Evaluation of stat orders in a teaching hospital: a chart review

Deviations From Best Practice: Findings From a Certified Patient Safety Organization Remote-Verification Observational Study of Intravenous Compounding of Chemotherapeutic and Ancillary Drugs

Background: Chemotherapeutic and immunomodulatory medications can pose a serious risk to patient and healthcare provider safety because of complex processes, cytotoxicity, and prevalent medication use. Objective: To evaluate chemotherapeutic and ancillary medication compounding in hospital pharmacies using a remote verification system, focusing on pharmaceutical deviations from best practice, compounding time, medication waste, and cost. Methods: This retrospective, blinded observational study used a remote intravenous (IV) workflow verification system to examine IV chemotherapeutic compounding errors in large hospital systems. A Patient Safety Organization securely obtained >5000 compounding records and photos from the IV workflow system. Blinded pharmacists evaluated IV chemotherapy preparations using picture slide viewers to assess any deviations from best practice. Time variables, medication waste, STAT vs non-STAT orders, and cost were also evaluated. Results: The most frequently reported deviations from best practice included medications exceeding the >10% additive volume guideline (35.9%) and inaccurate dose labels (28.3%). Time flow analyses demonstrated a substantial increase in total compounding time per vial for 1 vs 2 vials. Most medications in this analysis had an average waste ranging from 0-.36 vials. STAT orders, accounting for 38.4% of all orders, wasted more medication than non-STAT orders. Gemcitabine cost analyses showed an association for number of vials and compounding time with overall cost per dose. Conclusion: Substantial inconsistencies between workflow stations were observed-highlighting the lack of standardization across chemotherapeutics, volume of medication waste during preparation, and the need to establish improved quality controls to safeguard patient and health care provider safety.

The anatomy of the saphenous and sural nerves as a source of processed nerve allografts

As an alternative to autologous nerve donors, acellular nerve allografts (ANAs) have been studied in many experiments. There have been numerous studies on processing ANAs and various studies on the clinical applications of ANA, but there have not been many studies on sources of ANAs. The purposes of the present study were to evaluate the course of the saphenous and sural nerves in human cadavers and help harvest auto- or allografts for clinical implications. Eighteen lower extremities of 16 fresh cadavers were dissected. For the saphenous nerve and sural nerve, the distances between each branch and the diameters at the midpoint between each branch were measured. In the saphenous nerve, the mean length between each branch ranged from 7.2 to 28.6 cm, and the midpoint diameter ranged from 1.4 to 3.2 mm. In the sural nerve, the mean length between each branch ranged from 17.4 to 21 cm, and the midpoint diameter ranged from 2.3 to 2.8 mm. The present study demonstrates the length of the saphenous and sural nerve without branches with diameters larger than 1 mm. With regard for the clinical implications of allografts, the harvest of a selective nerve length with a large enough diameter could be possible based on the data presented in the present study.

A Quality Improvement Intervention Reduces the Time to Administration of Stat Medications

INTRODUCTION

The delivery of urgent ("stat") medications to hospitalized children is important for safe quality care. The goal of this study was to evaluate the effect of a set of interventions on the percentage of stat medications administered within 30 minutes of ordering.

METHODS

A pre-post study in 2 pediatric units (36 beds) in a private hospital in Saudi Arabia between January 2015 and September 2016. Interventions included structured communication requirements, introduction of a dedicated electronic inbox for stat medication orders sent by nurses to the pharmacy, and the use of a pink envelope for the delivery of stat medications. A multivariate logistic regression model was used to model percentage of medications administered within goal.

RESULTS

Three hundred four stat orders met inclusion criteria. The proportion of orders meeting the 30-minute goal increased from a mean of 20% to a mean of 49% after the interventions (P < 0.001). In the final month of the study, compliance reached a peak of 67%. The mean turnaround time from ordering to the administration of the medication decreased from 59.7 to 40.7 minutes (P < 0.001). On multivariate analysis, medication type and unit-based availability of medications were statistically significant predictors of turnaround time. The odds of compliance being achieved was 0.3 times less if the medication was not available on the unit.

CONCLUSIONS

A set of interventions significantly increased the percentage of stat medications delivered within 30 minutes.

Evaluation of STAT medication ordering process in a community hospital

Background:

In most health care facilities, problems related to delays in STAT medication order processing time are of common concern.

Objective:

The purpose of this study was to evaluate processing time for STAT orders at Kimball Medical Center.

Methods:

All STAT orders were reviewed to determine processing time; order processing time was also stratified by physician order entry (physician entered (PE) orders vs. non-physician entered (NPE) orders). Collected data included medication ordered, indication, time ordered, time verified by pharmacist, time sent from pharmacy, and time charted as given to the patient.

Results:

A total of 502 STAT orders were reviewed and 389 orders were included for analysis. Overall, median time was 29 minutes, IQR 16–63; p<0.0001.). The time needed to process NPE orders was significantly less than that needed for PE orders (median 27 vs. 34 minutes; p=0.026). In terms of NPE orders, the median total time required to process STAT orders for medications available in the Automated Dispensing Devices (ADM) was within 30 minutes, while that required to process orders for medications not available in the ADM was significantly greater than 30 minutes. For PE orders, the median total time required to process orders for medications available in the ADM (i.e., not requiring pharmacy involvement) was significantly greater than 30 minutes. [Median time = 34 minutes (p<0.001)].

Conclusion:

We conclude that STAT order processing time may be improved by increasing the availability of medications in ADM, and pharmacy involvement in the verification process.

Using A3 thinking to improve the STAT medication process

BACKGROUND

Although the term STAT conveys a sense of urgency, it is sometimes used to circumvent a system that may be too slow to accomplish tasks in a timely manner. We describe a quality-improvement project undertaken by a US Department of Veterans Affairs (VA) hospital to improve the STAT medication process.

METHODS

We adapted A3 Thinking, a problem-solving process common in Lean organizations, to our problem. In the discovery phase, a color-coded flow map of the existing process was constructed, and a real-time STAT order was followed in a modified "Go to the Gemba" exercise. In the envisioning phase, the team brainstormed to come up with as many improvement ideas as possible, which were then prioritized based on the anticipated effort and impact. The team then identified initial experiments to be carried out in the experimentation phase; each experiment followed a standard Plan-Do-Study-Act cycle.

RESULTS

On average, the number of STAT medications ordered per month decreased by 9.5%. The average time from STAT order entry to administration decreased by 21%, and time from medication delivery to administration decreased by 26%. Improvements were also made in technician awareness of STAT medications and nurse notification of STAT medication delivery.

CONCLUSIONS

Adapting A3 Thinking for process improvement was a low-cost/low-tech option for a VA facility. The A3 Thinking process led to a better understanding of the meaning of STAT across disciplines, and promoted a collaborative culture in which other hospital-wide problems may be addressed in the future.

Bibliographic review of research publications on access to and use of medicines in low-income and middle-income countries in the Eastern Mediterranean Region: identifying the research gaps

OBJECTIVES

We assessed the situation of academic publications on access to and use of medicines (ATM) in low-income and middle-income countries (LMICs) of the Eastern Mediterranean Region (EMR). We aimed to inform priority setting for research on ATM in the region.

DESIGN

Bibliographic review of published studies.

SETTING

LMICs in EMR.

INCLUSION CRITERIA

Publications on ATM issues originating from or focusing on EMR LMICs covering the period 2000-2011. Publications involving multinational studies were included if at least one eligible country had been included in the study.

INFORMATION SOURCES AND DATA EXTRACTION

We conducted comprehensive searches of the PubMed, Social Science Citation Index and Science Citation Index. We used the WHO ATM framework for data extraction and synthesis. We analysed the data according to the ATM issues, health system levels, year of publication and the countries of origin or focus of the studies.

RESULTS

151 articles met the inclusion criteria. Most articles (77%) originated from LMICs in EMR, suggesting that the majority of evidence on ATM in the region is home-grown. Over 60% of articles were from Iran, Pakistan, Jordan and Lebanon (in order of volume), while we found no studies assessing ATM in Somalia, Djibouti and South Sudan, all low-income countries. Most studies focused on the rational use of medicines, while affordability and financing received limited attention. There was a steady growth over time in the number of ATM publications in the region (r=0.87).

CONCLUSIONS

There is a growing trend, over the years, of more studies from the region appearing in international journals. There is a need for further research on the financing and affordability aspects of ATM in the region. Cross-border issues and the roles of non-health sectors in access to medicines in the region have not been explored widely.