AnevaluationoftheintroductionofaWard-basedPharmacyTechnicianinchildren’smedication

administrationontwowards.

October2017

FINALREPORT

Dr.AxelKaehne1,2,SergioA.Silverio1,andLouiseC.Cope1,3

1Evidence-basedPracticeResearchCentre,FacultyofHealthandSocialCare2InstituteforPublicPolicyandProfessionalPractice

3PostgraduateMedicalInstitute

EdgeHillUniversity,Ormskirk,UnitedKingdomCiteas:AlderHeyChildren’sNHSHospitalTrust (2017).FinalReport:Anevaluationof theintroductionofaWard-basedPharmacyTechnician inchildren’smedicationadministrationontwowards.Liverpool,UnitedKingdom:A.Kaehne,S.A.Silverio,andL.Cope.

AnindependentevaluationundertakenbyEdgeHillUniversityonbehalfofAlderHeyChildren’sHospitalNHSFoundationTrust

Programmeteam:PaulineBrown,CatrinBarker,andMatthewPeak

AlderHeyprojectteam:LouiseBracken,JenniferBellis,andDonnaBartlett

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Acknowledgements

Theauthorsaregratefulfortheconstantsupportandassistancebyallthemembersoftheprogrammeteam,PaulineBrown,CatrinBarkerandMatthewPeak.Wewouldalso liketothankeveryonewhoagreedtotakepartinthisstudy,inparticularthosemembersofstaffwho took the time tobe interviewedbyus.A special thanksgoes toDonnaBartlettwhohelpedusimmeasurablybyprovidinguswithhernotesandlogbookforanalysis.

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ExecutiveSummary

Reducingmedication errors is one of the priorities of NHS hospitals. The introduction ofpharmacytechniciansfornurseleddrugadministrationtopatientsisincreasinglyviewedasasuitablemechanismtoimprovemedicationreportingandreducemedicationerrorsinthelongterm.Therearenostudiesatpresentwhichinvestigatetheuseandeffectofpharmacytechniciansupportedmedicationadministrationwithinachildren’shospitalintheUK.Our study evaluated the implementation of a pharmacy technician supportedmedicationadministrationsystematAlderHeyChildren’sNHSFoundationTrust.Thenewsystemwasintroducedattwowardsconsecutivelywithonepharmacytechnician.Theevaluationusedmixedmethodstoascertainwhetherthenewsystemhadanimpactonthemedicationerrorsreportedandmedicationerrorsoccurring.Italsoexploredthewiderimpactofthepharmacytechnicianworkingalongsidenursesonthewards.Theanalysisofmedicationerrorsloggedonhospitalsystemsrevealedthatnodirecteffectofthe pharmacy technician could be observedon the reporting ofmedication errors or thereductionoferrorsduringtheimplementationperiod.Additionalanalysisofthelogbookofthepharmacytechnicianhowevershowedthattherewereclearlymedicationerrorsonbothwardsoccurring.Ourstudythenexploredthroughqualitativeinterviewswhattheimpactofapharmacytechniciansupportedmedicationadministrationsystemwouldbeontheward,includinginter-professionalworking,qualityandsafetyissuesandnurses’awarenessofthem,as well as roles and competences. The study findings demonstrate that the impact ofpharmacytechniciansonthewardisconsiderableandthatthereisclearlypotentialforthisimpacttoinfluencemedicationadministrationpractices.Our study findings support the view that a pharmacy technician supported medicationadministration systemwould have to be carefully calibrated tomake a direct impact onmedicationerrorsandthatfutureresearchneedstomodelinmoredetailthewaysinwhichsuchanimpactcouldoccurandhowitcouldbemeasured.Futurestudiesalsoneedtoestablishthecostsandbenefitsofpharmacytechniciansupportedsystemscomparedtotheprovisionofadditionalnursingresourceatwardlevel.Focussingontheinter-professionalworking,additionalexpertiseandprocessesofsharedknowledgeandhowthiscouldbefostered inapharmacytechniciansupportedmedicationadministrationsystem is essential in producing evidence based knowledge for organisational changes inmedicationadministration.

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Contents

Background.......................................................................................................................5

EvaluationAimsandObjectives.........................................................................................7Changestoprotocol...................................................................................................................8EvaluationMethods...................................................................................................................8Recruitment...............................................................................................................................9Interviews................................................................................................................................10DataAnalysis...........................................................................................................................10EthicsandGovernance.............................................................................................................11

Results............................................................................................................................12Medicationerrorlog................................................................................................................12ResultsSemi-structuredinterviews..........................................................................................13

Role,tasksandjobdescription....................................................................................................13Impactandeffect.........................................................................................................................18

Discussion.......................................................................................................................23

Limitationsofstudy.........................................................................................................26

Futureresearch...............................................................................................................27

References......................................................................................................................28

Appendices.....................................................................................................................31

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Background

AlderHeyChildren'sNHSFoundationTrust isoneof the largestchildren'shospitals in theUnited Kingdom [UK] and Europe. Located in the NorthWest of England, each year thehospitalprovidescareforover270,000children,youngpeople,andtheirfamilies.AlderHeyisacentreofexcellenceforheart,cancer,spinal,andbraindisease;andisadesignatedMajorTrauma Centre and national Children’s Epilepsy Surgical Centre. The Trust is a leadingpaediatric researchcentre intochildren’smedicines, infection, inflammationandoncology(AlderHeyChildren'sNHSFoundationTrust,2017).

The pharmacy department at Alder Hey provides both inpatients and outpatients withmedicines thataresafe,appropriate,evidence-basedandcost-effective.The treatmentofchildren with medicines poses particular pharmaceutical and pharmacological challengescomparedtoadults.Forexample, infantsareunable toswallowregularsizedtablets,andneonatesmayrequireverysmallvolumesofaparenteralmedicinetoavoidvolumeoverload(Zajiceketal.,2013).Acceptabilityofandpreferencefordosageformsmayalsovarybetweenchildren.Thechild’sage,healthstatus,behaviour,disabilities,backgroundandculturemustbe taken into account (European Medicines Agency, 2013). Pharmacokinetic changes inchildhoodalsohaveasignificanteffectonhowamedicineishandledbyachild’sbody;andneedtobetakenaccountofwhendecidingupontheappropriatedosingregimen(Choonara&Sammons,2014).

Additionally,intheUK,unlicensedandoff-labelproductsaccountfor25%ofmedicinesusedfor children in hospital generalwards, 40% in paediatric intensive care units, and 80% inneonatal intensive care units (Nunn, 2003). Off-label use includes using amedicine: At adifferentdose;foradifferentindication;inadifferentagegroup;orbyadifferentroutetothatrecommendedbytheproductlicence(Choonara,2004).Prescribingofunlicensedoroff-labelmedicinesinsecondarycarebringsitsownlegalimplications,andfurthermore,canleadto problems obtaining themedicine and treatment disruption when the child returns toprimarycare(Tomlinetal.,2016).

Thepharmacyteamiscomprisedofpharmacists,pharmacytechniciansandawiderangeofsupportstaff,experiencedinthefieldofpaediatricmedicineanditsassociatedchallenges.Thepharmacists andpharmacy techniciansoftenwork as part of thewider clinical team,supportingmedicalandnursingstaffinprovidingtreatmentstopatients,beingresponsibleforensuringthatthecorrectmedicinesareprescribedanddispensed.Pharmacytechniciansare a vital part of the pharmacy team, working under the supervision of a pharmacist.pharmacy technicians practicing in Great Britain are required to be registered with theGeneralPharmaceuticalCouncil[GPhC],theirprofessionalregulatorybody(GPhC,2017).Inorder to register with the GPhC, pharmacy technicians must possess both appropriatecompetency and knowledgebasedqualifications, alongwith two years consecutivework-basedexperience(GPhC,2013).

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Qualifiedpharmacytechniciansworkinginhospitalsmaybeinvolvedinareasofworksuchasmanufacturing,asepticdispensing,qualitycontrol,clinicaltrials,traininganddevelopment,procurement, information technology, medicines information, and the supervision andmanagement of staff. Pharmacy technicians may also be embedded in ward teams:Organisingandrationalisingmedicines;reviewingprescriptionchartsandorderingnon-stockitems;encouragingthetransferofdispensedmedicinesandpatients’owndrugswithpatientswhomovewards;optimisingmedicinesdischargeto improvepatient flow;andcontactingwardpharmacistswithdruginformationinquiriesandwhenclarificationwithmedicalstaffisrequired(EmergencyCareImprovementProgramme,2015).

AshospitalsettingsbecomeincreasinglypressuredintheUK,nurse-leddrugadministrationworkloadsarebeingalleviatedbytheintroductionofpharmacytechnicianstosupportbusywardsandsupporttheadministrationofmedicines(Sinclairetal.,2016,Keersetal.,2017).Arecentpilotstudy(Sinclairetal.,2016)ontheintroductionofpharmacytechniciansontoanoncologyward as part of thenursing team, reported a reduction in adverse events, areductioninnursework-relatedstressassociatedwithpreparingcomplexmedicines,andthefreeingupofnurses’time.

An earlier study involving ward-based pharmacy assistants (support staff who are notregisteredwiththeGPhCbutareinvolvedinpharmacyservices;GPhC,2017),demonstratedthat pharmacy assistant supported medication rounds significantly reduced the rate ofomitted medication doses (Baqir et al., 2015). In contrast, an evaluation of pharmacytechnician supported medication administration rounds on medical and surgical wards,demonstratedthatpharmacy techniciansupportedmedicinesadministrationmaybebothacceptable and potentially feasible to implement in NHS hospitals, but had no impact inreducingomitteddoses(Keersetal.,2017).

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EvaluationAimsandObjectives

Thestudyevaluatedtheintroductionofa‘Ward-basedPharmacyTechnician’ontwowards(oneforpatientswithneurologicalorlifelongconditionsandthoseonlong-termventilation–referredtointhisreportas“Ward1”;theotheramedicalspecialitiesward–“Ward2”)inaChildren’sNHSFoundationTrustintheNorthWestofEnglandoveraperiodofeightmonthsbetweenOctober2016andJune2017.Itaimedtoaddressthefollowingresearchquestion:

Whatistheimpactofthepilotofapharmacy-techniciansupportedmedicineadministrationsystem(PTSMAS)onselectedin-patientwardsatAlderHey?

Toachievethistheevaluationundertook:

1) Adatatrawlandcomparisonexerciseofmedicationerrorssixmonthsprior to theserviceandsixmonthsaftertheintroductionoftheserviceintwowards

2) A qualitative study to explore the views and experiences of members of staff(pharmacyandnursingteams)involvedinthePTSMAS.

Theevaluationconductedaretrospectivereviewofexistingmedicationerrordatafromtwowards.Weobtainedandanalyseddatacontainingreportedmedicationerrorsontherelevantwards,andconductedacomparativeanalysisof reported incidencesbeforeandafter theimplementationofaPTSMAS.Thetimeframeforthedatatrawlwassetatsixmonthspriorandsixmonthsaftertheimplementationofthenewsystem.

ThestudywastoincludetwopharmacytechnicianswhoweretobeplacedontwodifferentwardsattheTrust.Thewardsdifferedinsofarasonewardoperatedanear-patientpharmacyteam(Ward2),whereasthefirstwarddidnot.Near-patientpharmacymeansthatthewardhas a fixed pharmacy on-site stocked with medicines and staffed with pharmacists andpharmacytechnicianswhoworkalongsidenursesfivedaysoftheweekforveryspecifictaskssuchasre-stocking.Thetaskoftheward-basedpharmacytechnicianinthenewsystemtobeimplemented, differed from near-patient pharmacy technicians. The data analysiswas toinclude four outcome measures: Medication errors on the wards; delayed medicationnotifications;adversedrugreactions;and,drugsafetyissuesraisedbystaff.

The study protocol hypothesised that the new system would lead to improved, higherreportingofincidencesinthesefourcategories.Theevaluationalsoconductedaqualitativestudyontheviewsandexperiencesofstaffwiththenewmedicationadministrationsystem.

Award-basedpharmacytechnicianwasappointedinAugustandunderwentamonthofin-housetraining,startingworkonWard1inSeptember2016.Shemovedfromthiswardto

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Ward2onMonday23rdJanuary2017andcontinuedtoworkthereuntilFriday2ndJune2017.Her post was then discontinued, and she took up a position elsewhere. Theward-basedpharmacy technicianmet the educational and qualification requirements of the post andreceivedadditionaltrainingupontakingupthepositiononthefirstward.Assetoutabovepharmacy technicians generally hold a BTEC in Pharmacy Sciences (National VocationalQualification[NVQ]Level3–2yearcourse),astandarddefinedbytheGPhC(2017).Inourcase,thepharmacytechnicianhadalsosuccessfullycompletedanAccuracyCheckercourse(Health Education England, 2017). In addition, she received a NurseAdministrationCompetencyBookletandcompletedanIntravenousTherapyTrainingCourse.ShealsocompletedMeditech6(electronicmedicalrecordsystem;Meditech,2017)TrainingandMedicinesAdministrationRecord[MAR]chartTraining.Moreover,shereceivedtrainingontheUlyssesSafeguardSystem(Ulysses,2017), theTrust’s IntegratedRiskManagementsystem,whichenablesallmembersofstaffto,amongstotherthings,reportincidentsastheyoccur.

Changestoprotocol

Theinitialdatatrawlfromtheexistingmedicationerrorrecordsrevealedthattherewerefewrelevantdataforanalysis.RecordsfromWard1containedonlysixmedicationerrorsloggedoverasixmonthsperiodbeforetheimplementationofthenewmedicationadministrationsystem.Thismeantthatdatachangesinmedicationerrorreportingpostimplementationofthepilotcouldnotbereliablyattributedtothenewsystem.

The team then identified an alternative method of investigating the primary outcomemeasureofmedicationerrorsbasedonaqualitativeresearchapproach.Theyconductedacontent analysis of the ward-based pharmacy technician’s daily log, and subsequentlyquantified the data of logged incidences. Simple frequencies of incidenceswith differentseveritieswerecalculatedandarereportedbelow.

EvaluationMethods

Evaluativeresearchstrivesforanunderstandingofnewornovelimplementations,suchasnewrolesandnovelwaysofworking, theiroutcomes,and the impactof suchchanges inpreviously outlined settings (Fink, 2014). Qualitative data allows the research to elicit a“breadthofexperiencestoensurecertain ‘voices’arenotexcluded,toprovideadepthofinsight,tohelpclarifywhyindividuals’experiencesvaryandtoascertaintheextenttowhichtheoriginsofthesevariationscanbeaffectedbyproviders.”(Chapman,Hadfield,&Chapman,2015,p.201).

Thestudyusedqualitativemethodologyintheformofface-to-faceandtelephoneinterviewswith the ward-based pharmacy technician, their Colleagues, and two of the hospital’sStrategicLeadsanalysedusingThematicAnalysis;andaContentAnalysisoftheward-based

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pharmacy technician’smedication error log across the twowards. Content Analysis andThematicAnalysisarereportedtobecomplementarymethodsforqualitativestudies(Crowe,Inder,&Porter,2015;Schwappach,&Gehring,2014;Vaismoradi,Turunen,&Bondas,2013).

Toensurerigourinthequalitativeinterviews,theteamusedtwotechniques,thefirst“fairdealing” which ensured we incorporated a wide range of perspectives from the hospitalsetting(Mays&Pope,2000,p.51).Thisenabledourfindingstoberepresentativeofthelargenumber of different professional and strategic standpoints, which exist within theorganisation.Secondly,tworesearchersworkedindependentlyofeachotherwhilstcodingtranscripts and then came together to check the inter-rater reliability and assumed a“negotiatedagreement” system (Campbell,Quincy,Osserman,&Pedersen,2013,p.305).This iswheresomeof the themeshadbeenpresenteddifferently,although therewasanexcellentagreementoncodesandsubsequentquotationstosupporttheclaimsmadebyeachresearcher(Armstrong,Gosling,Weinman,&Martheau,1997).

Forthecontentanalysisoftheward-basedpharmacytechnician’smedicationerrorlog,wefollowedHsiehandShannon’s(2005,p.1283)guidelinesfor“summativecontentanalysis”wherebywequantifiedthequalitativedataprovidedtounderstandwhicherrorswerebeingmade and their frequency. Each error was then scored for severity using the NationalCoordinating Council for Medication Error Reporting Prevention [NCC MERP] Index forCategorizingMedicationErrorsAlgorithm(basedonHartwig,Denger,&Schneider,1991).

Recruitment

For semi-structured interviews a purposive sampling strategy was employed. Potentialparticipantswere identified and sent an e-mail inviting them to take part in a telephoneinterview.Theward-basedpharmacytechnicianandthetwostrategicleadsforpharmacyandnursingwereinterviewedface-to-face.Allotherinterviewswereconductedviatelephone.Intotal,14interviewswerecarriedout.Alistofrespondentsisbelow:

• Theward-basedPharmacyTechnician(onceaftereachward)

• TheDirectorofNursing

• OneWardManager

• OneSister

• FourStaffNurses

• TheChiefPharmacist

• ThreePharmacists

• OneNear-PatientPharmacyTechnician

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Interviews

Interviewswereconductedwithasemi-structuredinterviewschedule,andconversationalinnature.TheschedulewasdevisedtocapturesalientpointsrelevanttotheimplementationofPTSMASanditincludedquestionsabouteachparticipant’sunderstandingoftheroleofaward-basedpharmacytechnician,howPTSMAShadchangedtheward,andhowtheirroleinteracted with the new appointment. Informed consent was obtained verbally prior tointerviews,andinwritingforthosewhohadface-to-faceinterviews.

All interviewsweredigitally recordedandtranscribedverbatim. Interviews forcolleaguesaveraged 20minutes,whilst for theward-based pharmacy technician and strategic leadsinterviewsrangedbetween30minutestoonehour.

Ourrecruitmentstrategyensuredthatparticipantswithdifferentprofessionalbackgroundswere interviewed, representing a wide range of perspectives meeting requirements forsubstantialdatatriangulation(Denzin,2017).

DataAnalysis

After interviews were transcribed and anonymised, the transcripts were subjected to arigorousThematicAnalysis(Braun&Clarke,2006)bytworesearchers(SASandAK)codingindependentlyofeachother(Polit&Beck,2010).Codinginstanceswerethendiscussedandkeythemeswereproduceduponconsensusbetweenthetworesearchers.ThematicAnalysisisoftenusedasananalytical tool inhealthcareresearchoffering thoseworking inclinicalsettings a critical review of the implementation within a setting (Chapman, Hadfield, &Chapman, 2015; Pope, Ziebland, & Mays, 2000). Braun and Clarke’s Thematic Analysisprocess involved each researcher (re)familiarizing themselves with the transcript data,generatinginitialcodes,andsearchingforpotentialthemesemergingfromthedata.Themeswerewrittenupnarrativelybelow.Theyareevidencedthroughverbatimquotes.

Tworesearchers(LCCandSAS)undertookthecontentanalysis,withathirdresearcher(AK)arbitrating over any discrepancies between the two sets of coding for the ward-basedpharmacytechnician’smedicationerrorlogsfromthetwowards.Theprocessconsistedofinterpreting the data and formulating key categories of incidences (Vaismoradi, Jones,Turunen, & Snelgrove, 2016). Six categories were formulated from the content analysis:‘Supply’; ‘Storage Issues’; ‘Communication & Linking-up’; ‘Expiry Date Issue’; ‘MedicationAdministration/Dosing Issues’;and ‘Information–whereward-basedpharmacy technicianwas theSource’. Eachmedicationerrorwas then scoredusing theNationalCoordinatingCouncil forMedicationErrorReportingandPrevention (NCCMERP) algorithmon severity(adaptedbytheNCCMERP,fromHartwig,Denger,&Schneider,1991).

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Severity scores ranged from ‘No Error’ to ‘Category D’ where there was a subsequentinterventiontoprecludeharmorextramonitoringwasrequired.Asbeforetworesearchers(LCC & SAS) scored independently of each other, coming together to reach a sharedagreement,withanydisagreementsdecideduponbyathirdresearcher(AK).

EthicsandGovernance

The study protocol was reviewed by the Faculty Research Ethics Committee at Edge HillUniversityandconsideredtobeanevaluationnotrequiringfullethicalreview.Alettertothiseffectwasobtainedbytheevaluationteam.AlderHeyHospitalgrantedresearchgovernanceapprovalinJuly2016.

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Results

Studyfindingswillbereportedintwosectionsbelow.Thefirstsectionwillcontaintheresultsoftheanalysisoftheward-basedpharmacytechnician’slog;thesecondsectionreportsthethemesemergingfromtheanalysisofthesemi-structuredinterviewswithstaff.

Medicationerrorlog

Asmentionedinthemethodologysectionabove,existingdatasetsobtainedthroughAlderHey from the reporting system Ulysses, did not contain sufficient numbers of reportedincidencesofmedicationerrorstoconductapre-postimplementationcomparativeanalysistoassesstheeffectofPTSMASonmedicationerrors.

Theanalysisoftheward-basedpharmacytechnician’slogs,however,revealedasignificantnumber of incidences at different levels of severity. The logs contained 152 recordedincidencesonWard1overathreemonthsperiod,and88recordedincidencesonWard2overasubsequentthreemonthsperiod.IncidencesinWard1triggered226actionsbytheward-basedpharmacy technician, and126actions inWard2. The tablebelowdetails thenumber of incidences in each category by ward. Table 1 sets out the actions taken percategorythatfollowedincidences.Oneincidencemayhavepromptedmultipleactions.

Table1:FrequencyofTypeofErrorsacrossWard1andWard2

ACTIONTAKEN Ward1

(152RecordedIncidents;

226ActionsTaken)

Ward2

(88RecordedIncidents;

126ActionsTaken)

Supply 58 23

StorageIssues 15 14

Communication&LinkingUp 43 19

Medication Administration/DosingIssues

30 25

Information (where Ward-basedPharmacy Technician was theSource)

25 6

ExpiryDate/Issue 55 39

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Table2:FrequencyofErrorSeverityacrossWard1andWard2

SEVERITY Ward1 Ward2

No Patient Involvement (i.e. action which was recorded, but not inrelationtoanypatientsocouldnotusealgorithm)

28 15

Noerroractuallyoccurred(A) 17 0

Error,butdidnotreachPatient(B) 81 64

Patientwasnotharmedandnointerventionrequired(C) 14 8

Patientnotharmed,butinterventionorextramonitoringrequired(D) 2 1

Error led toTemporaryHarmofPatient, butdidnot require furtherhospitalization(E)

0 0

Error led to Temporary Harm of Patient, and required furtherhospitalization(F)

0 0

ErrorledtoPermanentHarmofPatient(G) 0 0

ErrordidnotleadtoPermanentHarmofPatient(H) 0 0

ErrorLedtoPatientDeath(I) 0 0

Oneofthekeyfindingofthisstudyisthat,asthelogrevealed,therearesignificantnumbersof incidences thatwere not reported by nurses asmedication errors. The overall pictureemergingisaconsiderablediscrepancybetweenthenumbersofmedicationerrorsreportedbystaffonbothwardsandasignificantnumberofpotentialorpossiblemedicationerrorsidentifiedbytheward-basedpharmacytechnician.

ResultsSemi-structuredinterviews

Data from semi-structured interviews revealed a series of emerging themes. Two broadcategoriesof themeswere identified, and the findings reportedbelow. The first categorycontainsthemesrelatingtotherole,jobdescriptionandtasksoftheward-basedpharmacytechnicianandotherstaff.Thesecondcategorycontainsthemesabouttheimpactandeffectoftheward-basedpharmacytechnicianonthewards.

Role,tasksandjobdescription

Astrongthemethatreverberatedthroughoutmanyinterviewswasthedirectpositiveeffectofthepharmacytechnician’sworkontimemanagementofnursesonthewards.Therewasabroadconsensusamongstintervieweesthatthepharmacytechnicianallowednursesonthewardtobereleasedforotherduties,whichinturnledtoanimprovementinnursingcareand

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increasedcontacttimeofnurseswithpatients.Thiseffectwasparticularlystrongduringthemorningroundofmedicationadministration.

So,itwasverydifficultofamorning,becausetwoNursesusedtotryandstarttheoralmedicines,whileonewentofftopreparetheIVs.Andthenwe’dhavetowaituntiltheendofthemedicineroundforsomebodytocomeandtocheckthroughamultitudeofIVs,andalotofthemarecontrolleddrugs.So,when[name1]cameimmediatelyshewasabletodooraldrugswithoneNursewhiletwoNursesdidallthoseIVsandthat.(Wardmanager)

Therewasalsoaconsensusamongststaffintervieweesthatthepresenceofthepharmacytechnician led topositivechanges in thenursingandpharmacist routineson theward. Inparticular,itallowednursingstafftofreeupsomeoftheirtimetoattendtopatients.

…shehasallowedustobeabitmorefreeoftimetofocusondruglevelsandthingslikethatbydoingsomeaccuracychecking,whichhashelpedusoutalittlebitmore.(Pharmacist3)

IthinktheroledoesbringsomethingdifferentandIthinkitdoesreleasetimetocare.(StrategicLeadforNursing)

It frees up their care contact time. Yes, there’s still a Nurse involved inmedicinesadministration,ofcourse,butthere’soneNurseinvolved,nottwo.Soitisfreeingupnursingtimetocarewhichiswhat’simportant.(StrategicLeadforNursing)

Therewasalsoawidelysharedrecognitionthatthejobdescriptionandanticipatedroleofthepharmacytechnicianwerewelladjustedtootherstaffrolesandtasksontheward, inparticularwherenearpatientpharmacywasoperatingontheward.Thisissignificantasthepharmacy technician’s role could have duplicated some of the tasks carried out by thepharmacy staff on the ward. That this was not the case demonstrated that there wasparticularbenefitindevelopingacomplementarypositiononthewardevenwhereapatientnearpharmacywasinplace.

Well,thedifferencebeingthat,ourPharmacyTechnicianwhodoesthestockis justlookinginourcabinetandismaybenotalwaysmakingthelinkbetweenwhatweusingalotofandwhatpatientshavegoton.(Wardmanager)

Staffinterviewsalsorevealedaclearacknowledgementofthepositiveeffectsofthewiderrole of pharmacy technician on the ward, with activities that went beyond supportingmedicationadministration.Therewasasensethattheseadditionalactivitiessuchaspatient

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medicationcounsellingcontributedtoapositiveperceptionofpharmacystaffand,forstaff,awiderunderstandingoftheroleoftheward-basedpharmacytechniciansinthefirstplace.

Idon't thinkward-based technicians shouldbehampereddown toomuchwith thedispensing role. I feel that they shouldbedoingabetterdrughistory, full-roundedmedicinesmanagement,and inmyopinion that involves speaking topatients, andtheirparents inour case,aboutwhen to takemedicationathome,how to take it,actuallygivingeach familya full counsellingexperience,and I think that thegreatopportunitytodothatisactuallyviagivingthechildthemedication,'causeitallowspharmacythatinletintothemanditexplainsalittlebitmoreofourroletothefamilyaswell,sotheycanunderstandwhatwe'redoingandwhy,typeofthing.(Pharmacist3)

Thisechoedasimilarindicationaboutashiftintheperceptionoftheroleoftheward-basedpharmacytechnicianbycolleagues.

IthinkitisgoodtobeabletoexpandourknowledgebecauseIthinkwe’vebecomeabitstuckatthemomentoncewe’vequalified.We’vekindofjuststuckinarutdoingthesamejobwhereasIthink[PharmacyTechnician]’sjob,thejobthatwas[PharmacyTechnician]wasdoingortriallingout,itseemedlikeitwasgood,lookedlikethere’dbe good opportunities to expand your knowledge and working along otherprofessionals.(NearPatientPharmacyTechnician)

Thisshiftinrolesandresponsibilitiesresonatedwithpharmacystaffandreflectedaperceivedneedtoredefineandexpandthescopeoftheroleofward-basedpharmacytechnicianwhereappropriate.

We've always been a bitmore cautious, I've always felt, in pharmacy. You've gotopportunitiestointeractwithparents,andIthinkweshouldtakethem.(Pharmacist3)

…our technicians have a lot of informationwhich they don't get to utilise becausethey'reboggeddownwithdoingre-supply,dispensing,which isn't, inmyopinion,ahospitaltechnician'srole.Theyshouldbeout,medsanddoingmedsmanagementsothatwecangetpatientsconvertedoverfromliquidstotabletssothatwecanexplaintoparentswhythedrugisn'tbrandedanymore.(Pharmacist3)

There has also been a clear recognition of the skills and knowledge that theward-basedpharmacytechnicianbroughttothewardandanincreasedawarenessoftheneedtoutilisethisexpertiseto improvethequalityofpatientcare.Wherestaff felt thattheward-based

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pharmacytechnicianwasabletosharethisknowledgewithnursingstaff,elementsofsharedlearningand,ultimately,increasedconfidenceofstaff,werementioned.

Shewasmoreclued[up]inthataspectandithelpedmyroleinthatshewouldalertmetothinktheymightnothavebeenright,soIcouldprioritisemyselfbetter,soitgivemeabitmoreconfidencetoknowthatshewasalsocheckingandIwasawareofthatduetoherrole…(Pharmacist2)

Animportantpartofanyorganisationalchangeistoensurethatstafffeelcomfortablewithchangestotheirroutinesanddonotfeelthreatenedbynewstaff.TheinterviewswithstaffrevealedfewinstanceswerestafffelthesitantorapprehensiveaboutthechangesthatwereimplementedthroughPTSMAS.However,theinterviewswereconductedatatimewhenstaffhadalreadyhadachancetoassessthebenefitofthechangestotheirownworkingpatternsand to the ward as a whole. The data from the interviews with nursing colleagues maythereforenotgiveacompletepictureofapprehensionoranxietyaboutsystemchangesthatmaywellhaveexistedattheearlydaysofthepilot.

Somecommentsofsomestaffandtheward-basedpharmacytechnicianherself,however,indicated that there may have been some reservations by staff before the ward-basedpharmacytechnicianstartedherwork.ThesereservationsquicklyevaporatedasfarasthedatatellsbutitappearsanimportantpartofthepilotfindingstonotethattheintroductionofthePTSMASwasseentoentailsignificantchangestoworkpatternsandroutinesbynursingstaffandthosechangesmayhavebeengreetedbysomelevelsofapprehensionorconcern.

…whyaren’tyoufreeinguponetodoIVsandlet[name1]checkthem.Andtheywerelike, oh no, it’s all right, we’ll do them. And I think they were unsure as to what[name1]’srolewasgoingtobe.Butoncethey’verealisedyouknowandIsaidno,no,[name1]cancheckeverything,letherdothat.AndImean,asIsay,staffhavebeenlike,don’tlet[name1]haveannualleavesortofthingtheywantedhereveryday.AndI think you know, I thinkwe’ll allmiss herwhen she goes, you know, because it’sbecomethenormtoacceptthat[name1]isinthere,doingthatroleforussowecandosomethingelse.Soyouknowevenatweekendsnow,youknow,asIsay,younoticethedifferencewhen[name1]’snotaround,becauseit’sbacktotheoldsystemofwhatweusedtodo.(WardManager)

Inparticular,staffconcernsabouttheintroductionofthenewsystemmayrevolvearoundgrading,remunerationreflectingclinicalexpertiseandjobdefinitionandencroachmentontasksets,leadingtolossofstatusand/ornarrowingoftherangeoftasks.Asfaraswecanobserve in the data, none of these reservations and concerns proved enduring or deep-seated.

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…onthewardthatIwasworking,thatIworkon,therewassome-notresistance,whatworddoIwanttouse-hesitanceaboutwhatwouldIdo,howwouldIfitin,wouldIbetakingaNurse'splace-butIcan'tdoeverythingthataNursecan,amIgoingtobeuseful,amInot-andsomestaffwereopen-Yeah,extraperson,let'shelp-somewere,Oh,don'tknow,notsosure.Butbybeingthere,explainingtherole,andactuallydoingthe role with them, all the nursing staff had a complete turnaround (Ward-basedPharmacyTechnician–Interview1)

Ithinktheresistancewasbasically-Isshegoingtotakeajobfromus?Well,whywouldwehaveher-'causetheywereveryinterested-Well,whatbandareyou,whathaveyoudone.'Causetheequivalent,potentially-I'mabandfive,andthestaffNurseisabandfive,soiftheywere-itmaybethat,Well,you'regettingpaidthesameasme,butyoucan'tdoallwhatIdotypething-well,Orareyougoingtotakeourjobfromus?Areyougoingtode-skillus?Thatwasnevergoingtohappenhere…(Ward-basedPharmacyTechnician–Interview1)

One important aspect of inter-professionalwork onwards is shared learning andmutualsupportutilisingdifferentskillssetsandknowledge.Thestaff interviewsrevealedastrongsenseamongststaffinthepilotthatworkingalongsidetheward-basedpharmacytechnicianledtoanincreasedawarenessofdosing,sideeffectsofmedicationandstoragerequirements.This reflects an important side of the placement of PTSMASwhere knowledge is sharedbetweendifferentstaffgroupsandprofessionalsleadingtoareductionofincidencesonthewardand,ultimately,improvedpatientcare.

She was also—‘cause she’s got the pharmacy knowledge as well, you know, herknowledgeofsomeofthemedicationswasalotbetterthanoursaswell.(Sister)

I would, you know, ask her sometimes about medications if I wasn’t sure aboutsomething,andshecouldthenfindoutformeifshewasn’tsure,whichagainsavedtime.(Sister)

…justsimplethingslikehowdoIorderthisonMeditech-Well,Icanshowyouthat'causeIknowhowtodothat,ratherthanringingvariouspeople,tryingtodoitoverthe phone, 'cause normally they'd ring the dispensary, they'd have to describe theprocedureover thephonewhich, if youcan't see it in frontof you it'squitehard…(Ward-basedPharmacyTechnician–Interview1)

Soshewasexplainingtometheexpenseofhowmuchitactuallycostsobviouslytomake themeds and stuff, especially the fridge items. So I think,myself, I’mmoreconsciousofmakingsurethemedsarebackinthefridge,becauseobviouslyIdon’twantthatmoneytobewasted,‘causeI’venowgotanunderstandingofhowexpensivesomeofthemactuallyare.(LearningDisabilitiesNurse)

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Impactandeffect

The analysis of semi-structured interviews revealed strongmessages around the positiveimpactandfacilitatingeffectoftheworkoftheward-basedpharmacytechnicianfornursingstaff. The positive effects of her work could be seen in medication management duringmedication administration rounds and safety related issues such as medication errors,dosage,andexpiredpharmaceuticalproducts.

Thefirstnoticeableeffectoftheward-basedpharmacytechnicianonthewardwas inthetimelyadministrationofmedication.Thisoccurredmainlyduring themorningshiftwheremostintervieweescommentedonasignificantfreeingupoftimeforonenurse,whilsttheward-basedpharmacytechnicianwouldprepareandsecondcheckpatientmedications.

I justthinkittook—itwasamassiveloadoff, like,sortofpressure-wise. ‘Causethewayweusedtodoit,Imean,obviouslywewerethreeseparatewardsthen,butthewaymyoldwardusedtodoitwouldbewe’d—twopeoplewouldstandatthedrugstrolley,andtheywoulddoallofthemedications,whichmeantreally,forthathourinamorning,youweren’tabletosortofgoanddoanythingelseforyourpatientsorcheckyourpatients.(StaffNurse2)

Shewouldprepare,like,getmedicationsoutinadvanceforyoutothencomeanddothem.Sothatwouldsaveyoutime‘causeshe’dbepreparingit inadvanceforyou.(Sister)

MedicationsIthinkweregivenontimemoreregular.(Pharmacist2)

Thebigdifference,Ithink,wasaroundsupplyofmedicines,because-'causetheydon'thaveaserviceinthemorning,iftheyneededanythingforamorningdosebeforethePharmacistcameupathalfpasttwo,it'llbeacaseoftheywouldneedtoeitherringdispensary,tellthemthat itneededordering… (Ward-basedPharmacyTechnician–Interview1)

It appeared that there was a noticeable improvement in the timely administration ofmedicationtopatientswhilsttheward-basedpharmacytechnicianwasworkingontheward.

Well,shewasduemedsatoneo'clockandshe'snothadthemyet.Sothehealthcareislike,Well,there'sonlyoneNurse,andshe'sbusy,orWecan'tgetanotherNursetocomeandcheckthem,andthey'dhavetoexplainthat,whereastheycouldjust-they

19

go,Oh,[P]'sdonemedsnow,'causeshe'shere,youknow,'causeIturnuptodothemedsasopposedtothemhavingtoremindtheNursesotheNursethenhastofindsomeoneelse(Ward-basedPharmacyTechnician–Interview1)

…thechildrenwouldbeduemedicinesayforexampleeighto’clockandteno’clock,everyoneatthesametimebutyoucouldbewaitingoverhalfanhourtogetanotherstaffNursefromanotherbaytocomeandcheckyourmedicineandbecausethelayoutoftheward,allthewardsaresimilarnowin[hospital],therearethreedifferentzonesandyou’remeanttostaywithinyourzoneobviouslywiththechildrenyou’relookingafter.Sometimesyoucanbewaitinguptohalfanhourforsomebodytocomefromanotherzoneandthenobviouslythere’saknockoneffectbecauseallyourmedicationsarelateandthentheparentsobviouslyaren’thappy…(StaffNurse1)

Ingeneral,staffalsocommentedthatherworkledtoconsiderablereliefofworkpressuresduringthemorningshift.

Soitcertainlyeasedthepressureatthosetimes.AndthenwhenDishere,itwasaloteasier,andnowwe’rebackto,youknow,nothavingsomebodyhere,soit’sgotbusyagain.(Sister)

ObviouslywhenDwasthere,thatsortoftookthepressureoff,becauseitleftyou—unlessyouwerecheckingthemforyourpatients,itleftyouabletodootherthings,ifthatmakessense.(StaffNurse2)

Itwasvery,veryhelpfulat,like,particularpeaktimeslikeeighto’clockinthemorning,inparticular,andtheearly,youknow,thatmorningtime,andagainat lunchtime.(Sister)

…itwasreally,theyweregiven,itwasalotquicker,therewasextrahelpwe’dgotitandthentheNurseswhowere,otherNurseswerelikeabletodotheemergencychecksfirstthinginthemorningsothatNurseswerefreetodoemergencychecks,andotherthingstodowiththepatients…(Band5Children’sNurse)

…when D started, the medication rounds were getting done so much quicker, soinevitablyitwashelpingsupporttheNursestobeabletogetonwithourjobsalotquicker.(LearningDisabilitiesNurse)

Therewas also a noticeable improvement inmedication errors identified and rectified atvarious points of incidence. One interviewee commented on increased medicationincidences, even though thiswas not reflected in the list ofmedication errors logged bynursingstaffinUlysses.

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I’mamedicationsafetyPharmacist[and]Ididseeanincreaseinmedicationincidentscomefromthewardbecauseshewasable, fromherbackground I thinkshehadamedicinegovernancebackgroundanywaysoshedidreport,itbroughtattentiontomeor instances that were happening on other wards that maybe not normally gotreported(Pharmacist2)

IthinktherehasbeenanimprovementinmedssafetyandI’venotnecessarilyseenareductioninmedicationerror,butthentheyweren’tparticularlyhighonthatoneontheward,oratleastnotreportedhigh(StrategicLeadforNursing)

Parallel to this, respondents noted that theward-based pharmacy technician gave usefuladvice to staff on dosage, which would relate to shared learning processes andcomplementarycompetences.Keyanticipatedimpactsofthenewsystem.

…she'salsobeenverygoodatgivingadvicetothenursingteamaboutmedicationandwhatmedicationtogivetogether,andunderstandingofdosesaswell,andqueryingdoses.(Pharmacist3)

Somerespondentsalsocommentedthattheimpactoftheward-basedpharmacytechnicianwasfeltbeyondtheimmediatewardstaffandincludedpatients.Thismayhavehadapositiveeffect on the way pharmacy staff were perceived by patients in addition to potentiallyimprovingpatientcare.

IthinkitwasgoodaswellforparentstoseethatitwasaNurseandsomebodysortofrepresentingpharmacytechinthemedications,‘causethat’stwodifferentsortofskillsetscomingtogether.(StaffNurse2)

She's verygoodat beingable todo that andactually to speak to theparents andpatients about medication as well. I know of several occasions where she's hadconversationswithparentsthathaveledtousgoinginanddoingfurthercounselling,soIthinkthatpartofherrolehasbeenreallygreat.(Pharmacist3)

There was some evidence that the introduction of the ward-based pharmacy technicianchangedtheorganisationalsetupoftheward,thewayinwhichdifferentprofessionsworkedtogethertoaddresspatientneeds,aswellasarecognitionofimprovedoverallperformanceby all. Her work was felt to impact positively on inter-staff communication, staff-patientcommunicationaswellasbridgingbetweendifferentprofessionalgroups.

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Ithinkherroleactuallyallowsbettercommunication.Ithinkwedo-we'reveryluckyhereatA[hospital],wedohavegoodrelationshipsbetweenthepharmacyteamandthe nursing and clinical teams because we are ward-based rather than beingsegregatedinapharmacydepartment,soweareallbasedupontheward-butsheactuallyimprovedthatevenfurtherbybeingthereonthedrugrounds.(Pharmacist3)

Ithinkactuallyshewasproviding,andcontinuestoprovide,abitmoreofanin-depthlook intowhatwe're doing - a greater challengebecause she's re-tellingwhat theNurses are discussing and not necessarily bringing to pharmacy's attention, so theNursesmightbequestioning,Well,whyhaven'tweroundedupaparacetamoltoamoremeasurableamount?Andit'dbesomethingthatwe[inthepharmacy]couldveryeasilyoverlookbecauseitistherecommendeddose,butby[technician]sayingtous,Oh, can you, you know, get that changed - we would get it changed for them.(Pharmacist3)

…itwasnicetoseethatpharmacywasplayingarolehelpingtheNurses,youcouldsayliketheydidwelcomeheronthewardandshedidlookthepartofaNurseandhelpingthemoutyeah(Pharmacist2)

…sheplayedsortofaveryintegralroleonsortofbridgingthegapbetweentheNursesandourteam.Ithink,primarily(Pharmacist1)

Surprisingly,therewerefewcommentsontheimpactoftheward-basedpharmacytechnicianonthemorecost-effectiveuseofmedicationsontheward.Whilstnotedbysome,itappearsthatthisissuemaynotbeofprimaryimportancetostaff.Therefore,clearly,themeasurableimpactoftheward-basedpharmacytechnicianonthis issueasevidencedthroughthe log(seesectionabove),wasnotdeemedasnoteworthyastheinter-socialandinter-professionaleffectofherroleontheward.

Only one nursementioned that conversations with the ward-based pharmacy technicianalertedhertomedicationwaste,andhowtoreduceit.

…that’sdefinitely changedmypractice in trying tobemore cost-effective,becauseobviouslynowIknowhowmucheverythingcosts(LearningDisabilitiesNurse)

AsIsay,Ilearntalotfromherand,youknow,‘causeiftherewasevermedsI’dleftout,she’dsay,youknow,“D’youknowhowmuchthiscoststomake?”Andifanyonepouredtoomuch,oritwasn’tdoneacertainway,she’dgo,“D’youknowhowmuchthisactuallycosts?”Andthatwasconstantlyreinforcedwhenshewasthere,anditjustmademerealise,andIthought,yeah,d’youknowwhat?Actually,Idon’tthinkIdogiveitmuchcreditastohowmuchthingscost.Anditmadememoremindfulof

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wasteandstufflikethat,soitdefinitelymadememoremindfulofmypracticesandhowIam.(LearningDisabilitiesNurse)

Finally,itshouldbenotedthatsomestafffeltthatthepharmacytechnicianroleshouldbecarefully calibratedwith existing resourceson theward, to ensure that all this additionalresourceiseffectivelyusedthroughouttheday,andnotjustatpeaktimes.

SotheonecriticismIdidhaveoftheroleisIthinkitcouldbelookedintomoreinitbeing a littlemore efficient…. Therewould be timeswhere [Pharmacy Technician]obviouslywouldbeoccupyinghertime,butthenshewouldn’tbedoingverymuch;butthatwasprimarilybecausetherewasaPharmacyTechniciantherewithmyselftakingprimary ownership of most of the other side of the pharmacy-based service. So[PharmacyTechnician]sortofdidn’twanttogetinvolvedwiththat,becausetherewasaPharmacyTechnicianthatwasgoingtobedoingthatlateroninthatafternoon….Ithinkintermsofrollingoutintoothertrusts,Ithinkthatsortofmodelcouldworkverywell,but,likeIsaid,Ithinkitneedstobelookedatintermsofmakingitmoreefficient.(Pharmacist1)

Butithastobelookedatandtailoredtowardsdifferentwards,andeverysinglewardisdifferentobviously.Withthewardthatshewasworkingonwithmeissortofalong-stay/rehabsortofwardwherepatientsareon long-termmedicationsatsortofsettimes,butit’sforexample,you’reinamoreofasurgicalwardwheredrugsaregivensortofad-hocandsortofthey’rewhenneeded;medicationadministrationtimescouldbeanytime,sothatmightsortofchangetheworkings.SoIthink,ingeneral,Ithinkitneedstobelookedatsortofwhattypeofwardshe’sworkingon,andthatshouldbetailoredaroundwhattimesmedicationsaregenerallygiven,‘causethat’swhenshe’sneededforthatpartoftherole.(Pharmacist1)

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Discussion

Thestudyhypothesisedthattheintroductionofapharmacytechniciansupportedmedicationadministrationsystem(PTSMAS)wouldincreasethereportingofmedicationerrorsbystaffand,ultimately,reducemedicationerrorsinthelongterm.TheanalysisshowedthattherewasnoeffectonmedicationerrorsorreductionofmedicationerrorsonthewardscouldbeobservedwhilePTSMASwasimplemented.Thisindicatesthateitherthedesignofthepresentstudywasinadequatetoobserveanyeffect,oralternatively,thatthemainimpactofPTSMASistooccurinsofteroutcomes.TheanalysisofourqualitativedataclearlyshowsthattherehasbeenaconsiderableeffectofthePTSMASonstaffintheirdailyroutines.Thedataalsoshows that there exists a significant number of incidences that may or may not be ofreportablestatuswithinthewards,andrequireattentionbythepharmacytechnician.ThisindicatesthatPTSMASasaprogramme,hasthepotentialtohaveapositiveimpactbothonprimary and secondary softer outcomes, but any evaluation of such a programmewouldrequireanappropriatedesignusingsufficientlysensitiveinstrumentstoobserveeffectsovertime.

There is some research aboutmedication error reporting by nurses in hospitals and theattitudesofstafftoeffectivereporting(Flynnetal.,2012;Parry,BarriballandWhile,2015;Björksténetal.,2016;Hungetal.,2016).Itappearsthateffectivemedicationerrorreportingis hampered by wider issues of nurse perceptions of malpractice, accountability,proportioningofblameinworkcontextwithhighlyhierarchicalstructuresbetweenclinicalstaff.ItmaysimplybethecasethattheintroductionofPTSMASistooaspirationaltoaddresstheselong-standingproblemsofmedicationerrorreporting.

Inourstudy,itappearsthatthewayinwhichPTSMASwassetupinoursite,thereexistedseveralbarrierstotheward-basedpharmacytechnicianhavinganimpactonthereportingpatterns of medication errors. These barriers may be linked to professional status,perceptionsofprofessionalboundariesanddifferent responsibilitiesaswellas theway inwhich the reportingportal (Ulysses)operatespractically. Severalpractical issuesmayalsoprevent thepharmacy technician fromeffectively influencingmedicationerrors reporting.First,pharmacytechniciansmaynothaveaccesstoUlyssesorbepermittedtologincidences.Iftheydid,thismaybeperceivedasanencroachmentofnursingresponsibilitieschallengingestablishedsocialandprofessionaldynamicsbetweenpharmacytechniciansandnursesontheward.

Second,nursesmayreportincidencesatatimeoftheirconvenienceratherthanatthetimeof occurrence. This means that reporting practices may fall outside of the pharmacytechniciansviewandhencedifficulttoinfluenceeffectively.Third,nursesmayseemedicationerrorsasakeymeasureofaccountabilityandofqualityofcareandmayresistimprovementsinthereportingthatarenotinitiatedbythemselvesorperceivethemasattemptstoexercisecontrol.

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Oneoranyof these issuesmayhavecontributed to thedifficulty toobserveanypositivechangesinthereportingofmedicationerrorsonthetwoPTSMASwards.Thereisnodataatpresenttosupporteithertheexistenceornon-existenceofeitheroftheseprohibitingfactors.Anyfutureresearchshouldthereforeutiliseamixedmethoddesigntoinvestigatethevariousinfluencingfactorsinmedicationerrorreportingandmodelthepotentialcontributionward-basedpharmacytechnicianscanmakeinthiscontext.

TheanalysisofthequalitativedatahowevershowedthatPTSMAShadaconsiderableimpacton various other domains. The most promising is the release of nursing time duringmedication rounds in the morning. Our respondents pointed to this as one of the mostimportanteffectsofPTSMASimplementationontheirward.Itshouldbenotedthatitwasunclearfromourdatawhetherthiseffectcouldonlyhavebeenproducedbyaward-basedpharmacytechnicianorpossiblyequallybyadditionalnursingstaff.Themainmessageinthiscontextrelatedtotheavailabilityofanadditionalresourcewhichfreedupnursingtimetoattendtootherwork.Thisdoesnotprecludethatthesameeffectcouldhavebeenachievedthroughadditionalnursingstaff.

TherewerehoweverclearadvantagesofPTSMAStonursesandotherstaffonthewardthatwerespecific to theworkofward-basedpharmacy technician. It is theseadvantages thatrequirecarefuladditionalinvestigationtoassesstheeffectivenessofPTSMASincomparisontoalternativesystemsofmedicationadministration.

Themostprominentthemeemergingfromourinterviewswasthepositiveimpactofinter-professional working on theward brought about by PTMAS. This inter-professional workclearlywasseentoincludeinstancesofsharedlearningandknowledgeexchangewhichmaybeseenastheprerequisitesforthepotentialtoinfluencemedicationerrorreportinginthelongrun. Inthisrespectourstudydemonstratedtheclearpositive impactofPTSMASandrevealedthepotentialtoeffectwiderchangesinmedicationadministrationand,ultimately,medicationerrorreduction.

Likeanyinter-professionalworking, introducinganewmemberofstaff intoateamwithadifferentprofessionalbackgroundandtrainingmayhaveproducedsomeinitialreservationsandcontributedtoconcernsamongstnursesandwehavefoundsomeevidencefortheseearly on in the programme; self-reported by the ward-based pharmacy technician. Thisindicates that any PTMAS implementation requires careful preparation, clarify andtransparencyofrolesandresponsibilities,andgoodleadershiptomakeitwork.

OurdataalsoappearstosuggestthatthesuccessofPTSMASimplementationdependstoahighdegreeontheindividualwhojoinstheward,aswellexistingcircumstancesandworkingconditionsonwardsatthetimeofimplementation.Thequalitiesandinterpersonalskillsoftheward-basedpharmacy technician appear to play an important role in any PTSMAS tosucceed.

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OurstudyrevealedtheneedtostrengthentherationaleofPTSMASasamedicationsupportsystemasopposedtotheprovisionofadditionalnursingtimeontheward.FurtherevidenceisneededtodemonstratethatthesecondarysofteroutcomesofPTSMAScannotbeachievedthrough the provision of equivalent additional nursing resource. This links to a relatedconcern amongst some respondents that a full time placement of ward-based pharmacytechnicianonthewardmaynotbeanefficientuseofthisresource,inparticularonwardswithapatientnearpharmacy.Itwasnotedthatafterthemorningmedicationrounds,theward-basedpharmacytechnicianmayhavehadsomesignificantworkingtimethatwasnoteffectivelyused.

Itraisesthequestionastowhetherornottheroleofaward-basedpharmacytechnicianinaPTSMAScouldpotentiallybedeliveredbypharmacytechnicianswhoareoperatingthenear-patient pharmacy on some wards. Although in our case, the two roles were clearlydemarcatedandneatlycomplementary,itwascommentedthatpharmacytechniciansinthenear patient pharmacy role could also potentially deliver PTSMAS equivalent work. It isthereforeessentialthattherationaleforthePTSMASspecificroleofpharmacytechniciansisstrengthenedandjustifiedincomparisontoanyothernear-patientpharmacytechnicianrole.Sucha justificationwouldhave toaddress the issueofpotentially significant surplus timewithin PTSMAS for the pharmacy technician outside the medication rounds. A carefulcalibrationofworkpatternsandworkingtimemayaddressthis.

A second issue relates to the specificity of context in our study. Standards ofmedicationadministrationsaredifferentinchildren’shospitalstoadulthospitalsduetopharmaceuticaland pharmacological challenges experienced within paediatric medicine. In theory, thisstrengthensthecaseforpharmacytechniciansupportedmedicationadministrationsystems,as theknowledgeandexpertiseofpharmacy techniciansextend todosageandour studyclearly demonstrated that staff on wards appreciated and recognised the considerablepositive impact of PTSMAS on dosage practices. It appears thus important to gauge howimportantthiseffectisincomparisontoothereffects.AbetterunderstandingofitsrelevanceforthesuccessofPTSMASwouldproducesomeindicationaboutthepossibleimpact,orlackthereof,ofPTSMASwithintheadultsectorand,ultimately,howmuchPTSMASiscontingentuponcontextualfactors.

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Limitationsofstudy

Thiswasasinglesite,non-controlled,cross-sectionalcomparativestudyofaPTSMASwithoneindividualatachildren’shospitalTrust.Limitationsofthestudyarisefromthenatureofthis design. The use of a single sitewith one individualward-based pharmacy technicianproducedfindingsthatarevalidwithinthespecificcontextofachildren’shospitalwithitsspecialdosagerequirementsinmedicationadministration.Italsomadethefindingshighlydependent on the characteristics of the particular wards with and without near-patientpharmacy, and of the individual placed on the wards and her training background andexpertise.Asnoeffectcouldbeobservedontheprimaryoutcomes,itcouldbeexpectedthatcontingentfactorssuchasthespecificcircumstancesandcontextofthepresentPTSMASmayhaveheavilyinfluencedqualitativedata.

Thequalitativedatacomprisedtheward-basedpharmacytechnician’slogaswellasdatafromsemi-scheduled data. Whilst our analysis of interview data was robust as we followedcommonpracticeinqualitativedataanalysiswithasecondrater,thedataintheward-basedpharmacy technician’s log required content analysis and coding by two independentresearchers.FollowingcodingseverityscoreswereappliedtoeachincidentaccordingtoNCCMERPguidelines.Thisinterpretationreliedontheadequacyandcompletenessofinformationprovidedinthelog.Whilsttherewereusuallyabundantnotestoallowanalysis,thenotesoftheward-basedpharmacytechnicianrepresentedtheviewofasingularmemberofstaffandwerenotverifiedthroughconsultationwithnurses.Thismakeslognotesadifferenttypeofdata,withlowerqualityandnocross-verificationcomparedtoreportedmedicationerrors.

Theallocationof severity categories to the logged incidencesalso representedwithin thestudy,mayalso introducethepossibilityofbias.As theseveritygradingwasdonebytwoindependentresearchersexternaltothehospital,itmaynotmirrorthegradingusedroutinelyby hospital staff in our study. Although clearly defined by national guidelines, whatconstitutesmedicationerrors,andatwhichlevelofseverityisstilllikelytocontainanelementofcontingentpractice,andmaybecontextdependent.Thisisdemonstratedbythefactthatnoneoftheincidencesloggedintheward-basedpharmacytechnician’snoteswerereportedandcapturedbywardnursesthroughthemedicationerrorsystemUlysses.

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Futureresearch

Our studydemonstrated the importanceof amixedmethods approach. Existing researchindicates that theremaynotbeanobservable impactofPTSMASonmedicationerrors inhospitalwards(Keersetal.,2017).Asdiscussedabove,theremaybevariousreasonsforthis.Ourstudyclearlyshowedthattheward-basedpharmacytechnicianidentifiedasignificantnumberofincidencesonarangeofseverity.Thishighlightstheneedtoinvestigatewhytheworkoftheward-basedpharmacytechniciandoesnotresultdirectlyinimprovedmedicationerrorreportingand,ultimately,inareductionofmedicationerrors.Animmediateimpactofthenewsystemonprimaryoutcomesislikelytobehamperedbyissuesofinter-professionalworking, perceptions of professional status and boundaries, as well as notions ofresponsibilityandaccountability.OnlyresearchutilisingqualitativeapproachescanexploretheseissuessufficientlyandpermitresearcherstomodelthepotentialeffectsonPTSMASonmedication error reporting for future verification. Initial work should therefore focus onexploratorystudiesandmodellingofpossiblecauseandeffectchainsofPTSMASimpactonmedicationerrors.Nosuchmodelsarecurrentlyavailablefortesting.

Oncemodellinghasbeenundertaken,evaluationsofPTSMASwould likely require severalimplementationsites(wards)withsufficientlylongtermobservationperiodstocountervailtheinfluenceofcontingentfactorssuchassectorspecificcircumstances(childrenvs.adulthospitals),theroleoflocalleadershipandindividualcharacteristicsofwardsandpharmacytechnicians.FuturePTSMASshouldalsocarefullyalignthepositionofpharmacytechnicianwithexistingnear-patientpharmaciesonwards,aswellasarriveataclearjustificationforthe knowledge and expertise of a ward-based pharmacy technician, as opposed to theprovision of additional nursing resources on wards. A clear rationale for ward-basedpharmacy technicians supporting medication administration needs to be widened toincorporatethepositiveeffectsofinter-professionalworking.Thiswouldalsorequireamoreindepthunderstandingofhowtostructuresharedlearning,andtheexchangeofexpertisebetweenpharmacytechniciansandnurses.Asthismayturnouttobethemainobservableimpact of any PTSMAS, it appears important that any future PTSMAS maximises theopportunitiesandeffectivenessofsharedlearningonthewardthroughamorestructuredapproach.

SincethesofteroutcomesofPTSMASmaymaterialiseonlyoverthelongerterm,anyfutureresearch should utilise a longitudinal study design. A comparative study including variousdifferent work patterns of pharmacy technicians may also help in ascertaining the cost-effectiveness of the possible models of providing pharmacy technician expertise on thewards. In particular, potential overlapwithnear-patient pharmacy couldbe explored andcomparedtoafulltimepositionofward-basedpharmacytechnician.AcomparativestudydesigncouldalsoaccommodatetheneedtoinvestigatethedifferentialeffectofPTSMASinnon-nearpatientpharmacywardsandnearpatientpharmacywards.

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Appendices

SUMMARYREPORTAPRIL2017

Evaluationoftheintroductionofapharmacy-techniciansupportedpaediatric

medicinesadministrationsystem:Parentperspectives

Investigator(s):ProfessorMatthewPeak,DrJennyBellis,DrLouiseBracken,MrsCatrinBarker,Ms

PaulineBrown,MrSergioASilverio,DrAxelKaehne

ABSTRACT

BackgroundThepreparationandadministrationofmedicinestochildrencarriesariskoferrorand

subsequentharm.Theprocessiscomplicatedbytheneedtoindividualisedrugdosesaccordingtothe

patient’sageorweightaswellastherequirementtopreparedosesfromproductsdesignedtobe

administeredtoadults.Inmanypaediatricinpatientsettings,inordertoreducetheriskoferrorand

subsequentharmthereisarequirementforallorsomemedicationpreparationandadministration

processestobecarriedoutbyoneregisterednurseandcheckedbyanotherregisterednurse.Atour

centre,achangetopracticewasimplementedinwhichoneofthenursesinvolvedinthedual-checking

processwas released toundertakeotherdutiesandapharmacy technicianundertook the second

checks.Weundertookaserviceevaluationofthischange.

MethodsFamilieswererecruitedfromtwowardsatAlderHeyChildren’sNHSFoundationTrust.Data

werecollected,fromclinicalrecords,foreachpatientwhoseparentwasinterviewed.Parentviews

andexperiencesofthecontributionofthepharmacytechnicianweregatheredviasemi-structured

interviews.Anexploratoryapproachtoanalysiswastakenusingthematicanalysis.

ResultsTwelvefamilieswererecruited.Parentsspokeabouttheimportanceofcommunicationabout

theirchild’smedicinesinhospital.Some(butnotall)parentswereawareofthepharmacytechnician’s

roleassecondchecker.Themajorityofparentsfeltfineaboutthetechnician’srole,somewerevery

positive and none expressed any concerns. Parents recognised the benefits of the technician’s

backgroundandexpertiseandtheircontributiontothewardteam.

ConclusionAlthoughfurtherevaluationisrequired,ourfindingsindicatethatparentalviewssupport

thefuturedevelopmentofthisservice.

32

BACKGROUND

Thepreparationandadministrationofmedicinestochildrencarriesariskoferrorandsubsequent

harm.Theprocessiscomplicatedbytheneedtoindividualisedrugdosesaccordingtothepatient’s

ageorweightaswellastherequirementtopreparedosesfromproductsdesignedtobeadministered

toadults.Theincidenceoferrorsinpaediatricmedicationpreparationandadministrationinhospital

isbetween11.7%and89.9%(1).Theuseofoff-labelandunlicensedmedicinesandthemanipulation

of medicines for children contribute to the risk of errors and some errors cause harm (2-4).

Interventionswhichcontributetoareduction inmedicationerrorswill reducetheriskofharm. In

manypaediatricinpatientsettings,inordertoreducetheriskoferrorandsubsequentharmthereis

arequirementforallorsomemedicationpreparationandadministrationprocessestobecarriedout

byoneregisterednurseandcheckedbyanother. Itshouldbenotedhoweverthatthere is limited

evidencethatthisdual-checkingprocessreducestheriskoferrors(5,6).

Changestomedicationprescribing,preparationandadministrationprocessesshouldaimtoreduce

theriskofmedicationerror(7).Theimpactofpharmacysupportstaffontheseprocesseshasbeen

investigatedinpreviousstudies.IntwostudiesonadultmedicalwardsintheUKandDenmark,the

contributionoftechnicianstoprescriptionreview,inclusiveoftheidentificationofprescribingerrors

(atypeofmedicationerror)wasdemonstrated(8,9).Astudyofpharmacyassistantinvolvementin

medication administration rounds was undertaken on an adult medical ward in the UK and

demonstratedasignificantreductioninunacceptableomitteddoses(atypeofmedicationerror)(10).

A recent study in which pharmacy technicians assisted in the preparation and administration of

intravenousmedicinesonapaediatriconcologywardintheUKdemonstratedareductioninadverse

events, a reduction inwork-related stressassociatedwithpreparing complexmedicationamongst

nursingstaffandanincreaseinnursingtimeavailableforpatientcare(11).

Atourcentre,achangetopracticewasimplementedinwhichoneofthenursesinvolvedinthedual-

checking process was replaced by a pharmacy technician. Having undertaken additional in-house

training, the pharmacy technician undertook, in accordance with the principles of the Alder Hey

MedicinesManagementCode,thefollowingrolesrelatingtomedicinesadministration(whichwould

havebeenpreviouslyundertakenbyanurse):

1. Attendedmedicinesadministrationroundsontheward

2. Checkedtheaccuracyandappropriatenessoftheprescription

3. Checkedthepreparationandadministrationofprescribedmedicines

33

4. Independentlyundertookcalculationsrequiredduringthemedicinesadministrationprocess

andcross-checkedthemwiththoseoftheotherpractitioner

5. Recordedtheadministrationofthemedicine

We undertook a service evaluation of parent perspectives on this change to practice. To our

knowledge, there are no previous studies which explore these perspectives in this context.

Understandingwhatfamiliesthinkabouttheservicewillcomplementthefindingsofaseparate,but

related,staff-orientatedimpactevaluationandwillinformthefuturedevelopmentoftheservice.

AIMSANDOBJECTIVES

Aim

1. To explore the views and experiences of parents of patients involved in the pharmacy

techniciansupportedpaediatricmedicinesadministrationsystem

2. To determine what is important to families in the context of in-hospital medication

administration

Objectives

1. Undertake semi-structured interviews with the parents of patients who have been

administeredmedicineswhilstthepharmacytechniciansupportedmedicinesadministration

systemwasinplace.

METHODS

Design

Aqualitativeinterviewstudy

Setting

Families were recruited from twowards at Alder Hey Children’s NHS Foundation Trust, a neuro-

medicalwardandamedicalspecialtyward(totalinpatientbeds=56).

InclusionCriteria

Thestudyincludedtheparentsofchildrenwho:

1. wereaged0-15years11months

2. wereaninpatientforatleastonedayonaparticipatingward

3. wereadministeredatleastonemedicineduringtheiradmissionwhenpharmacytechnician

supportedpaediatricmedicinesadministrationwasinplace

4. had experience of being administered at least one medicine when nurse-only medicines

administrationwasinplace,eitheroncurrentorpreviousadmission(if itwasthepatient’s

34

first admission to hospital they may still have had experience of the nurse-only system

becausethiscontinuedwhenthetechnicianwasnotatworke.g.overnightoratweekends).

ExclusionCriteria

Parentsofchildrenwho:

1. had not been administered at least onemedicine during their admissionwhen pharmacy

techniciansupportedpaediatricmedicinesadministrationwasinplace

2. had not had experience of being administered at least one medicine when nurse-only

medicinesadministrationwasinplace,eitheroncurrentorpreviousadmission

3. the treating clinical team felt there was pronounced family distress or child protection

interventionthatwouldmakeitinappropriatetoapproachthefamilytotakepartinthestudy

Sampling&Recruitment

Weaimedtoapproachallparentsofchildrenwhomettheinclusioncriteriaduringtheirhospitalstay

tobeaskediftheywouldliketoparticipateinthisstudy.Potentialparticipantswereidentifiedbythe

pharmacy technician, who provided themwith a participant information sheet. Recruitment was

undertaken by a member of the research team. Informed consent was obtained from parent

participants. Where possible, assent was obtained from patients aged 8-15 years 11 months.

Participantswerefreetowithdrawfromthestudyatanytime.Weaimedtorecruit12parents(12).

Datacollection

PatientCharacteristics

The following data were collected from clinical records for each patient whose parent was

interviewed:

1. Age

2. Reasonforadmission

3. Lengthofstay

4. Detailsof regularmedicine(s) to include:nameofmedicine, routeofadministration,dose,

frequency

5. Detailsofmedicinesadministeredondayofinterviewtoinclude:nameofmedicine,routeof

administration,dose,frequency

6. Numberofprevioushospitaladmissions

35

ParentInterviews

Parentviewsandexperiencesof thecontributionof thepharmacy technicianweregatheredviaa

semi-structured interviewundertaken face-to-face in aquiet roomonhospital premises. Thiswas

carriedoutbyamemberoftheresearchteamwhohadnotbeeninvolvedinthepatient’sclinicalcare.

Aninterviewpromptguidewasused(seeAppendixA)andinterviewswereaudiorecorded.Brieffield

notes (memo writing) were recorded by the interviewer immediately after the interview. Audio

recordingsweretranscribedverbatim.

Analysis

PatientCharacteristics

Thesedataweresummarisedtoprovideabackgroundtothefindingsofqualitativeinterviews.

ParentInterviews

Anexploratoryapproachwas takenusing thematicanalysis.Researchers JBandLBmet todiscuss

emerging themesanddevelopanalyticalcategories. Analysiswasverified throughoutby frequent

review of transcripts to identify recurrent patterns and themes. A third researcher was used to

reconciledifferencesinthemesasandwhentheyarosebetweenthetwoanalysts.

Ethics

FollowingadvicefromaNHSRECManager(RECReference:16/NW/0605, IRASProject ID:212142)

this studywasdeemed tobea serviceevaluationnot requiring formal researchethics committee

evaluation or HRA approval. It was registered with the clinical audit department at Alder Hey

Children’sNHSFoundationTrust.

RESULTS

Thirtyonefamilieswereapproachedtoparticipateininterviews,twelve(tenmothersandtwofathers)

wererecruited.Interviewswereundertakenovera4monthperiod(November2016–March2017).

PatientCharacteristics

ThecharacteristicsofthechildrenwhoseparentswereinterviewedaresummarisedinTable1.

Not all characteristics are reported here in order to reduce the likelihood that individual

patients/familieswillbeidentifiedbyreaders.

36

Table1 Characteristicsofchildren

PatientID Age Number of

previous hospital

admissions

Numberofregular

medicines prior to

admission

Numberofmedicines

administered on day

ofinterview

PT001 12years 0 0 3

PT002 4years 0 0 11

PT003 12years 0 0 2

PT007 5years >10 12 12

PT011 2weeks 0 2 3

PT016 6years >10 6 9

PT020 18months >10 3 3

PT021 1month 0 0 4

PT023 14years 5-10 8 4

PT027 2years 1 1 11

PT028 15years 1 2 16

PT029 9years 0 21 17

ParentInterviews

Duringtheanalysisgroupmeetingswediscussedthecodedinterviewsandagreedonthefollowing

broad themes: ‘medicines administration for children in hospital’ and ‘the role of the pharmacy

technicianinthewardteam’.

Medicinesadministrationforchildreninhospital

Understandingtheprocess

Parentshaddifferentlevelsofunderstandingaboutthecheckingprocessformedicinesinhospital,

two parents were health care professionals and one had experience of working in a community

pharmacy.Somewereveryclearabouttheprocess

‘…..checkedonMeditech[electronicprescribingsystem]againstherdateofbirthandherID

numberandcheckedonthelabelofthebottleandthedosesaredoublecheckedbyasecond

person….’[PT002].

Othersknewonlyafewdetails

37

‘Theyaskaboutallergies’[PT023].

Importantaspectsoftheprocess

Theywereconcernedaboutthetimingandaccuracyofthemedicinesadministrationprocess.

`‘Thattheyareaccuratewe’vehadoverdosesinthepast…..thingslikeanti-epilepticsandpain

reliefneedtobeontime’[PT002].

‘…..moreor lessatthesametimehehas itathomebecausehe’sonregularmedications’

[PT016].

Whenmedicineswereadministeredlate,thishadanegativeimpactonthechild’ssymptoms:

‘thenursesaregivingthematdifferenttimesIwouldnormallygivewhichcanhaveaneffect

on [child’s name]becauseof theway it’s inher system…..it just has a knockoneffecton

behaviouraswell’[PT007].

‘…..oftenthemedswerealittlebitlate…..whenhewassymptomatic,especiallywithblood

pressureitdidhaveanimpactonhisbloodpressure’[PT001].

Atimelyresponsetothechild’ssymptomswasalsoimportanttoparents:

‘…..doseofparacetamol…..youjustcan’tgetitandyou’vegottowait’[PT007].

‘soifIwastoaskforsomeparacetamolthatIkindofgetitwhenIaskandtherewasnolong

wait’[PT020].

However,oneparentrecognisedthatsomeadaptationoftheirnormalroutinewastobeexpected

whilstinhospital:

‘…..Iunderstandthattheyarenotheretowaiton[child’sname]every15minutes.Theyhave

otherpeople…..’[PT007].

Accesstosuitableorpreferredformulationsofmedicineswasmentionedbyseveralparents:

‘…..when she went from liquids to tablets some of the nurses didn’t know, sometimes

someonewouldcomeinwithaliquid…..’[PT003].

‘…..hegotalittleupsetbecauseoneofthetabletswasn’tthesametowhathenormallyhas’

[PT016].

38

‘…..in theotherhospital theywantedtogivehima lotof thingsdissolved inwaterandhe

doesn’tlikeitatallanditwasabigstruggleforhim.....butheistakingallhismedicinesreally

wellnow’[PT027].

Ownershipoftheprocess

Someparentswerealsokeentotake(orretain)ownershipoftheirchild’smedicineswhileinhospital:

’andthenIcheckaswell…..they’relateandIwishIcoulddoitmyselfasI’musedtodoingit

myself…..yougetquitefrustratedandwhenyourwhole life issurroundedbyhermedicine

routineandkeepingthatontrackandontime…..’[PT007].

‘Icheckeverything…..Ialwayscheckandaskwhatisitnowandcheckthedose’[PT028].

Othersexpressedthattheyjusttrustedthehealthprofessionalteam:‘Wethinkdoctorsknow

best,wejustacceptthat…..’[PT027].

Communication

Several parents spoke about the importance of communication about their child’s medicines in

hospital.

‘themainthingreallyisthetiming,listeningtoparentsofhowtheirroutineis’[PT007].

‘communicationismassivelyimportantandlisteningtopatients,understandingandlistening

toparents……takingintoaccountwhatparentsandchildrenaretellingthem’[PT020].

‘Communication is probably the first thing…..I’m his dad and I like to knowwhat’s going

on…..it’snotgoodifhe’sgettingthesemedicinesandno-onehastoldmeit’scomingup,it

setsoffalarmbells’[PT027].

Someparentsdescribedcommunicationwhichdidnotmeettheirexpectations:

‘Ihavetokeeptellingthemthatit’ssupposedtobediluted…..Ihadtotellthenursestostagger

them’[PT023].

Theroleofthepharmacytechnicianinthewardteam

Awarenessoftherole

Someparentswereawareofthepharmacytechnician’sroleassecondchecker:

39

‘…..we’re right by the nurses’ station, I’ve seen [technician’s name] working with the

nurses…..’[PT001]

‘…..Inoticedheron thewardand thenwediscussed itafterwards…..sheworeadifferent

uniformapharmacyuniformratherthananurse’suniform’[PT002].

Otherswerenotaware:

‘I’vegottoadmitIhaveseenherbutnoIwasn’taware’[PT020],

‘No,Ihadnoideaatallwhatwasgoingonbehindthescenes’[PT027].

Opinionsabouttherole

Themajorityofparentsfeltfineaboutthetechnician’srole,noneexpressedanyconcerns:

‘wellIthinkit’sfine,Ithinkit’sagoodidea’[PT001],

‘noIthinkit’sfineaslongassomebodyischeckingit’[PT003].

Twoexpressedadesiretoknowmoreabouttheexperienceofthetechnicianbeforebeingabletosay

howtheyfeltaboutit:

‘youknowthetechniciansaretheyactuallyattachedtothiswardandwilltheybeabletodo

everyone’smedicinesandstuff?’[PT020].

‘…..I need to know what kind of person she is, the pharmacy technician, what kind of

experienceshehas…..’[PT028].

Impactoftherole

Someparentswereverypositiveabouttheroleandgavefurtherinformationtoexplaintheiroutlook:

‘…..whenwefirstcametothiswardanditwasjustnursescheckingthemedsquiteoftenthe

medswerealittlebitlate…..whatI’venoticedsince[technician’sname]hasbeenhelpingout,

isthey’vejustbeenontimeandsortofregularly’[PT001].

‘ThemainthingInoticedfirstlythatthemedswereontimealotmoreyouweren’tconstantly

waiting…..’[PT002].

‘…..ithasmadeamassivedifference,amassivedifferencemainlybecause[child’sname]gets

hismedicinesontime[PT029].

40

Parentsrecognisedthebenefitsofthetechnician’sbackgroundandexpertise:

‘…..eyedrops…..theyexpireprettyquickly….[technician’sname]hasbeenabletogetthem

really,reallyquickly…..’[PT001].

‘…..it’sagoodidea,that’swhatthey’redoingdayinanddayout,sortingoutmedicinesand

stuff….the knowledge that they’ve got would be as good as what the nurses have got in

relationtoallthemedicines’[PT020].

‘…..you know thepharmacy techs sometimeshave a little bitmoreof an idea about how

differentthingsworktogether.Sotheywouldbeabletoquerysomethingmaybealittlebit

morereadilythannurseswhoaren’tmedicineexperts’[PT001].

‘…..Ithinkhavingtwodifferentdisciplinescomingtogetherisgreat’[PT027].

Twoparentsalsoidentifiedthatthetechnician’srolehadapositiveimpactonnursingtime:

’…..obviouslyitispullinganurseawayfromdoingherotherjobs………….thisistheirspecialjob

whereanursehaslotsofdifferentjobs,itcouldgettoobusyandconfusing…..youknowthe

nurseshavegotthatextrapressuretakenoffthemwhileit’sabusytimegoingon’[PT007].

‘Ittakesalotofpressureoffthenursesaswell.Insomepods[wardareas]…..there’sonlyone

nursesoeverybodyisrunningaroundaftereachotherlookingforchecks……themainthingis

thatittakesalotofpressureoffthegirlsittakesahugeamountandthegirlscanconcentrate

alsoonwhattheyneedtodo…..’[PT029].

DISCUSSION

Parents’mainconcernsabouttheirchildren’smedicineswerethattheyweregivenontimeandthat

they were given accurately. In addition, some parents described the importance of access to

formulations that were acceptable to their child. Retaining some control of the medicines

administration process was important to some parents specifically when parents were used to

managing this process themselves at home. Parents valued good communication about their

children’smedicines,theywantedthewardteamtolistentowhattheyhadtosayabouttheirchild’s

normalmedicineroutineandtheywantedtobetoldaboutchanges.

Just as parents’ understanding about the medicines administration process differed between

individuals,thereweredifferentlevelsofawarenessaboutthepharmacytechnician’sroleasasecond

41

checkerontheward.Thoseparentswhowereawareofthischangetopracticewerepositiveabout

it, none expressed any objections. Specifically, some parents had noticed an improvement in the

timelyadministrationofmedicines,somethingwhichwasimportanttothem.Parentsalsorecognised

that thepharmacy technicianbroughtskillsandexpertise to themedicinesadministrationprocess

whichcomplementedthoseofthenursingstaff.Anotherobservationwasthepositiveimpactofthe

pharmacy technician’s roleon thenursing team’s time; thepharmacy technicianwasdescribedas

takingpressureoffthenursingteam.

Theinterviewsdescribedherewereundertakenontwohospitalwardsbytworesearcherswhoare

pharmacists. They were not involved in the clinical care of the children on the included wards,

however it isconceivablethatthesettingof the interviewandtheprofessionalbackgroundof the

interviewersmayhaveintroducedbias.Thefindingsarealsolimitedtotwopaediatricwardsettings

andotherthemesmayhaveemergediftheserviceevaluationhadbeenextendedtootherwardsor

hospitals been included. However, resource limitations meant that a pragmatic approach was

requiredtomeettheaimsofthisserviceevaluation.

Toourknowledge,nopreviousstudieshaveevaluatedtheperspectivesofparentsinthiscontext.A

previousstudyhashoweverhighlightedhowcommunicationaboutmedicine-relatedissuesdoesnot

alwaysmeetparents’expectations(13)andanotherfoundthatparentswerekeentotakeownership

ofthemedicinesadministrationprocess(14).

Thefindingsofthisserviceevaluationprovidepositivesupportforthischangetopractice.Theywill

bereviewedalongsidetheotheraspectsoftheevaluationinordertoobtainanoverallperspectiveon

the impactandfeasibilityofthischange.Futureworkshouldfocusonconfirmingthesefindings in

othersettings,forexampleonothertypesofwardandatdifferentcentres.Considerationshouldbe

given to undertaking interviewswith patients. In addition, efforts should bemade to reduce the

potentialforbias,forexamplebyconductingtheinterviewsoutsideoftheacutehospitalsetting.

CONCLUSION

Parentswerepositiveaboutachangetopracticewhichinvolvedapharmacytechnicianratherthana

nurseactingasasecondcheckerformedicinesadministeredinhospital. Inaddition,someparents

expressedadesiretobeinvolvedintheprocess.Parentsdidnotexpressanynegativeopinionsabout

the system. Although further evaluation is required, these findings indicate that parental views

supportandshouldinformthefuturedevelopmentofthisservice.

42

REFERENCES

1. AmeerA,GhalebM,DhillonS.Systematicreview:epidemiology,natureandinterventionsofhospitalmedicationadministrationerrorsinpaediatrics.HealthServicesResearchandPharmacyPracticeConference;Preston,UK:InternationalJournalofPharmacyPractice;2013.p.43-4.2. ZoghbiY,NelsonD.Scientificandtechnologicalsynergy:BaylorCollegeofMedicineandtheMentalRetardationResearchCenter.Internationaljournalofdevelopmentalneuroscience:theofficialjournaloftheInternationalSocietyforDevelopmentalNeuroscience.2002;20(3):467.3. NunnA,RicheyR,ShahU,BarkerC,CraigJ,PeakM,etal.Estimatingtherequirementformanipulationofmedicinestoprovideaccuratedosesforchildren.EuropeanJournalofHospitalPharmacy.2013;20(1):3-7.4. TashaniM,RashidH,RiddaI,HeronL,MemishA,HaworthE,etal.Oseltamivirforcontrolofinfluenzaatmassgatherings.Infectiousdisordersdrugtargets.2013;13(1):46.5. AlsulamiZ,ConroyS,ChoonaraI.Asystematicreviewoftheeffectivenessofdoublecheckinginpreventingmedicationerrors.ArchivesofDiseaseinChildhood.2012;97(5):e2-e.6. ArmitageG.Doublecheckingmedicines:defenceagainsterrororcontributoryfactor?JEvalClinPract.2008;14(4):513-9.7. RinkeML,BundyDG,VelasquezCA,RaoS,ZerhouniY,LobnerK,etal.InterventionstoReducePediatricMedicationErrors:ASystematicReview.Pediatrics.2014;134(2):338-60.8. GrønkjærLS,RosholmJU.Pharmacytechnicianscancontributetoanimprovementinthedrugtreatmentingeriatricbed-wards.EuropeanGeriatricMedicine.4:S181.9. BrancaleoneC,BroughS,KrskaJ,MorecroftC.Evaluatingtheimpactofawardpharmacytechnicianonclinicalpharmacistinterventionsinamedicaladmissionsunit(Abstract).InternationalJournalofPharmacyPractice.2013;21(IssueSupplement:S1):9-16.10. BarrettS,BaqirW,HorsleyW,JonesK,O'DolanR,O'Sullivan,etal.Reducingunacceptableomitteddoses:pharmacyassistantsupportedmedicineadministration.ClinicalPharmacist.2012;Supplement3:S2.11. SinclairA,EyreC,PettsH,ShuardR,CorreaJ,GuerinA.Introductionofpharmacytechniciansontoabusyoncologywardaspartofthenursingteam.EuropeanJournalofHospitalPharmacy.2016(Onlinefirstdoi:10.1136/ejhpharm-2016-000951).12. GuestG,BunceA,JohnsonL.HowManyInterviewsAreEnough?FieldMethods.2006;18(1):59-82.13. ArnottJ,HesselgreavesH,NunnAJ,PeakM,PirmohamedM,SmythRL,etal.EnhancingCommunicationaboutPaediatricMedicines:LessonsfromaQualitativeStudyofParents'ExperiencesofTheirChild'sSuspectedAdverseDrugReaction.PLoSOne.2012;7(10):e46022-e.14. WilliamsL,CaldwellN,CollinsE.HELPINGPARENTS/CARERSTOGIVEMEDICINESTOCHILDRENINHOSPITAL.ArchDisChild.2016;101(9):e2.

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AppendixA–InterviewPromptGuide

Evaluation of the introduction of a pharmacy-technician

supported paediatric medicines administration system:

Parentperspectives

Interviewpromptguide

PatientCharacteristics

Name

Age

Gender

Admissiondetails

Reasonforadmission

Lengthofstay

InterviewQuestions

Duringthisinterview,whenwesay‘medicines’,wemeanoralmedicinesliketabletsandliquids,rectal

medicineslikesuppositories,injections,patchesandcreams.Weareaskingthesequestionstohelp

usfindoutwhatourpatientsandparentsknowabouthowwegiveoutmedicinestopatientswhoare

staying inhospital.Wedon’texpectyou toknowallabout it,wewillexplain thedetailsaswego

throughtheinterview.Weareinterestedyourviewsontheprocess.

Firstwehavesomequestionstofindoutwhatyoualreadyknowabouttheprocess:

1. Whatdoyouknowaboutwhatchecksarecarriedoutbefore[child’sname]medicinesare

givenwhentheyareinhospital?

2. What you knowaboutwho checks [child’s name]medicines before you are given them

whenyouareinhospital?

44

Thenameanddoseofthemedicinearecheckedontheprescription.Thenthemedicineisprepared

andthisischecked(e.g.rightnumberoftablets)andcross-checkedwiththeprescription.Finallythey

checkyouridentityandthisiscross-checkedwiththeprescriptionbeforethemedicineisgiventoyou.

Medicinesarecheckedbytwomembersofstaff,usuallytwonurses,butinourstudyonenurseand

onepharmacytechnician.

Nextwehaveaquestiontofindoutwhatyouthink:

3. During yourhospital stay, someor all of [child’sname]medicineswere checkedbyone

nurseandonepharmacytechnician(insteadoftwonurses).

a. Wereyouawareofthis?

b. Whatdoyouthinkaboutthis?

Prompts:didyouperceiveadifference?anythinggood?anythingbad?anyconcerns?anycomments?

Finally,twoquestionsaboutwhatisimportanttoyou,whenitcomesto[child’sname]medicines:

4. When[child’sname]isinhospitalandtheyneedtobegivenamedicine,whatmattersto

youmost?

5. Whatdoyouthinkdoctors,nurses,pharmacistsandpharmacytechniciansshouldfocuson

tomaketheprocessofadministeringmedicinesthebestitcanbe?

45