Digital transformation of injectable ophthalmic medication circuit: enhancing safety and efficiency
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Catarina Diogo, Rui Caceiro, Maria Helena Duarte, Armando Alcobia
Why was it done?
The core objective of healthcare institutions is to ensure patient safety and maintain the highest quality of care throughout every medical procedure.
This principle must extend to the drug circuit as well. Within our hospital, pharmaceutical services have a dedicated route for producing injectable ophthalmic medications, serving 795 patients and yielding 3720 solutions, in 2022. However, the existing paper-based procedure for medication management is laborious, time consuming and error-prone, demanding full-time constant pharmacist involvement to ensure the secure progression of these medications.
What was done?
A software application was developed on the Power Apps platform to streamline medication management for injectable ophthalmic medications. This application aimed to replace manual paper-based procedures with digital solutions, enhancing efficiency, reducing errors, and providing a comprehensive platform for patient registration, prescription tracking, schedule management, and oversight of injectable solutions’ production.
How was it done?
Over two months, needs of pharmaceutical and ophthalmology services were assessed, soliciting input from pharmacists, ophthalmologists, nurses and administrative personnel. Subsequently, a software application was developed featuring four distinct interfaces, customised for each professional group involved. This application enables patient registration, medical prescription, schedule management and monitoring the injectable solutions’ production – prescription and agenda validation, batch management and generation of identification labels.
This project is presented, therefore, as a customised digital solution, the result of a multidisciplinary collaboration.
What has been achieved?
It is the authors’ belief that this software has allowed for the development of a safer, more efficient, and integrated workflow, as an alternative to paper – which is more prone to errors. In this manner, from a pharmaceutical perspective, it simplifies the workflow, freeing the pharmacist to focus on other important tasks and optimizing personnel management. Furthermore, it is also valuable for ophthalmologists, enabling prescription repetition and access to patient history, as well as for administrative staff, streamlining schedule management. In conclusion, this software is set to transform our injectable ophthalmic medication circuit.
What next?
Further studies confirming its advantages are needed. Its validation would establish its potential and applicability across healthcare settings.
Sustainable adherence in the sector transition for schizophrenia patients
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Lene Juhl Biltsted, Louise Stilling Rasmussen
Why was it done?
In Denmark, patients with schizophrenia receive free antipsychotic medication for the initial two years post-diagnosis. Post this period, patients transition to the primary sector and assume the medication costs. Historically, the clinic dispensed larger medication quantities, offering short-term relief but not addressing the issue. This approach risks medication waste. The new workflows empower healthcare professionals to help patients establish stable financial arrangements with local pharmacies, curbing fluctuating medication expenses. This enhances patient safety by reducing at-home medication stockpiles. Financial barriers often undermine patient compliance. Healthcare professionals strive to aid patients, curbing relapses and readmissions, through rational, sustainable medication management that minimises resource wastage.
What was done?
Training improved healthcare professional’s understanding of the Danish medication subsidy system and options for deferment in the primary sector.
The healthcare professionals’ new knowledge has provided the foundation for the development of optimised workflows in the treatment process, ensuring a more sustainable medication management during the transition to the primary sector. The project establishes the framework for reducing the risk of medication waste upon the patient’s completion of treatment at the clinic.
It also created a favourable setting for healthcare providers to collaborate with patients, enhancing adherence.
How was it done?
Healthcare professionals received training on deferment arrangements, subsidies, and compliance, with supervision from clinical pharmacists.
Patient cases were analysed to determine factors for future guidelines.
Guidelines were formulated to aid healthcare professionals during the patients’ transition to the primary sector.
A tool (calculator) was created for assessing the patients’ economic choices regarding medication expenses.
What has been achieved?
Healthcare professionals gained confidence in guiding patients on stable medication expenses.
Enhanced rational and sustainable medication use by incorporating the seven rights.
New guidelines now allow an appropriate quality assurance strategy to ensure sustainability and adherence.
Tool to assess medication costs which improves the patients adherence in the sector transition.
Lowered risk of over/under treatment and improper storage.
Diminished treatment failure risk by predicting patient medication expenses during the primary sector transition
What next?
In the next 6 months, the clinic will trial the established guidelines and routines with patients concluding their 2-year treatment.
Integration of Farmis-Oncofarm ® and Oncosafety RC® pharmacy software to improve safety in the administration of antineoplastic drugs with intelligent infusion pumps
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
MARÍA ELENA CÁRDABA GARCÍA, SILVIA FERNÁDEZ PEÑA, AMPARO SALVADOR PALACIOS, MERCEDES FERNÁNDEZ PRIETO, CLAUDIA GONZÁLEZ GONZÁLEZ, MARÍA TERESA SÁNCHEZ SÁNCHEZ
Why was it done?
Antineoplastic drugs, chemotherapy specifically, are a clear example of “high risk” medications. The drug administration phase, within the drug utilisation circuit, is where the highest incidence of errors has been detected, ranging between 38%-81%, so the development and implementation of tools aimed at improving security at this stage is very important.
What was done?
The integration of Farmis-Oncofarm ® and Oncosafety-RC® pharmacy software was done, in order to improve the prevention, detection and reduction of medication errors in the administration phase of antineoplastic treatment in the Onco-Haematology Day Hospital (OHDH).
How was it done?
A Drug Library was created in Farmis-Oncofarm® software (v.4.0.11.107). Dosage units, stability, standard concentrations, maximum and minimum doses, time and infusion rate, and preparation and administration recommendations were parameterised and standardised. Parameters for the implantation of Oncosafety-RC® software (accepted percentage of volume deviation in the mixtures, types of intravenous lines, possible adverse reactions, drugs to be used in case of extravasation) were also defined. When the connectivity between Farmis-Oncofarm® and Oncosafety RC® was validated, Oncosafety RC® was implemented in the OHDC.
To evaluate the results of the implementation of this strategy, a retrospective study from May 2022 to May 2023 was carried out. Collected data, obtained from Oncosafety RC® software were: number of mixtures (antineoplastic, supportive drugs and intravenous fluid therapy) and treatments administered, dose deviations, adverse events, incorrect infusion rates, errors avoided due to incorrect medication.
What has been achieved?
12,294 treatments (44,898 mixtures) have been administered in OHDC.
Dose deviations were registered in the 0.01% of the mixtures, due to adverse events that required termination of the infusion. Only three adverse events happened in the study period.
The infusion rate was incorrect in the 0.5% of the mixtures; this information is useful to improve drugs administration and prevent infusion-associated reactions.
This strategy prevented errors due to incorrect medication on 2,499 occasions.
What next?
The integration between Farmis-Oncofarm® and Oncosafety RC® has improved the security in the administration of onco-haematological treatments, allowing the reduction of administration and medication errors. This strategy can be implemented in hospitals that have assisted electronic prescription software and information management software between different clinical management systems and infusion pumps.
Impact of drug-drug interaction alerts on prescribing patterns in a teaching hospital
European Statement
Patient Safety and Quality Assurance
Author(s)
Joana Pinto, José Feio, Sebastião Silva, Francisco Machado, Ana Dinis, Margarida Abreu, João Peres, Mariana Guia
Why was it done?
Clinical decision support systems comprising information on DDI improve DDI risk detection, avoiding preventable patient harm. The resulting DDI alerts can change prescribers’ behaviour to benefit patient care. However, an excessive number of alerts can lead to alerts’ desensitisation by prescribers.
What was done?
We monitored the drug-drug interactions (DDI) alerts displayed in the prescription system through three subsequent homologous periods, occurring after the integration of a DDI database in the prescribing software system of a teaching hospital to assess its impact on the prescribing pattern.
How was it done?
We developed a DDI database – MedH® – to be integrated into the prescribing software system to support hard stop DDI alerts. only the higher clinical risk DDIs were included in this database in order to restrain the burden of alerts and warrant acceptance by health professionals.
Data of all inpatient hospital prescriptions over a 12-month period prior to MedH® implementation were extracted and intersected with MedH® DDI BD to identify the top 10 co-prescribed binomials at risk of severe DDI. The number of alerts for the same binomials was then monitored through three subsequent, post-implementation, homologous periods.
What has been achieved?
Considered the TOP10 observed in the pre-implementation period, the number of alerts for all binomials has consistently reduced over the three post-implementation periods analysed.
The integration of MedH® DDI BD into the prescribing system, resulted in changes in the prescribing pattern, translated by a decrease, between 67% and 100%, in the number of alerts for a sample of control risk binomials coinciding with the top 10 co-prescribed risk binomials observed in the pre-implementation period. These results reflect the good acceptance by the professionals and the didactic effect achieved by the exposure to alerts.
More importantly, these results are indicative of the effectiveness of the implementation of MedH® Alerts in reducing patient exposure to high-risk combinations of medicines, thus promoting patient safety.
What next?
It will be important to ensure that data from IDD alerts are rigorously analysed to recognise clinical situations in which the co-administration of risk binomials is justified, to ensure consistent application of recommended risk minimisation measures, and the availability of safer therapeutic alternatives whenever possible.
Implementation of automated alert system in high-alert medications in a network of hospitals
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
ROSALIA FERNANDEZ CABALLERO, ALMUDENA GARCÍA GARCÍA, MARTA HERNÁNDEZ SEGURADO, MARTA GÓMEZ PÉREZ, CARMEN MAYO LÓPEZ, ARACELI HENARES LÓPEZ, VIRGINIA COLLADOS ARROYO
Why was it done?
Our aim was to improve the safety of HAM appointed by ISMP Spain (Institute for Safe Medication Practices) specially restricting the prescription, creating automated alerts and advising in administration.
What was done?
The main objective was to identify and standardise in prescription and administration the high-alert medications (HAM), included in pharmacotherapeutic guide (PG) in a network of Spanish hospitals with about 1.330 beds.
How was it done?
Literature about HAM and recommended strategies was reviewed. We divided these drugs into two groups: HAM (heightened risk of causing significant patient harm when they are used in error) and very HAM (an error could cause death of patient). We identified both groups in electronic prescription system as follows:
– HAM: all prescribers are able to prescribe these drugs and they find yellow warning sign in left side of the drug in prescription screen and nursing electronic work plan for administration.
– Very HAM: these drugs need tracheal intubation or monitoring measures when they are administered to patients. Only prescribers in intensive care (ICU) and surgery units (SU) are able to prescribe them. For certain drugs, needed in medical hospitalisation units, all prescribers are able to prescribe them and they must confirm the prescription with confirmation message: “You are prescribing a HAM, an error could cause significant patient harm. Are you sure to continue?”. They find red warning sign in prescription screen and nursing electronic work plan.
Alerts were configured by systems team in our electronic prescription system.
What has been achieved?
We have identified 379 drugs as HAM. 324 drugs were configured with yellow warning sign.
Sixty-five drugs were identified as very HAM. Fifty-eight drugs were disabled to prescribe by all prescribers (only in ICU and SU).
Seven drugs were configured with red warning alert and confirmation message: dobutamine, isoprenaline, ketamine, labetalol, levosimendan, carboprost and methylergometrine.
What next?
As next phase of our project, we must develop a procedure to identify and create alerts in new drugs added to our PG as systematic risk assessment process. Moreover, we must evaluate the real impact of our alert system in prescribers and nurse team, to reduce alert fatigue. We will work in automatic reports with ignored alerts.
Implementation of therapeutic drug monitoring active proposal in the hospitalised patient
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Alba María Fernández Varela, María Isaura Pedreira Vázquez, Sandra Koprivnik, Ana María Montero Hernández, Isaura Rodríguez Penín
Why was it done?
Therapeutic drug monitoring (TDM) allows an optimised pharmacological treatment and increases safety. Lately, we detected low interest in TDM which was confirmed from our annual activity report. An observational prospective study was carried out in a second- level hospital attending an area of 175 930 patients. The study included all inpatients prescribed a drug eligible for TDM from November 2020 to January 2021. The aim was to improve treatment individualisation of hospitalised patients through an active proposal for drug level determination of drugs susceptible for TDM at our institution: digoxin, vancomycin, antiepileptic drugs (carbamazepine, phenytoin, phenobarbital and valproic acid).
What was done?
The pharmacist encouraged therapeutic drug monitoring of susceptible treatments by an active proposal for drug level determination in the prescriptions programme.
How was it done?
Daily, a list of eligible patients was obtained. To this end, a filtering software was used. Taking into account patient’s demographics, clinical and analytical variables (creatinine clearance, the last TDM result, diagnosis) and active prescriptions (treatment initiation, interactions), the pharmacist makes a recommendation for plasma drug level determination.
Data sources: electronic prescription program, pharmacokinetic validation program and electronic medical record.
What has been achieved?
119 proposals of TDM were made in 107 patients: 79 digoxin, 31 vancomycin, 4 valproic acid, 3 carbamazepine and 2 phenytoin. 45,8% women.
74 drugs were discontinued before possible sample extraction and 5 monitorisations could not be performed due to patient death. Of the 40 remaining proposals, the physician requested monitoring of 35 drugs, which meant 87,5% acceptance rate.
It was observed that 17 levels were low or at a lower limit (a dose increase with subsequent verification of levels was proposed in 8 cases and accepted in all of them), 13 levels were in range, 4 were high or at an upper limit (in 3 of them the dose was decreased). One sample was extracted after the drug administration (vancomycin) therefore without value.
What next?
Pharmacists can contribute to treatment optimisation by being proactive. Many resources are not needed unless the burden of care was a limiting factor. The education and promotion of TDM would be interesting to improve the use of this service.
Optimising anticoagulation counselling using video media
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
Suzanne Al-Rawi, Sadeer Fhadil, Sotiris Antoniou, Rodnie Oro, Paul Wright
Why was it done?
It is suggested that 40-80% of information provided by healthcare professionals is forgotten immediately by patients (1). The trust has a checklist of counselling requirements for anticoagulants, completed in consultations with patients before discharge. Recognising the complexity of anticoagulation counselling and its time constraints, we sought to assess the use of pre-recorded counselling videos for use at ward level and as a resource for patients to refer to post discharge.
What was done?
We sought to develop anticoagulation counselling videos for ward use, with hyperlinks for patient access post-discharge. We aimed to improve information provided to patients and optimise pharmacists’ time undertaking counselling.
How was it done?
Using a patient focused questionnaire, feedback was sought on patient satisfaction as well as time totality following anticoagulation counselling. A series of short and digestible video clips (1-2minutes each) that reflected the trust checklist were recorded. The videos were played to the patient and then a follow-up face-to-face consultation was undertaken to answer any questions. Patient satisfaction and time taken was assessed through the use of the questionnaires and compared to consultations without the pre-recorded clips.
What has been achieved?
Over 4 weeks, 121 patients received anticoagulation counselling. 77 patients were counselled using videos and compared to 45 patients counselled without videos. There was a 70% reduction in time spent; an average face-to-face counselling required 24 minutes, compared to only 7 minutes if the patient had seen the videos. There was an overall increase in patient satisfaction with use of videos to 86% from 70%.
What next?
We have shown optimisation of the anticoagulation counselling process through the use of pre-recorded videos. Time spent counselling has been significantly reduced and feedback from pharmacy staff has suggested more patient-centric counselling is achieved. It has allowed for information to be standardised, with an increase in patient satisfaction and understanding. Patients have access to the videos on discharge to improve patient safety. There have not been any reported incidences since switching methods. There has been a reduction in patient queries related to anticoagulation post- discharge. Areas for further development include dubbing of the videos to several languages to improve access to all.
Pharmacological reconciliation as an improvement chance: a hospital ward experience
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Annamaria Tesse, Cataldo Procacci, Domenica Ancona, Salvatore Lenti
Why was it done?
Often the elderly patient suffers from several pathologies at once and commonly he is in polytherapy. According to the Italian Ministerial Recommendation No. 17, errors in drug therapy can cause serious harm to the patient. By increasing the patient’s awareness and reducing the number of potentially inappropriate prescriptions, it will be possible to improve the effectiveness of therapies and to reduce side effects.
What was done?
In an Internal Medicine department, the concurrence between doctors and pharmacists has led to a project that aims to reduce duplications of therapy and to improve the health status of the patients. This through pharmacological recognition and subsequent therapeutic reconciliation carried out on patients in discharge.
How was it done?
In Internal Medicine ward, from June to August 2022, we gather the terapies for 48 hospitalised patients aged over 65 years and suffering from two or more chronic diseases. Reconciliation boards were then developed using Intercheck Web a “Mario Negri” Institute of Pharmacological Research’s software. Sequentially the physician, according to the chemist, proceeded to remodulate the therapies especially in those cases where there were serious interactions.
What has been achieved?
140 drug interactions were detected, on average 2.91 interactions per patient. Especially, 16 class D (very serious), 22 class C (major), 83 class B (moderate), 19 class A (minor) reactions were archived. The modified or partially modified therapies at discharge were 71%. This restriction bought to a curtailment of drugs taken and a removal of unnecessary drugs.
What next?
The team are doing a patient follow-up to six months and a year so earlier results will be soon available. Reducing drug intake is possible, and it involves a downsizing in side effects and in an increase in patient compliance. Information to the patient is essential and, by using this procedure on a large scale, it will be possible to optimise the management of the chronic patient at home and inpatient care.
Opioids room of horrors – an interactive learning to improve safety of drug administration
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Sophia Hannou, Cristina Nicorici, Patricia Spitz, Samuel Cotte, Wanda Bosshard, Nancy Perrottet, Pierre Voirol, Farshid Sadeghipour
Why was it done?
Medication use process is at high risk especially for opioids. In our geriatric rehabilitation unit, self-reporting incidents are submitted regularly to our quality system. Among the 44 drugs incidents reported in 2021, 11 included opioids. Prevention with training is a way to reduce these errors. However, theoretical teaching covering the “5 rights” rule remains insufficient. Therefore, an interactive learning with a room of horrors focused on opioids was selected by our unit to prevent these errors. The objective was to cartography and identify the most risky steps and to introduce specific actions to reduce these risks.
What was done?
A room of horrors with a specific focus on opioids has been developed and implemented to reduce errors in medication circuit.
How was it done?
An interprofessional group created the room of horrors based on real incidents. Fictional patient, clinical situation and opioid prescription were created in the medical software. Several drugs and medical devices were available. A model wore an identification bracelet. Ten errors, covering the five rights, were hidden in the room. A pair of healthcare givers had 20 minutes to realise the simulation (5 for the briefing, 10 for the exercise and 5 for debriefing).
What has been achieved?
During the World Patient Safety Day 2022, 38 healthcare professionals (19 nurses, 10 assistant nurses, 9 geriatricians) participated to this training. Errors were detected in variable proportions. For example, 58% of the participants uncover the patient identification error, 53% the pharmaceutical form, 53% the expired date, 47% the allergy contraindication and 47 % used the oral syringe.
What next?
Results and theoretical notions will be presented to all professionals of the unit. This room of horrors is transposable and can be used in other units of the hospital. A video of this simulation was created as an e-learning. It will be implemented as a continuous training or for new collaborators in our unit and can be shared to other units of the institution. Incidents will be continuously monitored and the training will be adjusted in the future. Based on the success of the room of horrors, this interactive learning will be used in other areas with other clinical or technical dimension.
Automated dispensing systems: improving and digitising medicines optimisation
Pdf
European Statement
Patient Safety and Quality Assurance
Why was it done?
Medicines storage was low tech in a new high tech Private Finance Initiative (PFI) hospital and security was operationally heavy on nursing teams. The trust was on a journey to Electronic Patient Records (EPR). What was needed was a solution that bought both challenges together – how we implement improved medicines storage that fully leverage the power of a hospital EPR system.
What was done?
Trust-wide implementation of Automated Dispensing Systems, initially to drive safer and legislative compliance with storage. Since implementation, we have improved management of medicines during shortages, taken waste out of operational delivery around supply of medicines, informed teams around medicines safety during heat waves, and we are on a journey to closed loop medicines administration.
How was it done?
A business case recognising the reputational impact of poor Care Quality Commission (CQC) assessment of security, nurse led audit work recognising the impact of medicines handling on Time to Care and recruiting enthusiasts to support the programme.
What has been achieved?
All wards and departments have automated dispensing systems for medication storage – 72 units, including two in pharmacy for controlled drugs and after-hours support.
Medication Safety officer (MSO) used live view to track high risk medicines throughout Covid-19 and beyond. Never missed a dose of high risk medicines by utilising this technology over the Covid period.
Temperature monitoring gives an overview of real time temperature of all stock areas to support informed decision-making during hot and warm weather. Digital ordering by automated dispensing systems has reduced nurse time handling medicines by using pharmacy team time saved from ordering medicines redeployed to fill cabinets instead of nurses.
Increasing breadth of stock holding as top up thrice or more weekly rather than just weekly across Trust.
What next?
Planning benefits of integrating a robot dispensing system and hospital information system next spring. Robotic storage supporting real-time medicines management from stock to temperature all with enhanced security and removes process waste from process especially when combined with other digital initiatives. Trust Go-Live with Cerner in spring 2023 and use of cabinets to support closed loop administration.