INTRODUCTION:Intravenous medication administration has traditionally been regarded as error prone, with high potential for harm. A recent US multisite study revealed few potentially harmful errors despite a high overall error rate. However, there is limited evidence about infusion practices in England and how they relate to prevalence and types of error. OBJECTIVES:To determine the prevalence, types and severity of errors and discrepancies in infusion administration in English hospitals, and to explore sources of variation, including the contribution of smart pumps. METHODS:We conducted an observational point prevalence study of intravenous infusions in 16 National Health Service hospital trusts. Observers compared each infusion against the medication order and local policy. Deviations were classified as errors or discrepancies based on their potential for patient harm. Contextual issues and reasons for deviations were explored qualitatively during observer debriefs. RESULTS:Data were collected from 1326 patients and 2008 infusions. Errors were observed in 231 infusions (11.5%, 95% CI 10.2% to 13.0%). Discrepancies were observed in 1065 infusions (53.0%, 95% CI 50.8% to 55.2%). Twenty-three errors (1.1% of all infusions) were considered potentially harmful; none were judged likely to prolong hospital stay or result in long-term harm. Types and prevalence of errors and discrepancies varied widely among trusts, as did local policies. Deviations from medication orders and local policies were sometimes made for efficiency or patient need. Smart pumps, as currently implemented, had little effect, with similar error rates observed in infusions delivered with and without a smart pump (10.3% vs 10.8%, p=0.8). CONCLUSION:Errors and discrepancies are relatively common in everyday infusion administrations but most have low potential for patient harm. Better understanding of performance variability to strategically manage risk may be a more helpful tactic than striving to eliminate all deviations.

Background: Procedural and documentation deviations relating to intravenous (IV) infusion administration can have important safety consequences. However, research on such deviations is limited. To address this we investigated the prevalence of procedural and documentation deviations in IV infusion administration and explored variability in policy and practice across different hospital trusts. Methods: We conducted a mixed methods study. This involved observations of deviations from local policy including quantitative and qualitative data, and focus groups with clinical staff to explore the causes and contexts of deviations. The observations were conducted across five clinical areas (general medicine, general surgery, critical care, paediatrics and oncology day care) in 16 National Health Service (NHS) trusts in England. All infusions being administered at the time of data collection were included. Deviation rates for procedural and documentation requirements were compared between trusts. Local data collectors and other relevant stakeholders attended focus groups at each trust. Policy details and reasons for deviations were discussed. Results: At least one procedural or documentation deviation was observed in 961 of 2008 IV infusions (deviation rate 47.9%; 95% confidence interval 45.5-49.8%). Deviation rates at individual trusts ranged from 9.9 to 100% of infusions, with considerable variation in the prevalence of different types of deviation. Focus groups revealed lack of policy awareness, ambiguous policies, safety and practicality concerns, different organisational priorities, and wide variation in policies and practice relating to prescribing and administration of IV flushes and double-checking. Conclusions: Deviation rates and procedural and documentation requirements varied considerably between hospital trusts. Our findings reveal areas where local policy and practice do not align. Some policies may be impractical and lack utility. We suggest clearer evidence-based standardisation and local procedures that are contextually practical to address these issues.

Objective: Complex medical devices such as infusion pumps are increasingly being used in patients' homes with little known about the impact on patient safety. Our aim was to better understand the risks to patient safety in this situation and how these risks might be minimised, by reference to incident reports. Design: We identified 606 records of incidents associated with infusion devices that had occurred in a private home and were reported to the UK National Reporting and Learning Service (2005-2015 inclusive). We used thematic analysis to identify key themes. Results: In this paper we focus on two emergent themes: detecting and diagnosing incidents; and locating the patient, lay caregivers and their family in incident reports. The majority of incidents were attributed to device malfunction, and resulted in the patient being under-dosed. Delays in recognising and responding to problems were identified, alongside challenges in identifying the cause. We propose a process model for fault diagnosis and correction. Patients and caregivers did not feature strongly in reports; we highlight how the device is in the home but of the care system, and propose an agent model to describe this; we also identify ways of mitigating this disjoint. Conclusion: Devices need to be appropriately tailored to the setting in which they are employed, and within a system of care that ensures they are used optimally and safely. Suggested features to improve patient safety include devices that can provide better feedback to identify problems and support resolution, alongside greater monitoring and technical support by care providers for both patients and frontline professionals. The proposed process and agent models provide a structure for reviewing safety and learning from incidents in home health care. (C) 2017 The Authors. Published by Elsevier Ltd.

Plain English summary Patient safety is a growing research area. However, although patients and the public are increasingly involved in clinical research, there is little guidance on how best to involve patients in patient safety research. Here we focus on how patients can contribute to the design of patient safety research. We conducted a workshop with patients as part of a project exploring errors and safety in the delivery of intravenous medication (medication given via a vein). The workshop was designed to explore how best to engage with hospital inpatients about these issues, to generate research topics, and to inform researchers about patients’ experiences. Nine patients participated, each of whom had previously received intravenous medication. Participants advised against using terms such as ‘error’; they also advocated caution when using terms such as ‘safety’ when describing the study to patients as this may worry some who had not thought about these issues before. We received thorough and useful feedback on our patient information sheets to ensure they were clear and understandable to patients. Patients also shared rich experiences with us about their treatment, which emphasised the need to extend our research focus to include a wider range of factors affecting quality and safety. Abstract Background Patient safety has attracted increasing attention in recent years. This paper explores patients’ contributions to informing patient safety research at an early stage, within a project on intravenous infusion errors. Currently, there is little or no guidance on how best to involve patients and the wider public in shaping patient safety research, and indeed, whether such efforts are worthwhile. Method We ran a 3-hour workshop involving nine patients with experience of intravenous therapy in the hospital setting. The first part explored patients’ experiences of intravenous therapy. We derived research questions from the resulting discussion through qualitative analysis. In the second part, patients were asked for feedback on patient information sheets considering both content and clarity, and on two potential approaches to framing our patient information: one that focused on research on safety and error, the other on quality improvement. Results The workshop led to a thorough review of how we should engage with patients. Importantly, there was a clear steer away from terms such as ‘error’ and ‘safety’ that could worry patients. The experiences that patients revealed were also richer than we had anticipated, revealing different conceptions of how patients related to their treatment and care, their role in safety and use of medical devices, the different levels of information they preferred, and broader factors impacting perceptions of their care. Conclusion Involving patients at an early stage in patient safety research can be of great value. Our workshop highlighted sensitivities around potentially worrying patients about risks that they might not have considered previously, and how to address these. Patient representatives also emphasised a need to expand the focus of patient safety research beyond clinicians and error, to include factors affecting perceptions of quality and safety for patients more broadly.

Introduction Intravenous medication is essential for many hospital inpatients. However, providing intravenous therapy is complex and errors are common. ‘Smart pumps’ incorporating dose error reduction software have been widely advocated to reduce error. However, little is known about their effect on patient safety, how they are used or their likely impact. This study will explore the landscape of intravenous medication infusion practices and errors in English hospitals and how smart pumps may relate to the prevalence of medication administration errors. Methods and analysis This is a mixed-methods study involving an observational quantitative point prevalence study to determine the frequency and types of errors that occur in the infusion of intravenous medication, and qualitative interviews with hospital staff to better understand infusion practices and the contexts in which errors occur. The study will involve 5 clinical areas (critical care, general medicine, general surgery, paediatrics and oncology), across 14 purposively sampled acute hospitals and 2 paediatric hospitals to cover a range of intravenous infusion practices. Data collectors will compare each infusion running at the time of data collection against the patient's medication orders to identify any discrepancies. The potential clinical importance of errors will be assessed. Quantitative data will be analysed descriptively; interviews will be analysed using thematic analysis. Ethics and dissemination Ethical approval has been obtained from an NHS Research Ethics Committee (14/SC/0290); local approvals will be sought from each participating organisation. Findings will be published in peer-reviewed journals and presented at conferences for academic and health professional audiences. Results will also be fed back to participating organisations to inform local policy, training and procurement. Aggregated findings will inform the debate on costs and benefits of the NHS investing in smart pump technology, and what other changes may need to be made to ensure effectiveness of such an investment.

Aim To test the effectiveness of a tailored, pharmacist-led centralised advice service to improve adherence to patients on established medications. Methods A parallel group randomised controlled trial was conducted. Patients prescribed at least one oral medication for type 2 diabetes and/or lipid regulation were eligible to participate. 677 patients of a mail-order pharmacy were recruited and randomised (340 intervention, 337 control). The intervention comprised two tailored telephone consultations with a pharmacist, 4–6 weeks apart, plus a written summary of the discussion and a medicines reminder chart. The primary outcome was self-reported adherence to medication at 6-month follow-up, collected via a postal questionnaire, analysed using generalised estimating equations. Secondary outcomes included prescription refill adherence, lipid and glycaemic control and patient satisfaction. Results In intention-to-treat analysis 36/340 (10.6%) of the intervention group were non-adherent (<90% of medication taken in the past 7 days) at 6 months compared with 66/337 (19.6%) in the control group, yielding an unadjusted OR of 1.54 (95% CI 1.11 to 2.15, p=0.01). Analyses of dispensing data also showed that the odds of being classified as adherent (≥90%) were 60% greater for the intervention group compared with the control group (OR 1.60, 95% CI 1.14 to 2.24, p<0.01). In a subsample of patients who provided blood samples, glycaemic and lipid control did not differ significantly between groups (p=0.06 and p=0.24, respectively) but positive trends were observed. Ninety-two per cent of intervention group patients reported that they were satisfied with the service overall. Conclusions A telephone intervention, led by a pharmacist and tailored to the individuals’ needs, can significantly improve medication adherence in patients with long-term conditions, using a mail-order pharmacy. Further work is needed to confirm a trend towards improved clinical outcome. Trial registration number NCT01864239.

Non-adherence to medicines for long-term conditions is a complex and prevalent phenomenon, with significant clinical and economic consequences for patients and health providers worldwide. Simple effective solutions have eluded researchers over many decades. A mixed methods randomised controlled trial was conducted to test the effectiveness of a pharmacist-led intervention to improve adherence, in the context of mail-order pharmacy. 677 patients prescribed at least one oral medication for type 2 diabetes and/or lipid regulation were recruited from a UK pharmacy, and randomised (340 interventions, 337 controls). The intervention was patient-centred, comprising spoken information and advice by phone, and written information by post, delivered by a pharmacist. All elements of the intervention were tailored to the individuals’ needs. The primary outcome was self-reported adherence to medication at six-month follow up. Secondary outcomes included prescription refill adherence, lipid and glycaemic control, and patient satisfaction. Patients who received the intervention had 54% increased odds of being adherent (defined as ≥90% of medication taken in the past 7 days), compared to the control group (OR 1.54, 95%CI 1.11-2.15, p=0.01). Analyses of dispensing data also showed that the odds of being classified as adherent (≥90%) were 60% greater for the intervention group compared to the control group (OR 1.60, 95%CI 1.14-2.24, p<0.01). For patients who provided a blood sample at six-month follow up, 67% vs 31% (16 interventions, 5 controls, p=0.06) and 65% vs 55% (64 interventions, 38 controls, p=0.24) achieved guideline targets for glycaemic and lipid control, respectively. Satisfaction with the Medicines Advice Service was high, with 91.8% (n=245) agreeing that they were satisfied overall. Intervention, led by a pharmacist and tailored to the individuals’ needs, can significantly improve medication adherence in patients with long-term conditions. The findings provide further support for the enhanced role of pharmacists in supporting and advising patients, and improving outcomes.

Non-adherence to medication is a ‘worldwide problem of striking magnitude’.1 It has consequences for the health of patients and is a great concern for healthcare providers in terms of patient outcomes and healthcare costs. Theoretical research has mainly focused on intentional non-adherence: for example, when people choose not to take their medication. However, unintentional non-adherence also accounts for a significant proportion of the problem: when people mean to take their medication in the right way but do not. This area is under-researched. In this paper, we bring a new perspective to this problem by exploring what contribution ‘resilience’ could make to it. Resilience engineering focuses on a system's ability to maintain performance, avoid error, compensate for poor circumstances and cope with disturbances. So, rather than focus on how things go wrong, we propose to exploit and enhance how things go right.The National Health Service in England processed 962 million prescriptions in 2011, which had an ingredient cost of £8.8 billion,2 and it is estimated that 30%–50% of prescribed medication are not taken correctly.3 A report prepared for a summit of European health ministers in 2012 estimated that non-adherence contributes approximately 57% of $500 billion total avoidable costs attributed to suboptimal medicine use globally each year.4 Horne et al 3 provide a broad and comprehensive review of the research in this area. Their report shows that the problem is complex and multifaceted, and they call for more research to tackle this important issue. They argue that improving the effectiveness of adherence interventions could have a greater impact on public health than improvements in specific medical treatments.3Haynes et al 5 note that current successful interventions for non-adherence are multifaceted, complex, labour intensive and at best have modest effects; they call for innovative approaches to assist …

The aim of this paper is to inform the development of social work practice and policy by applying a practice-based evidence perspective to the experiential knowledge of social workers responsible for managing cases of elder abuse in Ireland. The study adopted a qualitative descriptive research design. Semi-structured interview data were collected from a purposive sample of eighteen senior case workers and inductive thematic analysis was undertaken. The findings are presented according to three themes: elder abuse case management, practice strategies for overcoming challenges and augmenting protective practice. By examining practice in the context of wider socio-political and legislative contexts, the paper provides learning in key areas for the protection of older people. The challenges to case management practice and the strategies employed to respond to these challenges are discussed in terms of adult protective service policy development and its relationship to practice. While recognising the imperative to respect a client's right to self-determination, increased statutory authority for the duty of the state to protect older people from abuse as well as the role of the case worker to act on behalf of the state to implement protective interventions is important for the future development of the service.

ABSTRACT Background: Awareness and experiences of elder abuse have been researched as separate entities; this study examined the relationship between awareness of elder abuse, disclosure of abuse, and reporting of abuse among people aged 65 years or older. Methods: A national cross-sectional survey of a random sample of 2,012 community-dwelling older people was carried out in Ireland. People described their understanding of the term elder abuse followed by their experiences of mistreatment. Descriptive statistics and logistic regression were used with frequency, percentage, odds ratios (OR), and 95% confidence intervals (CI) presented. Results: The prevalence of elder abuse, including stranger abuse, since 65 years of age was 5.9% (95% CI 4.6–7.3). Overall, 80% of the population demonstrated some understanding of the term elder abuse. Older people who experienced physical abuse (OR 5.39; 95% CI 2.31–12.5) and psychological abuse (OR 2.51; 95% CI 1.58–3.97) were significantly more likely than older people who had not experienced mistreatment to relate the term elder abuse to their personal experiences. There was no association between experiences of financial abuse or neglect and awareness of the term elder abuse. Conclusions: There was a relatively high level of awareness of the term elder abuse; however, a substantial proportion of people could not readily associate abusive behaviors within their personal lives with elder abuse. Public information campaigns need to move beyond simple awareness rising to enable people to bridge the gap between a theoretical understanding of elder abuse and recognizing inappropriate behavior in their own circumstances.

The number of older people who are at risk of mistreatment and abuse is likely to grow as the proportion of older people in the population continues to increase. Prevalence evidence indicates that approximately 2.2 per cent of older people in Ireland have been abused in the previous twelve months (Naughton et al. 2012). Elder abuse is becoming increasingly recognised as a problem that needs to be addressed. Attention was first drawn to this issue in Ireland when the National Council on Ageing and Older People (NCAOP) published Abuse, Neglect and Mistreatment: An Exploratory Study (O’Loughlin and Duggan 1998). Since this publication, a number of developments have taken place in response to the issue. In 2002, a seminal policy document was published by the Working Group on Elder Abuse. Entitled Protecting our Future, it proposed a framework of how best to address elder abuse. In response to this policy document, dedicated elder abuse services were established by the Health Service Executive (HSE) in 2007. This service included dedicated officers for the protection of older people, with responsibility for training and policy development, and senior case workers (SCWs), social workers with responsibility for assessing and managing suspected cases of elder abuse. In addition to this specialised service, the HSE funded the establishment of the National Centre for the Protection of Older People (NCPOP) to undertake a programme of research into elder abuse.

In the report Protecting Our Future it was recommended that, following its establishment, the National Centre for the Protection of Older People should identify ‘current practices in residential care that result in the abuse of older people’ (Working Group on Elder Abuse 2002: 22). This report is part of the process of enacting that recommendation. With the support of the Health Service Executive, the National Centre for the Protection of Older People (NCPOP) undertook a national survey of staff in residential care homes in Ireland.

Objective: to measure the 12-month prevalence of elder abuse and neglect in community-dwelling older people in Ireland and examine the risk profile of people who experienced mistreatment and that of the perpetrators.Design: cross-sectional general population survey.Setting: community.Participants: people aged 65 years or older living in the community.Methods: information was collected in face-to-face interviews on abuse types, socioeconomic, health, and social support characteristics of the population. Data were examined using descriptive statistics and logistic regression, odds ratios (OR) and 95% confidence intervals (95% CI) are presented.Results: the prevalence of elder abuse and neglect was 2.2% (95% CI: 1.41-2.94) in the previous 12 months. The frequency of mistreatment type was financial 1.3%, psychological 1.2%, physical abuse 0.5%, neglect 0.3%, and sexual abuse 0.05%. In the univariate analysis lower income OR 2.39 (95% CI: 1.01-5.69), impaired physical health OR 3.41 (95% CI: 1.74-6.65), mental health OR 6.33 (95% CI: 3.33-12.0), and poor social support OR 4.91 (95% CI: 2.1-11.5) were associated with a higher risk of mistreatment but only social support and mental health remained independent predictors. Among perpetrators adult children (50%) were most frequently identified. Unemployment (50%) and addiction (20%) were characteristics of this group.

As the proportion of older people continues to increase in many countries worldwide, there has been growing global recognition of the problem of elder abuse and an emergent international body of research into the abuse of older people. In Ireland, several initiatives have been introduced in recent years as part of a national response strategy to elder abuse. Arising out of recommendations made in a report by the Working Group on Elder Abuse entitled Protecting Our Future (2002), one such development adopted to tackle this problem was the establishment in 2007 of a dedicated elder abuse service for those who have been affected by abuse. This specialist service is delivered by qualified social workers, known as senior case workers (SCWs), who assess and manage cases of suspected elder abuse referred to the HSE. This paper reports the findings of a qualitative study on the SCWs’ experiences of investigating, assessing and managing cases of elder abuse. The findings provide an insight into SCWs’ perspectives and experiences in dealing with elder abuse cases, in particular the challenges and dilemmas they face in responding to complex cases and how these are overcome. The study provides a greater understanding of current practices adopted in the management of elder abuse cases and aims to identify factors which play a central role in good practice relating to elder abuse. This paper will discuss the implications of the findings and outline the priorities identified for future service development and provision for elder abuse.

Falls in the older population are associated with increased morbidity and mortality especially in the absence of risk reduction measures. The study aims were to compare the characteristics of older people who present to the Emergency Department (ED) following a fall with the general older ED population and examine referral patterns following ED discharge.Face-to-face interviews were carried out with 306 people aged 65 years or older. Data was collected on demographic, socio-economic, health and social support factors. Descriptive and inferential statistics (Pearson chi-square test or independent t-test) were used to compare the falls and non-falls group.Falls occurred in 17% (53/306) of the study population and 43% sustained an injury requiring medical intervention. Patients in the falls group were significantly more likely to be female (68%), older (79 years (SD 6.6)) and living alone (59%). The physical and mental health profile of the falls and non-falls group was similar with 30-40% of people in both groups experiencing moderate to severe physical health impairment. A third of the falls group was discharged from the ED without evidence of referrals.Conclusion: The older population that present to the ED following a fall requires comprehensive risk factor assessment especially physical function and referrals that include falls prevention. Implications for staff: ED staff need to examine current practice within their ED in relation to falls assessment, management and referral pathways. (C) 2011 Elsevier Ltd. All rights reserved.

Hepatitis C has a global prevalence of 3%, causing chronic infection in 75% of cases, and is currently the main cause of liver transplant in the United Kingdom. This study reviewed patients' and service providers' perspectives on hepatitis C as an enduring condition, using a constructivist grounded theory approach. A constant comparative approach to data collection and analyses incorporating a coding paradigm was applied to semistructured interviews, focus groups, and memos. Sixteen patients and three focus groups of staff (n = 17) were recruited via purposive theoretical sampling (February through August 2008). A negative synergistic relationship between the condition hepatitis C, patients, and service providers that creates isolating and insulating effects for the relevant parties emerged from the data as a middle-range theory. Stigma and contagion create a "real" or perceived sense of isolation for hepatitis C comorbid and itinerant patients, who require the right support at the right time. Healthcare staff adhere to professional demarcation lines to manage potentially untenable patient caseloads. In turn, patients and professionals perceive that a crisis may be required to bring about successful therapeutic intervention. A service that incorporates seamless outreach services and facilitates interdisciplinary working is needed to manage complex patients with this enduring condition.

Aims. This paper is a report of a study of older emergency department attendees demographic, health and social profiles. Background. Relative to the general population, older people are higher users of hospital emergency departments. Attendance is most often associated with medical need, including a chronic condition and related morbidities. Method. A series of standardized health and social profiling questionnaires was administered to a non-probability sample of 307 older emergency department attendees. The sample was recruited during the spring-summer and autumn-winter periods in 2008 and 2009 at two hospitals in the city of Dublin. Subjects who met the inclusion criteria were recruited as they presented to the emergency department during the hours 8 am to midnight. The sample was stratified into those admitted and those discharged, with the aim of equally representing each stratum. Data were collected at the time of the index visit or shortly following hospital admission. Findings. Medical conditions accounted for almost half of all reasons for attendance and the health profile of the sample was characteristic of a population of chronically ill older people. Relative to the national picture for older peoples social networks in Ireland, a proportion of the sample was at risk of social isolation. Conclusions. In the absence of other avenues to treatment and based on health profile and diagnostic category, older peoples attendance at the emergency department was appropriate. The hospital emergency department remains a major arm of the Irish health service in dealing with the morbidity associated with enduring illness.

ABSTRACTPublic discourses concerning older people are available in a variety of texts, including popular media, and these discourses position older people with particular age identities. This study examined discursive formations of ageing and age identities in print media in Ireland. Constituting a single media event, newspaper texts concerned with revised welfare provision for older people were subjected to critical discourse analysis and revealed particular ways of naming and referencing older people and distinct constructions of ageing and age identities. The use of nouns and phrases to name and reference older people positioned them as a distinct demographic group and a latent ageism was discernible in texts that deployed collective names like ‘grannies and grandads’ and ‘little old ladies’. Five distinct identity types were available in the texts, variously constructing older people as ‘victims’; ‘frail, infirm and vulnerable’; ‘radicalised citizens’; ‘deserving old’ and ‘undeserving old’. The discourses made available subject positions that collectively produced identities of implied dependency and otherness, thereby placing older people outside mainstream Irish society. The proposition that older people might be healthy, self-reliant and capable of autonomous living was largely absent in the discourses. Newspaper discourses betray taken-for-granted assumptions and reveal dominant social constructions of ageing and age identity that have consequences for older people's behaviour and for the way that society behaves towards them.