"Being careful": How much caution is enough? The relational context of fear of older adult falling in older adult-family caregiver dyads.

Family caregivers play an important role in coping with older adult falls; however, their perspectives on fear of older adult falling are lacking from the falls prevention literature. A mixed-method design (N=25 dyads) with interview and survey data examined linguistic characteristics and coping strategies used by older adult and family caregiver dyads to manage fear of older adult falling. Fear of older adult falling consisted of both affective (e.g., worry) and cognitive (e.g., cautious) properties. Family caregivers more frequently used affective words and first-person plural pronouns ("we" language) when talking about fear of older adult falling, while older adults more frequently used cognitive and first-and-second person singular pronouns ("I", "you"). The concept of "being careful" was shared within dyads. However, dyad partners differed in their perspectives of what constituted "being careful" and the possibilities of future falling. Findings suggest that the need for family-centered interventions to prevent falls are needed.

Fear of older adult falling questionnaire for caregivers (FOAFQ-CG): Evidence from content validity and item-response theory graded-response modelling.

AIMS: (1) Determine the content validity of the Fear of Older Adult Falling Questionnaire-Caregivers using a panel of gerontological experts and a target sample of family caregivers (Stage 1) and (2) Examine the response patterns of the Fear of Older Adult Falling Questionnaire-Caregivers and compare it with older adult version of Fear of Falling Questionnaire Revised using graded-response modelling (Stage 2). DESIGN: Cross-sectional mixed-method design. METHODS: Five content experts and 10 family caregivers were involved in the Stage 1 study and 53 family caregiver-older adult dyads (N = 106) were included in the Stage 2 study. The content-validity index and graded-response modelling were used to analyse data. RESULTS: Among experts, the Fear of Older Adult Falling Questionnaire-Caregivers content-validity index for relevancy, importance, and clarity of individual items and total scale ranged from 0.60-1.00 and from 0.77-0.87, respectively. Among family caregivers, the ratings of the item and scale level content-validity index for relevancy, importance, and clarity ranged from 0.90-1.00 and from 0.95-0.97, respectively. Combining feedback from both groups, we revised one item. Subsequently, the graded-response modelling revealed that a 1-factor, 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers had acceptable psychometric properties. CONCLUSIONS: The brief 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers is promising for assessing caregivers' fear of their older adult care recipient falling. IMPACT: A significant concern for family caregivers is fearing that older adult care recipients will fall, but a lack of validated measures limits the study of this phenomena. A 3-item version of the Fear of Older Adult Falling Questionnaire-Caregivers has the potential to identify family caregivers with high fear of older adult falling so that fall risk can be appropriately assessed and addressed.

Is fall self-efficacy an independent predictor of recurrent fall events in older adults? Evidence from a 1-year prospective study.

Falls, which are prevalent among older adults, may not only cause severe physical injuries, but also lead to low fall self-efficacy (FSE). Low FSE is associated with restricted activity, which putatively increases risk of future falls. However, emerging studies have failed to confirm this association. Furthermore, the interplay between age, gender, and fall history with falls has not been adequately addressed in adults aged 70 years or older. The aims of this secondary analysis were to: (1) prospectively explore the association of FSE and fall events considering age, gender, and fall history, and (2) examine the characteristics of fall events and fall-related outcomes. Forty-seven community-dwelling adults over 70 years of age were followed for about 12 months. During the follow-up, 22 participants with low FSE experienced 119 fall events whereas 25 participants with high FSE reported 106 fall events. Among fallers, 72.3% (n = 34) experienced recurrent fall events. About 15.0% (n = 34) of 225 fall events resulted in injuries and 4.0% of injuries required medical care. FSE was a statistically significant predictor of future fall events (incident rate ratio = 0.96, p = .013) regardless of age, gender, and fall history. Participants with low FSE were more likely than those with high FSE to fall more frequently without noticeable prodromal symptoms and apparent reasons. These findings suggest that FSE is an important protective factor against future fall events. However, interpretation of these results requires caution given the small sample size and effect size.

Individual versus interprofessional team performance in formulating care transition plans: A randomised study of trainees from five professional groups.

Health professions trainees' performance in teams is rarely evaluated, but increasingly important as the healthcare delivery systems in which they will practice move towards team-based care. Effective management of care transitions is an important aspect of interprofessional teamwork. This mixed-methods study used a crossover design to randomise health professions trainees to work as individuals and as teams to formulate written care transition plans. Experienced external raters assessed the quality of the written care transition plans as well as both the quality of team process and overall team performance. Written care transition plan quality did not vary between individuals and teams (21.8 vs. 24.4, respectively, p = 0.42). The quality of team process did not correlate with the quality of the team-generated written care transition plans (r = -0.172, p = 0.659). However, there was a significant correlation between the quality of team process and overall team performance (r = 0.692, p = 0.039). Teams with highly engaged recorders, performing an internal team debrief, had higher-quality care transition plans. These results suggest that high-quality interprofessional care transition plans may require advance instruction as well as teamwork in finalising the plan.

Factors that influence physical function and emotional well-being among Medicare-Medicaid enrollees.

Dually enrolled Medicare-Medicaid older adults are a vulnerable population. We tested House's Conceptual Framework for Understanding Social Inequalities in Health and Aging in Medicare-Medicaid enrollees by examining the extent to which disparities indicators, which included race, age, gender, neighborhood poverty, education, income, exercise (e.g., walking), and physical activity (e.g., housework) influence physical function and emotional well-being. This secondary analysis included 337 Black (31%) and White (69%) older Medicare-Medicaid enrollees. Using path analysis, we determined that race, neighborhood poverty, education, and income did not influence physical function or emotional well-being. However, physical activity (e.g., housework) was associated with an increased self-report of physical function and emotional well-being of ß = .23, p < .001; ß = .17, p < .01, respectively. Future studies of factors that influence physical function and emotional well-being in this population should take into account health status indicators such as allostatic load, comorbidity, and perceived racism/discrimination.

Psychotropic-related hip fractures: meta-analysis of first-generation and second-generation antidepressant and antipsychotic drugs.

BACKGROUND: In 2007, more than 18,000 adults aged 65 or older died from injuries related to falls, with up to 30% experiencing severe injuries such as hip fracture or head trauma. The economic impact of falls and fractures among older people is substantial, with direct economic consequences totaling $19 billion in 2000. OBJECTIVE: To evaluate the association between antipsychotic and antidepressant agents and the risk of hip fracture in older adults, across multiple studies. METHODS: An English-language PubMed/MEDLINE search for studies from January 1966 to January 2011 was conducted, using key words including aged, hip fracture, fractures, antidepressive agents, and antipsychotic agents, as well as individual drug names. Criteria for study inclusion were mean subject age greater than or equal to 65 years, adjusted for age and sex, hip fracture-specific results provided, data specific to a drug class, subclass, or single agents, and cohort or case-controlled study design. Two authors reviewed all studies for inclusion/exclusion. A random effects model was used to calculate summary odds ratios. RESULTS: A total of 166 studies were identified in the initial search. Ten antipsychotic-related and 14 antidepressant-related studies, representing more than 70,000 hip fracture cases and approximately 270,000 subjects from 4 continents, met the inclusion criteria. Summary odds ratios (95% CI) were first-generation (conventional) antipsychotics 1.68 (1.43 to 1.99), second-generation (atypical) antipsychotics 1.30 (1.14 to 1.49), first-generation (tricyclic) antidepressants 1.71 (1.43 to 2.04), and second-generation (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and unique agents such as bupropion, mirtazapine, and trazodone) antidepressants 1.94 (1.37 to 2.76). Clear evidence of heterogeneity was noted among all antidepressant study analyses (I(2) > 87%; Q statistic p < 0.05). CONCLUSIONS: All drug classes studied-first- and second-generation antipsychotics and antidepressants-were associated with an increased risk of hip fracture in predominantly older adult populations.

Medication reconciliation in nursing homes: thematic differences between RN and LPN staff.

The purpose of this qualitative descriptive study was to describe medication reconciliation practices in nursing homes with a specific focus on nursing staff involvement in the process. The study was conducted in eight Midwestern nursing homes and included 46 onsite observations of resident transfers to the nursing home. Informal interviews of nursing staff performing medication reconciliation were conducted during each observation. Findings suggest nursing home nursing staff, including both RN and licensed practical nurse (LPN) staff, were primarily responsible for performing medication reconciliation; however, these staff often varied in how they processed resident transfer information to identify medication order discrepancies. Patterns of differences were found related to their perceptions about medication reconciliation, as well as their actions when performing the process. RN staff were more often focused on resident safety and putting the "big picture" together, whereas LPN staff were more often focused on the administrative assignment and "completing the task."

The mediating role of power distance and face-saving on nurses' fear of medication error reporting: A cross-sectional survey.

BACKGROUND: The fear of social and professional consequences is a significant barrier to medication error reporting among nurses. Although some studies have identified cultural factors as playing a significant role in medication error reporting, little is known about the mechanisms by which these cultural characteristics influence the relationship between patient safety emphasis and the fear of medication error reporting. OBJECTIVES: (1) Identify nurses' perceptions of patient safety emphasis, face-saving, power distance, and fear of medication error reporting; and (2) explore face-saving and power distance as the underlying mechanisms for cultural factors in the relationship between nurses' perceptions of safety emphasis and the fear of medication error reporting. DESIGN: A cross-sectional, descriptive, and correlational design. SETTINGS: Three tertiary teaching hospitals located in China, including one children's hospital and two adult hospitals. PARTICIPANTS: We recruited a total of 569 female registered nurses with at least one year of work experience. Most of the participants (73.8%) were junior nurses with mid-associate or associate degrees (55.4%). METHODS: Participants completed four questionnaires, including Safety Emphasis subscales from the Safety Climate Scale, Face-Saving Scale, the Index of Hierarchy of Authority, and the Nurses' Fear of Medication Error Reporting. RESULTS: The average scores of safety emphasis, face-saving, power distance, and the fear of medication error reporting were 20.27 (SD=2.36), 14.63 (SD=3.57), 17.36 (SD=3.49), and 18.92 (SD=4.20), respectively. There were no demographic characteristics associated with these variables, except education (B=-0.16, p = 0.013) and work experience (B=-0.14, p = 0.019), which were related to power distance. Face-saving and power distance were significant mediators that explained the effect of safety emphasis on nurses' fear of medication error reporting. The overall indirect effect for both mediators was statistically significant (ß=-0.27, p<0.05). When we compared the specific mediators' indirect effects, face-saving was a more powerful mediator than power distance (ß=-0.24 vs. ß=-0.04). These mediation effects remained after we adjusted for the effects of education and work experience on power distance. CONCLUSIONS: When nurses have a common cultural background, they tend to perceive similar barriers to medication error reporting. For this study, face-saving and power distance are the two most important cultural factors because they significantly influence the relationship between safety emphasis and the fear of medication error reporting among Chinese nurses. It may not be possible to develop a work culture that minimizes fears of medication error reporting without first addressing face-saving needs and power differences.

Medication safety teams' guided implementation of electronic medication administration records in five nursing homes.

BACKGROUND: The 1.6 million nursing home residents in the United States are at high risk for adverse effects from medication errors. In an attempt to decrease medication errors and improve safety practices, from 2003 through 2007 the study investigators partnered with five Midwestern nursing homes in implementing electronic point-of-care medication administration records (eMARs) and focused quality improvement (QI) efforts. METHODS: The eMAR, designed by a vendor as a part of a larger integrated electronic health record, provided a point of information integration for a variety of users, including practitioners, nursing staff, medication administrators, and nursing home leadership. At each nursing home, a medication safety team guided the transition from traditional paper-based systems to the eMAR. RESULTS: The implementation and integration of the eMAR was monitored in more than 300 hours of detailed observation, resulting in nearly 16,000 medication doses across approximately 200 medication administrations (passes) for 3,700 residents. The types of medication errors most receptive to the combined impact of the eMAR and focused QI efforts were late and omitted (or missing) medications. DISCUSSION: Technology provided the structures and processes that improved communication and integrated complex processes. Yet, regardless of how effectively the technology was designed, it was "laid upon" nursing home medication administration systems that were archaic and fragmented. The implementation of technology could not solve chronic structure and process issues in isolation. However, using the technology to streamline processes, support effective decision making, integrate complex tasks, and bring real-time data to a medication safety team provided an effective mechanism to maximize the impact of technology and to minimize the unintended consequences of large-scale change.

Nursing home error and level of staff credentials.

Providing safe nursing home care is both a clinical and fiscal challenge in many countries. The fiscal realities result in the addition of other workers, such as medication technicians or aides (CMT/A), to the health care team. The purpose of this study was to determine the impact of various levels of credentialing among nursing home staff who deliver medications (RN, LPN, or CMT/A) on medication error. In addition, the impact of distractions and interruptions was explored. Using naïve observation, 39 medication administrators representing various levels of credentialing were unobtrusively observed to determine the number of medication errors, distractions, and interruptions in five nursing homes. There were no differences in medication error rates by level of credential. However, RNs had more interruptions during their medication administration, and these increased interruptions were associated with increased medication error rates when wrong time errors were excluded (p = .0348).

Assessing the appropriateness of pain medication prescribing practices in nursing homes.

OBJECTIVES: To test a tool for screening the quality of nursing home (NH) pain medication prescribing. DESIGN: Validity and reliability of measurement tool developed for a pre/postintervention with untreated comparison group. SETTING: Six treatment NHs and six comparison NHs in rural and urban Colorado. PARTICIPANTS: NH staff, physicians, and repeated 20% random sample of each home's residents (N = 2,031). INTERVENTION: Nurse and physician education; NH internal pain team to champion better pain management using a pain vital sign, consultations, and rounds. MEASUREMENTS: An expert panel reviewed the Pain Medication Appropriateness Scale (PMAS) for content validity. Research assistants interviewed NH residents, assessed them for pain using standardized instruments, and reviewed their medical records for prescriptions and use of pain and adjuvant medication. Construct validity was assessed by comparing the PMAS of residents in pain with the PMAS of those not in pain and comparing scores in homes in which the intervention was more effective with those in which it was less effective, using the Fisher exact and Student t tests. Interrater and test-retest reliability were measured. RESULTS: The mean total PMAS was 64% of optimal. Fewer than half of residents with predictably recurrent pain were prescribed scheduled pain medication; 23% received at least one high-risk medication. PMAS scores were better for residents not in pain (68% vs 60%, P = .004) and in homes where nurses' knowledge of pain assessment and management improved or stayed the same during the intervention (69% vs 61%, P = .03). CONCLUSION: The PMAS is useful for assessing pain medication prescribing in NHs and elucidates why so many residents have poorly controlled pain.

Balancing acts: deciding for or against antibiotics in acute respiratory infections.

BACKGROUND: Overprescribing of antibiotics for acute respiratory infections (ARIs) has contributed to antibiotic resistance. Multiple clinician, patient, and system-related factors contribute to the prescribing of antibiotics for ARIs; however, these factors do not explain how clinicians arrive at their decisions to prescribe antibiotics. The purpose of our study was to describe this decision-making process. METHODS: We conducted comprehensive interviews with 21 primary health care clinicians practicing in a rural Western US community. Our study used a qualitative descriptive design informed by grounded theory, and we analyzed data with a constant comparative method. RESULTS: Two theoretical concepts emerged from the interviews: 1) individual best practice described how each clinician attempted to do what he or she believed to be clinically best for the patient presenting with acute respiratory symptoms. The second concept, perceived patient satisfaction, described how the clinicians endeavored to satisfy patients, according to their own perceptions of the patient's potential to be satisfied. 2) Balancing acts emerged as the basic social process and is defined as the process whereby clinicians weigh individual best practice against perceived patient satisfaction when deciding whether to prescribe antibiotics for patients presenting with ARIs. CONCLUSION: The results of this investigation have important clinical and educational implications for reducing inappropriate antibiotic use for ARIs. Further controlled trials are warranted.

Medication errors observed in 36 health care facilities.

BACKGROUND: Medication errors are a national concern. OBJECTIVE: To identify the prevalence of medication errors (doses administered differently than ordered). DESIGN: A prospective cohort study. SETTING: Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado. PARTICIPANTS: A stratified random sample of 36 institutions. Twenty-six declined, with random replacement. Medication doses given (or omitted) during at least 1 medication pass during a 1- to 4-day period by nurses on high medication-volume nursing units. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered. METHODS: Medication errors were witnessed by observation, and verified by a research pharmacist (E.A.F.). Clinical significance was judged by an expert panel of physicians. MAIN OUTCOME MEASURE: Medication errors reaching patients. RESULTS: In the 36 institutions, 19% of the doses (605/3216) were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). Seven percent of the errors were judged potential adverse drug events. There was no significant difference between error rates in the 3 settings (P =.82) or by size (P =.39). Error rates were higher in Colorado than in Georgia (P =.04) CONCLUSIONS: Medication errors were common (nearly 1 of every 5 doses in the typical hospital and skilled nursing facility). The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. The problem of defective medication administration systems, although varied, is widespread.

Association of Transcobalamin II (TCN2) and Transcobalamin II-Receptor (TCblR) Genetic Variations With Cobalamin Deficiency Parameters in Elderly Women.

Cobalamin (vitamin B12) deficiency is a subtle progressive clinical disorder, affecting nearly 1 in 5 individuals > 60 years old. This deficiency is produced by age-related decreases in nutrient absorption, medications that interfere with vitamin B12 absorption, and other comorbidities. Clinical heterogeneity confounds symptom detection for elderly adults, as deficiency sequelae range from mild fatigue and weakness to debilitating megaloblastic anemia and permanent neuropathic injury. A better understanding of genetic factors that contribute to cobalamin deficiency in the elderly would allow for targeted nursing care and preventive interventions. We tested for associations of common variants in genes involved in cobalamin transport and homeostasis with metabolic indicators of cobalamin deficiency (homocysteine and methylmalonic acid) as well as hematologic, neurologic, and functional performance features of cobalamin deficiency in 789 participants of the Women's Health and Aging Studies. Although not significant when corrected for multiple testing, eight single nucleotide polymorphisms (SNPs) in two genes, transcobalamin II (TCN2) and the transcobalamin II-receptor (TCblR), were found to influence several clinical traits of cobalamin deficiency. The three most significant findings were the identified associations involving missense coding SNPs, namely, TCblR G220R (rs2336573) with serum cobalamin, TCN2 S348F (rs9621049) with homocysteine, and TCN2 P259R (rs1801198) with red blood cell mean corpuscular volume. These SNPs may modify the phenotype in older adults who are more likely to develop symptoms of vitamin B12 malabsorption.

Packaging interventions to increase medication adherence: systematic review and meta-analysis.

OBJECTIVE: Inadequate medication adherence is a widespread problem that contributes to increased chronic disease complications and health care expenditures. Packaging interventions using pill boxes and blister packs have been widely recommended to address the medication adherence issue. This meta-analysis review determined the overall effect of packaging interventions on medication adherence and health outcomes. In addition, we tested whether effects vary depending on intervention, sample, and design characteristics. RESEARCH DESIGN AND METHODS: Extensive literature search strategies included examination of 13 computerized databases and 19 research registries, hand searches of 57 journals, and author and ancestry searches. Eligible studies included either pill boxes or blister packaging interventions to increase medication adherence. Primary study characteristics and outcomes were reliably coded. Random-effects analyses were used to calculate overall effect sizes and conduct moderator analyses. RESULTS: Data were synthesized across 22,858 subjects from 52 reports. The overall mean weighted standardized difference effect size for two-group comparisons was 0.593 (favoring treatment over control), which is consistent with the mean of 71% adherence for treatment subjects compared to 63% among control subjects. We found using moderator analyses that interventions were most effective when they used blister packs and were delivered in pharmacies, while interventions were less effective when studies included older subjects and those with cognitive impairment. Methodological moderator analyses revealed significantly larger effect sizes in studies reporting continuous data outcomes instead of dichotomous results and in studies using pharmacy refill medication adherence measures compared with studies with self-report measures. CONCLUSIONS: Overall, meta-analysis findings support the use of packaging interventions to effectively increase medication adherence. Limitations of the study include the exclusion of packaging interventions other than pill boxes and blister packs, evidence of publication bias, and primary study sparse reporting of health outcomes and potentially interesting moderating variables such as the number of prescribed medications.

Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities.

The validity and cost-effectiveness of three methods for detecting medication errors were examined. A stratified random sample of 36 hospitals and skilled-nursing facilities in Colorado and Georgia was selected. Medication administration errors were detected by registered nurses (R.N.s), licensed practical nurses (L.P.N.s), and pharmacy technicians from these facilities using three methods: incident report review, chart review, and direct observation. Each dose evaluated was compared with the prescriber's order. Deviations were considered errors. Efficiency was measured by the time spent evaluating each dose. A pharmacist performed an independent determination of errors to assess the accuracy of each data collector. Clinical significance was judged by a panel of physicians. Observers detected 300 of 457 pharmacist-confirmed errors made on 2556 doses (11.7% error rate) compared with 17 errors detected by chart reviewers (0.7% error rate), and 1 error detected by incident report review (0.04% error rate). All errors detected involved the same 2556 doses. All chart reviewers and 7 of 10 observers achieved at least good comparability with the pharmacist's results. The mean cost of error detection per dose was $4.82 for direct observation and $0.63 for chart review. The technician was the least expensive observer at $2.87 per dose evaluated. R.N.s were the least expensive chart reviewers at $0.50 per dose. Of 457 errors, 35 (8%) were deemed potentially clinically significant; 71% of these were detected by direct observation. Direct observation was more efficient and accurate than reviewing charts and incident reports in detecting medication errors. Pharmacy technicians were more efficient and accurate than R.N.s and L.P.N.s in collecting data about medication errors.

Medication reconciliation: A qualitative analysis of clinicians' perceptions.

BACKGROUND: Medication reconciliation has been at the forefront of national patient safety efforts for nearly a decade, yet health care institutions remain challenged with implementation. OBJECTIVES: The objective of this article was to report an analysis of a qualitative study of the experiences of physicians, nurses, and pharmacists with medication management practices, specifically focusing on the practice of medication reconciliation. METHODS: This study used focus groups in a qualitative approach to explore participant perceptions about interprofessional communication and adverse drug events. Three focus groups were conducted at each of 3 Veterans Administration hospitals, 1 each for physicians (13), nurses (19), and pharmacists (16). The analysis for this article focused on specific discussions about medication reconciliation. RESULTS: Two primary thematic questions emerged from the discussion about medication reconciliation: What does medication reconciliation really mean? Who is actually responsible for the process? Participants from each profession had differing perspectives about the purpose and processes of medication reconciliation. Perceived responsibilities appeared to be influenced by their distinct views regarding the meaning and purpose of medication reconciliation. The pharmacist role emerged as a critical role to assure medication safety. CONCLUSIONS: Translating the intent of medication reconciliation into effective practice requires acknowledgment of the involved professionals' diverse perspectives on the independent, joint, and overlapping functions of medication management as well as recognizing the limitations of technology.

Predictors of quality in rural nursing homes using standard and novel methods.

We examined the effect of market and organizational characteristics on nursing home quality as measured by deficiencies (number and weighted) on states in a rural region of the United States. Rural nursing homes in five Mountain West states (N = 161) were sampled from the Online Survey Certification and Reporting system between January 1, 2004 and June 15, 2005. State comparisons indicated that rural nursing homes in Nevada had a higher number of deficiencies and weighted deficiency score as compared with Utah, Colorado, Wyoming, and Idaho. Using regression analyses, we found that a higher percentage of licensed practical nurses in the staffing mix were predictive of a greater number of deficiencies. Nursing homes with more beds or higher Medicaid occupancy had higher weighted deficiency scores. Although rural Mountain West nursing homes average a similar number of deficiencies as nursing homes nationwide, these nursing homes had a greater number of serious deficiencies and higher weighted deficiency scores, suggesting greater actual harm to resident health and safety.