Author(s)

Mohammed Almeziny, Fahad Alkharji , Ali Alkhudair , Jameel Al Mutairi

Why was it done?

Poor allergies’ documentation may cause harm to the patients, if the concerned medication reaches them. The hospital is planning to implement a new Health Information System, which includes a Computerised Provider Order Entry. However, this is a long-term project, so in order to minimise that risk, the hospital administration gave the pharmacists the privilege to do so. The percentage of documented drug allergies was 14%. The issue of compliance from the medical, nursing and pharmacy staff was a major obstacle in allergies’ documentation. For that reason, the pharmaceutical services initiated an improvement project to enhance allergies’ documentation. it is the responsibility of the physician to document any allergy on the inpatient prescription form (IPPF). On the other hand, it is the responsibility of the nurse to ensure that all information is completed on the IPPF before it is sent to the pharmacy. The role of the pharmacist is to document the patient’s allergy in the pharmacy system.

What was done?

Increase the allergy documentation from 14% to 96%.

How was it done?

The FOCUS PDCA was adopted. Find: It was found that the compliance rate was not satisfactory. Patients might receive a medication that is known to cause an allergic reaction, because the allergy was not documented and communicated with other healthcare providers. Organise: The team consisted of all involved departments. Clarify: Some IPPF may not contain allergies and some pharmacy staff do not document the allergy in the pharmacy system. Understand: The factors that may influence the process were identified, although some healthcare professionals consider the documentation as a time-consuming process. The pharmacy system is an old system which does not support enforcing function. Select: The targeted outcome was 90% within 1 year of its inception, July 2017 to July 2018. Plan: All allergies MUST be assisted, and the pharmacy will act as the enforcing body. Do the plan: All pharmacists were reminded to enforce hospital policies by not accepting any incomplete prescription and document all drug allergies in the pharmacy system. Check: Statistics regarding compliance were presented in monthly meetings to highlight the challenges, difficulty or any serious issue. It is a proactive meeting and members can freely suggest any tools required to improve the situation.

What has been achieved?

There was a significant improvement from 14% to 96%.

What next?

Start e-prescription to enforce the documentation of allergies.

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Author(s)

Nina Kærgaard Hansen

Why was it done?

The initiative was performed to investigate the accessibility and usability of the current intranet in order to improve intranet information and communication from the hospital pharmacy to the clinic.

What was done?

Workshops with usability tests were performed with four different professions who are expected to use the intranet information and communication from the hospital pharmacy.

How was it done?

Workshops for selected professionals including pharmacists, pharmaconomists and nurses were held. The workshops consisted of four parts:
1. Video capture and recording test: Participants were asked to find specific information on the intranet. Comments, clicks and movements of the mouse were recorded during the task.
2. Sorting and prioritization the pages: Participants were given screen shots of 57 pages from the intranet. The participants were asked to sort the pages in three categories: need to know, nice to know and insignificant.
3. Evaluation of selected texts: Participants were given 5 examples of texts from the intranet and asked to assess if the text was relevant and understandable.
4. Structured focus group interview: Using a structured interviewguide the use and challenges experienced by the participants were explored.

What has been achieved?

From the present initiative it was found that the structure of the intranet was not optimal and did not reflect the daily needs from the users. The results from the workshops provided a clear guideline on how to restructure the intranet. It is important to make short cuts and optimize search function.
In addition, the initiative revealed how to improve texts:
– Write shortly, concisely and action oriented: “Tell us what to do”.
– Write the most important first, then elaborate and insert links to learn more.
– Use subheadings for skimming the text.

What next?

A campaign is planned to advertise the new intranet structure. Number of users and subscribers on the intranet pages is followed to see if the activity increases. Editors have been educated to write texts that are short, concise and written in an action oriented language

Author(s)

Emma Ramos Santana, Enrique Tevar Alfonso, Maria Jose Castillos Mendez, Maria Luz Padilla Salazar, Lucy Abella Vazquez, Jesus Ode Febles, Marcelino Hayek Peraza, Javier Merino Alonso

Why was it done?

The implementation of an antimicrobial stewardship program (AMS) is very important, but it has to be accompanied by personal resources. It is therefore necessary to effectively use the time spent in the AMS.

What was done?

We have worked with the Information Technology Service to develop an “Intelligent Antimicrobial Screening Program” (IASP).

How was it done?

Using the information available in Electronic Health Record (EHR) and in pharmacy and microbiology applications we have developed a computer tool that analyze hundreds of situations through pre-established conditions

What has been achieved?

Currently the system analyzes more than 40 conditions related to the correct use of antimicrobials based on antibiotic characteristics, patient situation and microbiological data.
Some of the most relevant conditions are:
●Antibiotic prescribed more than 6 days.
●Patient with parenteral antibiotic for more than 3 days and with other oral medicines.
●Antibiotic that must be adjusted in patients with renal impairment prescribed in patients with glomerular filtration rate (GFR)65 years old, GFR5 days prescribed or other nephrotoxic prescribed.
●Patients with linezolid and thrombocytopenia or anemia or without an hemogram in the last week.
●Patients with daptomicyn and high creatininkinase (CK) or without a recent determination.

What next?

This software allows to collect information contained in different systems and displays it in an organized view to the user. This makes it an easily system that can be exported to other hospitals.
Our next objective is to consult the microbiological information. Therefore the system will be able to recommend about the optimal antimicrobial treatment, detecting situations in which the treatment can be de-escalated or alerting in case of resistance.

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Author(s)

A Elsheashaey, A Elshishiny, A Orabi, A Almutairi, A Aboulwafa, H Alobaid, F Dashti, D Saeed, R Yassin, M Salama

Why was it done?

Kuwait Cancer Control Center (KCCC) is the only oncology hospital in Kuwait. Chemotherapy Preparation Unit (CTPU) was unable to meet the increased orders; causing delivery delay and more patients’ waiting time. Moreover; rework and more waste due to defective and faulty processes of current workflow resulting in frequent incident reports of wrong final products dispatched.

What was done?

Shifting to a systematic multi-step production workflow to increase compounding capacity, minimize risk of errors, reduce processing time, and maximize utilization of integrated technological resources.

How was it done?

Using multiple PDSA cycles, a comprehensive educational and practical training was conducted, proceeded by staff rotation with newly trained team. Every three weeks a new pharmacist trained and assigned to CTPU. Raw materials stores were rearranged for better accessibility and diminishing unnecessary staff movement. A staging step as the first independent double-check before the start of compounding, and for assembly of raw materials and supplies required for compounding. A verification Step as the second independent double-check upon compounding, using bar-code scanners, touchscreens and cross-checking with the chemotherapy order to assure the quality and integrity of the finished product. Production workload were restructured over three parallel line of manual stations and one automated preparation unit. Pharmacy Information System (PIS) screens were customized to give a first and second audio-visual alarms after 30 and 45 minutes of transcription time respectively. Chemotherapy sessions appointment system were established to assess the daily chemotherapy compounding needs from CTPU in advance with an incremental increase of production capacity to reach 100~120 patients/day or 180~200 preparations/day.

What has been achieved?

Number of preparation compounded by CTPU was increase by 8%, where more than 43% of preparations were validated to release in less than 30 minutes and approximately 88% of preparations were delivered in less than 45 minutes. Number of preparation by automation was increased by 82%, Furthermore, all production incidences has been completely eliminated after full implementation of final verification and validation step.

What next?

The new workflow has increase the workload capacity with less production errors and zero incident reports. Patient experience was improved by comparable preparation time to other international Pharmacy Workload Unit and average time required per patient visit.

Pdf

Author(s)

María Lourdes Recio Blázquez, Alberto Pérez Morales

Why was it done?

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

What was done?

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

How was it done?

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

What has been achieved?

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

What next?

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

Author(s)

Sophie Renet, Florian Le seigneur, Ratiba Haddad, Andre Rieutord, Marie Camille Chaumais

Why was it done?

The high turn over rate of medical and pharmacy residents (every 6 months) could jeopardize the patient’s care management as they generally lack of appropriate skills upon arrival. Our former process medication review was relying on individual and heterogeneous competencies of pharmacy residents likely to lead to sub-optimal medication review and treatment optimisation. We had to design a training program for residents according to the constraints of time and characteristics of related treatment of the considered clinical ward recruited patients.

What was done?

A training program for pharmacy residents was developed and implemented. The aim was to develop the skills of the residents to allow them to perform, after 72 hours, a secure, optimized and standardized (SOS) medication review orders, according to the specificities and the “real-life practice” of the clinical department.

How was it done?

Through a collaborative approach (residents and seniors pharmacists, physicians, PhD student in education sciences), ADDIE (Analyse, Design, Development, Implantation, Evaluation) method was used. First, the most frequent pathologies and drugs prescribed in the cardiology department were identified to define specificities and thus custom the educational needs and skills that residents have to acquire to ensure a SOS medication review orders. The program included a 3 steps process over 3 days: (1) recognize the organisation and learning tools; (2) practice 3 clinical medication review orders simulation; (4) assess and feed-back with a senior clinical pharmacist. Some learning tools were developed: a training tool kit to guide the learners ; an aid kit, including a SOS medication review orders algorithm to follow throughout the whole process. Two years after implementation, 4 pharmacy residents have used this training program.

What has been achieved?

Our 72-hours-training program is routinely used for new pharmacy residents. It has been implemented successfully with a high acceptance. They also felt more comfortable to suggest therapeutic advices to the physicians.

What next?

The proof of concept of SOS was successfully done. We are currently extending it for 5th year pharmacy students and develop similar training program for other clinical wards (Surgery, oncology, immunology). In 2017, we expect to share it with our pharmacist colleagues working in the two closest hospitals.

Pdf

Author(s)

Janne Kutschera Sund, Martin Grotnes, Ingvild Klevan, Lene Lilleaas, Johan Fredrik Skomsvoll

Why was it done?

Lack of comprehensive strategies and funding has made it difficult to develop and implement extensive clinical pharmacy services in our hospital. It has been challenging to secure hospital involvement. A new financial model securing funding from the regional health authority made way for a new joint approach.

What was done?

A dialog based process involving hospital management, clinicians and the pharmacy led to a large increase in clinical pharmacy services in our university hospital.

How was it done?

A literature review was conducted. Based on this, a multidisciplinary project group decided that all clinics and wards were eligible for clinical pharmacy services and should receive extensive information on the topic. As there were limited resources allocated, all clinics were asked to apply for the service. The hospital management received applications three times the number of funded clinical pharmacists.
Prioritizing was based on the following criteria; use of the Integrated Medicines Management (IMM)-method, patient flow, evaluation and research, in- or out –patient clinics, continuation of established services, localization and time schedules on the wards.

What has been achieved?

The long term funding of clinical pharmacy in the health region enabled the hospital pharmacy to recruit and educate highly competent clinical pharmacists.
In less than a year, the number of clinical pharmacists has increased from three to twelve. The number of wards receiving clinical pharmacy services has also grown from three to twelve and there are still plans for further implementation.

The hospital and the ward managements are much more involved in evolving a common patient safety strategy with focus on medication. Specific quality indicators for each patient population and ward are being developed, and clinical pharmacists are now important members of multidisciplinary teams all over the hospital. Pharmacists are integrated in ongoing clinical research projects and publishing.

User surveys show that clinical pharmacy is assessed as a highly beneficial service by both nurses and physicians.

What next?

Develop the IMM-model to include the clinical pharmacists in standard patient care in every clinic and department. We plan to perform follow-up studies on the effects of clinical pharmacy services in different settings.

Pdf

Author(s)

Ane Hornbaek Mortensen

Why was it done?

Previously, a quarterly report showing adherence to national treatment guidelines was issued to all hospital administrations in our region. It was their responsibility to forward this to the appropriate specialists/consultants. This often failed and even when it was done, our experience showed that it wasn’t read by the consultants. Consequently, prescription patterns didn’t change despite the report highlighting the wards that weren’t complying with the national treatment guidelines.

What was done?

Short newsletters including graphs/tables showing the ward’s degree of adherence to national treatment guidelines were emailed to the chief consultant of the specific ward.

How was it done?

In our region a 6-person analytical team, which includes 3 hospital pharmacists, monitors adherence to national treatment guidelines issued by our national council for the use of expensive hospital medicines (RADS). Based on the results, the analytical team decides which newsletters to write. The hospital pharmacists in the analytical team are responsible for writing the newsletters and emailing them direct to the relevant specialist/consultant.

What has been achieved?

It seems as if the introduction of more targeted information has led to more rapidly changing prescription patterns. One example is oral iron chelating agents to hematological patients where a RADS guideline was issued recommending that all new patients should receive deferipron instead of deferasirox. This information was initially issued through the usual channels (via hospital administration) but no change in the use of deferipron/deferasirox was seen. This only happened after emailing a newsletter directly to the chief consultants of the three hematology wards in our region, showing the current use of deferipron/deferasirox and the potential cost reduction. Nine months and three newsletters later the percentage of deferipron use on the hematology wards increased from 2% to 27%, leading to a 22% cost reduction. Target was 25% deferipron (the guideline only covered new patients). The total increase in the percentage of deferipron use on hospitals in our region was 351% compared to an increase of between 0 and 19% in the other four national regions.

What next?

Continued and increased use of targeted communication in the health care system is required to ensure that specific information reaches the relevant players.

Author(s)

F. Reidy, M. Duggan, A. Mathew, G. Duignan, S. Nasim, H. Ryder, B. Giblin, B. O’Connell, J. Corcoran

Why was it done?

The management of patients on oral anticoagulant drugs in the perioperative period has become confusing due to the introduction of:
– Newer oral anticoagulant and antiplatelet drugs
– Increased number of day case surgeries and early discharge, leading to lack of optimum care of patients, with anticoagulation and thrombophylaxis measures being undermanaged, resulting in prolonged hospital stays and cancellations of procedures.

What was done?

Following informal discussions with pre-assessment clinic (PAC) nursing staff, anaesthetists, pharmacists and surgeons, an evidence based management plan for thrombophylaxis and anticoagulation in the perioperative period for surgical patients was developed comprising of:

Thromboembolism risk assessment and bleeding risk stratification tool, to risk stratify all patients being admitted for surgery.

Prescribing guidelines on the management of anticoagulant drugs in the perioperative period.

Patient information leaflets on the management of anticoagulant drugs and thrombophylaxis measures pre and post procedure.

Preprocedure and discharge pharmaceutical plans to facilitate patients’ anticoagulation drugs to be managed effectively in the community.

How was it done?

Draft guidelines were disseminated to relevant staff and an opportunity was given for feedback over a period of 1 month. Following these recommendations, the guideline was introduced at the weekly surgical meeting. Information was then disseminated to the relevant departments.

One year later an audit demonstrated that these guidelines provided clarity with the decision making process regarding anticoagulation and thrombophylaxis, resulting in improved patient safety outcomes in the perioperative period. The need for educational training on the guidelines and simplification of the risk assessment tool was highlighted.

What has been achieved?

• Patients’ anticoagulation needs pre and post procedure can be managed with clear instructions in the perioperative period across the hospital/community interface.

What next?

The tool will be adapted to help with the decision making process regarding anticoagulation and thrombophylaxis for medical patients.
The complexities of perioperative anticoagulation are addressed in a simple way that the development of an App would benefit patient safety.

Pdf

Author(s)

A. Valladolid-Walsh, E. Domingo-Chiva, P. Cuesta-Montero, J.A. Monsalve-Naharro, E.M. García-Martínez, S. Plata-Paniagua, M.D. Pardo-Ibañez, G. Romero-Candel, J.M. Jiménez-Vizuete, R. Peyró-García

Why was it done?

To determine the incidence of medication errors in our environment and implement enhancement systems to prevent them, which is a priority for the improvement of the drug treatment process in critically ill patients.

What was done?

A clinical pharmacist was integrated on a full time basis into the multidisciplinary team of an anaesthesia intensive care unit (ICU).

How was it done?

The project was carried out in 3 different stages:

– First stage: a prospective observational study was carried out over 1 month to detect medication errors in anaesthesia ICU and to determine the baseline situation before the pharmacist´s intervention. During this stage, 36.27% errors were detected in overall treatments.

– Second stage (intervention stage): Over 10 months, the pharmacist reviewed the prescriptions of all patients admitted to the anaesthesia ICU, performing the appropriate interventions regarding medications. Furthermore, to educate physicians and nursing staff, we organised educational meetings, and also pharmacotherapeutic protocols and guidelines of medication administration were created to standarise clinical practice. Finally, a system for reporting medication errors was introduced.

– Third stage: a prospective observational study was carried out for 1 month to detect medication errors after the pharmacist’s intervention. During this stage, 5.9% of errors were detected in overall treatments.

What has been achieved?

– Medication errors were reduced by more than 30%.
– A pharmacist is now part of the multidisciplinary team in the ICU.
– The experience has been broadcast to the national level to promote the implementation of clinical pharmacist activities in our environment.

What next?

We are still working on the same areas to improve safety in drug therapy in critically ill patients. Currently, improvement measures that are being developed are: new pharmacotherapeutic protocols specifically for this unit; drugs and drug-diluent compatibility guidelines; new training sessions; standarised medication kits in operating rooms and implementation of the computerised prescription; and a new labelling system for syringes.