Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis

Effectiveness of pharmacist-led antimicrobial stewardship programs in perioperative settings: A systematic review and meta-analysis

OBJECTIVE

We sought to characterize and evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use and subsequent surgical site infections (SSI) in perioperative settings.

METHODS

A systematic review and meta-analysis was conducted by searching PubMed, Embase and CINAHL. Two independent reviewers extracted the data using the Descriptive Elements of Pharmacist Intervention Characterization Tool and undertook quality assessment using the Crowe Critical Appraisal. A meta-analysis was conducted using a random-effect model.

RESULTS

Eleven studies were included in this review. Pharmacists were found to have various roles in AMS, including educational sessions, ward rounds, audits and feedback, and guidelines development. The discussion of interventions lacked details on the development. A meta-analysis revealed that pharmacist-led AMS programs in perioperative settings was associated with a significant improvement in antibiotic selection (OR 4.29; 95 % CI 2.52-7.30), administration time (OR 4.93; 95 % CI 2.05-11.84), duration (OR 5.27; 95 % CI 1.58-17.55), and SSI (OR 0.51; 95 % CI 0.34-0.77).

CONCLUSION

Pharmacist-led AMS programs were effective in improving antimicrobial prescribing while reducing SSI; however most studies were of moderate quality. Studies lacked the utilization of theory to develop interventions, therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. High-quality, multicomponent, theory-derived, interventional studies using appropriate methodology and standardized data collection, are needed.

Development of an innovative clinical pharmacy service in a urology surgical unit: a new initiative from Qatar

Purpose

To provide an insight into the role of a clinical pharmacy initiative in a surgical urology unit through evaluating the nature, significance, associated medications, and acceptance rate of pharmacist interventions.

Methods

A cross-sectional study was carried out at the Ambulatory Care Center (ACC), Doha, Qatar. Data related to clinical pharmacist interventions and associated rationale were classified according to the nature of the intervention using an adapted classification system. The assessment of the severity followed the National Patient Safety Agency (NPSA) Risk Matrix. Linear regression, Kruskal-Wallis, and post-hoc analyses were performed to determine the association between patient-related and medication-related characteristics on pharmacist interventions.

Results

A total of 3284 interventions (on 1486 patients) were analysed. Most patients (n = 1105; 74.4%) had 1-2 interventions. Age and gender showed a positive linear correlation with the number of interventions per patient (p < 0.01). Majority of interventions were related to pharmacological strategy (n = 1858; 56.6%) and quantity of drug (n = 821; 25%). Additional drug therapy (n = 748; 22.78%) was the most common subcategory followed by optimum dose/frequency (n = 691; 21.04%) and discontinuation of medications (n = 352, 10.72%). Anti-infectives were the most identified drug category (n = 798, 55.1%). Most interventions (59.4%) were of moderate significance; patients with moderate interventions were found to be older compared to patients with minor interventions (p = 0.032). Prescribers' acceptance rate was high (>90%), with a notable increase of 6.6% from 2021 to 2023.

Conclusion

This study showed that the clinical pharmacy service in the urology surgical field was a fruitful initiative. The clinical pharmacist's role has expanded to include not only therapeutic optimisation while ensuring medication safety across the continuum of perioperative care but also the identification and management of untreated health problems. The dynamic and complexity of the urology patient population challenge clinical pharmacists; however, the practice concepts remain the same as in any other clinical setting.

Characteristics and causes of reported clozapine-related medication errors: analysis of the Ministry of Health database in Saudi Arabia

BACKGROUND

Clozapine has shown great efficacy in treating treatment-resistant schizophrenia, but it is associated with a variety of medication- related safety problems. Despite this, there remains a lack of research on medication errors (MEs) associated with its use.

AIM

To characterize the nature and contributory factors of clozapine-related MEs reported from government hospitals and primary care centres in Saudi Arabia (SA).

METHOD

A cross-sectional analysis was carried out on MEs related to clozapine use reported to the General Administration of Pharmaceutical Care at the Ministry of Health (MOH) in Saudi Arabia between 2018 and 2022. The data were analysed descriptively to examine the nature and contributory factors of MEs.

RESULTS

A total of 1,165 MEs were reported. The majority of reported errors involved patients aged > 18 years old, with 72.2% (n = 841) being male. The central region was found to report errors more frequently (32.3%, n = 376). Pharmacists were reported to detect errors most frequently (59.6%, n = 695). MEs most often occurred in the prescribing stage (77.8%, n = 906), with "missing prescription information" (30.1%, n = 351) being the most frequent finding. The most frequent contributing factor was the lack of policy (33.1%, n = 351). The majority of errors did not reach the patients (92.3%, n = 1,075), and those that did reach patients rarely resulted in harm (0.3%, n = 2).

CONCLUSION

This study identified areas for improvement which could expedite the development of remedial interventions to reduce the risk of errors.

Reducing medication errors in HIV-positive patients: Influence of a clinical pharmacist

Background

The roll-out of antiretroviral medicines has improved life expectancy in people living with HIV (PLHIV). This has resulted in more patients being hospitalised for non-communicable diseases, increasing risk for medication errors (MEs). Pharmacists, through medication reconciliation, may identify and reduce MEs in this population.

Objectives

To describe the importance of a pharmacist's involvement in identifying and quantifying types of MEs.

Method

A quantitative, prospective observational study was conducted over 14 weeks. A pharmacist reviewed HIV-positive, hospitalised patients' files, using a data collection instrument, to determine the prevalence of MEs in PLHIV. The study pharmacist recommended appropriate actions to the prescriber to resolve MEs and documented resolution of the MEs.

Results

The study population of n = 180 patient files were reviewed 453 times, identifying 466 MEs. Medication errors included incorrect medication reconciliation from history (19; 4.1%), prescription omission (17; 3.7%), duplication of therapy (10; 2.2%), missed doses (265; 57.1%), incorrect dosing (103; 22.2%), incorrect administration frequency (2; 0.4%), incorrect duration of therapy (15; 3.2%) and drug-drug interactions (18; 3.9%). More than half (58.2%) of the MEs were resolved in less than 24 h, with involvement of the pharmacist.

Conclusion

This study demonstrates the magnitude of MEs experienced in hospitalised PLHIV and highlights the role clinical pharmacists play in identifying and resolving MEs to improve patient outcomes.

Interventions and impact of pharmacist-delivered services in perioperative setting on clinically important outcomes: a systematic review and meta-analysis

Background

The perioperative arena is a unique and challenging environment that requires coordination of the complex processes and involvement of the entire care team. Pharmacists' scope of practice has been evolving to be patient-centered and to expand to variety of settings including perioperative settings.

Objectives

To critically appraise, synthesize, and present the available evidence of the characteristics and impact of pharmacist-led interventions on clinically important outcomes in the perioperative settings.

Design

A systematic review and meta-analysis.

Methods

We searched PubMed, Embase, and CINAHL from index inception to September 2023. Included studies compared the effectiveness of pharmacist-led interventions on clinically important outcomes (e.g. length of stay, readmission) compared to usual care in perioperative settings. Two independent reviewers extracted the data using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) and undertook quality assessment using the Crowe Critical Appraisal (CCAT). A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and standard mean difference (SMD) for continuous data] with 95% confidence intervals (CIs).

Results

Twenty-five studies were eligible, 20 (80%) had uncontrolled study design. Most interventions were multicomponent and continuous over the perioperative period. The intervention components included clinical pharmacy services (e.g. medication management/optimization, medication reconciliation, discharge counseling) and education of healthcare professionals. While some studies provided a minor description in regards to the intervention development and processes, only one study reported a theoretical underpinning to intervention development. Pooled analyses showed a significant impact of pharmacist care compared to usual care on length of stay (11 studies; SMD -0.09; 95% CI -0.49 to -0.15) and all-cause readmissions (8 studies; OR 0.60; 95% CI 0.39-0.91). The majority of included studies (n = 21; 84%) were of moderate quality.

Conclusion

Pharmacist-led interventions are effective at improving clinically important outcomes in the perioperative setting; however, most studies were of moderate quality. Studies lacked the utilization of theory to develop interventions; therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. Future research should prioritize the development and evaluation of multifaceted theory-informed pharmacist interventions that target the whole surgical care pathway.

Assessing the applicability and appropriateness of ChatGPT in answering clinical pharmacy questions

OBJECTIVES

Clinical pharmacists rely on different scientific references to ensure appropriate, safe, and cost-effective drug use. Tools based on artificial intelligence (AI) such as ChatGPT (Generative Pre-trained Transformer) could offer valuable support. The objective of this study was to assess ChatGPT's capacity to correctly respond to clinical pharmacy questions asked by healthcare professionals in our university hospital.

MATERIAL AND METHODS

ChatGPT's capacity to respond correctly to the last 100 consecutive questions recorded in our clinical pharmacy database was assessed. Questions were copied from our FileMaker Pro database and pasted into ChatGPT March 14 version online platform. The generated answers were then copied verbatim into an Excel file. Two blinded clinical pharmacists reviewed all the questions and the answers given by the software. In case of disagreements, a third blinded pharmacist intervened to decide.

RESULTS

Documentation-related issues (n=36) and drug administration mode (n=30) were preponderantly recorded. Among 69 applicable questions, the rate of correct answers varied from 30 to 57.1% depending on questions type with a global rate of 44.9%. Regarding inappropriate answers (n=38), 20 were incorrect, 18 gave no answers and 8 were incomplete with 8 answers belonging to 2 different categories. No better answers than the pharmacists were observed.

CONCLUSIONS

ChatGPT demonstrated a mitigated performance in answering clinical pharmacy questions. It should not replace human expertise as a high rate of inappropriate answers was highlighted. Future studies should focus on the optimization of ChatGPT for specific clinical pharmacy questions and explore the potential benefits and limitations of integrating this technology into clinical practice.

Study to evaluate awareness about medication errors and impact of an educational intervention among healthcare personnel in a cancer hospital

INTRODUCTION

Medication errors (MEs) are preventable incidents that can result in harm to patients. Therefore, it is essential for healthcare professionals (HCPs) to be well-informed about MEs. This study aims to assess the awareness levels of HCPs and the impact of educational intervention on their understanding of MEs.

METHODS

Responses to a 17-question structured, self-administered questionnaire assessing the awareness of HCPs regarding fundamental aspects of MEs, ME reporting systems, and their ability to make recommendations for improving the system for handling the MEs were collected both before and after two weeks of educational intervention administration.

RESULTS

Of a total of 114 HCPs who initially participated in the study, six dropped following the intervention. The awareness regarding the Class A questionnaire was good in most physicians (60%), nurses (60%), and pharmacists (57%) before the intervention, which improved postintervention, with physicians (80%), nurses (32%), and pharmacists (78%) demonstrating excellent awareness. The awareness level in the Class B questionnaire was also improved to excellent in most physicians (70%), pharmacists (85%), and nurses (85%) following the intervention, while it was excellent only in 50%, 35%, and 1% of physicians, pharmacists, and nurses, respectively, preintervention. In the Class C questionnaire, most physicians (40%) and nurses (60%) had good awareness, while pharmacists (35%) demonstrated excellent awareness preintervention. Postintervention, most physicians (70%), nurses (77%), and pharmacists (64%) exhibited excellent awareness.

CONCLUSION

Most oncology practice HCPs demonstrate a good to average level of awareness regarding MEs. Clinical pharmacists' educational interventions can significantly enhance awareness among HCPs concerning MEs.

Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review

BACKGROUND

Medication errors are common events that compromise patient safety. Outpatient and ambulatory settings enhance access to healthcare which has been linked to favorable outcomes. While medication errors have been extensively researched in inpatient settings, there is dearth of literature from outpatient settings.

AIM

To synthesize the peer-reviewed literature on the prevalence, nature, contributory factors, and interventions to minimize medication errors in outpatient and ambulatory settings.

METHOD

A systematic review was conducted using Medline, Embase, CINAHL, and Google Scholar which were searched from 2011 to November 2021. Quality assessment was conducted using the quality assessment checklist for prevalence studies tool. Data related to contributory factors were synthesized according to Reason's accident causation model.

RESULTS

Twenty-four articles were included in the review. Medication errors were common in outpatient and ambulatory settings (23-92% of prescribed drugs). Prescribing errors were the most common type of errors reported (up to 91% of the prescribed drugs, high variations in the data), with dosing errors being most prevalent (up to 41% of the prescribed drugs). Latent conditions, largely due to inadequate knowledge, were common contributory factors followed by active failures. The seven studies that discussed interventions were of poor quality and none used a randomized design.

CONCLUSION

Medication errors (particularly prescribing errors and dosing errors) in outpatient settings are prevalent, although reported prevalence range is wide. Future research should be informed by behavioral theories and should use high quality designs. These interventions should encompass system-level strategies, multidisciplinary collaborations, effective integration of pharmacists, health information technology, and educational programs.

Quality indicators of hospitalized children influenced by clinical pharmacist services: A systematic review

BACKGROUND

Care for children who are hospitalized can be optimized if the pharmacist, in conjunction with the multidisciplinary team, promotes the rational use of medicines. In this sense, the evaluation of the quality of these clinical services through indicators is important in the planning, decision making of pharmacists and managers of these services.

OBJECTIVE

To characterize which health indicators were influenced by the pharmaceutical clinical services for the care of children in hospitals.

METHODS

A systematic review was performed. The search for data was made on the bases: Cochrane, Embase, Lilacs, Pubmed and Web of Science. Then, the search included studies in which evaluated the impact of pharmaceutical clinical services on clinical, economic and humanistic outcomes.

RESULTS

The search resulted in 11 included studies. In this review, four pharmaceutical clinical services were found: pharmacotherapy review, multiprofessional team interventions, antimicrobial stewardship program and pharmaceutical services at discharge hospital. The most influenced outcome indicators were length of hospital stay, with average time in the group that received the pharmacotherapy review service, and interventions multiprofessional team with a 6.45-day vs. 10.83 days in the control group; hospital readmissions with a significant reduction of non-scheduled readmission of 30 days in the ntimicrobial stewardship program; reduction of hospital costs and caregiver satisfaction.

CONCLUSION

In this study, we can highlight that pharmacotherapy review, multiprofessional team interventions and Antimicrobial Stewardship Program that significantly reduced the clinical results of length of hospital stay and hospital readmission, as well as a significant reduction of hospital costs.

Human Error Analysis and Modeling of Medication-Related Adverse Events in Taiwan Using the Human Factors Analysis and Classification System and Logistic Regression

Medical institutions worldwide strive to avoid adverse medical events, including adverse medication-related events. However, studies on the comprehensive analysis of medication-related adverse events are limited. Therefore, we aimed to identify the error factors contributing to medication-related adverse events using the Human Factors Analysis and Classification System (HFACS) and to develop error models through logistic regression. These models calculate the probability of a medication-related adverse event when a healthcare system defect occurs. Seven experts with at least 12 years of work experience (four nurses and three pharmacists) were recruited to analyze thirty-seven medication-related adverse events. The findings indicate that decision errors, physical/mental limitations, failure to correct problems, and organizational processes were the four factors that most frequently contributed to errors at the four levels of the HFACS. Seven error models of two types (error occurrence and error analysis pathways) were established using logistic regression models, and the relative probabilities of failure factor occurrences were calculated. Based on our results, medical staff can use the error models as a new analytical approach to improve and prevent adverse medication events, thereby improving patient safety.

Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the National Reporting and Learning System

INTRODUCTION

Direct oral anticoagulants (DOACs) are considered high risk medicines and are frequently associated with medication errors. The nature of incidents and associated outcomes of such incidents are poorly understood.

AREAS COVERED

Using a national patient safety reporting database, the National Reporting and Learning System (NRLS), this study aimed to report the contributory factors and outcomes including severe harm and deaths related to all safety incidents involving DOACs reported in England and Wales between 2017-2019. Reason's accident causation model was used to classify the incidents.

EXPERT OPINION

A total of 15,730 incident reports were analyzed. A total of 25 deaths were reported with a further 270 and 55 incidents leading to moderate and severe harm, respectively. A further 8.8% (n = 1381) of incidents were associated with low degree of harm. The majority of the incidents involved active failures (n = 13776; 87.58) including duplication of anticoagulant therapies, patients being discharged without DOACs, non-consideration of renal function, and lack of commencement of DOACs post-surgery suggesting preventability of such reported incidents. This study shows that medication incidents involving DOACs have the potential to cause severe harm and deaths, and there is a need to promote guideline adherence through education, training, and decision support technologies.

Understanding the Risk Factors and Stressors Impacting Optimal Work Practices in New Zealand Pharmacies: A S.H.E.L.L Model Analysis

(1) Background: The safe performance of pharmacists is an important issue for patients and regulators. It is recognized that pharmacists interact with a variety of healthcare professionals and act as a bridge between other healthcare providers and systems and patients in the health setting. There has been growing activity in exploring factors that impact optimal performance and determinants that are linked with medication errors and practice incidents. The aviation and military industries have used S.H.E.L.L modeling to identify how personnel interact with factors that affect outcomes. A human factors approach is a useful angle to take when trying to improve optimal practice. Little is known about the experiences of New Zealand pharmacists and S.H.E.L.L factors that affect day-to-day practices in their work environment. (2) Methods: We investigated environment, team, and organizational considerations as the determining factors of optimal work practices using an anonymous online questionnaire. The questionnaire was built from a modified version of the software, hardware, environment, and liveware (S.H.E.L.L) model. This identified components of a work system that were vulnerable and that provided risks to optimal practice. Participants were New Zealand pharmacists approached through a subscriber list provided by the regulatory authority of the profession. (3) Results: We received responses from 260 participants (8.56%). The majority of participants indicated that optimal practice was occurring. More than 95% of respondents agreed that knowledge, fatigue interruptions, complacency, and stress affected optimal practice. Equipment and tools, medication arrangement on the shelf, lighting, physical layout, and communication with staff and patients were important factors for optimal practice. A smaller cohort of participants, 13 percent (n = 21), stated that dispensing processes, dissemination, and enforcement of standard operating procedures and procedural guidance did not affect pharmacy practice, 21.3% responded that professional and ethical requirements did not affect optimal practice, 20% stated that having a staffroom affected optimal practice, 20% did not think substance use affected optimal practice, and 30% did not state that cultural differences affected optimal practice. Optimal practice is constrained when there is a lack of experience, professionalism, and communication among staff, patients, and external agencies. COVID-19 also has had an impact on pharmacists both personally and in their work environments. Exploring how the pandemic has affected pharmacists and their work environment warrants further research. (4) Conclusions: Pharmacists across New Zealand agreed that optimal practices were occurring and considered other factors that were perceived to not affect optimal practice. A human factor S.H.E.L.L framework has been used to analyze themes to understand the optimal practice. The rising body of international literature on the effect of the pandemic on pharmacy practice serves as a foundation for many of these themes. Longitudinal data would be useful in exploring some factors, such as pharmacist well-being over time.

Disaster Preparedness Amongst Emergency Pharmacists for the FIFA World Cup Qatar 2022™: A Cross-Sectional Survey

Purpose

The aim of this study is to assess the level of preparedness of pharmacists working in the emergency department at Hamad Medical Corporation (HMC) for any emergency disasters that may take place during the FIFA World Cup Qatar 2022™ by evaluating their awareness (A), attitude (A), and readiness (R).

Methods

A cross-sectional quantitative observational study was conducted through a web-based survey. The survey was distributed among emergency pharmacists working in general hospitals under HMC. The questionnaire was composed of three major domains assessing awareness, attitude, readiness, as well as an additional domain to collect the participants' demographics. Student's t-test, analysis of variance, Pearson's correlation, and linear regression were used with an alpha level of 0.05.

Results

Most pharmacists working in the emergency departments at HMC had high levels of awareness (76.9%), attitude (92%), and readiness (53.8%) for any emergency disasters that may occur during the FIFA World Cup 2022. Nonetheless, almost half of the respondents reported moderate level of readiness for emergency events. Pharmacists with >10 years' practice experience had significantly higher AAR score compared to those with <5 years' experience (P = 0.002). Significant direct positive correlations were found among the 3 AAR parameters (P < 0.05). Attitude was found to be a significant predictor of readiness (P < 0.05). A model composed of attitude and awareness could predict 12% of readiness score.

Conclusion

Emergency pharmacists at HMC have high level of preparedness for any emergency disaster event during the World Cup. Future research should focus on the development of theory-based action framework for pharmacy departments during mass gathering events.

The Pitfall of Over-Sedation During Recovery From Acute Kidney Injury

A 14-year-old boy with movement disorder and epilepsy developed status dystonicus leading to rhabdomyolysis and subsequent acute kidney injury requiring continuous renal replacement therapy (CRRT). He was given multiple intravenous sedatives and analgesics to control his dystonia and dyskinesia. 8 days after admission, his condition had improved and a trial termination of CRRT was carried out. The sedatives and analgesics were switched to oral diazepam, morphine, clonidine, and chloral hydrate. However, his renal function did not recover fully. There was rising trend of serum creatinine level with evolving hyperphosphatemia and metabolic acidosis. He also gradually developed hypoventilation, hypercapnia and pinpoint pupils after weaning CRRT. The clinical impression was over-sedation resulting in hypoventilation and respiratory failure, contributed by the deteriorating renal function. Non-invasive ventilatory support was then started and CRRT was resumed. His condition improved over the next 24 hours. Dexmedetomidine infusion was used during CRRT and he slowly required stepping up of sedatives again. A separate set of dosage for all his oral sedative agents was prepared for his subsequent CRRT weaning challenge and no more over-sedative episode was then encountered. Our case illustrated that patients at recovery phase of AKI are susceptible to medication overdose, especially during the period of CRRT weaning. Sedatives and analgesics including morphine and benzodiazepines should be used with caution during this period and alternatives may need to be considered. Advanced planning of medication dosage adjustment is advised to reduce the risk of medication overdose.

How can we optimise the pharmaceutical analysis of radiopharmaceutical pediatric prescriptions?

OBJECTIVES

In France, dispensation is defined by the validation of a prescription associated with a pharmaceutical analysis, preparation of medication and provision of information necessary for proper use. There are very few data available in the literature that describe prescription analysis modality in radiopharmacy. The aim was to secure a place for paediatric prescription analysis in radiopharmacy by designing a flow chart validated by experts.

METHODS

Experts from different disciplines and health setups (ie, public, private) were selected to represent the various paediatric patient care processes. A review of the literature on pharmaceutical analysis and paediatric prescription in radiopharmacy was conducted. A Delphi approach comprising two rounds (Google Form survey) was used to validate the flow chart. Answers were graded according to a nine-point Likert scale for agreement. Open-ended questions allowed experts to comment on the propositions. A consensus between experts was reached if more than 70% of the experts agreed on an item and fewer than 30% disagreed.

RESULTS

Sixty-five experts were solicited: two oncopaediatricians, three nuclear medicine physicians, 46 radiopharmacists, three residents in radiopharmacy, one hospital pharmacist, five medical physicists, one pharmacy technician, two X-ray technicians and two patients who are pharmacists. The first round survey included a draft of the flow chart: 31 experts answered (48%). All professional disciplines were represented except pharmacy technician. The second round survey was sent with a new flow chart that had been improved by the experts' comments. After 3 weeks, 18 answers were obtained (28%). After the first round, consensus was obtained for each item. Experts gave a total of 97 comments. The second flow chart had three steps: regulatory aspects, patient data, and radiopharmaceutical data, and it was accompanied by descriptive text explaining the field of application.

CONCLUSION

The resulting flow chart will secure the pharmaceutical analysis step for this special patient population.

The impact of pharmacist-led medication reconciliation and interprofessional ward rounds on drug-related problems at hospital discharge

BACKGROUND

During transitions of care, including hospital discharge, patients are at risk of drug-related problems (DRPs).

AIM

To investigate the impact of pharmacist-led services, specifically medication reconciliation at admission and/or interprofessional ward rounds on the number of DRPs at discharge.

METHOD

In this retrospective, single-center cohort study, we analyzed routinely collected data of patients discharged from internal medicine wards of a regional Swiss hospital that filled their discharge prescriptions in the hospital's community pharmacy between June 2016 and May 2019. Patients receiving one of the two or both pharmacist-led services (Study groups: Best Care = both services; MedRec = medication reconciliation at admission; Ward Round = interprofessional ward round), were compared to patients receiving standard care (Standard Care group). Standard care included medication history taken by a physician and regular ward rounds (physicians and nurses). At discharge, pharmacists reviewed discharge prescriptions filled at the hospital's community pharmacy and documented all DRPs. Multivariable Poisson regression analyzed the independent effects of medication reconciliation and interprofessional ward rounds as single or combined service on the frequency of DRPs.

RESULTS

Overall, 4545 patients with 6072 hospital stays were included in the analysis (Best Care n = 72 hospital stays, MedRec n = 232, Ward Round n = 1262, and Standard Care n = 4506). In 1352 stays (22.3%) one or more DRPs were detected at hospital discharge. The combination of the two pharmacist-led services was associated with statistically significantly less DRPs compared to standard care (relative risk: 0.33; 95% confidence interval: 0.16, 0.65). Pharmacist-led medication reconciliation alone showed a trend towards fewer DRPs (relative risk: 0.75; 95% confidence interval: 0.54, 1.03).

CONCLUSION

Our results support the implementation of pharmacist-led medication reconciliation at admission in combination with interprofessional ward rounds to reduce the number of DRPs at hospital discharge.

Clinical decision support methods for children and youths with mental health disorders in primary care

BACKGROUND

Mental health disorders among children and youths are common and often have negative consequences for children, youths, and families if unrecognized and untreated. With the goal of early recognition, primary care physicians (PCPs) play a significant role in the detection and referral of mental disorders. However, PCPs report several barriers related to confidence, knowledge, and interdisciplinary collaboration. Therefore, initiatives have been taken to assist PCPs in their clinical decision-making through clinical decision support methods (CDSMs).

OBJECTIVES

This review aimed to identify CDSMs in the literature and describe their functionalities and quality.

METHODS

In this review, a search strategy was performed to access all available studies in PubMed, PsychINFO, Embase, Web of Science, and COCHRANE using keywords. Studies that involved CDSMs for PCP clinical decision-making regarding psychosocial or psychiatric problems among children and youths (0-24 years old) were included. The search was conducted according to PRISMA-Protocols.

RESULTS

Of 1,294 studies identified, 25 were eligible for inclusion and varied in quality. Eighteen CDSMs were described. Fourteen studies described computer-based methods with decision support, focusing on self-help, probable diagnosis, and treatment suggestions. Nine studies described telecommunication methods, which offered support through interdisciplinary (video) calls. Two studies described CDSMs with a combination of components related to the two CDSM categories.

CONCLUSION

Easy-to-use CDSMs of good quality are valuable for advising PCPs on the detection and referral of children and youths with mental health disorders. However, valid multicentre research on a combination of computer-based methods and telecommunication is still needed.

An umbrella review of systematic reviews on contributory factors to medication errors in health-care settings

INTRODUCTION

Medication errors are common events that compromise patient safety and are prevalent in all health-care settings. This umbrella review aims to systematically evaluate the evidence on contributory factors to medication errors in health-care settings in terms of the nature of these factors, methodologies and theories used to identify and classify them, and the terminologies and definitions used to describe them.

AREAS COVERED

Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and Google Scholar were searched from inception to March 2022. The data extraction form was derived from the Joanna Briggs Institute (JBI) Reviewers' Manual, and critical appraisal was conducted using the JBI quality assessment tool. A narrative approach to data synthesis was adopted.

EXPERT OPINION

Twenty-seven systematic reviews were included, most of which focused on a specific health-care setting or clinical area. Decision-making mistakes such as non-consideration of patient risk factors most commonly led to error, followed by organizational and environmental factors (e.g. understaffing and distractions). Only 10 studies had a pre-specified methodology to classify contributory factors, among which the use of theory, specifically Reason's theory was commonly used. None of the reviews evaluated the effectiveness of interventions in preventing errors. The collated contributory factors identified in this umbrella review can inform holistic theory-based intervention development.

Intercepting Medication Errors in Pediatric In-patients Using a Prescription Pre-audit Intelligent Decision System: A Single-center Study

OBJECTIVES

Medication errors can happen at any phase of the medication process at health care settings. The objective of this study is to identify the characteristics of severe prescribing errors at a pediatric hospital in the inpatient setting and to provide recommendations to improve medication safety and rational drug use.

METHODS

This descriptive retrospective study was conducted at a tertiary pediatric hospital using data collected from Jan. 1st, 2019 to Dec. 31st, 2020. During this period, the Prescription Pre-audit Intelligent Decision System was implemented. Medication orders with potential severe errors would trigger a Level 7 alert and would be intercepted before it reached the pharmacy. Trained pharmacists maintained the system and facilitated decision making when necessary. For each order intercepted by the system the following patient details were recorded and analyzed: patient age, patient's department, drug classification, dosage forms, route of administration, and the type of error.

RESULTS

A total of 2176 Level 7 medication orders were intercepted. The most common errors were associated with drug dosage, administration route, and dose frequency, accounting for 35.2%, 32.8% and 13.2%, respectively. Of all the intercepted oerrors. 53.6% occurred in infants aged < 1 year. Administration routes involved were mainly intravenous, oral and external use drugs. Most alerts came from the neonatology department and constituted 40.5% of the total alerts, followed by the nephrology department 15.9% and pediatric intensive care unit (PICU) 11.3%. As to dosage forms, injections accounted for 50.4% of alerts, with 21.3% attributable to topical solutions, 9.1% to tablets, and 5.7% to inhalation. Anti-infective agents were the most common therapeutic drugs prescribed with errors.

CONCLUSIONS

The Prescription Pre-audit Intelligent Decision System, with the supervision of trained pharmacists can validate prescriptions, increase prescription accuracy, and improve drug safety for hospitalized children. It is a medical service model worthy of consideration.

Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews

Background and aim

Improving health care quality and ensuring patient safety is impossible without addressing medical errors that adversely affect patient outcomes. Therefore, it is essential to correctly estimate the incidence rates and implement the most appropriate solutions to control and reduce medical errors. We identified such interventions.

Methods

We conducted a systematic review of systematic reviews by searching four databases (PubMed, Scopus, Ovid Medline, and Embase) until January 2021 to elicit interventions that have the potential to decrease medical errors. Two reviewers independently conducted data extraction and analyses.

Results

Seventysix systematic review papers were included in the study. We identified eight types of interventions based on medical error type classification: overall medical error, medication error, diagnostic error, patients fall, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide. Most studies focused on medication error (66%) and were conducted in hospital settings (74%).

Conclusions

Despite a plethora of suggested interventions, patient safety has not significantly improved. Therefore, policymakers need to focus more on the implementation considerations of selected interventions.

Sudanese Medical Doctors' Perceptions, Expectations, Experiences and Perceived Barriers Towards the Roles of Clinical Pharmacists: A Cross-Sectional Study

Purpose

Interprofessional collaboration between physicians and clinical pharmacists has been shown to improve patients’ outcome by reduce medical errors, costs and patient adherence. Thus, the purpose of this study was to investigate the medical doctors’ perceptions, expectations, experiences, and perceived barriers regarding clinical pharmacists in Wad Medani.

Methods

A cross-sectional study was conducted at five major hospitals in Wad Medani, between April and June 2021 using a self-administered questionnaire. The questionnaire was distributed among 178 physicians. The questionnaire consists of four sections, in addition to a demographic section. These four sections measure physicians’ perceptions, expectations, experience, and perceived barriers.

Results

A total of 178 physicians were enrolled in the study. Physicians were comfortable with clinical pharmacists detecting and preventing prescription errors (55.1%); providing patient education (56.3%). Generally, physicians had high expectations with agreement rate of all the items ranged from 51.7% to 85.4%. Most physicians (79.8%) agreed that clinical pharmacists were a reliable source of general and clinical drug information. 64.0% and 59.0% of physicians perceive the unclear responsibility of clinical pharmacists and the lack of physicians’ experience with clinical pharmacists were barriers that can hinder clinical pharmacists’ contributions, respectively.

Conclusion

Physicians had positive perceptions, expectations, and experiences with clinical pharmacists, and pointed out some barriers clinical pharmacists face. It was suggested that hospitals should recruit more clinical pharmacists to cover each unit within the hospital with clear job description and provide them CPD.

Incidence and nature of adverse drug events in paediatric intensive care units: A prospective multicentre study

AIMS

The aim of this study was to assess the incidence, nature, preventability and severity of adverse drug events (ADEs) across three paediatric intensive care units (PICUs) in England.

METHODS

A prospective observational cohort study was conducted across three PICUs over a three-month period during 2019. Included patients were aged ≤18 years and stayed in PICU for a minimum of 24 hours. Identification of suspected ADEs was performed by trained PICU pharmacists. A multidisciplinary expert panel assessed causality, preventability and severity of events.

RESULTS

A total of 302 patients were included and 62 ADEs were confirmed (definite/probable causality). One in six patients experienced one or more ADEs. The estimated incidence of ADEs were 20.5 per 100 patients (95% CI 15.3-27.5) and 16.7 per 1000 patient-days (95% CI 9.3-29.9). The majority of ADEs were judged preventable by the expert panel (36/62, 58.1%). ADEs were commonly involved with medicines prescribing (29/62, 46.8%) and caused temporary patient harm (42/62, 67.7%). Medications for the central nervous system (14/62, 22.6%), infections (13/62, 20.9%) and cardiovascular system (12/62, 19.4%) were commonly implicated with ADEs. Multivariable analysis revealed that patients who stayed in PICU for ≥7 days (OR 6.29, 95% CI 2.42-16.32) were more likely to experience an ADE compared to patients with a stay of 1-6 days.

CONCLUSION

ADEs are common in English PICUs and most of them may be preventable. There is a strong association between ADE occurrence and duration of PICU stay, which represents a target for remedial interventions. Exploring contributory factors of preventable ADEs is now necessary to inform preventive policies.

Manipulations of Oral Medications in Paediatric Neurology and Oncology Care at a Swedish University Hospital: Health Professionals' Attitudes and Sources of Information

Oral administration of medications to children requires age-appropriate dosage forms and strengths. In this study, we: (i) assessed the extent of oral dosage form manipulations, (ii) documented how it is carried out, and (iii) examined the attitudes and sources of information regarding the handling from healthcare professionals. Prospective reviews of electronic records, ward observations, and clinician surveys were performed at a paediatric neurology ward and a paediatric oncology ward in Sweden during April to May of 2018. Approximately 15% of oral medications were manipulated for the studied patient group (median age 12.9 years in oncology, 5.8 years in neurology) with approximately 30% of the patients having an enteral feeding tube. Manipulations were performed both to obtain an appropriate dose from, for example, a fraction of the original tablet or to obtain a powder that could be used to prepare a slurry for administration through enteral feeding tubes. Risks identified were related to patient safety such as cross contamination, suboptimal absorption/pharmacokinetics and inaccurate dose. When examining the working environment of nurses, we observed safe handling of hazardous substances but the nurses occasionally experienced stress and a fear of making mistakes due to absence of information. Paediatricians experienced a lack of time to search for proper information on manipulations. As a step towards improving safety in paediatric medication, we suggest the introduction of clinical pharmacists into the team and further evaluating the possibilities of using more ready-to-administer medications with necessary product information and pharmacovigilance support.

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using reason's accident causation theory

Background Direct oral anticoagulants (DOACs) have revolutionised anticoagulant pharmacotherapy. However, DOAC-related medication incidents are known to be common. Objective To assess medication incidents associated with DOACs using an error theory and to analyse pharmacists’ contributions in minimising medication incidents in hospital in-patients. Setting A large University academic hospital in the West Midlands of England. Methods Medication incident data from the incident reporting system (48-months period) and pharmacists’ interventions data from the prescribing system (26-month period) relating to hospital in-patients were extracted. Reason’s Accident Causation Model was used to identify potential causality of the incidents. Pharmacists’ intervention data were thematically analysed. Main outcome measure (a) Frequency, type and potential causality of DOAC-related incidents; (b) nature of pharmacists’ interventions. Results A total of 812 reports were included in the study (124 medication incidents and 688 intervention reports). Missing drug/omission was the most common incident type (26.6%, n = 33) followed by wrong drug (16.1%, n = 20) and wrong dose/strength (11.3%, n = 14). A high majority (89.5%, n = 111) of medication incidents were caused by active failures. Patient discharge without anticoagulation supply and failure to restart DOACs post procedure/scan were commonly recurring themes. Pharmacists’ interventions most frequently related to changes in pharmacological strategy, including drug or dose changes (38.1%, n = 262). Impaired renal function was the most common reason for dose adjustments. Conclusion Prescribers’ active failure rather than system errors (i.e. latent failures) contributed to the majority of DOAC-related incidents. Reinforcement of guideline adherence, prescriber education, harnessing pharmacists’ roles and mandating renal function information in prescriptions are likely to improve patient safety.

Effect of a pharmacist-led educational intervention on clinical outcomes: a randomised controlled study in patients with hypertension, type 2 diabetes and hypercholesterolaemia

OBJECTIVES

In recent years, hospital pharmacists have gained more importance in the clinical support of patients. However, most of the studies evaluating the impact of clinical pharmacy have only studied patients' adherence or satisfaction. The aim of this study was to evaluate the direct clinical outcomes of a pharmacist-led educational intervention in patients with chronic disease.

METHODS

We conducted a randomised, controlled, parallel, physician-blinded study in a day hospital and a consultation unit of a French teaching hospital over a 1-year period. Patients with hypertension, type 2 diabetes or hypercholesterolaemia who did not reach their therapeutic goals despite drug therapy were eligible. Patients in the intervention group received an intervention from a hospital pharmacist who provided patient education on pathology and drug management. The primary outcome was the proportion of patients reaching their therapeutic goals for blood pressure, glycated haemoglobin level or low-density lipoprotein cholesterol level at the 3-month follow-up consultation.

RESULTS

From January to December 2015, 89 patients were included and 73 completed the study. In the intervention group, 61.7% (21/34) of the patients reached their therapeutic goals compared with 33.3% (13/39) in the control group (p=0.015). The intervention was significantly more effective in polypharmacy patients (60.0% (12/20) vs 16.7% (4/24); p=0.005), in those aged >60 years (57.9% (11/19) vs 26.1% (6/23); p=0.037) and in patients with a high education level (68.8% (11/16) vs 29.4% (5/17); p=0.024).

CONCLUSION

A single pharmacist-led educational intervention has a clinical impact, doubling the proportion of patients reaching their therapeutic goals at 3 months, especially in polypharmacy patients and those aged >60 years. This study confirms the value of clinical involvement of hospital pharmacists in patient care in a consultation unit and day hospital.

Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis

INTRODUCTION

Medication errors are avoidable events that can occur at any stage of the medication use process. They are widespread in healthcare systems and are linked to an increased risk of morbidity and mortality. Several strategies have been studied to reduce their occurrence including different types of pharmacy-based interventions. One of the main pharmacist-led interventions is educational programs, which seem to have promising benefits.

OBJECTIVE

To describe and compare various pharmacist-led educational interventions delivered to healthcare providers and to evaluate their impact qualitatively and quantitatively on medication error rates.

METHODS

A systematic review and meta-analysis was conducted through searching Cochrane Library, EBSCO, EMBASE, Medline and Google Scholar from inception to June 2020. Only interventional studies that reported medication error rate change after the intervention were included. Two independent authors worked through the data extraction and quality assessment using Crowe Critical Appraisal Tool (CCAT). Summary odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model for rates of medication errors. Research protocol is available in The International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42019116465.

RESULTS

Twelve studies involving 115058 participants were included. The two main recipients of the educational interventions were nurses and resident physicians. Educational programs involved lectures, posters, practical teaching sessions, audit and feedback method and flash cards of high-risk abbreviations. All studies included educational sessions as part of their program, either alone or in combination with other approaches, and most studies used errors encountered before implementing the intervention to inform the content of these sessions. Educational programs led by a pharmacist were associated with significant reductions in the overall rate of medication errors occurrence (OR, 0.38; 95% CI, 0.22 to 0.65).

CONCLUSION

Pharmacist-led educational interventions directed to healthcare providers are effective at reducing medication error rates. This review supports the implementation of pharmacist-led educational intervention aimed at reducing medication errors.

A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children's Intensive Care

BACKGROUND

Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas.

OBJECTIVE

This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs).

METHODS

We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents.

RESULTS

In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols.

CONCLUSIONS

Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.

A Methodological Assessment of Pharmacist Therapeutic Intervention Documentation (TID) in a Single Tertiary Care Hospital in Jeddah, Kingdom of Saudi Arabia

Pharmacist intervention has valuable input to the healthcare system by reducing medication errors, costs of treatment and improving therapeutic outcomes. This study aimed to analyze pharmacists’ interventions during the verification of computerized physician order entry and to determine the association between prescribers’ level and type of prescribing errors. In this cross-sectional, observational study, data collection was carried out over three months starting from 1 January 2020 to 31 March 2020. Included were 2405 interventions documented by 52 different pharmacists. The prevalence of prescribing order entry errors was 9.1%. The most identifiable type of intervention was incorrect dilution (40.2%) followed by dose substitution (27.7%). The drug category associated with a high percentage of interventions was perfusion solutions (41%), followed by antibacterial (35%). The number of junior physician orders that required pharmacist intervention was higher than other prescribers (45.2%), followed by specialist and senior physicians, (31.4% and 15.5%, respectively). Prescriber ordering time and types of prescribing errors were shown to have a significant (p < 0.05) association. Internal medicine physicians entered the highest percentage of prescribing errors, representing 22.7%. The current study concluded that TID has significant potential to reduce drug-related problems; TID fatigue is a real problem that might be under-reported and addressing this point in future studies would be of great value.

Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis

Objective

Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST).

Methods

To identify studies, the following databases were systematically searched on October 14^th, 2018 and repeated on September 12^th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review.

Results

Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I² = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I² = 36%).

Conclusion

This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.

The Impact of Clinical Pharmacist Interventions on Medication Errors Management in the Postoperative Cardiac Intensive Care Unit

Background: Medication errors (MEs) frequently occur in intensive care unit (ICU) admittedpatients. The present study aimed to evaluate the frequency and types of MEs in an open heartsurgery heart ICU and clinical pharmacists’ role in the management of them. Methods: This cross-sectional, observational study was performed from October 2016 toMarch 2017 in the Shahid Madani Heart Center. A clinical pharmacist reviewed patients’ files,laboratory data, and physician orders during morning hours. All of the MEs and the clinicalpharmacies’ recommendations for the management of them were analyzed. Results: A total of 311 MEs were observed in the medical files of 152 patients. The rate of MEswas 2.04 errors per patient and 0.19 errors per ordered medication. The acceptance rate of MEswas 72.6%. The most type of MEs was ‘forgot to order’ (75 cases, 24.1%) followed by "wrongfrequency" and "adding a drug" in 56 (18%) and 49 (15.8) patients, respectively. Most MEs wereinsignificant. Conclusion: MEs occur at different stages of the therapeutic process in the postoperative cardiacintensive care unit, and clinical pharmacists play an essential role in detecting and managingMEs.