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Reducing clinical variations with clinical pathways?do pathways work??

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Understanding Accidental Falls among Older Adults

According to the National Health Service UK (2017) anyone can encounter fall but the older people are more vulnerable towards encountering accidental fall especially if they have certain long term conditions. Fall though common but are often overlooked as injury. The strategies that must be undertaken to reduce fall among the older adults as per the NHS guidelines include use of non-slip mats in the bathroom, mopping up spills to prevent wet or slippery floors and constant support of a carer against older adults who are suffering from mobility difficulties or vision problems. As per the NICE guidelines (2017), the two most prevelant fall prevention policies in UK is risk assessment of falls along with occupational therapy in prevention and management of falls in adults. The following report aims to analyse the practise error of human (occupational therapist) in the domain of accidental falls among older adults and other associated latent factors that increases the susceptibility of fall.

According to Dekker (2017) human error is cited as the primary contributing factor behind the accidents and disaster. Dekker (2017) is of the opinion that human error signifies that something than been done in an erroneous manner but the actor does not intend the same act. In short human error can be explained as a deviation from intention, expectation or desirability. Reason (2017) is of the opinion that all human beings make errors at certain point of time in their professional or personal life and the healthcare professionals are no different. Here incidents of safety are rarely an outcome of actions of a single individual and rather fundamentally occurs due to a chain of underlying failures in the system as a whole. Clarification of the role of the human errors along with the missing defences while identifying potential hazards can be effectively done via the application of Swiss Cheese Model. According to Li and Thimbleby (2014), Reason’s Swiss Cheese Model (SCM) is an extra-ordinarily good educational tool for formal use. Notably, apart from focusing blame or investigate efforts over one particular human being who has apparently committed the action, SCM promotes the analysis of all surrounding factors that has gave rise to the incident. For example nurses or the occupational therapists who administered an overdose of a patients’, Swiss Cheese Model (SCM) promotes investigator to analyse such actions rather than the only cause. SCM has two types of failures; active failures are committed as failure. Active failures are mainly committed by individuals who undergo their duty at the so-called dead-end of the system. Latent conditions are also main contributing factor that stays as dormant in the entire system and happens upstream at one or more remote layers known as blunt ends (Li and Thimbleby 2014).

Practice Error in Occupational Therapy: An Analysis

According to the census report published by Office of National Statistics UK (2017), UK scored highest ever population during in the year 2016, with the population density increasing to 65.6 million. National Statistics UK (2017) further opined that this population is expected to increases with year with the number reaching at 74 million by the end of 2039. This increase in population is also associated with rise in the population of the older adults. During 2016, 18% of the population aged 65 and 2.4% aged 70 years or above. Moreover, since the number of birth is outnumbering the death toll, along with the increase in the rate of immigration and average life span of people in UK, the number of older adults is suppose increase exponentially. According to Government Office of Science UK (2017), the increase in the number of the older adults is directly proportional with greater prevalence of age related complications including mental health conditions like dementia. Government Office of Science UK (2017) further opined that more than half of the older adults who are over 85 years of age are frail and are associated with disability and crisis related hospital admission. During the tenure of 2011-12, the total number of the disable older adults increases by 400,000 with an estimated growth of 8.5%. Moreover, this group of ailing older are also prone to get affected with numerous physical health complications like musculoskeletal complications, heart muscle complications and problems with circulatory system (Parliamentary Business UK 2017). According to Padrón-Monedero et al. (2017), this older group of population who are suffering from the dementia or musculoskeletal disorder or cardiac complications are more prone to accidental falls and it is considered as the major health related problems. The reports published by World Health Organisation (2016) highlighted that one-third of the older adults who are more than 65 years year has increased risk of accidental falls. This accidental ground level fall have significant consequences of mortality and morbidity. In European Union, older adults who are over 65 years account for half of the deaths from unintentional injuries. These unintentional injuries represented as 5 most leading cause of death in developed countries and the majority of the injuries are caused by falls (Centers for Disease Control and Prevention 2012).

Figure: Representation of mortality rates in older adults by accidental falls on the basis of age and sex

(Source: Padrón-Monedero et al. 2017)

Factors Contributing to Practice Error in Occupational Therapy

Ping and Xiaohua (2012) have highlighted that common cause of accidental falls among the older adults is slips and trips. Ping and Xiaohua (2012) have further highlighted that this accidental falls results in increase rate of hospital admission along with increase cost of care. Apart from this, there occurs decrease independence and increase need for long-term care among the older adults. Occupational therapy practitioners are required to possess certain critical skills, which are crucial to address the risk of fall prevention with older adults. Research conducted by Chase et al. (2012), have highlighted that the fall causes are multi-factorial in nature which is influenced by the conditions prevailing within the individual and within the surrounding environment. However, in the majority of times, the occupational therapists (OT) lack the required experience and skills for evaluating and addressing the risks of fall prevention and this increases the risk of injury among the older adults and thereby hampering their quality of life and their independence in daily living activities. This accidental injury among the older adults arising out of lack of skills and experience of OT is regarded as practice error (Chase et al. 2012).

The following reports aims to analyze an issue of practice error in human that occurs from lack of experience and skills among the OTs in the time of fall prevention of older adults under clinic settings. The importance of this analysis is, it will help to elucidate the degree of harm conferred to the older adults because of practice error and how such practice errors can be overcome. The possible reasons of the incident will be examined in details in this report along with outline for the implications of the prevailing practice, which will aim to restrict any similar events in the future. Thus as a whole, this report aims to inform OT about the practice error and in turn helps to assist them in improving the degree of patient safety further.  

Falls are deadly and dangerous among older adults and results in the use of the heavy healthcare services along with premature nursing homes admissions (Painter et al., 2012). One of the main factors behind is the main factors that increase the tendency of fall. According to (Painter et al., 2012), fear of falling is a kind of psychological symptom and is common in 35% to 55% of the community dwelling older adults irrespective of whether they have experienced the fall. Multifaceted factors contributing towards the fear of falling have been independently linked with multiple medications, history of previous falls, injuries associated with fall, age, performance, decreased activity of living, physical deconditioning (decreased balance, mobility, strength and lowered functions of bones and muscles) and activity restriction. Other associated factors include social isolation, decreased quality of life and sedentary lifestyle (Painter et al., 2012). However, at times the occupational therapists though aware of the fear of falling concept among the older adults, fail to analyze the main underlying reason behind the fall. According to Gillespie (2012) multifactorial interventions including proper assessment of risk, home safety assessment and further modifications of the standard interventions help in reducing the rate of falls and other associated risk of falling. Gillespie (2012) is of the opinion that these interventions are more effective upon the patients who are suffering from the visual impairments and when delivered by a professional yet experienced occupational therapist. According to Kaskutas et al. (2013), fall prevention and subsequent error control via negating the effects of the latent factors can be effectively achieved via communication with the patients and other healthcare professionals.

Implications of Practice Error in Occupational Therapy

The situation in this paper is deals with an OT working with older adults who have issues of mobility and balancing problems. The main role of the OT was to undertake balance exercises and mobility assistances in order to improve the overall physical function of the client and thereby enabling them to perform daily activities in an independent manner. At the follow-up session with a particular patient (Mrs. X, age: 70) suffering from musculoskeletal complication (osteoporosis), the therapist commenced via assisting the patient to bathroom. The OT first initiated by helping the patient to stand and then assisting her towards the bathroom with minimal assistance. At the onset, Mrs. X stated that she is uncomfortable without her walking stick but the therapist assumed that she is suffering from lack of confidence and can easily manage her balance and mobility for few more steps to bathroom. Once Mrs. X entered the bathroom, therapist stepped aside and asked the patient to seat over the bathroom seat independently. Patient walked few steps and then in an attempt to grip the support near the bathroom commode she slipped and fell on the ground. The outcome of this fall was severe as Mrs. X suffered from major knee injury and mentally she was petrified while her son was extremely disappointed and worried with the overall situation. Here the concerned OT made a significant error in judgment in leaving the patient with balance issue to walk without assistance and assuming that patient will not triple. Moreover, the therapist did not conducted any visual assessment for before the initiation of treatment because OT had no reason to assume that Mrs. X suffers from visual problems and has lack of proper hand eye co-ordination. This impairment is eventually discovered when Mrs. X son complained that her mom was bumping into things on her return to home. Her home physician for a detailed visual assessment eventually referred her to an ophthalmologist.

Source: Created by author

From the above-mentioned scenario and from the comparable literature related with the associated literature, the main areas highlighted for improvement are the domains related with the clinical practice. Numerous elements other than proper skills and experience of an OT have together contributed as the latent factors towards encountering the fatal accident of Mrs. X. The below mentioned fish bone diagrams helps in analysis of the all latent factors that have contributed towards development of the fatal accident of Mrs. X.

Solutions to Combat Practice Error in Occupational Therapy

According to the NICE guidelines UK (2017) the prime factors that must be taken into considerations while analysis the susceptibility of encountering an error or an accident is surrounding environmental conditions, the main role of the attending health care professionals, the patient risk factors, main threat factor and the organizational factor under which the entire setup is being based. So the following analysis will mainly be based on fall prevention context, OT staff factor, and Organizational Factor, Patient Factor and Environmental condition.

According to Leland et al. (2012), the accidental falls among the older adults are associated with the limited physical activities, loss of independence and institutionalization. Leland et al. (2012) if of the opinion that fall is often cause by an amalgamation of medical, environmental and social factors. The role of the occupational therapy is to address this multifactorial nature of the falls via framing strategies of fall screening and subsequent prevention. For instance, exercise interventions helps to improve strength along with motion balance and hand eye co-ordination. In addition behavioural factors like fear of falling, lack of confidence which adversely affect the activity performance can be improved via period counselling and proper education about the present physical condition (Gillespie et al. 2012). However, this profession experiences certain difficulties in identifying their role in the health care settings. Peterson et al. (2012) stated that majority of the practise error of occupational therapist have occurred during the intervention phase and the severity range is from minor to major. Peterson et al. (2012) further stated that this kind of practise error has both ethical and moral dimensions because; the profession constantly uses strategies, which do not fall, within the scope of their practise. The patients might suffer and on the other hand, their care givers (OT) suffering from the role incompatibility and role conflict thus resulting compromised care.

According to Sinaki (2012), proper maintenance of bone health demands mechanical strain. However, mechanical force needs to be within the biomechanical competence of bone. Osteoporosis is the common skeletal complications among women after menopause. It causes loss of biochemical competence of bone leading to insidious outcomes. However, osteoporosis may not necessarily be associated with chronic pain but this absence of pain does not signify absence of vertebral deformity or vertebral microfracture. This might be the case with Mrs. X as she does not reported any signs of joint pain but suffering from disequilibrium in body balance and agility that might have generated from osteoporosis (Laliberté et al. 2013). According to Damián et al. (2013) patients who are more than 65 years of age suffering from moderate to severe vision problem however, in the majority of times in remain unreported due to lack of awareness and detailed visual check and in the case of Mrs. X. Moreover, age over 65 years along with reported case of osteoporosis is associated with balance and mobility problems along with lack of co-ordination of hand eye movement which increases the susceptibility of encountering fall (Shatil 2013).

Conclusion

With respect to the major mistakes that are committed in the occupational care sector, it has to be mentioned that there are two particular factors associated identified, technical error and human error. Elaborating more, the technical error, as explained by the Lattanzi and Pechak (2011), occurs due to the lack of ability to synthesize and process patient information and perform adequate care techniques based on either interpretation of the collected data or the incorporation of different equipments. Along with that, establishment of a therapeutic relationship between the care professional and the client is also a very important aspect on avoiding the risks. When the patient is able to express her choices and demands effectively, then the possibility any risks are generally avoided. In this case, despite having gait and vision challenges, the patient did not verbalize her issues with the occupational therapist. This indicates that the patient did not feel comfortable with the therapist and the therapist had been incompetent in establishing a sound therapeutic relationship (Turpin and Iwama, 2011).

According to Swiss Cheese Model of Accident Causation (Reason 1990), the holes slices are the pitfalls in the system which increases the rate of encountering hazards (Hosseinian and Torghabeh 2012). Reason (2017) opined that the complex interaction between the local triggering incidents, the latent failures, and the failures to take proper action could simultaneously breach the layers of system’s defence. Latent conditions can further be described as the holes of flaws under each defence that may weaken these barriers. When the conditions arises where the latent conditions aligns in a row in a step-by-step manner, the flaws get exposed through the barriers leading error prone situation to occurs (Jeffs et al. 2012). These latent conditions can be organizational, contextual and diffuse in nature or that may be designed related to do with the system that people work in (Li and Thimbleby 2014).  In case of Mrs X, the main pitfall in the system is the OT failed to analyse that the bathroom floor may be slippery which might increases the risk of slippage. This fault in the risk assessment has coincided or aligned with the vision problem and lack of body balance of Mrs. X which have increased the “trajectory of accident opportunity” and thereby leading to the hazards like fatal injury of knee. This failure domain can be linked with lack of proper supervision. Another lack of super vision in the failure domain which have created holes in the slices include inability of the OT to gauge that Mrs X is unable to maintain her body balance and movement in the absence of external support which have further increases the susceptibility of encountering accidental fall.  In failure domains specific acts include improper assessment of the gait performance by the OT and preconditions include osteoporosis (Scott, Dawson and Jones 2012).

References

Figure: Swiss Cheese Model of Accident Causation

Source: Underwood and Waterson 2014

Swiss Cheese Model of Accident Causation

Holes in slices Failure Domains Linking with the case study Outcomes Organisational influences Lack of proper information about the patient (active failure)

Supervision inability of the OT to gauge that Mrs X is unable to maintain her body balance (latent failure)

Precondition Osteoporosis and partial loss in vision (latent failure)

Specific acts Improper assessment of the gait performance and neglecting her fear of walking without clutch as her lack of confidence (latent failure)

Table: Swiss Cheese Model of Accident Causation analysis in relation to case study

Source: created by author

According to Taylor (2017), an ability of an OT to conduct practise in an organised manner dependents on the availability of evidence based practise model, sociocultural condition, relationship with clients and workplace environment. Nevertheless, when the care plan fails to qualify for the expected standards, the OT becomes accountable for entire mishaps with not scratch on the organisation administration. However, Pendleton and Schultz-Krohn (2017) is of the opinion that errors in practise is more likely to occur due to failure in the healthcare setup other than in the individual level. Moreover, error alone may not necessarily cast harm but may cause a string of errors leading to fatal harm to patient. Study highlighted that lack of proper recognition along with inappropriate organisational work pressure and expectation influence clinical reasoning and decision making of an OT (Upton et al. 2014). For example, occupational therapy is at times considered equivalent to medication therapy or physiotherapy and this hampers the treatment plans thereby decreasing the quality of care. Moreover, lack of proper strategic structure in an organisation leads to the development of improper co-ordination among the healthcare professionals causing delay in decision making and thereby creating ambiguity in the role of occupational therapist (Upton et al. 2014).

Thus from the above analysis of the factor it can be highlighted that the main organisational factor about the active failure is the lack of proper communication about the patient’s information to the attending occupational therapist. According to Quan et al. (2013), it is the duty of a change in shift nurses or other healthcare professionals to communicate the proper and updated information of the patient to the next attending healthcare professionals. Thus this domain can be regarded as active failure in abiding by the job role and thus an active factor behind fall. Other factors like lack of proper judgement and patients factors are unintended and are mostly resulting out of lack of proper experiences and skills. 

Hudon et al. (2014) is of the opinion that occupational therapy is based on the relationship of reflectivity. According to Robertson and Blaga (2013), use of proper clinical supervision along with the use of reflective diaries will help the professionals working as OT to screen their behaviour along with performance. This in turn will help them to establish distinct identity in the profession under certain care settings. Hudon et al. (2014) opined that reflective practise helps in the development of strong identity along a clear view of the job role. This motivation, further influence the professionals working as OT to go beyond their defined norms of profession and explore new heights in the therapy plan. Finally it can be said that as the profession of develops, the professional identity also gets modifies, this self-generating system creates a flexible nature in the profession which helps the OT to revise their role in the profession constantly and thereby making change in the subsequent fall prevention strategy (Hudon et al. 2014).  

While addressing the patient with osteoporosis, OT must be guided with a list of questioner that will help to assess the chronicity of disease among the patients who are not passing through pain. After ascertaining the degree of severity of the disease, an OT must abide by the interventions designed for fall prevention among the osteoporosis patients (Donnelly et al. 2013). According to Sinaki (2012), exercise can be regarded as comprehensive management of patients with osteoporosis however the exercise prescription needs to align with the requirement of the patients. Exercise needs to be framed in such a way that it accesses the recreational and therapeutic needs. Common exercise practised for osteoporotic patients to prevent fall include balance and lower extremity strength training. In the domain of vision loss an OT must consult with an ophthalmologist to undergo a thorough eye check before framing an intervention for fall prevention with older adults who are above 65 years (Liu et al. 2013).  According to Liu et al. (2013), multidisciplinary interventions which are focused over the personal goals have helpful in generating positive outcomes in comparison to the interventions which are not personalised. Moreover, multiple sessions with low devices along with special viewing skills to overcome the loss of vision are crucial to cast positive effect on daily activities.

According to Halvarsson, Franzén and Ståhle (2015), proper balance training program include dual and multi-task helps in the improvement of the fall-related self-efficacy along with overall gait speed, body balance performance and overall physical functions of the older adults suffering from osteoporosis. Furthermore, it is also the duty of an OT to measure the gait performance speed in order to ascertain the chances of accidental falls. If the gait performance speed along with direction is found lower than the standard requirement then that individual (older adults) are more prone to encounter accidental fall. An OT must first analyse the overall nature of the gait speed in order to ascertain the percentage of encountering falls and thereby framing gait improvement exercises accordingly (Chan et al. 2012).

Clinical reasoning is a very important aspect of care planning and delivery procedure, the therapists are required to employ an extensive and detailed patient situational analysis and assessment before commencing with any care activities. It has to be mentioned in this context, that NICE (2018), it is imperative for the occupational therapists to be able to perform patient situation analysis and ask the elderly patients whether they have experienced falls in the past and what had been the frequency and severity of the falls. In this case as well, the patient should have been asked about her past experience of falls and whether she can walk on her own without any risk for falling. Along with that the occupational therapist should have also performed a basic cognitive functioning and sensory assessment for the patent as well to understand if the patient was able to perform adequate cognitive an sensory functionality. According to the Duncan (2011), for chronically ill elderly patents it is crucial for the occupational therapists to utilize different equipment like walking support, safety rotational transfer benches, wheel chairs to perform activities of daily living involving mobility. In this case as well, the therapist should have utilized the help of these devices.

The improvement of the proper environmental conditional can be effectively done via the application of Swiss Cheese Model of accident causation. This model generally deals with risk analysis and effective risk management. Here management of risk can be done via assessment of the surrounding environmental condition like the traction of the bathroom floor, the reason behind the lack of confidence among the patients (in this case Mrs. X) in walking without support. Other risk management issues include proper assessment of osteoporotic condition and vision problem along with problem in the gait performance. According to Cosman et al. (2014), proper assessment of the chronicity of osteoporosis, along with partial loss of vision among the elderly group of population helps in the proper assessment of the risk of encountering fall and thereby framing subsequent risk management strategies. Wakefield et al. (2014) have opined that it is the duty of an OT to take proper follow up from the assigned healthcare physicians in order to get a detailed medical history of the patients. Moreover, it is the duty an OT to provide proper physical support to the older adults via means of walker or wheel chair who are suffering from mobility complications in order prevent accidental falls (Martins et al. 2012).

For any occupational therapist to perform optimally and successfully, it is crucial for the care professional to have the adequate training and skills fit for the job and the different complication that can arise in the situation (Wilding et al.2012). For the case study, it is clear that the care professional lacked basic occupational therapy training in various different domains. The therapist lacked better understanding of the care protocols to follow while handling the different aged chronically ill individuals. It has to be mentioned that the therapist could neither perform proper patient assessments as per the standard guidelines of occupational therapy and along with that, utilize the different tools and equipment needed for ensuring optimal patient safety, nor even establish a mutually respectful therapeutic relationship to make the patient comfortable enough to share her issues and grievances effectively (Rodger et al. 2011).

Hence, it has to be mentioned that the occupational therapist will require a detailed skill enhancement and performance enhancing training to ensure better safety of the patients and better performance standards and enhanced quality of care (Gupta et al. 2012). On a more elaborative note, the care professional will require care planning training, communication training, patient situation assessment training, and a skill enhancement workshop to help her gain better understanding and working knowledge regarding the different tools and equipment for better planning, assessment, and care delivering (Thomas and Law 2013). However, the cost for the detailed training and skill enhancement for the newly appointed occupational therapists can become a huge financial burden on the health care facility (Donnelly et al. 2013). Hence, there is need for better funding and budget allocation for the occupational therapy sector so that the newly appointed staff can be trained adequately to avoid such incidents which not harms the patients but also is a huge risk to the reputation and market viability of the facility. Along with that, from the analysis of the case study it is clear that the therapist lacked better understanding on the exact protocol t follow while addressing the activities of daily living of chronically ill and mobility restricted elderly patients. There is need for a policy or practice guideline development with systematic guide helping the therapists with an easy and step-by-step protocol to follow which will minimize the rate of misdiagnosis, incomplete or inadequate risk assessment and accidents (Maloney and Griffith 2013; Muir 2012).

Conclusion

Thus from the above discussion, it can be concluded that in order to minimise the chances of practise errors, the OT must start learning from their previously committed errors. Moreover, the organisation along with government must also come forward towards framing new polices and guidelines for the OT therapists, defining their role along with proper establishment of the concept of multidisciplinary team. Moreover, OT must also analyse the patient’s conditions carefully via direct communication or via analysing the patients report and must not rely on tier own intuition to take decision in the therapy plan.

Recommendation for proper strategic planning in organisation

The strategic planning managers must take the role of proper co-ordination and communication between the multi-disciplinary team of health care professionals so that the   in order to reduce the potential of practise error while improving the overall service delivery. Moreover, effective communication also helps in collaborative learning along with shared decision making which further reduces the chance of practise error along with proper communication of relevant patient health information (Upton et al. 2014).

While doing this assignment I came into consideration that the falls among the older adults can be prevented easily if the occupational therapists or the other healthcare information effectively manage the entire active and the latent risk factors associated with the fall. In this case, the OT must be skilled and experienced so that he or she can quickly anticipate the upcoming events and take necessary actions beforehand. Moreover, I also understood that it a practise error to assume things while handling older adults as the actual symptoms or the expected outcomes may differ. At the end, I would like to say that fall among older adults can be detrimental and effective analysis of the associated factors will help the older adults to maintain the daily living activities.

References

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Chan, K.S., Liu, C.W., Chen, T.W., Weng, M.C., Huang, M.H. and Chen, C.H., 2012. Effects of a single session of whole body vibration on ankle plantarflexion spasticity and gait performance in patients with chronic stroke: a randomized controlled trial. Clinical rehabilitation, 26(12), pp.1087-1095.

Chase, C.A., Mann, K., Wasek, S. and Arbesman, M., 2012. Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. American Journal of Occupational Therapy, 66(3), pp.284-291.

Cosman, F., De Beur, S.J., LeBoff, M.S., Lewiecki, E.M., Tanner, B., Randall, S. and Lindsay, R., 2014. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis international, 25(10), pp.2359-2381.

Damián, J., Pastor-Barriuso, R., Valderrama-Gama, E. and de Pedro-Cuesta, J., 2013. Factors associated with falls among older adults living in institutions. BMC geriatrics, 13(1), p.6.

Dekker, S., 2017. The field guide to understanding'human error'. CRC Press.

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Gupta, S., Paterson, M.L., Lysaght, R.M. and Von Zweck, C.M., 2012. Experiences of burnout and coping strategies utilized by occupational therapists. Canadian Journal of Occupational Therapy, 79(2), pp.86-95.

Halvarsson, A., Franzén, E. and Ståhle, A., 2015. Balance training with multi-task exercises improves fall-related self-efficacy, gait, balance performance and physical function in older adults with osteoporosis: a randomized controlled trial. Clinical rehabilitation, 29(4), pp.365-375.

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Laliberté, M.C., Perreault, S., Damestoy, N. and Lalonde, L., 2013. The role of community pharmacists in the prevention and management of osteoporosis and the risk of falls: results of a cross-sectional study and qualitative interviews. Osteoporosis international, 24(6), pp.1803-1815.

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Liu, C.J., Brost, M.A., Horton, V.E., Kenyon, S.B. and Mears, K.E., 2013. Occupational therapy interventions to improve performance of daily activities at home for older adults with low vision: A systematic review. American Journal of Occupational Therapy, 67(3), pp.279-287.

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