IMPLEMENTATION OF A MEDICATION RECONCILIATION PROGRAMME UPON DISCHARGE (submitted in 2019)
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
José Marco-del Río, María Luisa Ibarra-Mira, Gregorio Romero-Candel, Ana Ramirez-Córcoles, Ana Valladolid-Walsh, Francisco Tomás Pagán-Nuñez
Why was it done?
Our main goal was to improve patient’s safety, because we noticed that many patients did not take actually all the drugs that were prescribed by the physicians, and other times there were drugs that the patients were taking because they had an active prescription, but they were not supposed to. Additionally, we aimed to improve the drug-related information that the patients take home.
What was done?
A programme which includes every patient admitted into the Internal Medicine department. It consists of three steps: clarification of chronic medication that the patients are taking, we handle them and updated schedule of their drugs upon discharge and we check the coherence with the active prescriptions.
How was it done?
We interview the patients during the admission in order to clarify and update the chronic medication that they are taking. When a patient is about to be discharged, the nurses call us, so at this moment we talk to the physician to know what changes are going to be made on the medication. To coordinate with the physicians and nurses, we had two meetings in which we established the timing of the programme, so the patients don’t have to wait too long for us. When we know the changes that the physician is going to make, we update the medication schedule to handle it to the patients or their family, and we explain to them the changes and how they should manage the new drugs. If any discrepancy or medication-related problem is detected, we talk to the physician to solve it.
What has been achieved?
In the last four months, we performed 180 discharges and we solved together with the physicians 20 discrepancies. Patients are now receiving more comprehensive information about their treatment.
What next?
To continue with the programme and broaden it to the rest of our hospital departments. Also we are working on a way of uploading our pharmacy schedules to the electronic medical record of the patients, so they can be available for every healthcare worker, which would improve even more the transitions of care.
SAFETY IMPROVEMENT IN PAEDIATRICS: ASSISTED PRESCRIPTION OF INTRAVENOUS MIXTURES (submitted in 2019)
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Iván Maray Mateos, Miguel Alaguero Calero, Adrián Rodriguez Ferreras, Cristina Calzón Blanco, Cristina Álvarez Asteinza, Lucía Velasco Roces, Ana Lozano Blazquez
Why was it done?
Intravenous drugs in the paediatric population bring up additional issues than the usual in adults. In their prescription, not only does the dose have to be adapted to the patient’s weight, the volume in which the drug is diluted must also be adapted to the reduced fluids requirement without jeopardising the stability of the mixture. In view of these facts, IV drug prescription in paediatrics implies a higher risk of medication errors. This new prescribing system simplifies prescription and reduces risks.
What was done?
Development of an assisted prescription system of intravenous mixtures adapted to paediatric patients in which both the drug dose and the diluent volume are automatically calculated according to the patient’s weight.
How was it done?
A literature review of drug dosing in paediatrics and their stability in different diluents was performed. For every drug the following parameters were considered: maximum dose in children (mg/kg), maximum concentration allowed (mg/ml), common doses and volumes in adults. Using these values, a system was built which calculated drug dose and diluent volume according to the patient’s weight and the maximum concentration allowed for stability reasons. For safety and to ease the preparation, the diluent volume in millilitres was rounded up to the next 10. In order to avoid overdosing overweight or older paediatric patients, maximum dose and diluent volume were narrowed down to the usual quantities in adults. Ultimately, this system was integrated in the electronic prescription system. A protocol was created, named “drug name” IV mixture PEDIATRICS. So, by selecting this protocol in a specific patient, the target dose and the diluent volume are automatically calculated.
What has been achieved?
This system was implemented for 38 drugs. From July 2018 to April 2019, 910 IV mixtures have been prescribed from the following Anatomical Therapeutic Chemical (ATC) groups: A02 Drugs for acid related disorders (39), J01 Antibacterials for systemic use (287), J02 Antimycotics for systemic use (3), J05 Antivirals for systemic use (8), A04 Antiemetics and antinauseants (175), N02 Analgesics (395), N03 Antiepileptics (3).
What next?
This method could be implemented in other electronic prescription programmes. The system must be updated by the Pharmacy Department, introducing new drugs and constantly reviewing stability databases, posology regimens, and information regarding dilution of parenteral drugs.
SUCCESSFUL DEVELOPMENT OF A SHARED INFORMATION DATABASE FOR HOSPITAL PHARMACIES IN DENMARK – BENEFITING FROM AGILE PROJECT MANAGEMENT (submitted in 2019)
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Stine Ulsø, Hilde Omestad, Susanne Weng Rømer, Sisse Emilie Mejsner, Mads Nielsen, Jesper Heltoft-Christensen
Why was it done?
The existing solution, established in 2001, was running on an insecure platform, the system was expensive to maintain and changes difficult and slow to implement. The need for an update led to a change of supplier, hosting and platform.
What was done?
A new database was developed for documentation and quality assurance of drug related queries received by hospital pharmacies in Denmark. The information in the database is shared across all hospital pharmacies in Denmark and is an important tool for the Medicines Information Centers located there. Existing queries were transferred from the old to the new database.
How was it done?
A working group was established consisting of three pharmacists and superusers from three different hospital pharmacies, one project manager employed by the sponsor (Amgros) and two developers employed by the new supplier (Progressive). The project was structured using monthly physical meetings and ad hoc video conference meetings. The work tasks in the development process were divided and carried out in two-week sprints by the developers and subsequently tested and validated by the pharmacists. All participants agreed to a periodic heavy workload and showed great flexibility. The close and frequent collaboration between all members affected the teamwork in a positive way, hence the group was motivated and managed to agree on common solutions and compromises despite different database usage and different locations.
What has been achieved?
A new, stable and more intuitive database was developed in only 5 months due to the structured and flexible way of working and a close motivated teamwork. The database was taken into use from one day to another and quickly adapted. Since the development several hospital pharmacies have increased their use of the database. The amount of information shared nationally has improved.
What next?
The initiative resulted in a useful tool implemented within a short time. The way of working intensively and focused with physical meetings and video conferences made a good basis to succeed. Especially the sprint cycles can be used in different healthcare settings involving different projects.
COMPREHENSIVE SMOKING CESSATION PROGRAMME RUN BY CLINICAL PHARMACIST IN COLLABORATION WITH THE ADDICTOLOGY DEPARTMENT
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Mathilde ROCHE, Niccolo CURATOLO, Marion ADLER, José POLO DEVOTO, André RIEUTORD
Why was it done?
Many smoking patients are not identified as smokers when admitted at the hospital, depriving them of any help to quit smoking. During medication reconciliation at admission (MR), the pharmacist is in a position to identify smoking patients and then offer a support programme.
What was done?
An integrated care model based on a smoking cessation programme was designed to assist smoking patients to quit tobacco. Pharmacy and addictology departments co-built and led the project. It was implemented and proposed to patients from May 2018 in three medical and surgical wards.
How was it done?
The project included five steps:
1. Training of one clinical pharmacist about smoking cessation by the addictology team.
2. Designing the process and developing tools used for a smoking cessation programme.
3. Implementing the programme.
4. Evaluating the pilot phase.
5. Developing a comprehensive training programme (including role-play sessions) for the pharmaceutical team.
The process counted six steps:
1. Smoking patients’ identification (MR, patient record, request from doctors). If the patient was polyaddicted, the addictology team was informed.
2. First patient visit: patient consent was collected, anamnesis related to tobacco and explanation about nicotine’s mechanisms and nicotine substitutes given. Appropriate nicotine substitutes were selected and tested with the patient.
3. Prescription and administration of nicotine substitutes.
4. Second patient visit (24 to 48 hours’ later): nicotine substitutes adjusted if needed.
5. Third patient visit if needed.
6. Discharge medication reconciliation.
What has been achieved?
During 4 months, 62 patients were identified as smokers during MR interviews. Twenty-seven per cent of the patients (n= 17) were sent to the addictology team because of polyaddiction, 39% (n=24) refused the programme and 34% (n=21) accepted to experience our support programme. Of these, 62% (n=13) either reduced or quit smoking during hospitalisation.
What next?
According to our encouraging preliminary results, this programme will continue to be carried on by the pharmaceutical team, while keeping a close link with the addictology team. We decided to call the patients one week and one month after discharge to better assess the performance of our smoking cessation programme.
DRUG-FOOD INTERACTION GUIDE PREPARATION FOR OUTPATIENT CONSULTATION
European Statement
Patient Safety and Quality Assurance
Author(s)
Gregorio Romero Candel, Paula Ruiz Belda, Carmen Caballero Requejo, Maria Jesus Sanchez Cuenca, Jose Marco del Rio, Juilan Castillo Sanchez, Luna Carratala Herrera
Why was it done?
Some drugs dispensed in the outpatient office present interactions with food, leading to changes in their bioavailability. These changes which can result in a decrease in therapeutic activity or an increase in adverse effects, when dealing with narrow therapeutic margin drugs, may lead to alterations in their efficacy and/or toxicity. Developing the quick and accessible consultation table, we improved the quality and effectiveness of the treatment.
What was done?
Preparation of the drug and food interaction guide for outpatient consultations.
How was it done?
The technical specifications of all drugs that are dispensed in the hospital outpatient office were consulted, and the possible interactions with food of every one of them were analysed by consulting the following electronic databases: Technical sheet, Bot Plus, Micromedex, Pubmed, UpToDate and Online Medicine Information Centre of the AEMPS. A database was developed with drugs that presented some type of restriction with meals, designing a quick reference table for outpatient consultation.
What has been achieved?
One-hundred specialities were reviewed, of which 22 were to be taken without food, 43 with food and 35 could be taken with or without food. The information given to the patient was quick and efficient, improving the effectiveness and safety of the treatment.
What next?
Our goal is to continue developing tools that allow us to provide quality information to the patient, improving the effectiveness and safety of treatments.
IMPLEMENTATION OF THE FIRST MEDICINES INFORMATION SERVICE IN BELGIUM
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Elise Deyaert, Hilde Collier, Pieter-Jan Cortoos, Claudine Ligneel
Why was it done?
Medication errors are often caused by insufficient knowledge among healthcare professionals. Given limited clinical pharmacists’ presence on Belgian hospital wards, a pharmacy-led MIS can efficiently provide fast, accurate and objective medication-related information.
What was done?
We implemented the first Belgian Medicines Information Service (MIS) in our university hospital. In several countries, a MIS is common in most hospitals but until our project, no such MIS was available
in Belgian hospitals.
How was it done?
Best practices were researched through literature review and site visit at Charing Cross Hospital (London, UK). Secondly, in order to customize activities, all nurses and physicians were surveyed on medicines information needs. Our MIS was set up to centrally (1 dedicated pharmacist, phone number and e-mail address) receive medication-related questions from healthcare workers with the option to request additional clinical-pharmaceutical interventions (e.g. drug review). Implementation was accompanied by mailings, posters, business cards and presentations. All enquiries were registered in the MiDatabank® (UKMi National Medicines Information) and evaluated after 4 months, together with user satisfaction.
What has been achieved?
221 respondents (113 physicians, 103 nursing) to our survey found ‘drug administration/dosing’ (79.7%), interactions (69.6%) and ‘tablet crushing’ (49.7%) major problematic topics. Physicians rated the MIS to be useful for drug review, counselling and interactions while nursing preferred support on drug administration and tablet crushing. 96.8% intended to use the MIS.
Between 09/01 and 09/05/2017, our MIS received 247 enquiries (45.5% residents, 34.0% nursing, 13.8% clinical staff). Drug administration/dose-related questions (43.3%) was the most important category, followed by drug choice/indication (10.5%) and interactions (9.7%). 80.2% were answered within 1 hour (median: 11min). 81% of users mentioned the MIS improving their knowledge, with 59% and 56% reporting positive patient outcomes and time savings. Our MIS scored high on accessibility, timeliness, comprehensiveness and quality (average 4.34, 4.29, 4.42 and 4.47 on 5-point scale). MIS activity corresponded to 0.4FTE pharmacist with an average cost of €15.4/enquiry.
What next?
Our project shows that fast and reliable medication-related information is greatly needed. For the future, this service should be organized with other hospitals as to optimally use resources, share information and increase expertise. Also providing such service to primary care and patients will have be explored.
SAFER DRUGS WITH AWARD WINNING DATABASE
European Statement
Patient Safety and Quality Assurance
Author(s)
Kaveh Teimori, Hannah Colldén, Reza Asasdian
Why was it done?
Hospitalized patients often need multiple intravenous drugs simultaneously which are commonly mixed in-line before entering the blood stream. Physicochemically incompatible drugs cause reduced efficacy, clogged catheters and drug precipitation, which can be harmful or even fatal. The risks add uncertainty to the stressful working environment for clinical practitioners. According to a local 2012 survey 68% (n=44) of Sahlgrenska University Hospital (SUH) intensive care unit (ICU) nurses had co-administered drugs uncertain of their compatibility. Hospital pharmacists are hence asked for guidance to optimize compatibility and patient safety.
What was done?
Nurses, doctors and pharmacists were provided with accessible and evidence based information on IV drug compatibility in order to improve drug therapy, working environment and patient safety.
How was it done?
Drug compatibility data was collected by hospital pharmacists who assessed its applicability to Swedish conditions. The results were documented in charts and procedure documents. A project for creating a database was initiated in collaboration with the IT organization in Västra Götaland Region (VGR). A survey was designed to evaluate how the SUH’s ICU nurses experienced the database. Collaboration with nurses, doctors and clinical pharmacists helped improving the quality of the database.
What has been achieved?
Drug compatibility lectures given to nurses, doctors, pharmacists on a continuous basis. Procedure documents implemented in eight clinics. A peer-reviewed work flow is established. The database contains over 2500 assessed drug combinations. Over 700 nurses, doctors and pharmacists from 11 counties plus Norway and Denmark have requested access to the database. Clinics avoid drug mixing by choosing multi-lumen catheters with greater capacity. The 2016 survey showed that 88% (n=86) of SUH’s ICU nurses had co-administered drugs uncertain of their compatibility. The database affected their decisions in 93% (n=45) of the cases, 85% (n=34) found information easier and 88% (n=34) felt more certain when making decisions. A new pharmacist role – IV Compatibility Manager – was introduced and implemented in VGR. In 2016, this work received the national annual award Guldpillret (“The Golden Pill”).
What next?
In the next years, the database will become nationally available and integrated into electronic journal systems. Compatibility issues may then be identified already when prescribing, further improving patient safety.
LET’S DIVERSIFY TO GUARANTEE ACCESS TO THE HOSPITAL PHARMACIST’S EXPERTISE: ALL GOOD THINGS COME IN FOURS!
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Maria Kundracikova, Petra Pölzleitner, Katharina Ocko, Bernadette Aretin, Barbara Datterl, Klara Jadrna, Eva-Luise Hobl, Martin Holbik, Sonja Steininger-Salmer, Helga Fend, Gerda Laml-Wallner, Martina Anditsch, Gunar Stemer
Why was it done?
Due to limited human ressources (8 FTE) in the medicines information and clinical pharmacy department only selected wards could be provided with daily clinical pharmacists’ presence offering medication review, patient discharge counselling and ward round participation. To expand the reach of our clinical services, two further service pillars were introduced complementing the already existing services.
What was done?
The Vienna General Hospital is a 1900 bed university hospital in which patients and health care professionals have access to hospital pharmacists’ expertise via various channels. In addition to already existing services (i.e. provision of hospital-wide medicines information and clinical pharmacy services on particularly selected wards) two new services (i.e. e-pharmacy consult and a dedicated drug interactions and pharmacotherapy clinic) have recently been implemented.
How was it done?
As ward services are staff-intensive, alternatives to expand the access of patients and health care professionals to the hospital pharmacists’ expertise were examined. An e-pharmacy consult was designed, implemented, and promoted in collaboration with the hospital IT department. E-consults can electronically be requested by all wards (e.g. for medication review, patient counselling), but mainly aim at those areas which are not regularly covered by a clinical pharmacist. E-consults are executed by the medicines information pharmacist on duty. Recently, a special clinic was implemented as a collaborative project with the clinical pharmacology department addressing the specific medicines-related needs of patients with complex medication regimens.
What has been achieved?
The scope of services provided by the department currently comprises four pillars: (1) provision of medicines information (2016: 1.200 requests), (2) clinical pharmacy services (2016: 9.000 medication-related problems prevented), (3) pharmacy e-consults, and (4) the drug interactions and pharmacotherapy clinic. While the scope and reach of services was expanded by diversification, the two new services are operated with existing ressources after reassignment of tasks.
What next?
After the implementation of new services (i.e. e-consult, clinic) constant promotion is needed to increase the awareness level among health care professionals in the hospital. Quality assurance and continuity of service provision is crucial for acceptance.
EMERGENCY DEPARTMENT PHARMACY ROTATION, WHAT IS A PHARMACY RESIDENT DOING HERE?
Pdf
European Statement
Patient Safety and Quality Assurance
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.
Development of a guide intravenous administration
European Statement
Clinical Pharmacy Services
Author(s)
Gregorio Romero Candel, Esther Domingo Chiva, Jose Marco del Rio, Marca Diaz Rangel, Wals Valladolid, Sergio Plata Paniagua, Nuria Maryinez Monteagudo
Why was it done?
Critically ill patients often require the administration of several intravenous drugs. Besides, we have many times limited intravenous accesses in which the administration of drugs and other intravenous compounds such as parenteral nutrition must be shared.
Because of that, it is very important to have drug administration guides standarizing every-day clinical practice.
This guide was developed in order to reduce the health care workers burden and promote patient’s safety.
What was done?
We developed an updated guide on direct intravenous administration of drugs for health care workers of both critical care and emergency departments.
How was it done?
A database with every intravenous drug that is included in the Pharmacotherapeutic Guide in our hospital was prepared, alphabetically organized by Active Pharmaceutical Ingredient (API). The following data were collected: API, tradename, available dosage forms and recommendations for direct intravenous administration.
For each API, a bibliographic research of information was conducted, among other hospital administration guides, manufacturer´s product information, drug databases (BOT plusR, Micromedex) and requests of information to the technical departments of the manufacturer.
In case of a discrepancy in the information, the guide with higher evidente or more recent was selected.
The antineoplastic drugs were not included in this guide because they are not used or prepared in critical care or emergency departments.
What has been achieved?
This guide promotes safe administration of drugs in critically ill patients, being a useful, accesible and easy-to-use tool for nurses.
Its elaboration allows us to standarize the direct intravenous drug administration, to inform every health care worker and make them aware about its importance. Besides, the Pharmacy Department actively participated in the process of safe drug administration in our hospital
What next?
We are still working on the same departments to improve safety in drug therapy in critically ill patients. Currently, improvement measures that are being developed are: new pharmacotherapeutic protocols specifically for this unit; drugs and drug-diluent compatibility guidelines and new training sessions.