Medication monitoring for people with dementia in care homes: the feasibility and clinical impact of nurse-led monitoring.

OBJECTIVES: People with dementia are susceptible to adverse effects of medicines. However, they are not always closely monitored. We explored (1) feasibility and (2) clinical impact of nurse-led medication monitoring. DESIGN: Feasibility "before-and-after" intervention study. SETTING: Three care homes in Wales. PARTICIPANTS: Eleven service users diagnosed with dementia, taking at least one antipsychotic, antidepressant, or antiepileptic medicine. INTERVENTION: West Wales Adverse Drug Reaction (ADR) Profile for Mental Health Medicines. OUTCOME MEASURES: (1) Feasibility: recruitment, retention, and implementation. (2) Clinical impact: previously undocumented problems identified and ameliorated, as recorded in participants' records before and after introduction of the profile, and one month later. RESULTS: Nurses recruited and retained 11 of 29 eligible service users. The profile took 20-25 minutes to implement, caused no harm, and supplemented usual care. Initially, the profile identified previously undocumented problems for all participants (mean 12.7 (SD 4.7)). One month later, some problems had been ameliorated (mean 4.9 (3.6)). Clinical gains included new prescriptions to manage pain (2 participants), psoriasis (1), Parkinsonian symptoms (1), rash (1), dose reduction of benzodiazepines (1), new care plans for oral hygiene, skin problems, and constipation. CONCLUSIONS: Participants benefited from structured nurse-led medication monitoring. Clinical trials of our ADR Profile are feasible and necessary.

Development and clinical gains of nurse-led medication monitoring profiles.

AIM: This paper reports on the development of an instrument for nurse-led medication monitoring, the West Wales Adverse Drug Reaction profile for respiratory medicines, as part of a strategy to reduce avoidable adverse drug reactions. BACKGROUND: Preventable adverse drug reactions account for 3.7% hospital admissions. Nurse-led medication monitoring may reduce drug-related harm. However, development of medication monitoring strategies is not reported elsewhere. METHODS: The profile was developed by: (1) cognitive interviews (n = 4), (2) the content validity index (n = 10) involving academics, clinicians and service users prescribed respiratory medicines, (3) inter-rater reliability (n = 48) and clinical gains in a nurse-led outpatient clinic. RESULTS: Cognitive interviews prompted more profile changes than either the content validity index or inter-rater reliability testing. Cohen's κ for inter-rater reliability for each item ranged from 0.73-1.00 (good to complete agreement). The profile identified previously unsuspected problems in all participants, including muscular weakness, skin and mouth problems. CONCLUSIONS: The West Wales Adverse Drug Reaction profile was valid and reliable, and helped to detect and ameliorate drug-related harm. IMPLICATIONS FOR NURSING MANAGEMENT: The West Wales Adverse Drug Reaction profile offers opportunities to improve care. Medication monitoring provides the structure to concurrently monitor known adverse drug reactions. Practice-based adverse drug reaction profiles benefit from cognitive, content validity and inter-rater reliability testing.

Adverse drug reactions: treatment burdens and nurse-led medication monitoring.

AIM: This paper focuses on adverse drug reactions and the potential for introduction of nurse-led medication monitoring. BACKGROUND: The prevention of patient harm caused by health-care organizations was accorded international priority over a decade ago, yet adverse drug reactions remain a significant treatment burden to patients. EVALUATION: This paper reviews the literature to summarize existing knowledge and understand treatment burdens associated with adverse drug reactions. KEY ISSUES: While epidemiological studies explore the magnitude and complex nature of adverse incidents in health-care organizations, the monitoring of prescribed medications and their adverse effects remains an area of concern. Nurse-led medication monitoring has been highlighted as an initiative to minimize unnecessary drug-related patient harm. CONCLUSION: This paper indicates that nurses are well-placed to monitor and reduce drug-related morbidity, and builds upon previous work which prioritizes the monitoring of prescribed medicine in a nurse-led adverse drug reaction profile. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse-led medication monitoring presents a unique opportunity to curtail unnecessary treatment burdens. However, important considerations including, patients' and professionals' time, added paperwork, nurse education and training and inter-professional communication need to be explored. Further work is now needed to establish the clinical gains and patient outcomes of nurse-led medication monitoring.

Medication monitoring in a nurse-led respiratory outpatient clinic: pragmatic randomised trial of the West Wales Adverse Drug Reaction Profile.

OBJECTIVE: To assess the clinical effect of medication monitoring using the West Wales Adverse Drug Reaction (ADR) Profile for Respiratory Medicine. DESIGN: Single-site parallel-arm pragmatic trial using stratified randomisation. SETTING: Nurse-led respiratory outpatient clinic in general hospital in South Wales. PARTICIPANTS: 54 patients with chronic respiratory disease receiving bronchodilators, corticosteroids or leukotriene receptor antagonists. INTERVENTION: Following initial observation of usual nursing care, we allocated participants at random to receive at follow up: either the West Wales ADR Profile for Respiratory Medicine in addition to usual care ('intervention arm' with 26 participants); or usual care alone ('control arm' with 28 participants). MAIN OUTCOME MEASURES: Problems reported and actions taken. RESULTS: We followed up all randomised participants, and analysed data in accordance with treatment allocated. The increase in numbers of problems per participant identified at follow up was significantly higher in the intervention arm, where the median increase was 20.5 [inter-quartile range (IQR) 13-26], while that in the control arm was -1 [-3 to +2] [Mann-Whitney U test: z = 6.28, p<0.001]. The increase in numbers of actions per participant taken at follow up was also significantly higher in the intervention arm, where the median increase was 2.5 [1]-[4] while that in the control arm was 0 [-1.75 to +1] [Mann-Whitney U test: z = 4.40, p<0.001]. CONCLUSION: When added to usual nursing care, the West Wales ADR Profile identified more problems and prompted more nursing actions. Our ADR Profile warrants further investigation as a strategy to optimise medication management. TRIAL REGISTRATION: Controlled-trials.com ISRCTN10386209.

Better drug monitoring will reduce risk and benefit patients.

I read with interest the news story on a specialised drug prescribing system that aims to improve surveillance in hospitals and highlight patients at risk of harm resulting from clinical error or criminal activity (news August 8).