Susan Koch

Strategies to reduce medication errors with reference to older adults.

Background  In Australia, around 59% of the general population uses prescription medication with this number increasing to about 86% in those aged 65 and over and 83% of the population over 85 using two or more medications simultaneously. A recent report suggests that between 2% and 3% of all hospital admissions in Australia may be medication related with older Australians at higher risk because of higher levels of medicine intake and increased likelihood of being admitted to hospital. The most common medication errors encountered in hospitals in Australia are prescription/medication ordering errors, dispensing, administration and medication recording errors. Contributing factors to these errors have largely not been reported in the hospital environment. In the community, inappropriate drugs, prescribing errors, administration errors, and inappropriate dose errors are most common. Objectives  To present the best available evidence for strategies to prevent or reduce the incidence of medication errors associated with the prescribing, dispensing and administration of medicines in the older persons in the acute, subacute and residential care settings, with specific attention to persons aged 65 years and over. Search strategy  Bibliographic databases PubMed, Embase, Current contents, The Cochrane Library and others were searched from 1986 to present along with existing health technology websites. The reference lists of included studies and reviews were searched for any additional literature. Selection criteria  Systematic reviews, randomised controlled trials and other research methods such as non-randomised controlled trials, longitudinal studies, cohort or case-control studies, or descriptive studies that evaluate strategies to identify and manage medication incidents. Those people who are involved in the prescribing, dispensing or administering of medication to the older persons (aged 65 years and older) in the acute, subacute or residential care settings were included. Where these studies were limited, evidence available on the general patient population was used. Data collection and analysis  Study design and quality were tabulated and relative risks, odds ratios, mean differences and associated 95% confidence intervals were calculated from individual comparative studies containing count data where possible. All other data were presented in a narrative summary. Results  Strategies that have some evidence for reducing medication incidents are: •  computerised physician ordering entry systems combined with clinical decision support systems; •  individual medication supply systems when compared with other dispensing systems such as ward stock approaches; •  use of clinical pharmacists in the inpatient setting; •  checking of medication orders by two nurses before dispensing medication; •  a Medication Administration Review and Safety committee; and •  providing bedside glucose monitors and educating nurses on importance of timely insulin administration. In general, the evidence for the effectiveness of intervention strategies to reduce the incidence of medication errors is weak and high-quality controlled trials are needed in all areas of medication prescription and delivery.

Psychometric evaluation of the english language person-centered climate questionnaire--patient version

The aim of this study was to evaluate psychometric properties of a questionnaire measuring to what extent the climate of health care settings are perceived as being person-centered. The English Person-Centered Climate Questionnaire—Patient version (PCQ-P) was distributed to a sample of hospital patients (n = 108) and data were subjected to psychometric evaluation using statistical estimates of validity and reliability. Content and construct validity of the PCQ-P was satisfactory in literature reviews and factor and item analysis. Cronbachs alpha was satisfactory for the total scale (0.90) and also for sub-scales: safety = 0.96 and hospitality = 0.89. The intraclass correlation coefficient indicating test-retest reliability was 0.70 with a 95% confidence interval ranging between 0.63 and 0.77. Even though the sample should be considered, the results indicate that the PCQ is a valid and reliable contribution for assessing to what extent the climate of health care settings are perceived to be person-centered by patients.

Psychometric evaluation of the English language person-centred climate questionnaire : staff version

AIM The present study aimed to evaluate psychometric properties of the English language Person-centred Climate Questionnaire--staff version (PCQ-S). BACKGROUND Person-centred care emphasizes the individuals perspective in the care process. However, the concept is subject to some debate and few measurement tools exist. METHODS During 2 months in 2007, the Swedish PCQ-S was translated to English and distributed to a sample of Australian hospital staff (n = 52). Psychometric evaluation using statistical estimates of validity and reliability were performed. RESULTS The 14-item questionnaire showed high reliability as Cronbachs alpha was satisfactory for the total scale (0.89), and for the four subscales: 0.87, 0.79, 0.82 and 0.69. Test-retest reliability were evaluated in a subsample of 40 staff and resulted in P-values >0.05 between mean scores of the PCQ-S at test and retest, r-values between 0.6 and 0.9, and a two-way mixed effects model, single measures intra-class correlations of 0.75 with a confidence interval of 0.58-0.86. Validity of the scale needs further evaluation. CONCLUSIONS AND IMPLICATIONS FOR NURSING MANAGEMENT The English PCQ-S makes possible studies of associations between person-centredness and different organizational systems, environments, staff characteristics and health and managerial styles. However, scale validity needs further evaluation.

Ability of older people with dementia or cognitive impairment to manage medicine regimens: a narrative review

Impaired cognition has a significant impact on a person’s ability to manage their medicines. The aim of this paper is to provide a narrative review of contemporary literature on medicines management by people with dementia or cognitive impairment living in the community, methods for assessing their capacity to safely manage medicines, and strategies for supporting independent medicines management. Studies and reviews addressing medicines management by people with dementia or cognitive impairment published between 2003 and 2013 were identified via searches of Medline and other databases. The literature indicates that as cognitive impairment progresses, the ability to plan, organise, and execute medicine management tasks is impaired, leading to increased risk of unintentional non-adherence, medication errors, preventable medication-related hospital admissions and dependence on family carers or community nursing services to assist with medicines management. Impaired functional capacity may not be detected by health professionals in routine clinical encounters. Assessment of patients’ (or carers’) ability to safely manage medicines is not undertaken routinely, and when it is there is variability in the methods used. Self-report and informant report may be helpful, but can be unreliable or prone to bias. Measures of cognitive function are useful, but may lack sensitivity and specificity. Direct observation, using a structured, standardised performance-based tool, may help to determine whether a person is able to manage their medicines and identify barriers to adherence such as inability to open medicine packaging. A range of strategies have been used to support independent medicines management in people with cognitive impairment, but there is little high-quality research underpinning these strategies. Further studies are needed to develop and evaluate approaches to facilitate safe medicines management by older people with cognitive impairment and their carers.

Medication management: The perspectives of people with dementia and family carers:

The safe self management of medicines will be affected by the presence of dementia. A qualitative study using grounded theory was undertaken by a community nursing organisation in Melbourne, Australia, in order to develop a strength-based and person-centred approach to the assessment of medication ability. The perspectives of the person with dementia and their carers were explored to see if there were any significant differences in their medication management experiences when compared to those of older adults without dementia and their carers. People with dementia are able to sustain self management of their medicines using established routines and strategies. As cognitive changes affect short-term memory, external strategies and task allocation to family members are introduced by the individual to support their continuing independence. The family member assumed the carer role as their concern for medication safety increased, but this role engendered stress and a burden that was unacknowledged by the health professional.

Clinical practice guidelines for dementia in Australia

About 9% of Australians aged 65 years and over have a diagnosis of dementia. Clinical practice guidelines aim to enhance research translation by synthesising recent evidence for health and aged care professionals. New clinical practice guidelines and principles of care for people with dementia detail the optimal diagnosis and management in community, residential and hospital settings. The guidelines have been approved by the National Health and Medical Research Council. The guidelines emphasise timely diagnosis; living well with dementia and delaying functional decline; managing symptoms through training staff in how to provide person-centred care and using non-pharmacological approaches in the first instance; and training and supporting families and carers to provide care.

Contrasting perceptions of health professionals and older people in Australia: what constitutes elder abuse?

To explore the perceptions of family carers, older people and health professionals in Australia about what constitutes elder abuse.

CHALLENGES FOR AUSTRALIAN NURSING IN THE INTERNATIONAL YEAR OF OLDER PERSONS

Some of the major issues challenging gerontic nursing in Australia are addressed in this article. The broad context of change that has been introduced by successive Australian governments is presented briefly. The problems of attracting and keeping qualified nurses in aged care exacerbated by a trend toward employers actively seeking to replace qualified nurses with unregulated staff are discussed. Education and work practice changes are proposed as minimum responses required from nursing if the profession is to remain relevant and central to aged care into the 21st century.

Hospital Discharge: Recommendations for Performance Improvement for Family Carers of People with Dementia

UNLABELLED BACKGROUND; It is acknowledge that discharge planning benefits both consumers and hospitals. What is not widely understood is the experience that the family carer of a person with a dementia has and whether the hospitals meet their in-hospital and post-hospital needs. OBJECTIVE To explore whether metropolitan and rural hospital discharge practices meet the needs of the family carer of a person with dementia. RESULTS Although this and other research indicates that a continuum of care model is beneficial to family caregivers, no evidence has been identified that family carers currently experience this type of quality planning. Family carers were often unaware of the existence of a hospital discharge plan and were rarely engaged in communication about the care of their family member with a dementia or prepared for discharge. CONCLUSION AND RECOMMENDATIONS; Discharge planning processes for family carers of people with dementia could be substantially improved. It is recommended that hospitals develop policy, process and procedures that take into account the family carers needs, develop key performance indicators and adopt best practice standards that direct discharge planning activities and early engagement of the family carer in healthcare decisions. It is recommended that health professionals be educated on communication, consultation and needs of family carers.

Overcoming restraint use: examining barriers in Australian aged care facilities.

The purpose of this article is to discuss the outcomes of a project that sought to identify alternatives to restraint use in aged care facilities. (In Australia, the term aged care facility refers to those facilities previously known as hostels and nursing homes.) A literature review was conducted and discussion forums and individual interviews were held with interested stakeholders in Australian capital cities, as well as in a rural city in each state. Site visits were conducted at 16 aged care facilities. Participants identified legal concerns, existing organizational culture, and lack of alternatives as barriers to implementing restraint-minimization practices. Recommendations to facilitate minimal restraint are implementing national policy guidelines, adopting a best practice philosophy in relation to restraint minimization, continuing staff education related to alternatives, and maintaining constant communication with families.