Medicines Optimisation in Paediatric In-Patients (MOPPEt): A Qualitative Ethnographic Human Factors Study

Abstract

Introduction Medication Related Problems (DRPs) affecting hospitalised children and young people (CYP) are common, and yet the incidence of harm associated with these events appears to be relatively low (1-2% of events). Recent systematic reviews relating to Adverse Drug Events (ADEs) and DRPs in children and young people have synthesised global data from the last 25 years, UK-focussed systematic reviews of the incidence and prevalence of ADEs and DRPs are now almost 20 years old. Concurrently, there is a growing interest in the use of Human Factors and Ergonomics (HF/E) methodology in improving healthcare safety. HF/E approaches are based in socio-technical theory, whereby the complex interactions of technology and people are acknowledged. They involve the use of multiple methods to explore and understand problems, and empower stakeholders and service users in engineering theoretically sound interventions. This PhD thesis aimed to explore the prevalence and nature of DRPs for hospitalised CYP in the UK, and then use HF/E approaches to explore how healthcare systems in English acute paediatric hospital care maintain medicines safety. The findings of such explorations will enable the identification of potential interventions to improve these processes. Methods A systematic review was conducted to estimate the prevalence and nature of DRPs among hospitalised CYP in the UK. Nine electronic databases were searched from January 1999 to March 2023. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted. Subsequently, a prospective qualitative study in paediatric wards in three hospitals in the north of England was conducted between October 2020 and May 2022. Ethnographic data were collected from documentary analysis, observations and interviews with staff and patients’ families. I analysed the data thematically in collaboration with methodological experts (a HF/E practitioner, a social anthropologist and a practicing pharmacist researcher) and four parents through a “family forum.” The analysis consisted of work domain analysis ((WDA, Vicente, 1999) to understand the structure and components of the medicines safety system and orientate later elements of the study. Fieldnotes and interview transcripts were analysed inductively using thematic analysis to understand how medicines safety work was conducted and maintained. Parents and families were involved in this analysis, as well as experienced researchers. To conclude this project, experience-based co-design (EBCD) methods were used involving broad stakeholders including medical, nursing and pharmacy staff and parents and families, to propose and prioritise potential new interventions to improve medicines safety in acute paediatric care and identify future research. Results 26 studies were included in the systematic review of which 13 were considered high quality. DRPs were distributed throughout the medication system and affected 23.1% of CYP admitted to hospital (range 20.1-46%). 45% of children were affected by DRPs in documentation on admission or discharge, 70% (range 50-78%) of which were potentially harmful. Clinically significant prescribing errors are estimated to affect 6.5% of prescriptions (IQR 4.7-13.3).16.3% (IQR 6.4-23) of observed administrations were associated with medication administration errors (MAEs), including dosing errors. 25.6% (IQR 21.8-29.9) of patients were also affected by adverse drug reactions, 79.2% of which were harmful enough to require cessation of therapy. These results suggested that there were considerable risks associated with medicines within paediatric medication management processes, and a deeper theoretical exploration and understanding of these processes, and how safety was maintained were necessary in order to develop future interventions.

Date of Award	31 Dec 2023
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Darren Ashcroft (Supervisor) & Denham Phipps (Supervisor)