In my PhD-project I will explore practices of medication safety from the perspective of multiple actors in the context of medication review implementation in selected hospital units in Sweden. Based on these multiple accounts, it is aimed to better understand how safe and patient-centered medication review practices are being integrated into routine clinical practice in hospital settings. A further objective is to explore organizational conditions for integration of medication reviews practices into these settings and how this can be supported by clinician managers and implementation developers.
Adverse drug events are common and are a significant burden in terms of patient harm and reduced quality of life as well as societal cost. A significant proportion of medication-related problems are preventable and medication reviews constitute a promising and potentially important strategy to reduce medication-related harms.
As yet, patients’ expectations, needs, preferences or perceived benefit with respect to medication reviews are unknown. Studies have found that patients, particularly those with long-standing medication therapy, wish to be involved in medication treatment decisions and want to better understand the role of the prescribed medicine and expected risks and outcomes. Further, a patient's understanding of their medication and active engagement in their medication management is expected to prevent error and improve therapeutic outcomes. However, opportunities to engage patients in discussions about medication management are often missed. There is limited understanding of how patients actually participate, or are encouraged to participate, in medication management during hospitalization.
While there is some evidence that medication reviews have beneficial outcomes, there is a lack of knowledge on how these interventions can best be implemented in routine practice. Only a few studies exploring implementation processes of medication reviews have been published. Thus, if medication reviews are put into practice, implementation should be systematically evaluated.
A mixed methods multiple-case study approach will be employed to investigate implementation processes in selected hospital settings. Within this case study, methodological and data triangulation will be utilized as a means to enhance study quality and rigor. Using data from multiple sources (clinicians, patients, implementers), collected by a range of different - predominantly qualitative - methods (observation/ethnography, interviews, document analysis, survey) can contribute to higher construct validity and to an enhanced understanding of the phenomenon studied. Analysis of qualitative data collected at fieldwork during the pilot study will start with making broad descriptive inferences and will inform the development of an analytic framework.
Ethnographic methods will be used to observe medication practices at each of the participating hospital wards; these methods allow paying attention to the multiple dimensions of these practices in a routine clinical context and from the perspective of the practitioners engaging in these practices. This will be complemented by accounts from the perspective of patients getting a better understanding of how they make medication reviews work in practice and the contextual conditions in which this occurs. Also, it will be explored how clinician managers and implementation developers make sense of the work to implement medication review practices, how they engage with it and appraise the implementation work.
Clinical (hospital) units in the Region of Östergötland and Jönköping will serve as cases. A total of six to eight cases will be recruited to participate in the study. Purposive sampling will be used to generate information-rich cases based on characteristics, such as hospital settings (hospital wards and probably also emergency rooms) from a range of specialties (various surgical and medical), geographical location, and local implementation or adaption strategies. Within cases (clinical units), we are aiming for selecting individuals from a range of stakeholder groups, actively seeking different perspectives.