Non‐therapeutic omission of medications in acutely ill patients

Aims and objectives: To examine documentation of medication administration in medical and surgical patients. Study objectives: (1) Determine the point prevalence of non‐therapeutic medication omissions; (2) identify documented reasons for non‐therapeutic medication omissions; (3) examine the relationship between length of stay and medication omissions; and (4) explore the impact of outlier status (e.g. medical patients managed on surgical wards) on medication administration. Background: Acutely ill patients are particularly sensitive to health care errors. We previously identified a 26% rate of non‐therapeutic medication omissions in patients admitted unexpectedly to intensive care unit (ICU) from medical and surgical wards. Design: A point prevalence survey of 162 medical and surgical patients across four sites in the South West of England. Method: Data collected included: all instances of, and reasons for, non‐therapeutic medication omission. We also recorded whether the patient was an ‘outlier’ and examined nursing documentation where no reason for medication omission was given on the drug chart. Results: The number of patients who missed at least one medication was high across all sites (n = 129/162; 79.6%, range 60–88%), with a total of 1077 doses omitted. Patients who were outliers (e.g. surgical patients on a medical ward) were more likely to miss medications (100% versus 74%, p < 0.001). The most common missed medications were analgesia and anti‐inflammatory drugs (28%, 299/1077); 203 of these were due to patient refusal. Conclusions: The extent of medications omitted for non‐therapeutic reasons in medical and surgical patients is of concern. None were recorded as an adverse drug event; however, the extent of omitted or refused medications suggests the need for a review of prescribing and drug administration processes. These findings have important implications for the role of ICU outreach and liaison services, for example, including medication management in the monitoring of patients pre/post‐ICU admission and support/education provided for ward staff. Relevance to clinical practice: Detailed analysis of medication records suggests a number of areas of medication administration that would benefit from review.     

Pharmacist prescribing in the UK - a literature review of current practice and research

OBJECTIVE: To review the research literature to date on pharmacist prescribing in the United Kingdom (UK) and to explore the main areas of care and practice settings including any benefits and limitations. FINDINGS: There are two models of pharmacist prescribing in the UK: pharma\cist supplementary prescribing (SP) introduced in 2003, involving a voluntary partnership between the responsible independent prescriber (a physician or a dentist), the supplementary prescriber and the patient, to implement an agreed patient-specific clinical management plan; and pharmacist independent prescribing (IP) introduced in 2006, responsible for the assessment and consequent management, including prescribing of both undiagnosed and diagnosed conditions. There have been narrative reports of pharmacist SP in different health care settings including primary care, community pharmacies, secondary care and at the primary/secondary care interface; published research within these areas of care is conflicting as to which setting is more suitable for pharmacist prescribing. Initial research reports that almost 50% of pharmacist supplementary prescribers self-reported prescribing with both benefits of and barriers to implementing SP. Research involving other healthcare professionals has indicated that encroachment of traditional roles is likely to occur because of the advent of pharmacist prescribing. A small-scale study has concluded that patients are likely to accept pharmacist prescribing favourably, with another study showing pharmacist prescribing leading to improved adherence to guidelines. There is no published research yet available about practices involving pharmacist IP. DISCUSSION: Most of the literature focuses on pharmacists' perceptions of SP, with little information referring to other stakeholders, including patients. There is also limited published research focusing on clinical and economic outcomes of pharmacist SP. CONCLUSION: This is a rapidly changing aspect of pharmacy practice in the UK, particularly with the more recent introduction of pharmacist IP. It is likely that this area of research will expand rapidly over the coming years.     

Documentation of ED patient pain by nurses and physicians

The purpose of this study was to evaluate ED documentation of patient pain in light of the Joint Commission of Accreditation of Healthcare Organization's emphasis on pain assessment and management. A prospectively designed pain management survey was offered to patients on ED discharge. Documentation of pain intensity by ED nurses and physicians was retrospectively reviewed. Of 302 patients surveyed, 261 (86%) complete charts were available for review. Initial pain assessments were noted on 94% of the charts, but a pain scale was used for only 23% of the patients. Documentation of pain subsequent to therapy was noted on 39% of the charts, but a pain scale was used only 19% of the time. Subsequent to therapy, nurses were 2.2 x more likely to document pain assessments than physicians (30% vs 16%, P <.001). Patients with severe pain on arrival (46% vs 31%, odds ratio [OR] = 1.9, P <.02), chest pain (72% vs 32%, OR = 5.4, P <.001), or those receiving powerful analgesics (62% vs 32%, 3.5, P <.001) were more likely to receive a documented subsequent pain assessment than other patients. Pain severity is not consistently documented in ED patients, especially after therapy has been provided. Patients with severe pain and those receiving powerful analgesics were more likely to have a pain assessment subsequent to ED therapy.     

On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study

Introduction  

Patients admitted to an intensive care unit (ICU) are at high risk for prescribing errors and related adverse drug events (ADEs). An effective intervention to decrease this risk, based on studies conducted mainly in North America, is on-ward participation of a clinical pharmacist in an ICU team. As the Dutch Healthcare System is organized differently and the on-ward role of hospital pharmacists in Dutch ICU teams is not well established, we conducted an intervention study to investigate whether participation of a hospital pharmacist can also be an effective approach in reducing prescribing errors and related patient harm (preventable ADEs) in this specific setting.     

Real-time pharmacy surveillance and clinical decision support to reduce adverse drug events in acute kidney injury: a randomized, controlled trial

OBJECTIVES: Clinical decision support (CDS), such as computerized alerts, improves prescribing in the setting of acute kidney injury (AKI), but considerable opportunity remains to improve patient safety. The authors sought to determine whether pharmacy surveillance of AKI patients could detect and prevent medication errors that are not corrected by automated interventions. METHODS: The authors conducted a randomized clinical trial among 396 patients admitted to an academic, tertiary care hospital between June 1, 2010 and August 31, 2010 with an acute 0.5 mg/dl change in serum creatinine over 48 hours and a nephrotoxic or renally cleared medication order. Patients randomly assigned to the intervention group received surveillance from a clinical pharmacist using a web-based surveillance tool to monitor drug prescribing and kidney function trends. CDS alerting and standard pharmacy services were active in both study arms. Outcome measures included blinded adjudication of potential adverse drug events (pADEs), adverse drug events (ADEs) and time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications. RESULTS: Potential ADEs or ADEs occurred for 104 (8.0%) of control and 99 (7.1%) of intervention patient-medication pairs (p=0.4). Additionally, the time to provider modification or discontinuation of targeted nephrotoxic or renally cleared medications did not differ between control and intervention patients (33.4 hrs vs. 30.3 hrs, p=0.3). CONCLUSIONS: Pharmacy surveillance had no incremental benefit over previously implemented CDS alerts.     

Characteristics of Frequent Users of Emergency Medical Services in Singapore

Objectives: This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates. Methods: All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n?=?243), with admission the primary outcome. Results: The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p?=?0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p?=?0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p?<?0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p?<?0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p?<?0.001). Many were picked up from public areas (45.5% vs. 19.6%, p?<?0.001), and had lower acuity triage scores at both EMS (p?<?0.001) and ED (p?=?0.001). They had lower admission rates (40.5% vs. 78.7%, p?<?0.001) and shorter length of stay (4.3 vs. 5.9 days, p?<?0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions. Conclusion: Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission     

Antiretroviral prescribing errors in hospitalized patients

OBJECTIVE: To quantify error type and frequency and to identify factors associated with antiretroviral prescribing errors in hospitalized HIV-infected patients. DESIGN: Systematic evaluation of all medication prescribing errors involving antiretroviral medications between January 1, 1996, and October 31, 1998. Each error was concurrently evaluated for the potential to result in adverse patient consequences. Each error was retrospectively evaluated by three pharmacists and assigned a "likely related factor." SETTING: A 631-bed tertiary care teaching hospital. PARTICIPANTS: All physicians prescribing antiretroviral medications during the study period and all staff pharmacists involved in the routine review of medication orders. MAIN OUTCOME MEASURES: Type and frequency of prescribing errors involving antiretrovirat medications and frequency of association of likely related factors to errors. RESULTS: A total of 108 clinically significant prescribing errors involving antiretrovirals were detected during the 34-month study period. The most common errors were overdosing and underdosing. Overall, errors occurred in 5.8% of admitted patients prescribed antiretroviral medications. The rate of error increased from 2% of admissions in 1996 to 12% of admissions in 1998. The most common likely related factors associated with errors were confusion/lack of familiarity regarding appropriate dosing frequency (30.3%) or dosage (25.5%), and confusion due to need for multiple dosage units per dose (13%). CONCLUSIONS: Hospitalized patients taking antiretrovirals are at risk for adverse outcomes due to prescribing errors. This risk has increased with the rising complexity of antiretroviral drug regimens. A limited number of factors are associated with a large proportion of antiretroviral prescribing errors. This information should be considered in the development of medication error prevention strategies necessary to prevent adverse patient outcomes resulting from such errors.     

Reducing preventable medication safety events by recognizing renal risk

Evidence suggests that medication safety may be improved through more accurate assessment of renal function and appropriate dosing of renally cleared medications. The purpose of this article is to describe patient renal risk groups, associated medication errors, and ways that nurses can improve renal assessment. METHODS: Medication safety data were collected through voluntary reporting, computerized triggers, pharmacist surveillance, and retrospective chart review. Data were analyzed across 3 renal risk groups. RESULTS: Findings indicated that regarding the detected medication errors, elderly women were more likely to have hidden renal risk and that prescribing errors involving a wrong dose occurred more often in patients with high and hidden renal risk. Antibiotic and diabetic medications were the primary drug categories involved in these medication errors. RECOMMENDATIONS: Results indicated that identification of patients with hidden renal risk can be improved by routinely assessing serum creatinine and estimated creatinine clearance levels during renal assessments. Clinical nurse specialists can use this evidence to promote safer nursing care of renal patients.     

A comparison of pharmacists and physicians on the quality of prescribing for ambulatory hypertensive patients

This article discusses a quasi-experimental study of the quality of pharmacists' and physicians' drug prescribing for ambulatory hypertensive patients in a health maintenance organization. The null hypothesis was that there is no difference between pharmacists and physicians as to the quality of drug prescribing for hypertensive patients. Analysis revealed no difference in prescribing between the physician group and the pharmacist group on the scoring for the presence of drug interactions, appropriateness of quantities, dose, and patient directions. The pharmacist prescriber group did significantly better than the physician group, however, on choosing the appropriate drug, prescribing for a "positive effect on the patient's health," and overall appropriateness from combining all the above scales (p less than 0.05). The diastolic pressures of the patients assigned to the pharmacists' group were not significantly different from the physicians' group on pretest, but on posttest the diastolic pressures were slightly lower in the pharmacists' group (p less than 0.10).     

Diffusion of pharmacist interventions within the framework of clinical pharmacy activity in the clinical ward

BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors. OBJECTIVES: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance. METHODS: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital. RESULTS: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01). CONCLUSION: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.     

Raising Our HEADSS: Adolescent Psychosocial Documentation in the Emergency Department

Objectives: To determine the effectiveness of a chart stamp featuring the acronym "HEADSS" (Home, Education, Alcohol, Drugs, Smoking, Sex) at improving adolescent psychosocial documentation in the emergency department (ED) chart. Methods: The study sample consisted of ten emergency physicians. The ED charts of 306 adolescent patients (aged 13–18 years) completed by these physicians were surveyed. An analysis of ED chart psychosocial documentation was conducted that compared a six-week control phase (with no chart stamp) with a four-week intervention phase (with a chart stamp featuring the HEADSS acronym). Presenting complaints in the ED, psychosocial documentation in the ED, and information from past medical records were compared between the two groups. Results: The ED charts surveyed consisted of 153 charts from each phase. HEADSS documentation ranged from 8% to 12% in the intervention phase and 0% to 7% in the control phase. Emergency physicians were more likely to document the topics of education (p = 0.029), alcohol (p = 0.045), and smoking (p = 0.009) as well as whether the patient was interviewed alone (p = 0.0001) in the intervention phase charts. Documentation of a detailed psychosocial assessment (>4/6 HEADSS topics addressed; p = 0.003) was more likely during the intervention phase. Conclusions: The HEADSS stamp is useful in prompting psychosocial documentation in the ED chart. Further study is needed to determine whether routine use of the HEADSS stamp technique can improve the detection and management of adolescent psychosocial problems.     

Recording of drug allergies: are we doing enough?

OBJECTIVE: To assess the implementation of local and national guidelines concerning documentation of drug/clinical hypersensitivities. DESIGN: Audit with retrospective and prospective components used to assess the process of drug hypersensitivity documentation. PATIENTS: Fifty surgical inpatients' notes were retrospectively analysed followed by 63 patients prospectively. SETTING: West London teaching hospital. MAIN OUTCOME MEASURES: Drug hypersensitivity status correctly indicated on clinical notes, drug 'Kardex' charts, and anaesthetic records; these three documents were to concur. Hypersensitivities qualified according to symptoms experienced. RECOMMENDATIONS: Standardization of preoperative clinical notes and multidisciplinary responsibility for records between doctor, nurse and pharmacist. RESULTS: Hypersensitivity documentation in clinical notes improved by 7% after the introduction of a formalized history sheet for preoperative clinics. These were based upon the anaesthetic charts, which had demonstrated 100% documentation previously. Considerable improvements (70.8%) in the clarification of adverse reaction symptoms post recommendation were shown; this was also attributed to the new history sheet. Concurrence improved by 2%. CONCLUSIONS: The original study revealed areas for improvement and provided part of the solution--a more standardized preoperative assessment tool. Multidisciplinary cooperation in addition to formalizing the assessment process has led to a more efficient and safer service for patient and medicolegally for health care professionals. KEY MESSAGES: (1) Standardized forms, for the recording of clinical information preoperatively, ensure relevant guidelines are implemented in practice. (2) Multidisciplinary teams provide a vital safety net for their patients and colleagues.     

A retrospective observation of corticosteroid use at the end of life in a hospice

This study aimed to clarify corticosteroid prescribing during final hospice care, realizing the clinical and ethical dilemmas that may be associated with this therapy. A retrospective review was performed of deaths occurring at our unit during a 6-month period. Corticosteroid use was recorded from drug charts and cross-referenced by case note review. Fifty-one percent of 178 patients received corticosteroids, which were continued until death in 53%. Only 2% were switched from oral to parenteral corticosteroids. The reason for using corticosteroids was documented in 67% of patients. The main indications included treatment for raised intracranial pressure and to give a "boost." The foremost reason for withdrawing corticosteroids was loss of the oral route. These data confirm the high prevalence of corticosteroid use in the terminal phase, even until death. This contrasted with the near absolute withdrawal of corticosteroids once the oral route was lost. The study suggests a need for greater vigilance in corticosteroid prescribing, and identified issues to be addressed in the prescribing of these drugs.