Kan, Ka Lai Carrie. / "May 2008." / Thesis (M.Phil.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves 118-125). / Abstracts in English and Chinese, some text in appendix also in Chinese. / Chapter CHAPTER 1: --- INTRODUCTION --- p.1 / Chapter CHAPTER 2: --- LITERATURE REVIEW / Introduction --- p.3 / Medication error --- p.4 / Definition of medication error --- p.4 / Incidents of medication error --- p.6 / The issues of defining medication error --- p.7 / The issue of medication error reporting --- p.8 / Near miss --- p.9 / Factors associated with medication error --- p.10 / System factors --- p.10 / Environmental factors --- p.12 / Human factors --- p.13 / Slips and lapses and medication error --- p.14 / "Distraction, slips and lapses and medication error" --- p.15 / Distraction --- p.15 / Definition of distraction --- p.15 / Consequences of distraction --- p.16 / Factors associated with distraction --- p.16 / Cognitive factors --- p.17 / Personality factors --- p.18 / Environmental factors --- p.18 / Studies on distraction during medication administration --- p.19 / Distraction and medication error --- p.21 / Strategies to reduce distraction --- p.22 / Visual Sign --- p.23 / Definition of visual sign --- p.23 / Nature of visual sign --- p.24 / Studies on visual sign to reduce distraction --- p.25 / Summary of literature review --- p.25 / Chapter CHAPTER 3: --- METHODOLOGY / Introduction --- p.27 / Aims and objectives --- p.27 / Operational definitions --- p.28 / Research design --- p.28 / Setting --- p.31 / Stage one --- p.32 / Setting --- p.32 / Sampling --- p.33 / Instrument --- p.35 / Data collection method --- p.36 / Data analysis --- p.37 / Stage two --- p.38 / Stage three --- p.40 / Pilot study --- p.40 / Validity and reliability of methodology --- p.41 / Interview --- p.41 / Observation --- p.42 / Ethical considerations --- p.43 / Chapter CHAPTER 4: --- FINDINGS / Introduction --- p.44 / Stage one --- p.44 / Baseline interview --- p.44 / Informants' characteristics --- p.44 / Categories and sub-categories --- p.45 / Feelings of medication error --- p.46 / Causes of medication error --- p.47 / Causes of distraction --- p.49 / Perception of distraction --- p.50 / Feelings about distraction --- p.52 / Strategies to reduce distraction --- p.53 / Strategies to reduce medication error --- p.54 / Baseline observation --- p.56 / Findings of stage one --- p.59 / Stage two --- p.60 / One week after implementation observation --- p.60 / Findings of stage two --- p.63 / Stage three / Three months after implementation observation --- p.63 / Follow-up interview --- p.66 / Informants' characteristics --- p.66 / Categories and sub-categories --- p.67 / Conflicting feelings --- p.68 / Different effects on nursing service --- p.69 / Feelings about wearing the red vest --- p.70 / Enhanced a non-distractive culture --- p.72 / Improved cognitive process --- p.73 / Improved performance --- p.75 / Findings of stage three --- p.76 / Comparison of the three stages of quantitative observational data --- p.77 / "Lapse time, items given, and number of patients" --- p.77 / Comparison of lapse time and total distraction --- p.78 / Comparison of the ten items on distraction --- p.78 / Comparison of total distraction --- p.79 / Comparison of near misses --- p.80 / Overall Summary of the findings --- p.80 / Chapter CHAPTER 5: --- DISCUSSION / Introduction --- p.82 / Characteristics of informants and observational data --- p.82 / Nurseśة perception of distraction as a cause of medication administration error --- p.83 / Causes of distraction during medication administration --- p.87 / Evaluation outcome --- p.91 / Evaluation process --- p.98 / Chapter CHAPTER 6: --- "LIMITATIONS, IMPLICATIONS AND RECOMMEDATIONS" / Limitations --- p.111 / Setting --- p.111 / Population and sampling --- p.111 / Observer's influence --- p.112 / Interviewer's influence --- p.112 / Implications for nursing practice --- p.113 / Recommendations for future studies --- p.114 / Conclusion --- p.116 / REFERENCES --- p.118 / APPENDICES / Chapter 1: --- Literature search --- p.126 / Chapter 2: --- Medication Administration Distraction Observation Sheet (MADOS) --- p.127 / Chapter 3: --- Adapted MADOS --- p.128 / Chapter 4: --- Baseline interview guide --- p.129 / Chapter 5: --- Interview consent form --- p.130 / Chapter 6: --- Observation consent form --- p.136 / Chapter 7: --- Informal letter to nursing staff --- p.142 / Chapter 8: --- Follow-up interview guide --- p.144 / Chapter 9: --- Rationale for pilot study --- p.145 / Chapter 10: --- Ethical approval (CUHK) --- p.147 / Chapter 11: --- Ethical approval ( Hospital Administrative Council) --- p.148 / Chapter 12: --- Baseline interview (1) --- p.149 / Chapter 13: --- Baseline observation (MAC 4) --- p.154 / Chapter 14: --- One week after observation (MAC 01) --- p.155 / Chapter 15: --- Three months after observation (MAC 005) --- p.156 / Chapter 16: --- Follow-up interview (08) --- p.157 / TABLES / Chapter 1: --- Different units and the approximate numbers of nurses --- p.30 / Chapter 2: --- Proposed sample size for baseline interview --- p.33 / Chapter 3. --- Medication administration at different scheduled time --- p.35 / Chapter 4. --- Informantśة characteristics at baseline interview --- p.45 / Chapter 5: --- Categories and subcategories: baseline interview --- p.46 / Chapter 6: --- "Elapse time, items given, number of patients, distractions and near misses at baseline observation" --- p.57 / Chapter 7: --- Frequency of the ten items of distraction at baseline observation --- p.57 / Chapter 8: --- Ranking of the ten items on distraction at baseline observation --- p.58

Parkinson' Disease (PD) is a motor disorder characterized by rigidity, tremor, and hypokinesia with secondary manifestations like defective posture and gait, mask like face and dementia. Over the years it may lead to inability to move, breath and ultimately patient may succumb to chest infection and embolism. Prevalence studies show that more than six million people around the world suffer from PD. At present, there is no cure for PD but there are effective treatments that can slow the progression of the disease and regulate its affects. PD results from a deficiency of dopamine so most drugs that produce a salutary effect in PD either potentiate dopamine or work as dopamine agonists. Hence, to keep the symptoms of PD to a minimum it is very important that the medications be consumed regularly, so that the dopamine level is maintained in the body of the subject. Electronic pillbox logger is a device that has been designed to ensure this very much required medication adherence in PD subjects, which can also be used to measure the response to oral medication. This work describes the design and implementation of an electronic pillbox logger for use by people suffering from Parkinson's disease (PD). The pillbox logger is designed to track medication adherence and prompt the user to take medication on time. It is pocket-sized, portable, and compartmented. It has a variety of alarm systems to remind the user to take the correct dose of their medication at the correct time. Most importantly, it keeps an electronic log of the time of dosage consumption by detecting the presence/absence of pills in the pillbox. This overcomes major limitations of other pillboxes with a logging function that are often too large to carry, contain a single compartment, or only record the time the container was opened rather than the presence or absence of pills. The proposed pillbox logger complements a wearable device under development for people with Parkinson's disease that continuously monitors impaired movement. The combination of the pillbox logger with the wearable sensor will permit clinicians to determine the response to oral therapies, which can be used to optimize therapy. People with PD consume similar pills throughout the day hence the pillbox logger has been designed to detect the presence/absence of pills in general in the pillbox rather than which specific pills are absent or present in the pillbox logger. This feature of the current design that the device records knowledge about pills in general in the pillbox logger and not about any specific pills is a major reason why the current design is specific to PD subjects only. However, though the current design of the pillbox logger is designed for people with Parkinson's Disease, the pillbox is suitable for other maladies in which the timing of the medication is critical. The described pillbox logger was built and the design was validated after running a number of tests. The battery powered pillbox logger is able to accurately store the information about the actual presence/absence of pills in each compartment of the pillbox. It is capable of sending out reminder alarms at the right time of the day and can be connected to a host computer using a USB cable to read the stored information from it. The proper functional working of the pillbox logger after thorough testing proves that the design of pillbox logger was successful.

Det övergripande syftet med den här avhandlingen har varit att, inom området läkemedelsinformatik, studera utvecklingen av elektroniska stöd inom läkemedelsförskrivning; för klinisk praxis, uppföljning och forskning. Under århundraden har det handskrivna receptet varit det sätt, med vilket läkare förmedlat sina läkemedelsordinationer till apotekare, vilket också för patienten blivit en informationskälla för hur läkemedel ska användas för att göra bästa nytta. Nu genomgår receptet en förändring från pappersbaserat till elektroniskt meddelande och att anpassa en traditionell process till en ny elektronisk era innebär både möjligheter och utmaningar. Studierna som ingår i avhandlingen har visat att exponeringen av förskrivna läkemedel i en allmän befolkning har ökat under de senaste tre decennierna. Risken för potentiella interaktioner mellan läkemedel, varmed avses den risk som finns att olika läkemedel kan påverka varandras effekter och biverkningar, har också visat sig öka starkt desto fler läkemedel som används av en individ. Denna ökade samtidiga användning av flera olika läkemedel, så kallad polyfarmaci, medför att det finns en större anledning för förskrivare och farmacevter att uppmärksamma risken för potentiella interaktioner mellan läkemedel. De nyinrättade nationella receptregistren över uthämtad receptförskriven medicin bör användas bland annat för att upptäcka potentiella läkemedelsinteraktioner, såväl i vårdens utövning som inom läkemedelsepidemiologisk forskning. Den svenska läkemedelsförteckningen, som omfattar information om uthämtade receptförskrivna läkemedel för huvuddelen av den svenska befolkningen, bedöms ha en stor klinisk potential. Den enskilde individens historiska information om uthämtade läkemedel är tillgänglig för individen på Internet med hjälp av e-legitimation; även förskrivare och farmacevter på apotek kan ta del av informationen med den enskildes samtycke. Brist på tillgång till enhetliga och säkra autenticeringsmetoder inom hälso- och sjukvården kan dock fördröja tillgången på individuell läkemedelsinformation för förskrivare. I och med att de flesta recepten i Sverige nu skrivs och överförs elektroniskt är det viktigt att kvalitetsmässiga aspekter tas tillvara så att en iakttagen ökad risk för receptförskrivningsfel inte överförs i informationskedjan. Avhandlingens slutsats är att e-förskrivning, med kommunikation och användning av lagrad information om receptexpeditioner, möjliggör att läkemedelsbehandling som process kan följas och studeras på ett helt nytt / The thesis aimed to study the developments, in the area of pharmacoinformatics, of the electronic prescribing and dispensing processes of drugs - in medical praxis, follow-up, and research. For hundreds of years, the written prescription has been the method of choice for physicians to communicate decisions on drug therapy and for pharmacists to dispense medication. Successively the prescription has also become a source of information for the patient about how to use the medication to maximize its benefit. Currently, the medical prescription is at a transitional stage between paper and web, and to adapt a traditional process to the new electronic era offers both opportunities and challenges The studies in the thesis have shown that the exposure of prescribed drugs in the general population has increased considerably over three decades. The risk of receiving potentially interacting drugs was also strongly correlated to the concomitant use of multiple drugs, polypharmacy. The pronounced increase in polypharmacy over time constitutes a growing reason for prescribers and pharmacists to be aware of drug interactions. Still, there were relatively few severe potential drug interactions. Recently established national prescription registers should be evaluated for drug interaction vigilance, both clinically and epidemiologically. The Swedish National Pharmacy Register provides prescription dispensing information for the majority of the population. The medication history in the register may be accessed online to improve drug utilization, by registered individuals, prescribers, and pharmacists in a safe and secure way. Lack of widespread secure digital signatures in healthcare may delay general availability. With a relatively high prevalence of dispensed drugs in the population, the National Pharmacy Register seems justified in evaluating individual medication history. With a majority of prescriptions transferred as ePrescriptions, the detected increased risk for prescription errors warrants quality improvement, if the full potential of ePrescriptions is to be fulfilled. The main conclusion of the studies was that ePrescribing with communication of prescribed drug information, storing and retrieving dispensed drug information, offers new opportunities for clinical and scientific

Indiana University-Purdue University Indianapolis (IUPUI) / Medication administration error remains a leading cause of preventable death. A gap exists in understanding attentional dynamics, such as nurse situation awareness (SA) while managing interruptions during medication administration. The aim was to describe SA during medication administration and interruption handling strategies. A crosssectional, descriptive design was used. Cognitive task analysis (CTA) methods informed analysis of 230 interruptions. Themes were analyzed by SA level. The nature of the stimuli noticed emerged as a Level 1 theme, in contrast to themes of uncertainty, relevance, and expectations (Level 2 themes). Projected or anticipated interventions (Level 3 themes) reflected workload balance between team and patient foregrounds. The prevalence of cognitive time-sharing during the medication administration process was significant or may be remarkable. Findings substantiated the importance of the concept of SA within nursing as well as the contribution of CTA in understanding the cognitive work of nursing during medication administration.