We talk to Médecins Sans Frontières about why women are so vulnerable in times of crisis, and about what they are doing to help. Plus, we discover a new technology that could change the way nurses interact with their patients. And with up to 50 per cent of medication errors preventable, what can we do to stop them from happening?

https://soundcloud.com/thinkhealth/23-sexual-health-during-conflict-positive-feedback-for-nurses

Presenter: Ninah Kopel
Producers: Sam King and Ninah Kopel

Speakers:
Kara Blackburn- Medical Advisor, Women’s Health for Médecins Sans Frontières
Dr. Sam Lapkin- Researcher and Lecturer at the University of Technology Sydney
Professor Val Wilson- Director of Nursing Research & Practice Development at the Children’s Hospital at Westmead, and Professor of Nursing Research & Practice Development at the University of Technology Sydney

START OF TRANSCRIPT

Ninah Kopel: Hi, I’m Ninah Kopel. Welcome to the show. Today we look at errors in medication. With 50% of mistakes preventable, how can we stop them from happening. And:

Val Wilson: It’s seen as quite a soft science, but we believe that the potential is there for it to be a bit revolutionary.

Ninah Kopel: We look at new technology that could change the way nurses interact with patients. But first we look at women’s health in conflict zones. In conflict stricken countries emergency teams’ first response often relates to food, shelter and medical supplies, but in the effort to provide emergency aid, women and children can be left out. Pregnant women are particularly vulnerable, and finding safe delivery spaces can be hard. But there is also a real health concern relating to sexual violence for people during conflicts. Kara Blackburn is a women’s health advisor and midwife with Médecins Sans Frontières (Doctors Without Borders). I asked her whether sexual violence increased in terms of conflict, or if conflict is just exacerbating an existing problem.

Kara Blackburn: Unfortunately we see in a crisis situation, whether that be a natural disaster or an acute conflict, we see increases in the cases of sexual violence. I guess it’s related to people being displaced from their homes, living in unfamiliar environments in large groups all together.

Ninah Kopel: Is there any political conflict that comes into play when you’re talking about providing things like safe abortions to people in other countries.

Kara Blackburn: Yeah, it’s a very sensitive and difficult issue in a lot of places to implement and even to talk about. I guess I always try and remember that abortion is only completely illegal in six countries in the world, and in fact, as MSF, we’re not working in any of those countries. So what that means is there is generally the legal ability to provide safe abortion care in most circumstances. Now that does not mean that it’s easily accepted in the community, because that may be actually where the majority of your barriers are, in that people perceive it as illegal, they perceive it as the wrong thing to do because of religious or cultural beliefs, and so it’s very much about understanding the context that you work in, but really, because we know the complications of unsafe abortion contribute so highly to maternal mortality rates around the world, we feel we have an obligation as an organisation to respond to a request for a safe abortion by either having the means to do it ourselves or referring it to another provider. But that’s certainly part of our policy in terms of sexual violence, but also as a policy in general for the provision of safe termination of pregnancy.

Ninah Kopel: How do you go about having those discussions with women that are in communities where it can be perceived as such a negative thing to have happened?

Kara Blackburn: Yes, it takes time. So, an example I can give is we’ve been in the north of Yemen. It’s been a country that’s unfortunately undergone many many years of conflict. Different conflict in different stages. The last twelve months, or twelve to eighteen months, has been a very tumultuous time there. We’ve had an emergency obstetric hospital in the north of Yemen for many years. When we opened that project, sexual violence, termination of pregnancy was an area that we couldn’t discuss at all. But because the community now has a lot more confidence that we are going to be there and going to stay there, and they confidence in the care that we’ve been providing, they’ve become much more open to talk about these issues. So again, it’s about building trust in the community and providing good quality of care, and you will find that the community and the elders of the community, the leaders of the community understand what you’re there for, these cases will come to you, and we found that in the north of Yemen actually, which is an extremely conservative society where I didn’t believe at first that we’d even be able to look at any of these issues. But slowly, slowly we’ve been able to talk about some of the cases that are presenting, give women options about what they’d like to do… Again, it’s about building confidence in the community and having a good and safe service available.

Ninah Kopel: What about the way that laws apply to rape and informing government and local law enforcement about rape that has occurred. How do you navigate that very fragile situation where you might have people coming to you with a problem that you are then legally obligated to report?

Kara Blackburn: Yeah, so this is again a very important issue. So, we primarily are a medical organisation, so we provide a medical response to the woman, but we also work very closely… we have a legal department that is part of our organisation that has been responsible for looking very specifically at the laws that exist in a country and how they can apply. So, for instance, in Papua New Guinea where they have fairly restrictive abortion laws, we worked very closely with the judicial system and with the police system in that context to create what was a very positive working environment, So we provided the medical evidence and certificate for a victim of sexual violence, and worked very hard on advocacy in terms of supporting the woman if she wished to go to the police about this case and supporting her through the judicial system. So it’s very much about establishing relationships. We employ lawyers in country to help us understand the criminal code and how that applies, and then also to establish relationships with the police and with the judiciary to help if a woman wants to pursue a case through the courts.

Ninah Kopel: I know we’ve mentioned a few countries already in the broader discussion about what’s going on and the challenges facing dealing with people who’ve experienced sexual violence. But do you have another example that might highlight for people just how complicated the situation can be, or a country where this is playing out right now?

Kara Blackburn: So, I can give an example of how difficult it is providing this care. We can talk about a country like Afghanistan where there are just so many cultural issues around the position of women in society and what an event of sexual violence might mean. We’re running a large obstetric program in Kabul in the capital of Afghanistan and we’re looking at the moment about how we can implement care for victims of sexual violence and starting to look at even if there is the possibility of discussing safe termination of pregnancy. So, this is proving extremely challenging because of where sexual violence sits within this culture related to the positon of women in society. So, slowly through our investigations we’ve found that there are some grassroots organisations already in place, and our plan is to start more of a dialogue with them. But we’ve been in the project for over a year now and these discussions are only just starting. So, yeah, in a place that has a lot of…it’s very difficult to talk about these issues with women. It’s just about going really slowly, finding the organisations that already exist or supportive practitioners in the community that you can talk with to see if there is a way of starting the conversation and perhaps starting services that women can access then, but it is certainly not easy.

Ninah Kopel: Is that generally what the response is? It’s finding the people who are already doing this work on the ground and just encouraging them to do that work better?

Kara Blackburn: I mean, that’s absolutely part of it. Because we know that even though… even if abortion laws are extremely restrictive, that women will seek an abortion if they desire it, and that is not something that happens in settings of conflict only. That happens throughout the world. So, this is always the issue, that just because you might not see in your hospital requests, we know that women worldwide are seeking termination of pregnancy if they desire it for whatever their reasons- we don’t ever ask the reason – they will seek it. And if there is not a safe way for them to access care, they will seek unsafe abortion. And that’s what we see in our hospitals. We see the complications of unsafe abortions, terrible situations where there have been young girls, fourteen year old girls, having to have their uterus removed because of the damage that’s been done by a backyard practitioner.

Ninah Kopel: Are there any countries where you’ve gone in and you’ve really had to start from scratch, where there hasn’t been any grassroots support already happening? Or do you always generally find that there’s at least some small organisation already functioning on some level?

Kara Blackburn: Yeah it’s interesting, I mean I guess generally now it seems you’ll always find at least some small grassroots organisation doing something, but I guess it depends where the issue is occurring. In the very remote regions of South Sudan for example, we’re seeing a lot of refugee movements because of the most recent crisis which is causing the South Sudanese refugees to move around a lot bordering but also within South Sudan itself. So they’re often moving to extremely remote places where we’re having trouble accessing them, but also they’re having trouble accessing any kind of healthcare, so in fact, when we’ve set up health clinics in those situations, there is absolutely nothing around, so in essence we are starting from scratch actually. And so that really means, as a medical organisation, we’re looking at what we can actually provide as emergency support before their situation stabilises and perhaps they can find then the other processes, the legal processes that may be in place when they move back to their original villages and things like that.

Ninah Kopel: We’ve touched on it already, especially in terms of how communities and people in positions of authority respond to, or don’t respond to sexual violence. But is it ever really hard to have this conversation with women who might not know what their rights are or who have a completely different cultural perception of what’s going on around them.

Kara Blackburn: Yeah, absolutely. So our responsibility is to primarily provide medical care – so protection for the woman physically after the incident. But then also part of our services is to refer her to our own mental health counsellors, social workers or the like, that can counsel her about what her options are. Because you’re absolutely right. They might not have an idea about what legal avenues that they can pursue or even if they want to. So our responsibility is to provide a medical certificate that clearly documents their story and any injuries that have been sustained bearing in mind that often they are not visible injuries as a result of a rape. But it’s very important to document the woman’s story, and that is written in a legal document called a medical certificate. And we give that to a woman, and then she can make the decision after she’s had counselling about how she wishes to pursue or not, what’s happened to her through a legal process.

Ninah Kopel: Kara Blackburn, women’s health advisor and midwife with Médecins Sans Frontières.

Practicing healthcare can be stressful, and when GPs pharmacies and hospitals all have to work together, mistakes can happen. But when it comes to receiving the right medication, up to 50% of errors are actually preventable. Dr Sam Lapkin from the UTS Faculty of Health has devoted his PhD to looking at these medication mistakes. He joined producer Sam King to talk us through what he’s found.

Sam Lapkin: The most surprising thing was the magnitude of the problem. You know, the number of errors and the fact that they’re potentially preventable. So we know that about 50% of the errors that we know about can be prevented by some already existing interventions.

Sam King: 50%?

Sam Lapkin: Yes.

Sam King: That’s insane.

Sam Lapkin: Yeah.

Sam King: Can you give us some examples of the main errors that happen?

Sam Lapkin: Omission errors – patients not getting their medication on time. That’s a big one. You know, the most severe ones are patients receiving the wrong type of medication, so the wrong dosage or actually the totally wrong medication.

Sam King: Is that more common than not getting them at all?

Sam Lapkin: The most common one is not getting them at all.

Sam King: Is this an Australian problem or a NSW problem?

Sam Lapkin: It’s worldwide. So the total that we have in NSW is similar to what’s reported elsewhere in the literature, like, you know, in North America or in Europe. So those statistics are not only confined to Australia – it’s a worldwide problem.

Sam King: And they’re saying 50% as well?

Sam Lapkin: 50%, yes.

Sam King: Wow…

Sam Lapkin: So 50% – that’s a United Nations WHO statistic that up to 50% of medications are not used appropriately.

Sam King: What kind of impact could a serious error have on a patient?

Sam Lapkin: A patient could possibly die. You know, people can die from receiving the wrong medication, so that’s the worst case scenario. But some of them you know, are preventable. You know, it creates an issue that can be addressed with other medication. It could lead to an extended stay in the hospital, which is actually a significant cost on the health system. As you know, health is at the top of the agenda here in Australia, and the cost of the amounts that we are investing in medicine and health are not sustainable going forward.

Sam King: So as I understand it, you notice that reviews of strategies looking to improve this situation had a sort of tendency to contradict each other. Why do you think that is?

Sam Lapkin: Yeah, there is. I think it’s because we’ve got weak evidence. That’s one thing that actually came up. You know the evidence is weak in the instance that, you know, we depend on self-reported incidents. And you know, recent work that was actually done in Australia claimed that less than 2% of medication errors are reported, so one of the recommendations or the findings of the work that we did is in fact that we need to improve the way that we report and capture these medication instances.

Sam King: How would you suggest doing that?

Sam Lapkin: So, ensuring that it’s a no-blame culture; ensuring that we report near-incidences or near-misses, because, you know that up to 48% of medication errors are actually prevented at the moment of administration by nurses. So nurses are best placed to play a significant role in this area.

Sam King: Just on that point of near-misses, is there a culture of nurses almost getting it wrong and then kind of covering it up?

Sam Lapkin: Yes, it’s not really around nurses. You know, the medication process is a multi-disciplined, complex process. It’s a process that involves prescribing, dispensing and the last part is when the nurses actually give the medication. So errors can occur in any stage or any phase within that process. So, the main point being is that at the point of actually giving the patient the medication, that is when nurses can actually play a significant role in avoiding and preventing some of those errors.

Sam King: Did you hit any major setbacks when conducting your thesis?

Sam Lapkin: We did. The first one is that we couldn’t find any… we identified very few Australian studies that have been done in this area, so it’s an opportunity actually for us to really focus and do some work, to do some innovative work mainly around, you know, observing nurses and clinicians in this area. And we’re actually moving towards observation studies as the gold standard as opposed to people self-reporting these medication errors because we know that there is significant underreporting.

Sam King: How would an observation system work?

Sam Lapkin: So some work that has been done overseas is you actually observe… a person stands at a distance – a trained clinician – and observes that the interactions are OK within this process. So we know that interruptions and distractions have been identified as one of the major causes… as you know, the clinical environment is very busy. You’ve got to give medications, you’ve got to tend to other care needs and you’ve got to communicate and deal with other members of the healthcare team. So the very nature of the clinical environment has got interruptions.

Sam King: You talked a little bit before about the collaborative nature of your research. Can you talk a little bit about that?

Sam Lapkin: Yes actually this work is an extension of the work I did for my PhD, and I’m very passionate about this area, about patient safety, medication safety. So this article or publication that we’re talking about that was recently published in the Journal of Nursing Management is a collaboration of three universities: myself at the University of Technology Sydney; Professor Levett-Jones at the University of Newcastle; Professor Lynn Chenoweth from UNSW and; Professor Marie Johnson from ACU. So it’s the institutions coming together to try and solve this significant healthcare issue.

Sam King: Why are you so passionate about it? Is there a personal story?

Sam Lapkin: It was for my PhD, and as a clinician I’ve found that most of these errors are actually preventable. The focus has been on the technical issues, like calculations and pharmacology knowledge. But what I discovered in my PhD was that some of these key non-technical skills are actually crucial. These involve, you know, good communication, open disclosure when an error occurs and working as a team. So, you know, I think we need to turn our focus a little bit from the emphasis on the technical skills to try and understand some of the nontechnical skills that are involved in medication process.

Sam King: I’m going out on a bit of a limb here, but are there certain conditions or areas that have a higher rate of errors than others?

Sam Lapkin: Yes there is. I mean, to begin with, data that we have from last year is that 200 million prescriptions were dispensed in Australia alone. So that’s something like 10 prescriptions per person in Australia. Medication administration or taking medications is the most common medical intervention, so errors are bound to happen. So we are saying here, let’s try and minimise those errors here that we can sort of avoid. So, we are looking at 10 prescriptions per person, that’s actually a significant number.

Sam King: Sure.

Sam Lapkin: So polypharmacy is actually one of the significant issues as well, where one person gets a number of medications. So, the higher the number of medications a patient takes, the higher the risk of medication errors.

Sam King: You’ve talked about observation at a prescription level. What about at pharmacies – is there anything that can be improved there?

Sam Lapkin: Yes there are. What’s being done – it’s also being done here in NSW – is the use of technology, so some technological interventions. But what you’re finding out from countries that have already done this like in North America is that we still have errors even after introducing technology. And some of these technological advancements are quite expensive. We’re talking about billions of dollars of investment in infrastructure to try and solve this problem. So, yes, there are some issues that can easily be eradicated by the use of technology, for example, poor handwriting on prescriptions. If you use computers, you can easily eliminate some of those issues. But the problem still remains at the point of administration, especially in an acute care setting. You know, you might have correct drugs along the process, but what happens at the moment of administration is actually a key step and a key are of my research. Really, there is no safeguard. An error that occurs at the moment the patient receives the medication are likely to reach the patient.

Sam King: You’re talking about handwriting – it’s incredible, some doctors just have the most scrawly kind of handwriting, don’t they?

Sam Lapkin: It is, and it has actually been identified in a number of reports as a contributing factor to medication errors. So, you know, another risk factor is medications with similar names. There are some strategies that are being done targeting those areas.

Sam King: Are you optimistic about the future in this area?

Sam Lapkin: I am. I am optimistic, you know, as a clinician and an educator, there is a role for us to play to ensure that when you train these future health professionals in universities, we can make them better as professionals by equipping them with the necessary skills they can use to try and change the culture with the health services and within the clinical area.

Ninah Kopel: Dr Sam Lapkin, researcher and lecturer at UTS talking with producer Sam King.

Now, you might remember in previous weeks developing positive key performance indicators for nurses. The idea was that by gauging responses from hospitals around the world, nurses would have a benchmark to compare themselves to. Val Wilson is the Director of Nursing Research and Practice Development at Sydney Children’s Hospital network and a Professor of Nursing Research and Practice Development at the University of Technology Sydney. She was one of the researchers working on the project and now the team has gone a step further:

Val Wilson: Well I’ve been working with my colleague Professor Tanya McCance from the University of Ulster on this project where we’ve been testing out measures of nursing and midwifery practice that are based on the perspectives of patients and their families. Tanya and I and a research assistant Nicole kind of worked together to come up with this idea of developing an app for iPad basically that is a one-stop-shop to not only collect the data more readily from patients and families, but it actually analyses the data, and once you reach your numbers, it gives you a report. So, we think that nursing staff will really like the ability for them to be in control of doing that, but it’s easy to do and can be done relatively quickly.

Ninah Kopel: So is that something we’re going to see rolling out now across all of these places you’ve been working?

Val Wilson: So certainly the aim of the app is that we’re going to be testing it. We’re actually going to be testing it in two new centres rather than in the centres that we’ve already been working with, and we’re mainly going to be testing it across adult services, because our project was in paediatrics and we know that it’s not paediatric specific, so we’re going to be testing it across the adult sectors. However, the paediatric centres that have been with us for the last two to three years – if they’re continuing to use the KPIs, we’re certainly going to be offering them the app, so that they can be doing that in, perhaps, a reduced time frame from what they’ve currently been using.

Ninah Kopel: Do you see this having a mass use in the future?

Val Wilsion: I think so, I mean our plan is that we check out the app and test it if you like, and make sure that it’s as good as it can be before putting it in open access. The idea is that we could have any organisation across the world wanting to use the app, and they can select to be benchmarked against other organisations that are already using the app. So the idea is that we spread it as wide as we can.

Ninah Kopel: Why hasn’t anyone done this before?

Val Wilson: I don’t know! We’ve been so focussed on measuring other things that I just think that’s it’s always been the case in nursing that we haven’t been clear about what we should be measuring that says something about nursing practice. So when Tanya was looking at developing these KPIs, she wanted something that really spoke about the contribution of nurses and midwives. The kinds of things that we currently measure are usually things where care hasn’t gone so well. So we measure things like falls or medication incidents, and they’re indicators of when things haven’t gone so well. And they’re not specific to nursing or midwives – they kind of could be any cause. So we came in to kind of look at, well, what it that nurses do is and how do they add value to the care experience of patients and families.

Ninah Kopel: Have you met any resistance or are people just generally positive about jumping on board.

Val Wilson: Yeah, it’s kind of interesting because we have 20 clinical units in this paediatric study and we haven’t had any drop-out. Once people have signed up – and we have a kind of strict guidelines in terms of them needing executive support and support from outside their clinical area to help them do it and then they’ve got to have internal buy-in. And once we got that up and running, staff could see the information they were getting back, there was a real sense of positivity about it, and we certainly haven’t had any drop-out. And we’ve expanded from those original 20 units and we know have a number of other centres, and they’re the same. There’s positivity about the nurses and midwives getting information back about their practices in a timely manner that gives them something that they can work on then.

Ninah Kopel: And that positive reinforcement is always such a great learning tool. But from the perspective of the patients, what do you envisage them getting back from this experience?

Val Wilson: Yes, well if you can imagine in those 20 centres, we’ve had over 60 changes in practice already based on the feedback that staff have got.

Ninah Kopel: What things have been changed?

Val Wilson: So, things like… a concrete example is providing better information to parents and children when they’re admitted to the clinical unit. In some of our centres, we have parents who come from long distances and they suddenly find themselves in a ward and they’re not sure of anything around about them. So just simple information like where to get a cup of tea, where the local bank is… things like that. We’re finding that staff were assuming that families knew all this information, so just preparing information booklets or discharge information that’s easy for patients and family to understand.

Ninah Kopel: Does this really come down to the fact that we haven’t been appreciating our nurses enough and telling them that they’re doing a good job? Does that get lost in the busy day to day life?

Val Wilson: Well, I certainly think that’s part of it. You kind of just get busy doing and you don’t stop and pause and think about that. And I’m not saying that people haven’t been telling nurses that they’re appreciated – of course they have. But that’s been fairly non-specific. It’s not given them information about what they could do to improve. It’s basically been, “yeah, great, thanks” or “actually no, there’s a problem here.” And what we haven’t been able to do is isolate what are the things that are really working well and what might we be doing differently, and I think this kind of data gives them that information. But the positivity of it –you know yourself, if someone tells you something really positive about how you’re doing at work or how you are in your personal life, you get that sense of feeling really good about yourself. And when you feel really good about yourself and what you’re doing, you’re more likely to do more of it. And that’s what we think. The more you get feedback… you know, we get nurses saying, “Oh, I didn’t realise that the parents felt that way that we were doing such a good job.” The more that you get that, the more positivity that can spread, and I think that’s what we believe is the potential of this project. I think that we’ve started to get some real grant funds for this research is really indicating to us the potential that establishments feel in the data that we’re collecting. And so, I certainly managed to get money to build the app, which is simple in our heads how to do it, but of course, it’s much more complex than that. And then my colleague Tanya in Northern Ireland has worked hard to get a grant to test that out, and we believe we’re at the stage in the platform that we can probably… once we get this information we can fly, and that we will get the support from the establishment to do this kind of work, which is not easy because it’s seen as quite a soft science, but we believe that the potential is there for it to be a bit revolutionary.

Ninah Kopel: Val Wilson, Professor of Nursing Research and Practice Development at the University of Technology Sydney.

Ninah Kopel: Don’t forget, if you want to hear more from us here at Think:Health, you can find us online at 2ser.com/thinkhealth. We’re also available on demand. Just search for Think:Health in your favourite podcast app.

And remember, I’m not a doctor, so if this show has raised questions for you, head to a GP. This show is produced with the assistance of the University of Technology Sydney, Faculty of Health. I’m Ninah Kopel, see you next week for more health research and news.

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