Hospital pharmacists', doctors' and nurses' perceptions of intra- and inter- professional communication in the context of electronic prescribing and medication administration systems: A qualitative study.

BACKGROUND: Effective, integrated and coordinated communication is essential in providing high quality patient care. Little prior research has detailed the impact of electronic prescribing and medication administration (ePMA) systems on healthcare professionals' (HCPs') communication. We investigated hospital pharmacists', doctors' and nurses' perceptions of how ePMA systems have affected, or are expected to affect, the way they communicate with each other in an inpatient setting. METHODS: A qualitative study in three English NHS hospitals: two used different inpatient ePMA systems, and one used paper-based prescribing. We conducted focus groups with pharmacists, and semi-structured individual interviews with doctors and nurses. Transcribed data were analysed inductively using thematic analysis. RESULTS: Nine focus groups, three at each hospital, were conducted with pharmacists with different levels of seniority (58 pharmacists in total). Fourteen doctors and twelve nurses took part in individual interviews. Four themes were generated: modes of communication, reduced pharmacist visibility, system limitations, and future aspirations for ePMA. Whether working with ePMA or paper-based systems, all participants preferred to communicate face-to-face to facilitate collaborative discussions regarding patient care. Participants perceived that ePMA reduced contact time with patients. Pharmacists perceived that both their physical ward presence and their written communication on medication charts had reduced since introduction of ePMA. Doctors felt they were now less likely to ask pharmacists questions due to pharmacists' reduced physical presence on the ward. Hardware and software limitations were identified by all HCPs, with suggestions made for future developments to better support communication. CONCLUSION: ePMA does not necessarily support communication among HCPs. Pharmacists and doctors were also concerned that ePMA reduces communication between themselves and their patients. Hospital managers should ensure sufficient hardware for HCPs, including pharmacists, to conduct their work in clinical areas, and work with ePMA system suppliers to develop ways of enhancing, rather than inhibiting, communication.

The impact of electronic prescribing systems on healthcare professionals' working practices in the hospital setting: a systematic review and narrative synthesis.

BACKGROUND: The aim of this systematic review was to synthesise peer-reviewed literature assessing the impact of electronic prescribing (eP) systems on the working practices of healthcare professionals (HCPs) in the inpatient setting and identify implications for practice and research. METHODS: We searched PubMed, Medline, Embase, Cochrane and the Cumulative Index to Nursing Allied Health Literature databases for studies published from inception to November 2018. We included controlled, uncontrolled, observational and descriptive studies that explored the effect of eP on HCPs' working practices in an inpatient setting. Data on setting, eP system and impact on working practices were extracted. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Emergent themes were identified and subjected to narrative synthesis. The protocol was registered with PROSPERO (registration CRD42017075804). RESULTS: Searches identified 1301 titles and abstracts after duplicate removal. 171 papers underwent full-text review. A total of 25 studies met the inclusion criteria, from nine different countries. Nineteen were of commercial eP systems. There were a range of study designs; most (n = 14) adopted quantitative methods such as cross-sectional surveys, ten adopted qualitative approaches and a further one used mixed methods. Fourteen of the 25 studies were deemed to be of high quality. Four key themes were identified: communication, time taken to complete tasks, clinical workflow, and workarounds. Within each theme, study findings differed as to whether the effects of eP on HCPs' working practices were positive or negative. CONCLUSION: There is a lack of consensus within the literature on the impact of eP on HCPs' working practices. Future research should explore the strategies resulting in a positive impact on HCPs' working practices and learn from those that have not been successful.

AN AUDIT OF PAEDIATRIC VANCOMYCIN DOSING.

AIM: To audit whether a new paediatric vancomycin guideline is being adhered to and if therapeutic levels are being achieved. METHOD: Data on doses, age, weight, vancomycin levels, time taken and renal function were collected prospectively by reviewing drug charts of paediatric patients on vancomycin. The patients were followed for their whole vancomycin journey in order to observe if the guidelines were followed throughout. Data were collected between 7th and 30th January 2015. The data were analysed using an excel spreadsheet. STANDARDS: ▸ 100% of patients <1 month without renal failure should be prescribed an initial dose of 15 mg/kg three times a day▸ 100% of patients ≥1 month without renal failure should be prescribed an initial dose of 20 mg/kg three times a day▸ 100% of patients of all ages with renal impairment (defined as Glomerular filtration rate <50 ml/min) should be prescribed a single dose of 10 mg/kg▸ 90% of patients should have their vancomycin levels taken at the correct time (pre-third dose)▸ 80% of the third dose trough levels should be in range (10-15 mg/L)▸ In 90% of patients with levels out of range, appropriate action should be taken to correct their levels. RESULTS: Data from 15 patients were collected resulting in 62 vancomycin levels.Three of six standards were met. Standards 1 and 3 could not be assessed as no patients were under the age of 1 month or had renal impairment. 100% patients were initiated on the correct staring dose meeting standard 2. One patient excluded from this standard as a clinical decision was made to start the patient on a lower starting dose of 15 mg/kg three times a day due to previous high levels. 90% of vancomycin levels had been taken at the correct time (pre-third dose) thus standard 4 was achieved. However there were 6 occasions when the levels were taken post-third dose or taken pre-maturely. These levels were not in range. Only 33% of patients had the initial level within range for standard 5; after a dose change a further 31% were in range.For standard 6, 93% of actions taken by doctors when the vancomycin levels came back out of range were correct. This standard was achieved. CONCLUSION: This audit has shown that the guidelines are being followed but the paediatric dosing of vancomycin requires modification to achieve therapeutic levels. Limitations of the audit included low patient numbers, standard 1 and 3 could not be assessed and an assumption was made that all the levels documented were taken at the correct time, unless stated. Not enough data were collected to make suggestions based on different ages. An option would be to follow recommendation that frequency of dosing is changed from three to four times a day.1 A continuous infusion of vancomycin could also be considered.

Patient involvement in medication safety in hospital: an exploratory study.

BACKGROUND: Medication errors are common in hospital inpatients. While many interventions have been proposed to address these problems, few have been shown to have significant benefits. A complementary approach is to facilitate greater involvement of patients with their inpatient medication. However, there is relatively little research in this area and it is not known which interventions lead to improved healthcare outcomes. Work is therefore needed to investigate the roles that healthcare professionals and patients believe are appropriate for hospital inpatients to take relating to safety. OBJECTIVE: To explore the extent to which hospital inpatients reported that they engaged with medication safety-related behaviours, the extent to which they would like to, and the extent to which healthcare professionals reported that they would support such engagement. SETTING: An NHS hospital Trust in West London. METHODS: 100 Patients and healthcare professionals were recruited on ten wards within the Trust and invited to complete quantitative questionnaires. Data were analysed descriptively and exploratory comparisons made between different groups of respondents. MAIN OUTCOME MEASURES: inpatient medication safety involvement scale and control preference scale for patient involvement in decision making. RESULTS: 100 patients (98 % response rate) and 104 healthcare professionals (59 % response rate) were recruited. The majority of patients and healthcare professionals were supportive of hospital inpatients being involved with their medication. However there was a significant gap between desire for patient involvement and what patients reported having experienced. Female patients and those under 65 wanted a significantly higher level of involvement than males and over 65s. Few associations were found between healthcare professionals' reported support for involvement and their profession or gender. However, pharmacists and nurses were significantly more likely to report supporting patients asking questions about their medicines and self administering their own medicines than doctors. CONCLUSION: Healthcare professionals and patients desire a higher level of patient involvement with their medication while in hospital than patients currently report. Interventions need to be developed to bridge the gap between desired and actual patient involvement.