Building engagement to support adoption of community-based substance use prevention initiatives.

BACKGROUND: System-level approaches that target social determinants of health are promising strategies to support substance use prevention, holistic youth development and wellbeing. Yet, the youth services system is largely based on individual-focused programs that do not adequately account for social determinants of health and place the responsibility for wellness on the individual. There is a need to understand how to enhance adoption of complex system-level approaches that support comprehensive youth development. The Icelandic Prevention Model (IPM) represents a collaborative initiative that takes an ecological, system-level approach to prevent substance use and promote wellness in youth. This research was designed to examine key stakeholder perceptions to better understand social motivations and contextual complexities that influence stakeholder support to garner community-level adoption of the IPM in a rural Canadian community. METHODS: This research applies a case study approach using qualitative interviews to explore strategies to support uptake in the early stages of IPM adoption associated with developing community buy-in and acceptance. A thematic analysis was applied using QSR NVivo. RESULTS: Nine interviews were conducted with community partners leading the implementation of the IPM. Three over-arching themes emerged from the data: 1) Motivating influences 2) Strategies to develop buy-in, and 3) Resistance to the adoption of the IPM. Findings reflect issues that affect behaviour change in system transformation in general as well as upstream prevention and the IPM, in particular. CONCLUSIONS: The findings from this research describe critical insight derived from implementing community-driven initiatives that are designed to support health promotion. It contributes new scientific knowledge related to implementation of complex system-level innovations and practical information that is useful for communities interested in implementing the IPM or following similar approaches to prevent substance use.

Derivation, Evaluation, and Validation of Illustrations of Key Counselling Points for a Pediatric Eczema Action Plan.

BACKGROUND: Current eczema action plans (EAP) are based on written instructions without illustrations. Incorporating validated illustrations into EAPs can significantly improve comprehension and usability. OBJECTIVE: To produce and validate a set of illustrations for key counselling points of a pediatric EAP. METHODS: Illustrations were developed using key graphic elements and refined by subject experts. Illustrations were evaluated during one-on-one structured interviews with parents/caregivers of children ages 9 and younger, as well as with children ages 10 to 17 years between September 2015 and June 2016. The concepts of transparency, translucency, and short-term recall were assessed for validation. RESULTS: Of 245 participants, 81.3% were parents and/or caregivers of children 0 to 9 years old, and 18.7% were children between 10 and 17 years old. A total of 15 illustrations and 2 storyboards were evaluated; 9 illustrations and 2 storyboards were redesigned to reach the preset validation targets. Overall, 13 illustrations and 2 storyboards were validated. CONCLUSION: A set of illustrations for use in an EAP was prospectively designed and validated, achieving acceptable transparency, translucency, and recall, with input from patients and a multidisciplinary medical team. The incorporation of validated illustrations into eczema action plans benefits patients with limited health literacy. Future studies should evaluate if illustrations improve understanding of eczema management and translate into improved clinical outcomes.

Usability, Satisfaction, and Usefulness of an Illustrated Eczema Action Plan.

BACKGROUND: An eczema action plan (EAP) is an individualized tool to help caregivers and patients self-manage eczema. While novel illustrated EAPs have been developed and validated, there is limited literature examining the value of EAPs from patient and caregiver perspectives. OBJECTIVES: The objective of this study was to test the usability, satisfaction, and usefulness of our validated EAP from the perspective of patients and caregivers. METHODS: Consecutive patients from the pediatric dermatology clinic of a tertiary children's hospital from July 2016 to July 2017 were offered enrolment in a prospective survey study; informed consent was obtained from participants. The illustrated EAP was explained to the participant by a trained research assistant. Participants were sent electronic postvisit surveys using Likert scale questions via REDCap on EAP usability and satisfaction (9 items) as well as on usefulness (3 items). RESULTS: Of 233 consecutive clinic patients, 192 participants (82%) were enrolled, and 112 (58%; 85 caregivers and 22 patients) completed the postvisit surveys. Characteristics were similar between responders and nonresponders. Overall, participants rated the usability (96%), satisfaction (85%), and usefulness (78%) of the EAP positively. Education level, experience with eczema, previous dermatology consultation, and participant type (caregiver vs patient) did not significantly affect the usability or usefulness ratings. However, caregivers' overall EAP ratings were significantly higher ( P = .02) than the patients'. CONCLUSION: The caregivers and participants demonstrate that the EAP is a useful and highly usable tool. Future research should examine the effectiveness of EAP use on objective atopic dermatitis outcomes using a pragmatic clinical trial design.

Instructions for masking the taste of medication for children: Validation of a pictogram tool.

BACKGROUND: Medications that taste unpleasant can be a struggle to administer to children, most often resulting in low adherence rates. Pictograms can be useful tools to improve adherence by conveying information to patients in a way that they will understand. METHODS: One-on-one structured interviews were conducted with parents/guardians and with children between the ages of 9 and 17 years at a pediatric hospital. The questionnaire evaluated the comprehension of 12 pictogram sets that described how to mask the taste of medications for children. Pictograms understood by >85% of participants were considered validated. Short-term recall was assessed by asking participants to recall the meaning of each pictogram set. RESULTS: There were 51 participants in the study-26 (51%) were children aged 9 to 17 years and 25 (49%) were parents or guardians. Most children (54%) had health literacy levels of grade 10 or higher. Most parents and guardians (92%) had at least a high school health literacy level. Six of the 12 pictogram sets (50%) were validated. Eleven of 12 pictogram sets (92%) had a median translucency score greater than 5. All 12 pictogram sets (100%) were correctly identified at short-term recall and were therefore validated. CONCLUSION: The addition of validated illustrations to pharmaceutical labels can be useful to instruct on how to mask the taste of medication in certain populations. Further studies are needed to assess the clinical impact of providing illustrated information to populations with low health literacy.

Evaluation, Modification, and Validation of Pictograms Depicting Medication Instructions in the Elderly.

Poor health literacy has been recognized as a limiting factor in the elderly's ability to comprehend written or verbal medication information and also to successfully adhere to medical regimens. The objective of this study was to validate a set of pictograms depicting medication instructions for use among the elderly to support health literacy. Elderly outpatients were recruited in 3 community pharmacies in Canada. One-on-one structured interviews were conducted to assess comprehension of 76 pictograms from the International Pharmaceutical Federation. Comprehension was assessed using transparency testing and pictogram translucency, or the degree to which the pictogram represents the intended message. A total of 135 participants were enrolled in this study, and 76 pictograms were assessed. A total of 50 pictograms achieved more than 67% comprehension. Pictograms depicting precautions and warnings against certain side effects were generally not well understood. Gender, age, and education level all had a significant impact on the interpretation scores of certain individual pictograms. When all pictograms were included, younger males had a significantly higher comprehension score than older females, and participants with a higher level of education provided significantly higher translucency scores. Even when pictograms reached the comprehension threshold set by the International Organization for Standardization in the general populations, only 50 of these pictograms achieved more than 67% comprehension among the elderly, confirming that validation in this subpopulation should be conducted prior to using specific pictograms. Accompanying pictograms with education about these pictograms and important counseling points remains extremely important.

Cannabis Use for Therapeutic Purposes by Children and Youth at a Tertiary Teaching Hospital in Canada: A Retrospective Chart Review.

BACKGROUND: The study of the use of cannabis for therapeutic purposes in the pediatric population is increasing, yet data on efficacy and safety are limited. Characterization of pediatric cannabis use for therapeutic purposes will improve understanding of the circumstances under which it occurs and the associated outcomes. OBJECTIVE: To describe the use of cannabis for therapeutic purposes, regardless of authorization, in a pediatric tertiary teaching hospital. METHODS: A retrospective chart review was completed for patients 18 years of age or younger who used cannabis for therapeutic purposes, regardless of authorization, between May 1, 2014, and May 1, 2017. Patients whose cannabis use was documented as recreational were excluded. RESULTS: In total, 300 patients were identified, of whom 37 met the inclusion criteria. Of these, 30 patients had documentation of medically supervised cannabis use. Most were using cannabis for seizures (n = 28), and many of these (n = 23) were patients with seizures described as intractable or refractory. Of the 27 patients who were experiencing seizures at initiation of medical cannabis, 21 had documentation of a decrease in seizure frequency. This decrease was transient for 16 patients, with a mean duration of 130.4 days (standard deviation 99.1 days). Seven patients self-medicated with cannabis. They obtained cannabis without authorization and used it for chronic pain (n = 5) and/or anxiety (n = 5). CONCLUSIONS: Medically supervised cannabis use occurred most often in patients with intractable or refractory seizures. According to these data, seizure response is variable, and initial decreases may be transient for pediatric patients using cannabis. To ensure greater consistency and rigour in the conduct of prospective research and thus to generate better-quality research on the therapeutic effects of medical cannabis, development of a standardized care record is needed.

CONTEXTE: Les études portant sur l'utilisation du cannabis à des fins thérapeutiques par les enfants augmentent, mais les données concernant l'efficacité et la sécurité de cette drogue sont limitées. La caractérisation de l'usage du cannabis à des fins thérapeutiques permettra de mieux comprendre les circonstances de l'utilisation de cette drogue ainsi que les effets qui lui sont associés. OBJECTIF: Décrire l'utilisation du cannabis à des fins thérapeutiques, qu'elle soit autorisée ou non, dans un hôpital d'enseignement de soins pédiatriques tertiaires. MÉTHODES: Un examen rétrospectif des dossiers a été mené auprès de patients d'âge égal ou inférieur à 18 ans, qui ont fait un usage autorisé ou non de cannabis à des fins thérapeutiques entre le 1er mai 2014 et le 1er mai 2017. Les patients qui utilisaient du cannabis à des fins récréatives ont été exclus de l'étude. RÉSULTATS: Au total 300 patients ont été identifiés et 37 d'entre eux répondaient au critère d'inclusion. La prise de cannabis sous supervision médicale de 30 d'entre eux était documentée. La plupart utilisaient le cannabis en cas de crise (n = 28) et bon nombre d'entre eux (n = 23) étaient des patients dont les crises étaient décrites comme insolubles ou réfractaires. Des 27 patients qui avaient des crises au début de la prise de cannabis médical, 21 ont enregistré une diminution de la fréquence des crises. Seize patients ont obtenu une diminution éphémère, qui a duré en moyenne 130,4 jours (écart type : 99,1 jours). Sept patients se soignaient eux-mêmes à l'aide de cannabis. Ils obtenaient du cannabis sans autorisation et l'utilisaient pour soulager des douleurs chroniques (n = 5) ou leur anxiété (n = 5). CONCLUSIONS: Les patients qui subissaient des crises incurables ou réfractaires utilisaient le plus souvent du cannabis sous supervision médicale. Selon ces données, la réponse aux crises est variable et les baisses initiales du nombre de crises pourraient être éphémères chez les enfants utilisant du cannabis. Il convient de préparer un dossier de soins normalisé pour mener des recherches prospectives plus cohérentes et rigoureuses et donc générer des recherches de meilleure qualité sur les effets thérapeutiques du cannabis médical.

The Canadian anaphylaxis action plan for kids: development and validation.

OBJECTIVES: We designed a written Canadian Anaphylaxis Action Plan for Kids (Kids' CAP) which incorporates validated pictograms with written instructions. Using a patient-centered approach, we aimed to validate the Kids' CAP and assess its impact on anaphylaxis recognition and treatment, and to determine its' perceived usefulness. PATIENT INVOLVEMENT: Children and their parents were involved in appraising the design and written contents of the Kids' CAP. METHODS: The design process consisted of a development phase and clinical validation phase. First, we assessed the readability and understandability of the Kids' CAP using validated instruments. Then, patients (12-17 years of age) and parents of patients (<12 years of age) were given the Kids' CAP during the first consultation with allergy specialists or an Emergency Department visit for anaphylaxis. Subsequently, we conducted a phone interview 2-3 weeks later to assess their comprehension of anaphylaxis management. We also used the Consumer Information Rating Form to measure the participants' perception of the design quality and usefulness of the Kids' CAP. RESULTS: Of the 230 participants enrolled, 205 (89%) completed the follow-up interview. The written contents of the Kid's CAP were modified to match grade 7 readability level. The total mean score of the Consumer Information Rating Form for comprehensibility was 23.1 (SD 2.4), and 25.1 (SD 2.3) for design quality. The mean comprehension score was 11.3 (SD 1.8) (reference range 0-12), with no significant difference between participants with and without previous experience with anaphylaxis, or high vs. low literacy level. CONCLUSION: Engaging children and parents in the design and contents of written anaphylaxis action plan is an innovative approach to produce a useful document for the end-users. PRACTICE IMPLICATIONS: The Kids' CAP is a valid tool that can be used in emergency departments and allergy clinics to improve patient's comprehension of anaphylaxis manifestations and treatment.

Defining and identifying concepts of medication reconciliation: An international pharmacy perspective.

BACKGROUND: Medication discrepancies occur in up to 80% of hospitalized patients during transitions of care, either at admission or discharge. However, numerous organization have different definitions of medication reconciliation which may result in variations of services being implemented. OBJECTIVE: To develop a consensus definition of medication reconciliation and define the essential components of medication reconciliation based on international consensus using a modified Delphi process. METHODS: Statements and definitions about medication reconciliation found in the literature were used to build a Delphi Questionnaire and sent to experts around the world. Experts were identified based on their leadership in publication, education, professional interest and participation in the area of medication management. Delphi rounds continued until an 80% agreement was achieved. RESULTS: In total, 24 experts were included in the Delphi panel. Three Delphi rounds were required to reach consensus on the key concepts included in a medication reconciliation. These concepts included 65 statements classified under (1) tasks involved, (2) who can conduct them, (3) when they should be conducted, (4) who should receive them, (5) how should it be measured and (6) clarifying the difference between medication reconciliation and medication review. This led to a proposed definition for medication reconciliation tasks as "the process of creating the most accurate list possible of all medications a patient is taking and comparing that list against the prescriber's orders. In addition, the patient's allergies, history of side effects from medications and medication aids are listed with the goal of providing correct medication to the patient at all transition points within the health care system." CONCLUSION: An international expert panel was able to receive consensus on the definition of tasks involved in medication reconciliation and its essential concepts after four Delphi rounds. This definition is broader in scope than previous definitions.

Recall of Pharmaceutical Pictograms by Older Adults.

BACKGROUND: Low health literacy and high medication burden in the older adult population are contributing factors to the misunderstanding of medication instructions, leading to an increased risk of poor adherence and adverse events in this group of patients. OBJECTIVE: To evaluate the ability of older adults to recall the meaning of 13 pharmaceutical pictograms 4 weeks after receipt of feedback on pictogram meaning. METHODS: Older adults (aged 65 or older) were recruited from one community pharmacy in Canada. One-on-one structured interviews were conducted to assess the comprehensibility of 13 pharmaceutical pictograms from the International Pharmaceutical Federation's database of pictograms. Each participant was then told the meaning of each pictogram. Recall was assessed 4 weeks later. RESULTS: A total of 58 participants met the inclusion criteria and agreed to participate. The number of pictograms meeting the ISO threshold for comprehensibility of symbols increased from 10 at the initial comprehensibility assessment to 13 at the recall assessment. Analysis of demographic data showed no associations between initial comprehensibility of the pictograms and age, sex, education level, or number of medications taken. CONCLUSIONS: The results of this study indicate that after being informed of the meaning of pharmaceutical pictograms, older adults were able to recall the pictogram meanings for at least 4 weeks.

CONTEXTE: Les faibles connaissances en matière de santé des personnes âgées et le lourd fardeau des médicaments qui pèse sur elles sont des facteurs qui contribuent à l'incompréhension des instructions relatives à l'administration des médicaments, ce qui entraîne un risque plus élevé de mauvaise adhésion au traitement et d'événements indésirables dans ce groupe de patients. OBJECTIF: Évaluer la capacité des adultes plus âgés à se souvenir du sens des 13 pictogrammes pharmaceutiques, quatre semaines après avoir été informés de leur sens. MÉTHODES: Les adultes plus âgés (65 ans et au-delà) ont été recrutés dans une pharmacie communautaire du Canada. Des entrevues structurées en tête-à-tête ont été menées pour évaluer l'intelligibilité de 13 pictogrammes pharmaceutiques extraits de la base de données de la Fédération internationale pharmaceutique. Le sens de chaque pictogramme a ensuite été communiqué à chaque participant et, quatre semaines plus tard, leur capacité à s'en souvenir a été évaluée. RÉSULTATS: Cinquante-huit participants répondaient au critère d'inclusion et ont accepté de participer à l'étude. Le nombre de pictogrammes répondant au seuil ISO d'intelligibilité des symboles est passé de 10 (au moment de l'évaluation d'intelligibilité initiale) à 13 (au moment de l'évaluation du rappel). L'analyse des données démographiques n'a indiqué aucune association entre l'intelligibilité initiale des pictogrammes et l'âge, le sexe, le niveau de formation ou le nombre de médicaments que prenaient ces personnes. CONCLUSIONS: Les résultats de cette étude indiquent qu'après avoir été informés du sens des pictogrammes pharmaceutiques, les aînés étaient en mesure de s'en souvenir pendant au moins quatre semaines.

Bilingual Text With or Without Pictograms Improves Elderly Singaporeans' Understanding of Prescription Medication Labels.

BACKGROUND AND OBJECTIVES: In Singapore, primarily English-language prescription medication labels challenge elderly Singaporeans, many of whom are unable to read English. We investigated whether bilingual text and pictograms can help them understand prescription medication labels. RESEARCH DESIGN AND METHODS: We randomized 1,414 elderly respondents of a national survey into four prescription medication labels: English-text; English-text-and-pictograms; Bilingual-text; and Bilingual-text-and-pictograms, which were similar except for the addition of another language and/or pictograms (International Pharmaceutical Federation, FIP). Respondents answered 16 label-related questions; an expert panel rated answers for correctness. Outcomes were (1) complete understanding (16 correct); (2) any understanding (≥1 correct); and (3) number of incorrect answers among those with any understanding. We evaluated associations of each prescription medication label (vs. English-text) with outcomes (1), (2), and (3) using logistic and negative binomial regression, respectively. RESULTS: The elderly respondents were similar across the four prescription medication labels (English-text, English-text-and-pictograms, Bilingual-text, Bilingual-text-and-pictograms), for which the proportions with outcomes (1) and (2) were (17.9%, 25.6%, 36.9%, 40.1%) and (50.4%, 62.6%, 75.9%, 76.5%), respectively. We observed statistically significant higher odds of outcomes (1) and (2) among those assigned the three labels (vs. English-text): English-text-and-pictograms, 1.96 and 2.51; Bilingual-text, 3.54 and 6.73; and Bilingual-text-and-pictograms, 4.51 and 7.93. Those assigned the three labels also had 0.94, 1.98, and 2.12 fewer outcome (3) on average (vs. English-text). DISCUSSION AND IMPLICATIONS: Adding bilingual text with or without pictograms on prescription medication labels considerably improved elderly Singaporeans' understanding of the labels, strongly suggesting its application in practice. Other issues in prescription medication labels design and content, including adapting FIP pictograms for elderly Singaporeans, warrant further investigation.

Validation of Pictograms for Safer Handling of Medications: Comprehension and Recall among Pharmacy Students.

BACKGROUND: Medication preparation and administration are higher-risk steps in the medication management process. Therefore, medication management strategies, such as warnings and education about medication safety, are essential in preventing errors and improving the safe handling of medications by health care workers. OBJECTIVES: To validate comprehension of 9 pictograms designed to improve medication safety, and to assess long-term recall of these pictograms in a sample of pharmacy students. METHODS: First- and second-year pharmacy students were recruited as participants. The study was divided into 2 phases: comprehension (Phase 1) and long-term recall (Phase 2). In Phase 1, a slideshow of the 9 pictograms was presented to participants, who were asked to write the meaning of and required action for each pictogram. The intended meaning of each pictogram was then presented to the participants. Four weeks later, long-term recall was assessed in Phase 2 of the study using the same method. The meaning and required action that participants provided for each pictogram were reviewed by 3 independent raters. A pictogram was considered to be validated in the pharmacy student population if at least 67% of participants identified the correct meaning or required action during the recall phase. RESULTS: A total of 101 pharmacy students participated in Phase 1 and 67 in Phase 2. In Phase 1, 4 pictograms met the 67% threshold for comprehension. In Phase 2, after training, 7 of the 9 pictograms were validated. CONCLUSIONS: Given the results obtained with pharmacy students, redesign may be necessary for 2 of the pictograms. The use of validated medication safety pictograms on medication labels and other identifiers may prevent errors during medication handling and administration; this is an important avenue of investigation for future studies.

CONTEXTE: La préparation et l'administration des médicaments sont des étapes à risque plus élevé dans le processus de gestion des médicaments. Or, les stratégies de gestion des médicaments, dont les mises en garde et les informations sur la sécurité des médicaments, sont essentielles à la prévention des erreurs et à une manipulation plus sécuritaire des médicaments par les travailleurs de la santé. OBJECTIFS: Valider la compréhension de neuf pictogrammes conçus pour accroître la sécurité des médicaments et vérifier si ces pictogrammes s'inscrivent dans la mémoire à long terme des étudiants en pharmacie. MÉTHODES: On a recruté des participants auprès des étudiants de première et de deuxième année en pharmacie. L'étude était composée de deux phases : compréhension (phase 1) et mémoire à long terme (phase 2). Dans la phase 1, un diaporama de neuf pictogrammes a été présenté aux participants à qui l'on a demandé d'interpréter chaque pictogramme et la mesure qu'il impose. On a ensuite présenté aux participants la signification qu'on voulait donner à chaque pictogramme. Quatre semaines plus tard durant la phase 2, un test de mémoire à long terme employant la méthode de la phase 1 a été effectué. Les réponses des participants quant à la signification et à la mesure à prendre pour chaque pictogramme ont été analysées par trois évaluateurs indépendants. Un pictogramme était considéré comme validé dans la population des étudiants en pharmacie si un minimum de 67 % des participants se souvenait de la signification adéquate et de la mesure à prendre recherchée pendant la phase de test de mémoire à long terme. RÉSULTATS: Au total, 101 étudiants en pharmacie ont participé à la phase 1 et 67 à la phase 2. Dans la phase 1, quatre pictogrammes ont atteint le seuil de 67 % pour la compréhension. Dans la phase 2, après une formation, 7 pictogrammes sur 9 ont été validés. CONCLUSIONS: Compte tenu des résultats obtenus auprès des étudiants en pharmacie, deux des pictogrammes pourraient être appelés à retourner à la planche à dessin. L'ajout de pictogrammes validés de sécurité des médicaments sur les étiquettes et autres marques d'identification de médicaments pourrait éviter des erreurs pendant la manipulation et l'administration de médicaments. Il s'agit là d'une piste de recherche importante pour de futures études.

Development of Pictograms to Enhance Medication Safety Practices of Health Care Workers and International Preferences.

BACKGROUND: A panel of medication management experts previously identified 9 key medication safety issues and high-alert drug classes as representing the most pressing medication-handling issues in health care. OBJECTIVE: To develop medication safety pictograms depicting medication safety issues and high-alert drug classes that represent medication-handling risks for health care personnel. METHODS: An iterative design process, including activities such as semiotic analysis, design/redesign, and evaluation, was used to develop medication safety pictograms. Nurses, physicians, pharmacists, and students listed and drew graphic elements to depict each of the 9 key medication safety issues. Graduate students in graphic design developed the preliminary pictograms for the study. A Delphi survey was then conducted with experts recruited from the International Pharmaceutical Federation to reach consensus on the pictograms and provide feedback to the graphic designers. Health care providers from around the world were invited to participate in a survey to determine a preferred pictogram for each safety warning. RESULTS: For each medication safety issue, 3 to 5 pictograms were developed on the basis of graphic elements suggested by 52 health care providers. These pictograms were then presented to 58 experts in 2 rounds of a Delphi process. For each medication safety issue, consensus on the 2 best pictograms was reached and feedback provided. A total of 799 participants from 61 countries responded to the international preference survey. Most of the participants (n = 536, 67.1%) were Canadian, and of those, 385 (71.8%) were pharmacists. In 8 categories, consensus on the preferred pictogram was reached across the health care professions; however, a difference in preference was apparent for the pictogram representing "neuromuscular blocking agent", with nurses' preferred pictogram differing from the preference of other participants. CONCLUSION: This project produced pictograms to illustrate 9 important medication safety issues, which can now be validated through comprehension and recall assessments. Further study can also determine their potential to reduce medication administration errors.

CONTEXTE: Un groupe d'experts en gestion des médicaments avait auparavant établi neuf principales questions de sécurité des médicaments ou classes de médicaments de niveau d'alerte élevé qui méritaient l'attention la plus urgente en santé du point de vue de la manipulation des médicaments. OBJECTIF: Concevoir des pictogrammes de sécurité des médicaments qui illustrent adéquatement les questions de sécurité des médicaments et les classes de médicaments de niveau d'alerte élevé représentant des risques pour le personnel en santé lors de la manipulation des médicaments. MÉTHODES: Un processus de conception itératif (comprenant des activités comme l'analyse sémiotique, la conception et la rectification, et l'évaluation) a été employé pour créer des pictogrammes de sécurité des médicaments. Du personnel infirmier, des médecins, des pharmaciens et des étudiants ont dressé une liste d'éléments graphiques qu'ils ont dessinés afin d'illustrer chacune des neuf principales questions de sécurité des médicaments. Des étudiants diplômés en graphisme ont conçu les ébauches de pictogrammes destinées à l'étude. Un sondage Delphi a ensuite été mené auprès d'experts recrutés au sein de la Fédération internationale pharmaceutique afin de dégager un consensus quant aux pictogrammes et de fournir des commentaires constructifs aux graphistes. Des fournisseurs de soins de santé de partout dans le monde ont été invités à répondre à un sondage pour déterminer quel pictogramme privilégier pour chacune des mises en garde. RÉSULTATS: Pour chaque question de sécurité des médicaments, entre trois et cinq pictogrammes ont été conçus à partir d'éléments graphiques proposés par 52 fournisseurs de soins de santé. Ces pictogrammes ont ensuite été présentés à 58 experts au cours d'un processus Delphi à deux phases. Pour chacune des questions de sécurité des médicaments, un consensus sur les deux meilleurs pictogrammes a été atteint et des commentaires constructifs ont été émis. Au total, 799 participants de 61 pays ont répondu au sondage international sur leurs préférences. La majorité des participants (n = 536, 67,1 %) étaient Canadiens et parmi eux, 385 (71,8 %) étaient pharmaciens. Dans huit catégories, l'ensemble des professions ont atteint un consensus quant au pictogramme à privilégier. Cela n'a pas été le cas pour le pictogramme représentant les « bloqueurs neuromusculaires ¼, car le personnel infirmier a privilégié un pictogramme différent de celui préféré par les autres professions participantes. CONCLUSIONS: Ce projet a produit des pictogrammes pour illustrer neuf importantes questions de sécurité des médicaments. Ces pictogrammes peuvent maintenant être validés à l'aide de tests de compréhension et de mémoire. De plus amples études pourront aussi déterminer dans quelle mesure ces pictogrammes aident à réduire les erreurs d'administration de médicaments.

Defining and identifying concepts of medication literacy: An international perspective.

BACKGROUND: Multiple concepts to define health literacy in the context of medication use exist, such as medication literacy, pharmacotherapy literacy, pharmacy health literacy; however, no studies have looked at consensus among experts internationally. METHOD: A Delphi process was used to achieve consensus on the statements about medication literacy. Experts for the Delphi were selected from a review of the literature and suggestions from an international survey conducted with members of the International Pharmaceutical Federation on medication literacy. The preliminary Delphi questionnaire was built using the statements about medication literacy found in the scientific literature. Responses and comments were analyzed using a pre-established method and communicated to the experts after each round of Delphi. Statements with an agreement of at least 80% were accepted and used to develop a definition of medication literacy. RESULTS: The Delphi process started with 21 experts and included 4 rounds. Overall, 30 statements regarding medication literacy were accepted and divided into 4 clusters representing: (1) type of information necessary for optimal and safe use of medication, (2) skills and abilities, (3) format of information, and (4) outcomes. These statements were used to propose 2 different definitions of medication literacy. One of the definitions was preferred by 75% of the expert panel, which provided further comments for improvements. Of the 11 experts who answered the final questionnaire, nine strongly agreed with the refined definition. CONCLUSION: Medication literacy is the degree to which individuals can obtain, comprehend, communicate, calculate and process patient-specific information about their medications to make informed medication and health decisions in order to safely and effectively use their medications, regardless of the mode by which the content is delivered (e.g. written, oral and visual). Future studies should focus on how this definition can be operationalized to support the role that pharmacists and other healthcare providers.

The evaluation of pharmaceutical pictograms among elderly patients in community pharmacy settings - a multicenter pilot study.

INTRODUCTION: The search for new ways to optimize the use of medications by patients has led the pharmaceutical community to promote the idea of introducing pictograms into routine practice. The main intention of pictograms is to ease patient adherence and to reduce potential risks or errors associated with the use of medications. PURPOSE: To evaluate a series of pharmaceutical pictograms for patient comprehension. PATIENTS AND METHODS: The study was conducted in community pharmacies within a European Union country that belongs to the professional research network. Structured interviews were used to evaluate the pictograms for patient comprehension. This consisted of an assessment of the following: the transparency and translucency of the pictograms, health literacy, and pictogram recall. Participants were also given the opportunity to provide feedback on how to improve the pictograms. The primary endpoint was pictogram comprehension. Secondary outcomes included recall of the pictograms and pictogram translucency. RESULTS: The study included 68 patients with whom face-to-face interviews were performed. Low transparency results (≤25%) and extensive patient feedback in initial interviews led to the withdrawal of certain pictograms (n=15) from the evaluation. Among the pictograms included in the final stage of our research, 22 pictograms (62.8%) obtained an acceptable transparency level ≥66%. All pictograms passed the short-term recall test with positive results. CONCLUSION: A majority of the designed and modified pictograms reached satisfactory guess-ability scores. Feedback from patients enabled modification of the pictograms and proved that patients have an important voice in the discussion regarding the design of additional pictograms.

Pictograms for Safer Medication Management by Health Care Workers.

BACKGROUND: Inherent risks are associated with the preparation and administration of medications. As such, a key aspect of medication safety is to ensure safe medication management practices. OBJECTIVE: To identify key medication safety issues and high-alert drug classes that might benefit from implementation of pictograms, for use by health care providers, to enhance medication administration safety. This study was the first step in the development of such pictograms. METHODS: Self-identified medication management experts participated in a modified Delphi process to achieve consensus on situations where safety pictograms are required for labelling to optimize safe medication management. The study was divided into 3 phases: issue generation, issue reduction, and issue selection. Issues achieving at least 80% consensus and deemed most essential were selected for future studies. Retained issues were subjected to semiotic analysis, and preliminary pictograms were developed. RESULTS: Of the 87 health care professionals (pharmacists, pharmacy technicians, nurses, and physicians) invited to participate in the Delphi process, 30 participated in all 3 phases. A total of 55 situations that could potentially benefit from safety pictograms were generated initially. Through the Delphi process, these were narrowed down to 10 situations where medication safety might be increased with the use of safety pictograms. For most of the retained issues, between 3 and 6 pictograms were designed, based on the results of the semiotic analysis. CONCLUSIONS: The pharmacists, pharmacy technicians, nurses, and physicians participating in this study reached consensus and identified 10 medication administration safety issues that might benefit from the development and implementation of safety pictograms. Pictograms were developed for a total of 9 issues. In follow-up studies, these pictograms will be validated for comprehension and evaluated for effectiveness.

CONTEXTE: Il y a des risques inhérents associés à la préparation et à l'administration de médicaments. Pour cette raison, l'un des principaux aspects de la sécurité des médicaments est d'assurer des pratiques de gestion des médicaments sécuritaires. OBJECTIF: Déterminer les principales questions de sécurité des médicaments et les classes de médicaments de niveau d'alerte élevé pour lesquelles l'ajout de pictogrammes, destinés aux fournisseurs de soins de santé, permettrait de rendre l'administration de médicaments plus sécuritaire. La présente étude représentait la première étape dans l'élaboration de ces pictogrammes. MÉTHODES: Des professionnels qui se définissaient comme experts en gestion de médicaments ont participé à un processus Delphi modifié dans le but d'arriver à un consensus à propos des situations où des pictogrammes de sécurité doivent être ajoutés à l'étiquette afin d'optimiser la gestion sécuritaire des médicaments. L'étude a été divisée en trois phases : génération de questions de sécurité, élimination de questions de sécurité et sélection de questions de sécurité. Les questions qui atteignaient un consensus d'au moins 80 % et qui étaient considérées comme les plus essentielles ont été retenues pour des études ultérieures. Les questions de sécurité retenues ont été soumises à une analyse sémiotique, puis des ébauches de pictogrammes ont été créées. RÉSULTATS: Parmi les 87 professionnels de la santé (notamment des pharmaciens, des techniciens en pharmacie, du personnel infirmier et des médecins) invités à participer au processus Delphi, 30 ont pris part aux trois étapes. Au total, 55 situations pour lesquelles il pourrait être avantageux d'utiliser des pictogrammes de sécurité ont été générées au départ. Grâce au processus Delphi, ce nombre a été réduit à 10 situations pour lesquelles la sécurité des médicaments pourrait être accrue à l'aide de pictogrammes de sécurité. Pour la plupart des questions retenues, entre trois et six pictogrammes ont été conçus à l'aide des résultats de l'analyse sémiotique. CONCLUSION: Les pharmaciens, les techniciens en pharmacie, le personnel infirmier et les médecins qui ont participé à l'étude ont atteint un consensus sur dix questions au sujet de l'administration sécuritaire des médicaments pour lesquelles l'élaboration et la mise en place de pictogrammes de sécurité pourraient être avantageuses. Ensuite, des pictogrammes ont été conçus pour neuf questions au total. Dans les études ultérieures, il faudra évaluer l'efficacité des pictogrammes et s'assurer qu'ils sont interprétés correctement.

Taste and Odour Disturbances in Pediatric Patients Undergoing IV Flush with Normal Saline Administered by Prefilled or Freshly Prepared Syringes: Randomized Single-Blind Study.

BACKGROUND: Previous studies have reported the occurrence of taste and odour disturbances among patients undergoing IV flush with prefilled syringes of 0.9% sodium chloride (normal saline [NS]). These disturbances have been attributed to the leaching of volatile substances into the NS from the plastic of the syringe. To date, there have been no studies comparing the occurrence of taste and odour disturbances with different NS preparations. OBJECTIVE: To compare the occurrence of taste and odour disturbances in pediatric patients undergoing IV flush with commercially available prefilled NS syringes and NS syringes prepared fresh daily. METHODS: Patients aged 6 to 18 years who underwent routine flushing of central or peripheral IV tubing were asked to participate in this follow-up randomized single-blind study. Flushing was performed with NS from BD PosiFlush 10-mL sterile prefilled syringes or NS transferred from a polyolefin bag (Baxter AVIVA) to a polypropylene syringe and stored for a maximum of 12 h before use. RESULTS: Fifty pediatric patients (mean age ± standard deviation 13.4 ± 3.8 years) who had undergone flushing of IV tubing with NS were interviewed. Taste or odour disturbances were reported by 18 (72%) of the 25 patients who underwent flushing with NS from a prefilled syringe, whereas only 1 (4%) of the 25 who underwent flushing with NS from a freshly prepared syringe experienced such disturbances (p < 0.001). CONCLUSIONS: There were significant differences in taste and odour disturbances experienced by patients who underwent IV flush with commercial prefilled NS syringes and freshly prepared NS syringes.

CONTEXTE: Des études antérieures ont signalé des cas d'altération du goût et de l'odorat chez des patients lors du rinçage de leur tubulure intraveineuse (i.v.) au moyen de seringues préremplies d'une solution de chlorure de sodium à 0,9 % (solution physiologique salée [SP]). Ces cas d'altération ont été attribués à des substances volatiles qui se seraient échappées du matériel composant la seringue plastique pour passer dans la SP. À ce jour, aucune étude comparant les cas d'altération du goût et de l'odorat en fonction de l'utilisation de différentes SP n'a été effectuée. OBJECTIF: Comparer les cas d'altération du goût et de l'odorat chez des enfants dont la tubulure i.v. a été rincée à l'aide d'une seringue commerciale préremplie de SP et chez ceux pour qui on a utilisé une seringue de SP préparée le jour même. MÉTHODES: On a demandé à des patients âgés de 6 à 18 ans chez qui on procédait à un rinçage habituel de leur tubulure i.v. périphérique ou centrale de participer à cette étude complémentaire avec répartition aléatoire et à simple insu. Le rinçage a été effectué à l'aide de la SP de seringues stériles préremplies BD PosiFlush de 10 mL ou à l'aide de SP prélevée d'un sac de polyoléfine (Baxter AVIVA) et introduite dans des seringues de polypropylène conservées pendant une période ne dépassant pas 24 heures avant l'utilisation. RÉSULTATS: Cinquante enfants (l'âge moyen ± l'écart-type était de 13,4 ± 3,8 ans) chez qui on a procédé à un rinçage de leur tubulure i.v. à l'aide d'une SP ont été interviewés. Des cas d'altération du goût ou de l'odorat ont été signalés par 18 (72 %) des 25 patients chez qui on a procédé à un rinçage à l'aide de la SP d'une seringue préremplie, alors qu'un seul (4 %) des 25 patients chez qui on a procédé à un rinçage à l'aide de la SP d'une seringue remplie dans les 24 heures précédentes a signalé un cas d'altération (p < 0.001). CONCLUSIONS: On a constaté d'importantes différences en ce qui a trait aux cas d'altération du goût et de l'odorat entre les patients chez qui on a procédé au rinçage des tubulures i.v. à l'aide de seringues commerciales préremplies de SP et ceux chez qui ont été utilisées des seringues remplies de SP dans les 24 heures précédentes. [Traduction par l'éditeur].

Impact of exercise-induced fatigue on the strength, postural control, and gait of children with a neuromuscular disease.

OBJECTIVE: Children with a neuromuscular disease are prone to early muscular fatigue. The objective of the present study was to evaluate the effects of fatigue induced by a walking exercise on the strength, postural control, and gait of children with a neuromuscular disease. DESIGN: Maximal isometric knee strength (extension and flexion), quiet standing postural control, and gait were evaluated in 12 children (8.8 [1.4] yrs) with a neuromuscular disease before and after a walking exercise. The participants were asked to stop walking when they considered themselves "very fatigued." RESULTS: After the exercise-induced fatigue, a significant increase in range of motion in pelvis obliquity, hip abduction and adduction, and ankle flexion and extension during gait was reported along with an increase in stride length variability. Fatigue also reduced the knee flexor strength and had a detrimental effect on postural control. CONCLUSIONS: Fatigue affects the strength, postural control, and gait of children with a neuromuscular disease and could notably increase the risks of falling and the occurrence of serious injuries.

How Many Words Does a Picture Really Tell? Cross-sectional Descriptive Study of Pictogram Evaluation by Youth.

BACKGROUND: Communicating health-related instructions with pictograms is useful, but such graphics can be interpreted in different ways. It is crucial to understand which pictogram components are best for accurate communication. OBJECTIVES: To catalogue pictograms used to label drugs in clinical practice; to identify the common graphic elements for defined categories of pictograms, by performing a semiotic analysis (studying how signs are perceived and how they should be designed); to identify the key graphic elements common to pictograms preferred by users; and to develop suggestions for future pictogram design on the basis of users' input. METHODS: Literature and Internet searches were performed to identify pictograms and pictogram categories. A call for pictograms was also circulated through the International Pharmaceutical Federation (FIP). Youth at a Canadian pediatric hospital were asked to rate pictograms (including storyboards and prescription labels generated by FIP pictogram software) in terms of how best they represented their intended meanings. Pictograms for which at least 80% of participants "somewhat agreed", "agreed", or "strongly agreed" that the graphic conveyed the intended meaning were designated as "preferred" and were selected for analysis. Elements appearing in at least 50% of these preferred pictograms were highlighted as key graphic elements for design of future pictograms. RESULTS: In total, 21 categories were identified for pictograms used in clinical practice, and a total of 204 pictograms were analyzed. Eighty-six participants took part in the survey. For each pictogram category, certain elements were identified as "preferred" and as "key graphic elements", whereas other elements met neither designation. For all 21 pictogram categories, at least 80% of survey respondents agreed that the FIP storyboard conveyed the intended meaning. CONCLUSIONS: Certain key, preferred graphic elements are required for pharmaceutical pictograms to convey their intended meaning. The overlap between preferred and key pictogram elements indicates that both must be considered in development of future pictograms. Redesign of existing pictograms with consideration of the best semiotic elements is in progress.

CONTEXTE: La communication des instructions concernant la santé à l'aide de pictogrammes est utile, mais ces graphiques peuvent être interprétés de différentes façons. Il est crucial de connaître quels éléments de ces pictogrammes sont les plus adéquats pour permettre une communication précise. OBJECTIFS: Répertorier les pictogrammes utilisés pour étiqueter les médicaments en pratique clinique; déterminer les éléments graphiques courants pour chaque catégorie de pictogrammes, en effectuant une analyse sémiotique (étude de la perception des signes et de leur représentation graphique); définir les éléments graphiques clés communs aux pictogrammes préférés des usagers; et formuler des suggestions pour la conception de futurs pictogrammes en tenant compte des commentaires des usagers. MÉTHODES: Une recherche bibliographique et une recherche dans Internet ont été menées pour déterminer les pictogrammes et les catégories de pictogrammes. Une demande de soumission de pictogrammes a aussi été diffusée par l'entremise de la Fédération internationale pharmaceutique (FIP). Dans un hôpital pour enfants du Canada, on a demandé à des jeunes d'évaluer les pictogrammes (y compris des étiquettes de médicaments prescrits et des scénarios illustrés générés par le logiciel de pictogrammes de la FIP) quant à l'exactitude de leur représentation du message qu'on voulait livrer. Les pictogrammes pour lesquels au moins 80 % des participants étaient « plutôt d'accord ¼, « d'accord ¼ ou « tout à fait d'accord ¼ que le graphique livrait le message voulu ont été jugés comme étant « préférés ¼ et retenus aux fins d'analyse. Les éléments apparaissant dans au moins 50% des pictogrammes préférés ont été sélectionnés comme éléments graphiques clés pour la conception de futurs pictogrammes. RÉSULTATS: En tout, 21 catégories de pictogrammes utilisés dans la pratique clinique ont été déterminées, 204 pictogrammes ont été analysés et 86 participants ont répondu au sondage. Pour chaque catégorie de pictogrammes, certains éléments ont été définis comme étant « préférés ¼ et comme des « éléments graphiques clés ¼, alors que d'autres éléments n'ont satisfait ni l'une ni l'autre de ces désignations. Pour les pictogrammes de l'ensemble des 21 catégories, au moins 80 % des répondants ont affirmé que le scénario illustré généré par le logiciel de la FIP communiquait le message qu'on voulait livrer. CONCLUSIONS: Certains éléments graphiques clés et préférés sont requis afin que les pictogrammes pharmaceutiques communiquent le message qu'on veut livrer. Le chevauchement entre les éléments graphiques préférés et les éléments graphiques clés indiquent que les deux doivent être pris en compte dans la création de futurs pictogrammes. La reconception des pictogrammes existants qui tient compte des meilleurs éléments sémiotiques est en cours. [Traduction par l'éditeur].