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Cavagna P, Bizet S, Fieux F, Houillez E, Chirk C, Zulian C, Perreux J, Fernandez C, Lescot T, Antignac M. Assessment of Good Practice Guidelines for Administration of Drugs via Feeding Tubes by a Clinical Pharmacist in the Intensive Care Unit. Crit Care Nurse 2022; 42:54-65. [DOI: 10.4037/ccn2022395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background
In intensive care units, patients are frequently unable to take oral drugs because of orotracheal intubation or sedation.
Local Problem
Adverse events occurred during the administration of drugs by feeding tube. This study assessed the impact of implementing good practice guidelines by a clinical pharmacist on the prescription and administration of drugs through feeding tubes.
Methods
Nonconformity of drug prescription and administration in patients with feeding tubes was assessed before and after implementation of good practice guidelines in the intensive care unit of a large teaching hospital. Data were collected from medical records and interviews with physicians and nurses using a standardized form. Assessment of prescription nonconformity included compatibility of a drug’s absorption site with the administration route. Assessment of administration nonconformity included the preparation method.
Results
The analysis included 288 prescriptions and 80 administrations before implementation and 385 prescriptions and 211 administrations after implementation. Prescriptions in which the drug’s absorption site was not compatible with the administration route decreased significantly after implementation (19.8% vs 7.5%, P < .01). Administration nonconformity decreased significantly in regard to crushing tablets and opening capsules (51.2% vs 4.3%, P < .01) and the solvent used (67.1% vs 3.5%, P < .01). Simultaneous mixing of drugs in the same syringe did not decrease significantly (71.2% vs 62.9%, P = .17).
Conclusion
Implementation of good practice guidelines by a multidisciplinary team in the intensive care unit significantly improved practices for administering crushed, opened, and dissolved oral forms of drugs by feeding tube.
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Affiliation(s)
- Pauline Cavagna
- Pauline Cavagna is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University, Paris, France
| | - Simon Bizet
- Simon Bizet is a physician, surgical intensive care unit, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Fabienne Fieux
- Fabienne Fieux is a physician, surgical intensive care unit, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Emilie Houillez
- Emilie Houillez is a nurse, surgical intensive care unit, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Caroline Chirk
- Caroline Chirk is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Chloé Zulian
- Chloé Zulian is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Jennifer Perreux
- Jennifer Perreux is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Christine Fernandez
- Christine Fernandez is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Thomas Lescot
- Thomas Lescot is a physician, surgical intensive care unit, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Marie Antignac
- Marie Antignac is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
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Teder K, Jõhvik L, Meos A, Saar M, Visbek A, Volmer D, Karjagin J. Solid oral medications' suitability for use in enteral feeding tubes. Nurs Crit Care 2021; 27:698-705. [PMID: 34755443 DOI: 10.1111/nicc.12729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/18/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is a lack of specific data about the efficacy and safety of medications administered via feeding tubes, although there is a general awareness that not all drug formulations are suitable. AIMS AND OBJECTIVES To overview the current situation with solid medications administered through feeding tubes in the Tartu University Hospital intensive care units. To evaluate the availability of information on the suitability of drug formulations for administration via feeding tubes. DESIGN This was a descriptive retrospective document analysis study. METHODS During visits to the intensive care units, medication data for current patients were collected from paper medical charts and nurses. In addition, package information leaflets, summaries of product characteristics, and two practical handbooks were used for evaluating the medicines' suitability for administration via feeding tubes. A request for information was also sent to manufacturers or marketing authorization holders. RESULTS In 3 months, data were collected from 113 intensive care patients' medical charts. A total of 306 medication administrations via feeding tubes were documented and analysed, 67% of which were solid oral dosage forms. Exactly 91.2% of these were conventional tablets. After the analysis of information availability, 88% of the medications were classified as suitable for administration via feeding tubes, but only 48% had the manufacturer-provided information. CONCLUSION This study showed that the information about the suitability of formulations administration through a feeding tube is not readily available for almost half of the medications. The manufacturers seem to have the relevant information, but it is not always added to their medications' official information, putting these patients at higher risk for errors. RELEVANCE TO CLINICAL PRACTICE This study shows that if there is no clear statement about administration through feeding tubes on official manufacturers' information, this should be sought directly from manufacturers or marketing authorization holders, and the data could be incorporated into local guidelines.
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Affiliation(s)
- Kersti Teder
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Liisa Jõhvik
- Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Andres Meos
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Marika Saar
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Alesya Visbek
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Daisy Volmer
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Juri Karjagin
- Institute of Clinical Medicine, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
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3
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Boullata JI. Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective. Nutr Clin Pract 2020; 36:111-132. [PMID: 33373487 DOI: 10.1002/ncp.10615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/15/2020] [Indexed: 12/26/2022] Open
Abstract
The administration of medication through an enteral access device requires important forethought. Meeting a patient's therapeutic needs requires achieving expected drug bioavailability without increasing the risk for toxicity, therapeutic failure, or feeding tube occlusion. Superimposing gut dysfunction, critical illness, or enteral nutrition-drug interaction further increases the need for a systematic approach to prescribing, evaluating, and preparing a drug for administration through an enteral access device. This review will explain the fundamental factors involved in drug bioavailability through the gut, address the influencing considerations for the enterally fed patient, and describe best practices for enteral drug preparation and administration.
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Affiliation(s)
- Joseph I Boullata
- Department of Clinical Nutrition Support Services, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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4
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Escrivá Gracia J, Aparisi Sanz Á, Brage Serrano R, Fernández Garrido J. Medication errors and risk areas in a critical care unit. J Adv Nurs 2020; 77:286-295. [PMID: 33107622 DOI: 10.1111/jan.14612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/03/2020] [Accepted: 10/02/2020] [Indexed: 11/28/2022]
Abstract
AIMS The aim of this study was to identify the main medication errors, their causality and the highest risk areas in critical care. DESIGN A descriptive, longitudinal and retrospective study. METHODS We performed a systematic analysis of the prescription, transcription and administration records of 2,634 dose units of medications that were administered to a total of 87 critically ill patients during 2018. RESULTS Final results have shown important medication errors and a high number of significant drug interactions; prescription phase had the highest mistake rate (71%) and cause of errors (68%); transcription stage had a more variable error typology. A significant correlation was observed between the presence of causes and contributing factors to error during the prescription and the commission of errors during the nurse transcription, being the main risk areas the time of antibiotic administration, dilution errors, concentration and speed of administration of high-risk medications and the technique used for nasogastric tube drug administration. CONCLUSION In critical care, an intolerable number of medication errors are still committed, placing the origin of many of them in the causality and contributing factors identified in the prescription stage. IMPACT The origin of many of the medication errors and most interactions is in the prescription stage, being the nurse transcription (nurse intervention) in an important filter that prevents a considerable number of errors from finally reaching the patient. The schedule of administration of time-dependent antibiotics, high-risk medications and the technique of administering medications through a nasogastric tube are important risk areas for the commission of medication errors.
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Affiliation(s)
| | - Álvaro Aparisi Sanz
- Cardiology Department, Valladolid University Clinical Hospital, Valladolid, Spain
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5
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Escrivá Gracia J, Brage Serrano R, Fernández Garrido J. Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC Health Serv Res 2019; 19:640. [PMID: 31492188 PMCID: PMC6729050 DOI: 10.1186/s12913-019-4481-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 08/28/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Medication errors are a serious and complex problem in clinical practice, especially in intensive care units whose patients can suffer potentially very serious consequences because of the critical nature of their diseases and the pharmacotherapy programs implemented in these patients. The origins of these errors discussed in the literature are wide-ranging, although far-reaching variables are of particular special interest to those involved in training nurses. The main objective of this research was to study if the level of knowledge that critical-care nurses have about the use and administration of medications is related to the most common medication errors. METHODS This was a mixed (multi-method) study with three phases that combined quantitative and qualitative techniques. In phase 1 patient medical records were reviewed; phase 2 consisted of an interview with a focus group; and an ad hoc questionnaire was carried out in phase 3. RESULTS The global medication error index was 1.93%. The main risk areas were errors in the interval of administration of antibiotics (8.15% error rate); high-risk medication dilution, concentration, and infusion-rate errors (2.94% error rate); and errors in the administration of medications via nasogastric tubes (11.16% error rate). CONCLUSIONS Nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU.
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Affiliation(s)
- Juan Escrivá Gracia
- Department of nursing, University of Valencia, 46001 Jaume Roig St, Valencia, Spain
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6
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Gimenes FRE, Pereira MCA, Prado PRD, Carvalho REFLD, Koepp J, Freitas LMD, Teixeira TCA, Miasso AI. Nasogastric/Nasoenteric tube-related incidents in hospitalised patients: a study protocol of a multicentre prospective cohort study. BMJ Open 2019; 9:e027967. [PMID: 31345968 PMCID: PMC6661907 DOI: 10.1136/bmjopen-2018-027967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 06/26/2019] [Accepted: 07/01/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Hospitalised patients with nasogastric/nasoenteric tube (NGT/NET) are at constant risk of incidents; therefore, healthcare professionals need to routinely monitor risks and adopt strategies for patient safety and quality of care. AIM This study aimed to evaluate the NGT/NET-related incidents in hospitalised patients and associated factors. METHODS This is a multicentre study, with a prospective cohort design. Data will be collected at the general medical ward of seven Brazilian hospitals in the north, northeast, southeast and south. The sample will consist of 391 patients that require an NGT/NET during hospitalisation. Three different methods will be used to identify the incidents: (1) healthcare professionals and patients/caregivers will be required to report any NGT/NET-related incidents; (2) researchers will visit the wards to get information about the incidents with healthcare professionals and patients/caregivers; (3) the researchers will review the medical records looking for information on the occurrence of any NGT/NET-related incidents. Demographic, clinical and therapeutic details will be obtained from the medical records and will be registered in an electronic data collection tool developed for the purposes of this study. The complexity of patients will be assessed by the Patient Classification System, and the severity of comorbid diseases will be assessed through the Charlson Comorbidity Index. IMPLICATION FOR PRACTICE The results may encourage the use of evidence effectively to influence the scientific foundation for clinical practice and the development of evidence-based policies that will prevent, manage and eliminate complications caused by NGT/NET-related incidents, and improve the quality and safety of care provided to hospitalised patients. ETHICS AND DISSEMINATION The study has been approved by the Research Ethics Committee. Detailed information about the study can be provided by the principal investigator. The findings will be reported through academic journals, seminar and conference presentations, social media, print media, the internet and community/stakeholder engagement activities.
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Affiliation(s)
- Fernanda Raphael Escobar Gimenes
- General and Specialized Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
| | - Marta Cristiane Alves Pereira
- General and Specialized Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
| | | | | | - Janine Koepp
- Nursing Department, University of Santa Cruz do Sul, Santa Cruz do Sul, Rio Grande do Sul, Brazil
| | - Ligia Menezes de Freitas
- Nursing Department, Faculty of Science and Technology of Campos Gerais, Campos Gerais, Minas Gerais, Brazil
| | | | - Adriana Inocenti Miasso
- Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, Brazil
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7
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Lord LM. Enteral Access Devices: Types, Function, Care, and Challenges. Nutr Clin Pract 2018; 33:16-38. [PMID: 29365361 DOI: 10.1002/ncp.10019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 08/06/2017] [Indexed: 02/06/2023] Open
Abstract
Enteral access feeding devices are placed in patients who have a functional and accessible gastrointestinal (GI) tract but are not able to consume or absorb enough nutrients to sustain adequate nutrition and hydration. For many individuals, enteral nutrition support is a lifesaving modality to prevent or treat a depleted nutrient state that can lead to tissue breakdown, compromised immune function, and poor wound healing. Psychological well-being is also affected with malnutrition and dehydration, triggering feelings of apathy, depression, fatigue, and loss of morale, negatively impacting a patient's ability for self-care. A variety of existing devices can be placed through the nares, mouth, stomach or small intestine to provide liquid nutrition, fluids, and medications directly to the GI tract. If indicated, some of the larger-bore devices may be used for gastric decompression and drainage. These enteral access devices need to be cared for properly to avert patient discomfort, mechanical device-related complications, and interruptions in the delivery of needed nutrients, hydration, and medications. Clinicians who seek knowledge about enteral access devices and actively participate in the selection and care of these devices will be an invaluable resource to any healthcare team. This article will review the types, care, proper positioning, and replacement schedules of the various enteral access devices, along with the prevention and troubleshooting of potential problems.
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Affiliation(s)
- Linda M Lord
- University of Rochester Medical Center, Rochester, New York, USA
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8
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Chahin A, Opal SM. Severe Pneumonia Caused by Legionella pneumophila: Differential Diagnosis and Therapeutic Considerations. Infect Dis Clin North Am 2017; 31:111-121. [PMID: 28159171 PMCID: PMC7135102 DOI: 10.1016/j.idc.2016.10.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Severe legionella pneumonia poses a diagnostic challenge and requires early intervention. Legionnaire's disease can have several presenting signs, symptoms, and laboratory abnormalities that suggest that Legionella pneumophila is the pathogen, but none of these are sufficient to distinguish L pneumophila pneumonia from other respiratory pathogens. L pneumophila is primarily an intracellular pathogen and needs treatment with antibiotics that efficiently enter the intracellular space.
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Affiliation(s)
- Abdullah Chahin
- Critical Care Division, Miriam Hospital, Brown University Alpert School of Medicine, Providence, RI, USA; Infectious Disease Division, Rhode Island Hospital, Brown University Alpert School of Medicine, Providence, RI, USA.
| | - Steven M Opal
- Critical Care Division, Miriam Hospital, Brown University Alpert School of Medicine, Providence, RI, USA; Infectious Disease Division, Rhode Island Hospital, Brown University Alpert School of Medicine, Providence, RI, USA
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9
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Sohrevardi SM, Jarahzadeh MH, Mirzaei E, Mirjalili M, Tafti AD, Heydari B. Medication Errors in Patients with Enteral Feeding Tubes in the Intensive Care Unit. J Res Pharm Pract 2017; 6:100-105. [PMID: 28616433 PMCID: PMC5463544 DOI: 10.4103/jrpp.jrpp_17_9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective: Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. Methods: A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Findings: Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. Conclusion: In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients’ pharmacotherapy, and more attention should be paid to this issue.
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Affiliation(s)
- Seyed Mojtaba Sohrevardi
- Department of Clinical Pharmacy, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Mohammad Hossein Jarahzadeh
- Department of Anesthesiology and Critical Care, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Ehsan Mirzaei
- Department of Clinical Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Arefeh Dehghani Tafti
- Department of Biostatics and Epidemiology, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Behrooz Heydari
- Department of Clinical Pharmacy, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
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10
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Boullata JI, Carrera AL, Harvey L, Escuro AA, Hudson L, Mays A, McGinnis C, Wessel JJ, Bajpai S, Beebe ML, Kinn TJ, Klang MG, Lord L, Martin K, Pompeii-Wolfe C, Sullivan J, Wood A, Malone A, Guenter P. ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]. JPEN J Parenter Enteral Nutr 2016; 41:15-103. [PMID: 27815525 DOI: 10.1177/0148607116673053] [Citation(s) in RCA: 235] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.
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Affiliation(s)
- Joseph I Boullata
- 1 Clinical Nutrition Support Services, Hospital of the University of Pennsylvania and Department of Nutrition, Drexel University, Philadelphia, Pennsylvania, USA
| | | | - Lillian Harvey
- 3 Northshore University Hospital, Manhasset, New York, and Hofstra University NorthWell School of Medicine, Garden City, New York, USA
| | - Arlene A Escuro
- 4 Digestive Disease Institute Cleveland Clinic Cleveland, Ohio, USA
| | - Lauren Hudson
- 5 Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew Mays
- 6 Baptist Health Systems and University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Carol McGinnis
- 7 Sanford University of South Dakota Medical Center, Sioux Falls, South Dakota, USA
| | | | - Sarita Bajpai
- 9 Indiana University Health, Indianapolis, Indiana, USA
| | | | - Tamara J Kinn
- 11 Loyola University Medical Center, Maywood, Illinois, USA
| | - Mark G Klang
- 12 Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Linda Lord
- 13 University of Rochester Medical Center, Rochester, New York, USA
| | - Karen Martin
- 14 University of Texas Center for Health Sciences at San Antonio, San Antonio, Texas, USA
| | - Cecelia Pompeii-Wolfe
- 15 University of Chicago, Medicine Comer Children's Hospital, Chicago, Illinois, USA
| | | | - Abby Wood
- 17 Baylor University Medical Center, Dallas, Texas, USA
| | - Ainsley Malone
- 18 American Society for Enteral and Parenteral Nutrition, Silver Spring, Maryland, USA
| | - Peggi Guenter
- 18 American Society for Enteral and Parenteral Nutrition, Silver Spring, Maryland, USA
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11
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Hsu CC, Chou CY, Chou CL, Ho CC, Chen TJ, Chiang SC, Wu MS, Wang SW, Lee CY, Chou YC. Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients. PLoS One 2014; 9:e114359. [PMID: 25479360 PMCID: PMC4257670 DOI: 10.1371/journal.pone.0114359] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 11/06/2014] [Indexed: 11/20/2022] Open
Abstract
Background Prescribing inappropriate pill splitting is not rare in clinical practice. To reduce inappropriate pill splitting, we developed an automatic warning system linked to a computerized physician order entry (CPOE) system for special oral formulation drugs in outpatient settings. We examined the impact of the warning system on inappropriate prescribing of pill splitting and assess prescribers' responses to the warnings. Methods Drugs with extended-release or enteric-coated formulations that were not originally intended to be split were recognized as “special oral formulations”. A hard-stop system which could examine non-integer doses of drugs with special oral formulations, provide warnings to interrupt inappropriate prescriptions was integrated in CPOE in a medical center since June 2010. We designed an intervention study to compare the inappropriate splitting before and after the implementation of the warning system (baseline period 2010 January to May vs. intervention period 2010 June to 2011 August). During the intervention period, prescription changes in response to a warning were logged and analyzed. Results A total of 470,611 prescribed drug items with 34 different drugs with special oral formulations were prescribed in the study period. During the 15-month intervention period, 909 warnings for 26 different drugs were triggered among 354,523 prescribed drug items with special oral formulations. The warning rate of inappropriate splitting in the late intervention period was lower than those in baseline period (0.16% vs. 0.61%, incidence rate ratio 0.27, 95% CI 0.23–0.31, P<0.001). In respond to warnings, physicians had to make adjustments, of which the majority was changing to an unsplit pill (72.9%). Conclusions The interruptive warning system could avoid the prescriptions with inappropriate pill splitting. Accordingly, physicians changed their behavior of prescribing special oral formulations regarding inappropriate pill splitting. We suggest the establishment of such system to target special oral formulations with warnings to prevent inappropriate pill splitting.
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Affiliation(s)
- Chia-Chen Hsu
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Yu Chou
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department and Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
- Department of Internal Medicine, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Chia-Lin Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chin-Chin Ho
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Institute of Hospital and Health Care Administration, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Chiung Chiang
- Institute of Hospital and Health Care Administration, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Min-Shan Wu
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sen-Wen Wang
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Yuan Lee
- Information Management Office, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yueh-Ching Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department and Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
- College of Pharmacy, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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