Barriers to the safe and effective use of intravenous gentamicin and vancomycin in Scottish hospitals, and strategies for quality improvement

Abstract

Objectives Avoiding harm when patients interact with healthcare services is a global issue. Guidelines are often produced to improve the prescribing and monitoring of medication with a narrow therapeutic index. Adherence to guidelines may not occur in clinical practice. This paper aims to explore the barriers faced by clinical pharmacists and junior doctors when using complex guidelines to support the prescribing and therapeutic drug monitoring of gentamicin and vancomycin. Methods Twenty-three junior doctors and 27 clinical pharmacists took part in focus groups at four hospital sites in four Scottish health boards between March and July 2011. Focus groups were run separately at each hospital site for the two clinical groups. The data were organised using the framework approach, validated, and a thematic analysis was conducted. Results Five themes emerged to explain barriers to effective initial prescribing and therapeutic drug monitoring, which were divided into two types. Barriers could be a direct result of the content of the guidelines—specifically that clinicians required experience to use the guidelines effectively. Barriers also resulted from a failure in the context in which the guidelines function which was related to insufficient dissemination, communication issues within the hospital site, unmet educational needs and staffing issues. Conclusions Improved patient safety cannot be assumed due to the existence of gentamicin and vancomycin guidelines. The findings of this study highlight the complexities associated with their appropriate use. Future quality improvement strategies must consider where the guidelines will be implemented, and the context in which they will function

A needs assessment study for optimising prescribing practice in secondary care junior doctors: the Antibiotic Prescribing Education among Doctors (APED)

“…Third, we found that junior doctors self-reported a need for additional training in the areas of both clinical review of infected patients, and principles of prescribing. This links to established patient safety agendas, and clearly establishes a need for education on sepsis resuscitation [27], and therapeutic drug monitoring [28, 29] respectively.…”

Would they accept it? An interview study to identify barriers and facilitators to user acceptance of a prescribing advice service

“…Studies that have explored factors influencing uptake of TDM interventions have identified barriers including poor coordination of TDM processes, time constraints, perceived lack of user competency and the prescribing hierarchy [ 8 , 15 , 16 ]. While these findings are useful, systematically identifying barriers and facilitators to uptake using a theory-based framework provides an evidence-based approach to enhance intervention design and achieve successful integration into routine workflow [ 17 , 18 ].…”

Optimizing carbapenem use through a national quality improvement programme

“…SAPG had previously completed a quality improvement programme for gentamicin and vancomycin 23 and this work on carbapenems used a similar approach. Such programmes utilise several methods to gain intelligence about clinical practice and target areas for improvement.…”