Barriers to managing medications appropriately when patients have restrictions on oral intake

Abstract

Rationale, aims, and objectives: Investigation of several serious adverse events in our organization highlighted that medications were managed inappropriately when patients have oral intake restrictions. The aim of this work was to identify the barriers to optimal medication management when patients have restrictions on their oral intake.Method: Data were feedback and comments obtained between 2011 and 2014 from a hospital-wide quality assurance project. Data had not been purposefully collected and were in response to a general request for feedback regarding managing oral medications when patients have oral intake restrictions. Data came from a range of clinical staff and from various forums associated with the quality assurance project, including 37 presentations, 34 group meetings, and over 50 one-on-one meetings, as well as emails and other sources.Data were analysed using the thematic analysis approach. Data were coded inductively, and the domains of the Theoretical Domains Framework were used to categorize the data. Subthemes and themes were then developed.Results: Barriers could be broadly grouped into systems-level issues (organizational guidance and work environment) and the individual person-level issues (staff knowledge and beliefs). These barriers highlight the complexity of the medication management task. The lack of standardized guidance and consistent terminology regarding medication administration when patients have restrictions on oral intake, particularly when fasting or nil by mouth, were important systems factors, as were workflow issues and the "culture" of the environment in which staff practiced. Lack of knowledge about medication administration, social influences, and role interpretation were important individual person factors. Conclusion:Systems-and individual person-level issues were significant contributors to inappropriate medication management when patients have oral intake restrictions. Many of the barriers may be addressed with systems approaches such as hospital-wide guidance that simplifies and standardize oral medication administration instructions, particularly regarding fasting and nil by mouth terminology.

Care Coordination Strategies and Barriers during Medication Safety Incidents: a Qualitative, Cognitive Task Analysis

“…The retrospective study design may have introduced recall bias regarding HCPs' interpretation of events. However, our results for role ambiguity and heavy EHR reliance for communication align with other literature, 33,34,36 supporting the external validity of our findings. HCPs could complete multiple interviews; thus, their strategies may be overrepresented in the larger study, but we mitigated this by including only one interview per HCP in the care coordination analysis.…”

“…Role ambiguity was a barrier for physicians and pharmacists alike, and has been reported by other studies 33,34 Ambiguity is likely to escalate as the complexity of care coordination increases, with patients receiving care from multiple provider types and institutions. This reflects coordination challenges associated with HCPs' situation awareness 35 of the patients' clinical status and desire to forecast the future clinical state of the patient, which can become more difficult as knowledge of the patient is dispersed across HCPs.…”