The most common medication care-related communication factors and solutions contributing to medication incidents in

hospitals

The most common contributing factors varied slightly between the data from incident reports, the structured questionnaire, and the open-ended answers. However, the most common challenges represented similar challenge types (Figure 18). Communication challenges were experienced most often within teams in the same unit, either between nurses (incident reports), nurses and physicians (Likert scale answers), or health

professionals and patients or their families (factor levels).

The traditionally reported challenges are between units or organisations (Smith, 2016; Kerstenetzky, 2018; Wilkin, 2018; Michaelson et al., 2017;

Pellegrin et al., 2018; Shah et al., 2020; Sarzynski et al., 2019; Glans et al., 2022). However, challenges are often described in communication between physicians, or between physicians and pharmacists in discharge phase (Garcia et al., 2017; Ozavci et al., 2021; Hahn-Goldberg et al., 2022; Munshi et al., 2022). Similarly, patient transfer is traditionally recognised as the phase that is most prone to medication errors (Michaelson et al., 2017).

However, even if the communication challenges between units appeared less often than within the teams in this study, they seemed to relate to slightly more serious incidents. Therefore, several international medication safety programmes consider discharge and transfer one of the main development areas (WHO, 2017, 2021a; ACSQHC, 2020). However, health professionals’ perceptions in this study suggest that attention in strategies should also be paid to communication during the inpatient phase.

There might be at least two reasons for these new results. First, since most respondents work in inpatient wards, post-discharge communication challenges might not appear in the results. However, the results represent the views of most staff throughout the care pathway. Medication-related readmission as the reason for hospitalisation is not always reported

systematically (Lee et al., 2022). Therefore, staff in inpatient wards may not receive information about communication challenges during discharge.

Second, all communication factors have not been previously assessed simultaneously, with studies focusing either on outpatient, admission, inpatient or, most often, discharge phases (Michaelson et al., 2017). These new results are promising from the managers’ and leaders’ perspectives because they highlight the possibility of leading the change towards improved medication communication within the units.

The most common detailed communication factors differed between previous studies and this study. For example, medication administration challenges have traditionally been the major concern for medication safety (Härkänen et al., 2017; Westbrook et al., 2017; Härkänen et al., 2019;

Karttunen et al., 2020). These challenges were also identified in this study, but they were not the primary concern from the communication

perspective. Instead, it seems that studying detailed communication factors revealed the root causes behind the medication administration errors. The results suggest that communication challenges most often relate to prescribing, prescriptions, noticing the prescriptions,

understanding the prescriptions, and being aware of and following the guidelines. Thus, the results showed that common communication challenges were non-structured prescribing and medication

documentation, leading to missing information. The results are supported by a retrospective chart review study by Marques Cavalcante-Santos and colleagues (2021), who found that three quarters of prescription changes were documented insufficiently, compromising medication

communication. Similarly, Manias et al. (2021) found that >30% of communication failures resulting in medication errors were caused by unread or missed prescriptions.

Earlier studies have concentrated mainly on solutions concerning the admission (Lee et al., 2022; Chen et al., 2018) and discharge phases (Michaelson et al., 2017; Foged et al., 2018; Uitvlugt et al., 2015;

Kerstenetzky et al., 2018; Pellegrin et al., 2018; Wilkin et al., 2018) of the medication care process. The primary solutions in this study focused on implementing inpatient phase interventions to standardise digital medication prescriptions and unifying documentation about a given medication. However, the results also suggest standardizing medication reconciliation between health professionals within and between

organisations. The literature contains quite a few potentially successful methods and tools for securing medication reconciliation (Latimer et al., 2020), structured documentation and reporting during admission,

inpatient, transition, and discharge phases (McCarthy et al., 2019; Sarzynski et al., 2019; Visade et al., 2021). It would be beneficial to strengthen the implementation of these solutions in practice.

Interestingly, in this study, five methods out of six identified digital prescriptions given outside of regular ward rounds as one of the main communication challenges, resulting in medication administration delays that spanned from hours to days or omitted medication, at worst. This result is important, as it mirrors the findings of Härkänen et al. (2019) in

their study of medication administration errors that resulted in death in England and Wales. In their study, the most serious errors occurred in the inpatient ward. Omissions were the main reason for medication errors.

Therefore, digital prescriptions given outside regular ward rounds should be considered a key development area to improve medication

communication and safety. Physicians should ensure they systematically give oral notice about prescriptions given outside regular ward rounds.

The previous studies, instead, suggested prescribing training for early- stage physicians (Myers et al. 2017), structured handover for nursing staff (Braaf et al., 2015; Manias et al., 2015), and structured ward rounds regarding power relationships as solutions (Braaf et al. 2017; Liu et al.

2016). Thus, attention should be paid to both the structure of the

prescribing system and to the actions taken during the prescribing process.

These results encourage managers and leaders to strengthen

prescribing and documentation standardisation and to support guideline compliance. It is important to communicate compliance expectations since the Original Study II’s incident report analysis results showed that the number of cases where guidelines were not followed was higher than the number where professionals were unaware of the guidelines. This finding is supported by previous studies that reported about bending rules and workarounds (Härkänen et al., 2017; Haneka et al., 2018; Karttunen et al., 2020).

One major multisectoral challenge recognised in this thesis was non- communicable software between units or organisations. This result is supported by several previous studies and programmes (Bates & Singh, 2018; WHO, 2021a). The health professionals suggested enforcing

development and adoption of communicable software for medication records nationally. This supports the findings about longstanding

challenges nationally and internationally. The continuing challenges raise ethical questions for software developers — should patient safety

outcomes be given even more importance during the software

development process? Since software businesses are commercial, they may prefer unique and noncommunicable products to competitors’

products. Therefore, further international (WHO, 2021a) and national

discussion is needed regarding criteria for EHR communicability. It might be beneficial to consider if regulative actions are needed, as were

similarly recently required by the EU (2021) to unify mobile phone charger connectors.

Until 2022, in Finland, there had also been legislative restrictions for transferring EHR information, but that legislation is under reform in an effort to overcome this challenge (STM, 2022c). However, removing legislative barriers will not solve the communication problems if the EHR software interaction requirements are not in place. Requiring one specific software for all public stakeholders nationally would not solve the

communication challenges between the public and private sectors. Lacking the skills to use the software was identified as a technical

communication challenge (text mining/manual analysis). Supporting findings are described by Glans et al. (2022) in their physician focus group study. They concluded that software system training is not always available or prioritised. Thus, software user training could be beneficial to improve medication communication.

Due to the current risk-prone situation resulting from the utilization of noncommunicable software, standardised reporting is needed during discharge and patient transition. This might be done by utilizing existing evidence-based checklists for medication information communication (Hohmann et al., 2014; Claeys, 2015; Monfort et al., 2016; Shah et al., 2020;

Visade et al., 2021; Munshi et al., 2022) and digital tools for summarizing medication information (Hohmann et al. 2014; Sarzynski et al. 2019;

Pellegrin et al. 2018; Smith et al. 2016).

This thesis’ results suggest, as a novel finding, that pharmacist availability may improve communication about guideline

implementation but might decrease communication with patients and their families. Pharmacists should further strengthen communication with patients and their families, or the responsibilities among professional groups should be clarified. Most evidence in the literature has shown clear benefits in reducing medication errors when pharmacists perform

medication assessment and reconciliation (Ooi et al., 2017; Miller et al., 2018; Pellegrin et al., 2018; Choi et al., 2019; Guerin et al., 2020; Manias et

al., 2020). However, Jošt et al. (2021) found no difference in medication incidents in their RCT study, where they tested the effect of pharmacist-led medication reconciliation on ADEs during hospital admission. This

discrepancy might be due to the factors found in this study:

noncommunicable software, non-structured documentation phases, and digital prescriptions that are not communicated orally to the implementing team that may go unnoticed.

The factor levels measured with the MIComHos-S1 scale showed challenges in communication with patients and their families. In Original Study II, the patient-related factors supported Manias’ finding about the effectiveness of error prevention through patient

communication. Manias et al. (2021) concluded that patients and their families have crucial information that may stop up to 15% of errors from happening. Thus, patient and family involvement in communication about their medication should be accelerated to increase medication safety.

However, according to the literature, communication about medication with patients can also decrease patients’ medication compliance if the provided information causes anxiety about side effects (Pajaro et al., 2021).

Therefore, attention should be paid to the information provided and how and by whom the information is given. Literature provides several tools and methods to increase patient involvement in medication care.

Evidence in the literature shows the potential benefits of using educational cards (Begum et al., 2020), teach-back methods (Hahn-Goldberg et al., 2022; Pajaro et al., 2022), and whiteboards (Hahn-Goldberg et al., 2022) for patient education and post-discharge communication with patients using checklists (Visade et al., 2021; Munshi et al., 2022). There is also some potential evidence regarding digital medication solutions for patients, such as bedside stations, depending on their age and individual abilities to use them (Begum et al., 2020; Cho et al., 2020). Informal discussions with patients about medication at the bedside may greatly increase the odds that they will recognise medication errors (Manias et al., 2021). However, the implementation of the available tools might be low, which may be due to a general unawareness of some potential solutions. Managers and leaders should be offered support for the implementation of effective

methods. Strong collaboration with clinical and research stakeholders would potentially strengthen use of scientific evidence.

Furthermore, supporting earlier findings in literature (Fronda et al., 2016; Slawomirski et al., 2017; Berry et al., 2020; WHO, 2021a), the results showed that giving collegial feedback among professionals and reporting medication incidents transparently resulted in improved medication communication. Thus, active feedback culture and mentoring should be implemented in clinical practice. Health professionals with the

highest/widest responsibilities perceived the highest communication challenge frequencies in inpatient units. This trend might be explained by the fact that they receive condensed information from the remarkable incidents, inflating their frequencies. However, this perception does not necessarily mirror the factual situation in a single unit.

When all the perceived challenges were compared to the ‘General communication process in Figure 2’, it was concluded that communication challenges, specifically in the blunt end, need further attention. In

Appendix 8, the word ‘leadership’ has been added to the original Figure 2 as a contributing factor with the following subcategories: communication about guidelines and guideline compliance expectations; mentoring and collegial feedback. In addition, the terms ‘technological compatibility’ and

‘user training’ were added to the communication methods and channels box.

Recent literature highlights the importance of implementing

communication curricula for the education and continuous professional training of healthcare professionals (Noble et al., 2018; Bachmann et al., 2022; STM, 2022a). However, the suggested communication education for the curricula is mainly concentrated on communication dyads of health professionals-patients and aimed at their shared decision making. The results of this study suggest also including inter- and intra-professional communication viewpoints in the future communication curriculum of health professionals’ educations. The background literature search showed that there exist multifaceted national and international networks of medication safety stakeholders with whom to discuss the top challenges and solutions further.