Intention to get naloxone among patients prescribed opioids for chronic pain

BACKGROUND

Prescription opioids have been increasingly prescribed for chronic pain while the opioid-related death rates grow. Naloxone, an opioid antagonist, is increasingly recommended in these patients, yet there is limited research that investigates the intention to get naloxone. This study aimed to investigate intention toward getting naloxone in patients prescribed opioids for chronic pain and to assess the predictive utility of the theory of reasoned action (TRA) constructs in explaining intention to get naloxone.

METHODS

This was a cross-sectional study of a panel of U.S. adult patients prescribed opioids for chronic pain using a Qualtrics_®^XM survey. These patients participated in the study during February to March 2020. The online internet survey assessed the main outcome of intention to get naloxone and constructs of TRA (attitudes and subjective norms); additional measures assessed the characteristics of patients' opioid overdose risk factors, knowledge of naloxone, and their demographics. The relationship between TRA constructs, namely, attitudes and subjective norms, and the intention variable was examined using logistic regression analyses with the intention outcome contrasted as follows: high intention (scores ≥ 5) and non-high intention (scores < 5).

RESULTS

A total of 549 participants completed the survey. Most of them were female (53.01%), White or Caucasian (83.61%), non-Hispanic (87.57%) and had a mean age of 44.16 years (SD = 13.37). Of these, 167 (30.42%) had high intention to get naloxone. The TRA construct of subjective norm was significantly associated with increased likelihood of higher intentions to get naloxone (OR 3.04, 95% CI 2.50-3.70, P < 0.0001).

CONCLUSIONS

Our study provides empirical support of the TRA in predicting intention to get naloxone among chronic pain patients currently taking opioids. Subjective norms significantly predicted intention to get naloxone in these patients. The interventions targeting important reference groups of these patients would have greater impact on increasing intention to get naloxone in this population. Future studies should test whether theory-based interventions focusing on strengthening subjective norms increase intention to get naloxone in this population.

The value of incorporating patient-consulted medication reconciliation in influencing drug-related actions in the outpatient rheumatology setting

Background

Unintentional changes to patients’ medicine regimens and drug non-adherence are discovered by medication reconciliation. High numbers of outpatient visits and medication reconciliation being time-consuming, make it challenging to perform medication reconciliation for all outpatients. Therefore, we aimed to get insight into the proportion of outpatient visits in which information obtained with medication reconciliation led to additional drug-related actions.

Methods

In October and November 2018, we performed a cross-sectional observational study at the rheumatology outpatient clinic. Based on a standardized data collection form, outpatient visits were observed by a pharmacy technician trained to observe and report all drug-related actions made by the rheumatologist. Afterwards, the nine observed rheumatologists and an expert panel, consisting of two rheumatologists and two pharmacists, were individually asked which drug information reported on the drug list composed by medication reconciliation was required to perform the drug-related actions. The four members of the expert panel discussed until consensus was reached about their assessment of the required information. Subsequently, a researcher determined if the required information was available in digital sources: electronic medical record (electronic prescribing system plus physician’s medical notes) or Dutch Nationwide Medication Record System.

Results

Of the 114 selected patients, 83 (73%) patients were included. If both digital drug sources were available, patient’s input during medication reconciliation resulted in additional information to perform drug-related actions according to the rheumatologist in 0% of the visits and according to the expert panel in 14%. If there was only access to the electronic medical record, the proportions were 8 and 29%, respectively. Patient’s input was especially required for starting a new drug and discussing drug-related problems.

Conclusions

If rheumatologists only had access to the electronic medical record, in 1 out of 3 visits the patient provided additional information during medication reconciliation which was required to perform a drug-related action. When rheumatologists had access to two digital sources, patient’s additional input during medication reconciliation was at most 14%. As the added value of patient’s input was highest when rheumatologists prescribe a new drug and/or discuss a drug-related problem, it may be considered that rheumatologists only perform medication reconciliation during the visit when performing one of these actions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08391-7.

The German Guidelines for Medication Safety in Pediatric Emergencies

Medication errors are a significant threat to the safety of patients of all ages. These errors are more common in children than in adults due to age specific drug dosages, drug dilutions and individual dose calculation based on body weight. In addition, it may be necessary to rapidly administer several potentially harmful or even life-threatening drugs during the emergency situation. It is not possible to provide specialized pediatric emergency teams for every prehospital or intra-hospital emergency and technical resources are frequently not identical to those of a specialized facility further increasing the risk of medication errors. This narrative review of the German Guidelines for Medication Safety in Pediatric Emergencies introduces the main principles for medication safety in pediatric emergencies and the highlights its most important pragmatic measures and recommendations.

Evaluation of Peripheral Administration of 10% Calcium Chloride in a Retrospective, Single-Center Electronic Health Record Cohort

BACKGROUND

Calcium chloride is commonly used in emergency departments in the treatment of a variety of emergencies. Historically, administration via central venous catheters has been preferred owing to its high osmolarity and vesicant properties. Although preferred, central access may not always be available in time-sensitive, emergent situations leading to many instances of peripheral administration. The objective of this analysis was to evaluate the charted safety of peripheral venous administration of 10% calcium chloride.

METHODS

A single-center retrospective chart review was performed in patients who received 10% calcium chloride in the adult emergency department evaluating for the incidence of infusion-related adverse events. Patients were excluded if they were less than 18 years of age or had a lack of catheter documentation during 10% calcium chloride administration or if the 10% calcium chloride was documented as given through a central venous catheter.

RESULTS

A total of 72 administrations were evaluated. Patients were predominantly male (67%), with a median age of 55 years and body mass index of 29.2. The primary outcome demonstrated that 4 infusion-related adverse events occurred (6%) with grade 1 (n = 1) and grade 0 (n = 3) documented incidence of infusion-related adverse events. None of the documented incidence of infusion-related adverse events resulted in permanent tissue injury, and all patients had conservative management.

DISCUSSION

This study demonstrated that administration of 10% calcium chloride via peripheral venous catheters may be feasible and seemed to carry a low incidence of documented complications. Further prospective studies are needed to confirm study observations.

Performance of a trigger tool for detecting adverse drug reactions in patients with polypharmacy acutely admitted to the geriatric ward

Aim

To investigate the performance of an adverse drug reaction (ADR) trigger tool in patients with polypharmacy acutely admitted to our geriatric ward.

Findings

The ADR trigger tool had a positive predictive value (PPV) of 41.8%. Usual care recognised 83.5% of ADRs considered as possible, probable or certain, increasing to 97.1% when restricted to probable and certain ADRs.

Message

It is unlikely that implementation of the ADR trigger tool will improve detection of unrecognised ADRs in older patients acutely admitted to our geriatric ward.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00649-x.

Purpose

Adverse drug reactions (ADRs) account for 10% of acute hospital admissions in older people, often under-recognised by physicians. The Dutch geriatric guideline recommends screening all acutely admitted older patients with polypharmacy with an ADR trigger tool comprising ten triggers and associated drugs frequently causing ADRs. This study investigated the performance of this tool and the recognition by usual care of ADRs detected with the tool.

Methods

A cross-sectional study was performed in patients ≥ 70 years with polypharmacy acutely admitted to the geriatric ward of the University Medical Centre Utrecht. Electronic health records (EHRs) were screened for trigger–drug combinations listed in the ADR trigger tool. Two independent appraisers assessed causal probability with the WHO-UMC algorithm and screened EHRs for recognition of ADRs by attending physicians. Performance of the tool was defined as the positive predictive value (PPV) for ADRs with a possible, probable or certain causal relation.

Results

In total, 941 trigger–drug combinations were present in 73% (n = 253/345) of the patients. The triggers fall, delirium, renal insufficiency and hyponatraemia covered 86% (n = 810/941) of all trigger–drug combinations. The overall PPV was 41.8% (n = 393/941), but the PPV for individual triggers was highly variable ranging from 0 to 100%. Usual care recognised the majority of ADRs (83.5%), increasing to 97.1% when restricted to possible and certain ADRs.

Conclusion

The ADR trigger tool has predictive value; however, its implementation is unlikely to improve the detection of unrecognised ADRs in older patients acutely admitted to our geriatric ward. Future research is needed to investigate the tool’s clinical value when applied to older patients acutely admitted to non-geriatric wards.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00649-x.

Mindful Workarounds in Bar Code Medication Administration

Bar-Coded Medication Administration systems (BCMA) are often used with workarounds. These workarounds are usually judged against standard operating procedures or the use of the technology as 'designers' intended'. However, some workarounds may be reasonable and justified to prevent safety errors. In this conceptual paper, we clarify BCMA safety mechanisms and provide a framework to identify workarounds with BCMA that nullify the error prevention mechanisms inherent in the technology design and process. We also highlight the importance of understanding the purpose behind a nurse's workaround in BCMA, focusing on the notion of mindful (thoughtful) workarounds that have the potential to improve patient safety.

Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients

Background

The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies.

Methods

For each trial, we will recruit 8–12 clinics (24–36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act. Process. (LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently.

Discussion

MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings.

Trial registration

ClinicalTrials.gov: NCT05065502. Registered October 4, 2021—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00297-z.

Pictograms for safer medication handling by health care workers: a validation study in nursing students in Poland

Background and objective

Medication use often causes errors that are dangerous to the health of patients. Previous studies indicate that the use of pharmaceutical pictograms can effectively reduce medication errors. The purpose of this study was to determine the comprehensibility, representativeness, and recall rate of nine medication safety pictograms in a sample of nursing students in Poland in order to validate these images.

Methods

A pictogram validation study was conducted in two phases among nursing students at the Hipolit Cegielski State University of Applied Sciences, Gniezno, Poland.

All experimental protocols were approved by the Children's Hospital of Eastern Ontario Research Ethics Board (REB Protocol No: 19/122X). All methods were carried out in accordance with relevant guidelines and regulations.

In phase 1, the participants' first exposure to the pictograms, the students were asked to guess the meaning of the pictograms without any additional information in order to assess the pictograms' comprehensibility. To be considered valid, according to ISO standards, the pictograms had to be correctly understood by at least 66.7% of participants. After testing all pictograms, students were given explanations and meanings of the pictograms and asked to rate the representativeness of pictograms. To do so, participants were asked to select a number on a seven-point Likert-style scale to indicate the perceived strength of the relationship between the pictogram and its intended meaning for each pictogram. To be considered valid, a pictogram had to be rated at least five on this scale by at least 66.7% of participants. Phase 2 took place four weeks later, during which recall of the intended meaning and representativeness were assessed following the same procedure.

Results

A total of 66 third-year nursing students participated in both phases. In phase 1, of the nine pictograms, six met ISO requirements for comprehensibility and seven met ISO requirements for representativeness. In phase 2, all nine pictograms were correctly understood and rated at least 5 by at least 66.7% of participants. Therefore, all nine pictograms are considered valid.

Conclusions

The nine medication safety pictograms can be deployed, but must be combined with training and a written hazard statement to improve comprehension.

Epidemiology of adverse drug events and medication errors in four nursing homes in Japan: the Japan Adverse Drug Events (JADE) Study

BACKGROUND

Worldwide, the emergence of super-ageing societies has increased the number of older people requiring support for daily activities. Many elderly residents of nursing homes (NHs) take drugs to treat chronic conditions; however, there are few reports of medication safety in NHs, especially from non-western countries.

OBJECTIVE

We examined the incidence and nature of adverse drug events (ADEs) and medication errors (MEs) in NHs for the elderly in Japan.

DESIGN, SETTING, AND PARTICIPANTS

The Japan Adverse Drug Events Study for NHs is a prospective cohort study that was conducted among all residents, except for short-term admissions, at four NHs for older people in Japan for 1 year.

MEASUREMENTS

Trained physicians and psychologists, five and six in number, respectively, reviewed all charts of the residents to identify suspected ADEs and MEs, which were then classified by the physicians into ADEs, potential ADEs and other MEs after the exclusion of ineligible events, for the assessment of their severity and preventability. The kappa score for presence of an ADE and preventability were 0.89 and 0.79, respectively.

RESULTS

We enrolled 459 residents, and this yielded 3315 resident-months of observation time. We identified 1207 ADEs and 600 MEs (incidence: 36.4 and 18.1 per 100 resident-months, respectively) during the study period. About one-third of ADEs were preventable, and MEs were most frequently observed in the monitoring stage (72%, 433/600), with 71% of the MEs occurring due to inadequate observation following the physician's prescription.

CONCLUSION

In Japan, ADEs and MEs are common among elderly residents of NHs. The assessment and appropriate adjustment of medication preadmission and postadmission to NHs are needed to improve medication safety, especially when a single physician is responsible for prescribing most medications for the residents, as is usually the case in Japan.

Dose error reduction software in medication safety risk management - optimising the smart infusion pump dosing limits in neonatal intensive care unit prior to implementation

Background

Smart infusion pumps with dose error reduction software can be used to prevent harmful medication errors. The aim of this study was to develop a method for defining and assessing optimal dosing limits in a neonatal intensive care unit’s smart infusion pump drug library by using simulation-type test cases developed based on medication error reports.

Methods

This mixed-methods study applied both qualitative and quantitative methods. First, wrong infusion rate-related medication errors reported in the neonatal intensive care unit during 2018–2019 were explored by quantitative descriptive analysis and qualitative content analysis to identify the error mechanisms. The researchers developed simulation-type test cases with potential errors, and a literature-based calculation formula was used to set upper soft limits to the drug library. The limits were evaluated by conducting programming of pumps without errors and with potential errors for two imaginary test patients (1 kg and 3.5 kg).

Results

Of all medication errors reported in the neonatal intensive care unit, 3.5% (n = 21/601) involved an error or near-miss related to wrong infusion rate. Based on the identified error mechanisms, 2-, 5-, and 10-fold infusion rates, as well as mix-ups between infusion rates of different drugs, were established as test cases. When conducting the pump programming for the test cases (n = 226), no alerts were triggered with infusion rates responding to the usual dosages (n = 32). 73% (n = 70/96) of the erroneous 2-, 5-, and 10-fold infusion rates caused an alert. Mix-ups between infusion rates triggered an alert only in 24% (n = 24/98) of the test cases.

Conclusions

Simulation-type test cases can be applied to assess the appropriateness of dosing limits within the neonatal intensive care unit’s drug library. In developing the test cases, combining hospital’s medication error data to other prospective data collection methods is recommended to gain a comprehensive understanding on mechanisms of wrong infusion rate errors. After drug library implementation, the alert log data and drug library compliance should be studied to verify suitability of dosing limits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03183-8.

Tolerability of memantine monotherapy versus adding memantine as combination therapy

INTRODUCTION

Prior studies have focused on the clinical efficacy of combination therapy, donepezil and memantine, for patient's diagnosed with Alzheimer's disease. As a result, it has become increasingly routine for providers to prescribe both medications for all-cause neurodegenerative disorders in variable stages of disease. However, the potential adverse drug reactions while described as mild can have serious sequelae in older adults who are already managing the side effects of polypharmacy. This study looks to explore the tolerability of switching cholinesterase inhibitors to memantine monotherapy versus adding memantine as combination therapy for all-cause neurodegenerative disorders.

MATERIALS & METHODS

The study is an IRB approved retrospective chart review that includes 175 patients diagnosed with neurocognitive disorders (ICD 10 F00-F03.91 and ICD10 G30-G31.84). Only side effects reported to and recorded by a neurocognitive subspecialist at Jefferson's Memory Disorder Center from 2016 to 2019 were included.

RESULTS & DISCUSSION

The odds of a patient reporting side effects on combination therapy in comparison with those patients on memantine monotherapy reporting side effects were significantly greater (OR = 4.33, CI 95% (1.62, 11.52), p = 0.003). In our patient sample, more than 80% of the patients reporting side effects qualified as polypharmacy or excessive polypharmacy (Table 2). As a result, variable polypharmacy (p = 0.047) was statistically significant in the in a binary logistic regression model for predicting outcomes for patients on combination therapy (Table 3). Therefore, as a patient progresses to moderate-severe stages of disease, we recommend switching CI monotherapy to memantine monotherapy as opposed to adding memantine as combination therapy for those patients on more than 10 other medications to increase tolerability. Given the limitations of a smaller sample size, variables such as severity of disease, renal and liver impairment as well as medication dosing were not significant predictors (Table 3) for those reporting side effects on combination therapy.

Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019

BACKGROUND

Drug shortages contribute to avoidable medication error and patient harm; these shortages are exacerbated in the Emergency Department due to the time-sensitive nature of acute care.

METHODS

We performed a cross-sectional study to describe the frequency and duration of drug shortages associated with the most frequent medications administered in the ED. We identified the most frequently used ED medications and calculated number of visits associated with these medications using the 2006-2019 National Hospital Ambulatory Medical Care Survey. We obtained the frequency and duration of shortages associated with these medications from the University of Utah Drug Information System. We calculated duration and total ED visits associated with shortages of the most frequently used ED medications.

RESULTS

From 2006 through 2019, the most frequently used drugs were ondansetron (255.1 million ED visits), 0.9% normal saline (251.3 million ED visits), and ibuprofen (188.5 million ED visits). All but two of the top thirty most frequently used medications experienced a shortage. The median shortage duration was 425 days, while the longest were for injectable morphine (3,202 days). The number of ED visits associated with drugs experiencing shortages increased from 2,564,425 (2.2% of U.S. ED visits) in 2006 to 67,221,968 (60.4%) in 2019. The most common reasons for shortage include manufacturing delays and increased demand.

CONCLUSIONS AND RELEVANCE

Drug shortages were more frequent and persistent from 2006 through 2019. Further studies on the clinical impact of these shortages are needed, in addition to policy interventions to mitigate shortages.

Risk factors for clinically relevant deviations in patients' medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting

Background Personal health records have the potential to identify medication discrepancies. Although they facilitate patient empowerment and broad implementation of medication reconciliation, more medication discrepancies are identified through medication reconciliation performed by healthcare professionals. Aim We aimed to identify the factors associated with the occurrence of a clinically relevant deviation in a patient’s medication list based on a personal health record (used by patients) compared to medication reconciliation performed by a healthcare professional. Method Three- to 14 days prior to a planned admission to the Cardiology-, Internal Medicine- or Neurology Departments, at Amphia Hospital, Breda, the Netherlands, patients were invited to update their medication file in their personal health records. At admission, medication reconciliation was performed by a pharmacy technician. Deviations were determined as differences between these medication lists. Associations between patient-, setting-, and medication-related factors, and the occurrence of a clinically relevant deviation (National Coordinating Council for Medication Error Reporting and Prevention class \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ E) were analysed. Results Of the 488 patients approached, 155 patients were included. Twenty-four clinically relevant deviations were observed. Younger patients (adjusted odds ratio (aOR) 0.94; 95%CI:0.91–0.98), patients who used individual multi-dose packaging (aOR 14.87; 95%CI:2.02–110), and patients who used \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 8 different medications, were at highest risk for the occurrence of a clinically relevant deviation (sensitivity 0.71; specificity 0.62; area under the curve 0.64 95%CI:0.52–0.76). Conclusion Medication reconciliation is the preferred method to identify medication discrepancies for patients with individual multi-dose packaging, and patients who used eight or more different medications.

Postmarketing safety of orphan drugs: a longitudinal analysis of the US Food and Drug Administration database between 1999 and 2018

Background

Information about the specific regulatory environment of orphan drugs is scarce and inconsistent. Uncertainties surrounding the postmarketing long-term safety of orphan drugs remain. This study aimed to evaluate the labelling changes of orphan drugs and to identify postmarketing safety-associated approval factors.

Methods

This retrospective cohort study includes all drugs with orphan drug designation approved by the Center for Drug Evaluation and Research of the US Food and Drug Administration between 1999 and 2018. Main outcomes are safety-related labelling changes up to 31 December 2019. We defined any safety-related labelling changes as postmarketing safety events (PMSE). Safety-related withdrawals, suspensions, and boxed warnings were further categorised as severe postmarketing safety events (SPSE). Outcome measurements include frequencies of PMSE, SPSE, and association between approval factors and the occurrence of safety events.

Results

Amongst the 214 drugs identified with orphan drug designation (25.7% biologics), 83.6% were approved through at least one expedited programme, and 29.4% were approved with boxed warnings. During a median follow-up of 6.74 years since approval, 69.2% and 14.5% of the analysed orphan drugs had PMSE and SPSE, respectively. Safety-related withdrawal (0%, 0/214), suspended marketing (0.46%, 1/214) and new boxed warnings are uncommon (3.7%, 8/214). The safety-related labelling changes were more frequent in the drugs approved with boxed warnings [Incidence rate ratio (IRR): 1.95 (1.02–3.73)] and approved for long-term use [IRR: 2.76 (1.52–5.00)].

Conclusions and Relevance

In this long-term postmarketing analysis, approximately 70% of FDA-approved orphan drugs had safety-related labelling changes although severe safety events were rare. While maintaining early access to orphan drugs, the drug regulatory body has taken timely regulatory action with postmarketing surveillance to ensure patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-021-02166-9.

An Economic Analysis of Critical Care Nurse Resourcing Following the Uptake of Ready-to-Administer Noradrenaline for Hypotensive Shock in Adults in England

Introduction

Ready-to-administer formulations for intravenous administration of noradrenaline are now broadly recommended and predicted to reduce pressure on critical care nursing. This analysis sought to quantify the nurse resource released from national level transition.

Methods

The annual number of noradrenaline support days for hypotensive shock was determined and the administration of noradrenaline was simulated over 24 h using a decision tree. A ‘best-practice’ ready-to-administer strategy (RtA) of volumetrically pumped noradrenaline was compared to a ‘nil uptake’ strategy (AfC) of bedside prepared solution delivered either volumetrically or using a double syringe pump. A mix of noradrenaline concentrations, flow rates, product sizes, and preferences for ampoule pooling, preparation volume, and sterility were included. The consumption of nurse days and product units was then projected over 1 year for a population of adults in critical care in England.

Results

Noradrenaline was administered over 231,011 days per year across 4123 critical care beds in England. Implementing a transition from AfC to RtA strategies on this scale released 35,791 nurse days or 176 whole-time nurse equivalents at 50/50 NHS band 5 and 6, a monetised release of £11.6 million. There was an increase in drug acquisition cost of £2.1 million using the licensed commercial product Sinora^®. Annual net monetary benefit was + £9.5 million, or + £65,961 per critical care unit (CCU) of 29 beds, equivalent to one nurse released per unit for patient care.

Conclusions

This modelling of ready-to-administer noradrenaline with volumetric delivery quantifies and bears out the recommendations of the Lord Carter review, the Royal Pharmaceutical Society, and the NHS Specialist Pharmacy Service in their encouragement of ready-to-administer formulations for safe and resource-effective critical care.

[Medication management in home care-The medication use process from the perspective of clients and their caregivers]

BACKGROUND

Professional home care nurses are often tasked with the medication management of older, polymedicated clients. The medication use process is often complex and prone to medication errors. From the perspective of professional caregivers, the interprofessional interfaces of care as well as the integration of clients and informal caregivers are a major challenge.

AIM

With this study, we explored the perspective of home care clients and their informal caregivers on the medication use process supported by professional caregivers with a focus on medication safety.

METHOD

We chose a qualitative research approach, using guideline-based interviews with eight clients and five caregivers. Data were analyzed applying the topical analysis according to Braun and Clarke.

RESULTS AND DISCUSSION

Before engaging professional home care nurses in the medication use process, clients reached their physical, psychological and social limits. They were relieved when the professional home care organization took care of the overall coordination of the medication use process and felt safe. They trust professional caregivers and see limited need to be preoccupied with medication safety themselves, despite risks inherent in self-medication, adherence and transition of care.

CONCLUSION

Through the relief provided by professional caregivers, home care clients and their informal caregivers no longer perceive themselves as active partners in maintaining medication safety. Healthcare professionals should keep an eye on self-medication as well as adherence and support the use of the medication plan.

Impact of a clinical pharmacist on medication safety in mental health Hospital-in-the-Home: a retrospective analysis

BACKGROUND

Integration of clinical pharmacists into multidisciplinary Mental Health Hospital-in-the-Home teams is increasing but little is known about the medication safety contribution these pharmacists make.

AIM

To evaluate whether clinical pharmacist involvement in a Mental Health Hospital-in-the-Home service improved medication safety key performance indicators.

METHOD

Medical records were retrospectively reviewed of all patients admitted to 2 Western Australian Mental Health Hospital-in-the-Home services from September to November 2015. SITE 1: was a 16-bed service incorporating a clinical pharmacist as part of its multidisciplinary team. SITE 2: was a similarly structured 18-bed service but without clinical pharmacist involvement. The primary outcome measure was completion of medication safety key performance indicators obtained from the Western Australian Government Pharmaceutical Review Policy and mental health-specific best practice guidelines.

RESULTS

Key performance indicators from Site 1 (n = 75 records), which incorporated a clinical pharmacist, demonstrated significantly (p < 0.001) higher rates of completion of medication reconciliation [65 (87%) versus 17 (29%)], accurate adverse drug reaction list [73 (97%) versus 34 (58%)], accurate discharge medication list [51 (74%) versus 18 (45%)], accurate medication profile [74 (99%) versus 40 (68%)] and medication chart review [74 (99%) versus 0 (0%)] than Site 2 (n = 59).

CONCLUSION

Integrating a clinical pharmacist into a Mental Health Hospital-in-the-Home program significantly improved achievement of medication safety key performance indicators.

Older patients' engagement in hospital medication safety behaviours

BACKGROUND

Increasing age is associated with more medication errors in hospitalised patients. Patient engagement is a strategy to reduce medication harm.

AIMS

To measure older patients' preferences for and reported medication safety behaviours, identify the relationship between preferred and reported medication safety behaviours and identify whether perceptions of medication safety behaviours differ between groups of young-old, middle-old and old-old patients (65-74 years, 75-84 years, and ≥ 85 years).

METHODS

A survey, which included the Inpatient Medication Safety Involvement Scale (IMSIS) was administered to 200 older patients from medical settings, at one hospital. Data were analysed using descriptive statistics, Spearman's rho and the Kruskal-Wallis test.

RESULTS

Patients reported a desire to ask questions (59.5% n = 119) and check with healthcare professionals if they perceived that a medication was wrong (86.5% n = 173) or forgotten (87.0% n = 174). Patients did not have particular preferences, which differed from their experiences in terms of viewing the medication administration chart and self-administering medications. Preferred and reported behaviours correlated positively (r = 0.46-0.58, n = 200, p ≤ 0.001). Young-old patients preferred notifying healthcare professionals of perceived medication errors more than middle-old and old-old patients (p ≤ 0.05).

CONCLUSIONS

Older patients may prefer verbal medication safety behaviours like asking questions and notifying healthcare professionals of medication errors, over viewing medication charts and self-administering medications. The young-old group wanted to identify perceived medication errors more than other age groups. Older patients are willing to engage in medication safety behaviours, and healthcare professionals and organisations need to embrace this engagement in an effort to reduce medication harm.

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

Regionalized Health System Review of Automated Dispensing Cabinet Overrides

Automated dispensing cabinet (ADC) overrides are used to access emergent or urgent medications when time delay from computerized provider order entry may result in patient harm. [1] Although necessary, ADC overrides bypass the safety features of order entry and verification which increase the risk of an error occurring and potential patient harm. To protect patient safety, national organizations such as The Joint Commission and Institute for Safe Medication Practices have called for hospitals to review overriding trends and available medications on override. AdventHealth Central Florida Division - South (CFD-S) met the recommendations to track overrides but there was limited understanding of the data. A quality improvement project was necessary to investigate the division's risk of error and identify interventions to proactively limit patient risk. The initial task of the quality improvement project was to create a standardized ADC override report that could be shared with pharmacy and nursing leaders within AdventHealth CFD-S monthly. As the project progressed, multiple interventions were identified such as standardizing the information reflected in the report, improving education about ADC overrides across multi-disciplinary departments, and critically reviewing the data to identify needed changes within the division. The efforts to share the ADC override metrics across all levels has improved understanding of ADC override goals and intentions of monitoring ADC overrides. This has paved the path to improving ADC override unit culture and identify gaps within the system that allows overrides to occur.

Healthcare professionals' perceptions on medication communication challenges and solutions - text mining and manual content analysis - cross-sectional study

BACKGROUND

Communication challenges contribute to medication incidents in hospitals, but it is unclear how communication can be improved. The aims of this study were threefold: firstly, to describe the most common communication challenges related to medication incidents as perceived by healthcare professionals across specialized hospitals for adult patients; secondly, to consider suggestions from healthcare professionals with regard to improving medication communication; and thirdly, to explore how text mining compares to manual analysis when analyzing the free-text content of survey data.

METHODS

This was a cross-sectional, descriptive study. A digital survey was sent to professionals in two university hospital districts in Finland from November 1, 2019, to January 31, 2020. In total, 223 professionals answered the open-ended questions; respondents were primarily registered nurses (77.7 %), physicians (8.6 %), and pharmacists (7.3 %). Text mining and manual inductive content analysis were employed for qualitative data analysis.

RESULTS

The communication challenges were: (1) inconsistent documentation of prescribed and administered medication; (2) failure to document orally given prescriptions; (3) nurses' unawareness of prescriptions (given outside of ward rounds) due to a lack of oral communication from the prescribers; (4) breaks in communication during care transitions to non-communicable software; (5) incomplete home medication reconciliation at admission and discharge; (6) medication lists not being updated during the inpatient period due to a lack of clarity regarding the responsible professional; and (7) work/environmental factors during medication dispensation and the receipt of verbal prescriptions. Suggestions for communication enhancements included: (1) structured digital prescriptions; (2) guidelines and training on how to use documentation systems; (3) timely documentation of verbal prescriptions and digital documentation of administered medication; (4) communicable software within and between organizations; (5) standardized responsibilities for updating inpatients' medication lists; (6) nomination of a responsible person for home medication reconciliation at admission and discharge; and (7) distraction-free work environment for medication communication. Text mining and manual analysis extracted similar primary results.

CONCLUSIONS

Non-communicable software, non-standardized medication communication processes, lack of training on standardized documentation, and unclear responsibilities compromise medication safety in hospitals. Clarification is needed regarding interdisciplinary medication communication processes, techniques, and responsibilities. Text mining shows promise for free-text analysis.

Application of intervention mapping to develop and evaluate a pharmaceutical discharge letter to improve information transfer between hospital and community pharmacists

BACKGROUND

Insufficient information transfer is a major barrier in the transition from hospital to home. This study describes the systematic development and evaluation of an intervention to improve medication information transfer between hospital and community pharmacists.

OBJECTIVE

To develop and evaluate an intervention to improve the medication information transfer between hospital and community pharmacists based on patients', community and hospital pharmacists' needs.

METHODS

The intervention development and evaluation was guided by the six-step Intervention Mapping (IM) approach: (1) needs assessment to identify determinants of the problem, with a scoping review and focus groups with patients and healthcare providers, (2) formulation of intervention objectives with an expert group, (3) inventory of communication models to design the intervention, (4) using literature review and qualitative research with pharmacists and patients to develop the intervention (5) pilot-testing of the intervention in two hospitals, and (6) a qualitative evaluation of the intervention as part of a multicenter before-after study with hospital and community pharmacists.

RESULTS

Barriers in the information transfer are mainly time and content related. The intervention was designed to target a complete, accurate and timely medication information transfer between hospital and community pharmacists. A pharmaceutical discharge letter was developed to improve medication information transfer. Hospital and community pharmacists were positive about the usability, content, and comprehensiveness of the pharmaceutical discharge letter, which gave community pharmacists sufficient knowledge about in-hospital medication changes. However, hospital pharmacists reported that it was time-consuming to draft the discharge letter and not always feasible to send it on time. The intervention showed that pharmacists are positive about the usability, content and comprehensiveness.

CONCLUSION

This study developed an intervention systematically to improve medication information transfer, consisting of a discharge letter to be used by hospital and community pharmacists supporting continuity of care.