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Author(s)

Fionnuala Nevin, Gail Melanophy, Aisling Collins, Miriam Moriarty, Grainne Courtney, Tamasine Grimes, Gaye Stephens

Why was it done?

The available literature strongly advocates the importance of training for users of electronic prescribing systems to ensure their safe and effective use. However, there is a lack of evidence to demonstrate the effect that ongoing training has on the use and impact of these systems. This study was carried out to strengthen the case for staff training resources for electronic prescribing systems.

What was done?

A study was carried out to investigate the effect of a training intervention on the prevalence of prescribing errors found in an outpatient electronic prescribing system currently in use. Audit and feedback methods were used. Prescription audits were carried out before and after the delivery of a classroom-based training intervention. The audits were used to measure and analyse the effect of the intervention on prescribing errors found in the electronic prescribing system. A questionnaire and clinician observations were carried out with prescribers. The pre-intervention audit results, questionnaire, and clinician observations were used to inform the prescriber training intervention.

How was it done?

Key stakeholders were recruited and assisted in the planning and delivery of the study methods. This was to ensure participate buy-in and study success. The audit tools and questionnaire were initially piloted to test their design, and allow adjustments to be made based on feedback received.

What has been achieved?

The prevalence of prescribing errors was significantly reduced, following the delivery of the training intervention. Statistically significantly more medications prescribed during the pre-intervention audit contained one or more errors when compared with the post-intervention audit (28.6% versus 9.2%, p < 0.05). Most errors found were deemed to be system-related errors.

What next?

The study demonstrates the positive impact that ongoing training can have on users’ interactions with an electronic prescribing system. Electronic prescribing systems are being increasingly considered and implemented in healthcare settings internationally. The results of this study could be used to inform the planning for training interventions to be delivered as part of ongoing system maintenance. The study stands to inform those managing electronic prescribing projects that, despite initial training, errors can still occur and must be addressed. This study supports the need to provide adequate training resources for users of electronic prescribing systems.

Author(s)

María Mar Alañón Pardo, Sacramento Corral Vinuesa, Raúl Pérez Serrano, Isabel Benet Giménez, Alfonso Ambrós Checa, Álvaro Díaz Castro, Miguel Ángel García Cabezas, Élida Vila Torres, Carmen Encinas Barrios, Marta Rodríguez Martínez

Why was it done?

Acute intoxications cause significant morbidity-mortality worldwide, and their rapid treatment is vital.
APP-Antídotos is the first free Spanish mobile application for toxicology research, designed to facilitate immediate access to relevant information on antidote applications in toxicological emergencies.

What was done?

The “Antídotos” application for mobile devices (APP) was developed by our Departments of Pharmacy, Emergencies, Intensive Medicine and Paediatrics to facilitate consultations by healthcare professionals on the pharmacological treatment of the most frequent acute intoxications in our setting.

How was it done?

The APP contains toxicological data from the “Antidote Guidelines” developed in our third-level university hospital, based on primary (drug information sheets, original scientific articles), secondary (Medline results, using “antidotes”, “poisoning”, “hospital pharmacy department” and “guideline” as search terms) and tertiary (toxicology databases) sources of information.
The Pharmacy Department was responsible for the graphic design, structural development and programming of the APP for mobile devices (smartphones, tablets) with Android or IOS9 operating systems, which could be downloaded free from Google Play or Apple Store.
APP-Antídotos is organized in 31 chapters on different types of intoxication and their definition, mechanism and symptoms, with recommendations on antidotes and references. It is structured in seven sections: “Information”, “Intoxication index”, “Antidote index” (37 antidotes), “Toxin index”(>240 toxins), “Notes”, “See Antidote Book in PDF” and “Telephone for Toxicological Emergencies”.

What has been achieved?

Between April and August 2016, users downloaded 2091 installations from Google Play (72.5%-Android) and Apple Store (27.5%-iOS9); 73.6% of devices were smartphones and 26.4% tablets.
The APP was downloaded from Android in Spain, 55.8%; Brazil, 5.7%; India, 5.5%; Columbia, 4.3%, Mexico, 4.0%; Ecuador, 2.7%; others, 22.0%. The distribution by language/country was: Spanish/Spain, 60.2%; Spanish/USA, 11.1%; English/USA, 7.9%; Portuguese/Brazil, 5.0%; English/UK, 4.7%; Spanish/Mexico, 1.2%; others, 9.9%. The geographic distribution of iOS9 installations was: Europe, 90.5%; Latin-America/Caribbean, 5.9%; USA/Canada, 1.4%; Africa/Middle-East/India, 0.4%, Asia/Pacific, 1.8%.
Mean user evaluations were 4.6 (Android) and 5.0 (iOS9) stars (maximum of 5 stars).
Fifty-four publications were found on social networks (48.2%-Facebook, 51.8%-Twitter), 444 shares, 1094 “I like” and 1045 video plays.

What next?

The APP will be regularly updated by the authors taking user suggestions into account, and it will be translated into English to extend its reach to other healthcare.

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Author(s)

Eliln Trapnes, Nina Carstens, Merethe Nilsen, Solveig Vist, Margareth Wiik, Janne Kutschera Sund

Why was it done?

In 2012 all the regional hospital pharmacy trusts in Norway decided to implement the IMM-model as a national method for clinical pharmacy practice in hospital settings. Although an extensive amount of training and education has been provided locally and regionally, there was a lack of defined core competencies for clinical pharmacists in Norway. Furthermore, a complete post graduate education program for clinical pharmacists did not exist. Based on this, the managements of the regional hospital pharmacy trusts requested defined skills sets and identification of relevant educational needs and opportunities.

What was done?

A joint national overview of core competencies for clinical pharmacists working in Norwegian hospitals has been compiled. Learning objectives have been defined for each of the steps in the Integrated Medicines Management (IMM)-model (Medication Reconciliation, Medication Review, Patient Counseling and Discharge Service). Relevant education opportunities were identified and recommendations on courses, practical training and other educational activities were described.

How was it done?

A group of six experienced clinical pharmacists representing all the hospital pharmacy trusts in Norway agreed upon core competencies needed to perform the main steps in the Integrated Medicines Management (IMM)-model (Medication Reconciliation, Medication Review, Patient Counseling and Discharge Service) in Norwegian hospitals. Existing education opportunities were compared to the defined learning objectives and a recommended time schedule for the training was made.

What has been achieved?

A national consensus on core competencies in clinical pharmacy services has been reached among all hospital pharmacies in Norway. The consensus, including the evaluation and recommendation of educational activities, makes it easier for leaders of clinical pharmacists to decide on which educational activities to prioritize, and for the Universities to know what educational areas they should cover.

What next?

The report with the identified core competencies will be adjusted according to local requirements and implemented in all Norwegian hospital pharmacies. Hopefully, our work will encourage further cooperation on educational activities between regions. An initiative has already started towards Norwegian Universities to try to integrate relevant competencies into the curricula of pharmacists, and this will continue.

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.

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Author(s)

Charlotte Ménage, Mickaël Le Barbu, Adrien Borowik, Christine Housset, Sandrine Voisin, Florence Lémann, Jean-Michel Descoutures

Why was it done?

An audit of the medication storage cabinets was performed in 2015 in 19 care units. Over a three month period, more than 5000 inappropriate medecines were found which are likely to alter the process of pillboxes prepation by the nurses. Our objective was to develop a training program for nurses to identify and avoid near miss events during the medication administration process.

What was done?

A simulation learning program for nurses was implemented to secure the drug pillboxes preparation.

How was it done?

A multiprofessional team (i.e., pharmacist, physician, pharmacist resident, head nurse, risk manager, hospital hygienist) collaboratively developed a simulation-based workshop. Two mobile cabinets were designed. They were composed of 28 medicine boxes, a patient pillbox and a laptop with a mock prescription. They included the use of a simulation scenario with errors (e.g., expired tablets, damaged blister packs, mixed pharmaceutical forms or dosages, non-formulary drugs). The nurses had to prepare the patient’s pillbox for one day and then were asked to solve five questions about good practices. A validated assessment grid was filled in by two team members, and finally discussed with the nurse about the successes and pitfalls as an education purpose. At the end of the simulation program, nurses had to answer a satisfaction survey.

What has been achieved?

47 nurses experienced the simulation-based workshop. It took 40 min for each nurse on the same week. 89% removed the deteriorated tablets remaining in the pillbox and did not unpack any unit dose. However, 81% were unable to prepare the right medicine, the right dose, the right route for the right patient at the right time, because of a lack of patient identification on the pillbox. Some critical procedures were considered not appropriately followed: i.e., detecting acetaminophen prescription duplicate (only 26%), throwing away medicines in the right disposable bin (21%), checking the tablet expiry dates (70%), using a drug for which the patient was not allergic (62%). The 47 nurses were all together satisfied (100%) with this workshop.

What next?

The simulation based program was adopted by the hospital department of nurse care. It is now integrated in the yearly re-assessment skills program of all nurses.

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Author(s)

Chloé HERLEDAN, Laura BEAUMIER, Laurence MINISCHETTI, Marie-Christine ALBERTO-GONDOUIN

Why was it done?

Existing floor stocks are limited to usual psychiatric drugs. On-call resident pharmacists dispense additional treatments during pharmacy closing hours. Hence, extending the floor stocks would facilitate continuity of care. SASC centralisation enables simple and secured access to medication while saving space in care units.

What was done?

A new drug and medical device floor stock was implemented in our psychiatric hospital. The floor stock is contained in a secured automated storage cabinet (SASC) located in a protected area inside the pharmacy and accessible during its closing hours. Utilisation training was offered to nurses through multiple formats.

How was it done?

Floor stock composition has been established from frequent requests made during on-call time and can be consulted on the pharmacy website. Prescriptions and patient informations can be checked before removal on a computer in the SASC area. The SASC requires badge identification, unit and patient name entry and provides traceability of removals. Moreover, cold storage requiring drugs are housed in a refrigerator unlocked through the SASC. Regarding utilisation training, all night nurses had to attend a demonstration of the SASC performed by the resident pharmacists. This demonstration was also offered to day nurses and head nurses during weekly pharmacy open days for three months. In addition, an instruction manual and a video tutorial were produced and uploaded on the website.

What has been achieved?

60/67 (89.5%) night nurses, 80/256 (31.2%) day nurses and 10/20 (50.0%) head nurses have attended the SASC demonstration. A satisfaction survey conducted among trained nurses or head nurses had an 18.7% response rate. 26/28 (92.9%) of respondents attended the demonstration and all were satisfied by its quality. 2/28 (7.1%) only used the instruction manual. All respondents declared being able to use the SASC, however 7/28 (25.0%) would need assistance from the instruction manual or video tutorial.

What next?

Further utilisation training or assistance will be provided by the video tutorial. Removals and prescriptions will be checked by pharmacists to uncover picking errors. Impact on resident pharmacists’ workload will be assessed within six months. Finally, SASC centralised floor stock is an interesting approach for hospital pharmacies with limited staff to improve continuity of care.

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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)

Ane Hornbaek Mortensen

Why was it done?

Previously, a quarterly report showing adherence to national treatment guidelines was issued to all hospital administrations in our region. It was their responsibility to forward this to the appropriate specialists/consultants. This often failed and even when it was done, our experience showed that it wasn’t read by the consultants. Consequently, prescription patterns didn’t change despite the report highlighting the wards that weren’t complying with the national treatment guidelines.

What was done?

Short newsletters including graphs/tables showing the ward’s degree of adherence to national treatment guidelines were emailed to the chief consultant of the specific ward.

How was it done?

In our region a 6-person analytical team, which includes 3 hospital pharmacists, monitors adherence to national treatment guidelines issued by our national council for the use of expensive hospital medicines (RADS). Based on the results, the analytical team decides which newsletters to write. The hospital pharmacists in the analytical team are responsible for writing the newsletters and emailing them direct to the relevant specialist/consultant.

What has been achieved?

It seems as if the introduction of more targeted information has led to more rapidly changing prescription patterns. One example is oral iron chelating agents to hematological patients where a RADS guideline was issued recommending that all new patients should receive deferipron instead of deferasirox. This information was initially issued through the usual channels (via hospital administration) but no change in the use of deferipron/deferasirox was seen. This only happened after emailing a newsletter directly to the chief consultants of the three hematology wards in our region, showing the current use of deferipron/deferasirox and the potential cost reduction. Nine months and three newsletters later the percentage of deferipron use on the hematology wards increased from 2% to 27%, leading to a 22% cost reduction. Target was 25% deferipron (the guideline only covered new patients). The total increase in the percentage of deferipron use on hospitals in our region was 351% compared to an increase of between 0 and 19% in the other four national regions.

What next?

Continued and increased use of targeted communication in the health care system is required to ensure that specific information reaches the relevant players.

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Author(s)

S. Walk-Fritz, T. Hoppe-Tichy

Why was it done?

To improve drug safety, it is crucial to develop and maintain core competencies in a multidisciplinary medical team. Current clinical pharmacy education may provide some exposure to ward based clinical pharmacy, but so far there is no structured prerequisite training for pharmacists practising clinical medication management.

What was done?

A training framework for clinical pharmacists practising medication management was developed and implemented. The area of activity included medication reconciliation, participation in medical rounds, discharge counseling, etc. The novel curriculum was designed in order to (1) support junior hospital pharmacists in acquiring clinical pharmacy skills, communication skills and personal skills and (2) help senior clinical pharmacists to maintain and improve their skills.

How was it done?

Senior clinical pharmacists developed a training framework:

– Initial skill adaptation for junior hospital pharmacists (eg, observe an experienced clinical pharmacist participating in medical rounds, patient case presentation and evaluation, and participation in the drug information centre).

– Maintain and improve the skills of all clinical pharmacists performing patient centred care (eg, Jour Fixe (presentation and discussion of clinical treatment guidelines, patient case presentations), journal club, supervision discussion (patient case discussion with two senior clinical pharmacists) and supervision of participation in medical rounds by senior clinical pharmacists).

What has been achieved?

The training framework has been implemented successfully with a high general acceptance. Particularly, the Jour Fixe has allowed junior staff to acquire appraisal skills and senior staff to achieve continuing professional development. The supervision discussion of patient cases has also been well appreciated as a mean of acquiring additional skills. Parts of the training programme have been implemented in the training of pharmacy interns, such as performing medication reconciliation on admission.

What next?

The implemented training programme needs to be further expanded and adapted over time. A future aim is to establish a model with the German Association of Hospital Pharmacists (ADKA) for a national systematic training module (eg, for performing medication reconciliation).

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Author(s)

E. Past, C. Hofer-Dueckelmann, U. Porsche, G. Fellhofer

Why was it done?

The increasing demand for clinical pharmacy services was combined with the will of the MI pharmacists to expand their roles and become advanced practitioners. There is no formal clinical pharmacy education in our country. Studying abroad is costly and often incompatible with private life. The head of our department promoted the introduction of the teaching bundle as a form of quality assurance for new clinical services.

What was done?

A clinical pharmacy training scheme was founded for and by pharmacists of the medicines information (MI) department. Over 1 year, four UK trained clinical pharmacists facilitated: 10 workshops on clinical topics focusing on pharmaceutical care planning; monthly discussions on patient cases collected in our hospital; and bedside teaching on two wards.

How was it done?

The main drivers were the pharmacists´ willpower to become more clinically orientated and the prospect of being able to offer new clinical services. The instructors incorporated the preparation of the educational activities into their routine workload. There were no monetary incentives. The workshops lasted 1 h with any further discussions held after work, a challenge for parents.

Instructors presented the newest insights of the respective clinical area, alternating with group activities. Continuous evaluation led to a stronger focus on real patient cases. This approach was continued during the monthly coffee break case studies. Incorporation of bedside teaching into the rota was a challenging task.

What has been achieved?

Two pharmacists set up a clinical service on an intensive care unit. Another pharmacist started to attend ward rounds on a neurosurgery ward. Medicines reconciliation will be introduced with pharmacy involvement in a pilot project.

What next?

This training scheme is transferable to any hospital setting. Prerequisites are idealistic and formally trained clinical pharmacists combined with highly motivated colleagues wishing to take on more responsibility and willing to learn from their peers. Workshops, a journal club and bedside teaching are ongoing.