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OBJECTIVES: The objective of this study was to determine the frequency of omitted doses of antibacterial agents and explore a number of risk factors, including the effect of a restricted antibacterial system. METHODS: Antibacterial data were extracted from a hospital electronic prescribing and medication administration system for the period 1 January to 30 April 2014. Percentage dose omission rates were calculated. Omission rates for the first dose of antibacterial courses were analysed using logistic regression to identify any correlation between first dose omission rates and potential risk factors, including the antibacterials' restriction status and whether or not they were ward stock. RESULTS: The study included 90â761 antibacterial doses. Of these, 6535 (7.2%) were documented as having been omitted; omission of 847 (0.9% of 90â761) was due to medication being unavailable. Non-restricted, ward stock antibacterials had the lowest frequency of omission, with 6.2% (271 of 4391) first doses omitted. The prevalence was 10.4% (27 of 260) for restricted, ward-stock antibacterials (ORâ=â1.6, 95% CIâ=â1.0-2.4, Pâ=â0.027) and 15.5% (53 of 341) for non-restricted, non-ward stock antibacterials (ORâ=â2.7, 95% CIâ=â2.0-3.7, Pâ<â0.001). Restricted, non-ward stock antibacterials had the highest frequency (30.7%, 71 of 231; ORâ=â6.2, 95% CIâ=â4.5-8.4, Pâ<â0.001). CONCLUSIONS: Antibacterials not stocked in clinical areas were significantly more likely to be omitted. The prevalence of omitted doses increased further if the antibiotic was also restricted. To achieve safe, effective antimicrobial use, a balance is needed between promoting antimicrobial stewardship and preventing unintended omitted doses.
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Antibacterianos/administração & dosagem , Infecções Bacterianas/tratamento farmacológico , Uso de Medicamentos/normas , Prescrição Eletrônica/normas , Erros de Medicação , Adulto , Armazenamento de Medicamentos/métodos , Hospitais , Humanos , Estudos Retrospectivos , Medição de RiscoRESUMO
BACKGROUND: Adverse drug reactions, poor patient adherence and errors, here collectively referred to as medication-related harm (MRH), cause around 2.7-8.0% of UK hospital admissions. Communication gaps between successive healthcare providers exist, but little is known about how MRH is recorded in inpatients' medical records. We describe the presence and quality of MRH documentation for patients admitted to a London teaching hospital due to MRH. Additionally, the international classification of disease 10th revision (ICD-10) codes attributed to confirmed MRH-related admissions were studied to explore appropriateness of their use to identify these patients. METHODS: Clinical pharmacists working on an admissions ward in a UK hospital identified patients admitted due to suspected MRH. Six different data sources in each patient's medical record, including the discharge summary, were subsequently examined for MRH-related information. Each data source was examined for statements describing the MRH: symptom and diagnosis, identification of the causative agent, and a statement of the action taken or considered. Statements were categorised as 'explicit' if unambiguous or 'implicit' if open to interpretation. ICD-10 codes attributed to confirmed MRH cases were recorded. RESULTS: Eighty-four patients were identified over 141 data collection days; 75 met our inclusion criteria. MRH documentation was generally present (855 of 1307 statements were identified; 65%), and usually explicit (705 of 855; 82%). The causative agent had the lowest proportion of explicit statements (139 of 201 statements were explicit; 69%). For two (3%) discharged patients, the causal agent was documented in their paper medical record but not on the discharge summary. Of 64 patients with a confirmed MRH diagnosis at discharge, only six (9%) had a MRH-related ICD-10 code. CONCLUSIONS: Availability of information in the paper medical record needs improving and communication of MRH-related information could be enhanced by using explicit statements and documenting reasons for changing medications. ICD-10 codes underestimate the true occurrence of MRH.
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Codificação Clínica , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Registros Eletrônicos de Saúde , Admissão do Paciente , Documentação/normas , Humanos , Auditoria Médica , Erros de Medicação/efeitos adversos , Estudos Prospectivos , Reino UnidoRESUMO
UNLABELLED: A Check and Correct checklist has previously been developed to increase feedback on prescribing quality and enhance physicians' focus on patients' drug charts during ward rounds. Our objective was to assess the impact of introducing such a prescribing checklist on the quality and safety of inpatient prescribing in two paediatric wards in a London teaching hospital. Between 15 March 2011 and 15 May 2011 (pre-intervention) and between 23 May 2011 and 23 July 2011 (post-intervention), we recorded rates of both technical prescription writing errors and clinical prescribing errors twice a week. During the pre-intervention period, the overall technical error rate was 10.8 % (95 % confidence interval 10.3 %-11.2 %); the clinical error rate was 4.7 % (3.4 %-6.6 %). The most common errors were absence of prescriber's contact details and dose omissions. After the implementation of Check and Correct, error rates were 7.3 % (6.9 %-7.8 %) and 5.5 % (3.9 %-7.9 %), respectively. Segmented regression analysis revealed a significant decrease of -5.0 % in the technical error rate (-7.1 to -2.9 %; -37.7 % relative decrease; R (2) = 0.604) following the intervention, independent of changes in overall medical records' documentation quality. Regarding clinical errors, no significant impact of the intervention could be detected. CONCLUSION: Implementing a Check and Correct checklist led to an improvement in the quality of prescription writing. Although a change in culture may be needed to maximise its potential, we would recommend its more widespread use and evaluation.
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Lista de Checagem , Prescrições de Medicamentos/normas , Erros de Medicação/prevenção & controle , Pediatria/normas , Melhoria de Qualidade , Criança , Documentação/normas , Hospitais de Ensino/normas , Humanos , Londres , Erros de Medicação/estatística & dados numéricos , Segurança do Paciente , Estudos Prospectivos , Garantia da Qualidade dos Cuidados de Saúde/métodos , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Melhoria de Qualidade/organização & administração , Análise de Regressão , Fatores de TempoRESUMO
OBJECTIVES: The UK Department of Health has made recommendations on safe and appropriate prescribing of anti-infectives. In response, we reviewed our anti-infective policies to ensure they were in line with best practice. As a result, a new adult anti-infective policy was launched. To help facilitate its implementation, a quality improvement programme was established, with the aim of achieving >90% compliance with the new policy. METHODS: Patients under the care of the medical admissions teams who had been prescribed one or more systemic anti-infectives between January and November 2008 were included in the study. Study pharmacists collected data daily on all patients, including the anti-infective(s) prescribed and indication(s) documented on either the patient's drug prescription chart or health records. A definition of compliance was developed, which required documented indication(s) and associated anti-infectives to match the anti-infective policy. A baseline compliance level was established; we then implemented a series of interventions using the plan-do-study-act ('PDSA') approach to monitor and improve compliance. Three overlapping intervention phases were retrospectively identified: raising awareness; education; and weekly feedback of results in the form of run charts distributed to medical teams. RESULTS: Over the 11 month study period, compliance with the policy increased from 30% to 71%. Since 2008, we have seen the average compliance increase year-on-year to over 90% in 2010 using a sustainable once weekly data collection model. CONCLUSIONS: This study shows that it is possible to use quality improvement methodology to support antimicrobial stewardship within existing resources and suggests that an improvement in policy compliance can be both achieved and sustained.
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Anti-Infecciosos/uso terapêutico , Uso de Medicamentos/normas , Fidelidade a Diretrizes/normas , Melhoria de Qualidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Política de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Reino Unido , Adulto JovemRESUMO
AIM: To compare the prevalence and causes of prescribing errors in newly written medication orders and how quickly they were rectified, in three NHS organisations. METHODS: Errors in newly written inpatient and discharge medication orders were recorded in Spring/Summer 2009 by ward pharmacists on medical admissions and surgical wards, as well as the number of erroneous doses administered (or omitted) before errors were corrected. Logistic regression analysis was used to explore the effects of ward (nested within organisation) and clinical specialty, and whether the pharmacist had checked the patient's medication history during data collection. Causes were explored using semistructured interviews with key informants. RESULTS: Overall, 1025 prescribing errors were identified in 974 of 6605 medication orders (14.7%, 95% confidence interval (CI) 13.8% to 15.6%). A mean of 0.9 doses were administered (or omitted) before each error was corrected (range 0-11), with differences between specialties and organisations. The error rate on medical admissions wards (16.3%) was significantly higher than that on surgical wards (12.2%), but this was accounted for by the higher proportion of prescribing being on admission, where omission of patients' usual medication was often identified. There were significant differences among wards (and organisations). Contributing factors included lack of feedback on errors, poor documentation and communication of prescribing decisions, and lack of information about patients' medication histories from primary care. CONCLUSIONS: There were variations among wards, organisations and specialties in error rates and how quickly they were rectified. Exploring reasons for differences between organisations may be useful in identifying best practice and potential solutions.
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Competência Clínica/normas , Pacientes Internados/estatística & dados numéricos , Erros de Medicação/estatística & dados numéricos , Sistemas de Medicação no Hospital/normas , Farmacêuticos/normas , Serviço de Farmácia Hospitalar/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Prescrições de Medicamentos/normas , Humanos , Sistemas de Medicação no Hospital/estatística & dados numéricos , Pessoa de Meia-Idade , Farmacêuticos/psicologia , Farmacêuticos/estatística & dados numéricos , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Padrões de Prática Médica/normas , Prevalência , Estudos Prospectivos , Estresse Fisiológico , Reino Unido/epidemiologia , Tolerância ao Trabalho Programado/psicologiaRESUMO
This study aimed to compare interventions made by pharmacists attending consultant-led ward rounds in addition to providing a ward pharmacy service, with those made by pharmacists providing a word pharmacy service alone. A prospective non-randomised controlled study on five inpatient medical wards was carried out at two teaching hospitals. A mean of 1.73 physician-accepted interventions were made per patient for the study group, compared to 0.89 for the control (Mann Whitney U, p < 0.001) with no difference between groups in the nature or clinical importance of the interventions. One physician-accepted intervention was made every eight minutes during the consultant-led ward rounds, compared to one every 63 minutes during a ward pharmacist visit. Pharmacists attending consultant-led ward rounds in addition to undertaking a ward pharmacist visit make significantly more interventions per patient than those made by pharmacists undertaking a ward pharmacist visit alone, rectifying prescribing errors and optimising treatment.
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Erros de Medicação/prevenção & controle , Serviço de Farmácia Hospitalar/organização & administração , Encaminhamento e Consulta/organização & administração , Visitas de Preceptoria/organização & administração , Hospitalização , Humanos , Quartos de Pacientes , Papel Profissional , Estudos ProspectivosRESUMO
BACKGROUND: Almost every patient admitted to hospital will receive medication during their stay. Medication errors are an important cause of patient morbidity and mortality, as well as an economic burden for healthcare institutions. Research suggests that current methods of storing medication on hospital wards are not fit for purpose, contributing to inefficiency and error. AIM: To improve medication storage in inpatient areas, by exploring variation and challenges related to medication storage and designing a prototype solution. METHODS: Set in four hospitals in an English teaching hospital trust, the study used a mixed methods approach comprising a quantitative descriptive survey of storage facilities and practices followed by mixed methods observations of medication rounds and interviews with patients, nurses and pharmacy staff. Quantitative data were presented descriptively and qualitative data analysed thematically and using a human-centered design approach. RESULTS: We identified wide variation in medication storage facilities and practices across 77 wards. Observations and staff interviews in six wards revealed five problem areas: poor management of multiple storage facilities; lack of visibility and organisation of medication within trolleys; inadequate size of storage; lack of ownership and knowledge of standard practice; and use of key locks. Patients were largely satisfied with receiving their medication. Systematic and consistent physical organisation of medication in medication trolleys, and integrating and implementing principles of best practice, were identified as areas for intervention. DISCUSSION AND CONCLUSION: Variation in medication storage facilities and practices existed both across the organization and on individual wards. Multiple challenges were identified in how medication was stored, which if addressed may improve the efficiency and safety of medication administration and in turn, staff and patient experience. The use of design principles alongside a research approach resulted in a rapid, iterative process for developing and refining potential solutions to improve inpatient medication storage.
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Sistemas de Medicação , Humanos , Pacientes Internados , Erros de Medicação , Segurança do PacienteRESUMO
This paper reports a study undertaken in the UK to gather lessons learned from hospital sites that have implemented electronic prescribing systems. The work was commissioned by NHS Connecting for Health, the UK Department of Health agency responsible for the implementation of the National Programme for Information Technology. The aim was to capture front-line experience of the project and systems implementation, and to share it with staff who will in the future participate in other implementations. Data were drawn from detailed interviews with staff and a survey in 13 hospitals in England, as well as a review of published studies of implementations. The study output is a report and six user-facing briefing documents targeted at key stakeholder groups; nurses, pharmacist, doctors, senior executives, implementation team members and IM&T staff.
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Atitude do Pessoal de Saúde , Difusão de Inovações , Prescrição Eletrônica/estatística & dados numéricos , Sistemas de Medicação no Hospital/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde/métodos , Prevenção Secundária/organização & administração , LondresRESUMO
PURPOSE: To compare four methods of detecting prescribing errors (PE) in the same patient cohorts before and after an intervention (computerised physician order entry; CPOE) and to determine whether the impact of CPOE is identified consistently by all methods. METHODS: PEs were identified using (1) prospective detection by ward pharmacist; (2) retrospective health record review; (3) retrospective use of a trigger tool and (4) spontaneous reporting over two separate 4-week periods on one surgical ward in a UK teaching hospital. RESULTS: We reviewed 93 patients pre- and 114 post-CPOE. Using all four methods, we identified 135 PE (10.7% of all medication orders) pre-CPOE, and 127 (7.9%) post-CPOE. There was little overlap in PE detected by the different methods: prospective detection identified 48 (36% of all PE) pre- and 30 (24%) post-CPOE; retrospective review (RR) revealed 93 (69%) pre- and 105 (83%) post-CPOE, trigger tool 0 pre- and 2 (2%) post-CPOE and spontaneous reporting 1 (1%) pre- and 1 (1%) post-CPOE. The calculated relative reduction in risk of PE was 50% using prospective data, 12% with RR and 26% using data from all four methods. CONCLUSIONS: In this study, each method predominantly identified different PE. A combination of methods may be required to understand the true effectiveness of different interventions.
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Prescrições de Medicamentos/normas , Sistemas de Registro de Ordens Médicas/organização & administração , Erros de Medicação/prevenção & controle , Erros de Medicação/estatística & dados numéricos , Sistemas de Medicação no Hospital/organização & administração , Eficiência Organizacional , Hospitais de Ensino , Humanos , Londres , Sistemas de Registro de Ordens Médicas/normas , Sistemas de Registro de Ordens Médicas/estatística & dados numéricos , Sistemas de Medicação no Hospital/normas , Sistemas de Medicação no Hospital/estatística & dados numéricos , Estudos Prospectivos , Estudos RetrospectivosRESUMO
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Electronic prescribing has been shown to reduce prescribing errors in US hospitals. However we know little about its effect on prescribing quality, or its effectiveness in UK hospitals where systems for medication prescribing and supply are very different. Hospital pharmacists already review prescriptions to both detect errors and improve prescription quality. WHAT THIS STUDY ADDS: Electronic prescribing significantly increased prescribing quality in a UK hospital, as shown by fewer pharmacists' interventions and fewer prescribing errors. However, some new types of error were introduced. There was relatively little overlap between prescribing errors and pharmacists' interventions, signifying their different contributions to prescribing quality. Electronic prescribing and pharmacists' interventions should be viewed as an integrated system. AIMS: To investigate the effects of electronic prescribing (EP) on prescribing quality, as indicated by prescribing errors and pharmacists' clinical interventions, in a UK hospital. METHODS: Prescribing errors and pharmacists' interventions were recorded by the ward pharmacist during a 4 week period both pre- and post-EP, with a second check by the principal investigator. The percentage of new medication orders with a prescribing error and/or pharmacist's intervention was calculated for each study period. RESULTS: Following the introduction of EP, there was a significant reduction in both pharmacists' interventions and prescribing errors. Interventions reduced from 73 (3.0% of all medication orders) to 45 (1.9%) (95% confidence interval (CI) for the absolute reduction 0.2, 2.0%), and errors from 94 (3.8%) to 48 (2.0%) (95% CI 0.9, 2.7%). Ten EP-specific prescribing errors were identified. Only 52% of pharmacists' interventions related to a prescribing error pre-EP, and 60% post-EP; only 40% and 56% of prescribing errors resulted in an intervention pre- and post-EP, respectively. CONCLUSIONS: EP improved the quality of prescribing by reducing both prescribing errors and pharmacists' clinical interventions. Prescribers and pharmacists need to be aware of new types of error with EP, so that they can best target their activities to reduce clinical risk. Pharmacists may need to change the way they work to complement, rather than duplicate, the benefits of EP.
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Prescrições de Medicamentos , Sistemas de Medicação no Hospital , Hospitais de Ensino/métodos , Hospitais de Ensino/tendências , Humanos , Erros de Medicação/prevenção & controle , Erros de Medicação/tendências , Sistemas de Medicação no Hospital/tendências , Farmacêuticos/tendências , Serviço de Farmácia Hospitalar/métodos , Serviço de Farmácia Hospitalar/tendênciasRESUMO
The aim of this study was to determine the impact of two specialised admissions pharmacists on an acute medical admissions ward. For a one-week period, contributions made to the medical post-take ward round (PTWR), the number of drug histories taken and interventions made as a result, and the availability of medication needed on discharge were documented. An average of 1.1 contributions per patient were made on the PTWR; a large proportion of these concerned therapeutic choice. Pharmacists also intervened to stop medication due to adverse drug reactions in 12% (n=10) of contributions. Fifty-two drug histories were checked by a pharmacist, resulting in 61 interventions (1.1 interventions per patient). The majority of interventions resulted from the unintentional omission of a regular medication (65%, n=39). Only 24% (n=29) of items needed on discharge had to be dispensed in pharmacy and 33% (n=41) were available as patients' own drugs.
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Hospitais de Distrito/organização & administração , Equipe de Assistência ao Paciente , Farmacêuticos , Serviço de Farmácia Hospitalar/organização & administração , Unidades Hospitalares , Humanos , Londres , Anamnese , Erros de Medicação/prevenção & controle , Admissão do Paciente , Papel Profissional , Medicina Estatal , Reino UnidoRESUMO
BACKGROUND: Prescribing errors occur in up to 15% of UK inpatient medication orders. However, junior doctors report insufficient feedback on errors. A barrier preventing feedback is that individual prescribers often cannot be clearly identified on prescribing documentation. AIM: To reduce prescribing errors in a UK hospital by improving feedback on prescribing errors. INTERVENTIONS: We developed three linked interventions using plan-do-study-act cycles: (1) name stamps for junior doctors who were encouraged to stamp or write their name clearly when prescribing; (2) principles of effective feedback to support pharmacists to provide feedback to doctors on individual prescribing errors and (3) fortnightly prescribing advice emails that addressed a common and/or serious error. IMPLEMENTATION AND EVALUATION: Interventions were introduced at one hospital site in August 2013 with a second acting as control. Process measures included the percentage of inpatient medication orders for which junior doctors stated their name. Outcome measures were junior doctors' and pharmacists' perceptions of current feedback provision (evaluated using quantitative pre-questionnaires and post-questionnaires and qualitative focus groups) and the prevalence of erroneous medication orders written by junior doctors between August and December 2013. RESULTS: The percentage of medication orders for which junior doctors stated their name increased from about 10% to 50%. Questionnaire responses revealed a significant improvement in pharmacists' perceptions but no significant change for doctors. Focus group findings suggested increased doctor engagement with safe prescribing. Interrupted time series analysis showed no difference in weekly prescribing error rates between baseline and intervention periods, compared with the control site. CONCLUSION: Findings suggest improved experiences around feedback. However, attempts to produce a measurable reduction in prescribing errors are likely to need a multifaceted approach of which feedback should form part.
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Prescrições de Medicamentos/normas , Feedback Formativo , Corpo Clínico Hospitalar , Melhoria de Qualidade , Humanos , Erros de Medicação/prevenção & controle , Padrões de Prática Médica , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Patients prescribed intravenous (IV) glycopeptides usually remain in hospital until completion of this treatment. Some of these patients could be discharged earlier if a switch to an oral antibiotic was made. This study was designed to identify the percentage of inpatients currently prescribed IV glycopeptides who could be discharged earlier if a switch to an oral agent was used, and to estimate the number of bed days that could be saved. We also aimed to identify the patient group(s) most likely to benefit, and to estimate the number of days of IV therapy that could be prevented in patients who remained in hospital. METHODS: Patients were included if they were prescribed an IV glycopeptide for 5 days or more. Predetermined IV to oral antibiotic switch criteria and discharge criteria were applied. A multiple logistic regression model was used to identify the characteristics of the patients most likely to be suitable for earlier discharge. RESULTS: Of 211 patients, 62 (29%) could have had a reduced length of stay if they were treated with a suitable oral antibiotic. This would have saved a total of 649 inpatient days (median 5 per patient; range 1-54). A further 31 patients (15%) could have switched to oral therapy as an inpatient thus avoiding IV line use. The patients most likely to be suitable for early discharge were those with skin and soft tissue infection, under the cardiology, cardiothoracic surgery, orthopaedics, general medical, plastic surgery and vascular specialities, with no high risk comorbidity and less than five other regularly prescribed drugs. CONCLUSION: The need for glycopeptide therapy has a significant impact on length of stay. Effective targeting of oral antimicrobials could reduce the need for IV access, allow outpatient treatment and thus reduce the length of stay in patients with infections caused by antibiotic resistant gram-positive bacteria.
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Antibacterianos/administração & dosagem , Farmacorresistência Bacteriana Múltipla , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções por Bactérias Gram-Positivas/microbiologia , Tempo de Internação , Teicoplanina/administração & dosagem , Vancomicina/administração & dosagem , Administração Oral , Antibacterianos/uso terapêutico , Feminino , Humanos , Injeções Intravenosas , Masculino , Teicoplanina/uso terapêutico , Vancomicina/uso terapêuticoRESUMO
BACKGROUND: Inpatient medication errors are a significant concern. An approach not yet widely studied is to facilitate greater involvement of inpatients with their medication. At the same time, electronic prescribing is becoming increasingly prevalent in the hospital setting. In this study we aimed to explore hospital inpatients' involvement with medication safety-related behaviours, facilitators and barriers to this involvement, and the impact of electronic prescribing. METHODS: We conducted ethnographic observations and interviews in two UK hospital organisations, one with established electronic prescribing and one that changed from paper to electronic prescribing during our study. Researchers and lay volunteers observed nurses' medication administration rounds, pharmacists' ward rounds, doctor-led ward rounds and drug history taking. We also conducted interviews with healthcare professionals, patients and carers. Interviews were audio-recorded and transcribed. Observation notes and transcripts were coded thematically. RESULTS: Paper or electronic medication records were shown to patients in only 4 (2%) of 247 cases. However, where they were available during patient-healthcare professional interactions, healthcare professionals often viewed them in order to inform patients about their medicines and answer any questions. Interprofessional discussions about medicines seemed more likely to happen in front of the patient where paper or electronic drug charts were available near the bedside. Patients and carers had more access to paper-based drug charts than electronic equivalents. However, interviews and observations suggest there are potentially more significant factors that affect patient involvement with their inpatient medication. These include patient and healthcare professional beliefs concerning patient involvement, the way in which healthcare professionals operate as a team, and the underlying culture. CONCLUSION: Patients appear to have more access to paper-based records than electronic equivalents. However, to develop interventions to increase patient involvement with medication safety behaviours, a wider range of factors needs to be considered.
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Pacientes Internados/psicologia , Erros de Medicação/psicologia , Participação do Paciente/psicologia , Prescrições de Medicamentos , Prescrição Eletrônica , Pessoal de Saúde/psicologia , Hospitais , Humanos , Preparações Farmacêuticas/administração & dosagem , Serviço de Farmácia Hospitalar/métodos , Pesquisa Qualitativa , SegurançaRESUMO
PLAIN ENGLISH SUMMARY: There is a consensus that patients and the public should be involved in research in a meaningful way. To date, lay people have been mostly involved in developing research ideas and commenting on patient information but not as much in actual data collection. We have had firsthand experience with lay people helping to conduct a study on how patients in hospital are involved with their medicines. In the first part of this study, we observed doctors' ward rounds, pharmacists' ward visits and nurses' drug administration rounds, to find out if and how healthcare professionals interacted with patients about their medicines. Lay people conducted some of these observations. We wanted to explore the benefits and challenges of having lay people conduct these observations, to tell us more about how lay people can be involved in conducting such research. We interviewed the lay members and researchers involved in this research to find out their views. We also looked at the observation notes to identify what the lay people had noticed that the researchers had not. The lay members and researchers reported that lay members added value to the study by bringing new perspectives. Lay people had noticed some different things to the researchers. We experienced some challenges which need to be addressed. These weregetting the lay observers registered with the hospitals to allow them to be on the wards in this capacitylay observers and researchers having different understanding of research procedures such as patient consenttrying to find lay observers of different backgrounds and ethnic groups. ABSTRACT: Background: It is recognised that involving lay people with research in a meaningful rather than tokenistic way is both important and challenging. In a recent health services research study addressing inpatient involvement in medication safety, we sought to overcome this challenge by including lay people in collecting observational data in the hospital setting. The aim of this study was to evaluate lay and researcher perspectives on lay involvement in data collection in order to inform and enhance the future role of lay people in carrying out health services research. Methods: We conducted semi-structured interviews with the lay members who collected observational data in our wider study and the researchers who provided support and/or were involved in their recruitment and training. The interviews were transcribed verbatim and coded using open thematic analysis. In addition, we conducted secondary analysis of the observational data to identify the specific contributions of lay observers. Results: We interviewed the three lay members and the four researchers involved. Both these interviews and the secondary data analysis demonstrated that the lay members added value to the study by bringing additional general perspectives on communication with hospital inpatients. Combined with researchers' perspectives on interactions more specifically related to medication, this provided a broader answer to our research question of how healthcare professionals facilitate inpatient understanding of their medication and involvement in medication safety. This contrasted to the involvement lay observers reported having in previous research where their role had been more consultative. The lay members all reported that carrying out the observations had been an interesting and informative experience. Some challenges arose including the infrastructure not having been in place to support this specialist lay research role, differing paradigms of research governance held by the public and researchers in relation to consent procedures and difficulties in recruiting a diverse range of members of the public to carry out the role. Conclusions: Lay members can add value to research by being involved in data collection within health services research. There is a need to build infrastructure to better support this involvement.
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OBJECTIVES: To describe current use of electronic prescribing (EP) in English acute NHS hospital trusts, and the use of multiple EP systems within the same hospital. DESIGN: Descriptive cross-sectional postal survey. SETTING: Acute NHS hospital trusts in England. PARTICIPANTS: The survey was sent to chief pharmacists in all acute English NHS hospital trusts in 2011. Where trusts comprised multiple hospitals, respondents were asked to complete the questionnaire for their main acute hospital. MAIN OUTCOME MEASURES: Prevalence of EP use in acute NHS hospitals; number of different EP systems in each hospital; stages of the patient pathway in which EP used; extent of deployment across the hospital; comprehensiveness regarding the drugs prescribed; decision support functionalities used. RESULTS: We received responses from 101 trusts (61%). Seventy (69%) respondent hospitals had at least one form of EP in use. More than half (39;56%) of hospitals with EP had more than one system in use, representing 60 different systems. The most common were systems used only for discharge prescribing, used in 48 (48% of respondent hospitals). Specialist chemotherapy EP systems were second most common (34; 34%). Sixteen specialist inpatient systems were used across 15 hospitals, most commonly in adult critical care. Only 13 (13%) respondents used inpatient electronic prescribing across all adult medical and surgical wards. Overall, 24 (40%) systems were developed 'in-house'. Decision support functionality varied widely. CONCLUSIONS: It is UK government policy to encourage the adoption of EP in hospitals. Our work shows that EP is prevalent in English hospitals, although often in limited clinical areas and for limited types of prescribing. The diversity of systems in use, often within the same hospital, may create challenges for staff training and patient safety.
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Medicina Estatal/organização & administração , Estudos Transversais , Coleta de Dados , Sistemas de Apoio a Decisões Administrativas , Inglaterra , Hospitais PúblicosRESUMO
BACKGROUND: Prescribing errors are common in hospital inpatients. However, the literature suggests that doctors are often unaware of their errors as they are not always informed of them. It has been suggested that providing more feedback to prescribers may reduce subsequent error rates. Only few studies have investigated the views of prescribers towards receiving such feedback, or the views of hospital pharmacists as potential feedback providers. OBJECTIVES: Our aim was to explore the views of junior doctors and hospital pharmacists regarding feedback on individual doctors' prescribing errors. Objectives were to determine how feedback was currently provided and any associated problems, to explore views on other approaches to feedback, and to make recommendations for designing suitable feedback systems. SETTING: A large London NHS hospital trust. METHODS: To explore views on current and possible feedback mechanisms, self-administered questionnaires were given to all junior doctors and pharmacists, combining both 5-point Likert scale statements and open-ended questions. MAIN OUTCOME MEASURES: Agreement scores for statements regarding perceived prescribing error rates, opinions on feedback, barriers to feedback, and preferences for future practice. RESULTS: Response rates were 49% (37/75) for junior doctors and 57% (57/100) for pharmacists. In general, doctors did not feel threatened by feedback on their prescribing errors. They felt that feedback currently provided was constructive but often irregular and insufficient. Most pharmacists provided feedback in various ways; however some did not or were inconsistent. They were willing to provide more feedback, but did not feel it was always effective or feasible due to barriers such as communication problems and time constraints. Both professional groups preferred individual feedback with additional regular generic feedback on common or serious errors. CONCLUSION: Feedback on prescribing errors was valued and acceptable to both professional groups. From the results, several suggested methods of providing feedback on prescribing errors emerged. Addressing barriers such as the identification of individual prescribers would facilitate feedback in practice. Research investigating whether or not feedback reduces the subsequent error rate is now needed.
Assuntos
Corpo Clínico Hospitalar/normas , Erros de Medicação/prevenção & controle , Farmacêuticos/organização & administração , Padrões de Prática Médica/normas , Estudos Transversais , Retroalimentação , Feminino , Humanos , Londres , Masculino , Serviço de Farmácia Hospitalar/organização & administração , Papel Profissional , Inquéritos e QuestionáriosRESUMO
BACKGROUND: In UK hospitals, traditional ward pharmacy services involve pharmacists visiting their wards once or twice a day each weekday. However, to provide a more patient orientated ward pharmacy service, we developed the Imperial Model of Ward Pharmacy. This is based on pharmacists seeing every drug chart every other day, allowing increased focus towards patients' needs on other days. OBJECTIVE: To assess the impact of the Imperial Model of Ward Pharmacy on the prevalence of new medication orders that have not been screened by pharmacists, and doses omitted due to medication being unavailable. METHOD: We conducted an uncontrolled before-and-after study on eight medical wards. In each phase, we collected data on the number and prevalence of active medication orders that had not been screened by a pharmacist at the point of data collection, and the number and prevalence of regular doses documented as being omitted due to drug unavailability, or for which the administration record was left blank. RESULTS: The prevalence of unscreened medication orders reduced from 7.6 % of 1,433 orders to 4.1 % of 1,495 orders (p = 0.0002; Chi square test). There was no change in the prevalence of dose omissions (1.4 % in each phase of the study). CONCLUSION: This is a practical way to move to a more patient-focused service without affecting the safety of the service provided.
Assuntos
Sistemas de Medicação no Hospital/estatística & dados numéricos , Farmacêuticos , Serviço de Farmácia Hospitalar/métodos , Serviço de Farmácia Hospitalar/estatística & dados numéricos , Papel Profissional , Segurança do Paciente/estatística & dados numéricos , Desenvolvimento de Programas , Reino UnidoRESUMO
We present the findings of a discrete event simulation study of the hospital pharmacy outpatient dispensing systems at two London hospitals. Having created a model and established its face validity, we tested scenarios to estimate the likely impact of changes in prescription workload, staffing levels and skill-mix, and utilisation of the dispensaries' automatic dispensing robots. The scenarios were compared in terms of mean prescription turnaround times and percentage of prescriptions completed within 45 min. The findings are being used to support business cases for changes in staffing levels and skill-mix in response to changes in workload.
Assuntos
Eficiência Organizacional , Pacientes Ambulatoriais , Serviço de Farmácia Hospitalar/organização & administração , Automação , Simulação por Computador , Humanos , Admissão e Escalonamento de Pessoal/organização & administração , Carga de TrabalhoRESUMO
OBJECTIVES: To evaluate the implementation and adoption of the NHS detailed care records service in "early adopter" hospitals in England. DESIGN: Theoretically informed, longitudinal qualitative evaluation based on case studies. SETTING: 12 "early adopter" NHS acute hospitals and specialist care settings studied over two and a half years. DATA SOURCES: Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers' field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents. RESULTS: Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems; and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals. CONCLUSIONS: Implementation of the NHS Care Records Service in "early adopter" sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.