Joseph E. Ibrahim

Resilience in healthcare and clinical handover

Background: Understanding and applying human factors in healthcare provides significant opportunities for improving patient safety. A key human factors concept is “resilience,” which investigates how individuals, teams and organisations monitor, adapt to and act on failures in high-risk situations. Although it is a new concept to healthcare, it is well accepted in other high-risk industries. Resilience moves the focus away from “What went wrong?” to “Why does it go right?”, that is, it moves from simplistic reactions to error making toward valuing a proactive focus on error recovery. Resilience is a better match for healthcare settings than the principles for high reliability because it more effectively addresses the unique complexities of healthcare. Objective: This article introduces the concept of resilience and how it applies to healthcare using clinical handover as an exemplar. Clinical handover and the risks it presents to patient safety are used to illustrate the key principles of resilience to healthcare professionals. The overall aim of this paper is to motivate research which focuses on understanding how frontline staff “fix” mistakes. Researching resilience in healthcare needs to focus on developing measurement, improvement and prediction tools. Conclusion: Resilience can benefit patient safety efforts because it represents a change in emphasis from a traditional, reactive focus on errors to seeing humans as a defence against failure. Translating this concept into practice requires identifying and testing mechanisms for measuring and building resilience within complex healthcare processes.

Improving measurement in clinical handover.

Background: Poor clinical handover creates discontinuities in care leading to patient harm. However, the field of handover research continues to lack standardised definitions and reliable measurement tools to identify factors that would lead to harm reduction and improved safety strategies. Objective: This paper introduces a conceptual framework to underpin a research agenda around the important patient safety topic of clinical handover. Methods: Five frameworks with potential application to clinical handover were identified in a consultation process with clinicians, researchers and policy makers. Results: The framework consists of three key handover elements—information, responsibility and/or accountability and system—in relation to three key measurement elements—policy, practice and evaluation. Using this framework an analysis of current “gaps” in the measurement of handover was completed. Conclusion: The paper argues that measurement will identify gaps in knowledge about handover practice and promote rigor in the design and evaluation of interventions to reduce patient harm.

The Significance of Subnormal Serum Vitamin B12 Concentration in Older People: A Case Control Study

OBJECTIVES: To determine the clinical significance of subnormal serum vitamin B12 concentration in older people by comparing the hematological, neurological, and biochemical findings in patients with subnormal serum B12 with a control group with normal B12 levels.

Reference-based pricing schemes: Effect on pharmaceutical expenditure, resource utilisation and health outcomes

Pharmaceutical expenditure is rising more rapidly than the general inflation rate in most advanced countries. One strategy that has been introduced to control pharmaceutical costs is reference-based pricing (RBP). Its potential is restricted to those specific segments of the drug market where several drugs (and/or their generic forms) exist without substantial evidence that any particular agent is superior.Three broad approaches have been adopted. These involve the aggregation of drugs into generic groups, related drug groups (e.g. ACE inhibitors) or drugs grouped by therapeutic indication (e.g. antihypertensives). For each drug group, a single reimbursement level or reference price is set. Drugs above the reference price require part or total payment by the patient.The experience with RBP ranges from over 10 years in Germany (involving all levels of RBP) to the more recent implementation of RBP for related drug groups in Australia. This review summarises the current state of knowledge on RBP from the published experiences in the countries where RBP has been adopted. The published systematic reviews of RBP from the countries that have implemented it suggest that RBP has been successful at temporarily capping drug prices for the RBP drug groups and achieving short term cost savings. However, other factors influencing total pharmaceutical expenditure have often occurred simultaneously and make it difficult to isolate specific effects of RBP. Further investigation is required before any valid conclusions can be drawn about the net effect of RBP on healthcare costs.RBP has withstood the initial legal challenges of pharmaceutical companies and the criticisms of some clinicians. Where the reference price is based on the lowest priced drug(s) in the group, RBP appears to be one of the few strategies likely to be effective at encouraging doctors to use the least expensive agents as first-line therapy and utilise more expensive agents in those who experience side effects or poor efficacy.

A Randomized Controlled Trial of a Multifactorial Falls Prevention Intervention for Older Fallers Presenting to Emergency Departments

OBJECTIVES: To investigate the effect of a referral‐based targeted multifactorial falls prevention intervention on the occurrence of recurrent falls and injuries in older people presenting to an emergency department (ED) after a fall and discharged directly home from the ED.

Development and validation of reporting guidelines for studies involving data linkage

Objective: Data or record linkage is commonly used to combine existing data sets for the purpose of creating more comprehensive information to conduct research. Linked data may create additional concerns about error if cases are not linked accurately. It is important that factors compromising the quality of studies using linked data be reported in a clear and consistent way that allows readers and researchers to accurately appraise the results. The aim of this study was to develop and test reporting guidelines for evaluating the methodological quality of studies using linked data.

A systematic review of medication non-adherence in persons with dementia or cognitive impairment

Background Adherence to medication is vital for disease management while simultaneously reducing healthcare expenditure. Older persons with cognitive impairment (CI) are at risk for non-adherence as cognitive processes are needed to manage medications. This systematic review focuses on the relationship between medication non-adherence and specific cognitive domains in persons with CI, and explores determinants of medication non-adherence. When available, relationships and factors are compared with cognitively intact populations. Methods A seven database systematic search of studies published between 1 January 1949–31 December 2015 examining medication non-adherence in community dwelling persons with CI or dementia was conducted. Articles reporting medication non-adherence in people with CI or dementia in the community, with or without caregiver supports were eligible for inclusion. Papers reporting adherence to treatments in cognitively intact populations, populations from hospital or institutional settings, for non-prescribed medication or those describing dementia as a factor predicting medication non-adherence were excluded. Data on study and population characteristics, research design, data sources and analysis, specific cognitive domains, non-adherence prevalence, measurement of adherence, salient findings, factors associated with adherence and strategies to improve medication adherence were extracted. Study limitations included inconsistencies between data sources and definitions, resulting in a loss of fidelity in the value and comprehensiveness of data, as well as exclusion of non-pharmacological treatments and regimens. Findings Fifteen studies met inclusion criteria. Adherence among CI subjects ranged from 10.7%-38% with better rates of adherence in non-CI individuals. Medication non-adherence definitions varied considerably. New-learning, memory and executive functioning were associated with improved adherence and formed the focus of most studies. Multiple factors were identified as modulators of non-adherence. Conclusion This review highlights a gap in knowledge on how specific cognitive domains contribute to medication non-adherence amongst CI populations, and demonstrates the current focus is limited to two domains: memory and executive functioning.

Resident-to-resident physical aggression leading to injury in nursing homes: a systematic review

BACKGROUND resident-to-resident aggression (RRA) is an understudied form of elder abuse in nursing homes. OBJECTIVE the purpose of this systematic review was to examine the published research on the frequency, nature, contributing factors and outcomes of RRA in nursing homes. METHODS in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research published in English, French, German, Italian or Spanish between 1st January 1949 and 31st December 2013 describing incidents of RRA in nursing homes. The following information was extracted for analysis: study and population characteristics; main findings (including prevalence, predisposing factors, triggers, nature of incidents, outcomes and interventions). RESULTS eighteen studies were identified, 12 quantitative and 6 qualitative. The frequency of RRA ranged from 1 to 122 incidents, with insufficient information across the studies to calculate prevalence. RRA commonly occurred between exhibitors with higher levels of cognitive awareness and physical functionality and a history of aggressive behaviours, and female targets who were cognitively impaired with a history of behavioural issues including wandering. RRA most commonly took place in the afternoon in communal settings, was often triggered by communication issues and invasion of space, or was unprovoked. Limited information exists on organisational factors contributing to RRA and the outcomes for targets of aggression. CONCLUSIONS we must continue to grow our knowledge base on the nature and circumstances of RRA to prevent harm to an increasing vulnerable population of nursing home residents and ensure a safe working environment for staff.

Nature and Extent of External-Cause Deaths of Nursing Home Residents in Victoria, Australia

To describe the nature and extent of external‐cause deaths of residents of nursing homes in Victoria, Australia.

Minimising harm from heatwaves: a survey of awareness, knowledge, and practices of health professionals and care providers in Victoria, Australia

ObjectivesHeatwaves cause illness and death, and are likely to become more severe and frequent in the future. This study has investigated the awareness, knowledge and practices of health professionals and care providers regarding heatwaves and health of older clients, in order to inform harm minimisation strategies for Victoria, Australia.MethodsAn electronic survey of personnel of six health profession and care provider groups that support the health of older people living in the community was conducted in Victoria, Australia, in 2008. Descriptive statistics were derived through quantitative analysis.ResultsSurvey respondents showed a high level of awareness that heatwaves can be harmful for older people. Gaps in knowledge were identified regarding thermoregulation, risk factors, heat-related illness, and the use of fans. Few organisations had existing heatwave response plans, and responses to heatwaves were mostly reactive and opportunistic.ConclusionsDespite a broad level of understanding of the dangers of heatwaves, an opportunistic, reactive approach by health profession and carer personnel, in conjunction with gaps in knowledge, leaves older people in Victoria at risk of preventable harm from extreme hot weather.