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Objective: There is a wide range of strategies that could help in minimizing medication errors during healthcare delivery. We undertook a qualitative study to identify recommended solutions to minimize medication errors in an adult oncology department in Saudi Arabia from the perspectives of healthcare professionals. Methods: This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining the required ethical approvals and written consents from the participants, seven focus group discussions were carried out for data collection. A stratified purposive sampling strategy was used to recruit medical doctors, pharmacists, and nurses. NVivo Pro version 11 was used for data analyses. Inductive content analysis was adopted in the coding of collected data. Result: Our study showed that improving organizational support, staff education, and communication could help in minimizing medication errors in the adult oncology department. Conclusion: The adoption of multiple strategies is required to improve the safety of the medication process in the adult oncology department. We argue that the availability of supportive leadership should be prioritized as it plays a crucial role in determining the effectiveness and efficiency of both staff education and communication. Keywords: Medication errors, Adult Oncology, Saudi Arabia, Solutions, Qualitative study

Objective: Adverse events which result from medication errors are considered to be one of the most frequently encountered patient safety issues in clinical settings. We undertook a qualitative investigation to identify and explore factors relating to medication error in an adult oncology department in Saudi Arabia from the perspective of healthcare professionals. Methods: This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining required ethical approvals and written consents from the participants, semi-structured interviews and focus group discussions were carried out for data collection. A stratified purposive sampling strategy was used to recruit medical doctors, pharmacists, and nurses. NVivo Pro version 11 was used for data analyses. Inductive thematic analysis was adopted in the primary coding of data while secondary coding of data was carried out deductively applying the Hospital Survey of Patient Safety Culture (HSOPSC) framework. Result: The total number of participants were 38. Majority of the participants were nurses (n = 24), females (n = 30), and not of Saudi nationality (n = 31) with an average age of 36 years old. Causes of medication errors were categorized into 6 themes. These causes were related teamwork across units, staffing, handover of medication related information, accepted behavioural norms, frequency of events reported, and non-punitive response to error. Conclusion: There were numerous causes for medication errors in the adult oncology department. This means substantive improvement in medication safety is likely to require multiple, inter-relating, complex interventions. More research should be conducted to examine context-specific interventions that may have the potential to improve medication safety in this and similar departments. Keywords: Medication errors, Adult oncology, Saudi Arabia, Healthcare professionals, Qualitative study

الملخص: أهداف البحث: يعتبر خلق ثقافة سلامة المرضى الإيجابية أساسا لتحسين نتائج سلامة المرضى. تهدف هذه الدراسة لإجراء التقييم الأول لثقافة سلامة المرضى في محيط الرعاية الثانوية في الكويت. طرق البحث: أجريت هده الدراسة الاستطلاعية –المقطعية في القسم الطبي في مستشفى عام في الكويت باستخدام مسح لثقافة سلامة المرضى في المستشفى. وتم عمل تحليل الانحدار الخطي المتعدد لتحديد توقعات ثقافة سلامة المرضى. تم استخدام كلا من اختبار أنوفا وكروسكال واليس لتقييم الاختلافات بين مجموع الدرجات والدرجات التي تم تحقيقها في كل بُعدٍ حسب ترتيب الجنسيات. النتائج: تم استلام ١٠٠٨ استبانة مكتملة، بمعدل استجابة ٧٥.٢٪. وجدنا ثلاثة أبعاد لثقافة سلامة المرضى لتكون مجالات ذات أولوية للتحسين: استجابة غير- عقابية للأخطاء، والتوظيف، وانفتاح التواصل. تم تحديد العمل الجماعي داخل الوحدات والتعليم التنظيمي مع التحسين المستمر كمجالات للقوة. كان لدى الذين استجابوا من الكويت⁄ دول الخليج إيجابية أقل لثقافة سلامة المرضى بالمقارنة بالمستجيبين الآسيويين. وأظهر تحليل الانحدار للمستجيبين أن” بلد المنشأ “، والمهنة، والعمر والحضور لدورات ⁄ محاضرات ثقافة سلامة المرضى كانت مرتبطة ارتباطا كبيرا لإدراك ثقافة سلامة المرضى. الاستنتاجات: أظهرت هذه الدراسة أن سلامة المرضى ينظر إليها بشكل مختلف بين الطاقم الطبي من مختلف بلدان المنشأ، والمجموعات المهنية، والفئات العمرية. يجب الإقرار بهذه المتغيرات ومعالجتها عند تخطيط وتقييم مبادرات سلامة المرضى. Abstract: Objectives: To improve patient safety outcomes, it is considered essential to create a positive culture of patient safety. This study carried out an initial evaluation of the patient safety culture in a secondary care setting in Kuwait. Methods: This cross-sectional questionnaire study was conducted in a general hospital medical department in Kuwait, using the Hospital Survey on Patient Safety Culture (HSPSC). Multiple linear regression analyses were used to identify patient safety culture predictors. Both an ANOVA and a Kruskal Wallis test were carried out to assess the differences between participants' total scores and the scores they achieved in each dimension, categorized by nationality. Results: A total of 1008 completed questionnaires were received, yielding a response rate of 75.2%. Three dimensions of patient safety culture were found to be priority areas for improvement: non-punitive responses to errors, staffing, and communication openness. Teamwork within units and organizational learning with continuous improvement were identified as areas of strength. Respondents from Kuwait and the Gulf State countries had a less positive perception of the hospital's patient safety culture than did Asian respondents. A regression analysis showed that the respondents' countries of origin, professions, age, and patient safety course/lecture attendance were significantly correlated with their perceptions of the hospital's patient safety culture. Conclusion: This study demonstrates that patient safety is perceived differently by medical staff members from different countries of origin, professional groups, and age groups. These variables must be acknowledged and addressed when planning or evaluating patient safety initiatives. الكلمات المفتاحية: بلد المنشأ, الكويت, الخدمات الطبية, ثقافة سلامة المرضى, Keywords: Country of origin, Kuwait, Medical services, Patient safety culture

The majority of medical patients presenting to hospital in the UK are cared for in acute medical units (AMUs). Such units are also increasingly present internationally. Care delivery varies across units: this review aims to examine the evidence for how best to deliver AMU care.\ud \ud Six electronic databases and grey literature were searched. Inclusion criteria comprised interventions applied to undifferentiated patients in AMU settings. All studies were quality assessed. A narrative approach was undertaken.\ud \ud Nine studies, all conducted in the UK or Ireland, evaluated 1.3 million episodes, 3617 patients and 49 staff. There was single study evidence for beneficial effects of: enhanced pharmacy care, a dedicated occupational therapy service, an all-inclusive consultant work pattern, a rapid-access medical clinic and formalized handovers. Two studies found increased consultant presence was associated with reduced mortality; one of these studies found an association with a reduction in 28-day readmissions; and the other found an association with an increased proportion of patients discharged on the day they were admitted. Three studies provide evidence of the beneficial effects of multiple interventions developed from local service reviews.\ud \ud Overall, the quality of the evidence was limited. This review has identified operationally relevant evidence that increased consultant presence is associated with improved outcomes of care; has highlighted the potential to improve outcomes locally through service reviews; and has demonstrated an important knowledge gap of how best to deliver AMU care. These findings have importance given the challenges acute services currently face.

Purpose:\ud To evaluate the evidence for the effectiveness of acute medical units (AMUs) compared with other models of care and compare the components of AMU models.\ud \ud Data sources:\ud Six electronic databases and grey literature sources searched between 1990 and 2014.\ud \ud Study selection:\ud Studies reporting on AMUs as an intervention for unplanned medical presentations to hospital with the inclusion of all outcome measures/study designs/comparators.\ud \ud Data extraction:\ud Data on study characteristics/outcomes/AMU components were extracted by one author and confirmed by a second.\ud \ud Data synthesis:\ud Seventeen studies of 12 AMUs across five countries were included. The AMU model was associated with a reduction in-hospital length of stay (LOS) in all analyses ranging from 0.3 to 2.6 days; and a reduction in mortality in 12 of the 14 analyses with the change ranging from a 0.1% increase to a 8.8% reduction. Evidence relating to readmissions and patient/staff satisfaction was less conclusive. There was variation in the following components of AMUs: admission criteria, entry sources, functions and consultant work patterns.\ud \ud Conclusion:\ud This review provides evidence that AMUs are associated with reductions in-hospital LOS and, less convincingly, mortality compared with other models of care when implemented in European and Australasian settings. Reported estimates may be affected by residual confounding. This review reports heterogeneity in components of the AMU model. Further work to identify what constitutes the key components of an AMU is needed to improve the quality and effectiveness of acute medical care. This is of particular importance given the escalating demand on acute services.

Background Patient histories in electronic health records currently exist mainly in free text format thereby limiting the possibility that decision support technology may contribute to the accuracy and timeliness of clinical diagnoses. Structuring and/or coding make patient histories potentially computable. Methods A systematic review was undertaken of the benefits and risks of structuring and/or coding patient history by searching nine international databases for published and unpublished studies over the period 1990–2010. The focus was on the current patient history, defined as information reported by a patient or the patient's caregiver about the patient's present health situation and health status. Findings were synthesised through a theoretically based textural analysis. Findings Of the 9207 potentially eligible papers identified, 10 studies satisfied the eligibility criteria. There was evidence of a modest number of benefits associated with structuring the current patient history, including obtaining more complete clinical histories, improved accuracy of patient self-documented histories, and better associated decision-making by professionals. However, no studies demonstrated any resulting improvements in patient care or outcomes. When more detailed records were obtained through the use of a structured format no attempt was made to confirm if this additional information was clinically useful. No studies investigated possible risks associated with structuring the patient history. No studies examined coding of the patient history. Conclusions There is an insufficient evidence base for sound policy making on the benefits and risks of structuring and/or coding patient history. The authors suggest this field of enquiry warrants further investigation given the interest in use of decision support technology to aid diagnoses.

Background Globally, diabetes mellitus presents a substantial and increasing burden to individuals, health care systems and society. Structuring and coding of information in the electronic health record underpin attempts to improve sharing and searching for information. Digital records for those with long-term conditions are expected to bring direct and secondary uses benefits, and potentially to support patient self-management. Aims and objectives We sought to investigate if how and why records for adults with diabetes were structured and coded and to explore a range of UK stakeholders’ perceptions of current practice in the National Health Service. Methods We carried out a qualitative, theoretically informed case study of documenting health care information for diabetes in family practice and hospital settings in England, using semi-structured interviews, observations, systems demonstrations and documentary data. Results We conducted 22 interviews and four on-site observations. With respect to secondary uses – research, audit, public health and service planning – interviewees clearly articulated the benefits of highly structured and coded diabetes data and it was believed that benefits would expand through linkage to other datasets. Direct, more marginal, clinical benefits in terms of managing and monitoring diabetes and perhaps encouraging patient self-management were also reported. We observed marked differences in levels of record structuring and/or coding between family practices, where it was high, and the hospital. We found little evidence that structured and coded data were being exploited to improve information sharing between care settings. Conclusions Using high levels of data structuring and coding in records for diabetes patients has the potential to be exploited more fully, and lessons might be learned from successful developments elsewhere in the UK. A first step would be for hospitals to attain levels of health information technology infrastructure and systems use commensurate with family practices.

Background Drug allergy represent an important subset of adverse drug reactions that is worthy of attention because many of these reactions are potentially preventable with use of computerised decision support systems. This is however dependent on the accurate and comprehensive recording of these reactions in the electronic health record. The objectives of this study were to understand approaches to the recording of drug allergies in electronic health record systems. Materials and Methods We undertook a case study comprising of 21 in-depth interviews with a purposefully selected group of primary and secondary care clinicians, academics, and members of the informatics and drug regulatory communities, observations in four General Practices and an expert group discussion with 15 participants from the Allergy and Respiratory Expert Resource Group of the Royal College of General Practitioners. Results There was widespread acceptance among healthcare professionals of the need for accurate recording of drug allergies and adverse drug reactions. Most drug reactions were however likely to go unreported to and/or unrecognised by healthcare professionals and, even when recognised and reported, not all reactions were accurately recorded. The process of recording these reactions was not standardised. Conclusions There is considerable variation in the way drug allergies are recorded in electronic health records. This limits the potential of computerised decision support systems to help alert clinicians to the risk of further reactions. Inaccurate recording of information may in some instances introduce new problems as patients are denied treatments that they are erroneously believed to be allergic to.

OBJECTIVE: To explore the reasons for enrolling, experiences of participating and reasons for remaining in a family-based, cluster randomised controlled trial of a dietitian-delivered lifestyle modification intervention aiming to reduce obesity in South Asians at high risk of developing diabetes.DESIGN: Qualitative study using narrative interviews of a purposive sample of trial participants following completion of the intervention. Data were thematically analysed.SETTING: The intervention was conducted in Scotland and resulted in a modest decrease in weight, but did not statistically reduce the incidence of diabetes.PARTICIPANTS: We conducted 21 narrative interviews with 24 participants (20 trial participants and four family volunteers).RESULTS: Many participants were motivated to participate because of: known family history of diabetes and the desire to better understand diabetes-related risks to their own and their family's health; ways to mitigate these risks and to benefit from personalised monitoring. Home-based interventions, communication in the participant's chosen language(s) and continuity in dietitians supported their continuing engagement with the trial. Adaptations in food choices were initially accommodated by participants, although social and faith-based responsibilities were reported as important barriers to persevering with agreed dietary goals. Many participants reported that increasing their level of physical activity was difficult given their long working hours, physically demanding employment and domestic commitments; this being compounded by Scotland's challenging climate and a related reluctance to exercise in the outdoors.CONCLUSIONS: Although participants had strong personal interests in participation and found the information provided by dietitians useful, they nonetheless struggled to incorporate the dietary and exercise recommendations into their daily lives. In particular, increasing levels of physical exercise was described as an additional and in some cases unachievable burden. Consideration needs to be given to strengthening and supporting lifestyle interventions with community-based approaches in order to help overcome wider social and environmental factors.

Background The case has historically been presented that structured and/or coded electronic health records (EHRs) benefit direct patient care, but the evidence base for this is not well documented.Methods We searched for evidence of direct patient care value from the use of structured and/or coded information within EHRs. We interrogated nine international databases from 1990 to 2011. Value was defined using the Institute of Medicine’s six areas for improvement for healthcare systems: effectiveness, safety, patient-centredness, timeliness, efficiency and equitability. We included studies satisfying the Cochrane Effective Practice and Organisation of Care (EPOC) group criteria.Results Of 5016 potentially eligible papers, 13 studies satisfied our criteria: 10 focused on effectiveness, with eight demonstrating potential for improved proxy and actual clinical outcomes if a structured and/or coded EHR was combined with alerting or advisory systems in a focused clinical domain. Three studies demonstrated improvement in safety outcomes. No studies were found reporting value in relation to patient-centredness, timeliness, efficiency or equitability.Conclusions We conclude that, to date, there has been patchy effort to investigate empirically the value from structuring and coding EHRs for direct patient care. Future investments in structuring and coding of EHRs should be informed by robust evidence as to the clinical scenarios in which patient care benefits may be realised.

BackgroundWe sought to understand how clinical information relating to the management of depression is routinely coded in different clinical settings and the perspectives of and implications for different stakeholders with a view to understanding how these may be aligned.Materials and methodsQualitative investigation exploring the views of a purposefully selected range of healthcare professionals, managers, and clinical coders spanning primary and secondary care.ResultsOur dataset comprised 28 semi-structured interviews, a focus group, documents relating to clinical coding standards and participant observation of clinical coding activities. We identified a range of approaches to coding clinical information including templates and order entry systems. The challenges inherent in clearly establishing a diagnosis, identifying appropriate clinical codes and possible implications of diagnoses for patients were particularly prominent in primary care. Although a range of managerial and research benefits were identified, there were no direct benefits from coded clinical data for patients or professionals. Secondary care staff emphasized the role of clinical coders in ensuring data quality, which was at odds with the policy drive to increase real-time clinical coding.ConclusionsThere was overall no evidence of clear-cut direct patient care benefits to inform immediate care decisions, even in primary care where data on patients with depression were more extensively coded. A number of important secondary uses were recognized by healthcare staff, but the coding of clinical data to serve these ends was often poorly aligned with clinical practice and patient-centered considerations. The current international drive to encourage clinical coding by healthcare professionals during the clinical encounter may need to be critically examined.

Findings Many participants were aware of their family history of diabetes and attracted by the availability of information and monitoring. Offering home or clinic-based interventions, communication in the participant’s chosen language(s) and excellent relationships between participants and dieticians contributed to retention. Adaptations in food choices were accommodated by participants, although community and faith based considerations made consistent adherence challenging. Participants found increasing their level of physical activity difficult given other demands, including long working hours, physically demanding employment and domestic commitments.