Medication management is a complex clinical task. It requires substantial collaboration and coordination between physicians, nurses and pharmacists. Addressing ineffective communication has been identified by the Institute of Medicine as a high priority. Ineffective communication regarding medication management coordination can result in increased medication errors, rates of adverse drug events (ADEs), delays in treating adverse drug events and less effective treatment. ADEs are frequent in hospitalized patients, ranging from less than 3% to over 32%. The purpose of this study was to evaluate communication patterns associated with medication management between providers, physicians and pharmacists in the inpatient setting.
Specific Aim 1. Assess clinicians' beliefs and concerns regarding the role of communication in preventing, detecting and managing ADEs in elderly inpatients (focus groups).
Specific Aim 2. Evaluate and characterize communication events between nurses, physicians and pharmacists in an inpatient medicine setting (ethnographic observation).
Phase 1: Focus Groups
Design: The design of this study was qualitative and used focus group methodology.
Settings: Three VA sites that differed in size, location and academic affiliation were selected.
Participants: Three focus groups were conducted at each site (one each of pharmacists, nurses and physicians). A total of 19 nurses, 16 pharmacists and 13 doctors participated.
Phase 2: Observation
Design: The design of this study was quantitative and descriptive.
Settings: Two inpatient units at the VA Salt Lake City Health Care System (medicine and telemetry).
Participants: Twelve residents were selected randomly from each of the 4 medical teams, 19 nurses were selected randomly from the two in-patient medicine wards, and 8 clinical pharmacists (the total number of clinical pharmacists available) agreed to participate.
Focus Groups: Five major themes emerged: 1) Getting the big picture (knowing what the patient has actually taken, what the current goals of care are, and the status of the patient's current condition) is hard. 2) Diffusion of responsibility (hot potato syndrome) occurs; taking responsibility and identifying who else is responsible for different components of medication management is not a clear process. 3) Communication processes do not match workflow. 4) All roles reported engaging in a number of "games" designed to either minimize interruptions and unnecessary contact or to trick other roles into increasing availability. 5) All groups reported that the complexity inherent in inpatient care was often so intense that deliberate, systematic medication management and communication felt nearly impossible.
Observation Study: Fifty-three observation sessions were conducted, ranging in duration from 2.2 to 3.8 hours, with 714, 477, and 799 events for physicians, pharmacists, and nurses, respectively. Observer inter-rater reliability was acceptable, ranging from 0.66 to 0.77. Significant chi-square differences were found: between clinician roles for mode of communication (p =0.002), with verbal much higher for nurses than all others; between topics (p<0.01); in the likelihood of addressing medications (p<0.01); and in the likelihood of communicating ADE issues across roles (p<0.01). Physicians only communicated about 10% of ADE issues to nurses, but 100% of ADEs identified by nurses were communicated to physicians.
The results indicate that communication patterns regarding medication management differ significantly across roles -- physician, pharmacist, nurse. The results highlight areas of needed improvement for work process re-engineering and informatics support to improve communication and medication management. This study lays the groundwork for designing communication technologies and work processes that improve the collective shared understanding of medication management issues for patients.
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