Transition of care from adult intensive care settings - implementing interventions to improve medication safety and patient outcomes

Peer reviewe

How to make medication error reporting systems work : Factors associated with their successful development and implementation

This study explored factors associated with successful development and implementation of medication error reporting (MER) systems in different healthcare contexts. A descriptive online questionnaire comprising of structured and open-ended questions was responded to by 16 medication safety experts in 16 countries. The present paper describes the rich and multidimensional qualitative data from the experts’ narratives from open-ended questions. Several factors related to the national context of MER systems, i.e., the operational environment, were identified to impact successful development and implementation of these systems. The factors were: awareness of deficiencies in medication safety at local and national levels to justify the need for MER systems; gaining political will for the development and implementation actions together with international and governmental support; creating or reforming legislation and national regulations, guidelines and strategies to support MER; allocation of adequate human and financial resources; establishment of an organisation or centre to coordinate and lead MER; and extending systems approach and safety culture to all parts of the operational environment to facilitate openness on and learning from medication errors. In conclusion, operational environments of MER systems must be constructed to support functionality of these systems, and need to be improved in many countries.Peer reviewe

Developing an interprofessional people-centred care model for home-living older people with multimorbidities in a primary care health centre : A community-based study

Background: The ageing population with multiple conditions and complex health needs has forced healthcare systems to rethink the optimal way of delivering services. Instead of trying to manage numerous diseases in a siloed approach, the emphasis should be on people-centred practice, in which healthcare services are tailored to people's needs and provided in partnership with them. Objective: The aim was to develop an interprofessional people-centred care model (PCCM), including the contribution of a clinically trained pharmacist for home-living multimorbid older people in primary care. Methods: Participatory action research method, including the active involvement of healthcare professionals, was utilised to develop the PCCM in a public health centre in Finland. The data comprised interview transcripts, workshop materials, field notes, surveys, and memos and were analysed using inductive content analysis. Results: The PCCM was developed in iterative phases, including planning, acting, observing, and reflecting. The PCCM comprised: 1) A selfmanagement evaluation questionnaire sent before a home visit; 2) A person-centred patient interview at home with a named nurse and a pharmacist; 3) A nurse-led health review and a pharmacist-led clinical medication review; 4) An interprofessional (a GP, a pharmacist and a named nurse) case conference meeting; 5) A care plan, including health and medication plans; and 6) Health support and empowerment interventions. The PCCM shifted working practices in the health centre from parallel and consultative practice towards interprofessional peoplecentred practice and more holistic care. The patient's active involvement in their own care was encouraged. Healthcare professionals appreciated the advantages of the new skill-mix, including the clinically trained pharmacist. Building trust among healthcare professionals and between the professionals and the patients was essential. Conclusion: The successfully developed PCCM improved holistic and more people-centred care in primary care. Healthcare professionals appreciated the advantages of the skill mix and found that trust was essential for implementing the PCCM.Peer reviewe

Describing voluntarily reported fluid therapy incidents in the care of critically ill patients: Identifying, and learning from, points of risk at the national level

Background:Fluid therapy is a common intervention in critically ill patients. Fluid therapy errors may cause harm to patients. Thus, understanding of reported fluid therapy incidents is required in order to learn from them and develop protective measures, including utilizing expertise of pharmacists and technology to improve patient safety at the national level. Objectives:To describe fluid therapy incidents voluntarily reported in intensive care and high dependency units (ICUs) to a national incident reporting system, by investigating the error types,fluid products, consequences to patients and actions taken to alleviate them, and to identify at which phase of the medication process the incidents had occurred and had been detected. Methods:Medication related voluntarily reported incident (n= 7623) reports were obtained from all ICUs in2007–2017. Incidents concerning fluid therapy (n= 2201) were selected. The retrospective analysis utilized categorized data and narrative descriptions of the incidents. The results were expressed as frequencies and percentages. Results:Most voluntarily reported incidents had occurred during the dispensing/preparing phase(n= 1306, 59%) of the medication process: a point of risk. Most incidents (n= 1975, 90%) had reached the patient and passed through many phases in the medication process and nursing shift change checks before detection. One third of the errors (n=596,30%) were reported to have caused consequences to patients. One quarter (n= 492, 25%) of the errors were reported to have required an additional procedure to alleviate or monitor the consequences. Conclusions:Utilizing national incident report data enabled identifying systemic points of risk in the medication process and learning to improve patient safety. To prevent similar incidents, initial interventions should focus on the dispensing/preparing phase before implementing active medication identification procedures at each phase of the medication process and nursing shift changes. Strengthening clinical pharmacy services, utilizing technology, co-ordinated by IV Fluid Coordinators and Medication Safety Officers, could improve patient safety in the ICUs.Peer reviewe

Exploring the challenges for clinical pharmacists in Sudan

Background Clinical pharmacy practice in hospitals is a new role for pharmacists in Sudan. Pharmacists have to face the challenge of moving from their traditional roles within the pharmacy premises to new roles on the wards with direct contact with patients and other healthcare professionals. Objectives To explore the role and challenges facing the clinical pharmacists of Sudan. Settings Two of the main government hospitals in Sudan and an online survey. Method This study applied a two phase mixed method, a focus group discussion and a survey. A FGD was conducted with the clinical pharmacists in two of the main government hospitals in Sudan. This was followed by an on-line survey among the clinical pharmacists of Sudan. Main outcome measure The role of the clinical pharmacists of Sudan and the challenges facing clinical pharmacy practice. Results Four pharmacists participated in the focus group and 51 out of 140 pharmacists (34%) completed the on-line survey. The roles that were perceived by the majority of pharmacists as part of their duties in hospitals in Sudan were identifying drug-related problems (100%, n = 51), providing drug-related information to healthcare professionals by (96%, n = 47), and educating patients about their medicines (96%, n = 48). The pharmacists identified a number of obstacles that hindered their progress in practice. These obstacles were related to the pharmacists themselves, the lack of senior clinical pharmacists for leadership, the environment they were working in and the training they had received in clinical pharmacy. Conclusion The new clinical pharmacists in Sudan faced several challenges that need to be overcome in order to move forward in their clinical practice. To do so they will require support from pharmacy educational institutions, other healthcare professionals and the healthcare institutions they are working within.Peer reviewe

Reminding staff of diligence during the medication process is not enough to ensure safety : Learning from wrong fluid product selection incidents in the care of critically ill patients

Background and objectives: Wrong fluid product selection may cause harm to patients. This study aimed to describe voluntarily reported wrong fluid product selection incidents, including their consequences, the reported latent conditions and active failures leading to these and the suggested safeguards to prevent their occurrence, and to compare the suggested and literature-based safeguards to improve the fluid therapy safety within the intensive care (ICU) environment. Methods: All voluntarily and anonymously reported wrong fluid product selection incidents in all Finnish ICUs during 2007–2017 were reviewed. The incident reports included categorized data that were analyzed quantitatively, and narratives that were analyzed qualitatively, using content analysis. The results were reported as frequencies and percentages and described by using Reason's model of human error. Results: Over the eleven years, one wrong fluid product selection incident was reported every six days (n=663; 584 errors, 79 near misses); most were reported to have occurred during the dispensing/preparing phase (92%). Of the 584 reported selection errors, a quarter (26%) was reported to have caused consequences to patients, and one third (35%) to have required corrective or monitoring actions. The main reported latent conditions to the incidents were Working environment and resources (e.g. workload and time pressure) (29%), Similar-looking and -sounding names or shared features of the product containers (i.e. the LASA phenomenon) (28%) and Working methods (22%); and the main reported active failures were a lack of concentration, or forgetfulness (26%). Some usable suggestions of safeguards were made, e.g. optimizing fluid storage (15%) or utilizing checking practices (21%). While requiring accuracy, i.e. reminding staff of diligence and to be more attentive to detail during the whole medication process, was emphasized in most reports (71%), involving manufacturers in redesigning labels of fluid products, utilizing technology and strengthening pharmacy services are advocated existing literature. Conclusions: Wrong fluid product selection incidents with various latent conditions and active failures were reported more than once a week. To minimize the serious LASA phenomenon,multi-professional collaboration, coordinated international discussion and agreements of solutions with manufacturers, regulators and end-users, are needed. However, work is also needed to reduce the other latent factors, such as Working environment and resources as well as cognitive biases in daily work that may contribute to the occurrence of LASA related errors.Peer reviewe

Kliinisen farmasian palveluiden kohdentaminen sairaaloissa sähköisten potilaiden priorisointityökalujen avulla

English summary.Johdanto: Rajallisten resurssien takia kliinisen farmasian palveluita, joita voidaan hyödyntää sairaalapotilaiden lääkehoidon ongelmien vähentämiseksi, ei voida tarjota kaikille. Interventiot tulisi kohdentaa potilaille, joilla on suurin riski lääkehoidon ongelmille. Tämä voi lisätä kliinisen farmasian palveluiden vaikuttavuutta ja tehokkuutta. Tässä katsauksessa kuvataan ja verrataan erilaisia sähköisiä riskipisteytystyökaluja, joita voidaan käyttää kliinisen farmasian palveluiden kohdentamiseen niille potilaille, jotka niistä suurimmalla todennäköisyydellä hyötyvät. Aineisto ja menetelmät: Systemaattisen tietokantahaun (Pubmed ja Medline) ja manuaalisen haun avulla kerättiin vuodesta 2010 kesäkuuhun 2019 tutkimuksia, jotka liittyivät potilaiden priorisoimiseen käytettävien riskipisteytystyökalujen kehittämiseen. Narratiiviseen kirjallisuuskatsaukseen valittiin riskipisteytystyökaluja, jotka oli kehitetty lääkehoidon ongelmien riskin todennäköisyyden määrittämiseksi aikuisilla sairaalapotilailla kliinisen farmasian palveluiden kohdentamista varten. Tarkastelun ulkopuolelle jätettiin tutkimukset riskipisteytystyökaluista, jotka keskittyvät yksittäisiin sairauksiin tai lääkeaineryhmiin tai avohoidon tai lapsipotilaiden riskien ennustamiseen. Riskipisteytystyökaluja kuvailtiin ja vertailtiin toisiinsa. Tulokset ja johtopäätökset: Kirjallisuuskatsaukseen valikoitui yhdeksän eri riskipisteytystyökalua 13 eri tutkimuksessa, mukaan lukien kaksi aihetta käsittelevää systemaattista kirjallisuuskatsausta. Riskipisteytystyökalujen riskiä ennustavina muuttujina käytettiin yleisimmin lääkkeiden määrää, suuren riskin lääkkeitä ja potilasryhmiä, kuten monilääkittyjä ja monisairaita, sekä munaisten vajaatoiminnasta kärsiviä potilaita. Tutkimuksissa hyödynnettiin erilaisia lopputulemamääritelmiä ja tutkimusmenetelmiä, mikä vaikeutti työkalujen suoraa vertaamista toisiinsa. Riskipisteytystyökalun käyttäminen vaatii validoinnin ja toimintamallien suunnittelun siinä organisaatiossa, jossa se on tarkoitus ottaa käyttöön. Erityisesti ulkoisesti validoidut riskipisteytystyökalut, joita kuvattiin tässä katsauksessa, voisivat soveltua Suomessakin kliiniseen käyttöön. Riskipisteytystyökalut vaikuttavat olevan hyödyllisiä kliinisen farmasian palveluiden kohdentamisessa niille potilaille, jotka niistä eniten hyötyvät.Peer reviewe

The perceived development needs for medicines information services in university hospital pharmacies : A mixed methods study

Background: Reliable and evidence-based medicines information (MI) is critical for patient care. To guarantee this, in many countries, there are medicines information centers (MICs) which offer medicines information services (MISs). While there are no MICs in Finland, pharmacists in all five university hospital pharmacies provide MISs. A proposal for establishing five MICs has been made by the National Medicines Information Network. Objectives: The aim was to explore the current MISs and the perceptions of current and potential MI service providers of the need for the proposed national MICs. Barriers and facilitators for potential transition from the current MISs provided by the university hospital pharmacies to establishing national MICs, were examined. Methods: This sequential explanatory mixed methods study was conducted nationally during September 2019–April 2020 as an online survey and semi-structured individual, pair and group theme interviews with hospital representatives. The survey questionnaire was sent to chief pharmacists and MI pharmacists in all five Finnish university hospital pharmacies (n= 5, census). The interviews (n=13) were carried out with chief pharmacists, MI pharmacists, medication safety officers (pharmacists), chairs of the Medicines Advisory Board (physicians) and clinical pharmacologists (physicians) (participants n=19). The data was analyzed using descriptive quantitative analysis and qualitative content analysis. Results: All invited representatives participated in the study. Offered MISs are quite similar but the human resources vary among the organizations. Answering MI questions was one of the core MISs. Most representatives considered a proposal of establishing five MICs to Finland positively. The expected benefits were related to achieving an official status to enhance MI, establishing the MICs within the university hospitals and close to where the MISs are needed, and fostering multiprofessional collaboration and collaboration between the MICs. Limited financial and human resources were seen the most critical challenges. Conclusion: The existing expertise of the pharmacists and the similarities in MISs provided by the university hospital pharmacies seem to provide a good basis and preconditions for expanding MI operations and forming MICs at the national level. By pooling current limited resources, synergies could be achieved and MISs, and potentially MICs developed. The establishment of MICs may enhance utilization of networking and multiprofessional collaboration in producing MISs at the national level.Peer reviewe

The need for medication reconciliation: a cross-sectional observational study in adult patients

SummaryBackgroundPoor communication of drug therapy at care interface often results in medication errors and adverse drug events. Medication reconciliation has been introduced as a measure to improve continuity of patient care. The aim of this cross-sectional observational study was to evaluate the need for medication reconciliation.MethodsComprehensive information on pre-admission therapy was obtained by a research pharmacist for adult medical patients, admitted to a teaching hospital, specialised in pulmonary and allergic diseases, in Slovenia. This information was compared with the in-patient and discharge therapies to identify unintentional discrepancies (medication errors) whose clinical significance was determined by an expert panel reaching consensus.ResultsMost of the included 101 patients were elderly (median age: 73 years) who had multiple medications. Among their in-patient drugs (880), few discrepancies were a medication error (54/654), half of which were judged to be clinically important. A higher rate was observed in the discharge drug therapy (747): 369 of the identified discrepancies (566) were a medication error, over half of which were judged as clinically important. A greater number of pre-admission drugs, poorly taken medication histories and a greater number of medication errors in in-patient therapy predisposed patients to clinically important medication errors in discharge therapy.ConclusionsThis study provided evidence in a small sample of patients on the discontinuity of drug therapy at patient discharge in a hospital in Slovenia and its implications for patient care. To ensure continuity and safety of patient care, medication reconciliation should be implemented throughout a patient's hospital stay

Miksi hakea apteekkilupaa? : kyselytutkimus tuoreiden apteekkareiden työ- ja uratyytyväisyydestä

English summaryPeer reviewe