Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors

Background

Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge.

Objective

To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list.

Design, Participants

We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL?CCVD) Study.

Main Measures

Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors.

Key Results

On admission, 174 of 413 patients (42%) had ??1 PAML error, and 73 (18%) had ??1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ??1 discharge medication error, and 126 (31%) had ??1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR?=?1.46; 95% CI, 1.00?C 2.12) and number of pre-admission medications (IRR?=?1.17; 95% CI, 1.10?C1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR?=?0.54; 95% CI, 0.30?C0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR?=?1.31; 95% CI, 1.19?C1.45) and number of medications changed prior to discharge (IRR?=?1.06; 95% CI, 1.01?C1.11).

Conclusions

Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.     

Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: An observational study

OBJECTIVE: To determine the frequency of medication errors that occurred during the preparation and administration of IV drugs in an intensive care unit. SETTING: The study was conducted in a 12-bed intensive care unit of one of the largest teaching hospitals in Tehran. DESIGN: Data were collected over 16 randomly selected days at different medication round times, between July and September 2006. A trained observer accompanied nurses during intravenous (IV) drug rounds. Medication errors were recorded during the observation times of IV drug administration and preparation. Drugs with the highest rate of use in the intensive care unit (ICU) were selected. Details of the process of preparation and administration of the selected drugs were compared to an informed checklist which was prepared using reference books and manufacturers' instructions. RESULTS: We observed a total of 524 preparations and administrations. The calculated number of opportunities for error was 4040. The number of errors identified were 380/4040 (9.4%). Of those, 33.6% were related to the preparation process and 66.4% to the administration process. The most common type of error (43.4%) was the injection of bolus doses faster than the recommended rate. Amikacin was involved in the highest rate of error (11%) among all the selected medications. It was found that the IV rounds conducted at 9:a.m. had the highest rate of error (19.8%). No significant correlation was found between the rate of error and the nurses' age, sex, qualification, work experience, marital status, and type of working contract (permanent or temporary). CONCLUSIONS: Since our system is devoid of a well-organized reporting system, errors are not detected and consequently not prevented. Administrators need to take the initiative of developing systems that guarantee safe medication administration.     

Optimization of anti‐pseudomonal antibiotics for cystic fibrosis pulmonary exacerbations: VI. Executive summary

Acute pulmonary exacerbations (APE) are well‐described complications of cystic fibrosis (CF) and are associated with progressive morbidity and mortality. Despite aggressive management with two or more intravenous anti‐pseudomonal agents, approximately 25% of exacerbations will result in a loss of lung function. The aim of this review is to provide an overview of the classes of intravenous anti‐pseudomonal antibiotics, the findings of anti‐pseudomonal antibiotic utilization surveys, the current antibiotic dosing recommendations from the U.S. and Europe, and the pharmacokinetic (PK) and pharmacodynamic (PD) differences between CF and non‐CF individuals. Anti‐pseudomonal antibiotic classes include beta‐lactams, aminoglycosides, fluoroquinolones, and colistimethate sodium. Recent surveys of antibiotic utilization in CF Foundation‐accredited care centers have shown that a large number of centers are not following recommended dosing strategies despite published recommendations in the U.S. and Europe. The recommended doses for anti‐pseudomonal antibiotics may be higher than FDA‐approved doses due to PK and PD differences. As a large portion of CF patients will not regain their lung function following an APE, it seems possible that currently available anti‐pseudomonal agents are being used sub‐optimally. As new anti‐pseudomonal agents are not currently available, we suggest the need to optimize antibiotic dosing and dosing regimens used to treat pulmonary exacerbations in an effort to improve outcomes for CF patients infected with Pseudomonas aeruginosa. Pediatr Pulmonol. 2013; 48:525–537. © 2013 Wiley Periodicals, Inc.     

Optimization of anti‐pseudomonal antibiotics for cystic fibrosis pulmonary exacerbations: II. cephalosporins and penicillins

Acute pulmonary exacerbations (APE) are well‐described complications of cystic fibrosis (CF) and are associated with progressive morbidity and mortality. Despite aggressive management with two or more intravenous anti‐pseudomonal agents, approximately 25% of exacerbations will result in a loss of lung function. The aim of this review is to provide an evidence‐based summary of pharmacokinetic/pharmacodynamic (PK/PD), tolerability, and efficacy studies utilizing anti‐pseudomonal cephalosporins (i.e., ceftazidime and cefepime) and penicillins (i.e., piperacillin–tazobactam and ticarcillin–clavulanate) in the treatment of APE and to identify areas where further study is warranted. The ceftazidime and cefepime dosing ranges from the literature are 200–400 mg/kg/day divided every 6–8 hr, maximum 8–12 g/day, and 150–200 mg/kg/day divided every 6–8 hr, up to 6–8 g/day, respectively. The literature supported dosing ranges for piperacillin and ticarcillin are 350–600 mg/kg/day divided every 4 hr, maximum 18–24 g/day of piperacillin component, and 400–750 mg/kg/day divided every 6 hr, up to 24–30 g/day of ticarcillin component, respectively. As a large portion of CF patients will not regain their lung function following an APE, we suggest the need to optimize antibiotic dosing and dosing regimens used to treat an APE in efforts to improve outcomes for CF patients infected with Pseudomonas aeruginosa. Future studies are needed to determine the clinical efficacy of higher than FDA‐approved doses of ceftazidime, cefepime, and ticarcillin–clavulanate in APE. The usefulness of high dose piperacillin (>600 mg/kg/day) may be limited due to treatment‐related adverse effects. Further understanding of these adverse effects in CF patients is needed. Pediatr Pulmonol. 2013; 48:107–122. © 2012 Wiley Periodicals, Inc.     

Optimization of anti‐pseudomonal antibiotics for cystic fibrosis pulmonary exacerbations: III. fluoroquinolones

This review is the third installment in a comprehensive State of the Art series and aims to evaluate the use of fluoroquinolones in the management of P. aeruginosa infection in both children and adults with cystic fibrosis (CF). Oral and intravenous ciprofloxacin have been shown to be well‐tolerated in the treatment of acute pulmonary exacerbations (APE) secondary to P. aeruginosa. Older literature supports an oral dosing regimen of 40 mg/kg/day divided every 12 hr, up to 2 g/day, and intravenous (IV) ciprofloxacin 30 mg/kg/day divided every 8 hr, maximum 1.2 g/day in children, and 750 mg administered orally twice a day or 400 mg IV every 8 hr in adults. However, a recent pharmacodynamic (PD) modeling study shows that the literature, U.S. Food and Drug Administration (FDA)‐approved, and Cystic Fibrosis Foundation (CFF) guideline dosing regimens may be suboptimal for the treatment of P. aeruginosa in APE. Further study is warranted to determine if higher doses of ciprofloxacin are needed. Limited pharmacokinetic (PK), PK/PD, and efficacy studies involving levofloxacin exist in adult patients with CF. No pediatric data exists for levofloxacin in CF patients. Further study is needed to determine the tolerability and efficacy of levofloxacin in APE. At this time, the routine use of levofloxacin in the treatment of APE in pediatric and adult patients cannot be recommended. Pediatr Pulmonol. 2013; 48:211–220. © 2012 Wiley Periodicals, Inc.     

Impact of the Nationwide Intravenous Selenium Product Shortage on the Development of Selenium Deficiency in Infants Dependent on Long‐Term Parenteral Nutrition

Background: For patients dependent on parenteral nutrition (PN), selenium must be supplemented intravenously. A nationwide intravenous selenium shortage began in April 2011. The impact of this shortage on PN‐dependent infants was evaluated by examining the provision of selenium, development of biochemical deficiency, and costs associated with the shortage. Materials and Methods: This single‐center, retrospective study included PN‐dependent infants aged ≤1 year who weighed ≤30 kg, received PN for ≥1 month, and had ≥1 serum selenium measurement. The primary outcome was the incidence of biochemical selenium deficiency. Secondary outcomes included severity of biochemical deficiency, clinical manifestations, costs, and relationship between serum selenium levels and selenium dose. Results: The average selenium dose decreased 2‐fold during the shortage (2.1 ± 1.2 µg/kg/d; range, 0.2–4.6 µg/kg/d) versus the nonshortage period (3.8 ± 1 µg/kg/d; range, 2.4–6 µg/kg/d; P < .001). A linear relationship between serum selenium concentration and selenium dose was observed (r² = 0.42), with a dose of 6 µg/kg/d expected to result in normal serum levels in most cases. Similar proportions of patients developed biochemical deficiency in both groups: shortage period, 59.1%; nonshortage, 66.7%; P = .13. The severity of biochemical deficiency was similar between groups. A significant increase in incremental cost during the shortage was observed. Conclusion: This is the first study examining the impact of the intravenous selenium shortage on PN‐dependent infants. Both groups exhibited similarly high incidences of biochemical selenium deficiency, suggesting higher empiric doses may benefit this population. However, ongoing shortages limit the ability to provide supplementation.