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

A pilot survey of junior doctors’ attitudes and awareness around medication review: time to change our educational approach?

© 2015, BMJ Publishing Group. All rights reserved.Objectives Our aim was to explore junior doctors attitudes and awareness around concepts related to medication review, in order to find ways to change the culture for reviewing, altering and stopping inappropriate or unnecessary medicines. Having already demonstrated the value of team working with senior doctors and pharmacists and the use of a medication review tool, we are now looking to engage first year clinicians and undergraduates in the process. Method An online survey about medication review was distributed among all 42 foundation year one (FY1) doctors at the Chelsea and Westminster Hospital NHS Foundation Trust in November 2014. Descriptive statistics were used for analysis. Results Twenty doctors completed the survey (48%). Of those, 17 believed that it was the pharmacists duty to review medicines; and 15 of 20 stated the general practitioner (GP). Sixteen of 20 stated that they would consult a senior doctor first before stopping medication. Eighteen of 20 considered the GP and consultant to be responsible for alterations, rather than themselves. Sixteen of 20 respondents were not aware of the availability of a medication review tool. Seventeen of 20 felt that more support from senior staff would help them become involved with medication review. Conclusions Junior doctors report feeling uncomfortable altering mediations without consulting a senior first. They appear to be building confidence with prescribing in their first year but not about the medication review process or questioning the drugs already prescribed. Consideration should be given to what we have termed a bottom-up educational approach to provide early experience of and change the culture around medication review, to include the education of undergraduate and foundation doctors and pharmacists

Parents’ Experiences of Communication in neonatal care (PEC): a neonatal survey refined for real-time parent feedback

Objective Assessing parent experiences of neonatal services can help improve quality of care; however, there is no formally evaluated UK instrument available to assess this prospectively. Our objective was to refine an existing retrospective survey for ‘real-time’ feedback. Methods Co-led by a parent representative, we recruited a convenience sample of parents of infants in a London tertiary neonatal unit. Our steering group selected questions from the existing retrospective 61-question Picker survey (2014), added and revised questions assessing communication and parent involvement. We established face validity, ensuring questions adequately captured the topic, conducted parent cognitive interviews to evaluate parental understanding of questions,and adapted the survey in three revision cycles. We evaluated survey performance. Results The revised Parents’ Experiences of Communication in Neonatal Care (PEC) survey contains 28 questions (10 new) focusing on communication and parent involvement. We cognitively interviewed six parents, and 67 parents completed 197 PEC surveys in the survey performance evaluation. Missing entries exceeded 5% for nine questions; we removed one and format-adjusted the rest as they had performed well during cognitive testing. There was strong inter-item correlation between two question pairs; however, all were retained as they individually assessed important concepts. Conclusion Revised from the original 61-question Picker survey, the 28-question PEC survey is the first UK instrument formally evaluated to assess parent experience while infants are still receiving neonatal care. Developed with parents, it focuses on communication and parent involvement, enabling continuous assessment and iterative improvement of family-centred interventions in neonatal care

Improving mental health outcomes: achieving equity through quality improvement

Objective. To investigate equity of patient outcomes in a psychological therapy service, following increased access achieved by a quality improvement (QI) initiative. Design. Retrospective service evaluation of health outcomes; data analysed by ANOVA, chi-squared and Statistical Process Control. Setting. A psychological therapy service in Westminster, London, UK. Participants. People living in the Borough of Westminster, London, attending the service (from either healthcare professional or self-referral) between February 2009 and May 2012. Intervention(s). Social marketing interventions were used to increase referrals, including the promotion of the service through local media and through existing social networks. Main Outcome Measure(s). (i) Severity of depression on entry using Patient Health Questionnaire-9 (PHQ9). (ii) Changes to severity of depression following treatment (ΔPHQ9). (iii) Changes in attainment of a meaningful improvement in condition assessed by a key performance indicator. Results. Patients from areas of high deprivation entered the service with more severe depression (M = 15.47, SD = 6.75), com-pared with patients from areas of low (M = 13.20, SD = 6.75) and medium (M = 14.44, SD = 6.64) deprivation. Patients in low

Mixed ice accretion on aircraft wings

Ice accretion is a problematic natural phenomenon that an effects a wide range of engineering applications including power cables, radio masts and wind turbines. Accretion on aircraft wings occurs when supercooled water droplets freeze instantaneously on impact to form rime ice or runback as water along the wing to form glaze ice. Most models to date have ignored the accretion of mixed ice, which is a combination of rime and glaze. A parameter we term the `freezing fraction', is defined as the fraction of a supercooled droplet that freezes on impact with the top surface of the accretion ice to explore the concept of mixed ice accretion. Additionally we consider different `packing densities' of rime ice, mimicking the different bulk rime densities observed in nature. Ice accretion is considered in four stages: rime, primary mixed, secondary mixed and glaze ice. Predictions match with existing models and experimental data in the limiting rime and glaze cases. The mixed ice formulation consequently however provides additional insight into the composition of the overall ice structure, which ultimately influences adhesion and ice thickness; and shows that for similar atmospheric parameter ranges, this simple mixed ice description leads to very different accretion rates. A simple one-dimensional energy balance was solved to show how this freezing fraction parameter increases with decrease in atmospheric temperature, with lower freezing fraction promoting glaze ice accretion

The Lantern Vol. 41, No. 2, Spring 1975

• Awakening • 10:27 • The Box • God\u27s Children • The Blasphemous Bean Beetle Levels Limpidland • First Flight • In April • Butterfly • In the Garden • The Emperor\u27s Pond • The Mob • Date with Destiny • While Awaiting Death • Sweet Jane • Final Thoughtshttps://digitalcommons.ursinus.edu/lantern/1106/thumbnail.jp

The Lantern Vol. 41, No. 1, Fall 1974

• The Fable • Landscape - Clear Weather in the Valley • Josephine Palooka • Don\u27t Bark Twice - It\u27s All Right • Masks • Suicide Note From a Lemming • The Death of Dame Sexton • Come September • Leaves • Spruce Grove • The Class of \u2775 • The Promise • Images • Sixth Station • Borealis • To Gemhttps://digitalcommons.ursinus.edu/lantern/1105/thumbnail.jp

The aesthetics of ritual--contested identities and conflicting performances in the Iraqi Shi’a diaspora: Ritual, performance and identity change

What are the processes through which identity change takes place at the individual and collective level? How might a focus on embodied religious performance and ritual contribute to understandings of such identity change? Through an ethnographic analysis of the Muharram rituals of Iraqi Shi’is in London, I take religious rites as a starting point from which to theorise a performative theory of identity change to highlight the role of ritual and performance in shaping changing notions of identity at both the individual and collective level. Such a project necessarily engages both with processes of identity change and with the paradox of identity/difference, particularly the ways in which articulations of subjective identity are ontologically dependent on an external ‘other’. Ultimately, I argue that paying close critical attention to the performative and (re)iterative processes of micro-level identificatory practices allows a more nuanced understanding of the mechanisms through which identity change comes to take effect, both at the level of individual subjectivity and that of collective social belonging

Quantifying the prevalence of frailty in English hospitals

OBJECTIVES: Population ageing has been associated with an increase in comorbid chronic disease, functional dependence, disability and associated higher health care costs. Frailty Syndromes have been proposed as a way to define this group within older persons. We explore whether frailty syndromes are a reliable methodology to quantify clinically significant frailty within hospital settings, and measure trends and geospatial variation using English secondary care data set Hospital Episode Statistics (HES). SETTING: National English Secondary Care Administrative Data HES. PARTICIPANTS: All 50 540 141 patient spells for patients over 65 years admitted to acute provider hospitals in England (January 2005—March 2013) within HES. PRIMARY AND SECONDARY OUTCOME MEASURES: We explore the prevalence of Frailty Syndromes as coded by International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-10) over time, and their geographic distribution across England. We examine national trends for admission spells, inpatient mortality and 30-day readmission. RESULTS: A rising trend of admission spells was noted from January 2005 to March 2013(daily average admissions for month rising from over 2000 to over 4000). The overall prevalence of coded frailty is increasing (64 559 spells in January 2005 to 150 085 spells by Jan 2013). The majority of patients had a single frailty syndrome coded (10.2% vs total burden of 13.9%). Cognitive impairment and falls (including significant fracture) are the most common frailty syndromes coded within HES. Geographic variation in frailty burden was in keeping with known distribution of prevalence of the English elderly population and location of National Health Service (NHS) acute provider sites. Overtime, in-hospital mortality has decreased (>65 years) whereas readmission rates have increased (esp.>85 years). CONCLUSIONS: This study provides a novel methodology to reliably quantify clinically significant frailty. Applications include evaluation of health service improvement over time, risk stratification and optimisation of services