Drug-related problems : Nurses role and responsibility

Drug-related problems (DRPs) are common and can cause serious adverse effects, even death. The elderly are an exposed group having a higher prevalence of DRPs. As nurses are involved in all steps of the medication process they are particularly well positioned to detect, prevent and alert for DRPs. Nurses are usually situated in the frontline when medication errors occur and are thus exposed to being responsible for such. The aims of this thesis was to evaluate if nurses can improve the quality of drug therapy, and to investigate what types of medication error most frequently reported and which factors most frequently preceded an error. Study 1 was designed to determine whether medication reviews made by a clinical pharmacologist and a nurse could affect rates of re-hospitalisation and/or death in hospitalized patients. DRPs detected and judged to be of clinical relevance resulted in written advice to the physician in charge of the patient. In 150 patients, 299 DRPs were found which resulted in 106 advice s to the physicians. After 6 months readmission and death was measured and compared with patients in a control group receiving usual care, and there was no statistically significant difference in the two groups. In Study II 15 nurses conducted structured, nurse-led medication reviews after a 1-day education in clinical pharmacology. The nurses identified 59 clinically relevant DRPs in 80 patients, not detected by the usual care. Out of these, 37 DRPs resulted in an intervention such as dose reduction or withdrawal of one or more drugs. Study III was designed to determine whether medication reviews made by nurses could improve the quality of the drug therapy of elderly hospitalized patients. In 250 patient, 86 clinically significant DRPs were found not detected by the usual care. After 3 months re-admission and inappropriate drug use were measured and compared with patients in a control group receiving usual care, and there was no statistically significant difference in the two groups. In studyIV a content analysis was used to develop a tentative classification model of medication errors and contributing factors. The findings showed a high level of complexity with system and human factors interacting. In study V 585 errors made by nurses were analyzed. Inexperienced nurses and male nurses were reported for a higher number of medication errors than their number in Sweden would lead one to expect. “Lack of knowledge” was a contributing factor more often associated with inexperienced nurses. “Practice beyond scope of practice” was more often associated with male nurses. Conclusion, DRPs are common. By using nurse-led medication review DRPs not detected by the usual care could be found. Medication errors made by nurses are a result of interrelated human and system factors. Experienced nurses can be a valuable resource for improving the quality of drug-treatment and for ensuring patient safety. Popularvetenskaplig sammanfattning Lakemedel raddar och forlanger liv samt lindrar lidande, men lakemedelsbehandling innebar ocksa en risk for lakemedelsrelaterade problem (LRP). LRP ar olika problem relaterade till lakemedelsbehandling, allt ifran att inte kunna svalja den forskrivna tabletten till allvarliga lakemedelsbiverkningar. Aldre personer ar kansligare for lakemedel och anvander ofta fler lakemedel an yngre och drabbas darmed lattare. Upp till 30 % av alla sjukhusinlaggningar av aldre personer ar relaterade till lakemedel. En lakemedelsgenomgang ar en systematisk genomgang for att optimera patientens lakemedelsbehandling och utfors ofta i samarbete med klinisk farmakolog eller apotekare. Sjukskoterskor ar involverade i alla delar av lakemedelshanteringen, har farmakologisk kunskap och arbetar nara patienten under dygnets alla timmar. Sjukskoterskornas helhetsbild talar for deras lamplighet att upptacka och forebygga LRP. En del LRP utgors av lakemedelsfel som uppstar av manga olika faktorer saval organisatoriska som manskliga. Sjukskoterskan ar ofta den som utgor den sista barriaren innan ett lakemedelsfel nar fram till patienten. Syftet med denna avhandling var att ta reda pa om sjukskoterskor kan forbattra kvaliten pa patienters lakemedelsbehandling. Vidare var syftet att ta reda pa vilken typ av lakemedelsfel som oftast rapporteras till Socialstyrelsen samt dess bidragande orsaker. Delstudie I genomfordes av en klinisk farmakolog och en sjukskoterska for att studera vilken betydelse lakemedelsgenomgangar, hade pa aterinlaggning och dod av patienter pa en internmedicinsk klinik. De kliniskt relevanta LRP som hittades resulterade i ett skriftligt rad till den ansvarige lakaren om att forandra patientens lakemedels behandling. Hos 150 patienter hittads 299 LRP som den vanliga varden inte hade upptackt. Detta resulterade i 106 skriftliga rad. I delstudie II utforde sjukskoterskor, efter att forst genomgatt en 1-dagsutbildning i klinisk farmakologi, sjalvstandigt strukturerade lakemedelsgenomgangar. Sjukskoterskorna kunde identifiera 59 kliniskt relevanta LRP hos 80 patienter som den ordinarie varden inte upptackt. Av dessa resulterade 37 i en forandring av patientens lakemedelsbehandling. I delstudie III undersoktes om lakemedelsgenomgangar utforda av sjukskoterskor kunde forbattra kvaliten pa aldre patienters lakemedelsbehandling. Alla sjukskoterskor pa en internmedicinsk avdelning genomgick en heldags utbildning i klinisk farmakologi och genomforde darefter sjalvstandigt lakemedelsgenomgangar pa inneliggande patienter. Hos 250 patienter hittads 86 LRP som den vanliga varden inte hade upptackt. I delstudie IV utvecklades en preliminar klassificering av lakemedelfel och dess bidragande orsaker dar sjukskoterskor varit ansvariga. Resultatet visade att omstandigheterna kring sjukskoterskors lakemedelsfel ar komplexa dar systemfaktorer och manskliga faktorer paverkar varandra. I delstudie V analyserades 585 lakemedelsfel dar en sjukskoterska varit ansvarig. Oerfarna sjukskoterskor och manliga sjukskoterskor var anmalda for lakemedelsfel i hogre utstrackning an erfarna och kvinnliga sjukskoterskor och var ansvariga for olika typer av fel. ”Bristande kunskap” var en bidragande orsak som oftare associerades med oerfarna sjukskoterskor. Att ”agera utanfor sina befogenheter” var vanligare bland manliga sjukskoterskor. Slutsatser. LRP ar vanligt. En intervention utford av en klinisk farmakolog och sjukskoterskor ledde inte till nagon minskning av aterinlaggning eller dod. Genom att anvanda en sjukskoterskeledd lakemedelsgenomgang kunde flera LRP identifieras som den vanliga varden inte upptackt. Omstandigheterna kring sjukskoterskors lakemedelsfel ar komplexa dar systemfaktorer och manskliga faktorer paverkar varandra. Sjukskoterskors erfarenhet har betydelse for patientens sakerhet och sjukskoterskors insatser ar en vardefull resurs for att forbattra kvalitet och sakerhet i patienters lakemedelsbehandling.