Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review

Background Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management. Objectives To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio. Methods Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) ‘Key Components of an Ideal Transfer of Care’, (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored. Results Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support. Conclusion The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.


Included Excluded Population
Must focus on all three of the following: • Patients transferring between care settings (including between wards within a single organisation).• Patients taking anti-coagulants, insulin or high-risk medications in general.
• Focus on care in a single setting, e.g., Intensive Care Units with no reference to the transfer process.
• Focus of study not on insulin, anticoagulants, or high-risk medications.

Construct of interest
Any measure used to describe the effectiveness of the safety intervention including: • Performance-based

Outcomes
All measures used to assess whether the safety intervention had an impact will be identified from the studies and used for analysis to determine the comprehensiveness of the measures in terms of: • Whether they represent all the essential elements of transfer of care using the Key Components of an Ideal Transfer of Care framework.• Whether they provide insight into the work-system, processes and outcomes using the Systems Engineering Initiative for Patient Safety framework.
• Whether they include lagging, leading and real-time measures.The potential for identifying the measure in real-time using electronic health systems will also be examined.
Measures where there is not enough description or detail to understand how these were obtained or calculated.

Study design Primary research studies
Case reports, case reviews, review articles, unpublished studies, opinion pieces, cross-sectional studies.

No limit
No limit

Search strategy for identification of studies
Four databases will be searched to identify relevant studies: Embase, Medline, Cinahl, and Cochrane databases.These are the prominent health and care related databases deemed most likely to contain studies relating to safety in healthcare.
Search terms will include:

Study Selection
An initial review of titles from the search results will identify any potentially meeting the inclusion criteria.A second review of the studies against the abstracts will identify any studies that do not meet the inclusion criteria.Where there is uncertainty, the full text of the article will be obtained to confirm.Any articles meeting the inclusion criteria will be selected, and the full text of the study will be obtained.Where articles are excluded, the reason for exclusion will be documented.

Assessment of methodological quality
The type of article will be identified and recorded, for example whether it was an article published in a journal, or an abstract presented at a conference.Methodological quality assessments will not be performed, as the aim of the study is to identify as many measures of improvement for medications during transfer of care as possible.

Method of data extraction
Each study included in the review will be listed in an excel spreadsheet.For each article, the full text will be read line-by-line and the following will be recorded: • Citation (author and year of publication)

Data synthesis
The author, CL, will review each measure and consider where they can be grouped together into a broader category, for example different types of adverse events.Each category of measure will then be mapped against three different frameworks in a table, using the framework synthesis approach.
The first framework is the Key Components of an ideal Transfer of Care.[4] This framework lists 10 stages of a discharge that must be completed for that transfer to be successful.By mapping against this framework, the measures will be assessed to understand whether they represent all the activities key to safe transfer.Each measure will be considered as to which component it best represents.
The second framework is the Systems Engineering Initiative for Patient Safety (SEIPS).[6][7][8][9] This conceptualises healthcare as taking place in a work system comprising of people, their environments, the tasks performed, and tools used.Processes are performed, and outcomes are influenced by the combination and interactions between the components of the work system and their impact on processes.The measures will be categorized as to whether they are providing insight into work systems, processes, or outcomes.Where possible, the author will use her knowledge and experience to consider what work system factors may influence the measure and list these.
Finally, the measures will be assessed to determine whether they measure past events (lagging indicators), provide an indication of whether an event may occur in the future (leading indicator), or provide real-time data about relevant measures.[10] The results will be displayed in a table showing how the measures map across different frameworks, and where there are gaps and opportunities for new measures to be developed.
At each stage of data synthesis, the preliminary results will be shared and discussed with the coauthors (categorisation and mapping against each framework and consideration of digital use).The categorisation and mapping will be reviewed, and any ambiguities or challenges will be discussed and considered.The mapping and categorisation will then be agreed by all authors.This process will be repeated at regular intervals as the data synthesis progresses.The three authors are all healthcare professionals, two have a hospital-based background and one with a background in primary care.This provides insight into the context of the studies and measures identified and some aspects of the work-systems.

Results
The search results will use the PRISMA flowchart, detailing the review process and search results, how many articles were excluded and the reasons for exclusion for the exclusion for the articles where the full text was screened.
The included articles will be shared in a table listing the citation, type of study, intervention used, medication involved, the type of transfer of care studied and all the measures used to evaluate the intervention, and digital health system use.Descriptions of the geographical areas will be given in the text.
The measures mapped against the different frameworks will also be presented in a table, and a description of the gaps will be provided in the narrative text.
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Measures used to evaluate the intervention • Use of digital health systems in identifying, calculating or sharing the measurement data