Introducing multifactorial quality improvement into the medicine supply services of Australian pharmacies and aged care facilities
thesisposted on 23.02.2017, 00:28 by Gilmartin, Julia Fiona-Maree
Australian community pharmacies frequently supply dose administration aids (DAAs) to residential aged care facilities (RACFs) to assist with medicine administration. These medicine organisers are packed manually or via automation, either onsite at the pharmacy or offsite by a DAA packing company. In all cases, medicines are removed from their original containers and packed into the DAA according to the medicine record of the RACF resident. Limited available literature indicates that the process of packing medicines into DAAs can be inaccurate or unsuitable, leading to DAA incidents. Targeted evidence-based interventions have not been developed, introduced and assessed to address these incidents. To improve the overall quality of medicine supply from community pharmacies to RACFs and specifically address these DAA incidents, a large-scale Australian study was needed to identify how widespread this problem is and propose strategies to address it. The overall aim of the study presented in this thesis was to evaluate how accurately and suitably medicines were packed into DAAs supplied by Victorian community pharmacies for RACF medicine administration. This study also aimed to develop, introduce and evaluate an evidence-based intervention, designed to reduce the occurrence of DAA incidents and improve the overall DAA medicine supply service. The study was conducted over four phases. Phase 1 of this study identified the types of DAA incidents and how frequently they occurred in Victorian DAAs. Cross-sectional DAA audits were conducted at 49 RACFs that were supplied DAAs from 40 community pharmacies in Victoria. A DAA incident included discrepancies between DAAs and medicine records, unsuitable medicine packing according to pharmaceutical guidelines, and medicines that were damaged, inappropriately altered or incorrectly divided. Of the 3,959 DAAs audited for 1,757 residents, 684 incidents involving 457 DAAs were identified (11.5% incident rate). The top five DAA incident types were unsuitable packing according to pharmaceutical guidelines (50.1% of all incidents identified), added medicine (9.8%), incorrect medicine quantity packed (5.4%), omitted medicine (5.3%) and damaged medicine (5.1%). This study phase confirmed the occurrence of DAA incidents, at a higher rate than previous research, and highlighted the need for an intervention to improve RACF standard of care. Phase 2 of this study identified health professionals’ perceptions regarding the types and frequencies of DAA incidents in their workplaces, as well as factors contributing to these incidents and strategies to reduce their occurrence. A questionnaire was sent by email or facsimile to one contact from all 49 RACFs and 14 of their affiliated community pharmacies (recruited pharmacies). Three focus groups were also conducted with six pharmacists, five nurses, a personal care assistant and a pharmacy technician, who were employees of the workplaces involved in Phase 1. Questionnaires were returned from 25 RACFs (51.0% response rate) and 12 pharmacies (85.7%). On average, RACF respondents perceived DAA incidents to occur more frequently (daily or weekly) than pharmacy respondents, who mostly perceived DAA incidents to occur monthly. The DAA incident types noted by respondents were similar to those identified in Phase 1. Four themes contributing to DAA incidents emerged from the focus groups, with strategies to reduce their occurrence aligned to these themes: medicine handling, communication, knowledge and awareness, and attitude. Constructive feedback was generated regarding researcher-suggested intervention strategies, including educational strategies, DAA guidelines and protocols, a pharmacist conducting additional DAA checks at the RACF, a stamp or bookmark to be used with medicine records, a communication logbook and sticker, and a medicine identification sheet. Of these, focus group participants did not universally identify one strategy that would improve the DAA medicine supply service and both advantages and disadvantages were outlined for each. It was also highlighted that the development and implementation of a multifactorial intervention would be more favourable than a single strategy, as it may increase the chance that at least one component may be useful for a specific workplace. A stakeholder-derived intervention was then developed, introduced and initially evaluated in Phase 3. The researcher-suggested intervention strategies from the second phase were refined using input from the research team and feedback from pharmacy and nursing organisations and focus group participants. The final intervention included a 30 minute education session and a 12 component toolkit, titled ‘Be alert and work together for medicine safety - DAA incident awareness toolkit.’ The toolkit included a guideline outlining what medicines should not be packed into DAAs, a research article concerning sodium valproate instability within DAAs, posters, bookmarks and stickers for the medicine record, a compact disk-read only memory (CD-ROM) with a presentation, a handout with the CD-ROM presentation slides, a question, answer and reflection handout, template certificates, a medicine identification sheet, a DAA incident policy and procedure, and DAA guidelines for the RACF or pharmacy workplace. The intervention was piloted in one RACF and one community pharmacy. It was later introduced to staff from 45 RACFs and 29 pharmacies that were involved in Phase 1. A questionnaire identified initial perceptions of the potential usefulness and effectiveness of the intervention. Four-hundred and thirty-five questionnaires were returned (85.0% response rate). Respondents believed the toolkit had the potential to reduce the occurrence of DAA incidents ‘very’ (49.6% of those who responded to this question) or ‘extremely’ well (20.5%), and felt that the education session was ‘very’ (46.6%) or ‘extremely’ (38.0%) useful. The intervention was evaluated both qualitatively and quantitatively in Phase 4. At least three months after the intervention was introduced at participating workplaces, the DAA audits were repeated at the 45 RACFs that were introduced to the intervention, to quantitatively assess whether the DAA incident rate identified in Phase 1 had decreased. Field notes also recorded which toolkit components were implemented. A questionnaire was sent by email or facsimile to one contact at each of the 45 RACFs and the 14 recruited community pharmacies to evaluate the perceived usefulness and effectiveness of the toolkit after it was implemented. Lastly, all of the DAA incidents identified in the Phase 1 and 4 DAA audits were classified according to their risk of causing an adverse event if they were transferred to the RACF resident. Of 2,389 DAAs audited from 39 pharmacies for 983 residents, 770 incidents involving 502 DAAs were identified (21.0% incident rate) in Phase 4. There was a significant increase in the DAA incident rate post-intervention compared to pre-intervention (p<0.001). Statistically significant increases occurred in the proportion of DAAs experiencing specific DAA incident types post-intervention, including added medicine, inaccurate medicine division, incorrect time interval and ‘other’ incidents (p<0.001). However, statistically significant decreases were seen in the frequency of specific incident types when compared to the total number of incidents identified, including unsuitable medicine packing according to pharmaceutical guidelines (p<0.001), incorrect medicine quantity (p<0.001), omitted medicine (p<0.001), incorrect medicine strength (p<0.05), incorrect tablet division (p<0.05) and incorrect medicine form (p<0.05). The poster was the most commonly implemented toolkit component and the survey identified generally positive feedback from health professionals regarding the toolkit. The majority of incidents identified post-intervention were also of a lower risk category, compared to those identified pre-intervention. This final phase identified that an intervention more specifically designed for the RACF or community pharmacy workplace and targeting specific DAA incident types, may be more successful at reducing the occurrence of DAA incidents and improving the DAA medicine supply service.