Author(s)

Mariosa Kieran

Why was it done?

Review of the 2019 Health Information and Quality Authority (HIQA) Medication Safety Monitoring Programme, and in-house Emergency Department (ED) medication variances review identified that risk reduction strategies for specific high-risk drugs and high-risk situations were required.

What was done?

A multidisciplinary team reviewed and implemented initiatives to improve medication safety practices for procedural sedation, emergency tray drugs and ketamine use in emergency settings was undertaken.

How was it done?

• Multidisciplinary teams (MDT) of key stakeholders were formed to review each high-risk drug / practice requiring improvement.
• The MDT developed the required procedures and policies that were further reviewed and approved by the relevant hospital committees.
• The MDT supported roll out of the improvement initiatives through communication, staff education and process review.

What has been achieved?

• A hospital wide procedural sedation policy and patient information leaflet was developed. Competencies for staff that perform procedural sedation have been identified. A specific procedural sedation incident report form has been piloted. A poster detailing the process for sedation reversal is in development.
• Emergency tray drug preparation, storage and use has been standardised across all hospital settings, including the introduction of dedicated emergency drug bags. The bags enable prompt drug retrieval during emergencies and supports safe storage, documentation and disposal of used /unused emergency drugs.
• A protocol for ED use of ketamine was developed. The protocol supports safe use of ketamine for specific emergency indications for which there is little published information, e.g. procedural sedation, analgesia and agitation.
• The initiatives were implemented and included in ED simulation training.

What next?

The described medication safety initiatives have considered the practice challenges for high risk drug access and use in emergency settings. The initiatives have standardised processes for specific high-risk drugs, supporting safer use. MDT collaboration ensured early and ongoing staff engagement from applicable disciplines, facilitating implementation and practice changes. Evaluation of the initiatives in practice is currently under review. The initiatives and learnings are transferrable to other emergency clinical settings.

Author(s)

MOHAMMED ADNANE EL WARTITI, WAFAA ENNEFFAH, BOUCHRA MEDDAH, MUSTAPHA BOUATIA

Why was it done?

The GPG was developed in a concern of practices standardization to guarantee the safety and efficacy of parenteral antibiotics, especially those stored in vials which reuse in possible only if conditions of administration and stability are respected.

What was done?

We developed a Good Practice Guide (GPG) for the usage of major available parenteral antibiotics.

How was it done?

After we listed all parenteral antibiotics available at the hospital pharmacy, we selected the most used ones and we synthesized all manufacturers’ data to establish a GPG for their administration. We also used literature data to complete missing information in “Summaries of Product Characteristics” related to pediatric use of these drugs. Finally we determined the most antibiotics consuming units according to their defined daily doses, where GPG recommendations will be implemented, before their extension to all other units.

What has been achieved?

The GPG concerned the most used antibiotics, which mainly belong to the following classes: Beta-lactam, Glycopeptide and Imidazole antibiotics, Aminoglycosides and Quinolones. It specifies the galenical presentation, used solvents, volume and duration of administration, stability after reconstitution as well as incompatibilities and special measures relating to the use of these drugs. The most antibiotics consuming units are pediatric intensive care units, “IIB” pediatric unit and pediatric surgical emergency department.

What next?

The approach used in this work can be adopted in other similar structures in order to establish GPGs within the framework of a quality control policy aiming to raise the standard of care.

Author(s)

Jon Michaeli, Bryan Li

Why was it done?

The novel delivery method provides an on-demand option for senior citizens at higher risk of serious Covid-19 infections to receive health essentials while maintaining social distancing. The program launched before Covid-19 vaccines were publicly available, and was sustained during a period of especially intense Covid-19 spread in the US from Nov 2020 – Jan 2021.

What was done?

In early May 2020, Matternet, CVS, and UPS launched direct-to-consumer drone delivery of prescription medicines and other health goods to The Villages, the United States’s largest retirement community with more than 135,000 residents. The operations have expanded in scope since and are ongoing

How was it done?

The drone flights were conducted by Matternet’s M2V9 UAV platform and drew upon the companies’ experience operating other US healthcare drone networks. Deliveries are dispatched from CVS store 8381 and flown to New Covenant United Methodist Church, with final delivery to front porches via golf cart. This is an important milestone on the journey to drone delivery to individual homes at scale.

What has been achieved?

Matternet and UPS have completed 2,500+ deliveries to date. The partnership has expanded operations to Elan Buena Vista, another retirement community nearby. The program’s success helped pave the way for other healthcare drone programs, including a new route at Wake Forest Baptist where Matternet and UPS are transporting Pfizer-BioNTech Covid-19 vaccines (first ever in the US).

What next?

Full automation achieved via Matternet’s proprietary drone port, the “Station,” will permit pharmaceutical drone delivery at scale and accelerate the roll-out of city-wide networks that give pharmacists more flexibility around where and how patients receive medicines. These networks will support and accelerate the shift to tele-health and “hospital at home” as well as just-in-time inventory management, with significant potential to reduce medical waste through stock centralization. First commercial deployment of the Station occurred in Lugano, Switzerland in September 2021. The same month, Matternet announced a partnership with the Abu Dhabi Department of Health and the UAE’s General Civil Aviation Authority to launch a city-wide medical network serving 40+ locations by 2023. Similar systems are planned for Europe, in cities such as Zurich, Berlin and Athens.

Why was it done?

To achive the international Organization for Standardization (ISO)´s objectives related to medication errors.

What was done?

A multidisciplinary isoappearances group formed by a clinical pharmacist, a nurse, and two physicians has been set up on site at the ER.

How was it done?

Observational study.

What has been achieved?

In the future, hopefully medication errors at the emergency setting would be reduced.

What next?

Because the Isoappearance group will promote patient safety.

Author(s)

SILVIA CORNEJO-UIXEDA, M JOSE MARTINEZ-PASCUAL

Why was it done?

The anticholinergic burden is the cumulative effect of concomitantly taking multiple drugs with anticholinergic properties. It estimates the risk of suffering anticholinergic adverse effects. Anticholinergic scales are lists that rank the anticholinergic potential of drugs into categories.

What was done?

Our aim is to know the use of drugs with anticholinergic effect (ACD) in a regional hospital.

How was it done?

Observational study in patients older than 70 years admitted to a regional hospital from January to September 2021. We reviewed the medication of the patients looking for ACD. Then, we calculated anticholinergic burden with the “Drug Burden Index” available in: http://www.anticholinergicscales.es/calculate. The variables collected were: age, gender, number of drugs with anticholinergic effect, if ACD were prescribed before hospitalization, readmission, anticholinergic burden, risk of suffering anticholinergic effect and anticholinergic symptoms.

What has been achieved?

average 81 years (70-100), 102 (56% woman), 46 (25%) did not have any ACD. 58 patients had 1 ACD, 56 patients 2 ACD, 12 patients 3 ACD, 8 patients 4 ACD, 2 patients 5 ACD. Of patients with ACD, anticholinergic burden average was 0.98 in surgical patients (medium risk) and 1 in medical patients (elevated risk). 68 patients had medium risk and 68 patients elevated risk. We found constipation in 17 patients, somnolence in 6 patients, and disorientation in 2 patients. ACD used were the following (surgical vs. medical patients): Antidepressants: 3 vs.10, benzodiazepines: 28 vs. 33, opioids: 17 vs. 27, antiemetics: 13 3 vs. 38, Antipsychotics: 4 3 vs. 49, antihistamines: 2 vs. 2, antiepileptic: 0 vs 9, other: 0 vs. 3.
56 patients (31%) were prescribed the same ACD that they took before hospitalization. Only 17 patients were readmitted in hospital in less than a month.
We just made 2 interventions. We proposed to lower the dose in one case. In another, we proposed give metoclopramide just if necessary.

What next?

Most of hospitalized patients have ACD prescribed. Half of them had a high risk. However, just a few had anticholinergic reactions. This could be explained because we only had the information of electronic history and maybe some of them were not collected.

Author(s)

Julia Santucci, Céline Vaesken, Guillaume Saint-Lorant

Why was it done?

FMT is a therapy introduced in 2016 at the hospital. It is indicated for the management of recurrent and refractory Clostridioides difficile (CD) infections. In November 2020, with the resumption of the activity, we note a lack of knowledge of the different actors on this circuit: physician, nurses, fellows, patients himself.
The objective of the study is to reinforce the understanding and safety of the FMT circuit in a university hospital after the evaluation of the knowledge of the different actors.

What was done?

Implementation of a document to represent the circuit of fecal microbiota transplantation (FMT) in a French university hospital.

How was it done?

In this context, two questionnaires containing less than five questions on the functioning of the circuit were carried out with the nurse coordinators (NC) and the interns of the hepato-gastrology department. Subsequently, a document was drafted in consultation with the referring physician, the head of department and the pharmaceutical team to represent the FMT circuit.

What has been achieved?

With regard to the questionnaires, we obtained six answers from the NC, with 42% correct answers, 25% partial answers and 33% incorrect answers, and then six answers from the residents, with 20% correct answers, 7% partial answers and 77% incorrect answers.
These questions made it possible to draw up a diagram adapted to A4 format intended for all the actors in the circuit. It defines the different missions of all the actors with the corresponding deadlines and associated procedures.
In order to improve information, two interventions were carried out by the pharmacy: a staff meeting dedicated to the management of CD infections with the interns, co-hosted with the referring physician, and a presentation of the circuit to the NC.

What next?

Finally, this study made it possible to reinforce the safety of the FMT activity for the patient and to improve the management of the circuit for the various health professionals involved in this specialized therapy.

Pdf

Author(s)

Theodora Steindl-Schönhuber, Gittler G.

Why was it done?

Medication dispensing is a time-consuming, labour-intensive, error-prone process in the daily routine on the wards. The project was triggered by the tight personnel situation during the Coronavirus pandemic: In November 2020 three wards with COVID-19 patients (91 beds) were integrated into our Unit Dose blister service to assist the nursing staff. A multidisciplinary effort (management, IT-department, doctors, nursing staff, pharmacy holding a GMP-manufacturer´s certificate) and long-established electronic patient records including medication data enabled fast realisation.
After transformation back to a chirurgical, an internal and a geriatric ward the service was continued and extended to the neurological unit (49 beds) due to positive feed-back. We wanted to study the observed positive effects of Unit Dose supply in more detail.

What was done?

In our hospital medication distribution has been switched from manual dispensing by ward staff to automated Unit Dose blister packaging by the pharmacy. Our study investigates the impacts of this change on medication safety, staff satisfaction, time and drug resources.

How was it done?

The percentage of pharmacy-blistered drugs, time gain for nursing staff, employee satisfaction, medication consumption and erroneous blister fillings were investigated.

What has been achieved?

Unit Dose in hospitals is not standard for many countries and is so far unique in Austria. Therefore, we would like to share our experiences and findings with our colleagues: Solid, oral dosage forms could be supplied by 99% via Unit Dose. Time for manual drug dispensing was reduced by 75%. A survey showed high employee satisfaction with the supply process as well as the quality and correctness of the blisters. Consumption of blisterable drugs and stocks on the ward were reduced by 44% and 78%, respectively. Errors in blister fillings in our setting amount to 0,006%. When compared to literature references on error rates for manual medication dispensing (up to low double-digit rates), patients benefit from increased drug therapy safety. On the basis of these results our initiative was granted the Austrian Patient Safety Award 2021 in the field of medication safety.

What next?

We plan to extend Unit Dose to the remaining wards and to investigate patient satisfaction with the blisters, cost-efficiency and distribution of high-cost medications.

Why was it done?

Long waiting times and delays in patients leaving ED increase the risk for missed doses. Medication reviews and analysing incident reports identified missed doses as a patient safety issue where the strategies implemented aimed to improve this.

What was done?

Reducing missed doses and improving patient safety was addressed as follows:
 Integrated pharmacy service was established
 Audit completed
 Education model developed
 Stock list reviewed

How was it done?

Integrated pharmacy service:
-Outlined the role of the pharmacy team in ED.
-Pharmacist medication review service established which identified medication incidents particularly missed doses.
-Pharmacy technician role expanded: Reviewed patient charts, identified issues, collaborated with the ED team, and dispensed medication in medication
transfer bags.
-Implemented medication transfer service: Individual patient medication transfer bags were sent from ED to the transfer ward ensuring timely availability
of medication during transitions of care.

Data collection and analysis:
-Quantified missed doses and reviewed the percentage of these which were time-critical. Time-critical medications are medications where timely
administration is crucial to prevent patient harm.

Education model:
-Developed and implemented a pharmacy technician training programme: This ensured an optimal medication management service.
-A local list of time-critical medication was agreed upon. A poster was developed and erected in ED to highlight time-critical medication.
-Structured and targeted multi-disciplinary education was provided on time-critical medication and the impact of missed doses.

Stock list modified so medication was immediately available in ED. Capacity in the automated dispensing unit (ADU) was an obstacle so the ADU was reconfigured to overcome this.

What has been achieved?

 A clinical pharmacy service was established which reduced medication errors.
 Missed doses decreased by 75%.
 Time-critical medications are readily available.
 Medication transfer bags ensured timely availability of medication during transitions of care.
 Education model implemented which improved patient safety.

What next?

 Continue the integrated pharmacy service in ED.
 Missed doses will be assessed through point prevalence surveys, medication reviews, and incident reports.
 Extend the education model to other areas of the hospital and apply learning.
 This initiative can be adapted to other hospital settings.

Why was it done?

Falls in older people are a significant public health problem due to their high prevalence, the injuries they cause and the associated economic burden. They are often caused by multifactorial risks, being the Fall-Risk-Increasing-Drugs (FRIDs) one of the most significant ones. The aim of this initiative is to reduce FRIDs prescriptions among elderly at risk of falling, by assessing their individual Benefit-Risk Balance.

What was done?

A circuit was designed and implemented to review and optimize the medication of patients admitted to hospital after a fall.

How was it done?

On an everyday basis, the Health Management Unit of our tertiary university hospital sends a list of fall-related hospital admissions to the clinical pharmacists (CP), who review those patients’ medication and identify FRIDs (drugs affecting central nervous system, hypoglycemic/antihypertensive agents, among others). Electronic Health Records (EHR) are consulted to evaluate if medication could have had a role in those falls. When a patient’s medication is subject to any optimization, CP contact the referring physician to propose therapeutic modifications. This pharmacist-doctor communication is carried out during the hospitalization period in case of Internal Medicine admissions and by an administrative appointment with the primary care physician (PCP) when patients are admitted in other units, such as Traumatology or Neurosurgery. The PCP evaluates the medication review report attached by CP in patients’ EHR and modifies medication if necessary.

What has been achieved?

Between May and September 2021, 114 patients were admitted to hospital due to a fall. After excluding 10 institutionalized patients (pharmaceutical care provided by their own team), 6 patients having fallen after alcohol consumption or intentional drug overdose, and 7 palliative patients, the medication of 91 patients was reviewed. The mean age was 80 and the 64.8% were female. An average of 3 FRIDs was identified per patient. 52 pharmaceutical interventions were made, mainly dose reductions and FRIDs deprescribing suggestions.

What next?

This initiative is feasible and potentially beneficial for patients’ health care. Medication review leads to the identification of not only FRIDs, but also different drug related problems. We look forward to assessing the impact of our practice in terms of interventions accepted; drug-related negative outcomes avoided and decreased hospital readmissions.

Author(s)

Françoise LONGTON, Olivia Polinard, Linda Mattar, Anna Pauels, Mireille Bourton, Michel Mattens

Why was it done?

A thorough medication history at admission reduces medication errors. The presence of a clinical pharmacist in the preoperative clinic increases the number of inpatients who receive a standardized medication history by a pharmacist.

On admission, the adaptation of home medications to the hospital formulary can also be a source of error or delay. The fact that the patient is seen by a pharmacist prior to hospitalization makes it possible to anticipate drug substitutions and possible orders for non-formulary drugs.

Moreover, surgeons do not always have the possibility to prescribe medications taken at home upon admission, which results in a delayed availability of the medication. Thanks to this multidisciplinary project the continuity of treatment is assured.

What was done?

During the preoperative consultation, a pharmacist takes a medication history and enters it into the computerized medical record, making it available for the anaesthetist.

Upon admission of the patient, the continuity of the medication is ensured by the pharmacy.

Indeed, during the admission, the nurse follows a procedure that informs the pharmacy of any medication changes since the preoperative consultation. Afterwards, the pharmacy encodes the treatment into the computerized intra-hospital prescription and delivers it to the department.

Before any drug administration, this treatment is signed by the doctor responsible for the patient.

How was it done?

Preoperative consultations had to be structured so that each patient was first seen by the pharmacist, second by a nurse and third by the anaesthetist.

Thus, the main obstacle was organizational and it was overcome through the centralized management of preoperative clinic appointments.

What has been achieved?

In 2020, 54% of patients admitted for surgery (elective or emergency surgeries) were seen in the preoperative clinic.

What next?

This is an example of good practice as it ensures a standardized medication history and admission management.