The tomato: an important part of the urologist's diet?
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Antioxidants↗
Biomedical subjects
N Barber
Publications and source records attributed to N Barber.
Should we consider non-compliance a medical error?
Non-compliance is an extensive intractable problem. This paper argues that we can gain significant insight into non-compliance if we apply theories developed to explain human error in organisations. The resultant framework encompasses intentional and unintentional non-compliance, shifts blame from the patient, and recognises the influence of other factors, including organisational ones. There are also consequences for the measurement of compliance and new strategies to improve it. Terminology will need to be addressed, particularly whether intentional non-compliance by a patient should be considered an error. If empirical research supports the arguments in this paper then, with some further theory development, the application of human error theory will offer a useful new approach to understanding and reducing undesired non-compliance.
Communication↗
Prescribing errors in hospital inpatients: their incidence and clinical significance.
BACKGROUND: It has been estimated that 1-2% of US inpatients are harmed by medication errors, the majority of which are errors in prescribing. The UK Department of Health has recommended that serious errors in the use of prescribed drugs should be reduced by 40% by 2005; however, little is known about the current incidence of prescribing errors in the UK. This pilot study sought to investigate their incidence in one UK hospital. METHODS: Pharmacists prospectively recorded details of all prescribing errors identified in non-obstetric inpatients during a 4 week period. The number of medication orders written was estimated from a 1 in 5 sample of inpatients. Potential clinical significance was assessed by a pharmacist and a clinical pharmacologist. RESULTS: About 36200 medication orders were written during the study period, and a prescribing error was identified in 1.5% (95% confidence interval (CI) 1.4 to 1.6). A potentially serious error occurred in 0.4% (95% CI 0.3 to 0.5). Most of the errors (54%) were associated with choice of dose. Error rates were significantly different for different stages of patient stay (p<0.0001) with a higher error rate for medication orders written during the inpatient stay than for those written on admission or discharge. While the majority of all errors (61%) originated in medication order writing, most serious errors (58%) originated in the prescribing decision. CONCLUSIONS: There were about 135 prescribing errors identified each week, of which 34 were potentially serious. Knowing where and when errors are most likely to occur will be helpful in designing initiatives to reduce them. The methods developed could be used to evaluate such initiatives.
Delphi Technique↗
Validity and reliability of observational methods for studying medication administration errors.
The validity and reliability of observational methods for studying medication administration errors (MAEs) were studied. Between January and June 1998, two pharmacists observed consecutive drug administration rounds by nurses on two wards in a U.K. hospital and recorded all MAEs identified. The observers intervened in cases of potentially harmful errors. MAE records were audited to determine the percentage of omitted doses for which a corresponding reason was documented for the observation periods and for nonobservation periods. Error rates for each drug administration round were analyzed according to whether they were for the nurse's first, second, third (and so on) observed round. Error rates were calculated before and after the first intervention with nurses for whom an intervention was made. Observer reliability was calculated by comparing the rates of errors identified by the two observers. There was no difference between the observation and nonobservation periods in the percentage of omitted doses for which a reason was documented, and there was no change in the error rate with repeated observations. There was no difference in error rates before and after the first intervention for each nurse. There was also no difference in error detection between the two observers and no change with increasing duration of observation. Observation of nurses during drug administration at a U.K. hospital did not significantly affect the MAE rate; nor did tactful interventions by the observers. Observer reliability was high. Concerns about the validity and reliability of observational methods for identifying MAEs may be unfounded.
Chi-Square Distribution↗
Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor-patient communication in general practice.
Mishler (The discourse of medicine. The dialectics of medical interviews. Norwood, NJ: Ablex), applying Habermas's theory of Communicative Action to medical encounters. showed how the struggle between the voice of medicine and the voice of the lifeworld fragmented and suppressed patients' multi-faceted, contextualised and meaningful accounts. This paper investigates and critiques Mishler's premise that this results in inhumane, ineffective medical care. Using a more complex data collection strategy, comprising patient interviews, doctor interviews and transcribed consultations we show more complex relations than emerged from Mishler's analysis. We found four communication patterns across 35 general practice case studies. When doctor and patient both used the voice of medicine exclusively (acute physical complaints) this worked for simple unitary problems (Strictly Medicine). When both doctor and patient engaged with the lifeworld, more of the agenda was voiced (Mutual Lifeworld) and patients were recognised as unique human beings (psychological plus physical problems). Poorest outcomes occurred where patients used the voice of the lifeworld but were ignored (Lifeworld Ignored) or blocked (Lifeworld Blocked) by doctors' use of voice of medicine (chronic physical complaints). The analysis supports the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings. Some doctors switched communication strategies in different consultations, which suggests that their behaviour might be open to change. If doctors could be sensitised to the importance of dealing with the concerns of the lifeworld for patients with chronic physical conditions as well as psychological conditions, it might be possible to obtain better care for patients. This would require attention to structural aspects of the healthcare system to enable doctors to work fully within the patient-centred model.
Adult↗
Pharmaceutical care and medicines management--is there a difference?
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Drug Therapy↗
Ensuring patients' satisfaction with information about their medicines.
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Drug Information Services↗
Can simulation be used to reduce errors in health care delivery? The hospital drug distribution system.
OBJECTIVES: To construct a simulation model of the hospital drug distribution system, to evaluate the effects of different changes to the system on unavailability-related medication administration errors (U-MAEs), to test the most promising system in a controlled trial and to explore the model's validity. METHODS: A discrete-event simulation model of the drug distribution system was constructed, using data collected on a vascular surgery ward and a renal medicine ward as model inputs. The model's output was the U-MAE rate. The model was used to explore the effects on U-MAEs of different changes to the system. One of the changes predicted to reduce U-MAEs, a patients' own drugs scheme, was introduced on each study ward; U-MAE rates were measured using observations before and after its introduction and compared with those predicted by the model. RESULTS: The model predicted that the introduction of a patients' own drugs system would reduce unavailability-related errors on each ward; in practice, there was a slight decrease on the medical ward but an increase on the surgical ward. Reasons for these findings were explored and four contributing factors identified. Three of these related to failure to follow hospital procedures, the fourth to an issue for which no policy existed. If these factors had been taken into account, the error rates predicted by the model would have been similar to those observed. CONCLUSIONS: Simulation modelling is a potentially useful approach to the study of U-MAEs, although care must be taken to ensure that such models reflect actual practice rather than stated policy.
Computer Simulation↗
Patients' unvoiced agendas in general practice consultations: qualitative study.
OBJECTIVE: To investigate patients' agendas before consultation and to assess which aspects of agendas are voiced in the consultation and the effects of unvoiced agendas on outcomes. DESIGN: Qualitative study. SETTING: 20 general practices in south east England and the West Midlands. PARTICIPANTS: 35 patients consulting 20 general practitioners in appointment and emergency surgeries. RESULTS: Patients' agendas are complex and multifarious. Only four of 35 patients voiced all their agendas in consultation. Agenda items most commonly voiced were symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items were: worries about possible diagnosis and what the future holds; patients' ideas about what is wrong; side effects; not wanting a prescription; and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 14 consultations with problem outcomes at least one of the problems was related to an unvoiced agenda item. CONCLUSION: Patients have many needs and when these are not voiced they can not be addressed. Some of the poor outcomes in the case studies were related to unvoiced agenda items. This suggests that when patients and their needs are more fully articulated in the consultation better health care may be effected. Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agendas.
Adult↗
Misunderstandings in prescribing decisions in general practice: qualitative study.
OBJECTIVES: To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice. DESIGN: Qualitative study. SETTING: 20 general practices in the West Midlands and south east England. PARTICIPANTS: 20 general practitioners and 35 consulting patients. MAIN OUTCOME MEASURES: Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine. RESULTS: 14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing. CONCLUSIONS: Patients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.
Adult↗
Doctor-patient communication about drugs: the evidence for shared decision making.
The traditional paternalistic model of medical decision-making, in which doctors make decisions on behalf of their patients, has increasingly come to be seen as outdated. Moreover, the role of the patient in the consultation has been emphasised, notably through the adoption of 'patient-centred' strategies. Models that promote patients' active involvement in the decision-making process about treatment have been developed. We examine one particular model of shared decision making [Charles, C., Gafni, A., Whelan, T, 1997. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine 44, 681-692.]. The model has four main characteristics. These are that (1) both the patient and the doctor are involved, (2) both parties share information, (3) both parties take steps to build a consensus about the preferred treatment and (4) an agreement is reached on the treatment to implement. Focusing on the first two of the four characteristics of the model, we use the findings from a study of 62 consultations, together with interviews conducted with patients and general practitioners, to consider participation in the consultation in terms of sharing information about, and views of, medicines. We found little evidence that doctors and patients both participate in the consultation in this way. As a consequence there was no basis upon which to build a consensus about the preferred treatment and reach an agreement on which treatment to implement. Thus even the first two of the four conditions said to be necessary for shared decision making were not generally present in the consultations we studied. These findings were presented in feedback sessions with participating GPs, who identified a number of barriers to shared decision making, as well as expressing an interest in developing strategies to overcome these barriers.
Decision Making↗
Qualitative methods and prescribing research.
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Confidentiality↗
What is a prescribing error?
OBJECTIVE: To develop a practitioner led definition of a prescribing error for use in quantitative studies of their incidence. DESIGN: Two stage Delphi technique. SUBJECTS: A panel of 34 UK judges, which included physicians, surgeons, pharmacists, nurses and risk managers. MAIN OUTCOME MEASURES: The extent to which judges agreed with a general definition of a prescribing error, and the extent to which they agreed that each of 42 scenarios represented a prescribing error. RESULTS: Responses were obtained from 30 (88%) of 34 judges in the first Delphi round, and from 26 (87%) of 30 in the second round. The general definition of a prescribing error was accepted. The panel reached consensus that 24 of the 42 scenarios should be included as prescribing errors and that five should be excluded. In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not. CONCLUSIONS: Health care professionals are in broad agreement about the types of events that should be included and excluded as prescribing errors. A general definition of a prescribing error has been developed, together with more detailed guidance regarding the types of events that should be included. This definition allows the comparison of prescribing error rates among different prescribing systems and different hospitals, and is suitable for use in both research and clinical governance initiatives.
Attitude of Health Personnel↗
Deep vein thrombosis prophylaxis protocol--needs active enforcement.
Each hospital department tends to have its own DVT prophylaxis protocol generally based on the recommendations of the THRIFT consensus group. This is developed to help the junior medical staff to prescribe the appropriate prophylaxis according to risk assessment. However, adherence to the protocol tends to be haphazard unless actively enforced. This study is aimed at determining whether active enforcement of the protocol improves the uptake of prophylaxis.
Adult↗
Patient-centredness and outcomes in primary care.
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Communication↗
Hospital drug distribution systems in the UK and Germany--a study of medication errors.
The aim of this study was to compare the incidence of medication errors and the stages of the drug distribution system at which they occur in a United Kingdom (UK) hospital using the ward pharmacy system, a German hospital using the unit dose system and a German hospital using their traditional system. Medication errors were identified by observing the preparation and administration of regularly scheduled solid oral medication. In the UK hospital using the ward pharmacy system, the medication error rate was 8.0% (95% confidence interval 6.2-9.8%). The majority of these errors occurred at the stage of medication administration. In the hospital using the traditional German system, the error rate was 5.1% (4.4-5.8%). With the German unit dose system, the error rate was 2.4% (2.0-2.8%). In both German systems the errors were mainly attributable to the stage of transcription. It was noted that patient turnover was much higher in the wards using the ward pharmacy system and therefore the study sites may not be comparable. However, recommendations can be made in order to reduce the error rate associated with each system. Errors associated with the ward pharmacy system may be reduced if medication is stored in individual patient medicine cabinets and patients' own drugs used. Errors occurring with the traditional system and the unit dose system may be reduced if the original prescription is used for medication administration.
Data Collection↗
When should pharmacists visit their wards? An application of simulation to planning hospital pharmacy services.
This paper reports a pilot study of the use of simulation in planning hospital pharmacy services. The objectives were to create a simulation model of the hospital drug distribution system, to use the model to investigate a simple problem and to assess the potential for simulation to aid decision making in hospital pharmacy management. The problem chosen for investigation focused on the UK ward pharmacy system, where a pharmacist visits each ward daily to initiate the supply of newly prescribed non-stock medication. A simulation model was used to investigate how changing the time of the ward pharmacist's visit could affect the mean time delay between the prescription of a non-stock drug and the arrival of that drug on the ward. The simulation results suggest that the time of day at which pharmacists visit their wards can have a major impact on delay times, and that the relative benefit of different visit times is likely to vary between wards. Simulation was found to be a useful approach to investigating different service alternatives without the expense and disruption of assessing each in practice.
Computer Simulation↗