Applying Quality Improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

© Published by the BMJ Publishing Group Limited.Objectives Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge. Setting An acute 400-bedded teaching hospital in London, UK. Participants The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18â €...months. Interventions Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives. Results Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems. Conclusions New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers

Formalising social representation to explain psychiatric symptoms

Recent work in social cognition has moved beyond a focus on how people process social rewards to examine how healthy people represent other agents and how this is altered in psychiatric disorders. However, formal modelling of social representation has not kept pace with these changes, impeding our understanding of how core aspects of social cognition function, and fail, in psychopathology. Here, we suggest that belief-based computational models provide a basis for an integrated sociocognitive approach to psychiatry, with the potential to address important but unexamined pathologies of social representation, such as maladaptive schemas and illusory social agents

Archaeoentomological Perspectives on Dorset Occupations in Newfoundland: A Case Study from the Site of Phillip’s Garden (EeBi-1)

The Dorset Paleo-Inuit occupied the island of Newfoundland for over 800 years (1990 BP to 1180 BP), producing a unique and identifiable archaeological record. Despite this, our current understanding of this sea-mammal hunting population is essentially based on past analysis of architecture, artefacts, and animal remains. While these data show that the Dorset intensively used sites at different locations through the Arctic and Subarctic, very little information is known regarding their impact on their surroundings and the environment. Our research is based on soil samples collected at the site of Phillip’s Garden, which is considered to be one of the most intensely occupied sites within the Dorset culture’s geographic range. Beetles, which are known to be ecological specialists, were used as a proxy in this research in order to document the composition and fluctuation in vegetation, and environmental change through time at the site. The analysis demonstrates that the Dorset communities of Phillip’s Garden harvested trees, and modified the environment and the flora surrounding their settlement more intensively than previously thought.Entre 1990 AA et 1180 AA, l’île de Terre-Neuve a connu une période d’occupation de plus de 800 ans par la culture dorsétienne. Cette occupation, documentée dans les données archéologiques, a laissé des traces uniques et visibles. Malgré cette richesse archéologique laissée par les Dorsétiens, notre compréhension de cette culture axée sur la chasse aux mammifères marins est principalement basée sur les données architecturales, artéfactuelles et zooarchéologiques. Ces données ont permis de démontrer que la culture dorsétienne a occupé de façon très intensive plusieurs sites localisés dans l’Arctique et le Subarctique. Cependant, peu d’informations sont fournies par ces données quant à l’impact de cette culture sur son environnement et ses lieux d’occupation. Les données utilisées au cours de notre recherche ont été récupérées dans des échantillons de sols ayant été prélevés sur le site de Phillip’s Garden, considéré comme l’un des sites les plus intensément occupés par la culture dorsétienne. En tant que spécialistes de leur niche écologique, les coléoptères ont été utilisés dans cette recherche afin de documenter la composition et les modifications visibles dans la végétation du site à travers le temps. Cette analyse permet de changer notre perception de l’étendue des modifications faites à la flore et à l’environnement par les Dorsétiens établis au site de Phillip’s Garden, modifications dues entre autres à l’exploitation des arbres

Delusions and belief formation: a cognitive neuropsychiatric approach

There is no accepted definition of belief and it is likely that the everyday use of the term does not represent a single neuropsychological entity. Nevertheless, cognitive neuropsychiatry is likely to be useful in understanding belief-related phenomena, as it does not necessarily require the focus of study to be a unitary construct. The label 'delusion' is likely to be an umbrella term for a variety of pathologies that lead a person to make an unlikely belief-claim or to have an unlikely belief attributed to them on the basis of their behaviour, in tandem with the person experiencing significant distress and / or causing social stress. Social network analyses and case studies suggested that the traditional psychopathological boundaries of delusion are influenced by socio-cultural developments and that the diagnostic criteria need revising. Despite the central role of anomalous perceptual experience in many delusion formation models, it is unclear whether it is a necessary condition. A new, valid measure of perceptual anomalies, the Cardiff Anomalous Perceptions Scale (CAPS), was developed, and a study of delusional patients suggested that pathological levels of anomalous experience are not necessary for delusion formation. A principal components analysis suggested three factors underlying anomalous experience in the general population: 'clinical psychosis', 'chemosensation' and 'temporal lobe experience'. A study using transcranial magnetic stimulation indicated that disrupting the left lateral temporal cortex in healthy participants can alter processes related to magical thinking, suggesting these areas play a causal role in delusion formation. To investigate the determinants of pragmatically pathological beliefs, as opposed to simply 'magical' ones, participants with religious beliefs (Christians and Pagans) were compared to non-religious controls and delusional patients. Pagans reported similar levels of anomalous experience to psychotic patients, but were no more distressed than the general population, suggesting distress is the more important factor in delusion formation

Neuropsychiatric Features of Fregoli Syndrome: An Individual Patient Meta-Analysis

OBJECTIVE: Fregoli syndrome is a rare delusion characterized by the belief that familiar people are presenting themselves disguised as others to the affected person. Theories of delusional misidentification have suggested secondary ("organic") underlying mechanisms; however, the pathoetiology of Fregoli syndrome has not been systematically evaluated. The investigators aimed to compare the neuropsychiatric features of Fregoli syndrome in primary and secondary psychoses. METHODS: A systematic review and patient-level meta-analysis were conducted. Five databases were searched, ultimately yielding 83 studies that met selection criteria. Demographic characteristics, diagnosis, delusional content, neuropsychiatric features, investigations, and treatment information were extracted. Random-effects models were calculated, and odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. RESULTS: A total of 119 patients with Fregoli syndrome were identified: 62 patients (52%) with primary psychosis, 50 (42%) with secondary psychosis, and seven (6%) with an unclear etiology. Patients with secondary psychosis were less likely than patients with primary psychosis to experience persecutory features (OR=0.26, 95% CI=0.10, 0.67; p=0.0057). Moreover, patients with secondary psychosis were more likely to experience Fregoli syndrome during a first episode of psychosis (OR=11.00, 95% CI=2.45, 49.39; p=0.0017). Right-sided brain lesions were more prominent than left-sided brain lesions in the total sample (χ2=5.0, df=1, p=0.025) and in the secondary psychosis subgroup (χ2=4.26, df=1, p=0.039). CONCLUSIONS: This is the first meta-analysis to investigate Fregoli syndrome. An estimated 42% of the reported cases involved a secondary etiology. These findings provide clinicians with a better understanding of the symptomatology of Fregoli syndrome and have potential to be applied in future research and clinical practice

Longitudinal associations between stroke and psychosis: a population-based study

BACKGROUND: The co-occurrence of stroke and psychosis is a serious neuropsychiatric condition but little is known about the course of this comorbidity. We aimed to estimate longitudinal associations between stroke and psychosis over 10 years. METHODS: A 10-year population-based study using data from the English Longitudinal Study of Ageing. A structured health assessment recorded (i) first-occurrence stroke and (ii) psychosis, at each wave. Each were considered exposures and outcomes in separate analyses. Logistic and Cox proportional hazards regression and Kaplan-Meier methods were used. Models were adjusted for demographic and health behaviour covariates, with missing covariates imputed using random forest multiple imputation. RESULTS: Of 19 808 participants, 24 reported both stroke and psychosis (median Wave 1 age 63, 71% female, 50% lowest quintile of net financial wealth) at any point during follow-up. By 10 years, the probability of an incident first stroke in participants with psychosis was 21.4% [95% confidence interval (CI) 12.1-29.6] compared to 8.3% (95% CI 7.8-8.8) in those without psychosis (absolute difference: 13.1%; 95% CI 20.8-4.3, log rank p < 0.001; fully-adjusted hazard ratio (HR): 3.57; 95% CI 2.18-5.84). The probability of reporting incident psychosis in participants with stroke was 2.3% (95% CI 1.4-3.2) compared to 0.9% (95% CI 0.7-1.1) in those without (absolute difference: 1.4%; 95% CI 0.7-2.1, log rank p < 0.001; fully-adjusted HR: 4.98; 95% CI 2.55-9.72). CONCLUSIONS: Stroke is an independent predictor of psychosis (and vice versa), after adjustment for potential confounders

Sleep disorders predict the 1-year onset, persistence, but not remission of psychotic experiences in preadolescence: a longitudinal analysis of the ABCD cohort data

The relationship between sleep disorder and psychotic experiences in preadolescence has not been extensively studied despite the potential for intervention. The current study addressed this relationship using the Adolescent Brain and Cognitive Development (ABCD) cohort, which provided baseline data from 11,830 10- to 11-year-old; for 4910 of these, 1-year follow-up data were also available. A set of pre-registered multi-level regression models were applied to test whether (a) sleep disorder is associated with psychotic experiences at baseline; (b) baseline sleep disorder predicts psychotic experiences at follow-up; (c) the persistence of sleep disorder predicts persistence of psychotic experiences at follow-up; d) the remission of sleep disorder predicts the remission of psychotic experiences at follow-up. After controlling for potential confounders, sleep disorder was associated with psychotic experiences cross-sectionally (OR = 1.40, 95% CI 1.20–1.63), at 1-year follow-up (OR = 1.32, 95% CI 1.11–1.57), and the persistence of sleep disorder predicted the persistence of psychotic experiences (OR = 1.72, 95% CI 1.44–2.04). However, remission of sleep problems did not predict remission of psychotic experiences (OR = 1.041, 95% CI 0.80–1.35). The results indicate that sleep disorders in preadolescence are common and associated with psychotic experiences, although the lack of co-remission raises questions about the mechanism of association. However, given these findings, and existing evidence in later adolescence and adults, further investigation of sleep as a preventative mental health intervention target in this age group is warranted

Association between stroke and psychosis across four nationally representative psychiatric epidemiological studies

BACKGROUND: Both stroke and psychosis are independently associated with high levels of disability. However, psychosis in the context of stroke has been under-researched. To date, there are no general population studies on their joint prevalence and association. AIMS: To estimate the joint prevalence of stroke and psychosis and their statistical association using nationally representative psychiatric epidemiology studies from two high-income countries (the UK and the USA) and two middle-income countries (Chile and Colombia) and, subsequently, in a combined-countries data-set. METHOD: Prevalences were calculated with 95% confidence intervals. Statistical associations between stroke and psychosis and between stroke and psychotic symptoms were tested using regression models. Overall estimates were calculated using an individual participant level meta-analysis on the combined-countries data-set. The analysis is available online as a computational notebook. RESULTS: The overall prevalence of probable psychosis in stroke was 3.81% (95% CI 2.34-5.82) and that of stroke in probable psychosis was 3.15% (95% CI 1.94-4.83). The odds ratio of the adjusted association between stroke and probable psychosis was 3.32 (95% CI 2.05-5.38). On the individual symptom level, paranoia, hallucinated voices and thought passivity delusion were associated with stroke in the unadjusted and adjusted analyses. CONCLUSIONS: Rates of association between psychosis and stroke suggest there is likely to be a high clinical need group who are under-researched and may be poorly served by existing services

Pediatric traumatic brain injury as a risk factor for psychosis and psychotic symptoms: a systematic review and meta-analysis

BACKGROUND: Psychosis is one of the most disabling psychiatric disorders. Pediatric traumatic brain injury (pTBI) has been cited as a developmental risk factor for psychosis, however this association has never been assessed meta-analytically. METHODS: A systematic review and meta-analysis of the association between pTBI and subsequent psychotic disorders/symptoms was performed. The study was pre-registered (CRD42022360772) adopting a random-effects model to estimate meta-analytic odds ratio (OR) and 95% confidence interval (CI) using the Paule–Mandel estimator. Subgroup (study location, study design, psychotic disorder v. subthreshold symptoms, assessment type, and adult v. adolescent onset) and meta-regression (quality of evidence) analyses were also performed. The robustness of findings was assessed through sensitivity analyses. The meta-analysis is available online as a computational notebook with an open dataset. RESULTS: We identified 10 relevant studies and eight were included in the meta-analysis. Based on a pooled sample size of 479686, the pooled OR for the association between pTBI and psychosis outcomes was 1.80 (95% CI 1.11–2.95). There were no subgroup effects and no outliers. Both psychotic disorder and subthreshold symptoms were associated with pTBI. The overall association remained robust after removal of low-quality studies, however the OR reduced to 1.43 (95% CI 1.04–1.98). A leave-one-out sensitivity analysis showed the association was robust to removal of all but one study which changed the estimate to marginally non-significant. CONCLUSIONS: We report cautious meta-analytic evidence for a positive association between pTBI and future psychosis. New evidence will be key in determining long-term reliability of this finding