Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports

Using Digital Health Technologies to Monitor Pain, Medication Adherence and Physical Activity in Young People with Juvenile Idiopathic Arthritis: A Feasibility Study

Juvenile idiopathic arthritis can be influenced by pain, medication adherence, and physical activity. A new digital health intervention, InteractiveClinics, aims to monitor these modifiable risk factors. Twelve children, aged 10 to 18 years, received daily notifications on a smartwatch to record their pain levels and take their medications, using a customised mobile app synchronised to a secure web-based platform. Daily physical activity levels were automatically recorded by wearing a smartwatch. Using a quantitative descriptive research design, feasibility and user adoption were evaluated. The web-based data revealed the following: Pain: mean app usage: 68% (SD 30, range: 28.6% to 100%); pain score: 2.9 out of 10 (SD 1.8, range: 0.3 to 6.2 out of 10). Medication adherence: mean app usage: 20.7% (SD, range: 0% to 71.4%), recording 39% (71/182) of the expected daily and 37.5% (3/8) of the weekly medications. Pro-re-nata (PRN) medication monitoring: 33.3% (4/12), one to six additional medications (mean 3.5, SD 2.4) for 2-6 days. Physical activity: watch wearing behaviour: 69.7% (439/630), recording low levels of moderate-to-vigorous physical activity (mean: 11.8, SD: 13.5 min, range: 0-47 min). To conclude, remote monitoring of real-time data is feasible. However, further research is needed to increase adoption rates among children.

Nurses' use of pro re nata medication in adult acute mental healthcare settings: An integrative review

This integrative review explores the current pro re nata (PRN) medication practice in acute adult mental health settings. PRN medication is commonly used in acute mental health settings but there is lack of evidence of effectiveness of this practice. PRN medications have a number of adverse effects and increase the risk of morbidity in patients with a mental illness. Articles were identified from MEDLINE, CINAHL, Scopus, PubMed, PsycINFO, and Web of Science database. The STROBE critical appraisal tool was used to evaluate the quality of evidence, and inductive thematic analysis was used to extract main themes. Five themes regarding prescription practices, poor documentation, reasons to administer, medication misuse, and insufficient use of non-pharmacological interventions emerged among the 12 eligible articles. The study identified PRN medication practice gaps in adult mental health settings included insufficient documentation practice, underuse of therapeutic non-pharmacological interventions, and significant variability in PRN medication practice across the mental health professionals due to different levels of knowledge and experience.

Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review

Background

The adoption of electronic health records (EHRs) and electronic medical records (EMRs) has been slow in the mental health context, partly because of concerns regarding the collection of sensitive information, the standardization of mental health data, and the risk of negatively affecting therapeutic relationships. However, EHRs and EMRs are increasingly viewed as critical to improving information practices such as the documentation, use, and sharing of information and, more broadly, the quality of care provided.

Objective

This paper aims to undertake a scoping review to explore the impact of EHRs on information practices in mental health contexts and also explore how sensitive information, data standardization, and therapeutic relationships are managed when using EHRs in mental health contexts.

Methods

We considered a scoping review to be the most appropriate method for this review because of the relatively recent uptake of EHRs in mental health contexts. A comprehensive search of electronic databases was conducted with no date restrictions for articles that described the use of EHRs, EMRs, or associated systems in the mental health context. One of the authors reviewed all full texts, with 2 other authors each screening half of the full-text articles. The fourth author mediated the disagreements. Data regarding study characteristics were charted. A narrative and thematic synthesis approach was taken to analyze the included studies’ results and address the research questions.

Results

The final review included 40 articles. The included studies were highly heterogeneous with a variety of study designs, objectives, and settings. Several themes and subthemes were identified that explored the impact of EHRs on information practices in the mental health context. EHRs improved the amount of information documented compared with paper. However, mental health–related information was regularly missing from EHRs, especially sensitive information. EHRs introduced more standardized and formalized documentation practices that raised issues because of the focus on narrative information in the mental health context. EHRs were found to disrupt information workflows in the mental health context, especially when they did not include appropriate templates or care plans. Usability issues also contributed to workflow concerns. Managing the documentation of sensitive information in EHRs was problematic; clinicians sometimes watered down sensitive information or chose to keep it in separate records. Concerningly, the included studies rarely involved service user perspectives. Furthermore, many studies provided limited information on the functionality or technical specifications of the EHR being used.

Conclusions

We identified several areas in which work is needed to ensure that EHRs benefit clinicians and service users in the mental health context. As EHRs are increasingly considered critical for modern health systems, health care decision-makers should consider how EHRs can better reflect the complexity and sensitivity of information practices and workflows in the mental health context.

Exploration of note writing by mental health nurses using a video scenario

AIMS AND OBJECTIONS

We aimed to explore the content and language of nursing documentation and gain insight into the internal processes of nurses while notetaking.

BACKGROUND

Documentation is a core competency of mental health nursing, has clinical and ethical importance and is the integral to the efficient and effective care provided to patients. However, issues related to the content and quality of nursing notes continues to be a concern and there remains gaps in our understanding about the internal processes that nurses engage in when writing notes.

DESIGN

We used a mixed method design that included a content analysis with note review and interviews.

METHODS

After watching a video, psychiatric nurses (n = 27) wrote a note and then were interviewed about their note taking process. We used the COREQ guidelines for reporting our data.

RESULTS

Participants relied on four main themes when determining what to include in their notes-what happened and what the patient said or did, plus anything different than baseline, and safety concerns. Analyses revealed the presence of bias in the notetaking and participants were not familiar with effective strategies to mitigate these during the documentation process. Lastly, we found that notes are typically consistent in using some of the SOAPE format with notes focused on direct observations and the use of 'facts', while assessment and construction of treatment plans are used to a lesser extent.

CONCLUSIONS

Our results provide insight into the decision-making process of nursing staff regarding their documentation practices: overall they appear unaware of the importance of their notes, and believe that capturing the facts about their patients is important, while devaluing their own input and interpretations.

RELEVANCE TO CLINICAL PRACTICE

Our results provide evidence that mental health nurses may need additional training regarding documentation, more specifically about what to include, word choice and bias.

Practical Considerations of PRN Medicines Management: An Integrative Systematic Review

Background and objectives: Highly widespread use of pro re nata (PRN) medicines in various healthcare settings is a potential area for improper medication prescription and administration leading to patient harm. This study aimed to summarize and integrate the findings of all relevant individual studies regarding the practical considerations of PRN medicines management including strategies and interventions by healthcare professionals for safe prescription, dispensing, administration, monitoring, and deprescription of PRN medicines in healthcare settings. Methods: An integrative systematic review on international databases were performed. Electronic databases including Web of Knowledge, Scopus, PubMed (including MEDLINE), and Cinahl were searched to retrieve articles published until end of May 2021. Original qualitative, quantitative, and mixed methods studies written in English were included with a focus on PRN medicines management in healthcare settings. Research synthesis using the narrative method was performed to summarise the results of included studies. Results: Thirty-one studies on PRN medicines in healthcare settings by different healthcare providers were included after the screening of the databases based on eligibility criteria. They were published from 1987 to 2021. The majority of studies were from Australia, the United States, Canada, and the United Kingdom and were conducted in psychiatric settings. Given variations in their purposes, methods, and outcomes, the research synthesis was conducted narratively based on diversities and similarities in findings. Eight categories were developed by the authors as follows: "PRN indications and precautionary measures," "requirements of PRN prescription," "interventions for PRN administration," "monitoring and follow up interventions," "deprescription strategies," "healthcare professionals' role," "participation of patients and families," and "multidisciplinary collaboration." Each category consists of several items and describes what factors should be considered by healthcare professionals for PRN medicines management. Conclusion: The review findings provide insights on the practical considerations of PRN medicines management in clinical practice. The suggested list of considerations in our review can be used by healthcare professionals for optimal PRN medicines management and safeguarding patient care.

Ethical Tenets of PRN Medicines Management in Healthcare Settings: A Clinical Perspective

Prescription and administration of pro re nata (PRN) medications has remained a poorly discussed area of the international literature regarding ethical tenets influencing this type of medication practice. In this commentary, ethical tenets of PRN medicines management from the clinical perspective based on available international literature and published research have been discussed. Three categories were developed by the authors for summarising review findings as follows: 'benefiting the patient', 'making well-informed decision', and 'follow up assessment' as pre-intervention, through-intervention, and post-intervention aspects, respectively. PRN medicines management is mainly intertwined with the ethical tenets of beneficence, nonmaleficence, dignity, autonomy, justice, informed consent, and error disclosure. It is a dynamic process and needs close collaboration between healthcare professionals especially nurses and patients to prevent unethical practice.

Implementation of Electronic Medical Records in Mental Health Settings: Scoping Review

BACKGROUND

The success of electronic medical records (EMRs) is dependent on implementation features, such as usability and fit with clinical processes. The use of EMRs in mental health settings brings additional and specific challenges owing to the personal, detailed, narrative, and exploratory nature of the assessment, diagnosis, and treatment in this field. Understanding the determinants of successful EMR implementation is imperative to guide the future design, implementation, and investment of EMRs in the mental health field.

OBJECTIVE

We intended to explore evidence on effective EMR implementation for mental health settings and provide recommendations to support the design, adoption, usability, and outcomes.

METHODS

The scoping review combined two search strategies that focused on clinician-facing EMRs, one for primary studies in mental health settings and one for reviews of peer-reviewed literature in any health setting. Three databases (Medline, EMBASE, and PsycINFO) were searched from January 2010 to June 2020 using keywords to describe EMRs, settings, and impacts. The Proctor framework for implementation outcomes was used to guide data extraction and synthesis. Constructs in this framework include adoption, acceptability, appropriateness, feasibility, fidelity, cost, penetration, and sustainability. Quality assessment was conducted using a modified Hawker appraisal tool and the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses.

RESULTS

This review included 23 studies, namely 12 primary studies in mental health settings and 11 reviews. Overall, the results suggested that adoption of EMRs was impacted by financial, technical, and organizational factors, as well as clinician perceptions of appropriateness and acceptability. EMRs were perceived as acceptable and appropriate by clinicians if the system did not interrupt workflow and improved documentation completeness and accuracy. Clinicians were more likely to value EMRs if they supported quality of care, were fit for purpose, did not interfere with the clinician-patient relationship, and were operated with readily available technical support. Evidence on the feasibility of the implemented EMRs was mixed; the primary studies and reviews found mixed impacts on documentation quality and time; one primary study found downward trends in adverse events, whereas a review found improvements in care quality. Five papers provided information on implementation outcomes such as cost and fidelity, and none reported on the penetration and sustainability of EMRs.

CONCLUSIONS

The body of evidence relating to EMR implementation in mental health settings is limited. Implementation of EMRs could benefit from methods used in general health settings such as co-designing the software and tailoring EMRs to clinical needs and workflows to improve usability and acceptance. Studies in mental health and general health settings rarely focused on long-term implementation outcomes such as penetration and sustainability. Future evaluations of EMRs in all settings should consider long-term impacts to address current knowledge gaps.

A Qualitative Review of What Forensic Mental Health Nurses Include in Their Documentation

BACKGROUND

Documentation of mental health care is a critical component of nursing practice. Despite being identified as playing a critical role, researchers continue to question the quality of nursing documentation and missing and/or inaccurate information.

PURPOSE

Our aim is to explore the content of nursing documentation among mental health nurses providing care to forensic inpatients.

METHODS

Using a constructed semi-grounded emergent theme approach for data analysis, we reviewed the types of activities, subjects, and interactions described within nursing notes and identified themes of the content.

RESULTS

Our results demonstrate that nursing documentation could be categorized into one of seven themes: interactions, food, activities, sleep, mental health, physical health and hygiene. These areas were not consistent with the recommendations from nursing bodies in Canada, specifically the areas of assessment, planning, implementation, and evaluation. Furthermore, missing in the nursing notes is context.

CONCLUSIONS

The discussion highlights the importance of nursing documentation within the context of best practice, bias, and the impact on patient care. We also discuss missing information (context, clinical relevance, and case conceptualization), and suggest that nurses are not injecting this expertise in patient notes. Clinical implications for documentation practices are presented in relation to education and reflective practice.

Prescribing errors among adult patients in a large tertiary care system in Saudi Arabia

BACKGROUND

Multiple studies have investigated medication errors in hospitals in Saudi Arabia; however, prevalence data on prescribing errors and associated factors remains uncertain.

OBJECTIVE

Assess the prevalence, type, severity, and factors associated with prescribing errors.

DESIGN

Retrospective database review.

SETTING

Large tertiary care setting in Riyadh.

PATIENTS AND METHODS

We described and analyzed data related to prescribing errors in adults (>14 years of age) from the Medication Error Electronic Report Forms database for the two-year period from January 2017 to December 2018.

MAIN OUTCOME MEASURE

The prevalence of prescribing errors and associated factors among adult patients.

SAMPLE SIZE

315 166 prescriptions screened.

RESULTS

Of the total number of inpatient and outpatient prescriptions screened, 4934 prescribing errors were identified for a prevalence of 1.56%. The most prevalent types of prescribing errors were improper dose (n=1516; 30.7%) and frequency (n=987; 20.0%). Two-thirds of prescribing errors did not cause any harm to patients. Most prescribing errors were made by medical residents (n=2577; 52%) followed by specialists (n=1629; 33%). Prescribing errors were associated with a lack of documenting clinical information (adjusted odds ratio: 14.1; 95% CI 7.7-16.8, P<.001) and prescribing anti-infective medications (adjusted odds ratio 2.9; 95% CI 1.3-5.7, P<.01).

CONCLUSION

Inadequate documentation in electronic health records and prescribing of anti-infective medications were the most common factors for predicting prescribing errors. Future studies should focus on testing innovative measures to control these factors and their impact on minimizing prescribing errors.

LIMITATIONS

Polypharmacy was not considered; the data are from a single healthcare system.

CONFLICT OF INTEREST

None.

Causality and avoidability of adverse drug reactions of antibiotics in hospitalized children: a cohort study

BACKGROUND

Adverse drug reactions are a problem in healthcare systems worldwide. Children are more susceptible than adults, especially when exposed to specific drug classes, such as antibiotics.

OBJECTIVE

To assess the incidence, causality, severity, and avoidability of antibiotic-associated adverse drug reactions in hospitalized pediatric patients.

SETTING

Pediatric ward of a high-complexity public hospital in northeast Brazil.

METHODS

A prospective cohort study was conducted over six months, including children aged between 28 days and 12 years, hospitalized for more than 48 h, and receiving antibiotics. Liverpool's causality and avoidability assessment tools were used. Primary outcome measures: Incidence of adverse drug reactions, causality, severity, and avoidability, major antibiotics implicated, risk factors.

RESULTS

A total of 183 patients were followed, and 35 suspected adverse drug reactions were recorded overall incidence equal to 14.7%. Most adverse drug reactions were classified as moderate severity (76.7%), probable (57.1%) and defined (28.6%) causality, and unavoidable (66.7%). The affected organs were the gastrointestinal system (74.1%) and skin (25.9%). Major antibiotics implicated were ceftriaxone (40.7%), azithromycin (25.9%), and crystalline penicillin (11.1%). The number of antibiotics prescribed per patient during hospitalization and the length of stay were the risk factors identified.

CONCLUSION

Causality and severity assessment indicated that most adverse drug reactions were probable and moderate. Possibly avoidable reactions occurred due to inappropriate prescribing when preventive measures were not implemented. Monitoring the use of antibiotics in children is essential to ensure the safety of these patients.

An analysis of documentation language and word choice among forensic mental health nurses

Documenting patient care is an important part of mental health services. The documentation is expected to be accurate, relevant, and informative for all future readers as it provides details about patients and the care they are receiving. Language can produce positive or negative emotions in individuals, and these emotions can influence their thoughts and actions. Considering this, nursing documentation can impact the future care of patients. In this study, our aim was to analyse the language and words nurses use when documenting about their patients. Through a qualitative review of notes transcribed by mental health nurses in a forensic setting (n = 55), we explored the adjectives and verbs used across a subsection of their documentation over a three-month period. More specifically, we identified the most common words used, looked for patterns in use, and examined the emotional weight - or valence - of word choice. Examination of valence scores of the adjectives and verbs in the notes indicates that while nurses describe their patients in a rather neutral manner overall, some words and phrases are ambiguous and/or repetitive, and have the potential to negatively influence the perceptions of the reader regarding the patient. Clinical implications of patient care are discussed in the context of bias management. Nurses need to consider how word choice is linked to negative prosody and the need to provide additional information to avoid ambiguity. Without such care, notes can be subject to misinterpretation by readers leading to undue labels, stigma, and bias.

PRN Medicines Optimization and Nurse Education

Medicines management is a high-risk and error prone process in healthcare settings, where nurses play an important role to preserve patient safety. In order to create a safe healthcare environment, nurses should recognize challenges that they face in this process, understand factors leading to medication errors, identify errors and systematically address them to prevent their future occurrence. ''Pro re nata'' (PRN, as needed) medicine administration is a relatively neglected area of medicines management in nursing practice, yet has a high potential for medication errors. Currently, the international literature indicates a lack of knowledge of both the competencies required for PRN medicines management and the optimum educational strategies to prepare students for PRN medicines management. To address this deficiency in the literature, the authors have presented a discussion on nurses' roles in medication safety and the significance and purpose of PRN medications, and suggest a model for preparing nursing students in safe PRN medicines management. The discussion takes into account patient participation and nurse competencies required to safeguard PRN medication practice, providing a background for further research on how to improve the safety of PRN medicines management in clinical practice.

How forensic mental health nurses' perspectives of their patients can bias healthcare: A qualitative review of nursing documentation

AIMS AND OBJECTIVES

Our aim was to examine the notes produced by nurses, paying specific attention to the style in which these notes are written and observing whether there are concerns of distortions and biases.

BACKGROUND

Clinicians are responsible to document and record accurately. However, nurses' attitudes towards their patients can influence the quality of care they provide their patients and this inevitably impacts their perceptions and judgments, with implications to patients' care, treatment, and recovery. Negative attitudes or bias can cascade to other care providers and professionals.

DESIGN

This study used a retrospective chart review design and qualitative exploration of documentation using an emergent theme analysis.

METHODS

We examined the notes taken by 55 mental health nurses working with inpatients in the forensic services department at a psychiatric hospital. The study complies with the SRQR Checklist (Appendix S1) published in 2014.

RESULTS

The results highlight some evidence of nurses' empathic responses to patients, but suggest that most nurses have a style of writing that much of the time includes themes that are negative in nature to discount, pathologise, or paternalise their patients.

CONCLUSIONS

When reviewing the documentation of nurses in this study, it is easy to see how they can influence and bias the perspective of other staff. Such bias cascade and bias snowball have been shown in many domains, and in the context of nursing it can bias the type of care provided, the assessments made and the decisions formed by other professionals.

RELEVANCE TO CLINICAL PRACTICE

Given the critical role documentation plays in healthcare, our results indicate that efforts to improve documentation made by mental health nurses are needed and specifically, attention needs to be given to the writing styles of the notation.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.