Francis, SA; Yardley, S; Franklin, BD; Ogden, M; Kajamaa, A; Mattick, K; (2024) Getting palliative medications right: an activity theory analysis to improve patient safety and carer confidence

Getting palliative medications rightThe Health and Care Act 2022 made provision of palliative and end of life care a statutory requirement.By 2040, demand for palliative care in England and Wales is expected to increase by 25% to nearly half a million people per year.About 1 in 5 NHS serious incident reports about palliative care involve medication.Patients, carers and healthcare professionals all experience daily hassles with medication and engage in hidden work to address gaps in the ways the system works for getting medication right for good symptom control.We wanted to find out what is needed to improve patient safety and carer confidence with palliative medication in home, hospital and hospice settings.Scoping review.We looked at nearly 20,000 pieces of published evidence.212 of these named medication process steps without giving any practical detail.We used a further 96 to identify themes and active ingredients necessary for an ideal model of the system.New data.We completed more than 120 hours of observations and 83 interviews with patients, carers, and professionals in home (community), hospital and hospice settings in London.Professionals included doctors, nurses, pharmacists, pharmacy technicians, discharge coordinators, rapid response teams, social workers, ambulance staff and service managers. WHY DOES THIS MATTER?WHAT IS THIS STUDY ABOUT?We have created an interactive model of the multi-step tasks of prescribing and using medication in palliative care, representing the voices of everyone involved and highlighting essential targets for improvement.Please scan this QR code to view the model in full.Our analysis extends understanding of process disturbances and safety concerns at home, hospital and hospice, or when moving between places.It also illuminates 'hidden work' undertaken by people to enable good medication management. WHAT DID WE FIND OUT?1Acknowledge symbolic significance of medication decisions.Carer support for concerns about potential medication errors.Expand options for carer involvement in administration.All pharmacies to have access to a stock supply of basic palliative medications.Routine palliative medication management support for carers at home.Shared records across patients/ carers/professionals and care settings.Address tensions between delegation of care and responsibility for medication.Pharmacy professional involvement in medication-decision making.Transition management.Proactive planning in community pharmacies for palliative patient/ carer needs.Address inequities in availability of medications and home delivery services.What aspects of the system require attention to improve safety and confidence?(More detail presented on pages 10-11).Hidden work: a carer's perspective 2 3 2 System innovation and new forms of practice to improve care -how could it be done?People can only work effectively to a common goal when they share common understandings and practices.We used Activity Theory as a framework to help us understand what happens, who does what with which parts of medication processes including the tools they use, how formal and informal rules operate, and what occurs when a patient moves between home, hospital and hospice care.