An audit of the pharmacological management of ischaemic stroke patients in a metropolitan Australian hospital

BACKGROUND

According to the Australian Bureau of Statistics, stroke is the second leading cause of death in Australia. The clinical Guidelines for stroke management published by the National Stroke Foundation provide a series of evidence based recommendations to assist clinicians in the management of stroke patients. Appropriate management of patients admitted to stroke units reduces death and disability by 20 %. Moreover, a multidisciplinary team approach also improves patient outcomes.

OBJECTIVE

To retrospectively review the pharmacological management of ischaemic stroke patients in a metropolitan Australian hospital, and to compare adherence with the guidelines for stroke management with the national stroke foundation data with and without pharmacist intervention.

METHOD

A retrospective audit of medical records was undertaken of all patients admitted to a large teaching hospital with the diagnosis of stroke or cerebral infarction from January 2013 to May 2013.

RESULTS

A total of 124 patients were included in the study. Most patients were discharged on appropriate pharmacological intervention for the prevention of secondary stroke: antihypertensive agents (71 %), lipid lowering agents (67 %) and antithrombotic (85 %) medications.

CONCLUSION

The majority of the cohort was discharged on the appropriate evidence based medications for the management of secondary stroke. Further improvement may be achieved by pharmacist intervening as part of a multidisciplinary team.

[Quality healthcare and pharmaceutical care practice indicators to HIV+ patient]

OBJECTIVE

To identify and to promote improvements in the quality of the sanitary attention to the HIV+ patients in the Clinical Units of the hospitals in our country, there being included and reinforcing the perspective of Pharmaceutical Care.

METHODS

To carry out the project, during the period January- June 2012, the following phases were defined. First, a bibliographical review was realized and reading criticizes related to the pathology HIV and quality criteria. Later, a presencial qualitative investigation phase was carried out with the expert participants. The first one was carried out by means of two technologies: the nominal group and a variant of groups of discussion. The application of the technologies was supported by an technical support that allowed the codification and valuation organized. The last phase of the project consisted of a meeting presencial, where there were outlined the aims of the first meeting and put jointly all the work that the subgroups of work had elaborated to agree on the contents. Of the first selection of ideas, the equipment of investigation worked and prioritized those elements that describe and give response to the raised aims. Concretely, the correct definition of the safety and quality indicators in the area of the hospital pharmacist, there being elaborated a card that was describing every aspect to bear in mind for the later measurement of the indicator. Finally, a plan of actions was elaborated to improve the clinical practice synthesized according to his level of priority.

RESULTS

Across the methodology of the project, the experts identified the quality criterias in pharmaceutical care procedure. The principal barriers identified were: asistencial pressure, personnel management system's, security and ignorance of the pharmacotherapy, lack of quality culture and difficulties of access to the information. Principals clinical risks identified were: mistakes in the guidelines with the changes of treatments, lack of information of the whole medication of the patient, lack in resources and time adapted to realize the processes, lack of communication between professionals, ignorance of interactions or adverse events. The principal results that were extracted from the analysis of situation were that the priority line of action had to happen for a link between patients, specialists and primary care. It should promote the clinical management of the units of HIV, the access to the information for all the professionals who realize pharmacoterapeutical follow-up to these patients and the major implication on the part of these. Finally, 29 quality indicators were defined in the pharmaceutical care to the HIV+ patient distributed in structure, processes and results and the plan of improvement for the attention and his level of priority considered.

DISCUSSION

This document gives response to the increasing demand for homogenizing the clinical practice and establishing common criteria of quality that result a benefit for the sanitary system and, in consequence, for the professionals and the patients.

Quality of pharmaceutical care in surgical patients

Background

Surgical patients are at risk for preventable adverse drug events (ADEs) during hospitalization. Usually, preventable ADEs are measured as an outcome parameter of quality of pharmaceutical care. However, process measures such as QIs are more efficient to assess the quality of care and provide more information about potential quality improvements.

Objective

To assess the quality of pharmaceutical care of medication-related processes in surgical wards with quality indicators, in order to detect targets for quality improvements.

Methods

For this observational cohort study, quality indicators were composed, validated, tested, and applied on a surgical cohort. Three surgical wards of an academic hospital in the Netherlands (Academic Medical Centre, Amsterdam) participated. Consecutive elective surgical patients with a hospital stay longer than 48 hours were included from April until June 2009. To assess the quality of pharmaceutical care, the set of quality indicators was applied to 252 medical records of surgical patients.

Results

Thirty-four quality indicators were composed and tested on acceptability and content- and face-validity. The selected 28 candidate quality indicators were tested for feasibility and ‘sensitivity to change’. This resulted in a final set of 27 quality indicators, of which inter-rater agreements were calculated (kappa 0.92 for eligibility, 0.74 for pass-rate). The quality of pharmaceutical care was assessed in 252 surgical patients. Nearly half of the surgical patients passed the quality indicators for pharmaceutical care (overall pass rate 49.8%). Improvements should be predominantly targeted to medication care related processes in surgical patients with gastro-intestinal problems (domain pass rate 29.4%).

Conclusions

This quality indicator set can be used to measure quality of pharmaceutical care and detect targets for quality improvements. With these results medication safety in surgical patients can be enhanced.

[Quality indicators in the storage and dispensing process in a Hospital Pharmacy]

OBJECTIVE

To establish indicators for the evaluation of the quality of the storage and dispensing processes related to semiautomatic vertical (SAVCS) and horizontal (SAHCS) carousel systems.

MATERIAL AND METHODS

Descriptive observational study conducted between January-December 2012. Definition of quality indicators, a target value is established and an obtained value is calculated for 2012.

RESULTS

Five quality indicators in the process of storage and dispensing of drugs were defined and calculated: indicator 1, error filling unidose trolleys: target (<1.67%), obtained (1.03%); indicator 2, filling accuracy unidose trolleys by using an SAVCS: target (<15%), obtained (11.5%); indicator 3, reliability of drug inventory in the process of drug entries using an SAHCS: target (<15%), obtained (6.53%); indicator 4, reliability of drug inventory in the picking process of orders replacement stock of clinical units using an SAHCS: target (<10%), obtained (1.97%); indicator 5, accuracy of the picking process of drug orders using an SAHCS: target (<10%), obtained (10.41%).

CONCLUSIONS

Establishing indicators has allowed the quality in terms of safety, precision and reliability of semiautomatic systems for storage and dispensing drugs to be assessed.

Application of the Pareto principle to identify and address drug-therapy safety issues

PURPOSE

Adverse drug events (ADE) and medication errors (ME) are common causes of morbidity in patients presenting at emergency departments (ED). Recognition of ADE as being drug related and prevention of ME are key to enhancing pharmacotherapy safety in ED. We assessed the applicability of the Pareto principle (~80 % of effects result from 20 % of causes) to address locally relevant problems of drug therapy.

METHODS

In 752 cases consecutively admitted to the nontraumatic ED of a major regional hospital, ADE, ME, contributing drugs, preventability, and detection rates of ADE by ED staff were investigated. Symptoms, errors, and drugs were sorted by frequency in order to apply the Pareto principle.

RESULTS

In total, 242 ADE were observed, and 148 (61.2 %) were assessed as preventable. ADE contributed to 110 inpatient hospitalizations. The ten most frequent symptoms were causally involved in 88 (80.0 %) inpatient hospitalizations. Only 45 (18.6 %) ADE were recognized as drug-related problems until discharge from the ED. A limited set of 33 drugs accounted for 184 (76.0 %) ADE; ME contributed to 57 ADE. Frequency-based listing of ADE, ME, and drugs involved allowed identification of the most relevant problems and development of easily to implement safety measures, such as wall and pocket charts.

CONCLUSIONS

The Pareto principle provides a method for identifying the locally most relevant ADE, ME, and involved drugs. This permits subsequent development of interventions to increase patient safety in the ED admission process that best suit local needs.

[Evaluation of the quality of scientific evidence of pharmaceutical interventions in an emergency department]

OBJECTIVES

To assess the quality of Pharmaceutical Interventions of starting a drug treatment based on the available scientific evidence, in an Emergency Department with a Clinical Pharmacist working full-time. To analyze the rate of Pharmaceutical Interventions over chronic or acute treatments and the ATC group of drugs involved.

METHOD

The pharmacotherapy recommendations on Clinical Practice Guidelines (CPG) were classified and for every Pharmaceutical Intervention was assessed the quality of scientific evidence, strength of clinical recommendation, morbidity/mortality reduction, chronic or acute treatment and ATC group of drug involved.

RESULTS

During the study period 2776 Pharmaceutical Interventions were performed of which 47% were starting-drug interventions, being 73% justified with scientific evidence. The 84% of starting-drug interventions were assessed with quality of evidence and strength of recommendation IA, 9% IC and 4% IB and 67% have been shown to reduce the morbidity/mortality according the CPG. 73% of interventions were related with patients' chronic treatment and ATC groups most frequently involved were N group (nervous system) and C group (cardiovascular system). In acute treatment the most frequent were B group and A group (Alimentary tract and metabolism).

CONCLUSIONS

The starting-drug Pharmaceutical Interventions performed by an emergency department clinical pharmacist show a high adherence to CPG for most frequent pathologies, with good quality of evidence and good strength of recommendation as well as an associated morbidity/mortality reduction. Most starting-drug interventions were related to chronic treatment reconciliation, being drugs of N and C ATC group the most frequent involved.

Compounding practices in Iran

This article has been presented by pharmacists of the Razi Hospital Pharmacy, which is located within the Dermatology Center of Tehran University of Medical Sciences in Tehran, Iran, and by members of the staff at the Tehran University of Medical Sciences. Discussed within this article are the legalization and regulation of pharmaceutical compounding in Iran, the restrictions on pharmaceutical compounding, the general equipment used in Iran pharmacies, beyond-use dating/expiration dating, the required pharmacy education, as well as information related specifically to Razi Hospital Pharmacy.

[Different models are used to obtain medication history and medication review in Danish hospitals]

The objective of the article is to characterize the models used by pharmacists to obtain medication history and medication review in Danish hospitals. The models are characterized based on the sources used to create an overview of the patient's medication as well as the time spent per patient. Currently pharmacists perform medication review at 16 departments. The sources frequently used are the patient journal (81%) and clinical data (81%). The patient contributes to the medication review in 25%.

[Comprehensive drug safety plan in a health department]

OBJECTIVE

To develop and implement a comprehensive drug safety plan in a hospital for the years 2009-2011.

MATERIAL AND METHODS

Applying the Strengths Weaknesses/Limitations Opportunities Threats (SWOT) methodology, the baseline situation was analyzed and a broad strategy or plan was subsequently developed, defining the scope, responsibilities, objectives and strategic actions and indicators in order to measure the achievement of the results.

RESULTS

A comprehensive drug safety plan with the main objective of identifying and reducing the medication-related problems in patients treated in the Hospital de San Juan in Alicante has been developed. The plan contains five strategic objectives, twenty strategic actions and the indicators to assess its outcomes. It also contains a timetable for its establishment and evaluation.

DISCUSION

Developing a comprehensive strategic plan allows the current situation relating to drug safety to be determined. The results obtained after its introduction will define its applicability. Due to the lack of publications of similar plans and results, the evaluation of this plan will be useful whether it is favorable or not. As a side benefit of the development, the multidisciplinary team continues to work on improving patient safety in the care process, and the safety culture continues to grow among the professionals.

Effects on patient care caused by drug shortages: a survey

BACKGROUND

Drug shortages pose a serious challenge for health care institutions, often interfering with patient care. A common practice during a drug shortage is to select an alternate therapeutic; however, these agents often present challenges and may create safety concerns. Patient harms including adverse events and medication errors may occur. Patients may also file complaints because of drug shortages.

OBJECTIVE

To measure the effect of drug shortages on patient outcomes, clinical pharmacy operations, patient complaints, and institutional cost.

METHODS

An e-mail link to an online survey was sent to pharmacy director members in the MedAssets Pharmacy Group Purchasing Organization. Data were collected within a 3-week period from October 2-23, 2012. The survey focused on 6 different domains: demographics, adverse events, medication errors, patient outcomes, patient complaints, and institutional cost.

RESULTS

The survey was sent to 1,516 directors of pharmacy. There were 193 respondents (response rate 13%) who participated in the survey. Approximately 40% of respondents reported between 1 and 5 adverse events probably or possibly associated with drug shortages at their institution. The majority of respondents reported between 1 and 10 medication errors. The most common types of medication errors reported were omission (n = 86, 55.5%), wrong dose dispensed/administered (n = 85, 54.8%), and wrong drug dispensed/administered (n = 54, 34.8%). The most common outcomes reported by respondents were alternative medication used (n=146, 85.3%), delay of therapy (n = 121, 70.8%), and increased patient monitoring necessary (n = 84, 49.1%). Patient complaints were reported by 38% of respondents. The majority of respondents reported an estimated quarterly institutional cost from shortages of less than $100,000, and approximately one quarter of respondents reported adding at least 1 full-time equivalent to manage drug shortages. The majority of participant comments mentioned the increasing institutional costs attributed to drug shortages.

CONCLUSIONS

Medication errors and adverse events continue to occur from drug shortages, often resulting in inadequate patient care, high institutional costs, and patient complaints. Delayed care and cancelled care have been reported from shortages. Further research is necessary to better classify medication errors and adverse events during a drug shortage.

[Validation of aseptic technique of parenteral nutrition compounding in a pharmacy service according to USP Chapter 797]

INTRODUCTION

During the process of parenteral nutrition preparation, aseptic techniques by nursing staff must be guaranteed. Chapter 797 of the United States Pharmacopeia classifies the risk levels of sterile compounding and defines the requirements that must be followed throughout the compounding.

OBJECTIVE

To describe the development of an aseptic technique validation procedure for nurses who compound parenteral nutrition at the compounding area Pharmacy Service according to Chapter 797 United States Pharmacopeia guidelines.

MATERIAL AND METHODS

Chapter 797 United States Pharmacopeia was reviewed and parenteral nutritions were classified as medium risk level compounded sterile preparations.

RESULTS

We adapted the United States Pharmacopeia guidelines for medium risk level compounded sterile preparations and we performed a procedure of aseptic technique validation for parenteral nutrition compounding.

CONCLUSIONS

The aseptic technique validation procedure allows the validation of aseptic management quality of nursing staff. The procedure has been incorporated into practice and is performed monthly by the nursing staff in the nutrition area.

[Multiple correspondence analysis in the evaluation of hospital pharmacy services in Brazil]

This study aimed to evaluate associations among variables in hospital pharmacy services. Thirty variables were used from the project Diagnosis of Hospital Pharmacies in Brazil pertaining to the overall description of the hospital, overall characterization of the hospital pharmacy service, and stages in pharmaceutical care. The statistical techniques were multiple correspondence and cluster analysis. Dimension 1 of the multiple correspondence analysis explained 90.6% of variance, differentiating between hospital pharmacy services based on the presence of certain activities, thus suggesting an axis of characterization for the hospital pharmacy services. The results indicate a direct relationship between compliance with the activities and the type of hospital and pharmacists with specialized training. Cluster analysis identified six clusters related to hospital size; greater compliance with the activities was associated with large hospitals and those with a pharmacist (more time dedicated to the hospital pharmacy service and higher level of training). The study concludes that the techniques were able to identify associations and a concise range of variables for a comprehensive evaluation of hospital pharmacy services in Brazil.

Delivery of optimized inpatient anticoagulation therapy: consensus statement from the anticoagulation forum

OBJECTIVE

To provide recommendations for optimized anticoagulant therapy in the inpatient setting and outline broad elements that need to be in place for effective management of anticoagulant therapy in hospitalized patients; the guidelines are designed to promote optimization of patient clinical outcomes while minimizing the risks for potential anticoagulation-related errors and adverse events.

DATA SOURCES

The medical literature was reviewed using MEDLINE (1946-January 2013), EMBASE (1980-January 2013), and PubMed (1947-January 2013) for topics and key words including, but not limited to, standards of practice, national guidelines, patient safety initiatives, and regulatory requirements pertaining to anticoagulant use in the inpatient setting. Non-English-language publications were excluded. Specific MeSH terms used include algorithms, anticoagulants/administration and dosage/adverse effects/therapeutic use, clinical protocols/standards, decision support systems, drug monitoring/methods, humans, inpatients, efficiency/ organizational, outcome and process assessment (health care), patient care team/organization and administration, program development/standards, quality improvement/organization and administration, thrombosis/ drug therapy, thrombosis/prevention and control, risk assessment/standards, patient safety/standards, and risk management/methods.

STUDY SELECTION AND DATA EXTRACTION

Because of this document's scope, the medical literature was searched using a variety of strategies. When possible, recommendations are supported by available evidence; however, because this paper deals with processes and systems of care, high-quality evidence (eg, controlled trials) is unavailable. In these cases, recommendations represent the consensus opinion of all authors and are endorsed by the Board of Directors of the Anticoagulation Forum, an organization dedicated to optimizing anticoagulation care. The board is composed of physicians, pharmacists, and nurses with demonstrated expertise and experience in the management of patients receiving anticoagulation therapy.

DATA SYNTHESIS

Recommendations for delivering optimized inpatient anticoagulation therapy were developed collaboratively by the authors and are summarized in 8 key areas: (1) process, (2) accountability, (3) integration, (4) standards of practice, (5) provider education and competency, (6) patient education, (7) care transitions, and (8) outcomes. Recommendations are intended to inform the development of coordinated care systems containing elements with demonstrated benefit in improvement of anticoagulation therapy outcomes. Recommendations for delivering optimized inpatient anticoagulation therapy are intended to apply to all clinicians involved in the care of hospitalized patients receiving anticoagulation therapy.

CONCLUSIONS

Anticoagulants are high-risk medications associated with a significant rate of medication errors among hospitalized patients. Several national organizations have introduced initiatives to reduce the likelihood of patient harm associated with the use of anticoagulants. Health care organizations are under increasing pressure to develop systems to ensure the safe and effective use of anticoagulants in the inpatient setting. This document provides consensus guidelines for anticoagulant therapy in the inpatient setting and serves as a companion document to prior guidelines relevant for outpatients.

A simulated hospital pharmacy module using an electronic medical record in a pharmaceutical care skills laboratory course

OBJECTIVES. To implement and evaluate the effects of a simulated hospital pharmacy module using an electronic medical record on student confidence and abilities to perform hospital pharmacist duties. DESIGN. A module was developed that simulated typical hospital pharmacist tasks. Learning activities were modified based upon student feedback and instructor assessment. ASSESSMENTS. Ninety-seven percent of respondents reported full-time hospital internship experience and 72% had electronic medical record experience prior to completing the module. Mean scores on confidence with performing typical hospital pharmacist tasks significantly increased from the pre-module survey to the post-module survey from 1.5-2.9 (low comfort/confidence) to 2.0-3.4 (moderate comfort/confidence). Course assessments confirmed student achievement of covered competencies. CONCLUSIONS. A simulated hospital pharmacy module improved pharmacy students' hospital practice skills and their perceived comfort and confidence in completing the typical duties of a hospital pharmacist.

[Chemotherapeutical department: surgical infection prevention and treatment in ICU]

The article discusses the issues of chemotherapeutical department organization and functioning in multidisciplinary surgical hospital. In connection with a worldwide spread of antibiotic-resistant agents of surgical infections, it becomes necessary to unite efforts of surgeons, resuscitation specialists, clinical pharmacologists - chemiotherapeutists and microbiologists. The main approaches in solving of surgical infection problems are: in-hospital epidemiological situation monitoring, the study ofmicroflora resistance to antibiotics used in the surgical and resuscitation practice, the study of antibacterial therapy clinical-pharmacological aspects (pharmacokinetics, pharmacodynamics, tolerance and efficacy of antimicrobial drugs). The development of pre-emptive antibiotics rotation principles curbs the spread ofnosocomial infections pathogens resistant strains. The 40-year experience of surgical infections prevention and treatment laboratory functioning professes this.

Pharmacists' expectations for entry-level practitioner competency

Objective. To determine if defined subgroups of pharmacists' have variability in their expectations for competency of entry-level practitioners.Methods. Rating scale data collected from the 2009 National Pharmacy Practice Survey were analyzed to determine to what extent pharmacists' degree, practice setting, and experience as a preceptor were associated with the ratings they assigned to 43 competency statements for entry-level practitioners. The competency statements determine the content on the North American Pharmacist Licensure Examination (NAPLEX).Results. Pharmacists with a doctor of pharmacy (PharmD) degree rated the co mpetency statements higher in terms of criticality to entry-level practice than did those with a bachelor of science (BS) degree (p< 0.05). Pharmacists working in inpatient settings gave slightly higher ratings to the competency statements than did pharmacists working in outpatient settings, pharmacists without direct patient care responsibilities, and those in academia. However, there were no significant differences among practitioner subgroups' criticality ratings with regard to practice setting. Preceptor pharmacists' criticality ratings of the competency statements were not significantly different from those of non-preceptor practitioners. Conclusion. Pharmacists exhibited a fair amount of agreement in their expectations for the competence of entry-level practitioners independent of their practice sites and professional roles. As the pharmacy profession embraces patient-centered clinical practice, evaluating practicing pharmacists' expectations for entry-level practitioners will provide useful information to the practitioners and academicians involved in training future pharmacists. Stakeholders in pharmacy education and regulation have vested interests in the alignment of the education of future practitioners with the needs of the profession.