Nurse-led medicines’ monitoring in care homes, implementing the Adverse Drug Reaction (ADRe) Profile improvement initiative for mental health medicines: An observational and interview study

Abstract

IntroductionPreventable adverse effects of medicines often pass unnoticed, but lead to real harm.InterventionNurse-led monitoring using the structured Adverse Drug Reaction (ADRe) Profile identifies and addresses adverse effects of mental health medicines.ObjectivesThis study investigated the implementation and clinical impact of ADRe, and barriers to and facilitators of sustained utilisation in routine practice.MethodsAdministration of ADRe was observed for 30 residents prescribed mental health medicines in ten care homes. The study pharmacist reviewed completed ADRes against medication records. Policy context was explored in 30 interviews with service users, nurse managers and strategic leads in Wales.ResultsResidents were aged 60–95, and prescribed 1–17 (median 9 [interquartile range (IQR) 7–13]) medicines. ADRe identified a median of 18 [IQR 11.5–23] problems per resident and nurses made 2 [1–2] changes to care per resident. For example: falls were reported for 9 residents, and care was modified for 5; pain was identified in 8 residents, and alleviated for 7; all 6 residents recognised as dyspnoeic were referred to prescribers. Nurses referred 17 of 30 residents to prescribers. Pharmacists recommended review for all 30. Doubts about administering ADRe, sometimes expressed by people who had not yet used it, diminished as it became familiar. ADRe was needed to bridge communication between resident, nurses and prescribers. When barriers of time, complacency, and doctors’ non-availability were overcome, reporting with ADRe made prescribers more likely to heed nurses’ concerns regarding residents’ welfare. Clinical gains were facilitated by one-to-one time, staff-resident relationships, and unification of documentation.ImplicationsTo our knowledge, ADRe is the only instrument that brings a full account of patients’ problems to medication reviews. This juxtaposition of signs and symptoms against prescriptions facilitates dose adjustments and de-prescribing and leads to: reduced pain and sedation; early identification of problems linked to ADRs, such as falls; and timely medication reviews e.g. for dyspnoea.

Disclosing and Reporting Practice Errors by Nurses in Residential Long-Term Care Settings: A Systematic Review

“…Alleviation of moral distress after making errors, following up by apologizing to patients and their families [70], standardized tools and feedback [71,72], training regarding communication skills, and coping strategies to reduce nurses' emotional stress [37,73] are considered key leadership roles for nurses. Systematic, in-built support for error identification [19,20] and disclosure should remove the responsibility to inform patients and their families from individual nurses [59]. User-friendly guidelines and reporting mechanisms should be implemented [74,75].…”

“…Conditions that could be prevented and safely managed in such settings can lead to hospitalization and increased healthcare costs [18]. In general, residential long-term care settings have been recognized as fertile environments to expand patient safety initiatives, due to the high rate of adverse events [19,20] and institutional barriers to reporting practice errors [21,22].…”

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

“…Since many ADRs are preventable, some screening tools have been devised, including Beers' Criteria and the Inappropriate Prescribing in the Elderly Tool (IPET), which augment professionals' clinical judgement in medicine selection and prescription [46]. Profiling the adverse effects of psychotropic medications detects any changes in the patient following PRN administration [47,48]. Additionally, medicine reviews and checks for drug interactions, cautions, and doses have been suggested, including the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) [27,49], the Screening Tool to Alert to Right Treatment (START) [49,50] for older people, and the Norwegian General Practice (NORGEP) tool [51] for those under 71 years.…”

“…Prescription and administration of PRN psychotropic medications should not expose patients to the feelings of inferiority and coercion [3]. Since the decision-making process regarding PRN management is complex [11,12], there is a need for a decision support tool for PRN medicines management to prevent medication-related harm in long-term care settings: this should encompass systematic checks for the signs and symptoms of ADRs [47,48].…”

“…Additionally, there are controversies regarding the use of PRN medications and non-pharmacological strategies including counselling, distraction, verbal and non-verbal de-escalation, massage, and education [4,5,29,56,57]. The improvement of PRN prescription practice and promotion of PRN prescription and administration requires changes in the healthcare policies of patient safety in care homes [27,58,59], including the mandate of formalised, systematic checking of residents for potential ADRs [47,48]. The implementation of system-level standards of practice for PRN administration, impact assessment, and documentation can help to improve overall patient safety in care homes [52].…”