Barriers to managing medications appropriately when patients have restrictions on oral intake.
Journal
Journal of evaluation in clinical practice
ISSN: 1365-2753
Titre abrégé: J Eval Clin Pract
Pays: England
ID NLM: 9609066
Informations de publication
Date de publication:
Feb 2020
Feb 2020
Historique:
received:
11
11
2018
revised:
19
03
2019
accepted:
22
03
2019
pubmed:
11
4
2019
medline:
29
7
2021
entrez:
11
4
2019
Statut:
ppublish
Résumé
Investigation of several serious adverse events in our organization highlighted that medications were managed inappropriately when patients have oral intake restrictions. The aim of this work was to identify the barriers to optimal medication management when patients have restrictions on their oral intake. Data were feedback and comments obtained between 2011 and 2014 from a hospital-wide quality assurance project. Data had not been purposefully collected and were in response to a general request for feedback regarding managing oral medications when patients have oral intake restrictions. Data came from a range of clinical staff and from various forums associated with the quality assurance project, including 37 presentations, 34 group meetings, and over 50 one-on-one meetings, as well as emails and other sources. Data were analysed using the thematic analysis approach. Data were coded inductively, and the domains of the Theoretical Domains Framework were used to categorize the data. Subthemes and themes were then developed. Barriers could be broadly grouped into systems-level issues (organizational guidance and work environment) and the individual person-level issues (staff knowledge and beliefs). These barriers highlight the complexity of the medication management task. The lack of standardized guidance and consistent terminology regarding medication administration when patients have restrictions on oral intake, particularly when fasting or nil by mouth, were important systems factors, as were workflow issues and the "culture" of the environment in which staff practiced. Lack of knowledge about medication administration, social influences, and role interpretation were important individual person factors. Systems- and individual person-level issues were significant contributors to inappropriate medication management when patients have oral intake restrictions. Many of the barriers may be addressed with systems approaches such as hospital-wide guidance that simplifies and standardize oral medication administration instructions, particularly regarding fasting and nil by mouth terminology.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
172-180Informations de copyright
© 2019 John Wiley & Sons, Ltd.
Références
Kennedy JM, van Rij AM, Spears GF, Pettigrew RA, Tucker IG. Polypharmacy in a general surgical unit and consequences of drug withdrawal. Br J Clin Pharmacol. 2000;49(4):353-362.
Pass SE, Simpson RW. Discontinuation and reinstitution of medications during the perioperative period. Am J Health Syst Pharm. 2004;61(9):899-912. quiz 913-894
National Patient Safety Agency. Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted and delayed medicines in hospital. UK 2010.
Thornton P. Medication safety: Australian incidents. Nil-by-mouth. J Pharm Pract Res. 2010;40:224.
Daily Express Reporter. Nil by mouth patient dies after being fed pudding. Exp Dermatol. 2 February, 2011.
Kelly J, Wright D, Wood J. Medicine administration errors in patients with dysphagia in secondary care: a multi-centre observational study. J Adv Nurs. 2011;67(12):2615-2627.
Leder SB, Lerner MZ. Nil per os except medications order in the dysphagic patient. QJM: Intern J Med. 2013;106(1):71-75.
Cornish P. “Avoid the crush”: hazards of medication administration in patients with dysphagia or a feeding tube. CMAJ. 2005;172(7):871-872.
To TP, Story DA, Booth J, Nielsen F, Heland M, Hardidge A. Oral medication administration in patients with restrictions on oral intake-a snapshot survey. J Pharm Pract Res. 2013;43:177-181.
Braun V, Clarke V. Thematic analysis. In: Cooper H, Camic PM, Long DL, Panter AT, Rindskopf D, Sher KJ, eds. APA handbook of research methods in psychology, Vol 2: Research designs: quantitative, qualitative, neuropsychological, and biological. Washington DC: American Psychological Association; 2012:57-71.
Joffe H. Thematic Analysis. In: Harper D, Thompson A, eds. Qualitative Research Methods in Mental Health and Psychotherapy. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2012:209-223.
Braun V, Clarke V. What can “thematic analysis” offer health and wellbeing researchers? Intern J Qual Stud Health Well-being. 2014;9:26152. Published 2014 Oct 16. https://doi.org/10.3402/qhw.v9.26152
Cane J, O'Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37.
Lipworth W, Taylor N, Braithwaite J. Can the theoretical domains framework account for the implementation of clinical quality interventions? BMC Health Serv Res. 2013;13(1):530.
Australian Commission on Safety and Quality in Health Care. National Inpatient Medication Chart User Guide Sydney: ACSQHC; 2016.
Symons VC, McMurray A. Factors influencing nurses to withold surgical patients' oral medications pre- and postoperatively. Collegian. 2014;21(4):267-274.
Lawler C, Welch S, Brien JE. Omitted medication doses: frequency and severity. J Pharm Pract Res. 2004;34:174-177.
Chand M, Dabbas N. Nil by mouth: a misleading statement. J Perioper Pract. 2007;17(8):366):368-371.
Miller J, Warren A. Nil by mouth needs defining. Hospital Pharm Pract. 1994;53-55.
Green CJ, Du-Pre P, Elahi N, Dunckley P, McIntyre AS. Omission after admission: failure in prescribed medications being given to inpatients. Clin Med. 2009;9(6):515-518.
van Waes JA, de Graaff JC, Egberts AC, van Klei WA. Medication discontinuity errors in the perioperative period. Acta Anaesthesiol Scand. 2010;54(10):1185-1191.
Nil by mouth patient 'given pills to swallow' at Hull Royal Infirmary. Hull Daily Mail. 2014. http://www.hulldailymail.co.uk/Nil-mouth-patient-given-pills-swallow-Hull-Royal/story-22875920-detail/story.html.
Daily Express Reporter. Nil by mouth patient dies after being fed pudding. Exp Dermatol 2011. http://www.express.co.uk/news/uk/226664/Nil-by-mouth-patient-dies-after-being-fed-pudding. Accessed Feb 2.
Australian Commission on Safety and Quality in Health Care. National Inpatient Medication Chart User Guide. Sydney: ACSQHC; 2009.
New South Wales Agency for Clincal Innovation. Preoperative fasting in NSW public hospitals. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0006/299301/ACI_Key_Principles_Preoperative_fasting_in_NSW_public_hospitals.pdf. Accessed 12/02/19.
Hanssens Y, Woods D, Alsulaiti A, Adheir F, Al-Meer N, Obaidan N. Improving oral medicine administration in patients with swallowing problems and feeding tubes. Ann Pharmacother. 2006;40(12):2142-2147.
Logrippo S, Ricci G, Sestili M, et al. Oral drug therapy in elderly with dysphagia: between a rock and a hard place! Clin Interv Aging. 2017;12:241-251.
Stubbs J, Haw C, Dickens G. Dose form modification-a common but potentially hazardous practice. A literature review and study of medication administration to older psychiatric inpatients. Int Psychogeriatr. 2008;20(3):616-627.
Jackson LD, Little J, Kung E, Williams EM, Siemiatkowska K, Plowman S. Safe medication swallowing in dysphagia: a collaborative improvement project. Healthc Q. 2008;11(3 Spec):110-116.
SHPA Publications Reference Group. Australian Don't Rush to Crush Handbook: Therapeutic Options for People Unable to Swallow Solid Oral Medicines. 3rd ed. Victoria, Australia: Society of Hospital Pharmacists of Australia; 2018.
Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington DC: National Academy Press; 2000.
Australian Council for Safety and Quality in Healthcare. Second National Report on Patient Safety-Improving Medication Safety. Canberra: Australian Council for Safety and Quality in Healthcare; 2002.
Anderson DJ, Webster CS. A systems approach to the reduction of medication error on the hospital ward. J Adv Nurs. 2001;35(1):34-41.
Kannampallil TG, Schauer GF, Cohen T, Patel VL. Considering complexity in healthcare systems. J Biomed Inform. 2011;44(6):943-947.
Schneider PJ. Applying human factors in improving medication-use safety. Am J Health-System Pharm. 2002;59(Jun 15):1155-1158.
Ravitz AD, Sapirstein A, Pham JC, Doyle PA. Systems approach and systems engineering applied to health care: improving patient safety and health care delivery. Johns Hopkins APL Technical Digest (Appl Phys Lab). 2013;31(4):354-365.