Skip to content

Implementation of an opioid stewardship programme (OSP) at San Ignacio University Hospital

Pdf

PDF Icon

European Statement

Patient Safety and Quality Assurance

Author(s)

Viviana Andrea Pinzon Garcia, Paula Camila Murcia Jaramillo, Reinaldo Grueso Angulo

Why was it done?

In 2018, concerned with the opioid crisis in USA, the pharmacy and therapeutic committee began to work on safer opioid use; an initial diagnosis showed an increase in the use of in hospital opioids and a lack of protocol for the disposal of the resultant remnants. Standard single-dose syringes (SSDS) were devised to avoid remnants, subsequently noticing that the strategies to be used should involve the whole medication order cycle (MOC). This gave rise to the OSP, which involves physician’s pain management and prescribing practices, pharmacy preparing and dispensing process, nurse’s custody, administration and disposing protocols.

What was done?

An Opioid Stewardship Programme (OSP) led by a multidisciplinary team: scientific direction, pharmacy and pain clinic, was implemented to ensure adequate and safe opioid prescription, dispensation, administration and disposing practices in San Ignacio University Hospital (HUSI), a tertiary level hospital in Bogota, Colombia.

How was it done?

Institutional pain practice guidelines were assessed, unifying the titration doses with SSDS and developing disposal protocols in which care staff is constantly being trained ever since. To trace the impact of the OSP, indicators for IV opioid consumption, SSDS prescription, naloxone use and guideline adherence were created.
Main obstacles on SSDS: <10% prescribing adherence, availability failures and dose expiration. In response, the whole ampoule prescription was narrowed to only pain specialists to face SSDS expiration costs and avoid shortage.

What has been achieved?

SSDS prescription proportion above 70% by July 2022, decreased milligram morphine equivalent (MME) consumption per hospital discharge (January 2019: 37, January 2020: 47, January 2021 (COVID 2nd surge): 39, January 2022: 25, July 2022 (COVID 3rd surge):16) and monthly costs decrease in 1997 USD, between 2019 and 2022.
An opioid shortage during the COVID surges, deepened in Colombia due to a hydromorphone recall, was avoided.

What next?

The OSP initiative could be replied in healthcare institutions considering our achievements. To keep working in a safer opioid MOC, our OSP has formulated new strategies with an active role of pharmacists, pain specialists and nurses oriented to: remnants disposal protocol, prescribing policies, medication error detection and healthcare staff and patient education.

Implementation in a pharmacy service of a big data analysis programme for successful treatment

Pdf

PDF Icon

European Statement

Patient Safety and Quality Assurance

Author(s)

LUCIA SOPENA, ALBERTO FRUTOS, VICENTE GIMENO, OLGA PEREIRA, RAQUEL FRESQUET, ARITZ MERCHAN, REYES GARCIA, PAULA GOMEZ, ALBERTO APESTEGUIA, MARIA ANGELES ALLENDE, TRANSITO SALVADOR

Why was it done?

The growing technological development of pharmacy services involves the coexistence of traditional warehouses with automated medicine dispensing systems controlled by different computer programs. The information is split into different systems and databases giving rise to possible errors due to the greater complexity. This is a threat but also an opportunity for the hospital pharmacist to lead the development, review, and improvement of medicine use processes and the use of health technologies to improve quality of care, patients’ safety and reduce costs. KNIME data analysis covered the need of our Pharmacy Service to blend data from any source in a single file simplifying the process.

What was done?

The Pharmacy Service of a university hospital has implemented Konstanz Information Miner (KNIME) data analysis and develop successful treatment project to optimise the stock management of several medicines.

How was it done?

An initial algorithm was designed by the union of seven files and can be executed at any time to obtain the updated data.

What has been achieved?

This file provides up-to-date information about the stocks, stock-outs, consumptions, orders and purchasing data of all medicines (average price, laboratory, date and number of orders, units to be received).
In addition, KNIME calculated the coverage time in days and months from weekly and monthly consumption, and the current stock in the warehouses, obtaining a global vision of highest turnaround pharmaceuticals drugs.
The program also allows to link and merge data of the list for shortages of medicines, supply disruptions and restocking time, and to improve the storing, delivering and administering of COVID-19 vaccines.
KNIME program has been especially important in our Pharmacy Service to get better care outcomes and more precise medication ordering, which allows significantly higher patient safety.

What next?

KNIME is a tool that could be successfully implemented and appropriately generalised as recommended to all Pharmacy Services that use different data sources and want to have a generalised view of the information. KNIME represents an advance in the stock and purchase management of medicines specialties to work more efficiently, which improve patient care and safety. Digital medication management also contributes to greener pharmacies by preventing unnecessary overstocking and thus excessive disposal arising from expired medications.

Healthcare impact of a digital health programme for patients with chronic or high-frequency episodic migraine

Pdf

PDF Icon

European Statement

Patient Safety and Quality Assurance

Author(s)

Anna de Dios-López, Neus Pagès-Puigdemont, Montserrat Masip-Torné, Pau Riera-Armengol, Rebeca Pelegrín-Cruz, Cristina Martínez-Molina, Noemí Morollón, Robert Belvís-Nieto, Maria Antònia Mangues-Bafalluy, Mar Gomis-Pastor

Why was it done?

Migraine is a neurological disorder characterised by frequent headache. Patients with an episodic migraine pattern have <15 monthly migraine days (MMD), whereas patients with a chronic pattern have ≥15 MMD. Migraine has a high prevalence (15-20% of female and 5-8% of male) and a great impact on their quality of life. Many migraine patients can benefit from preventive treatment. The use of a digital health programme in these patients can allow a real-time monitoring of treatment effectiveness (through the register of migraine attacks frequency) and adverse events. Additionally, it can improve the communication between patients and HCP.

What was done?

We tested a patients’ mobile phone (mHealth) application in chronic and high-frequency episodic migraine patients. This application was synchronically linked with a website for healthcare professionals (HCP) and hospital clinical records.

How was it done?

MyPlan is a mHealth application adapted from another one developed in our hospital for heart transplant patients. Firstly, we conducted a focus group with patients to understand their needs and preferences. This platform fulfils the quality and Data Protection Regulation.

What has been achieved?

13 patients and carers participated in two different focus groups. Another focus group was conducted with the Neurology Department of our institution. The results permitted to adapt the mHealth application with the following functionalities and registers:
• Synchronous (videocall) and asynchronous (direct message) communication between patients and HCP
• Medication adherence
• Treatment adverse events
• MMD and monthly headache days (MHD)
• Monitoring through the register of biomeasures (blood pressure, weight), lifestyle habits (diet, exercise) and questionnaires (MIDAS, HIT-6, EQ-5D, MSQ)
• Information
Data registered by the patient was used to guide clinical management and improve patients’ healthcare route.

What next?

The introduction of mHealth in the healthcare route of patients with migraine could benefit both patients and HCP. This strategy could be incorporated in other health facilities that attend migraine patients in an outpatient setting. Nowadays, a clinical trial is being conducted to demonstrate its clinical benefit.

Opioids room of horrors – an interactive learning to improve safety of drug administration

Pdf

PDF Icon

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

PDF Icon

European Statement

Patient Safety and Quality Assurance

Author(s)

Easter Mark

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.

Implementation of a standardised parenteral nutrition solution on a neonatal ward

Pdf

PDF Icon

European Statement

Patient Safety and Quality Assurance

Author(s)

Isabelle Sommer, Farshid Sadeghipour

Why was it done?

PN can be composed of 14 different ingredients, including an amino acids admixture. Therefore, PN represents a complex and high risk preparation. Medication errors (ME) are often related to PN management and may include prescription, transcription, preparation, and administration errors. As the treatment with PN is essential for a good cerebral and neurologic development and a postnatal weight gain, ME can result in growth retardation, developmental disturbances, and infections. The implementation of the standardised PN aimed to achieve a reduction of ME having an impact on vulnerable newborns and to improve the security and quality of their nutritional treatment.

What was done?

A multidisciplinary development of a hospital’s neonatology and pharmacy departments as well as of an industrial manufacturer resulted in a standardised parenteral nutrition (PN) solution for neonatal patients. This PN solution was implemented as “standard-of-care” for newborn term and preterm infants requiring nutritional treatment within their first days of life.

How was it done?

The standardised PN solution for a peripheral administration route was developed in accordance with ESPGHAN guidelines (2018).
The neonatologists defined internal guidelines for the PN administration and trained the concerned personnel (physicians and nurses).
The industrial manufacturer delivered the ready-to-use PN solution as a sterile double-chamber infusion bag in accordance with Swiss and European regulatory.

What has been achieved?

The ready-to-use PN solution with a 24/7 availability on ward by means of an 18 months stability at room temperature allowed a considerable reduction (-80%) of on ward preparation of nutritional solutions by nurses.
One-third of individual PN solutions being prepared at the hospital’s pharmacy has been replaced by the standardised PN solution.
This high-quality PN solution allows a secured administration to the vulnerable patients as well as a reduction of ME related the whole PN management resulting in an improvement of the nutritional treatment of neonates and its outcomes on their development.

What next?

This special PN solution is already implemented in two Swiss university hospitals and others will follow. Further standardised PN for a central venous administration to neonates need to be developed to allow the completion of a safe nutritional treatment. On ward PN preparations must be prohibited to prevent undetectable ME.

Closing the loop: barcode scan for drug administration at bedside patient

European Statement

Patient Safety and Quality Assurance

Why was it done?

This solution, an integrated module of our electronic health record (EHR) (Millennium Oracle Cerner), allows the computerised validation of the administration of medication in real-time at the patient’s bed by scanning a bar code identifying the medication or the infusion.

What was done?

The implementation of a solution allowing the secure administration of medication (oral or injectable) at the patient’s bed is one of the latest processes we have put in place to improve the security of the medication circuit and the quality of patient care within our establishment.

How was it done?

Our pharmacy has a robot for automated dispensing of unit forms of medication by over-packaging (PillPick Swisslog). A unique code of each oral medication is affixed to each sachet and this code, once scanned, will be used to verify the concordance between the physical medication in the hands of the nurse dispensed by the pharmacy and the medication prescribed in the EHR.
For infusions, a tool of our EHR makes it possible to generate a barcode label taking again information of the prescription as well as patient identity and that one is affixed on the infusion after reconstitution/dilution the barcode being scanned at the time of the installation.

What has been achieved?

In collaboration with the care services we have set up a Bluetooth barcode reader connected to the nursing cart for the scanning of the therapeutics and the patient. The process allows after scanning and verification of the patient’s identity, to scan all the drugs to be administered orally or by injection directly at the time of administration and their validation in the patient’s file at once.

What next?

The approach around this work and its deployment has allowed team work between the pharmacy, the care services and the IT services in charge of the EHR to achieve the rapid and sustainable implementation of this solution, fast learning and saving nursing time. It allows us to secure our circuit from the production of therapeutics by our robot to the administration to the patient and also to respect the 5B rule of the drug circuit.

Pharmacist-led education of social and healthcare assistants in drug dispensing and administration in hospital wards to alleviate the shortage of nurses

Pdf

PDF Icon

European Statement

Patient Safety and Quality Assurance

Author(s)

Trine Birkholm, Trine Rune Høgh Andersen

Why was it done?

The Danish Ministry of Health has declared which healthcare professionals should handle medication such as dispensing and administration to patients in hospitals. Traditionally, primarily nurses and physicians handle administration of medicines in the Danish hospitals. In recent years a massive shortage of nurses in Danish healthcare has called for other professions to participate in administration of medicines. As Denmark has employed less than one clinical pharmacist per 100 beds in hospitals, pharmacists are not able to contribute to the task. However, clinical pharmacists can have an important role in educating other healthcare professionals e.g. HCAs in handling medicines.

What was done?

Because of massive lack of nurses and thereby healthcare professionals to administer medicine in psychiatric wards in Region Zealand, Denmark, the pharmacists developed and implemented a training course for social and healthcare assistants (HCAs) to participate in the task.

How was it done?

As hospital pharmacists should ensure that the information needed for safe medicines use, including both preparation and administration, is accessible at the point of care (EAHP statement 5.9), aiding in the development of a training course for HCAs was ideal for the clinical pharmacists. The training course has a duration of 3 days followed by a mentored trainee period. The course includes psychopharmacology lessons to teach HCAs to observe and react to overdoses, lack of effect or side effects as declared in medicine handling guidelines.

What has been achieved?

Approximately 150 HCAs have attended the course since 2020. Eight out of ten state that the course has enabled them to take on the new work tasks. Nine out of ten believe that they can use the newly acquired knowledge and practical skills for their new work tasks. Today, the administration of medicines in the psychiatry ward is also managed by HCAs, thus relieving the nurses’ time needed for more specialised tasks.

What next?

There is also a shortage of nurses in the somatic hospitals. To ensure patient safety and enough staff to dispense and administer medicines, several hospital wards have requested similar training for HCAs. It is believed that similar training courses with modifications can target somatic wards as well.

Optimised and sustainable distribution and handling of medicines to psychiatric outpatients

Pdf

PDF Icon

European Statement

Patient Safety and Quality Assurance

Author(s)

Louise Stilling Rasmussen, Lene Juhl Biltsted, Majken Nørskov Petersen

Why was it done?

To implement EAHP statements on Patient Safety and Quality Assurance the hospital pharmacist carried out the intervention in one of the largest psychiatric clinics in the region. The following challenges were observed: Lack of transparency for healthcare professionals. Inflexible and time consuming workflow which did not accommodate the needs in the medical treatment at the clinic. The workflow caused waste of medicine. Changes in the medical treatment, which caused medicine being surplus and ended up expiring. The distribution was expensive and not sustainable.

What was done?

By changing the handling and distribution of medication for psychiatric patients who are entitled to free medicine from the hospital, we now have an agile, streamlined, patient-safe and transparent workflow that ensures patient safety by accommodation of the seven rights, increases the flexibility and availability of medicine to the patient’s current treatment and gives a more sustainable handling of medicine. Furthermore, resulted in direct and indirect financial savings (estimated direct savings 8%, DKK 250,000).

How was it done?

A medication room was reorganised by the pharmacist according to ATC codes, shelf fronts, active ingredients and expiry date.
Establishment of a computer and scanner, linked to the national Shared Medication Record containing all patients’ prescriptions.
Medicine is ordered online from the hospital pharmacy.

What has been achieved?

New modern quality assured medication room with electronic registration of medicines dispensed to the patients. This provides transparency of the medical treatment across the healthcare sector. The medicines are stored correctly, and the integrity is maintained until immediate use and permit correct administration. Elimination of medication waste and reduced time consumption for healthcare personnel gave an estimated direct savings of approx. DKK 250,000 plus an uncalculated saving of staff time. Finally, a more sustainable management of medicines and reduced the risk of errors regarding medical distribution was achieved.

What next?

The results of this project have scaling potential. A presentation for decision-makers about implementing the solution elsewhere is ongoing. The handling and distribution has been changed from patient-labelled medication to secure digital registration of the medication dispensing from the medicine room, which now allows complete traceability of all medicines dispensed by the pharmacy.

DEVELOPMENT OF A PROTOCOL TO STANDARDISE CELL-BASED MEDICINAL PRODUCTS HANDLING IN AN ONCO-HAEMATOLOGY CLINICAL TRIALS UNIT

Pdf

PDF Icon

European Statement

Patient Safety and Quality Assurance

Author(s)

JOSE MANUEL DEL RIO GUTIERREZ, EUGENIA SERRAMONTMANY MORANTE, SARA GIMENEZ GINER, PILAR ROVIRA TORRES, PATRICIA GARCIA ORTEGA, CARLOTA VARON GALCERA, ISABEL CIDONCHA MUÑOZ, MARIA QUERALT GORGAS TORNER

Why was it done?

One of the most important challenges we currently face is the increase of clinical trials (CTs) including CBMPs. These drugs require special storage, preparation, delivery and administration; so developing standard operating procedures (SOPs) and ensuring proper coordination between all professionals involved, including pharmacists, is essential.

What was done?

Management of cell-based medicinal products (CBMPs) was protocolised in an onco-haematology clinical trials unit.

How was it done?

Pharmacists, doctors and nurses participate in a multidisciplinary team to standardise CBMPs handling. The following protocol was agreed:
1.The entire multidisciplinary team is notified when a CBMP prescription is planned to ensure proper coordination.
2.The CBMP is manufactured by the CT sponsor. Then, it is transferred to the blood bank for cryopreservation. CBMPs usually require a temperature between -80ºC and -200ºC and expire in some weeks.
3.Before CBMP administration, patients undergo lymphodepletion. The lymphodepletion regimen is performed according to the CT protocol or arranged between medical and pharmacy teams. Chemotherapy, serum therapy and antiemetic regimen are discussed and specified.
4.Once the treatment is prescribed, it is verified by a pharmacist who ensures its suitability.
5.On the infusion day, the blood bank delivers the CBMP. Then, a pharmacist checks if it arrives in proper condition and it is defrosted. The pharmacy department reconditions the CBMP in another infusion bag or syringe if required. This is the most critical point because CBMP expires after some minutes of defrosting, requiring extensive coordination.
6.CBMP is administered according to the CT protocol.

What has been achieved?

72 patients were recruited in 15 CT. 8 of them use as CBMP Chimeric Antigen Receptor T-Cells (CAR-T-CELLS), 4 Specific Peptide-Enhanced Affinity Receptor T-Cells (SPEAR-T-CELLS), 2 Tumour-Infiltrating Lymphocytes (TILs) and one cytokine-stimulated Natural-Killer-Cells (CS-NK-CELLS). Seven assays are intended for haematological neoplasms and eight for solid malignant neoplasms. One assay requires CBMP syringe reconditioning in the pharmacy department.
The described process optimises CBMPs handling, avoids delays in administration and reduces the risk of misuse.

What next?

CBMPs represent a novel therapy, and pharmacists have an essential role in developing new procedures to incorporate them into clinical practice. This protocol may be helpful for other centres to implement guidelines to work with CBMPs.