Drug shortages in hospitals: Actors’ perspectives

BackgroundDespite an increasing focus on drug shortages, no standardized global definition of a drug shortage seems to exist. This raises the question of whether healthcare actors are discussing the same phenomenon, which may influence their actions when managing, solving and preventing drug shortages. Further, the literature reports a lack of national contingency plans for managing drug shortages in hospitals.ObjectiveTo explore national-level communication, decision-making and collaboration on drug shortage management carried out in Denmark by secondary healthcare actors.MethodsSeven semi-structured interviews were conducted with actor representatives from Amgros, the procurement department of the hospital pharmacy in the Capital Region of Denmark, two medicine suppliers, two pharmaceutical wholesalers and distributors, and the Danish Medicines Agency. Data was analyzed using a social constructivist approach.ResultsNo common definition of a drug shortage exists among the actors, but referential definitions related to “contract” and delivered “as expected” were identified. Additionally, actors initiate drug shortage procedures differently, and, as efforts are minimally coordinated, the work procedures are often needlessly duplicated. Further, discrepancies in available drug shortage information arise, as information is distributed through different electronic systems, unavailable to all actors. Besides, Amgros (a national organization responsible for tendering and procuring medicines in hospitals) and the procurement department of the hospital pharmacy in the Capital Region of Denmark make joint decisions regarding the choice of alternative drugs. However, the study found that actors had diverse collaborative relationships, especially those with the Danish Medicines Agency, and that these were limited to contact regarding medicine regulations and unlicensed medicine.ConclusionThe study provided insight into national-level communication, decision-making and collaboration on drug shortage management by different actors in hospitals. This knowledge is useful in the development of a national contingency plan for drug shortage management.     

A pharmacist-led medicines review intervention in community-dwelling Māori older adults– a feasibility study protocol

BackgroundPharmacists have a role to play in supporting the optimal use of medicines to ensure older adults receive therapeutic benefit whilst minimising medicines-related harm. In Aotearoa New Zealand (NZ), Māori (Indigenous people of NZ) experience inequities in the determinants of health, including access to medicines, resulting in increased morbidity, earlier onset of chronic conditions and reduced life expectancy. This study aims to test the feasibility of a pharmacist-led medicines review intervention in community-dwelling Māori older adults.MethodThis is a non-randomised, non-controlled feasibility study undertaken within a kaupapa Māori methodological framework which supports the right of Māori to be included throughout the research process and seeks to potentiate transformational, positive change for Māori. The research pharmacist will recruit 30 participants (Māori; 55 years or older; community-dwelling). Participants will undergo a medicines education session with the pharmacist (medicines reconciliation, medicines information, well-being goal setting), with the option to proceed to a medicines optimisation session that includes the participant, pharmacist and primary prescriber (review of potentially inappropriate prescribing (PIP); medicines management plan development). Primary outcomes: participant and prescriber acceptability of intervention. Secondary outcomes include baseline and post-intervention medicines knowledge, PIP and quality of life scores, and number of changes made to the medicines regimen.Ethics and disseminationEthical approval was granted by the Northern B Health and Disability Committee (9/NTB/106). Study results will be disseminated to various stakeholders including Māori communities, health practitioners and providers, and researchers through meetings and conference presentations, lay summaries and peer-reviewed journals. This study is an example of health service design, delivery and evaluation, informed by Indigenous knowledge and methodology, developed explicitly to address inequities in health outcomes for, and with, Māori and will inform the decision to proceed to a randomised controlled trial to test the effect of this intervention.Trial registration numberACTRN12619001070123.     

Effect of pharmacist intervention on antibiotic prophylaxis in orthopedic internal fixation: A retrospective study

BackgroundDespite the availability of guidelines and official policies, antibiotic prophylaxis in clean surgery remains suboptimal.ObjectiveThe aim of this study was to evaluate the clinical effects and cost-effectiveness of pharmacist-led intervention in the perioperative anti-infection prophylaxis of patients undergoing orthopedic internal fixation.MethodsWe performed a retrospective analysis based on the medical records of internal fixation surgery in a tertiary hospital from July 2019 to June 2020. Data were divided into two groups based on whether a full-time pharmacist participated in the treatment. The research parameters included use of antibiotics, rationality of medication, postoperative complications, and related cost. To deal with selection bias, propensity score matching method was employed at a ratio of 1:1. Meanwhile, a cost-effectiveness analysis was used to evaluate the impact of pharmacist intervention on antibiotic prevention in internal fixation surgery.ResultsA total of 537 participants were included in this study. After matching, 236 patients were comparable in each group. During the pharmacist intervention period, less pharmacologic prophylaxis (96.6% vs 100.0%, p = 0.007) and shorter prophylaxis duration (1.60 vs 2.28 days, p < 0.001) were observed. The reasonable rate increased dramatically in usage and dosage (96.6% vs 83.9%, p < 0.001), timing of administration (94.5% vs 78.4%, p < 0.001) and medication duration (64.4% vs 37.7%, p < 0.001). In addition, pharmacist intervention yielded net economic benefits. A remarkable reduction was observed in average length of stay (10.43 vs 11.14 days, p = 0.012), drug cost ($610.57 vs $706.60, p = 0.001) and defined daily doses (2.31 vs 3.27, p < 0.001). The cost-effectiveness ratios, divided drug cost savings by cost of pharmacist time, were 28:1 for drug and 2:1 for antibiotics, respectively.ConclusionPharmacist-driven antibiotic stewardship for orthopedic internal fixation patients improved compliance with peri-procedure antibiotic prophylaxis, and reduced the cost and utilization of antibiotics. This helped to bring significant clinical and economic benefits.     

Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit

BackgroundMinimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists.ObjectiveWe assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team.MethodsIn this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions).ResultsAfter the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p < 0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p = 0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p = 0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month.ConclusionsThe implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.     

Development of a process-oriented quality improvement strategy for the medicines pathway in nursing homes using the SEIPS model

Background and objectiveMedication errors in nursing homes are highly prevalent and occur in different stages of the medicines pathway. The application of the SEIPS (System Engineering Initiative for Patient Safety) model facilitates the identification of work system factors that contribute to errors. Therefore, the aim of our research was to investigate in-depth the medicines pathway in nursing homes by using the SEIPS model and to develop a set of key activities and aggregated key interventions to be used as a basis for quality-improvement strategies.MethodsA variety of qualitative methods, including observations, semi-structured interviews, the development of a flowchart, an expert meeting and a working symposium, were used to identify processes and work system components. Key interventions and activities were developed in three rounds (one development and two validation rounds) across the different research methods to fine-tune the defined key interventions and activities.ResultsOur analysis revealed a large variety of tasks as well as persons elements, aspects related to technology and tools, organisational factors and environmental elements that all interact and influence the medicines pathway. The large number of tasks could be linked to eight overarching processes: prescribing, purchase and ordering, delivery, storage, preparation, administration, monitoring and (re-)admission. After three rounds (one development and two validation rounds), a final set of 137 key activities and 27 aggregated key interventions, concretising the eight processes, was obtained.ConclusionThe in-depth analysis of processes within the medicines pathway in nursing homes resulted in a set of key activities and aggregated key interventions which may serve as a basis for the nursing home sector and policy makers to enhance a safe and efficient medicines pathway.