Medication errors journal of nursing bjn,diabetes mellitus treatment methods,treatment of diabetes type 2 pdf bestanden,pc 207 klein verlet - For Begninners


If you have any comments on patient safety issues in general, or medication errors in specific, please respond to this blog, or better yet…please drop by the Macklem House, my door is always open.
As a Pediatric Emergency Medicine Physician this story is very disturbing yet unfortunately has plagued medicine and in particular the field of pediatrics. People at University Health Network in Toronto, headed by Dr Joseph Fisher, developed a device, the Duocheck, that eliminates (zero errors in more than 300,000 uses as of April 2012) drug administration errors in the OR. The following is a guest blog from Angela Luedke, PhD student, Centre for Neuroscience Studies. One of the best things about being a Dean at Queen’s is the close and special relationship I have with our three academic hospitals in Kingston. Measurements: The primary outcome measurements comprised the percentage of medication orders with one or more MEs and the percentage of patients with one or more pADEs. Results: Pre-implementation, the mean percentage of medication orders containing at least one ME was 55%, whereas this became 17% post-implementation. Since the publication of the Institute of Medicine (IOM) report, “To Err is Human”, many strategies for making health care safer have been created and implemented.1 One of these strategies is electronic prescribing through the use of a Care Provider Order Entry (CPOE) system. The study was set up as an interrupted time series that is characterized by a series of measurements over time interrupted by an intervention. In both hospitals, pre-implementation data were collected from Jul through Nov 2005 (Figure 1). In both hospitals, the conventional process of medication ordering during the baseline period was paper-based; physicians wrote handwritten medication orders on charts and nurses transcribed these medication orders onto the administration charts.
During the conventional process, central order entry by the pharmacy was performed in the TweeSteden Hospital only. Physicians receive safety alerts in real time when prescribing drugs that, for example, interact with already prescribed drugs or when the dosage is too high.
Prospectively, the following patient data were collected by two research pharmacists: patients' characteristics (gender, age, height, weight, duration of stay in the ward), medical history, diseases (reasons for admission and diagnoses during hospital stay), medication (medication orders [MOs] during hospital stay), laboratory values and adverse events. For the assessment of the severity of the identified prescribing and transcribing errors (including whether a related pADE had occurred), the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) scheme15 and the simplified Yale algorithm16 were combined into a new assessment tool.17 The NCC MERP scheme categorizes MEs into nine categories (A through I) based on the severity of the related patient outcomes. The assessment procedure (on severity of medication errors and incidence of pADEs) was carried out by five pharmacists. The study design met the criteria for a robust ITS, that is, 3 data points pre- and post-intervention, each consisting of at least 30 admissions.18 To detect an assumed 50% decrease in the primary endpoint of medication orders with one or more medication errors (assuming a baseline prevalence of 10%) with a power of 80% and ? = 5%, 474 medication orders, counted two times, would be required for the Student's t-test. These three basic principles have been shown repeatedly to reduce anger, lead to fewer lawsuits with lower settlements, decrease litigation costs, shorten the time required to settle cases (months instead of years), eliminate many non-meritorious cases, reduce the overall number of medical errors, and, perhaps most important, lead to satisfied patients and families.
As of 2014, thirty-six states have enacted laws excluding expressions of sympathy after accidents as proof of liability. The many obvious reasons for the increasing popularity of these laws were explained by Robert J Walling and Shawna S.
Apology laws appear to have the potential to reduce overall medical malpractice liability costs by lowering the amount of lawsuits, attorney fees, and claim costs. And the Federal Government followed suit, through active sponsorship, at the time, by then Senators Hillary Rodham Clinton and Barrack Obama, and pushed medical liability reform by emphasizing the benefits of "I'm Sorry" legislation.
Similar results were produced when a medical malpractice insurance company in Denver, Colorado began a new program recommending the use of apologies and quick settlements. Of course, none of the preceding analysis should be taken to imply that there are no detractors or skeptics.
Of course, notwithstanding the skeptics, the overwhelming body of research and evidence appears to strongly support the full disclosure early compensation strategy when medical errors occur. Evidence regarding the enormous financial and professional benefits of issuing a perfect medical apology when medical errors occur is simply too obvious to ignore.
Read about medical errors, lawsuits and apologies or visit our homepage to explore other areas of the site. Relationship between local quality improvement projects, hospital QI committees, national reporting organizations and surveillance systems. This journal is a member of and subscribes to the principles of the Committee on Publication Ethics.
Background Computerised physician order entry offers a potential means of reducing prescribing errors, and can also increase the feasibility of pharmacy validation as a secondary filter for eliminating errors. Objective To describe (i) the pharmacists’ interventions during validation of drug prescriptions on a computerized physician order entry system, (ii) the impact of these interventions on the prescribing process and (iii) the extent to which computerized physician order entry was responsible for the identified errors. Method Prospective collection of all medication order lines during five days in a tertiary care university hospital using computerized physician order entry for drug prescription.
Results About 399 (11%) prescription order lines, corresponding to 222 (52%) patients, required a pharmacy alert during the study period.
Conclusion Pharmacy validation produced only a moderate short-term impact on the reduction of potential prescribing errors. Keywordsmedical record systemsprescriptionspharmacistsmedical errorsCPOEcomputerized provider order entryAdverse drug events are associated with increases in the duration of hospital stay, additional costs and mortality [1] and have been recognized as a safety priority [2, 3]. In France, the physician is entirely responsible for the writing of prescriptions, including specification of the brand name of the drug (rather than its international denomination), infusion time and solution for reconstitution of intravenous medication. The drug prescription facility is available in 10 departments and has been used for 2 to 3 years. For each patient, the software displays a screen with all the prescription order lines, one for each drug. The ‘accepted’ symbol indicates that the pharmacist agrees with the prescription, unless a comment is added relating to good practice, which may or may not suggest a modification of the prescription line.
The ‘refused’ symbol indicates that the pharmacist disagrees with the prescription, having identified a potentially severe prescribing error suggesting modification of the prescription. There are two kinds of ‘availability problem’: ‘substitution’, where a new prescribing order is required before the nurse can deliver the suggested drug because the molecule is not the same as that initially requested by the doctor, and ‘equivalence’ in which a new prescribing order is not required because the molecule suggested is the same, but simply has a different brand name. In this prospective quantitative and qualitative study, we aimed to describe the prevalence and impact of pharmacy alerts.
An independent multidisciplinary committee of three physicians (cardiology, clinical immunology, internal medicine) and one pharmacist not taking part in the validation process retrospectively reviewed all the investigated alerts to rate the more subjective items. The impact of all ‘new’ pharmacy alerts targeted to the prescriber was investigated by two researchers, a physician and a pharmacist (C.E.
Among the 81 pharmacy alerts targeted at the physician, 21 [26% (95% CI = 17–37)] resulted in modification by the prescriber. We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you. The editor and reviewers' affiliations are the latest provided on their Loop research profiles and may not reflect their situation at time of review.
Objective: Effective stroke care does not end with acute treatment during hospitalization, but extends through rehabilitation and secondary stroke prevention.
Methods: The intervention was a standardized verbal handoff by phone between the discharging neurology resident and the admitting rehabilitation resident regarding each patient at transfer. Results: The pre- and post-intervention groups were similar with respect to number of patients (50 vs. Conclusion: Standardized handoffs decreased errors in communication of diagnosis and critical medications for secondary stroke prevention.
State of the art stroke care spans a continuum of care environments, from the emergency room to the stroke unit to the rehabilitation facility and finally home.
Following a stroke, there is urgency for stroke patients to participate in early rehabilitation, which can mitigate residual disability (5).
For such medically complicated patients, errors at the time of transfer across care environments are common and may be associated with adverse events and readmission (4, 15). This study implemented a standardized verbal handoff between the discharging neurology stroke team and the admitting rehabilitation team. This was a retrospective quality improvement cohort study of stroke patients transferring from the acute care hospital (Hospital of the University of Pennsylvania) inpatient stroke service to the affiliated, but physically and administratively separated, inpatient rehabilitation hospital (Penn Institute for Rehab Medicine). Data were abstracted for each patient from the acute care hospital and the rehabilitation hospital inpatient electronic medical records. A standardized verbal handoff was instituted between the discharging acute care hospital neurology team and the admitting rehabilitation hospital team. The study was powered to detect a 50% reduction in number of patients with medication errors from an error rate of one medication per discharge as seen in a prior survey of stroke discharges from our institution. The two study groups, pre- and post-intervention, were similar with respect to demographics including gender, age, and the number of major medical co-morbidities.
Implementation of the verbal handoff resulted in fewer errors in communication of diagnosis in the post-intervention group, as measured by communication of both stroke severity (92 vs. The intervention did not alleviate interruptions of rehabilitation, such as emergent brain imaging (8 vs. This study found that a formalized verbal handoff between neurologists at an acute care hospital and the physiatrists at a rehabilitation facility significantly improved communication of stroke diagnosis and reconciliation of critical medications. The literature suggests that medication errors occur for 49–86% of patients at discharge from the hospital and that such errors can result in adverse events (4, 15). This study also identified a vulnerable population of patients with a readmission rate of 19%, which is comparable to some prior studies (9–12, 14), but is nearly double the rate of readmission for stroke patients discharged elsewhere from our hospital. There are several limitations to this study, including minimal prior data to inform the study design and a limited sample size to detect a difference between study groups.
While many aspects of stroke care have been extensively studied and protocolized, handoff of stroke patients has been largely neglected despite evidence that a substantial proportion of preventable adverse events in this population are attributable to errors in communication between providers (21). CH – designed protocol, facilitated study intervention, completed data collection, performed statistical analysis, and drafted manuscript.
This research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Kim Sears from Queen’s School of Nursing, along with her colleagues from across Canada, O’Brien-Pallas, Stevens, and Murphy, published their findings on a Pan-Canadian study of medication errors in the paediatric hospital population.
The Relationship Between the Nursing Work Environment and the Occurrence of Reported Paediatric Medication Administration Errors: A Pan Canadian Study. I agree that an never ending focus on patient safety starts with establishing, refining and practicing all of the requisite competences. I agree with the inference, that we should more widely deploy technology to assist us with mitigation of medical error. The Electronic health record with electronic physician order entry provides real time dose and indication guidance for MDs adn RNs and eliminates issues of abbreviations, legibility etc. Before the first introduction of this system in the United States in the 1970s, expectations about CPOE systems reducing medication errors and patient harm were high. The findings from these studies may not apply to the European hospital setting due to differences in computer systems and work processes between the two continents.
In the TweeSteden Hospital, the post-implementation data collection on the geriatric ward was from Apr through Aug 2006, and on the general internal medicine ward from mid-Jun through mid-Nov 2006. From these administration charts nurses read what medication should be administrated to which patients. As a result, it was only in the TweeSteden Hospital that medication orders were reviewed by pharmacists during the baseline period. This is a computer-based system by which physicians order medication electronically in a standardized way.
When an alert is shown, physicians can continue prescribing by accepting the order (while knowing there is a safety issue) or they can cancel the order.
Adverse events were defined as any untoward medical occurrences during hospital stay, which do not necessarily need to be related to medication use. The two research pharmacists were thoroughly trained in the classification scheme before the data collection. Category A is a category for “circumstances or events that have the potential to cause an error”, for example, a drug–drug interaction that seems not to be relevant in a specific patient. After individual assessment by the pharmacists, consensus meetings took place where consensus was reached for all cases of causality, between error and adverse event, as well as for severity of the error. The MEs were analyzed using weeks as data points due to their high incidence, while pADEs were analyzed using months as data points.
Med Pro, for example, began to offer a 5% premium discount for insured physicians who participate in the company's "accredited risk management education program."4 Again, one of the key goals of the program was to dispel mistaken assumptions held by hospital administrators and doctors that "greed" rather than "anger" is the central motivation for malpractice lawsuits. And studies have shown that doctors themselves are beginning to understand the problems and implications for patient care. Among the 81 pharmacy alerts targeted to the prescriber, 21 [26% (IC95% = 17–37%)] resulted in a modification of the prescription.
However, pharmacy validation may also provide ongoing benefits by identifying necessary improvements in the computerized physician order entry system. Medication errors account for a large proportion (20 to 28%) of adverse drug events and are preventable [4, 5]. In this context, pharmacy validation is implemented in a different way, as the pharmacist must alert the prescriber (in cases of unavailability or non-conformity with best practice) but cannot modify the prescription directly (with the exception of replacing one drug with another having the same international denomination).
A patient information system, integrating an electronic patient record and a CPOE (Dx-Care, Medasys™) is implemented throughout the hospital since its inception (year 2000).
This study focuses on these 10 departments: two surgical and eight medical wards, 210 beds, 25% of the hospital's beds. The physician must click on an order line to display a new window with all the prescription order line details: drug name (from a pull-down menu), dose, unit (from a multiple choice list), frequency, reconstitution process, route and an optional annotation field. The physician may click on the symbol to visualize the pharmacist's comment, but is not obliged to take that comment into account.
To describe prevalence, we collected data on discontinuous rather than a block of time to avoid counting twice the same alert: we included all medication order lines validated by the hospital's pharmacy on three Mondays (7, 14 and 21 March 2005).
Potential prescribing errors were classified by the pharmacists using a classification adapted from published classifications [1, 7, 10, 19, 25, 26].
The committee had access to the whole prescription but was blind to the impact of the alert, the ward, the names of the prescriber and of the patient. To describe the ‘prevalence’ of pharmacy alerts, all medication order lines validated by the hospital's pharmacy on three Mondays (7, 14 and 21 March 2005) were included. No tendency was observed between the rate of modification and the potential severity of the error: pharmacy alerts with potential life-threatening prescribing errors resulted in a larger number of prescription modifications [38% (15–65%) of modifications] than did significant or serious errors [17% (6–33%) of modifications], but the latter did not result in more modifications than purely preventive alerts with no potential severity [31% (15–51%) of modifications] (Table 3). The aim of the study was to identify and describe, from a patient perspective, processes that are significant to coping with advanced cancer.
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In transitions across care environments, stroke patients are vulnerable to errors in communication of diagnosis and treatment. This retrospective cohort study compared a pre-intervention control group (September 2012 to February 2013) and a post-intervention group transferred with the handoff (September 2013 to January 2014). While expertise at different stages of treatment and recovery has been shown to reduce patient morbidity and mortality (1–3), transitions across these care environments can be hazardous (4).
Furthermore, stroke patients are discharged with complicated treatment plans, which vary by stroke mechanism and can require delayed initiation of new medications (such as anticoagulants and antihypertensives) (16).
The first aim was to promote secondary stroke prevention care by improving communication regarding the stroke mechanism and improving medication reconciliation of critical medications. The University of Pennsylvania institutional review board approved this study; informed consent was waived for this study. On the day of transfer, in addition to reviewing the discharge document in the electronic medical record, the admitting physical medicine and rehabilitation resident would call and receive a verbal handoff over the phone.
Additionally, there were no significant differences in severity of illness as measured by the NIHSS, stroke mechanism, or length of stay in the acute hospital (see Table 1). As both of these have direct bearing on secondary stroke prevention, this handoff could potentially also impact longer-term outcomes, such as recurrent stroke and disability. This study found that over half (56%) of the medication errors that were made involved patients’ antihypertensive regimen, which can be confusing because these medications are often held in the acute setting and restarted in the days to weeks after stroke. The intervention did not significantly alleviate interruptions of the rehabilitation program, in keeping with previous studies of transitional care interventions that have failed to improve emergency room visits and hospital readmission rates (20); however, reduction in communication errors could perhaps impact this important outcome in a larger study. In a small sample of 18 hospital wards, she uncovered four deaths attributable to medication error. Establishing such as system in our region is an essential step in reducing medication errors. Legibility and completeness of prescriptions would be ensured2 and Clinical Decision Support Systems (CDSS) incorporated in the CPOE systems would be able to assist physicians by triggering alerts in case of drug–drug interactions and inappropriate dosing. A waiver of the Medical Ethical Committee was obtained for this study, as the study fell within the boundaries of quality of care improvement. In the University Medical Center Groningen, the post-implementation period on the general internal medicine ward was from Aug through Dec 2006.


The safety alerts for the accepted medication orders are seen by pharmacists who can contact the physicians and nurses if necessary. Moreover, in the first period of the study the research pharmacists discussed their findings weekly so as to guarantee that they were using the scheme in the same way. For the baseline period and the post-intervention period, the frequencies of the different types of MEs and pADEs were calculated, as well as the percentage of medication orders with one or more MEs and the percentage of patients with one or more pADEs.
The low incidence of pADEs and the limited number of admissions (<30) per week that was expected would otherwise lead to an unstable baseline. Furthermore, defense litigation bills decreased significantly and the hospital saved money overall.
One study by a group of researchers at Harvard University found that full disclosure and fair compensation certainly avoided trials, but many of these cases did not necessarily mean lower payouts.9 The Harvard study found that overall claims cost more with disclosure, not less. These types of apologies take ownership of medical errors, remove the sting from most cases, and eliminate the anger that pushes most patients and families to file a medical malpractice lawsuit.
We described the frequency of pharmacy alerts and their short-term impact on the correction of potential prescribing errors (modification of the prescription).
Among the 95 potential prescribing error, the independent review committee judged 16 (17%) as potentially life-threatening and attributed 47 (49%) to the use of computerized physician order entry system (unit error, no use of typical order prespecified, prescription inconsistency or other). Those improvements would allow pharmacists to concentrate on the most relevant interventions. The hospital information system currently collates prescriptions and results of biological tests and imaging procedures. Forty-two residents, fellows or staff physicians are in charge of these patients and may write prescription of drugs for them. Four pharmacists (two senior pharmacists and two residents), assisted by two part-time pharmacy students, perform these validations. We define as potential prescribing errors, all lines with a ‘refused’ symbol or an ‘accepted’ symbol associated with a comment from the pharmacist (i.e. Following guidelines, the committee rated (i) the potential severity on a three-category scale (none, purely preventive; serious or significant and life-threatening) adapted from previous publications [5, 7, 26] and (ii) the possible implication of the CPOE system in the error. We first recorded whether the prescription order line was modified in the CPOE system before the next administration of the drug.
Some qualitative examples are given to illustrate the impact of pharmacy alerts and possible future improvement in CPOE.
To describe the ‘impact’ of pharmacy alerts, we only followed up ‘new’ pharmacy alerts on these three Mondays.
The most common type of potential prescribing errors concerned incomplete order [34 errors (36%)] and treatment adaptation [31 errors (33%)]. This study aimed to demonstrate that formalized communication between the neurology team and the rehabilitation medicine team would promote secondary stroke prevention and minimize interruptions during rehabilitation.
The outcomes measured included errors in communication of stroke severity, stroke mechanism, medications, and recommended follow-up (appointments and tests) as well as emergent brain imaging, return to the acute care facility, and readmission. Therefore, the forward communication of a patient’s hospital course and treatment plan at time of hospital discharge to the rehabilitation setting is vital and focused study of effective communication methods is warranted.
This study compared a pre-intervention cohort of patients transferred without a verbal handoff from September 2012 through February 2013 to a post-intervention cohort of patients transferred with a verbal handoff from September 2013 through January 2014. The specific documents reviewed were the acute care discharge document, the rehabilitation admission document, and the rehabilitation discharge document; when these records were found to be discordant, further inquiry into the chart was performed.
The recommended handoff conversation included discussion of diagnosis, treatment and medications, outstanding studies (either tests completed but not yet resulted or tests planned for the future), and anticipatory guidance about potential short-term problems (see Supplementary Material for details). Logistic regression analysis was performed to test associations between errors and return to hospital. These interruptions were characterized and the observed range of chief complaints overlaps with prior studies of stroke patients requiring transfer back to acute medical care (14). Lastly, the analysis made the assumption that the verbal handoff was completed for every patient during the post-intervention study period; if the handoff were not uniformly implemented, then this study would be underestimating its impact.
This study demonstrates that this risk can be modified, and the observed improvements are similar to other recently published data supporting a decrease in medical error rates with implementation of a formal verbal handoff program (23). Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke * editorial comment.
Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities.
Time to inpatient rehabilitation hospital admission and functional outcomes of stroke patients. Over the three-month period of the study, which involved a questionnaire in which nursing staff reported medication errors or “near misses”, there were 372 errors or potential errors uncovered. There have been literally thousands of studies since, and more importantly, a systematic movement around the world, to minimize and mitigate medical error. The culture of quality which I know you and the hospitals are partnering on fostering, through the SEAMO reward for Departmental Quality committee, should also help. The post-implementation data collection period started 8 weeks after finishing the implementation process in order to make sure that initial problems were solved. In the system, medication can be selected from menus in which medication from the local ward stock or from the pharmacy drug database is shown. They also individually assessed ten pilot patients and afterwards discussed differences in classification.
Categories B through D are associated with the absence of a preventable ADE, and Categories E through I are associated with the presence of a pADE (Table 1). Durbin-Watson statistics and visual inspection of the residuals versus time were used to check for possible autocorrelation (correlation between error terms of consecutive observations). An independent committee reviewed their type and link with the computerized physician order entry system. Eight hundred computers, both laptops and fixed posts, are used to in care procedures (in care departments and medical offices). Various types of prescription aid are available: information about reconstitution processes for intravenous drugs, typical orders prespecified by pharmacists for intravenous drugs and an integrated drug–drug interaction system. We described the impact of pharmacy alerts by including all ‘new’ pharmacy alerts on the three Mondays plus all ‘new’ pharmacy alerts on two Wednesdays (9 and 16 March 2005) to increase the number of alerts investigated, as follow-up can only be done on new alerts. A training session was organized before the study, and each pharmacist was provided with a handout including examples and definitions of the categories (available on request).
An error was identified by the committee as related to the use of CPOE if it occurs more easily than would have occurred in the traditional medication ordering system. Then, for all non-modified orders, the reasons for non-compliance with the pharmacist's advice were investigated by semi-structured interviews with the prescriber.
We added all ‘new’ pharmacy alerts on two Wednesdays (9 and 16 March 2005) in order to increase the number of alerts investigated. Most pharmacy alerts concerned significant or serious potential prescribing errors, 48 (50%), but 16 (17%) were considered potentially life-threatening.
64.0 years), severity of illness as measured by the National Institutes of Health Stroke Scale (NIHSS) (10 vs. The period between these times (February 2013 to September 2013) was used for training of the residents as well as creation and refinement of the verbal handoff and therefore was not included in the analysis.
A standardized template was employed to guide collection of neurological diagnosis and stroke type (hemorrhagic or ischemic stroke), the National Institutes of Health Stroke Scale (NIHSS) as a measure of stroke severity (17), stroke mechanism, treatment plan, medication reconciliation on discharge and admission documents, emergent brain imaging during rehabilitation, unplanned returns to the hospital, readmission, and follow-up plan. In the training phase, neurology residents had a reference available to guide them through the recommended handoff conversation. The majority of these errors were due to missing data (not recorded in the medical record) (see Figure 1). Each of these errors represents a major missed opportunity as there is evidence that stroke patients are more likely to continue taking medications which were started during their hospitalization (18, 19).
As readmissions tended to be medical rather than neurological in nature, perhaps readmissions are not the best measure of the impact of this study’s intervention, which had a primarily neurological focus.
A more structured approach to this handoff might further augment the effect of this intervention. Still, fourteen years later, Sears’ publication illustrates just how difficult this is, and underscores the fact that we still need to be vigilant and attentive to medical error with virtually everything we, as health professional clinicians, do.
Systems that work are imperative as are the practice sessions required to perfect the choreographed dance of pediatric resuscitation.
The CPOE was implemented per ward, that is, simultaneously for all hospital beds in that ward. Physicians are obliged to complete fields with key prescription characteristics (such as frequency and administration route).
The commercially available system used in the University Medical Center Groningen was Medicator® (iSOFT, Leiden, the Netherlands). In this scheme, a distinction was made between prescribing, transcribing, dispensing, administering, and “across setting” errors.
In order to define whether an ME was categorized in the first group (B through D) or the second group (E through I), a causality assessment needed to be performed between the ME and an adverse event.
In the case of non-significant trends in pADEs, a more parsimonious statistical analysis of mean pADE rate pre- and post-implementation with a Student's t-test was also performed. We further evaluated these 62 new alerts along with 36 other new pharmacy alerts collected on the two Wednesdays (9 and 16 March). To ensure consistency in data ascertainment from the electronic medical record, a single reviewer (Chloé E. This intervention was piloted in June 2013 and became standard for stroke discharges by August 2013. Although errors in recommended evaluation after discharge are also common and have been shown to significantly increase the likelihood of readmission (15), this handoff intervention did not decrease errors in follow-up. In future studies, it may be useful to look at longer-term outcomes, such as recurrent stroke and medication compliance. SK – conceptualized study, guided study design, performed statistical analysis, and edited manuscript. Post-implementation data collection for each ward started 8 weeks after CPOE was implemented and lasted for 5 months for all beds in each ward. Moreover, standardized prescriptions and medication protocols (a set of prescriptions belonging to one protocol) can be programmed. In this system, only the process of ordering medication is computerized, the process of dispensing and administering the medication is still paper-based. Therefore, we adopted the first three items of the Yale algorithm in the new assessment tool (knowledge about the relationship between this drug and the event, influence of other clinical conditions, and the time relationship between drug and event). Some studies that use time series to evaluate the effects of CPOE with different levels of clinical decision support systems have shown a decrease of more than 50% in non-intercepted serious medication errors (potential or actual) [1, 8–10] or a decrease of more than 33% in prescribing errors in an emergency department [11]. Physicians and pharmacists have access to the patient's administrative and clinical data, biological results, images, nursing transmissions notes, vital signs, appointments and all reports. Each of the reviewers rated all the alerts individually, and discrepancies in assessment were then resolved by consensus between all reviewers. We also investigated whether an adverse drug event, defined as an injury resulting from the use of a drug [5], had occurred following the potential prescribing error.
If a patient was admitted more than once during the study period, only the first admission for stroke was considered; this resulted in 50 patients in the pre-intervention group and 52 patients in the post-intervention group. Hill) completed data abstraction using a standardized data abstraction form (see Supplementary Material).
Return to the hospital was most commonly due to altered mental status followed by tachycardia, anemia, seizure, infection, and headache. In this system, transcription of medication orders by both the nurses and the pharmacy staff was no longer necessary.
After the medication orders are entered into the computer, labels are printed out, which nurses then stick onto the administration charts. The causal relationship could be assessed as unlikely (score < 0), possible (score ? 0 and ? 3), and probable (score = 4).
However, the effect of CPOE on clinical outcomes (mortality rates, adverse drug events, or length of stay) remains questionable [9, 12–16]. This theme involved three processes: prioritising, downplaying and self-preservation, each of which in different ways endeavours to either maintain or reestablish the feeling of being a participant. Errors in medications included more commonly incorrect medications (such as wrongful continuation of home antihypertensive regimen, incorrect medication dosage, or early initiation of anticoagulation) as well as less commonly missing medications that were intended for the patient but were absent from the medication reconciliation (such as absent aspirin or statin) (see Figure 1); in the case of apparent medication error, further review of the chart was performed to confirm the change was not purposeful.
These errors were subdivided into administrative and procedural errors (errors in readability, patient data, ward and prescriber data, drug name, dosage form, and route of administration), dosing errors (errors in strength, frequency, dosage, length of therapy, and directions for use) and therapeutic errors (drug–drug interactions, contra-indications, incorrect mono-therapy, duplicate therapy, and errors in therapeutic drug monitoring or laboratory monitoring; inappropriate drug choices were not actively assessed and were only taken into account when these were obvious).
When the relationship was possible or probable, the ME was categorized as E, F, G, H, or I and was defined as a pADE. Other studies have qualitatively analysed the possible side effects of the integration of CPOE into a patient care information system, including the induction of specific prescribing errors due to a lack of flexibility of the system, and over-completeness or fragmentation of the information relating to prescriptions [17, 18].By reviewing the prescriptions, pharmacists can identify errors, thereby reducing the frequency of medication errors [19]. The awareness of the processes complement existing knowledge about coping in advanced cancer patients, by showing how patients make use of meaning-based coping efforts to increase their experience of being a participant in their own lives. This study was performed under the hypothesis that the intervention would improve the flow of accurate data from the acute care hospital to the rehabilitation hospital. No differences were found between the two groups in errors in follow-up, such as appointments recommended and tests completed (20 vs.
Transcribing errors are errors that occur in the process of the interpreting, verifying, and transcribing of medication orders. When the relationship was unlikely, the ME was categorized as B, C, or D, and was not associated with a pADE. Pharmacists participating in medical rounds can prevent 66 to 80% of adverse drug events [20, 21], decrease drug costs by 41% [22] or be associated with a low frequency of medication errors [23].
Therefore, if the data were available in the acute hospital care record but not in the rehab hospital record, then this was considered an error because that information did not clearly pass the transition. Pharmacy validation is mandatory in France [24] but often hardly feasible, given the small number of hospital pharmacists, the large number of prescriptions and the compulsory feedback to the prescriber.
INTRODUCTIONWhen the status of patients with advanced cancer changes from that of being a cancer patient in active treatment to being in the palliative stage of the treatment with little or no chance of surviving the illness, their ability to express and cope with their physical, psychosocial and spiritual problems deteriorates greatly [1,2].
Furthermore, the handoff decreased the proportion with errors in reconciliation of critical medications (42 vs.
Errors were tallied from the rehabilitation documents as well as the acute care discharge document.
CPOE offers a potential means of reducing prescribing errors and can also increase the feasibility of pharmacy validation as a secondary filter for eliminating errors.
In this situation patients express an increasing need for professional support to cope with their suffering [2-4].
From a patient perspective one of the great challenges in providing a professional support system is that the support from healthcare professionals may be dominated by a focus on symptom treatment and effectiveness and there may be less focus on individual and situation-determined needs [1,4-7].
However, the intervention did not significantly reduce interruptions of the rehabilitation program, such as emergent brain imaging (8 vs. In a review that draws upon relevant research in the period 1996-2006 we show how coping strategies have been pivotal in coping research from the patient perspective [10]. The limitation of focusing on coping strategies could be that coping appears to be presented exclusively as a behavioural pattern in patients, instead of being founded in the dynamic relationship between the individual and their environment [8]. Lazarus therefore recommends that, in addition to studies that employ measurements and questionnaires to reveal actual coping strategies, qualitative studies also be carried out that identify how patients evaluate the conditions they experience in the actual situation that underpins the coping process [8:125]. Thus a study by Davies and Sque [11] shows how eight women with advanced breast cancer facilitated their re-entry into everyday life through “reconciling a different me”, which described the ongoing process of adaptation and coping. Research further shows how patients with an advanced cancer struggle to cope with the illness and simultaneously maintaining their routine daily lives [12,13] and living a life with continued meaning [14].The collective research in the area points to coping in advanced cancer patients as a complex process. At the same time it is clear that only very little research deals with the connections between factors that characterise coping.
The article forms part of a larger, grounded theory study focusing on key characteristics of coping—and the connection between the key characteristics—in advanced cancer patients seen from a patient perspective.
In another article we show how coping involved four significant life conditions: Alleviation from a life-threatening illness, Carry on a normal life, Live with powerlessness and Find courage and strength.
METHODSWe chose to employ the grounded theory method, as described by Strauss and Corbin [16,17] because a particular coding layer in a Strauss and Corbin-inspired methodological approach called “axial coding” allows for intense coding around significant categories. From the epistemological viewpoint, the method is firmly rooted in the pragmatic and symbolic, interactive perspective [17,18].
They were admitted to seven medical and surgical departments in the Capital Region of Denmark during the period June 2006-March 2009. Ten patients between 43 and 80 years of age (mean age 61) consented to participate: four women (mean age 58) and six men (mean age 62). The patients had known of their cancer diagnosis for between one month and three years (mean 18 months). Screening Procedure To be included in the study patients had to be over 18 years of age, born in Denmark and Danish-speaking.


Additionally, it should be evident in the patient’s records that any continued treatment would be of a palliative nature or that at least one course of treatment for relapse had not had a satisfactory effect on the cancer condition. In advance of being interviewed, it was ascertained that the participants had scored 24 points or more in Folstein’s “Mini-Mental State Examination” (MMSE), which is proven to be applicable as a screening test of cognitive function in cancer patients [20].
This did not occur in this study.A range of principles was employed in the screening process [21]. One such principle was availability, which meant that the first patients were chosen as soon as they were identified by the chosen departments. A third principle was development over time, which allowed for time-related variation in coping to be studied, as the patients were interviewed three times at intervals of approximately one month, on condition that they had enough energy to undergo an interview and their illness allowed it. A fourth principle employed was theoretical sampling [16,17,21], where the patients were chosen according to the descriptive needs of the emerging categories and theory. By employing the principle “theoretical sampling” it was possible to study specific aspects of the developed categories.
This principle also supported the assessment of the point when new data no longer led to new theoretical insights nor identified new features in relation to the theoretical categories, i.e.
In the first interviews a semi-structured interview guide was used in the conversation, which ensured that significant information about coping in advanced cancer patients was collected. The semi-structured interview guide was inspired by Lazarus and Folkman’s understanding of the connection between problems, emotions, assessment and coping [8,9]. The following themes were included in the questions: Problems and emotions, assessment of resources and limitations, actual handling of the situation, knowledge and experience, prevention and hope—see Table 2. Over time the interview guide was refined to make it possible to develop and validate categories and processes that were revealed through the analysis [16].Table 1.
The interviewer was also careful to check agreement between what was said and her own understanding of the words. Whenever implicit or unclear descriptions arose, for example, interpreting questions were used to check meaning [22]. On a very few occasions the interviewer was challenged by emotional engagement in the patient’s situation, which entailed a break in the interview technique. ETHICS The study touched on themes that could bring up intimate and unconscious or repressed thoughts and feelings [23,24], which necessitated an assessment of whether individual patients were capable of participating in the study and understanding patient information.
Patients were informed both orally and in writing about their rights, the scope of the study, and that at all times they could determine for themselves what they wanted to, and felt they could participate in.
The patients expressed that it was a relief to be able to tell someone, who had time and the willingness to listen, about their current situation. They further expressed that it was meaningful for them to contribute to a study that over time could help to improve the coping conditions associated with an advanced cancer illness.
The study was approved by the local Scientific Ethical Committee, number KF 01297281, and registered with the Data Authority.4. The inductive-deductive process was carried out as three, not necessarily sequential, analysis steps: open, axial and selective coding [16,17].
At the same time, one is qualifying those concepts in terms of their properties and dimensions” [17]. In the open coding the individual interview was analysed by breaking up the text into smaller meaning units. By addressing questions in each unit of meaning and by undertaking constant comparisons between the meaning units it was possible to specify what the unit was about and on this basis to identify the categories. Corbin and Strauss [17] recommend that in this coding phase the analytic focus be placed on both context—which is also termed “structural context” or “structure”, see for example Strauss and Corbin [16]—and process. It allows the relations between the developed categories to be infused with a kind of “life” or movement. In addition process coding serves to encourage the researcher to incorporate variation in the findings and thereby to look for new patterns. Thus process coding is an essential aspect in the development towards a substantive grounded theory. One way to code for process is, according to Corbin and Strauss, to pose questions such as “What happens?” and “What conditions and activities connect a series of events with other series of events?” [17]. In the current study the process coding was most obvious in specific memos, because the ongoing memo-writing made it possible, by using few or many words, to describe the processes which emerged, for example by addressing the above questions in the data.Selective coding is defined as “the final step in analysis—the integration of concepts around a core category and filling in of categories in need of further development and refinement” [16]. Selective coding thus allowed us to nuance and refine both the theory’s core category, which represents the main theme or central tendency in the developed theory, and the integration between the core category and other categories.
One element in the selective coding was integrative diagrams, which from a visual perspective helped us to focus on the logical integration between concepts and categories and between the core category and sub-categories [16]. ASSESSMENT OF VALIDITY The research process was assessed on an ongoing basis by giving critical attention to each step of the process. Similarly, all codings, memos and critical reflections were systematised to ensure both stringency and transparency.
The empirical foundation of the study was maintained by undertaking continual comparative analyses at each step and between the steps. At the same time these analyses supported the control of systematics, variation and density at all three steps of the analysis [22, 26].The meaning of what the patients said was validated by the researcher, who enquired about what was said, and repeated interviews with the same patient allowed for further exploration and validation of what the patient had said. After each interview the researcher wrote down her immediate reflections and hypotheses in a research diary, thereby ensuring that the verbal and non-verbal assertions could be followed up in the subsequent interviews, and which could lead to further exploration [27]. Many of the patients subsequently told the researcher that the interviews had given them the opportunity to formulate their own thoughts and feelings, which had been a good experience. The patients’ assertions helped to validate that the interviews were not experienced as an extra burden in an otherwise highly vulnerable situation.
In order to avoid bias the connections between the developed categories and sub-categories were discussed frequently in the research group. They were also discussed in relevant clinical and research situations so that the researcher could ascertain to what extent the findings found resonance with health professionals’ own clinical experience [16,17].6. FINDINGSA pattern emerged around a central theme “The struggle to be a participant in one’s own life”, that involved four significant life conditions [15] and three processes: Prioritising, Downplaying and Self-preservation. The three processes in different ways were seen to underpin the patients’ continual struggle to maintain or re-establish the experience of participating. The Struggle to Participate in One’s Own Life All the patients found themselves at a stage where they experienced their progressive illness and the many accompanying social and relational challenges as an intense pressure, which could be felt both physically and mentally.Coupled with this they also described how thoughts about the severity of the situation and the possibility of becoming a burden on those around them cropped up constantly.
Enduring and coping with the pressure was incredibly demanding, and the patients often became overwhelmed by strong emotional reactions, which on the one hand meant that at times they could not think clearly, acted unfocusedly and could no longer take the initiative and control that they otherwise would have done. However, the constant pressure also prompted patients to fight for, and put a lot of energy and strength into, maintaining or re-establishing the feeling of influence on life despite of little or no hope of surviving the illness—that is in this context, being a participant in their own lives.A central element in “the struggle to be a participant in one’s own life” was that the patients had the opportunity to act in ways that, despite their failing powers and lack of energy, gave them a sense of being able to affect or steer the situation they found themselves in at that moment, and thereby have a meaningful influence on their lives. In the process of discovering how to act appropriately in their actual situation, the patients used to a great extent the knowledge or experiences they had from before the onset of the illness. However the situation was so unique that the patients often found themselves without a precedent, and therefore did not have any specific knowledge or experience to draw upon. A consequence of this was that the patients either gave up and became passive, tried to move forward as best they could, or threw themselves into gathering knowledge and information, especially from the internet, because the health professionals had a tendency to give different or more knowledge and information than the patient needed which could lead to an increase in uncertainty and anxiety. Therefore the patients often left it to their relatives to gather knowledge, which in a way made them feel bothFigure 1.
Model to illustrate the connection between the central tendency and three processes developed from data.more secure and relieved, but which at the same time could mean that the relatives and professionals began to take over more and more. Prioritising was shown to be a process where the patents fought to be an active participant in relation to judging, prioritising and finally deciding which actions and interactions to take or not to take.
Several patients described how they were happy to leave the responsibility for symptom alleviation and palliative care to the health professionals, because over time they had come to acknowledge that they symptoms were of such a character that neither they nor their relatives could do anything about them. In this way it was easier to keep an overview of an otherwise pressured and sometimes chaotic situation. It was, however, essential, that the goals were constantly reviewed, so they fitted the ever-changing situation. Many patients described how they often spent time and energy on making lists of purely practical tasks that they wanted to have control over, before they finally would have to give up on life.The prioritising process was largely based on the patients’ accumulated knowledge and experience about what had helped in similar situations. At the same time, many patients expressed confusion, and to a certain extent astonishment, about how the health professionals in some situations apparently did not consider the patients’ experiences to be as important as factual knowledge about, for example, the effects of medicines. One patient told how he had experienced that if he sat in a certain way he could reduce the increasing pains. However, his experience was that it was difficult to get help to buy the right chair, because the health professionals considered that the pains would be best alleviated by changes to his medicine. The Downplaying Process To be a participant in one’s own life furthermore involved Downplaying, which was visible in how the patients put time and energy into making sure that the illness and its consequences did not take up more time than absolutely necessary in their lives. The patients thus spoke of how, on the one hand, they were forced to prepare themselves to live with increasing symptoms and palliative care for the rest of their lives. On the other hand, however, they described how important it was, whether or not they were admitted to hospital, that they had the opportunity to continue to live out aspects of the life that they had built up over many years together with their relatives.
Without that, there was no point in living.The downplaying process was closely linked to the possibility of maintaining and adapting daily customs and activities which really meant something to the patients.
All the patients, however, described how admission to hospital made it almost impossible to maintain customs and habits because the whole hospital organisation was based on system logistics, which to a far greater extent were designed to meet the needs of the system and not the advanced cancer patient’s struggle to be a participant in their own life. During admission, therefore, small daily activities, such as wearing one’s own clothes and taking a drive or a short walk out in the sun to hear the birds sing and for a short while experience life outside the hospital, took on a great significance in relation to downplaying the invading illness and perhaps even for short periods completely drop all thought of the illness and possible death. In the same way, receiving visits—as far as the patients’ energies allowed—emails, telephone calls or SMS’s, also from more distant acquaintances, held great significance, because it meant that the patients still had social worth and were not completely forgotten, despite their serious illness.Patients living at home described how they constantly fought to adapt everyday customs and activities, so that they and their families could continue to live out the life that they had built up together over the years. That could mean that far more “ready meals” were bought, or that the children had to take on more chores, such as tidying up, shovelling snow, etc.
At the same time it was significant to all the patients to move and use their body as much as their failing strengths allowed, in that it gave an immediate feeling of doing something good for oneself and strengthened the feeling of being present and alive.In connection with living out their usual lives and maintaining and adapting habits and daily activities, family members and close friends were indispensable, both because they often came just when they could see there was a need of their help with practical tasks, and because their company gave the patients the feeling of social worth.
Self-preservation was shown to be a process, which made it possible for patients to suddenly find themselves face to face with a feeling of powerlessness and yet not lose their strength and courage to face reality and continue live. Specifically, the use of self-preservation could manifest in patients mixing thoughts and talk of their own death and funeral with, for example, the language of music, faith and spirituality.
Another patient, while describing what his Christian faith meant to him, suddenly began to relate about a very difficult conversation that had taken place the day before, where he had been confronted with his own death completely unprepared. Afterwards, he returned to talking about his increasing religious faith.Similarly, it was possible to tolerate powerlessness when patients got the opportunity to carry out specific actions that they themselves judged to be significant in their situation. Thus, several patients described that the powerlessness became more tolerable when they threw themselves into fighting the uphill battle for instance by finding the treatment that could prolong their life a little. Other patients described how finding an inner peace or balance allowed them for a brief moment not to relate to the powerlessness.All the patients described self-preservation as a very personal and often intimate process, which the patients usually kept to themselves or certainly only involved those with whom they had a relationship built upon mutual understanding and respect, and where the patients felt sure that what they said would be kept confidential.
This could include close relatives or very good friends, but it could also include health professionals who meant something special to the patient.
The findings indicate that advanced cancer patients involve “relational meaning” when choosing appropriate coping strategies.
According to Lazarus and Folkman relational meaning is an essential part of the appraisal process, which refers to a constant interaction between personal and environmental factors, although it is the person themselves who in the end judges what the situation means to them [8,9]. Relational meaning can explain why it is apparently significant for patients to be actively participant in evaluating and prioritising specific actions. At the same time relational meaning can also explain why some patients in the study experienced the prioritising process as a conflictual and vulnerable process, in that a personal judgement of a hugely complex and often totally chaotic situation necessarily opens up relational conflicts and conflicts of interest. A similar process was found in a study of Houldin and Lewis [12], where an interview study demonstrated how 14 patients with terminal cancer fought to find a way of living where it was possible to balance between the illness and normal life.
The patients’ struggle to both relate to the burdensome illness and to a meaningful life can be understood as a perspective shift between illness and wellness.
The concept of the perspective shift between illness and wellness is elaborated in a meta-study, what included 292 qualitative studies pertaining to chronic physical illness [31].
The study shows chronic illness as an ongoing, continually shifting process in which people experience a complex dialectic between an illness-in-the-foreground perspective and a wellness-in-the-foreground perspective. According to Patterson the shift between the two perspectives can take place either as a gradual process or as a result of sudden actions. Despite the fact that The Shifting Perspective Model focuses on chronically ill patients and not specifically on patients with advanced and incurable cancer, the description of the constant perspective shift between illness and wellness can be used to understand how patients who cannot look forward to being cured of their illness find themselves in a situation which is characterised by constant readjustment processes.A third process shown in this study was Self-preservation.
Self-preservation was characterised by patients on the one hand being forced to live with powerlessness that arose from a growing acknowledgement of impending death. On the other hand, the patients were able in certain situations to find the courage and strength necessary so that the powerlessness did not completely overwhelm them.
While the pendulum is swinging, the informants strove to find factors that fitted their conceptual system and supported their inner balance and structure, all to keep death at a distance and preserve their links to life. From a symbolic interactional perspective [18] it is described how human beings act towards things on the basis of the meanings that the things have for them. The meanings of such things are derived from, or arise out of, the social interaction that one has with one’s fellow humans. This understanding of the connection between action and meaning underpins how patients do not act solely to solve the many problems that crop up in their complex illness and life situation [33,34], but also act to create meaning and connection in their lives.
It is thereby suggested that, apart from using problem-focused and emotion-focused coping [8,9] patients also make use of meaning-based coping.
The concept “meaning-based coping” was developed by Folkman [35], and describes the role of meaning in dealing with the pressures of stressful situations, because it shows that, when people don’t succeed in solving a problem with the help of emotion-focused or problem-focused coping strategies, they might try to use meaning-based actions, which gives rise to a re-evaluation of the situation and thereby the achievement of a better connection between their outlook on the world and the actual situation. Thus it becomes possible to increase positive feelings in the midst of an otherwise very difficult situation [36]. By drawing upon Folkman’s understanding of meaning-based coping as an element of the theoretical context, Lethborg et al.
The positive reappraisal encouraged the patients to focus their energies and appreciate what was meaningful in their lives and thereby respond to the impact of cancer by embodying their life fully and with meaning. The same response to the impact of cancer can be found in results from this study, given that the patients attempt to act in a meaningful way in specific situations.
In this way the patients create a form of an “adaptive pathway towards coherence and the sense of self” [14], which is central to meaning-based coping.The use of grounded theory methodology, as described by Strauss and Corbin [16,17], has given rise to intense codings in the axial coding layer, which were directed to various aspects in the data material—namely context and process. Context and process can, on the one hand, be considered as two directions of analysis, which can demonstrate different theoretical dimensions in the analysis material. Since we put particular focus in this article on the connection between the central tendency and the three processes, it is therefore necessary to point out that coding for process took place alongside coding for context. A further limitation could be the small number of participants from only one area in Denmark, which means that the results cannot be generalised.8.
CONCLUSION The purpose of the article was to identify and describe processes that from a patient perspective are significant to coping in advanced cancer patients. The findings point to how the central tendency in coping in advanced cancer patients was the patients’ struggle to be a participant in their own lives. This central tendency involved three processes: Prioritising, Downplaying and Self-preservation. Prioritising was shown to be a process where patients were active participants in relation to evaluating, prioritising and finally deciding which actions and interactions they considered constituted appropriate coping efforts in their situation. Downplaying showed how patients fought to play down the invasive influence of the illness on the lives they had built up over many years together with their relatives. Self-preservation pointed to how patients set coping efforts in motion that made it possible for them to find the courage and strength necessary to live with the powerlessness that an acknowledgement of imminent death inherently brought to bear.
The discussion indicated that the three processes allowed the patients to make use of meaning-based coping efforts which increased their experience of being a participant in their own lives.9. PERSPECTIVESFrom a clinical perspective the findings can contribute to greater understanding by professionals in the clinical field of processes significant to coping in advanced cancer patients, which have been shown to come into play when coping is considered from a patient perspective. Furthermore, the results of the research project can feature in debates around how patients can be optimally supported to prioritise the activities on which they should spend their remaining strengths. This could include assessment of tools considered appropriate by the patient to pinpoint and express the goals they see as meaningful— see for example the Ph.D. Thesis written by Zoffmann [37], which focuses on as well a theory as guidelines that describes a life-skills approach called Guided Self-Determination.
From a research perspective the findings can contribute to further research that investigates coping in advanced cancer patients from other perspectives, for example from the relatives’ and health professionals’ perspectives. By juxtaposing the results from such studies a detailed and multi-faceted picture of coping can be delineated.10.
ACKNOWLEDGEMENTSThe authors received financial support for the research of this article from: The Danish Cancer Society, CVU University College Oeresund, The Novo Nordic Foundation, University of Southern Denmark, The Harboe Foundatio, The Family Hede Nielsens’ Foundation, and Aase and Einar Danielsen Foundation.
A qualitative study to enhance knowledge about coping abilities in advanced cancer patients.



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