To identify medicine information needs of patients and explore differences in information needs between different disease groups of patients.
Semistructured interviews with general medical patients selected via convenience sampling.
Patients were recruited while inpatients during a hospital stay or as outpatients attending a specific clinic at the hospital.
Patients’ responses to standardised data-collection tools, including previously validated scale, the Extent of Information Desired scale (EID) to identify their information needs.
Data from interviews with 1717 patients were included in the analysis. Each item on the EID scale was scored on a Likert scale (from 1 to 5). The internal consistency of the scale in this sample was good (coefficient = 0.78). Scores to the EID scale correlated with age and socio-demographic variables. The extent of information desired positively correlated with socio-economic status (Pearson’s r = 0.29, p<0.001). The extent of information desired negatively correlated with the patient’s age (Pearson’s r = –0.32, p<0.001), implying that medicine-information desires decreases with age. Subsequently, significant differences were found in the extent of information desired between disease categories, which remained significant when controlling for age (ANCOVA, F6,1703 = 26.04, p<0.001, partial
These findings suggest that the diagnosis and disease have a significant bearing on patients’ medicine-information desires and recommend that healthcare professionals view patients as individuals when providing information that meets their needs. It will be important for healthcare professionals to identify and understand that patients with different diseases have different desires for information about their disease and their drugs which may influence the way they take their medicines and subsequently the ways we manage their long-term disease. We need to determine if the EID scale is an efficient and effective way to identify patients’ desires for drug information and a useful tool for practitioners to effectively target interventions in healthcare provision over time.
One in 10 patients admitted to hospital will suffer an adverse event as a result of their medical treatment. A reduction in adverse events could happen if patients could be engaged successfully in monitoring their care.
This study explored: (1) surgical patients’ willingness to question healthcare staff about their treatment; (2) differences between patients’ willingness to ask factual vs. challenging questions related to the quality and safety of their healthcare; (3) patient demographic characteristics that could affect patients’ willingness to ask questions; and (4) the impact of doctors’ instructions on patients’ willingness to ask questions.
Cross-sectional study using the Patient Willingness to Ask Safety Questions Survey (PWASQS). The PWASQS questions were devised in accordance with current patient safety initiatives aimed at encouraging patients to ask healthcare staff specific safety-related questions about their healthcare. The PWASQS includes factual questions (eg, "when can I return to my normal activities?") and challenging questions (eg, "have you washed your hands?"), and examines the impact of doctors’ instructions on patients’ willingness to ask challenging questions (eg, if instructed to by a doctor would you be willing to ask: "have you washed your hands?"). Data were analysed using non-parametric tests.
An inner-city London teaching hospital.
A convenience sample of 80 patients who had undergone surgery.
Surgical patients were significantly more willing to ask: doctors factual versus challenging questions (z = 7.59, p<0.001); nurses factual versus challenging questions (z = 5.39, p<0.001); doctors versus nurses factual questions (z = 4.98, p<0.001); and, nurses versus doctors challenging questions (z = 4.40, p<0.001). Doctor’s instructions to the patient increased patient willingness to challenge doctors (z = 6.56, p<0.001) and nurses (z = 6.15, p<0.001).Women, educated patients, and patients in employment, were more willing to ask questions (p<0.05).
Surgical patients, particularly those who are men, less educated or unemployed are less willing to challenge healthcare staff regarding their care than to ask healthcare staff factual questions. Patient involvement strategies which take into account patient characteristics need to be developed for patients and staff in order to encourage patient involvement in this much neglected area.
To determine patient preferences for information and for participation in decision-making, and the determinants of these preferences in patients recently admitted to an acute hospital.
Prospective questionnaire-based study.
Medical wards of an acute teaching hospital.
One hundred and fifty-two consecutive acute medical inpatients, median age 74 years.
Standardised assessment included abbreviated mental test and subjective measure of severity of illness. Patients’ desire for information was assessed using a 5-point Likert scale, and their desire for a role in medical decision-making using the Degner Control of Preferences Scale.
Of the 152 patients, 93 (61%) favoured a passive approach to decision-making (either "leave all decisions to the doctor" or "doctor makes final decision but seriously considers my opinion." In contrast, 101 (66%) patients sought "very extensive" or "a lot" of information about their condition. No significant effects of age, sex, socio-economic group or severity of acute illness on desire for information or the Degner scale result were found. There was no agreement between patients’ preferences on the Degner scale and their doctors’ predictions of those preferences.
Acute medical inpatients want to receive a lot of information about their illness, but most prefer a relatively passive role in decision-making. The only way to determine individual patient preferences is to ask them; preferences cannot be predicted from clinical or sociodemographic data.
The subjective experiences of patients with little or no English who either attended the Emergency Department or were admitted to the wards of a tertiary referral hospital were explored.
The reports of experiences from 49 patients of a tertiary referral hospital were analysed using grounded theory methods applied to translated transcriptions from focus groups held with discharged patients in seven languages.
Inability to communicate in English, poor patient and family involvement with staff, a lack of control or powerlessness, staff shortages, staff negligence or incompetence, and treatment delays were reported by some patients. Others tended to discount or minimise the significance of similar experiences, suggesting a construct, "The Happy Migrant Effect," in which there is reluctance to assert healthcare rights. Patients appear "happy" and satisfied, despite problems with their hospital care. Explanatory factors for the construct include extreme powerlessness related to being unable to communicate, a positive comparison of healthcare in the new country compared with the old, patriotism for the new country, cultural norms that proscribe acceptance, politeness or social desirability, self-denigration for not having learnt English and, for a few, a fear of reprisals if they spoke out in complaint.
Some immigrant patients with poor language skills might not report serious problems with healthcare delivery. In all patients in this study where problems with healthcare were reported, the events were considered to be largely preventable by appropriate language facilitation, patient and family involvement, and provider respect and compassion.
Falls are the most frequently reported adverse event among frail nursing home residents and are an important resident safety issue. Incident reporting systems have been successfully used to improve quality and safety in healthcare. The purpose of this study was to test the effect of a systematically guided menu-driven incident reporting system (MDIRS) on documentation of post-fall evaluation processes in nursing homes.
Six for-profit nursing homes in southeastern USA participated in the study. Over a 4-month period, MDIRS was used in three nursing homes matched with another three nursing homes which continued using their existing narrative incident report to document falls. Trained geriatric nurse practitioner auditors used a data collection audit tool to collect medical record documentation of the processes of care for residents who fell. Multivariate analysis of covariance was used to compare the post-fall nursing care processes documented in the medical records.
207 medical records of resident who fell were examined. Over 75% of the sample triggered at high risk for falls by the minimum data set. An adequate neurological assessment was documented for only 18.4% of residents who had experienced a fall. Although two-thirds of the sample had a diagnosis of incontinence, less than 20% of the records had incontinence-related interventions in the nursing care plan. Overall, there was more complete documentation of the post-fall evaluation process in the medical records in nursing homes using the MDIRS than in nursing homes using standard narrative incident reports (p<0.001).
Further improvements are necessary in reporting mechanisms to improve the post-fall assessment in nursing home residents.
To explore the causes of preventable drug-related admissions (PDRAs) to hospital.
Qualitative case studies using semi-structured interviews and medical record review; data analysed using a framework derived from Reason’s model of organisational accidents and cascade analysis.
62 participants, including 18 patients, 8 informal carers, 17 general practitioners, 12 community pharmacists, 3 practice nurses and 4 other members of healthcare staff, involved in events leading up to the patients’ hospital admissions.
Nottingham, UK.
PDRAs are associated with problems at multiple stages in the medication use process, including prescribing, dispensing, administration, monitoring and help seeking. The main causes of these problems are communication failures (between patients and healthcare professionals and different groups of healthcare professionals) and knowledge gaps (about drugs and patients’ medical and medication histories). The causes of PDRAs are similar irrespective of whether the hospital admission is associated with a prescribing, monitoring or patient adherence problem.
The causes of PDRAs are multifaceted and complex. Technical solutions to PDRAs will need to take account of this complexity and are unlikely to be sufficient on their own. Interventions targeting the human causes of PDRAs are also necessary—for example, improving methods of communication.
Registered nurses have a vital role in discovering and correcting medical error.
To describe the type and frequency of errors detected by American critical care nurses, and to ascertain who made the errors discovered by study participants.
Daily logbooks were used to collect information about errors discovered by a random sample of 502 critical care nurses during a 28-day period.
Although the majority of errors discovered and corrected by critical care nurses involved medications (163/367), procedural errors were common (n = 115). Charting and transcription errors were less frequently discovered. The errors discovered by participants were attributed to a wide variety of staff members including nurses, doctors, pharmacists, technicians and unit secretaries.
Given the importance of nurses in maintaining patient safety, future studies should identify factors that enhance their effectiveness to prevent, intercept and correct healthcare errors.
Little is known regarding how internal medicine residents manage uncertainty during decision making and subsequent effects on patient care. The aims of this study were to describe types of uncertainty faced by residents, strategies employed to manage uncertainty and effects on patient care.
Using critical incident technique, residents were asked to recall important clinical decisions during a recent call night, with probes to identify decisions made during uncertainty. They were also asked to report who they approached for advice. Three authors independently coded transcripts using the constant comparative method.
The 42/50 (84%) interviewed residents reported 18 discrete critical incidents. Six categories emerged and mapped to the domains of the Beresford Model of Clinical Uncertainty: technical uncertainty (procedural skills, knowledge of indications); conceptual uncertainty (care transitions, diagnostic decision making and management conflict) and personal uncertainty (goals of care). In managing uncertainty, residents report a "hierarchy of assistance", using colleagues and literature for initial management, followed by senior residents, specialty fellows and, finally, the attending physician. Barriers to seeking the attending physician’s input included the existence of a defined hierarchy for assistance and fears of losing autonomy, revealing knowledge gaps, and "being a bother". For 12 of the 18 cases reported, patient care was compromised: delay in procedure or escalation of care (n = 8); procedural complications (n = 2); and cardiac arrest (n = 2).
Resident uncertainty results in delays of indicated care and, in some cases, patient harm. Despite the presence of a supervisory figure, residents adhere to a hierarchy when seeking advice in clinical matters.
To examine staff perceptions of teamworking practice in the field of stroke care.
Qualitative interview study.
Three teams providing care to patients with stroke across a typical care pathway of acute hospital ward, specialist stroke unit, and community rehabilitation.
37 staff members from a range of professions.
Healthcare staff perceptions of teamworking.
Through detailed coding and analysis of the transcripts, five perceptions regarding the impact of teamworking on staff and patients were identified. These were: (1) mutual staff support, (2) knowledge and skills sharing, (3) timely intervention/discharge, (4) reduced individual decision-making and responsibility and (5) impact on patient contact time.
Teamworking practice may be associated with a number of perceived benefits for staff and patient care; however, the potential for losses resulting from reduced patient contact time and ill-defined responsibility needs further investigation.
The performance of NHS research ethics committees (RECs) is of growing interest. It has been proposed that they confine themselves to "ethical" issues only and not concern themselves with the quality of the science. This study aimed to identify current practices of RECs in relation to scientific issues in research ethics applications.
Letters written by UK RECs expressing provisional or unfavourable opinions in response to submitted research applications were sampled from the research ethics database held by the Central Office for Research Ethics Committees. Ethnographic content analysis (ECA) was used to develop a coding framework. QSR N6 software was used to facilitate coding.
"Scientific issues" were raised in 104 (74%) of the 141 letters in our sample. The present data suggest that RECs frequently considered scientific issues and that judgments of these often informed their decisions about approval of applications. Current processes of peer review seemed insufficient to reassure RECs about the scientific quality of applications they were asked to review.
This study provides evidence that scientific issues are frequently raised in letters to researchers and are often considered a quality problem by RECs. In the discussion, the authors reflect on how far issues of science can and should be distinguished from those of ethics and the policy implications.
In paediatric inpatients, medication errors occur as frequently as 1 in 4.2 drug orders, with up to 80% of these being prescribing errors.
The children’s unit of a district general hospital in West Yorkshire, UK.
Prescribing errors and preventable adverse drug events
(1) The introduction of a junior doctor prescribing tutorial. (2) The introduction of a bedside prescribing guideline.
The introduction of the junior doctor prescribing tutorial decreased the prescribing errors by 46%. The introduction of a bedside prescribing guideline did not decrease prescribing errors but may have been helpful to those doctors unable to attend a prescribing tutorial.
By investing time and providing appropriate written resources, we have been able to reduce our paediatric prescribing errors on the children’s ward by almost half.