To be presented with the permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in MS302 Auditorium,. The results showed that medication incident reporting, peer feedback and mentoring reduced communication challenges and medication incidents.
ACKNOWLEDGEMENTS
I also express my deep gratitude to Professor Marja Kaunonen (University of Tampere) for agreeing to act as an opponent for my thesis. I express my deepest gratitude to my colleague MNSc Leena Timonen, clinical nurse, for your wise advice, warm encouragement and deep.
LIST OF ORIGINAL PUBLICATIONS
CONTENTS
CONCEPT OF COMMUNICATION CONTRIBUTING TO MEDICATION INCIDENTS IN HOSPITALS (ORIGINAL STUDY I)
CVI Content Validity Index Content Content Validity Ratio DRP Drug Related Problem DRM Drug Related Morbidity DTP Drug Therapy Problem EFA Exploratory Factor. ISMP Institute for the Safe Practice of Medicine MeSH Medical Subject Headings MI Multiple Imputation Medication Incidents MIComHos.
1 INTRODUCTION
Similarly, while the general necessity of communication promotion is widely recognized in health care (Bachmann et al., 2022), specific plans for medication communication improvement are rare (WHO, 2021a). The results can be used to develop medication communication strategies, training and practices to improve medication safety and guide future research.
2 REVIEW OF THE LITERATURE
MEDICATION COMMUNICATION
- Definition of communication
- Communication contributing to medication incidents in research
Factors from Manias' (2010) concept and Kitson et al. 's CCM framework (2013) is included in the general communication process map (Figure 2). Kitson et al. 's framework focuses on the community context, while this thesis focuses on the hospital context.
MEDICATION SAFETY
- Medication safety terminology
- Medication safety process
- Patient safety culture and communication
- Guidelines and regulations
Organized by AHRQ, the Patient Safety International Network (PSNet) shares knowledge and tools to improve patient safety nationally in the US and internationally (AHRQ, 2022). The Finnish Center for Client and Patient Safety (2022) promotes health care safety based on the Parliamentary Decree on the Centralization of Specialized Health Services (582/2017).
MEDICATION SAFETY IN SPECIALIZED HEALTHCARE
- Specialised hospitals
- Enhancing clinical medication communication and safety Several practical means are available for advancing clinical medication
- Medication safety in specialised hospitals
Tall Man letters are a method in clinical settings to reduce medication name confusion (ISMP, 2016; Iglesias Gomez et al., 2022). The change in ratio may be due to software changes in EPDs (Linden-Lahti et al., 2022) during this period.
REVIEW OF RESEARCH ON MEDICATION INCIDENT-RELATED COMMUNICATION IN HOSPITALS
- Studied care phases and the geographical location of the studies
- Solutions to enhance medication communication in hospitals Five solution types have been studied for enhancing medication
In the admission phase (Table 4), communication is insufficient about medication events that cause hospital readmission (Lee et al., 2022). A patient can confront multiple medication errors, most of which are omissions (Chen et al., 2018). Communication gaps can compromise the implementation of medication prescriptions after physicians' ward rounds (Myers et al., 2017).
Digital solutions: Smith et al. 2016) investigated computerized discharge medication reconciliation to improve medication communication during hospitalization. Sharing information about events was suggested to improve medication communication throughout all phases of the care process (Chua et al., 2017).
LITERATURE REVIEW SUMMARY
Preference of single patient rooms Manias et al. 2014) Tool to assess missing documents Sarzynski et al. for pharmacists Pellegrin et al. medication reconciliation Smith et al. back method Hahn-Goldberg et al. with the patient, discharge checklists. Reporting and analysis of medication incidents in specialized healthcare has been implemented internationally and nationally in Finland. Multi-level national and international networks, guidelines and regulations have been developed to promote medication safety.
Choosing tools to enhance medication communication can be difficult if communication challenges are not measured. Neither concept of communication was found to contribute to medication incidents, but one is needed to develop a scale to measure communication challenges.
3 AIMS OF THE THESIS
4 SUBJECTS AND METHODS
- STUDY DESIGN AND SETTINGS
- To describe the concept of
- To test the conceptual
- To develop a scale
- To assess perceptions
- A CONCEPT ANALYSIS (ORIGINAL STUDY I)
- ANALYSIS OF MEDICATION INCIDENT REPORTS (ORIGINAL STUDY II)
- DEVELOPMENT AND TESTING OF A ‘MEDICATION INCIDENTS AND COMMUNICATION IN HOSPITALS’ SCALE (ORIGINAL
- TEXT MINING AND MANUAL CONTENT ANALYSIS: CROSS- SECTIONAL SURVEY FOR HEALTH PROFESSIONALS
- ETHICAL ISSUES
Therefore, the framework was further developed with an inductive content analysis of the articles (Walker & Avant, 2019). Here, the imaginary model case was to satisfy all the concept's antecedents and present examples of all the concept's main features. Replacement of missing data should be used for a maximum of 5% of the data (Kääriäinen et al., 2011).
Based on the normality tests, parametric or non-parametric tests were chosen to test for differences between the means of the factors. User experience of the analysis methods was described qualitatively between text mining and manual analysis.
5 RESULTS
CONCEPT OF COMMUNICATION CONTRIBUTING TO
Parts of several earlier theories (described in the Original Study I publication) were incorporated into the concept. The MIComHos concept partially overlaps with Kitson's medication cycle model, which describes communication networks focused primarily on primary care networks, but also describes some communicators in hospitals. The current thesis supports Kitson's framework by describing a broad network of hospital communication pairs that contribute to medication incidents (Figure 11).
TYPES OF COMMUNICATION ISSUES IN INCIDENT REPORTS AND THE CASES THAT CAUSE SERIOUS OR MODERATE HARM
The most frequent task-related issues affecting medication communication were misconceptions about colleagues' work processes (25.6%; n = 128). Prescription-related communication problems (Figure 13) were: lack of communication in a care team about guidance given along. Cases of moderate injuries were rare, but mostly associated with structural, process or occupationally related problems.
Incidents that prevent communication problems were communication with the patient (5.4%; n = 27), collegial feedback between professionals (15.0%; n = 75), and mutual respect that promotes communication between. According to an analysis of incident reports, more than 90% of MIComHos subjects were found in voluntary drug incident reports.
A SCALE FOR MEASURING COMMUNICATION FACTORS CONTRIBUTING TO MEDICATION INCIDENTS IN HOSPITALS
- Respondents
- Imputation and EFA results
The six factors for assessing communication contributing to medication incidents were: (1) communication about medication prescriptions, (2) communication about instructions and reports, (3) patient and family communication, (4) communication about implementing instructions, (5) communication about powers or responsibilities, and (6).
COMMUNICATION CHALLENGES PERCEIVED BY HEALTH PROFESSIONALS MEASURED USING MICOMHOS-S1
- Respondents
- The most frequent communication items indicated by health professionals (Unpublished content)
- Factor levels of the communication factors and differences between them
Most professionals indicated that communication challenges occurring at least weekly (Appendix 4) were: incomplete, missing or unclear guidance in prescribing medicines (20.5%; n = 62) and being. Transferring patients between units or organizations was reported as a communication challenge by 13.9% (n = 42) of respondents at least weekly. Communication problems occurring at least weekly mostly involved communication between a nurse and a doctor (25.1%; n = 76) or more commonly occurred within the home ward among colleagues (16.5%; n = 50).
The most frequently perceived individual communication challenges (i.e., items) per week belonged to the factors of prescribing medications, communicating with the patient, and implementing guidelines. Repeated ANOVA tests identified two pairs of factors with no statistically significant difference in factor levels: communication challenges in prescribing medication (factor [F]1) and communication with patient and family (F3).
However, the factor level range was wider for atmosphere factor (F6) than for guideline and reporting factor (F2) (Figure 14).
- Differences in health professionals’ perceptions of detailed communication challenges
The highest factor levels (i.e., prevalence of communication difficulties) of all factors were reported by participants who did not name their clinical area (mean = 3.71) or had more than one area of responsibility (mean = 3.51). Drug prescribing problems were noted more often in inpatient wards (mean = 3.10) than in intensive care, operating room, or. Managers (mean = 3.08), middle managers (mean = 3.75), and supervisors (mean = 3.75) assigned the highest rating to medication prescription-related challenges.
When the pharmacist was available, the most common factor concerned communication with patients and family (mean = 3.16). When the pharmacist was not available, the most frequent factor was communication regarding the implementation of instructions (mean = 2.61).
Prescrip-
Participants who said they had sufficient information about actions derived from incident reports showed a significantly lower incidence of all.
Guidelines
Patient and
Implemen
Competen-
Attitude
- HEALTH PROFESSIONALS’ PERCEPTIONS ON MEDICATION COMMUNICATION CHALLENGES AND SOLUTIONS
- The most frequent communication challenges contributing to medication incidents, perceived by health professionals in
- Suggestions to enhance medication communication from health professionals
- Qualitative comparison of the text mining and manual content analyses of free text survey data
- SUMMARY OF THE RESULTS
Combined results from text mining and manual analyzes identified seven key communication challenges: (1) the documentation of prescribed and administered medications is inconsistent; (2) verbally given prescriptions are left undocumented; (3) nurses fail to note prescriptions given outside of ward rounds due to lack of verbal communication from prescribers; (4) communication interruptions during care transitions due to non-communicable software; (5) incomplete reconciliation of home medications during admission and discharge due to unclear responsibilities among professionals; (6) inpatient medication lists are not updated due to the unclear division of responsibilities between professionals; (7). The pooled results from all three analyzes (text topics, text clusters, and manual inductive content analysis; table presented in the published Original Study IV article) identified seven main solutions to improve medication communication to help prevent medication incidents in hospitals. The text topic and clustering methods used in text mining and manual content analyzes identified similar challenges and solutions.
Lack of skills to use the software, non-transferable software and unclear task coordination for medication matching were seen as challenges for medication communication. As stated by health professionals, the preferred solutions to improve medication communication in hospitals have been standardizing prescriptions, documentation, and tailoring and improving medication.
6 DISCUSSION
MAIN RESULTS
- The concept of communication factors contributing to medication incidents in hospitals
- A scale to measure communication factors
- The most common medication care-related communication factors and solutions contributing to medication incidents in
Similarly, patient transfer is traditionally recognized as the phase most prone to medication errors (Michaelson et al., 2017). Second, all communication factors have not previously been assessed simultaneously, with studies focusing on either the outpatient, admission, inpatient or, most commonly, discharge phases (Michaelson et al., 2017). The literature contains many potentially successful methods and tools for ensuring medication reconciliation (Latimer et al., 2020), structured documentation and reporting during admission.
However, according to the literature, communication about medication with patients can also reduce patient compliance if the information provided causes fear of side effects (Pajaro et al., 2021). Informal conversations with patients about medication at the bedside can significantly increase the chance that they recognize medication errors (Manias et al., 2021).
LIMITATIONS AND STRENGTHS
- Literature review (Original Study I)
- Incident report analysis (Original Study II)
- Scale development, EFA (Original Study III) and statistical analysis of the scale’s testing data (Unpublished content)
- Text mining and manual content analysis (Original study IV) In Original Study IV, conducting text mining before the manual analysis
A considerable number of statistical units were discarded due to a large number of missing responses. We increased the transparency of the results by describing the commonality, the reasons for choosing the number of factors, the method of rotation and the loading of all items (Watson & Thompson, 2006). Based on this observation, even when factor levels are aggregated, they provide useful indications of the most important challenges.
Using two text mining methods and a manual content analysis strengthened results' credibility (Grove et al., 2013). The transferability of the results was enhanced by the detailed and visualized description of the analysis process (Grove et al., 2013; Morse, 2015).
7 CONCLUSIONS
THE CONCLUSIONS BASED ON THE RESULTS
The results reinforced previous evidence that communication with patients and their families needs to be improved.
RECOMMENDATIONS BASED ON THE RESULTS For clinical development and education
Recently developed core communication curriculum for health professionals training mainly concentrates on communication between professionals and patients.
FUTURE RESEARCH SUGGESTIONS
Educational intervention research for the implementation of available patient education and engagement tools in medication management to improve medication communication with patients and family.
Available at https://www.hus.fi/sites/default/files/2022-03/laatu- ja-potilasturlissinisluinnula-2022-ja-raportti-2021.pdf. Available at https://www.ismp.org/resources/special-edition-tall-man-lettering-ismp-updates-its-list-drug-names-tall-man-lettering. Available at https://www.ismp.org/resources/guidelines-safe-electronic-communication-medication-information Retrieved 29 Jul 2022.
Available at https://www.who.int/news-room/articles-detail/expression-of-interest-patients-for-patient-safety-network. Medicines without harm (who.int), available at https://www.who.int/publications/i/item/WHO-HIS-SDS-2017.6.
APPENDICES
SCOPING LITERATURE SEARCH
FORM FOR SCALE’S TECHNICAL TESTING Dear Testing Participant,
BACKGROUND VARIABLES IN LIKERT SCALE SURVEY (N=303)
He was unaware that a new medication prescription had been made outside of a routine ward visit. Documentation was missing because the person responsible for documentation was not appointed to bypass the department. No guidelines were given regarding the problems to consider due to the prescribed drugs.
Reporting was missing if the recipe was not executed, an execution error occurred, or the recipe was modified during execution. The medication incident was not reported because the atmosphere in the clinic is not conducive to it.
PAIRWISE COMPARISON OF FACTOR LEVELS
SUMMARY OF COMMUNICATION CHALLENGES BY RESEARCH METHOD Incident report Analysis (n=500)
SUMMARY OF SOLUTIONS TO ENHANCE MEDICATION COMMUNICATION Incident reports' Analysis (n=500)
KEY: Grayscale area consists of the three most common solutions to improve medication communication through each research method.
AUGMENTED FIGURE 2 BASED ON THE STUDY RESULTS
ORIGINAL PUBLICATIONS (I – IV)
Communication related to medication incidents— A concept analysis and literature review
