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A Lot of Difficulties in Reporting Drug Side-Effects (ADRs); Adverse Drug Reactions Reporting in Dunedin Hospital

Background

Historically, hospital doctors have apparently been poor reporters of adverse drug reactions (ADRs) compared to general practitioners.  A much smaller proportion of all reports come from hospitals (doctors and pharmacists combined) than expected, given the severity of illness of patients in hospital and the extensive use of drugs.  The Centre for Adverse Reactions Monitoring (CARM) is putting together a programme to raise the profile of CARM, and requires information to determine where to direct their attention, and what sort of barriers to reporting might exist in different practice circumstances.

Aims

  1. To describe the current situation of adverse drug reaction reporting from hospitals.
  2. To determine the knowledge, attitudes and reporting practices of a sample of hospital doctors and pharmacists
  3. To describe the barriers and incentives to reporting by hospital doctors and suggest ways to address these barriers.

Methods

A face to face structured interview/telephone interview using a 19-question questionnaire was carried out among a random sample of 30% of doctors and 50% of pharmacists at Dunedin Public Hospital (DPH).

Results

The response rate was 88%.  Of the 90 doctors and 5 pharmacists interviewed, 89% had been involved with patients with ADRs.  However, only 55.8% of them had actually reported an adverse drug reaction.  Among the doctors, the likelihood of reporting increased with seniority and was greater among physicians (69.4%) than surgeons (46.2%). The reporting rate also increased with seniority, as well as increasing years at DPH.  However, these rates decreased as either the respondents’ time at DPH and the time since graduation increased to beyond 10 years and 20 years respectively.  The total reporting rate for the doctors in DPH was 40%.  The two most important criteria for reporting were the seriousness of the reaction and if the reaction was of clinical concern.  Only around 50% of doctors had heard of CARM and knew to use the CARM form to report ADRs, as against 100% of pharmacists.  Overall surveillance was thought to be the main purpose for ADR reporting (64.2%) and CARM itself (78.6%).  There were 51.6% respondents who felt that everyone was responsible for reporting.  However, most respondents felt that reporting was the doctor’s role. Not enough time (66.3%), uncertainty about diagnosis of an ADR (61.1%), unsure about the criteria for reporting (50.5%), unavailability of reporting cards (48.4%) or being unsure how to report (45.3%) were the most important barriers to reporting.

Conclusion

There is a considerable degree of underreporting, which might partly be explained by a lack of knowledge or misconceptions about spontaneous reporting of adverse drug reactions.

Authors of Report

Kannie Chuang, Charles Tie, Kim Weng, Po Yee Yip, Simon Young

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Discharge Letter Processing and Relevance

Introduction

Delay in General Practitioners (GPS) receiving information on their patients’ stay in hospital is an important problem because discharge letters are an important link between in-patient and primary care.  A Trainee Intern Evaluation Projection in February 1997 identified this as a major problem and recommended that further research should be undertaken to find out about the delay.  A recent audit of the General Medicine service also suggested major delays for reasons undetermined.

Aims

  1. to investigate the process and possible reasons for delay in the generation of discharge letters following discharge of patients from ward 8A to general practitioners.
  2. to investigate the relevance of the contents of the letter for the intended audience.

Methods

  1. We interviewed all hospital staff involved with generating and processing discharge letters, and selected GPs who receive the letters to obtain qualitative data.
  2. We conducted a discharge letter analysis by examining letters from patients discharged from 8A in October 2000.

Results

Quantitative Data

We found a mean time delay of 18.0 days (SD:5.4 days, range: 7 to 29 days) for GPs to receive discharge letters after hospital discharge from ward 8A.  For discharge letter analysis of format and content, results showed that 94.1% had a diagnosis (61.8& with a heading); 76.5% had discharge medications recorded (51.0% with a heading); 85.3% had patients’ investigations recorded (11.8% with heading); 41.2% had discharge instructions to the GP (8.8% with heading); 10.8% had community follow up and 13.7% mentioned about information given to the patient.

Qualitative Data

Hospital System

There are a number of problems identified in the hospital system.  These included an overly complex process, increased patient admissions, staff specific issues under resourcing and consequent staff shortages.

General Practitioners

There was no consensus among GPs in terms of discharge letters’ length and relevance.  The length is related to the complexity of the admission, and GPs who considered letters useful were prepared to read longer letters.  The relevance decreases with increasing time elapsed between discharge and letter.  The format and content were found to be satisfactory.

Conclusion

In conclusion, the present delay of the discharge letter processing is perceived by primary care practitioners as unacceptable.  The discharge letters are of less value because the delay is so long, and some information is therefore no longer relevant.  The problems in generating discharge letters are multi-factorial and sources of delay occur at every stage.  In order to improve the situation, major changes should b considered in the guidelines, system streamlining and staff allocation.

Authors of Report

Sharon Sagee, Mohd Fauzi Sharudin, Marzilawati Abd. Rahman, Stefen Kuiper, Andy Watt, Ahmad Riaz Fami Razali

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Guns, Knives, Onlookers and Overalls. Violence Against Ambulance Officers in New Zealand

Violent attacks against ambulance officers is of growing concern and has recently been highlighted in the media.  There have been very few studies looking at ambulance officers and workplace violence and none have been done in New Zealand.  The aims of our study were to assess the level of violence encountered by New Zealand ambulance officers, to asses any predisposing risk factors to violence, and possible solutions for violence reduction.

We distributed 695 questionnaires to ambulance union members across New Zealand.  We received a total of 216 completed questionnaires, a response rate of 31%.  Results were analysed using SPSS Spreadsheet and Microsoft Excel. 

Of the respondents, 67% felt that there has been an increase in violence towards ambulance officers.  The majority of the respondents (87%) felt that their personal safety had been threatened during their work.  In the past 12 months, 78% had experienced verbal threats while 35% had experienced physical assaults.  According to 86% of the respondents, personal safety was most at risk during nights.  Weapons and alcohol/drug use were reported as the two most important risk factors precipitating violence.  There was no significant difference in the rates of physical or verbal violence between the 4 main cities (Dunedin, Christchurch, Wellington, Auckland).  We found no difference between the rates of violence and the experience or gender of the ambulance officer.  The number of verbal assaults experienced by ambulance officers who had talking down skills was found to be significantly less.  We found significant differences in the types of training received by ambulance officers between the 4 main cities.  In terms of possible solutions, 81% wanted courses in talking down skills and 67% wanted self-defense courses.  The majority was against the use of weapons such as batons (90%) and pepper sprays (77%). 

Authors of Report

Gerome Hsiung, Mazuan Ismail, Susan Macleod, Muiz Mahyudin, Ahmad Mohamed, Shahnaz Mohd Nazri, Ami Nukada, Michelle Simmons

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Is There a Doctor in the House? (and should they be wearing a white coat?)

Aims

To investigate patients’, doctors’ and medical students’ attitudes towards the wearing of white coats, and issues surrounding identification, communication and professionalism in the hospital setting.

Method

Three separate questionnaires were designed; one for each study population.  General medical and surgical inpatients older than 16 years were approached and asked to participate in our survey by means of short structured. Doctors employed by Healthcare Otago were sent a questionnaire in the mail.  Clinical Medical Students studying at the Dunedin School of Medicine, University of Otago, were approached during their scheduled lectures and asked to complete a written questionnaire.  Results were analysied using the statistical programme, SPSS.

Results

Eighty-one percent of patients consented to be interviewed.  Forty-six percent of patients felt all doctors should wear white coats, while when shown a picture of a white coated doctor 89% said it was an appropriate standard of dress.  Sixty-six percent of patients felt that a clearly visible identification badge alone was sufficient to identify doctors.

Fifty-nine percent of doctors returned our completed questionnaire, with only 12% feeling that all doctors should wear white coats.  Eighty-one percent never wear a white coat while on the ward, with 43% indicated they would not wear one even if patients felt more comfortable with it.

We had a 77% response rate from students.  Forty-one percent wore white coats always or almost always when on the wards with the most common reason for this being because they “had to”.  In contrast to the doctors, 72% said they would be more likely to wear one if the patients felt more comfortable with it.

Doctors and medical students were significantly more likely than patients to believe white coats to be intimidating and a barrier to communication.

Patients were significantly more likely to believe that white coats signified professionalism.

Conclusion

Doctors should maintain a professional dress standard while on the ward.  Patients deem white coats to be an appropriate standard of dress, believe them to promote professionalism, and did not find them to be a barrier to communication, or intimidating.  Overall, the manner, attitudes and clinical competence of doctors was felt to be more important than their attire.

Authors of Report

Steven Alexander, Danny Chuang, Nicola Graham, Conlin Locke, Judy Ormandy, Arvind Raju, Tony Young

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T E A C H - Dunedin: Tobacco Education and Control in High Schools

Project Aims

  • To find out what smoke free education is currently being taught in Dunedin secondary schools and to compare this with the current New Zealand syllabus.
  • To find out what smoke free policy are in place in Dunedin secondary schools.
  • To identify an educational package on smoking which is appropriate for secondary school students and could possibly be delivered by medical students – (originally included in our aims but removed to focus our study).
  • To find out whether it’s a good idea for medical students to be actively involved in the smoke free education.

Authors of Report

Adibah Ibrahim, Ben Campbell, Boon Ghee Chong, Chester Chong Lun Yin, Daniel Pettigrew, Ee Min Kho, Logan Mitchell, Suraya Abdul Razak

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To Report or Not to Report: A Study of the Reporting of Notifiable Diseases by General Practitioners in the Greater Dunedin Area

Aims          

  • To quantify the level of reporting of a specific disease, namely pertussis, by general practitioners in Otago during a 12 month period.
  • To determine the knowledge, attitudes and reporting practices of general practitioners in the greater Dunedin area.
  • To identify barriers to notification of infectious diseases by general practitioners.
  • To make recommendations to the Medical Officer of Health to improve notification rates by general practitioners.

Methods

A database containing READ codes and clinical notes was used to identify the number of suspected cases of pertussis in a 12 month period.  Comparing these values with the actual notification rates for the same time period we demonstrated the level of under-reporting of pertussis.  A face-to-face questionnaire survey was conducted to examine attitudes, beliefs and reporting practices of general practitioners in the greater Dunedin area.

Results

From the database analysis we demonstrated a rate of notification of 7.59% (95% CI 3.8 – 13.5). 

The questionnaire survey found that the top 3 factors influencing reporting rates were the need for laboratory confirmation prior to reporting a notifiable disease, time away from clinical work spent reporting and a perceived lack of information regarding notifiable diseases.  Higher rates of reporting was found amongst GPs who:

  • Found the reporting process easy
  • Had a specific member of practice responsible for reporting
  • Thought that there was an effective public health response
  • Thought that there was adequate feedback
  • Notified frequently on suspicion
  • Thought that both laboratories and GPs should notify

Conclusions

There is a significant level of under-reporting of pertussis, an important notifiable disease.  Notification rates may be improved by allocating a specific member of a practice the role of reporting all the notifiable diseases.  Improved feedback and a regular education programme will further enhance notification rates by general practitioners.

Authors of Report

Joanne Barclay, Louise Bremer, Michele Cameron, Nitin Mathur, Marie Neylon, Jacqueline Pitchforth, Robert Slade

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When Parents and Doctors Disagree About Children's Treatment

Aims

To research the facts of the cases involving Liam Williams-Holloway and Tovia Laufau, and examine the issues involved in parent versus doctor treatment conflicts raised by these cases, including the role of alternative treatments.

Method

Preliminary research to identify issues raised by the public with regard to these cases and to establish the legal and medical facts, as well as the ethical issues involved.  Using the issues and facts identified by our preliminary research, a questionnaire was compiled to determine the degree to which publicly aired views were representative, and to attempt to investigate the factors involved in the formation of these views.

Two sample populations were randomly selected from the University of Otago 2000 calendar.  One comprised of medical professionals, the other of non-medical academic staff.  We compared these groups to evaluate any differences between the two populations.

Results

Overall, 107 responses were received to the written survey, a response rate of 65%.  The salient features included:

  • General support for the seeking of treatment orders in the two key cases.  Overall 77% of respondents supported the decision of Liam’s doctors in seeking such an order.  A significant difference was noted between genders with males more likely to agree (85%) than females (58%), and this was true for both medical and non-medical respondents.  Regarding Tovia’s case, 70% of respondents believed that Tovia’s doctors should also have sought a treatment order.  Again, males were more strongly in favour of an order being sought, but the gender differences were not statistically significant.
  • Little support (10% of respondents only), for treatment decisions being solely the right of the parents.  The majority view, held by 75% of respondents, was that society had a role to intervene in some situations to ensure that the best interests of the child were being served.
  • The court process was viewed by many as a last resort due to its confrontational nature – best preceded by some form of mediation/arbitration, to attempt to reach a consensus decision in the best interest of the child.
  • Enhanced communication between health professionals and parents was considered crucial to hopefully avoid such conflicts arising.
  • Respondents considered the scientific evidence for a treatment as the most important feature to consider when deciding between treatments, with the likely treatment outcome being another very important consideration.  Cultural and religious issues were seen to be of lesser importance to respondents, and of least importance were the basis of the treatment (i.e. pharmacological vs natural), and financial considerations.
  • Strong concerns as to the accountability of alternative practitioners and the absence of any regulations in this area.  This was ranked as a major concern in the Liam Williams-Holloway case, second only to the concern about a potentially avoidable death.
  • Heavy criticism of media reporting in such situations with comments that it is often biased and uncritical.

Conclusions

We concluded that our findings can be generalised to the greater population of medical professionals and academics, on the basis of our sample size, sample group matching and response rate.  We cannot make any inferences however about the wider population and further research may be needed in this area.

Our results showed that amongst this academic population there was general support for the doctors to pursue all avenues when the child’s best interests were at stake.

We identified several concerns however about the current situation, including the need for improved communication between health professionals and parents, the need for some form of doctor/parent mediation process when disputes arise, and the requirement for regulations to be established to govern alternative practitioners.  A full list of our recommendations follows later in this document.

Authors of Report

Sharon Brandon, Deborah Clarke, Angela George, Janice Jensen

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Young Carers: Unseen and Unheard

Aim

To estimate the number of young people aged 7 to 17 in Dunedin who may be caring for a relative that is ill or disabled, the degree of care being provided, the types of care provided, the effects these responsibilities may have on the children and the range of supports that are currently available to this group of people.

Methods

The study was conducted by means of a questionnaire sent to relevant community support agencies in Dunedin. The responses to the questionnaire were subsequently gathered by means of a structured interview. Information recorded during the interviews included both qualitative and quantitative data. The questionnaire was pre-tested in a pilot study involving four agencies.

Results

Twenty organisations out of 49 participated in the study (response rate of 41%). Results were analysed for two groups, group 1 including agencies with children as clients, and group 2 including agencies with adults as clients. Questions 1 to 3 of the questionnaire covered the demographics of the organisations, including the client number per agency, the client number per representative and the number of clients with dependent children. Results showed great variation between agencies. Also there was great variation in the percentage of solo parents per agency. Question 4 covered the demographics of young carers. Fourteen agencies (70%) had involvement with young carers over the last one year period. Only eight agencies were able to give an estimate of a gender split for young carers. The majority of young carers were reported to care for parents, some also cared for siblings and in only three families grandparents were being cared for. Question 5 covered the different levels of care provided by young carers. 45% of young carers were reported to provide high level care, 38% provided medium level care and 17% low level care. Question 6 covered the types of care young carers were providing. Domestic chores were the most commonly reported, followed by physical care and the provision of companionship and support. Providing supervision, assistance with communication, personal care and assisting with medication care followed in this order. Examples of other types of care were also recorded. Question 7 covered the impacts of caring. Emotional impacts were the most commonly reported, followed by impacts on education, friendship and financial impacts. An unreasonable degree of responsibility and a change in family structure were next most commonly reported, followed by placement outside the home and impacts on health. 80% of agencies had direct contact with young carers (question 8). 20% of agencies with adults as clients included children in needs assessments (question 9). 50% of agencies reported offering services to young carers (question 10). 60% of agencies reported awareness of other services for young carers (question 11). These agencies frequently referred to each other when young carers were identified.

Conclusions

The number of young carers in Dunedin cannot be accurately estimated, as a lot of the data collected from the agencies were anecdotal. The lack of awareness of agencies of young carers as a significant proportion of their clientele was probably the major contributor for this. This is in keeping with similar studies done overseas.

However, there is a core of themes that seem to come up repeatedly, raising important issues. Young carers do exist in Dunedin largely unrecognised and may suffer adverse effects because they continue to exist without their needs being met.

Authors of Report

Pete Ferguson, Maryke Griessel, Louis Lao, Rajdev Singh, Kate Ure

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