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Implementation of a protocol to ensure continuity of pharmaceutical care in hospitalised outpatients

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European Statement

Clinical Pharmacy Services

Author(s)

MARCELO DOMINGUEZ CANTERO, CARMEN MARIA DOMINGUEZ SANTANA, MARCELINO MORA CORTES, ESMERALDA RIOS SANCHEZ, JUAN MANUEL BORRERO RUBIO

Why was it done?

Patients who withdraw medication from outpatient pharmacies in Spanish hospitals are provided with pharmaceutical care and pharmaceutical care stratification tools in specific outpatient pharmacy consultations. These patients are usually multi-pathological with multiple drug interactions, contraindications, and important adverse effects. Therefore, during the hospital admission of these outpatients, it was appropriate to provide continuous care from the hospital pharmacy. Before the implementation of the protocol, there was no specific and systematic follow-up of hospitalized outpatients.

What was done?

Implementation of a protocol that provides pharmaceutical care to outpatients during hospitalization, ensuring continuity of care through the pharmacy service.

How was it done?

The main problem with the implementation was the real-time detection of hospitalized outpatients. The development of a software tool to facilitate the location of patients provided an impetus for the implementation of the project. The computer tool selected patients who met the inclusion criteria (hospitalized outpatients with medication withdrawal in the outpatient unit in the last two months). Patients treated with erythropoietin and colony stimulants were excluded.

What has been achieved?

Seventy-nine patients were included in the study between April and September 2023; 62.1% were male. Main pathologies included 41.9% oncohaematologic diseases, 18.9% human immunodeficiency virus, and 17.7% immune-mediated inflammatory diseases.
The reason for admission was related to the pathology for which outpatient medication was withdrawn in 27 patients (34.2%), and six patients (7.6 %) were admitted due to an AE of the medication withdrawn in outpatients. Pharmaceutical interventions (PI) were performed in 21.5% of the patients reviewed, and 76.5% were accepted. PI reasons included discontinuation of treatment (64.7 %), modification (17.7 %), initiation (11.8 %) and monitoring (5.9 %).

What next?

With our protocol, we want to show that outpatients within the pool of patients admitted to a hospital are a priority target group. For these patients, the hospital pharmacist can improve treatment during hospitalization with a high degree of pharmaceutical intervention.

A new medication-use process implemented in the perioperative setting

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European Statement

Patient Safety and Quality Assurance

Author(s)

Almudena Ribed, Alvaro Gimenez-Manzorro, Beatriz Torroba-Sanz, Ana De Lorenzo-Pinto, Maite Portas-Gonzalez, Maria Dolores Ginel-Feito, Pilar Cabrerizo-Torrente, Maria Luisa Martin-Barbero, Ana Herranz-Alonso, Javier Hortal-Iglesias, María Sanjurjo-Saez

Why was it done?

There is a high prevalence of medication errors in the perioperative setting. Health organizations highlight the need for effective practices to ensure safe medication use. A group of pharmacists, surgeons, anaesthesiologists, nurses, and IT technicians coordinated by the management was formed in 2020. Failure mode and effects analysis (FMEA) of the perioperative use of drugs was performed in 2021. The group detected up to 25 failure modes and conducted a bibliographic review to gather and prioritise the implementation of safety practices.

What was done?

We re-engineered the process of medication use in the perioperative setting, from pre-admission to discharge, and implemented safety practices to improve safe medication use in the daily practice.

How was it done?

Obstacles were overcome as a result of the multidisciplinary teamwork, management support and the safety culture existing in our hospital. In addition, we listened to health professionals’ opinions, provided monthly information sessions in the Anaesthesia and Pharmacist Department in 2022 and disseminated information through the hospital website.

What has been achieved?

Eight safety practices were implemented in daily practice:
1.Eight safety practices were implemented in daily practice:
1. Implementation of automated dispensing cabinets.
2. Identification and recommendations for high risk drugs.
3. Standardisation of anaesthesia and difficult airway trolleys.
4. Preparation of general anaesthesia trays with ready to administer drugs.
5. Design, development, and implementation of a one-step computerised provider order entry (CPOE) in the operating room, with bar code administration technology.
6. Implementation of a pharmaceutical care programme for surgical patients based on medication reconciliation in all transitions of care.
7. Implementation of new alerts in the clinical decision support system linked to the CPOE to improve pain, anticoagulation, and antibiotic management in the surgical patient during follow-up.
8. Development of new protocols for perioperative management of chronic medications, anticoagulation, diabetes, and antibiotic prophylaxis in the surgical setting.

What next?

The new medication-use process describes a practical and real approach to promote perioperative patient safety in the daily practice. Transfer into other centres is achievable by motivating healthcare professionals, engaging in safety culture and creating multidisciplinary alliances. There is a need to assess the impact and evaluate these safety practices to ensure ongoing improvement.

Checklist for optimal pharmaceutical validation in very low-birth-weight preterm newborns in the neonatal intensive care unit

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European Statement

Patient Safety and Quality Assurance

Author(s)

IGNASI SACANELLA ANGLÈS, MARTA MARTIN MARQUÉS, JULIA BODEGA AZUARA, PILAR LÓPEZ BROSETA, DAVID PASCUAL CARBONELL, HELENA SUÑER BARRIGA, ALEJANDRO SANJUAN BELDA, CARLA DAIANA CIUCIU, SILVIA CONDE GINER, ERIKA ESTEVE PITARCH, ANTONIO GARCÍA MOLINA, SÒNIA JORNET MONTAÑA, ISABEL PLO SECO, Mª ÁNGELES ROCH VENTURA, MARÍA VUELTA ARCE, LAURA CANADELL VILARRASA

Why was it done?

The NICU is a complex area of paediatric hospitalisation that necessitates specialised healthcare professionals. The role of the NICU pharmacist is vital in ensuring the appropriate and optimised use of medications in various critical situations.

What was done?

To develop a checklist that facilitates pharmacotherapy validation for preterm newborns (PTNB) weighing less than 1000 g and hospitalised in the neonatal intensive care unit (NICU). The primary objective is to ensure a higher quality of hospital care in terms of pharmacotherapy.

How was it done?

We conducted a literature review to identify the pharmacotherapy requirements for preterm newborns (PTNB) weighing less than 1000 g during their first 30 days of life.

In order to design the checklist, we compiled various elements, including drugs, dosages, treatment duration, initiation date, and drug monitoring (when necessary). Additionally, we incorporated recommendations for specific scenarios.

What has been achieved?

The drugs considered for this supportive tool include: pulmonary surfactant, ampicillin, gentamicin, fluconazole, caffeine, ibuprofen, iron (ferrum), dexamethasone, nystatin, vitamin D3, and other vitamins. The checklist was designed to cover the first 30 days of life.

From day 0 to 1: Administer pulmonary surfactant and caffeine citrate. For antibiotic prophylaxis, use ampicillin and gentamicin, and fluconazole for antifungal prevention. In cases of an open ductus arteriosus, intravenous ibuprofen should be added.

Between day 10 to 15: Administer vitamin D3 and a multivitamin complex if the neonate tolerates oral administration. If there is a risk of bronchopulmonary dysplasia, which is characterized by more than 7 days of intubation and difficulty with extubation, consider adding dexamethasone and nystatin.

From day 15 onward: Monitor ferritin and vitamin D3 levels. Begin oral iron supplementation (ferrum) 30 days after birth. Both drugs should be continued for one year.

We have included dose adjustments in case of renal or hepatic dysfunction and pharmacokinetic monitoring for antibiotics. In cases where meningitis is suspected, we have provided recommendations for increasing the dose to ensure adequate penetration into the central nervous system.

What next?

This tool simplifies pharmaceutical validation, particularly for pharmacists who may not specialise in the care of these complex patients. By utilising this tool, we can reduce errors and enhance the quality of care provided to preterm newborns (PTNB) weighing less than 1000 g.

Digital transformation of injectable ophthalmic medication circuit: enhancing safety and efficiency

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European Statement

Patient Safety and Quality Assurance

Author(s)

Catarina Diogo, Rui Caceiro, Maria Helena Duarte, Armando Alcobia

Why was it done?

The core objective of healthcare institutions is to ensure patient safety and maintain the highest quality of care throughout every medical procedure.
This principle must extend to the drug circuit as well. Within our hospital, pharmaceutical services have a dedicated route for producing injectable ophthalmic medications, serving 795 patients and yielding 3720 solutions, in 2022. However, the existing paper-based procedure for medication management is laborious, time consuming and error-prone, demanding full-time constant pharmacist involvement to ensure the secure progression of these medications.

What was done?

A software application was developed on the Power Apps platform to streamline medication management for injectable ophthalmic medications. This application aimed to replace manual paper-based procedures with digital solutions, enhancing efficiency, reducing errors, and providing a comprehensive platform for patient registration, prescription tracking, schedule management, and oversight of injectable solutions’ production.

How was it done?

Over two months, needs of pharmaceutical and ophthalmology services were assessed, soliciting input from pharmacists, ophthalmologists, nurses and administrative personnel. Subsequently, a software application was developed featuring four distinct interfaces, customised for each professional group involved. This application enables patient registration, medical prescription, schedule management and monitoring the injectable solutions’ production – prescription and agenda validation, batch management and generation of identification labels.
This project is presented, therefore, as a customised digital solution, the result of a multidisciplinary collaboration.

What has been achieved?

It is the authors’ belief that this software has allowed for the development of a safer, more efficient, and integrated workflow, as an alternative to paper – which is more prone to errors. In this manner, from a pharmaceutical perspective, it simplifies the workflow, freeing the pharmacist to focus on other important tasks and optimizing personnel management. Furthermore, it is also valuable for ophthalmologists, enabling prescription repetition and access to patient history, as well as for administrative staff, streamlining schedule management. In conclusion, this software is set to transform our injectable ophthalmic medication circuit.

What next?

Further studies confirming its advantages are needed. Its validation would establish its potential and applicability across healthcare settings.

Sustainable adherence in the sector transition for schizophrenia patients

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European Statement

Patient Safety and Quality Assurance

Author(s)

Lene Juhl Biltsted, Louise Stilling Rasmussen

Why was it done?

In Denmark, patients with schizophrenia receive free antipsychotic medication for the initial two years post-diagnosis. Post this period, patients transition to the primary sector and assume the medication costs. Historically, the clinic dispensed larger medication quantities, offering short-term relief but not addressing the issue. This approach risks medication waste. The new workflows empower healthcare professionals to help patients establish stable financial arrangements with local pharmacies, curbing fluctuating medication expenses. This enhances patient safety by reducing at-home medication stockpiles. Financial barriers often undermine patient compliance. Healthcare professionals strive to aid patients, curbing relapses and readmissions, through rational, sustainable medication management that minimises resource wastage.

What was done?

Training improved healthcare professional’s understanding of the Danish medication subsidy system and options for deferment in the primary sector.
The healthcare professionals’ new knowledge has provided the foundation for the development of optimised workflows in the treatment process, ensuring a more sustainable medication management during the transition to the primary sector. The project establishes the framework for reducing the risk of medication waste upon the patient’s completion of treatment at the clinic.
It also created a favourable setting for healthcare providers to collaborate with patients, enhancing adherence.

How was it done?

Healthcare professionals received training on deferment arrangements, subsidies, and compliance, with supervision from clinical pharmacists.
Patient cases were analysed to determine factors for future guidelines.
Guidelines were formulated to aid healthcare professionals during the patients’ transition to the primary sector.
A tool (calculator) was created for assessing the patients’ economic choices regarding medication expenses.

What has been achieved?

Healthcare professionals gained confidence in guiding patients on stable medication expenses.
Enhanced rational and sustainable medication use by incorporating the seven rights.
New guidelines now allow an appropriate quality assurance strategy to ensure sustainability and adherence.
Tool to assess medication costs which improves the patients adherence in the sector transition.
Lowered risk of over/under treatment and improper storage.
Diminished treatment failure risk by predicting patient medication expenses during the primary sector transition

What next?

In the next 6 months, the clinic will trial the established guidelines and routines with patients concluding their 2-year treatment.

Integration of Farmis-Oncofarm ® and Oncosafety RC® pharmacy software to improve safety in the administration of antineoplastic drugs with intelligent infusion pumps

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European Statement

Patient Safety and Quality Assurance

Author(s)

MARÍA ELENA CÁRDABA GARCÍA, SILVIA FERNÁDEZ PEÑA, AMPARO SALVADOR PALACIOS, MERCEDES FERNÁNDEZ PRIETO, CLAUDIA GONZÁLEZ GONZÁLEZ, MARÍA TERESA SÁNCHEZ SÁNCHEZ

Why was it done?

Antineoplastic drugs, chemotherapy specifically, are a clear example of “high risk” medications. The drug administration phase, within the drug utilisation circuit, is where the highest incidence of errors has been detected, ranging between 38%-81%, so the development and implementation of tools aimed at improving security at this stage is very important.

What was done?

The integration of Farmis-Oncofarm ® and Oncosafety-RC® pharmacy software was done, in order to improve the prevention, detection and reduction of medication errors in the administration phase of antineoplastic treatment in the Onco-Haematology Day Hospital (OHDH).

How was it done?

A Drug Library was created in Farmis-Oncofarm® software (v.4.0.11.107). Dosage units, stability, standard concentrations, maximum and minimum doses, time and infusion rate, and preparation and administration recommendations were parameterised and standardised. Parameters for the implantation of Oncosafety-RC® software (accepted percentage of volume deviation in the mixtures, types of intravenous lines, possible adverse reactions, drugs to be used in case of extravasation) were also defined. When the connectivity between Farmis-Oncofarm® and Oncosafety RC® was validated, Oncosafety RC® was implemented in the OHDC.
To evaluate the results of the implementation of this strategy, a retrospective study from May 2022 to May 2023 was carried out. Collected data, obtained from Oncosafety RC® software were: number of mixtures (antineoplastic, supportive drugs and intravenous fluid therapy) and treatments administered, dose deviations, adverse events, incorrect infusion rates, errors avoided due to incorrect medication.

What has been achieved?

12,294 treatments (44,898 mixtures) have been administered in OHDC.
Dose deviations were registered in the 0.01% of the mixtures, due to adverse events that required termination of the infusion. Only three adverse events happened in the study period.
The infusion rate was incorrect in the 0.5% of the mixtures; this information is useful to improve drugs administration and prevent infusion-associated reactions.
This strategy prevented errors due to incorrect medication on 2,499 occasions.

What next?

The integration between Farmis-Oncofarm® and Oncosafety RC® has improved the security in the administration of onco-haematological treatments, allowing the reduction of administration and medication errors. This strategy can be implemented in hospitals that have assisted electronic prescription software and information management software between different clinical management systems and infusion pumps.

Opioids room of horrors – an interactive learning to improve safety of drug administration

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European Statement

Patient Safety and Quality Assurance

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.

Implementation of a standardised parenteral nutrition solution on a neonatal ward

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European Statement

Patient Safety and Quality Assurance

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.

Development of standard kits with utensils for outpatient parenteral antibiotic therapy

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European Statement

Production and Compounding

Author(s)

Louise Rasmussen Duckert, Marianne Kjettrup Jensen, Mette Lethan, Trine Schnor

Why was it done?

The hospital pharmacy wishes to support the implementation of OPAT and during the process the need for standardised kits with utensils was identified. The availability of kits with necessary utensils for aseptic handling of parenteral infusion would simplify and standardise the work for hospital and home nurses. Considerations regarding patient safety and sustainability were also in favour of the kits, as choice of utensils could secure compliance to regional guidelines considering use of closed systems and rinse of the line after infusion. Kits containing the exact needed utensils for an administration also reduces the possible waste.

What was done?

The hospital pharmacy has composed standard kits with utensils for outpatient parenteral antibiotic therapy (OPAT).

How was it done?

The kit is composed in collaboration between the pharmacy, hospital nurses and home nurses. The best suited infusion set was chosen – a closed system with two spikes for antibiotic mixing and infusion. Hereby nurses avoid direct contact with antibiotics and avoid antibiotic aerosols in the citizen’s home. The infusion set contains no PVC, phthalates or latex. When fully emptied the infusion set can be discarded as regular waste.
The kit also contains a sterile cover for the workstation, sterile ethanol swabs, gloves, pre-filled saline syringes for rinse of the line after infusion and a written manual. All is packed and labelled by the hospital pharmacy and lot numbers are registered for traceability.

What has been achieved?

The kits have been tested in selected municipalities and the content of the kit has been adjusted. As a result of the feedback a film has been recorded showing the handling of the infusion set. The video is used for training and a QR code on the written manual guides the home nurse to the video if needed. The kit is now used widely in the region and response is positive. With the set-up being identical in all municipalities in the region, handling antibiotics and utensils is simpler for the hospital nurse at discharge.

What next?

As the number of patients in home-based OPAT rises, experiences with the kits will probably result in wishes for adjustments. A new kit with utensils for changing PVK is under development.

Improving people living with HIV therapies compliance: a practical tool customised for patients and designed by hospital pharmacists

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European Statement

Patient Safety and Quality Assurance

Author(s)

Sabrina Trivellato, Daniele Mengato, Maria Mazzitelli, Anna Maria Cattelan, Francesca Venturini

Why was it done?

An optimal compliance is an essential requirement for people living with HIV (PLWHA) to grant drugs effectiveness and safety. Given the complexity of the therapeutic regimen, and the multiple changes to it due to the clinical status, compliance to therapy may be suboptimal. Patients who are not well educated on how to follow their therapy are more keen on quitting the treatment or facing virological failure. According to previous analysis, we reported that 120 patients out of more than 1500 managed by our centre experienced suboptimal adherence to therapy.

What was done?

We created a user-friendly tool to educate HIV-patients on their drugs’ adherence in our University Hospital.

How was it done?

We studied every drug prescribed in our centre and we analysed it from the patient’s point of view. The question we aimed to answer was: “If I were a PLWHA, what would help me assuming the correct drug, at the proper time, avoiding misunderstandings?”. We analysed the shape, colour and dimensions of both the package and the pills/capsules. We focused on the most appropriate way to take every drug and we investigated possible interactions with OTC drugs or dietary supplements.

What has been achieved?

A poster reporting all the drugs available in our formulary was developed: 34 medicines were described in alphabetical order, specifying for each one the image of the package, the usual dosage, the picture of the pill/capsule compared to the dimension of current coins and special warnings about possible drug-drug interactions. We also adopted practical symbols to indicate whether to assume the drug with or without food. The poster became available starting from April 2022 and during the following 5 months a cohort of 960 patients could rely on it.

What next?

In order to help our patients taking their therapies, we expect to get a digital form of this poster to make it available on the phone scanning a QR code. Alongside, we aim to enlarge and improve this digital version by adding a final section with an interactive survey to closely monitor the compliance of the patients and help them to improve it. Through this project we could also obtain an active pharmacovigilance setting.