Neil J. MacKinnon

Identifying, understanding and overcoming barriers to medication error reporting in hospitals: A focus group study

Objectives The under-reporting of medication errors can compromise patient safety. A qualitative study was conducted to enhance the understanding of barriers to medication error reporting in healthcare organisations. Methods Focus groups (with physicians, pharmacists and nurses) and in-depth interviews (with risk managers) were used to identify medication error reporting beliefs and practices at four community hospitals in Nova Scotia, Canada. Audio tapes were transcribed verbatim and analysed for thematic content using the template style of analysis. The development and analysis of this study were guided by Safety Culture Theory. Results Incentives for medication error reporting were thematised into three categories: patient protection, provider protection and professional compliance. Barriers to medication error reporting were thematised into five categories: reporter burden, professional identity, information gap, organisational factors and fear. Facilitators to encourage medication error reporting were classified into three categories: reducing reporter burden, closing the communication gap and educating for success. Participants indicated they would report medication errors more frequently if reporting were made easier, if they were adequately educated about reporting, and if they received timely feedback. Conclusions Study results may lead to a better understanding of the barriers to medication error reporting, why these barriers exist and what can be done to successfully overcome them. These results could be used by hospitals to encourage reporting of medication errors and ultimately make organisational changes leading to a reduction in the incidence of medication errors and an improvement in patient safety.

Development of a list of consensus-approved clinical indicators of preventable drug-related morbidity in older adults

BACKGROUND Older patients (aged >65 years) may experience drug-related problems that, if unrecognized, can result in drug-related morbidities (DRMs). According to the literature, 49% to 76% of all DRMs may be preventable; however, there is little consensus as to which are preventable and which are not. OBJECTIVE The aim of this study was to develop consensus-approved clinical indicators of preventable DRM (PDRM) in older adults. Geriatricians, clinical pharmacologists, general practitioners, and clinical pharmacists were included in the consensus-building process. METHODS In 2001, a survey containing potential indicators of PDRM was prepared based on previous research and the input of 2 clinical pharmacists. The survey was administered concurrently via the Delphi technique to 2 separate specialist panels (6 geriatricians and 6 clinical pharmacologists) to generate clinical indicators of PDRMs in older adults. Subsequently, a focus group of 12 general practitioners (GPs) assessed these PDRM indicators in Nova Scotia, Canada. RESULTS The specialist panels generated 58 consensus-approved clinical indicators of PDRMs in older adults after 2 rounds of the Delphi technique. The GPs agreed with 52 (90%) of these PDRM indicators. CONCLUSIONS This study generated consensus-approved indicators of PDRMs in older adults, which could be used by health professionals to identify patients at risk for PDRMs. The indicators could also have a role in quality measurement systems and in epidemiologic research. Furthermore, the indicators could complement existing clinical indicators and establish an important link between patterns of care and clinical outcomes.

Practice Change Challenges and Priorities: A National Survey of Practising Pharmacists

Background: Vision and action plans have been created to address the future of pharmacy and help pharmacists progress into expanded roles in order to provide more patient-centred care. To assess the thoughts and perceptions of pharmacists in these new roles, a survey was conducted among practising pharmacists in Canada. Methods: A Web-based survey, developed as part of the Canadian Pharmacists Associations Moving Forward initiative, was open to all practising pharmacists in September and October of 2007. This survey educated pharmacists on potential future roles and sought to gain feedback on the human resource challenges and priorities that might result from the proposed practice changes. Results: From the 1003 respondents, it was found that the majority of pharmacist time is spent on dispensing duties. However, over 60% of pharmacists felt that it was time to begin taking on new responsibilities and over 70% of pharmacists want to be performing expanded clinical duties within 5 years. Discussion: It is encouraging to see that most pharmacists are open to new expanded clinical roles in the near future. Despite the challenges identified, such as the need for additional training, increases in workload and stress and expected poor physician acceptance, it was felt that changes would result in improved patient health outcomes and better personal job satisfaction. Conclusion: Pharmacists have responded positively to the proposed vision for the future of pharmacy and are eager to move away from the traditional dispensing role to an expanded clinical role that more fully utilizes their unique skills and knowledge.

Medication-Related Emergency Department Visits and Hospital Admissions in Pediatric Patients: A Qualitative Systematic Review

OBJECTIVE To review and describe the current literature pertaining to the incidence, classification, severity, preventability, and impact of medication-related emergency department (ED) and hospital admissions in pediatric patients. STUDY DESIGN A systematic search of PubMED, Embase, and Web of Science was performed using the following terms: drug toxicity, adverse drug event, medication error, emergency department, ambulatory care, and outpatient clinic. Additional articles were identified by a manual search of cited references. English language, full-reports of pediatric (≤18 years) patients that required an ED visit or hospital admission secondary to an adverse drug event (ADE) were included. RESULTS We included 11 studies that reported medication-related ED visit or hospital admission in pediatric patients. Incidence of medication-related ED visits and hospital admissions ranged from 0.5%-3.3% and 0.16%-4.3%, respectively, of which 20.3%-66.7% were deemed preventable. Among ED visits, 5.1%-22.1% of patients were admitted to hospital, with a length of stay of 24-72 hours. The majority of ADEs were deemed moderate in severity. Types of ADEs included adverse drug reactions, allergic reactions, overdose, medication use with no indication, wrong drug prescribed, and patient not receiving a drug for an indication. Common causative agents included respiratory drugs, antimicrobials, central nervous system drugs, analgesics, hormones, cardiovascular drugs, and vaccines. CONCLUSION Medication-related ED visits and hospital admissions are common in pediatric patients, many of which are preventable. These ADEs result in significant healthcare utilization.

Development of Clinical Pharmacy Key Performance Indicators for Hospital Pharmacists Using a Modified Delphi Approach

Background: Key performance indicators (KPIs) are quantifiable measures of quality. There are no published, systematically derived clinical pharmacy KPIs (cpKPIs). Objective: A group of hospital pharmacists aimed to develop national cpKPIs to advance clinical pharmacy practice and improve patient care. Methods: A cpKPI working group established a cpKPI definition, 8 evidence-derived cpKPI critical activity areas, 26 candidate cpKPIs, and 11 cpKPI ideal attributes in addition to 1 overall consensus criterion. Twenty-six clinical pharmacists and hospital pharmacy leaders participated in an internet-based 3-round modified Delphi survey. Panelists rated 26 candidate cpKPIs using 11 cpKPI ideal attributes and 1 overall consensus criterion on a 9-point Likert scale. A meeting was facilitated between rounds 2 and 3 to debate the merits and wording of candidate cpKPIs. Consensus was reached if 75% or more of panelists assigned a score of 7 to 9 on the consensus criterion during the third Delphi round. Results: All panelists completed the 3 Delphi rounds, and 25/26 (96%) attended the meeting. Eight candidate cpKPIs met the consensus definition: (1) performing admission medication reconciliation (including best-possible medication history), (2) participating in interprofessional patient care rounds, (3) completing pharmaceutical care plans, (4) resolving drug therapy problems, (5) providing in-person disease and medication education to patients, (6) providing discharge patient medication education, (7) performing discharge medication reconciliation, and (8) providing bundled, proactive direct patient care activities. Conclusions: A Delphi panel of hospital pharmacists was successful in determining 8 consensus cpKPIs. Measurement and assessment of these cpKPIs will serve to advance clinical pharmacy practice and improve patient care.

Workplace Wellness Programs in Canada: An Exploration of Key Issues

Faced with the reality of rising health costs, Canadian employers are thinking beyond traditional notions of responsibility for employee health and have begun to embrace Workplace Wellness Programs (WWPs). This article investigates the critical issues of WWPs in the Canadian context from the perspective of key stakeholders. Using a combination of literature and key informant interviews, seven key themes are presented along with recommendations for wider implementation of WWPs in Canada.

Outcomes Assessment of a Pharmacist-Directed Seamless Care Program in an Ambulatory Oncology Clinic

The primary goal of seamless care is improved patient outcomes and improved standards of care for patients with cancer. The pharmacy service of the Newfoundland Cancer Treatment and Research Foundation conducted a randomized control study that measured clinical and humanistic outcomes of a pharmacist-directed seamless care program in an ambulatory oncology clinic. This article focuses on the intervention group, particularly the identification of drug-related problems (DRPs) and utilization of health care services as well the satisfaction of 3 types of health professionals with the services provided by the pharmacist-directed seamless care program. Overall, the seamless care pharmacist (SCP) identified an average of 3.7 DRPs per intervention patient; the most common DRP reported was a patient not receiving or taking a drug therapy for which there is an indication. The SCP identified more DRPs in patients receiving adjuvant treatment compared to those receiving palliative treatment. On average, family physicians, oncology nurses, and hospital pharmacists were satisfied with the SCP intervention indicating that they agreed the information collected and distributed by the SCP was useful to them. Pharmacist-directed seamless care services in an ambulatory oncology clinic have a significant impact on clinical outcomes and processes of patient care. The presence of a SCP can help identify and resolve DRPs experienced by patients in an outpatient oncology clinic, ensuring that patients are receiving the highest standard of care.

Challenges of standardized continuous quality improvement programs in community pharmacies: The case of SafetyNET-Rx

BACKGROUND Research on continuous quality improvement (CQI) in community pharmacies lags in comparison to service, manufacturing, and various health care sectors. As a result, very little is known about the challenges community pharmacies face when implementing CQI programs in general, let alone the challenges of implementing a standardized and technologically sophisticated one. OBJECTIVE This research identifies the initial challenges of implementing a standardized CQI program in community pharmacies and how such challenges were addressed by pharmacy staff. METHODS Through qualitative interviews, a multisite study of the SafetyNET-Rx CQI program involving community pharmacies in Nova Scotia, Canada, was performed to identify such challenges. Interviews were conducted with the CQI facilitator (ie, staff pharmacist or technician) in 55 community pharmacies that adopted the SafetyNET-Rx program. Of these 55 pharmacies, 25 were part of large national corporate chains, 22 were part of banner chains, and 8 were independent pharmacies. A total of 10 different corporate chains and banners were represented among the 55 pharmacies. Thematic content analysis using well-established coding procedures was used to explore the interview data and elicit the key challenges faced. RESULTS Six major challenges were identified, specifically finding time to report, having all pharmacy staff involved in quality-related event (QRE) reporting, reporting apprehensiveness, changing staff relationships, meeting to discuss QREs, and accepting the online technology. Challenges were addressed in a number of ways including developing a manual-online hybrid reporting system, managers paying staff to meet after hours, and pharmacy managers showing visible commitment to QRE reporting and learning. CONCLUSIONS This research identifies key challenges to implementing CQI programs in community pharmacies and also provides a starting point for future research relating to how the challenges of QRE reporting and learning in community pharmacies change over time.

The Medical Home in Canada: Patient Perceptions of Quality and Safety:

With evidence suggesting that primary health care can lead to increased quality and safety of health care, we examined the relationship between the presence of a medical home and the safety and quality of health care in Canada. Our results conclude that the presence of a medical home is associated with improved self-reported access to health care services, coordination of and confidence in services received, and provider knowledge and fewer medical errors.

Medication-Related Emergency Department Visits in Pediatrics: a Prospective Observational Study

BACKGROUND AND OBJECTIVE: There are few data on the rate and characterization of medication-related visits (MRVs) to the emergency department (ED) in pediatric patients. We sought to evaluate the frequency, severity, preventability, and classification of MRVs to the ED in pediatric patients. METHODS: We performed a prospective observational study of pediatric patients presenting to the ED over a 12-month period. A medication-related ED visit was identified by using pharmacist assessment, emergency physician assessment, and an independent adjudication committee. RESULTS: In this study, 2028 patients were enrolled (mean age, 6.1 ± 5.0 years; girls, 47.4%). An MRV was found in 163 patients (8.0%; 95% confidence interval [CI]: 7.0%–9.3%) of which 106 (65.0%; 95% CI: 57.2%–72.3%) were deemed preventable. Severity was classified as mild in 14 cases (8.6%; 95% CI: 4.8%–14.0%), moderate in 140 cases (85.9%; 95% CI: 79.6%–90.8%), and severe in 9 cases (5.5%; 95% CI: 2.6%–10.2%). The most common events were related to adverse drug reactions 26.4% (95% CI: 19.8%–33.8%), subtherapeutic dosage 19.0% (95% CI: 13.3%–25.9%), and nonadherence 17.2% (95% CI: 11.7%–23.9%). The probability of hospital admission was significantly higher among patients with an MRV compared with those without an MRV (odds ratio, 6.5; 95% CI: 4.3–9.6) and, if admitted, the median (interquartile range) length of stay was longer (3.0 [5.0] days vs 1.5 [2.5] days, P = .02). CONCLUSIONS: A medication-related cause was found in ∼1 of every 12 ED visits by pediatric patients, of which two-thirds were deemed preventable. Pediatric patients who present to the ED with an MRV are more likely to be admitted to hospital and when admitted have a longer length of stay.