Diabetes in residential aged care: Pharmacological management and concordance with clinical guidelines.

OBJECTIVE: Existing studies have highlighted suboptimal diabetes management in residential aged care facilities (RACFs). However, understanding of diabetes management in Australian metropolitan RACFs has been limited. This retrospective cohort study aimed to explore the pharmacological management of diabetes in 25 RACFs in Sydney Australia and assess concordance with clinical practice guidelines (CPGs). METHODS: Data from 231 permanent RACF residents aged ≥65 years and over with type 2 diabetes mellitus over the period from 1 July 2016 to 31 December 2019 were used. Concordance was measured by assessing the medications and medical history data for each individual resident for concordance with evidence-based CPGs. Multivariable logistic regression was used to estimate the effect of resident characteristics on concordance with CPGs. RESULTS: Of the 231 residents with diabetes, 87 (38%) were not taking any antidiabetic medication. Pharmacological management inconsistent with CPG recommendations was observed for 73 (32%) residents, with the most common reason for non-concordance being the use of medications with significant adverse effects in older adults (47, 2%). Residents with hypertension or other heart diseases in addition to their diabetes had greater odds of their diabetes management being non-concordant with CPGs (OR = 2.84 95% CI = 1.54, 5.3 and OR = 2.64, 95% CI = 1.07, 6.41, respectively). CONCLUSIONS: Pharmacological diabetes management in metropolitan Australian RACFs is suboptimal, with a high prevalence of inconsistency with CPGs (32%) observed. Additionally, having hypertension or heart diseases significantly increased the possibility of non-concordance among diabetic RACF residents. Further investigation into the underlying relationships with comorbidities is required to develop better strategies.

Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study.

INTRODUCTION: At least 10% of hospital admissions in high-income countries, including Australia, are associated with patient safety incidents, which contribute to patient harm ('adverse events'). When a patient is seriously harmed, an investigation or review is undertaken to reduce the risk of further incidents occurring. Despite 20 years of investigations into adverse events in healthcare, few evaluations provide evidence of their quality and effectiveness in reducing preventable harm.This study aims to develop consistent, informed and robust best practice guidance, at state and national levels, that will improve the response, learning and health system improvements arising from adverse events. METHODS AND ANALYSIS: The setting will be healthcare organisations in Australian public health systems in the states of New South Wales, Queensland, Victoria and the Australian Capital Territory. We will apply a multistage mixed-methods research design with evaluation and in-situ feasibility testing. This will include literature reviews (stage 1), an assessment of the quality of 300 adverse event investigation reports from participating hospitals (stage 2), and a policy/procedure document review from participating hospitals (stage 3) as well as focus groups and interviews on perspectives and experiences of investigations with healthcare staff and consumers (stage 4). After triangulating results from stages 1-4, we will then codesign tools and guidance for the conduct of investigations with staff and consumers (stage 5) and conduct feasibility testing on the guidance (stage 6). Participants will include healthcare safety systems policymakers and staff (n=120-255) who commission, undertake or review investigations and consumers (n=20-32) who have been impacted by adverse events. ETHICS AND DISSEMINATION: Ethics approval has been granted by the Northern Sydney Local Health District Human Research Ethics Committee (2023/ETH02007 and 2023/ETH02341).The research findings will be incorporated into best practice guidance, published in international and national journals and disseminated through conferences.

Quality indicators to monitor the quality and safety of care for older people: a scoping review protocol.

OBJECTIVE: The objective of this review is to identify quality indicators used to monitor the quality and safety of care provided to older people (≥ 65 years old) in 8 care settings: primary care; hospital/acute care; aged care (including residential aged care and home or community care); palliative care; rehabilitation care; care transitions; dementia care; and care in rural areas. INTRODUCTION: There is a need for high-quality, holistic, person-centered aged and health care for older people. Older people receive care across multiple care settings, and population-level monitoring of quality and safety of care across settings represents a significant challenge. INCLUSION CRITERIA: National and international quality indicators used to monitor and evaluate quality and safety of care at the population level for older individuals in the 8 key care settings will be considered for inclusion. English-language quantitative and mixed method studies published from 2012 will be considered. METHODS: Academic (MEDLINE, Embase) and gray (government websites, clinical guidelines, Google) literature searches will be conducted. A standardized data extraction tool will be used to describe the identified quality indicators and associated tools. Quality indicators will be categorized by key domains (ie, pain, function, consumer experience, service delivery), quality indicator type (structure, process, outcome) and the Institute of Medicine's 6 dimensions of care quality (eg, efficiency, effectiveness, appropriateness, accessibility, acceptability/person-centered, safety). The scoping review will be conducted in accordance with the JBI methodology for scoping reviews and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). REVIEW REGISTRATION: Open Science Framework osf.io/8czun.

A Longitudinal Study of the Use and Effects of Fall-Risk-Increasing Drugs in Residential Aged Care.

OBJECTIVES: Fall-risk-increasing drugs (FRIDs)-psychotropics and cardiovascular disease (CVD) drugs-may elevate the risk of falling, with strong evidence observed in psychotropic FRIDs, whereas findings from cardiovascular disease (CVD) FRIDs remain inconclusive. Existing studies on FRIDs and falls are often hampered by methodologic limitations. Leveraging longitudinal observational data, we aimed to determine the long-term patterns of FRID use and their association with falls in residential aged care (RAC) homes. DESIGN: A retrospective longitudinal cohort study. SETTING AND PARTICIPANTS: A total of 4207 permanent residents newly admitted to 27 RAC homes in Sydney, Australia. METHOD: The outcomes were incidence of all and injurious falls. We measured exposure to each FRID over 60 months using the Proportion of Days Covered (PDC) metric. We used group-based multitrajectory modeling to determine concurrent usage patterns of psychotropics and CVD FRIDs and applied negative binomial regression to assess their associations with the outcomes. RESULTS: A total of 83.6% (n = 3516) and 77.3% (n = 3254) residents used psychotropic and CVD FRIDs, respectively. The PDC values ranged from 67.3% (opioids) to 86.9% (antidepressants) for specific psychotropics and 79.0% (α-adrenoceptor antagonists) to 89.6% (ß blockers) for CVD FRIDs. We identified 4 groups: group 1, low psychotropics-low CVDs use (16.7%, n = 701); group 2, low psychotropics-high CVDs (25.0%, n = 1054); group 3, high psychotropics-high CVDs (41.0%, n = 1723); and group 4, high psychotropics-low CVDs (17.3%, n = 729). Group 4 had a significantly higher rate of falls than the other groups for both outcomes, including relative to group 3, in which exposure to both FRID classes was high. CONCLUSIONS AND IMPLICATIONS: Our findings reveal concerningly high FRID use in RAC homes and highlight a critical difference in the impact of the 2 major FRID classes on falls. Psychotropics were strongly associated with falls, whereas the studied CVD FRIDs did not elevate risk of falling.

Evaluation of a culture change program to reduce unprofessional behaviours by hospital co-workers in Australian hospitals.

BACKGROUND: Unprofessional behaviours between healthcare workers are highly prevalent. Evaluations of large-scale culture change programs are rare resulting in limited evidence of intervention effectiveness. We conducted a multi-method evaluation of a professional accountability and culture change program "Ethos" implemented across eight Australian hospitals. The Ethos program incorporates training for staff in speaking-up; an online system for reporting co-worker behaviours; and a tiered accountability pathway, including peer-messengers who deliver feedback to staff for 'reflection' or 'recognition'. Here we report the final evaluation component which aimed to measure changes in the prevalence of unprofessional behaviours before and after Ethos. METHODS: A survey of staff (clinical and non-clinical) experiences of 26 unprofessional behaviours across five hospitals at baseline before (2018) and 2.5-3 years after (2021/2022) Ethos implementation. Five of the 26 behaviours were classified as 'extreme' (e.g., assault) and 21 as incivility/bullying (e.g., being spoken to rudely). Our analysis assessed changes in four dimensions: work-related bullying; person-related bullying; physical bullying and sexual harassment. Change in experience of incivility/bullying was compared using multivariable ordinal logistic regression. Change in extreme behaviours was assessed using multivariable binary logistic regression. All models were adjusted for respondent characteristics. RESULTS: In total, 3975 surveys were completed. Staff reporting frequent incivility/bullying significantly declined from 41.7% (n = 1064; 95% CI 39.7,43.9) at baseline to 35.5% (n = 505; 95% CI 32.8,38.3; χ2(1) = 14.3; P < 0.001) post-Ethos. The odds of experiencing incivility/bullying declined by 24% (adjusted odds ratio [aOR] 0.76; 95% CI 0.66,0.87; P < 0.001) and odds of experiencing extreme behaviours by 32% (aOR 0.68; 95% CI 0.54,0.85; P < 0.001) following Ethos. All four dimensions showed a reduction of 32-41% in prevalence post-Ethos. Non-clinical staff reported the greatest decrease in their experience of unprofessional behaviour (aOR 0.41; 95% CI 0.29, 0.61). Staff attitudes and reported skills to speak-up were significantly more positive at follow-up. Awareness of the program was high (82.1%; 95% CI 80.0, 84.0%); 33% of respondents had sent or received an Ethos message. CONCLUSION: The Ethos program was associated with significant reductions in the prevalence of reported unprofessional behaviours and improved capacity of hospital staff to speak-up. These results add to evidence that staff will actively engage with a system that supports informal feedback to co-workers about their behaviours and is facilitated by trained peer messengers.

Factors affecting 12-month unplanned readmissions for chronic obstructive pulmonary disease patients: the effect of mental disorders in an Australian cohort.

BACKGROUND: Many individuals with chronic obstructive pulmonary disease (COPD) experience frequent hospitalization and readmissions, which is burdensome on the health system. This study aims to investigate factors associated with unplanned readmissions and mortality following a COPD-related hospitalization over a 12-month period in Australia, focusing on mental disorders and accounting for the acute phase of the COVID-19 pandemic. METHODS: A retrospective cohort study using linked hospitalization and mortality records identified individuals aged ≥40 years who had at least one hospital admission with a principal diagnosis of COPD between 2014 and 2020 in New South Wales, Australia. A semi-competing risk analysis was conducted to examine factors associated with unplanned readmission and mortality. RESULTS: Adults with a mental disorder diagnosis, specifically anxiety, had a higher risk of 12-month unplanned readmission. Individuals with anxiety and dementia also had a higher risk of mortality pre- and post-unplanned readmission. Individuals who were admitted during the acute phase of the COVID-19 pandemic period had lower risk of unplanned readmission, but higher risk of mortality without unplanned readmission. CONCLUSION: Interventions aimed at reducing admissions should consider adults living with mental disorders such as anxiety or dementia to improve healthcare delivery and health outcomes for individuals living with COPD.

Child Age and Risk of Medication Error: A Multisite Children's Hospital Study.

OBJECTIVE: The objective of this study was to examine associations between patient age and medication errors among pediatric inpatients. STUDY DESIGN: Secondary analysis of data sets generated from 2 tertiary pediatric hospitals: (1) prescribing errors identified from chart reviews for patients on 9 general wards at hospital A during April 22 to July 10, 2016, June 20 to September 20, 2017, and June 20 to September 30, 2020; prescribing errors from 5 wards at hospital B in the same periods and (2) medication administration errors assessed by direct prospective observation of 5137 administrations on 9 wards at hospital A. Multilevel models examined the association between patient age and medication errors. Age was modeled using restricted cubic splines to allow for nonlinearity. RESULTS: Prescribing errors increased nonlinearly with patient age (P = .01), showing little association from ages 0 to 3 years and then increasing with age until around 10 years and remaining constant through the teenage years. Administration errors increased with patient age, with no association from 0 to around 8 years and then a steady rise with increasing age (P = .03). The association differed by route: linear for oral, no association for intravenous infusions, and U-shaped for intravenous injections. CONCLUSIONS: Older age is an unrecognized risk factor for medication error on general wards in pediatric hospitals. Contributors to risk may be the clinical profiles of these older children or the general level of attention paid to medication practices for this group. Further investigation may allow the design of more targeted interventions to reduce errors.

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system.

OBJECTIVES: To compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and severity of errors detected and reported by staff. METHODS: This is a comparison study at two tertiary referral paediatric hospitals between 2016 and 2020 in Australia. Prescribing errors were identified from a medication chart audit of 7785 patient records. Medication administration errors were identified from a prospective direct observational study of 5137 medication administration doses to 1530 patients. Medication errors reported to the hospitals' incident reporting system were identified and matched with errors identified at audit and observation. RESULTS: Of 11 302 clinical prescribing errors identified at audit, 3.2 per 1000 errors (95% CI 2.3 to 4.4, n=36) had an incident report. Of 2224 potentially serious prescribing errors from audit, 26.1% (95% CI 24.3 to 27.9, n=580) were detected by staff and 11.2 per 1000 errors (95% CI 7.6 to 16.5, n=25) were reported to the incident system. Although the prescribing error detection rates varied between the two hospitals, there was no difference in incident reporting rates regardless of error severity. Of 40 errors associated with actual patient harm, only 7 (17.5%; 95% CI 8.7% to 31.9%) were detected by staff and 4 (10.0%; 95% CI 4.0% to 23.1%) had an incident report. None of the 2883 clinical medication administration errors observed, including 903 potentially serious errors and 144 errors associated with actual patient harm, had incident reports. CONCLUSION: Incident reporting data do not provide an accurate reflection of medication errors and related harm to children in hospitals. Failure to detect medication errors is likely to be a significant contributor to low error reporting rates. In an era of electronic health records, new automated approaches to monitor medication safety should be pursued to provide real-time monitoring.

The relationship between participation in leisure activities and incidence of falls in residential aged care.

BACKGROUND: Active engagement in leisure activities has positive effects on individuals' health outcomes and social functioning; however, there is limited understanding of the link between participation in leisure activities, particularly non-exercise activities, and falls in older adults. This study aimed to determine the relationship between participation in leisure activities and the incidence of falls, and the variation of this relationship by dementia status in residential aged care facilities (RACFs). METHODS: A retrospective longitudinal cohort study utilising routinely collected data (January 2021-August 2022) from 25 RACFs in Sydney, Australia, was conducted. The cohort included 3,024 older permanent residents (1,493 with dementia and 1,531 without) aged ≥65 and with a stay of ≥1 week. The level of participation in leisure activities was measured using the number of leisure activities per 1,000 resident days and divided into quartiles. Outcome measures were the incidence rate of all falls and injurious falls (i.e., number of falls per 1,000 resident days). We used multilevel negative binary regression to examine the relationship between leisure participation and fall incidence. RESULTS: For the whole sample, leisure participation was significantly inversely associated with the incidence rate of all falls and injurious falls. For example, residents in the high leisure participation group were 26% less likely to experience a fall compared to those in the low leisure participation group after controlling for confounders (incidence rate ratio = 0.74, 95% confidence interval = 0.60, 0.91). Such inverse relationship was observed in both exercise and non-exercise activities and was stronger among residents without dementia. CONCLUSIONS: Leisure participation is associated with a lower rate of falls, a key quality indicator by which RACFs are benchmarked and funded in Australia and many other countries. More recognition and attention are needed for the currently underfunded leisure activities in RACFs in future funding arrangement.

Co-worker unprofessional behaviour and patient safety risks: an analysis of co-worker reports across eight Australian hospitals.

A key component of professional accountability programmes is online reporting tools that allow hospital staff to report co-worker unprofessional behaviour. Few studies have analysed data from these systems to further understand the nature or impact of unprofessional behaviour amongst staff. Ethos is a whole-of-hospital professional accountability programme that includes an online messaging system. Ethos has now been implemented across multiple Australian hospitals. This study examined reported unprofessional behaviour that staff indicated created a risk to patient safety. This study included 1310 Ethos submissions reporting co-worker unprofessional behaviour between 2017 and 2020 across eight Australian hospitals. Submissions that indicated the behaviour increased the risk to patient safety were identified. Descriptive summary statistics were presented for reporters and subjects of submissions about unprofessional behaviour. Logistic regression was applied to examine the association between each unprofessional behaviour (of the six most frequently reported in the Ethos submissions) and patient safety risk reported in the submissions. The descriptions in the reports were reviewed and the patient safety risks were coded using a framework aligned with the World Health Organization's International Classification for Patient Safety. Of 1310 submissions about unprofessional behaviour, 395 (30.2%) indicated that there was a risk to patient safety. Nurses made the highest number of submissions that included a patient safety risk [3.47 submissions per 100 nursing staff, 95% confidence interval (CI): 3.09-3.9] compared to other professional groups. Medical professionals had the highest rate as subjects of submissions for unprofessional behaviour with a patient safety risk (5.19 submissions per 100 medical staff, 95% CI: 4.44-6.05). 'Opinions being ignored' (odds ratio: 1.68; 95% CI: 1.23-2.22; P < .001) and 'someone withholding information which affects work performance' were behaviours strongly associated with patient safety risk in the submissions (odds ratio: 2.50; 95% CI: 1.73-3.62; P < .001) compared to submissions without a patient safety risk. The two main types of risks to patient safety described were related to clinical process/procedure and clinical administration. Commonly reported events included staff not following policy or protocol; doctors refusing to review a patient; and interruptions and inadequate information during handover. Our findings indicate that unprofessional behaviour was associated with risks to patient safety. Co-worker reports about unprofessional behaviour have significant value as they can be used by organizations to better understand how unprofessional behaviour can disrupt work practices and lead to risks to patient safety.

Marked variations in medical provider and out-of-pocket costs for radical prostatectomy procedures in Australia.

Objectives Unwarranted clinical variations in radical prostatectomy (RP) procedures are frequently reported, yet less attention is given to the variations in associated costs. This issue can further widen disparities in access to care and provoke questions about the overall value of the procedure. The present paper aimed to delve into the disparities in hospital, medical provider and out-of-pocket costs for RP procedures in Australia, discussing plausible causes and potential policy opportunities. Methods A retrospective cohort study using Medibank Private claims data for RP procedures conducted in Australian hospitals between 1 January 2015 and 31 December 2020 was undertaken. Results Considerable variations in both medical provider and out-of-pocket costs were observed across the country, with variations evident between different states or territories. Particularly striking were the discrepancies in the costs charged by medical providers, with a notable contrast between the 10th and 90th percentiles revealing a substantial difference of A$9925. Hospitals in Australia exhibited relatively comparable charges for RP procedures. Conclusions Initiatives such as enhancing transparency regarding individual medical provider costs and implementing fee regulations with healthcare providers may be useful in curbing the variations in RP procedure costs.

Qualitative study of challenges with recruitment of hospitals into a cluster controlled trial of clinical decision support in Australia.

OBJECTIVE: To identify barriers to hospital participation in controlled cluster trials of clinical decision support (CDS) and potential strategies for addressing barriers. DESIGN: Qualitative descriptive design comprising semistructured interviews. SETTING: Five hospitals in New South Wales and one hospital in Queensland, Australia. PARTICIPANTS: Senior hospital staff, including department directors, chief information officers and those working in health informatics teams. RESULTS: 20 senior hospital staff took part. Barriers to hospital-level recruitment primarily related to perceptions of risk associated with not implementing CDS as a control site. Perceived risks included reductions in patient safety, reputational risk and increased likelihood that benefits would not be achieved following electronic medical record (EMR) implementation without CDS alerts in place. Senior staff recommended clear communication of trial information to all relevant stakeholders as a key strategy for boosting hospital-level participation in trials. CONCLUSION: Hospital participation in controlled cluster trials of CDS is hindered by perceptions that adopting an EMR without CDS is risky for both patients and organisations. The improvements in safety expected to follow CDS implementation makes it challenging and counterintuitive for hospitals to implement EMR without incorporating CDS alerts for the purposes of a research trial. To counteract these barriers, clear communication regarding the evidence base and rationale for a controlled trial is needed.

Risk Factors Associated with Medication Administration Errors in Children: A Prospective Direct Observational Study of Paediatric Inpatients.

INTRODUCTION: Limited evidence exists regarding medication administration errors (MAEs) on general paediatric wards or associated risk factors exists. OBJECTIVE: The aim of this study was to identify nurse, medication, and work-environment factors associated with MAEs among paediatric inpatients. METHODS: This was a prospective, direct observational study of 298 nurses in a paediatric referral hospital in Sydney, Australia. Trained observers recorded details of 5137 doses prepared and administered to 1530 children between 07:00 h and 22:00 h on weekdays and weekends. Observation data were compared with medication charts to identify errors. Clinical errors, potential severity and actual harm were assessed. Nurse characteristics (e.g. age, sex, experience), medication type (route, high-risk medications, use of solvent/diluent), and work variables (e.g. time of administration, weekday/weekend, use of an electronic medication management system [eMM], presence of a parent/carer) were collected. Multivariable models assessed MAE risk factors for any error, errors by route, potentially serious errors, and errors involving high-risk medication or causing actual harm. RESULTS: Errors occurred in 37.0% (n = 1899; 95% confidence interval [CI] 35.7-38.3) of administrations, 25.8% (n = 489; 95% CI 23.8-27.9) of which were rated as potentially serious. Intravenous infusions and injections had high error rates (64.7% [n = 514], 95% CI 61.3-68.0; and 77.4% [n = 188], 95% CI 71.7-82.2, respectively). For intravenous injections, 59.7% (95% CI 53.4-65.6) had potentially serious errors. No nurse characteristics were associated with MAEs. Intravenous route, early morning and weekend administrations, patient age ≥ 11 years, oral medications requiring solvents/diluents and eMM use were all significant risk factors. MAEs causing actual harm were 45% lower using an eMM compared with paper charts. CONCLUSION: Medication error prevention strategies should target intravenous administrations and not neglect older children in hospital. Attention to nurses' work environments, including improved design and integration of medication technologies, is warranted.

Drug-Drug Interactions and Actual Harm to Hospitalized Patients: A Multicentre Study Examining the Prevalence Pre- and Post-Electronic Medication System Implementation.

INTRODUCTION: Drug-drug interactions (DDIs) have potential to cause patient harm, including lowering therapeutic efficacy. This study aimed to (i) determine the prevalence of potential DDIs (pDDIs); clinically relevant DDIs (cDDIs), that is, DDIs that could lead to patient harm, taking into account a patient's individual clinical profile, drug effects and severity of potential harmful outcome; and subsequent actual harm among hospitalized patients and (ii) examine the impact of transitioning from paper-based medication charts to electronic medication management (eMM) on DDIs and patient harms. METHODS: This was a secondary analysis of the control arm of a controlled pre-post study. Patients were randomly selected from three Australian hospitals. Retrospective chart review was conducted before and after the implementation of an eMM system, without accompanying clinical decision support alerts for DDIs. Harm was assessed by an expert panel. RESULTS: Of 1186 patient admissions, 70.1% (n = 831) experienced a pDDI, 42.6% (n = 505) a cDDI and 0.9% (n = 11) an actual harm in hospital. Of 15,860 pDDIs identified, 27.0% (n = 4285) were classified as cDDIs. The median number of pDDIs and cDDIs per 10 drugs were 6 [interquartile range (IQR) 2-13] and 0 (IQR 0-2), respectively. In cases where a cDDI was identified, both drugs were 44% less likely to be co-administered following eMM (adjusted odds ratio 0.56, 95% confidence interval 0.46-0.73). CONCLUSION: Although most patients experienced a pDDI during their hospital stay, less than one-third of pDDIs were clinically relevant. The low prevalence of harm identified raises questions about the value of incorporating DDI decision support into systems given the potential negative impacts of DDI alerts.

Development and internal validation of a dynamic fall risk prediction and monitoring tool in aged care using routinely collected electronic health data: a landmarking approach.

OBJECTIVES: Falls pose a significant challenge in residential aged care facilities (RACFs). Existing falls prediction tools perform poorly and fail to capture evolving risk factors. We aimed to develop and internally validate dynamic fall risk prediction models and create point-based scoring systems for residents with and without dementia. MATERIALS AND METHODS: A longitudinal cohort study using electronic data from 27 RACFs in Sydney, Australia. The study included 5492 permanent residents, with a 70%-30% split for training and validation. The outcome measure was the incidence of falls. We tracked residents for 60 months, using monthly landmarks with 1-month prediction windows. We employed landmarking dynamic prediction for model development, a time-dependent area under receiver operating characteristics curve (AUROCC) for model evaluations, and a regression coefficient approach to create point-based scoring systems. RESULTS: The model identified 15 independent predictors of falls in dementia and 12 in nondementia cohorts. Falls history was the key predictor of subsequent falls in both dementia (HR 4.75, 95% CI, 4.45-5.06) and nondementia cohorts (HR 4.20, 95% CI, 3.87-4.57). The AUROCC across landmarks ranged from 0.67 to 0.87 for dementia and from 0.66 to 0.86 for nondementia cohorts but generally remained between 0.75 and 0.85 in both cohorts. The total point risk score ranged from -2 to 57 for dementia and 0 to 52 for nondementia cohorts. DISCUSSION: Our novel risk prediction models and scoring systems provide timely person-centered information for continuous monitoring of fall risk in RACFs. CONCLUSION: Embedding these tools within electronic health records could facilitate the implementation of targeted proactive interventions to prevent falls.

Developing a process to measure actual harm from medication errors in paediatric inpatients: From design to implementation.

AIMS: The potential harm associated with medication errors is widely reported, but data on actual harm are limited. When actual harm has been measured, assessment processes are often poorly described, limiting their ability to be reproduced by other studies. Our aim was to design and implement a new process to assess actual harm resulting from medication errors in paediatric inpatient care. METHODS: Prescribing errors were identified through retrospective medical record reviews (n = 26 369 orders) and medication administration errors through direct observation (n = 5137 administrations) in a tertiary paediatric hospital. All errors were assigned potential harm severity ratings on a 5-point scale. Multidisciplinary panels reviewed case studies for patients assigned the highest three potential severity ratings and determined the following: actual harm occurrence and severity level, plausibility of a link between the error(s) and identified harm(s) and a confidence rating if no harm had occurred. RESULTS: Multidisciplinary harm panels (n = 28) reviewed 566 case studies (173 prescribing related and 393 administration related) and found evidence of actual harm in 89 (prescribing = 22, administration = 67). Eight cases of serious harm cases were found (prescribing = 1, administration = 7) and no cases of severe harm. The panels were very confident in 65% of cases (n = 302) where no harm was found. Potential and actual harm ratings varied. CONCLUSIONS: This harm assessment process provides a systematic method for determining actual harm from medication errors. The multidisciplinary nature of the panels was critical in evaluating specific clinical, therapeutic and contextual considerations including care delivery pathways, therapeutic dose ranges and drug-drug and drug-disease interactions.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability.

BACKGROUND: This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change. METHODS: We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. RESULTS: CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. CONCLUSIONS: A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

The Economics of Medication Safety: A Cost-Benefits Analysis Framework for Evaluating an Electronic Medication System.

Medication prescribing in paediatrics is complex and compounded by the need to provide age and weight related doses, and errors continue to be problematic. Electronic medication systems (EMS) can reduce errors through dosing calculators and computerised decision support. However, evidence on costs and benefits of these systems is limited, particularly in paediatric hospitals. This paper presents the development of a cost-benefit analysis (CBA) framework to assess the impact of an EMS implementation in a paediatric tertiary hospital. An innovative component of the framework is the incorporation of the impact of the effects of the EMS for both the health system as well as for patients and their wider family networks, allowing a net social benefit assessment. We describe the impact of non-clinical out-of-pocket costs of admission and use discrete choice experiments to measure both medication related harm and the importance of medication safety to families and members of the community.

Usability of Clinical Decision Support for Adult Sepsis Detection.

This review summarized current literature investigating the usability of computerized clinical decision support (CCDS) systems for the early detection of sepsis in adult inpatients. Ten databases were systematically searched, identifying nine studies. Overall, the lack of good usability testing and the critical need for setting-specific testing were highlighted, as each different CCDS and unique hospital environment brings a diverse range of usability concerns that must be managed for CCDS systems to effectively improve patient care.