Homecare safety and medication management: a scoping review of the quantitative and qualitative evidence

Review question/objective This review will be guided by the following research questions: 1. What are the range of issues encountered by individuals, families, caregivers, and healthcare providers related to the medication management of individuals living in the community and receiving homecare services? 2. What are the documented errors or adverse events that occur in this population that relate to the management of medications? 3. What strategies have been implemented and evaluated that address the issues encountered by this population? Background Introduction Patient safety is a current national and international priority, and one of the most prevalent, high-risk fields within patient safety is medication safety.1-4 The links in the chain of events necessary for medication safety include assessment, prescription, dispensing, and monitoring of medications. A weakness in any one of these essential links or a tenuous connection between links may result in an adverse event and harm to the patient. While medication safety in general demands consideration, there is a critical gap in our understanding of medication safety in the home care sector. Understanding what factors contribute to, and/or reduce the risk of adverse drug events in the home setting will enable the identification and promotion of safer medication administration practices. Key Definitions Homecare research and literature is rife with inconsistent terminology related to roles. Thus, discussion of medication safety in homecare necessitates clarification of terms. For the purposes of this discussion, caregivers refers to family members or friends in a paid or unpaid role who are responsible for or charged with caring for the patient. Family members are individuals identified by the patient and/or caregiver as being close to the patient through blood, legal, or emotional ties, and who may or may not reside in the same home as the patient. Finally, providers are employees of organizations providing homecare services. Providers may be professionals or non-professionals, and regulated or unregulated (e.g. case managers, nurses, aides, pharmacists, and therapists.) Compromised Medication Safety for Older Adults When medications are not managed safely, the associated costs for patients, their caregivers/families, providers, and the healthcare system can be severe.4-10 There is limited evidence from the international literature on safety in homecare or safety in medication management in home care. However, Canadian studies indicate that as many as one in five hospitalized Canadians suffer adverse events following their discharge home, and two thirds of those events are related to compromised medication safety.11-13 Furthermore, patients themselves have identified problematic outcomes related to insufficient medication safety processes. For example, in the Commonwealth Survey (2002), 11% of Canadian patients reported that they received an incorrect medication at least once.14 Medication safety issues are often augmented for older adults. Management of multiple chronic illnesses as well as other care needs frequently compounds the complexity of the medication regimens common in this population. In Canada's seniors, the total annual cost of preventable drug-related morbidity (PDRM) was estimated to be $11 billion in 2000.7 In addition, a recent study observed that up to one in 11 seniors in Halifax, Nova Scotia experienced a PDRM within a two-year period.15 Many of these lapses in medication safety occur in patients' homes. Because of the myriad of issues faced by elderly homecare recipients, this review will focus on medication safety issues for older adults who receive homecare services, their caregivers/families, and providers. Complexity of Care in the Home Homecare is inherently complex, and the demands on the knowledge, ability, energy, and finances of patients and their families/caregivers are intensifying as a result of increasing acuity of patients, decreasing length of hospital stays, and increasing availability of mobile health care technology such as peritoneal and hemodialysis, long term intravenous catheters, and oxygen/inhalation therapy.16 Family relationships, the home environment, which is not designed for providing health care, and the cognitive and physical abilities of both patients and caregivers further influence care provision. While in-hospital, care is predominantly the responsibility of regulated professional providers who work in shifts whereas unregulated providers, family, and caregivers provide much of the care in private homes.17 Caregivers for home care patients are frequently elderly, and they often grapple with health challenges of their own in addition to lack of sleep as they provide around-the-clock care with little assistance or relief. Family and caregivers often agree to care for patients at home out of love and/or a sense of responsibility, but are unaware of the extent of the commitment involved and the drastic impact it can have on their own lives and health.18;19 Additionally, providers who work in patients' homes are exposed to the risks inherent in providing care alone in an unregulated and potentially ill-equipped setting. Thus, the safety of the patient, caregiver/family, and provider are inextricably linked, and the care and safety of patients around medication management cannot be addressed without including caregivers, family members, and providers in the equation.20-22 Medication Safety in Homecare Current medication safety research focuses predominantly on institutions and paid providers. This research may have little applicability to the homecare setting, just as the traditional means of identifying and describing medication errors (e.g. “drug without indication” or “indication without drug”23) may be neither sufficient nor practical for homecare.24 Assessing medication-related problems in the home often demands consideration of issues that are often irrelevant in the hospital setting. Examples of these are economic issues, such as whether the patient can afford to fill his or her prescriptions; access issues, such as whether the patient has the physical capacity to get to a pharmacy; and social issues, such as living with an overwhelmed caregiver who has his or her own health concerns. Additionally, there is a great deal of variation in the abilities of caregivers, many of whom are lay people with no formal health care training. There is little in the way of education or preparation for these caregivers, who manage an array of medications in potentially ill-equipped home settings, frequently while under the influence of stress and fatigue. Though providers can help to alleviate risks through assessment and collaborative discussions with patients and caregivers, the nature of the home setting requires patients and caregivers to make frequent autonomous decisions about medication use with minimal professional supervision, and deficient or absent home and community supports.17 In addition, the home setting presents unique difficulties in documentation and communication related to medications. Research shows points of transfer across sectors already hold increased challenges in these essential functions.11-13;25 One related danger to homecare patients is the implications of insufficient communication for medication reconciliation, defined as the “systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed or discontinued are carefully assessed and documented.”26,p.5 As the potential for receiving inappropriate medication increases, so too does the potential for harmful incidents (an incident which results in harm to a patient).27,p.23 Shifting Perspective: New Knowledge Requirements Homecare continues to be chronically under-funded within a health care system dominated by the acute care setting, despite an ever-increasing demand for homecare services. Health care strategies for the elderly, including seniors with chronic conditions and those that need end-of-life care, require a fundamental change in perspective. This change is necessary from a short-term, disease-oriented perspective with an emphasis on diagnosis and treatment, as well as from a long-term perspective with an emphasis on functional capacity, health maintenance, prevention of further deterioration, health promotion for the patient and caregivers/families, as well as comfort and supportive care. This shift in perspective calls for a new set of competencies (education, skills), and alternative approaches (including behavioral strategies) to care for these patients and caregivers/families. The safety implications for medication management in home care need to be addressed in relation to service provision for vulnerable patients (i.e., elderly, chronically and/or terminally ill), ethical considerations for the myriad of daily decisions in homecare, and the critical role of patients, caregivers, and family members as integral members of the health care delivery team. In line with the view proposed by the Canadian Institutes for Health Research (CIHR), “Decision-makers need information and implementation strategies on how to shift from a world of acute care solutions for chronic care needs to a world of chronic care solutions for chronic care needs,”28 this review will explore existing knowledge related to medication management from a safety perspective for older adults receiving home care as well as their caregivers, families and providers. Examining existing research related to the issues and challenges faced by this population, as well as any strategies used to mitigate or ameliorate safety risks, will illuminate gaps in current knowledge, identify priority research areas, and advance patient safety research in home care. The following explanations/definitions are relevant to the review: Homecare services personnel • Homecare services are the provision of care by a licensed or unlicensed health care provider who is contracted with a home-care agency. • Include any paid caregiver, (regulated or unregulated), with or without training, including personal support workers, home support workers, health care aides and lay health care workers. Homecare services • Include services to address the treatment of any health condition but must specifically address medication management. Home-dwelling • Home-dwelling includes people living at home, with friends or family, in retirement homes, senior's apartments, residential centers, or communal residences. This review will be a mixed method (quantitative and qualitative) scoping review to establish the state of knowledge on this topic in the current research literature. It is anticipated that the scoping review will provide an indication of areas to explore further and at greater depth using systematic review methodology. An initial search of the Joanna Briggs Institute Library and the Cochrane Library, Medline and CINAHL has been done and has determined that there are no previous reviews done on this topic.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.