Medication Tasks Research Articles

Junior doctors’ prescribing work after-hours and the impact of computerized decision support

Background and objectivecomputerized provider order entry (CPOE) systems with integrated decision support (DS) can reduce prescribing errors, but their impact may vary depending on the clinical setting. This study aimed to assess the impact of partial implementation of CPOE on junior doctors’ prescribing work after-hours and to examine differences in junior doctors’ use of DS during transcribing and their own prescribing tasks. MethodsTwelve junior doctors at a 350-bed teaching hospital in Sydney, Australia were shadowed between 16:30 and 22:30 over eight weeks for 65h. CPOE was available on all wards except for the emergency department (ED). All medication tasks, computerized alerts, prescriber responses, and uses of reference material were recorded. ResultsOf 306 medication orders entered into the CPOE, 78.4% were transcribed from paper ED charts. A total of 113 alerts were triggered, most (78%) were read but only 6 (5%) resulted in prescribers changing an order. Reference material was accessed three times more frequently when junior doctors made their own prescribing decisions than when they transcribed other doctors’ orders, but a similar proportion of alerts was read during decision-making and transcribing tasks. ConclusionJunior doctors spent most of their after-hours prescribing time transcribing other doctors’ orders. This is a new task brought about by partial CPOE implementation. Junior doctors read computerized alerts and used online reference material to support their decision-making. However they rarely made changes to a medication order following alert generation, suggesting the alert information was often not clinically relevant.

How much time do nurses have for patients? A longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals.

BackgroundTime nurses spend with patients is associated with improved patient outcomes, reduced errors, and patient and nurse satisfaction. Few studies have measured how nurses distribute their time across tasks. We aimed to quantify how nurses distribute their time across tasks, with patients, in individual tasks, and engagement with other health care providers; and how work patterns changed over a two year period.MethodsProspective observational study of 57 nurses for 191.3 hours (109.8 hours in 2005/2006 and 81.5 in 2008), on two wards in a teaching hospital in Australia. The validated Work Observation Method by Activity Timing (WOMBAT) method was applied. Proportions of time in 10 categories of work, average time per task, time with patients and others, information tools used, and rates of interruptions and multi-tasking were calculated.ResultsNurses spent 37.0%[95%CI: 34.5, 39.3] of their time with patients, which did not change in year 3 [35.7%; 95%CI: 33.3, 38.0]. Direct care, indirect care, medication tasks and professional communication together consumed 76.4% of nurses' time in year 1 and 81.0% in year 3. Time on direct and indirect care increased significantly (respectively 20.4% to 24.8%, P < 0.01;13.0% to 16.1%, P < 0.01). Proportion of time on medication tasks (19.0%) did not change. Time in professional communication declined (24.0% to 19.2%, P < 0.05). Nurses completed an average of 72.3 tasks per hour, with a mean task length of 55 seconds. Interruptions arose at an average rate of two per hour, but medication tasks incurred 27% of all interruptions. In 25% of medication tasks nurses multi-tasked. Between years 1 and 3 nurses spent more time alone, from 27.5%[95%CI 24.5, 30.6] to 39.4%[34.9, 43.9]. Time with health professionals other than nurses was low and did not change.ConclusionsNurses spent around 37% of their time with patients which did not change. Work patterns were increasingly fragmented with rapid changes between tasks of short length. Interruptions were modest but their substantial over-representation among medication tasks raises potential safety concerns. There was no evidence of an increase in team-based, multi-disciplinary care. Over time nurses spent significantly less time talking with colleagues and more time alone.

Medication reconciliation: Barriers and facilitators from the perspectives of resident physicians and pharmacists

Medication reconciliation can prevent medication errors and harm when patients transition between hospital and other care settings. Though a Joint Commission hospital Patient Safety Goal since 2006, organizations continue to have difficulty implementing the process. To determine factors that influence performance of medication reconciliation in a hospital setting with a computerized medication reconciliation tool. Cognitive task analysis (CTA) and focus group interviews. Urban, academic, tertiary-care Veterans Affairs medical center. Internal medicine house staff physicians (n = 23) and inpatient staff pharmacists (n = 12). CTA participants verbalized their thoughts while they completed medication reconciliation with the computerized tool. Focus group participants described medication reconciliation's purpose and effectiveness, how they completed the task, and its barriers and facilitators. Interviews were recorded and analyzed using social science methods for analyzing qualitative data. Participants agreed that a central goal of medication reconciliation is to prevent prescribing errors, but disagreed about whether it achieves this goal. Computerization facilitated the task, but participants said that computers and patients can be unreliable sources of information. Participants varied in how they sequenced components of the task. When time was limited, physicians considered other responsibilities higher priority. Both physicians and pharmacists expressed low self-efficacy, ie, low perceived capability to achieve the objectives of the process. Key barriers to medication reconciliation are unreliable sources of medication information and tasks that compete for providers' time and attention that they consider higher priority. Addressing these barriers while increasing providers' self-efficacy might improve medication reconciliation and its outcomes.

Respecting Elders by Respecting Their Paid Caregivers

The vast majority of older persons will need to be cared for by another person in their final years of life. A recent UK study demonstrated that 55% of persons over age 85 in their last year of life were moderately to severely cognitively impaired, 63% needed help bathing, 43% needed help dressing, 67% could walk no further than their home gate, and 50% needed help with their medications.1 Despite popular media hype offering the promise of longevity free of disability as a reward for healthy living, the vast majority of our elderly patients, parents, grandparents, and even those of us who live to old age will need a caregiver for a short period or even years at the end of life. How do we want our frail elderly patients and family members to be treated? The quality of their lives depends upon the quality of their caregiving. If we want our elders to be treated with the respect and dignity they deserve, we need to make sure those who care for them are treated with the respect and dignity they deserve.

Assessment of transition readiness skills and adherence in pediatric liver transplant recipients

To examine transition readiness, adherence, and health outcomes in pediatric liver transplant recipients using a clinically administered screening measure. Seventy-one pediatric liver transplant recipients (11-20 yr) and 58 parents completed a clinic-based TRS measuring perceived and demonstrated self-management skills, AoR for health-related tasks, regimen knowledge, and psychosocial adjustment. Adherence was measured using s.d. of immunosuppressants, proportion of immunosuppressant blood levels out of target range, and clinic attendance. Health outcomes included liver test panels, biopsies, rejection episodes, and hospitalizations. Results indicate that all domains of transition readiness, with the exception of demonstrated skills, and non-adherence were positively correlated with age. Proportion of immunosuppressant blood levels below target range was positively correlated with self-management skills and increased responsibility for medication tasks. Parent regimen knowledge was associated with clinic attendance. Health outcomes were significantly related to medication non-adherence, but not to transition readiness domains. Medication adherence is considered to be a key factor in the transition from pediatric to adult-centered transplant care. Non-adherence is associated with an increased risk for medical complications and is potentially modifiable. Interventions to promote self-management skills and adherence should be an essential component of transition planning.

A comparison of self-reported and observational work sampling techniques for measuring time in nursing tasks

To compare self-reported and observational work sampling techniques when applied to ward-based nurses. A self-reported work sampling study was undertaken with nine registered nurses in an Australian teaching hospital over 8.5 weeks, followed by an observational work sampling study conducted over 4.5 weeks. Both studies used a random reminder method and a multidimensional work task classification. Field notes were also recorded and analysed. 3910 data points were collected, 667 during the self-report study and 3243 in the observational study. The two techniques yielded significant differences in work patterns of registered nurses. The observational study showed that compared with the self-reported study, patient care (40% versus 33%, P <0.000) and ward-related activities (7% versus 3%; P <0.001) were recorded significantly more frequently, and documentation less frequently (8% versus 19%; P <0.000). Both the techniques generated similar proportions of time spent in breaks (12%), medication tasks (13%) and clinical discussion (15%). The self-report technique was poorly accepted by nursing staff. The observational technique was well accepted and data collection was more effcient. The self-report work sampling technique is not a reliable method for obtaining an accurate reflection of the work tasks of ward-based nurses. The observational technique was preferred by nurses, and despite concern regarding a potential Hawthorne effect, this was not substantiated.