Definition: Organisational values, beliefs and practices surrounding the management of safety and learning from error.
Values and beliefs cannot be directly ascertained during observations, however, some cautious inferences can be drawn from these observations. Processes and individual behaviour observed at the ‘sharp-end’ can be indicative of the safety culture of an organisation. The two sites were observed to operate very different methods for managing medicines at discharge. Site 2 had an allocated ward pharmacist who would see each patient shortly before they were
discharged to highlight which medicines were new and which had been changed or discontinued, which potentially enhanced patients’ knowledge of their new medicines regimens and may prevent medicines errors once they were home. Site 1 also had an allocated ward pharmacist, who changed three times during the observation period. The pharmacist at Site 1 was less involved with the patient at discharge, even though they would have had a face-to-face interaction at some point during the patient’s hospitalisation.
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Site 2, like Site 1, had a discharge lounge where patients could wait for
transport, however medicines were always handed to the patient on the ward, usually by a member of staff who had been involved in their care. Medicines explanations to patients were usually given more emphasis on wards compared to the discharge lounge, where giving patients’ medicines seemed to be more process driven, aimed at completing the discharge rather than on the needs of the patient.
Defences
No defences were observed in this domain.
4.5 Discussion
This section has explored the various contributory factors to risk from medicines and defences that come into play when patients are discharged from hospital.
Contributory factors included:
• Active failures: execution failures, for example lapses; skill-based mistakes; and violations;
• Individual factors, such as staff attitudes to counselling patients;
• Patient factors, such as tiredness, frustration, becoming distracted and eagerness to return home;
• Team factors, such as waiting for colleagues to perform tasks;
• Task characteristics, such as the complex nature of discharging patients with medicines and internal patient transfer;
• Lines of responsibility, for example the responsibility for discharging individual patients;
• Staff workload, which may result in interruptions and limited time to conduct discharge conversations about medicines. Importantly, no defences were observed in this domain;
• Management of staffing levels, for example on some days large number of patients was discharged and staffing did not change accordingly;
• Communication systems, such as the ordering and internal delivery of medicines;
• Scheduling and bed management.
162 Defences included:
• Defences against active failures, such as using the discharge summary as a checklist;
• Patient factors, such as note-taking during the discharge and having relatives present;
• Individual factors, such as in-depth, person-centred conversations about medicines;
• Team factors, such as a ward pharmacist charting discharge progress;
• Equipment and supplies, such as medicines being available on the ward.
• Training and education, such as having staff who were knowledgeable about cardiology medicines (nurses and pharmacists) on the wards;
• Support from central functions, such as the presence of a ward pharmacist;
• Communication systems, such as giving patients a written list of their medicines.
It was clear that in some cases the safety of patients could be improved if the discharge took into account patients’ individual capabilities, for example a patient’s ability to take notes and absorb large amounts of complicated
information. Discharge with medicines was also sometimes conducted with staff who had no prior involvement in the patient’s care. Risk was introduced when team pressures affected the timing of discharge and the amount of time the staff member had to spend with the patient explaining their medicines. At one of the sites hospital policy had introduced an additional patient transfer to a discharge lounge to wait to be discharged. The rationale for this transfer off the ward was to free-up bed space once it had been decided that the patient was well enough to go home. It is possible that giving the patients their medicines is not seen as a core element of their care, rather it is a process that must be completed
before they can go home. The ward needs to see medicines as a central patient care issue with a demonstrable knock-on effect in primary care.
Using the YCFF as a framework to exploring the safety of discharging patients with medicines presented some difficulties. First of all the tool was compiled from a systematic review which explored the contributory factors in patient safety incidents. To use the framework it was necessary to predict how
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observations in some of the domains might impact on the safety of how medicines were managed by the patient, their families and healthcare professionals. For example, not encouraging patients to ensure their GP practice had been made aware of changes to their medicines may have resulted in some patients receiving prescriptions for incorrect medicines.
Indeed, Chapter 6 will describe patients’ accounts of receiving incorrect repeat medicines sets after leaving hospital. However, at the time observations were made, the researcher could not be aware of whether subsequent patient safety incidents occurred. In addition, incorrect sets of medicines arriving on a ward to be given to a patient would qualify as a patient safety incident, even if the staff member at the ‘sharp end’ noticed and took action. However, observation at the
‘sharp end’ made it extremely difficult to identify the contributory factors to such events. It was also difficult using observation alone to identify where latent organisational factors and latent external factors, such as internal and external policies, might have contributed to a potential patient safety incident. In the same way, observing and identifying safety culture is difficult and inferences needed to be made to assess how culture impacted on practice on site.
This study has explored the variation in the practice of discharging patients with medicines from hospital. Recent NICE guidance on medicines optimisation states that medicines-related communication systems should include transfer information about what the patient, their family members and carers have been told about the patient’s medicines when their care is transferred between providers.72 It offers no suggestions about what patients should be told about their medicines when their care is transferred, although it does emphasise that medicines optimisation should be patient-centred. This lack of detail in external policies is reflected in the internal policies of both hospital sites, which also do not give guidance about what patients should be told about their medicines when they are leaving the care of the hospital with their medicines in front of them and an HCP at their side. Whilst we do not know from this study what patients were told about their medicines during their stay, for some patients the point of discharge may be the first time they had been talked through their medicines as a group and in a systematic fashion. The depth of preparation patients receive to self-manage their medicines is likely to impact on their capability to safely manage them and also their confidence in them once they
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have left hospital. Given that patients have reported feeling confused by their medicines after discharge and can find it difficult to co-ordinate support in primary care, additional time spent talking about sets of medicines with caregivers may help enhance their abilities with their medicines and reduce both re-admission and preventable harm. Chapter 6 will describe how confused about their medicines some patients were after leaving hospital.
Medicines information has been found to enhance understanding and reduce anxiety about side effects.317 The number of patients being told about side effects in this study was low compared to other aspects of their medicines, such as medicines purpose. Nationally, there is a similar picture: the most recent CQC/NHS in-patient survey reported that 41% of patients who had TTO
medicines were not told about medicines side effects to look out for.318 There is debate about the impact of explaining side effects of medicines to patients; and the ‘nocebo effect’ of giving patients negative expectations about their
medicines has been discussed in depth.319–321 However, explaining effects to look out for in a patient-centred way, exploring the level of detail that is right for each patient and empowering them to seek help should they wish to or need to, might contribute to the safe management of their treatment.322 Giving structured information about levels of risk may also be an important step.323,324
In this study, the task of giving patients their discharge medicines occurred just before they left the ward and medicines education activities at this time
concerning their medicines varied from care-giver to care-giver, and as such it was an individual factor in sub-optimal practice. Although all patients were given written information, not all staff highlighted this information to patients, which may explain why patients in another study reported not receiving written information.144 On the ward, the staff discharge style seemed to be the
individual choice of the staff member, mediated by the relationship between the staff member and the patient, and the pressures on the individual staff
members. The discharge lounge appeared to be highly process-driven: its focus was on completing the process of discharging the patient by handing them their medicines and requesting their signature on the discharge summary. From the observer’s perspective, it appeared to be a task that occurred after the ‘caring’
duty of the hospital had ended, despite the best intentions of the staff on duty.
In this way, the task characteristic became a contributory factor because it was,
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in many cases, detached from other care tasks and managed discretely. The fact that patients were transferred to the discharge lounge risked their safety as it constituted an additional gap in the continuity of care;41 and so required an additional hand-off of care to discharge lounge staff.44
Patient factors were evident during many observations: many patients appeared to be anxious to be discharged and perhaps did not pay full attention to the list of medicines that was read to them. They had, after all, been in hospital after experiencing a health crisis or intervention. In 2005, a multi-agency report identified that giving patients medicines just before discharge was a problem in the patient journey because it allowed no time for meaningful patient education or advice.92 In this way, giving patients their medicines and helping them
understand them is not perceived as an integral part of the care that the hospital offers. Providing more in-depth support with medicines at discharge and
bridging the gap in care by continued support after discharge may have a significant impact on hospital resources and it is debatable whether the time, skills and money are available to do so.55
External policy for patients with cardiology conditions to access the clinical services of community pharmacy did not, in most cases, impact on what they were told at discharge. Patients were signposted to their community pharmacy for help with their medicines only twice. This suggests a continued lack of integration of community pharmacy into the discharge pathway in a role supporting medicines use. Nevertheless, community pharmacists can play a valuable medicines management role for patients after discharge.129,325,326
Recent guidance from the RPS Innovators Forum suggests that hospital
patients should be routinely referred to community pharmacy services after their discharge to support their medicines use,327 not least because community pharmacy can help identify problems patients may have with their medicines after they have left hospital.125–127,129,195 The role of community pharmacy after discharge is explored in more detail in Chapter 6. Patients were also told that their GP would be informed that they had been in hospital, although they were not given any additional information about what to expect (or not to expect) from their GP practice. A clearer care pathway set out to patients at discharge would help them understand more about who is responsible for their ongoing care and who they should seek support from after they arrive at home, especially if they
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have co-morbidities which may increase their chances of readmission.328,329 Who should talk to patients about their discharge medicines?
In many instances in this study a nurse who knew the patient and had been involved in their care conducted the discharge. If the staff member knows the patient then it is likely that their understanding of that patient will impact on their ability to provide person-centred as well as safe care. For example, the patient may have previously expressed preferences or concern about medicines to staff on the ward that other staff members might not be aware of. Much has been written about the concept of ‘knowing the patient’. In the 1970s patterns of knowing the patient were described by Carper,330 encompassing professional skills; professional knowledge and personal knowledge of the patient. A later review of the literature subsequently identified several key areas of knowing the patient:331
• Understanding and treating the patient as an individual – which upholds a professional nursing value;
• This results in individualised care;
• It is an integral part of nursing decision making;
• That the amount of time the nurse can have with the patients affects how well they can know them, which is influenced by staffing policy;
• That it enhances outcomes and earlier recovery.
Further work drew a distinction between ‘knowing’ the patient through
information sources such as the medical records, a personal care record used by different staff on the ward who care for the patient, and other sources of information such as verbal information from the patient and their family, and verbal information, such as hand-offs, from colleagues.332 Staff on the wards in this study often had more time to ‘know the patient’ through using these sources of information than staff in the discharge lounge. They also had more specialist knowledge of cardiology conditions and knowledge of the medicines prescribed to treat them, which constitutes a higher level of specific clinical expertise. Staff in the discharge lounge had fewer resources to rely on, such as hand-off
information and medical notes. Not knowing the patient is more aligned to a process led, managed model of healthcare,333 which reflects the nature of the observations made in the discharge lounge at Site 1. Indeed, recent work in the
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area of knowing the patient acknowledges the challenges posed by
discontinuity of care and staff workload in acute healthcare environments which mean the process of knowing patients is not supported.334
This chapter has explored how patients are discharged from hospital with their medicines. It has set the scene describing how safely the hospital prepared patients as they were discharge to manage their medicines once they were back at home. Using Social Network Analysis, Chapters 5–7 will explore how patients and their medicines are subsequently managed once they have been transferred back to primary care. In the first instance the structure of the patients’ medicines management networks will be described through ego-network analysis.
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Chapter 5 – The structure of patients’ ego-networks
5.1 Introduction
This chapter presents the results of the structural analysis of 61 patients’
medicines management ego-networks. It is based on data collected in patient diaries (n=39) and augmented with semi-structured interviews (n=60) and network visualisation six weeks after hospital discharge.
The results are in the following four sections: ego network size; alter roles in patients’ ego networks; ego-network connectedness; and medicines
management alter value to patients. To aid interpretation of this chapter definitions of some of the commonly used terms in SNA are detailed below:
Actor An individual (a patient or a contact of a patient) Alter Another individual present in the ego’s network
Betweenness A measure of the extent to which an actor connects other actors
Broker An individual who connects other individuals to each other Degree The number of ties of one individual
Density A measure of the proportion of connections in the network Dyad Two individuals who are connected
Ego network The personal network of one individual (patient) Ego The individual (patient) who is the focus of interest Homophily The similarity between actors in a network
Sociogram A visualisation of the network showing individuals and the connections between them
Ties Connections between individuals