Allison Williams

Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study

Objectives To investigate patients’ and family members’ perceptions and experiences of disclosure of healthcare incidents and to derive principles of effective disclosure. Design Retrospective qualitative study based on 100 semi-structured, in depth interviews with patients and family members. Setting Nationwide multisite survey across Australia. Participants 39 patients and 80 family members who were involved in high severity healthcare incidents (leading to death, permanent disability, or long term harm) and incident disclosure. Recruitment was via national newspapers (43%), health services where the incidents occurred (28%), two internet marketing companies (27%), and consumer organisations (2%). Main outcome measures Participants’ recurrent experiences and concerns expressed in interviews. Results Most patients and family members felt that the health service incident disclosure rarely met their needs and expectations. They expected better preparation for incident disclosure, more shared dialogue about what went wrong, more follow-up support, input into when the time was ripe for closure, and more information about subsequent improvement in process. This analysis provided the basis for the formulation of a set of principles of effective incident disclosure. Conclusions Despite growing prominence of open disclosure, discussion about healthcare incidents still falls short of patient and family member expectations. Healthcare organisations and providers should strengthen their efforts to meet patients’ (and family members’) needs and expectations.

Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review

AIMnThis paper is a report of a literature review to identify research involving interventions to improve medication adherence in people with multiple co-existing chronic conditions. Title. Interventions to improve medication adherence in people with multiple chronic conditions: a systematic review. Background. The importance of managing co-existing, chronic conditions in people of all ages is critical to prevent adverse health outcomes.nnnDATA SOURCESnDatabases, including Cumulative Index of Nursing and Allied Health Literature, Medline, PubMed and Web of Science were searched for the period January 1997-2007 using the combined keywords adherence, compliance, drug therapy, medication, clinical trial, randomized controlled trial, intervention, chronic condition, chronic disease, multiple morbidity and comorbidity. References of retrieved papers were also considered.nnnMETHODSnThe inclusion criteria were: English language, oral medication adherence, self-administered medications, multiple prescribed medications for three or more chronic conditions and randomized controlled trials lasting at least 3 months.nnnRESULTSnStudies examining medication adherence in people with multiple chronic conditions targeted people over 70 years of age, and were primarily focused on the management of polypharmacy and reducing healthcare costs. Adherence was measured using different tools and estimates of adherence, and interventions were predominantly delivered by pharmacists. The evidence for effective interventions to enhance medication adherence in multiple chronic conditions was weak, and psychosocial interventions were absent.nnnCONCLUSIONnInterventions that improve medication adherence for people with multiple chronic conditions are essential, given the increased prevalence of these conditions in people of all ages. Outcomes of improved adherence, such as disease control and quality of life, require investigation. Psychosocial interventions engaging people in medication self-management offer potential for improved patient outcomes in complex diseases.

Eczema workshops reduce severity of childhood atopic eczema

An intervention study was conducted to assess the effectiveness of a nurse‐led eczema workshop in reducing the severity of atopic eczema in infants, children and adolescents. Ninety‐nine new patients referred to the Dermatology Department of The Royal Childrens Hospital in Melbourne, Australia, for the management of atopic eczema were randomized to receive care from an eczema workshop or a dermatologist‐led clinic. Patients were followed‐up 4u2003weeks after the intervention. The primary outcome was the severity of eczema as determined by scores obtained using the Scoring of Atopic Dermatitis (SCORAD) index at a 4‐week follow‐up visit. The secondary outcome was a comparison of treatments used in both clinics. At the 4‐week review the mean improvement in SCORAD was significantly greater in those patients attending the eczema workshop than those attending the dermatologist‐led clinic (−9.93, 95% confidence interval −14.57 to −5.29, Pu2003<u20030.001). Significantly more patients from the eczema workshop improved from moderate severity eczema at baseline to mild at review. There was greater adherence to eczema management in the eczema workshop compared with the dermatologist‐led clinic. In this study, patients attending the eczema workshop had a greater improvement in eczema severity thanpatients attending a dermatologist‐led clinic, supporting collaborative models of service provision.

Interventions to reduce medication errors in adult intensive care: a systematic review

Critically ill patients need life saving treatments and are often exposed to medications requiring careful titration. The aim of this paper was to review systematically the research literature on the efficacy of interventions in reducing medication errors in intensive care. A search was conducted of PubMed, CINAHL EMBASE, Journals@Ovid, International Pharmaceutical Abstract Series via Ovid, ScienceDirect, Scopus, Web of Science, PsycInfo and The Cochrane Collaboration from inception to October 2011. Research studies involving delivery of an intervention in intensive care for adult patients with the aim of reducing medication errors were examined. Eight types of interventions were identified: computerized physician order entry (CPOE), changes in work schedules (CWS), intravenous systems (IS), modes of education (ME), medication reconciliation (MR), pharmacist involvement (PI), protocols and guidelines (PG) and support systems for clinical decision making (SSCD). Sixteen out of the 24 studies showed reduced medication error rates. Four intervention types demonstrated reduced medication errors post-intervention: CWS, ME, MR and PG. It is not possible to promote any interventions as positive models for reducing medication errors. Insufficient research was undertaken with any particular type of intervention, and there were concerns regarding the level of evidence and quality of research. Most studies involved single arm, before and after designs without a comparative control group. Future researchers should address gaps identified in single faceted interventions and gather data on multi-faceted interventions using high quality research designs. The findings demonstrate implications for policy makers and clinicians in adopting resource intensive processes and technologies, which offer little evidence to support their efficacy.

Patients' and family members' experiences of open disclosure following adverse events

OBJECTIVEnTo explore patients and family members perceptions of Open Disclosure of adverse events that occurred during their health care.nnnDESIGNnWe interviewed 23 people involved in adverse events and incident disclosure using a semi-structured, open-ended guide. We analyzed transcripts using thematic discourse analysis.nnnSETTINGnFour States in Australia: New South Wales, Victoria, Queensland and South Australia.nnnSTUDY PARTICIPANTSnTwenty-three participants were recruited as part of an evaluation of the Australian Open Disclosure pilot commissioned by the Australian Commission on Safety and Quality in Health Care.nnnRESULTSnAll participants (except one) appreciated the opportunity to meet with staff and have the adverse event explained to them. Their accounts also reveal a number of concerns about how Open Disclosure is enacted: disclosure not occurring promptly or too informally; disclosure not being adequately followed up with tangible support or change in practice; staff not offering an apology, and disclosure not providing opportunities for consumers to meet with the staff originally involved in the adverse event.nnnANALYSISnof participants accounts suggests that a combination of formal Open Disclosure, a full apology, and an offer of tangible support has a higher chance of gaining consumer satisfaction than if one or more of these components is absent.nnnCONCLUSIONSnStaff need to become more attuned in their disclosure communication to the victim s perceptions and experience of adverse events, to offer an appropriate apology, to support victims long-term as well as short-term, and to consider using consumers insights into adverse events for the purpose of service improvement.

Adherence to multiple, prescribed medications in diabetic kidney disease: A qualitative study of consumers’ and health professionals’ perspectives

BACKGROUNDnIndividuals are adherent to approximately 50% of their prescribed medications, which decreases when multiple, chronic conditions are involved.nnnOBJECTIVEnTo examine factors affecting adherence to multiple prescribed medications for consumers with co-existing diabetes and chronic kidney disease (diabetic kidney disease) from the time of prescription to the time they took their medications.nnnDESIGNnA descriptive exploratory design was used incorporating in-depth interviews and focus groups.nnnSETTINGnThe diabetes and nephrology departments of two metropolitan, public hospitals in Melbourne, Australia.nnnPARTICIPANTSnA convenience sample of 23 consumers with diabetic kidney disease participated in an in-depth interview. Inclusion criteria involved English-speaking individuals, aged > or =18 years, with co-existing diabetes and chronic kidney disease, and who were mentally competent. Exclusion criteria included impending commencement on dialysis, pregnancy, an aggressive form of cancer, or a mental syndrome that was not stabilised with medication. Sixteen health professionals working in diabetes and nephrology departments in Melbourne, Australia also participated in one of two focus groups.nnnMETHODSnIn-depth structured interviews and focus groups were conducted and analysed according to a model of medication adherence.nnnRESULTSnConsumers were not convinced of the need, effectiveness and safety of all of their medications. Alternatively, health professionals focussed on the importance of consumers taking their medications as prescribed and believed that the risk of medication-related adverse effects was over-rated. Accessing prescribed medications and difficulties surrounding continuity of care contributed to consumers unintentional medication non-adherence. In particular, it was hard for consumers to persist taking their ongoing medication prescriptions. Healthcare system inadequacies were highlighted, which affected relationships between consumers with diabetic kidney disease and health professionals.nnnCONCLUSIONSnAcknowledging the barriers as perceived by consumers with diabetic kidney disease can facilitate effective communication and partnerships with health professionals necessary for medication adherence and medication safety.

Nurse‐led clinics reduce severity of childhood atopic eczema: a review of the literature

Backgroundu2002 The increasing prevalence and impact of atopic eczema in children in Western countries such as Australia substantiate the need to evaluate the current management of this illness. It has been well documented that the most important aspects in the management of atopic eczema are to allow adequate time for education and demonstration of treatments. However, current models of healthcare funding restrict the opportunity for patient education during medical consultation times. The contribution of nursing to patient care through nurse‐led clinics has significant potential in the management of many common chronic illnesses, although atopic eczema has received minimal attention by researchers to date.

A multifactorial intervention to improve blood pressure control in co-existing diabetes and kidney disease: a feasibility randomized controlled trial

AIMSnThe aim of this study was to test the feasibility and impact of an intervention consisting of self-monitored blood pressure, medicine review, a Digital Versatile Disc, and motivational interviewing telephone calls to help people with diabetes and kidney disease improve their blood pressure control and adherence to prescribed medications.nnnBACKGROUNDnPeople with co-existing diabetes, kidney disease and hypertension require multiple medications to manage their health. About 50% of people are non-adherent to their prescribed medications with non-adherence increasing in the presence of chronic conditions.nnnDESIGNnRandomized controlled trial.nnnMETHODSnPatients aged ≥18u2003years with diabetes, chronic kidney disease and systolic hypertension were recruited from nephrology and diabetes outpatients clinics of an Australian metropolitan hospital between 2008-2009. Participants were randomly allocated on a 1:1 basis to one of two groups in a randomized controlled trial: the intervention delivered over 3u2003months (nu2003=u200339) and usual care (nu2003=u200341), with follow-up at 3, 6 and 9u2003months postintervention. People collecting data and assessing outcomes were blinded to group assignment.nnnRESULTSnu2002 Seventy-five participants completed the study. The intervention was acceptable and feasible for this cohort. There were no statistically significant differences between groups, although the mean systolic blood pressure reduction in the intervention group (nu2003=u200336) was -6·9u2003mmHg 95% CI (-13·8, -0·02) at 9u2003months postintervention.nnnCONCLUSIONnThe study was feasible and statistically significant differences may be determinable in a larger sample to overcome the variability between groups, paying attention to recommendations for further research.nnnTRIAL REGISTRATIONnu2002 The trial was prospectively registered with the Australian and New Zealand Clinical Trials Register (ACTRN12607000044426).

Medication Adherence in People of Culturally and Linguistically Diverse Backgrounds: A Meta-Analysis

Background: Medication adherence is of particular importance (or people of culturally and linguistically diverse (CALD) backgrounds due to language difficulties, lack of social and organizational supports, lack of access to healthcare resources, and disengagement with the health-care system. Objective: To evaluate the impact of interventions to improve medication adherence in people of CALD backgrounds through a systematic review and meta-analysis. Methods: A search was performed using the following databases: Cochrane Database of Systematic Reviews, Cumulative Index to Nursing & Allied Health Literature, EMBASE, Journals@Ovid, PsychInfo, PubMed, Science Direct, Scopus, and Web of Science. Databases were searched from January 1978 to October 2009. Results: Forty-six articles reviewed were assessed as being relevant, which included 36 randomized controlled trials, 2 observational cohort studies, and 8 quasi-experimental studies. The most common method for assessing medication adherence was self-reporting measures, such as the Morisky Scale and its modifications. Few studies used combinations of adherence measures, and adherence involving a medication event monitoring system (MEMS) was used in only 6 studies. Individuals of CALD backgrounds were recruited with people of non-CALD backgrounds and subsequent analyses tended to be undertaken of the whole sample. Twenty studies showed statistically significant improvements in medication adherence, 15 of which were randomized controlled trials. Six of the successful interventions involved delivery by a bilingual person or the use of translated materials and 4 involved the use of a conceptual model. Metaanalyses demonstrated modest improvements in medication adherence. Conclusions: Relatively little high-quality work has been conducted on adherence-enhancing interventions for people of CALD backgrounds. Greater attention needs to be given to examining the needs of specific CALD population groups. Future researchers should consider rigorously testing interventions that take into account the enormous diversity and differences that exist within any particular CALD group.

Health care professionals’ views of implementing a policy of open disclosure of errors

Objectives: To understand the views of doctors, nurses, allied health professionals and health managers of open disclosure of medical errors. Methods: Semi-structured interviews were conducted with 131 health professionals to understand their experiences of implementing open disclosure in 21 providers in Australia. Results: Health professionals are positive about open disclosure and are applying the model to patient- clinician communication encounters more generally. Workforce and systems competencies enable clinicians and health service managers to implement open disclosure principles and practices, although a propensity to hide errors, wavering commitment and to exacerbate the problem inhibits implementation as policy intends. The gap between policy objectives and their implementation limits the benefits to health professionals. Conclusion: Health services must develop organizing capabilities if open disclosure is to be implemented as intended. Activities should identify and address factors that impede implementation and enable workforce and system competencies to develop. These activities will allow health services to adapt central open disclosure policy to local conditions and to embed its principles and practices organization-wide.