Improving medication safety in a neonatal intensive care unit.

PURPOSE: A revision of the medication-use process intended to reduce errors on a neonatal intensive care unit (NICU) is described. SUMMARY: A multidisciplinary team conducted a systematic review and implemented multifaceted changes to improve the NICU's medication-use process. These changes were made to improve safety and consistency and make the system more user-friendly. A distinct, unit-specific formulary was created for the drug products used on the NICU. Rules were built into the order-entry computer system for these NICU formulary items to identify doses outside the documented range on the basis of body weight. A unit-specific reference was developed detailing all formulary mnemonics, oral drug compounding and i.v. admixture procedures, and guidelines for appropriate product selection. Emergency medication sheets listing the calculated doses by weight for critical or urgent medications were developed; these sheets are provided for every new admission and are updated weekly. End-product-testing procedures for i.v. admixtures and a medication-checking process for the unit's automated dispensing machine were implemented. CONCLUSION: Systematic changes in the medication-use process designed to reduce the opportunity for errors were implemented on an NICU.     

Research on medication use in the neonatal intensive care unit

Introduction: Research on medication use aims at assessing how much of current pharmacotherapy is rational. In neonates, this is hampered by extensive off-label drug use and limited knowledge.

Areas covered: We report on medication use research and have conducted a systematic review of observational studies on medication use to provide an updated overview on characteristics, objectives, methods, and patterns in hospitalized neonates. Moreover, a review on aspects of medication use for opioids, anti-epileptics, gastric acid-related disorders and respiratory stimulants with emphasis on trends and impact of interventions is presented, illustrating how research on medication use can contribute to improved neonatal pharmacotherapy and more focused research. Medication use reports describe patterns and provide signals on irrational use, benchmarking, or can guide research priorities. Moreover, this may generate information on how neonatal health topics and their pharmacotherapy are handled over time or across regions.

Expert opinion: Research on medicine utilization is relevant, since it will inform us on aspects like trends, variability, or about the impact and pattern of implementation of guidelines in neonates. Further progress necessitates to merge datasets on medication use with clinical characteristics, and perinatal drug use remains an area in need of additional research.     

重症监护患者营养支持用药分析

目的 调查我院重症监护患者使用营养制剂情况,为临床合理用药提供参考.方法 统计我院重症监护患者使用营养支持药品的数据,对重症监护患者使用营养支持药品的品种、总金额及各种营养支持药品的用药频度,利用限定日剂量方法进行相关计算和分析.结果 重症监护患者使用的肠外营养制剂共16种,总用药频度是5978,总金额是561 042.54元;使用的肠内营养制剂共4种,总用药频度是1093,总金额276 591.97元.复方氨基酸类、脂肪乳类和肠内营养制剂的金额构成比分别为27.0％、32.9％、33.0％,总金额构成比为92.9％.重症监护患者使用最多的前10位营养支持药品中,肠外营养制剂有9种,而肠内营养制剂仅1种,即肠内营养混悬液(TPF),但是其用药频度达到897,占肠内营养制剂总用药频度(1093)的82.1％,并且在所有营养制剂中排在首位.结论 我院重症监护患者的营养支持方式以肠外营养为主,而肠内营养混悬液是临床易于接受的一种营养制剂.临床为重症监护患者选择营养支持药物,应综合考虑各种因素.     

Simulated medication therapy management activities in a pharmacotherapy laboratory course

Objective. To measure the impact of medication therapy management (MTM) learning activities on students’ confidence and intention to provide MTM using the Theory of Planned Behavior.Design. An MTM curriculum combining lecture instruction and active-learning strategies was incorporated into a required pharmacotherapy laboratory course.Assessment. A validated survey instrument was developed to evaluate student confidence and intent to engage in MTM services using the domains comprising the Theory of Planned Behavior. Confidence scores improved significantly from baseline for all items (p < 0.00), including identification of billable services, documentation, and electronic billing. Mean scores improved significantly for all Theory of Planned Behavior items within the constructs of perceived behavioral control and subjective norms (p < 0.05). At baseline, 42% of students agreed or strongly agreed that they had knowledge and skills to provide MTM. This percentage increased to 82% following completion of the laboratory activities.Conclusion. Implementation of simulated MTM activities in a pharmacotherapy laboratory significantly increased knowledge scores, confidence measures, and scores on Theory of Planned Behavior constructs related to perceived behavioral control and subjective norms. Despite these improvements, intention to engage in future MTM services remained unchanged.     

Impact of a clinical pharmacist on cost saving and cost avoidance in drug therapy in an intensive care unit

The authors performed a study to document the impact of a clinical pharmacist on cost saving and cost avoidance in an intensive care unit, and to evaluate the cost saving and avoidance to justify additional clinical pharmacist positions. Over 13 consecutive 5-day weeks, a clinical pharmacist with 50% teaching responsibility documented time spent and all interventions that impacted the cost of drug therapy. Both cost avoidance and cost saving were documented on change in route, change in dosage, change to another drug, discontinuation of therapy, discontinuation of therapeutic duplication, discontinuation of inappropriate therapy, notification of pharmacy of discrepancy, and improper drug-level monitoring avoidance. Cost analysis was calculated based on acquisition costs. The final cost saving was derived from adding cost avoided and cost saved minus pharmacist salary for the time spent in conducting the study. A total of 310 interventions were documented during the 13 weeks (65 days) of the study. The final cost saving was $79,723, which would extrapolate to an annual savings of $318,891. Although 31.3% of interventions involved change of dosage, interventions involving change to another drug (13.9%) had the largest economic impact ($62,527). The majority (85.4%) of the savings involved costs of medications saved (actual dollars saved rather than avoided). The authors concluded that the clinical pharmacist had a significant impact on the cost of drug therapy in the intensive care unit and that the cost of additional clinical pharmacist positions should be justified.     

Identification of priorities for medication safety in neonatal intensive care.

BACKGROUND: Although neonates are reported to be at greater risk of medication error than infants and older children, little is known about the causes and characteristics of error in this patient group. Failure mode and effects analysis (FMEA) is a technique used in industry to evaluate system safety and identify potential hazards in advance. The aim of this study was to identify and prioritize potential failures in the neonatal intensive care unit (NICU) medication use process through application of FMEA. METHODS: Using the FMEA framework and a systems-based approach, an eight-member multidisciplinary panel worked as a team to create a flow diagram of the neonatal unit medication use process. Then by brainstorming, the panel identified all potential failures, their causes and their effects at each step in the process. Each panel member independently rated failures based on occurrence, severity and likelihood of detection to allow calculation of a risk priority score (RPS). RESULTS: The panel identified 72 failures, with 193 associated causes and effects. Vulnerabilities were found to be distributed across the entire process, but multiple failures and associated causes were possible when prescribing the medication and when preparing the drug for administration. The top ranking issue was a perceived lack of awareness of medication safety issues (RPS score 273), due to a lack of medication safety training. The next highest ranking issues were found to occur at the administration stage. Common potential failures related to errors in the dose, timing of administration, infusion pump settings and route of administration. Perceived causes were multiple, but were largely associated with unsafe systems for medication preparation and storage in the unit, variable staff skill level and lack of computerised technology. CONCLUSION: Interventions to decrease medication-related adverse events in the NICU should aim to increase staff awareness of medication safety issues and focus on medication administration processes.     

Impact of pharmaceutical care on pain and agitation in a medical intensive care unit in Thailand

Background Currently, a lack of pharmaceutical care exists concerning pain and agitation in medical intensive care units (MICU) in Thailand. Pharmaceutical care focusing on analgesics/sedatives would improve clinical outcomes. Objective To investigate the impact of pharmaceutical care of pain and agitation on ICU length of stay (LOS), hospital LOS, ventilator days and mortality. Setting The MICU of a university hospital. Method A before/after study was conducted on mechanically ventilated patients receiving analgesics/sedatives. Medical chart reviews and data collection were conducted in the retrospective group (no pharmacists involved). In the prospective group, pharmacists involved with the critical care team helped select analgesics/sedatives for individual patients. Main outcome measure ICU LOS Results In total, 90 and 66 patients were enrolled in retrospective and prospective groups, respectively. The median duration of ICU LOS was reduced from 10.00 (2.00–72.00) in the retrospective group to 6.50 days (2.00–30.00) in the prospective group (p = 0.002). The median hospital stay was reduced from 30.50 days (2.00–119.00) in the retrospective group to 17.50 days (2.00–110.00) in the prospective group (p < 0.001). Also, the median ventilator days was reduced from 14.00 days (2.00–90.00) to 8.50 days (1.00–45.00), p = 0.008. Mortality was 53.03% in the prospective group and 46.67% in the retrospective group (p = 0.432). Conclusion Pharmacist participation in a critical care team resulted in a significant reduction in the duration of ICU LOS, hospital LOS and ventilator days, but not mortality.     

A description of medication errors reported by pharmacists in a neonatal intensive care unit

Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.     

Sedation in the intensive care unit: an overview

Sedation in the critically ill patient is essential to ensure maximal quality of life in the high-stress environment of the intensive care unit. The main goals of sedation include augmentation of pain control, management of agitation and psychological distress, and improvement of patient tolerance and acceptance of the endotracheal tube and ventilatory support. Ideally, the sedated patient should be asleep yet easily rousable. This is most commonly achieved in practice with a combination of morphine and benzodiazepines although a variety of combinations of drugs have been utilized. Other agents which have been employed include, other opiates such as fentanyl and sufentanil, butyrophenones such as haloperidol, and anesthetics such as propofol. These agents will be reviewed with respect to their role in sedating the critically ill patient.     

A practical approach to hyperglycemia management in the intensive care unit: evaluation of an intensive insulin infusion protocol

STUDY OBJECTIVES: To evaluate the effectiveness and safety of maintaining a target blood glucose concentration of 91-130 mg/dl with a standardized, nurse-managed, intensive insulin infusion protocol outside a study setting, and to determine if a statistically significant favorable effect on morbidity and mortality was achieved. DESIGN: Retrospective, observational, chart review. SETTING: Medical and surgical intensive care units (ICUs) in a community teaching hospital. PATIENTS: One hundred forty-three adult patients who received insulin infusions managed at the discretion of the physician over a 1-year period before initiation of the protocol (control group), and 70 patients who received insulin infusions over a 6-month period with infusion dosages titrated by using the protocol (protocol group). MEASUREMENTS AND MAIN RESULTS: Episodes of hypoglycemia, time within target range, mean blood glucose concentration, frequency of measurement, length of ICU stay, duration of mechanical ventilation, and overall mortality were collected. Hypoglycemic episodes were not significantly different between the groups. Blood glucose concentrations were within target range in 34% of all measurements in the protocol group compared with 23% in the control group (p<0.001, relative risk [RR] 1.48, 95% confidence interval [CI] 1.38-1.58). Once target range was reached on one measurement, 43% of concentrations remained in target range in the protocol group compared with 29% in the control group (p<0.001, RR 1.47, 95% CI 1.38-1.56). Frequency of measurements was higher in the protocol group versus control group (p=0.01); however, clinical difference was minimal. Protocol group had lower overall mortality rate (27% [19/70] vs 32% [46/143], p=0.45), reduced mean ICU length of stay (16.7 +/- 10.6 vs 18.4 +/- 16.0 days, p=0.37), and less mechanical ventilation time (16.5 +/- 9.7 vs 17.0 +/- 15.0 days, p=0.79). CONCLUSION: The nurse-managed insulin infusion protocol improved glycemic control with minimal hypoglycemic episodes compared with baseline practice. A trend toward decreased mortality, ICU length of stay, sand days of mechanical ventilation was observed. When compared with other published protocols, our insulin protocol displays comparable effectiveness with the use of less-frequent blood glucose measurements.     

重症监护室医院感染监控与护理管理

目的降低重症监护室医院感染的发病率。方法总结和探讨1997年～2006年9年间重症监护室医院感染监控与管理的方法和经验。结果机械通气、气管插管、气管切开、呼吸机管道等易引发医院感染。结论控制医院感染,护理部的作用不可低估,护士长的管理作用是关键,全民动员是落实措施的保证。     

神经外科重症监护病房实行规范化有陪管理模式探讨

社会进步改变了人们的生活方式,提高了人们的生活质量,人们的需要层次也在不断地发生着变化。医院从过去严格限制探视陪护到今天成立家庭病房,是“人文关怀”相关理论的充分体现,是建立和谐高效的医患关系的必然趋势。目前,对于重症监护病房(ICU)仍采用无陪管理,目的是减少感染机会,便于病房秩序的管理,避免陪护影响医疗护理工作。我院神经外科重症监护病房(N ICU),2004年7月成立之初亦采用了无陪管理,随着现代医疗制度的不断完善,这种缺少亲情关怀的医疗护理在日常工作中,或多或少出现了医患、护患关系的不和谐。为此我院N ICU从人文关怀的角度出发,自2006年1月进行了规范化有陪管理模式尝试,取得了明显的成效,现报告如下。1对象与方法1.1对象我科N ICU床位5张,配备护士8人,护工1人。2004年7月~2005年12月实施无陪管理患者241例及其家属代表作为对照组;2006年1月~2007年12月实施有陪管理患者276例及其家属代表作为研究组。两组患者在年龄、性别、病种、入住时间及格拉斯哥昏迷评分(GCS)等方面,差异无统计学意义(P>0.05),具有可比性,见表1。表1患者一般情况比较组别例数年龄(岁,x±s)性...     

Antibacterial resistance in the intensive care unit: mechanisms and management

The incidence of multiple antimicrobial resistance of bacteria which cause infections in the intensive care unit is increasing. These include methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, penicillin-resistant Streptococcus pneumoniae and cephalosporin and quinolone resistant coliforms. More recently, pan antibiotic resistant coliforms, including carbapenems, have emerged. The rapidity of emergence of these multiple antibiotic-resistant organisms is not being reflected by the same rate of development of new antimicrobial agents. It is, therefore, conceivable that patients with serious infections will soon no longer be treatable with currently available antimicrobials. Strict management of antibiotic policies and surveillance programmes for multiple resistant organisms, together with infection control procedures, need to be implemented and continuously audited. As intensive care units provide a nidus of infection for other areas within hospitals, this is critically important for prevention of further spread and selection of these resistant bacteria.     

Impact of residential medication management reviews on anticholinergic burden in aged care residents

Objectives:

The primary objective of this study was to investigate the impact of Residential Medication Management Reviews (RMMRs) on anticholinergic burden quantified by seven anticholinergic risk scales.

Design:

Retrospective analysis.

Setting:

Accredited pharmacists conducted RMMRs in aged-care facilities (ACFs) in Sydney, Australia.

Participants:

RMMRs pertained to 814 residents aged 65 years or older.

Measurements:

Anticholinergic burden was quantified using seven scales at baseline, after pharmacists’ recommendations and after the actual GP uptake of pharmacists’ recommendations. Change in the anticholinergic burden was measured using the Wilcoxon sign rank test.

Results:

At baseline, depending on the scale used to estimate the anticholinergic burden, between 36% and 67% of patients were prescribed at least one regular anticholinergic medication (ACM). Anticholinergic burden scores were significantly (p?<?0.001) lower after pharmacists’ recommendations as determined by each of the seven scales. The reduction in anticholinergic burden was also significant (p?<?0.001) after GPs’ acceptance of the pharmacists’ recommendations according to all scales with the exception of one scale which reached borderline significance (p?=?0.052).

Conclusion:

Despite the limitations of the retrospective design and differences in the estimation of anticholinergic burden, this is the first study to demonstrate that RMMRs are effective in reducing ACM prescribing in ACF residents, using a range of measures of anticholinergic burden. Future studies should focus on whether a decrease in anticholinergic burden will translate into improvement in clinical outcomes.     

Survival of patients ventilated in an intensive therapy unit.

The survival of patients who were artificially ventilated in an intensive therapy unit (ITU) of a district general hospital was studied. The first 100 such patients admitted were followed up for at least four years. Of these, 67 survived treatment in the ITU, 47 were discharged from hospital, and 30 survived four years. (Survival in the ITU of patients who did not require ventilation was 89%.) The effects of age, duration of ventilation, and disease were studied, and a higher survival was found in children, in patients ventilated for under 24 hours, and in patients admitted with drug overdosage. Survival was poor in patients aged over 75 and in those who required ventilation after cardiac arrest or myocardial infarction or for chronic obstructive lung disease. The cost of a bed in an ITUs to be used to the greatest effect it is important to define those patients who are most likely to benefit from the facilities they offer.