Author(s)

Kaveh Teimori, Hannah Colldén, Reza Asasdian

Why was it done?

Hospitalized patients often need multiple intravenous drugs simultaneously which are commonly mixed in-line before entering the blood stream. Physicochemically incompatible drugs cause reduced efficacy, clogged catheters and drug precipitation, which can be harmful or even fatal. The risks add uncertainty to the stressful working environment for clinical practitioners. According to a local 2012 survey 68% (n=44) of Sahlgrenska University Hospital (SUH) intensive care unit (ICU) nurses had co-administered drugs uncertain of their compatibility. Hospital pharmacists are hence asked for guidance to optimize compatibility and patient safety.

What was done?

Nurses, doctors and pharmacists were provided with accessible and evidence based information on IV drug compatibility in order to improve drug therapy, working environment and patient safety.

How was it done?

Drug compatibility data was collected by hospital pharmacists who assessed its applicability to Swedish conditions. The results were documented in charts and procedure documents. A project for creating a database was initiated in collaboration with the IT organization in Västra Götaland Region (VGR). A survey was designed to evaluate how the SUH’s ICU nurses experienced the database. Collaboration with nurses, doctors and clinical pharmacists helped improving the quality of the database.

What has been achieved?

Drug compatibility lectures given to nurses, doctors, pharmacists on a continuous basis. Procedure documents implemented in eight clinics. A peer-reviewed work flow is established. The database contains over 2500 assessed drug combinations. Over 700 nurses, doctors and pharmacists from 11 counties plus Norway and Denmark have requested access to the database. Clinics avoid drug mixing by choosing multi-lumen catheters with greater capacity. The 2016 survey showed that 88% (n=86) of SUH’s ICU nurses had co-administered drugs uncertain of their compatibility. The database affected their decisions in 93% (n=45) of the cases, 85% (n=34) found information easier and 88% (n=34) felt more certain when making decisions. A new pharmacist role – IV Compatibility Manager – was introduced and implemented in VGR. In 2016, this work received the national annual award Guldpillret (“The Golden Pill”).

What next?

In the next years, the database will become nationally available and integrated into electronic journal systems. Compatibility issues may then be identified already when prescribing, further improving patient safety.

Author(s)

Gregorio Romero Candel, Esther Domingo Chiva, Laura Rodenas Herraez, Cristina Urbano, Jose Marco del Rio, Nieves Cuenca Cano, Maria Jesus Sanchez Cuenca, Antonio Sanz Arrufat, Ana Valladolid Wals, Angel Escudero Jimenez

Why was it done?

In the areas of critically ill patients such as emergency, intensive care and resuscitation, the use of intravenous drugs (IV) in “Y” are common in clinical practice. Stability and physical-chemical compatibility of IV drugs admistered in “Y” are important, affecting directly the safety of patients and the therapeutic efficacy of medicines, which can lead to medication errors (ME). A quick reference chart was developed in order to facilitate the administration of these drugs and reduce errors in these areas.

What was done?

A chart for quick reference of compatibility of drugs in “Y” for the most commonly used drugs in the areas of critically ill patients of our hospital.

How was it done?

It was a team composed of a doctor specializing in emergency medicine, a nurse and two hospital pharmacists. Economic management of pharmacy program Farmatools® was used to obtain the list of drugs most consumed and those most relevant and specific of these areas were selected.
A chart was made where the header of the rows and the columns was the list of drugs in the study. Finally, we conducted a systematic research on Micromedex® “Y” compatibility with each drug with the remaining, completed the chart with a visual color code: green (compatible), red (incompatible), white (not tested) and orange (precaution, existence of various stability dilutions and consult your pharmacist).

What has been achieved?

The elaboration and implementation of this table will provide a fast and visual consultation instrument to nurses before the administration of drugs in “Y”. This tool intended to facilitate decision-making, contributing to increase the effectiveness of the drugs and avoid possible adverse reactions in patients, increasing the quality of care and lowering the ME.

What next?

We are still working on the same areas to increase safety in drug therapy in critical care. Currently, that improvement measures that are being developed are: new pharmacotherapeutic protocols specifically for those units: high risk medications perfusion protocols and new safety guidelines.

Author(s)

MERCEDES GIMENO-GRACIA, TRANSITO SALVADOR-GOMEZ, ROSA MARECA, JOSE IGNACIO GARCIA-MONTERO, MIGUEL ANGEL SALVO, PILAR ABAD, BEATRIZ ABAD, CESAR VELASCO

Why was it done?

The Spanish Agency of Medicines and Health Products (AEMPS) issues drug and health product-related alerts to the health centres through each region’s Department of Health. The means through which said alerts reach the health professional is not always adequate. The procedures for alert dissemination in our hospital hadn’t been standardized yet: some professionals were alerted more tan once while others weren’t alerted at all. Furthermore, there was no record of these alerts

What was done?

We developed a safety alert management and dissemination system implementation in a hospital setting.

How was it done?

In April 2014, a multidisciplinary workgroup was established (3 members of the Preventive Medicine Service, 2 pharmacists, 2 members of the Supplies Service, 2 computer technicians and 2 members of the hospital’s Management) to analyse management and dissemination of alerts within the hospital at that time. Safety alerts can attain to different elements: drugs, medical devices and public health. Throughout 2015 new circuits and actions were established and in 2016 their implementation was initiated.

What has been achieved?

The workgroup held 7 meetings from April 2014 to June 2016. The project started focusing on drug-related alerts. An algorithm was designed to handle them, in which a pharmacist filtered the alerts (via e-mail) and assessed which had to be spread, and among which professionals. Additionally, the pharmacist managed the alert. The dissemination worked as follows: from the Pharmacy Service to Medical or Nursing Directors, who spread the message to the different units recommended by pharmacist, specifically to their respective Manager, Tutor of Residents and Quality Manager. All alerts were recorded in a database, along with how they were handled.
From January to June of 2016, a total of 235 drug-related alerts were sent from AEMPS. The dissemination was as follows: 44.3% (104) were spread among pharmacists, 36.6% among doctors, 5.5% among nurses and 9.4% to other professionals. The types of drug-alert received were classified as: supply problems (84.7%), use recommendations (7.2%), quality alerts (7.7%) and others (0.5%).

What next?

Next step is implantation of this alert management system with medical devices alerts and public health alerts.

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Author(s)

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

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

Author(s)

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

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

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Author(s)

Gregorio Romero Candel, Esther Domingo Chiva, Nuria Martinez Monteagudo, Jose Marco del Rio, Marca Diaz Rangel, Francisca Sanchez Rubio, Ismael Perez Alpuente, Eva Garcia Martinez, Ana Valladolid Wals

Why was it done?

The ED is an area where medication errors are common given it´s complexity, the large number of patients with different pathologies, having to make quick decisions with little clinical information and the coexistence of professionals with different training.
The use of intravenous (IV) and high risk drugs, as well as the mixture of two or more intravenous drugs in the same diluent are usual and can lead to medication errors.
We designed an educational program based on a session for nurses of the ED to standardize the use of the most commonly administered drugs and improve patient safety

What was done?

A training session for nursing staff on safe drug administration in the emergency department (ED) was performed

How was it done?

A training session was conducted by the fourth year resident during a two month rotation period in this area. The most common mistakes were presented to nurses based on national studies, as well as techniques for safe administration of drugs. Guides on parenteral administration of the hospital were reviewed with special emphasis on high risk drugs and how to manage them according to the Institute for Safe Medication Practices. We also developed a guide including the most frequent drug incompatibilities and direct intravenous administration of drugs for the ED.

What has been achieved?

The aim of the session was to train personnel at the ED in order to reduce medication errors and promote a safety culture. In turn, the development of guidelines to standardize clinical practice are useful, making information accessible and easy to use. Clinical sessions between departments allow the integration of the pharmacist in other areas.

What next?

We are still working with the ED to increase safety in drug therapy by developing new pharmacotherapeutic protocols (high risk medications protocols, perfusion protocols and new safety guidelines and training sessions). We are also working with more departments at our hospital with the experienced gained

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Author(s)

Nadia El Hilali Masó, Elvira Ramió Montero, Gemma Baronet Jordana, Marina De temple Pla, Paula Montoliu Alcon, Maria Jaume Gaya, Núria Pi Sala, Joan Altimiras Ruiz, Montserrat Pons Busoms

Why was it done?

The confusion between drug names represents a common cause of medication errors due to similarities between trade names and active ingredients or vice versa. Very new drugs coexisting with others that are very well known can easily induce errors in wards, unclear prescription may lead to misunderstanding of prescription.

What was done?

Development and implementation of measures to improve patient’s safety from purchase to drug prescription and administration.When we switch to a new provider maybe forced by drug shortage, we perform a review to avoid medication errors in all dosage forms.If needed, we elaborated alerts (pharmalerts) and newsletters. We applied Tall Man letters (TML) method to manage look-alike and sound-alike drugs, and to reduce prescription errors we elaborated a “Best practices on drug prescription” validated by Commission of pharmacy.

How was it done?

We prepared a formulary online on the intranet where pharmacist introduces relevant drug information as composition (i.e, excipients, contents latex or not, etc.), dilution, stability, source of errors (name, brand name,etc) among others. We compare them with existing ones to take an action, if necessary, that will be spread to all professionals. To implement TML method we followed the ISMP recommendations. First, we selected 3 antibiotics: cefOTAXime, cefAZOLin, cefTRIAXone. We changed these names in the prescription program so that the differentiation is reflected when drugs are prescribed, dispensed and administered. The implementation was explained to pharmacy, nursery and medical staff.After a month, we evaluated its acceptance.

What has been achieved?

We reviewed 61 new products: 50 trademarks, 14 new drugs and 7 dosage forms. 70.48% of products, acquired temporally or permanently, were new trademarks; 19.71% new drugs and 9.81% new dosage forms. The review is a good tool for a safe use of drugs and improves communication between healthcare providers. To evaluate TML implementation 240 questionnaires were completed: Acceptance was 92.05% (nursery and medical staff). 91.17% thought that it is possible to make a mistake with look-alike or sound-alike drugs and 68.72% that TML is useful to minimise medication errors.

What next?

The huge acceptance of TML encourages us to select other drugs from ISMP list. We have 6 pairs of drugs. We are planning to extend its use to storage shelves on wards.

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Author(s)

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

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

Author(s)

PALOMA CRESPO-ROBLEDO, MARIA SEGURA BEDMAR, IRENE ESCRIBANO VALENCIANO, NURIA BLAZQUEZ-RAMOS, BEATRIZ MARTIN CRUZ, CARMEN MORIEL SANCHEZ

Why was it done?

Patient safety is an essential component of quality care. It’s known that EDs are an element of risk for the onset of adverse events due to conditions related to patients’ comorbidity, communication problems, medication errors and working conditions like limited information about the patient, workload, interruptions, shifts, etc. It was detected that reconciliation of medication was not performed; neither validation of the medication prescribed and medications were stocked with no order and control.

What was done?

A project was developed to increase patient safety in the Emergency Department (ED) based on the presence of a hospital pharmacist in the team.

How was it done?

First thing was to review and validate the medication prescribed in patients who were under observation, at the same time performing a reconciliation given their acute situation. This way a relationship between nurses, physicians, patients and pharmacist was established.
Then, electronic prescription software was integrated within the automated dispensing cabinet (ADC), eliminating potential errors choosing the right drug. Only when a pharmacist has checked the medication, the list appears in the display and can be taken out all at once. The main problem has been to agree the stocks and how nurses can return easily and operatively the medication in order to not accumulate it out of the ADC.

What has been achieved?

Pharmacists’ clinical figure is being disclosed in a country where Hospital Pharmacy is a central and close department. In 43 days, 428 patients got their prescription checked in the ED, 346 pharmaceutical interventions were made in 198 patients, a median (IQR) average of 1 (1,2) interventions per patient. The main reason for an intervention was the adequacy to pharmaceutical forms included in the Hospital(n=130), followed by reconciliation interventions(n=77). Category of errors detected were mostly B (NCC MERP), showing pharmacists can detect an error occurred but that did not reach the patient

What next?

Hospital pharmacists should show their clinical and logistic potential, fighting with other health professionals to increase safety and care in patients. ED is the entrance of patients into the health system and where more errors can be committed, the work of a pharmacist should start at ED to prevent errors and give support and be part of the team.

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Author(s)

Nuria Monteagudo-Martínez, Ana Valladolid-Walsh, Gregorio Romero-Candel, Esther Domingo-Chiva, Jose Marco-del Río, Marca Diaz-Rangel, Francisca Sanchez-Rubio

Why was it done?

To acquire clinical skills in this setting and detect and prevent medication errors. It is also an area in which pharmacists had previously never participated in our hospital and it was an opportunity to integrate in this multidisciplinary team.

What was done?

Hospital pharmacy specialization programs include one year of rotations in clinical areas. The emergency department (ED) was chosen in order to develop a program to detect and prevent medication errors as a part of a multidisciplinary team.
Other tasks such as organizing drug storage, drug labelling and conservation, nurse counselling and education on issues related to medication were developed.

How was it done?

The pharmacy resident completed a rotation period based on the national educational program in clinical areas. Over a two month rotation period she reviewed treatments (61 patients, detecting 67 medication errors), organized and labelled drug storage, listed and identified thermolabile drugs, participated in a protocol design,…

What has been achieved?

The resident was able to improve care in acute patients in the ED. The most common errors found and prevented were: missed doses (25.3%); incorrect form to administer the drug (incompatibility diluent, infusion rate…) (13.4%); drug interaction/incompatibility (8.9%) and others.
The resident was able to organized refrigerator drug stored and developed a protocol to explain how to act in case of fridge failure.

What next?

To try to implement an ED-based clinical pharmacist program in order to detect and manage medication errors to improve safety in drug therapy, as well as to contribute to patient care with a different point of view from clinicians.