Interventions to Enhance Medication Safety in Residential Aged-care Settings: An Umbrella Review.

AIM: To conduct a systematic synthesis of existing evidence reviews on interventions to enhance medication safety in residential aged-care settings (RACS) to establish and compare their effectiveness. METHOD: This umbrella review included examination of meta-analyses, scoping and systematic reviews. Four electronic databases were examined for eligible reviews. Two authors critically appraised those meeting the inclusion criteria using the Joanna Briggs Institute Critical Appraisal Instrument. RESULTS: Fifteen reviews covering 171 unique, primary studies were included. Of the variety of interventions identified in the literature, five main categories of interventions were commonly reported to be effective in promoting medication safety in RACS (medication review, staff education, multidisciplinary team meetings, computerised clinical decision support systems and miscellaneous). Most reviews showed mixed evidence to support intervention effectiveness due to the significant heterogeneity between studies in their sites, sample sizes and intervention periods. In all intervention categories, pharmacists' collaboration was most beneficial, showing definitive evidence for improving medication safety and quality of prescribing in RACS. Eight reviews recommended multicomponent interventions, particularly medication reviews and staff education, but specific details were infrequently provided. Only five reviews presented insights into implementation facilitators and barriers, while the sustainability of interventions was only discussed in one review. CONCLUSION: There is strong evidence to support the four main categories of interventions identified. However, limited details are available regarding the most appropriate design and implementation of multicomponent interventions and the sustainability of all interventions, thus solid recommendations cannot be made. Future research in this field should focus on producing theoretically informed, methodologically robust, original research, particularly regarding the design, implementation and sustainability of multicomponent interventions, which appears the most promising approach.

Developing a conceptual framework for patient safety culture in emergency department: A review of the literature.

Patient safety culture is a critical component of modern health care. However, the high-paced, unpredictable nature of the emergency department (ED) environment may impact adversely on it. The aim of this paper is to explore the concept of patient safety culture as it may apply to emergency health care, and to propose a conceptual framework that could form the basis for interventions designed to improve it. This is a systematic review of the literature. A search was undertaken of common electronic bibliographic databases using key words such as safety culture, safety climate, and Emergency Department. Articles were analysed for consistent themes with the aim to construct a conceptual framework. Ten articles met the inclusion criteria that specifically examined safety culture in the ED. Synthesis of the literature resulted in the emergence of three overarching themes of ED practice found to impact on safety culture in the ED. These were the dimensions of patient safety culture, the factors influencing it, and the interventions for improving it. A conceptual framework was constructed that identifies elements that significantly impact the patient safety culture in the ED. This framework may assist managers and researchers to take a comprehensive approach to build an effective safety culture in ED setting.

Electron paramagnetic resonance spectroscopy of nitroxide-labeled calmodulin.

Calmodulin (CaM) is a highly conserved calcium-binding protein consisting of two homologous domains, each of which contains two EF-hands, that is known to bind well over 300 proteins and peptides. In most cases the (Ca(2+))(4-)form of CaM leads to the activation of a key regulatory enzyme or protein in a myriad of biological processes. Using the nitroxide spin-labeling reagent, 3-(2-iodoacetamido)-2,2,5,5-tetramethyl-1-pyrrolidinyl oxyl, bovine brain CaM was modified at 2-3 methionines with retention of activity as judged by the activation of cyclic nucleotide phosphodiesterase. X-band electron paramagnetic resonance (EPR) spectroscopy was used to measure the spectral changes upon addition of Ca(2+) to the apo-form of spin-labeled protein. A significant loss of spectral intensity, arising primarily from reductions in the heights of the low, intermediate, and high field peaks, accompanied Ca(2+) binding. The midpoint of the Ca(2+)-mediated transition determined by EPR occurred at a higher Ca(2+) concentration than that measured with circular dichroic spectroscopy and enzyme activation. Recent data have indicated that the transition from the apo-state of CaM to the fully saturated form, [(Ca(2+))(4-)CaM], contains a compact intermediate corresponding to [(Ca(2+))(2-)CaM], and the present results suggest that the spin probes are reporting on Ca(2+) binding to the last two sites in the N-terminal domain, i.e. for the [(Ca(2+))(2)-CaM] → [(Ca(2+))(4-)CaM] transition in which the compact structure becomes more extended. EPR of CaM, spin-labeled at methionines, offers a different approach for studying Ca(2+)-mediated conformational changes and may emerge as a useful technique for monitoring interactions with target proteins.

Measures of adiposity and risk of breast cancer in older postmenopausal women.

OBJECTIVES: To determine whether higher adiposity is associated with greater breast cancer risk in older postmenopausal women. DESIGN: Prospective cohort study with mean follow-up of 11.3 years. SETTING: Four U.S. clinical centers. PARTICIPANTS: Seven thousand five hundred twenty-three women (mean age 73.5) enrolled in the Study of Osteoporotic Fractures. MEASUREMENTS: Weight, height, and waist and hip circumference were measured at baseline. Body composition was determined using bioelectrical impedance. Risk factor information was obtained by interview and questionnaire. Bone mineral density was measured using dual energy x-ray absorptiometry. The outcome was incident invasive breast cancer, confirmed using medical records. RESULTS: After adjustment for multiple risk factors, including bone density, women in the uppermost quartiles of weight, weight gain since age 25, body mass index, waist circumference, and percentage of body fat had higher breast cancer rates than women in the first quartiles of each measure. For example, breast cancer rates were 49% higher for women in the uppermost quartile of weight (hazard ratio (HR)=1.49, 95% confidence interval (CI)=1.05-2.10), 64% higher for women in the top quartile of weight gain since age 25 (HR=1.64, 95% CI=1.15-2.34), and 58% higher for women in the top quartile of percentage of body fat (HR=1.58, 95% CI=1.11-2.23) than for women in the lowest quartile of each measure. The associations between adiposity measures and breast cancer rates were not altered when the analyses were limited to very elderly women (> or = 70). CONCLUSION: Higher adiposity is an independent risk factor for breast cancer in elderly women.

Long-term prediction of incident hip fracture risk in elderly white women: study of osteoporotic fractures.

OBJECTIVES: To identify independent risk factors for first hip fracture over 10 years of follow-up. DESIGN: Prospective cohort study. SETTING: Four U.S. clinical centers. PARTICIPANTS: A total of 6,787 women aged 66 and older in the Study of Osteoporotic Fractures. MEASUREMENTS: Total hip bone mineral density (BMD) using dual-energy x-ray absorptiometry and a comprehensive set of potential risk factors were collected. Incident hip fractures were identified prospectively and confirmed using radiographic report. RESULTS: Six hundred two women (8.9%) had a hip fracture during a mean +/- standard deviation (SD) follow-up of 10.1 +/- 3.2 years. Older age, previous self-reported fracture after age 50, maternal history of hip fracture after age 50, greater height at age 25, impaired cognition, slower walking speed, nulliparity, type II diabetes mellitus, Parkinson's disease, and depth perception each independently predicted a 1.17- to 1.83-fold increase in hip fracture risk, whereas each SD (0.13 g/cm2) decrease in hip BMD was independently associated with a 1.84-fold increase in risk. Lower body mass index also was associated with an increased risk of hip fracture, although lower hip BMD largely explained this association. CONCLUSION: Although hip BMD is strongly related to hip fracture risk in elderly white women, other clinical risk factors also are independent predictors of long-term risk and provide additional insight into the prevention of fracture in high-risk women. Clinicians should be alert to factors other than BMD that place older women at a high risk of hip fracture.

Intentional and unintentional weight loss increase bone loss and hip fracture risk in older women.

OBJECTIVES: To test the hypothesis that unintentional weight loss increases the rate of bone loss and risk of hip fracture more than intentional weight loss. DESIGN: Prospective cohort study. SETTING: Four communities within the United States. PARTICIPANTS: Six thousand seven hundred eighty-five elderly white women with measurement of weight change and assessment of intention to lose weight. MEASUREMENTS: Weight change between baseline and fourth examinations (average 5.7 years between examinations) and assessment of intention to lose weight. Weight loss was defined as a decrease of 5% or more from baseline weight, stable weight was defined as less than a 5% change from baseline weight, and weight gain was defined as an increase of 5% or more from baseline weight. Rate of change in bone mineral density at the hip between fourth and sixth examinations (average 4.4 years between examinations) was measured using dual-energy x-ray absorptiometry. Incident hip fractures occurring after the fourth examination until June 1, 2001 (average follow-up 6.6 years) was confirmed using radiographic reports. RESULTS: The adjusted average rate of decline in total hipbone density steadily increased from -0.52% per year in women with weight gain to -0.68% per year in women with stable weight to -0.92% per year in women with weight loss (P-value for trend <.001). Higher rates of hip-bone loss were observed in women with weight loss irrespective of body mass index (BMI) or intention to lose weight. During follow-up of an average 6.6 years after the fourth examination, 400 (6%) of the cohort suffered a first hip fracture. Women with weight loss had 1.8 times the risk (95% confidence interval (CI)=1.43-2.24) of subsequent hip fracture as those with stable or increasing weight. The association between weight loss and increased risk of hip fracture was consistent across categories of BMI and intention to lose weight. Even voluntary weight loss in overweight women with a BMI of 25.9 kg/m2 (median) or greater increased the risk of hip fracture (multivariate hazard ratio=2.48, 95% CI=1.33-4.62). CONCLUSION: Older women who experience weight loss in later years have increased rates of hip-bone loss and a two-fold greater risk of subsequent hip fracture, irrespective of current weight or intention to lose weight. These findings indicate that even voluntary weight loss in overweight elderly women increases hip fracture risk.

Central nervous system active medications and risk for fractures in older women.

BACKGROUND: Use of central nervous system (CNS) active medications may increase the risk for fractures. Prior studies are limited by incomplete control of confounders. METHODS: To determine whether use of CNS active medications, including benzodiazepines, antidepressants, anticonvulsants, and narcotics, increases fracture risk in elderly, community-dwelling women, we examined use of these 4 categories of medications in a cohort of 8127 older women and followed the participants prospectively for incident nonspine fractures, including hip fractures. Current use of CNS active medications was assessed by interview with verification of use from containers between 1992 and 1994 and between 1995 and 1996. Use was coded as a time-dependent variable. Incident nonspine fractures occurring after the initial medication assessment until May 31, 1999, were confirmed by radiographic reports. RESULTS: During an average follow-up of 4.8 years, 1256 women (15%) experienced at least one nonspine fracture, including 288 (4%) with first hip fractures. Compared with nonusers, women taking narcotics (multivariate hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.06-1.83) and those taking antidepressants (multivariate HR, 1.25; 95% CI, 0.99-1.58) had increases in the risks for any nonspine fractures. Women taking tricyclic antidepressants and those using selective serotonin reuptake inhibitors (SSRIs) had similar fracture rates. There were no independent associations between benzodiazepine use or anticonvulsant use and risk for nonspine fracture. Women taking antidepressants compared with nonusers had a 1.7-fold increase in the risk for hip fracture (multivariate HR, 1.65; 95% CI, 1.05-2.57). We did not observe independent associations between use of any of the other 3 classes of CNS active medications and risk of hip fracture. CONCLUSIONS: Community-dwelling older women taking narcotics have an increased risk for any nonspine fracture, and those taking antidepressants have a greater risk for nonspine fractures, including hip fracture. Rates of fracture were similar in women taking tricyclic antidepressants and those using SSRIs. Benzodiazepine use and anticonvulsant use were not independently associated with an increased risk of nonspine fractures, including hip fracture.

Central nervous system-active medications and risk for falls in older women.

OBJECTIVES: To determine whether current use of central nervous system (CNS)-active medications, including benzodiazepines, antidepressants, anticonvulsants, and narcotics, increases the risk for subsequent falls. DESIGN: Prospective cohort study. SETTING: Four clinical centers in Baltimore, Maryland; Portland, Oregon; Minneapolis, Minnesota; and the Monongahela Valley, Pennsylvania. PARTICIPANTS: Eight thousand one hundred twenty-seven women aged 65 and older participating in the fourth examination of the Study of Osteoporotic Fractures between 1992 and 1994. MEASUREMENTS: Current use of CNS-active medications was assessed with an interviewer-administered questionnaire with verification of use from medication containers. A computerized dictionary was used to categorize type of medication from product brand and generic names. Incident falls were reported every 4 months for 1 year after the fourth examination. RESULTS: During an average follow-up of 12 months, 2,241 women (28%) reported falling at least once, including 917 women (11%) who experienced two or more (frequent) falls. Compared with nonusers, women using benzodiazepines (multivariate odds ratio (MOR) = 1.51, 95% confidence interval (CI) = 1.14-2.01), those taking antidepressants (MOR = 1.54, 95% CI = 1.14-2.07), and those using anticonvulsants (MOR = 2.56, 95% CI = 1.49-4.41) were at increased risk of experiencing frequent falls during the subsequent year. We found no evidence of an independent association between narcotic use and falls (MOR = 0.99 for frequent falling, 95% CI = 0.68-1.43). Among benzodiazepine users, both women using short-acting benzodiazepines (MOR = 1.42, 95% CI = 0.98-2.04) and those using long-acting benzodiazepines (MOR = 1.56, 95% CI = 1.00-2.43) appeared to be at greater risk of frequent falls than nonusers, although the CIs overlapped 1.0. We found no evidence to suggest that women using selective serotonin-reuptake inhibitors (MOR = 3.45, 95% CI = 1.89-6.30) had a lower risk of frequent falls than those using tricyclic antidepressants (MOR 1.28, 95% CI = 0.90-1.84). CONCLUSIONS: Community-dwelling older women taking CNS-active medications, including those taking benzodiazepines, antidepressants, and anticonvulsants, are at increased risk of frequent falls. Minimizing use of these CNS-active medications may decrease risk of future falls. Our results suggest that fall risk in women taking benzodiazepines is at best marginally decreased by use of short-acting preparations. Similarly, our findings indicate that preferential use of selective serotonin-reuptake inhibitors is unlikely to reduce fall risk in older women taking antidepressants.

Cost drivers of ambulatory physiotherapy episodes of care provided in acute public hospital settings.

This study examined cost drivers of 2,490 completed episodes of ambulatory physiotherapy care provided over an eight-month period in seven public hospitals in three Australian states. An episode described the physiotherapy outpatient management for a particular patient with a particular condition, and consisted of start and finish dates, and all the occasions of service in between. The most robust description of a physiotherapy episode of care was unit record attributable time, split at 120 minutes. Factors which were strongly associated with physiotherapy episodes were age, referral mechanism, source of income, chronicity, country of origin and travel arrangements. This study highlights areas which require attention before further large scale studies can be conducted, and provides a basis for future investigations into the cost of providing physiotherapy ambulatory services.