Fatal Adverse Events in Femoral Neck Fracture Patients Undergoing Hemiarthroplasty or Total Hip Arthroplasty-A Retrospective Record Review Study in a Nationwide Sample of Deceased Patients.

OBJECTIVES: Patient safety is a core component of quality of hospital care and measurable through adverse event (AE) rates. A high-risk group are femoral neck fracture patients. The Dutch clinical guideline states that the treatment of choice is cemented total hip arthroplasty (THA) or hemiarthroplasty (HA). We aimed to identify the prevalence of AEs related to THA/HA in a sample of patients who died in the hospital. METHODS: We used data of a nationwide retrospective record review study. Records were systematically reviewed for AEs, preventability and contribution to the patient's death. We drew a subsample of THA/HA AEs and analyzed these cases. RESULTS: Of the 2998 reviewed records, 38 patients underwent THA/HA, of whom 24 patients suffered 25 AEs (prevalence = 68.1%; 95% confidence interval, 51.4-81.2), and 24 contributed to death. Patients with a THA/HA AE were of high age (median = 82.5 y) and had severe comorbidity (Charlson score ≥5). The majority of THA/HA AEs had a patient-related cause and was considered partly preventable. Examples of suggested actions that might have prevented the AEs: refraining from surgery, adhering to medication guidelines, uncemented procedures, comprehensive presurgical geriatric assessment, and better postsurgical monitoring. DISCUSSION: Our study shows a high prevalence of (fatal) adverse events in patients undergoing THA/HA. This seems particularly valid for cemented implants in frail old patients, indicating room for improvement of patient safety in this group. Therefore, we recommend physicians to engage in comprehensive shared decision making with these patients and decide on a treatment fitting to a patient's preexisting health status, preferences, and values.

Evaluating deviations and considerations in daily practice when double-checking high-risk medication administration: A qualitative study using the FRAM.

Background: Double-check protocol compliance during administration is low. Regardless, most high-risk medication administrations are performed without incidents. The present study investigated the process of preparing and administrating high-risk medication and examined which variations occur in daily practice. Additionally, we investigated which considerations were taken into account when deviating from the guidelines. Methods: Ten Dutch hospital wards participated. The Functional Resonance Analysis Method was applied to construct a model depicting the Dutch guidelines and a ward-overarching model visualizing daily practice. To create the ward-overarching model, eight semi-structured interviews were conducted per ward discussing the preparation and administration of high-risk medication. Work related Efficiency-Thoroughness Trade-Off rules were used to structure subconscious considerations. Results: In total, 77 nurses were interviewed. Six model deviations were found between the guideline model and ward-overarching model. Notably, four variations in double-check procedures were found. Here, time pressure was an important factor. Nurses made a risk-assessment, considering for patient stability, and difficulty of calculations, to determine whether the double-check would be executed. Additionally, subconscious reasonings, such as trusting their own or colleagues expertise, weighed on the decision. Conclusion: Time pressure is the most important factor that withholds nurses from performing the double-check. Nurses instead conduct a risk-assessment to decide if the double-check will be executed. The double-check can thus become habitual or unnecessary for certain medications. In future research, insights of the FRAM could be used to make ward-specific alterations for the double-check procedure of medications, that focus on feasibility in daily practice, while maintaining patient safety.

Patient participation during discharge medication counselling: Observing real-life communication between healthcare professionals and patients.

OBJECTIVES: Previous studies on hospital discharge showed limited patient involvement, despite its positive outcomes. In this study, provider-patient communication used to enhance patient participation during discharge medication counselling was examined. METHODS: This study comprises a qualitative descriptive observational study. Thirty-four discharge consultations were observed, audio recorded and analysed. We conducted a deductive analysis, elaborating on findings from earlier research. We selected themes and underlying codes illustrating professional-patient communication. For every theme, we identified examples to demonstrate its manifestation during discharge medication counselling. We also assessed what information healthcare professionals (HCPs) shared. RESULTS: HCPs used cues to increase patient participation, e.g. inquired about patient's preferences, showed empathy and support, and verified understanding of information shared. Patient participation occurred through asking questions, and expressing concerns. A central component in discharge medication counselling was the transmission of information from HCPs to patients. This resulted in HCPs taking a leading role. CONCLUSIONS: Several HCP cues were detected inviting patients to participate in consultations. Some patients participated in discharge medication counselling. This was influenced by timing of discharge consults, the performing HCP and presence of a relative. PRACTICE IMPLICATIONS: HCPs shared a lot of information with patients. However, this does not automatically mean that patients will be able to understand and apply this information. HCPs should understand the importance of using cues to enable patient participation. One example is using the teach-back method for verifying patient understanding. It may also be desirable to ensure that a relative is present when discharge information is offered.

Can using the functional resonance analysis method, as an intervention, improve patient safety in hospitals?: a stepped wedge design protocol.

BACKGROUND: Healthcare professionals are sometimes forced to adjust their work to varying conditions leading to discrepancies between hospital protocols and daily practice. We will examine the discrepancies between protocols, 'Work As Imagined' (WAI), and daily practice 'Work As Done' (WAD) to determine whether these adjustments are deliberate or accidental. The discrepancies between WAI and WAD can be visualised using the Functional Resonance Analysis Method (FRAM). FRAM will be applied to three patient safety themes: risk screening of the frail older patients; the administration of high-risk medication; and performing medication reconciliation at discharge. METHODS: A stepped wedge design will be used to collect data over 16 months. The FRAM intervention consists of constructing WAI and WAD models by analysing hospital protocols and interviewing healthcare professionals, and a meeting with healthcare professionals in each ward to discuss the discrepancies between WAI and WAD. Safety indicators will be collected to monitor compliance rates. Additionally, the potential differences in resilience levels among nurses before and after the FRAM intervention will be measured using the Employee Resilience Scale (EmpRes) questionnaire. Lastly, we will monitor whether gaining insight into differences between WAI and WAD has led to behavioural and organisational change. DISCUSSION: This article will assess whether using FRAM to reveal possible discrepancies between hospital protocols (WAI) and daily practice (WAD) will improve compliance with safety indicators and employee resilience, and whether these insights will lead to behavioural and organisational change. TRIAL REGISTRATION: Netherlands Trial Register NL8778; https://www.trialregister.nl/trial/8778 . Registered 16 July 2020. Retrospectively registered.

Pharmacists' responses to cues and concerns of polypharmacy patients during clinical medication reviews-A video observation study.

OBJECTIVE: The research questions of this study are 1) How do pharmacists respond to negative emotions of patients during a clinical medication review (CMR)? 2) How do patients express negative emotions during a CMR? 3) Who (pharmacist or patient) initiates a negative emotion to be discussed during a CMR? METHODS: We used video-recordings to observe 132 CMR interviews of 49 pharmacists. Videos were coded with the Verona coding definitions on emotional sequences(-provider responses) (VR-CoDES(-P)). RESULTS: In total 2538 negative emotions were identified, mainly expressed as cues (95.0 %). Often cues were expressed as verbal hints to hidden concerns (33.2 %) or were related to cognitive or physical causes (28.3 %).Three-quarters of the negative emotions were elicited by patients. 2670 pharmacists' responses were coded. The most common response was non-explicit providing space (77.6 %) and the least common response was explicit reducing space (5.8 %). CONCLUSION: Pharmacists are mainly non-explicitly providing space in their responses. While this hinders their ability to capture patients' problems it also may enable patients to initiate topics. PRACTICE IMPLICATIONS: Pharmacists are able to respond to patients' negative emotions. Training should focus on developing pharmacist's skills to be more explicit in their responses to get more in-depth knowledge of patients' problems.

A systematic review in select countries of the role of the pharmacist in consultations and sales of non-prescription medicines in community pharmacy.

BACKGROUND: Much has been studied in regard to non-prescription medicines (NPMs), but the impact of greater emphasis toward patient self-selection of such agents is still not well understood, and evidence in the literature might be equivocal. OBJECTIVE: The aim was to examine whether or not pharmacist interventions are important in the sale of NPMs and to summarize the evidence of pharmacists' contribution in maintaining patient safety and improving the quality of consultations involving NPMs. METHODS: Seven online databases were searched to identify the literature on studies conducted within the UK and in countries comparable to the UK reporting on consultations and selling of NPMs published between 1980 and 2013. All study designs except for quantitative surveys were eligible for inclusion into the review. The data extraction and quality assessment were performed according to the National Institute for Health and Care Excellence guidelines. The data extracted from the studies were analyzed and presented qualitatively. RESULTS: Eighty-three studies from an original 12,879 citations were included in this review. Just under half of the studies were published between 2000 and 2009 (n = 38; 46%). Thirty-three (44%) of the studies were conducted in the UK. The review showed that in terms of the contribution of community pharmacy staff in consultations for NPMs, non-pharmacist staff dealt with a large proportion of the consultations and pharmacists were usually involved in the consultation through referral from non-pharmacist staff member. Counseling was not consistently offered to everyone. Where counseling was provided it was not always of sufficient quality. Consultations were performed much better when symptoms were presented compared to when people made a direct product request. Pharmacists were reported to conduct better consultations than non-pharmacist staff. There was evidence to suggest that where counseling was appropriately provided this afforded the person a safe environment to utilize their NPMs. CONCLUSIONS: Seeking methods to develop better engagement with customers accessing pharmacy services for NPMs is necessary to enhance the interaction between these two parties. Efforts to enhance the community pharmacy environment to bring about a more positive experience for people using pharmacy is needed at present and will be important if the model for the selection of NPMs is modified in the UK. More studies are needed to allow a better understanding of the impact self-selection may have on patient safety in the community pharmacy context.

Pharmacist-Led Self-management Interventions to Improve Diabetes Outcomes. A Systematic Literature Review and Meta-Analysis.

Background: Treatment of diabetes requires a strict treatment scheme which demands patient self-management. Pharmacists are in a good position to provide self-management support. This review examines whether pharmacist-led interventions to support self-management in diabetes patients improve clinical and patient-reported outcomes. Methods: This review was conducted according to the PRISMA guidelines. An extended literature search was conducted with the keywords "pharmacist," "diabetes," and "self-management" using the electronic databases Pubmed, Embase, CINAHL, PsycINFO, Web of Science, and the Cochrane Library from the beginning of the database through September 2017. In addition reference lists of systematic reviews and included studies were searched. Eligibility criteria included; self-management intervention tested with an RCT, performed in an ambulatory care setting, led by a pharmacist and reporting at least one clinical- or patient-reported outcome. Primary outcomes were HbA1c (-as this is a clinical parameter for long-term diabetes follow-up), self-management and components of intervention. Secondary outcomes were blood glucose, blood pressure, BMI, lipids, adherence to medication, quality of life, and diabetes knowledge. For the meta-analysis HbA1c values were pooled with a random-effects model in Revman 5.3. Risk of bias was assessed with the Cochrane Risk of Bias tool. Results: Twenty-four studies representing 3,610 patients were included. Pharmacist-led self-management interventions included education on diabetes complications, medication, lifestyle, and teaching of self-management skills. Some studies focused on patient needs through a tailored intervention. No key components for a successful self-management intervention could be identified. Pharmacist-led self-management interventions improve HbA1c levels with a mean of 0.71% (CI -0.91, -0.51; overall effect P < 0.0001) and had a positive effect on blood pressure (SBP -5.20 mm Hg [-7.58; -2.92], DBP -3.51 mmHg [-6.00; -1.01]), BMI (-0.49 kg/m2 [-0.79; -0.19]), lipids (total cholesterol -0.19 mmol/l [-0.33; -0.05], LDL-C mmol/l -0.16 [-0.26; -0.06], HDL-C 0.32 mmol/l [0.02; 0.61]), self-management skill development, and adherence to medication. Conclusion: Pharmacist-led self-management interventions significantly improve HbA1c values in diabetes patients. These results underline the added value of pharmacists in patient-related care. Pharmacists should offer self-management support to diabetes patients in order to improve diabetes outcomes.