Caroline Alice McGraw - King's College London

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Management of medication for older people living at home : home carer involvement
and patient safety
McGraw, Caroline
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Medication Management for Older People Living
at
Home: Home Carer Involvement Patient Safety
and
Caroline Alice McGraw
Thesis for
the
submitted
Degree Doctor Philosophy
of of
Kings College London
2006
Ir2).
a
Abstract
Home for the
carers are responsible meeting personal care needs of ever more
dependent living home. Personal includes the
older people at care management of
from district Medication
transferred
prescribed medication nursing services.
is hazardous The this
management a complex and potentially process. aims of study
in home involvement in
to the
were understand circumstances which carer
for living home jeopardise
medication related activities older people at might patient
identify diminishing
to the
safety and ways of risk of adverse events.
The to human This
study adopted a systems approach understanding error. approach
has tools to help the
generated a number of conceptual models and practical specify
factors that to in hospital None these
range of predispose adverse events settings. of
have been in domiciliary The develop
to
models used care. study sought a
framework specifying the range of factors that predispose to adverse events when
from
for living home transferred
at are
medication related activities older people
from
district home Data
to open-ended
nursing care services. were collected
in highly
interviews 64 district home two
contrasting
with nursing and care personnel
study sites.
by
Data analysis catalogued the variety of medication related activated undertaken
factors
home developed framework the
that range of
carers and a specified
This
identified
respondents as predisposing to adverse medication events. was called
Framework Factors Influencing Medication Management by Home Carers
the
of
(FFIHC). The the
study critically assesses applicability of conceptual models
developed in hospital to domiciliary It discusses the to
settings care. also extent
FFIHC has in the identification
which the utility of appropriate and effective
in
this
strategies to minimise errors and adverse events area of care.
Acknowledgments
There have been
this thesis
are a number of people without whom would not
Foremost I to the in this I
possible. am grateful all anonymous respondents study.
like to thank Professor Charlotte Humphrey Dr Vari Drennan for
would also and
their the this PhD. Thanks to
excellent supervision and advice over course of also
Camden Islington Community Health Trust latterly Camden Primary
and and more
Care Trust for the funding to this PhD
undertake
Index Contents
of
Chapter 1: Introduction 12
.............................................................................................
1.1. Motivation for 12
research
.................................................................................
1.2. Patient 19
safety
.................................................................................................
1.3. Strategies in home 23
to
minimise risk care
......................................................
1.4. Aims 28
thesis
and structure of
..........................................................................
Chapter 2: Communication between district home
and collaboration nursing and care
30
services
.......................................................................................................................
2.1. Unified 1946 71 30
provision
-
..........................................................................
2.2. Fragmentation joint 1971 90 34
and working
-
.................................................
2.3. Supporting 1960 2000 40
older people
-
...........................................................
2.4. Modernisation 1997 2005 48
-
..........................................................................
2.5. Conclusion 51
....................................................................................................
Chapter 3: Medication for living home 53
management older people at
......................
3.1. Medicines handling the law 53
and
...................................................................
3.2. Adherence to 53
prescribed medication
.............................................................
3.3. Iatrogenic illness 59
...........................................................................................
3.4. Assistance 62
with medication related activities
...............................................
3.5. Conclusion 64
....................................................................................................
66
Chapter 4: Studying
adverse events and patient safety
..............................................
66
4.1. Understanding
error and adverse events
.......................................................
74
4.2. Systems
to the
approach analysis of risk
......................................................
4.3. Complex high industries 79
technology
and patient safety
...............................
82
4.4. Applying
the to
systems approach patient safety
.........................................
95
4.5. Developing framework for domiciliary
a care settings
.................................
4.6. Conclusion 104
......................................................................................................
106
Chapter 5: Study
methods
.......................................................................................
5.1. Study design 106
................................................................................................
5.2. Study 113
methods
.............................................................................................
5.3. Ethical 146
practice
............................................................................................
148
5.4. Data
analysis
...............................................................................................
5.5. Critique 155
of methods
.....................................................................................
5.6. Reflexivity bias 156
and reducing researcher
....................................................
5.7. Characteristics 157
of study sites
.......................................................................
5.8. Characteristics 161
of respondents
....................................................................
5.9. Characteristics 163
of service providers
............................................................
5.10. Presentation findings 166
of
............................................................................
Chapter 6: Medication 167
related activities undertaken
..............................................
6.1. Medication by home 167
related activities undertaken carers
...........................
6.2. Medication by 173
related activities undertaken nurses
....................................
6.3. Negotiating 176
responsibilities
........................................................................
6.4. Variation between 182
study sites
.....................................................................
6.5. Conclusion 183
..................................................................................................
Chapter 7: Domains in in
of risk and patient safety medication management
domiciliary
184
care
.......................................................................................................
7.1. Factors influencing 184
medication management
..............................................
7.2. Variations between home 235
sites and care sectors
..........................................
7.3. Factors to to 238
expected predispose adverse events
.......................................
7.4. Taxonomy factors to 239
of predisposing adverse events
...................................
7.5. Conclusion 251
....................................................................................................
Chapter 8: From to taking 252
minimising errors risks
.................................................
8.1. Exploring the for to 254
scope strategies minimise errors and adverse events
...
8.2. An to 264
alternative approach risk
.....................................................................
References 271
................................................................................................................
Appendices 295
...............................................................................................................
Index Figures
of
Figure 1.1: Combined (patient district home
articles safety and nursing and/or care)
18
....................................................................................................................................
Figure 1.2: Combined (medication district home 19
articles and nursing and/or care).
Figure 2.1: Management funding district home help
and of nursing and services
from 1946 1971 31
-
.......................................................................................................
Figure 3.1: The (Goldstein 1993a) 54
medication management process et al
...............
Figure 4.1: Zeebrugge-Harrisburg Syndrome (Pheasant 1988) 75
................................
Figure 4.2: Model Threat Error in Aviation (Helmreich 1999) 76
of and et al
.............
Figure 4.3: Organisational Accident Model (Reason 1993) 78
.....................................
Figure 4.4: Model Threat Error in Medical Environment (Helmreich 2000)
of and a
83
....................................................................................................................................
Figure 4.5: Taxonomy the (Ternov 1999) 86
of major causes of medical mistakes
......
Figure 4.6: Checklist background influencing factors (Taylor-
of or performance
Adams 1999) 88
et al
......................................................................................................
Figure 4.7: Framework Factors Influencing Clinical Practice (Clinical Risk Unit
of
ALARM 1999) 91
and
....................................................................................................
Figure 4.8: ' Hazards identified in domiciliary fit in Framework
that the
care settings
Factors Influencing Clinical Practice 96
of
.....................................................................
Figure 5.1: Intended 112
categories of respondents
.......................................................
Figure 5.2: Local distribution (Site A) 119
authority organisation and of respondents
Figure 5.3: Local distribution (Site B). 120
authority organisation and of respondents
Figure 5.4: Selection local home in Site A 121
of authority care respondents
..............
Figure 5.5: Selection local home in Site B 122
of authority care respondents
..............
Figure 5.6: Distribution independent home (Site A) 125
of sector care respondents
....
Figure 5.7: Distribution independent home (Site B) 126
care respondents
of sector
....
Figure 5.8: Selection independent home in Site A 127
of sector care organisations
.....
Figure 5.9: Selection independent home in Site A 128
of sector care respondents
.......
Figure5.10: Selection independent home in Site B 129
of sector care organisations
...
Figure 5.11: Selection independent home in Site B 130
of sector care respondents
.....
Figure 5.12: District distribution (Site A
of respondents
nursing organisation and
(north locality)) 133
.........................................................................................................
Figure 5.13: District distribution (Site A
nursing organisation and of respondents
(south locality)) 133
........................................................................................................
Figure 5.14: Selection district in Site A 136
of nursing respondents
.............................
Figure 5.15: Selection district in Site B 137
of nursing respondents
.............................
Figure 5.16: Interview 140
guide
...................................................................................
Figure 5.17: Example thematic 152
of chart entries
......................................................
Figure 6.1: Overlap between district home in to
nursing and care services relation
for 177
responsibility medication related activities
........................................................
Figure 7.1: Framework Factors Influencing Medication Management by Home
of
Carers (FFIHC) 241
........................................................................................................
Figure 7.2: Overlap between the factors listed in the FFICP the FFIHC 242
and
.........
Figure 7.3: Institutional factors in the FFICP the FFIHC 243
and
................................
Figure 7.4: Organisation factors in FFICP FFIHC 244
the the
and management and
...
Figure 7.5: Work factors in the FFICP FFIHC 245
environment and
...........................
Figure 7.6: Team factors in the FFICP the FFIHC 246
and
..........................................
Figure 7.7: Staff factors in the FFICP the FFIHC 247
and
............................................
248
Figure 7.8: Task factors in the FFICP the FFIHC
and
............................................
249
Figure 7.9: Patient factors in the FFICP FFIHC
and
..............................................
Index Tables
of
Table 2.1: Medical by in home
problems reported people receipt of care services
(PSSRU 1998) 46
........................................................................................................... .
Table 5.1: Theoretical 114
the
criteria guiding selection of study sites
........................
Table 5.2: Anticipated distribution home district
number and of care and nursing
116
respondents
..............................................................................................................
Table 5.3: Anticipated distribution district in Si te B
number and of nurse respondents
116
..................................................................................................................................
Table 5.4: Questionnaires by home district 145
returned care and nursing respondents
Table 5.5: Thematic 151
charts
......................................................................................
Table 5.6: Thematic 154
chart groupings
......................................................................
Table 5.7: Age 158
structure
..........................................................................................
Table 5.8: Ethnic 158
group
...........................................................................................
Table 5.9: Population density 159
.................................................................................
Table 5.10: Traffic 159
congestion
................................................................................
Table 5.11: Deprivation 160
ranking
.............................................................................
Table 5.12: Economic 160
activity
................................................................................
Table 5.13: Household 160
composition
.......................................................................
Table 5.14: Percentage 161
of adults who were carers
..................................................
Table 5.14: Number home had been in 161
of years care respondents post
..................
Table 5.16: Number home had been in home 162
of years care respondents care
........
Table 5.17: Number district had been in 163
of years nurse respondents post
.............
Table 5.18: District 165
nursing vacancy rates
..............................................................
joint (numbers 1000 head
Table 5.19: Measures
of effective provision per of
166
75
population aged years and over)
.........................................................................
by h
Table6.1: Types of medication that home carers were allowed or prohibited ome
from 178
care policies administering
..............................................................................
Table 7.1: Patient identified by 192
respondents
problems and remedial measures
.....
Table 7.2: Difficult decisions in home 195
care
............................................................
Table 7.3: Task identified by 197
respondents
problems and remedial measures
.........
Table 7.4: Staff identified by 202
respondents
problems and remedial measures
.........
Table 7.5: Team identified by 210
respondents
problems and remedial measures
.......
identified by
Table 7.6: Work
environment problems and remedial measures
(continued following 220
respondents on page)
.............................................................
identified by
Table 7.6: Work
environment problems and remedial measures
(continued from 221
respondents previous page)
...........................................................
Table 7.7: Organisation identified
and management problems and remedial measures
by 227
respondents
.........................................................................................................
Table 7.8: Institutional identified by ts
problems and remedial measures responden
234
..................................................................................................................................
Index
Boxes
of
Box 1.1: Administration
doses in hospital (Sutherland
of solid oral settings and
Falconer 1999)
13
...........................................................................................................
Box 1.2: Precautions for the Fosamax (manufacturer's insert) 14
use of
......................
Box 1.3: Critical incident
difficulties in
to
related
communication and collaboration
identified in
15
practice
..................................................................................................
Box 1.4: Critical incident
to the domiciliary identified
related nature of care settings
in
16
practice
...................................................................................................................
Box 1.5: Databases
17
searched
.....................................................................................
Box 1.6: Key
ternis 17
concepts and related
..................................................................
Box 1.6: Key in
(Wilson Sheikh 2002;
safety considerations primary care and
Jacobson 2003)
21
et al
...................................................................................................
Box 1.7: Key be
that to home
areas need considered when preparing a care medicine
(Pharmacy Community Care Liaison Group 1998) 24
policy
........................................
Box 1.8: Suggested home
training (Pharmacy Community Care
carer objectives
Liaison Group 1998)
25
..................................................................................................
Box 1.9: Components home briefings (SPRU (University York) 2000) 27
of carer
of
Box 2.1. Key for
(DH 1989) 42
proposals community care reform
..............................
Box 2.2: The
43
community care assessment process
...................................................
Box 2.3: Different types by departments
contract used social services to
purchase
home (Matosevic 2001)
43
care et al
..............................................................................
Box 2.4: Trends in home levels from 1999 2003 (National Statistics
care activity
-
2004)
45
..........................................................................................................................
Box 2.5: Mechanisms to joint (DH 1998b) 49
make working easier
............................
Box 2.6: Factors between district
affecting collaboration and communication nurses
home
51
and care services
..............................................................................................
Box 2.7: Factors identified from the literature describing the health
problems at and
boundary for
social care that might predispose to adverse events when responsibility
medication related activities is transferred from district nursing to home care services
52
....................................................................................................................................
Box 3.1: Factors identified from the literature describing
medication management
that for
to
might predispose adverse events when responsibility medication related
is
transferred from district home 64
activities to
nursing care services
..........................
Box 4.1: Florida leg (Cook 2000) 68
wrong case et al
..................................................
Box 4.2: Similarities between (Helmreich
anaesthesia, surgery and aviation and
Davies 2004)
80
..............................................................................................................
Box 4.3: Factors distinguishing healthcare from high
technology
other complex
industries (Reason 2003)
81
............................................................................................
Box 4.4: Summary the failures identified in
of some of the
case of a post partum
haemorrhage (Taylor-Adams 1999)
89
et al
...................................................................
Box 4.5: Factors identified in
as contributing to health
an adverse event mental
(Vincent 2000)
93
et al.
...................................................................................................
Box 4.6: Factors identified
to incident in
as contributing
an adverse general practice
(Rogers 2002)
94
.............................................................................................................
Box 4.7: Factors that distinguish domiciliary from hospital 105
care settings
settings
Box5.1: Questions home
steering care respondents to describe incidents 141
specific
Box 5.2: Vignette hesitant
to
142
presented respondents
..............................................
Box 5.3: Key features framework
the (Ritchie
of approach Spencer 1994) 149
and
....