Occupational therapists need a means to efficiently and accurately screen a client’s medication management capacity, especially for clients post-stroke. Most therapists are not aware of, nor do they utilize specific assessments for medication management capacity, partly due to lack of thorough assessments. The purpose of this study was to compare the scores of the ManageMed Screen (MMS), the Screening for Self-Medication Safety Post Stroke (S5), and the Montreal Assessment of Cognition (MoCA) on a population of rehabilitation clients post-stroke to evaluate consistency of scores and determine their usefulness in clinical practice. All screens were designed for use in occupational therapy; the MMS was validated for the general adult population, the S5 for clients post-stroke, and the MoCA is a cognitive screen used with adult clients with a variety of diagnoses including stroke. The MoCA was used to explore the potential relationship between cognition and medication management capacity. Study participants included five clients post-stroke and three occupational therapists. Clients were screened by the occupational therapists with the MMS, S5, and MoCA, and clinicians also participated in a focus group to assess their perceived usefulness of the screens. Results demonstrated that the MMS was consistent with the S5 in identifying the clients who performed the poorest. The MoCA has no consistent relationship with either the MMS or S5. Additionally, through a focus group, clinicians deemed both the MMS and S5 as useful, but felt the MMS was a more useful screen for their clinical practice in regards to efficient and practical use with clients post-stroke in a rehabilitation setting

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Yes / Multiple changes are made to older patients' medicines during hospital admission, which can sometimes cause confusion and anxiety. This results in problems with post-discharge medicines management, for example medicines taken incorrectly, which can lead to harm, hospital readmission and reduced quality of life. To explore the experiences of older patients and their family carers as they enacted post-discharge medicines management. Semi-structured interviews took place in participants' homes, approximately two weeks after hospital discharge. Data analysis used the Framework method. Recruitment took place during admission to one of two large teaching hospitals in North England. Twenty-seven participants aged 75 plus who lived with long-term conditions and polypharmacy, and nine family carers, were interviewed. Three core themes emerged: impact of the transition, safety strategies and medicines management role. Conversations between participants and health-care professionals about medicines changes often lacked detail, which disrupted some participants' knowledge and medicines management capabilities. Participants used multiple strategies to support post-discharge medicines management, such as creating administration checklists, seeking advice or supporting primary care through prompts to ensure medicines were supplied on time. The level to which they engaged with these activities varied. Participants experienced gaps in their post-discharge medicines management, which they had to bridge through implementing their own strategies or by enlisting support from others. Areas for improvement were identified, mainly through better communication about medicines changes and wider involvement of patients and family carers in their medicines-related care during the hospital-to-home transition. / This work was supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). This independent research is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0317-20010).

Yes / The complex healthcare system that provides patients with medicines places them at risk when care is transferred between healthcare organisations, for example discharge from hospital. Consequently, under-standing and improving medicines management, particularly at care transfers, is a priority.Objectives: This study aimed to explore the medicines management system as patients experience it and determine differences in the patient-perceived importance of people in the system.Methods: We used a Social Network Analysis framework, collecting ego-net data about the importance of people patients had contact with concerning their medicines after hospital discharge. Single- and multi-level logistic regression models of patients' networks were constructed, and model residuals were explored at the patient level.This enabled us to identify patients' networks with support tie patterns different from the general patterns suggested by the model results. Qualitative data for those patients were then analysed to understand their differing experiences.Results: Networks comprised clinical and administrative healthcare staff and friends and family members.Networks were highly individual and the perceived importance of alters varied both within and between patients. Ties to spouses were significantly more likely to be rated as highly important and ties to community pharmacy staff (other than pharmacists) and to GP receptionists were less likely to be highly rated. Patients with low-value medicines management networks described having limited information about their medicines and alack of understanding or help. Patients with high-value networks described appreciating support and having confidence in staff.Conclusions: Patients experienced medicines management as individual systems within which they interacted with healthcare staff and informal support to manage their treatment. Multilevel models indicated that there are unexplained variables impacting on patients' assessments of their medicines management networks. Qualitative exploration of the model residuals can offer an understanding of networks that do not have the typical range of support ties. / National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC)

Ankylosing Spondylitis (AS) and Chronic Pain Syndrome (CPS) can be treated in many different ways. I found a problem in the balance of healing modalities surrounding diagnosis and care of illness and disease. This struggle is not singular to AS and CPS, but universal to physical and mental concerns. Some effective treatments and therapies are not recognized as such or are just beginning to become so. The scope of my work reflects on the course of my life. It was heavily influenced by the way my medical care was managed from an early age and how it evolved over the years. Through my educational program, I examined the necessity to bridge the gap between treatment paradigms and to expand on a broader, more inclusive, healing rubric. This rubric includes a broader emphasis on skill-based and complementary and alternative medicines. The viability to incorporate holistic health therapies earlier in life is explored through my use of the Scholarly Personal Narrative (SPN) qualitative research method. I chose this methodology because scientific fact could be argued either way for one therapeutic approach over another. By incorporating lived experience through SPN the union and cohesion necessary in all healing modalities, and their positive aspects, can be seen. The truth becomes self-evident. The results of this examination showed awareness earlier in life toward alternative and holistic treatments being paramount. Parents and educators lack information concerning modern therapeutic approaches. It also showed each situation will vary, but choice in treatment for ailments and illness of all kinds is not only viable, but highly recommended and researched. Access issues such as health insurance remain obstacles with some treatments and therapies, while others are a matter of cost prohibition, such as nutrition therapies. The implications of my work indicate a need for earlier incorporation of holistic healing programs and skill based therapies alongside perpetuated medical models in early childhood development and education. In conclusion, awareness towards medical concerns and how we as a society treat them can be improved upon by systemically incorporating less harmful therapies earlier in life. Fostering relations between medical providers, care providers and educators for students' wellbeing should be the foreground of any educational policy. Educators and parents alike should be made aware of and take advantage of effective skill-based treatments before a physical or mental condition surfaces or medication only approaches are authoritatively recommended. Integrating programs that build strong mental resilience and focus on youth development and education can reduce the necessity for more invasive treatments or medications should an ailment or illness develop.

The aim of this study was to analyse the role of the registered nurse in the management of pro re nata (PRN) medication in a care home (nursing) for older people. Studying PRN medication provides insights into the role of the nurse in care homes (nursing) who act as assessor, decision maker and evaluator in residents' care. It also provides a lens by which to explore how residents and their carers interact and participate in day-to-day care decisions about residents' health. The case study draws on ethnography. It is a multi-method study, using documentary and medication reviews, observations and interviews to answer the research questions. Thirty-four residents were recruited to the study and 60 care home staff. Findings showed that 88.2% of residents (n=30) were prescribed PRN medication and that all residents were on a minimum of 1 and a maximum of 7 medication. During each 28-day MAR sheet period between 35 and 44 PRN prescriptions were written. They contributed 12.7% of all medication prescribed, accounting for between 1.2 and 1.5 medication per resident. Nurses were found to administer PRN medication, but a finding of this study was that this activity could be delegated to carers who were identifying resident needs. There was some evidence of resident engagement but this was often a three-way process between resident, GP and family or resident, carer and nurse. A percentage of medication that could have been PRN were routinely prescribed. Observations also identified that nurses would decide not to administer routine medication in certain circumstances and that this was directly related to their assessment of the resident. The process of medication management was dominated by the regulations and governance processes of the care home. Observations and interviews found that care home staff recognised and affirmed residents' pain but did not take action for analgesia to be administered. They were familiar with the use of pain assessment tools for older people living with dementia and had received training in dementia care. Many of the staff were also able to interpret signs and symptoms of a resident's distress. Nevertheless, their preoccupation with meeting internal and external regulator standards was a barrier to addressing residents' needs. This is the first study that has looked at an aspect of medication management to understand how nurses and care home staff work for and with residents to moderate and address their health care needs. It suggests that additional training in aspects of medication management and resident assessment may not be able to address deeper seated issues of autonomy and how the nursing role is understood and enacted in care home settings.

Medication management is important and very complex part of health care, which is ensured by many healthcare professionals. Intensive care specifics include not only extensive pharmacotherapy but also the administration of medication that can directly and very promptly affect vital signs. This fact brings huge demands on safety during providing care. Traditionally, it is assumed the medication is prescribed by physician, and the nurse ensure administration based on physician?s detailed written prescription. However, activities related to this part of healthcare are currently much more complex. The nurses are expected to be fully competent to fulfil their role in this area at the point of graduation, even in the specialized environment. In addition, it seems that the formal nurses? competencies in medication management are not, in spite of heavy regulation, clearly specified. Although the close relationship between medication management and quality of provided healthcare is obvious, the role of nurses including expected and required demands of current practice have not been analysed in detail yet. The aim of the thesis was to analyse the competencies and nursing role in medication management at intensive care units.Mixed methods design was chosen. Quantitative techniques were used to analyse extent of education and nurses? knowledge in this area, and qualitative techniques were used to analyse current practice and requirements on competence of nurses. There is no difference in formal nurses? clinical competencies in the field of medication management in the Czech Republic depending on the level of education. There is also no difference in extent of pharmacology education during qualifying study at diploma and degree level. However, the current practice in medication management at intensive care units is hugely multifaceted. In some respects its demands greatly exceed the expectations that can be derived from formal set of nurses? clinical competencies in medication management. Although the previous medical doctor?s prescription, especially in case of medication with systemic effect, is considered to be the necessity, the experience of administering this medication in certain circumstances without previous medical doctor?s prescription has been also described. Patient assessment and dose titration of certain medication according to its effect or e.g. laboratory values were described as relatively common part of complex nursing care at this type of workplace, as well as adherence to specific procedures during administration. Particular procedures were workplace related and varied among units but the importance of quality of care was emphasized. The administration of topical medication in specific circumstances, such as eye, oral or skin care in patients with decreased level of consciousness, was perceived more as basic nursing care than medicine administration. However further research will be necessary to verify the extent of this practice. The nurses? knowledge in medication management varied according to the specific topic, but also according to the level of education or previous work experience including previous practice at intensive care environment, although formal competencies in medication management do not differ. Due to the complexity of the medication management and increasing demands on the competence of all healthcare professionals including nurses, it is essential to consider a fundamental revision of the formal nurses? competencies to be necessity at least in this area. Consequently, it could be possible to address the scope, form and content of nursing pharmacology education so that set requirements are met.

Les hôpitaux sont confrontés à des contraintes économiques fortes et à des exigences de plus en plus élevées en termes de qualité et de sécurité des soins. La prise en charge médicamenteuse est également soumise à ces contraintes d'autant qu'elle relève d'un processus complexe pluriprofessionnel et présentant également des enjeux économiques et sociétaux importants. Afin de répondre à ces difficultés, une solution pourrait être la réorganisation des processus et la relocalisation des ressources grâce aux démarches d'amélioration de processus issues du génie industriel. Le Lean, une approche d'amélioration des processus métiers mise au point dans les années 90 par les chercheurs du Massachussetts Institute of Technology, consiste à optimiser la valeur pour le patient tout en minimisant les gaspillages et en recherchant l'excellence opérationnelle à travers l'amélioration continue. Des résultats encourageants consécutifs à l'utilisation de cette approche en milieu hospitalier ont déjà été rapportés. Cependant, une analyse approfondie de la littérature a montré qu'aucune des démarches Lean décrites dans la littérature n'était construite de manière à fournir un support méthodologique robuste permettant d'entreprendre une démarche Lean pour l'amélioration des processus métiers à l'hôpital. Face à ce constat, nous proposons une méthode Lean pour l'amélioration des processus métier, structurée et adaptée au milieu hospitalier, basée sur une triangulation entre données de la littérature, entretiens semi-dirigés et un cas d'étude. Cette méthode a été validée sur le site de l'hôpital Antoine Béclère lors d'un projet d'amélioration du processus de prise en charge médicamenteuse. Son application a entre autre permis d'améliorer la qualité, la sécurité et l'efficience de la prise en charge médicamenteuse en Médecine Adulte Polyvalente. / Hospitals are facing strong economic constraints and increasing requirements in terms of quality and safety of care. Medication management, a complex and multi-professional process with major economic and social issues, is also subject to these constraints. To address these difficulties, a solution could be to reorganize processes and relocate resources through the use of industrial engineering Business Process Improvement approaches. Lean is a Business Process Improvement approach developed in the 90s by researchers of the Massachusetts Institute of Technology. It aims at maximizing the value for the patient while minimizing waste and seeking operational excellence through continuous improvement. Many encouraging results related to the use of this approach in hospitals have been reported. However, a thorough analysis of the literature showed that none of the Lean approaches described in the literature was structured to provide sufficient methodological to perform a Lean journey aiming at improving business process in hospitals. This is why we propose a Lean method to improve business processes in hospitals based on a triangulation between literature data, semi-structured interviews and a case study. This method was tested and validated in the Antoine Béclère hospital where quality, safety and efficiency of the medication management process in a medicine unit were improved.

Bakgrund: Patienter inom intensivvården sviktar oftast i flera organsystem. Miljön inom intensivvården är stressfull, högteknologisk och intensivvårdssjuksköterskan måste alltid finnas tillgänglig. Inom intensivvårdssjuksköterskans ansvarsområde ligger läkemedelshantering. Tidigare forskning har visat att frekvensen av feladministrerade läkemedel är högre inom intensivvården än övrig sjukvård, dock saknas det tidigare forskning om läkemedelshantering på vårdsal inom intensivvården. Syfte: Syftet med denna studie är att belysa intensivvårdssjuksköterskors erfarenheter av fördelar och risker med läkemedelshantering på vårdsal. Metod: En fokusgruppsintervju genomfördes på en intensivvårdsavdelning i Mellansverige och en kvalitativ innehållsanalys, inspirerad av Graneheim och Lundman, användes för att analysera materialet. Resultat: Distraktion, trängsel, bristande hygien och ett behov av att visa hänsyn till patienten gjorde att arbetsmiljön inte var optimal. Trots detta var intensivvårdssjuksköterskorna positiva till läkemedelshantering på vårdsal. Att hantera läkemedel bedside gav intensivvårds-sjuksköterskorna en överblick som de upplevde ökade patientsäkerheten. Deltagarna upplevde dock att det tog tid att vänja sig med detta. Slutsats: Resultatet visar att läkemedelshantering på vårdsal inte är helt enkelt, speciellt inte för den oerfarna intensivvårdssjuksköterskan. Med tiden vande sig intensivvårdssjuksköterskorna med arbetsmiljön. Det upplevdes då som en fördel, patientsäkerhetsmässigt, att bereda läkemedel på vårdsal. Detta då de ständigt kunde vara nära patienten, dock upplevde intensivvårdssjuksköterskorna att det fanns flera faktorer i arbetsmiljön som inte var optimala. Klinisk betydelse: Denna studie belyser fördelar och risker med läkemedelshantering på vårdsal. Studien kan vidare ligga till grund för förbättringsarbete inom patientsäkerhet och läkemedelshantering på berörd avdelning och vidare forskning i ämnet. Detta är något som saknas i dagsläget. / Background: Patients in critical care often falters in multiple organ systems. The environment in critical care is stressful, high-tech and the critical care nurse must always be available. Within the critical care nurses responsibility lays medication management. Previous research has shown that the frequency of incorrectly administrated drugs is higher in critical care than other health care settings, however, there is no previous research on medication management at the bedside in intensive care. Aim: The aim of this study is to highlight critical nurses’ experiences of the benefits and risks of medication management bedside. Method: A focus group interview was conducted in an intensive care unit in Mid Sweden and a qualitative content analysis, inspired by Granheim and Lundman, was used to analyze the material. Results: Distraction, overcrowding, lack of hygiene and the need to show respect to the patient contributed to that the work environment was not optimal. Despite this, critical care nurses were in favor of medication management bedside. Preparing drugs at the bedside gave the critical care nurses an overview that they experienced increased patient safety. Although the participants felt that it took a while to get used to this. Conclusion: The results show that bedside medication management is not entirely easy, especially not for the novice critical care nurse. Over time, the critical care nurses got used to the work environment. Preparing drugs at the bedside was perceived as a benefit in terms of patient safety, this because they always could be close to the patient. However, the critical care nurses felt that there were several factors in the work environment that was not optimal. Clinical relevance: This study highlights the benefits and risks of medication management at the bedside. The study can form the basis for improvements in patient safety and medication management on the affected ward and also further research on the subject. This is something that is missing at this date.

Medication is vital in treating chronic disease. Increasing use of medication, however, can lead to (potentially preventable) medication-related adverse events. Medication management offers a means of addressing such adverse events and pharmacists have an important role in this solution, especially in terms of reviews of patient medication. Improved availability and sharing of patient-related information are critical factors in medication management, so that providing access to this information becomes a major factor in effective medication reviews. Although clinical decision support tools can significantly assist doctors in accessing relevant point-of-care information for greater patient safety, it has proven difficult to ensure the availability and appropriate structure of patient-related information for such support tools. These information access and input problems are further exacerbated by a lack of existing research into suitable decision support solutions for pharmacists. This research project explored the suitability of an essential information model to support an electronic document solution to support clinical documentation and allow effective communication between pharmacists and doctors for medication reviews. The project investigated whether this approach could improve safety, quality and efficiency in the medication review process; as well as more generally identifying factors influencing development and uptake of document-based support tools in the Health sector. The project used a qualitative Design Research approach and iterated through three scenarios. The first, information-rich, hospital scenario developed an information model of essential medication management components, which underpinned the development of a digital document prototype implemented using XForms technology. In the second scenario, accredited pharmacists evaluated the digital document to enable refinement of the information model and its associated digital document for the broader community context. The third scenario involved field studies which evaluated the digital document (and thus the underlying information model) within the community, assessing its contribution to quality, safety and efficiency throughout the medication review process. The investigation identified a number of themes which guided design and development of the prototype; and which appeared likely to have a broader impact on successful uptake of decision support tools. Missing information proved to be a constant and serious problem for health professionals although, in this project, it also became a way of determining the value of an information element and thus its inclusion in the information model. Conversation played a significant role in the hospital environment to help supply pharmacists information needs. Information granularity, the language of health professionals; and their time constraints were major factors influencing design. Health professionals extensive use of their personal knowledge also suggested decision support tools in this sector should be systems for experts rather than expert systems, i.e. the decision support tool and its users personal knowledge should complement one another. The results of this proof-of-concept project suggest practice improvement in medication management is possible, with perceived improvements in safety, quality and efficiency of the medication management process. These benefits, however, now need to be affirmed in larger field studies. The contributions of this research are two-fold: firstly, it is possible to develop a model of essential medication-related information which is succinct, relevant and can be understood and shared by health professionals in conjunction with the individuals personal knowledge. Secondly, a document metaphor is a natural fit with health professionals for representing and communicating information. Expressing this metaphor as digital document overcomes the main problems of paper-based documents sharing and communication; and the dynamic properties of digital documents assist in decision-making.