Assessing the Application of Essential Medication Errors Prevention Strategies in Healthcare Institutes: STOP Medication Error Project
European Statement
Patient Safety and Quality Assurance
Author(s)
Monira Alwhaibi
Why was it done?
This study is the first project of the STOP ME projects which aims to develop a tool that can assess the application of the essential strategies that can stop or minimize MEs in healthcare institutes in Saudi Arabia. Consequently, stakeholders in the healthcare system can identify current gaps that need feature improvement to enhance patient safety
What was done?
Medication Errors (ME) are defined as unintentional drug-induced harm that led to morbidity and mortality. The STOP (ME) project is a comprehensive series of research studies that aim to explore MEs in Saudi Arabia and how to stop such harmful events.
How was it done?
Extensive search of the literature review for the essential strategies to stop or minimize MEs was carried by the research team to develop a draft of the aimed tool. The survey tool was sent in round 1 to the Delphi experts’ panel for review. Based on received recommendations, the tool was updated and sent for round 2 review and consensus. The developed tool was then piloted to test the practicability of the tool before running the survey on large sample size (second project). The study was approved by the King Saud University Medical Centre IRB ethics committee [20/0153/IRB].
What has been achieved?
After using the Delphi technique two major changes happened to the survey. 1) Section A was removed (high alert medications). 2) A new section was added (ISMP publications) with some minor changes. Launching a pilot survey on thirty healthcare practitioners (physicians n=11, pharmacists n=10, nurses n=9) resulted in further minor changes by adding two new columns. The final tool was a survey consists of six sections including Demographics, Prescription, Dispensing, Administration, Monitoring and Quality, and Targeted Medication Safety Best Practices for Hospitals. All combined 86 questions with the determined time to answer the survey is in the range of 25-30 minutes. Overall feedback of the pilot survey was good.
What next?
This initiative “STOP ME” will have a significant impact in the field of medication safety research and will build awareness among institutes in Saudi Arabia that are lacking important strategies that prevent MEs
IMPROVING HIGH-RISK DRUG PRACTICES IN THE EMERGENCY DEPARTMENT – A MULTIDISCIPLINARY APPROACH
European Statement
Patient Safety and Quality Assurance
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.
Elaboration of a Good Practice Guide for the administration of parenteral antibiotics at children’s hospital
European Statement
Patient Safety and Quality Assurance
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.
Drone delivery of prescription medicines: contact-free, direct-to-consumer shipment reduces risk of Covid-19 infection for vulnerable populations
European Statement
Patient Safety and Quality Assurance
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.
ANTICHOLINERGIC MEDICATION IN HOSPITALIZED PATIENTS
European Statement
Patient Safety and Quality Assurance
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.
Optimizing information on the fecal microbiota transplantation circuit
European Statement
Patient Safety and Quality Assurance
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.
Improving Patient Safety: A step forward in reducing missed medication in the Emergency Department (ED)
European Statement
Patient Safety and Quality Assurance
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.
Improved drug management for surgical inpatients through the presence of a clinical pharmacist at the preoperative clinic
European Statement
Clinical Pharmacy Services
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.
Quality Improvement Project of Clozapine Prescribing Process in a Mental Health Unit
European Statement
Clinical Pharmacy Services
Author(s)
Charlotte Stafford, Aoife Delaney, Virginia Silvari, Thomas Cronin, Deirdre Lynch
Why was it done?
The Pharmacy Department dispenses clozapine to 142 patients. A new prescription was issued each time a patient was dispensed clozapine (approximately 40 new prescriptions per week). From January 2019 to June 2020 there were 42 clozapine incidents (incidents/month= 2) reported by the Pharmacy Department to the MHU. A four week review also showed that prescription queries (dose changes and transcription errors) consumed 6 hours of pharmacy staff time. The new 6-monthly, electronically stored prescription and the dedicated email address should address these issues.
What was done?
A newly devised proforma clozapine prescription has been developed by the Pharmacy Department and has become valid for 6 months for patients on 4-weekly blood monitoring. A copy of each patient’s prescription is stored electronically in the Mental Health Unit (MHU) share drive. A new dedicated pharmacy clozapine email address has been generated for all clozapine dose changes to be communicated to.
How was it done?
Four new clozapine prescriptions were developed by the Pharmacy Department:
– a maintenance dose prescription
– standard titration days 1 to 8
– standard titration days 8 to 15
– blank titration prescription.
The new prescriptions for patients on 4-weekly blood monitoring, valid for 6 months, are now stored in the MHU share drive to reduce the risk of transcribing errors.
What has been achieved?
Once the new system had been established, a further 4 week review showed that only 10 minutes over 4 weeks was spent by pharmacy staff dealing with a prescription query. All dose changes were now communicated by email. Incident reporting has decreased, with 5 clozapine incidents being reported by the Pharmacy Department between January to June 2021 (incident/month <1).
What next?
A business case highlighting the importance of a dedicated Clozapine Pharmacist has been submitted to further develop the clinic and ensure safety of this vulnerable cohort of patients.
IMPLEMENTATION OF ASSISTED ELECTRONIC PRESCRIPTION IN THE OUTPATIENT AREA
European Statement
Patient Safety and Quality Assurance
Author(s)
JUDIT PERALES PASCUAL, HERMINIA NAVARRO AZNAREZ, ANA LOPEZ PEREZ, LUCIA CAZORLA PODEROSO, IRENE AGUILO LAFARGA, ANA PEÑAS FERNANDEZ, Mª REYES ABAD SAZATORNIL
Why was it done?
Despite the volume of patients seen at UPEX, the complexity of care and the cost of the treatments, in 2019 the prescription was transcribed by pharmacists with the consequent risk/investment of time that this entails. The aim was to incorporate organizational/technological changes that would improve the safety and quality of pharmaceutical care.
What was done?
An outpatient is a patient who goes to the outpatient unit of their Hospital Pharmacy Service (UPEX) to collect a drug for hospital use/diagnosis or foreign drug (it will be administered without health personnel intervention).
We collaborated in the design and validation of the PresSalud®(Dominion®) program, developing the implementation of assisted electronic prescribing (AEP) as an objective in the SAMPA project (Registration and Promotion Service for Adherence to Medications for Elderly Patients).
How was it done?
Access from the electronic medical record to the prescription, the integration of the latter with the dispensing program and the latter with the pharmacy item program guarantees an increase in the safety of medication use by incorporating clinical decision aids.
Different prescription assistance protocols were developed. Presentations and sessions were given to hospital doctors explaining how to prescribe through PresSalud® adapting them to the different services implemented with AEP.
What has been achieved?
In 2018, the AEP was implemented in the infectious, digestive, dermatology, rheumatology, neurology and hematology service (only in hemophilia consultations). Between May-September 2020, it was expanded. It is currently 92.3% implemented and 100% is expected by the end of 2021 (with the rest hematology consultations).
Currently, the percentage of prescriptions to outpatients using AEP with respect to the total prescriptions in this area is 83%; this increase contributes to avoid errors in transcription and to reduce the time spent in checking the prescription, providing greater safety in the use of the medication and better patient care which translates into higher quality of care.
What next?
The implementation of the AEP guarantees safe and efficient prescription; in short, the organizational/technological changes that this entails contribute to improving the quality of pharmaceutical care received by the patient. The proposed solution can be easily extended to other hospitals implementing AEP.