Would they accept it? An interview study to identify barriers and facilitators to user acceptance of a prescribing advice service.

OBJECTIVES: Few studies have explored the factors influencing user uptake of interventions designed to enhance therapeutic drug monitoring (TDM). This study aimed to identify barriers and facilitators to acceptance of a pilot intervention, the TDM Advisory Service (the Service), that provided prescribing advice for the antibiotic, vancomycin at an Australian public hospital. METHODS: A sample of prescribers and pharmacists who had interacted with the Service (n = 10), and a sample who had not (n = 13), participated in semi-structured interviews. Interviews were transcribed verbatim and analysed independently by two researchers for emerging themes. The Theoretical Domains Framework (TDF) was used to synthesise barriers and facilitators to Service acceptance. RESULTS: Key barriers reported by participants who had interacted with the Service aligned with two TDF domains: 'Social Influences' (prescribing hierarchy) and 'Environmental Context and Resources' (accessibility of dose advice). For participants who had not interacted with the Service, key barriers aligned with two TDF domains: 'Knowledge' (uncertainty of Service processes) and 'Environmental Context and Resources' (accessibility of dose advice). Key facilitators for both participant groups aligned with 'Beliefs about Consequences' (improved prescribing and patient outcomes) and 'Environmental Context and Resources' (accessibility of dose advice). A novel domain, 'Trust', was identified. CONCLUSIONS: Independent of participant interaction with the Service, knowledge of Service processes, perceived beneficial outcomes, improved accessibility, and trust in Service capabilities were key determinants of acceptance. This evidence can be used to inform the adoption of strategies to adapt and enhance integration of the Service into clinical workflow.

An Exploratory Study of Allied Health Students' Experiences of Electronic Medical Records During Placements.

BACKGROUND: Allowing students to access and document in electronic medical records (eMRs) during clinical placements is viewed as critical for ensuring that graduates have a high level of digital proficiency prior to entering the workforce. Limited studies have explored student access to eMRs in health disciplines outside of medicine and nursing. OBJECTIVE: Our main objective was to examine allied health students' experiences and perceptions of the opportunity to develop eMR competencies during their placement, across a range of allied health disciplines and placement settings. METHODS: An explanatory sequential design was used, comprising a quantitative survey (n = 102) followed by qualitative semi-structured interviews (n = 6) with senior allied health students to explore their experiences and perceptions of eMR access during placements. RESULTS: Of the 93 students who responded to the question about their placement eMR, nine (10%) reported their placement site did not use an eMR and four students reported that they were not allowed to access the eMR during their placement. Most students (64%, 54 out of 84) accessed the system using their own credentials, but 31% (26 out of 84) used someone else's log-in and password. Students were satisfied with the eMR training and support received while on placement, but there was significant variability across sites on the level of training and support provided. All students believed that eMR access was beneficial for learning and preparation for work, improved delivery of care, taking ownership of work, and feeling responsible for patient care. CONCLUSION: Providing students with access to eMRs during placements is fundamental to the development of a student's professional identity and to recognizing their role in the delivery of interprofessional patient care. For graduates to be equipped to effectively contribute to multi-disciplinary care in a digital health environment, universities need to work with practice partners to standardize and formalize eMR access, registration, training, and support, and to provide students with early exposure and training on eMRs in university courses.

Mapping eHealth Education: Review of eHealth Content in Health and Medical Degrees at a Metropolitan Tertiary Institute in Australia.

BACKGROUND: With the increasing use of digital technology in society, there is a greater need for health professionals to engage in eHealth-enabled clinical practice. For this, higher education institutions need to suitably prepare graduates of health professional degrees with the capabilities required to practice in eHealth contexts. OBJECTIVE: This study aims to understand how eHealth is taught at a major Australian university and the challenges and suggestions for integrating eHealth into allied health, nursing, and medical university curricula. METHODS: Cross-disciplinary subject unit outlines (N=77) were reviewed for eHealth-related content, and interviews and focus groups were conducted with the corresponding subject unit coordinators (n=26). Content analysis was used to identify themes around challenges and opportunities for embedding eHealth in teaching. RESULTS: There was no evidence of a standardized approach to eHealth teaching across any of the health degrees at the university. Where eHealth content existed, it tended to focus on clinical applications rather than systems and policies, data analysis and knowledge creation, or system and technology implementation. Despite identifying numerous challenges to embedding eHealth in their subjects, unit coordinators expressed enthusiasm for eHealth teaching and were keen to adjust content and learning activities. CONCLUSIONS: Explicit strategies are required to address how eHealth capabilities can be embedded across clinical health degrees. Unit coordinators require support, including access to relevant information, teaching resources, and curriculum mapping, which clearly articulates eHealth capabilities for students across their degrees. Degree-wide conversations and collaboration are required between professional bodes, clinical practice, and universities to overcome the practical and perceived challenges of integrating eHealth in health curricula.

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

BACKGROUND: Double-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades. While the practice is widespread, evidence of its effectiveness in reducing errors or harm is scarce. OBJECTIVES: To measure the association between double-checking, and the occurrence and potential severity of medication administration errors (MAEs); check duration; and factors associated with double-checking adherence. METHODS: Direct observational study of 298 nurses, administering 5140 medication doses to 1523 patients, across nine wards, in a paediatric hospital. Independent observers recorded details of administrations and double-checking (independent; primed-one nurse shares information which may influence the checking nurse; incomplete; or none) in real time during weekdays and weekends between 07:00 and 22:00. Observational medication data were compared with patients' medical records by a reviewer (blinded to checking-status), to identify MAEs. MAEs were rated for potential severity. Observations included administrations where double-checking was mandated, or optional. Multivariable regression examined the association between double-checking, MAEs and potential severity; and factors associated with policy adherence. RESULTS: For 3563 administrations double-checking was mandated. Of these, 36 (1·0%) received independent double-checks, 3296 (92·5%) primed and 231 (6·5%) no/incomplete double-checks. For 1577 administrations double-checking was not mandatory, but in 26·3% (n=416) nurses chose to double-check. Where double-checking was mandated there was no significant association between double-checking and MAEs (OR 0·89 (0·65-1·21); p=0·44), or potential MAE severity (OR 0·86 (0·65-1·15); p=0·31). Where double-checking was not mandated, but performed, MAEs were less likely to occur (OR 0·71 (0·54-0·95); p=0·02) and had lower potential severity (OR 0·75 (0·57-0·99); p=0·04). Each double-check took an average of 6·4 min (107 hours/1000 administrations). CONCLUSIONS: Compliance with mandated double-checking was very high, but rarely independent. Primed double-checking was highly prevalent but compared with single-checking conferred no benefit in terms of reduced errors or severity. Our findings raise questions about if, when and how double-checking policies deliver safety benefits and warrant the considerable resource investments required in modern clinical settings.

Researchers' views on, and experiences with, the requirement to obtain informed consent in research involving human participants: a qualitative study.

BACKGROUND: Informed consent is often cited as the "cornerstone" of research ethics. Its intent is that participants enter research voluntarily, with an understanding of what their participation entails. Despite agreement on the necessity to obtain informed consent in research, opinions vary on the threshold of disclosure necessary and the best method to obtain consent. We aimed to investigate Australian researchers' views on, and their experiences with, obtaining informed consent. METHODS: Semi-structured interviews were conducted with 23 researchers from NSW institutions, working in various fields of research. Interviews were analysed and coded to identify themes. RESULTS: Researchers reported that consent involved information disclosure, understanding and a voluntary decision. They emphasised the variability of consent interactions, which were dependent on potential participants' abilities and interests, study complexity and context. All researchers reported providing written information to potential participants, yet questioned the readability and utility of this information. The majority reported using signed consent forms to 'operationalise' consent and reported little awareness of, and lack of support in implementing more dynamic informed consent procedures, such as verbal informed consent, that was fit for the purposes of their studies. Views on Human Research Ethics Committees (HRECs) varied. Some reported inconsistent, arduous inputs on the information form and consent process. Others expressed reliance on HRECs for guidance, viewing them as institutional safeguards. CONCLUSIONS: This study highlights the importance of transparent relationships, both between researchers and participants, and between researchers and HRECs. Where the relationship with study participants was reported as more robust, researchers felt that they were better able to ensure participants made better, more informed decisions. Where the relationship with HRECs was reported as more robust, researchers were more likely to view them as institutional safeguards, rather than as bureaucratic hindrances. Conscientious and mindful researchers are paramount to ensuring the procedure accommodates individual requirements. This study advocates that when designing ethical informed consent practices, researchers should be integrated as autonomous players with a positive input on the process, rather than, in the worst case, predatory recruiters to be curtailed by information forms and oversight.

A Late Attempt to Involve End Users in the Design of Medication-Related Alerts: Survey Study.

BACKGROUND: When users of electronic medical records (EMRs) are presented with large numbers of irrelevant computerized alerts, they experience alert fatigue, begin to ignore alert information, and override alerts without processing or heeding alert recommendations. Anecdotally, doctors at our study site were dissatisfied with the medication-related alerts being generated, both in terms of volume being experienced and clinical relevance. OBJECTIVE: This study aimed to involve end users in the redesign of medication-related alerts in a hospital EMR, 4 years post implementation. METHODS: This work was undertaken at a private not-for-profit teaching hospital in Sydney, Australia. Since EMR implementation in 2015, the organization elected to implement all medication-related alert types available in the system for prescribers: allergy and intolerance alerts, therapeutic duplication alerts, pregnancy alerts, and drug-drug interaction alerts. The EMR included no medication administration alerts for nurses. To obtain feedback on current alerts and suggestions for redesign, a Web-based survey was distributed to all doctors and nurses at the site via hospital mailing lists. RESULTS: Despite a general dissatisfaction with alerts, very few end users completed the survey. In total, only 3.37% (36/1066) of doctors and 14.5% (60/411) of nurses took part. Approximately 90% (30/33) of doctors who responded held the view that too many alerts were triggered in the EMR. Doctors suggested that most alerts be removed and that alerts be more specific and less sensitive. In contrast, 97% (58/60) of the nurse respondents indicated that they would like to receive medication administration alerts in the EMR. Most nurses indicated that they would like to receive all the alert types available at all severity levels. CONCLUSIONS: Attempting to engage with end users several years post implementation was challenging. Involving users so late in the implementation process may lead to clinicians viewing the provision of feedback to be futile. Seeking user feedback on usefulness, volume, and design of alerts is extremely valuable; however, we suggest this is undertaken early, preferably before system implementation.

Barriers and facilitators of appropriate vancomycin use: prescribing context is key.

PURPOSE: Audit studies reveal frequent non-compliance with dosing and monitoring guidelines for vancomycin. This study aimed to qualitatively explore the barriers and facilitators of compliance with vancomycin dosing and monitoring guidelines. METHODS: Interviews were conducted with 16 prescribers in a large tertiary teaching hospital in Sydney, Australia. Questions explored knowledge, attitudes, and perceived complexities associated with vancomycin use. Interviews were analysed using thematic analysis. RESULTS: Prescribers reported utilising vancomycin guidelines, citing familiarity with guidelines, a positive perception of guidelines, awareness of poor guideline compliance, and assistance from specialist staff as facilitators of the uptake of guideline recommendations. Barriers existing within the prescribing environment such as the prescribing culture, a lack of time, and poor communication and coordination of therapeutic drug monitoring processes were identified as hindrances to guideline compliance. CONCLUSIONS: The provision of guidelines may not be sufficient in ensuring appropriate prescribing and monitoring of vancomycin when barriers relating to the prescribing environment exist. Developing interventions targeted toward these barriers, such as having dedicated phlebotomists for vancomycin blood sampling, fostering better handover processes, and educating staff on poorly understood aspects of guidelines, is likely to improve the uptake of guideline recommendations for vancomycin and other medications requiring therapeutic drug monitoring.

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study.

OBJECTIVES: To identify system-related risk factors perceived to contribute to prescribing errors in Australian long-term care settings, that is, residential aged care facilities (RACFs). DESIGN AND SETTING: The study used qualitative methods to explore factors that contribute to unsafe prescribing in RACFs. Data were collected at three RACFs in metropolitan Sydney, Australia between May and November 2011. Participants included RACF managers, doctors, pharmacists and RACF staff actively involved in prescribing-related processes. Methods included non-participant observations (74 h), in-depth semistructured interviews (n=25) and artefact analysis. Detailed process activity models were developed for observed prescribing episodes supplemented by triangulated analysis using content analysis methods. RESULTS: System-related factors perceived to increase the risk of prescribing errors in RACFs were classified into three overarching themes: communication systems, team coordination and staff management. Factors associated with communication systems included limited point-of-care access to information, inadequate handovers, information storage across different media (paper, electronic and memory), poor legibility of charts, information double handling, multiple faxing of medication charts and reliance on manual chart reviews. Team factors included lack of established lines of responsibility, inadequate team communication and limited participation of doctors in multidisciplinary initiatives like medication advisory committee meetings. Factors related to staff management and workload included doctors' time constraints and their accessibility, lack of trained RACF staff and high RACF staff turnover. CONCLUSIONS: The study highlights several system-related factors including laborious methods for exchanging medication information, which often act together to contribute to prescribing errors. Multiple interventions (eg, technology systems, team communication protocols) are required to support the collaborative nature of RACF prescribing.