"Kind of blurry": Deciphering clues to prevent, investigate and manage prescribing cascades.

BACKGROUND: Prescribing cascades, where a medication is used to treat the side effect of another medication, contribute to polypharmacy and related morbidity. Little is known about clinicians' and patients' experiences with prescribing cascades. In this study, we explored why and how prescribing cascades occur across a variety of care settings and how they are managed. METHODS AND FINDINGS: This descriptive qualitative study employed semi-structured interviews with older adults who may have experienced a prescribing cascade(s), their caregivers, and healthcare providers. Interviewees were recruited through physician referral from a Geriatric Day Hospital, two long-term care homes in Ottawa, Ontario, and through self-referral across Ontario, Canada. An inductive approach was used to code data and determine themes. Thirty-one interviews were conducted for ten unique patient cases. Some interviewees were involved in more than one case, resulting in 22 unique interviewees. Three themes were identified. First, recognition of prescribing cascades is linked to awareness of medication side effects. Second, investigation and management of prescribing cascades is simultaneous and iterative (rather than linear and sequential). Third, prevention of prescribing cascades requires intentional strategies to help people anticipate and recognize medication side effects. Difficulty with recruitment from both long-term care homes and through self-referral was the central limitation. This exemplifies challenges associated with studying a poorly recognized and underexplored phenomenon. CONCLUSIONS: In order to better recognize, investigate and manage prescribing cascades, clinicians and patients need to know more about medication side effects; they need to ask 'can this be caused by a drug?' when signs and symptoms arise or worsen; and they need access to information about medication experiences to have benefit-risk discussions and make decisions about deprescribing. Approaches for raising public awareness of prescribing cascades should be trialed to raise the profile of this issue and facilitate continued exploration of the phenomenon.

Patient and provider perspectives on the development and resolution of prescribing cascades: a qualitative study.

BACKGROUND: Prescribing cascades occur when the side effect of a medication is treated with a second medication. The aim of the study was to understand how prescribing cascades develop and persist and to identify strategies for their identification, prevention and management. METHOD: This qualitative study employed semi-structured interviews to explore the existence of prescribing cascades and to gather patients', caregivers' and clinicians' perspectives about how prescribing cascades start, persist and how they might be resolved. Participants were older adults (over age 65) at an outpatient Geriatric Day Hospital (GDH) with possible prescribing cascades (identified by a GDH team member), their caregivers, and healthcare providers. Data were analyzed using an inductive content analysis approach. RESULTS: Fourteen participants were interviewed (eight patients, one family caregiver, one GDH pharmacist, three GDH physicians and one family physician) providing a total of 22 interviews about patient-specific cases. The complexity and contextually situated nature of prescribing cascades created challenges for all of those involved with their identification. Three themes impacted how prescribing cascades developed and persisted: varying awareness of medications and cascades; varying feelings of accountability for making decisions about medication-related care; and accessibility to an ideal environment and relevant information. Actions to prevent, identify or resolve cascades were suggested. CONCLUSION: Patients and healthcare providers struggled to recognize prescribing cascades and identify when they had occurred; knowledge gaps contributed to this challenge and led to inaction. Strategies that equip patients and clinicians with resources to recognize prescribing cascades and environmental and social supports that would help with their identification are needed. Current conceptualizations of cascades warrant additional refinement by considering the nuances our work raises regarding their appropriateness and directionality.

The Senior Toronto Oncology Panel (STOP) Study: Research Participation for Older Adults With Cancer and Caregivers.

Background: Patient engagement in research may lead to better-designed studies and improved health outcomes. The objectives of this study were to identify the research priorities of older adults with cancer (OAWCs) and their caregivers and examine how to engage these individuals in research teams and what supports are needed. Methods: We conducted 3 public meetings and 7 focus groups to delineate research priorities and the supports needed to facilitate integration of OAWCs and their caregivers on research teams. Results: A total of 33 older adults and 19 caregivers attended a public meeting and 27 older adults and 17 caregivers participated in a focus group. Most of the OAWCs and their caregivers had never participated in research before. Three themes were identified from the focus groups: (1) motivation to be on a team; (2) ability to make meaningful contributions; and (3) logistical considerations to facilitate engagement. Most participants were motivated to be a research team member and be involved in all steps of research if it could benefit them or future patients and caregivers. OAWCs and their caregivers were highly motivated to improve outcomes. Required logistics included flexibility regarding time and location, accessibility to computer technology, transportation support, materials worded in lay language, and attending/having short training sessions, as well as the presence of peer support. Conclusions: OAWCs and their caregivers are very motivated and willing to participate in research and to be research team members. Logistics and the social aspects of being on a team are important.

Frailty and Potentially Inappropriate Medication Use at Nursing Home Transition.

BACKGROUND/OBJECTIVES: To estimate the prevalence of potentially inappropriate medication (PIM) use among older adults with cognitive impairment or dementia prior to and following admission to nursing homes and in relation to frailty. DESIGN: Retrospective cohort study using health administrative databases. SETTING: Ontario, Canada. PARTICIPANTS: 41,351 individuals with cognitive impairment or dementia, aged 66+ years newly admitted to nursing home between 2011 and 2014. MEASUREMENTS: PIMs were defined with 2015 Beers Criteria and included antipsychotics, H2 -receptor antagonists, benzodiazepines, and drugs with strong anticholinergic properties. Medication information was obtained at nursing home admission and in the subsequent 180 days. Multivariable Cox proportional-hazards models were used to assess the impact of frailty status (determined by a 72-item frailty index) on the hazard of starting and discontinuing PIMs. RESULTS: At admission, 44% of residents with cognitive impairment or dementia were on a PIM and prevalence varied by frailty (38.7% non-frail, 42.8% pre-frail, and 48.1% frail, P < .001). Following admission, many residents discontinued PIMs (23.5% for antipsychotics, 49.3% benzodiazepines, 32.2% anticholinergics, and 30.9% H2 -receptor antagonists). However, PIMs were also introduced with 10.9% newly started on antipsychotics, benzodiazepines (10.1%), anticholinergics (6.6%), and H2 -receptor antagonists (1.2%). After adjustment for other characteristics, frail residents had a similar risk of PIM discontinuation as non-frail residents except for anticholinergics (HR = 1.21, 95% CI 1.06-1.39) but were more likely to be newly prescribed benzodiazepines (HR = 1.32, 95% CI 1.20-1.44), antipsychotics (HR = 1.36, 1.23-1.49), and anticholinergics (HR = 1.34, 95% CI 1.20-1.50). CONCLUSION: Many residents with cognitive impairment or dementia enter nursing homes on PIMs. PIMs are more likely to be started in frail individuals following admission. Interventions to support deprescribing of PIMs should be implemented targeting frail individuals during the transition to nursing home.

The effect of an organizational network for patient safety on safety event reporting.

Health care organizations continue to implement organization-wide educational approaches to enhance patient safety with less attention on evaluating the impact of these approaches. In this context, a study was conducted to measure the impact of an organization-wide patient safety network approach on patient safety event reporting. A time-series analysis with reported rates of adverse events (major and moderate), near misses, sentinel events, and incidents from 2 years prior through 13 months following implementation was conducted. Study findings include a significant increase in reporting of patient safety events (an approximately 50% increase in overall reporting of safety events was observed; p < .001), especially near misses (an approximately 100% increase following implementation; p = .002). Study findings suggest that a multifaceted networked approach does contribute to improving patient safety event reporting.

Enablers and barriers to implementing bedside reporting: insights from nurses.

As part of efforts to improve patient safety, quality of care and patient- and family-centred care, there is a growing interest in moving away from traditional taped nursing reports or reporting at the nursing station to reporting at the bedside. Although a body of knowledge exists regarding what nurses view as benefits and challenges experienced in nurse-to-nurse bedside reporting, less is known about the perceptions of nurses who have experienced this change in reporting practice on their unit. In this context, a qualitative study using semi-structured interviews was undertaken to explore nurses' perceptions of a newly implemented nurse-to-nurse bedside reporting practice at one acute care hospital. A total of 43 interviews were conducted on four units with seven nurses from respirology, 10 from obstetrics and gynecology, 10 from nephrology and 16 from general surgery. Data were analyzed using a directed content analysis approach. Three themes emerged that captured nurses' perceptions of the implementation of nurse-to-nurse bedside reporting: (a) being supported to change and embrace bedside reporting, (b) maintaining confidentiality and respecting patients' preferences and (c) experiencing challenges with bedside reporting. Our findings provide insight for other organizations in their efforts to change reporting practices. Specifically, there is a need for multi-pronged initiatives including leadership support, educational opportunities and ongoing monitoring and feedback mechanisms. Future research is required to examine how enablers can be leveraged and barriers mitigated or removed to ensure successful implementation and sustainability of nurse-to-nurse bedside reporting.

Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.

INTRODUCTION: The extent to which individuals in healthcare use near misses as learning opportunities remains poorly understood. Thus, an exploratory study was conducted to gain insight into the nature of, and contributing factors to, organisational learning from near misses in clinical practice. METHODS: A constructivist grounded theory approach was employed which included semi-structured interviews with 24 participants (16 clinicians and 8 administrators) from a large teaching hospital in Canada. RESULTS: This study revealed three scenarios for the responses to near misses, the most common involved 'doing a quick fix' where clinicians recognised and corrected an error with no further action. The second scenario consisted of reporting near misses but not hearing back from management, which some participants characterised as 'going into a black hole'. The third scenario was 'closing off the Swiss-cheese holes', in which a reported near miss generated corrective action at an organisational level. Explanations for 'doing a quick fix' included the pervasiveness of near misses that cause no harm and fear associated with reporting the near miss. 'Going into a black hole' reflected managers' focus on operational duties and events that harmed patients. 'Closing off the Swiss-cheese holes' occurred when managers perceived substantial potential for harm and preventability. Where learning was perceived to occur, leaders played a pivotal role in encouraging near-miss reporting. CONCLUSION: To optimise learning, organisations will need to determine which near misses are appropriate to be responded to as 'quick fixes' and which ones require further action at the unit and corporate levels.

Catching and correcting near misses: the collective vigilance and individual accountability trade-off.

Despite the focus on patient safety and quality health care for the last two decades, there is still limited understanding of how interprofessional interactions at an organizational or work unit level influence how clinicians perceive and respond to safety events and errors. Within the rubric of safety events, there has been a growing interest in near misses as precursors to adverse events in health care. Given the interactive nature of the variety of professionals working together in the delivery of health care, understanding how the different clinicians experience and respond to near misses in practice is important. A constructivist grounded theory approach was employed for this study which included semi-structured interviews with 24 participants in a large teaching hospital in Canada. Findings from this study provide a deeper understanding into how different clinicians experience and respond to near misses in clinical practice. This understanding indicates that collective vigilance can potentially create risk by eroding individual professional accountability through reliance on other team members to catch and correct their errors. Further research is needed to explore in more depth the trade-offs between collective vigilance and individual accountability by relying on others to catch and correct the potentially harmful errors and avert negative outcomes.

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures.

This article provides findings on the role of the nurse in simulated team-based error disclosures. Triangulation of 3 qualitative data sets revealed that a tension exists for nurses in the error disclosure process as they attempt to balance professional boundaries. Study findings point to multilevel strategies including cultural, structural, and educational approaches to enhancing the key roles that nurses need to play in error disclosure to patients and families.

A new way of relating: perceptions associated with a team-based error disclosure simulation intervention.

BACKGROUND: Despite the call for open and team-based approaches to error disclosure, the participation beyond physicians and managers is not a common practice in health care settings. Moreover, within the growing literature base on error disclosure, team-based error disclosure is an emerging concept. To address this knowledge gap, a study was undertaken to explore the perceptions associated with an educational simulation intervention for team-based error disclosure. METHODS: A qualitative study that involved analysis of data obtained from semi-structured interviews with a sample of 6 physicians, 6 surgeons, and 12 nurses recruited from the three participating hospitals. RESULTS: Perceptions from study participants elucidated a tension between team-based error disclosure as an unrealistic, forced practice and as a realistic, beneficial practice. This tension was highly contextual and differentiated by study participants' perceptions of the nature of the error; patient's preferences; and prevailing cultural and professional norms. Regardless of the view, study participants described the simulation experience as a new way of relating that departed from existing practice. CONCLUSIONS: Study findings revealed that a team-based approach to disclosure is not realistic or necessary for all error situations, such as when the error involves a single discipline. However, when the error involves a variety of health care professionals interacting with the patient, a team-based approach is beneficial to them and the patient. Further work is required by researchers and administrators to develop and test out interventions that enable health care professionals to practice team-based error disclosure in a safe and supported environment.

Building knowledge for safer care: nursing research advancing practice.

Organizational and professional efforts to support nurses engaging in research projects that advance patient safety practices are needed. In this context, the purpose of this article is to provide a description of the design, implementation, and evaluation of a research capacity strategy designed for clinical nurses and the lessons learned. Participating nurses evolved from research novices to key champions in advancing nursing practice, patient safety, and quality improvement.

Leveraging safer nursing care by conceptualizing near misses as recovery processes.

The purpose of this study was to elicit perceptions and experiences of nurses associated with a recovery process (near miss) intervention (wound care management). From the content analysis of interview data involving 12 registered nurses, 2 key themes emerged. Both themes illuminated the links among pattern recognition, alignment of care processes and practice guidelines, and nurses' accountability for safe pressure ulcer care.

Near misses: paradoxical realities in everyday clinical practice.

This qualitative study was conducted to define and describe what constitutes and contributes to near miss occurrences in the health-care system and what is needed to ensure safer processes of care. Nine health-care organizations (13 sites total) including six academic health sciences centres (acute care, mental health and geriatric) and three community hospitals participated in this study. The final sample consisted of 37 focus groups (86 in the nursing staff only; 62 in the pharmacy staff only; and 99 in the mixed nursing and pharmacy focus groups respectively) and 120 interviews involving 144 health-care consumers. Data were collected using focus groups (health-care professionals) and key informant interviews (health-care consumers). A multi-level content analyses schema (transcription, coding, categorizing, internal consistency, thematic analysis and community validation) was used. Six themes emerged from the multi-level content analyses that combined focus group (health-care professionals) and key informant interview (health-care consumers) data. These themes are discussed under the three original research questions with supporting data derived from codes and categories. Study findings implicate changes for the health-care landscape relative to system, health policy, professional development and quality improvement.

Creating reporting and learning cultures in health-care organizations.

Patient safety has emerged as an important issue in Canadian health care, as reflected in the Canadian Council on Health Services Accreditation's patient/client safety goals. Achieving these goals calls for concerted efforts within health-care organizations. To assist nurse leaders in their efforts in developing a culture of safety that is receptive to reporting and learning from adverse events and near misses, the authors explore the challenges and provide four recommendations for action. By enacting these recommendations, nurse leaders can support the analysis and actions necessary to identify improvements that will create safer health-care environments.

Building capacity for nursing research.

Given how important care processes are to the nursing profession, it is imperative that nurses take a lead role in building capacity for nursing research and that they make a strong contribution to building the body of knowledge in the area of patient safety. The authors present an overview of a current nursing-led patient safety study in which building capacity for research is a core component.

Patient safety culture and leadership within Canada's Academic Health Science Centres: towards the development of a collaborative position paper.

Currently, the Academy of Canadian Executive Nurses (ACEN) is working with the Association of Canadian Academic Healthcare Organizations (ACAHO) to develop a joint position paper on patient safety cultures and leadership within Academic Health Science Centres (AHSCs). Pressures to improve patient safety within our healthcare system are gaining momentum daily. Because AHSCs in Canada are the key organizations that are positioned regionally and nationally, where service delivery is the platform for the education of future healthcare providers, and where the development of new knowledge and innovation through research occurs, leadership for patient safety logically must emanate from them. As a primer, ACEN provides an overview of current patient safety initiatives in AHSCs to date. In addition, the following six key areas for action are identified to ensure that AHSCs continue to be leaders in delivering quality, safe healthcare in Canada. These include: (1) strategic orientation to safety culture and quality improvement, (2) open and transparent disclosure policies, (3) health human resources integral to ensuring patient safety practices, (4) effective linkages between AHSCs and academic institutions, (5) national patient safety accountability initiatives and (6) collaborative team practice.