation.

DESIGN

Twenty one-to-one semi-structured patient interviews from six intervention sites were conducted between November 2018 and January 2020. Data were analysed using the Framework method, involving patients as co-analysts. Interview data were triangulated with routine trial data, the Consolidated Framework for Implementation Research and a logic model.

RESULTS

Within the hospital setting patients engaged with the toolkit according to whether staff raised awareness of the My Medicines Toolkit's importance and the time and place of its introduction. Patients' engagement with community pharmacy depended on their awareness of the community pharmacist's role, support sources and perceptions of involvement in medicines management. The toolkit's impact on patients' medicines management at home included reassurance during gaps in care, increased knowledge of medicines, enhanced ability to monitor health and seek support and supporting sharing medicines management between formal and informal care networks.

CONCLUSION

Many patients perceived that the MaTI offered them support in their medicines management when transitioning from hospital into the community. Importantly, it can be incorporated into and built upon patients' lived experiences of heart failure. Key to its successful implementation is the quality of engagement of healthcare professionals in introducing the intervention.

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in the study design, as qualitative data co-analysts and as co-authors.

Interventions for self-management of medicines for community-dwelling people with dementia and mild cognitive impairment and their family carers: a systematic review

Background

people with dementia or mild cognitive impairment (MCI) and their family carers face challenges in managing medicines. How medicine self-management could be supported for this population is unclear. This review identifies interventions to improve medicine self-management for people with dementia and MCI and their family carers, and the core components of medicine self-management that they address.

Methods

a database search was conducted for studies with all research designs and ongoing citation search from inception to December 2021. The selection criteria included community-dwelling people with dementia and MCI and their family carers, and interventions with a minimum of one medicine self-management component. The exclusion criteria were wrong population, not focusing on medicine management, incorrect medicine self-management components, not in English and wrong study design. The results are presented and analysed through narrative synthesis. The review is registered [PROSPERO (CRD42020213302)]. Quality assessment was carried out independently applying the QATSDD quality assessment tool.

Results

13 interventions were identified. Interventions primarily addressed adherence. A limited number focused on a wider range of medicine self-management components. Complex psychosocial interventions with frequent visits considered the person’s knowledge and understanding, supply management, monitoring effects and side effects and communicating with healthcare professionals, and addressed more resilience capabilities. However, these interventions were delivered to family carers alone. None of the interventions described patient and public involvement.

Conclusion

interventions, and measures to assess self-management, need to be developed which can address all components of medicine self-management to better meet the needs of people with dementia and MCI and their family carers.

Using routine healthcare data to evaluate the impact of the Medicines at Transitions Intervention (MaTI) on clinical outcomes of patients hospitalised with heart failure: protocol for the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) cluster randomised controlled trial with embedded process evaluation, health economics evaluation and internal pilot

INTRODUCTION

Heart failure affects 26 million people globally, approximately 900 thousand people in the UK, and is increasing in incidence. Appropriate management of medicines for heart failure at the time of hospital discharge reduces readmissions, improves quality of life and increases survival. The Improving the Safety and Continuity Of Medicines management at Transitions (ISCOMAT) trial tests the effectiveness of the Medicines at Transition Intervention (MaTI), which aims to enhance self-care and increase community pharmacy involvement in the medicines management of heart failure patients.

METHODS AND ANALYSIS

ISCOMAT is a parallel-group cluster randomised controlled trial, randomising 42 National Health Service trusts with cardiology wards in England on a 1:1 basis to implement the MaTI or treatment as usual. Around 2100 patients over the age of 18 admitted to hospital with heart failure with at least moderate left ventricular systolic dysfunction within the last 5 years, and planned discharge to the geographical area of the cluster will be recruited. The MaTI consists of training for staff, a toolkit for participants, transfer of discharge information to community pharmacies and a medicines reconciliation/review. Treatment as usual is determined by local policy and practices. The primary outcome is a composite of all-cause mortality and heart failure-related hospitalisation at 12 months postregistration obtained from national electronic health records. The key secondary outcome is continued prescription of guideline-indicated therapies at 12 months measured via patient-reported data and Hospital Episode Statistics. The trial contains a parallel mixed-methods process evaluation and an embedded health economics study.

ETHICS AND DISSEMINATION

The study obtained approval from the Yorkshire and the Humber-Bradford Leeds Research Ethics Committee; REC reference 18/YH/0017. Findings will be disseminated via academic and policy conferences, peer-reviewed publications and social media. Amendments to the protocol are disseminated to all relevant parties as required.

TRIAL REGISTRATION NUMBER

ISRCTN66212970; Pre-results.

Implementation of a pharmacist‐led transitional pharmaceutical care programme: Process evaluation of Medication Actions to Reduce hospital admissions through a collaboration between Community and Hospital pharmacists (MARCH)

What is known and objective

The recently conducted Medication Actions to Reduce hospital admissions through a collaboration between Community and Hospital pharmacists (MARCH) transitional care programme, which aimed to test the effectiveness of a transitional care programme on the occurrence of ADEs post‐discharge, did not show a significant effect. To clarify whether this non‐significant effect was due to poor implementation or due to ineffectiveness of the intervention as such, a process evaluation was conducted. The aim of the study was to gain more insight into the implementation fidelity of MARCH.

Methods

A mixed methods design and the modified Conceptual Framework for Implementation Fidelity was used. For evaluation, the implementation fidelity and moderating factors of four key MARCH intervention components (teach‐back, the pharmaceutical discharge letter, the post‐discharge home‐visit and the transitional medication review) were assessed. Quantitative data were collected during and after the intervention. Qualitative data were collected using semi‐structured interviews with MARCH healthcare professionals (community pharmacists, clinical pharmacists, pharmacy assistants and pharmaceutical consultants) and analysed using thematic analysis.

Results and Discussion

Not all key intervention components were implemented as intended. Teach‐back was not always performed. Moreover, 63% of the pharmaceutical discharge letters, 35% of the post‐discharge home‐visits and 44% of the transitional medication reviews were not conducted within their planned time frames. Training sessions, structured manuals and protocols with detailed descriptions facilitated implementation. Intervention complexity, time constraints and the multidisciplinary coordination were identified as barriers for the implementation.

What is new and Conclusion

Overall, the implementation fidelity was considered to be moderate. Not all key intervention components were carried out as planned. Therefore, the non‐significant results of the MARCH programme on ADEs may at least partly be explained by poor implementation of the programme. To successfully implement transitional care programmes, healthcare professionals require full integration of these programmes in the standard work‐flow including IT improvements as well as compensation for the time investment.

To what extent are patients involved in researching safety in acute mental healthcare?

BACKGROUND

There is a growing need to involve patients in the development of patient safety interventions. Mental health services, despite their strong history of patient involvement, have been slow to develop patient safety interventions, particularly in inpatient settings.

METHODS

A systematic search was undertaken of both academic and grey literature. Whilst no lay member of the team worked directly on the review, they were part of the project steering group which provided oversight throughout the review process. This included people with lived experience of mental health services. From a research perspective the main focus for lay members was in co-producing the digital technology, the key project output. Smits et al.'s (Res Involv Engagem 6:1-30, 2020) Involvement Matrix was used to taxonomise levels of patient involvement. Studies were included if they were set in any inpatient mental health care context regardless of design. The quality of all selected studies was appraised using Mixed Methods Appraisal Methodology (MMAT).

RESULTS

Fifty-two studies were classified, synthesised and their levels of patient involvement in the research and development of patient safety interventions were taxonomised. Almost two-thirds of studies (n = 33) researched reducing restrictive practices. Only four studies reported engaging patients in the research process as decision-makers, with the remaining studies divided almost equally between engaging patients in the research process as partners, advisors and co-thinkers. Just under half of all studies engaged patients in just one stage of the research process.

CONCLUSION

Involvement of patients in researching patient safety and developing interventions in an inpatient mental health context seems diverse in its nature. Researchers need to both more fully consider and better describe their approaches to involving patients in safety research in inpatient mental health. Doing so will likely lead to the development of higher quality safety interventions.

Systemic safety inequities for people with learning disabilities: a qualitative integrative analysis of the experiences of English health and social care for people with learning disabilities, their families and carers

BACKGROUND

Failures in care for people with learning disabilities have been repeatedly highlighted and remain an international issue, exemplified by a disparity in premature death due to poor quality and unsafe care. This needs urgent attention. Therefore, the aim of the study was to understand the care experiences of people with learning disabilities, and explore the potential patient safety issues they, their carers and families raised.

METHODS

Two data sources exploring the lived experience of care for people with learning disabilities were synthesised using an integrative approach, and explored using reflexive thematic analysis. This comprised two focus groups with a total of 13 people with learning disabilities and supportive staff, and 377 narratives posted publicly via the feedback platform Care Opinion.

RESULTS

The qualitative exploration highlighted three key themes. Firstly, health and social care systems operated with varying levels of rigidity. This contributed to an inability to effectively cater to; complex and individualised care needs, written and verbal communication needs and needs for adequate time and space. Secondly, there were various gaps and traps within systems for this population. This highlighted the importance of care continuity, interoperability and attending to the variation in support provision from professionals. Finally, essential 'dependency work' was reliant upon social capital and fulfilled by paid and unpaid caring roles to divergent extents, however, advocacy provided an additional supportive safety net.

CONCLUSIONS

A series of safety inequities have been identified for people with learning disabilities, alongside potential protective buffers. These include; access to social support and advocacy, a malleable system able to accommodate for individualised care and communication needs, adequate staffing levels, sufficient learning disabilities expertise within and between care settings, and the interoperability of safety initiatives. In order to attend to the safety inequities for this population, these factors need to be considered at a policy and organisational level, spanning across health and social care systems. Findings have wide ranging implications for those with learning disabilities, their carers and families and health and social care providers, with the potential for international learning more widely.

Mapping the resilience performance of community pharmacy to maintain patient safety during the Covid-19 pandemic

Background

The first UK wave of the Covid-19 pandemic in 2020 placed unprecedented stress on community pharmacy. Various policies and initiatives were announced during this period to support community pharmacy to continue to perform in a manner that prioritised patient safety. However, little is understood about how these policies and initiatives were implemented by staff working in community pharmacy, and the system adaptions and responses that were initiated to maintain patient safety.

Objective

The study aimed to investigate how staff working in UK community pharmacy during the first waves of the COVID-19 pandemic in 2020 responded and adapted to system stressors to maintain patient safety.

Methods

We adopted a qualitative interview approach, underpinned by Resilient Healthcare theory, with interview data collected between July 2020 and January 2021. Data were synthesised and analysed using Framework Analysis.

Results

23 community pharmacy staff from England and Scotland were interviewed. We identified five themes supported by between two and six sub-themes: 1. Covid-19, an impending threat to system; 2. Patient safety stressors during the first waves of Covid-19; 3. Altering the system, responding to system stressors; 4. Monitoring and adjusting and 5. Learning for the future.

Conclusion

Privileging the accounts of community pharmacy staff working on the frontline during the pandemic illuminated how responses and adaptions were developed and deployed, how continual monitoring occurred, and the factors that supported or hindered system resilience. The key learning derived from this study can serve to shorten the gap between ‘work as imagined’ and ‘work as done’, and in doing so, support the future resilience performance of community pharmacy during future outbreaks of Covid-19 or similar events.

Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review

Background

Little is known about the epidemiology of medication errors and medication-related harm following transition from secondary to primary care. This systematic review aims to identify and critically evaluate the available evidence on the prevalence and nature of medication errors and medication-related harm following hospital discharge.

Methods

Studies published between January 1990 and March 2019 were searched across ten electronic databases and the grey literature. No restrictions were applied with publication language or patient population studied. Studies were included if they contained data concerning the rate of medication errors, unintentional medication discrepancies, or adverse drug events. Two authors independently extracted study data.

Results

Fifty-four studies were included, most of which were rated as moderate (39/54) or high (7/54) quality. For adult patients, the median rate of medication errors and unintentional medication discrepancies following discharge was 53% [interquartile range 33–60.5] (n = 5 studies) and 50% [interquartile range 39–76] (n = 11), respectively. Five studies reported adverse drug reaction rates with a median of 27% [interquartile range 18–40.5] and seven studies reported adverse drug event rates with a median of 19% [interquartile range 16–24]. For paediatric patients, one study reported a medication error rate of 66.3% and another an adverse drug event rate of 9%. Almost a quarter of studies (13/54, 24%) utilised a follow-up period post-discharge of 1 month (range 2–180 days). Drug classes most commonly implicated with adverse drug events were antibiotics, antidiabetics, analgesics and cardiovascular drugs.

Conclusions

This is the first systematic review to explore the prevalence and nature of medication errors and adverse drug events following hospital discharge. Targets for future work have been identified.

Electronic supplementary material

The online version of this article (10.1007/s40264-020-00918-3) contains supplementary material, which is available to authorized users.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge.

DESIGN

This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANTS

Nine patients aged 49-90 years were included close to the day of discharge.

RESULTS

The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued.

CONCLUSIONS

The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.

Using experience-based co-design with patients, carers and healthcare professionals to develop theory-based interventions for safer medicines use

BACKGROUND

Experience-Based Co-Design (EBCD) is a participatory design method which was originally developed and is still primarily used as a healthcare quality improvement tool. Traditionally, EBCD has been sited within single services or settings and has yielded improvements grounded in the experiences of those delivering and receiving care.

METHOD

In this article we present how EBCD can be adapted to develop complex interventions, underpinned by theory, to be tested more widely within the healthcare system as part of a multi-phase, multi-site research study. We begin with an outline of co-design and the stages of EBCD. We then provide an overview of how EBCD can be assimilated into an intervention development and evaluation study, giving examples of the adaptations and research tools and methods that can be deployed. We also suggest how to appraise the resulting intervention so it is realistic and tractable in multiple sites. We describe how EBCD can be combined with different behaviour change theories and methods for intervention development and finally, we make suggestions about the skills needed for successful intervention development using EBCD.

CONCLUSION

EBCD has been recognised as being a collaborative approach to improving healthcare services that puts patients and healthcare staff at the heart of initiatives and potential changes. We have demonstrated how EBCD can be integrated into a research project and how existing research approaches can be assimilated into EBCD stages. We have also suggested where behaviour change theories can be used to better understand intervention change mechanisms.

The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy

INTRODUCTION

Transitional care programs (i.e. interventions delivered both in hospital and in primary care), could increase continuity and consequently quality of care. However, limited studies on the effect of these programs on Adverse Drug Events (ADEs) post-discharge are available. Therefore, the aim of this study was to investigate the effect of a transitional pharmaceutical care program on the occurrence of ADEs 4 weeks post-discharge.

METHODS

A multicentre prospective before-after study was performed in a general teaching hospital, a university hospital and 49 community pharmacies. The transitional pharmaceutical care program consisted of: teach-back to the patient at discharge, a pharmaceutical discharge letter, a home visit by a community pharmacist and a clinical medication review by both the community and the clinical pharmacist, on top of usual care. Usual care consisted of medication reconciliation at admission and discharge by pharmacy teams. The primary outcome was the proportion of patients who reported at least 1 ADE 4 weeks post-discharge. Multivariable logistic regression was used to adjust for potential confounders.

RESULTS

In total, 369 patients were included (control: n = 195, intervention: n = 174). The proportion of patients with at least 1 ADE did not statistically significant differ between the intervention and control group (general teaching hospital: 59% vs. 67%, OR_adj 0.70 [95% CI 0.38-1.31], university hospital: 63% vs 50%, OR _adj 1.76 [95% CI 0.75-4.13]).

CONCLUSION

The transitional pharmaceutical care program did not decrease the proportion of patients with ADEs after discharge. ADEs after discharge were common and more than 50% of patients reported at least 1 ADE. A process evaluation is needed to gain insight into how a transitional pharmaceutical care program could diminish those ADEs.

Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review

OBJECTIVES

To produce a narrative synthesis of published academic and grey literature focusing on patient safety outcomes for people with learning disabilities in an acute hospital setting.

DESIGN

Scoping review with narrative synthesis.

METHODS

The review followed the six stages of the Arksey and O'Malley framework. We searched four research databases from January 2000 to March 2021, in addition to handsearching and backwards searching using terms relating to our eligibility criteria-patient safety and adverse events, learning disability and hospital setting. Following stakeholder input, we searched grey literature databases and specific websites of known organisations until March 2020. Potentially relevant articles and grey literature materials were screened against the eligibility criteria. Findings were extracted and collated in data charting forms.

RESULTS

45 academic articles and 33 grey literature materials were included, and we organised the findings around six concepts: (1) adverse events, patient safety and quality of care; (2) maternal and infant outcomes; (3) postoperative outcomes; (4) role of family and carers; (5) understanding needs in hospital and (6) supporting initiatives, recommendations and good practice examples. The findings suggest inequalities and inequities for a range of specific patient safety outcomes including adverse events, quality of care, maternal and infant outcomes and postoperative outcomes, in addition to potential protective factors, such as the roles of family and carers and the extent to which health professionals are able to understand the needs of people with learning disabilities.

CONCLUSION

People with learning disabilities appear to experience poorer patient safety outcomes in hospital. The involvement of family and carers, and understanding and effectively meeting the needs of people with learning disabilities may play a protective role. Promising interventions and examples of good practice exist, however many of these have not been implemented consistently and warrant further robust evaluation.

A non-randomised feasibility study of an intervention to optimise medicines at transitions of care for patients with heart failure

Background

Heart failure affects 26 million people globally, and the optimal management of medicines is crucial for patients, particularly when their care is transferred between hospital and the community. Optimising clinical outcomes requires well-calibrated cross-organisational processes with staff and patients responding and adapting to medicines changes. The aim of this study was to assess the feasibility of implementing a complex intervention (the Medicines at Transitions Intervention; MaTI) co-designed by patients and healthcare staff. The purpose of the intervention was to optimise medicines management across the gaps between secondary and primary care when hospitals handover care. The study objectives were to (1) assess feasibility through meeting specified progression criteria to proceed to the trial, (2) assess if the intervention was acceptable to staff and patients, and (3) determine whether amendment or refinement would be needed to enhance the MaTI.

Methods

The feasibility of the MaTI was tested in three healthcare areas in the North of England between July and October 2017. Feasibility was measured and assessed through four agreed progression to trial criteria: (1) patient recruitment, (2) patient receipt of a medicines toolkit, (3) transfer of discharge information to community pharmacy, and (4) offer of a community pharmacy medicines review/discussion or medicines reconciliation. From the cardiology wards at each of the three NHS Acute Trusts (sites), 10 patients (aged ≥ 18 years) were recruited and introduced to the ‘My Medicines Toolkit’ (MMT). Patients were asked to identify their usual community pharmacy or nominate a pharmacy. Discharge information was transferred to the community pharmacy; pharmacists were asked to reconcile medicines and invited patients for a medicines use review (MUR) or discussion. At 1 month following discharge, all patients were sent three questionnaire sets: quality-of-life, healthcare utilisation, and a patient experience survey. In a purposive sample, 20 patients were invited to participate in a semi-structured interview about their experiences of the MaTI. Staff from hospital and primary care settings involved in patients’ care were invited to participate in a semi-structured interview. Patient and staff interviews were analysed using Framework Analysis. Questionnaire completion rates were recorded and data were descriptively analysed.

Results

Thirty-one patients were recruited across three sites. Eighteen staff and 18 patients took part in interviews, and 19 patients returned questionnaire sets. All four progression to trial criteria were met. We identified barriers to patient engagement with the intervention in hospital, which were compounded by patients’ focus on returning home. Some patients described not engaging in discussions with staff about medicines and lacking motivation to do so because they were preoccupied with returning home. Some patients were unable or unwilling to attend a community pharmacy in person for a medicines review. Roles and responsibilities for delivering the MaTI were different in the three sites, and staff reported variations in time spent on MaTI activities. Staff reported some work pressures and staff absences that limited the time they could spend talking to patients about their medicines. Clinical teams reported that recording a target dose for heart failure medicines in patient-held documentation was difficult as they did not always know the ideal or tolerable dose. The majority of patients reported receiving the patient-held documentation. More than two-thirds reported being offered a MUR by their community pharmacists.

Conclusions

Delivery of the Medicines at Transitions Intervention (MaTI) was feasible at all three sites, and progression to trial criteria were met. Refinements were found to be necessary to overcome identified barriers and strengthen delivery of all steps of the intervention. Necessary changes to the MaTI were identified along with amendments to the implementation plan for the subsequent trial. Future implementation needs to take into account the complexity of medicines management and adaptation to local context.

Discharge processes and medicines communication from the patient perspective: A qualitative study at an internal medicines ward in Norway

BACKGROUND

Patients are expected to participate in the hospital discharge process, assume self-management after discharge and communicate relevant information to their general practitioner; however, patients report that they are not being sufficiently empowered to take on these responsibilities. The aim of this study was to explore and understand the discharge process with a focus on medicines communication, from the patient perspective.

METHODS

Patients were included at a hospital ward, observed during health-care personnel encounters on the day of discharge and interviewed 1-2 weeks after discharge. A process analysis was performed, and a content analysis combined data from observations and data from patient interviews focusing on medicines communication in the discharge process.

RESULTS

A total of 9 patients were observed on the day of discharge, equalling 67.5 hours of observations. The analysis resulted in the following themes: (a) the observed discharge process; (b) patient initiatives; and (c) the patient role. The medicines communication in the discharge process appeared unstructured. Various patient preferences and needs were revealed. The elements of the best practice structured discharge conversation were observed; however, some patients did not have a discharge conversation at all.

CONCLUSIONS

The study contributes to a broader understanding of the discharge process, how patients experience it, including their role. It is evident that the discharge process is not always tailored to meet the patients' needs. More focus on early patient involvement and communication, in order to better prepare patients for self-management of their medications, is important for their health outcomes.

Co-creating social licence for sharing health and care data

BACKGROUND

Optimising the use of patient data has the potential to produce a transformational change in healthcare planning, treatment, condition prevention and understanding disease progression. Establishing how people's trust could be secured and a social licence to share data could be achieved is of paramount importance.

METHODS

The study took place across Yorkshire and the Humber, in the North of the England, using a sequential mixed methods approach comprising focus groups, surveys and co-design groups. Twelve focus groups explored people's response to how their health and social care data is, could, and should be used. A survey examined who should be able to see health and care records, acceptable uses of anonymous health and care records, and trust in different organisations. Case study cards addressed willingness for data to be used for different purposes. Co-creation workshops produced a set of guidelines for how data should be used.

RESULTS

Focus group participants (n = 80) supported sharing health and care data for direct care and were surprised that this is not already happening. They discussed concerns about the currency and accuracy of their records and possible stigma associated with certain diagnoses, such as mental health conditions. They were less supportive of social care access to their records. They discussed three main concerns about their data being used for research or service planning: being identified; security limitations; and the potential rationing of care on the basis of information in their record such as their lifestyle choices. Survey respondents (n = 1031) agreed that their GP (98 %) and hospital doctors and nurses (93 %) should be able to see their health and care records. There was more limited support for pharmacists (37 %), care staff (36 %), social workers (24 %) and researchers (24 %). Respondents thought their health and social care records should be used to help plan services (88 %), to help people stay healthy (67 %), to help find cures for diseases (67 %), for research for the public good (58 %), but only 16 % for commercial research. Co-creation groups developed a set of principles for a social licence for data sharing based around good governance, effective processes, the type of organisation, and the ability to opt in and out.

CONCLUSION

People support their data being shared for a range of purposes and co-designed a set of principles that would secure their trust and consent to data sharing.

Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT): protocol for a process evaluation of a cluster randomised control trial

INTRODUCTION

A key priority for the UK National Health Service and patients is to ensure that medicines are used safely and effectively. However, medication changes are not always optimally communicated and implemented when patients transfer from hospital into community settings. Heart failure is a common reason for admission to hospital. Patients with heart failure have a high burden of morbidity, mortality and complex pharmacotherapeutic regimens. The Improving the Safety and Continuity Of Medicines management at Transitions of care programme comprises a cluster randomised controlled trial which will test the effectiveness of a complex behavioural intervention aimed at improving medications management at the interface between hospitals discharge and community care. We will conduct a rigorous process evaluation to inform interpretation of the trial findings, inform implementation of the intervention on a wider scale and aid dissemination of the intervention.

METHODS AND ANALYSIS

The process evaluation will be conducted in six purposively selected intervention sites (ie, hospital trusts and associated community pharmacies) using a mixed-methods design. Fidelity and barriers/enablers of implementation of the Medicines at Transitions Intervention (MaTI) will be explored using observation, interviews (20 patients, 40 healthcare professionals), surveys and routine trial data collection on adherence to MaTI. A parallel mixed analysis will be applied. Qualitative data will be thematically analysed using Framework analysis and survey data will be analysed descriptively. Data will be synthesised, triangulated and mapped to the Consolidated Framework for Implementation Research where appropriate. The process evaluation commenced on June 2018 and is due to end on February 2021.

ETHICS AND DISSEMINATION

Approved by Research Ethics Committee and the UK Health Research Authority REC: 18/YH/0017/IRAS: 231 431. Findings will be disseminated via academic and policy conferences, peer-reviewed publications and social media.

TRIAL REGISTRATION NUMBER

ISRCTN66212970.

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.

'Handing over to the patient': A FRAM analysis of transitional care combining multiple stakeholder perspectives

INTRODUCTION

The period following discharge can present risks for older adults. Most research has focused on hospital discharge with less attention paid to on-going care needs. Despite evidence that patients undertake 'invisible work' to improve care safety, their reported willingness to be involved in care, and the consensus that successful transitions interventions include patient involvement, in reality, this is variable. Further, little research has viewed transitional care as a 'system', with gaps, interdependencies and variability across settings, nor the role of patients and families in supporting the system resilience.

RESEARCH OBJECTIVES

1) model transitional care from multiple perspectives using the Functional Resonance Analysis Method (FRAM); 2) use the model to develop a theory of change to support intervention development.

METHOD

We drew data from two studies: i) exploring the perspective of older adults across transitional care, and ii) exploring how health services experience transitional care. We employed the FRAM to develop a model of transitional care, with a system boundary spanning an older patient's admission to hospital, through to thirty days post-discharge.

FINDINGS

Modelling transitional care from multiple perspectives was challenging. 27 functions were identified with interdependencies between hospital-based functions and patient-led functions once home, the success of which may impact on transitions 'outcomes' (e.g. safety events, readmissions). The model supported development of a theory of change, to guide future intervention development.

CONCLUSIONS

Supporting certain patient-facing upstream hospital functions (e.g. encouraging mobility, supporting a better understanding of medication and condition), may lead to improved outcomes for patients following hospital discharge.

Experience-based co-design-Adapting the method for a researcher-initiated study in a multi-site setting

Background

Experience‐based co‐design (EBCD) brings patients and staff together to co‐design services. It is normally conducted in one organization which initiates and implements the process. We used the traditional EBCD method with a number of adaptations as part of a larger research study in the British National Health Service.

Methods

The primary aim was to assess the feasibility and acceptability of conducting research‐initiated EBCD, to enhance intervention development prior to testing. As well as embedding the method in a research study, there were 3 further key adaptations: (a) working across primary and secondary care sectors, (b) working on multiple sites and (c) incorporating theory‐informed analysis.

Results

We recruited four sites (covering both primary and secondary care) and, on each site, conducted the initial traditional EBCD meetings, with separate staff and patient groups—followed by a single joint patient‐staff event, where four priority areas for co‐design were agreed. This event was driven by theory‐informed analysis, as well as the traditional trigger film of patient experiences. Each site worked on one priority area, and the four co‐design groups met over 2‐3 months to design prototype tools. A second joint event was held (not usually undertaken in single‐site EBCD) where they shared and compared outputs. The research team combined elements of these outputs to create an intervention, now being tested in a cluster randomized controlled trial.

Conclusions

EBCD can be successfully adapted for use across an entire patient pathway with multiple organizations and as part of a research process to identify an intervention for subsequent testing in a randomized trial. Our pragmatic approach used the patient experience to identify areas for improvement and co‐designed an intervention which directly reflected patient priorities.

How can patient-held lists of medication enhance patient safety? A mixed-methods study with a focus on user experience

Background

Patients often carry medication lists to mitigate information loss across healthcare settings. We aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use.

Methods

We used a mixed-methods design comprising two focus groups with patients and carers, 16 semistructured interviews with healthcare professionals, 60 semistructured interviews with people carrying medication lists, a quantitative features analysis of tools available for patients to record their medicines and usability testing of four tools. Findings were triangulated using thematic analysis. Distributed cognition for teamwork models were used as sensitising concepts.

Results

We identified a wide range of mechanisms through which carrying medication lists can improve medication safety. These included improving the accuracy of medicines reconciliation, allowing identification of potential drug interactions, facilitating communication about medicines, acting as an aide-mémoire to patients during appointments, allowing patients to check their medicines for errors and reminding patients to take and reorder their medicines. Different tools for recording medicines met different needs. Of 103 tools examined, none met the core needs of all users. A key barrier to use was lack of awareness by patients and carers that healthcare information systems can be fragmented, a key facilitator was encouragement from healthcare professionals.

Conclusion

Our findings suggest that patients and healthcare professionals perceive patient-held medication lists to have a wide variety of benefits. Interventions are needed to raise awareness of the potential role of these lists in enhancing patient safety. Such interventions should empower patients and carers to identify a method that suits them best from a range of options and avoid a ‘one size fits all’ approach.