Alison Strath

A systematic review of medical and non-medical practitioners’ views of the impact of ehealth on shared care

Purpose To explore medical and non-medical practitioners’ views of the impact of ehealth on shared care. Method A systematic review was conducted using a meta-narrative approach with publication search dates limited from 1 January 2005 to 28 February 2011 and English language only. Search results from the databases (ASLIB, EBSCO Host, Cochrane Library, Informa Healthcare, PsycNet, Sciverse Scopus, Zetoc) were independently reviewed and data extracted by two of the authors. The review included peer reviewed papers about medical and non-medical practitioners who provide ehealth supported shared care. Articles which focused solely on searching the internet or exchange of emails were excluded. Results Screening reduced the initial 327 papers identified to 12 which included three reviews, four qualitative, two mixed methods and three quantitative studies. Included studies collected data using combinations of questionnaires, case study, group/individual interviews, observation and extraction of data from records. Data were analysed using thematic, interpretive, analytic induction/constant comparative and statistical analysis methods. Practice settings were primary care, secondary care or both. The focus was on electronic records (7), telemedicine (2) or general ehealth implementation (3) predominantly from the perspective of doctors, nurses, IT developers, policy makers and managers plus one hospital pharmacist. The studies showed acceptance of ehealth technologies to support increasing levels of shared care but with cost effectiveness, level of resourcing and training questioned by respondents. Emerging themes across all study types were organisational, social and technical: resource and time implications, culture of the workplace and change management requirements; impact on patient consultation, extra workload, need for training suited to varying levels of IT literacy, usability, patient privacy and the practitioners role; systems incompatibility, technological inadequacies, need for shared definition and terminology. Conclusions Findings indicate acceptance of ehealth to support shared care but question anticipated efficiencies. Organisational, social and technical issues identified were similar to non-healthcare IT implementations and adoption of innovation theory. Evidence of medical and non-medical practitioners’ views of the impact of ehealth on shared care remains limited with further areas for pharmacy ehealth research identified.

Exploring behavioural determinants relating to health professional reporting of medication errors: a qualitative study using the Theoretical Domains Framework

PurposeEffective and efficient medication reporting processes are essential in promoting patient safety. Few qualitative studies have explored reporting of medication errors by health professionals, and none have made reference to behavioural theories. The objective was to describe and understand the behavioural determinants of health professional reporting of medication errors in the United Arab Emirates (UAE).MethodsThis was a qualitative study comprising face-to-face, semi-structured interviews within three major medical/surgical hospitals of Abu Dhabi, the UAE. Health professionals were sampled purposively in strata of profession and years of experience. The semi-structured interview schedule focused on behavioural determinants around medication error reporting, facilitators, barriers and experiences. The Theoretical Domains Framework (TDF; a framework of theories of behaviour change) was used as a coding framework. Ethical approval was obtained from a UK university and all participating hospital ethics committees.ResultsData saturation was achieved after interviewing ten nurses, ten pharmacists and nine physicians. Whilst it appeared that patient safety and organisational improvement goals and intentions were behavioural determinants which facilitated reporting, there were key determinants which deterred reporting. These included the beliefs of the consequences of reporting (lack of any feedback following reporting and impacting professional reputation, relationships and career progression), emotions (fear and worry) and issues related to the environmental context (time taken to report).ConclusionThese key behavioural determinants which negatively impact error reporting can facilitate the development of an intervention, centring on organisational safety and reporting culture, to enhance reporting effectiveness and efficiency.

Healthcare professionals’ perceptions of the facilitators and barriers to implementing electronic systems for the prescribing, dispensing and administration of medicines in hospitals: a systematic review

Objective To identify, critically appraise, synthesise and present the available evidence on healthcare professionals’ perceptions of the facilitators and barriers to implementing electronic prescribing, dispensing and/or administration of medicines in the hospital setting. Methods A systematic search of studies focusing on healthcare professionals’ perceptions of technologies for prescribing, dispensing and administering medicines in the hospital setting was performed using MEDLINE, Cumulative Index to Nursing and Allied Health, International Pharmaceutical Abstracts, PsycARTICLES, PsycINFO, Cochrane Database of Systematic Reviews and Centre for Reviews and Dissemination. Grey literature inclusive of manual searching of core journals, relevant conference abstracts and online theses were also searched. Independent duplicate screening of titles, abstracts and full texts was performed by the authors. Data extraction and quality assessment were undertaken using standardised tools, followed by narrative synthesis. Key findings Five papers were included in the systematic review after screening 2566 titles. Reasons for exclusion were duplicate publication; non-hospital setting; a lack of investigation of healthcare professionals’ perceptions and a lack of focus on implementation processes or systems specific to electronic prescribing, dispensing or administration of medicines. Studies were conducted in the USA, Sweden and Australia. All studies used qualitative interview methods. Healthcare professionals perceived systems improved patient safety and provided better access to patients’ drug histories and that team leadership and equipment availability and reliability were essential for successful implementation. Key barriers included hardware and network problems; altered work practices such as time pressure on using the system and remote ordering as a potential risk for errors; and weakened interpersonal communication between healthcare professionals and with patients. Conclusions Few studies were identified on healthcare professionals’ perceptions of the facilitators and barriers to system implementation in hospitals. Key facilitators included a perception of increased patient safety and better access to patients’ drug history while key barriers involved technical problems, changes to routine work practices and weakened interpersonal communication. Investigating this area further will assist in improving patient safety and reducing medication costs by informing and strengthening implementation strategies.

Toward interprofessional learning and education: Mapping common outcomes for prequalifying healthcare professional programs in the United Kingdom

Abstract Introduction: Interprofessional education (IPE) continues to be a key component in prequalifying health professional education, with calls for regulators to publish a joint statement regarding IPE outcomes. To date, the regulatory documents for healthcare education in the United Kingdom have not been examined for common learning outcomes; information that could be used to inform such a statement and to identify opportunities for interprofessional learning. Methods: A mapping of the outcomes/standards required by five, UK, health profession regulatory bodies was undertaken. This involved the identification of common outcomes, a keyword search and classification of common outcomes/standards; presented as themes and subthemes. Results: Seven themes were identified: knowledge for practice, skills for practice, ethical approach, professionalism, continuing professional development (CPD), patient-centered approach and teamworking skills, representing 22 subthemes. Each subtheme links back to the outcomes/standards in the regulatory documents. Conclusions: This study identifies the key areas of overlap in outcomes/standards expected of selected healthcare graduates in the United Kingdom. The mapping provides a framework for informing prequalifying IPE curricula, for example, identifying possible foci for interprofessional education outcomes and associated learning opportunities. It allows reference back to the standards set by regulatory bodies, a requirement for all institutions involved in health profession education.

A case study investigation into the use of multi-compartment compliance aids in older people resident in very sheltered housing.

BackgroundMulti-compartment compliance aids (MCAs) are repackaging systems for solid dosage form medicines, heralded by some as a solution to non-adherence but with little evidence of benefit.ObjectiveThe aim was to use a theoretical approach to describe the behavioural determinants impacting the use of MCAs in older people from the perspectives of the individual and health and social care providers.DesignA case study investigation was conducted.SettingThe study took place in three very sheltered housing sites in North East Scotland.SubjectsTwenty residents (≥65 years) using an MCA for at least 6 months and 34 members of their care team [17 formal carers, eight general practitioners (GPs), eight pharmacists, one family member].MethodsSemi-structured, face-to-face interviews with items based on the Theoretical Domains Framework were conducted. Interviews were audio-recorded, transcribed and analysed thematically.ResultsSeveral behavioural determinants impacted the use of MCAs from the perspectives of the stakeholders involved. Goals of use related to promoting adherence and safety, with less emphasis on independence. Beliefs of consequences related to these goals and were considered of value, with additional consequences of concern around reduced awareness of medicines and complexities of changing medicines. There was a lack of clearly defined roles of professionals for all processes of MCA use, with evidence of blurring and gaps in roles. There were additional issues relating to capabilities of older people in using MCAs and capacity issues for pharmacy-supplied MCAs.ConclusionsSeveral behavioural determinants impacted the use of MCAs, and while MCAs were valued, there is a need to more clearly define, develop, implement and evaluate a model of care encompassing resident and medicines assessment, supply and ongoing review of MCAs.

Tele-pharmacy in rural Scotland: a proof of concept study

Technology enables medical services to be provided to rural communities. This proof of concept study assessed the feasibility and acceptability of delivering community pharmacy services (CPS; including advice, sale of over‐the‐counter products and dispensing of prescriptions) by tele‐technology (the Telepharmacy Robotic Supply Service (TPRSS)) to a rural population in Scotland.

A modified Delphi study of structures and processes related to medicines management for elderly hospitalised patients in the United Arab Emirates.

RATIONALE AND AIM The structures and processes around the management of medicines for elderly, hospitalized patients are ill defined. This study aimed to determine consensus related to strategic and operational approaches in the United Arab Emirates. METHODS A modified Delphi technique, consensus study with first round statements developed from systematic reviews related to medicines management. Normalization process theory and the theoretical domains framework were applied in the construction of statements, organized into key elements of medicines management: guidelines for medicines management, medicines reconciliation, medicines selection, prescribing and review, medicines adherence, medicines counselling, health professional training and evaluation research. Seventy per cent (summative agree and strongly agree) was set as the target for consensus. Thirty panellists were recruited, representing senior physicians working within geriatrics, hospital pharmacy and nursing directors, chief health professionals (including social workers) and policy makers within the Health Authority of Abu Dhabi and academics. RESULTS A high level of consensus was obtained for most statements relating to the structures and processes of medicines management. While consensus was not achieved for targeting only those patients with medicines related issues, it was achieved for focusing on all elderly admissions. Similarly, consensus was not achieved for which professions were most suited to roles but was achieved for trained and competent staff. CONCLUSIONS High levels of consensus were obtained for structures and processes of medicines management relating to elderly hospitalized patients. Trained and competent health professionals were preferred to specific professions for any tasks and that all elderly patients and not targeted patients should be the focus for medicines management.

Interprofessional, student-led intervention to improve insulin prescribing to patients in an Acute Surgical Receiving Unit

Our aim was to test the feasibility of interprofessional, workplace-based learning about improvement through a 4-week placement for one medical and two pharmacy final year students in an Acute Surgical Receiving Unit (ASRU). The target was insulin because this is a common, high-risk medicine in this ASRU and the intervention was medicines reconciliation. Baseline data were collected from 10 patients and used to construct a cause and effect diagram and a process map through feedback and discussions with staff. Hypoglycaemia occurred in four patients but hyperglycaemia occurred in eight patients, of whom six were placed on intravenous insulin infusion (IVII). We estimated that £2454 could be saved by preventing one patient from going on IVII. The students designed and tested a sticker to improve medicines reconciliation for insulin patients. An online form was created to capture clinician feedback on the layout and usability of the sticker. The intervention was associated with improvements in the reliability of medicines reconciliation. The students’ work contributed to a larger project to reduce the risk of hypoglycaemia in the ASRU. This proved beneficial in enabling the students to engage with the clinical team. Nonetheless, it was challenging for students from two Universities to get a shared understanding of improvement methods and work effectively with the clinical team. The students said that they learnt more about quality improvement in a working healthcare environment than they would ever learn in a classroom and they valued the opportunity to work with students from other healthcare backgrounds in practice. Despite the additional staff time required to support students from two Universities, both have supported continuation of this work.

Health professionals’ beliefs, attitudes and experiences of medication error reporting: a systematic review protocol

Review objective The objective of this review is to critically appraise, synthesize and present the available evidence on health professionals’ beliefs, attitudes and experiences of medication error reporting. Review questions More specifically, this review seeks to answer the following questions. In relation to health professionals (i.e. doctors, nurses and pharmacists): What are their beliefs and attitudes towards medication error reporting? What are their experiences of medication error reporting? (E.g. nature of feedback obtained, any subsequent changes in their practice, ease of use of the reporting system, any improvements required to optimize medication error reporting.) What are the reasons given or factors which are associated with under‐reporting of medication errors? (E.g. lack of awareness or understanding of the reporting system, fear of possible consequences of reporting, and forgetting to report.) Background Promoting patient safety through minimizing medication errors is a key global healthcare objective. The most widely used and accepted definition of the term “medication error” is that of the United States (US) National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), which defines “medication error” as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient or consumer”.1 The United Kingdom (UK) National Patient Safety Agency (NPSA) proposes a similar definition of “any incident where there has been an error in the process of prescribing, dispensing, preparing, administering, monitoring, or providing medicines advice, regardless of whether any harm occurred or was possible”.2 In a philosophical discussion on the construction of the term, Ferner and Aronson suggest a definition of “failures in the treatment process that lead to, or have the potential to lead to harm to the patient”.3(p.1013) All definitions emphasize harm and prevention. There is some overlap and often confusion between the terms “medication error” and “adverse drug reaction”. The UK Medicines and Healthcare Products Regulatory Agency (MHRA) defines an “adverse drug reaction” as “a harmful and unintended reaction that occurs at a dose normally used for the prophylaxis, diagnosis or treatment of disease or the modification of physiological functions”.4 Those adverse drug reactions which are deemed preventable are also considered to be medication errors.5 The National Coordinating Council for Medication Error Reporting and Prevention highlights that medication errors “may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”.1 It proposes a classification system of severity of error ranging from no error: circumstances or events that have the capacity to cause error, error no harm, error harm and error death.1 Most of the published literature on medication errors appears to relate to “prescribing errors”. Aronson and Ferner distinguish between “prescription” and “prescribing”. While “prescription” is the “act of writing the prescription”, “prescribing” relates more to associated cognitive decision‐making processes.6(p.602) Aronson later proposes a definition of “prescribing error” as a “failure in the prescribing process that leads to, or has the potential to lead to harm to the patient”.6(p.602) Whatever the classification of medication error, it is clear that these greatly impact patient care. Indeed, medication errors are common. According to a report published by the US Institute of Medicine in 2006, medication errors accounted for 1.5 million injuries annually at a cost of up to

Experiences of Supervision at Practice Placement Sites

1.35 billion in the form of lost productivity, wages and additional medical expenses.7 Data from the United Kingdom, collated and reported by the NPSA for the period from October 2010 to September 2011, illustrates that medication errors are the second most common cause of patient safety issues (following patient accidents) during hospital stay, contributing to 11% of all incidents, affecting 134,684 patients.8 Several recent systematic reviews have focused on prescribing errors. Lewis et al. reported the prevalence, incidence and nature of prescribing errors in hospital in‐patients.9 They reported that prescribing errors were common, affecting 7% of all medication orders, 2% of patient days and 50% of hospital admissions, from studies largely conducted in the US and UK. They also noted that reporting rates varied widely due to inconsistent and often absent study definitions in the term, “prescribing error”, and differences in study methodologies, specifically the research outcome measures. In the same year, Ross et al. reported on the scale of prescribing errors committed by junior doctors, reporting error rates of two to 514 per 1000 items prescribed and 4.2‐82% of patients or charts reviewed.10 Dornan et al. further reported primary data on prescribing errors in the hospital setting, highlighting that errors are often multi‐factorial, with several active failures and error‐provoking conditions (e.g. lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals) often acting together to cause them.11 More recently, similar findings were reported by Ross et al.,12 Ryan et al.,13 and Duncan et al.,14 as part of the Prescribing Outcomes for Trainee doctors Engaged in Clinical Training (PROTECT) study of prescribing errors committed by junior doctors in Scottish hospitals. The NCCMERP in the US and the NPSA in the UK have similar mission statements in terms of promoting safe medication use and increasing awareness of medication errors through communication, reporting and promotion of medication error prevention strategies.1,2 Indeed the vision of NCCMERP is that “no patient will be harmed by a medication error”.2 Cohen notes that while most health professionals are familiar with the “five rights” of safe medication use (right patient, drug, time, dose, route of administration), there is a gulf between theory and practice, which can lead to error.15 Both the NCCMERP and the NPSA place much of their focus on medication error reporting. Goals of NCCMERP include stimulating the “development and use of reporting and evaluation systems by individual health care organizations” and stimulating “reporting to a national system for review, analysis and development of recommendations to reduce and ultimately prevent medication errors”.1 Similarly, the NPSA describes “tools and guidance to help organizations improve their reporting levels”.2 These include: ensuring quality reports, engaging frontline staff and management, reporting regularly, reporting serious incidents quickly, making reporting matter and ensuring consistency. Adopting these tools and guidance into practice should increase reporting system efficiency with subsequent impact on the incidence, prevalence, nature and severity of medication errors, thus improving patient safety and care. While several systematic reviews have reported error prevalence and associated causes of errors, the authors did not describe the current quantitative or qualitative data regarding medication error reporting and impact factors relevant to the reporting systems. Furthermore, a preliminary search of the JBI Database of Systematic Reviews and Implementation Reports and the Cochrane Library has revealed that there is not currently a systematic review either published or underway on this topic. There is therefore a major gap in the literature in terms of the beliefs, attitudes and experiences of health professionals in relation to medication error reporting. For error reporting systems to operate efficiently and optimize their positive contribution to medication errors and thus patient safety, it is vital that all health professionals understand the reporting processes, that appropriate errors are reported and that feedback on reports at the individual practitioner and organizational level allow reflection of practice to further improve patient safety. The systematic review will focus on these aspects and synthesize the available literature on issues of beliefs, attitudes and experiences, with specific attention to issues around under‐reporting of medication errors by health professionals. At this stage, any studies, which focus on patient reporting of medication errors, will be excluded.