SEAMLESS PHARMACEUTICAL CARE OPTIMISING ANTICOAGULATION MANAGEMENT IN THE PERIOPERATIVE PERIOD
European Statement
Education and Research
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.
INFLUENCE OF INTEGRATION OF A PHARMACIST IN MEDICATION ERRORS IN CRITICALLY ILL PATIENTS
Pdf
European Statement
Patient Safety and Quality Assurance
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.
IMPLEMENTATION OF A SAFETY AND HEALTH PROGRAMME FOR THE MANAGEMENT OF PATIENTS WITH HEPATITIS C RECEIVING TREATMENT WITH DIRECT ACTING ANTIVIRAL AGENTS
Pdf
European Statement
Clinical Pharmacy Services
Author(s)
S. IBAÑEZ GARCIA, C.G. RODRIGUEZ-GONZALEZ, A. GIMENEZ-MANZORRO, E. CHAMORRO DE VEGA, R. COLLADO-BORELL, E. LOBATO-MATILLA, A. DE LORENZO-PINTO, M. TOVAR-POZO, A. HERRANZ-ALONSO, M. SANJURJO-SAEZ
Why was it done?
CHC affects approximately 3% of the world’s population. The development of well tolerated and effective AADs has changed the therapeutic landscape. These therapies have a high efficacy with a good safety profile. Numerous challenges in terms of patient education, monitoring, medication errors, drug interactions and adherence exist. Our National Health System launched a strategy plan for proper CHC management in April 2015, establishing, among other things, measures to optimise AAD use.
What was done?
We have developed a pharmaceutical care programme.
I. The following protocols were defined:
– A case selection and treatment guideline, following the recommendations from health authorities.
– A protocol for the management of drug interactions.
– A protocol with recommended dosages and administration techniques.
– A protocol with potential adverse drug events and recommendations about how to prevent and manage them.
– A protocol about clinical interview to ensure patient literacy and co-responsability.
– Patients information leaflets.
II. The pharmacy department was provided with:
– 3 full time pharmacists.
– 2 patient information offices.
– a queue management system.
III. Appointment scheduling:
Pharmacy visits were scheduled after the hepatologist/infectious disease specialist appointments every 28 days.
IV. The clinical interviews were documented in the electronic health record.
How was it done?
A multidisciplinary team was formed with two hepatologists, one infectious disease specialist, three clinical pharmacists and one nurse to:
– Address the key points associated with the safe and efficient use of AADs.
– Create a useful clinical guideline.
– Identify staffing and logistics needs.
What has been achieved?
No of patients included in the programme: 674
No of initial visits: 674
No of follow-up visits: 1750
No of patients attended/day: 19.9
No (%) adherent patients at the end of treatment: 412/412 (100%)
No of pharmacist interventions: 195
No (%) pharmacist interventions accepted: 194 (99%)
Average waiting time to be attended by the pharmacist: 15 min
No of queries made to the hospital pharmacist: 84
No of adverse drug events reported to the pharmacovigilance centre: 31
Cost savings (€): 121 194
What next?
This initiative provides a set of recommendations regarding CHC management and a support guide to standardise and guarantee high quality pharmaceutical care.
The next step is to develop pharmaceutical care programmes for the management of other pathologies following the same methodology that we have used for this initiative.
DEVELOPMENT OF A COMPUTER APPLICATION TO REDUCE THE RISK OF ERRORS IN RECONSTITUTION OF CYTOTOXIC DRUGS
Pdf
European Statement
Production and Compounding
Why was it done?
The preparation of cytotoxic drugs perfusions can be accompanied by errors that can be fatal to some patients. Several methods were tested to minimise the risk of errors associated with reconstitution of cytotoxic perfusions (camera, HPLC, analytical balance, the presence of a second technician to monitor his colleague). All of these methods can be expensive and are not available to all hospital pharmacists.
What was done?
We present a simple and effective method that we have developed in our hospital to solve the problem of reconstitution errors.
How was it done?
Errors of cytotoxic drugs reconstitution can have catastrophic consequences for patients. Some studies have found that the incidence of major and minor errors were, respectively, 0.19% and 0.26%. Reconstitution control methods are numerous but not always accessible to all hospital pharmacists and preparers, particularly in developing countries.
This work involves the development of a computer application developed from an Open Source voice recognition software. The daily chemotherapy protocols are entered in the application that dictates to a technician the protocol prescribed by the physician, product by product, for all patients. The technician performs the cytotoxic preparations in the order in the centralised pharmaceutical unit for the preparation of cytotoxic drugs and he communicates with the application manually or by speaking.
The application begins with the patient’s ID, name and surname, the first drug, the dosage, the dilution solution and the volume of this solution. Then, it passes to the second product and so on. In the case of an observation, the application warns the technician to take this observation into account.
What has been achieved?
This application has helped provide better assistance to the technicians and pharmacists in the reconstitution of cytotoxic drugs, and no event or error has been detected to date.
What next?
To make a large number of reconstructions using this application to assess its effectiveness and install it in other hospitals who handle cytotoxic drugs.
PHARMACEUTICAL INITIATIVE FOR APPROPRIATE HANDLING WITH CYTOTOXIC DRUG ON NON-ONCOLOGY DEPARTMENT AT OUR CLINICAL HOSPITAL
Pdf
European Statement
Introductory Statements and Governance
Author(s)
T. DIMITROVSKA MANOJLOVIKJ
Why was it done?
To highlight the classification of this drug, its dangerous side effects even to those patients not receiving it, due to intoxication when handled inappropriate, and the precautions and measures that should be undertaken to minimise the risk/danger of occupational exposure and environmental pollution with inappropriate managing of the waste and spill.
What was done?
These 4 written statements were created: (1) Notification/instructions for handling cytotoxic agentS, (2) instructions for hygienic use of the toilets by patients receiving cytotoxic therapy and disposal of toxic waste on gynaecology and obstetrics wards, (3) instructions for a woman receiving methotrexate injection and (4) standard operating procedure for intramuscular application of methotrexate for nurses in the gynaecology-obstetric ward.
All statement were copied and disseminated to all departments on the ward. In November 2014 during verification of daily drug supplies to the gynaecology-obstetrics ward, I detected a package of methotrexate injections in the transporting container together with other drugs. I immediately contacted the head ward nurse and took control of the handling of the drugs on the ward, especially in the department for pathological pregnancy. The young departmental nurse responsible nurse was not aware of the classification of nethotrexate as a hazardous cytotoxic drug that should be handled with special care. Even though a drug is not given for cancer, it should still be treated as hazardous. Explanations were given to all those present at the time: nurses, gynaecologists and hygiene maintenance staff in the department.
How was it done?
Difficulties in persuading departmental staff of the occupational hazard, intoxication by other patients not receiving the drug and environmental pollution, particularly the danger of extravasation in this class of drugs when handled inappropriately, were overcome by repeating the explanations several times and disseminating the 4 statements.
What has been achieved?
Appropriate handling of cytotoxic drugs, improvement in patient care and protection from pollution of the environment.
What next?
Frequent controls on drug handling on all hospital wards for prevention of irregularities and to ensure safe medicines application.
National monitor for the quality of medication surveillance
Pdf
European Statement
Patient Safety and Quality Assurance
What has been achieved?
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eLearning Environment for Ensuring the Competence in Pharmacotherapy
Pdf
European Statement
Education and Research
Author(s)
Susanna Saano, Tiina Koskinen, Hillevi Rautiainen, Minna Taam-Ukkonen
BARCODESCANNING IN THE PHARMACY FOR A SAFER THERAPY
Pdf
European Statement
Selection, Procurement and Distribution
Why was it done?
Medication errors find their origin mostly in prescribing, transcribing and administration of medication. Only 4 % of the errors occurs in the pharmacy process. As we covered the major reasons by deployment of a electronic prescribing system with decision support and bedside scanning before administration the next step in augmenting patient safety is preventing dispension errors in the pharmacy.
What was done?
All medication orders from the electronic prescribing system are revised by a hospital pharmacist for appropriateness and send to a set of handheld barcode scanners for guiding the pharmacy technicians through the picking process. They identify themselves, the ship label, the picking location and the medication by scanning. The scanner checks if the right drugs are dispensed for the right patient.
How was it done?
Due to bedside scanning all orders are electronically available and all medication have barcodes on the single dose. All locations are barcoded for reasons of replenishment of stock. By simply sending the orders to handheld terminals it’s a small effort to verify the picking.
What has been achieved?
All electronic medication orders are checked by barcode scanning or a second hospital pharmacist resulting in a diminishment of picking errors to (nearly) zero. We can show an online status of the medication order to nurses and physicians and we shifted pharmacist time from checking drugs to checking appropriateness of therapy.
What next?
In a next step we will also check retour medication by barcode scanning preventing possible misplacement.
A NATIONALLY COORDINATED APPROACH TO DEVELOPING HOSPITAL PHARMACY SERVICES IN DENMARK
European Statement
Introductory Statements and Governance
Why was it done?
Approximately 450 people work within clinical and ward pharmacy in hospitals in Denmark. Despite Denmark being a relatively small country, these services have developed at differing paces, and sometimes in different directions. The initiative was set up to coordinate development and innovation in this field, across the whole country.
What was done?
A national group was established to coordinate and develop clinical and ward pharmacy services throughout Denmark. The working group consists of pharmacists and pharmaconomists representing the eight hospital pharmacies in Denmark.
How was it done?
In 2012/2013 fifteen people representing pharmacists and pharmaconomists from the five Danish regions were selected to the working group. These people were typically known to be experienced drivers of innovation and development in the field of clinical and ward pharmacy. The working group meets quarterly and additional work is carried out between meetings. There are no extra resources available to members of the group or their workplaces.
What has been achieved?
The group has produced and implemented minimum standards for ward pharmacy across Denmark. Benchmarking has been carried out using these standards and the baseline has been set. Progress will be measured regularly.
New standards for how often medicine shelf-life checks should be carried out on wards have been developed, resulting in the task being carried out less frequently on most wards, thus releasing resources to more clinically related tasks, at a time where extra resources are scarce.
Two national networking days for pharmacists and pharmaconomists have been held, where good initiatives are shared to all the regions and hospital pharmacies in Denmark.
What next?
The group is working on national standards for competency development of clinical pharmacy staff. Other logistics tasks will be scrutinized to see whether resources can be found for further investment in clinically related activities.
More benchmarking will be carried out, measuring other clinical and ward pharmacy activities throughout Denmark.
The work has just begun!