Background
Methods
Setting
The Dutch bundle intervention for medication reconciliation
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Collect information on the medication history from the community pharmacy
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Interview the patient by a trained professionala about medication use and history
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Create an up-to-date and complete list of the patient’s current medications
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Medication reconciliation on discharge
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Create an up-to-date medication list based on data from the hospital pharmacy, and the hospital’s medical record
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Write the discharge prescription medication list authorised by the clinician responsible
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Undertake patient counselling by a trained professional (a pharmacist, pharmacist assistant, nurse, pharmaceutical consultant or a pharmacy practitioner) at discharge
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Ensure handover of an up-do-date medication list, discharge prescription, as well as information about medication which were discontinued and changed and the reason for this, to the community pharmacy, general practitioner and other health care organizations
Study design
Interview participants
Data collection
Data analysis
Levels | Sublevels |
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Innovation | Complexity, Compatibility, Credibility, Accessibility, Amount of information, Feasibility, Attractiveness, Advantage, Utility, Usefulness |
Health care professionals | Cognition, Awareness, Attitude, Motivation to change, Knowledge, Education |
Patients | Compliance, Polypharmacy, Multiple co-morbidity, Knowledge, Skills, Attitude |
Social context | Culture of social network, Opinion of colleagues, Leadership, Collaboration, Social learning |
Organisation | Organisation of care processes, Organisational structure, Time, Staff, Capacities, Resources, ICT infrastructure |
Economic context | Financial support |
Political and legal context | Social developments, Political developments and policies, Legal obligations and regulations |
Results
Description of participants
Levels | Perceived Barriers | Perceived Drivers |
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Innovation
| ||
Usefulness | The bundle does not meet the wishes or needs of professionals | Bundle creates more clarity about medication |
Complexity | Complex process, many professionals involved | Clear written manual and protocol of bundle |
Compatibility | Tailoring bundle to individual departments or specialities | |
Credibility | Lack of evidence of the effectiveness of the bundle | |
Professionals
| ||
Knowledge | Insufficient knowledge of the health care problem, the bundle, | |
benefits of innovation, best performance and generating feedback | ||
Not convinced that innovation leads to better and more efficient care | ||
Cognition | Do not recognize the care problem | |
Physicians prefer to conduct medication reconciliation themselves | ||
Awareness | Resistance to the imposed way of working | Creating awareness of the health care problem by process mapping |
Attitude | Shifting responsibilities | Quality and safety are seen as important |
Involve all professionals, including community caregivers | ||
Patients
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Knowledge | Limited knowledge of their medications | Encourage patient empowerment through education |
Awareness | Increase the awareness and responsibility for, carrying an up-to-date medication list | |
Attitude | Patient has other needs or priorities | |
Social context
| ||
Social learning | Top down implementation results in less involvement of departments and professionals | Snowball effect of best practice |
Collaboration | No collaboration or arrangements between departments and hospital and community caregivers | Having a multidisciplinary project group in charge of the implementation |
Information from community pharmacies is not available during out of office hours | Regional collaboration and agreements | |
Leadership | No sanction for departments who do not implement the bundle | The reinforcement and support of the bundle by management |
Good and clear leadership | ||
Competition | Competitive spirit between departments | |
Organisation
| ||
Implementation resources | Extra resources not being available for adhering to the bundle and to measure indicators | Adopting a phased approach to implementation |
Investing time, effort and resources | ||
Having a detailed implementation plan | ||
Clear and uniform forms and protocols | ||
Chain of care | Medication reconciliation not being implemented at every transfer or in related departments | |
Task reallocation | No agreements regarding tasks and responsibilities | Clear descriptions of roles, tasks and responsibilities |
Task reallocation to and more involvement of pharmacy technicians | ||
Staff | High turnover of personnel and interns | Protocol for new personnel |
Feedback | Quality indicators are not measured, no feedback information available | Create an evaluation and feedback mechanism |
A central incident reporting system for both hospital and community caregivers | ||
Feasibility | Simultaneous implementation of multiple safety interventions | |
ICT | Digital support for implementation, measurement and feedback of quality indicators | |
Regional or national electronic medication patient file | ||
Economic, political and legal context
| ||
Economic | Market forces result in competition for tasks and funding among care professionals | |
Political | Social pressure to save money | Patient safety is an important political subject |
Legal | Uncertainty about patient privacy | Obligation by government |
Undersigning the discharge medication list implies a legal | Reinforcement by the Health Care Inspectorate | |
responsibility for all prescribed medication |
Perceived barriers to the implementation of medication reconciliation
Innovation
“We do not have rock hard evidence that this bundle will for example prevent death in a number of patients. It is more like a common sense measure.” – policy maker -
“My experience with this bundle is that it is pretty free. It provides a direction, but the rest should be filled in by the professionals themselves.” – nurse -
“Departments are not aware that they have to rearrange their way of working to make this change permanent.” – policy maker -
Health care professionals
“I think there was an investigation by the hospital pharmacy about medication errors. It showed that our department performed really well. So I think there was not much need to change.” – nurse -
“We, nurses, do history taking in which we also ask patients about their medications. The physician also asks patients about their medications. A clinician does not blindly accept the information of an ‘educated professional’. In all cases, the clinician makes sure the medication reconciliation is correct. So medications are discussed and noted twice.” – nurse -“The clinician is ultimately responsible, but a nurse could also perform this interview. The responsibility, qualification and competence to perform such a task does not need to be done by one professional only.” – hospital pharmacist -
Patients
“Often, the patient does not want to wait for the counselling at discharge, he just wants to go home.” – clinician -
Social context
”Departments all have their own way of working. We have to see how medication reconciliation can fit in. This leads to an obstacle, because if you let departments choose for themselves, each department will choose differently. Alignment should be improved, and the whole process should be standardised.” – policy maker -
“Departments have to report the progress towards implementation in quarterly meetings with the board. The hospital board does not, however, sanction departments.” – policy maker -
Organisation
“We are changing existing structures, because we want physicians to act differently. This is fairly intensive. Furthermore, we cannot expect departments to implement ten safety themes at once.” – policy maker -
“Error reports are mostly not about the discharge process, because we do not know what happens to the patient afterwards.” – nurse -
“The tasks and responsibilities are unclear regarding interviewing the patient about his or her medication.” – hospital pharmacist -
“It is important that medication reconciliation starts in the outpatient clinic. They should give the current medication list to the anaesthesiologist, and the anaesthesiologist should give the information to the department where the patient will be treated. Then, they will check if the medication list is correct. This is how it should happen.” – nurse -
Economic, political and legal context
“I am responsible for all medications, including those prescribed by other clinicians, simply because of this one signature on the discharge medication form.” – clinician -
“We are obliged to have each patient’s permission. We will be reprimanded by the Health Care Inspectorate if we do not receive this permission.” – community pharmacist -“The opinion of some pharmacists about privacy is very overrated. Medication safety is more important. Up to now, if I ask a patient, they all agree to sending the medication list (to the hospital).” – community pharmacist -
“Community pharmacists may regard the hospital performing medication reconciliation as if they want to take tasks away from them. This could be an obstacle for optimal contact between the hospital and the community pharmacies. Pharmacies have been financially stripped in the last 2–3 years, and some are even making losses. The medication review means income. Hospitals should allow these people to make a living, because their work is important.” – community pharmacist -
Perceived drivers to the implementation of medication reconciliation
Health care professionals
“If you organise it in a proper way then the patient receives the correct medication, there are no errors made and it is less work.” – nurse -
“Start the implementation by mapping out the process. This gives professionals insight into their performance; when are professionals performing medication reconciliation, which professionals perform it; and how much time is spent on it. This knowledge clarifies where to improve efficiency.” – hospital pharmacist -
Patients
"“For two years, we (community pharmacists) have been alerting patients to take a medication overview when they have to go to a hospital.” – community pharmacist -
Social context
“We were one of the worst performing departments, but we want to be top performers again.” – clinician -
“People have to see that the innovation is supported by the leader. The hospital board showed leadership when they compelled all departments to implement the bundle.” – policy maker -
“The content is the responsibility of the implementation content leader, but the responsibility of the process lies with the departments themselves.” – policy maker -
Organisation
“I think, based on the costs-quality ratio, that hospital pharmacy technicians are best suited to perform medication reconciliation, compared to clinicians, nurses and hospital pharmacists, and they should be the link between clinician, patient and pharmacy.” – community pharmacist -
“A review should be done by the community pharmacy; a hospital pharmacy is not fit for such a task at all. The hospital pharmacy does not know the GP, and has no connections with him or her, which we do have. They cannot walk into the GP’s office, which we can and do.” – community pharmacist -
“The implementation is an important phase. Making a good start is necessary for getting medication reconciliation embedded into the working process. We take on the implementation challenge with the whole department: nurses, physicians, etcetera, and discuss with each other how to implement it in this particular department.” – hospital pharmacist -
“Reports about medication errors should be given as feedback to professionals, otherwise people will return to their former way of working. But if they see that fewer medication errors are made, that will certainly motivate them to continue doing medication reconciliation. Another thing that should be given as feedback is whether or not medication reconciliation is performed correctly, so that we can learn from it - a kind of self-learning system.” – clinician -
“In the evening, community pharmacies are closed. Insight into the electronic files of community pharmacists would help us enormously. Otherwise, clinicians have to prescribe without medication history.” – nurse -
Economic, political and legal context
“I know we will not escape from the implementation and we will just have to do it, because it is a legal regulation.” – clinician -
Discussion
Barriers and drivers | Implementation strategy |
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A lack of awareness of benefits of bundle | Process mapping of the medication reconciliation process to get insight into inefficiencies |
The bundle does not meet the wishes or needs of professionals | Tailoring bundle to local barriers and needs of professionals |
Compatibility | Use uniform and electronic forms between departments and between inpatient and outpatient setting |
Insufficient knowledge of professionals | Inform, thoroughly, professionals about the medication reconciliation process |
Use a training and implementation toolbox, including tools for transferring knowledge and forms for generating feedback | |
Generate feedback about professionals’ performance with quality indicators | |
Feedback | Use a central database for medication errors occurring in inpatient and outpatient settings to generate feedback |
Collaboration between hospital and community caregivers | Adopt a multidisciplinary team approach including hospital and community caregivers generating a common purpose |
Limited knowledge of patient | Encourage patient empowerment through medication education |
Competitive spirit | Facilitate competition by publishing and comparing the performance of departments |
Extra resources to measure indicators | Integrate the measurement of indicators with existing ICT tools |
Unavailable information from community pharmacies | Adopt a regional or national electronic medication patient file |
during out of office hours | |
Task reallocation | Reallocate tasks to those professionals who are best educated to perform medication reconciliation |
Incorporate community pharmacists into the medication reconciliation process, due to their knowledge of comorbidities and medication history | |
Multiple interventions at once | Synthesise the implementation of different interventions when possible |