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Safe medication management in specialized home healthcare - An observational study
KTH, School of Technology and Health (STH). Ersta Sköndal University College, Stockholm, Sweden.
2017 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, no 1, article id 598Article in journal (Refereed) Published
Abstract [en]

Background: Medication management is a complex, error-prone process. The aim of this study was to explore what constitutes the complexity of the medication management process (MMP) in specialized home healthcare and how healthcare professionals handle this complexity. The study is theoretically based in resilience engineering. Method: Data were collected during the MMP at three specialized home healthcare units in Sweden using two strategies: observation of workplaces and shadowing RNs in everyday work, including interviews. Transcribed material was analysed using grounded theory. Results: The MMP in home healthcare was dynamic and complex with unclear boundaries of responsibilities, inadequate information systems and fluctuating work conditions. Healthcare professionals adapted their everyday clinical work by sharing responsibility and simultaneously being authoritative and preserving patients' active participation, autonomy and integrity. To promote a safe MMP, healthcare professionals constantly re-prioritized goals, handled gaps in communication and information transmission at a distance by creating new bridging solutions. Trade-offs and workarounds were necessary elements, but also posed a threat to patient safety, as these interim solutions were not systematically evaluated or devised learning strategies. Conclusions: To manage a safe medication process in home healthcare, healthcare professionals need to adapt to fluctuating conditions and create bridging strategies through multiple parallel activities distributed over time, space and actors. The healthcare professionals' strategies could be integrated in continuous learning, while preserving boundaries of safety, instead of being more or less interim solutions. Patients' and family caregivers' as active partners in the MMP may be an underestimated resource for a resilient home healthcare.

Place, publisher, year, edition, pages
BioMed Central, 2017. Vol. 17, no 1, article id 598
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:kth:diva-238808DOI: 10.1186/s12913-017-2556-xISI: 000443286700002PubMedID: 28836981Scopus ID: 2-s2.0-85028339124OAI: oai:DiVA.org:kth-238808DiVA, id: diva2:1262444
Note

QC 20181118

Available from: 2018-11-12 Created: 2018-11-12 Last updated: 2019-09-18Bibliographically approved
In thesis
1. Exploring patient safety in home healthcare: a resilience engineering approach
Open this publication in new window or tab >>Exploring patient safety in home healthcare: a resilience engineering approach
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of the thesis is to increase knowledge and understanding of patient safety in home healthcare.

This thesis has an explorative mixed-methods design, with both qualitative (Papers І and ІІ) and quantitative (Papers ІІІ, ІV and V) methods. Data for Papers І and ІІ were collected at three specialised home healthcare units. The aim for Paper І was to explore patient safety in home healthcare from the multidisciplinary teams and clinical managers’ perspective. Data collection for the study was done through seven individual and nine focus group interviews, a total of 51 participants, and analysed with qualitative content analysis. The aim of Paper ІІ was to explore the medication management process. The data collection was done by observing the medication management process for 27 days, 9 days per unit, and through interviews with the healthcare professionals who had been observed. Data was collected in iterative phases and analysed with grounded theory.

The aim of Paper ІІІ was to develop a trigger tool for structured retrospective record review to identify adverse events and no-harm incidents and their preventability that affect adult patients admitted into home healthcare. Another aim was to describe how the development was conducted. During the development, the trigger tool was tested twice, using 60 and 600 records, respectively, from ten different organisations from nine different regions across Sweden. The same 600 randomised home healthcare records were used for Papers ІV and V. The aim of Paper ІV was to explore the incidence, types and preventability of adverse events using the trigger tool. For Paper V the aim was to explore cumulative incidence, preventability, types and potential contributing causes of no-harm incidents using the trigger tool. Studies ІІІ, ІV and V were analysed with descriptive statistics.

The results showed that the clinical managers and the multidisciplinary teams considered patient safety as associated with their common mind-set of safe care, based on a well-established care ideology. This mindset included the establishment of a trustworthy relationship with patients and relatives. At the same time, provision of care in a home was characterised by weighing values against each other, between risks and patients’ and relatives’ autonomy and wishes. Other typical contradictory values were between collecting measurements for different quality registers (directives from policy-makers as a measure of quality and safety), or taking time for patient needs. Strategies and behaviours, such as not following routines, to get around problematic processes were the result of conflicting goals that either promoted or prevented patient safety (Papers І and ІІ). Results from Study ІІІ showed that the empirically tested triggers identified more triggers compared to several other studies and thus formed a rich material for validation. More than a third of the patients in home healthcare were affected by adverse events (37.7%), most of which were deemed preventable (71.6%). Most adverse events (69.1%) were temporary and led to that the patient required extra healthcare visits or led to a prolonged period of healthcare. The most common adverse events were “healthcare-associated infections, falls and pressure ulcers (Study ІV). Almost every third patient (29.5%) was affected by a no-harm incident, one-fifth of which were deemed preventable (21.2%). The most common types of no-harm incidents were “fall without harm,” “deficiencies in medication management,” and “moderate pain”. “Deficiencies in medication management” were deemed to have a preventability rate (98.4%) twice as high as “fall without harm” (40.9%) and “moderate pain” (50.0%). The most common potential contributing cause of “fall without harm” was “deficiencies in nursing care, i.e., delayed, erroneous, omitted or incomplete care”. For “deficiencies in medication management” and “moderate pain” the most common contributing cause was “delayed, erroneous, omitted or incomplete treatment”. Of the total number of no-harm incidents, the most common contributing causes were “deficiencies in nursing care, treatment or diagnosis” and “deficiencies in communication, information or collaboration” (Paper V).

The conclusion is that patient safety is generally strengthened by the fact that clinical managers and multidisciplinary teams have a common approach to safety built on an internationally and national well-established care ideology, which forms a “dyad” with safe care. In home healthcare, patient safety is formed by the team creating a trustworthy relationship with patients and their families and involving them as partners in their own care. Additionally, the trigger tool and associated manual adapted for home healthcare may be a valid method for identifying cumulative incidence, types, preventability and contributing causes for adverse events and no-harm incidents. Such patient safety knowledge can be used to develop valid process indicators for systemic failures, as well as outcome indicators for structured evaluation and lead to proactive patient safety work in home healthcare.

Abstract [sv]

Avhandlingens övergripande syfte är att öka kunskap och förståelse av patientsäkerhet inom hemsjukvård.

Avhandlingen har en explorativ design med både kvalitativ (studie І och ІІ) och kvantitativ (studie ІІІ, ІV och V) forskningsansats. Data för studie І och ІІ samlades in på tre verksamheter som bedriver specialiserad hemsjukvård. Syftet med studie І var att utforska de multidisciplinära teamens och de kliniska chefernas perspektiv på patientsäkerhet. Datainsamling för studie І gjordes via sju individuella- och nio fokusgruppsintervjuer med totalt 51 deltagare och analyserades med kvalitativ innehållsanalys. Syftet med studie ІІ var att utforska läkemedelshanteringsprocessen. Datainsamlingen gjordes genom att observera läkemedelshanteringsprocessen i 27 dagar, 9 dagar per verksamhet. Data samlades även in via intervjuer med den vårdpersonal som hade observerats och analyserades med grounded theory.

Syftet med studie ІІІ var att utveckla ett markörbaserat verktyg för strukturerad retrospektiv journalgranskning och tillhörande manual för att identifiera skador, vårdskador (=undvikbara skador) och tillbud som drabbar vuxna patienter inskrivna i hemsjukvården samt att beskriva metodutvecklingen. Under utvecklingen testades det markörbaserade verktyget två gånger i 60 respektive 600 journaler från tio olika verksamheter som bedriver hemsjukvård från nio olika regioner i Sverige. Samma 600 randomiserade hemsjukvårsjournalerna användes för datainsamling till studie ІV och V. Syftet med studie ІV, var att med det markörbaserade verktyget identifiera skador och vårdskador och för studie V att identifiera tillbud och dess bidragande orsaker. Studierna ІІІ, ІV och V analyserades med deskriptiv statistik.

Resultaten visade att grunden för patientsäkerhet var att kliniska chefer och de multidisciplinära teamen hade en gemensam syn på säker vård och stärktes av att teamen skapade en tillitsfull relation med patienter och närstående samt involverade dem som samarbetspartners i egen vård.  Samtidigt innebar att vårda i ett hem vanligtvis att väga olika värden mot varandra, till exempel att minska risker mot att respektera patienter och närståendes autonomi och vilja. Andra typiska motstridiga värden var att ta tid för att få information av patienterna till kvalitetsregister, (direktiv från beslutsfattare som mått på kvalitet och säkerhet), eller att lägga tiden på patientens behov. Strategier och beteenden, som att inte följa rutiner, för att komma runt problematiska processer var ett resultat av motstridiga värden som antingen främjade eller hindrade patientsäker vård (studie І och ІІ). Resultat från studie ІІІ visade att de empiriskt testade markörerna identifierades fler gånger jämfört med flera andra studier och utgjorde därmed ett rikt material för validering. Över en tredjedel av patienterna i hemsjukvården drabbades av skador (37.7%) varav de flesta bedömdes vara undvikbara, det vill säga vårdskador (71.6%). De flesta skador (69.1%) var temporära och ledde till att patienten fick göra extra besöka i öppenvård eller akutmottagning eller ledde till förlängd sjukvårdsperiod. De vanligaste skadorna var ”vårdrelaterade infektioner, ”fall” och ”trycksår” (studie ІV). Nästan var tredje patient (29.5%) drabbades av tillbud varav en femtedel bedömdes vara undvikbara (21.2%). De vanligaste typerna av tillbud var ”fall utan skada”, ”brister i läkemedelshantering” och ”måttlig smärta”.  ”Brister i läkemedelshantering” bedömdes ha dubbelt så hög undvikbarhet (98.4%) som ”fall utan skada” (40.9%) och ”måttlig smärta” (50.0%). Den vanligaste möjliga bidragande orsaken till ”fall utan skada” var ”bristande omvårdnad”, det vill säga att den var ”försenad, felaktig, utebliven eller ofullständig”. För "brister i läkemedelshantering" och "måttlig smärta" var den vanligaste bidragande orsaken "försenad, felaktig, utelämnad eller ofullständig behandling". Av det totala antalet tillbud, var vanligaste möjliga bidragande orsakerna "brister i omvårdnad, behandling eller diagnos" och "brister i kommunikation, information eller samarbete"” (studie V).

Slutsatsen är att patientsäkerhet, stärks generellt av att kliniska chefer och multidisciplinära team har ett gemensamt synsätt på säkerhet, som baseras på en internationell och nationell väletablerad vårdideologi, som bildar en "dyad" med säker vård. Patientsäkerhet, i hemsjukvård, bildas av att teamen skapar ett tillitsfullt förhållande med patienter och närstående samt involverar dem som samarbetspartner i sin egen vård. Ytterligare en slutsats är det markörbaserade verktyget med tillhörande manual anpassat för hemsjukvård kan vara en valid metod för att identifiera vårdskador, tillbud och bidragande orsaker. Sådan kunskap inom patientsäkerhetsområdet kan användas för att utveckla giltiga processindikatorer för systemfel, samt resultatindikatorer för strukturerad utvärdering och leder till ett proaktivt patientsäkerhetsarbete inom hemsjukvård.

Place, publisher, year, edition, pages
Stockholm: KTH Royal Institute of Technology, 2018. p. 81
Series
TRITA-CBH-FOU ; 2018:51
Keywords
patient safety, home healthcare
National Category
Medical and Health Sciences
Research subject
Technology and Health
Identifiers
urn:nbn:se:kth:diva-238685 (URN)978-91-7729-992-9 (ISBN)
Public defence
2018-11-29, Sal T1, Hälsovägen 11C, Flemingsberg, 08:30 (Swedish)
Opponent
Supervisors
Note

QC 20181118

Available from: 2018-11-12 Created: 2018-11-07 Last updated: 2018-12-05Bibliographically approved

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