Author(s)

Paula Hernando Martínez, María Antonia Meroño Saura, Caridad Marti Gil, Lidia Martínez Valdevieso, Jaime Fernández-Bravo Rodrigo, Dolores Barreda Hernández

Why was it done?

There is a wide bibliography on how human errors related to drugs put the patient’s health at risk. Drug preparation and administration errors, dose calculation errors, lack of knowledge about drugs or interactions, to name but a few. There must be protocols to ensure that drugs are safe for patients, including procedures which professionals should fulfill in order to reduce those errors in processes and guarantee, in such cases, that they will not have adverse effects on patients.

What was done?

Development of infographics for assembling drugs which are susceptible to a higher rate of errors in their preparation and administration to hospitalized patients.

How was it done?

During September 2021, a working group was formed in the pharmacy department (PD). Through the nominal group technique, the design and content of drug infographics was proposed as a solution to the raised problem. Subsequently, a bibliographic research of susceptible drugs to human errors during administration or preparation and those which requiring special handling was reviewed through the list of high-alert medication from National Institute for the Safe Use of Medications website and NIOSH list of hazardous drugs. To this end, the PD databases were analysed, obtaining the drugs that required the greatest number of pharmacotherapeutic consultations made by nursing staff on drug administration and recommendations made during pharmaceutical validation.

What has been achieved?

An infographic model has been designed which includes the description of the drug (name of drug, excipients, dose, pharmaceutical form, dosage regimen, route of administration, concentration), the preparation and administration protocol (reconstitution, dilution, infusion rate, premedication), observations (maximum doses, conditioning, incompatibilities, alerts) and storage conditions (conservation and stability). Infographics on dantrolene, intravenous phenytoin solution, intravenous nimodipine solution and potassium chloride solutions are currently being distributed. These documents are available at the nursing controls and on the hospital’s internal website.

What next?

To increase the availability of drug’s infographics and to update those that have already been developed when necessary. In addition, from the PD, the preparation of administration kits for the solicited drugs is proposed so as to ensure that all the necessary materials for the preparation and administration are included along with the corresponding drug and infographic.

Author(s)

Carmen Ortí Juan, Cristina Toro Blanch, Maria Àngels Gispert Ametller, Ana Perez Plasencia, Cristina Lecha Ochoa, Anna Dordà Benito, Rosa Sacrest Güell

Why was it done?

Prescribing errors (PE) are an important cause of medication-related adverse events in the Emergency Departments (ED) but limited data are available in ED with electronic prescribing and administration (ePA) systems. Knowing the frequency and types of PE can help healthcare professionals to prevent and reduce the risk of them occurring.

What was done?

To determine the rate of PE in the ED, to classify incident types and to identify critical points where measures should be implemented to improve patient safety.

How was it done?

Prospective, observational and cross-sectional study in an ED with ePA system during 6 working days (May-June 2021). The inclusion criteria were patients stayed more than 8 hours in the ED and all patients awaiting hospitalization. Prescriptions were analyzed by a multidisciplinary team made up of two pharmacists, an emergency physician and the person in charge of the hospital’s medication errors committee. PE were reported to the hospital’s patient safety-related incident notification system.

What has been achieved?

Of the 65 prescriptions revised during the study period, PE were reported in 84 cases and 15 situations with the capacity to cause errors were detected. The average age of patients was 67 ± (SD=17,9) years and each prescription had an average of 8.4 medications. The rate of PE was 1.52 errors per patient, being higher in less severe patients than monitored patients (1.09 vs 2.0 PE per patient, respectively). The most common types of EP were omission of the usual medication (60.7%), wrong dose (15.5%), wrong frequency (7.1%) and drug is not indicated (7.1%). No adverse reactions related to EP were detected. According to the Spanish consensus about Medication Reconciliation in Emergency Units, 47.1% of omissions of usual medication were drugs that should be reconciled during the first 4 hours in the ED. The results of the study and the importance of medication reconciliation are highlighted in a session in the ED.

What next?

The PE rate in the ED was 1.52 per patient and the main type was omission of the usual medication. A cross sectional study will be made in the future and compared to the current one to establish the impact of the implemented measures on the PE rate.

Author(s)

Pilar Fernández-Villacañas Fernández, Manuel Ríos Saorín, Patricia Ortiz Fernández, Alba María Martínez Soto, Consolación Pastor Mondéjar, Carmen Caballero Requejo, Lorena Rentero Redondo, Alberto Quesada Asencio, Elena Urbieta Sanz

Why was it done?

Due to kidney pathologies affect the normal pharmacokinetics of many drugs, it is necessary to adjust the dose of the drug for each patient. It is also necessary to ensure effectiveness and safety for the hospitalized patients with renal failure, associated with higher morbidity and mortality. The main objective is to minimise validation and prescription errors.

What was done?

A review of drug dosing according to the patient´s creatinine clearance was performed. This dose adjustment was included as alerts in the electronic prescription system.

How was it done?

For each drug, the data of the dosage adjustment in patients with renal impairment were compiled by consulting the technical data sheets and the national guidelines. In the case of antimicrobials, the information was obtained from the Antimicrobial Therapy Guide 31th Edition March 2021. The data were organized in an Excel table to later integrate them into the hospital’s electronic prescription system.

What has been achieved?

The dose adjustment was made for 848 presentations of different drugs: antibacterials (186), antipsychotics and antidepressants (109), antiepileptics (63), opiates (57), antivirals (49), NSAIDs (26), diuretics (24), anticoagulants (22), antimycotics (21), antidiabetics (15), antiparasitics (11), antiemetics (11), antitumors (4), among others. A large number of drugs are highly dependent on kidney function, especially antibacterials, antipsychotics and antidepressants, making that an incorrect dosage of renal drugs can worsen kidney function and produce toxic effects due to their accumulation.

What next?

This dosage adjustment for patients with renal failure should be periodically reviewed by the hospital’s pharmacy service in order to keep the alerts of the electronic prescription system up-to-date. Additionally, this system can be implemented for other pathologies such as liver failure, or to avoid overdose by establishing the maximum dose limit allowed. In conclusion, the importance of an adequate electronic prescription program that facilitates daily clinical practice is established, preventing possible medication errors.

Pdf

Author(s)

Vera Pires, Maria Teixeira, António Gouveia

Why was it done?

Cisplatin is a cytotoxic agent used in CT regimens in ST. (1) Nephrotoxicity is the main toxicity, and hydration is always indicated to prevent kidney damage. [1,2] In 2018, when we computerized the ST’s CT protocols, we verified the existence of variations in CH protocols. According to the bibliography, this lack of standardization could lead to sub-optimal treatment of patients, errors and unnecessary use of resources. [1,3] Thus, it was necessary to develop a standardized hydration protocol designed by pharmacists with the collaboration of oncologists.

What was done?

Standardize the cisplatin-based hydration (CH) protocols used in the solid tumors (ST) chemotherapy (CT) regimens in adults in our institution.

How was it done?

Audit of CH protocols used in ST in adults in our institution and literature review to build a standardized evidence-based protocol.

What has been achieved?

We gathered 31 CT regimens with cisplatin. Verified the existence of variations in the volume of hydration (VH) before and after cisplatin, in the volumes of drug dilution, perfusion time, in the use of oral hydration (OH) and in ionic supplementation. We found that all of them were indicated to perform cisplatin only “if urine output >100ml/min”, use of mannitol before cisplatin and furosemide in SOS. Through the consulted bibliography, 4 regimens were made and implemented in 2019, according to the dosage of cisplatin: HC1< 40mg/m2 (Hday) and HC21000ml, and mannitol is only administered if cisplatin ≥60 mg/m2 (RCM). All protocols have magnesium and potassium supplementation.

What next?

Thus, despite the lack of consensus in the bibliography, a standardized protocol was created based on the evidence and clinical practice of our Institution. It is our intention to assess the impact of this intervention, from the perspective of the patient and the Institution.

Author(s)

Juan Campillo, Manuel Bonete, Marta Zayas, Maria Molina, Laura Barrajón, Cristina Martínez, Ángela Rizo, Maria Ángeles Bernabeu, Maria Teresa Aznar

Why was it done?

Medication errors (ME) occur in different phases of the drug circuit: prescription (16%), transcription (27%), validation, preparation, dispensing (48%) and administration (9%). The AEP is a tool to guarantee the safety of this circuit, being able to avoid up to 65% of ME. There is also a learning curve in new users of an AEP, confirming the need for support to reduce ME.

What was done?

1-Maintenance of the Assisted Electronic Prescription Program (AEP)
2-Implementation in 11 wards and in the Emergency Department of a 396-bed tertiary hospital
3-Training
4-To set a pilot AEP
5-Reeducation strategies

How was it done?

1- 1465 drugs included in the Pharmacotherapeutic Guide were configured. 3 levels of danger were created for Hazardous Drugs (HD) and the recommendations for their preparation / administration were agreed upon. The Therapeutic Exchange Guide was integrated into 443 drugs (761 exchange proposals).
2- It started in the Emergency Department and every week a new ward with AEP was opened.Paper was eliminated throughout the circuit, drug dispensing trolleys were modified and a computer was fitted to record administrations at the bedside.114 pharmacotherapeutic protocols were created.
3- A technical training program, changes in procedures, schedules and training documents were designed. 72 sessions were given to 346 physicians and 88 sessions to 543 nurses.
4- 490 incidents were reported, prioritizing the most urgent (compromising patient safety). 224 claims to expedite resolutions. We also collaborated with other hospitals.
5- Welcome plan to train new staff and annual sessions. A tutorial video to focus on the points that caused the most errors was recorded. Preparation of new documents to report the changes.

What has been achieved?

First hospital to implement computerized administration. Elimination of transcription errors. Improved administration security. Greater visibility of the pharmacist and participation in decision-making. Contribution to development of the AEP and its implementation in 15 more hospitals.

What next?

Monitoring the necessary interventions to develop educational strategies when a growing trend is observed. Improve the welcome plan. Continue piloting the new AEP versions Follow the evolution of pending incidents. Evaluate the impact of the educational strategy of the tutorial video.

Author(s)

Elena Lee, Yue Feng Toh, Nathaniel Lim

Why was it done?

Older patients on polypharmacy are predisposed to drug related problems (DRPs). While MTM service with pharmacist involvement can reduce DRP occurrence, few have examined its impact on reducing unplanned readmissions.

What was done?

This study was designed to determine whether a pharmacist-provided medication therapy management (MTM) service can reduce unplanned readmissions through the comparison with patients receiving usual care.

How was it done?

A retrospective cohort study was conducted in Changi General Hospital. Patients present for MTM service from Jan 2016 to Dec 2019 were included in the intervention arm (n=96) while patients who attended specialist outpatient clinics were recruited as control (n=98). Index visits from the same patient within 6 months of an earlier visit were excluded. Primary outcome was the change of unplanned admission post and pre 6-month of index visit comparing intervention arm against control arm. Secondary outcomes were descriptive of DRPs identified, number of recommendations from pharmacists, types of interventions and the potential risks avoided. Primary outcome analysis was conducted with linear regression and adjusted for potential confounders.

What has been achieved?

MTM sessions resulted in the reduction of unplanned admission rate by 0.83 (95% CI: -1.31, -0.34), p=0.001, after adjusting for confounders. For patients with admission prior to the index visit, the intervention arm had statistically significant lower incidence of unplanned admission post and pre 6-month of index visit by 0.916 as compared to control group (p=0.018). There are higher number of DRPs (144 vs 2) and pharmacist recommendations (40 vs 2) were found in the intervention arm compared to control arm respectively. The most prevalent types of DRPs were ‘Non-adherence’ (80.6%), ‘Drug omission’ (5.6%), and ‘Inappropriate dose’ (2.8%). The most common potential risks avoided were increased cardiovascular risk, n=29 (22.1%), increased fall risk, n=18 (13.7%) and increased risk of fractures, n=17 (13.0%).

What next?

The study suggests that pharmacist-provided MTM service decreased unplanned readmission rate. It has improved medication safety and quality of care by identifying and resolving more DRPs.

Author(s)

Sonja Guntschnig

Why was it done?

The aim of this good practice initiative (GPI) was to identify local resistance patterns, improve prescribing quality, reduce hospital costs, calculate antibiotic use data, track problem organisms, infection clusters and enable transfer chains tracing.

What was done?

With the introduction of a new antimicrobial stewardship (AMS) group into Tauernklinikum, Zell am See, a new informatics tool called HyBase® by epiNet AG was implemented to establish an interface linking microbiological results, consumption of antimicrobials, the hospital infections surveillance system “Krankenhaus-Infektions-Surveillance-System”(KISS) and the hospitals antimicrobial resistance data. AMS teams need suitable AMS surveillance systems to track intervention changes and measure results.

How was it done?

After purchasing release by the hospital management, HyBase needed an interface with several IT system providers, namely the internal microbiology laboratory (KISS software), System Application and Product in processing (SAP), and two external microbiology laboratories.

What has been achieved?

Antibiotic consumption figures were obtained retrospectively by calculating defined daily doses (DDD). This also gave insight into problematic use of certain antibiotics and indicated potential for antibiotic restriction.
Antimicrobial resistance patterns were displayed, which led to the introduction of infection control and AMS measures. Alert organism surveillance data was obtained and evaluated for different wards.

What next?

Learning from this implementation will enable changes in antimicrobial prescribing which will lead to improvements, both in healthcare quality and patient safety as well as a potential reduction in prescribing costs. Alert organism clusters will be detectable as will be transfer chains in the healthcare setting. It will also allow for the introduction of infection control agent stewardship for example by testing hand disinfection compliance or recording the spread of surface adherent organisms.
This GPI addresses the WHO antimicrobial resistance global action plan and local antimicrobial medicines concerns. It may prove useful for other healthcare settings and can be easily implemented to obtain data necessary for robust effective antimicrobial stewardship.

Author(s)

Fabrizia Negrini, Giorgia Vella

Why was it done?

The aims of this project were firstly to optimize the content of the stock (choice of medicines and quantity) so that it is suitable for various potential events of different nature that may occur in the region. The second aim was to optimize the management processes in order to reduce costs.

What was done?

To manage extraordinary events (short-lasting phenomenon without contamination) in a region with 1.5 million inhabitants, the hospital pharmacy, in collaboration with a major acute Hospital, manages a designated stock containing medication that may be required during unplanned emergencies.

How was it done?

To achieve these two aims, the first step was to define which major events are possible and most likely to occur in the region. To do this we utilized a risk-based analysis of all disasters and emergencies relevant in the area that was performed by an external company that specializes in developing risk management projects in the context of civil protection1. Based on the identified events, we determined which types of injuries were more likely to occur. The medicine stock was subsequently updated and a process for minimizing the management cost was defined.

What has been achieved?

The hazards that were identified as being of particular importance for the analyzed region are likely to mainly result in blunt, perforating, and burn injuries. In collaboration with the Hospital, a list of 61 different medicines used to treat these types of injuries was established. In order to reduce costs, only drugs which were part of the main stock of the pharmacy were chosen. In this way, it is possible to exchange products with a longer shelf life from the main stock 6 months before expiring and use them without having to discard them.

What next?

In case of extraordinary events in a restricted region, the major acute hospital has an increased need for certain medicines. It is task of the hospital pharmacy to always be ready to supply them with such medicines. This is only possible if the probable emergency scenarios are well understood, and the stock and management processes are well-defined and communicated at all levels.

Author(s)

Margareth Kristiansen, Viola Melvik, Jahn Olav Svartsund, Randi Trondsen, Lise Nystad

Why was it done?

Patients admitted to the unit often have long-term illnesses, extensive medication histories and lengthy medication lists at admission. Psychopharmaceuticals are largely metabolized by enzymes that have polymorphism. We wanted to investigate the degree of pharmacogenetic variation in our patients and if genetic testing would have an impact on medication treatment.

What was done?

We have investigated the degree of genetic variation in our patients and to what extent the genetic profile impacted the choice of medication treatment.

How was it done?

We started out educating the staff at the ward. In 2018, 37 of a total 40 admitted patients were genetically tested at admission. The implication of the test result was discussed during the morning rounds for each patient ensuring implementation.
Results from each genetic test were continuously entered into a database including age, gender and medications at admission and discharge. Change of medication due to the genetic test result was recorded.
26 (70%) of patients had a genetic profile that could impact the choice of medication treatment. As a result, half of the patients had changes made to their medications. A total of 27 changes were made in these patients.

What has been achieved?

We have established that patients at the geriatric psychiatry unit in Nordland Hospital Trust have a pharmacogenetic profile that affects medication treatment options. Testing has an impact on the choice of pharmacotherapy to such an extent that all patients are now genetically tested at admission.

What next?

Pharmacogenetic testing has proven easy to implement and at the same time of substantial benefit for many patients. We also use our experiences to educate and inspire health care professionals in the community setting including GP’s so they can understand, reuse the test results and identify when a pharmacogenetic test would be a useful tool to determine the most adequate choice of pharmacotherapy.

Why was it done?

Chemotherapy prescribing errors could arise even when computerized systems are used. Additional evaluation of prescribed chemotherapy is needed, to prevent any harm to the patient and rise the level of patent’s safety.

What was done?

Preparation of written standard operating procedure that could help recognize the errors between the electronic chemotherapy record of prescribing and actual drug delivery.
Chemotherapy prescribing is a complex process encompassing prescription of cytotoxic medicines, infusion fluids and supportive care. Cytotoxic medicines have a narrow therapeutic range and actual dosage is usually adjusted according to the body surface area, weight or creatinine clearance. Minor alterations can have a significant effects on cytotoxicity, therefore the computerized prescribing is preferred. The dose is automatically calculated from the pre-inserted chemotherapy protocols and patient data.

How was it done?

Each computerized chemotherapy prescription should be closely reviewed by standard operating procedure, step by step, to complete the validation of chemotherapy accordingly.
Detected error should be noted by the pharmacist and corrected by the referring oncologist.

What has been achieved?

During the period from 1st January to 30st September 2021, approximatly. 13.400 chemotherapy prescription have been received at our pharmacy department. In 848 cases of prescribed chemotherapy, intervention of a pharmacist has been required because of inappropriate prescription. Among that, in 100 cases, computerized prescribing errors were identified. These errors identified were: wrong patient (2), incorrect dose prescribed (38), incorrect chemotherapy protocol chosen (30), incorrect day of chemotherapy administration prescribed (3), erroneous height or weight (1), incorrect glomerular filtration rate calculation for carboplatin (1), dual chemotherapy (9), change of the drug in pre-entered protocol (5), incomplete prescription (missing validation) (11).
Good cooperation with oncologist and oncology nurses, who are aware of clinical pharmacists pivotal role in
error avoidance, is needed.

What next?

Written standard operating procedure should be useful to detect common errors and to guide corrective actions, which can help
experienced clinical pharmacist and should be used as a tool for pharmacist trainees and student to learn
how to work accordingly to the protocols in use.