Author(s)

Guillaume Wabont, Jean-Philippe Hammelin, Guénaëlle Faure, Cathy Debruille, Kévin Raynaud, Pascale Guillain

Why was it done?

Clinical pharmacists and nephrologists noticed a recurrence of rehospitalization of patients who recently underwent ileostomy because of prerenal acute kidney injury. Ileostomy tends to enhance dehydration, but in each case there was a drug that was exacerbating the phenomenon by inhibiting the RAAS. The digestive and urologic surgeons had no knowledge of such pathophysiology and iatrogenia, explaining why they continued to prescribe such drugs.

What was done?

We elaborated an internal guideline for the treatment of high blood pressure (HBP) in patients with ileostomy. We decided to contraindicate to those patients the inhibitors of renin-angiotensin-aldosterone system (RAAS) such as angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs) or direct renin inhibitors (DRI); as well as the diuretics – even-though none of the summaries of the product characteristics (SmPC) of those drugs in question require such prohibition.
From now on, the drug(s) of the first line of treatment must be a beta-blocker and/or a calcic inhibitor. The drug(s) of the second line of treatment must be an alpha-blocker and/or an imidazoline-receptor agonist.

How was it done?

Therefore, we decided to set up a collective analysis of the situation with pharmacists, nephrologists and surgeons in digestive and urologic surgery, to understand the pathophysiology and to elaborate an internal guideline for HBP in patients with ileostomy.

The pharmacists first wrote a working paper retailing:
– the pathophysiology (water–electrolyte imbalance with ileostomy and deterioration under RAAS inhibitors or diuretic)
– the lack of information in the SmPC of the drugs in question
– an argued suggestion to contraindicate those drugs
– the therapeutic alternatives

Then we all met and exchanged views on the subject.

What has been achieved?

The guideline has been written in a collaborative and multi-disciplinary work. It applies to all the physicians and pharmacists of the hospital who have been informed of our approach and they have received a copy of it.

What next?

We will evaluate the respect of the guideline in our hospital as well as its impact in the lowering of the rehospitalization rate of patients who recently underwent ileostomy.
We will notify our national agency for medicines of our procedure because we think it should be a national standard.

Author(s)

Sophie Renet, Florian Le seigneur, Ratiba Haddad, Andre Rieutord, Marie Camille Chaumais

Why was it done?

The high turn over rate of medical and pharmacy residents (every 6 months) could jeopardize the patient’s care management as they generally lack of appropriate skills upon arrival. Our former process medication review was relying on individual and heterogeneous competencies of pharmacy residents likely to lead to sub-optimal medication review and treatment optimisation. We had to design a training program for residents according to the constraints of time and characteristics of related treatment of the considered clinical ward recruited patients.

What was done?

A training program for pharmacy residents was developed and implemented. The aim was to develop the skills of the residents to allow them to perform, after 72 hours, a secure, optimized and standardized (SOS) medication review orders, according to the specificities and the “real-life practice” of the clinical department.

How was it done?

Through a collaborative approach (residents and seniors pharmacists, physicians, PhD student in education sciences), ADDIE (Analyse, Design, Development, Implantation, Evaluation) method was used. First, the most frequent pathologies and drugs prescribed in the cardiology department were identified to define specificities and thus custom the educational needs and skills that residents have to acquire to ensure a SOS medication review orders. The program included a 3 steps process over 3 days: (1) recognize the organisation and learning tools; (2) practice 3 clinical medication review orders simulation; (4) assess and feed-back with a senior clinical pharmacist. Some learning tools were developed: a training tool kit to guide the learners ; an aid kit, including a SOS medication review orders algorithm to follow throughout the whole process. Two years after implementation, 4 pharmacy residents have used this training program.

What has been achieved?

Our 72-hours-training program is routinely used for new pharmacy residents. It has been implemented successfully with a high acceptance. They also felt more comfortable to suggest therapeutic advices to the physicians.

What next?

The proof of concept of SOS was successfully done. We are currently extending it for 5th year pharmacy students and develop similar training program for other clinical wards (Surgery, oncology, immunology). In 2017, we expect to share it with our pharmacist colleagues working in the two closest hospitals.

Author(s)

PALOMA CRESPO-ROBLEDO, MARIA SEGURA BEDMAR, IRENE ESCRIBANO VALENCIANO, NURIA BLAZQUEZ-RAMOS, BEATRIZ MARTIN CRUZ, CARMEN MORIEL SANCHEZ

Why was it done?

Patient safety is an essential component of quality care. It’s known that EDs are an element of risk for the onset of adverse events due to conditions related to patients’ comorbidity, communication problems, medication errors and working conditions like limited information about the patient, workload, interruptions, shifts, etc. It was detected that reconciliation of medication was not performed; neither validation of the medication prescribed and medications were stocked with no order and control.

What was done?

A project was developed to increase patient safety in the Emergency Department (ED) based on the presence of a hospital pharmacist in the team.

How was it done?

First thing was to review and validate the medication prescribed in patients who were under observation, at the same time performing a reconciliation given their acute situation. This way a relationship between nurses, physicians, patients and pharmacist was established.
Then, electronic prescription software was integrated within the automated dispensing cabinet (ADC), eliminating potential errors choosing the right drug. Only when a pharmacist has checked the medication, the list appears in the display and can be taken out all at once. The main problem has been to agree the stocks and how nurses can return easily and operatively the medication in order to not accumulate it out of the ADC.

What has been achieved?

Pharmacists’ clinical figure is being disclosed in a country where Hospital Pharmacy is a central and close department. In 43 days, 428 patients got their prescription checked in the ED, 346 pharmaceutical interventions were made in 198 patients, a median (IQR) average of 1 (1,2) interventions per patient. The main reason for an intervention was the adequacy to pharmaceutical forms included in the Hospital(n=130), followed by reconciliation interventions(n=77). Category of errors detected were mostly B (NCC MERP), showing pharmacists can detect an error occurred but that did not reach the patient

What next?

Hospital pharmacists should show their clinical and logistic potential, fighting with other health professionals to increase safety and care in patients. ED is the entrance of patients into the health system and where more errors can be committed, the work of a pharmacist should start at ED to prevent errors and give support and be part of the team.

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Author(s)

Nuria Monteagudo-Martínez, Ana Valladolid-Walsh, Gregorio Romero-Candel, Esther Domingo-Chiva, Jose Marco-del Río, Marca Diaz-Rangel, Francisca Sanchez-Rubio

Why was it done?

To acquire clinical skills in this setting and detect and prevent medication errors. It is also an area in which pharmacists had previously never participated in our hospital and it was an opportunity to integrate in this multidisciplinary team.

What was done?

Hospital pharmacy specialization programs include one year of rotations in clinical areas. The emergency department (ED) was chosen in order to develop a program to detect and prevent medication errors as a part of a multidisciplinary team.
Other tasks such as organizing drug storage, drug labelling and conservation, nurse counselling and education on issues related to medication were developed.

How was it done?

The pharmacy resident completed a rotation period based on the national educational program in clinical areas. Over a two month rotation period she reviewed treatments (61 patients, detecting 67 medication errors), organized and labelled drug storage, listed and identified thermolabile drugs, participated in a protocol design,…

What has been achieved?

The resident was able to improve care in acute patients in the ED. The most common errors found and prevented were: missed doses (25.3%); incorrect form to administer the drug (incompatibility diluent, infusion rate…) (13.4%); drug interaction/incompatibility (8.9%) and others.
The resident was able to organized refrigerator drug stored and developed a protocol to explain how to act in case of fridge failure.

What next?

To try to implement an ED-based clinical pharmacist program in order to detect and manage medication errors to improve safety in drug therapy, as well as to contribute to patient care with a different point of view from clinicians.

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Author(s)

Paula Arrabal-Durán, Carmen Herrero-Domínguez-Berrueta, María Norberta Sánchez-Fresneda, Ana Mur-Mur, Ana Herranz-Alonso, María Sanjurjo-Sáez

Why was it done?

MI and PI are normally recorded in Hospital Pharmacy Services as a method for evaluating safety. Nevertheless, classical methods for reporting MI do not allow for a correct classification in the field of clinical trials. The reason is their more complex processes involving drugs compared to the processes in daily clinical practice. If there are no specific categories, the information obtained by recording usually gets lost and could not reflect exactly what occurred. In September 2016, a clinical tool to notify MI and PI was implemented in the Pharmacy Service, with the aim of unifying their classification criteria and gathering complete information for analysis and further implementation of improvement measures.

What was done?

A database to notify medication incidents (MI) and pharmaceutical interventions (PI) in the Clinical Trials Unit was developed in the Pharmacy Service of a tertiary hospital.

How was it done?

All the processes involving drugs in clinical trials were evaluated by a Failure Mode and Effects Analysis (FMEA). For each process, the possible incidents and their resulting effects on the patient were recorded. After that, a database was designed in Microsoft® Access with defined lists of choices to allow pharmacists notify both MI and PI that occur in the Clinical Trials Unit.

What has been achieved?

A database with the following information has been implemented:

a) Identification of the MI:
1. Date of the MI.
2. Number of patient.
3. Clinical Trial protocol.
4. Investigational product.
b) Process in which the MI took place (16 options).
c) Process in which the MI was detected (16 options).
d) Process that caused the MI (24 options).
e) Person who detected the MI (9 options).
f) Did any PI take place? (Yes/No).
g) PI performed (12 options).
h) Did the MI reach the patient? (Yes/No).
i) MI that reached the patient (21 options).
j) Patient outcome (8 options).
k) Effect in the clinical trial (4 options).

What next?

The implemented notification system will be further expanded and adapted over time.
Future aim is to analyse MI for establishing improvement measures and checking their results.

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Author(s)

Janne Kutschera Sund, Martin Grotnes, Ingvild Klevan, Lene Lilleaas, Johan Fredrik Skomsvoll

Why was it done?

Lack of comprehensive strategies and funding has made it difficult to develop and implement extensive clinical pharmacy services in our hospital. It has been challenging to secure hospital involvement. A new financial model securing funding from the regional health authority made way for a new joint approach.

What was done?

A dialog based process involving hospital management, clinicians and the pharmacy led to a large increase in clinical pharmacy services in our university hospital.

How was it done?

A literature review was conducted. Based on this, a multidisciplinary project group decided that all clinics and wards were eligible for clinical pharmacy services and should receive extensive information on the topic. As there were limited resources allocated, all clinics were asked to apply for the service. The hospital management received applications three times the number of funded clinical pharmacists.
Prioritizing was based on the following criteria; use of the Integrated Medicines Management (IMM)-method, patient flow, evaluation and research, in- or out –patient clinics, continuation of established services, localization and time schedules on the wards.

What has been achieved?

The long term funding of clinical pharmacy in the health region enabled the hospital pharmacy to recruit and educate highly competent clinical pharmacists.
In less than a year, the number of clinical pharmacists has increased from three to twelve. The number of wards receiving clinical pharmacy services has also grown from three to twelve and there are still plans for further implementation.

The hospital and the ward managements are much more involved in evolving a common patient safety strategy with focus on medication. Specific quality indicators for each patient population and ward are being developed, and clinical pharmacists are now important members of multidisciplinary teams all over the hospital. Pharmacists are integrated in ongoing clinical research projects and publishing.

User surveys show that clinical pharmacy is assessed as a highly beneficial service by both nurses and physicians.

What next?

Develop the IMM-model to include the clinical pharmacists in standard patient care in every clinic and department. We plan to perform follow-up studies on the effects of clinical pharmacy services in different settings.

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Author(s)

Marie-Claire Jago-Byrne, Sinead McCool, Caroline Reidy, Stephen Byrne

Why was it done?

Published research had demonstrated that 50% of discharge prescriptions were non-reconciled(1). A recent study demonstrated that 43% of patients experienced post-discharge medication errors(2). The prevalence of polypharmacy (>5 medications) has increased over the 15 years to 2012, from 17.8% to 60.4% in people 65 years and older in Ireland(3).

What was done?

The aim of this project was to improve medication safety at the point of hospital discharge by using targeted medication reconciliation and producing a computer-generated prescription. This new model for discharge prescribing was introduced for patients who met both of the following criteria in two acute hospitals:
• Prescribed 9 or more medications, at the time of admission.
• Aged 70 years and over

How was it done?

The new model for discharge prescribing used collaborative medication reconciliation and the e-Discharge software to improve the quality of discharge prescriptions. The model was introduced in both hospitals and received support from community and hospital colleagues. Clinical pharmacists became the project champions and worked closely with medics during the change process. Key safety aspects were:
• Clinical double check for this high-risk process- the pharmacist and the doctor sign the prescription.
• Increased legibility
• Explanation for all prescription changes to community colleagues.
Phase 2: The software was further tested on 200 patients in a bench top exercise

What has been achieved?

Phase 1: The overall compliance with the national discharge prescription standards increased from 50.4% to 96.9% with the new model for discharge prescribing. The biggest change in compliance was observed in the three communication categories, which explain to community healthcare providers the rationale behind the medication changes made during the hospital stay. A user acceptability survey of HCP involved in the project demonstrated that all those involved had benefited from improved workflows in hospital and community settings, and more appropriate and efficient use of resources. All users requested expansion of this service.
Phase 2: This review allowed for the improvement of the e-Discharge Software using anonymised patient cases to test issues identified in Phase 1.

What next?

In Phase 3 the model will be introduced to a third hospital to evaluate transferability of the concept alongside current practice outlined above

Author(s)

Tine Van Nieuwenhuyse, Sabrina De Winter, Isabel Spriet, Thomas De Rijdt

Why was it done?

During the last decade, healthcare shifted in many ways towards a more patient-focused rather than a disease-focused approach. Hospital pharmacy services experienced a similar development. Traditional drug-oriented services expanded towards patient-oriented services by imbedding computerized clinical decision support (CCDS) in the prescribing process and implementing bedside clinical pharmacy services, both leading to improved efficacy and safety of medication use. However, due to limited resources, clinical pharmacy services are not implemented on a hospital-wide basis in Belgian hospitals.
To guarantee patient safety throughout the hospital, emphasizing patients at risk, we started in March 2016 with the development and implementation of central check of medication appropriateness.

What was done?

Development and implementation of central check of medication appropriateness (COMA) in hospitalized patients in a 2000-bed academic hospital.

How was it done?

Based on a risk analysis, high risk prescriptions are checked by a hospital pharmacist for appropriateness. A daily check (0.5 FTE) of automatically generated queries is performed using standardized algorithms. The queries are a result of the screening of all new prescriptions in the electronic prescribing system of the last 24 hours. If an urgent intervention is necessary, in case of a serious adverse event, a phone call is carried out to the treating physician. In all other scenarios, interventions are performed via electronic warnings in the patient’s file.

What has been achieved?

– Development of 75 specific algorithms covering 5 pharmacotherapeutic areas of interest: drugs with restrictive indication, medication-related biochemical changes, evaluation of overruled interventions raised by CCDS, reimbursement of drugs, sequential therapy for bio-equivalent drugs.
– Education of 8 pharmacist involved in the COMA
– During a 6-month period, 19220 prescriptions were checked for which 8284 (43%) electronic warnings were sent and 224 (1%) phone calls were carried out. When analysed without automatic warnings for sequential therapy, 11751 prescriptions were checked for which 815 (7%) electronic warnings were sent and 224 (2%) phone calls were carried out.

What next?

For the future we obtain next goals:
• Evaluation of the current COMA, with emphasis on improving specificity
• Development of new algorithms , also expanding to other areas of interest
• Development of an easy access training tool for hospital pharmacist to perform COMA

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Author(s)

Aude Desnoyer, Anne-Laure Blanc, Christian Skalafouris, Rolf Hauri, Alain Lorenz, Pascal Bonnabry, Bertrand Guignard

Why was it done?

PIM (i.e. over-/under-/mis-prescriptions, and drug interactions) occurs frequently and is a well-known risk factor for adverse drug events and morbi-mortality (1). Its incidence is high and underestimated in internal medicine (2). While many paper checklists, providing explicit statements, related to PIM in geriatrics exist (3), none had been developed for adults in internal medicine. Moreover, as all these tools are only available as paper versions, they are not easily accessible in daily practice (4). Therefore, we decided to develop an electronic checklist, dedicated to adults in internal medicine.

What was done?

We developed an electronic screening checklist to detect potentially inappropriate medication (PIM) in internal medicine.

How was it done?

We conducted a 4-step study including literature review, 17 semi-structured interviews, a 2-round Delphi survey, and a forward/back-translation process (French English) to develop PIM-Check (5). Sixty-five medical specialists and pharmacists, from 22 hospitals in Belgium, Canada, France, and Switzerland were enrolled. Experts agreed on 160 statements, in 17 medical domains, and 56 pathologies. These statements were then integrated in a specifically developed web-based electronic tool. Each statement is associated with at least one pathology and one medication (1600 ATC encoded).

What has been achieved?

The application is available in French and in English on a website (www.pimcheck.org). A “Screening” function allows users to select for a specific patient, his/her co-morbidities and medications to switch on statements that are the most relevant. A “Favourites” function, gives quick access to selected statements, and a “Learning” function gives access to the list of all statements, those unread and those already read. Details regarding the conception of the tool, direct access to the references (n=333) and useful links (n=29), publications related to the tool and a contact section, are also available. Between February and September 2016, PIM-Check has been visited more than 75.000 times, in over 66 countries.

What next?

Several studies assessing the impact of PIM-Check are ongoing. The algorithm and content of the tool are constantly updated. Thanks to the English version, PIM-Check can be used in different European countries and healthcare settings (6), and will be helpful to support clinical pharmacists’ education in appropriate prescription analysis.

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Author(s)

Caroline Hynes, Dolores Keating

Why was it done?

Psychiatric intensive care is for patients who are in an acutely disturbed phase of a serious mental disorder. Psychotropic medicines play a pivotal role in the treatment of these disorders which is why the pharmacist is a key part of the patient care team. The introduction of a designated pharmacist to address not only the clinical needs of the PICU team but also the medicines information needs of the patient was essential to optimise patient outcomes.

What was done?

A liaison pharmacist was assigned to the psychiatric intensive care unit (PICU) to provide both a clinical pharmacy service including regular medication chart review and development of patient-centred clinical guidelines, and to provide medicines information and support directly to patients.

How was it done?

The main obstacle to the introduction of this initiative was establishing a relationship with patients, as visible pharmacist interventions were new to patients on the PICU. In order to overcome this obstacle, the pharmacist was required to be present on the unit and regularly meet patients to enquire about their experience of taking medicine for their mental health and provide information as required.

What has been achieved?

• The pharmacist hosts a weekly medicines information group on the unit where; medicines are discussed openly, patients are provided with medicines information leaflets and medicines charts detailing all of their current medicines and what they are for, and those taking antipsychotics are systematically assessed for side-effects

• The pharmacist carries out a regular clinical pharmacy review where medication charts are clinically assessed and any interventions are relayed to the relevant consultant psychiatrist and registrar

• The pharmacist develops new patient-centred guidelines for use on the PICU e.g. Guidelines on the pharmacological prevention and management of violence or aggressive behaviour

What next?

By having an awareness of the patient experience of their medicine (especially side-effects) through regular contact at the medicines information groups, the pharmacist is in a position to provide more informed clinical advice to the PICU team. This patient-centred approach to the clinical pharmacy service could be transferred to any healthcare setting where the pharmacist can link directly with both patients and their multidisciplinary team.