Impact of medication reconciliation and review on clinical outcomes

To examine the evidence regarding the effectiveness of medication reconciliation and review and to improve clinical outcomes in hospitals, the community, and aged care facilities.

Determining clinical pharmacy workload by patient disease classification in medical and surgical patients

Aim: To determine the time needed to provide clinical pharmacy services to individual patient episodes for medical and surgical patients and the effect of patient presentation and complexity on the clinical pharmacy workload. Method: During a 5-month period in 2006 at two general hospitals, pharmacists recorded a defined range of activities that they provided for patients, including the actual times required for these tasks. A customised database linked to the two hospitals' patient administration systems stored the data according to the specific patient episode number. The influence of patient presentation and complexity on the clinical pharmacy activities provided was also examined. Results: The average time required by pharmacists to undertake a medication history interview and medication reconciliation was 9.6 (SD 4.9) minutes. Interventions required 5.7 (SD 4.6) minutes, clinical review of the medical record 5.5 (SD 4.0) minutes and medication order review 3.5 (SD 2.0) minutes. For all of these activities, the time required for medical patients was greater than for surgical patients and greater for 'complicated' patients. The average time required to perform all clinical pharmacy activities for 1071 completed patient episodes was 14.4 (SD 10.9) minutes and was greater for medical and 'complicated' patients. Conclusion: The time needed to provide clinical pharmacy services was affected by whether the patients were medical or surgical. The existence of comorbidities or complications affected these times. The times required to perform clinical pharmacy activities may not be consistent with recently proposed staff ratios for the provision of a basic clinical pharmacy service.

Challenges of managing medications for older people at transition points of care

In clinical practice, pharmacists play a very important role in identifying and correcting medication discrepancies as older patients move across transition points of care. With increasing complexity of health care needs of older people, these discrepancies are likely to increase. The major concern with identifying and correcting medication discrepancies is that medication reconciliation is considered a retrospective problem - that is, dealing with medication discrepancies after they have occurred. It is argued here that a more proactive stance should be taken where doctors, nurses and pharmacists collectively work together to prevent medication discrepancies from happening in the first place. Improved involvement of patients and family members will help to facilitate better management of medications across transition points of care. Efficient use of information technology aids, such as electronic medication reconciliation tools, should also assist with organizational systems problems associated with the working culture, heavy workloads, and staff and skill mix of health professionals.

Medication compliance and satisfaction with treatment for HIV disease in a sample of African-American crack cocaine smokers

The development of treatment regimes for African-American HIV-infected crack cocaine users has often been based on assumptions about compliance with medication regimes rather than evidence. This study sought to obtain baseline information on the adherence to antiretroviral medications by members of this important risk population in Houston, Texas. It was found that for only 5 of a range of 16 antiviral medications was there a significant correlation between levels of compliance reported by respondents and their beliefs as to how effective these medications are. Medication compliance was also found not to be associated with frequency of crack cocaine use in the month prior to interview. Furthermore, irrespective of both gender and their reported extent of medication compliance, the respondents tended to report positive relationships with their treating physician, with higher levels of satisfaction reported by women. These results suggest that the majority of African-American crack cocaine users are able to comply with HIV treatment regimes, with more than half (53%) claiming full compliance for one or more medications, and a further one third (31%) claiming compliance more than half the time. Moreover, these findings suggest that they will continue to take antiretroviral medications even if they have doubts about the effectiveness of these medications.

Medication knowledge and self-management by people with type 2 diabetes

Objective: To explore medication knowledge and self management practices of people with type 2 diabetes.

Design: A one-shot cross sectional study using in-depth interviews and participant observation.

Setting: Diabetes outpatient education centre of a university teaching hospital.

Subjects: People with type 2 diabetes, n=30, 17 males and 13 females, age range 33-84, from a range of ethnic groups.

Outcome measures: Ability to state name, main actions and when to take medicines. Performance of specific medication-related tasks; opening bottles and packs, breaking tablets in half, administering insulin, and testing blood glucose.

Results: Average medication use > or = 10 years. Respondents were taking 86 different medicines, mean 7 +/- 2.97 SD. Dose frequency included two, three and four times per day. All respondents had > or = 2 diabetic complications +/- other comorbidities. The majority (93%) were informed about how and when to take their medicines, but only 37% were given information about side effects and 17% were given all possible seven items of information. Younger respondents received more information than older respondents. Older respondents had difficulty opening bottles and breaking tablets in half. Twenty per cent regularly forgot to take their medicines. Increasing medication costs was one reason for stopping medicines or reducing the dose or dose interval. The majority tested their blood glucose but did not control test their meters and 33% placed used sharps directly into the rubbish.

Conclusion: Polypharmacy was common. Medication knowledge and self management were inadequate and could lead to adverse events.

Defuturing an architecture of destruction: a reconciliation of Van Berkel and Bos to the new design philosophy of Tony Fry

For some time now Tony Fry has promoted the idea of 'The Sustainment', an idea that asserts a paradigm shift in attitudes to consumption. 'The Sustainment' recognises that increasingly human futures are products of self-determination and not chance. Fry’s hypothesis can be understood through his concept of Defuturing, a philosophy that questions the role of design and the responsibility of designers to facilitating the ability to sustain (Fry 1999).
Central to Fry’s philosophy is an awareness that it is in the best interests of designers and their clients, as inhabitants of cultures increasingly driven by technology, to be aware of the relationships between the products and theories of design and the processes and implications of technological change. This is an awareness that is central to the concepts, work, and methodologies of the ‘UN Studio’ of Van Berkel and Bos described and elaborated upon in Move – Imagination, Techniques, and Effects (Van Berkel & Bos 1999). Here, Ben Van Berkel defines the parameters and methodologies employed by UN Studio in an environment of technological and socio-economic change. The Dutch practice could be said to exemplify something of a zeitgeist in current architectural design that sees architects, as Van Berkel and Bos view them, as “fashion designers of the future, dressing events to come and holding up a mirror to the world (Van Berkel & Bos 1999, back cover).” It is a zeitgeist that Fry might see as aligned to the resilient hype of ‘new creativity’, ‘globalisation’ the ‘romance with technology’, and the vacuous-ness of the world of fashion. (Fry The Voice of Sustainment: on Design Intelligence 2005).
A source of breaking down such design propaganda is identified by Fry in the notion of ‘scenarios,’ which “provide a mechanism for politico-practice assemblage in which dialogues and narratives of change can be rehearsed in ways that enable participants to re-educate themselves via critical confrontations” (Fry The Voice of Sustainment: on Design Intelligence 2005). From such a perspective this paper aims to practically illustrate and ground the Defuturing of Fry by establishing a dialogue between his writings and the theories that have generated the architectural designs of Van Berkel and Bos and there UN Studio. This will be a ‘scenario’ that examines therefore an appropriation and transformation of the applied intellectual practice of Van Berkel and Bos. Through this confrontation we shall explore the question of why sustainability appears to be so low in the agenda of many pre-eminent contemporary architects, and how we might refocus therefore practice and theory on the ability to sustain.

Reconciliation between Aboriginal and other Australians : the "Stolen Generations"

The current study presents an overview and content analysis of the "Stolen Generations" inquiry as an example of how structural violence, grounded in the geohistorical context of the invasion of Australia by Europeans, plays itself out in the relationship between Aboriginal and non-Aboriginal Australians. The inquiry, based on testimony received from 777 people and organizations, documented the impact of the government policy, from 1910 to 1970, of removing Aboriginal children of mixed heritage from their families. The consequences of these forced separations are examined and the implications of the inquiry are considered. We critically reflect on the role psychology has played in the past, and suggest roles for peace psychology, particularly in view of theoretical questions related to reconciliation processes.

Medication management by graduate nurses: before, during and following medication administration

The purpose of the present study was to explore graduate nurses' perceptions of their medication management activities in the acute care context. A qualitative research design with a semistructured interview schedule was used to elicit information from participants. The sampling population consisted of graduate nurses involved in direct patient care in medical and surgical wards of a Melbourne metropolitan teaching hospital, completing a graduate nurse program. Twelve graduate nurses participated in the interviews. Two major themes emerged: (i) monitoring medications and (ii) interventions for patient care. The findings indicate that graduate nurses are required to address several facets of the medication management role in their daily practice. It is pertinent to examine ward dynamics to ensure that graduate nurses have ready access to experienced health care professionals. Through collegial support, graduate nurses should also be encouraged to critically examine the different possibilities when making clinical judgments about monitoring patient medications.

Aboriginal and non-aboriginal Australia : the dilemma of apologies, forgiveness, and reconciliation

This article presents a qualitative study of the indigenous Australian perspective on reconciliation with nonindigenous Australia, with a focus on the role of an apology for the oppression and violence perpetrated by nonindigenous Australians, and forgiveness on the part of indigenous Australians. A brief historical analysis of the relationship between Aborigines and waves of settlers is presented to demonstrate the extent of the wrong that was perpetrated against Aborigines and the need for social as well as practical reconciliation in the current context. It is argued that negotiated forgiveness is a concept that is pertinent to the discussion of reconciliation, because it requires a dialogue between the parties and ultimately for the wrongdoer to accept accountability and responsibility for offending actions, thereby opening the door for forgiveness and, ultimately, possible reconciliation. It is suggested that a first step in the required reconciliation dialogue is an apology, but the issue of who should give and receive an apology is a complex one. The issue of who should forgive and who should be forgiven is shown to be similarly complex. Qualitative analysis of interview data from 10 participants indicated that at this point in time, forgiveness might not be salient to the indigenous population, whose primary focus is more on the matter of an apology. This suggests that negotiated forgiveness and reconciliation will remain elusive goals until the matter of an apology is resolved.

Managing complex medication regimens: perspectives of consumers with osteoarthritis and healthcare professionals

BACKGROUND: Managing medications is complex, particularly for consumers with multiple coexisting conditions for whom benefits and adverse effects are unpredictable and health priorities may be variable.

OBJECTIVE: To investigate perceptions of and experiences with managing drug regimens from the perspectives of consumers with osteoarthritis and coexisting chronic conditions and of healthcare professionals from diverse backgrounds.

METHODS: Using an exploratory research design, focus groups were formed with 34 consumers and 19 healthcare professionals. Individual interviews were undertaken with 3 community medical practitioners.

RESULTS: Consumers' management of medications was explored in terms of 3 themes: administration of medications, provision of information, and the perceived role of healthcare professionals. In general, consumers lacked understanding regarding the reason that they were prescribed certain medications. Since all consumer participants had at least 2 chronic conditions, they were taking many drugs to relieve undesirable symptoms. Some consumers were unable to achieve improved pain relief and were reluctant to take analgesics prescribed on an as - needed basis. Healthcare professionals discussed the importance of using non-pharmacologic measures to improve symptoms; however, consumers stated that physicians encourage them to continue using medications, often for prolonged periods, even when these agents are not helpful.

CONCLUSIONS: Consumers were dissatisfied about the complexity of their medication regimens and also lacked understanding as to how to take their drugs effectively. Dedicated time should be devoted during medical consultations to facilitate verbal exchange of information about medications. Pharmacists must communicate regularly with physicians about consumers' medication needs to help preempt any problems that may arise. Instructions need to be revised through collaboration between physicians and pharmacists so that "as needed" directions provide more explicit advice about when and how to use such drugs. Future research, using large, generalizable samples, should examine trends related to consumers' experiences of symptomatic relief from chronic conditions and their understandings about medications.

Self-administration of medication in hospital: patients' perspectives

Background. Little information is available about patients' perspectives on self- or nurse-related administration of medication.

Aim. The aim of the study was to determine patients' perspectives about self-medication in the acute care setting.

Methods. A qualitative approach, using in-depth semi-structured interviews, was taken. Ten patients with a chronic medical illness who had experienced multiple hospital admissions for treatment were interviewed about their experiences of medication administration in the acute care setting. Participants were recruited from two cardiovascular wards in a private, not-for-profit hospital in Melbourne, Australia. Data collection occurred between August and September 2002.

Findings. Four major themes were identified from the interviews: benefits of self-administration, barriers to self-administration, assessing appropriateness of self-administration and timing of medication administration. Seven participants had previously experienced self-administration of medications and six were in favour of this practice in the clinical setting. Nine managed their own medications at home, and one self-administered with some assistance from his family. Participants were very concerned about how nurses' heavily regulated routines affected delivery of medications in hospital and disrupted individualized plans of care maintained in the home setting.

Conclusions. In planning and implementing self-administration programmes, it is important to consider patients' views. Medication regimes should be simple and flexible enough to adapt to patients' lifestyles and usual routines. Nurses should also take advantage of opportunities to support and facilitate patient autonomy, to enable more effective management of health care needs when patients return home.