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.
Implementation of a standardised parenteral nutrition solution on a neonatal ward
Pdf
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
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
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
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.
Safe medicine practices: a multidisciplinary approach
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Betânia Abreu Faria, Sara Barroso, Antonieta Silva, Olga Martins
Why was it done?
Portuguese legislation “The Basic Health Law (No. 95/2019) and the National Plan for Patient Safety 2021-2026 (NPPS 2021-2026) and the goals of the World Health Organization (WHO) are fundamental pillars of healthcare safety. The NPPS has promoted patient safety in the Portuguese National Health Service, focusing on specific issues such as safety culture, unambiguous identification of patients, safe surgery, pressure ulcer prevention, prevention of falls, infections associated with healthcare and incident reporting and drug safety. Thus, it is essential to ensure the training of health professionals (HP) in the field of patient safety and the safe and rational use of medicines. The objectives of the training actions focused on the safe use of medication, promoting patient safety and sharing experiences between the various HP, in order to optimise the circuits and procedures already implemented.
What was done?
Multidisciplinary training actions were carried out within the scope of safe medicine practices.
How was it done?
A team of four pharmacists and one nurse carried out training actions in the context of Safe Medicines Practices. The following topics were addressed: medicine circuit; good practices in drug preparation; identification of medicines: Look-Alike Sound-Alike (LASA) and High-Alert Drugs; physicochemical incompatibilities; factors that modify stability after reconstitution/dilution; fractionation and crushing of Solid Oral Pharmaceutical Forms (SOPF); drug information sources; reporting adverse drug reactions and other incidents; good practices in medication administration.
What has been achieved?
Training actions were carried out with a total of 29 hours of training and 357 participants. Suggestions for improvement were presented: optimisation of drug signage, compliance with established circuits, logistical aspects, on time drug information, improvement of communication channels, increase in the frequency of training actions. The trainees expressed receptiveness and interest in this initiative, which provided content that was little discussed and very relevant to their daily practice.
What next?
The correct preparation and administration of medicines is essential to safeguard their effectiveness and patient safety, which is the ultimate goal of every health professional’s daily activity. The Pharmacist, as part of the multidisciplinary team, must promote strategies that safeguard Safe Practices throughout the drug circuit. Hence it is important to ensure the continuity of these trainings.
Improving people living with HIV therapies compliance: a practical tool customised for patients and designed by hospital pharmacists
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Sabrina Trivellato, Daniele Mengato, Maria Mazzitelli, Anna Maria Cattelan, Francesca Venturini
Why was it done?
An optimal compliance is an essential requirement for people living with HIV (PLWHA) to grant drugs effectiveness and safety. Given the complexity of the therapeutic regimen, and the multiple changes to it due to the clinical status, compliance to therapy may be suboptimal. Patients who are not well educated on how to follow their therapy are more keen on quitting the treatment or facing virological failure. According to previous analysis, we reported that 120 patients out of more than 1500 managed by our centre experienced suboptimal adherence to therapy.
What was done?
We created a user-friendly tool to educate HIV-patients on their drugs’ adherence in our University Hospital.
How was it done?
We studied every drug prescribed in our centre and we analysed it from the patient’s point of view. The question we aimed to answer was: “If I were a PLWHA, what would help me assuming the correct drug, at the proper time, avoiding misunderstandings?”. We analysed the shape, colour and dimensions of both the package and the pills/capsules. We focused on the most appropriate way to take every drug and we investigated possible interactions with OTC drugs or dietary supplements.
What has been achieved?
A poster reporting all the drugs available in our formulary was developed: 34 medicines were described in alphabetical order, specifying for each one the image of the package, the usual dosage, the picture of the pill/capsule compared to the dimension of current coins and special warnings about possible drug-drug interactions. We also adopted practical symbols to indicate whether to assume the drug with or without food. The poster became available starting from April 2022 and during the following 5 months a cohort of 960 patients could rely on it.
What next?
In order to help our patients taking their therapies, we expect to get a digital form of this poster to make it available on the phone scanning a QR code. Alongside, we aim to enlarge and improve this digital version by adding a final section with an interactive survey to closely monitor the compliance of the patients and help them to improve it. Through this project we could also obtain an active pharmacovigilance setting.
Reconciliation of shared medicine record at discharge: hospital pharmacy ensures correct information on patients’ transition
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Linda Jeffery, Maria Grønkjær Abrahamsen, Anja Alrø Bøtkjær, Lotte Aggergaard, Ann Brit Andersen
Why was it done?
Our country has a national SMR for every citizen. The SMR shows the current medication that the citizen has been prescribed, from all sectors. All sectors can see the SMR, which is considered/ought to be the ‘truth’ about the patient’s medication. On discharge from the hospital the SMR is updated by the doctor. Afterwards, pharmacy technicians dispense medicines for discharge. The technicians, at this stage, often find discrepancies in the SMR compared to the medication prescribed and given during admission. The SMR is electronically updated but not adequately reconciled. False information in the SMR may ultimately lead to adverse drug safety events in the primary sector.
What was done?
The regional hospital pharmacy patient safety network studied how many patients do not have a reconciled electronic Shared Medication Record (SMR) at discharge, despite the doctor having electronically updated it.
How was it done?
The technician recorded the discrepancies found before contacting the doctor to get the SMR corrected.
Each discrepancy was reported into the national patient safety database.
The technicians do not dispense medicines to all discharged patients, so our results were extrapolated to all discharged patients in the time period (there was no reason to expect bias).
The study was carried out in the whole region (5 hospitals) during the same week in September 2022.
What has been achieved?
Preliminary data shows that 994 patients were discharged from the wards studied.
Technicians dispensed medicines to 278 patients. They found one or more discrepancies in 65 SMRs (23,4%).
Extrapolation of these results revealed that, in the period, there were potentially 232 patients with drug-related problems from these wards (and approx. 17,000/year in the region).
What next?
Our results showed that the SMR is not adequately reconciled in 23% of discharges, despite the doctor feeling that the task is completed. This gives drug related problems in the primary sector, often resulting in calls to the ward etc. that are time consuming and difficult to solve after discharge. Updating the SMR at discharge is essential for patient safety under transition of care. Our results will be brought to the hospital administrations, patient safety organisations and the regional medicines board for further discussion about the problem and possible solutions.