Impacts on Practice
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Hospital electronic prescribing and medicine administration (HEPMA) system implementation results in improvements to hospital staff experience for prescribing and discharge communication
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After the implementation of a hospital electronic prescribing and medicine administration system, patient safety improvements are due to improved legibility and enhanced communication between secondary and primary care
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Hospital staff behaviour change amongst the different professional groups was evident as a direct consequence of HEPMA system implementation
Introduction
Aim of the study
Ethics approval
Method
Study design
Study setting
Sample size
Study participants
Data generation
Data analysis
Domain | Domain definition | Example constructs |
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Knowledge | An awareness of the existence of something | Procedural Knowledge Knowledge of task environment |
Skills | An ability or proficiency adapted through practice | Competence Practice |
Social/professional role and identity | A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting | Professional role Professional confidence |
Beliefs about capabilities | Acceptance of the truth, reliability or validity about an ability, talent or facility, that a person can put to constructive use | Self-confidence Perceived competence |
Optimism | The confidence that things will happen for the best or that desired goals will be obtained | Optimism Unrealistic optimism |
Beliefs about consequences | Acceptance of the truth, reliability or validity about outcomes of a behavior in a given circumstance | Outcome expectancies Consequences |
Reinforcement | Increasing the probability of a response by arranging a dependent relationship or contingency between the response and the given contingency | Rewards Punishments |
Intentions | A conscious decision to perform a behaviour or a resolve to act in a certain way | Stability of intentions Stages of change model |
Goals | Mental representation of outcomes or end states that an individual wants to achieve | Target setting Implementation intention |
Memory, attention and decision processes | The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives | Decision making Cognitive overload/tiredness |
Environmental context and resources | Any circumstances of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour | Resources Critical incidents |
Social influences | Those interpersonal processes that cause individuals to change their thoughts, feelings or behaviours | Social pressure Group conformity |
Emotion | A complex reaction pattern, involving experiential behavioural, and physiological elements, by which the individual attempts to deal with a personally significant event or circumstances | Anxiety Stress |
Behavioural regulation | Anything aimed at managing or changing objectively observed or measured actions | Self-monitoring Action planning |
Results
Interviewed staff
Pre-implementation | Post-implementation | |||||
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Profession | Gender | Years | Experience | Profession | Gender | Years |
ANP1 | F | 15–16 | Yes | ANP5 | F | 23 |
ANP2 | F | 27 | Yes | ANP6 | F | 15 |
ANP3 | F | 13 | Yes | ANP7 | F | 6 |
ANP4 | F | 15 | Yes | C7 | M | 2 |
C1 | M | 11 | Yes | C8 | M | 2.5 |
C2 | M | 9 | Yes | C9 | M | 12 |
C3 | M | 15 | No | C10 | M | 17 |
C4 | F | 5 | Yes | C11 | F | 7 |
C5 | M | 5.5 | No | C12 | M | 10 |
C6 | M | 8 | Yes | JD4 | F | < 1 year |
JD1 | F | < 1 year | Yes | JD5 | F | < 1 year |
JD2 | F | < 1 year | Yes | JD6 | M | < 1 year |
JD3 | F | < 1 year | Yes | JD7 | F | < 1 year |
PH1 | M | 2 | Yes | PH7 | M | 4.5 |
PH2 | M | 7 | Yes | PH8 | F | 6.5 |
PH3 | F | 13 | No | PH9 | F | 10 |
PH4 | F | 5 | Yes | PH10 | F | 6 |
PH5 | F | 4 | Yes | PH11 | M | 8 |
PH6 | F | 26 | Yes | PH12 | F | 12 |
General staff experience
“it’s not clear what (medicine) has and hasn’t been given.” [PH4]
“There isn’t anywhere to record the patients’ drug allergy status.” [ANP1]
“so 3 to 4 month delay in getting them (final typed letter) done,” [C1]
“I think it is really good and I do think it improves like prescribing and administration of drugs for the patients.” [PH10]
“So first of all it’s amazing compared to paper prescription charts because it’s legible.” [C8]
“It’s just the quality of the letters that are coming out now, is far better than what we had before with the handwritten prescriptions particularly the clinical information, much more detailed and will be much better for the GP.” [C7]
Future aspirations with HEPMA
“I think it (HEPMA) will make us safer and it will improve communication between primary and secondary care.” [C4]
“You probably have to be quite careful if you were starting someone on something that it (HEPMA) could come up with a whole range of different doses for somebody…you might want to be careful to pick the right dose…so many options you accidentally click the wrong one.” [JD1]
Staff behavioural determinants
Theoretical domains
Knowledge
“Ok,well the positive side is familiarity…so people understand…how the kardex (inpatient prescription chart) works…“[C1]
“Our current drug charts do not easily lend themselves to meeting SIGN requirements for discharge letters…” [C2]
“it gives the option…to write exactly what’s happened throughout the patient journey in hospital…medications that have been stopped, again it gives you the allergy status… if GPs should continue it or not, so again it’s very clear.” [PH11]
Skills
“Quite often it (prescription) is illegible.” [C6]
“I feel I can use it quite well,…I know how to like modify things, and can suspend things and resume them…I am probably better at using HEPMA than the doctors are…..” [PH8]
“Yeah, I mean it is quite easy…so when you type the name it gives you the doses for the administration so it’s quite straight forward” [C10]
“My skills are probably limited because I don’t do it.” [C9]
Social/professional role and identity
“If I’m asked to prescribe something I’ve never prescribed before I won’t do it unless I go and look up the BNF…” [ANP4]
“I think probably I’m writing much more on the discharge letters than maybe I would have done previously, maybe prescribing a bit more than previously. I don’t know if that’s the system or just the confidence…I think it has had a positive impact on the pharmacy profession” [PH12]
“I think I spend less time on formal discharge summaries I think that it allows us as a team to get much better information into the GP earlier…” [C7]
Beliefs about capabilities
“As a prescriber sometimes I don’t feel very secure, prescriptions may be altered after you have completed them and you don’t know by whom, as they don’t annotate the changes.” [ANP 4]
“Probably I think my confidence has improved to prescribing and I think that is because I know there is a bit of a safety back up with it” [ANP5]
“My skills are in the early stages I would say, as I rely very much on the junior staff.” [C12]
Beliefs about consequences
“There are deep concerns about the safety around about using the paper kardex (inpatient prescription chart), legibility, frequency, recording of administrations, start and finish times and reasons for drug…does lead to medication errors across the boundary into primary care and it also leads to readmissions.” [C1]
“Always just about please tell me why they are no longer on x,y,z,….Am I meant to be continuing this- it is just lack of clarity on the immediate discharge letter.” [C4]
Patient safety
“I think it’s definitely made a huge difference, a huge improvement in patient safety.” [PH12]
IDL quality
“the quality of the discharge prescription has improved because the doctors now use it as a letter to the GP… GPs are getting a lot more information. It’s much easier for the doctors to put in all the medicines that the patient came in on so they are more complete now” [PH10]
First and final communication
“the move to having the IDL as the principal discharge document, whereas I felt before that it was the final discharge summary that contained most of the important information…” [C7]
HEPMA engagement
“Well some consultants don’t even use it all…they don’t like it…it leaves a lot of responsibility for the junior members of staff to sort out the medications and it is reliant on just verbal communication from senior doctors telling them to adjust things” [JD4]
GP queries
“I’ve had probably one or two queries in the entire time it’s been up…We used to have frequently so maybe two or three phone calls per week from GPs about things.” [ANP5]
HEPMA new error types
“The drop down boxes it’s very easy for them to pick the first one that comes up when they choose a drug and they don’t actually scroll down to find the correct form for the drug…so it’s a different type of error” [PH9]
Environmental context and resources
“It’s often filled out by a passing doctor trying to facilitate a discharge in a pressurised system.” [C1]
“…when the wrong patient label was put on a discharge prescription…and it came to that it was actually the patient in the next bed.” [PH1]
“The layout is very good and I like the box at the bottom of the discharge where it gives you the discontinued drugs and why they have been discontinued” [PH9]
“I would guess and I can’t back it up with any figures that it actually has improved the number of incidents and adverse events” [C12]
Social influences
“Yeah I know other consultants are less comfortable with it, but having used it before…it took me a week or two and then I was back up to speed with it.” [C7]
Behavioural regulation
“I think as with any kind of prescribing…you’ve got to get into your own system of checking things and if I prescribe I go back and double check it straight after and yeah I do find the occasional mistake when I’ve put in the wrong strength or put in the wrong frequency but I’ll go and change that right there and then” [PH9]
Framework | Summary of findings pre-implementation | Summary of findings post-implementation | |
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Design of inpatient chart, insufficient space on IDL and delays with discharge communication process HEPMA anticipated to improve safety | Improved clarity on inpatient chart and improved quality of IDLs | ||
TDF Domain
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TDF Construct
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Summary of findings pre-implementation
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Summary of findings post- implementation
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Knowledge | Procedural knowledge, knowledge of task environment | Staff knew what to do and familiarity described as important, limitations of documentation and processes described | Staff provided detailed descriptions of HEPMA processes and tasks |
Skills | Competence, practice | Staff mainly felt competent and ease of access cited as a positive factor, although illegibility described as problematic | ANPs, junior doctors and pharmacists rated themselves as skilful HEPMA users; consultant doctors had varying skill levels |
Social/professional role and identity | Professional role, professional confidence | Non-medical prescribers described professional aspect of prescribing | Positive impact on professional role, an increase in confidence described by ANPs and pharmacists |
Beliefs about capabilities | Perceived competence, self confidence | Anxiety described due to existing documentation and processes | ANPs, junior doctors and pharmacists all perceived competent; variability with consultant doctors |
Beliefs about consequences | Outcome expectancies, consequences | Patient safety a major concern with prescribing errors reported by numerous interviewees, queries from GPs regarding missing or incomplete information frequently related to medicines were reported | Improvement in patient safety, quality of IDL and number of first and final discharge letters, lack of engagement by some consultant doctors and introduction of new error types |
Environmental context and resource | Resources, critical incidents | Constraints due to documentation design and time pressures were described, incident reports only completed by pharmacist professional group | Improved design for inpatient and discharge sections, no documentation of a formal incident about HEPMA |
Social influences | Social pressure, group conformity | Not applicable | Variability evident amongst practitioners |
Behavioural regulation | Self-monitoring, action planning | Not applicable | Process for self-checking developed by some staff |