Author(s)

Alison Brown, Gillian Cavell, Nikita Dogra, Cate Whittlesea

Why was it done?

Anticoagulants are high-risk drugs. An NHS England Patient Safety Alert was published in 2015 highlighting harm from inappropriate co-prescription of anticoagulants1.

What was done?

A ‘duplicate anticoagulant alert’ (Anticoagulant MLM) was implemented within our electronic prescribing system (EPMA) to alert prescribers if co-prescription of two or more anticoagulants was attempted, with the intention of preventing the completion of a potentially harmful prescription. We conducted a retrospective review of the impact of the Anticoagulant MLM on preventing co-prescription of low-molecular weight heparin (LMWH) and direct oral anticoagulants (DOACS)

How was it done?

The study took place in a 950 bed UK acute teaching hospital. A report of all Anticoagulant MLM alerts generated for adult inpatients between 26th June 2017 and 8th October 2018 was extracted from EPMA. Data on drugs prescribed, alert acceptance or override and duplicate anticoagulant administration were collected. Where alerts were overridden, appropriateness of the override was assessed by an anticoagulation specialist pharmacist. Ethics approval was not needed.

What has been achieved?

The Anticoagulant MLM triggered on 894 occasions; 113 in response to attempted prescription of a LMWH for a patient already prescribed a DOAC. 65 of 113 alerts were overridden (duplicate prescription completed). 48 alerts were accepted (duplicate prescription avoided). Of the 65 overridden alerts, consecutive doses of both anticoagulants were scheduled appropriately. No duplicate doses were administered in 44 cases (44/65, 67.7%). 15 duplicate prescriptions were either cancelled before administration or not administered concurrently (15/65, 23.1%). Duplicate doses were administered against 6 prescriptions (6/65, 9.2%), on 3 occasions. No patient harm was identified. The alert prevented inappropriate co-prescription of anticoagulants to 48 patients. Overrides were justified in 44 cases. Anticoagulants were correctly prescribed for 92/113 (81.4%) patients. It was outside the scope of this project to investigate why alerts were overridden. ‘Alert fatigue’2 and alert frequency3 are recognised factors limiting the effectiveness of electronic alerts in changing a planned course of action.

What next?

The alert remains in place as a barrier to error. Further work is needed to identify reasons for anticoagulant alert overrides.

Pdf

Author(s)

Linda Jeffery

Why was it done?

The primary aim was to increase patient safety by quality-assuring ESPs and guiding clinicians to rational and safe prescribing. The Central Denmark Region (1.3 million citizens) has five hospitals, each with their own hospital and ward management. ESPs were previously set up and maintained locally, often by clinicians at ward level, resulting in several thousand, and a huge variety of ESPs for the same indication/treatment. Often only small differences separated these, but larger differences were also observed. Both patients and clinicians move around hospitals within the region. Varying ESPs from hospital to hospital confused clinicians and compromised patient safety.

What was done?

The regional Drug and Therapeutics Committee (DTC) commissioned the Hospital Pharmacy, Central Denmark Region to take over management of electronic standard prescriptions (ESP) in the shared Electronic Prescribing System (EPS). The pharmacy was also commissioned to lead the unification of local to regional ESPs, in collaboration with clinical specialists. ESPs are electronic ‘packages’ of one or more prescriptions, set up for treatment of defined conditions/procedures e.g. knee-replacement. When the clinician prescribes an ESP, the predefined prescriptions appear automatically in the patient’s medicines list.

How was it done?

The Hospital Pharmacy highlighted clinical areas/treatments with several variations of the same ESP. The DTC appointed relevant clinicians to work with a pharmacist on unifying these, to one (or more) standardised ESPs, to be used in the whole region. The pharmacist was coordinator for the ad-hoc working groups. After approval by the DTC, these ESPs replaced the existing. If a department wanted an ESP that differed from the regional ESP, this had to be approved by the DTC.

What has been achieved?

Regional ESPs have been approved for:
• Abortion (reduced from 17 to six).
• Helicobacter pylori eradication (reduced from 28 to two).
• Treatment of paracetamol-overdosage.
Many new ESPs have been approved, promoting:
• Safe prescribing of complicated regimes e.g. fosphenytoin loading/maintenance.
• Use of regional formulary drugs e.g. antibiotics for pneumonia/urosepsis.

What next?

We continue to work on other regimes that can be unified e.g. treatment of Wernickes prophylaxis/syndrome and parenteral nutrition. We recently met with pharmacists from two other regions that use the same EPS as us – maybe we can share ESPs nationwide in future.

Pdf

Author(s)

Charlotte Ménage-Anjuère, Rakiba Belkir, Elisabeth Bergé, Audrey Decottignies, André Rieutord, Xavier Mariette, Raphaèle Séror

Why was it done?

We needed to assess the impact of our patient education program on Sjogren’s syndrome (SESAME) in order to continuously improve it.

What was done?

A playful online questionnaire was designed and implemented to assess patients’ knowledge about Sjogren’s syndrome.

How was it done?

A interprofessional team (3 rheumatologists, 3 pharmacists) and a 4-patient group who participated in the education program together proceeded to the questionnaire design: 1) definition of a competency framework for patients with Sjogren’s syndrome; 2) from literature review, identification of quality requirements for a questionnaire (scientific quality, opportunity to interact, means of expression, logical chaining of questions, simplicity, utility, shortness, bias prevention, playfulness, variety, online diffusion). To fulfill these criteria, we used a clear vocabulary and concise questions, included open-ended questions on patient experience, focused on the artwork, randomized the order of answer choices, and shared the questionnaire online. Once the SESAME quiz was established, a scoring system was defined by the expert group. Face validity, feasibility and reproducibility were assessed to validate the questionnaire. 25 patients were contacted to complete the questionnaire twice. Patients also evaluated the content, structure and feasibility using 12 items (understandable language, unambiguous sentences, length of the questionnaire, difficulty, web access). Reproducibility was calculated using intraclass correlation coefficient (ICC) on patient answers separated by 48 hours.

What has been achieved?

The questionnaire includes 28 questions divided into 4 parts: Sjogren’s signs, Sjogren’s causes, treatment, daily life with the disease. The 25 patients filled in the questionnaire twice (96% women, 54 years min-max[23;74], 4 years since the diagnosis min-max[1;20]). The questionnaire was filled in from a computer (n=38), a tablet (n=3) or a smartphone (n=9). The average response time was 19 minutes. The median score was 34 points min-max[22;46] out of 50. 18 patients evaluated the questionnaire. 15 patients or more regarded its content, organization and feasibility as “very good”. 5 patients found it difficult. The reproducibility was very high (total ICC = 0.87 IC95% [0.74-0.94], ICC on each part between 0.61 et 0.87).

What next?

The SESAME quiz is now freely available (https://etp-rhumato.typeform.com/to/qsVhR1) and all the Hospital centers caring for Sjogren patients can use it for their follow up.

Pdf

Author(s)

María Lourdes Recio Blázquez, Alberto Pérez Morales

Why was it done?

It was necessary to establish a quality control of this pharmaceutical process.

What was done?

A computer method of gravimetric quality control of the tablet splitting process was designed.

How was it done?

The procedure consists on a precision scale connected to a computer in which, according to the uniformity of mass assay of the European Pharmacopoeia, the weights of 20% of a batch of whole tablets destined to be split are automatically recorded in a spreadsheet, carrying out the following formulas:
=AVERAGE: provides the average weight of the sample of whole tablets.
=MAX and =MIN: selects respectively the largest and the smallest of the weights.
=STDEV: calculates the standard deviation of the sample weights.
With the average weight of the whole tablets, the theoretical weight of the half-tablets is calculated, establishing a maximum and a minimum admissible limit with the following formulas:
=AVERAGE(whole tablets)/2: determines the theoretical average weight of each half-tablet.
=AVERAGE(whole tablets)/2 ± 7.5%: establishes upper and lower gravimetric limits that cannot be exceeded by any half-tablet.
All the half-tablets need to be weighted, as the tablet-splitting process is carried out tablet-by-tablet and this modus operandi is not reproducible enough. In case of non-compliance with maximum and minimum weight criteria, the half-tablet must be discarded.
Conditional functions were established such that the spreadsheet itself reflects the half-tablet acceptance/rejection decision.
Basic technical computer skills, training in the technique of tablet splitting, appropriate clothing and environmental measures to avoid risks to the operator and the medications are required.

What has been achieved?

Since 2015, two different medicinal products were subjected to the tablet splitting technique. A total of 10,536 halves of suitable tablets were obtained, which permitted safe dosing at lower doses than commercialized, and also generated a financial asset of 101,724 Euros. 566 halves were discarded. The splitting efficiency was of 94.9%.

What next?

This quality control procedure is applicable to all divisible solid oral dosage forms. The standardization of the technique and the quality controls will allow to extend it to other medicinal products with dosing and economic purposes.

Pdf

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.

Author(s)

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

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

Pdf

Author(s)

S. Jornet Montaña, M. Martín Marqués, P. Jolonch Santasusagna, M. Juan Aguilar, C. Gomez Blanco, P. Salvador Collado

Why was it done?

The constant development of new therapies against hepatitis C and the lack of experience in their management requires health professionals to work together.

What was done?

An online platform was created to make inquiries, resolve doubts and establish a shared database among clinical pharmaceutics within the province.

How was it done?

Meetings of the provincial pharmaceutical association were conducted to jointly identify shared necessities across professionals and to determine the best communication system to be used in terms of efficiency, speed and reliability.

What has been achieved?

The pharmaceutical association created an interactive platform, which was easily accessible from a virtual campus. The platform eases the tasks of sending inquiries and comments about side effects to all pharmaceutical professionals in the system, simultaneously and in a timely fashion. This platform also allows the creation of debate forums to answer questions, and promotes knowledge sharing among participants. As time goes by and based on experience of new drugs, a drug interactions database is created. The platform also allows knowledge of whether specific combinations of drugs have been used and the hospital’s own experience, even if no official studies exist. In addition, the platform allows updating the previously introduced interactions and shows who has done it, so this participant can be asked if necessary. This system also allows the sharing of written information, such as patient brochures, recommendations, bibliography and scientific society links and other websites of interest.

What next?

The created platform meets the pharmaceutical participants’ expectations and allows equal treatment of all patients independently of the hospital where they are located. This platform allows professionals to work together for the same cause and overcome individual knowledge and resources constraints. This platform will be used for other illnesses for which special pharmaceutical attention is required. Finally, the platform will be expanded by inviting other provinces to join our project.

Why was it done?

So far, only pharmacists could access the pharmaceutical care record. The creation of the electronic medical record in the Health System has allowed patient data to be centralised and can be accessed easily and quickly. It is an opportunity to integrate our care service as pharmacists within the multidisciplinary care as well as to facilitate data consultation to other professionals that care for the same patient.

What was done?

Integrate the outpatient pharmaceutical care record to the electronic patient record via an application form included in the process of each pathology.

How was it done?

First question was where the application form should be included when the patient came in for a consultation. In order to unify all the actions relating to the process, it was decided to include the form in the main process instead of creating a specific process for the pharmacy department. For example, a form for an HIV patient should be included in his Infectious Disease Consult process.

Another issue was to define what items should be taken into account for the follow up.

Finally, the following items were included: reason for the visit, pathology, clinical data, outpatient treatment, regular treatment, drug-related problems, adverse drug allergies/past issues, adherence, checks to mark whether the patient has received the oral and written information, the leaflet from the host to the Outpatient Pharmacy Service and a free text to write down given recommendations.

What has been achieved?

Improvement of patient care, increased safety in the use of drugs and in the avoidance of medical errors has all been achieved, as well as the promotion of teamwork amongst professionals who attend to the patient. From the information technology perspective, data export can be provided for future researches.

What next?

All professionals should integrate their activities to take advantage of collaboration and increasing synergies.