Survey of Nurses' Experiences Applying The Joint Commission's Medication Management Titration Standards.

BACKGROUND: Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses' autonomous decision-making. OBJECTIVES: To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions. METHODS: A survey of nurses' experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses. RESULTS: The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress. CONCLUSIONS: Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.

Thematic Analysis of Nurses' Experiences With The Joint Commission's Medication Management Titration Standards.

BACKGROUND: For decades, medication titration has been within nurses' scope and practice. In 2017 The Joint Commission (TJC) revised elements for orders for the titration of continuous intravenous medications. OBJECTIVES: To explore the practice and perceptions of nurses regarding TJC standards for titration of continuous intravenous medications. METHODS: Nurses with experience titrating medications completed an investigator-designed, validated cross-sectional survey. Inductive thematic analysis was conducted in order to analyze the open-ended comments from that quantitative survey. RESULTS: From among 730 completed surveys, 159 comments were received. Analysis of the comments yielded 3 levels of abstraction. Two overarching themes were harm and professionalism. Additional abstraction for the harm theme revealed categories of erosion of workplace wellness, moral dilemma, and patient safety, which were coded as relating to workplace stress, workload, burnout/turnover, physical risk, inefficiency, demeaning/devalued, falsification of records, problematic orders, burden of documentation, suboptimal care, delay in care, individualized care, and provider availability. Within the professionalism theme, categories of autonomy and nurse proficiency were identified, with 7 associated codes: top of scope, critical thinking, overregulation, teamwork, education, registered nurse knowledge, and novice registered nurse guidance. CONCLUSIONS: The standards from TJC impose harm by eroding workplace wellness and introducing moral dilemmas and patient safety concerns. Professionalism is threatened through limits on scope and autonomy. Further advocacy is necessary in order to resolve unanticipated consequences related to the titration standards.

The Impact of the COVID-19 "Infodemic" on Drug-Utilization Behaviors: Implications for Pharmacovigilance.

The coronavirus disease 2019 (COVID-19) pandemic that hit the world in 2020 triggered a massive dissemination of information (an "infodemic") about the disease that was channeled through the print, broadcast, web, and social media. This infodemic also included sensational and distorted information about drugs that likely first influenced opinion leaders and people particularly active on social media and then other people, thus affecting choices by individual patients everywhere. In particular, information has spread about some drugs approved for other indications (chloroquine, hydroxychloroquine, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, favipiravir, and umifenovir) that could have led to inappropriate and therefore hazardous use. In this article, we analyze the rationale behind the claims for use of these drugs in COVID-19, the communication about their effects on the disease, the consequences of this communication on people's behavior, and the responses of some influential regulatory authorities in an attempt to minimize the actual or potential risks arising from this behavior. Finally, we discuss the role of pharmacovigilance stakeholders in emergency management and possible strategies to deal with other similar crises in the future.

Breaking the pain contract: A better controlled-substance agreement for patients on chronic opioid therapy.

"Pain contracts" for patients receiving long-term opioid therapy, though well-intentioned, often stigmatize the patient and erode trust between patient and physician. This article discusses how to improve these agreements to promote adherence, safety, trust, and shared decision-making.

[Proposed model for managing drugs used for unregistered indications in Colombia]. / Propuesta de un modelo de gestión de medicamentos en indicaciones no registradas en Colombia.

The use of drugs for unregistered indications, known as "off-label" use, is a practice that creates problems of rational use and access when other options are not available. Health systems should address this situation, particularly in connection with decisions concerning coverage, while trying to minimize health risks and clearly define the roles and responsibilities of the parties involved. Colombia's Ministry of Health and Social Protection (MinSalud), together with the National University of Colombia and national experts, developed a proposal for a model for managing drugs being used for unregistered indications (off-label) and their potential reimbursement with public resources, taking into account international practices and country characteristics. The management model is non-punitive and is geared toward promoting the rational use of these drugs so that barriers to access are reduced whenever their use is supported by solid scientific evidence. The model addresses patient safeguards in the bioethical domain and the roles and responsibilities of the prescriber and government entities.

Parents' information needs and influential factors when making decisions about TNF-α inhibitors.

BACKGROUND: Parents struggle when making treatment decisions for children with arthritis or other chronic conditions. Understanding their decision-making process is an essential step towards improving the decision-making experience. The objective of this study was to describe parents' information needs and the influences on their decision making about treatment with TNF-α inhibitors. METHODS: Survey domains were developed based on qualitative data and cognitive interviewing. We mailed the survey to parents of children with juvenile idiopathic arthritis or inflammatory bowel disease who had initiated treatment with TNF-α inhibitors in the prior 2 years. Data were analyzed using descriptive and non-parametric statistics. RESULTS: Survey response rate was 54.9 %. Each item had <2 % missing responses. Parents used an array of information sources when deciding about treatment with TNF-α inhibitors. Resources other than their child's specialist were most often used to increase confidence in parents' decisions or because they wanted to know more about other people's experiences being treated with TNF-α inhibitors, rather than due to a lack of understanding. All but two (cost and route of administration) of the influential decision factors were very or extremely important to the majority of participants with factors related to long-term side effects, treatment efficacy, and disease impact being most important. CONCLUSIONS: This study describes parents' information needs and influential factors in treatment decision making. Results suggest that future work should be aimed at helping families weigh risks and benefits, such as through decision support interventions, as well as developing opportunities to include people beyond the family and physician in the decision-making process.

Ética y prevención de la medicalización / Ethics and prevention of medicalization

La sociedad ha desplazado al campo médico problemas de la realidad subjetiva y social de las personas, y la obsesión por una salud perfecta se ha convertido en un factor patógeno predominante existiendo un aumento del número de enfermedades y enfermos, a la vez que mejora el nivel de salud de la población. El poder de la medicina ha hecho atractiva la idea de «medicalizar» aspectos de la vida que se pueden percibir como problemas médicos aun sin serlo. Vivir conlleva momentos de infelicidad y de angustia, pero ¿deberíamos tratar dichos momentos? Estamos en la cultura sanitaria del «todo, aquí y ahora». En este artículo se analizan las implicaciones éticas de las intervenciones innecesarias y se plantean distintas alternativas que pueden realizar los profesionales implicados para reconducir dicha situación; reflexionamos si queremos un mundo donde todos llevemos etiquetas de riesgo de presentar esta o aquella enfermedad (AU)

Society has shifted issues of subjective and social reality of the population into the medical field, with the obsession with perfect health becoming a predominant pathogenic factor in the increase in the number of diseases and patients, while the level of health in the population is improving. The power of medicine has made the idea of «medicalising» various aspects of life that can be perceived as medical problems as attractive even when it is not the case. Living entails times of unhappiness and anguish but, should we treat these episodes? We are in the health culture of «everything, here and now». In this article, the ethical implications of unnecessary interventions are analysed, along with the different alternatives that the professionals involved may perform to redirect this situation. It is reflected if we want a world where we all risk wearing labels for this or that disease (AU)

A qualitative study exploring the impact and consequence of the medicines use review service on pharmacy support-staff / Estudio cualitativo explorando el impacto y las consecuencias del servicio de revisión de uso de medicamento sobre el personal de apoyo en la farmacia

Background: Pharmacy support-staff (pharmacy technicians, dispensers and Medicines Counter Assistants) support the delivery of pharmaceutical and retail functions of the pharmacy. Workflow is supervised and at times dependent upon the pharmacist’s presence. Policy makers and pharmacy’s representative bodies are seeking to extend the community pharmacist's role including requiring the pharmacist to undertake private consultations away from the dispensary and shop floor areas. However, support-staff voices are seldom heard and little is known about the impact such policies have on them. Objective: The objective of this study is to explore the impact and consequences of the English Medicine Use Review (MUR) service on pharmacy support-staff. Method: Ten weeks of ethnographic-oriented observations in two English community pharmacies and interviews with 5 pharmacists and 12 supportstaff. A thematic approach was used to analyse the data. Results: Despite viewing MURs as a worthwhile activity, interviews with support-staff revealed that some felt frustrated when they were left to explain to patients why the pharmacist was not available when carrying out an MUR. Dependency on the pharmacist to complete professional and accuracy checks on prescriptions grieved dispensing staff because dispensing workflow was disrupted and they could not get their work done. Medicines Counter Assistants were observed to have less dependency when selling medicines but some still reported concerns over of customers and patients waiting for the pharmacist. A range of tacit and ad hoc strategies were consequently found to be deployed to handle situations when the pharmacist was absent performing an MUR. Conclusions: Consideration should be given to support-staff and pharmacists’ existing work obligations when developing new pharmacy extended roles that require private consultations with patients. Understanding organisational culture and providing adequate resourcing for new services are needed to avoid improvisations or enactments by pharmacy support-staff and to allow successful innovation and policy implementation(AU)

Antecedentes: El personal de apoyo en la farmacia (auxiliares de farmacia, dispensadores, y ayudantes de mostrador) ayuda en la entrega de medicamentos y las funciones de venta en la farmacia. El flujo de trabajo esta supervisado y a veces es dependiente de la presencia del farmacéutico. Los políticos y los cuerpos de representación de los farmacéuticos buscan extender el papel del farmacéutico comunitario, incluyendo exigir al farmacéutico que realice consultas privadas fuera de la zona de dispensación y de las partes del público. Sin embargo, rara vez se oyen las voces del personal de apoyo y se sabe poco del impacto de estas políticas sobre ellos. Objetivo: El objetivo de este estudio es explorar el impacto y las consecuencias del servicio ingles de revisión del uso de medicamentos (MUR) sobre el personal de apoyo en la farmacia. Métodos: Diez semanas de observaciones de tipo etnográfico en dos farmacias comunitarias inglesas y entrevistas con 5 farmacéuticos y 12 personas de apoyo. Se utilizó un abordaje temático para analizar los datos. Resultados: A pesar de ver las MUR como una actividad que valiosa, las entrevistas con el personal de apoyo reveló que se sienten frustrados cuando se les dejó y tuvieron que explicar a los pacientes porque el farmacéutico no estaba disponible cuando estaba realizando una MUR. La dependencia del farmacéutico para completar las comprobaciones profesionales y la idoneidad de las prescripciones incomodaba al personal dispensador porque el flujo de trabajo de la dispensación tenía que interrumpirse y no podían hacer el trabajo solos. Se observó que los ayudantes de mostrador tenían menos dependencia cuando vendían medicamentos, pero algunos reportaron preocupaciones sobre los clientes y pacientes cuando esperaban por el farmacéutico. Se encontró un abanico de estrategias tácitas y ad-hoc que se desarrollaron para manejar las situaciones en las que el farmacéutico estaba ausente realizando una MUR. Conclusiones: Se debería tener en cuenta las obligaciones del trabajo actual del personal de apoyo y del farmacéutico cuando se desarrollan nuevos papeles ampliados en la farmacia, que requieran consultas privadas con pacientes. Se necesita comprender la cultura organizaciones y realojar adecuadamente los recursos para los nuevos servicios para evitar improvisaciones o actuaciones del personal de apoyo en la farmacia y para permitir innovación y la implementación de políticas con éxito(AU)

Financiación de medicamentos: Los aspectos jurídicos / Financing of drugs: legal aspects

El derecho a la protección de la salud impulsa al poder ejecutivo a establecer una política sanitaria conducente, dentro de los principios de equidad, calidad y participación ciudadana, a la promoción del uso racional del medicamento y a adoptar medidas dirigidas a que la prestación farmacéutica, por el Sistema Nacional de Salud, se realice a precios razonables y con un gasto publico ajustado, dentro de la necesidad de optimizar los recursos disponibles. En la actualidad el Estado de Bienestar alcanzado en nuestro país se hace cada día más gravoso, de aquí que para garantizar la sostenibilidad del Sistema Nacional de Salud el Estado español haya promovido una reforma sanitaria a través de normas, entre otras, el Real Decreto Ley 16/ 2012 del cual analizamos el impacto y consecuencias más destacables en el sector farmacéutico

The right to health protection encourages the Executive to establish a leading health policy according to the principles of equity, quality and citizen participation, to promote a responsible use of drugs and to adopt measures in order to make the provision of pharmaceutical care affordable and with reasonable public health expenditure by the Spanish National Health System as part of the need of optimizing the available resources. Nowadays, the welfare state achieved in our V country is progressively more expensive. Hence, in order to guarantee the sustainability of the Spanish National Health System, the Spanish government has promoted a health reform through standards, among others the Royal Decree-]Law16/ 2012, of April 20, 2012. From this Royal Decree-] Law we analyze the impact and the most noteworthy consequences in the pharmaceutical sector

Prevalencia de polimedicación y riesgo vascular en la población mayor de 65 años / Prevalence of multiple medication and cardiovascular risk in patients over 65 years

Objetivo: Estudiar la prevalencia de polimedicación en mayores de 65 años. Diseño: Estudio descriptivo transversal. Emplazamiento: Distritos sanitarios de atención primaria Sevilla y Jerez-Costa Noroeste. Participantes: Población mayor de 65 años, seleccionada por un procedimiento aleatorio estratificando por centros. Se excluyeron pacientes institucionalizados, con trastornos de salud mental mayores y enfermedad terminal. Mediciones principales: Se definió polimedicación como el consumo de 5 o más fármacos de forma continuada durante los últimos 6 meses, basado en el registro en historia clínica. Se exploraron otras características de los pacientes mediante entrevista a una submuestra seleccionada aleatoriamente. Resultados: Se evaluaron las historias clínicas de 2.919 pacientes procedentes de 14 centros de salud. La prevalencia encontrada fue de 49,6% (IC 95%: 47,7-51,4), con un rango entre centros de un 33% (IC 95%: 26,8-39,3) a un 82% (IC 95%: 74,3-89,7). El 90,2% (IC 95%: 88,7-91,8) tenía criterios de entrada al Proceso Asistencial Integrado Riesgo Vascular. La entrevista confirmó un consumo promedio de 8,7 medicamentos (IC 95%: 8,4-9,0). Un 83,2% (IC 95%: 78,9-87,4) eran pacientes en riesgo vascular alto. Conclusiones: La prevalencia de polimedicación en mayores de 65 años es cercana al 50%, con amplia variabilidad entre centros. El consumo promedio de medicamentos por paciente es de 8 y la gran mayoría son pacientes en riesgo vascular alto(AU)

Objetive: To describe the prevalence of multiple medication in patients over 65 years. Design: Cross-sectional study. Setting: Sevilla and Jerez-Costa North-West Primary Health Care Districts. Participants: Patients older than 65 years randomly chosen from district databases. Patients in nursing homes, with major mental disease, or end-of- life situations were excluded. Main measurements: Multiple medication was defined as a prescription of five or more drugs during the last six months. We assessed the medication used by clinical health records audit. Other characteristics were studied by interviewing a subsample of patients. Results: A total of 2,919 clinical health records from 14 centres were reviewed. The prevalence of multiple medication was 49.6% (95% CI: 47.7-51.4) with a range from 33% (95% CI: 26.8-39.3) to 82% (95% CI: 74,3-89,7) between centres. The large majority of patients (90.2% [95% CI: 88.7-91.8]) of patients showed criteria to be included in Cardiovascular Risk Health Care Process. Interviewed patients confirmed taking an average of 8.7 drugs (95% CI: 8.4-9.0). Among them, 83.2% (95% CI: 78.9-87.4) were high cardiovascular risk patients. Conclusions: Prevalence of multiple medication in patients over 65 years is about 50% with wide variations between centres. The number of drugs per patient ratio was close to eight. A large majority of them were high risk cardiovascular patients(AU)

Professional values in community and public health pharmacy.

General practice (community) pharmacy as a healthcare profession is largely devoted to therapeutic treatment of individual patients whether in dispensing medically authorised prescriptions or by providing members of the public with over-the-counter advice and service for a variety of common ailments. Recently, community pharmacy has been identified as an untapped resource available to undertake important aspects of public health and in particular health promotion. In contrast to therapeutic treatment, public health primarily concerns the health of the entire population, rather than the health of individuals (Childress et al. in J Law Med Ethics 30:170-178, 2002). Thus, an important question for the profession is whether those moral and professional values that are appropriate to the therapeutic care of individual patients are relevant and adequate to support the additional public health role.

Estudo das crenças dos enfermeiros sobre sua responsabilidade na administração de medicamentos / Study of nurses' beliefs about their responsibility in administering medication

Este estudo foi realizado com enfermeiros que trabalham na Unidade de Terapia Intensiva (UTI) do Hospital das Clínicas da Faculdade de Medicina da USP. A pesquisa teve como objetivo: identificar as crenças pessoais r normativas dos enfermeiros quanto à administração de medicamentos, utilizando a Teoria da Ação Racional (TRA). A análise do conteúdo de 28 relatos escritos revelou o que os enfermeiros pensam sobre sua atuação e responsabilidade na administração de medicamentos. Os relatos dos participantes foram agrupados em unidades de significado e, estas, em unidades temáticas. Os resultados obtidos, com o grupo estudado, permitiram identificar quatro unidades temáticas: a) o enfermeiro como agente da prática de administrar medicamentos; b) o conhecimento científico; c) os referentes sociais; d) as causas externas que influenciam na prática de medicação. Em relação aos objetivos propostos, foram evidenciadas crenças pessoais positivas em relação à prática de administrar medicamentos pelo enfermeiro, sendo elas: 1) melhor qualidade de assistência ao paciente; 2) menor índice de erros na administração de medicamentos; 3) menor índice de infecção para o paciente; 4) a experiência profissional e o conhecimento científico facilitam a realização desta prática. Foram evidenciadas crenças normativas positivas em relação a esta prática realizada pelo enfermeiro, sendo elas: 1) a equipe multiprofissional aprova tal prática pelo enfermeiro; 2) os órgãos de normatização e fiscalização da profissão, como o COFEN e o COREN aprovam e incentivam tal prática; 3) há fatores externos que facilitam a prática tais como os aspectos administrativos da unidade de trabalho e a situação física e psicológica do paciente. Também foram identificadas crenças pessoais negativas, sendo elas: 1) não tem tempo para administrar medicamentos; 2) é uma tarefa secundária; 3) pode ser delegada a outros membros da equipe de enfermagem; 4) não tem ) oportunidade para discutir sobre o tema nem para realizar tal prática; 5) tarefas burocráticas impedem de fazê-lo; 6) só administra medicamentos em caso de urgência, falta de funcionários ou pacientes graves. Foram identificadas, também, crenças normativas negativas, sendo elas: 1) o próprio enfermeiro desaprova tal prática; 2) há fatores externos que dificultam a prática da medicação tais como os aspectos administrativos da unidade de trabalho e a situação física e psicológica do paciente.

This research was built interviewing nurses that works in Intensive Care Unit (ICU), in Hospital das Clínicas da Faculdade de Medicina da USP. The research had a purpose: identify nurse´s personal beliefs and normative beliefs about medication practice and using like a reference, Theory of Reasoned Action (TRA). The analysis of contents from 28 interviewee revealed the beliefs and values nurses about their function and responsibility in medication practice. The reports from interviewee were grouped in meaning of units, and subsequently, thematic of units. The results from research with study group, allow identify four thematic units: a) the nurse like agent´s practioner of medication, b) scientific knowledge, c) social referents, d) external cause that influence in medication practice. In regarding with the proposal was evidenced positive personal beliefs in regarding nurse´s medication practice, like is described: 1) quality in patient care, 2) few report about error in medication practice, 3) few report about patient´s infection, 4) professional experience and scientific knowledge help the nurses in medication practice. Was evidenced positive normative beliefs in regarding nurse´s medication practice, like is described: 1) health professional´s team approval medication practice like nurse´s function, 2) COREN and COFEN approval and incentive medication practice like nurse´s function, 3) there are external factors that help the medication practice like the administrative feature inside of care unit and psychological and physical patient´s situation. In analysis was identified negative personal beliefs, like is described: 1) the nurse don´t have time for medication practice, 2) medication practice is second task, 3) could be delegate to others professional, 4) the nurse don´t have opportunity to discuss about this theme even to achieve medication practice, 5) bureaucratic task don´t allow work it, 6) just do it, medication practice in emergency case, when don´t have others professional to do it or when patient is in serious. Was identified negative normative beliefs, like is described: 1) the nurse disapproval medication practice like his task, 2) there are external factor that to make difficult medication practice, like feature administrative in care unit and the psychological and physical patient situation.