Objective: To identify and analyse factors underlying intern prescribing errors to inform development of specific medication‐safety interventions. Design: A prospective qualitative study that involved face‐to‐face interviews and human‐factor analysis. Setting: A tertiary referral teaching hospital, Brisbane, Queensland, February–June, 2004. Participants: Fourteen intern prescribers involved in 21 errors. Method: A structured questionnaire was used to identify factors causing the errors. Transcripts were analysed on the basis of human‐error theory to identify underlying themes. Main outcome measures: Factors underlying prescribing errors. Results: Errors were multifactorial, with a median of 4 (range, 2–5) different types of performance‐influencing factors per error. Lack of drug knowledge was not the single causative factor in any incident. The factors in new‐prescribing errors included team, individual, patient and task factors. Factors associated with errors in represcribing were environment, task and number of weeks into the term. Defences against error, such as other clinicians and guidelines, were porous, and supervision was inadequate or not tailored to the patient, task, intern or environment. Factors were underpinned by an underlying culture in which prescribing is seen as a repetitive low‐risk chore. Conclusion: To reduce the risk of prescribing errors, a range of strategies addressing patient, task, individual, team and environment factors must be introduced.

BackgroundAdoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings.MethodologyA systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals’ adherence to evidence-based practice was also used.ResultsTen studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals’ limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals’, complex nature of some stroke care therapies or guidelines and patient level barriers.ConclusionsDespite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals’ domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings.Trial registrationThe review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481)Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-017-0599-3) contains supplementary material, which is available to authorized users.

Background: The General Level Framework (GLF) is a tool for evaluating pharmacists' performance, providing tailored feedback and training, and guiding professional development. Aim: To ascertain the changes in pharmacists' workplace performance over time using the GLF and to describe pharmacists' views on the baseline evaluation process. Method: The UK GLF was mapped against Australian pharmacy competency standards and practice guidelines. 61 of the 92 competencies from the Queensland Health version of the GLF representing core professional activities of Australian pharmacists were analysed. Trained evaluators used the adapted GLF to observe pharmacists from 18 Queensland public hospitals in their workplace (baseline and repeat) and rate the frequency with which competencies were completed to a defined standard. The evaluators then provided pharmacists with tailored feedback, encouraged self-problem solving, and identified and addressed their training needs. Pharmacists' views of the baseline evaluation process was assessed using a 7-point rating scale. Results: 66 pharmacists from 18 Queensland hospitals underwent the evaluation. At baseline, pharmacists had a median of 3 (1 to 10) years hospital experience. A median of 14 (5 to 22) months lapsed between baseline and repeat observations. Of the 61 competencies analysed, 35 (57%) competencies showed a significant improvement from baseline to repeat observations (p ≤ 0.05). Competencies that improved significantly from baseline included: aspects of medication history taking; medication management; identification, documentation and resolution of drug-related problems; appraisal of therapeutic options; and communication with doctors and nurses. For 9 (15%) competencies, pharmacists were already performing at the maximum level (median score 4) at baseline and no change was recorded between observations. No competency demonstrated a decrease in performance between observations. When the mean scores with 95% confidence intervals for the clusters of competencies were compared over time all the mean scores except for discharge

BackgroundStroke and other non-communicable diseases are important emerging public health concerns in sub-Saharan Africa where stroke-related mortality and morbidity are higher compared to other parts of the world. Despite the availability of evidence-based acute stroke interventions globally, uptake in low-middle income countries (LMIC) such as Ghana is uncertain. This study aimed to identify and evaluate available acute stroke services in Ghana and the extent to which these services align with global best practice.MethodsA multi-site, hospital-based survey was conducted in 11 major referral hospitals (regional and tertiary - teaching hospitals) in Ghana from November 2015 to April 2016. Respondents included neurologists, physician specialists and medical officers (general physicians). A pre-tested, structured questionnaire was used to gather data on available hospital-based acute stroke services in the study sites, using The World Stroke Organisation Global Stroke Services Guideline as a reference for global standards.ResultsAvailability of evidence-based services for acute stroke care in the study hospitals were varied and limited. The results showed one tertiary-teaching hospital had a stroke unit. However, thrombolytic therapy (thrombolysis) using recombinant tissue plasminogen activator for acute ischemic stroke care was not available in any of the study hospitals. Aspirin therapy was administered in all the 11 study hospitals. Although eight study sites reported having a brain computed tomographic (CT) scan, only 7 (63.6%) were functional at the time of the study. Magnetic resonance imaging (MRI scan) services were also limited to only 4 (36.4%) hospitals (only functional in three). Acute stroke care by specialists, especially neurologists, was found in 36.4% (4) of the study hospitals whilst none of the study hospitals had an occupational or a speech pathologist to support in the provision of acute stroke care.ConclusionThis study confirms previous reports of limited and variable provision of evidence based stroke services and the low priority for stroke care in resource poor settings. Health policy initiatives to enhance uptake of evidence-based acute stroke services is required to reduce stroke-related mortality and morbidity in countries such as Ghana.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2061-2) contains supplementary material, which is available to authorized users.

BackgroundMultidisciplinary patient management including a clinical pharmacist shows an improvement in patient quality use of medicine. Implementation of a clinical pharmacy service represents a significant novel change in practice in Sri Lanka. Although attitudes of doctors and nurses are an important determinant of successful implementation, there is no Sri Lankan data about staff attitudes to such changes in clinical practice. This study determines the level of acceptance and attitudes of doctors and nurses towards the introduction of a ward-based clinical pharmacy service in Sri Lanka.MethodsThis is a descriptive cross-sectional sub-study which determines the acceptance and attitudes of healthcare staff about the introduction of a clinical pharmacy service to a tertiary care hospital in Sri Lanka. The level of acceptance of pharmacist’s recommendations regarding drug-related problems (DRPs) was measured. Data regarding attitudes were collected through a pre-tested self-administered questionnaires distributed to doctors (baseline, N =13, post-intervention period, N = 12) and nurses (12) worked in professorial medical unit at baseline and post-intervention period.ResultsA total of 274 (272 to doctors and 2 to nurses) recommendations regarding DRPs were made. Eighty three percent (225/272) and 100% (2/2) of the recommendations were accepted by doctors and nurses, respectively. The rate of implementation of pharmacist’s recommendations by doctors was 73.5% (200/272) (95% CI 67.9 – 78.7%; P < 0.001). The response rate of doctors was higher at the post-intervention period (92.3%; 12/13) compared to the baseline (66.7%; 8/12). At the post-intervention survey 91.6% of doctors were happy to work with competent clinical pharmacists and accepted the necessity of this service to improve standards of care. The nurses’ rate of response at baseline and post-intervention surveys were 80.0 and 0.0% respectively. Their perceptions on the role of clinical pharmacist were negative at baseline survey.ConclusionsThere was high acceptance and implementation of clinical pharmacist’s recommendations regarding DRPs by the healthcare team. The doctors’ views and attitudes were positive regarding the inclusion of a ward-based pharmacist to the healthcare team. However there is a need to improve liaison between clinical pharmacist and nursing staff.Trial registrationSri Lanka Clinical Trials Registry SLCTR/2013/029 Date: 13 September 2013; retrospectively registered.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2001-1) contains supplementary material, which is available to authorized users.

Background Quality use of medicines (QUM) has been identified as a priority in Sri Lanka. Aim To identify opportunities to optimise QUM, and evaluate medication appropriateness and medication information exchanged with patients and carers on discharge in a Sri Lankan tertiary care hospital. Methods An observational, prospective, cohort study of patients systematically sampled from two medical wards. A research pharmacist determined their pre‐admission medication regimen via interview at time of discharge. Issues of poor adherence and discrepancies between the pre‐ and post‐admission medication regimens were recorded. Drug‐related problems were categorised into opportunities to optimise drug therapy. The appropriateness of discharge medications was evaluated using a validated tool. The patient or carer was interviewed after discharge regarding the quality of medicine information exchanged in hospital. Results The 578 recruited patients were taking 1756 medications prior to admission, and 657 (37.4%) of these medications were not continued during admission. Opportunities to optimise drug therapy were identified on 1496 occasions during admission (median, 2.0 opportunities/patient), 215 opportunities, (14.4%) were resolved spontaneously by the medical team prior to discharge. The median score for appropriateness of medications on discharge was 1.5 per patient (interquartile range, 0.0–3.5). Of 427 patients surveyed after discharge, 52% recalled being asked about their medications on admission to hospital, 75% about previous adverse medication reactions and 39% recalled being informed about changes to their medications on discharge. Conclusion Significant opportunities exist for pharmacists to enhance quality use of medicines for patients in the current hospital‐based healthcare system in Sri Lanka.

ObjectiveTo assess if a ward-based clinical pharmacy service resolving drug-related problems improved medication appropriateness at discharge and prevented drug-related hospital readmissions.MethodBetween March and September 2013, we recruited patients with noncommunicable diseases in a Sri Lankan tertiary-care hospital, for a non-randomized controlled clinical trial. The intervention group received usual care and clinical pharmacy service. The intervention pharmacist made prospective medication reviews, identified drug-related problems and discussed recommendations with the health-care team and patients. At discharge, the patients received oral and written medication information. The control group received usual care. We used the medication appropriateness index to assess appropriateness of prescribing at discharge. During a six-month follow-up period, a pharmacist interviewed patients to identify drug-related hospital readmissions.ResultsData from 361 patients in the intervention group and 354 patients in the control group were available for analysis. Resolutions of drug-related problems were higher in the intervention group than in the control group (57.6%; 592/1027, versus 13.2%; 161/1217; P < 0.001) and the medication was more appropriate in the intervention group. Mean score of medication appropriateness index per patient was 1.25 versus 4.3 in the control group (P < 0.001). Patients in the intervention group were less likely to be readmitted due to drug-related problems (44 patients of 311 versus 93 of 311 in the control group; P < 0.001).ConclusionA ward-based clinical pharmacy service improved appropriate prescribing, reduced drug-related problems and readmissions for patients with noncommunicable diseases. Implementation of such a service could improve health care in Sri Lanka and similar settings.

Objective The aim of this study was to investigate the feasibility of a structured patient‐centred educational exchange to facilitate a shared conversation about stroke prevention medications. Methods Participants (18 years or older) with a principal diagnosis of stroke or transient ischaemic attack were purposively sampled from the stroke unit of a 780‐bed teaching hospital in Australia and consented to participate in the study. A patient‐centred educational exchange was conducted face to face at the bedside before discharge and by telephone post discharge. The structure of these sessions was adapted from academic detailing, an educational strategy, which includes identifying experience, listening to the needs of the audience, and tailoring messages to influence behaviour. To facilitate sharing of needs, three questionnaires, validated as research tools, were used to identify participants' experience, perceptions, and beliefs. The identified perceptions were used to personalize educational messages. The outcomes of the study were to provide descriptions of patients' perceptions necessities and concerns about their condition and medications, provide examples of personalized responses to these, evaluate acceptability by patients, and determine the time taken to share the information. Results Sixteen participants completed both the bedside session (average duration 27 minutes) and the telephone follow‐up (average duration 23 minutes). The strongest patient concern identified was having another stroke. Personalized responses included emphasizing long‐term treatment in response to the perception that stroke will last for a short time, reinforcement of necessity for medications, and further exploration of concerns. Conclusion The questionnaires engaged the participants, allowing them to share perceptions and beliefs, facilitating a patient‐centred educational exchange in a timely manner.