Maria Woloshynowych

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Case record review of adverse events: a new approach

Objectives: To redesign the existing clinical review form (RF2) used in previous retrospective case record review studies in order to clarify the review process and provide a more powerful analysis of adverse events; and then to ask clinicians to pilot and evaluate the new modular review form (MRF2). The review form is divided into five sections, each with a defined purpose, providing a modular structure. Design: Design and testing of the MRF2 on a sample of medical and nursing records, and evaluation of the reviewers’ responses regarding the new review form. Setting: Hospital based teams from eight countries. Results: The modular review form was reported to be comprehensive, well structured, and clear. Most of the reviewers agreed with the positive statements regarding the review form. Overall, the modular structure was thought to be helpful. Several modifications have been made to the final version to take account of criticisms and suggestions. Conclusions: The full potential of case record review has yet to be explored. The benefits of this review form include a modular format which enables reviewers or project leaders to select the focus of their review based on resources and the purpose of the review, and to identify contributory factors which indicate areas for improvement and prevention. The training of reviewers is of vital importance for record review. Record review remains one of the primary methods for assessing the incidence of adverse events and the new format is suitable for both prospective and retrospective review.

Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions

To compare four methods of detecting prescribing errors (PE) in the same patient cohorts before and after an intervention (computerised physician order entry; CPOE) and to determine whether the impact of CPOE is identified consistently by all methods.

Teams under pressure in the emergency department: an interview study

Objective To identify key stressors for emergency department (ED) staff, investigate positive and negative behaviours associated with working under pressure and consider interventions that may improve how the ED team functions. Methods This was a qualitative study involving semistructured interviews. Data were collected from staff working in the ED of a London teaching hospital. A purposive sampling method was employed to recruit staff from a variety of grades and included both doctors and nurses. Results 22 staff members took part in the study. The most frequently mentioned stressors included the ‘4-hour’ target, excess workload, staff shortages and lack of teamwork, both within the ED and with inpatient staff. Leadership and teamwork were found to be mediating factors between objective stress (eg, workload and staffing) and the subjective experience. Participants described the impact of high pressure on communication practices, departmental overview and the management of staff and patients. The study also revealed high levels of misunderstanding between senior and junior staff. Suggested interventions related to leadership and teamwork training, advertising staff breaks, efforts to help staff remain calm under pressure and addressing team motivation. Conclusions This study highlights the variety of stressors that ED staff are subject to and considers a number of cost-efficient interventions. Medical education needs to expand to include training in leadership and other ‘non-technical’ skills in addition to traditional clinical skills.

Identifying Nontechnical Skills Associated With Safety in the Emergency Department: A Scoping Review of the Literature

STUDY OBJECTIVE Understanding the nontechnical skills specifically applicable to the emergency department (ED) is essential to facilitate training and more broadly consider interventions to reduce error. The aim of this scoping review is to first identify and then explore in depth the nontechnical skills linked to safety in the ED. METHODS The review was conducted in 2 stages. In stage 1, online databases were searched for published empirical studies linking nontechnical skills to safety and performance in the ED. Articles were analyzed to identify key ED nontechnical skills. In stage 2, these key skills were used to generate additional key words, which enabled a second search of the literature to be undertaken and expand on the evidence available for review. RESULTS In stage 1, 11 articles were retrieved for data analysis and 9 core emergency medicine nontechnical skills were identified. These were communicating, managing workload, anticipating, situational awareness, supervising and providing feedback, leadership, maintaining standards, using assertiveness, and decisionmaking. In stage 2, a secondary search, using these 9 skills and related terms, uncovered a further 21 relevant articles. Therefore, 32 articles were used to describe the main nontechnical skills linked to safety in the ED. CONCLUSION This article highlights the challenges of reviewing a topic for which the terms are not clearly defined in the literature. A novel methodological approach is described that provides a structured and transparent process for reviewing the literature in emerging areas of interest. A series of literature reviews focusing on individual nontechnical skills will provide a clearer understanding of how the skills identified contribute to safety in the ED.

Reflective analysis of safety research in the hospital accident & emergency departments.

Providing health care in emergency settings is complex, hazardous work that is vulnerable to failure. Human factors and ergonomics studies of hazardous work in other settings have produced useful insights, innovations, and contributions to improving safety in those fields, so there is great interest in applying similar methods to the study of clinical work. However, the clinical environment presents some unique challenges to researchers. We discuss some of those challenges, based on our experience in conducting a variety of studies in the emergency setting in the US and UK, and offer suggestions for future work in this area.

‘The ABC of Handover’: impact on shift handover in the emergency department

Introduction A study was undertaken to test the impact of a new tool for shift handover, ‘The ABC of Handover’, in the emergency department (ED). The impact on shift handover following implementation of this structured tool, the effect on clinical and organisational aspects of the subsequent shift and the opinions of users of this new tool are reported. Methods A prospective observational before and after study was performed to explore the effect of implementing ‘The ABC of Handover’ on clinical and organisational practice using a questionnaire. Results 41 handovers were observed before implementation of ‘The ABC of Handover’ and 42 were observed after. The new tool was successfully implemented and resulted in a change of practice which led to a significant increase in the operational issues mentioned at handover from a mean of 34% to a mean of 86% of essential items with the ABC method. Over the study period, middle-grade staff demonstrated improved situational awareness as they adopted proactive management of operational issues such as staffing or equipment shortages. All participants reported that ‘The ABC of Handover’ improved handover regardless of the seniority of the doctor giving it, and found the ABC method easy to learn. Conclusions Successful implementation of ‘The ABC of Handover’ led to a change of practice in the ED. Improving handover resulted in better organisation of the shift and heightened awareness of potential patient safety issues. The ABC method provides a framework for organising the shift and preparing for events in the subsequent shift.

Work conditions, mental workload and patient care quality: a multisource study in the emergency department

Background Workflow interruptions, multitasking and workload demands are inherent to emergency departments (ED) work systems. Potential effects of ED providers’ work on care quality and patient safety have, however, been rarely addressed. We aimed to investigate the prevalence and associations of ED staffs workflow interruptions, multitasking and workload with patient care quality outcomes. Methods We applied a mixed-methods design in a two-step procedure. First, we conducted a time-motion study to observe the rate of interruptions and multitasking activities. Second, during 20-day shifts we assessed ED staffs reports on workflow interruptions, multitasking activities and mental workload. Additionally, we assessed two care quality indicators with standardised questionnaires: first, ED patients’ evaluations of perceived care quality; second, patient intrahospital transfers evaluated by ward staff. The study was conducted in a medium-sized community ED (16 600 annual visits). Results ED personnels workflow was disrupted on average 5.63 times per hour. 30% of time was spent on multitasking activities. During 20 observations days, data were gathered from 76 ED professionals, 239 patients and 205 patient transfers. After aggregating daywise data and controlling for staffing levels, prospective associations revealed significant negative associations between ED personnels mental workload and patients’ perceived quality of care. Conversely, workflow interruptions were positively associated with patient-related information on discharge and overall quality of transfer. Conclusions Our investigation indicated that ED staffs capability to cope with demanding work conditions was associated with patient care quality. Our findings contribute to an improved understanding of the complex effects of interruptions and multitasking in the ED environment for creating safe and efficient ED work and care systems.

Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study

Objective To identify patient safety factors in pre-hospital and hospital management of critically ill children dying in a paediatric intensive care unit (PICU). Design Retrospective case notes review. Setting Single tertiary regional PICU in London. Participants 47 patients (7%) who died from a total of 679 children admitted during 2007 and 2008. Median age was 1.1 years and median predicted mortality from the Paediatric Index of Mortality 2 score was 39%. Main outcome measures Adverse events contributing to death (AEds) and critical incidents (CIs). AEd was defined as an unintended injury or complication caused by health care management, contributing to death. CI was defined as an undesirable event in healthcare management, which could have led to harm or did lead to harm of the patient but did not contribute to the patients death. Results 22 AEds occurred in 17 of 47 (36%) cases. Two AEds occurred in primary care, 20 in pre-PICU hospital care, and none in PICU. AEds were mainly problems in diagnosis and management of critical illness. 37 CIs occurred in 28 of 47 (60%) cases. Two CIs occurred prior to hospital admission, 17 occurred in pre-PICU hospital care, 1 during inter-hospital transport and 17 in PICU. CIs were predominantly medical management and procedure related. Individual, team and organisational factors caused the majority of AEds and CIs. Conclusion Adverse events in pre-PICU hospital care were common in children who subsequently died in PICU. CIs occurred throughout the patient journey. Interventional studies of healthcare organisation and delivery are necessary to identify appropriate strategies to improve patient safety.