Sustaining organizational culture change in health systems

Purpose – The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues. Design/methodology/approach – The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts. Findings – Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement. Practical implications – The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application. Originality/value – This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.</p

Antimuscarinic toxicity secondary to moist towelettes containing glycopyrronium tosylate: a case report

AbstractGlycopyrronium is an antimuscarinic drug that is available in a moist towelette preparation for the treatment of primary axillary hyperhidrosis, which is characterized by excessive sweating on the palms, soles of feet, and axillary region. Antimuscarinic toxicity is uncommon with therapeutic use. A 25-year-old female presented to the emergency department with urinary retention and visual changes after initiating topical glycopyrronium tosylate therapeutically. She was tachycardic with a heart rate of 115 beats/min and required a Foley catheter for urinary retention of over 1200 mL. She received 1.5 mg physostigmine for antimuscarinic symptoms and her heart rate improved. Despite treatment, she required a Foley catheter for four days with eventual improvement. This case demonstrates side effects of an unusual preparation of glycopyrronium and the need to take a detailed topical medication history in patients with antimuscarinic symptoms

Theophylline Desorption From Activated Charcoal Caused By Whole Bowel Irrigation Solution1

Abstract Whole bowel irrigation with polyethylene glycol electrolyte lavage solution has been recommended as an adjunct to traditional overdose management. Although combined activated charcoal and whole bowel irrigation could enhance the efficacy of both modalities, this improvement remains largely speculative. An in vitro experiment was designed to determine whether polyethylene glycol electrolyte lavage solution alters the adsorption of theophylline to activated charcoal. Theophylline was agitated with activated charcoal in either water or polyethylene glycol electrolyte lavage solution, at each of three activated charcoal:theophylline ratios; 1:1, 3:1, and 10:1. The concentration in the supernatant was determined by high pressure liquid chromatography, and the maximal adsorptive capacity of activated charcoal for theophylline was calculated from the Langmuir equation. The percent of theophylline adsorbed by activated charcoal in water was 16 ± 4%, 67 ± 5%, and 97 ± 3% for the 1:1, 3:1, and 10:1 ratios, respectively. This was decreased to 17 ± 5%, 37 ± 3%, and 62 ± 2% when polyethylene glycol electrolyte lavage solution was added. A statistical difference (p < 0.05) occurred at the 3:1 and 10:1 activated charcoal: theophylline ratios. Similarly the maximal adsorptive capacity was decreased 23% from 264 mg/g to 203 mg/g when polyethylene glycol electrolyte lavage solution was added to activated charcoal prior to theophylline. Polyethylene glycol electrolyte lavage solution significantly decreases adsorption of theophylline to activated charcoal in vitro. In vivo studies are required to confirm these findings. If activated charcoal is to be used clinically for theophylline toxicity, the authors suggest the possibility of larger quantities of activated charcoal, and administering activated charcoal in a slurry of water before the initiation of whole bowel irrigation