Administration of medicines. Part 1: The law and nursing

A Systematic Review of the Legal Considerations Surrounding Medicines Management

This study explores the legal considerations surrounding medicines management, providing a synthesis of existing knowledge. An integrative systematic review of the current international knowledge was performed. The search encompassed the online databases of PubMed (including Medline), Scopus, CINAHL, and Web of Science using MeSH terms and relevant keywords relating to the legal considerations of medicines management in healthcare settings. The search process led to the identification of 6051 studies published between 2010 and 2020, of which six articles were found to be appropriate for data analysis and synthesis based on inclusion criteria. Research methods were varied and included qualitative interviews, mixed-methods designs, retrospective case reports and cross-sectional interrupted time-series analysis. Their foci were on the delegation of medicines management, pharmacovigilance and reporting of adverse drug reactions (ADRs) before and after legislation by nurses, physicians and pharmacists, medico-legal litigation, use of forced medication and the prescription monitoring program. Given the heterogenicity of the studies in terms of aims and research methods, a meta-analysis could not be performed and, therefore, our review findings are presented narratively under the categories of 'healthcare providers' education and monitoring tasks', 'individual and shared responsibility', and 'patients' rights'. This review identifies legal aspects surrounding medicines management, including supervision and monitoring of the effects of medicines; healthcare providers' knowledge and attitudes; support and standardised tools for monitoring and reporting medicines' adverse side effects/ADRs; electronic health record systems; individual and shared perceptions of responsibility; recognition of nurses' roles; detection of sentinel medication errors; covert or non-voluntary administration of medication, and patient participation.

Oral drug therapy in elderly with dysphagia: between a rock and a hard place!

Demographic indicators forecast that by 2050, the elderly will account for about one-third of the global population. Geriatric patients require a large number of medicines, and in most cases, these products are administered as solid oral solid dosage forms, as they are by far the most common formulations on the market. However, this population tends to suffer difficulties with swallowing. Caregivers in hospital geriatric units routinely compound in solid oral dosage forms for dysphagic patients by crushing the tablets or opening the capsules to facilitate administration. The manipulation of a tablet or a capsule, if not clearly indicated in the product labeling, is an off-label use of the medicine, and must be supported by documented scientific evidence and requires the patient's informed consent. Compounding of marketed products has been recognized as being responsible for an increased number of adverse events and medical errors. Since extemporaneous compounding is the rule and not the exception in geriatrics departments, the seriousness and scope of issues caused by this daily practice are probably underestimated. In this article, the potential problems associated with the manipulation of authorized solid oral dosage forms are discussed.

Chemical and microbiological stability studies of an aqueous solution of pravastatin sodium salt for drug therapy of the dysphagic patients

Objective

This study is aimed to improve dysphagic patient compliance under therapy with cholesterol-lowering drugs. Patients suffering severe dysphagia, who do not feed independently, receive enteral nutrition through feeding tube and they need alternative oral route also for the administration of pharmacological therapy. This research deals with the development and stability (chemical and microbiological) of an aqueous solution of pravastatin sodium salt that will be administered orally directly in the feeding tube starting from commercial tablets. Tablets formulation is the only pharmaceutical dosage form available on the market for this type of drug.

Methods

Pravastatin sodium salt tablets are dissolved in a preserved sodium bicarbonate solution at the final concentration of 4 mg/mL. Samples are stored in two different conditions until 60 days. The samples are prepared for high-performance liquid chromatography analysis coupled to a diode array detector (HPLC-DAD), microbiological analysis and pH measurements.

Results

The chemical stability of the solution performed with HPLC-DAD analysis shows peaks' overlapping, which are characteristic of pravastatin, and correspondence of the concentration of the active ingredient in the solution. The detected values are analysed by one-way analysis of variance showing no statistically significant differences. Microbiological analyses proved that there is not microbial growth. By considering the dilution factor applied, it was possible to express the result as <10 CFU/mL in the two different culture media.

Conclusion

This study demonstrated the possibility to reformulate pravastatin tablets as liquid pharmaceutical formulation for enteral administration with the aim of improving drug therapy in dysphagic patients.

Learning outcomes associated with patient simulation method in pharmacotherapy education: an integrative review

STATEMENT

The aims of this systematic integrative review were to identify evidence for the use of patient simulation teaching methods in pharmacotherapy education and to explore related learning outcomes. A systematic literature search was conducted using 6 databases as follows: CINAHL, PubMed, SCOPUS, ERIC, MEDIC, and the Cochrane Library, using the key words relating to patient simulation and pharmacotherapy. The methodological quality of each study was evaluated. Eighteen articles met the inclusion criteria. The earliest article was published in 2005. The selected research articles were subjected to qualitative content analysis. Patient simulation has been used in pharmacotherapy education for preregistration nursing, dental, medical, and pharmacy students and for the continuing education of nurses. Learning outcomes reported were summarized as follows: (1) commitment to pharmacotherapy learning, (2) development of pharmacotherapy evaluation skills, (3) improvement in pharmacotherapy application skills, and (4) knowledge and understanding of pharmacotherapy. To develop effective teaching methods and ensure health care professionals' competence in medication management, further research is needed to determine the educational and clinical effectiveness of simulation teaching methods.

Patient participation in patient safety and nursing input - a systematic review

AIMS AND OBJECTIVES

This systematic review aims to synthesise the existing research on how patients participate in patient safety initiatives.

BACKGROUND

Ambiguities remain about how patients participate in routine measures designed to promote patient safety.

DESIGN

Systematic review using integrative methods.

METHODS

Electronic databases were searched using keywords describing patient involvement, nursing input and patient safety initiatives to retrieve empirical research published between 2007 and 2013. Findings were synthesized using the theoretical domains of Vincent's framework for analysing risk and safety in clinical practice: "patient", "healthcare provider", "task", "work environment", "organisation & management".

RESULTS

We identified 17 empirical research papers: four qualitative, one mixed-method and 12 quantitative designs. All 17 papers indicated that patients can participate in safety initiatives.

CONCLUSIONS

Improving patient participation in patient safety necessitates considering the patient as a person, the nurse as healthcare provider, the task of participation and the clinical environment. Patients' knowledge, health conditions, beliefs and experiences influence their decisions to engage in patient safety initiatives. An important component of the management of long-term conditions is to ensure that patients have sufficient knowledge to participate. Healthcare providers may need further professional development in patient education and patient care management to promote patient involvement in patient safety, and ensure that patients understand that they are 'allowed' to inform nurses of adverse events or errors. A healthcare system characterised by patient-centredness and mutual acknowledgement will support patient participation in safety practices. Further research is required to improve international knowledge of patient participation in patient safety in different disciplines, contexts and cultures.

RELEVANCE TO CLINICAL PRACTICE

Patients have a significant role to play in enhancing their own safety while receiving hospital care. This review offers a framework for clinicians to develop comprehensive practical guidelines to support patient involvement in patient safety.

A structural equation modeling of the factors affecting student nurses' medication errors

Across medication error literature, much attention has been given to incidence, types, causes and prevention of medication errors. Despite these efforts, medication errors continue to occur among registered and student nurses. Considering the numerous studies on medication errors committed by registered nurses, little is known on the nature of student nurses' medication error. This study employed factor analysis and structural equation modeling to explore the factors affecting medication errors by student nurses. With the participation of 329 junior and senior student nurses recruited from a comprehensive university in the Philippines, five factor dimensions of the causes of student nurses' medication error were identified, namely: In-violation, In-writing, In-excess, In-experience and In-tension. Results of path analysis showed an interaction among these variables. Additionally, poor adherence to the "five rights" was identified as an important mediator between In-violation, In-writing, In-excess, In-experience and In-tension and student nurses' medication error. By developing a model to explain how student nurses' medication errors occur, this study sheds light on the nature of student nurses' medication error and provides a basis for error prevention strategies.

Covert medication administration: the practice of hiding medications in long-term care settings

Covert medication administration is the purposeful hiding of medications from patients, and the topic receives little attention. Awareness and research regarding this practice is limited to a handful of studies outside of the United States. These studies suggest a larger prevalence than reported and identify significant ethical and legal implications for bedside nurses. A review of the literature, discussion of prevalence, contributing factors, and potential consequences of this practice build the foundation for practice recommendations and suggestions for future research. In addition to recommendations for nurses regarding covert medication administration, additional research and exploration of this issue in the United States are proposed.

Evaluation of outpatient computerized physician medication order entry systems: a systematic review

This paper provides a systematic literature review of CPOE evaluation studies in the outpatient setting on: safety; cost and efficiency; adherence to guideline; alerts; time; and satisfaction, usage, and usability. Thirty articles with original data (randomized clinical trial, non-randomized clinical trial, or observational study designs) met the inclusion criteria. Only four studies assessed the effect of CPOE on safety. The effect was not significant on the number of adverse drug events. Only one study showed a significant reduction of the number of medication errors. Three studies showed significant reductions in medication costs; five other studies could not support this. Most studies on adherence to guidelines showed a significant positive effect. The relatively small number of evaluation studies published to date do not provide adequate evidence that CPOE systems enhance safety and reduce cost in the outpatient settings. There is however evidence for (a) increasing adherence to guidelines, (b) increasing total prescribing time, and (c) high frequency of ignored alerts.