Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.

BackgroundThe first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.MethodsMARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.DiscussionA mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation

Self-medication with over-the-counter analgesics : a survey of patient characteristics and concerns about pain medication

Pain is a common reason for self-medication with over-the-counter (OTC) analgesics. However, this self-treating population has remained largely uncharacterized. This cross-sectional observational study investigated individuals who self-medicate their pain with OTC analgesics to elucidate their pain characteristics and medication use. In addition, presence of and risk factors for concerns about pain medication were examined. The clinical profile of the participants (n = 1,889) was worse than expected with long-standing pain complaints (median pain duration of 9 years), pain located at multiple body sites (median of 4, and 13% with ≥10 painful body areas), about one-third suffering from daily pain and about 40% experiencing substantial pain-related disability. Head (58.6% of sample), low back (43.6%), and neck (30.7%) were the most common pain locations. About 73% had a physician diagnosis, mainly migraine and osteoarthritis. Paracetamol (used by 68.6% of patients) and nonsteroidal anti-inflammatory drugs (46.8%) were the most frequently used pain medications. About 40% of our sample showed substantial concern about the perceived need for pain medication and the perceived potential for harmful effects (eg, fear for addiction). These findings highlight the importance for health professionals to systematically probe pain patients about their self-medication practices and explore attitudes about pain medication. Perspective: This study found that the clinical picture of people who self-medicate their pain with OTC analgesics looked worse than expected. We also identified substantial concerns about pain medication. Therefore, we recommend that health professionals systematically probe pain patients about their self-medication practices and explore concerns about pain medication. © 2018 the American Pain Societ

Pediatric Nurses\u27 Perspectives on Medication Teaching in a Children\u27s Hospital

Purpose To explore inpatient pediatric nurses\u27 current experiences and perspectives on medication teaching. Design and Methods A descriptive qualitative study was conducted at a Midwest pediatric hospital. Using convenience sampling, 26 nurses participated in six focus groups. Data were analyzed in an iterative group coding process. Results Three themes emerged. 1) Medication teaching is an opportunity. 2) Medication teaching is challenging. Nurses experienced structural and process challenges to deliver medication teaching. Structural challenges included the physical hospital environment, electronic health record, and institutional discharge workflow while process challenges included knowledge, relationships and interactions with caregivers, and available resources. 3) Medication teaching is amenable to improvement. Conclusion Effective medication teaching with caregivers is critical to ensure safe, quality care for children after discharge. Nursing teaching practices have not changed, despite advances in technology and major changes in hospital care. Nurses face many challenges to conduct effective medication teaching. Improving current teaching practices is imperative in order to provide the best and safest care. Practice Implications This study generated knowledge regarding pediatric nurses\u27 teaching practices, values and beliefs that influence teaching, barriers, and ideas for how to improve medication teaching. Results will guide the development of targeted interventions to promote successful medication teaching practices

Analyzing Medication Documentation in Electronic Health Records: Dental Students’ Self-Reported Behaviors and Charting Practices

The aim of this two-part study was to assess third- and fourth-year dental students’ perceptions, self-reported behaviors, and actual charting practices regarding medication documentation in axiUm, the electronic health record (EHR) system. In part one of the study, in fall 2015, all 125 third- and 85 fourth-year dental students at one U.S. dental school were invited to complete a ten-item anonymous survey on medication history-taking. In part two of the study, the EHRs of 519 recent dental school patients were randomly chosen via axiUm query based on age >21 years and the presence of at least one documented medication. Documentation completeness was assessed per EHR and each medication based on proper medication name, classification, dose/frequency, indication, potential oral effects, and correct medication spelling. Consistency was evaluated by identifying the presence/absence of a medical reason for each medication. The survey response rate was 90.6% (N=187). In total, 64.5% of responding students reported that taking a complete medication history is important and useful in enhancing pharmacology knowledge; 90.4% perceived it helped improve their understanding of patients’ medical conditions. The fourth-year students were more likely than the third-year students to value the latter (p=0.0236). Overall, 48.6% reported reviewing patient medications with clinic faculty 76-100% of the time. The respondents’ most frequently cited perceived barriers to medication documentation were patients’ not knowing their medications (68.5%) and, to a much lesser degree, axiUm limitations (14%). Proper medication name was most often recorded (93.6%), and potential oral effects were recorded the least (3.0%). Medication/medical condition consistency was 70.6%. In this study, most of the students perceived patient medication documentation as important; however, many did not appreciate the importance of all elements of a complete medication history, and complete medication documentation was low

What You Need to Know about Bar-Code Medication Administration

Medication errors are the most common type of preventable error. Bar-code medication administration (BCMA) technology was designed to reduce medication administration errors. Poor system design, implementation and workarounds remain a cause of errors. This paper reviews the literature on BCMA, identifies a gap in the findings and identifies three evidence based practices that could be used to improve system implementation and reduce error. The literature review identified that Bar-code medication administration and system workarounds are well documented and affect patient safety. Based on the critical analysis of 10 studies, we identified gaps in the standardization of BCMA planning, implementation, and sustainability. The themes that emerged from the literature were poor BCMA design and implementation that resulted in workarounds.The three evidence based strategies proposed to address this gap are, evidence based standardization in planning and implementation, the identification and elimination of workarounds and hard wiring. An evidence based checklist evaluates compliance with standard procedures. The LEAN model of Jodoka is used to assure adaptation of the machine to human workflow. Direct observation provides valuable workflow assessment. An effective BCMA implementation involves careful system design, identification of workflow issues which cause workarounds, and adapting the machine to nursing needs

An evaluation of nursing documentation as it relates to pro re nata (prn) medication administration : a research report presented in partial fulfilment of the requirements for the degree of Master of Nursing in Mental Health at Massey University

Aims of the project: l. To investigate if documentation related to pro re nata (Latin, prn) medication administration by mental health nurses, in a particular Forensic Psychiatry Clinic, in a metropolitan city in New Zealand, complies with the requirements of the National Mental Health Sector Standards (Ministry of Health, 1997), the specific District Health Board's policies, the local policies of the Forensic Psychiatry Clinic, the Code of Conduct for Nurses and Midwives (Nursing Council of New Zealand, 1999) and follows the nursing process. 2. To investigate whether there are any variations in the documentation practices between nursing shifts. Methods: A retrospective file audit was conducted at a forensic psychiatry clinic in a city in New Zealand. Non-random sampling was used. Data was collected from all admissions in 2002 that had prn medication administered during the first four weeks. A document questionnaire was designed to capture the required data to answer the research questions Results: From the sample of 27 files data was collected from up to 170 nursing entries. This was primarily a descriptive and exploratory study. None of the nursing entries met all the requirements of the National Mental Health Sector Standards (Ministry of Health, 1997), company policies, local area policies and/or the Code of Conduct for Nurses and Midwives (Nursing Council of New Zealand, 1999) in relation to nursing documentation. Nearly 47% of the prn medication administered had no documentation, apart from that in the medication-recording chart, to indicate it had been given. Approximately 85% of prn administrations had no evidence of an assessment prior to administration. Where it was documented that a client had requested medication. nearly 82% had no evidence of assessment. A large number of prn medications were administered from prescriptions that did not meet legal or policy requirements. Evidence of planning was lacking in the documentation with nearly 98% of the notes not indicating the rationale for a choice of route of administration where this was permitted on the prescription. No nursing entry offered a rationale for the choice of dose where this was allowed. The name of the medication, dose, route and/or time administered was frequently missing. Of the prn administrations considered for an outcome, nearly 60% had no documented outcome. Little difference was found in the nursing documentation between the shifts. However it was noted that for day and aftenoon shift, the earlier in the shift the medication was administered the less likely there was to be any mention of the medication being administered. Conclusion: The findings established extremely poor documentation practices. The lack of evidence of patient assessment, prior to administration of the medication in the documentation, raises the issue of whether this is being done prior to prn medication administration or simply not being documented. The documentation left questions about decision making in the planning of administration. The large number of medication administrations lacking a documented outcome raises uncertainty about nurses' knowledge of evaluating care, or even whether they are actually evaluating the care given. As a result of these findings, it is recommended that further research in this area be undertaken in New Zealand

Supporting adherence to oral anticancer agents : clinical practice and clues to improve care provided by physicians, nurse practitioners, nurses and pharmacists

Background: Healthcare provider (HCP) activities and attitudes towards patients strongly influence medication adherence. The aim of this study was to assess current clinical practices to support patients in adhering to treatment with oral anticancer agents (OACA) and to explore clues to improve the management of medication adherence. Methods: A cross-sectional, observational study among HCPs in (haemato-) oncology settings in Belgium and the Netherlands was conducted in 2014 using a composite questionnaire. A total of 47 care activities were listed and categorised into eight domains. HCPs were also asked about their perceptions of adherence management on the items: insight into adherence, patients' communication, capability to influence, knowledge of consequences and insight into causes. Validated questionnaires were used to assess beliefs about medication (BMQ) and shared decision making (SDM-Q-doc). Results: In total, 208 HCPs (29% male) participated; 107 from 51 Dutch and 101 from 26 Belgian hospitals. Though a wide range of activities were reported, certain domains concerning medication adherence management received less attention. Activities related to patient knowledge and adverse event management were reported most frequently, whereas activities aimed at patient's self-efficacy and medication adherence during ongoing use were frequently missed. The care provided differed between professions and by country. Belgian physicians reported more activities than Dutch physicians, whereas Dutch nurses and pharmacists reported more activities than Belgian colleagues. The perceptions of medication adherence management were related to the level of care provided by HCPs. SDM and BMQ outcomes were not related to the care provided. Conclusions: Enhancing the awareness and perceptions of medication adherence management of HCPs is likely to have a positive effect on care quality. Care can be improved by addressing medication adherence more directly e. g., by questioning patients about (expected) barriers and discussing strategies to overcome them, by asking for missed doses and offering (electronic) reminders to support long-term medication adherence. A multidisciplinary approach is recommended in which the role of the pharmacist could be expanded

Reducing Medication Mismanagement in Adult Care Residences

Educational Objectives 1. Describe the prevalence of medication mismanagement in adult care facilities in Virginia. 2. Explain the significance of selected medication management errors. 3. Recommend practices to improve medication management task performance in adult care facilities

Understanding patients’ experiences of hayfever and its treatment: a survey of illness and medication cognitions

Background: Although effective medication for hayfever (seasonal allergic rhinitis) is available, treatment outcomes are often be poor. Patient beliefs influence outcomes in many other diseases. Assessing patients’ beliefs about their illness and medication may identify targets for intervention to optimize self management and lessen disease impact. Objective: The application of validated health-related analytical models (Leventhal’s illness representations and Horne’s beliefs about medications) to explore patients’ understanding and experience of hayfever and its treatment. Methods: Cross-sectional postal questionnaire sent to 20% sample of adults attending four General Practices in South England and prescribed medication for hayfever symptoms in the previous two years. Measures included the Revised Illness Perception Questionnaire and the Beliefs about Medicines Questionnaire. Results: 316/586 questionnaires were returned (54%). Cluster analysis identified two patient groups; those with negative beliefs (n=132) and those with more positive beliefs about hayfever and its treatment (n=182). Those with negative beliefs were more likely to believe that their hayfever would last for a long time, that they have little personal control over their illness and that their treatment is not effective. Conversely, they reported greater consequences, greater emotional impact, less understanding of hayfever and more medication concerns than those with more positive beliefs. Conclusions and clinical relevance: Patients with hayfever fall into two distinct groups: nearly half (41% of those sampled) have negative beliefs about their condition. Eliciting patient beliefs during the consultation may reveal assumptions that differ from those of healthcare professionals. Such beliefs should be considered when negotiating treatment plans

Older people's experiences of changed medication appearance : a survey

This report details a survey of older people's experiences of changed medication appearance. The aims of the study were: • To develop a questionnaire in partnership with older people to survey older people’s views on fluctuating medication appearance • To elicit older people’s experiences of medication that changed appearance due to ‘generic prescribing’ and ‘parallel import’ practices and its impact on their medication taking practices. These common pharmacy practices mean that the same tablet medication can be issued to older people in different colours, sizes and shapes to their previous prescriptions. Older people from a local User/Carer Forum highlighted these problems to the research team and asked that we investigate to explore the extent of the problem. An eight-item questionnaire was developed and distributed to 2000 older people (50 years+) across participating PCTs in Greater Manchester in 2008. A 29% response rate was achieved. The data was analysed using the SPSS statistical package. Findings include: •63.3% experienced a change in the appearance of their tablet medications. •74.1% did not seek advice regarding the change in the appearance of their tablet medications. •Older people noted changes to the actual tablets, tablet packaging and written information that accompanies tablets. Changes are occurring to the colour, size and shape of tablets more than changes to packaging and written information. The majority of respondents had experienced changes in the appearance of their prescribed tablet medication in the previous two years which were not due to change in medication or dose etc. Worryingly, for some respondents, these changes prompted negative experiences such as anxiety, confusion and upset. Of particular concern was that a small number omitted the affected tablet medications and did not seek help or advice from GPs, pharmacists or relatives. Six older people have been study advisors from inception to dissemination of this study and significantly added to its quality. The study demonstrates substantive public engagement / user involvement in research. The findings suggest nurses and others have a role to play in promoting better medicines management and identifying those most at risk from changed appearance of medications