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Medicines management support to older people: understanding the context of systems failure.

ABSTRACT: Changing demographics and pressures on the healthcare system mean that more older people with complex medical problems need to be supported in primary and community care settings. The challenge of managing medicines effectively in frail elderly patients is considerable. Our research investigates what can go wrong and why, and seeks insight into the context that might set the scene for system failure.North London; a district general hospital and surrounding health authorities.7 patients who had been admitted to hospital and 16 informants involved in their care.Patients with preventable medication-related admissions were identified in an occurrence screening study. An accident investigation approach was used to create case studies from accounts of staff involved in each patient's care prior to their admission. Structured analysis of case studies according to the accident investigation approach was complemented by a separate analysis of interviews using open coding with constant comparison to identify and illustrate higher-level contextual themes.The study sheds light on care management problems, their causes and the context in which care management problems and their causes have occurred.Care management problems were rooted in issues with decision-making, information support and communications among staff members and between staff, patients and carers. Poor judgement, slips and deviations from best practice were attributed to task overload and complexity. Within general practice, at the interface with community services and with hospitals, we identified disruption to traditional intraprofessional and interprofessional roles, assumptions, channels and media of communication which together created conditions that might compromise patient safety.New ways of working driven by the ethos of productivity are disrupting traditional intraprofessional and interprofessional roles, assumptions, channels and media of communication. Concomitant improvements in communications technology, process and protocol are urgently required to offset potentially serious risks to patient safety.

SUBMITTER: Rogers S

PROVIDER: S-EPMC4120437 | biostudies-literature | 2014 Jul

REPOSITORIES: biostudies-literature

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Medicines management support to older people: understanding the context of systems failure.

Rogers Stephen S Martin Graham G Rai Gurcharan G

BMJ open 20140710 7

<h4>Objectives</h4>Changing demographics and pressures on the healthcare system mean that more older people with complex medical problems need to be supported in primary and community care settings. The challenge of managing medicines effectively in frail elderly patients is considerable. Our research investigates what can go wrong and why, and seeks insight into the context that might set the scene for system failure.<h4>Setting</h4>North London; a district general hospital and surrounding heal ...[more]

PMID: 25011989

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Project description:BackgroundOlder adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients' reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units.Study designQualitative study with semistructured interviews.Settings & participantsPatients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management.MethodologySemistructured interviews audiorecorded and transcribed verbatim.Analytical approachData were analyzed using thematic analysis.Results42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision.LimitationsRecruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited.ConclusionsOlder adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid alternative to dialysis for a subset of patients will aid informed decision making. There is a need for better evidence about conservative management to support shared decision making for older people with chronic kidney failure.

Project description:Background and Objectives: The global trend of healthcare is to improve the quality and safety of care for older people with cognitive disorders in their own home. There is a need to identify how medicines management for these older people who are cared by their family caregivers can be safeguarded. This integrative systematic review aimed to perform the needs assessment of medicines management for older people with cognitive disorders who receive care from their family caregivers in their own home. Methods: An integrative systematic review of the international literature was conducted to retrieve all original qualitative and quantitative studies that involved the family caregivers of older people with cognitive disorders in medicines management in their own home. MeSH terms and relevant keywords were used to search four online databases of PubMed (including Medline), Scopus, CINAHL, and Web of Science and to retrieve studies published up to March 2021. Data were extracted by two independent researchers, and the review process was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Given that selected studies were heterogeneous in terms of the methodological structure and research outcomes, a meta-analysis could not be performed. Therefore, narrative data analysis and knowledge synthesis were performed to report the review results. Results: The search process led to retrieving 1,241 studies, of which 12 studies were selected for data analysis and knowledge synthesis. They involved 3,890 older people with cognitive disorders and 3,465 family caregivers. Their methodologies varied and included cohort, randomised controlled trial, cross-sectional studies, grounded theory, qualitative framework analysis, and thematic analysis. The pillars that supported safe medicines management with the participation of family caregivers in home care consisted of the interconnection between older people's needs, family caregivers' role, and collaboration of multidisciplinary healthcare professionals. Conclusion: Medicines management for older people with cognitive disorders is complex and multidimensional. This systematic review provides a comprehensive image of the interconnection between factors influencing the safety of medicines management in home care. Considering that home-based medicines management is accompanied with stress and burden in family caregivers, multidisciplinary collaboration between healthcare professionals is essential along with the empowerment of family caregivers through education and support.

Project description:BackgroundMore older people are living in the community with multiple diagnoses and medications. Managing multiple medications produces issues of unrivalled complexity for those involved. Despite increasing literature on the subject, gaps remain in understanding how, why and for whom complex medication management works, and therefore how best to improve practice and outcomes. MEMORABLE, MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation, aimed to address these gaps.MethodsMEMORABLE used realism to understand causal paths within medication management. Informed by RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines, MEMORABLE involved three overlapping work packages: 1) Realist Review of the literature (24 articles on medication management exploring causality); 2) Realist Evaluation (50 realist-informed interviews with older people, family carers and health and care practitioners, explaining their experiences); and 3) data synthesis and theorising from 1) and 2).ResultsMedication management was viewed from the perspective of 'implementation' and structured into five stages: identifying a problem (Stage 1), getting a diagnosis and/or medications (Stage 2), starting, changing or stopping medications (Stage 3), continuing to take medications (Stage 4), and reviewing/reconciling medications (Stage 5). Three individual stages (1, 3 and 4) are conducted by the older person sometimes with family carer support when they balance routines, coping and risk. Stages 2 and 5 are interpersonal where the older person works with a practitioner-prescriber-reviewer, perhaps with carer involvement. Applying Normalisation Process Theory, four steps were identified within each stage: 1) sense making: information, clarification; 2) action: shared-decision-making; 3) reflection/monitoring; and 4) enduring relationships, based on collaboration and mutual trust. In a detailed analysis of Stage 5: Reviewing/reconciling medications, adopting the lens of 'burden', MEMORABLE identified five burdens amenable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Two initial improvement propositions were identified for further research: a risk screening tool and individualised information.ConclusionsOlder people and family carers often find medication management challenging and burdensome particularly for complex regimens. Practitioners need to be aware of this potential challenge, and work with older people and their carers to minimise the burden associated with medication management.Trial registrationPROSPERO 2016:CRD42016043506.

Project description:BackgroundIncreasing numbers of older people are receiving support with medicines management from community nursing services (CNSs) to enable them to live in their own homes. Little is known about these people and the support they receive.ObjectivesTo explore the characteristics of older people referred for medicines management support, type of support provided, medication errors and adverse medication events (AMEs).MethodsA retrospective observational study of a random sample of 100 older people referred to a large non-profit CNS for medicines management support over a 3-month period was conducted. Measures were: demographics, referral source, current medical problems, medicines, medication aids, types of medication authorisations used by nurses, frequency of nurse visits and type of support provided, medication errors, AMEs and interdisciplinary teamwork among community nurses, general practitioners and pharmacists.ResultsOlder people (median 80 years) were referred for medicines support most often by hospitals (39 %). Other referrals were from families/carers, case-managers, palliative care services and general practitioners. Multiple health conditions (median 5) and medicines (median 10) were common; 66 % used ≥5 medicines; 48 % used ≥1 high-risk medicines-most commonly opiates, anticoagulants and insulin. Medication aids were frequently used, mostly multi-compartment dose administration aids (47 %). Most people received regular community nurse visits (≥4 per week) to administer medicines or monitor medicine-taking. Only 16 % had a medication administration chart; for other clients nurses used medicine lists or letters from doctors for medication authorisation. Medication errors occurred in 41 % of people and 13 % had ≥1 AME requiring medical consultation or hospitalisation; 9/13 (64 %) AMEs were potentially preventable. There was little evidence of interdisciplinary teamwork or medication review.ConclusionCNS clients had multiple risk-factors for medication misadventure. Deficiencies in medicines management were identified, including low use of medication charts and interdisciplinary medication review. Strategies are needed to improve medicines management in the home-care setting.

Project description:BackgroundIt is well known that older adults are high users of the health care system. Older adults with chronic conditions receive care from multiple providers, across multiple settings, and this care is often unorganized and confusing. In 2005, Ontario established a model of inter-professional primary care (family health teams) with the aim of providing enhanced interdisciplinary primary care to patients. Primary care requires an in-depth understanding of the operations of primary care teams and their relationships with other community services. The aim of this study was to develop a deeper understanding of the current operations of two family health teams in Ontario, including their current processes for referrals, information sharing, and engagement of patients in decision-making.MethodsFocus group and individual semi-structured interviews with health care providers were conducted. Purposeful sampling was used to ensure information was obtained from different professional perspectives. Interviews were audio-recorded and transcribed verbatim. Using NVivo 10, data were analyzed using line by line thematic analysis techniques. A cluster technique was then applied to group similar codes into themes.ResultsThree focus group interviews (involving 4-6 health care providers/focus group) and six individual interviews were conducted with health care providers from two primary care teams and surrounding community care organizations. Six key themes were identified: 1) challenges engaging older adults in decisions about their care; 2) who is responsible for coordinating the care? 3) fragmented information sharing between health care providers; 4) lack of standardized referral processes and follow-up; 5) identifying services in the community for older adults; and 6) caring for older adults in rural communities.ConclusionsThe results of this study provide an in-depth understanding of the current context in which the primary care teams are currently operating. Improved primary care will require stronger processes of coordination, greater knowledge of and connections with other community services, and enhanced patient engagement processes. This information provides a helpful basis for implementing interventions in primary care.

Project description:BackgroundThe clinical decision-making process in pressure ulcer management is complex, and its quality depends on both the nurse's experience and the availability of scientific knowledge. This process should follow evidence-based practices incorporating health information technologies to assist health care professionals, such as the use of clinical decision support systems. These systems, in addition to increasing the quality of care provided, can reduce errors and costs in health care. However, the widespread use of clinical decision support systems still has limited evidence, indicating the need to identify and evaluate its effects on nursing clinical practice.ObjectiveThe goal of the review was to identify the effects of nurses using clinical decision support systems on clinical decision making for pressure ulcer management.MethodsThe systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. The search was conducted in April 2019 on 5 electronic databases: MEDLINE, SCOPUS, Web of Science, Cochrane, and CINAHL, without publication date or study design restrictions. Articles that addressed the use of computerized clinical decision support systems in pressure ulcer care applied in clinical practice were included. The reference lists of eligible articles were searched manually. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies.ResultsThe search strategy resulted in 998 articles, 16 of which were included. The year of publication ranged from 1995 to 2017, with 45% of studies conducted in the United States. Most addressed the use of clinical decision support systems by nurses in pressure ulcers prevention in inpatient units. All studies described knowledge-based systems that assessed the effects on clinical decision making, clinical effects secondary to clinical decision support system use, or factors that influenced the use or intention to use clinical decision support systems by health professionals and the success of their implementation in nursing practice.ConclusionsThe evidence in the available literature about the effects of clinical decision support systems (used by nurses) on decision making for pressure ulcer prevention and treatment is still insufficient. No significant effects were found on nurses' knowledge following the integration of clinical decision support systems into the workflow, with assessments made for a brief period of up to 6 months. Clinical effects, such as outcomes in the incidence and prevalence of pressure ulcers, remain limited in the studies, and most found clinically but nonstatistically significant results in decreasing pressure ulcers. It is necessary to carry out studies that prioritize better adoption and interaction of nurses with clinical decision support systems, as well as studies with a representative sample of health care professionals, randomized study designs, and application of assessment instruments appropriate to the professional and institutional profile. In addition, long-term follow-up is necessary to assess the effects of clinical decision support systems that can demonstrate a more real, measurable, and significant effect on clinical decision making.Trial registrationPROSPERO International Prospective Register of Systematic Reviews CRD42019127663; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=127663.

Dataset Information

Medicines management support to older people: understanding the context of systems failure.

Publications

Medicines management support to older people: understanding the context of systems failure.

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