Hospitalwide medication policies and standards

The development and composition of a hospitalwide medication policies and standards manual are described. Medication policies and procedures developed independently by individual hospital departments and services at a 789-bed private teaching institution created problems related to consistency, the approval process, accreditation standards, and retrievability. Therefore, a joint nursing-pharmacy task force was formed to create a master document containing medication policies and standards for the entire institution. The manual also contains departmental medication-related procedures, the formulary of approved drugs, and key drug information. Its format allows for periodic updating and ease of use by nurses, pharmacists, physicians, and other health care professionals. It meets the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement of a collaborative framework to ensure optimal medication-use outcomes. All medication-related procedures in individual departments must comply with the new policies and standards. A hospitalwide medication policy manual, created through multidisciplinary collaboration, made the policies and procedures consistent and more accessible and met JCAHO and other regulatory requirements.

Pediatric medication order error rates related to the mode of order transmission

OBJECTIVE

This study was undertaken to measure the medication error rates associated with verbal orders compared with handwritten and computer-entered orders in an acute-care children's hospital.

METHODS

All medication and intravenous fluid orders for a 3-month interval were entered into a computer database. For the same interval, all errors pertaining to the transmission of a medication or intravenous fluid order were also entered into the database. Errors were detected by the hospital pharmacy, which continuously reviews all inpatient medication and intravenous fluid orders for potential errors before dispensing. Errors were also detected by nurses on the floors, who submit incident reports when medication or intravenous fluid errors occur.

RESULTS

Verbal orders were associated with significantly lower error rates than either handwritten orders or computer-entered orders (2.6, 8.5, and 6.3 per 1000, respectively), with transcription errors and dosage errors in particular being reduced. Total error rates did not differ between residents and attending physicians. Error rates did not differ between verbal, written, and computer orders for medications with a low frequency of verbal orders and therefore presumed greater complexity. However, the verbal order error rates seemed more sensitive to order complexity than order error rates in general.

CONCLUSIONS

The hypothesis that verbal orders are more prone to transmission error than written or computer orders is not supported by the findings in this study. Identifying medications with high levels of order complexity for restriction of verbal order use seems justified. Suggested guidelines for verbal order transmission are presented.

Accuracy of dispensing in a high-volume, hospital-based outpatient pharmacy

Accuracy of dispensing was studied in the outpatient pharmacy setting, and error rates were compared with workload. All prescriptions filled in an outpatient pharmacy over 12 weekdays were audited to determine the rate of dispensing errors. In this pharmacy, pharmacists filled prescriptions and technicians delivered the medications to the patients. Before the medication reached the patient, the auditors recorded any dispensing errors and determined whether they were potentially serious. Of the 9846 prescriptions filled, 1229 (12.5%) contained a total of 1371 errors. Of these errors, 155 (1.6%) were potentially serious. Statistical analysis of the data revealed differences between error rates and (1) the total number of prescriptions dispensed per hour and (2) the number of prescriptions filled per pharmacist hour. However, no correlation existed between the number of prescriptions dispensed per hour and the total number of errors made. No significant correlation was found between the rate of potentially serious errors and increasing work volume, suggesting that important factors in error avoidance are continuous quality improvement mechanisms and minimal interruption of dispensing. No association was found between work volume and the number of dispensing errors or potentially serious errors. Error rates were consistent with published estimates.

Orientation teaching tool to prevent medication error

Patients can be harmed and even killed when a medication error occurs. The following questions are based on actual errors which have been reported through the Medication Error Reporting Program (MERP). This teaching tool is intended as a take home test to make newly hired pharmacists aware of common medication errors. An informed practitioner is another layer of safety in decreasing the possibility of a medication error occurring.

Pharmacist empowerment: taking practice guidelines to the next level (Part 2)

Empowering pharmacists to have direct control and responsibility for institutional drug-use protocols can assist in reducing costs and improving the quality of patient care. This article examines pharmacist involvement in two drug use protocols in place at St. Luke's Episcopal Hospital in Houston. The first is a pharmacist conversion order protocol in which pharmacists are given the responsibility of flagging and monitoring IV to oral dosage conversions of selected medications; the second is a pharmacist screening program for parenteral ketorolac dosing.

Patients' perceptions of increased pharmacy contact

This prospective, randomized study was conducted to determine if increased patient contact between pharmacists and patients would result in greater patient awareness and satisfaction with their hospital stay and particularly with pharmacists and pharmacy services. Eligible patients were randomized to receive either the usual pharmacy care with minimum contact with the pharmacist, or expanded services based on increased contact with the pharmacist. A questionnaire was used to determine patient awareness and satisfaction. Statistically significant differences were found between the groups on awareness and satisfaction with pharmacy services scales as well as total scores. Total patient scores were highly reliable, with an alpha coefficient of 0.87. In addition, comments by patients in the group with increased contact were overwhelmingly positive, in contrast to those receiving usual care. Patients desire and appreciate greater contact with pharmacists.

Quality assurance of radiopharmaceuticals. Radiopharmacy and Quality Control Pharmacists Subcommittees of the Regional Pharmaceutical Officers Committee

This paper describes a level of quality assurance deemed to be acceptable for the preparation of radiopharmaceuticals within hospitals in the UK. It is not intended to give detailed methodology or guidance on premises or procedures, but to give general guidance which can be tailored to meet local needs. It is hoped that a high standard of radiopharmaceutical preparation will be maintained nationwide.

A mechanism for professional and organizational audit of radiopharmacy departments

An audit document is presented which can be used to assess the radiopharmacy service in a particular institute. It can be used for self-assessment or can form the basis for peer review. The document covers a wide range of aspects of radiopharmacy. It is acknowledged that the document will need constant review and where appropriate, modification, in order to reflect changes in practice or legislation.

Quality and productivity assessment of clinical pharmacy interventions

The goal of our program was to implement an easily maintained system that could document, classify, and determine the economic significance of clinical pharmacy interventions on a medicine division of an 874-bed university teaching hospital. This clinical intervention documentation system, which emphasizing both quality of care issues and pharmacist productivity, can be easily implemented by other institutions.

A drug use evaluation of bedtime sedation in geriatric patients

A pilot study was designed to assess the feasibility of a shared regional drug use evaluation (DUE) program involving patients. A retrospective DUE on the use of benzodiazepines, chloral hydrate and neuroleptics for bedtime sedation was performed on geriatric patient populations from two hospitals. Regional program staff coordinated the DUE, including development of the criteria and chart review. The participating Pharmacy departments performed the internal administrative and Pharmacy and Therapeutics committee communications. Forty patient charts from two sites were reviewed. The DUE results indicated different rates of drug use and discontinuation of therapy between the two geriatric patient populations. The overall rates of inappropriate drug use were similar. One undesirable clinical outcome occurred. Benzodiazepine use for more than 30 days was high in both groups. Identification of the justification for drug use, dosage reduction and drug discontinuation did not occur in the majority of patients. The pilot study identified areas where use of bedtime sedation could be improved, and allowed development of DUE criteria for future evaluation.

Using pharmacist clinical intervention data for quality improvement of medication use and physician assessment

BACKGROUND

Patient-specific intervention data are often used for drug usage evaluation (DUE), but their use in physician assessment is less often discussed. In response to the quality assurance department's request, the pharmacy department at the Medical College of Georgia (Augusta) developed a database and a reporting system that supports quality assessment of the medical staff, identifies housestaff education needs, and directs efforts for improvement in medication use. THE REPORTING SYSTEM: In 1991 the comprehensive, concurrent screening of drug therapy by pharmacists formed the foundation of the hospital's DUE program. Each month information from the pharmacy database is sorted with use of a spreadsheet software program to generate medical department-level reports and for use in physician reappointment. Identified performance deficiencies can be used to educate individual prescribers and to develop educational programs for the department or specialty areas. Feedback from the medical staff assessment is useful for pharmacist education, such as identifying newly reported indications and dosage regimens.

RESULTS

During the first six months after all pharmacists began participating in the reporting program, a mean of 224 interventions were recorded monthly. For the period January through June 1994, 400-550 interventions were recorded monthly. System improvements in medication during the first year of implementation included hospitalwide guidelines for parenteral potassium and phosphate dosing and administration and a renewed focus on patient allergies.

CONCLUSION

Emphasis for use of intervention data has shifted from identifying "problem" persons to improving performance by identifying topics for corrective education and redesigning systems to promote positive patient outcomes.

Physician perceptions of clinical pharmacy encounters in a family practice clinic

The purpose of this study was to classify pharmacist-physician encounters in a family medicine center into three progressive levels of service in order to determine the physician's perception of the relative value of each level. The three levels of service were drug information, pharmacy consultation individualized to the patient, and pharmaceutical care-consultation with follow-up to monitor patient outcome. Physicians received a questionnaire with each encounter and were asked to rank questions regarding the quality of the information provided, the impact they perceived that the information had on patient care, and to assign a monetary value for each encounter. A total of 106 of 141 (75 percent) questionnaires suitable for analysis were stratified into drug information (25.5 percent), pharmacy consultation (49 percent), and pharmaceutical care (25.5 percent). Physicians' perceptions toward the quality, impact, and value of pharmacy services were favorable overall, but they perceived a significantly higher quality, impact, and value to pharmaceutical care encounters than for drug information and pharmacy consultation (p < 0.05).

A prospective evaluation of benzodiazepine guidelines in the management of patients hospitalized for alcohol withdrawal

Our institution adopted guidelines for the selection of benzodiazepines to be administered to patients hospitalized for alcohol withdrawal. We assessed the guidelines' impact on prescribing habits, benzodiazepine dosage requirements and costs, and length of intensive care unit (ICU) stay. A 6-month prospective, observational study was performed in 50 patients who exhibited signs of alcohol withdrawal and received benzodiazepine therapy. Appropriate therapy was defined as lorazepam for patients 60 years and older or those with hepatic dysfunction, and chlordiazepoxide for all other patients. Benzodiazepine costs were calculated based on acquisition cost. Based on our guidelines, 76% of patients were appropriate candidates for a long-acting agent such as chlordiazepoxide; 61% of these candidates actually received such a drug. Using a benzodiazepine conversion to compare doses in chlordiazepoxide equivalents, there was a significant difference in the total mean dose of chlordiazepoxide (1295.5 mg, SD +/- 1571) compared with lorazepam (365.5 mg; SD +/- 446) (p < 0.01). The mean total chlordiazepoxide acquisition cost was $61.74 (range $0.03-585.98) per patient (28 patients); prior to adoption of the guidelines, the mean cost of benzodiazepine therapy was $1008.72 (+/- $1554.45). For patients receiving chlordiazepoxide, the mean days of ICU and hospital stay were 1.1 days (range 0-9 days) and 5.6 days (range 1-17 days), respectively; before adoption of the guidelines, the mean number of days of ICU stay was significantly greater (4.1 days, p < 0.0001). The guidelines resulted in a substantial change in benzodiazepine prescribing patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

Educational effort and CQI program improves ordering of serum digoxin levels

In a 289-bed, acute-care, non-tertiary-care regional referral center, a continuous quality improvement educational effort successfully improved ordering of serum digoxin levels. Following a determination that physicians were not requesting serum digoxin levels correctly, the P & T Committee issued a letter describing appropriate wording of orders for serum digoxin levels. The number of incorrectly ordered serum digoxin levels requested dropped significantly over a 49-month period as a result of the intervention described below, which also resulted in cost savings.

Strategic management of therapeutic advances: experience with colony-stimulating factors

Recent therapeutic advances offer significant opportunities for improved patient outcomes while challenging our ability to deliver these outcomes in a cost-effective manner. This report describes the strategies for managing such advanced therapies--specifically, the recently introduced colony stimulating factors (CSFs)--that have been adopted at Cedars-Sinai Medical Center. Based on the principles of Continuous Quality Improvement (CQI), our approach begins with a multidisciplinary task force that develops and continuously refines guidelines for use of these agents. To provide immediate feedback when physician orders do not conform to the guidelines, the pharmacist notifies a physician expert, who promptly contacts the prescriber for a discussion of the case and how the guidelines do or do not apply. Since the introduction of CSFs, cost per admission has declined from $983 to $729 (26%) for oncology patients and from $737 to $281 (62%) for HIV patients. Although it is impossible to rigorously establish how much of this decrease has resulted from our proactive management strategy, costs have consistently decreased following each task force intervention.

Certification program in antineoplastic drug preparation for pharmacy technicians and pharmacists

A formal training program for technicians who prepare cytotoxic agents and pharmacists who check the doses is described. To handle an overwhelming workload in an oncology satellite pharmacy and to enable the pharmacists there to increase their clinical involvement, a program was developed to train technicians to prepare antineoplastic doses and pharmacists to check the technicians' work. The program consists of two days of classroom instruction, three weeks of hands-on training, and a written examination. In addition to handling and preparation of antineoplastic drugs, other topics related to oncology are covered to give the participants a better understanding of cancer and its treatment. The technicians must complete a refresher program annually. From 1991 to 1993, 15 pharmacists and 14 technicians and pharmacy students completed the program. The technicians have taken on additional responsibilities in the satellite pharmacy, including managing the inventory of oncology drugs. Implementation of a comprehensive cancer chemotherapy training class for technicians and pharmacists has benefited the pharmacy in terms of labor and inventory control.