The Paradox of Safety in Medication Management

Measuring health professionals' perceptions of communication contributing to medication incidents in hospitals - scale development and primary results of weekly perceived communication challenges

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.

Untenable Expectations: Nurses’ Work in the Context of Medication Administration, Error, and the Organization

We explored nurses’ work in the context of medication administration, errors, and the organization. Secondary analysis of ethnographic data included 92 hours of non-participant observation, and 37 unstructured interviews with nurses, administrators, and pharmacists. Think-aloud observations and analysis of institutional documents supplemented these data. Findings revealed the nature of nurses’ work was characterized by chasing a standard of care, prioritizing practice, and renegotiating routines. The rich description identified characteristics of nurses’ work as cyclical, chaotic and complex shattering studies that explained nurses’ work as linear. A new theoretical model was developed, illustrating the inseparability of nurses’ work from contextual contingencies and enhancing our understanding of the cascading components of work that result in days that spin out of the nurses’ control. These results deepen our understanding why present efforts targeting the reduction of medication errors may be ineffective and places administration accountable for the context in which medication errors occur.

International Society of Oncology Pharmacy Practitioners (ISOPP) position statement: Role of the oncology pharmacy team in cancer care

The Oncology Pharmacy Team (OPT), consisting of specialty-trained pharmacists and/or pharmacy technicians, is an integral component of the multidisciplinary healthcare team (MHT) involved with all aspects of cancer patient care. The OPT fosters quality patient care, safety, and local regulatory compliance. The International Society of Oncology Pharmacy Practitioners (ISOPP) developed this position statement to provide guidance on five key areas: 1) oncology pharmacy practice as a pharmacy specialty; 2) contributions to patient care; 3) oncology pharmacy practice management; 4) education and training; and 5) contributions to oncology research and quality initiatives to involve the OPT. This position statement advocates that: 1) the OPT be fully incorporated into the MHT to optimize patient care; 2) educational and healthcare institutions develop programs to continually educate OPT members; and 3) regulatory authorities develop certification programs to recognize the unique contributions of the OPT in cancer patient care.

Forms of trust and polypharmacy among older adults

This article examines how older adults make decisions about their medications through interconnected axes of trust that operate across social networks. Trust is negotiated by older adults enrolled in a deprescribing programme which guides them through the process of reducing medications to mitigate risks associated with polypharmacy. Habermas’ work on the significance of communicative action in negotiating trust within social relationships informs our analysis, specifically in-depth semi-structured interviews with older adults about their medication use and the role of social networks in managing their health. Participants were age 70+ and experiencing polypharmacy. Our analysis discusses the social nature of medication practices and the importance of social networks for older adults’ decision-making. Their perspective reflects the critique of late-modern society put forward by Habermas. Negotiating trust in pharmaceutical decision-making requires navigating tensions across and between system networks (health-care professionals) and life-world networks (family and friends). This study contributes to our knowledge of how distinct forms of trust operate in different social spheres, setting the context for the way health-care decisions are made across social networks. Our analysis reinforces the need for older adults to engage meaningfully in health-care decision-making such that a convergence between system-world and life-world structures is encouraged. This would improve deprescribing programmes’ efficacy as older adults optimise their medication use and improve overall quality of life.

Confronting Medicine's Dichotomies: Older Adults' Use of Interpretative Repertoires in Negotiating the Paradoxes of Polypharmacy and Deprescribing

To address the risks associated with polypharmacy, health care providers are investigating the feasibility of deprescribing programs as part of routine medical care to reduce medication burden to older adults. As older adults are enrolled in these programs, they are confronted with two dominant and legitimate accounts of medications, labeled the medication paradox: medications keep you healthy but they might be making you sick. We investigated how the medication paradox operates in the lives of older adults. In-depth qualitative interviews were conducted and analyzed with older adults aged 70+ to identify the various paradoxes that seniors live through regarding their medications and the narratives that they engage to negotiate these contradictions. Older adults were found to have established interpretative repertoires to make sense of the incongruent narratives of the medication paradox. In this article, we demonstrate older adults' efforts to carve out their unique place in the dichotomized institution of medicine.

The role of organizational and professional cultures in medication safety: a scoping review of the literature

PURPOSE

This scoping review explores what is known about the role of organizational and professional cultures in medication safety. The aim is to increase our understanding of 'cultures' within medication safety and provide an evidence base to shape governance arrangements.

DATA SOURCES

Databases searched are ASSIA, CINAHL, EMBASE, HMIC, IPA, MEDLINE, PsycINFO and SCOPUS.

STUDY SELECTION

Inclusion criteria were original research and grey literature articles written in English and reporting the role of culture in medication safety on either organizational or professional levels, with a focus on nursing, medical and pharmacy professions. Articles were excluded if they did not conceptualize what was meant by 'culture' or its impact was not discussed.

DATA EXTRACTION

Data were extracted for the following characteristics: author(s), title, location, methods, medication safety focus, professional group and role of culture in medication safety.

RESULTS OF DATA SYNTHESIS

A total of 1272 citations were reviewed, of which, 42 full-text articles were included in the synthesis. Four key themes were identified which influenced medication safety: professional identity, fear of litigation and punishment, hierarchy and pressure to conform to established culture. At times, the term 'culture' was used in a non-specific and arbitrary way, for example, as a metaphor for improving medication safety, but with little focus on what this meant in practice.

CONCLUSIONS

Organizational and professional cultures influence aspects of medication safety. Understanding the role these cultures play can help shape both local governance arrangements and the development of interventions which take into account the impact of these aspects of culture.

A qualitative exploration of the experiences of community dwelling older adults with sensory impairment/s receiving polypharmacy on their pharmaceutical care journey

BACKGROUND

Most developed countries have increasing numbers of community dwelling older people with both multi-morbidity and sensory impairment that includes visual, hearing or dual impairment. Older people with sensory impairment are more likely to have chronic health conditions and to be in receipt of polypharmacy (>4 medicines). It is important to understand their experience of pharmaceutical care provision to facilitate a safe, appropriate and person centred approach.

AIM

this study explored the pharmaceutical care experiences and perspectives of older people with sensory impairment receiving polypharmacy.

DESIGN AND SETTING

exploratory qualitative study with semi-structured telephone or face-to-face interviews with community dwelling older adults with sensory impairment receiving polypharmacy in Scotland in 2016.

METHODS

in total, 23 interviews were conducted with older people from seven of the 14 Scottish Health Board areas.

SUBJECTS

over half the participants (n = 12) had dual sensory impairment, six had visual impairment and five had hearing impairment.

RESULTS

three overarching themes were identified reflecting different stages of participants' pharmaceutical care journey: ordering and collection of prescriptions; medicine storage; and administration. At each stage of their journey, participants identified barriers and facilitators associated with their pharmaceutical care.

CONCLUSIONS

this is the first comprehensive, in-depth exploration of the pharmaceutical care journey needs of older people with sensory impairment. As the number of community dwelling older people with sensory impairment and polypharmacy increases there is a requirement to identify challenges experienced by this population and offer solutions for safe and effective pharmaceutical care provision.

Nurses' perceptions of high-alert medication administration safety: A qualitative descriptive study

AIMS

The aim of this study was to determine nurses' perceptions of supports and barriers to high-alert medication (HAM) administration safety.

DESIGN

A qualitative descriptive design was used.

METHODS

Eighteen acute care nurses were interviewed about HAM administration practices. Registered nurses (RNs) working with acutely ill adults in two hospitals participated in one-on-one interviews from July-September, 2017. Content analysis was conducted for data analysis.

RESULTS

Three themes contributed to HAM administration safety: Organizational Culture of Safety, Collaboration, and RN Competence and Engagement. Error factors included distractions, workload and acuity. Work arounds bypassing bar code scanning and independent double check procedures were common. Findings highlighted the importance of intra- and interprofessional collaboration, nurse engagement and incorporating the patient in HAM safety.

CONCLUSIONS

Current HAM safety strategies are not consistently used. An organizational culture that supports collaboration, education on safe HAM practices, pragmatic HAM policies and enhanced technology are recommended to prevent HAM errors.

IMPACT

Hospitals incorporating these findings could reduce HAM errors. Research on nurse engagement, intra- and interprofessional collaboration and inclusion of patients in HAM safety strategies is needed.

How do stakeholders experience the adoption of electronic prescribing systems in hospitals? A systematic review and thematic synthesis of qualitative studies

Background

Electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of health services, but the translation of this into reduced harm for patients remains unclear. This review aimed to synthesise primary qualitative research relating to how stakeholders experience the adoption of ePrescribing/CPOE systems in hospitals, to help better understand why and how healthcare organisations have not yet realised the full potential of such systems and to inform future implementations and research.

Methods

We systematically searched 10 bibliographic databases and additional sources for citation searching and grey literature, with no restriction on date or publication language. Qualitative studies exploring the perspectives/experiences of stakeholders with the implementation, management, use and/or optimisation of ePrescribing/CPOE systems in hospitals were included. Quality assessment combined criteria from the Critical Appraisal Skills Programme Qualitative Checklist and the Standards for Reporting Qualitative Research guidelines. Data were synthesised thematically.

Results

79 articles were included. Stakeholders’ perspectives reflected a mixed set of positive and negative implications of engaging in ePrescribing/CPOE as part of their work. These were underpinned by further-reaching change processes. Impacts reported were largely practice related rather than at the organisational level. Factors affecting the implementation process and actions undertaken prior to implementation were perceived as important in understanding ePrescribing/CPOE adoption and impact.

Conclusions

Implementing organisations and teams should consider the breadth and depth of changes that ePrescribing/CPOE adoption can trigger rather than focus on discrete benefits/problems and favour implementation strategies that: consider the preimplementation context, are responsive to (and transparent about) organisational and stakeholder needs and agendas and which can be sustained effectively over time as implementations develop and gradually transition to routine use and system optimisation.