Skip to content

Creating a standardized cisplatin hydration protocol

Pdf

PDF Icon

European Statement

Patient Safety and Quality Assurance

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.

Implementation and follow-up of an Assisted Electronic Prescription Program

European Statement

Patient Safety and Quality Assurance

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.

Evaluation of pharmacist-provided medication therapy management service on reducing unplanned readmissions in adult patients in Singapore

European Statement

Patient Safety and Quality Assurance

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.

Introduction of a new informatics tool to obtain important antimicrobial stewardship data

European Statement

Patient Safety and Quality Assurance

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.

Preparing for disaster – ensuring and optimizing the supply of medicines to a regional acute Hospital in the event of a major accident

European Statement

Patient Safety and Quality Assurance

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.

Pharmacogenetic variation and the importance for medication treatment in patients at a Geriatric Psychiatry Unit

European Statement

Patient Safety and Quality Assurance

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.

MODES OF PREVENTION OF COMPUTERIZED CHEMOTHERAPY PRESCRIBING ERORRS BY CLINICAL PHARMACIST

European Statement

Patient Safety and Quality Assurance

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.

Disposable Closed System for Sterile Drug Preparation and administration

European Statement

Patient Safety and Quality Assurance

Why was it done?

Our proposed system comes from the idea of a large clean room with pressure regimes, and airlock, hoods and other ancillary equipment, Which we made from it a very small clean room that is our box, when there will be no need for us as operators to get into it, or very simply take only those parts that are supposed to be sterile, and only those parts that are the two ends of the infusion bag and the end of the medicine vial

What was done?

“Closed” and airtight system for preparation (reconstitution, measurement, dilution) and injection of IV drugs at the patient’s bedside, in the various clinics and further home treatment, Disposable system, All its parts come in one piece without the need for threading, or assembly and disassembly
Estimated dimensions: 10 cm length, 5 cm width and 3.5 cm depth or similar, its shape can be rectangular or any shape convenient for use operation storage and destruction at the end of the process
Intended for a wide range of types of drugs – such as intravenous antibiotics, cytotoxic drugs, biological drugs, etc.
Designed according to its different variations for different types of vials and different amounts of drugs that come as a dry powder for dissolution, and are also suitable for drugs that come in the dissolved liquid form.
It is also intended for use with glass ampoules and there is a wide range of drugs that still come in glass ampoules
Intended for administration of drugs that do not need to be diluted in an infusion bag given in IV PUSH

How was it done?

We designed the device with 3D software (solid wark). It consists of a number of functional parts,
The sterile closed system comprises an airtight enclosure, which is shaped so as to define an enclosure interior; and an infusion-bag receptacle. An infusion-bag seal is configured, when in a sealing state, to make an airtight seal with respective external surfaces of a medication port and an IV tubing port of a bottom region of the infusion bag, when the medication port and an IV tubing port are inserted into the infusion-bag receptacle.

What has been achieved?

The proposed solution and its advantage
– A single-use system built in one piece, without the need for assemblies, disassembles, etc.
It will be possible to perform the entire process in one place, such as at the patient’s bedside or in the clinic, starting with the powdered drug dissolving process, mixing a measured dose, mixing it in an infusion bag and injecting it into the patient’s vein safely and accurately.
Maintains the perfect process under sterile conditions without fear of contamination of the injected drug
– Preparation in a system that is safe for the immediate environment and safe for the caregiver himself from contamination of drugs such as cytotoxic drugs, antibiotics and more
Savings in building very expensive infrastructure of clean rooms
Saving on very expensive disposables, such as closed system transfered deviced, robes and more
Save valuable work time dedicated team of pharmacists, nurses work time, work time transportation, storage places and more
Minimize the chance of errors in administering medications and confusion between different medications
Working with non-exposed needles reduces the chance of needle prick injury

What next?

Applied research will be carried out by pharmacists and nurses, in order to test the efficacy and safety of the device (by using a basic prototype), these experiments will use different IV administration drugs, we will test the method of dilution from a drug vials and glass ampoules, measure the exact dose and transfer to the infusion bag, and remove through the IV line, the accuracy of the preparation, the sterility of the preparation, the quality in terms of leakage or drip, comfort, safety and more are measured.

Assessing the Application of Essential Medication Errors Prevention Strategies in Healthcare Institutes: STOP Medication Error Project

European Statement

Patient Safety and Quality Assurance

Author(s)

Monira Alwhaibi

Why was it done?

This study is the first project of the STOP ME projects which aims to develop a tool that can assess the application of the essential strategies that can stop or minimize MEs in healthcare institutes in Saudi Arabia. Consequently, stakeholders in the healthcare system can identify current gaps that need feature improvement to enhance patient safety

What was done?

Medication Errors (ME) are defined as unintentional drug-induced harm that led to morbidity and mortality. The STOP (ME) project is a comprehensive series of research studies that aim to explore MEs in Saudi Arabia and how to stop such harmful events.

How was it done?

Extensive search of the literature review for the essential strategies to stop or minimize MEs was carried by the research team to develop a draft of the aimed tool. The survey tool was sent in round 1 to the Delphi experts’ panel for review. Based on received recommendations, the tool was updated and sent for round 2 review and consensus. The developed tool was then piloted to test the practicability of the tool before running the survey on large sample size (second project). The study was approved by the King Saud University Medical Centre IRB ethics committee [20/0153/IRB].

What has been achieved?

After using the Delphi technique two major changes happened to the survey. 1) Section A was removed (high alert medications). 2) A new section was added (ISMP publications) with some minor changes. Launching a pilot survey on thirty healthcare practitioners (physicians n=11, pharmacists n=10, nurses n=9) resulted in further minor changes by adding two new columns. The final tool was a survey consists of six sections including Demographics, Prescription, Dispensing, Administration, Monitoring and Quality, and Targeted Medication Safety Best Practices for Hospitals. All combined 86 questions with the determined time to answer the survey is in the range of 25-30 minutes. Overall feedback of the pilot survey was good.

What next?

This initiative “STOP ME” will have a significant impact in the field of medication safety research and will build awareness among institutes in Saudi Arabia that are lacking important strategies that prevent MEs

IMPROVING HIGH-RISK DRUG PRACTICES IN THE EMERGENCY DEPARTMENT – A MULTIDISCIPLINARY APPROACH

European Statement

Patient Safety and Quality Assurance

Author(s)

Mariosa Kieran

Why was it done?

Review of the 2019 Health Information and Quality Authority (HIQA) Medication Safety Monitoring Programme, and in-house Emergency Department (ED) medication variances review identified that risk reduction strategies for specific high-risk drugs and high-risk situations were required.

What was done?

A multidisciplinary team reviewed and implemented initiatives to improve medication safety practices for procedural sedation, emergency tray drugs and ketamine use in emergency settings was undertaken.

How was it done?

• Multidisciplinary teams (MDT) of key stakeholders were formed to review each high-risk drug / practice requiring improvement.
• The MDT developed the required procedures and policies that were further reviewed and approved by the relevant hospital committees.
• The MDT supported roll out of the improvement initiatives through communication, staff education and process review.

What has been achieved?

• A hospital wide procedural sedation policy and patient information leaflet was developed. Competencies for staff that perform procedural sedation have been identified. A specific procedural sedation incident report form has been piloted. A poster detailing the process for sedation reversal is in development.
• Emergency tray drug preparation, storage and use has been standardised across all hospital settings, including the introduction of dedicated emergency drug bags. The bags enable prompt drug retrieval during emergencies and supports safe storage, documentation and disposal of used /unused emergency drugs.
• A protocol for ED use of ketamine was developed. The protocol supports safe use of ketamine for specific emergency indications for which there is little published information, e.g. procedural sedation, analgesia and agitation.
• The initiatives were implemented and included in ED simulation training.

What next?

The described medication safety initiatives have considered the practice challenges for high risk drug access and use in emergency settings. The initiatives have standardised processes for specific high-risk drugs, supporting safer use. MDT collaboration ensured early and ongoing staff engagement from applicable disciplines, facilitating implementation and practice changes. Evaluation of the initiatives in practice is currently under review. The initiatives and learnings are transferrable to other emergency clinical settings.

×

Join us in Prague for

the 2nd edition of BOOST!

Secure your spot (limited seats available!)

BOOST is where visionaries, innovators, and healthcare leaders come together to tackle one of the biggest challenges in hospital pharmacy — the shortage of medicine and medical devices.

×

Deadline extended to July 15th

Problems caused by shortages are serious, threaten patient care and require urgent action.

Help us provide an overview of the scale of the problem, as well as insights into the impact on overall patient care.

Our aim is to investigate the causes of medicine and medical device shortages in the hospital setting,  while also gathering effective solutions and best practices implemented at local, regional, and national levels.

×

Join us in Prague for the 2nd edition of BOOST!

Secure your spot in the Movement for Shortage-Free World

BOOST is where visionaries, innovators, and healthcare leaders come together to tackle one of the biggest challenges in hospital pharmacy—medicine shortages.