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Atwood BI, Eberhardt GL, Smith JD, Lawton DN, Macdonald EM, Romito K. A Clean You Can Trust: Using an Evidence-Based Bundle to Transform Point-of-Use Treatment for Reusable Medical Devices at a Military Treatment Facility. Mil Med 2024:usae453. [PMID: 39302736 DOI: 10.1093/milmed/usae453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/26/2024] [Accepted: 09/07/2024] [Indexed: 09/22/2024] Open
Abstract
INTRODUCTION Throughout surgical and invasive procedures, reusable instruments and flexible endoscopes become soiled with organic and inorganic materials. When these substances are permitted to dry, a matrix of microbial cells, called biofilm, forms on the surface of devices, irreversibly binding and subsequently impeding the disinfection and sterilization process. To prevent biofilm formation from occurring, devices must be continuously flushed and wiped with water throughout the procedure and at the end of the case. This process, known as point-of-use treatment (POUT), is the critical first step in the decontamination of medical devices. Poor compliance with POUT can increase patient morbidity and mortality and result in failing hospital accreditation. MATERIALS AND METHODS An interdisciplinary team used the Plan-Do-Study-Act (PDSA) to develop and implement an audit assessing 29 evidence-based criteria for POUT treatment. Each PDSA cycle supported evidence-based opportunities addressing feedback, workflow analysis, policy development, competency assessment creation, training module development, and infection prevention grand rounds. Four audits were performed over ten months to achieve improved organizational POUT compliance. RESULTS Implementing recurrent PDSA cycles that included audits with feedback led to an evidence-based bundle of policies, competencies, and training for 34 different clinical areas. These interventions resulted in a 26% compliance increase (66% to 92%). Program-specific improvements included flexible endoscopes (+4%) and reusable instruments (+20%). CONCLUSIONS Multimodal evidence-based initiatives to improve compliance with workflow processes is a translatable POUT evidence-based practice project for similar Defense Health Agengy facilities. Workflow processes can be vetted and distributed using interdisciplinary teams to ensure viability, sustainability, and conformity with organizational requirements, resulting in a more ready force.
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Affiliation(s)
- Bethany I Atwood
- Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, MD 20814, USA
| | - Gina L Eberhardt
- CNSCI, Madigan Army Medical Center, Joint Base Lewis-McCord, WA 98431, USA
| | - Joshua D Smith
- Surgical Services, Womack Army Medical Center, Fort Bragg, NC 28310, USA
| | - Danielle N Lawton
- Operating Room, 96th Medical Group, Eglin Air Force Base, FL 32542, USA
| | - Erin M Macdonald
- Operating Room, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Kenneth Romito
- Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, MD 20814, USA
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2
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Carter M, Abutheraa N, Ivers N, Grimshaw J, Chapman S, Rogers P, Simeoni M, Antony J, Watson MC. Audit and feedback interventions involving pharmacists to influence prescribing behaviour in general practice: a systematic review and meta-analysis. Fam Pract 2023; 40:615-628. [PMID: 36633309 PMCID: PMC10745261 DOI: 10.1093/fampra/cmac150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Pharmacists, as experts in medicines, are increasingly employed in general practices and undertake a range of responsibilities. Audit and feedback (A&F) interventions are effective in achieving behaviour change, including prescribing. The extent of pharmacist involvement in A&F interventions to influence prescribing is unknown. This review aimed to assess the effectiveness of A&F interventions involving pharmacists on prescribing in general practice compared with no A&F/usual care and to describe features of A&F interventions and pharmacist characteristics. METHODS Electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, (Social) Science Citation Indexes, ISI Web of Science) were searched (2012, 2019, 2020). Cochrane systematic review methods were applied to trial identification, selection, and risk of bias. Results were summarized descriptively and heterogeneity was assessed. A random-effects meta-analysis was conducted where studies were sufficiently homogenous in design and outcome. RESULTS Eleven cluster-randomized studies from 9 countries were included. Risk of bias across most domains was low. Interventions focussed on older patients, specific clinical area(s), or specific medications. Meta-analysis of 6 studies showed improved prescribing outcomes (pooled risk ratio: 0.78, 95% confidence interval: 0.64-0.94). Interventions including both verbal and written feedback or computerized decision support for prescribers were more effective. Pharmacists who received study-specific training, provided ongoing support to prescribers or reviewed prescribing for individual patients, contributed to more effective interventions. CONCLUSIONS A&F interventions involving pharmacists can lead to small improvements in evidence-based prescribing in general practice settings. Future implementation of A&F within general practice should compare different ways of involving pharmacists to determine how to optimize effectiveness.PRISMA-compliant abstract included in Supplementary Material 1.
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Affiliation(s)
- Mary Carter
- Department of Life Sciences, University of Bath, Bath, United Kingdom
| | - Nouf Abutheraa
- School of Medicine, University of Aberdeen, Aberdeen, United Kingdom
| | - Noah Ivers
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Jeremy Grimshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sarah Chapman
- Department of Life Sciences, University of Bath, Bath, United Kingdom
| | - Philip Rogers
- Department of Life Sciences, University of Bath, Bath, United Kingdom
| | | | - Jesmin Antony
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Margaret C Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom
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Laur C, Ladak Z, Hall A, Solbak NM, Nathan N, Buzuayne S, Curran JA, Shelton RC, Ivers N. Sustainability, spread, and scale in trials using audit and feedback: a theory-informed, secondary analysis of a systematic review. Implement Sci 2023; 18:54. [PMID: 37885018 PMCID: PMC10604689 DOI: 10.1186/s13012-023-01312-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/05/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Audit and feedback (A&F) is a widely used implementation strategy to influence health professionals' behavior that is often tested in implementation trials. This study examines how A&F trials describe sustainability, spread, and scale. METHODS This is a theory-informed, descriptive, secondary analysis of an update of the Cochrane systematic review of A&F trials, including all trials published since 2011. Keyword searches related to sustainability, spread, and scale were conducted. Trials with at least one keyword, and those identified from a forward citation search, were extracted to examine how they described sustainability, spread, and scale. Results were qualitatively analyzed using the Integrated Sustainability Framework (ISF) and the Framework for Going to Full Scale (FGFS). RESULTS From the larger review, n = 161 studies met eligibility criteria. Seventy-eight percent (n = 126) of trials included at least one keyword on sustainability, and 49% (n = 62) of those studies (39% overall) frequently mentioned sustainability based on inclusion of relevant text in multiple sections of the paper. For spread/scale, 62% (n = 100) of trials included at least one relevant keyword and 51% (n = 51) of those studies (31% overall) frequently mentioned spread/scale. A total of n = 38 studies from the forward citation search were included in the qualitative analysis. Although many studies mentioned the need to consider sustainability, there was limited detail on how this was planned, implemented, or assessed. The most frequent sustainability period duration was 12 months. Qualitative results mapped to the ISF, but not all determinants were represented. Strong alignment was found with the FGFS for phases of scale-up and support systems (infrastructure), but not for adoption mechanisms. New spread/scale themes included (1) aligning affordability and scalability; (2) balancing fidelity and scalability; and (3) balancing effect size and scalability. CONCLUSION A&F trials should plan for sustainability, spread, and scale so that if the trial is effective, the benefits can continue. A deeper empirical understanding of the factors impacting A&F sustainability is needed. Scalability planning should go beyond cost and infrastructure to consider other adoption mechanisms, such as leadership, policy, and communication, that may support further scalability. TRIAL REGISTRATION Registered with Prospero in May 2022. CRD42022332606.
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Affiliation(s)
- Celia Laur
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.
| | - Zeenat Ladak
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
- Ontario Institute for Studies in Education, University of Toronto, 252 Bloor Street West, Toronto, ON, M5S 1V6, Canada
| | - Alix Hall
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- National Centre of Implementation Science, The University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Nathan M Solbak
- Physician Learning Program, Continuing Medical Education and Professional Development, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
- Health Quality Programs, Queen's University, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada
| | - Nicole Nathan
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- National Centre of Implementation Science, The University of Newcastle, Newcastle, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Shewit Buzuayne
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Janet A Curran
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Noah Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
- Institute of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada
- Department of Family and Community Medicine, University of Toronto, 500 University Ave, Toronto, M5G 1V7, Canada
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4
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Wuyts SCM, Scheyltjens S, Hubloue I, Dupont AG, Cornu P. Interdisciplinary knowledge gaps on intravenous fluid management in adult patients: Survey among physicians and nurses of a university hospital. J Eval Clin Pract 2022; 28:599-606. [PMID: 35080261 DOI: 10.1111/jep.13663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
RATIONALE Intravenous (IV) fluids are frequently involved in iatrogenic complications in hospitalized patients. Knowledge of IV fluids seems inadequate and is not covered sufficiently in standard medical education. METHODS Two surveys were developed, based on the 2016 British National Institute for Health and Care Excellence guideline 'IV fluid therapy in adults in hospital', to provide insight on the learning needs and expectations of physicians and nurses. Each survey focused on profession-specific practice and consisted of three parts: demographics, knowledge questions and evaluation of current habits. Physicians and nurses practicing in a Belgian university hospital were invited to complete the survey electronically, respectively, in January and May 2018. RESULTS A total of 103 physicians (19%) and 259 nurses (24%) participated. Although every indication for fluid therapy may require a specific fluid and electrolyte mixture, and hence, knowledge of their exact composition, most physicians and nurses did not know the composition of commonly prescribed solutions for IV infusion. Senior physicians did not score better than juniors did on questions concerning the daily needs of a nil-by-mouth patient. The availability of an IV fluid on the ward guides physicians to prescribe IV fluids (17%). Nurses (56%) feel they share responsibility in fluid management as they frequently intervene in urgent situations. More than half of participants (70% of physicians, 79% of nurses) indicated a need for additional information. CONCLUSIONS A clear need for more structured information on IV fluids was identified. Both physicians and nurses struggle with fluid therapy. Continuing education on IV fluid management, emphasizing multidisciplinary collaboration, and monitoring evidence-based practice is essential to support the clinical decision process in daily practice.
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Affiliation(s)
- Stephanie C M Wuyts
- Research Group Clinical Pharmacology and Clinical Pharmacy, Centre for Pharmaceutical Research, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Pharmacy Department, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Simon Scheyltjens
- Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Ives Hubloue
- Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Research Group in Emergency and Disaster Medicine, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Alain G Dupont
- Research Group Clinical Pharmacology and Clinical Pharmacy, Centre for Pharmaceutical Research, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Pieter Cornu
- Research Group Clinical Pharmacology and Clinical Pharmacy, Centre for Pharmaceutical Research, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium.,Department of Information and Communication Technologies, Universitair Ziekenhuis Brussel, Brussels, Belgium
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5
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Devarajan V, Nadeau NL, Creedon JK, Dribin TE, Lin M, Hirsch AW, Neal JT, Stewart A, Popovsky E, Levitt D, Hoffmann JA, Lee M, Perron C, Shah D, Eisenberg MA, Hudgins JD. Reducing Pediatric Emergency Department Prescription Errors. Pediatrics 2022; 149:e2020014696. [PMID: 35641470 PMCID: PMC10680440 DOI: 10.1542/peds.2020-014696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Prescription errors are a significant cause of iatrogenic harm in the health care system. Pediatric emergency department (ED) patients are particularly vulnerable to error. We sought to decrease prescription errors in an academic pediatric ED by 20% over a 24-month period by implementing identified national best practice guidelines. METHODS From 2017 to 2019, a multidisciplinary, fellow-driven quality improvement (QI) project was conducted using the Model for Improvement. Four key drivers were identified including simplifying the electronic order entry into prescription folders, improving knowledge of dosing by indication, increasing error feedback to prescribers, and creating awareness of common prescription pitfalls. Four interventions were subsequently implemented. Outcome measures included prescription errors per 1000 prescriptions written for all medications and top 10 error-prone antibiotics. Process measures included provider awareness and use of prescription folders; the balancing measure was provider satisfaction. Differences in outcome measures were assessed by statistical process control methodology. Process and balancing measures were analyzed using 1-way analysis of variance and χ2 testing. RESULTS Before our interventions, 8.6 errors per 1000 prescriptions written were identified, with 62% of errors from the top 10 most error-prone antibiotics. After interventions, error rate per 1000 prescriptions decreased from 8.6 to 4.5 overall and from 20.1 to 8.8 for top 10 error-prone antibiotics. Provider awareness of prescription folders was significantly increased. CONCLUSION QI efforts to implement previously defined best practices, including simplifying and standardizing computerized provider order entry (CPOE), significantly reduced prescription errors. Synergistic effect of educational and technological efforts likely contributed to the measured improvement.
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Affiliation(s)
- Veena Devarajan
- Division of Emergency Medicine, Seattle Children’s Hospital, Seattle, Washington
| | - Nicole L. Nadeau
- Division of Pediatric Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica K. Creedon
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Timothy E. Dribin
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Margaret Lin
- Department of Emergency Medicine and Pediatrics, University of California, San Francisco, California
| | - Alexander W. Hirsch
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Jeffrey T. Neal
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Amanda Stewart
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Erica Popovsky
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Danielle Levitt
- Division of Emergency and Transport, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael Lee
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Catherine Perron
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Dhara Shah
- Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts
| | - Matthew A. Eisenberg
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Joel D. Hudgins
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
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Gallier S, Topham A, Nightingale P, Garrick M, Woolhouse I, Berry MA, Pankhurst T, Sapey E, Ball S. Electronic prescribing systems as tools to improve patient care: a learning health systems approach to increase guideline concordant prescribing for venous thromboembolism prevention. BMC Med Inform Decis Mak 2022; 22:121. [PMID: 35505311 PMCID: PMC9066759 DOI: 10.1186/s12911-022-01865-y] [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: 02/01/2021] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. Risk factors for VTE are well known and there are validated risk assessment tools to support the use of prophylactic therapies. In England, reporting the percentage of patients with a completed VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance, defined as an assessment which led to an appropriate action-here prescribing prophylactic low molecular weight heparin where indicated, is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that a systems-based EPS intervention (prescribing rules which mandate approval or rejection of a proposed prescription of prophylactic low molecular weight heparin based on the mandated VTE assessment) would increase full VTE guideline compliance more than interventions which focused on targeting individual prescribers. METHODS All admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011 and 2020. The proportion of patients who received a fully compliant risk assessment and action was assessed over time. Interventions included teaching sessions and face-to-face feedback based on measured performance (an approach targeting individual prescribers) and mandatory risk assessment and prescribing rules into an EPS (a systems approach). RESULTS Data from all 235,005 admissions and all 5503 prescribers were included in the analysis. Risk assessments were completed in > 90-95% of all patients at all times, but full guideline compliance was lower (70% at the start of this study). Face-to-face feedback improved full VTE guideline compliance from 70 to 77% (p ≤ 0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p ≤ 0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p < 0.001), but this was then maintained including during changes to the low molecular weight heparin used for VTE prophylaxis. DISCUSSION An EPS-systems approach was more effective in improving sustained guideline-compliant VTE prevention over time. Non-compliance remained at 8-5% despite this mandated system. Further research is needed to assess the potential reasons for this.
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Affiliation(s)
- S. Gallier
- PIONEER Health Data Research Hub in Acute Care, Department of Health Informatics, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - A. Topham
- PIONEER Health Data Research Hub in Acute Care, Department of Health Informatics, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - P. Nightingale
- NIHR Clinical Research Facility, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - M. Garrick
- Department of Health Informatics, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - I. Woolhouse
- Respiratory Medicine, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - M. A. Berry
- Acute Medicine, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - T. Pankhurst
- Digital Healthcare and Department of Renal Medicine, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
| | - E. Sapey
- grid.6572.60000 0004 1936 7486PIONEER Health Data Research Hub in Acute Care, University of Birmingham, Edgbaston, Birmingham, B15 2TH UK
| | - S. Ball
- HDR-UK Midlands Site and Better Care Programme, Queen Elizabeth Hospitals NHS Foundation Trust, Mindlesohn Way, Edgbaston, Birmingham, B15 2WB UK
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Van Den Bulck S, Spitaels D, Vaes B, Goderis G, Hermens R, Vankrunkelsven P. The effect of electronic audits and feedback in primary care and factors that contribute to their effectiveness: a systematic review. Int J Qual Health Care 2021; 32:708-720. [PMID: 33057648 DOI: 10.1093/intqhc/mzaa128] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/21/2020] [Accepted: 10/06/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The aim of this systematic review was (i) to assess whether electronic audit and feedback (A&F) is effective in primary care and (ii) to evaluate important features concerning content and delivery of the feedback in primary care, including the use of benchmarks, the frequency of feedback, the cognitive load of feedback and the evidence-based aspects of the feedback. DATA SOURCES The MEDLINE, Embase, CINAHL and CENTRAL databases were searched for articles published since 2010 by replicating the search strategy used in the last Cochrane review on A&F. STUDY SELECTION Two independent reviewers assessed the records for their eligibility, performed the data extraction and evaluated the risk of bias. Our search resulted in 8744 records, including the 140 randomized controlled trials (RCTs) from the last Cochrane Review. The full texts of 431 articles were assessed to determine their eligibility. Finally, 29 articles were included. DATA EXTRACTION Two independent reviewers extracted standard data, data on the effectiveness and outcomes of the interventions, data on the kind of electronic feedback (static versus interactive) and data on the aforementioned feedback features. RESULTS OF DATA SYNTHESIS Twenty-two studies (76%) showed that electronic A&F was effective. All interventions targeting medication safety, preventive medicine, cholesterol management and depression showed an effect. Approximately 70% of the included studies used benchmarks and high-quality evidence in the content of the feedback. In almost half of the studies, the cognitive load of feedback was not reported. Due to high heterogeneity in the results, no meta-analysis was performed. CONCLUSION This systematic review included 29 articles examining electronic A&F interventions in primary care, and 76% of the interventions were effective. Our findings suggest electronic A&F is effective in primary care for different conditions such as medication safety and preventive medicine. Some of the benefits of electronic A&F include its scalability and the potential to be cost effective. The use of benchmarks as comparators and feedback based on high-quality evidence are widely used and important features of electronic feedback in primary care. However, other important features such as the cognitive load of feedback and the frequency of feedback provision are poorly described in the design of many electronic A&F intervention, indicating that a better description or implementation of these features is needed. Developing a framework or methodology for automated A&F interventions in primary care could be useful for future research.
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Affiliation(s)
- Steve Van Den Bulck
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok J, 3000, Leuven, Belgium
| | - David Spitaels
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok J, 3000, Leuven, Belgium
| | - Bert Vaes
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok J, 3000, Leuven, Belgium
| | - Geert Goderis
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok J, 3000, Leuven, Belgium
| | - Rosella Hermens
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok J, 3000, Leuven, Belgium.,Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Science (RIHS), Radboud University Medical Center, Radboud University Nijmegen, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
| | - Patrik Vankrunkelsven
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, blok J, 3000, Leuven, Belgium
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8
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Panickar R, Wo WK, Ali NM, Tang MM, Ramanathan GRL, Kamarulzaman A, Aziz Z. Allopurinol-induced severe cutaneous adverse drug reactions: Risk minimization measures in Malaysia. Pharmacoepidemiol Drug Saf 2021; 29:1254-1262. [PMID: 33084196 DOI: 10.1002/pds.5033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/03/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To describe risk minimization measures (RMMs) implemented in Malaysia for allopurinol-induced severe cutaneous adverse drug reactions (SCARs) and examine their impact using real-world data on allopurinol usage and adverse drug reaction (ADR) reports associated with allopurinol. METHODS Data on allopurinol ADR reports (2000-2018) were extracted from the Malaysian ADR database. We identified RMMs implemented between 2000 and 2018 from the minutes of relevant meetings and the national pharmacovigilance newsletter. We obtained allopurinol utilization data (2004-2018) from the Pharmaceutical Services Programme. To determine the impact of RMMs on ADR reporting, we considered ADR reports received within 1 year of RMM implementation. We used the Pearson χ2 test to examine the relation between the implementation of RMMs and allopurinol ADR reports. RESULTS The 16 RMMs for allopurinol-related SCARs implemented in Malaysia involved nine risk communications, four prescriber or patient educational material, and three health system innovations. Allopurinol utilization decreased by 21.5% from 2004 to 2018. ADR reporting rates for all drugs (n = 144 507) and allopurinol (n = 1747) increased. ADR reports involving off-label use decreased by 6% from 2011. SCARs cases remained between 20% and 50%. RMMs implemented showed statistically significant reduction in ADR reports involving off-label use for August 2014 [χ2 (1, N = 258) = 5.32, P = .021] and October 2016 [χ2 (1, N = 349) = 3.85, P = .0499]. CONCLUSIONS RMMs to promote the appropriate use of allopurinol and prescriber education have a positive impact. We need further measures to reduce the incidence and severity of allopurinol-induced SCARs, such as patient education and more research into pharmacogenetic screening.
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Affiliation(s)
- Rema Panickar
- National Pharmaceutical Regulatory Agency, Ministry of Health, Petaling Jaya, Malaysia.,Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wee Kee Wo
- National Pharmaceutical Regulatory Agency, Ministry of Health, Petaling Jaya, Malaysia
| | - Norleen M Ali
- National Pharmaceutical Regulatory Agency, Ministry of Health, Petaling Jaya, Malaysia
| | - Min Moon Tang
- Department of Dermatology, Hospital Kuala Lumpur, Ministry of Health, Kuala Lumpur, Malaysia
| | | | | | - Zoriah Aziz
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Faculty of Pharmacy, MAHSA University, Selangor, Malaysia
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Fernández-Liz E, Vivó-Tristante P, Aranzana-Martínez A, Barceló-Colomer ME, Larrosa-Garcia M, Del Val García JL, Martín-Gracia E. Long-term effectiveness of an intervention to enhance mirabegron use revision and its deprescribing: 36-month follow-up of a quasi-experimental trial in primary care. Curr Med Res Opin 2021; 37:703-710. [PMID: 33538192 DOI: 10.1080/03007995.2021.1885366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE This is a follow-up study from a multicenter, prospective, before-and-after quasi-experimental, controlled trial to assess effectiveness at 36 months of an intervention designed to promote the revision and deprescribing of mirabegron in primary care in patients with overactive bladder. METHODS Intervention included patients who attended in 17 PHCs located in North Barcelona; control included patients who attended in the other 34 PHCs located in South, East and West Barcelona. The primary endpoint was mirabegron review and deprescribing when GPs considered appropriate, which was measured by the percentage of change of the number of patients with treatment at 36 months compared to the baseline. The intervention consisted of meetings with all the directors of the PHCs; distribution of the infographic to the GPs; providing information regarding the intervention for urologist and gynaecologist; and review of the treatments by the GPs. A monthly follow-up was done during the first year, and every three months thereafter until month 36. RESULTS Overall, 1932 patients were included, mean age 71.6 years (female 53.8%). A total of 540 patients included in the intervention discontinued mirabegron at some point during the 36 months follow-up (540/762, 70.8%) compared to 759 patients in the control (759/1170, 64.9%), (p < 0.001). A total of 324/433 patients (74.8%) who discontinued mirabegron use at 12 months remained without pharmacological treatment at 36 months. With respect to the baseline cohort, there was a lower introduction of new patients with mirabegron in the intervention (546/762, 71.6%) compared to the control (1246/1170, 106.5%), (p < .001). Regarding the treated patients, there was an increase of 41.6% in the control and a slight increase of 0.8% in the intervention at 36 months, (p < .001). CONCLUSION Our data indicate that an intervention can enhance the review use of mirabegron in the primary care setting, and promote their deprescribing.
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Affiliation(s)
- Eladio Fernández-Liz
- Primary Health Care Barcelona, Gerència Territorial de Barcelona, Catalan Institute of Health, Barcelona, Spain
| | - Pere Vivó-Tristante
- Primary Health Care Center Montcada i Reixac, Catalan Institute of Health, Barcelona, Spain
| | | | | | | | - José Luís Del Val García
- Primary Health Care Research, Evaluation and Quality Unit, Gerència Territorial de Barcelona, Catalan Institute of Health, Barcelona, Spain
| | - Elisabeth Martín-Gracia
- Primary Health Care Service Muntanya, Gerència Territorial de Barcelona, Catalan Institute of Health, Barcelona, Spain
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Evaluating physicians' perspectives on the efficiency and effectiveness of the electronic prescribing system. Int J Technol Assess Health Care 2021; 37:e42. [PMID: 33622433 DOI: 10.1017/s0266462321000052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The implementation of the electronic prescribing system follows certain objectives, and users' perspectives can contribute to understanding the efficiency and effectiveness of this system. This study aimed to evaluate physicians' perspectives on the efficiency and effectiveness of the electronic prescribing system. METHODS This study was conducted on all physicians using the electronic prescribing system in clinics and hospitals affiliated with the treatment deputy of the Social Security Organization (SSO) in Sistan and Baluchistan Province in Iran. Data were collected using a self-administered questionnaire containing three sections: (i) Six items related to demographic data and clinical experience, (ii) Specific questions based on a five-point Likert scale-related physicians' perspectives about efficiency (19 questions) and effectiveness (13 questions), and (iii) Open-ended questions about the positive and negative aspects of using the electronic prescribing system. RESULTS The mean and standard deviation of the efficiency and effectiveness of the electronic prescribing system were 3.68 ± 0.67 and 3.84 ± 0.65, respectively. Patient safety had the highest mean score among all dimensions (4.0 ± 0.64). Most participants (n = 55, 79%) considered the efficiency and effectiveness of this system high. More than 90 percent of the physicians (n = 63) believed that the electronic prescribing system enables a better medication prescription by providing alerts and access to patients' medication history. CONCLUSION The findings showed that most physicians believed that the electronic prescribing system of Iran's SSO has high efficiency and effectiveness. In particular, physicians believed that using this system improves patient safety and reduces costs.
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Saiful Bahri A, Tuan Mahmood TM, Abdul-Aziz SA, Makmor-Bakry M, Mohamed Shah N. Use of Adjuvant Endocrine Therapy Among Post-Menopausal Breast Cancer Patients in Malaysia. Patient Prefer Adherence 2021; 15:227-235. [PMID: 33568899 PMCID: PMC7868301 DOI: 10.2147/ppa.s293029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/06/2021] [Indexed: 12/24/2022] Open
Abstract
CONTEXT Globally, breast cancer is the most common cancer affecting women, and adjuvant endocrine therapy (AET) is part of its treatment modality, which improves patients' outcome. However, there are concerns on side effects related to its use, which may affect treatment adherence. PURPOSE This study was conducted to explore attitude and practice on using AET among breast cancer patients in Malaysia. PATIENTS AND METHODS Postmenopausal breast cancer patients on at least 3 months of AET attending the outpatient oncology clinic at a tertiary care hospital were interviewed. Patients underwent in-depth interviews exploring their attitude and practices while on AET using a semi-structured interview guide. The interviews were transcribed verbatim and analyzed using thematic analysis. RESULTS There were four main themes for attitude toward the use of AET: 1) benefits of using AET, 2) concerns on taking AET, 3) beliefs on alternative treatment, and 4) beliefs toward the doctor. For practice, six themes were obtained: 1) correct use of AET, 2) appointment adherence, 3) information-seeking behavior, 4) counseling services obtained, 5) experienced side effects of AET, and 6) usage of complementary and alternative medicines. CONCLUSION Several themes concerning attitude and practice of breast cancer patients receiving AET were identified, which may be addressed during treatment consultations in clinical practice.
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Affiliation(s)
- Athirah Saiful Bahri
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Tuan Mazlelaa Tuan Mahmood
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Siti Azdiah Abdul-Aziz
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mohd Makmor-Bakry
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noraida Mohamed Shah
- Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Correspondence: Noraida Mohamed Shah Centre of Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300, MalaysiaTel +60 3 9289 8038 Email
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Cotterill S, Tang MY, Powell R, Howarth E, McGowan L, Roberts J, Brown B, Rhodes S. Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background
A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.
Objective
To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.
Design
A systematic review and meta-analysis of randomised controlled trials.
Data sources
The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).
Participants
Health workers took part in the study.
Interventions
Behaviour change interventions based on social norms.
Outcome measures
Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.
Methods
Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.
Results
A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I
2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).
Limitations
The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.
Conclusions
Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.
Future work
Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.
Study registration
This study is registered as PROSPERO CRD42016045718.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 41. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sarah Cotterill
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mei Yee Tang
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rachael Powell
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Elizabeth Howarth
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Laura McGowan
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jane Roberts
- Outreach and Evidence Search Service, Library and E-learning Service, Northern Care Alliance, NHS Group, Royal Oldham Hospital, Oldham, UK
| | - Benjamin Brown
- Health e-Research Centre, Farr Institute for Health Informatics Research, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Sarah Rhodes
- Centre for Biostatistics, School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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Exploring barriers to and enablers of antimicrobial stewardship in rural health services. Infect Dis Health 2020; 26:11-21. [PMID: 32868207 DOI: 10.1016/j.idh.2020.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND World-wide antimicrobial resistance is increasing, and antimicrobial stewardship (AMS) interventions aimed at increasing compliance with optimal antimicrobial prescribing are essential in tackling this issue. Local level research about antimicrobial use is important to tailor interventions in a place-based approach to solve local level problems. METHODS As part of a broader mixed methods study, Medical Practitioners and Senior Nurses at three rural health services were invited by email to participate in interviews to explore opinions and practices of antimicrobial prescribing. RESULTS Seven Medical Practitioners and thirteen Senior Nurses from three small rural health services participated in the study. The major findings were that nurses were perceived as the 'gatekeepers' to antimicrobial initiatives by all participants. Senior Nurses perceived AMS activities as being a link in a world-wide program to eradicate antimicrobial resistance, while Medical Practitioners perceived it as a local level program, aimed at educating individual prescribers. There was consensus that an intervention aimed at improved documentation at the point of prescribing and increased accessibility to antimicrobial prescribing guidelines had a high potential for increased compliance with optimal prescribing of antimicrobials. CONCLUSION The research enabled identification of interventions aimed at increasing optimal compliance with antimicrobial prescribing that are acceptable to and appropriate for Medical Practitioners and nursing staff at three rural health services.
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George D, Supramaniam ND, Hamid SQA, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement program to reduce medication errors during hospital discharge. Pharm Pract (Granada) 2019; 17:1501. [PMID: 31592290 PMCID: PMC6763293 DOI: 10.18549/pharmpract.2019.3.1501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/05/2019] [Indexed: 11/14/2022] Open
Abstract
Background: Patients requiring medications during discharge are at risk of discharge medication errors that potentially cause readmission due to medication-related events. Objective: The objective of this study was to develop interventions to reduce percentage of patients with one or more medication errors during discharge. Methods: A pharmacist-led quality improvement (QI) program over 6 months was conducted in medical wards at a tertiary public hospital. Percentage of patients discharge with one or more medication errors was reviewed in the pre-intervention and four main improvements were developed: increase the ratio of pharmacist to patient, prioritize discharge prescription order within office hours, complete discharge medication reconciliation by ward pharmacist, set up a Centralized Discharge Medication Pre-packing Unit. Percentage of patients with one or more medication errors in both pre- and post-intervention phase were monitored using process control chart. Results: With the implementation of the QI program, the percentage of patients with one or more medication errors during discharge that were corrected by pharmacists significantly increased from 77.6% to 95.9% (p<0.001). Percentage of patients with one or more clinically significant error was similar in both pre and post-QI with an average of 24.8%. Conclusions: Increasing ratio of pharmacist to patient to complete discharge medication reconciliation during discharge significantly recorded a reduction in the percentage of patients with one or more medication errors.
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Affiliation(s)
- Doris George
- Pharmacy Department, Raja Permaisuri Bainun Hospital; &. Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia. Penang (Malaysia).
| | | | - Siti Q Abd Hamid
- Pharmacy Department, Raja Permaisuri Bainun Hospital. Perak (Malaysia).
| | - Mohamad A Hassali
- Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia. Penang (Malaysia).
| | - Wei-Yin Lim
- Center for Clinical Epidemiology, Institute for Clinical Research, National Institutes of Health, Ministry of Health. Selangor (Malaysia).
| | - Amar-Singh Hss
- Pediatric Department, Raja Permaisuri Bainun Hospital, Ministry of Health. Perak (Malaysia).
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