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Author(s)

ROSALIA FERNANDEZ CABALLERO, ALMUDENA GARCÍA GARCÍA, MARTA HERNÁNDEZ SEGURADO, MARTA GÓMEZ PÉREZ, CARMEN MAYO LÓPEZ, ARACELI HENARES LÓPEZ, VIRGINIA COLLADOS ARROYO

Why was it done?

Our aim was to improve the safety of HAM appointed by ISMP Spain (Institute for Safe Medication Practices) specially restricting the prescription, creating automated alerts and advising in administration.

What was done?

The main objective was to identify and standardise in prescription and administration the high-alert medications (HAM), included in pharmacotherapeutic guide (PG) in a network of Spanish hospitals with about 1.330 beds.

How was it done?

Literature about HAM and recommended strategies was reviewed. We divided these drugs into two groups: HAM (heightened risk of causing significant patient harm when they are used in error) and very HAM (an error could cause death of patient). We identified both groups in electronic prescription system as follows:
– HAM: all prescribers are able to prescribe these drugs and they find yellow warning sign in left side of the drug in prescription screen and nursing electronic work plan for administration.
– Very HAM: these drugs need tracheal intubation or monitoring measures when they are administered to patients. Only prescribers in intensive care (ICU) and surgery units (SU) are able to prescribe them. For certain drugs, needed in medical hospitalisation units, all prescribers are able to prescribe them and they must confirm the prescription with confirmation message: “You are prescribing a HAM, an error could cause significant patient harm. Are you sure to continue?”. They find red warning sign in prescription screen and nursing electronic work plan.
Alerts were configured by systems team in our electronic prescription system.

What has been achieved?

We have identified 379 drugs as HAM. 324 drugs were configured with yellow warning sign.
Sixty-five drugs were identified as very HAM. Fifty-eight drugs were disabled to prescribe by all prescribers (only in ICU and SU).
Seven drugs were configured with red warning alert and confirmation message: dobutamine, isoprenaline, ketamine, labetalol, levosimendan, carboprost and methylergometrine.

What next?

As next phase of our project, we must develop a procedure to identify and create alerts in new drugs added to our PG as systematic risk assessment process. Moreover, we must evaluate the real impact of our alert system in prescribers and nurse team, to reduce alert fatigue. We will work in automatic reports with ignored alerts.

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Author(s)

Suzanne Al-Rawi, Sadeer Fhadil, Sotiris Antoniou, Rodnie Oro, Paul Wright

Why was it done?

It is suggested that 40-80% of information provided by healthcare professionals is forgotten immediately by patients (1). The trust has a checklist of counselling requirements for anticoagulants, completed in consultations with patients before discharge. Recognising the complexity of anticoagulation counselling and its time constraints, we sought to assess the use of pre-recorded counselling videos for use at ward level and as a resource for patients to refer to post discharge.

What was done?

We sought to develop anticoagulation counselling videos for ward use, with hyperlinks for patient access post-discharge. We aimed to improve information provided to patients and optimise pharmacists’ time undertaking counselling.

How was it done?

Using a patient focused questionnaire, feedback was sought on patient satisfaction as well as time totality following anticoagulation counselling. A series of short and digestible video clips (1-2minutes each) that reflected the trust checklist were recorded. The videos were played to the patient and then a follow-up face-to-face consultation was undertaken to answer any questions. Patient satisfaction and time taken was assessed through the use of the questionnaires and compared to consultations without the pre-recorded clips.

What has been achieved?

Over 4 weeks, 121 patients received anticoagulation counselling. 77 patients were counselled using videos and compared to 45 patients counselled without videos. There was a 70% reduction in time spent; an average face-to-face counselling required 24 minutes, compared to only 7 minutes if the patient had seen the videos. There was an overall increase in patient satisfaction with use of videos to 86% from 70%.

What next?

We have shown optimisation of the anticoagulation counselling process through the use of pre-recorded videos. Time spent counselling has been significantly reduced and feedback from pharmacy staff has suggested more patient-centric counselling is achieved. It has allowed for information to be standardised, with an increase in patient satisfaction and understanding. Patients have access to the videos on discharge to improve patient safety. There have not been any reported incidences since switching methods. There has been a reduction in patient queries related to anticoagulation post- discharge. Areas for further development include dubbing of the videos to several languages to improve access to all.

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Author(s)

Annamaria Tesse, Cataldo Procacci, Domenica Ancona, Salvatore Lenti

Why was it done?

Often the elderly patient suffers from several pathologies at once and commonly he is in polytherapy. According to the Italian Ministerial Recommendation No. 17, errors in drug therapy can cause serious harm to the patient. By increasing the patient’s awareness and reducing the number of potentially inappropriate prescriptions, it will be possible to improve the effectiveness of therapies and to reduce side effects.

What was done?

In an Internal Medicine department, the concurrence between doctors and pharmacists has led to a project that aims to reduce duplications of therapy and to improve the health status of the patients. This through pharmacological recognition and subsequent therapeutic reconciliation carried out on patients in discharge.

How was it done?

In Internal Medicine ward, from June to August 2022, we gather the terapies for 48 hospitalised patients aged over 65 years and suffering from two or more chronic diseases. Reconciliation boards were then developed using Intercheck Web a “Mario Negri” Institute of Pharmacological Research’s software. Sequentially the physician, according to the chemist, proceeded to remodulate the therapies especially in those cases where there were serious interactions.

What has been achieved?

140 drug interactions were detected, on average 2.91 interactions per patient. Especially, 16 class D (very serious), 22 class C (major), 83 class B (moderate), 19 class A (minor) reactions were archived. The modified or partially modified therapies at discharge were 71%. This restriction bought to a curtailment of drugs taken and a removal of unnecessary drugs.

What next?

The team are doing a patient follow-up to six months and a year so earlier results will be soon available. Reducing drug intake is possible, and it involves a downsizing in side effects and in an increase in patient compliance. Information to the patient is essential and, by using this procedure on a large scale, it will be possible to optimise the management of the chronic patient at home and inpatient care.

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Author(s)

Sophia Hannou, Cristina Nicorici, Patricia Spitz, Samuel Cotte, Wanda Bosshard, Nancy Perrottet, Pierre Voirol, Farshid Sadeghipour

Why was it done?

Medication use process is at high risk especially for opioids. In our geriatric rehabilitation unit, self-reporting incidents are submitted regularly to our quality system. Among the 44 drugs incidents reported in 2021, 11 included opioids. Prevention with training is a way to reduce these errors. However, theoretical teaching covering the “5 rights” rule remains insufficient. Therefore, an interactive learning with a room of horrors focused on opioids was selected by our unit to prevent these errors. The objective was to cartography and identify the most risky steps and to introduce specific actions to reduce these risks.

What was done?

A room of horrors with a specific focus on opioids has been developed and implemented to reduce errors in medication circuit.

How was it done?

An interprofessional group created the room of horrors based on real incidents. Fictional patient, clinical situation and opioid prescription were created in the medical software. Several drugs and medical devices were available. A model wore an identification bracelet. Ten errors, covering the five rights, were hidden in the room. A pair of healthcare givers had 20 minutes to realise the simulation (5 for the briefing, 10 for the exercise and 5 for debriefing).

What has been achieved?

During the World Patient Safety Day 2022, 38 healthcare professionals (19 nurses, 10 assistant nurses, 9 geriatricians) participated to this training. Errors were detected in variable proportions. For example, 58% of the participants uncover the patient identification error, 53% the pharmaceutical form, 53% the expired date, 47% the allergy contraindication and 47 % used the oral syringe.

What next?

Results and theoretical notions will be presented to all professionals of the unit. This room of horrors is transposable and can be used in other units of the hospital. A video of this simulation was created as an e-learning. It will be implemented as a continuous training or for new collaborators in our unit and can be shared to other units of the institution. Incidents will be continuously monitored and the training will be adjusted in the future. Based on the success of the room of horrors, this interactive learning will be used in other areas with other clinical or technical dimension.

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Author(s)

Aidan Morris, Louise Byrne

Why was it done?

• mAbs were considered hazardous if handled by staff – prepared in a dedicated isolator in the PAU in TUH.
• No widely accepted standards for safe handling of mAbs, although more recent guidance allows preparation of some mAbs outside of PAUs once risks appropriately assessed.
• Significant reduction in production capacity in the PAU in early 2022 for planned repair work. Benchtop preparation of mAbs implemented to maintain patients’ treatment regimens and to reduce costs associated with outsourcing.

What was done?

• Preparation of monoclonal antibodies (mAbs) on the pharmacy benchtop temporarily introduced in the Pharmacy Aseptic Unit (PAU) of Tallaght University Hospital (TUH).
• Guidance from Ireland’s National Cancer Control Programme (NCCP) on Pharmacy Benchtop Preparation of mAbs reviewed and implemented.
• Risk assessment carried out for individual mAbs. List of mAbs suitable for benchtop preparation prepared.

How was it done?

• Implementation of the NCCP guidance on Pharmacy Benchtop Preparation of mAbs. Advice on risk assessments and safety, equipment and facilities, and staffing and training when preparing mAbs on the benchtop.
• Literature review of the hazards associated with handling mAbs – toxicity, immunogenicity, risk reduction measures. Individual mAbs assessed for suitability for benchtop preparation using Health Service Executive (HSE) risk assessment tool. This considered toxicity, immunogenicity and closed system transfer device (CSTD)-compatibility of mAbs, and personal protective equipment required.
• CSTD vial adaptor based on air cleaning (filter) technology replaced with vial adaptor with physical barrier (balloon) – additional safety measure. Dedicated area assigned for benchtop preparation – well-ventilated, clutter-free and easy-to-clean.
• Additional training on new vial adaptor provided to pharmacy technicians already experienced in aseptic compounding.

What has been achieved?

• List of mAbs suitable for benchtop preparation prepared. Conjugated antibody-drug complexes, mAbs of fully murine origin and mAbs not CSTD-compatible deemed unsuitable.
• mAbs prepared on the benchtop during period of reduced capacity, maintaining patients’ treatment regimens and reducing outsourcing costs, wastage.
• Facilitated by risk assessment and risk reduction using PPE, training and CSTDs.

What next?

• Although safety and handling requirements of mAbs not fully known, prudent to handle them with more care than most drugs but less than for cytotoxics.
• Contingency plan for benchtop preparation of mAbs in case of future reduced PAU capacity.
• Can be applied to other organisations experiencing periods of reduced capacity.

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Author(s)

Isabelle Sommer, Farshid Sadeghipour

Why was it done?

PN can be composed of 14 different ingredients, including an amino acids admixture. Therefore, PN represents a complex and high risk preparation. Medication errors (ME) are often related to PN management and may include prescription, transcription, preparation, and administration errors. As the treatment with PN is essential for a good cerebral and neurologic development and a postnatal weight gain, ME can result in growth retardation, developmental disturbances, and infections. The implementation of the standardised PN aimed to achieve a reduction of ME having an impact on vulnerable newborns and to improve the security and quality of their nutritional treatment.

What was done?

A multidisciplinary development of a hospital’s neonatology and pharmacy departments as well as of an industrial manufacturer resulted in a standardised parenteral nutrition (PN) solution for neonatal patients. This PN solution was implemented as “standard-of-care” for newborn term and preterm infants requiring nutritional treatment within their first days of life.

How was it done?

The standardised PN solution for a peripheral administration route was developed in accordance with ESPGHAN guidelines (2018).
The neonatologists defined internal guidelines for the PN administration and trained the concerned personnel (physicians and nurses).
The industrial manufacturer delivered the ready-to-use PN solution as a sterile double-chamber infusion bag in accordance with Swiss and European regulatory.

What has been achieved?

The ready-to-use PN solution with a 24/7 availability on ward by means of an 18 months stability at room temperature allowed a considerable reduction (-80%) of on ward preparation of nutritional solutions by nurses.
One-third of individual PN solutions being prepared at the hospital’s pharmacy has been replaced by the standardised PN solution.
This high-quality PN solution allows a secured administration to the vulnerable patients as well as a reduction of ME related the whole PN management resulting in an improvement of the nutritional treatment of neonates and its outcomes on their development.

What next?

This special PN solution is already implemented in two Swiss university hospitals and others will follow. Further standardised PN for a central venous administration to neonates need to be developed to allow the completion of a safe nutritional treatment. On ward PN preparations must be prohibited to prevent undetectable ME.

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Author(s)

Carlos Santos Rodríguez, Silvia Irene Corrales Vargas, Maria de los Ángeles Peña Peloche, Alfredo Julian Jover Sáenz, Miguel Ángel Ramos Gil, Arturo Morales Portillo, Marta Mir Cros, Francisco Ignacio Torres Bondia, Lluis Marqués Amat, Joan Antoni Schoenenberger Arnaiz

Why was it done?

Beta-lactam antibiotics are the most commonly used group of antimicrobial drugs but are also the ones with the most significant induction of allergic reactions. However, it is known that many of these patients do not present reactions upon rechallenge or have false allergy warnings in the medical records.

What was done?

To assess the impact of a pharmacist-driven programme for active beta-lactam allergy warning removal in adults in collaboration with the Allergology service.

How was it done?

We identified adults with active beta-lactam allergy warnings among outpatients aged 35 to 45 years over 26 months.
Both in the hospital and primary care setting the pharmacist assessed the current information of the cases in the electronic medical records (EMR) and through personal interviews or by telephone. The following data were retrieved: year of allergy registration, type of reaction described, tolerance of beta-lactam antibiotics, and the existence of Allergology reports.
The pharmacist, previously trained by the Allergology service, could proceed to remove or confirm the allergy label, if applicable, or refer the patient to the Allergology service for allergy tests.

What has been achieved?

We reviewed a total of 1178 cases with active beta-lactam allergy warnings. The most frequently implicated beta-lactam drug was amoxicillin, with 170/1178 (14.4%) cases.
111/1178 (9.4%) of cases had an allergic reaction in childhood, and in 714/1178 cases (60.6%) EMR did not describe the symptomatology or treatment that justifies the allergy.
The allergy warning was directly removed in 93/1178 (7.9%) of patients, as they had previous reports of Allergology, had tolerated antibiotics after the allergic reaction, or did not present symptoms compatible with an allergic reaction.
The review confirmed allergic warnings in 43/1178 (3.65%) cases, according to the symptomatology and the information recorded in the Allergology reports.
One thousand and forty-two cases were referred for beta-lactam allergy test performance in the allergology service, of which 47% yielded a negative result.

What next?

The pharmacist is qualified to remove the warning in cases with a doubtful allergy to beta-lactam antibiotics after a thorough medical record review and informed consent. Moreover, the pharmacist can provide valuable information that allows the classification of warnings according to the detected risk and facilitates subsequent decision-making by the allergist.

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Author(s)

DEL RIO GUTIERREZ JOSE MANUEL, MARTA MIARONS FONT, SONIA GARCIA GARCIA, TONI SORIANO COLOMÉ, ALBA PAU PARRA, ARIADNA GRACIA MOYA, NIEVES HERRANZ MUÑOZ, BRUNO MONTORO RONSANO, PAU RELLO SABATE, GERARD ORISTRELL SANTAMARIA, MARIA QUERALT GORGAS TORNER

Why was it done?

Digoxin is a drug frequently implicated in medication errors due to its difficult clinical management. It has also been observed that digoxin pharmacokinetics could change in acute medical conditions, compromising its effectiveness and safety. As hospital pharmacists, we have the opportunity to review which dose is the most appropriate for every patient.

What was done?

Twice-weekly active and extensive pharmaceutical review of digoxin-treated inpatients was established to identify whether the prescription was adequate and to adjust dosage according to plasma concentrations (PCs) and clinical situation.

How was it done?

1. A multidisciplinary team comprising pharmacists and cardiologists was created to identify possible solutions to improve digoxin prescribing.
2. It was agreed that a twice-weekly extensive review of digoxin-treated inpatients would be conducted by a pharmacist. Candidates for digoxin monitoring were:
a. Patients on chronic digoxin therapy and with at least one of the following risk factors: presence of renal failure (RF), recent surgery, elderly patients (≥65 years), critically ill patients, or patients with suspected toxicity.
3. Once the patients were identified by the pharmacist, they would be discussed with the cardiology team.
4. Digoxin prescriber would be contacted to recommend performing a determination of digoxin PC. PC reference range was set at 0.8–1.2 µg/L for atrial fibrillation (AF) and 0.5–0.8 µg/L for heart failure (HF).
5. PCs would be interpreted using a pharmacokinetic monitoring software (PKS Abbot).
6. Monitoring results and recommended dosage adjustments would be communicated.

What has been achieved?

From August 2021 to May 2022, 190 patients were identified. Sixty-five (33.7%) were considered for monitoring, of whom 21 (32.3%) were women. The average age was 77.9 (SD 11.7). Sixty-five (100%) with AF and 8 (12.3%) also with HF. The most prevalent risk factors warranting monitoring were patients aged 65 years or older (N=57, 61.9%) and RF (N=31, 33.7%). Thirty-three (51%) of monitored patients required a dosage adjustment, of whom 23 (69.8%) required a dose decrease, 5 (15.1%) an increase and 5 (15.1%) to stop the treatment. Median digoxin concentrations were 1.23 µg/L (interquartile range: 0.75-2.03).

What next?

The process described applies to any centre able to monitor digoxin CPs both in inpatient and outpatient settings.

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Author(s)

Alexandre Benaiche, Mickael Tachon, Nathalie Arnouts, Amandine Gradelle, Kadidja Gribi, Remi Parsy

Why was it done?

The ‘Agrippal’ programme was created to strengthen the anti-influenza herd immunity in our hospital and reduce the risk of nosocomial influenza. It was then necessary to improve both the vaccination rate of the staff and the inhabitants of the institution’s living area who were potential users. The vaccines were previously distributed in departments and injections made by the nursing staff without any traceability. The purpose was also to improve knowledge about anti-influenza vaccination among staff and users.

What was done?

Our Healthcare-Associated Infectious Risk Prevention Unit (made up of hygienist pharmacists and nurses) launched a programme to fight against nosocomial influenza in our institution in winter 2018 to promote vaccination among staff and users and inform them about vaccination inside and outside the hospital.

How was it done?

Information conferences were held inside and outside the walls of the hospital for staff and residents of the city thanks to a partnership with the municipality to finance these events and communicate about their occurrence. Information materials (flyers) have also been made available to departments and some key departments (Emergency, Consultations, Obstetrics) were encouraged to inform patients at risk and their families about the positive impact of vaccination with provision of Health Insurance reimbursement forms. Our Healthcare-Associated Infectious Risk Prevention Unit created a Mobile Vaccination Team to vaccinate staff directly in the departments and encourage those who have not been vaccinated to do so.

What has been achieved?

The staff flu vaccination rate increased sharply, from 19% and 17% respectively in 2016 and 2017 to 34% in 2018 and 39% in 2019. Among vaccinated staff, 25% in 2018 and 17% in 2019 were primary vaccinated. Although the impact of actions aimed at users is difficult to measure, the number of nosocomial flu has been reduced in our hospital from 3.14 per 10,000 days of hospitalisation in 2017 to 0.58 and 0.61 respectively in 2018 and 2019.

What next?

This initiative has made it possible to double the rate of vaccinated staff in our institution and strengthen patient protection by reducing the risk of nosocomial flu. It only required a period of consultation between different actors without creating additional financial and human resources.

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Author(s)

Peder Nygard, Helle-Brit Fiebrich-Westra, Elise Smolders

Why was it done?

The aim of this project was to reduce paclitaxel waste caused by cancellation of administrations. Standardised dose bands make interchangeability of already reconstituted paclitaxel bags easier, as more patients use the same dose. This could potentially save drug- and material waste and costs even as manpower.

What was done?

Paclitaxel fixed dose bands were created for patients treated with a weekly dose of 80 mg/m2.

How was it done?

In consultation with prescribers the dose bands for paclitaxel where created (see table). These dosages were implemented as a dose-rounding rules in the drug preparation software (Hix 6.2, ChipSoft BV). The maximum deviation for dose-rounding rules for paclitaxel in our hospital is 10% of the prescribed dose. Dosage ≤72mg or >200mg were rounded as normal.

Prescribed dose (mg) Dose-band (mg) m2 (dose 80 mg/m2
>72 ≤88 78 1.0
>88 ≤102 96 1.2
>102 ≤116 114 1.4
>116 ≤136 126 1.6
>136 ≤152 144 1.8
>152 ≤168 162 2.0
>168 ≤184 174 2.2
>184 ≤200 192 2.4

What has been achieved?

These rules were implemented in April 2022. Data from 1 May 2022 to 31 August 2022 is compared with the same time period in 2021. In 2022, a total of 729 infusions where prepared compared with 872 infusions in 2021.
In this 4 month time period in 2022 a total of 14 different dosages were prescribed, compared with 24 in the same time period in 2021. Additionally, interchangeability was improved as the top 3 dosages prepared by the pharmacy were: 144 mg (36%), 162 mg (22%), and 126 mg (19%) compared with 144 mg (17%), 138 mg (14%), and 126 mg (10%) in 2021.
Furthermore, in 2021 we discarded 33 prepared dosages of paclitaxel of which three infusions could be reused. Compared to 13 discarded dosages in 2022 of which eight were reused giving a reduction of 25 infusions less waste (83% reduction, savings ~2500 euros).

What next?

Pharmacists need to be instructed to adapt these rounding rules, which must decrease the variation in dosages and thus waste. Secondly, this project will be monitored the upcoming year and evaluated together with prescribers. The aim is to implement dose bands for paclitaxel dosages 175 mg/m2 and other chemotherapeutic drugs (eg, oxaliplatin, docetaxel, cyclophosphamide).