Health care system vulnerabilities: Understanding the root causes of patient harm

Thompson-Moore, Nathaniel; Liebl, Michael

doi:10.2146/ajhp110299

Cited by 18 publications

(17 citation statements)

References 42 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Within 2 weeks of hospital discharge, 57% of patients experience medication problems and up to 20% experience adverse drug events (ADE) . On hospital discharge, 60% of patients have had three or more medication changes and the risk of an ADE increases with every new drug or alteration made …”

Section: Introductionmentioning

confidence: 99%

“…Patients' non‐adherence to their medication leads to negative outcomes. Non‐adherence results in 11–22% of hospitalisations for chronic disease exacerbations . It has been found that 4.3% of preventable hospital admissions are medication‐related, 19% of hospital re‐admissions are medication‐related and 50% of the latter are preventable .…”

Section: Introductionmentioning

confidence: 99%

“…[2,3] On hospital discharge, 60% of patients have had three or more medication changes and the risk of an ADE increases with every new drug or alteration made. [4][5][6] Communication of medication changes to the patient's general practitioner (GP) has improved immensely with the advent of electronic discharge letters. [7] However, discrepancies and ADE post-discharge still continue to occur.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Transfer of care – a randomised control trial investigating the effect of sending the details of patients’ discharge medication to their community pharmacist on discharge from hospital

Hockly

Williams

Allen

2017

International Journal of Pharmacy Practice

View full text Add to dashboard Cite

show abstract

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Transfer of care – a randomised control trial investigating the effect of sending the details of patients’ discharge medication to their community pharmacist on discharge from hospital

Hockly

Williams

Allen

2017

International Journal of Pharmacy Practice

View full text Add to dashboard Cite

show abstract

“…Five to twenty percent of hospital admissions are caused by medication misuse and more than half of these are avoidable. Medication nonadherence is one of the areas for concern, as it is estimated that 11% to 22% of hospital admissions for exacerbations of chronic disease are a direct result of it . However, potential interventions in this area seem more indicated for pharmacists influencing ambulatory care.…”

Section: Resultsmentioning

confidence: 99%

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

Costa

Rydant²,

Antoniou

2020

Evaluation Clinical Practice

View full text Add to dashboard Cite

Background This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration. Methods It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide. Results Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self‐management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals. Conclusion On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care.

show abstract

“…To provide an appropriate system of work for medicines management across care boundaries,21 it is therefore useful to understand the experiences of those who carry out this activity in practice. The current paper focuses on medicines management during actual or suspected acute kidney injury (AKI); this being an exemplar of a complex clinical situation that crosses care boundaries.…”

Section: Introductionmentioning

confidence: 99%

What is involved in medicines management across care boundaries? A qualitative study of healthcare practitioners' experiences in the case of acute kidney injury

et al. 2017

View full text Add to dashboard Cite

ObjectivesTo examine the role of individual and collective cognitive work in managing medicines for acute kidney injury (AKI), this being an example of a clinical scenario that crosses the boundaries of care organisations and specialties.DesignQualitative design, informed by a realist perspective and using semistructured interviews as the data source. The data were analysed using template analysis.SettingPrimary, secondary and intermediate care in England.Participants12 General practitioners, 10 community pharmacists, 7 hospital doctors and 7 hospital pharmacists, all with experience of involvement in preventing or treating AKI.ResultsWe identified three main themes concerning participants' experiences of managing medicines in AKI. In the first theme, challenges arising from the clinical context, AKI is identified as a technically complex condition to identify and treat, often requiring judgements to be made about renal functioning against the context of the patient's general well-being. In the second theme, challenges arising from the organisational context, the crossing of professional and organisational boundaries is seen to introduce problems for the coordination of clinical activities, for example by disrupting information flows. In the third theme, meeting the challenges, participants identify ways in which they overcome the challenges they face in order to ensure effective medicines management, for example by adapting their work practices and tools.ConclusionsThese themes indicate the critical role of cognitive work on the part of healthcare practitioners, as individuals and as teams, in ensuring effective medicines management during AKI. Our findings suggest that the capabilities underlying this work, for example decision-making, communication and team coordination, should be the focus of training and work design interventions to improve medicines management for AKI or for other conditions.

show abstract

Health care system vulnerabilities: Understanding the root causes of patient harm

Cited by 18 publications

References 42 publications

Transfer of care – a randomised control trial investigating the effect of sending the details of patients’ discharge medication to their community pharmacist on discharge from hospital

Transfer of care – a randomised control trial investigating the effect of sending the details of patients’ discharge medication to their community pharmacist on discharge from hospital

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

What is involved in medicines management across care boundaries? A qualitative study of healthcare practitioners' experiences in the case of acute kidney injury

Contact Info

Product

Resources

About