Exploring the impact of pharmacist-supported medication reviews in dementia care: experiences of general practitioners and nurses.

BACKGROUND: Dementia is a major global public health challenge, and with the growing elderly population, its prevalence is expected to increase in the coming years. In Sweden, municipalities are responsible for providing special housing for the elderly (SÄBO), which offers services and care for older individuals needing specific support. SÄBO is both the person´s home and a care environment and workplace. Polypharmacy in patients with dementia is common and increases the risk of medication interactions. Involving clinical pharmacists in medication reviews has been shown to enhance medication safety and improve prescribing practices. However, the views of the standard care team involved in medication prescribing, administration, monitoring and documentation on integrating pharmacist services have received less attention. Thus, this study aims to explore how pharmacists' contributions can enhance medication safety, improve patient care efficiency, and potentially alleviate the workload of general practitioners for people with dementia living in special housing. METHODS: This study has a descriptive qualitative study design using semi-structured interviews and qualitative content analysis. The study was conducted in a southern Swedish special housing and included nurses, assistant nurses, general practitioners (GPs), and a pharmacist. Due to the COVID-19 pandemic, interviews were conducted over the phone. The Swedish Ethical Review Authority approved the study. RESULTS: The analysis revealed three main categories, and eleven subcategories.: (1) Integrating multidisciplinary approaches for holistic dementia care, (2) Strengthening dementia care through effective medication management and (3) Advancing dementia care through pharmacist integration and role expansion. Nurses focused on non-pharmacological treatments, while GPs emphasized the importance of medication reviews in assessing the benefits and side-effects of prescribed medication. Pharmacists were valued for their reliable medication expertise, appreciated by GPs for saving time and providing recommendations prior to consultations with individuals with dementia and their next-of-kin. Although medication reviews were considered beneficial, there was skepticism about their ability to solve all medication-related problems associated with dementia care. CONCLUSIONS: This study highlights the critical role pharmacists play in enhancing medication safety and patient care efficiency in special housing for individuals with dementia. Despite the value of their contributions, communication barriers within healthcare teams pose significant challenges. Recognising potential pharmacist role expansion is essential to alleviate the workload of GPs and ensure effective collaborative practices for better patient outcomes.

Barriers and facilitators of pharmacists' integration in a multidisciplinary home care team: a qualitative interview study based on the normalization process theory.

BACKGROUND: There is a growing recognition of multidisciplinary practices as the most rational approach to providing better and more efficient healthcare services. Pharmacists are increasingly integrated into primary care teams, but there is no universal approach to implementing pharmacist services across healthcare settings. In Norway, most pharmacists work in pharmacies, with very few employed outside this traditional setting. The home care workforce is primarily made up of nurses, assistant nurses, and healthcare assistants. General practitioners (GPs) are not based in the same location as home care staff. This study utilized the Normalization Process Theory (NPT) to conduct a process evaluation of the integration of pharmacists in a Norwegian home care setting. Our aim was to identify barriers and facilitators to optimal utilization of pharmacist services within a multidisciplinary team. METHODS: Semi-structured interviews (n = 9) were conducted with home care unit leaders, ward managers, registered nurses, and pharmacists in Norway, in November 2022-February 2023. Constructs from the NPT were applied to qualitative data. RESULTS: Findings from this study pertain to the four constructs of the NPT. Healthcare professionals struggled to conceptualize the pharmacists' competencies and there were no collectively agreed-upon objectives of the intervention. Consequently, some participants questioned the necessity of pharmacist integration. Further, participants reported conflicting preferences regarding how to best utilize medication-optimizing services in everyday work. A lack of stakeholder empowerment was reported across all participants. Moreover, home care unit leaders and managers reported being uninformed of their roles and responsibilities related to the implementation process. However, the presence of pharmacists and their services were well received in the setting. Moreover, participants reported that pharmacists' contributions positively impacted the multidisciplinary practice. CONCLUSION: Introducing new work methods into clinical practice is a complex task that demands expertise in implementation. Using the NTP model helped pinpoint factors that affect how pharmacists' skills are utilized in a home care setting. Insights from this study can inform the development of tailored implementation strategies to improve pharmacist integration in a multidisciplinary team.

How much time do emergency department physicians spend on medication-related tasks? A time- and-motion study.

BACKGROUND: Medication-related problems are an important cause of emergency department (ED) visits, and medication errors are reported in up to 60% of ED patients. Procedures such as medication reconciliation and medication review can identify and prevent medication-related problems and medication errors. However, this work is often time-consuming. In EDs without pharmacists, medication reconciliation is the physician's responsibility, in addition to the primary assignments of examining and diagnosing the patient. The aim of this study was to identify how much time ED physicians spend on medication-related tasks when no pharmacists are present in the EDs. METHODS: An observational time-and-motion study of physicians in three EDs in Northern Norway was conducted using Work Observation Method by Activity Timing (WOMBAT) to collect and time-stamp data. Observations were conducted in predefined two-hour observation sessions with a 1:1 relationship between observer and participant, during Monday to Friday between 8 am and 8 pm, from November 2020 to October 2021. RESULTS: In total, 386 h of observations were collected during 225 observation sessions. A total of 8.7% of the physicians' work time was spent on medication-related tasks, of which most time was spent on oral communication about medications with other physicians (3.0%) and medication-related documentation (3.2%). Physicians spent 2.2 min per hour on medication reconciliation tasks, which includes retrieving medication-related information directly from the patient, reading/retrieving written medication-related information, and medication-related documentation. Physicians spent 85.6% of the observed time on non-medication-related clinical or administrative tasks, and the remaining time was spent standby or moving between tasks. CONCLUSION: In three Norwegian EDs, physicians spent 8.7% of their work time on medication-related tasks, and 85.6% on other clinical or administrative tasks. Physicians spent 2.2 min per hour on tasks related to medication reconciliation. We worry that patient safety related tasks in the EDs receive little attention. Allocating dedicated resources like pharmacists to contribute with medication-related tasks could benefit both physicians and patients.

Adapting a community pharmacy intervention to improve medication safety.

BACKGROUND: Community pharmacies are an ideal location to address challenges of over-the-counter medication safety, yet many successful interventions are only tested in a few pharmacies without expansion, creating unrealized opportunities to improve patient care on a larger scale. Scaling up to numerous pharmacies can be challenging because each community pharmacy has unique needs and layouts and requires individualized adaptation. OBJECTIVES: This paper reports techniques for (a) adapting a community pharmacy intervention to fit the unique physical layout and patient needs of health system pharmacy sites without increasing staff workload, (b) identifying strategies to gather feedback on adaptations from stakeholders, and (c) developing materials to share with pharmacy champions for them to independently implement and sustain the intervention in their organization. PRACTICE DESCRIPTION: The study team collaborated with Aurora Pharmacy, Inc to develop an intervention designed to increase awareness of safe over-the-counter medication use for older adults. PRACTICE INNOVATION: Senior Safe, a community pharmacy-based intervention, was designed, implemented, and tested using the Exploration, Preparation, Implementation, and Sustainment implementation framework. EVALUATION METHODS: Senior Safe was adapted through pilot testing and a randomized control trial. Feedback was collected from key stakeholders, including pharmacy staff, older adults, and a research advisory group. RESULTS: A finalized version of Senior Safe, as well as an implementation package, was provided to Aurora Pharmacy to integrate into all 63 sites. CONCLUSION: This multiphase study illustrated that refining an intervention is possible and welcomed by pharmacy staff, but it requires time, resources, and funds to create an impactful, sustainable community pharmacy intervention.

Completeness of medication information in admission notes from emergency departments.

BACKGROUND: Medication lists prepared in the emergency department (ED) form the basis for diagnosing and treating patients during hospitalization. Since incomplete medication information may lead to patient harm, it is crucial to obtain a correct and complete medication list at hospital admission. In this cross-sectional retrospective study we wanted to explore medication information completeness in admission notes from Norwegian EDs and investigate which factors were associated with level of completeness. METHODS: Medication information was assessed for completeness by applying five evaluation criteria; generic name, formulation, dose, frequency, and indication for use. A medication completeness score in percent was calculated per medication, per admission note and per criterion. Quantile regression analysis was applied to investigate which variables were associated with medication information completeness. RESULTS: Admission notes for patients admitted between October 2018 and September 2019 and using at least one medication were included. A total of 1,080 admission notes, containing 8,604 medication orders, were assessed. The individual medications had a mean medication completeness score of 88.1% (SD 16.4), while admission notes had a mean medication completeness score of 86.3% (SD 16.2). Over 90% of all individual medications had information about generic name, formulation, dose and frequency stated, while indication for use was only present in 60%. The use of an electronic tool to prepare medication information had a significantly strong positive association with completeness. Hospital visit within the last 30 days, the patient's living situation, number of medications in use, and which hospital the patient was admitted to, were also associated with information completeness. CONCLUSIONS: Medication information completeness in admission notes was high, but potential for improvement regarding documentation of indication for use was identified. Applying an electronic tool when preparing admission notes in EDs seems crucial to safeguard completeness of medication information.

Emergency department physicians' experiences and perceptions with medication-related work tasks and the potential role of clinical pharmacists.

PURPOSE: Medication-related problems are frequent among emergency department patients. Clinical pharmacists play an important role in identifying, solving, and preventing these problems, but are not present in emergency departments worldwide. We aimed to explore how Norwegian physicians experience medication-related work tasks in emergency departments without pharmacists present, and how they perceive future introduction of a clinical pharmacist in the interprofessional team. METHODS: We interviewed 27 physicians in three emergency departments in Norway. Interviews were audio-recorded, transcribed, and analysed using qualitative content analysis. RESULTS: Our informants' experience with medication-related work tasks mainly concerned medication reconciliation, and few other tasks were systematically performed to ensure medication safety. The informants were welcoming of clinical pharmacists and expressed a need and wish for assistance with compiling patient's medication lists. Simultaneously they expressed concerns regarding e.g., responsibility sharing, priorities in the emergency department and logistics. These concerns need to be addressed before implementing the clinical pharmacist in the interprofessional team in the emergency department. CONCLUSIONS: Physicians in Norwegian emergency departments welcome assistance from clinical pharmacists, but the identified professional, structural, and legislative barriers for this collaboration need to be addressed before implementation.

Elevating Safe Use of Over-The-Counter Medications in Older Adults: A Narrative Review of Pharmacy Involved Interventions and Recommendations for Improvement.

Over-the-counter (OTC) medications are products that have been made easily accessible to allow patients to treat common ailments without a prescription and the cost of a doctor's visit. These medications are generally considered safe; however, there is still a potential for these medications to lead to adverse health outcomes. Older adults (ages 50+) are especially susceptible to these adverse health outcomes, due to age-related physiological changes, a higher prevalence of comorbidities, and prescription medication use. Many OTC medications are sold in pharmacies, which provides pharmacists and technicians with the opportunity to help guide safe selection and use for these medications. Therefore, community pharmacies are the ideal setting for OTC medication safety interventions. This narrative review summarizes the findings of pharmacy-involved interventions that promote safe OTC medication use for older adults.

Patient perceptions and experiences with medication-related activities in the emergency department: a qualitative study.

BACKGROUND: Emergency department (ED) pharmacists reduce medication errors and improve quality of medication use. Patient perceptions and experiences with ED pharmacists have not been studied. The aim of this study was to explore patients' perceptions of and experiences with medication-related activities in the ED, with and without an ED pharmacist present. METHODS: We conducted 24 semistructured individual interviews with patients admitted to one ED in Norway, 12 before and 12 during an intervention, where pharmacists performed medication-related tasks close to patients and in collaboration with ED staff. Interviews were transcribed and analysed applying thematic analysis. RESULTS: From our five developed themes, we identified that: (1) Our informants had low awareness and few expectations of the ED pharmacist, both with and without the pharmacist present. However, they were positive to the ED pharmacist. (2) Our informants expressed a variation of trust in the healthcare system, healthcare professionals and electronic systems, though the majority expressed a high level of trust. They believed that their medication list was automatically updated and assumed to get the correct medication. (3) Some informants felt responsible to have an overview of their medication use, while others expressed low interest in taking responsibility regarding their medication. (4) Some informants did not want involvement from healthcare professionals in medication administration, while others expressed no problems with giving up control. (5) Medication information was important for all informants to feel confident in medication use, but the need for information differed. CONCLUSION: Despite being positive to pharmacists, it did not seem important to our informants who performed the medication-related tasks, as long as they received the help they needed. The degree of trust, responsibility, control and information varied among ED patients. These dimensions can be applied by healthcare professionals to tailor medication-related activities to patients' individual needs.

'Illuminating determinants of implementation of non-dispensing pharmacist services in home care: a qualitative interview study'.

OBJECTIVES: Medication errors are leading causes of hospitalization and death in western countries and WHO encourages health care providers to implement non-dispensing pharmacist services in primary care to improve medication work. However, these services struggle to provide any impact on clinical outcomes. We wanted to explore health care professionals' views on medication work to illuminate determinants of the implementation success. The research was designed to inform and adapt implementation strategies for non-dispensing pharmacist services. DESIGN: Semi-structured interview study with nine healthcare professionals. SETTING: Four Norwegian home care wards. SUBJECTS: Nine healthcare professionals working at different wards within one home care unit. MAIN OUTCOME MEASURES: Determinants of implementation outcomes. RESULTS: Contextual determinants of the implementation process were mainly related to characteristics of the setting such as poorly designed information systems, work overload, and chaotic work environments. The identified barriers question the innovation's appropriateness related to the setting's needs but also provide possibilities for tailoring pharmacist services to local medication work issues. The observable positive effects and the perceived advantage of the pharmacist services are likely to facilitate the implementation process. CONCLUSION: Our study provided information on contextual elements that influence the implementation process of non-dispensing pharmacist services. Awareness of these factors can help develop strategies to help the organization succeed in in achieving program outcomes.

The results in this study illuminate barriers and facilitators to the implementation of pharmacist services in a home care setting.Existing medication work methods and poor information handover systems are likely to counteract outcomes of the pharmacist services and inflict unfavorable conditions for implementation.Healthcare professionals' perception of increased medication work support and confidence in pharmacist skills suggest innovation acceptability and serve as indicators of implementation success. The identified barriers to improving medication work provide opportunities to develop tailored strategies to enhance the implementation of non-dispensing pharmacist services.

Communication about medication management during patient-physician consultations in primary care: a participant observation study.

OBJECTIVE: To explore communication about medication management during annual consultations in primary care. DESIGN: passive participant observations of primary care consultations. SETTING: Two primary care centres in southern Sweden. PARTICIPANTS: Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis. RESULTS: Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further. CONCLUSION: Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.

Self-reported medication information needs among medication users in a general population aged 40 years and above - the Tromsø study.

PURPOSE: To determine the prevalence and associated factors of self-reported medication information needs among medication users in a general population aged 40 years and above - The Tromsø Study. METHODS: Cross-sectional study of medication users (n = 10,231) among participants in the Tromsø Study, a descriptive analysis of questionnaire data and multivariable logistic regression (n = 9,194). RESULTS: Sixteen percent of medication users expressed a need for more information about own medications. Overall, medication users agreed to a higher degree to have received information from the GP compared to the pharmacy. Concerned medication users and those disagreeing to have received information about side effects had the highest odds for needing more information (OR 5.07, 95% CI 4.43-5.81) and (OR 2.21, 95% CI 1.83-2.68), respectively. Medication users who used heart medications (e.g., nitroglycerin, antiarrhythmics, anticoagulants) (OR 1.71, 95% CI 1.46-2.01), medication for hypothyroidism (OR 1.36, 95% CI 1.13-1.64) or had moderately health anxiety had expressed need for medication information. Whereas medication users with lower education, those that never used internet to search for health advice, and medication users who disagreed to have received information about reason-for-use were associated with lower odds (OR 0.75, 95% CI 0.62-0.91), (OR 0.85, 95% CI 0.74-0.98) and (OR 0.68, 95% CI 0.53-0.88), respectively. CONCLUSION: This study demonstrated that there is need for more information about own medications in a general population aged 40 years and above and shed light on several characteristics of medication users with expressed information need which is important when tailoring the right information to the right person.

Pharmacist's time spent: Space for Pharmacy-based Interventions and Consultation TimE (SPICE)-an observational time and motion study.

OBJECTIVE: To describe the pharmacists' workflow, including tasks and time spent, to better understand their work capacity. DESIGN: Cross-sectional, observational, time and motion study. SETTING: Community pharmacies in Western Australia and New South Wales, Australia. PARTICIPANTS: Currently registered and practising pharmacists were approached using snowball sampling and selected using purposive techniques to obtain balance representation of metropolitan and rural pharmacies, as well as high and low script volumes where possible. RESULTS: Twenty-four pharmacists across 15 pharmacies participated during the 135 sessions totalling over 274 hours of observation. Dispensing (30%), indirect patient services (17%), counselling (15%) and professional management activities (15%) were the top four duties pharmacists performed, while only 2% of time was spent on professional services such as pain clinics and influenza vaccinations. Tasks were frequently interrupted and often performed simultaneously. Breaks and consumer-contact times were limited. More time was spent on professional service activities in non-metropolitan pharmacies, in pharmacies with greater daily prescription volumes and those with one or more support pharmacists. CONCLUSIONS: This is the first study to quantify the pharmacists' tasks in Australian community pharmacies. Much time is being spent on dispensing, supply and management activities with little time for providing additional professional services. An extra supporting pharmacist is likely necessary to increase professional services. These findings could support future research around barriers and enablers of conducive workflows and of extended professional services.

Emergency department physicians' distribution of time in the fast paced-workflow-a novel time-motion study of drug-related activities.

Background In the emergency department physicians are forced to distribute their time to ensure that all admitted patients receive appropriate emergency care. Previous studies have raised concerns about medication discrepancies in patient's drug lists at admission to the emergency department. Thus, it is important to study how emergency department physicians distribute their time, to highlight where workflow redesign can be needed.Aim to quantify how emergency department physicians distribute their time between various task categories, with particular focus on drug-related tasks.Method Direct observation, time-motion study of emergency department physicians at Diakonhjemmet Hospital, Oslo, Norway. Physicians' activities were categorized in discrete categories and data were collected with the validated method of Work Observation Method By Activity Timing between October 2018 to January 2019. Bootstrap analysis determined 95% confidence intervals for proportions and interruption rates.Results During the observation time of 91.4 h, 31 emergency department physicians were observed. In total, physicians spent majority of their time gathering information (36.5%), communicating (26.3%), and documenting (24.2%). Further, physicians spent 17.8% (95% CI 16.8%, 19.3%) of their time on drug-related tasks. On average, physicians spent 7.8 min (95% CI 7.2, 8.6) per hour to obtain and document patients' drug lists.Conclusion Emergency department physicians are required to conduct numerous essential tasks and distributes a minor proportion of their time on drug-related tasks. More efficient information flow regarding drugs should be facilitated at transitions of care. The presence of healthcare personnel dedicated to obtaining drug lists in the emergency department should be considered.

Integrating the clinical pharmacist into the emergency department interdisciplinary team: a study protocol for a multicentre trial applying a non-randomised stepped-wedge study design.

INTRODUCTION: The 'emergency department (ED) pharmacist' is an integrated part of the ED interdisciplinary team in many countries, which have shown to improve medication safety and reduce costs related to hospitalisations. In Norway, few EDs are equipped with ED pharmacists, and research describing effects on patients has not been conducted. The aim of this study is to investigate the impact of introducing clinical pharmacists to the interdisciplinary ED team. In this multicentre study, the intervention will be pragmatically implemented in the regular operation of three EDs in Northern Norway; Tromsø, Bodø and Harstad. Clinical pharmacists will work as an integrated part of the ED team, providing pharmaceutical care services such as medication reconciliation, review and/or counselling. The primary endpoint is 'time in hospital during 30 days after admission to the ED', combining (1) time in ED, (2) time in hospital (if hospitalised) and (3) time in ED and/or hospital if re-hospitalised during 30 days after admission. Secondary endpoints include time to rehospitalisation, length of stay in ED and hospital and rehospitalisation and mortality rates. METHODS AND ANALYSIS: We will apply a non-randomised stepped-wedge study design, where we in a staggered way implement the ED pharmacists in all three EDs after a 3, 6 and 9 months control period, respectively. We will include all patients going through the three EDs during the 12-month study period. Patient data will be collected retrospectively from national data registries, the hospital system and from patient records. ETHICS AND DISSEMINATION: The Regional Committee for Medical and Health Research Ethics and Local Patient Protection Officers in all hospitals have approved the study. Patients will be informed about the ongoing study on a general basis with ads on posters and flyers. TRIAL REGISTRATION NUMBER: NCT04722588.

Time distribution for pharmacists conducting a randomized controlled trial-An observational time and motion study.

INTRODUCTION: An expected future increase in older adults will demand changes in health care delivery, making development, implementation and evaluation of new health care models essential. The rationale for political decision-making concerning the implementation and application of interventions in health care should include cost estimations, specifically those involving clinical interventions. To provide such data knowledge of time spent on the intervention is imperative. Time and motion methodology is suitable to quantify health care personnel's time distribution. AIM: To investigate the time distribution for pharmacists conducting a randomized controlled trial (RCT) implementing a clinical intervention. MATERIALS AND METHODS: The setting was an RCT with a 5-step pharmacist-intervention in collaboration with the interdisciplinary team in a geriatric ward. Two pharmacists were involved in the trial during the observation period. Pharmacist activities, classified as RCT-tasks (intervention or administrative), non-RCT tasks and social/breaks, were recorded applying the Work Observation Method By Activity Timing methodology, enabling recording of predefined work tasks as well as interruptions and multitasking. One observer collected data over eight weeks. RESULTS: In total, 109.1 hours were observed resulting in 110.2 hours total task time, including multitasking. RCT tasks comprised 85.4% of the total observed time, and nearly 60% of the RCT time was spent on intervention tasks. Medication reviews was the most time consuming task, accounting for 32% of the observed time. The clinical pharmacists spent 14% of the intervention time communicating verbally, mainly with patients and healthcare professionals. CONCLUSION: During the RCT, the clinical pharmacists spent about half their time performing the actual intervention. Consequently, costs for providing such a clinical pharmacist service should reflect actual time spent; otherwise, we may risk overestimating theoretical costs.

Community pharmacist workflow: Space for Pharmacy-based Interventions and Consultation TimE study protocol.

BACKGROUND: Pharmacists' roles are expanding to delivering a wider set of professional services including medication management optimisation, vaccinations and screening services. Robust research determining whether pharmacists have the capacity to offer such services in the Australian community pharmacy setting is lacking. This protocol details a mixed methods study that investigates the variation in pharmacists' daily tasks and the workspace they work in as a measure of their workload capacity for expanding pharmacy services. METHODS: An observational time and motion study will be conducted in up to twenty community pharmacies in metropolitan and rural regions of Australia. A trained observer will follow a pharmacist and record the type, location and duration of tasks undertaken over the course of their working day. Data will be collected and analysed using the electronic Work Observation Method By Activity Timing (WOMBAT) tool. Pharmacists' work patterns will be described as time for each task, and by proportionating multitasking and interruptions. This information will be combined with workspace data collected using floor plans, photographs and a qualitative assessment of the working environment completed by the observer. Analysis will include heat-mapped floor plans visually highlighting pharmacist movements. DISCUSSION: Pharmacists may provide solutions to the strained health workforce and system. There is limited quantitative evidence on whether pharmacists have the time or work setting to support such needs. The use of time and motion methodology is novel to Australian community pharmacy research, and the findings will provide a better understanding of pharmacists' capacity and work environment.

Challenges and Best Practices in Ethical Review of Human and Organizational Factors Studies in Health Technology: a Synthesis of Testimonies.

OBJECTIVE: Human and Organizational Factors (HOF) studies in health technology involve human beings and thus require Institutional Review Board (IRB) approval. Yet HOF studies have specific constraints and methods that may not fit standard regulations and IRB practices. Gaining IRB approval may pose difficulties for HOF researchers. This paper aims to provide a first overview of HOF study challenges to get IRB review by exploring differences and best practices across different countries. METHODS: HOF researchers were contacted by email to provide a testimony about their experience with IRB review and approval. Testimonies were thematically analyzed and synthesized to identify and discuss shared themes. RESULTS: Researchers from seven European countries, Argentina, Canada, Australia, and the United States answered the call. Four themes emerged that indicate shared challenges in legislation, IRB inefficiencies and inconsistencies, general regulation and costs, and lack of HOF study knowledge by IRB members. We propose a model for IRB review of HOF studies based on best practices. CONCLUSION: International criteria are needed that define low and high-risk HOF studies, to allow identification of studies that can undergo an expedited (or exempted) process from those that need full IRB review. Enhancing IRB processes in such a way would be beneficial to the conduct of HOF studies. Greater knowledge and promotion of HOF methods and evidence-based HOF study designs may support the evolving discipline. Based on these insights, training and guidance to IRB members may be developed to support them in ensuring that appropriate ethical issues for HOF studies are considered.

Mandatory Medication Indications in Electronic Systems - The Prescriber Perspective.

As hospitals transition from paper to electronic medication charts, an opportunity exists to 'nudge' prescribers to document medication indications by making this data-entry field mandatory. The aim of this study was to explore hospital doctors' perceptions of mandatory documentation of indications in an electronic medication management (EMM) system. Ten junior doctors took part in brief semi-structured interviews. Participants identified improved communication among staff as a key benefit of indication documentation. Recording indications was also seen to act as a prompt for medication review. Despite these benefits, indication documentation for all medications would be challenging to implement in practice. Users of the EMM system (i.e. junior doctors) explained that they are time poor and are often tasked with transcribing medication orders into the electronic system with limited knowledge of why medications are being prescribed. Determining the indication for use would require additional time and effort, and prescribers reported a high risk of working around the system if indication documentation was made mandatory.

Medication Errors and Safety Culture in a Norwegian Hospital.

Medication errors are associated with adverse health outcomes and may prolong hospital stays and increase societal costs. Safety initiatives to reduce adverse health outcomes should be based on reliable information of current shortcomings. The aim of this study was to identify barriers to medication error reporting in a hospital and to describe heath personnel's views of the safety culture. Seven interviews with health personnel (two doctors, four nurses and one pharmacist) were conducted November 2016-January 2017 at the University Hospital of North Norway. Nurses, more frequently than doctors, reported medication errors and discussed reported errors at staff meetings. Doctors preferred to solve the problem directly, for example writing a new medication order, rather than writing a report when a medication error had been identified. There was variation between the wards regarding the perception of support, confidence in and focus on error reporting, which indicates different safety cultures within the hospital. Identified barriers to medication error reporting included lack of time, and the impression that the reporting system is complicated and not user-friendly. Staff also reported inadequate training using the system, which could contribute to the perception that the system is inaccessible. Hospital management should take actions to improve the safety culture throughout the hospital based on the barriers identified in this study. This could include stronger focus on the importance of reporting medication errors, a transparent review process and clearly communicated actions.

A cross-country time and motion study to measure the impact of electronic medication management systems on the work of hospital pharmacists in Australia and England.

BACKGROUND: Qualitative studies have provided important insights into how hospital pharmacists' work changes when electronic medication management (EMM) systems are introduced. Quantitative studies of work practice change are rare. Despite the use of EMM systems internationally, there are no cross-country comparative studies of their impact on health professionals' work. We aimed to quantify and compare the type and magnitude of changes in hospital pharmacists' work pre- and post-EMM implementation in two countries. METHODS: Parallel, direct observational, time and motion studies of pharmacists in Australia and England pre- and post-EMM implementation. 20 pharmacists were observed: 9 in an Australian 440-bed hospital (155 h); and 11 pharmacists in a 500-bed English hospital (258 h). The Work Observation Method By Activity Timing (WOMBAT) software was used to collect observational data. Proportions of observed time in 11 tasks by study period (pre- versus post-EMM) and site, time spent with others or alone, and using different tools (e.g computers, paper) were calculated. Magnitude of changes between pre- and post-EMM by task and country were determined using z-tests for proportions adjusting for multiple testing. RESULTS: At baseline, Australian and English pharmacists spent the greatest proportion of time in medication review. Post-EMM, time in medication review (Australia 21.6%-27.5%; England 27.1%-33.8%) and history-taking (Australia 7.6%-13.3%; England 19.5%-28.9%) significantly increased. Despite country differences in these tasks at baseline, the magnitude of changes did not significantly differ. English pharmacists increased time engaged in medication discussions with patients post-EMM (from 5.9% to 10.8%; p = 0.01). The Australian rate did not change (18.0%-27.2%; p = 0.09), but was higher at baseline. Post-EMM, Australian pharmacists spent 63.4% of time working alone, compared to 92.0% for English pharmacists. CONCLUSIONS: EMM systems impacted the same core areas of work and had a similar magnitude of effect on pharmacists' work in both countries. Anticipated reductions in medication review and history taking were not observed.