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  • 1.
    Holmqvist, Malin
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Together towards safer medication treatment for older persons2023Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    This thesis focuses on promoting patient safety in older persons using medications. Given that medications can unintentionally harm patients, the World Health Organisation emphasises “Medication without harm” as a global patient safety challenge. Older persons are more likely to experience harm, and harm tends to occur when prescribing or monitoring medications. Co-production of healthcare with patients may reduce the risk of adverse events and can serve as a resource to promote safety in healthcare. Accordingly, this thesis aims to increase knowledge of how older persons and healthcare professionals can co-produce a solution for improved medication evaluation and thereby promote patient safety.

    Co-design is an approach that emphasises patient involvement in improvements of healthcare services. Therefore, the thesis was guided by the four phases of the Double Diamond framework for co-design. In the Discover phase experiences of medication evaluations were collected. Older persons were interviewed and data were analysed using qualitative inductive content analysis (Paper I). Critical Incident Technique was used to collect and analyse data from interviews with healthcare professionals in primary care (Paper II). In the Define and Develop phases, a case study design was used to explore older persons’, nurses’ and physicians’ design choices for a medication and their experiences of a remote co-design approach. Collected data were analysed using descriptive statistics along with directed content analysis (Paper III) and thematic analysis (Paper IV). In the Deliver phase, the feasibility of applying a medication plan in primary care, as well as the study methods used were examined. Data were analysed using descriptive statistics and inductive content analysis (Paper V).

    The findings showed that older persons reported having a responsibility to engage in their medication evaluations, even if some felt unable to do so or considered themselves unconcerned. Continuity of care and participation facilitate evaluations, but a comprehensive medication evaluation was lacking (Paper I). Healthcare professionals experienced that medication evaluations for older persons were influenced by working conditions and working in partnership. Actions taken to manage medication evaluations were carried out through working with a plan and collaborative problem-solving (Paper II). A medication plan, linked to the medication list, had to provide an added everyday value related to safety, effort and engagement, and support communication, continuity and interaction. Important functional requirements were to provide instant access, automation and attention, and content requirements were detailed information about the medication treatment (Paper III). Remote co-design can complement or substitute for face-to-face co-design sessions. The approach allowed an accessible environment, and sharing everyday life experiences created learning and awareness of possible risks and strategies that could promote patient safety (Paper IV). The feasibility of applying a medication plan, assessed as usability, varied and the participants’ experiences of usability concerned a de-prioritised medication plan, functionalities, individualisation and resources. The participants’ perceptions of patient safety addressed awareness and information, challenges beyond the medication plan and patient involvement (Paper V).

    Healthcare services could promote patient safety by involving older persons in medication evaluations and in co-designing patient safety solutions. However, implementing a medication plan in clinical practice is complex and requires continuous co-produced improvements at different levels within the healthcare system.

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  • 2.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Clinical Pharmacy, County Council of Jonkoping, County Hospital Ryhov, Jönköping, Sweden.
    Ekstedt, Mirjam
    School of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden.
    Walter, Scott R.
    Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
    Lehnbom, Elin C.
    Department of Pharmacy, Faculty of Health Science, UiT The Arctic University of Norway, Tromsø, Norway.
    Medication management in municipality-based healthcare: A time and motion study of nurses2018In: Home Healthcare Now, ISSN 2374-4529, Vol. 36, no 4, p. 238-246Article in journal (Refereed)
    Abstract [en]

    The objective of this observational time and motion study was to increase our understanding of how nurses in home healthcare currently distribute their work time with a focus on the medication management process. The research was conducted in four municipalities in the southern part of Sweden. Participants were nurses working in home healthcare. The study measured proportion of time, comparison of proportions of time, proportion of time spent multitasking, and rate of interruptions per hour. Of total observed time, 20.4% was spent on medication management and of these tasks the highest proportion of time was spent on communications and dispensing medications. Nurses in nursing homes spent more time (23.0% vs. 17.4%, p = 0.001) on medication management than nurses in private homes. Nurses spent 47.9% of their time completing tasks with someone else, including patients, but had minimal interaction with prescribers. We observed a rate of 1.2 (95% CI 1.1-1.4) interruptions per hour on average and 30% of all interruptions occurred during medication management tasks. Nurses spent 3.7% of their time multitasking. Interruptions while performing medication-related tasks were common, as well as multitasking. Causes and consequences of the results need to be addressed in order to improve the safety of medication management for patients receiving municipality-based home care.

  • 3.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Public Health and Healthcare, Region Jönköping County, Jönköping, Sweden.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Lindenfalk, Bertil
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership.
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County, Jönköping, Sweden.
    Older persons' and health care professionals' design choices when co-designing a medication plan aiming to promote patient safety: Case study2023In: JMIR Aging, E-ISSN 2561-7605, Vol. 6, article id e49154Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Harm from medications is a major patient safety challenge among older persons. Adverse drug events tend to arise when prescribing or evaluating medications; therefore, interventions targeting these may promote patient safety. Guidelines highlight the value of a joint plan for continued treatment. If such a plan includes medications, a medication plan promoting patient safety is advised. There is growing evidence for the benefits of including patients and health care professionals in initiatives for improving health care products and services through co-design.

    OBJECTIVE: This study aimed to identify participants' needs and requirements for a medication plan and explore their reasoning for different design choices.

    METHODS: Using a case study design, we collected and analyzed qualitative and quantitative data and compared them side by side. We explored the needs and requirements for a medication plan expressed by 14 participants (older persons, nurses, and physicians) during a co-design initiative in a regional health system in Sweden. We performed a directed content analysis of qualitative data gathered from co-design sessions and interviews. Descriptive statistics were used to analyze the quantitative data from survey answers.

    RESULTS: A medication plan must provide an added everyday value related to safety, effort, and engagement. The physicians addressed challenges in setting aside time to apply a medication plan, whereas the older persons raised the potential for increased patient involvement. According to the participants, a medication plan needs to support communication, continuity, and interaction. The nurses specifically addressed the need for a plan that was easy to gain an overview of. Important function requirements included providing instant access, automation, and attention. Content requirements included providing detailed information about the medication treatment. Having the plan linked to the medication list and instantly obtainable information was also requested.

    CONCLUSIONS: After discussing the needs and requirements for a medication plan, the participants agreed on an iteratively developed medication plan prototype linked to the medication list within the existing electronic health record. According to the participants, the medication plan prototype may promote patient safety and enable patient engagement, but concerns were raised about its use in daily clinical practice. The last step in the co-design framework is testing the intervention to explore how it works and connects with users. Therefore, testing the medication plan prototype in clinical practice would be a future step.

  • 4.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Lindenfalk, Bertil
    Jönköping University, School of Health and Welfare, HHJ, Dept. for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    What can co-design teach us about involving patients in patient safety work?2022Conference paper (Refereed)
    Abstract [en]

    Medication Without Harm is according to WHO the third Global Patient Safety Challenge and affects everyone of us. But how can we make medication management safer and what is our role in this improvement process as a person using medications, next-of-kin, physician, nurse, quality improvement leader etc.? How do we all get involved and what are our input and responsibilities?

  • 5.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Public Health and Healthcare, Region Jönköping County, Jönköping, Sweden.
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County, Jönköping, Sweden.
    Lindenfalk, Bertil
    Jönköping University, School of Health and Welfare, HHJ, Department for Quality Improvement and Leadership. Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    How older persons and health care professionals co-designed a medication plan prototype remotely to promote patient safety: Case study2023In: JMIR Aging, E-ISSN 2561-7605, Vol. 6, article id e41950Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Harm from medications is a major patient safety challenge. Most adverse drug events arise when a medication is prescribed or reevaluated. Therefore, interventions in this area may improve patient safety. A medication plan, that is, a plan for continued treatment with medications, may support patient safety. Participation of patients in the design of health care products or services may improve patient safety. Co-design, as in the Double Diamond framework from the Design Council, England, can emphasize patient involvement. As the COVID-19 pandemic brought restrictions to face-to-face co-design approaches, interest in remote approaches increased. However, it is uncertain how best to perform remote co-design. Therefore, we explored a remote approach, which brought together older persons and health care professionals to co-design a medication plan prototype in the electronic health record, aiming to support patient safety.

    OBJECTIVE: This study aimed to describe how remote co-design was applied to create a medication plan prototype and to explore participants' experiences with this approach.

    METHODS: Within a case study design, we explored the experiences of a remote co-design initiative with 14 participants in a regional health care system in southern Sweden. Using descriptive statistics, quantitative data from questionnaires and web-based workshop timestamps were analyzed. A thematic analysis of the qualitative data gathered from workshops, interviews, and free-text responses to the survey questions was performed. Qualitative and quantitative data were compared side by side in the discussion.

    RESULTS: The analysis of the questionnaires revealed that the participants rated the experiences of the co-design initiative very high. In addition, the balance between how much involved persons expressed their wishes and were listened to was considered very good. Marked timestamps from audio recordings showed that the workshops proceeded according to the plan. The thematic analysis yielded the following main themes: Everyone's perspective matters, Learning by sharing, and Mastering a digital space. The themes encompassed what helped to establish a permissive environment that allowed the participants to be involved and share viewpoints. There was a dynamic process of learning and understanding, realizing that despite different backgrounds, there was consensus about the requirements for a medication plan. The remote co-design process seemed appealing, by balancing opportunities and challenges and building an inviting, creative, and tolerant environment.

    CONCLUSIONS: Participants experienced that the remote co-design initiative was inclusive of their perspectives and facilitated learning by sharing experiences. The Double Diamond framework was applicable in a digital context and supported the co-design process of the medication plan prototype. Remote co-design is still novel, but with attentiveness to power relations between all involved, this approach may increase opportunities for older persons and health care professionals to collaboratively design products or services that can improve patient safety.

  • 6.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Department of Public Health and Healthcare, Region Jönköping County, Jönköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare.
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County, Jönköping, Sweden.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Applying a Co-designed Medication Plan for SaferMedication Treatment in Older Persons – A Feasibility Study2023Manuscript (preprint) (Other academic)
  • 7.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Hospital Pharmacy, Region Jönköping County; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Futurum, Region Jönköping County; Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Evaluation of older persons' medications: a critical incident technique study exploring healthcare professionals' experiences and actions2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 557Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Older persons with polypharmacy are at increased risk of harm from medications. Therefore, it is important that physicians and nurses, together with the persons, evaluate medications to avoid hazardous polypharmacy. It remains unclear how healthcare professionals experience such evaluations. This study aimed to explore physicians' and nurses' experiences from evaluations of older persons' medications, and their related actions to manage concerns related to the evaluations.

    METHOD: Individual interview data from 29 physicians and nurses were collected and analysed according to the critical incident technique.

    RESULTS: The medication evaluation for older persons was influenced by the working conditions (e.g. healthcare professionals' clinical knowledge, experiences, and situational conditions) and working in partnership (e.g. cooperating around and with the older person). Actions taken to manage these evaluations were related to working with a plan (e.g. performing day-to-day work and planning for continued treatment) and collaborative problem-solving (e.g. finding a solution, involving the older person, and communicating with colleagues).

    CONCLUSION: Working conditions and cooperation with colleagues, the older persons and their formal or informal caregivers, emerged as important factors related to the medication evaluation. By adjusting their performance to variations in these conditions, healthcare professionals contributed to the resilience of the healthcare system by its capacity to prevent, notice and mitigate medication problems. Based on these findings, we hypothesize that a joint plan for continued treatment could facilitate such resilience, if it articulates what to observe, when to act, who should act and what actions to take in case of deviations from what is expected.

  • 8.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Region Jönköpings län.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Region Jönköpings län.
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    "I trust my physician but want to be involved"  - Older persons' Experiences of regarding evaluation of their medication treatment2019Conference paper (Refereed)
  • 9.
    Holmqvist, Malin
    et al.
    Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare). Department of Clinical pharmacy, Region Jönköping County, Jönköping, Sweden.
    Thor, Johan
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Ros, Axel
    Jönköping University, School of Health and Welfare, The Jönköping Academy for Improvement of Health and Welfare. Jönköping University, School of Health and Welfare, HHJ. IMPROVE (Improvement, innovation, and leadership in health and welfare).
    Johansson, Linda
    Jönköping University, School of Health and Welfare, HHJ, Institute of Gerontology. Jönköping University, School of Health and Welfare, HHJ. ARN-J (Aging Research Network - Jönköping).
    Older persons’ experiences regarding evaluation of their medication treatment: An interview study in Sweden2019In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 22, no 6, p. 1294-1303Article in journal (Refereed)
    Abstract [en]

    Background: Older persons with polypharmacy are at increased risk of harm from medications, and this issue is a global patient safety challenge. Harm may arise at all stages of medication use and may cause hospital admission, additional resource uti ‐lization and lower patient satisfaction. Older persons’ participation in their own care may increase patient safety. Their views on the evaluation of their medication treat ‐ment, and their own involvement in it, are crucial yet poorly understood.

    Objectives: To identify opportunities to make the medication use process safer, we explored and described older persons’ experiences of evaluation of their medicationtreatment.

    Design: Semi‐structured interviews were performed with 20 community‐dwelling older persons (age 75‐91 years) in Sweden. Data were analysed using inductive quali ‐tative content analysis.

    Results: These older persons reported having a responsibility to engage in their med ‐ication evaluations, although some felt unable to do so or considered themselves un ‐concerned. Evaluation, in their experience, was facilitated by continuity of care and an invitation to participate. However, some older persons experienced not receivinga comprehensive medication evaluation.

    Discussion and conclusion: Older persons want to be actively involved in their medi ‐cation evaluations, and this may represent an underutilized resource in the pursuit of patient safety. Their trust in physicians to undertake evaluations on a regular basis, although that does not necessarily occur, may cause harm. Patient safety could benefit from a co‐production approach to medication evaluations, with health‐care professionals explicitly sharing information with older persons and agreeing on re ‐sponsibilities related to on‐going medication treatment.

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