Barriers and facilitators of pharmacists' integration in a multidisciplinary home care team: a qualitative interview study based on the normalization process theory

BACKGROUND

There is a growing recognition of multidisciplinary practices as the most rational approach to providing better and more efficient healthcare services. Pharmacists are increasingly integrated into primary care teams, but there is no universal approach to implementing pharmacist services across healthcare settings. In Norway, most pharmacists work in pharmacies, with very few employed outside this traditional setting. The home care workforce is primarily made up of nurses, assistant nurses, and healthcare assistants. General practitioners (GPs) are not based in the same location as home care staff. This study utilized the Normalization Process Theory (NPT) to conduct a process evaluation of the integration of pharmacists in a Norwegian home care setting. Our aim was to identify barriers and facilitators to optimal utilization of pharmacist services within a multidisciplinary team.

METHODS

Semi-structured interviews (n = 9) were conducted with home care unit leaders, ward managers, registered nurses, and pharmacists in Norway, in November 2022-February 2023. Constructs from the NPT were applied to qualitative data.

RESULTS

Findings from this study pertain to the four constructs of the NPT. Healthcare professionals struggled to conceptualize the pharmacists' competencies and there were no collectively agreed-upon objectives of the intervention. Consequently, some participants questioned the necessity of pharmacist integration. Further, participants reported conflicting preferences regarding how to best utilize medication-optimizing services in everyday work. A lack of stakeholder empowerment was reported across all participants. Moreover, home care unit leaders and managers reported being uninformed of their roles and responsibilities related to the implementation process. However, the presence of pharmacists and their services were well received in the setting. Moreover, participants reported that pharmacists' contributions positively impacted the multidisciplinary practice.

CONCLUSION

Introducing new work methods into clinical practice is a complex task that demands expertise in implementation. Using the NTP model helped pinpoint factors that affect how pharmacists' skills are utilized in a home care setting. Insights from this study can inform the development of tailored implementation strategies to improve pharmacist integration in a multidisciplinary team.

Adapting a community pharmacy intervention to improve medication safety

BACKGROUND

Community pharmacies are an ideal location to address challenges of over-the-counter medication safety, yet many successful interventions are only tested in a few pharmacies without expansion, creating unrealized opportunities to improve patient care on a larger scale. Scaling up to numerous pharmacies can be challenging because each community pharmacy has unique needs and layouts and requires individualized adaptation.

OBJECTIVES

This paper reports techniques for (a) adapting a community pharmacy intervention to fit the unique physical layout and patient needs of health system pharmacy sites without increasing staff workload, (b) identifying strategies to gather feedback on adaptations from stakeholders, and (c) developing materials to share with pharmacy champions for them to independently implement and sustain the intervention in their organization.

PRACTICE DESCRIPTION

The study team collaborated with Aurora Pharmacy, Inc to develop an intervention designed to increase awareness of safe over-the-counter medication use for older adults.

PRACTICE INNOVATION

Senior Safe, a community pharmacy-based intervention, was designed, implemented, and tested using the Exploration, Preparation, Implementation, and Sustainment implementation framework.

EVALUATION METHODS

Senior Safe was adapted through pilot testing and a randomized control trial. Feedback was collected from key stakeholders, including pharmacy staff, older adults, and a research advisory group.

RESULTS

A finalized version of Senior Safe, as well as an implementation package, was provided to Aurora Pharmacy to integrate into all 63 sites.

CONCLUSION

This multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but it requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.

Completeness of medication information in admission notes from emergency departments

BACKGROUND

Medication lists prepared in the emergency department (ED) form the basis for diagnosing and treating patients during hospitalization. Since incomplete medication information may lead to patient harm, it is crucial to obtain a correct and complete medication list at hospital admission. In this cross-sectional retrospective study we wanted to explore medication information completeness in admission notes from Norwegian EDs and investigate which factors were associated with level of completeness.

METHODS

Medication information was assessed for completeness by applying five evaluation criteria; generic name, formulation, dose, frequency, and indication for use. A medication completeness score in percent was calculated per medication, per admission note and per criterion. Quantile regression analysis was applied to investigate which variables were associated with medication information completeness.

RESULTS

Admission notes for patients admitted between October 2018 and September 2019 and using at least one medication were included. A total of 1,080 admission notes, containing 8,604 medication orders, were assessed. The individual medications had a mean medication completeness score of 88.1% (SD 16.4), while admission notes had a mean medication completeness score of 86.3% (SD 16.2). Over 90% of all individual medications had information about generic name, formulation, dose and frequency stated, while indication for use was only present in 60%. The use of an electronic tool to prepare medication information had a significantly strong positive association with completeness. Hospital visit within the last 30 days, the patient's living situation, number of medications in use, and which hospital the patient was admitted to, were also associated with information completeness.

CONCLUSIONS

Medication information completeness in admission notes was high, but potential for improvement regarding documentation of indication for use was identified. Applying an electronic tool when preparing admission notes in EDs seems crucial to safeguard completeness of medication information.

Emergency department physicians' experiences and perceptions with medication-related work tasks and the potential role of clinical pharmacists

PURPOSE

Medication-related problems are frequent among emergency department patients. Clinical pharmacists play an important role in identifying, solving, and preventing these problems, but are not present in emergency departments worldwide. We aimed to explore how Norwegian physicians experience medication-related work tasks in emergency departments without pharmacists present, and how they perceive future introduction of a clinical pharmacist in the interprofessional team.

METHODS

We interviewed 27 physicians in three emergency departments in Norway. Interviews were audio-recorded, transcribed, and analysed using qualitative content analysis.

RESULTS

Our informants' experience with medication-related work tasks mainly concerned medication reconciliation, and few other tasks were systematically performed to ensure medication safety. The informants were welcoming of clinical pharmacists and expressed a need and wish for assistance with compiling patient's medication lists. Simultaneously they expressed concerns regarding e.g., responsibility sharing, priorities in the emergency department and logistics. These concerns need to be addressed before implementing the clinical pharmacist in the interprofessional team in the emergency department.

CONCLUSIONS

Physicians in Norwegian emergency departments welcome assistance from clinical pharmacists, but the identified professional, structural, and legislative barriers for this collaboration need to be addressed before implementation.

Elevating Safe Use of Over-The-Counter Medications in Older Adults: A Narrative Review of Pharmacy Involved Interventions and Recommendations for Improvement

Over-the-counter (OTC) medications are products that have been made easily accessible to allow patients to treat common ailments without a prescription and the cost of a doctor's visit. These medications are generally considered safe; however, there is still a potential for these medications to lead to adverse health outcomes. Older adults (ages 50+) are especially susceptible to these adverse health outcomes, due to age-related physiological changes, a higher prevalence of comorbidities, and prescription medication use. Many OTC medications are sold in pharmacies, which provides pharmacists and technicians with the opportunity to help guide safe selection and use for these medications. Therefore, community pharmacies are the ideal setting for OTC medication safety interventions. This narrative review summarizes the findings of pharmacy-involved interventions that promote safe OTC medication use for older adults.

'Illuminating determinants of implementation of non-dispensing pharmacist services in home care: a qualitative interview study'

OBJECTIVES

Medication errors are leading causes of hospitalization and death in western countries and WHO encourages health care providers to implement non-dispensing pharmacist services in primary care to improve medication work. However, these services struggle to provide any impact on clinical outcomes. We wanted to explore health care professionals' views on medication work to illuminate determinants of the implementation success. The research was designed to inform and adapt implementation strategies for non-dispensing pharmacist services.

DESIGN

Semi-structured interview study with nine healthcare professionals.

SETTING

Four Norwegian home care wards.

SUBJECTS

Nine healthcare professionals working at different wards within one home care unit.

MAIN OUTCOME MEASURES

Determinants of implementation outcomes.

RESULTS

Contextual determinants of the implementation process were mainly related to characteristics of the setting such as poorly designed information systems, work overload, and chaotic work environments. The identified barriers question the innovation's appropriateness related to the setting's needs but also provide possibilities for tailoring pharmacist services to local medication work issues. The observable positive effects and the perceived advantage of the pharmacist services are likely to facilitate the implementation process.

CONCLUSION

Our study provided information on contextual elements that influence the implementation process of non-dispensing pharmacist services. Awareness of these factors can help develop strategies to help the organization succeed in in achieving program outcomes.

Self-reported medication information needs among medication users in a general population aged 40 years and above - the Tromsø study

PURPOSE

To determine the prevalence and associated factors of self-reported medication information needs among medication users in a general population aged 40 years and above - The Tromsø Study.

METHODS

Cross-sectional study of medication users (n = 10,231) among participants in the Tromsø Study, a descriptive analysis of questionnaire data and multivariable logistic regression (n = 9,194).

RESULTS

Sixteen percent of medication users expressed a need for more information about own medications. Overall, medication users agreed to a higher degree to have received information from the GP compared to the pharmacy. Concerned medication users and those disagreeing to have received information about side effects had the highest odds for needing more information (OR 5.07, 95% CI 4.43-5.81) and (OR 2.21, 95% CI 1.83-2.68), respectively. Medication users who used heart medications (e.g., nitroglycerin, antiarrhythmics, anticoagulants) (OR 1.71, 95% CI 1.46-2.01), medication for hypothyroidism (OR 1.36, 95% CI 1.13-1.64) or had moderately health anxiety had expressed need for medication information. Whereas medication users with lower education, those that never used internet to search for health advice, and medication users who disagreed to have received information about reason-for-use were associated with lower odds (OR 0.75, 95% CI 0.62-0.91), (OR 0.85, 95% CI 0.74-0.98) and (OR 0.68, 95% CI 0.53-0.88), respectively.

CONCLUSION

This study demonstrated that there is need for more information about own medications in a general population aged 40 years and above and shed light on several characteristics of medication users with expressed information need which is important when tailoring the right information to the right person.

Integrating the clinical pharmacist into the emergency department interdisciplinary team: a study protocol for a multicentre trial applying a non-randomised stepped-wedge study design

INTRODUCTION

The 'emergency department (ED) pharmacist' is an integrated part of the ED interdisciplinary team in many countries, which have shown to improve medication safety and reduce costs related to hospitalisations. In Norway, few EDs are equipped with ED pharmacists, and research describing effects on patients has not been conducted. The aim of this study is to investigate the impact of introducing clinical pharmacists to the interdisciplinary ED team. In this multicentre study, the intervention will be pragmatically implemented in the regular operation of three EDs in Northern Norway; Tromsø, Bodø and Harstad. Clinical pharmacists will work as an integrated part of the ED team, providing pharmaceutical care services such as medication reconciliation, review and/or counselling. The primary endpoint is 'time in hospital during 30 days after admission to the ED', combining (1) time in ED, (2) time in hospital (if hospitalised) and (3) time in ED and/or hospital if re-hospitalised during 30 days after admission. Secondary endpoints include time to rehospitalisation, length of stay in ED and hospital and rehospitalisation and mortality rates.

METHODS AND ANALYSIS

We will apply a non-randomised stepped-wedge study design, where we in a staggered way implement the ED pharmacists in all three EDs after a 3, 6 and 9 months control period, respectively. We will include all patients going through the three EDs during the 12-month study period. Patient data will be collected retrospectively from national data registries, the hospital system and from patient records.

ETHICS AND DISSEMINATION

The Regional Committee for Medical and Health Research Ethics and Local Patient Protection Officers in all hospitals have approved the study. Patients will be informed about the ongoing study on a general basis with ads on posters and flyers.

TRIAL REGISTRATION NUMBER

NCT04722588.

Medication Errors and Safety Culture in a Norwegian Hospital

Medication errors are associated with adverse health outcomes and may prolong hospital stays and increase societal costs. Safety initiatives to reduce adverse health outcomes should be based on reliable information of current shortcomings. The aim of this study was to identify barriers to medication error reporting in a hospital and to describe heath personnel's views of the safety culture. Seven interviews with health personnel (two doctors, four nurses and one pharmacist) were conducted November 2016-January 2017 at the University Hospital of North Norway. Nurses, more frequently than doctors, reported medication errors and discussed reported errors at staff meetings. Doctors preferred to solve the problem directly, for example writing a new medication order, rather than writing a report when a medication error had been identified. There was variation between the wards regarding the perception of support, confidence in and focus on error reporting, which indicates different safety cultures within the hospital. Identified barriers to medication error reporting included lack of time, and the impression that the reporting system is complicated and not user-friendly. Staff also reported inadequate training using the system, which could contribute to the perception that the system is inaccessible. Hospital management should take actions to improve the safety culture throughout the hospital based on the barriers identified in this study. This could include stronger focus on the importance of reporting medication errors, a transparent review process and clearly communicated actions.

What do Australian consumers, pharmacists and prescribers think about documenting indications on prescriptions and dispensed medicines labels?: A qualitative study

BACKGROUND

Documenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Australian consumers, pharmacists and prescribers on documenting the indication on prescriptions and dispensed medicines labels.

METHODS

Semi-structured interviews were conducted and mock-up of dispensed medicines labels were designed for participants. Consumers (n = 19) and pharmacists (n = 7) were recruited by convenience sample at community pharmacies in Sydney (Australia) and prescribers (n = 8), including two medical students, were recruited through snowballing.

RESULTS

Thirty-four participants were interviewed. Most participants agreed that documenting the indication would be beneficial especially for patients who are forgetful or take multiple medications. Participants also believed it would improve consumers' medication understanding and adherence. Prescribers and pharmacists believed it could help reduce prescribing and dispensing errors by matching the drug/dosage to the correct indication. Prescribers refrained from documenting the indication to protect patients' privacy; however, most patients did not consider documenting the indication as a breach of privacy. Prescribers raised concerns about the extra time to include indications on prescriptions and best language to document indications, using plain language as opposed to medical terminology.

CONCLUSIONS

All interviewed stakeholders identified numerous benefits of documenting the indication on prescriptions and dispensed medicines labels. Whether these potential benefits can be realized remains unknown and addressing prescribers' concern regarding the time involved in documenting the indication on prescriptions remains a challenge for vendors of electronic medication management systems.

Redesign of computerized decision support to improve antimicrobial prescribing. A controlled before-and-after study

OBJECTIVE

To determine the impact of the introduction of new pre-written orders for antimicrobials in a computerized provider order entry (CPOE) system on 1) accuracy of documented indications for antimicrobials in the CPOE system, 2) appropriateness of antimicrobial prescribing, and 3) compliance with the hospital's antimicrobial policy. Prescriber opinions of the new decision support were also explored to determine why the redesign was effective or ineffective in altering prescribing practices.

METHODS

The study comprised two parts: a controlled pre-post study and qualitative interviews. The intervention involved the redesign of pre-written orders for half the antimicrobials so that approved indications were incorporated into pre-written orders. 555 antimicrobials prescribed before (September - October, 2013) and 534 antimicrobials prescribed after (March - April, 2015) the intervention on all general wards of a hospital were audited by study pharmacists. Eleven prescribers participated in semi-structured interviews.

RESULTS

Redesign of computerized decision support did not result in more appropriate or compliant antimicrobial prescribing, nor did it improve accuracy of indication documentation in the CPOE system (Intervention antimicrobials: appropriateness 49% vs. 50%; compliance 44% vs. 42%; accuracy 58% vs. 38%; all p>0.05). Via our interviews with prescribers we identified five main reasons for this, primarily that indications entered into the CPOE system were not monitored or followed-up, and that the antimicrobial approval process did not align well with prescriber workflow.

CONCLUSION

Redesign of pre-written orders to incorporate appropriate indications did not improve antimicrobial prescribing. Workarounds are likely when compliance with hospital policy creates additional work for prescribers or when system usability is poor. Implementation of IT, in the absence of support or follow-up, is unlikely to achieve all anticipated benefits.

A time and motion study of junior doctor work patterns on the weekend: a potential contributor to the weekend effect?

BACKGROUND

Patients admitted to hospital on weekends have a greater risk of mortality compared to patients admitted on weekdays. Junior medical officers (JMO) make up the majority of medical staff on weekends. No previous study has quantified JMO work patterns on weekends.

AIM

To describe and quantify JMO work patterns on weekends and compare them with patterns previously observed during the week.

METHODS

Observational time and motion study of JMO working weekends using the Work Observation Method by Activity Timing (WOMBAT; Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia) software. Descriptive statistics were used to determine the proportion of total observed time spent in tasks.

RESULTS

Weekend JMO predominately spent time in indirect care (32.0%), direct care (23.0%) and professional communication (22.1%). JMO spent 20.9% of time multitasking and were interrupted, on average, every 9 min. Weekend JMO spent significantly more time in direct care compared with weekdays (13.0%; P < 0.001) and nights (14.3%; P < 0.001). Weekend JMO spent significantly less time on breaks (8.5%), with less than 1 h in an 11-h shift, compared with JMO during weekdays (16.4%; P = 0.004) and nights (27.6%; P = <0.001). Weekend JMO were interrupted at a higher rate (6.6/h) than on weekdays (rate ratio (RR) 2.9, 95% confidence intervals (CI) 2.6, 3.3) or nights (RR 5.1, 95% CI 4.2, 6.1). Multitasking on weekends (20.9%) was comparable to weekdays (18.9%; P = 0.19) but significantly higher than nights (6.4%; P = <0.001).

CONCLUSION

On weekends, JMO had few breaks, were interrupted frequently and engaged in high levels of multitasking. This pattern of JMO work could be a potential contributing factor to the weekend effect in terms of JMO abilities to respond safely and adequately to care demands.

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study

Aim

To evaluate the effectiveness of a ‘Do not interrupt’ bundled intervention to reduce non-medication-related interruptions to nurses during medication administration.

Methods

A parallel eight cluster randomised controlled study was conducted in a major teaching hospital in Adelaide, Australia. Four wards were randomised to the intervention which comprised wearing a vest when administering medications; strategies for diverting interruptions; clinician and patient education; and reminders. Control wards were blinded to the intervention. Structured direct observations of medication administration processes were conducted. The primary outcome was non-medication-related interruptions during individual medication dose administrations. The secondary outcomes were total interruption and multitasking rates. A survey of nurses' experiences was administered.

Results

Over 8 weeks and 364.7 hours, 227 nurses were observed administering 4781 medications. At baseline, nurses experienced 57 interruptions/100 administrations, 87.9% were unrelated to the medication task being observed. Intervention wards experienced a significant reduction in non-medication-related interruptions from 50/100 administrations (95% CI 45 to 55) to 34/100 (95% CI 30 to 38). Controlling for clustering, ward type and medication route showed a significant reduction of 15 non-medication-related interruptions/100 administrations compared with control wards. A total of 88 nurses (38.8%) completed the poststudy survey. Intervention ward nurses reported that vests were time consuming, cumbersome and hot. Only 48% indicated that they would support the intervention becoming hospital policy.

Discussion

Nurses experienced a high rate of interruptions. Few were related to the medication task, demonstrating considerable scope to reduce unnecessary interruptions. While the intervention was associated with a statistically significant decline in non-medication-related interruptions, the magnitude of this reduction and its likely impact on error rates should be considered, relative to the effectiveness of alternate interventions, associated costs, likely acceptability and long-term sustainability of such interventions.

Positive beliefs and privacy concerns shape the future for the Personally Controlled Electronic Health Record

The uptake of the Personally Controlled Electronic Health Record (PCEHR) has been slowly building momentum in Australia. The purpose of the PCEHR is to collect clinically important information from multiple healthcare providers to provide a secure electronic record to patients and their authorised healthcare providers that will ultimately enhance the efficiency and effectiveness of healthcare delivery. Reasons for the slow uptake of the PCEHR and future directions to improve its usefulness is discussed later.

The Precise Observation System for the Safe Use of Medicines (POSSUM): An Approach for Studying Medication Administration Errors in the Field

Medication administration errors (MAEs) in hospital are frequent and significantly more likely to result in serious harm to patients than other medication error types. Many interventions have been proposed in order reduce MAEs and the amount of harm associated with these errors. A major limitation in assessing the effectiveness of these interventions has been the lack of robust measures for assessing changes in MAEs and associated harms. Drawing upon extensive foundational research we have developed a robust approach and data collection software to be applied in direct observational studies of nurses to allow measurement of changes in MAE rates. We report how this approach is being applied in a large stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce MAEs in a paediatric hospital.

Little Things Matter: A Time and Motion Study of Pharmacists' Activities in a Paediatric Hospital

How healthcare providers distribute their time can impact on the quality and safety of care delivered, and this has been widely studied in hospitals providing care to adult patients. Children are different to adults and the workflow of healthcare providers in paediatric settings is largely unknown. The aim of this study was to quantify how clinical pharmacists working in a paediatric hospital spend their time. A direct observational time and motion study was conducted where two independent observers shadowed seven pharmacists covering eight wards for over 60 hours. Pharmacists spent the majority of time performing medication review (32.6%), followed by communication, non-clinical tasks, supply, medication discussion and in-transit. They were interrupted 3.5 times per hour and spent 4.4% of observed time multi-tasking. This is the first study to quantify how pharmacists in a paediatric hospital distribute their time. These results could act as useful baseline data against which to measure the impact of innovations, such as electronic medication management systems, on pharmacists' workflow.

iPad use at the bedside: a tool for engaging patients in care processes during ward rounds?

BACKGROUND

Previous work has examined the impact of technology on information sharing and communication between doctors and patients in general practice consultations, but very few studies have explored this in hospital settings.

AIMS

To assess if, and how, senior clinicians use an iPad to share information (e.g. patient test results) with patients during ward rounds and to explore patients' and doctors' experiences of information sharing events.

METHODS

Ten senior doctors were shadowed on ward rounds on general wards during interactions with 525 patients over 77.3 h, seven senior doctors were interviewed and 180 patients completed a short survey.

RESULTS

Doctors reported that information sharing with patients is critical to the delivery of high-quality healthcare, but were not seen to use the iPad to share information with patients on ward rounds. Patients did not think the iPad had impacted on their engagement with doctors on rounds. Ward rounds were observed to follow set routines and patient interactions were brief.

CONCLUSIONS

Although the iPad potentially creates new opportunities for information sharing and patient engagement, the ward round may not present the most appropriate context for this to be done.

Knowledge and attitudes regarding the personally controlled electronic health record: an Australian national survey

The personally controlled electronic health record (PCHER) was designed to bring important information together to facilitate effective communication between clinicians and so improve patient care. This national cross-sectional survey of 405 healthcare providers and consumers found that they had relatively low awareness and knowledge about the PCEHR; that 62% of respondents believed that healthcare providers with access to the PCEHR would be able to provide better quality of care but only 50% of respondents would sign up to have a PCEHR.

What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system

Objectives

To (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff.

Design

Audit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’.

Setting

Two major academic teaching hospitals in Sydney, Australia.

Main Outcome Measures

Rates of medication errors identified from audit and from direct observation were compared with reported medication incident reports.

Results

A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit.

Conclusions

Prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

Impact of Medication Reconciliation and Review on Clinical Outcomes

Objective: To examine the evidence regarding the effectiveness of medication reconciliation and review and to improve clinical outcomes in hospitals, the community, and aged care facilities. Data Source: This systematic review was undertaken in concordance with the PRISMA statement. Electronic databases, including MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for relevant articles published between January 2000 and March 2014. Study Selection and Data Extraction: Randomized and nonrandomized studies rating the severity of medication discrepancies and medication-related problems identified during medication reconciliation and/or review were considered for inclusion. Data were extracted independently by 2 authors using a data collection form. Data Synthesis: Of the 5292 articles identified, 83 articles met the inclusion criteria. Medication reconciliation identified unintentional medication discrepancies in 3.4% to 98.2% of patients. There is limited evidence of the potential of these discrepancies to cause harm. Medication reviews identified medication-related problems or possible adverse drug reactions in 17.2% to 94.0% of patients. The studies reported conflicting findings regarding the impact of medication review on length of stays, readmissions, and mortality. Conclusions: The evidence demonstrates that medication reconciliation has the potential to identify many medication discrepancies and reduce potential harm, but the impact on clinical outcomes is less clear. Similarly, medication review can detect medication-related problems in many patients, but evidence of clinical impact is scant. Overall, there is limited evidence that medication reconciliation and medication review processes, as currently performed, significantly improve clinical outcomes, such as reductions in hospital readmissions.

iPad use during ward rounds: an observational study

Much clinical information is computerised and doctors' use of mobile devices such as iPad tablets to access this information is expanding rapidly. This study investigated the use of iPads during ward rounds and their usefulness in providing access to information during ward rounds. Ten teams of doctors at a large teaching hospital were given iPads for ten weeks and were observed on ward rounds for 77.3 hours as they interacted with 525 patients. Use of iPads and other information technology devices to access clinical information was recorded. The majority of clinical information was accessed using iPads (56.2%), followed by computers-on-wheels (35.8%), stationary PCs (7.9%) and smartphones (0.1%). Despite having read-only access on iPads, doctors were generally happy using iPads on ward rounds. These findings provide evidence of the value of iPads as a tool to access information at the point of care.

A qualitative study of Swedes' opinions about shared electronic health records

European countries are world-leading in the development and implementation of e-Health. In Sweden, all primary healthcare centres and most hospitals use digital records. Some regions use the same software which allows for clinical information to be shared (regionally shared EHRs), but there is a movement towards making all EHRs inter-operable to allow for a National Patient Summary (NPS). The aim of this study was to explore the opinions of Swedish consumers and health professionals about shared EHRs and the NPS. Semi-structered phone interviews were conducted with consumers and health professionals. The majority of interviewed health professionals were currently using regionally shared EHRs. In their experience, having access to regionally shared EHRs facilitated a holistic patient approach, assisted in patient follow-up, and reduced inappropriate (over)prescribing. Consumers had a poor level of knowledge about shared EHRs and the NPS. Unlike health professionals, consumers perceived a NPS to be of great value. The findings indicate that there was a discrepancy between health professionals and consumers' knowledge of, and the perceived need for, a NPS.

A qualitative study of Australians' opinions about personally controlled electronic health records

BACKGROUND

A personally controlled electronic health record (PCEHR) system is being implemented in Australia. Every Australian that wants a PCEHR will be able to opt-in from July 2012.

AIM

To explore the opinions of Australian consumers and healthcare providers about the PCEHR.

METHODS

In this qualitative study, consumers and healthcare providers were interviewed using a semi-structured interview guide.

RESULTS

Perceived benefits identified by participants regarding the PCEHR included instant access to clinical information, and safer and more efficient healthcare delivery. The risk of unauthorised access and breaches of privacy were some of the perceived drawbacks. Although consumers seemed unwilling to opt-in to have a PCEHR, the vast majority of healthcare providers were positive towards this development and predicted better and safer healthcare as a result.

CONCLUSIONS

Consumers and healthcare providers appeared uniformed about the imminent PCEHR. The wide-spread unwillingness among participants to opt-in to have a PCEHR could potentially jeopardise successful implementation and uptake of this system. A well-designed system without security glitches and with individualised information from trusted healthcare providers regarding the benefits of having a PCEHR appears critical in engaging consumer opt-in.

Challenges in chronic illness management: a qualitative study of Australian pharmacists' perspectives

OBJECTIVE

To explore pharmacists' views on managing patients with chronic illness; to understand the incentives and barriers they perceive and the solutions they propose to overcome these barriers.

SETTING

Hospital pharmacists, with experience in managing people with chronic illnesses, working in western Sydney, Australia, were interviewed during June and July 2008.

METHOD

A qualitative study involving group and individual interviews using a semi-structured interview guide.

RESULTS

Hospital pharmacists identified lack of communication between different healthcare providers and with patients as a contributing factor to lack of continuity of care and this was perceived as a major barrier in managing patients with chronic illnesses. Pharmacists were also concerned about the effects of medication costs, and poor patient knowledge regarding their disease and medications, and the effects on adherence. Suggested solutions included taking a teamwork approach in the management of chronic illness and providing more information to patients to improve adherence.

CONCLUSION

The identified incentives and barriers have provided valuable information on what pharmacists face in managing patients with chronic illness. Most of the solutions suggested by them have been tested and proven unsuccessful. Develop successful health policy to address the identified barriers remains a challenge.