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ObjectiveTo understand the sociotechnical factors affecting medication safety when intensive care patients are transferred to a hospital ward. Consideration of these medication safety factors would provide a theoretical basis, on which future interventions can be developed and evaluated to improve patient care.DesignQualitative study using semistructured interviews of intensive care and hospital ward-based healthcare professionals. Transcripts were anonymised prior to thematic analysis using the London Protocol and Systems Engineering in Patient Safety V.3.0 model frameworks.SettingFour north of England National Health Service hospitals. All hospitals used electronic prescribing in intensive care and hospital ward settings.ParticipantsIntensive care and hospital ward healthcare professionals (intensive care medical staff, advanced practitioners, pharmacists and outreach team members; ward-based medical staff and clinical pharmacists).ResultsTwenty-two healthcare professionals were interviewed. We identified 13 factors within five broad themes, describing the interactions that most strongly influenced the performance of the intensive care to hospital ward system interface. The themes were: Complexity of process performance and interactions; Time pressures and considerations; Communication processes and challenges; Technology and systems and Beliefs about consequences for the patient and organisation.ConclusionsThe complexity of the interactions on the system performance and time dependency was clear. We make several recommendations for policy change and further research based on improving: availability of hospital-wide integrated and functional electronic prescribing systems, patient flow systems, sufficient multiprofessional critical care staffing, knowledge and skills of staff, team performance, communication and collaboration and patient and family engagement.

BackgroundMedicines optimisation and adherence support are essential to secondary prevention after myocardial infarction (MI). Following successful implementation of a consultant pharmacist-led post-MI medicines optimisation clinic, the service was expanded by training advanced clinical pharmacists to manage clinics (with appropriate multidisciplinary team support).MethodsKey steps in the development process were: definition of a key competency framework based on relevant qualifications and experience, knowledge, skills and clinic management practicalities; creation and enaction of trainee-specific development plans to address gaps (including independent learning, teaching from multidisciplinary colleagues and shadowing in clinics); establishment of relevant protocols and proformas to ensure consistent standards (eg, a patient self-reporting tool for identifying adherence barriers, consultation proforma, directory of clinical parameters and pathway for onward referral when needed); phased clinic roll-out, initially under supervision; and gathering of feedback from patients and colleagues. Clinic letters from 50 attending patients were reviewed to quantify resulting interventions; the first 50 anonymously completed patient feedback questionnaires were also analysed.ResultsExpansion of the service initially doubled capacity. A review of clinic letters from attending patients demonstrated that various interventions were recommended, including further investigations, medication changes, lifestyle adjustments and onward referrals. Most respondents to the patient feedback questionnaire thought the clinic was patient friendly and welcoming (n=48/50; 96%); felt listened to (n=48/50; 96%); considered that adequate explanation was given (n=47/50; 94%); and felt clear plans were provided (n=45/49; 92%). Most agreed that it was valuable (n=44/50; 88%), and the mean rating was 4.48 (on a scale of 1 (very poor) to 5 (excellent)).ConclusionsA person-centred post-MI medicines optimisation service was successfully delivered by appropriately trained advanced cardiology pharmacists. A structured competency framework and training programme were required, but once completed, the clinic was highly valued by patients. A similar model could be rolled out elsewhere with adaption to local requirements.

Pharmacological therapies are the mainstay in the management of primary and secondary prevention of cardiovascular disease. Nurses have an important role in medicines management in collaboration with professional colleagues, particularly physicians and pharmacists. Training nurses in advanced practice skills in relation to medications can improve post-acute event care. Approaches to nursing and allied health professional prescribing are described in three different ways, referred to as ‘independent’, ‘supplementary’, and ‘dependent’ prescribing. Up to half of patients prescribed medication for long-term conditions are not adherent to their prescribed regimen. It is important for nurses to identify the reason for non-adherence before attempting to implement strategies to address it. In cases of intentional non-adherence, it is essential to address patients’ beliefs or concerns, or advocate for the patient to have the treatment plan modified to an approach that fits the patient’s needs. Medications used in cardiovascular care include lipid-lowering agents, anticoagulants, antiplatelets, antiarrhythmics, new drugs to treat diabetes with cardiovascular benefits, drugs used to promote tissue perfusion, drugs that affect the renin–angiotensin–aldosterone system, beta-blockers, calcium channel blockers, and those used in emergencies and cardiogenic shock.