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Cass AR, Charlton KE. Prevalence of hospital-acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: A systematic review of the evidence. J Hum Nutr Diet 2022; 35:1043-1058. [PMID: 35377487 PMCID: PMC9790482 DOI: 10.1111/jhn.13009] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/11/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Malnutrition affects between 20% and 50% of hospital inpatients on admission, with further declines expected during hospitalisation. This review summarises the existing literature on hospital-acquired malnutrition that examines the magnitude of nutritional deterioration amongst adult inpatients and identifies preventable barriers to optimising nutrition support during episodes of care. METHODS A systematic review was conducted to answer the question: Among adult hospital inpatients, the presence of which modifiable factors contribute to hospital-acquired malnutrition? A database search was conducted between the 24 April and 30 June 2020 using CINAHL, MEDLINE, Scopus and PubMed databases according to a protocol registered with PROSPERO (CD42020182728). In addition, issues of the 10 top clinical nutrition journals published during the period of from 1 April 2015 to 30 March 2020 were hand-searched. RESULTS Fifteen articles were eligible for inclusion from a total of 5944 retrieved abstracts. A narrative synthesis of evidence was completed because of the high level of heterogeneity in methodologies. Nutritional deterioration is common among previously well-nourished and nutritionally compromised patients, with studies reporting that 10%-65% of patients experienced nutritional decline. Frequently reported barriers were mealtime interruptions, meal dissatisfaction, procedure-related fasting, effects of illness or treatment, chewing difficulties, poor appetite and malnutrition as a low clinical priority. CONCLUSIONS The findings of this review support the need for routine nutritional risk screening throughout each hospital admission with hospital-acquired malnutrition affecting up to 65% of inpatients. Clear establishment of the roles and responsibilities of each member within multidisciplinary healthcare teams in the provision of nutrition care and cost-benefit analyses are recommended to demonstrate the effectiveness of changes to models of care.
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Affiliation(s)
- Alyssa R. Cass
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongNSWAustralia
| | - Karen E. Charlton
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongNSWAustralia,Illawarra Health & Medical Research InstituteWollongongNSWAustralia
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2
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Corn AS, Sevy-Majers J, Tyson RL. Using Evidence: A Nursing Assessment Protocol for Acute Geropsychiatric Patients. J Am Psychiatr Nurses Assoc 2022; 28:402-412. [PMID: 33164643 DOI: 10.1177/1078390320970646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The Centers for Disease Control and Prevention estimates that approximately 20% of the United States population lives with at least one mental health issue. The most common mental illnesses affecting older Americans include anxiety, cognitive, and mood disorders. These patients may exhibit behaviors indicating agitation or anxiety during necessary hospital stays that warrant de-escalation techniques and appropriate medications to help manage emergent symptoms. AIMS This quality improvement intervention was intended to demonstrate enhancement of the nursing assessment and reassessment of patients demonstrating symptoms of agitation and anxiety requiring intervention. METHODS Assessment of the established nursing practice demonstrated compromised patient safety and led to planning and implementation of a new practice standard that incorporated an evidence-based tool. Nurses utilized a protocol that employed the Pittsburgh Agitation Scale to augment documentation of the nursing assessment for patients exhibiting symptoms of marked anxiety and agitation. RESULTS Following a 3-month trial, chart audits were completed to assess results of the protocol's implementation. Significant improvement was noted in the nursing assessment process as evidenced in required documentation of nursing assessment and reassessment including use of the protocol. CONCLUSIONS Implementing standards to guide nursing care can support both patient safety and professional practice.
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Affiliation(s)
| | - Joan Sevy-Majers
- Joan Sevy Majers, DNP, FACHE, CENP, CCM, University of Cincinnati, OH, USA
| | - R Lee Tyson
- R. Lee Tyson, DNP, DMIN, APRN-CNP, PMHNP-BC, ANP-BC, CARN-AP, University of Cincinnati, OH, USA
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3
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Martin K, Bickle K, Lok J. Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement. Int J Ment Health Nurs 2022; 31:897-907. [PMID: 35355387 DOI: 10.1111/inm.12997] [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: 07/26/2021] [Revised: 02/15/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
The clinical documentation of patients' mental status, behaviour and functioning is a fundamental aspect of inpatient mental health care. It is an important source of information-sharing with the interprofessional team and used by other clinicians within the circle of care to guide their decision-making process. Given the body of evidence highlighting concerns about the quality of nursing documentation and the growing literature demonstrating the presence of bias in healthcare, it is critically important that we examine the impact of this bias in nursing practice. The primary objective of this study was to determine whether clinical decisions and judgements change when nurses read documentation that is either biased or neutral. Using a quantitative, observational study that used surveys to collect data, participants were exposed to two patient vignettes and six clinical notes associated with each patient (notes were written with either biased or neutral language) and asked to make clinical decisions and judgements. Results from 199 nurse participants from a tertiary mental health hospital revealed a notable relationship between the type of notes read (biased vs. neutral) and clinical practice, namely, participants reading biased notes were less likely to offer health teaching when administering pro re nata (PRN) medication for sleep. We also found differences in decision-making and judgements based on the type of note read depending on years of experience and type of education. The results indicate that biased language in nursing documentation can influence other clinicians' decisions and judgements about patients, thereby indicating a cascade of bias.
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Affiliation(s)
- Krystle Martin
- Ontario Shores Centre for Mental Health Services, Whitby, Ontario, Canada.,University of Ontario Institute of Technology, Oshawa, Ontario, Canada
| | - Korri Bickle
- Ontario Shores Centre for Mental Health Services, Whitby, Ontario, Canada
| | - Jessica Lok
- Ontario Shores Centre for Mental Health Services, Whitby, Ontario, Canada
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4
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Mardani A, Paal P, Weck C, Jamshed S, Vaismoradi M. Practical Considerations of PRN Medicines Management: An Integrative Systematic Review. Front Pharmacol 2022; 13:759998. [PMID: 35496317 PMCID: PMC9039188 DOI: 10.3389/fphar.2022.759998] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objectives: Highly widespread use of pro re nata (PRN) medicines in various healthcare settings is a potential area for improper medication prescription and administration leading to patient harm. This study aimed to summarize and integrate the findings of all relevant individual studies regarding the practical considerations of PRN medicines management including strategies and interventions by healthcare professionals for safe prescription, dispensing, administration, monitoring, and deprescription of PRN medicines in healthcare settings. Methods: An integrative systematic review on international databases were performed. Electronic databases including Web of Knowledge, Scopus, PubMed (including MEDLINE), and Cinahl were searched to retrieve articles published until end of May 2021. Original qualitative, quantitative, and mixed methods studies written in English were included with a focus on PRN medicines management in healthcare settings. Research synthesis using the narrative method was performed to summarise the results of included studies. Results: Thirty-one studies on PRN medicines in healthcare settings by different healthcare providers were included after the screening of the databases based on eligibility criteria. They were published from 1987 to 2021. The majority of studies were from Australia, the United States, Canada, and the United Kingdom and were conducted in psychiatric settings. Given variations in their purposes, methods, and outcomes, the research synthesis was conducted narratively based on diversities and similarities in findings. Eight categories were developed by the authors as follows: "PRN indications and precautionary measures," "requirements of PRN prescription," "interventions for PRN administration," "monitoring and follow up interventions," "deprescription strategies," "healthcare professionals' role," "participation of patients and families," and "multidisciplinary collaboration." Each category consists of several items and describes what factors should be considered by healthcare professionals for PRN medicines management. Conclusion: The review findings provide insights on the practical considerations of PRN medicines management in clinical practice. The suggested list of considerations in our review can be used by healthcare professionals for optimal PRN medicines management and safeguarding patient care.
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Affiliation(s)
- Abbas Mardani
- Nursing Care Research Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Piret Paal
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria
| | - Christiane Weck
- Palliative Care, Paracelsus Medical University, Salzburg, Austria.,Department of Neurology, Klinikum Agatharied, Hausham, Germany
| | - Shazia Jamshed
- Clinical Pharmacy and Practice, Faculty of Pharmacy, University Sultan Zainal Abidin, Terengganu, Malaysia
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5
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Neurostimulation as an Efficacious Nonpharmacologic Analgesic following Arthroscopic Rotator Cuff Repair. Case Rep Anesthesiol 2022; 2022:2133998. [PMID: 35464189 PMCID: PMC9033313 DOI: 10.1155/2022/2133998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/26/2022] [Indexed: 11/18/2022] Open
Abstract
This case highlights the importance of pursuing nonpharmacologic analgesic modalities in orthopedic surgery to combat the current opioid epidemic. Presented is a patient who underwent an arthroscopic rotator cuff repair and biceps tenodesis operation and through the use of neurostimulation (in the form of auricular electrostimulation), fully recovered from surgery without the usage of any opioid or nonsteroidal anti-inflammatory medications. The patient was fitted with a novel auricular electrostimulation device (DyAnsys Primary Relief) in the immediate postoperative period that provided constant neurostimulation for 10 days, this neurostimulator was the only analgesic modality used in this case, and the patient reported minimal postoperative pain. The utility of this case centers around the lack of postoperative opioid use, presenting the idea that postsurgical orthopedic pain can be managed in a nonpharmacologic capacity, combatting the fields' ongoing opioid epidemic.
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Dowd LA, Reynolds L, Cross AJ, Veal F, Steeper M, Wanas Z, Wu N, Bell JS. A systematic review of opioid prevalence in Australian residential aged care facilities. Australas J Ageing 2022; 41:501-512. [PMID: 35394708 PMCID: PMC10083958 DOI: 10.1111/ajag.13071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To systematically review the prevalence of opioid prescribing, dispensing and administration in Australian residential aged care facilities (RACFs). METHODS MEDLINE, Embase, CINAHL, AgeLine, Web of Science Core Collection, InformIT and International Pharmaceutical Abstracts (inception to September 2021) were searched for studies reporting opioid prevalence in Australian RACFs. Regular and as-required (i.e. pro re nata, PRN) opioid uses were considered. Screening, data extraction and quality assessment were performed independently by two review authors. RESULTS Twenty-three studies (n = 286,141 residents) reported opioid prevalence, of which 16 provided overall regular or PRN prescribing, dispensing or administration data. Five studies reported 28%-34% of residents were prescribed regular opioids over assessment periods ranging from one week to one month. Five studies reported 11%-42% of residents were prescribed PRN opioids over assessment periods ranging from one week to 30 months. Three studies reported 27%-50% of residents were dispensed an opioid over 12 months. Five studies reported 21%-29% were administered both regular and PRN opioids over 24 hours. Two studies reported 22%-42% of residents were administered PRN opioids over 1 week to 12 months. Two studies reported 6%-13% of residents were using doses >100 mg oral morphine equivalents/day. CONCLUSIONS Up to half of the residents were dispensed opioids over 12 months. The prevalence of opioid prescribing, dispensing and administration was highly variable, suggesting the potential value of opioid quality indicators and analgesic stewardship interventions to ensure opioid appropriateness.
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Affiliation(s)
- Laura A Dowd
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Lorenna Reynolds
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Felicity Veal
- Unit for Medication Outcomes Research & Education (UMORE), School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | - Michelle Steeper
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Zainab Wanas
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - Nancy Wu
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Melbourne, Victoria, Australia.,National Health and Medical Research Council (NHMRC), Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia
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7
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The characteristics of patients receiving psychotropic pro re nata medication at discharge for the treatment of schizophrenia and major depressive disorder: A nationwide survey from the EGUIDE project. Asian J Psychiatr 2022; 69:103007. [PMID: 35051727 DOI: 10.1016/j.ajp.2022.103007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although several guidelines indicate that daily pharmacotherapy is an important part of the treatment of schizophrenia and major depressive disorder, there are few reports regarding pro re nata (PRN) prescriptions. The purpose of this study is to clarify the characteristics of patients receiving psychotropic PRN prescription for the treatment of schizophrenia and major depressive disorder. METHOD We used data from 'the effectiveness of guideline for dissemination and education in psychiatric treatment' (EGUIDE) project to evaluate the presence or absence of psychotropic PRN prescription at the time of discharge, the age and sex of patients receiving PRN prescription for each diagnosis, and the association between PRN prescription and regular daily psychotropics. RESULTS The psychotropic PRN prescription ratio was 29.9% among 2617 patients with schizophrenia and 31.1% among 1248 patients with major depressive disorder at discharge. In schizophrenia, the psychotropic PRN prescription ratio was 21.6% for patients aged 65 years or older, which was lower than that of all other age groups. In major depressive disorder, the psychotropic PRN prescription ratio was 34.2% for female patients, which was significantly higher than that for male patients (25.5%). In schizophrenia, there was an association between psychotropic PRN prescription and regular use of multiple psychotropic medications. CONCLUSIONS Psychotropic PRN prescription was less common in elderly patients with schizophrenia and more common in female patients with major depressive disorder. In schizophrenia, psychotropic PRN prescription led to polypharmacy of psychotropics. Further studies are needed to accumulate evidence and to provide education on appropriate PRN prescriptions.
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8
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Vaismoradi M, Fredriksen Moe C, Vizcaya-Moreno F, Paal P. Ethical Tenets of PRN Medicines Management in Healthcare Settings: A Clinical Perspective. PHARMACY 2021; 9:174. [PMID: 34707079 PMCID: PMC8552074 DOI: 10.3390/pharmacy9040174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/16/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022] Open
Abstract
Prescription and administration of pro re nata (PRN) medications has remained a poorly discussed area of the international literature regarding ethical tenets influencing this type of medication practice. In this commentary, ethical tenets of PRN medicines management from the clinical perspective based on available international literature and published research have been discussed. Three categories were developed by the authors for summarising review findings as follows: 'benefiting the patient', 'making well-informed decision', and 'follow up assessment' as pre-intervention, through-intervention, and post-intervention aspects, respectively. PRN medicines management is mainly intertwined with the ethical tenets of beneficence, nonmaleficence, dignity, autonomy, justice, informed consent, and error disclosure. It is a dynamic process and needs close collaboration between healthcare professionals especially nurses and patients to prevent unethical practice.
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Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway;
| | | | - Flores Vizcaya-Moreno
- Department of Nursing, Faculty of Health Sciences, University of Alicante, 03080 Alicante, Spain;
| | - Piret Paal
- WHO Collaborating Centre, Institute of Nursing Science and Practice, Paracelsus Medical University, 5020 Salzburg, Austria;
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9
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Ross SL, Bhushan Y, Davey P, Grant S. Improving documentation of prescriptions for as-required medications in hospital inpatients. BMJ Open Qual 2021; 10:bmjoq-2020-001277. [PMID: 34544692 PMCID: PMC8454436 DOI: 10.1136/bmjoq-2020-001277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 09/10/2021] [Indexed: 11/04/2022] Open
Abstract
It is estimated that 1 in 10 hospital inpatients in Scotland have experienced a medication error. In our unit, an audit in 2019 identified documentation of as-required prescriptions on drug Kardexes as an important target for improvement. This project aimed to reduce the percentage of these errors to <5% in the ward in 6 months.Weekly point prevalence surveys were used to measure medication error rates over a 12-week baseline period. Errors in route, frequency of dose and maximum dose accounted for >80% of all prescribing errors. The intervention was a poster reminder about the three most common errors linked to standards for prescribing pain medication. Barriers to change were identified through inductive thematic analysis of semistructured interviews with five ward doctors and two staff nurses.In the 6 weeks after intervention, our run chart showed a shift in maximum dose errors per patient, which fell from 75% to 26%. However, route and frequency errors remained high at >70% per patient. Most of these errors were due to use of abbreviations, and qualitative interviews revealed that senior doctors and nurses believed that these abbreviations were safe. We found some evidence from national guidelines to support these beliefs.Overall, the intervention was associated with decreased prevalence of patients without a maximum dose written on their prescription, but lack of space on drug prescriptions was identified as a key barrier to further improvement in both maximum dose and abbreviation errors.
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Affiliation(s)
| | | | - Peter Davey
- School of Medicine, University of Dundee, Dundee, UK.,Clinical Quality Improvement, University of Dundee, Dundee, UK
| | - Suzanne Grant
- School of Medicine, University of Dundee, Dundee, UK
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10
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Vaismoradi M, Jamshed S, Lorenzl S, Paal P. PRN Medicines Management for Older People with Long-Term Mental Health Disorders in Home Care. Risk Manag Healthc Policy 2021; 14:2841-2849. [PMID: 34262371 PMCID: PMC8274703 DOI: 10.2147/rmhp.s316744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022] Open
Abstract
Older people with long-term mental health conditions who receive care in their own home are vulnerable to the inappropriate use of medications and polypharmacy given their underlying health conditions and comorbidities. Inappropriate use of pro re nata (PRN) medications in these older people can enhance their suffering and have negative consequences for their quality of life and well-being, leading to readmission to healthcare settings and the increased cost of health care. This narrative review on published international literature aims at improving our understanding of medicines management in home care and how to improve PRN medication use among older people with long-term health conditions in their own home. Accordingly, the improvement of PRN medicines management for these older people requires the development of an individualised care plan considering ‘reduction of older people’s dependence on PRN medications’, ‘empowerment of family caregivers’, and ‘support by healthcare professionals.’ PRN medication use should be reduced through deprescription and discontinuation strategies. Also, older people and their family caregivers should be encouraged to prioritize the use of non-pharmacologic methods to relieve physical and psychological problems. Besides the empowerment of family caregivers through role development, education and training about PRN medications, and involvement in decision-making, they need support by the multidisciplinary network in terms of supervision, monitoring, and home visits.
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Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, Bodø, 8049, Norway
| | - Shazia Jamshed
- Clinical Pharmacy and Practice, Faculty of Pharmacy, University Sultan Zainal Abidin, Terengganu, 22200, Malaysia
| | - Stefan Lorenzl
- Professorship for Palliative Care, Institute of Nursing Science and -Practice, Paracelsus Medical University, Salzburg, 5020, Austria.,Department of Neurology, Klinikum Agatharied, Hausham, 83734, Germany
| | - Piret Paal
- WHO Collaborating Centre at the Institute for Nursing Science and Practice, Paracelsus Medical University, Salzburg, A-5020, Austria
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Nilsen MK, Sletvold H, Olsen RM. ‘Sometimes we just have to trust our gut feeling and hope the reporting is good’. TIDSSKRIFT FOR OMSORGSFORSKNING 2021. [DOI: 10.18261/issn.2387-5984-2021-03-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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12
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Vaismoradi M, Jordan S, Vizcaya-Moreno F, Friedl I, Glarcher M. PRN Medicines Optimization and Nurse Education. PHARMACY 2020; 8:E201. [PMID: 33114731 PMCID: PMC7712763 DOI: 10.3390/pharmacy8040201] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 12/11/2022] Open
Abstract
Medicines management is a high-risk and error prone process in healthcare settings, where nurses play an important role to preserve patient safety. In order to create a safe healthcare environment, nurses should recognize challenges that they face in this process, understand factors leading to medication errors, identify errors and systematically address them to prevent their future occurrence. ''Pro re nata'' (PRN, as needed) medicine administration is a relatively neglected area of medicines management in nursing practice, yet has a high potential for medication errors. Currently, the international literature indicates a lack of knowledge of both the competencies required for PRN medicines management and the optimum educational strategies to prepare students for PRN medicines management. To address this deficiency in the literature, the authors have presented a discussion on nurses' roles in medication safety and the significance and purpose of PRN medications, and suggest a model for preparing nursing students in safe PRN medicines management. The discussion takes into account patient participation and nurse competencies required to safeguard PRN medication practice, providing a background for further research on how to improve the safety of PRN medicines management in clinical practice.
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Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway
| | - Sue Jordan
- Department of Nursing, Swansea University, Swansea SA2 8PP, UK;
| | - Flores Vizcaya-Moreno
- Nursing Department, Faculty of Health Sciences, University of Alicante, 03080 Alicante, Spain;
| | - Ingrid Friedl
- Hospital Graz II, A Regional Hospital of the Health Care Company of Styria, 8020 Graz, Austria;
| | - Manela Glarcher
- Institute of Nursing Science and Practice, Paracelsus Medical University, 5020 Salzburg, Austria;
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13
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Looking for the "Little Things": A Multi-Disciplinary Approach to Medicines Monitoring for Older People Using the ADRe Resource. Geriatrics (Basel) 2020; 5:geriatrics5040079. [PMID: 33086499 PMCID: PMC7709700 DOI: 10.3390/geriatrics5040079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 01/29/2023] Open
Abstract
Advances in medicines have increased the effectiveness of treatments and the social and cultural authority of doctors. However, as prescribing has become the dominant modality of treatment, the “pharmaceuticalization” of medical practice has often resulted in treatment “at a distance”, with doctors having limited contact with patients. Older and poorer people, who are socially distanced from medical prescribers, suffer more adverse drug reactions (ADRs) than the general population. A team approach to checking patients systematically for ADRs, as detailed in manufacturers’ literature, can minimise medication errors, but regular review is rare. This paper explains the benefits of medicines monitoring to protect older patients from iatrogenic harm, such as over-sedation, falls, or drug-induced Parkinsonism. We show how multidisciplinary initiatives to optimise prescribing can be supported by using a recognised resource—the adverse drug reaction profile (ADRe). The profile identifies and documents patients’ signs and symptoms of putative ADRs. Better monitoring allows professionals to adjust prescribing and respond to identified problems with agility. Implementation of systematic monitoring will require changes to the regulatory regime and better inter-professional cooperation. Providing carers, nurses and pharmacists with a structured system to monitor patients would democratise relevant medical knowledge and help address ageism and the socio-economic health divide.
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14
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Ropri F, Weisse CS. Informal Caregivers' Administration of Hospice Prescribed Lorazepam to Homecare Patients With Anxiety. Am J Hosp Palliat Care 2020; 38:1071-1077. [PMID: 33034195 DOI: 10.1177/1049909120965955] [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: 11/15/2022] Open
Abstract
BACKGROUND A growing number of informal caregivers (IFCs) manage hospice patients' anxiety by administering lorazepam (Ativan), yet little is known about prescribing practices in home care or the extent to which IFCs carry out regimens. DESIGN AND METHODS Data on hospice prescribed lorazepam was determined through a retrospective review of medication records from 216 deceased patients. The dose of lorazepam and type of regimen (i.e., scheduled, PRN, combination) as well as frequency with which it was administered by IFCs was calculated upon admission to a residential care home and on patients' day of death. RESULTS The majority (63.1%) of patients were prescribed lorazepam on admission to the home, and more (79.5%) were prescribed lorazepam on the day of death. While higher doses of lorazepam were prescribed and administered on the day of death, the percentage of medication consumed was low on admission (17%) and day of death (27%). Nearly all (92.8%) prescribed lorazepam on the day of death were allowed PRN medication. For PRN only regimens, less than a quarter (24.4%) of patients were given lorazepam on admission with less than half (40.4%) given it while dying. Highest lorazepam administration rates (91.2%) occurred on the day of death when lorazepam was prescribed under a combined regimen. CONCLUSION The high frequency of PRN regimens reveal that IFCs are frequently tasked with making decisions about if and when to administer lorazepam. Low overall lorazepam administration suggests a closer monitoring of lorazepam use and enhanced support of IFCs may be needed.
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Affiliation(s)
- Fatima Ropri
- Neuroscience Program, 7254Union College, Schenectady, NY, USA
| | - Carol S Weisse
- Department of Psychology, 7254Union College, Schenectady, NY, USA
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15
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Procaccini D, Rapaport R, Petty B, Moore D, Lee D, Kudchadkar SR. Design and Implementation of an Analgesia, Sedation, and Paralysis Order Set to Enhance Compliance of pro re nata Medication Orders with Joint Commission Medication Management Standards in a Pediatric ICU. Jt Comm J Qual Patient Saf 2020; 46:706-714. [PMID: 32653365 DOI: 10.1016/j.jcjq.2020.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of pro re nata (PRN) medication orders increases nursing flexibility and efficiency of bedside patient care. However, misuse and/or ambiguity of PRN medication orders may increase the propensity for medication errors. The Joint Commission has Medication Management (MM) standards to mitigate such risks. This quality improvement study with a pre-post design aimed to increase compliance of PRN sedative and analgesic orders with use of failure mode and effects analysis (FMEA) and human factors risk assessment methodologies in a pediatric ICU (PICU). METHODS Staff education and a PICU analgesia, sedation, and paralysis order set, with predefined PRN orders, were implemented to enhance PRN medication compliance with Joint Commission MM standards. The primary goal was to achieve and maintain a weekly average compliance of ≥ 90%. Proportions of compliant PRN analgesic and sedative orders before and after interventions were compared. RESULTS Weekly average PRN orders compliance increased from 62.0% ± 9.2% to 77.7% ± 10.1% after staff education was implemented (p = 0.013). After order set implementation, weekly average compliance further increased to 93.2% ± 3.6% (p < 0.0001) and remained > 90% until the end of the study period. CONCLUSION Interdisciplinary synthesis using FMEA and human factors risk assessment is effective for identifying system failure modes associated with Joint Commission MM standard noncompliance. Implementation of an order set with forced functionality to include order information compliant with Joint Commission MM standards can enhance and maintain Joint Commission-compliant PRN medication orders.
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Vaismoradi M, Vizcaya Moreno F, Sletvold H, Jordan S. PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review. PHARMACY 2019; 7:pharmacy7040157. [PMID: 31775262 PMCID: PMC6958522 DOI: 10.3390/pharmacy7040157] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 01/03/2023] Open
Abstract
Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.
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Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway;
- Correspondence: ; Tel.: +47-75517813
| | | | - Hege Sletvold
- Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway;
| | - Sue Jordan
- College of Human and Health Sciences, Swansea University, Swansea SA2 8PP, UK;
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Dörks M, Allers K, Hoffmann F. Pro Re Nata Drug Use in Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc 2019; 20:287-293.e7. [DOI: 10.1016/j.jamda.2018.10.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/08/2018] [Accepted: 10/19/2018] [Indexed: 01/10/2023]
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Vaismoradi M. Call for Role Development and Application of the Monitoring Profile in ADEs and ADRs. PHARMACY 2018; 6:pharmacy6040118. [PMID: 30366421 PMCID: PMC6306921 DOI: 10.3390/pharmacy6040118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 10/23/2018] [Accepted: 10/24/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway.
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