Analysis of risk factors for adverse drug events in critically ill patients*. Crit Care Med. 2012;40:823-828. [PMID: 22036859 DOI: 10.1097/ccm.0b013e318236f473]

Prediction of adverse drug reactions in geriatric patients admitted to intensive care units

INTRODUCTION

Intensive Care Units (ICUs) pose challenges in managing critically-ill patients with polypharmacy, potentially leading to Adverse Drug Reactions (ADRs), particularly in the elderly.

OBJECTIVE

To evaluate whether the severity and clinical prognosis scores used in ICUs correlate with the prediction of ADRs in aged patients admitted to an ICU.

METHODS

A cohort study was conducted in a Brazilian University Hospital ICU. APACHE II and SAPS 3 assessed clinical prognosis, while GerontoNet ADR Risk Score and BADRI evaluated ADR risk at ICU admission. Severity of the patients' clinical conditions was evaluated daily based on the SOFA score. Adverse Drug Reaction (ADR) screening was performed daily through the identification of ADR triggers.

RESULTS

1295 triggers were identified (median 30 per patient, IQR = 28), with 15 suspected ADRs. No correlation was observed between patient severity and ADRs at admission (p=0.26), during hospitalization (p=0.91), or at follow-up (p=0.77). There was also no association between death and ADRs (p=0.28) or worse prognosis and ADRs (p>0.05). Higher BADRI scores correlated with more ADRs (p=0.001).

CONCLUSIONS

The data suggest that employing the severity and clinical prognosis scores used in Intensive Care Units is not sufficient to direct active pharmacovigilance efforts, which are therefore indicated for critically ill patients.

Understanding an epidemiological view of a retrospective audit of medication errors in an intensive care unit

BACKGROUND

Medication errors in the intensive care setting continue to occur at significant rates and are often associated with adverse events and potentially life-threatening repercussions.

AIM/OBJECTIVE

The aim of this study was to (i) determine the frequency and severity of medication errors reported in the incident management reporting system; (ii) examine the antecedent events, their nature, the circumstances, risk factors, and contributing factors leading to medication errors; and (iii) identify strategies to improve medication safety in the intensive care unit (ICU).

METHOD

A retrospective, exploratory, descriptive design was selected. Retrospective data were collected from the incident report management system and electronic medical records over a 13-month period from a major metropolitan teaching hospital ICU.

RESULTS

A total of 162 medication errors were reported during a 13-month period, of which, 150 were eligible for inclusion. Most medication errors occurred during the administration (89.4%) and dispensing phases (23.3%). The highest reported errors included incorrect doses (25.3%), incorrect medications (12.7%), omissions (10.7%), and documentation errors (9.3%). Narcotic analgesics (20%), anaesthetics (13.3%), and immunomodifiers (10.7%) were the most frequently reported medication classes associated with medication errors. Prevention strategies were found to be focussed on active errors (67.7%) as opposed to latent errors (32.3%) and included various and infrequent levels of education and follow-up. Active antecedent events included action-based errors (39%) and rule-based errors (29.5%), whereas latent antecedent events were most associated with a breakdown in system safety (39.3%) and education (25%).

CONCLUSION

This study presents an epidemiological view and understanding of medication errors in an Australian ICU. This study highlighted the preventable nature of most medication errors in this study. Improving administration-checking procedures would prevent the occurrence of many medication errors. Approaches aimed at both individual- and organisational-level improvements are recommended to address administration errors and inconsistent medication-checking procedures. Areas for further research include determining the most effective system developments for improving administration-checking procedures and verifying the risk and prevalence of immunomodifier administration errors in the ICU as this is an area not reported previously in the literature. In addition, the impact of single- versus two-person checking procedures on medication errors in the ICU should be prioritised to address current evidence gaps.

Prediction of adverse drug reactions in geriatric patients admitted to intensive care units

INTRODUCTION

Intensive care units (ICUs) pose challenges in managing critically ill patients with polypharmacy, potentially leading to adverse drug reactions (ADRs), particularly in the elderly.

OBJECTIVE

To evaluate whether the severity and clinical prognosis scores used in ICUs correlate with the prediction of ADRs in aged patients admitted to an ICU.

METHODS

A cohort study was conducted in a Brazilian University Hospital ICU. APACHE II and SAPS 3 assessed clinical prognosis, while GerontoNet ADR Risk Score and BADRI evaluated ADR risk at ICU admission. Severity of the patients' clinical conditions was evaluated daily based on the SOFA score. ADR screening was performed daily through the identification of ADR triggers.

RESULTS

1295 triggers were identified (median 30 per patient, IQR=28), with 15 suspected ADRs. No correlation was observed between patient severity and ADRs at admission (p=0.26), during hospitalization (p=0.91), or at follow-up (p=0.77). There was also no association between death and ADRs (p=0.28) or worse prognosis and ADRs (p>0.05). Higher BADRI scores correlated with more ADRs (p=0.001).

CONCLUSIONS

These data suggest that employing the severity and clinical prognosis scores used in ICUs is not sufficient to direct active pharmacovigilance efforts, which are therefore indicated for critically ill patients.

An Evaluation of the Relationship Between Medication Regimen Complexity as Measured by the MRC-ICU to Medication Errors in Critically Ill Patients

Purpose: The purpose of this study was to determine the relationship between medication regimen complexity-intensive care unit (MRC-ICU) score at 24 hours and medication errors identified throughout the ICU. Methods: A single-center, observational study was conducted from August to October 2021. The primary outcome was the association between MRC-ICU at 24 hours and total medication errors identified. During the prospective component, ICU pharmacists recorded medication errors identified over an 8-week period. During the retrospective component, the electronic medical record was reviewed to collect patient demographics, outcomes, and MRC-ICU score at 24 hours. The primary outcome of the relationship of MRC-ICU at 24 hours to medication errors was assessed using Pearson correlation. Results: A total of 150 patients were included. There were 2 pharmacists who recorded 634 errors during the 8-week study period. No significant relationship between MRC-ICU and medication errors was observed (r2 = .13, P = .11). Exploratory analyses of MRC-ICU relationship to major interventions and harm scores showed that MRC-ICU scores >10 had more major interventions (27 vs 14, P = .27) and higher harm scores (15 vs 7, P = .33), although these values were not statistically significant. Conclusion: Medication errors appear to occur independently of medication regimen complexity. Critical care pharmacists were responsible for mitigating a large number of medication errors.

Is acupuncture safe in the ICU? A systematic review and meta-analysis

Background and purpose

The safety of interventions for critically ill patients is a crucial issue. In recent years, several studies have treated critically ill patients with acupuncture. However, the safety of acupuncture in this setting remains to be systematically measured.

Methods

In May 2022, the electronic databases of PubMed and the Cochrane Library were searched for studies comparing acupuncture interventions to control interventions in critically ill patients. Study outcomes examined the incidence of severe adverse events (AEs), minor AEs, adverse reactions, ICU stays, and 28-day mortality.

Results

A total of 31 articles were analyzed, and no serious AEs related to acupuncture treatment were identified. No significant differences were found between the groups in the meta-analysis of minor AEs (risk ratio [RR] 5.69 [0.34, 96.60], P = 0.23, I2 = 76%). A reduced risk in the incidence of adverse reactions following acupuncture intervention was evidenced (RR 0.33 [0.22, 0.50], P = 0.00001, I2 = 44%). The patients in the acupuncture arm spent significantly less time in the intensive care unit (ICU) (Mean difference -1.45 [-11.94, -10.97], P = 0.00001, I2 = 56%) and also exhibited lower 28-day mortality rates (odds ratio 0.61 [0.48, 0.78], P = 0.0001, I2 = 0%).

Conclusion

There is no evidence to indicate a higher risk of severe or minor AEs in patients who receive acupuncture. Acupuncture demonstrated favorable results in both ICU stay and 28-day mortality measurements, in addition to presenting with fewer adverse reactions compared to routine ICU care. However, the low certainty of the evidence resulting from a high risk of bias in the included studies merits substantial consideration, and further research is still warranted.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=142131, identifier: CRD42020142131.

Comparison of Drug-Related Problems in COVID-19 and Non-COVID-19 Patients Provided by a German Telepharmacy Service for Rural Intensive Care Units

Telepharmacy is used to bridge the persisting shortage of specialist ward-based pharmacists, particularly in intensive care units (ICU). During the coronavirus disease 2019 (COVID-19), pharmacotherapy was rapidly developed, which resulted in multiple changes of guidelines. This potentially led to a differing risk for drug-related problems (DRPs) in ICUs. In this study, DRPs were detected in telepharmacy consultations of a German state-wide telemedicine network for adult patients in rural ICUs. The analysis included ICUs of ten general care hospitals with a total of 514 patients and 1056 consultations. The aim of this retrospective, observational cohort study was to compare and analyze the DRPs resulting from ICU patients with or without COVID-19. Furthermore, known risk groups for severe COVID-19 progression (organ insufficiency [kidney, liver], obesity, sex, and/or older age) were investigated with their non-COVID-19 counterparts. As a result, in both groups patients with acute renal insufficiency and without renal replacement therapy showed a significantly higher risk of being affected by one or more DRPs compared to patients with normal renal function. In COVID-19 patients, the initial recommendation of therapeutic anticoagulation (ATC-code B01AB 'Heparin group') resulted in significantly more DRPs compared to non-COVID-19 patients. Therefore, COVID-19 patients with therapeutic anticoagulation and all ICU patients with renal insufficiency should be prioritized for telepharmacy consultations.

Development and validation of the creatinine clearance predictor machine learning models in critically ill adults

BACKGROUND

In critically ill patients, measured creatinine clearance (CrCl) is the most reliable method to evaluate glomerular filtration rate in routine clinical practice and may vary subsequently on a day-to-day basis. We developed and externally validated models to predict CrCl one day ahead and compared them with a reference reflecting current clinical practice.

METHODS

A gradient boosting method (GBM) machine-learning algorithm was used to develop the models on data from 2825 patients from the EPaNIC multicenter randomized controlled trial database. We externally validated the models on 9576 patients from the University Hospitals Leuven, included in the M@tric database. Three models were developed: a "Core" model based on demographic, admission diagnosis, and daily laboratory results; a "Core + BGA" model adding blood gas analysis results; and a "Core + BGA + Monitoring" model also including high-resolution monitoring data. Model performance was evaluated against the actual CrCl by mean absolute error (MAE) and root-mean-square error (RMSE).

RESULTS

All three developed models showed smaller prediction errors than the reference. Assuming the same CrCl of the day of prediction showed 20.6 (95% CI 20.3-20.9) ml/min MAE and 40.1 (95% CI 37.9-42.3) ml/min RMSE in the external validation cohort, while the developed model having the smallest RMSE (the Core + BGA + Monitoring model) had 18.1 (95% CI 17.9-18.3) ml/min MAE and 28.9 (95% CI 28-29.7) ml/min RMSE.

CONCLUSIONS

Prediction models based on routinely collected clinical data in the ICU were able to accurately predict next-day CrCl. These models could be useful for hydrophilic drug dosage adjustment or stratification of patients at risk.

TRIAL REGISTRATION

Not applicable.

Acute liver injury in COVID-19 patients hospitalized in the intensive care unit: Narrative review

In recent years, humanity has been confronted with a global pandemic due to coronavirus disease 2019 (COVID-19), which has caused an unprecedented health and economic crisis worldwide. Apart from the respiratory symptoms, which are considered the principal manifestations of COVID-19, it has been recognized that COVID-19 constitutes a systemic inflammatory process affecting multiple organ systems. Across the spectrum of organ involvement in COVID-19, acute liver injury (ALI) has been gradually gaining increasing attention by the international scientific community. COVID-19 associated liver impairment can affect a considerable proportion of COVID-19 patients and seems to correlate with the severity of the disease course. Indeed, COVID-19 patients hospitalized in the intensive care unit (ICU) run a greater risk of developing ALI due to the severity of their clinical condition and in the context of multi-organ failure. The putative pathophysiological mechanisms of COVID-19 induced ALI in ICU patients remain poorly understood and appear to be multifactorial in nature. Several theories have been proposed to explain the occurrence of ALI in the ICU setting, such as hypoperfusion and ischemia due to hemodynamic instability, passive liver congestion as a result of congestive heart failure, ischemia-reperfusion injury, hypoxia due to respiratory failure, mechanical ventilation itself, sepsis and septic shock, cytokine storm, endotheliitis with concomitant coagulopathy, drug-induced liver injury, parenteral nutrition and direct cytopathic viral effect. It should be noted that no specific therapy for COVID-19 induced ALI exists. Therefore, the therapeutic approach lies in preventive measures and is exclusively supportive once ALI ensues. The aim of the current review is to scrutinize the existing evidence on COVID-19 associated ALI in ICU patients, explore its clinical implications, shed light on the underlying pathophysiological mechanisms and propose potential therapeutic approaches. Ongoing research on the particular scientific field will further elucidate the pathophysiology behind ALI and address unresolved issues, in the hope of mitigating the tremendous health consequences imposed by COVID-19 on ICU patients.

Cost benefit analysis of clinical pharmacist interventions in medical intensive care unit in Palestine medical complex: Prospective interventional study

Background

Clinical pharmacy services in the critical health care settings have expanded dramatically.Study problem.Clinical pharmacy services have limited implementation in Palestine. Many intensive care units (ICUs) patients do not get the intended beneficial effects of their treatment due to treatment related problems and their consequent cost burden.

Aim

To evaluate the impact of the clinical pharmacist interventions on costs of care and safety of patient by assessing treatment related problems among medical ICUs patients in Palestine.

Methodology

A prospective interventional study was conducted at medical ICU of the major public hospital in Ramallah city over a 4-month period (between September and December 2020). Patients were randomly assigned to either an intervention or a control group (With / without clinical pharmacist involvement). Treatment related problems were identified in both study groups by the clinical pharmacist, but interventions were only provided to the intervention group. The total economic benefit included both cost savings from intervention and cost avoidance from preventable adverse drug events (ADEs) resulted from CP interventions. The primary outcomes with the clinical pharmacist interventions were net benefit and benefit to cost ratio, which were calculated using previously published methodologies and adjusted to the Palestinian settings. The analysis of CP interventions acceptance by physicians was performed.

Results

During the 4-month study period, the 117 patients admitted to the ICU were included into the analysis; 66 patients in the intervention group and 51 in the control group. The interventions made by a clinical pharmacist resulted in direct cost saving of NIS8,990.05 ($2799.63) and cost avoidance of NIS22,087.5 ($ 6878.37). Translated into a net savings of NIS188.35 ($58.65) per intervention and NIS470 ($146.36) per patient. Comparison of benefits (NIS31,077.55) ($9678.00) and costs (NIS19,043.928) ($5930.55) indicate a net economic benefit to the institution of (NIS 12,033.623) ($3747.44) and a benefit cost ratio of 1.63.

Conclusion

Integrating a clinical pharmacist in the ICU team was investment that resulted in benefits in term of cost saving and cost avoidance.

Intravenous Smart Pumps at the Point of Care: A Descriptive, Observational Study

OBJECTIVE

This study was conducted to advance understanding of intravenous (IV) smart pump medication administration practices using the Baxter Spectrum IQ. The primary objective was to observe adherence with manufacturer required IV smart pump system setup at the point of care during actual clinical use.

METHODS

The study was conducted in a 285-bed acute care community hospital near Boston, Massachusetts. The study design was observational and noninterventional, and all data were collected by a single observer. Observations included measurement and documentation of adherence with the Baxter Spectrum IQ system setup requirements.

RESULTS

A total of 200 primary and secondary IV medication administration observations were included: 101 in critical care and 99 in medical-surgical. Overall adherence was found to be: 6.5% with IV smart pump position relative to the patient (aim 1); 6.5% with required position of the primary infusion bag (aim 2); and 69.5% adherence with required position of the secondary medication infusion bag (aim 3). Additional exploratory data were also collected.

CONCLUSIONS

These results add to the emerging body of knowledge, which support that adherence to required system setup for head-height dependent IV smart pumps is low and difficult to achieve during actual clinical use. Consideration of alternative human factors-designed technology to replace the current manual setup requirements is needed to improve the process of acute care IV medication administration in this very important area of patient safety.

Impact of Pharmacists to Improve Patient Care in the Critically Ill: A Large Multicenter Analysis Using Meaningful Metrics With the Medication Regimen Complexity-ICU (MRC-ICU) Score

OBJECTIVES

Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not optimized in the ICU. Medication regimen complexity (as measured by the Medication Regimen Complexity-ICU [MRC-ICU] scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population.

DESIGN

This was a multicenter, observational cohort study.

SETTING

Twenty-eight ICUs in the United States.

PATIENTS

Adult ICU patients.

INTERVENTIONS

Critical care pharmacist interventions (quantity and type) on the medication regimens of critically ill patients over a 4-week period were prospectively captured. MRC-ICU and patient outcomes (i.e., mortality and length of stay [LOS]) were recorded retrospectively.

MEASUREMENTS AND MAIN RESULTS

A total of 3,908 patients at 28 centers were included. Following analysis of variance, MRC-ICU was significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.08-1.11; p < 0.01), ICU LOS (β coefficient, 0.41; 95% CI, 00.37-0.45; p < 0.01), total pharmacist interventions (β coefficient, 0.07; 95% CI, 0.04-0.09; p < 0.01), and a composite intensity score of pharmacist interventions (β coefficient, 0.19; 95% CI, 0.11-0.28; p < 0.01). In multivariable regression analysis, increased patient: pharmacist ratio (indicating more patients per clinician) was significantly associated with increased ICU LOS (β coefficient, 0.02; 0.00-0.04; p = 0.02) and reduced quantity (β coefficient, -0.03; 95% CI, -0.04 to -0.02; p < 0.01) and intensity of interventions (β coefficient, -0.05; 95% CI, -0.09 to -0.01).

CONCLUSIONS

Increased medication regimen complexity, defined by the MRC-ICU, is associated with increased mortality, LOS, intervention quantity, and intervention intensity. Further, these results suggest that increased pharmacist workload is associated with decreased care provided and worsened patient outcomes, which warrants further exploration into staffing models and patient outcomes.

Use of Diagnosis Codes to Find Blood Transfusion Adverse Events in Electronic Health Records

OBJECTIVE

Electronic health records (EHRs) and big data tools offer the opportunity for surveillance of adverse events (patient harm associated with medical care). We used International Classification of Diseases, Ninth Revision, codes in electronic records to identify known, and potentially novel, adverse reactions to blood transfusion.

METHODS

We used 49,331 adult admissions involving critical care at a major teaching hospital, 2001-2012, in the Medical Information Mart for Intensive Care III EHRs database. We formed a T (defined as packed red blood cells, platelets, or plasma) group of 21,443 admissions versus 25,468 comparison (C) admissions. The International Classification of Diseases, Ninth Revision, Clinical Modification , diagnosis codes were compared for T versus C, described, and tested with statistical tools.

RESULTS

Transfusion adverse events (TAEs) such as transfusion-associated circulatory overload (TACO; 12 T cases; rate ratio [RR], 15.61; 95% confidence interval [CI], 2.49-98) were found. There were also potential TAEs similar to TAEs, such as fluid overload disorder (361 T admissions; RR, 2.24; 95% CI, 1.88-2.65), similar to TACO. Some diagnoses could have been sequelae of TAEs, including nontraumatic compartment syndrome of abdomen (52 T cases; RR, 6.76; 95% CI, 3.40-14.9) possibly being a consequence of TACO.

CONCLUSIONS

Surveillance for diagnosis codes that could be TAE sequelae or unrecognized TAE might be useful supplements to existing medical product adverse event programs.

Antimicrobial safety considerations in critically ill patients: part I: focused on acute kidney injury

INTRODUCTION

Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics.

AREAS COVERED

In the current article, we searched PubMed, Scopus, and Google Scholar for estimating renal function in acute kidney injury, nephrotoxicity of commonly used antibiotics, and nephrotoxin stewardship in intensive care units.

EXPERT OPINION

Early estimation of kidney function with an accurate method may be helpful to optimize antimicrobial treatment in critically ill patients. Different antibiotic dosing regimens may be required for patients with acute kidney injury. In many low-resource settings, therapeutic drug monitoring is not available for antibiotics. Acute kidney injury may influence treatment effectiveness and patient outcome.

Evaluation of medication risk at the transition of care: a cross-sectional study of patients from the ICU to the non-ICU setting

OBJECTIVES

To describe the incidence and types of medication errors occurring during the transfer of patients from the intensive care unit (ICU) to the non-ICU setting and explore the key factors affecting medication safety in transfer care.

DESIGN

Multicentre, retrospective, epidemiological study.

PARTICIPANTS

Patients transferred from the ICU to a non-ICU setting between 1 July 2019 and 30 June 2020.

MAIN OUTCOME MEASURES

Incidence and types of medication errors.

RESULTS

Of the 1546 patients transferred during the study period, 899 (58.15%) had at least one medication error. Most errors (83.00%) were National Coordinating Council (NCC) for Medication Error Reporting and Prevention (MERP) category C. A small number of errors (17.00%) were category D. Among patients with medication errors, there was an average of 1.68 (SD, 0.90; range, 1-5) errors per patient. The most common types of errors were route of administration 570 (37.85%), dosage 271 (17.99%) and frequency 139 (9.23%). Eighty-three per cent of medication errors reached patients but did not cause harm. Daytime ICU transfer (07:00-14:59) and an admission diagnosis of severe kidney disease were found to be factors associated with the occurrence of medication errors as compared with the reference category (OR, 1.40; 95% CI 1.01 to 1.95; OR, 6.78; 95% CI 1.46 to 31.60, respectively).Orders for bronchorespiratory (OR, 5.92; 95% CI 4.2 to 8.32), cardiovascular (OR, 1.91; 95% CI 1.34 to 2.73), hepatic (OR, 1.95; 95% CI 1.30 to 2.91), endocrine (OR, 1.99; 95% CI 1.37 to 2.91), haematologic (OR, 2.58; 95% CI 1.84 to 3.64), anti-inflammatory/pain (OR, 2.80; 95% CI 1.90 to 4.12) and vitamin (OR, 1.73; 95% CI 1.26 to 2.37) medications at transition of care were associated with an increased odds of medication error.

CONCLUSIONS

More than half of ICU patients experienced medication errors during the transition of care. The vast majority of medication errors reached the patient but did not cause harm.

Incidence and risk factors of adverse events in pediatric hemato-oncological patients: A cohort study

BACKGROUND

Pediatric hemato-oncological (HO) patients are highly susceptible to the occurrence of adverse events (AE), nevertheless few research has been done in this field. Our aim was to describe the incidence, type, severity and preventability of AE in these patients, including bone marrow transplant (BMT) patients, and to identify patient's risk factors for having an AE.

METHODS

Retrospective cohort study. Children under 18yo hospitalized at the HO or BMT ward in 2016 were eligible for the study. Type of AE, severity and preventability were described as absolute and relative frequencies. Cumulative incidence of patients with at least one AE (CI_AE) and the rate of occurrence of all AE were calculated. Risk factors (sex, recovery probability, comorbidities and being a BMT patient) were analyzed using logistic regression.

RESULTS

114 patients were included, 58% were male, average age was 8.7yo and 25 were BMT patients. 44 had at least one AE, with CI_AE of 38.6% (95%CI 29.7-47.5). Overall rate of occurrence of AE was 2.5 cases per 100 patients-day (95%CI 2.15-2.98). For BMT and non-BMT patients they were 2.8 (95%CI 2.2-3.6) and 2.5 (95%CI 1.98-3.1) respectively. Healthcare related infection was the most frequent AE. Most AE were moderate and with high preventability. Being a BMT patient was the only independent factor associated with the occurrence of at least one AE (OR=11.5, p<0.001).

CONCLUSIONS

Our findings suggest that AE tend to be moderate and preventable in HO pediatric patients. BMT patients seem to be at greater risk of having an AE. Strategies focused on patient safety need to account for their specific characteristics.

[Treatment and progression management of acute kidney injury]

Acute kidney injury (AKI) represents one of the greatest global health challenges and is associated with high mortality. The often multifactorial etiology and complex pathophysiological mechanisms have so far hampered the development of causal therapeutic options. The treatment should be stage-adapted according to the current KDIGO guideline: avoid nephrotoxicity, optimize volume status and perfusion pressure, monitor serum creatinine, urine output and proteinuria. New insights into the influence of mitochondrial dysfunction and cellular senescence in AKI, well-defined study endpoints, and innovations through nanotechnology may enable targeted drug-based AKI therapy in the future. Especially the weeks following an AKI are a vulnerable phase and crucial for progression management.

Risk Factors for Adverse Events in Patients With Breast, Colorectal, and Lung Cancer

OBJECTIVE

The aim of the study was to identify risk factors associated with medical errors and iatrogenic injuries during an initial course of cancer-directed treatment.

METHODS

In this retrospective cohort study of 400 patients 18 years or older undergoing an initial course of treatment for breast, colorectal, or lung cancer at a comprehensive cancer center, we abstracted patient, disease, and treatment-related variables from the electronic medical record. We examined adverse events (AEs) and preventable AEs by risk factor using the χ2 or Fisher exact tests. We estimated the association between risk factors and the relative risk of an additional AE or preventable AE in multivariable negative binomial regression models with backwards selection (P < 0.1).

RESULTS

There were 304 AEs affecting 136 patients (34%) and 97 preventable AEs affecting 53 patients (13%). In multivariable analyses, AEs were overrepresented in those with lung cancer compared with patients with breast cancer (incident rate ratio = 1.9, 95% confidence interval = 1.1-3.2). Nonwhite race (1.6, 1.0-2.6), Hispanic or Latino ethnicity (2.0, 0.9-4.1), advanced disease (1.7, 1.1-2.6), use of each additional class of high-risk nonchemotherapy medication (1.6, 1.3-1.9), and chemotherapy (2.1, 1.3-3.3) were all associated with risk of an additional AE. Preventable AEs were associated with lung cancer (7.4, 2.4-23.2), Hispanic or Latino ethnicity (5.5, 1.7-17.9), and high-risk nonchemotherapy medications (1.5, 1.2-2.0).

CONCLUSIONS

Risk factors for AEs among patients with cancer reflected patients' underlying disease, cancer-directed therapy, and high-risk noncancer medications. The association of AEs with ethnicity merits further research. Risk factor models could be used prospectively to identify patients with cancer at increased risk of harm.

Explaining the process of dealing with nursing errors in the emergency department: A grounded theory study

BACKGROUND

Errors are among the factors threatening patient safety. It is essential to understand how to deal with nursing errors in the emergency department. Thus, the present study aimed to explain the process of dealing with nursing errors in the emergency department.

METHOD

This qualitative study adopted Corbin and Strauss's (2008) grounded theory method. The data were collected by in-depth semi-structured interviews and field notes. Eighteen nurses, two doctors, and one patient companion participated in this study. The research setting was the emergency departments of five teaching hospitals in down tone of Tehran, Iran. The participants were selected by purposive sampling at first, and then by theoretical sampling.

RESULTS

Following the data analysis, four main categories of "reality shock", "formulating a situational response", "reactive measure", and "progress or regress" were extracted. The data analysis showed that "formulating a situational response" is the core category of the process of dealing with errors among nurses in the study emergency departments. The first step in the process of dealing with errors in ED was the reality shock, then nurses entered the stage of formulating a situational response, after that they entered the stage of "reactive measure" and finally they entered the stage of progress or regress.

DISCUSSION AND CONCLUSION

After an error occurs in the emergency department, nurses experience four stages during the process of dealing with nursing errors. When dealing with an error, nurses think about protecting the patients. However, some contextual factors direct the nurses towards protecting themselves rather than the patient. The decision-makers in the healthcare system can modify these contextual factors, provide in-service training, develop anonymous reporting systems, and establish a positive support environment, thus directing the nurses towards supporting the patients (in addition to trying to protect oneself).

Finding Potential Adverse Events in the Unstructured Text of Electronic Health Care Records: Development of the Shakespeare Method

BACKGROUND

Big data tools provide opportunities to monitor adverse events (patient harm associated with medical care) (AEs) in the unstructured text of electronic health care records (EHRs). Writers may explicitly state an apparent association between treatment and adverse outcome ("attributed") or state the simple treatment and outcome without an association ("unattributed"). Many methods for finding AEs in text rely on predefining possible AEs before searching for prespecified words and phrases or manual labeling (standardization) by investigators. We developed a method to identify possible AEs, even if unknown or unattributed, without any prespecifications or standardization of notes. Our method was inspired by word-frequency analysis methods used to uncover the true authorship of disputed works credited to William Shakespeare. We chose two use cases, "transfusion" and "time-based." Transfusion was chosen because new transfusion AE types were becoming recognized during the study data period; therefore, we anticipated an opportunity to find unattributed potential AEs (PAEs) in the notes. With the time-based case, we wanted to simulate near real-time surveillance. We chose time periods in the hope of detecting PAEs due to contaminated heparin from mid-2007 to mid-2008 that were announced in early 2008. We hypothesized that the prevalence of contaminated heparin may have been widespread enough to manifest in EHRs through symptoms related to heparin AEs, independent of clinicians' documentation of attributed AEs.

OBJECTIVE

We aimed to develop a new method to identify attributed and unattributed PAEs using the unstructured text of EHRs.

METHODS

We used EHRs for adult critical care admissions at a major teaching hospital (2001-2012). For each case, we formed a group of interest and a comparison group. We concatenated the text notes for each admission into one document sorted by date, and deleted replicate sentences and lists. We identified statistically significant words in the group of interest versus the comparison group. Documents in the group of interest were filtered to those words, followed by topic modeling on the filtered documents to produce topics. For each topic, the three documents with the maximum topic scores were manually reviewed to identify PAEs.

RESULTS

Topics centered around medical conditions that were unique to or more common in the group of interest, including PAEs. In each use case, most PAEs were unattributed in the notes. Among the transfusion PAEs was unattributed evidence of transfusion-associated cardiac overload and transfusion-related acute lung injury. Some of the PAEs from mid-2007 to mid-2008 were increased unattributed events consistent with AEs related to heparin contamination.

CONCLUSIONS

The Shakespeare method could be a useful supplement to AE reporting and surveillance of structured EHR data. Future improvements should include automation of the manual review process.

Conceptual advances and evolving terminology in acute kidney disease

Over the past decade, new insights into epidemiology, pathophysiology and biomarkers have modified our understanding of acute kidney dysfunction and damage, and their association with subsequent chronic kidney disease. The concept of acute kidney injury (AKI), which has relied on established but nonetheless flawed biomarkers of solute clearance (serum creatinine levels and urinary output), has been challenged by the identification of novel biomarkers of tubular stress and/or damage. The expression of some of these novel biomarkers precedes changes in conventional biomarkers or can increase their predictive power, and might therefore enhance the clinical accuracy of the definition of AKI. In addition, the need to consider AKI recurrence, duration and progression to chronic kidney disease within the clinical and epidemiological framework of AKI led to the emergence of the concept of acute kidney disease. New definitions of acute syndromes of kidney impairment and injury are needed.

Intravenous Smart Pumps During Actual Clinical Use: A Descriptive Comparison of Primary and Secondary Infusion Practices

This descriptive observational study was conducted to increase understanding of medication administration practices during actual clinical use between 2 commonly used, different types of intravenous (IV) smart pumps. Compliance with manufacturer-recommended setup requirements for both primary and secondary infusions and secondary medication administration delay was compared between a head-height differential system and a cassette system. A total of 301 medication administration observations were included in this study: 102 (34%) for the linear peristaltic IV smart pump (medical-surgical: N = 51; critical care: N = 51) and 199 (66%) for the cassette pump (medical-surgical: N = 88; critical care: N = 111). Results found a 0% compliance for primary line setup and 84% compliance for secondary line setup and 1 omitted medication due to a closed clamp with the linear peristaltic system. For the cassette system, there are no head-height requirements. Two roller clamps were found to be in the closed position on initiation of the secondary infusion, but the clinician was alerted by an alarm, so no medication delays occurred. These findings support that the current system requirements for flow rate accuracy using head-height differential systems are difficult to achieve consistently at the point of care. There is a need for additional human factor designed technology to replace manual actions to improve the process of care for nurses and the safety of care for patients.

Opioid Overdose in the Hospital Setting: A Systematic Review

OBJECTIVE

Our objective was to determine the percentage of opioid overdose events among medical and surgical inpatient admissions, and to identify risk factors associated with these events.

METHODS

We searched PubMed and CINAHL databases from inception through July 30, 2017 and identified additional studies from reference lists and other reviews. Articles were included if they reported original research on the rate of opioid overdoses or opioid-related adverse events, and the adverse events occurred in a general medical hospital during an inpatient stay. We extracted information on study population, design, results, and risk for bias using the Newcastle-Ottawa Quality Assessment Scale. We performed this review in accordance with recently suggested standards and report our findings as per the Meta-Analyses and Systematic Reviews of Observational Studies guidelines.

RESULTS

Thirteen studies met our eligibility criteria. The percentage of opioid overdoses ranged from 0.06% to 2.50% of hospitalizations. The majority of studies used only 1 method of event detection. Risk factors for overdose included older age, infancy, medical comorbidity, substance use disorder diagnosis, combining opioids with other sedatives, and admission to hospitals with higher opioid-prescribing rates.

CONCLUSIONS

Opioid overdose in the inpatient setting is a serious preventable harm and is likely underestimated in much of the current literature. Improved detection methods are needed to more accurately measure the rate of inpatient opioid overdose. Refined estimates of opioid overdose should be used to drive safety and quality improvement initiatives in hospitals.

Nephrotoxin Stewardship

Drugs are the third leading cause of acute kidney injury (AKI) in critically ill patients. Nephrotoxin stewardship ensures a structured and consistent approach to safe medication use and prevention of patient harm. Comprehensive nephrotoxin stewardship requires coordinated patient care management strategies for safe medication use, ensuring kidney health, and avoiding unnecessary costs to improve the use of nephrotoxins, renally eliminated drugs, and kidney disease treatments. Implementing nephrotoxin stewardship reduces medication errors and adverse drug events, prevents or reduces severity of drug-associated AKI, prevents progression to or worsening of chronic kidney disease, and alleviates financial burden on the health care system.

Nurse and Pharmacist Knowledge of Intravenous Smart Pump System Setup Requirements

OBJECTIVE

The primary purpose of this research was to describe nurse and pharmacist knowledge of setup requirements for intravenous (IV) smart pumps that require head height differentials for accurate fluid flow.

METHODS

A secondary analysis of anonymous electronic survey data using a database of prerecruited clinicians was conducted. A survey was sent by email to 173 pharmacists and 960 nurses. The response rate for pharmacists was 58% (100 of 173), and the response rate for nurses was 52% (500 of 960). After removing respondents who did not provide direct care and who did not use a head height differential IV infusion system, the final sample for analysis was 186 nurses and 25 pharmacists.

RESULTS

Overall, less than one-half of respondents (40%) were aware that manufacturer guidelines for positioning the primary infusion bag relative to the infusion pump were available. Slightly more (49.5%) were aware of the required head height differentials for secondary infusion. Only five respondents selected the correct primary head height, eight respondents selected the correct secondary head height, and one respondent selected both the correct primary and secondary head heights.

CONCLUSION

The results of this study identify a substantial lack of knowledge among frontline clinicians regarding manufacturer recommendations for accurate IV administration of primary and secondary infusions for head height differential infusion systems. Both increased clinician education and innovative technology solutions are needed to improve IV smart pump safety and usability.

The effect of different intensivist staffing patterns on the rate of potential drug-drug interactions in adult trauma intensive care units

BACKGROUND

Drug-drug interactions (DDIs) have created alarming challenges for public health, especially in those admitted to intensive care units (ICUs). Many studies have shown that involvement of intensivists in the ICUs improves the outcome and decreases the treatment costs. The effect of academic versus non-academic (therapeutic) intensivist as well as hours of coverage and attendance of intensivist on potential DDIs (pDDIs) was evaluated in six adult trauma ICUs of a level one trauma center.

METHODS

In this 6-month cross-sectional study, 200 patients were included. The DDIs were classified into five groups, including type A, B, C, D, and X. pDDIs were defined as interactions belonged to C, D and X categories. Patients in six adult ICUs with three different patterns of intensivist staffing models including type A (once-daily therapeutic intensivist visit followed by 24 h on-call), B (twice-daily academic intensivist visit, 8 h of attendance in ICU and 16 h on-call) and C (all criteria just like ICU type B, except for the presence of therapeutic instead of academic intensivist) were screened for pDDIs.

RESULTS

In total, 3735 drug orders and 3869 drugs (193 different types) were screened and 1826 pDDIs were identified. Type C, D and X interactions accounted for 60.6%, 35.5%, and 3.9% of all pDDIs, respectively. The mean of pDDI per patient was significantly higher (p-value < 0.001) in the ICU type A than ICU types C and B. The frequency of pDDIs was the highest in the type A ICUs. A statistically significant relationship was observed between the number of prescribed drugs and ICU length of stay (p-value < 0.001 and p = 0.009, respectively).

CONCLUSION

Different patterns of intensivist staffing affect pDDIs to varying degrees. In the studied ICUs academic versus therapeutic intensivist, twice versus once-daily visit, and 8 h attendance with16 h on-call versus 24 h on-call were associated with more reductions in pDDIs.

PLAIN LANGUAGE SUMMARY

The impact of different intensivist staffing patterns in ICUs on the rate of potential drug-drug interactionsDrug-drug interactions (DDIs) have created alarming challenges for public health, especially in patients admitted to intensive care units (ICUs). Many studies have shown that involvement of intensivists in the ICUs improves the outcome and limits the costs. Considering the high incidence of potential DDIs (pDDIs) occurring for critically ill patients and the importance of ADRs caused by pDDIs in ICUs, the effect of the presence of an academic versus therapeutic intensivist, as well as the hour of coverage of intensivist on prevalence of pDDIs was evaluated in six adult trauma ICUs of a level one trauma center in Shiraz, Iran. We also determined the prevalence of pDDIs and their associated risk factors. To the best of our knowledge, this is the first study that has assessed the effect of various ICU physician staffing models on the incidence and pattern of pDDIs.

Clinically relevant potential drug-drug interactions in intensive care patients: A large retrospective observational multicenter study

PURPOSE

Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all pDDIs are clinically relevant. Clinical decision support systems (CDSSs) warning for irrelevant pDDIs could result in alert fatigue and overlooking important signals. Therefore, our aim was to describe the frequency of clinically relevant pDDIs (crpDDIs) to enable tailoring of CDSSs to the ICU setting.

MATERIALS & METHODS

In this multicenter retrospective observational study, we used medication administration data to identify pDDIs in ICU admissions from 13 ICUs. Clinical relevance was based on a Delphi study in which intensivists and hospital pharmacists assessed the clinical relevance of pDDIs for the ICU setting.

RESULTS

The mean number of pDDIs per 1000 medication administrations was 70.1, dropping to 31.0 when considering only crpDDIs. Of 103,871 ICU patients, 38% was exposed to a crpDDI. The most frequently occurring crpDDIs involve QT-prolonging agents, digoxin, or NSAIDs.

CONCLUSIONS

Considering clinical relevance of pDDIs in the ICU setting is important, as only half of the detected pDDIs were crpDDIs. Therefore, tailoring CDSSs to the ICU may reduce alert fatigue and improve medication safety in ICU patients.

Clinical pharmacy interventions in intensive care unit patients

WHAT IS KNOWN AND OBJECTIVE

The drug therapy of critically ill patients requires intensive evaluation and management due to their severity of illness. These patients often require complex medication regimens. This study analysed the pharmaceutical care provided by clinical pharmacists (CPs) in a single medical centre in Taiwan. In addition, we explored the drug-related problems (DRPs) experienced by patients in intensive care units (ICUs) to determine how to improve the quality and safety of drug therapy.

METHODS

This retrospective study was conducted from February 2019 to January 2020. The CPs implemented Taiwan's National Health Insurance (NHI) Scheme for Improving Hospital Drug Safety and Quality programme to improve the safety and quality of drug therapy. The CPs included in the study had at least 2 years' clinical experience and had participated in an ICU team for at least 6 consecutive months. They provided individualized drug treatment evaluation and intervention. Content of care was documented in the Clinical Pharmacy Service Record.

RESULTS AND DISCUSSION

A total of 4374 pharmacy care records were evaluated by 12 CPs. The major category of ICU pharmaceutical care was medication reconciliation (n = 2938; 67.2%). Most of the medication interventions were for errors in dosing or dosing frequency (n = 218; 55.8%). Patients with renal dysfunction required more pharmaceutical interventions than did patients with normal renal function (odds ratio = 1.63; 95% confidence interval 1.31-2.01). The main interventions were related to antimicrobial agents (n = 386; 81.3%). During the study period, 99.2% of interventions were accepted and 90.8% were changed within 24 hours.

WHAT IS NEW AND CONCLUSION

Increased pharmaceutical interventions for patients with renal dysfunction compared with patients with normal renal function were observed. Most cases of inappropriate frequency of dosing or dosing of antimicrobial agents required intervention.

Framework and Outcomes of a Critical Care Pharmacy Visiting Clinical Professor Program

Objectives:

Experiences with utilizing a visiting clinical professor program to mentor institutions and collaborate on best practices in critical care pharmacy are described to provide a framework for these services and a synopsis of key outcomes.

Design:

The Society of Critical Care Medicine Clinical Pharmacy and Pharmacology Section implemented a visiting clinical professor program to address the need for collaboration, idea-sharing, mentorship, and diffusion of innovation to clinicians in critical care practice.

Setting:

Critical care pharmacy departments at 12 medical centers.

Subjects:

Twelve visiting clinical professors and host institutions from 2007-2018.

Intervention:

After an application is submitted to the section steering committee, an experienced clinician is paired with an institution, and a site visit is planned in collaboration with the visiting clinical professor program coordinators. The expert clinician visits the institution to share their insights and best practices based on visit goals and objectives. Reflective debriefing with both the host institution and the visiting clinical professor occurs after the visit.

Measurements and Main Results:

The program has demonstrated numerous benefits including shared best practices related to critical care clinical services, expansion and refinement of care delivery models, development and optimization of research programs, and advancement of new training programs including specialty pharmacy residencies. Both the site and visiting professor find these partnerships beneficial, which has resulted in sustained success of the program over an 11-year period. Key resultant deliverables after visits have included new pharmacist positions, advancement of pharmacy services, and expanded access to academic opportunities.

Conclusions:

A professional organization led visiting clinical professor program is viable, sustainable, and yields clear benefit for critical care pharmacy programs across the country. Application of this framework to other areas of pharmacy practice may be an avenue to share best practices and advance pharmacy services.

The management of anti-infective agents in intensive care units: the potential role of a 'fast' pharmacology

INTRODUCTION

Patients in intensive care units (ICU) are often developing severe infections in which are associated with significant mortality rates. A number of novel technologies for the rapid microbiological diagnosis of these infections have been developed, introducing the era of 'fast microbiology.' Treatment of bacterial and fungal infections in ICU is however complicated by alterations in the pharmacokinetics of antimicrobial agents.

AREAS COVERED

We review novel pharmacologic tools that can be used to optimize anti-infective therapies and patient management in ICU. A MEDLINE Pubmed search for articles published from January 1995 to 2019 was completed matching the terms pharmacokinetics and pharmacology with antimicrobial agents and ICU or critically ill patients. Moreover, additional studies were identified from the reference list of retrieved articles.

EXPERT OPINION

Several tools are in development for the full automation of the analytical methods used for the quantification of antimicrobial concentrations within a few hours after sample collection. Ad hoc software with adaptive feedback is also available for appropriate dose adjustments based on both individual patient covariate data and therapeutic drug monitoring (TDM) data when available. The application of these technological improvements in the clinical practice should open the way to a 'fast pharmacology' at the bedside.

Pharmacy Personnel's Involvement in Transitions of Care of Intensive Care Unit Patients: A Systematic Review

OBJECTIVE

Do pharmacy personnel- (ie, pharmacist or pharmacy technician) driven interventions at transitions of care into or out of the intensive care unit (ICU) improve medication safety measures compared to interventions made by other health-care team members or no intervention?

DATA SOURCES

A literature search of MEDLINE and Embase limited to English language and humans was performed (from 1969 until January 2019). Bibliographies of included investigations were reviewed for additional citations.

METHODS

Investigations were selected if they described a pharmacy-driven intervention at any point of transfer into or out of an ICU setting. Ten investigations were included. Five described interventions relevant to the entire ICU population, and 5 described interventions targeted to specific medications or disease.

RESULTS

A variety of interventions were utilized in the 10 included investigations. A significant improvement was demonstrated with pharmacy-driven intervention in all 4 studies that evaluated the entire ICU patient population. Interventions specific to certain medication and disease improved medication safety measures but were not always statistically significant. Medication error rates are high in patients transferred into and out of the ICU, and limited data exist to address this concern. This review compares and evaluates the current literature to guide future interventions and research in this area.

CONCLUSIONS

Although pharmacy-driven interventions demonstrated some benefit in various medication safety measures in the majority of studies, additional randomized and prospective trials with patient-centered outcomes that assess morbidity and mortality are needed.

Integrating a pharmacist into an anaesthesiology and critical care department: Is this worthwhile?

Background Operating rooms and Intensive Care Units are places where an optimal management of drugs and medical devices is required. Objective To evaluate the impact of a dedicated pharmacist in an academic Anaesthesiology and Critical Care Department. Setting This study was conducted in the Anaesthesiology and Critical Care Department of Grenoble University Hospital. Method Between November 2013 and June 2017, the drug-related problems occurring in three Intensive Care Units and their corrections by a full-time clinical pharmacist were analyzed using a structured order review instrument. Pharmaceutical costs in the Anaesthesiology and Critical Care Department were analyzed over a 7 year period (2010-2016), during which automated dispensing systems and recurrent meetings to review indications of medications and medical devices were implemented in the department. Main outcome measure Analysis of two issues: correcting drug-related problems and containing pharmaceutical costs. Results A total of 324 drug-related problems were identified. The most frequent problem concerned anti-infective agents (45%), and this was mainly due to the over-dosage of drugs (30%). Dosage adjustments were the most frequent interventions performed by the pharmacist (43%). Over the 7 year period, pharmaceutical costs decreased by 9% (€365,469), while the care activity of the department increased by 55% (+ 12,022 surgical procedures and + 1424 admissions in the ICU). Conclusion Integrating a pharmacist into the Anaesthesiology and Critical Care Department was associated with interventions to correct drug-related problems and containing pharmaceutical costs. Pharmacists should play a central role in such medical environments, to optimize the use of drugs and medical devices.

Pharmacists in Critical Care

The beginnings of caring for critically ill patients date back to Florence Nightingale's work during the Crimean War in 1854, but the subspecialty of critical care medicine is relatively young. The first US multidisciplinary intensive care unit (ICU) was established in 1958, and the American Board of Medical Subspecialties first recognized the subspecialty of critical care medicine in 1986. Critical care pharmacy services began around the 1970s, growing in the intervening 40 years to become one of the largest practice areas for clinical pharmacists, with its own section in the SCCM, the largest international professional organization in the field. During the next decade, pharmacy services expanded to various ICU settings (both adult and pediatric), the operating room, and the emergency department. In these settings, pharmacists established clinical practices consisting of therapeutic drug monitoring, nutrition support, and participation in patient care rounds. Pharmacists also developed efficient and safe drug delivery systems with the evolution of critical care pharmacy satellites and other innovative programs. In the 1980s, critical care pharmacists designed specialized training programs and increased participation in critical care organizations. The number of critical care residencies and fellowships doubled between the early 1980s and the late 1990s. Standards for critical care residency were developed, and directories of residencies and fellowships were published. In 1989, the Clinical Pharmacy and Pharmacology Section was formed within the Society of Critical Care Medicine, the largest international, multidisciplinary, multispecialty critical care organization. This recognition acknowledged that pharmacists are necessary and valuable members of the physician-led multidisciplinary team. The Society of Critical Care Medicine Guidelines for Critical Care Services and Personnel deem that pharmacists are essential for the delivery of quality care to critically ill patients. These guidelines recommend that a pharmacist monitor drug regimen for dosing, adverse reactions, drug-drug interactions, and cost optimization for all hospitals providing critical care services. The guidelines also advocate that a specialized, decentralized pharmacist provide expertise in nutrition support, cardiorespiratory resuscitation, and clinical research in academic medical centers providing comprehensive critical care.

Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting

OBJECTIVES

Assess interventions' impact on preventing IV infusion identification and disconnection mix-ups.

DESIGN

Experimental study with repeated measures design.

SETTING

High fidelity simulated adult ICU.

SUBJECTS

Forty critical care nurses.

INTERVENTIONS

Participants had to correctly identify infusions and disconnect an infusion in four different conditions: baseline (current practice); line labels/organizers; smart pump; and light-linking system.

MEASUREMENTS AND MAIN RESULTS

Participants identified infusions with significantly fewer errors when using line labels/organizers (0; 0%) than in the baseline (12; 7.7%) and smart pump conditions (10; 6.4%) (p < 0.01). The light-linking system did not significantly affect identification errors (5; 3.2%) compared with the other conditions. Participants were significantly faster identifying infusions when using line labels/organizers (0:31) than in the baseline (1:20), smart pump (1:29), and light-linking (1:22) conditions (p < 0.001). When disconnecting an infusion, there was no significant difference in errors between conditions, but participants were significantly slower when using the smart pump than all other conditions (p < 0.001).

CONCLUSIONS

The results suggest that line labels/organizers may increase infusion identification accuracy and efficiency.

Prevalence and profile of adverse drug reactions in high-risk pregnancy: a cohort study

Background

Commonly used drugs in pregnant women include antihypertensives, hypoglycemic agents, analgesics, antimicrobials, antiemetics and antispasmodics but the use of medicines during pregnancy, especially in high-risk pregnancy, may be associated with high risk of adverse drug reactions (ADR). The objective of this study was to determine the risk of an adverse drug reaction in hospitalized high-risk pregnant women and the factors associated with their occurrence.

Methods

The study received IRB approval and all patients gave written informed consent. Observational cohort study conducted from September 2015 to November 2016 in 1070 pregnant women consecutively admitted to the high risk sector of the University Maternity Januário Cicco in Brazil. ADR were detected through daily active search. Risk factors for the occurrence of ADR were determined using multivariate logistic regression.

Results

The mean age of the study population was 26.2 ± 7.2 years and gestational age was 31.2 ± 7.2 weeks. The average number of previous pregnancies was 2.4 ± 1.8 and 46.4% reported cases of previous abortion/miscarriage. ADR were observed in 10.7% of women. The main medicines involved, with the incidence rate of ADR per 100 prescriptions of the drug (IR), were parenteral scopolamine (IR 14.9%), methyldopa (IR 15.9%), insulin (IR 8.46%), oral scopolamine (IR 3.58%), captopril (IR 2.38%) and ceftriaxone (IR 18.4%). Multivariate analysis showed that only gestational age in weeks (odds-ratio 0.97, 95% confidence interval 0.95–0.98) was related to the occurrence of adverse reactions.

Conclusion

Lower gestational age is a risk factor for high-risk pregnant women, increasing the likelihood of adverse reactions, with parenteral medications being those that have the highest potential risk of harm.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2321-8) contains supplementary material, which is available to authorized users.

Factors associated with adverse drug reaction occurrence and prognosis, and their economic impacts in older inpatients in Taiwan: a nested case-control study

OBJECTIVE

Older patients are likely to have higher disease complexity and more drug prescriptions of which are associated with a higher incidence of adverse drug reactions (ADR). This study aimed to investigate factors associated with ADR occurrence, prognosis and medical expenses in older inpatients.

DESIGN

A nested case-control study.

SETTING

A medical centre located in north Taiwan.

PARTICIPANTS

539 reported ADR cases from a patient cohort containing 108 548 older inpatients were collected from 2006 to 2012. There were 1854 non-ADR matched controls; a maximum of 1:5 matched by age, sex and principal diagnosis were collected.

EXPOSURE

Polypharmacy, the number of drugs prescribed, comorbidities and the admission department were factors associated with ADRs, as well as subsequent poor prognosis, length of stay and medical expenses.

PRIMARY AND SECONDARY OUTCOME MEASURES

ADR occurrence and poor prognosis (mortality, discharge against medical advice in critical conditions, or admitted to intensive care unit) were the primary outcomes. Additional medical expenses and the length of hospital stay were the secondary outcomes.

RESULTS

The admission department, number of comorbidities and number of drug prescriptions before ADRs were associated with ADR occurrence among older inpatients. ADR severity was a significant prognostic factor among ADR cases. The multivariate-adjusted OR of 1.63 (95% CI 1.36 to 1.95) for poor prognosis was found as the number of comorbidities increased. Patients prescribed ≥11 drugs including psychoactive drugs showed 2.45-fold (95% CI 1.40 to 4.28) poorer prognosis than other patients. ADRs caused the addition of US$1803.8, US$360.8 and 5.6 days in total medical expenses, drug expenses and length of stay among affected older inpatients, respectively.

CONCLUSIONS

The number of comorbidities and polypharmacy including the use of psychoactive drugs has significant impacts on ADR occurrence and prognosis among older inpatients. The findings provide clues for future prescription modification and patient's safety improvement in geriatric care.

Stimulant Therapy in Acute Traumatic Brain Injury: Prescribing Patterns and Adverse Event Rates at 2 Level 1 Trauma Centers

BACKGROUND/OBJECTIVE

Pharmacological stimulant therapies are routinely administered to promote recovery in patients with subacute and chronic disorders of consciousness (DoC). However, utilization rates and adverse drug event (ADE) rates of stimulant therapies in patients with acute DoC are unknown. We aimed to determine the frequency of stimulant use and associated ADEs in intensive care unit (ICU) patients with acute DoC caused by traumatic brain injury (TBI).

METHODS

We retrospectively identified patients with TBI admitted to the ICU at 2 level 1 trauma centers between 2015 and 2018. Patients were included if they were stimulant naive at baseline and received amantadine, methylphenidate, or modafinil during ICU admission. Stimulant dose reduction or discontinuation during ICU admission was considered a surrogate marker of an ADE. Targeted chart review was performed to identify reasons for dose reduction or discontinuation.

RESULTS

Forty-eight of 608 patients with TBI received pharmacological stimulant therapy (7.9%) during the study period. Most patients were diagnosed with severe TBI at presentation (60.4%), although stimulants were also administered to patients with moderate (14.6%) and mild (25.0%) TBI. The median time of stimulant initiation was 11 days post-injury (range: 2-28 days). Median Glasgow Coma Scale score at the time of stimulant initiation was 9 (range: 4-15). Amantadine was the most commonly prescribed stimulant (85.4%) followed by modafinil (14.6%). Seven (14.6%) patients required stimulant dose reduction or discontinuation during ICU admission. The most common ADE resulting in therapy modification was delirium/agitation (n = 2), followed by insomnia (n = 1), anxiety (n = 1), and rash (n = 1); the reason for therapy modification was undocumented in 2 patients.

CONCLUSIONS

Pharmacological stimulant therapy is infrequently prescribed but well tolerated in ICU patients with acute TBI at level 1 trauma centers. These retrospective observations provide the basis for prospective studies to evaluate the safety, optimal dose range, and efficacy of stimulant therapies in this population.

Interprofessional safety reporting and review of adverse events and medication errors in critical care

Background

The intensive care unit (ICU) environment is prone to the risk of adverse events (AEs) and medication errors (MEs). The objective of this work was to describe a multidisciplinary safety program focused on AE and ME reporting and review in an ICU over a 7-year period.

Methods

The program was implemented in an 18-bed medical ICU of a 2,200-bed university hospital. A multidisciplinary steering committee (intensivist, clinical pharmacist, nurses, and research assistants) met monthly. The first part of the meeting was dedicated to the review of events targeted through an internal voluntary reporting system, and the second part concerned the analysis of the previous month's events, according to a standardized method called Orion, inspired by the aeronautic industry.

Results

A total of 808 AEs were reported, mostly related to medication processes (30.3% and 33.4% for prescription and administration, respectively). Among these, 526 AEs were related to medications (65.1%), of which 464 were MEs (88.2%). These MEs concerned mostly anti-infective drugs (23.5%) and related to wrong doses (35.8%). Among all AEs reported, 58 (43 MEs [74.1%]) were analyzed further and found to be associated with anti-infective (16.1%) and vasoactive drugs (16.1%). According to National Coordinating Council for Medication Error Reporting and Prevention classification, most AEs caused no harm to patients (category A-D: 38 events, 65.5%). Nurses were most often involved in the analysis (50.7%), along with pharmacists (37.5%). Training was identified as the most frequent corrective action (45.1%).

Conclusion

This program dedicated to AE and ME reporting, review, and analysis in ICU showed long-term engagement of the health care team in AE surveillance and helped in targeting measures for education, organization, and promoting teamwork and safety.

Evaluating intensive care unit medication charges in a teaching hospital in Jordan

Background: Intensive Care Unit (ICU) medication costs contribute to a large portion of the total ICU costs. Evaluating ICU drug expenditures is essential for optimal resource use especially in countries with limited resources. Considering the dearth of data regarding ICU medication expenses in the Middle East, we sought to evaluate ICU medication charges at a large academic hospital in Jordan. Methods: ICU drug charges were extracted from the hospital administration database at King Abdullah University Hospital for 2014-2015 fiscal years (FYs). ICU drug charges were compared to non-ICU drug charges that were incurred during the same patient admissions. ICU medications with the most significant charges were identified. The most frequent diagnoses with the highest ICU medication charges were described. Results: Average ICU medication charges per day were approximately twice that of non-ICU medication charges ($121.5 versus $55.7 in 2014 and $100.2 versus $52.2 in 2015; p < 0.001 in both FYs). Meropenem and human albumin were the most expensive ICU medications. Drug charge allocation was most expensive for sepsis, motor vehicle accidents and respiratory failure. Conclusion: Drug charges in the ICU are considerably higher than non-ICU drug charges, thus requiring more vigilant cost containment approaches. Further research is needed to evaluate the appropriateness of expensive ICU medications.

Impact of medication therapy management on pharmacotherapy safety in an intensive care unit

Background Drug-related problems are mostly preventable or predictable circumstances that may impact on health outcomes. Clinical pharmacy activities such as medication therapy management can identify and solve these problems, with potential to improve medication safety and effectiveness. Objective To evaluate ability of medication therapy management service to detect drug-related problems and prevent adverse drug events. This study also aimed to assess the risk factors for drugrelated problem occurrence. Setting Medical intensive care unit of a public tertiary hospital in Brazil. Methods Patients were evaluated by a clinical pharmacist, who provided medication therapy management service. Detected drug-related problems were categorized according to the Pharmaceutical Care Network Europe methodology and analyzed in multinomial regression to identify risk factors. Main outcome measure Potential risk factors for drug-related problem occurrence. Results The proposed medication therapy management service allowed detection of 170 drug-related problems that had potential to reach patients causing harm and other 50 unavoidable adverse events. Drug-related problems identified were more often associated with antibacterial use, caused by improper combinations or inadequate drug dosage. These problems required interventions that were accepted by the multidisciplinary team, resulting in more than 85% adherence and total problem solving. Main risk factors identified were previous diagnosis of kidney injury (OR = 8.38), use of midazolam (OR = 7.96), furosemide (OR = 5.87) and vancomycin (OR = 4.82). Conclusion Medication therapy management proved to be an effective method not only for drug-related problem detection, but also for adverse drug event prevention, contributing to improve patient safety.

Promoting oral potassium administration in a tertiary care hospital: An eleven-year study

INTRODUCTION

Potassium is used to treat or prevent hypokalemia and exhibits all the characteristics of an intravenous to oral therapy conversion program. Despite this, the intravenous route for potassium replacement seems frequently unjustified.

OBJECTIVES

To determine the impact of a conversion program on the use of intravenous and oral galenic forms in a university tertiary care hospital.

METHODS

Two promotion campaigns were conducted in 2006 and 2009. The following years this was completed by pharmacist interventions during prescription analysis and face-to-face discussions with physicians during ward rounds. The consumption of products containing potassium was obtained by analyzing the hospital's financial database.

RESULTS

The proportion of the oral route increased from 18% in 2006 to 22% in 2011, and from 25% in 2012 to 44% in 2016; the increase was significantly greater in the second period (P<0.0001). In 2016, in emergency, pulmonology, infectious diseases, and cardiology departments, the proportion of oral use ranged from 57% and 82%. The greatest progression from 2006 to 2016 was found for intensive care (4% vs. 12%) and visceral surgery departments (9% vs. 34%) that increased approximately four-fold, followed by the emergency department (28% vs. 57%) that increased approximately two-fold.

CONCLUSION

Promoting the oral route for potassium replacement modifies prescriber habits and is followed by a notable increase in the proportion of potassium administered orally irrespective of department type.

Trigger tools are as effective as non-targeted chart review for adverse drug event detection in intensive care units

Objective

This study aimed to compare the use of trigger tools and non-targeted chart review as methods for the detection of adverse drug events in an intensive care unit considering the health system of a developing country.

Methods

Patients were divided in groups that were submitted to different methods (trigger tool and non-targeted chart review) for adverse drug event detection. Medical records were retrospectively reviewed, and adverse drug events detected during the data collection were analyzed by a multidisciplinary team and classified according to their causality, predictability, severity and damage level.

Results

The search for adverse events performed by trigger tools and non-targeted chart review allowed the identification of similar numbers of events (61.09 and 64.04 ADE/1000 patient-days, respectively), types of event and related drugs. In both groups, the most frequently detected adverse events were related to metabolic, gastrointestinal, cardiovascular and hematological systems. These organic systems matched the drugs most associated with adverse event occurrence: anti-infectives, antithrombotics and insulins. Events identified by non-targeted chart review presented higher causality relationships and were considered less severe than those observed by trigger tool use (p < 0.05).

Conclusion

The similar performance between these methods supports trigger tool applicability in the ICU routine, as this methodology requires less time to retrieve information from the medical records.

Clinical pharmacist intervention reduces mortality in patients with acute myocardial infarction: a propensity score matched analysis

Background

Is it possible that the mortality rate from acute myocardial infarction (AMI) may decline after interventions by pharmacists?

Objective

To evaluate the impact of clinical pharmacist on the mortality of AMI.

Methods

Clinical pharmacists did not perform any interventions during phase 1 (pre-intervention), and consulted with physicians to address drug related problems (DRPs) during phase 2 (post-intervention). The main outcome was a decrease in mortality from AMI. The two phases were compared using propensity score matching (PSM).

Results

1388 interventions were suggested by clinical pharmacists during phase 2, of which 1239 (89.2%) were accepted. Logistic regression analysis demonstrated that interventions of clinical pharmacists were significantly associated with a reduced mortality in patients with both ST segment elevation myocardial infarction (STEMI) (OR 0.449; 95% CI 0.296 to 0.680) and non-ST segment elevation myocardial infarction (NSTEMI) (OR 0.268; 95% CI 0.125 to 0.572). Using PSM analysis, mortality reduced from 6.8% to 4.3% in STEMI patients (P=0.0034) and from 3.2% to 0.7% in NSTEMI patients (P=0.0202) after the interventions.

Conclusions

DRPs that caused or contributed to possible mortality were detected by clinical pharmacists in patients with AMI. Correcting these DRPs after pharmacists' interventions could result in a significant decrease in mortality.

Medication incidents in an outpatient emergency service: documental analysis

OBJECTIVE

To characterize medication incidents occurred in an outpatient emergency service.

METHOD

Descriptive, documental, retrospective and quantitative research. The International Classification for Patient Safety was the theoretical reference for the construction of the instrument used to collect and analyze the data from 119 notification and investigation forms of incidents occurred in 2014 in a teaching hospital. Data were collected twice, compared, corrected and transcribed to an Excel worksheet. The SPSS 19.0 Software and the non-parametric Mann-Whitney test were used in the analysis; p<0.05 indicated statistical significance.

RESULTS

A total of 142 incidents were analyzed, most of them involving the nursing team; 93.7% were avoidable; one-third involved high-alert medications; the majority involved parenteral administration. Harm was rare but proportional to the time elapsed for error detection. Management failures prevailed, especially omission.

CONCLUSION

Most of the incidents analyzed were characterized as potentially harmful and avoidable, with emphasis on personnel factors as contributors.