High-risk Medications Research Articles

Rapid (7-Day) Readmissions to an Inpatient Medical Service at a Tertiary, Academic Medical Center

Background: Rapid readmissions, occurring within 7 days of hospital discharge, are associated with significant morbidity and mortality. Objectives: Identify causes of rapid readmissions with a focus on clinical judgement errors and improve discharge practices. Methods: Records of 371 patients discharged from an inpatient medical service and readmitted within 7 days were reviewed. Causes for readmission were identified and classified into 10 categories, including diagnostic and/or therapeutic error leading to readmission. Results: Fifty percent of rapid readmissions were related to severity of underlying disease/failure to respond to treatment. Adherence challenges, patients with known high hospital utilization, and substance use disorder/uncontrolled psychiatric conditions accounted for 32.4% of 7-day readmissions. Readmissions related to clinical judgement accounted for 24 (6.5%) of the total readmissions. Clinical judgement errors were comprised of 6 diagnostic and 18 therapeutic errors, involving infections, diabetic medications and anticoagulation agents. Conclusions: Most rapid readmissions are related to the severity of the condition during the index hospitalization. Clinical judgement errors are a rare cause for rapid readmission and involve certain high-risk medications and symptoms which require a high degree of awareness from the discharging provider.

1067-P: A National Physician Survey Examining Clinical Scenarios for Deintensifying Diabetes Medications

Many older adults with type 2 diabetes (T2D) are tightly controlled with high hypoglycemia risk medications and may benefit from deintensifying (stopping/reducing) or switching to newer medications. As deintensifying rarely occurs in practice, we aimed to determine how physicians make these decisions. We conducted a national survey of a random sample of US physicians in general medicine, geriatrics, and endocrinology. The survey was designed by a team of patients, caregivers, and physicians, and distributed in 3 mailing waves. Physicians were asked what action they would take in three scenarios of patients with T2D treated below individualized targets: 1) a healthy 79F with HbA1c 6.3% on a sulfonylurea; 2) a 77M with stage 4 kidney disease with HbA1c 7.3% on basal insulin; 3) a 78F with advanced dementia with HbA1c 7.7% on a sulfonylurea. Scenarios started with a base case of the patient reporting no medication issues, then varied hypoglycemia history, health, and patient preferences. Statistical comparisons used multinomial logistic regression accounting for clustering. We received 427 responses to date, response rate 27%. In the base case, 57% of physicians made no change to the high-risk medication, 16% switched, 12% decreased, 12% stopped, and 3% increased. Decreasing/stopping occurred over twice as often in scenario 1 than other scenarios (p<0.001) . In scenario variations, hypoglycemia of any severity led >95% of physicians to decrease, stop or switch the high-risk medication. Worsening health status also caused substantially more deintensification, but polypharmacy, financial barriers, and patient preference did not. Endocrinologists were 3-5 times as likely to switch medications compared to other specialties (p<0.001) . Overall, we found clinical inertia to deintensify high-risk diabetes medications, especially in medically complex patients with HbA1c >7.0%. Hypoglycemia and worsening health were strong motivators to deintensify or switch to newer medications. Disclosure S.J.Pilla: None. N.Schoenborn: None. C.Boyd: Other Relationship; Dynamed, UpToDate. S.Golden: Advisory Panel; Abbott Diabetes, Medtronic. N.N.Mathioudakis: None. N.M.Maruthur: Other Relationship; Johns Hopkins HealthCare Solutions. Funding National Institutes of Health (1R24AG064025 and 1K23DK128572)

Coprescribing of opioids and high-risk medications in the USA: a cross-sectional study with data from national ambulatory and emergency department settings

ObjectiveDescribe trends in opioid plus high-risk medication coprescribing in the USA.DesignAnalyses of serial, cross-sectional, nationally representative data of the National Ambulatory Medical Care Survey (NAMCS) over 2007–2016 and the National...

Geriatrics Fellow-led Educational Session for Nursing Home Staff About High-Risk Medications

Older adults in skilled nursing facilities are often complex and at high-risk for polypharmacy and adverse medication reactions. To address these issues, an important step is to be able to identify medications that are high-risk for older adults. The goal of the session was to improve nursing facility interprofessional team awareness of polypharmacy and high-risk medication use for older adults. We aimed to address the core component of “medications” in the 4Ms framework of geriatric care for Age-Friendly Health Systems through collaboration with skilled nursing facility team members.

Initiation of a discharge pharmacy within a busy urban emergency department: The first year.

Discharge prescriptions represent an important aspect of care for patients seen in the emergency department (ED) setting and are used by providers to continue therapy for acute illness once patients leave the ED or to prevent future exacerbations of chronic conditions. The success of an ED discharge and the medications prescribed rely on patient compliance. Compliance depends on patients' ability to obtain prescriptions, which can be hindered by limited access to pharmacies and cost. In order to address issues traditionally associated with medication noncompliance, a discharge pharmacy was implemented within a busy urban ED. The pharmacy began processing prescriptions on December 18, 2019, using a formulary aimed towards providing commonly prescribed and high-risk medications. The pharmacy accepts insurance plans in addition to utilizing 340B Drug Pricing Program pricing to offer affordable medications to patients. During the first year of operation 10,230 prescriptions were filled for 5,703 patients, representing 13% of all patients discharged during that time. Of the prescriptions filled, 35.4% were for products considered high-risk medications, including epinephrine auto-injectors, insulin, and antibiotics. Over 50% of these high-risk medications were provided to patients through reduced cash pricing. Pharmacist interventions were made on 4.3% of prescriptions to address incorrect dosing, avoid use of inappropriate antibiotics, and recommend alternative therapies. The implementation of a discharge pharmacy within the ED allowed over 5,700 patients to be discharged with medications and represents a potential solution to issues surrounding medication noncompliance. Similar initiatives have the opportunity to improve medication access for a larger ED population.

A randomized trial of standard vs restricted opioid prescribing following midurethral sling

Postoperative opioid prescribing has historically lacked information crucial to balancing the pain control needs of the individual patient with our professional responsibility to judiciously prescribe these high-risk medications. This study aimed to evaluate pain control, satisfaction with pain control, and opioid use among patients undergoing isolated midurethral sling randomized to 1 of 2 different opioid-prescribing regimens. Patients who underwent isolated midurethral sling placement from June 1, 2020, to November 22, 2021, were offered enrollment into this prospective, randomized, open-label, noninferiority clinical trial. Participants were randomized to receive either a standard prescription of ten 5-mg oxycodone tablets provided preoperatively (standard) or an opioid prescription provided only during patient request postoperatively (restricted). Preoperatively, all participants completed baseline demographic and pain surveys, including the 9-Question Central Sensitization Index, Pain Catastrophizing Scale, and Likert pain score (scale 0-10). The participants completed daily surveys for 1 week after surgery to determine the average daily pain score, number of opioids used, other forms of pain management, satisfaction with pain control, perception of the number of opioids prescribed, and need to return to care for pain management. The online Prescription Drug Monitoring Program was used to determine opioid filling in the postoperative period. The primary outcome was average postoperative day 1 pain score, and an a priori determined margin of noninferiority was set at 2 points. Overall, 82 patients underwent isolated midurethral sling placement and met the inclusion criteria: 40 were randomized to the standard arm, and 42 were randomized to the restricted group. Concerning the primary outcome of average postoperative day 1 pain score, the restricted arm (mean pain score, 3.9±2.4) was noninferior to the standard arm (mean pain score, 3.7±2.7; difference in means, 0.23; 95% confidence interval,-∞ to 1.34). Of note, 23 participants (57.5%) in the standard arm vs 8 participants (19.0%) in the restricted arm filled an opioid prescription (P<.001). Moreover, 18 of 82 participants (22.0%) used opioids during the 7-day postoperative period, with 10 (25.0%) in the standard arm and 8 (19.0%) in the restricted arm using opioids (P=.52). Of participants using opioids, the average number of tablets used was 3.4±2.3, and only 3 participants used ≥5 tablets. On a scale of 1="prescribed far more opioids than needed" to 5="prescribed far less opioids than needed," the means were 1.9±1.0 in the standard arm and 2.7±1.0 in the restricted arm (P<.001). Restricted opioid prescription was noninferior to standard opioid prescription in the setting of pain control and satisfaction with pain control after isolated midurethral placement. Participants in the restricted arm filled fewer opioid prescriptions than participants in the standard arm. On average, only 3.4 tablets were used by those that filled prescriptions in both groups. Restrictive opioid-prescribing practices may reduce unused opioids in the community while achieving similar pain control.

High-Risk Medication in Home Care Nursing: A Delphi Study.

The aims of the study were to reach consensus on which medications in home care nursing should be considered high-risk medication (HRM) and to obtain recommendations about which interventions home care nurses can perform to improve quality of care and safety in managing these HRM. This is an international Delphi study with 13 purposively selected experts from 4 different countries. A 3-round iterative Delphi survey was conducted from May 2018 to October 2018, based on a list of 32 medications previously reported as HRM in community care. A proposal for HRM was based on this literature search, and experts were asked to reflect on which (groups of) medications should be considered HRM by home care nurses (completeness of the list, risk assessment per [group of] medication, the need for home care nurse interventions, and the need for an HRM care procedure). The cutoff point for consensus was set at 80% of expert agreement. The panel assessed the initial list and added 30 (groups of) medications. In the last round, consensus of 80% or more was reached for 27 (groups of) medications to be considered HRM by home care nurses. For 28 medications, additional interventions by a home care nurse were considered warranted. A procedure or protocol for home care nurses was deemed necessary for 12 medications. We identified a set of (groups of) medications that should primarily be considered HRM by home care nurses.Impact:• What problem did the study address? This study clarified which medications should be considered HRM by home care nurses.• What were the main findings? Experts identified a set of 27 (groups of) medications that should primarily be considered HRM by home care nurses.• Where and on whom will the research have an impact? The results provide essential information for home care agencies when setting up an HRM policy.

Admission Medication Reconciliations in Pediatric Patients Admitted to an Inpatient Psychiatry Unit.

Medication errors resulting in adverse drug events may occur during transition of care. Most can be prevented with a medication reconciliation. California Senate Bill 1254 requires a pharmacist to perform an admission medication reconciliation (AMR) to obtain an accurate medication list for each high-risk patient upon hospital admission. Adult patient literature reveals that antidepressant, antipsychotic, and mood-stabilizing drugs are high-risk medications likely to cause errors. Therefore, the purpose of this analysis is to determine if pediatric psychiatry inpatients should be considered high risk, meriting an additional AMR by the pharmacy team. This was a retrospective, single-center analysis of pediatric patients admitted to the inpatient psychiatry unit at Rady Children's Hospital, San Diego between January 1 and 31, 2021. All newly admitted patients had an AMR performed by the medical team (physician-led AMR). High-risk patients (prescribed a high-risk medication or 3 or more medications of any kind prior to admission) had an additional AMR by the pharmacy team (pharmacy-led AMR). Differences between these 2 AMRs were examined. Of the 58 patients admitted during the study period, 39 (67.2%) were identified as high risk, warranting an AMR by the pharmacy team. From the 170 medications reviewed, 51 differences (30%) were found between physician-led and pharmacy-led AMR, with 4 (2.4%) of the differences involving high-risk medications. No medications were incorrectly ordered, and no adverse drug events occurred. Given that physician-led and pharmacy-led AMRs of high-risk prescription medications were only marginally different and no medications were incorrectly ordered, the existing AMR methodology used by psychiatrists at our institution is effective at creating a safe medication list.

Understanding medication use behaviors and perspectives in an older cardiovascular patient population: Opportunities for patient-centered deprescribing

Study objectiveDescribe self-reported medication use behaviors and perspectives to identify opportunities for collaborative deprescribing among older cardiovascular patients. DesignPatient survey using convenience sampling. SettingPrivate cardiology practice in Maricopa County, Arizona, USA. ParticipantsEstablished patients aged ≥65 years with an active medication list indicating prescription polypharmacy (≥5 medications) and/or use of ≥1 high risk medication (anticoagulant, antiarrhythmic, anti-hypotensive, insulin). InterventionAnonymous online survey. Main outcome measuresCurrent medication use (prescription and over-the-counter), self-reported medication use behaviors measured by the Adherence to Refills and Medications Scale (ARMS-12), and perspectives on deprescribing. ResultsOverall, 138 participants were recruited, with a mean age of 76.7 years. All but two self-identified as Caucasian. Prescription polypharmacy was reported by 80 (58.0 %), with use of 5–9 medications by 66 (47.8 %) and use of ≥10 medications (excessive polypharmacy) by 14 (10.1 %). Approximately one-third (n = 45, 32.6 %) had ARMS = 12, indicating adherence to taking and refilling medications. More than 1 in 10 patients (11.6 %) used >1 high-risk medication. About 4 in 10 (40.6 %) used ≥5 OTC medications. Most highly prioritized reasons for continuing medications were to prolong life (40 %), feel better (17 %), and reduce stroke risk (15 %). Despite 66.7 % of patients indicating taking “just the right amount of medications,” willingness to stop ≥1 medication was very high at 80.4 %. ConclusionAmong older cardiovascular patients, prescription polypharmacy is prevalent as are medication use behaviors associated with some degree of nonadherence. Patients are supportive of deprescribing. Prioritizing what matters most to patients and focusing efforts to deprescribe potentially inappropriate medications is recommended.

MP07-13 MEDICATIONS MOSTLY ASSOCIATED WITH HAEMATURIA: ASSESSMENT OF THE EUDRAVIGILANCE (EV) AND FOOD AND DRUG ADMINISTRATION (FDA) PHARMACOVIGILANCE DATABASES ENTRIES

You have accessJournal of UrologyCME1 May 2022MP07-13 MEDICATIONS MOSTLY ASSOCIATED WITH HAEMATURIA: ASSESSMENT OF THE EUDRAVIGILANCE (EV) AND FOOD AND DRUG ADMINISTRATION (FDA) PHARMACOVIGILANCE DATABASES ENTRIES Lorenzo Maria Rovesti, Antonio Nacchia, Ferdinando Di Giacomo, Giuseppe Disabato, Carmen Gravina, Giacomo Gallo, Jordi Stira, Beatrice Turchi, Alessandro Guercio, Riccardo Lombardo, Antonio Cicione, Olivia Alessandra Voglino, Valeria Baldassarri, Giorgio Guarnotta, Elisa Mancini, Antonio Franco, Simone D'Annunzio, Andrea Tubaro, and Cosimo De Nunzio Lorenzo Maria RovestiLorenzo Maria Rovesti More articles by this author , Antonio NacchiaAntonio Nacchia More articles by this author , Ferdinando Di GiacomoFerdinando Di Giacomo More articles by this author , Giuseppe DisabatoGiuseppe Disabato More articles by this author , Carmen GravinaCarmen Gravina More articles by this author , Giacomo GalloGiacomo Gallo More articles by this author , Jordi StiraJordi Stira More articles by this author , Beatrice TurchiBeatrice Turchi More articles by this author , Alessandro GuercioAlessandro Guercio More articles by this author , Riccardo LombardoRiccardo Lombardo More articles by this author , Antonio CicioneAntonio Cicione More articles by this author , Olivia Alessandra VoglinoOlivia Alessandra Voglino More articles by this author , Valeria BaldassarriValeria Baldassarri More articles by this author , Giorgio GuarnottaGiorgio Guarnotta More articles by this author , Elisa ManciniElisa Mancini More articles by this author , Antonio FrancoAntonio Franco More articles by this author , Simone D'AnnunzioSimone D'Annunzio More articles by this author , Andrea TubaroAndrea Tubaro More articles by this author , and Cosimo De NunzioCosimo De Nunzio More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002529.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Drugs may have a direct causative role in triggering haematuria. The range of medications which may be responsible for haematuria is wide but little is known on those which are most frequently involved. We aimed at identifying 1) which medications are associated with most haematuria reports; 2) within the high-risk list of medications, comparing their potential to cause haematuria through a disproportionality analysis. METHODS: The Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database was queried to identify the drugs which were associated the most with haematuria individual reports till 30 June 2021 (Table). Only those drugs with a minimum of 400 haematuria reports were here considered for disproportionality analysis. 11 drugs were identified. We recorded the number of haematuria reports for these 11 drugs in EudraVigilance (EV) database. Proportional Reported Ratios (PRRs) were computed for all the drugs individuated in this way. RESULTS: Overall, 36315 haematuria reports were identified, 15319 of which (43%) were associated with those 11 medications which had a minimum of 400 reports each (Table). Within this group of high-risk medications, Rivaroxaban presented higher risk of haematuria. (Table). Most of the reported haematuria for drugs were presented in the 65-85 range of age (37%). Serious cases including death were 32131 (88%). EV database analysis confirmed the highest rate of haematuria reports for Rivaroxaban (5042 events of which 302 serious (6%), with 31 deaths (1%)) within anticoagulants and for Aspirin (2404 events of which 101 serious (4%) with 18 deaths (1%)) within antiplatelets. CONCLUSIONS: 11 drugs were here identified as being associated with significant reporting levels for haematuria. Among them Rivaroxaban was responsible for the most reports as in FDA FAERS database as in EV database and generated the strongest signal of disproportionate reporting. Prescribers should inform those treated with these medications about the risk of haematuria and its sequelae. These results require to be further integrated with clinical evidence. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e120 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lorenzo Maria Rovesti More articles by this author Antonio Nacchia More articles by this author Ferdinando Di Giacomo More articles by this author Giuseppe Disabato More articles by this author Carmen Gravina More articles by this author Giacomo Gallo More articles by this author Jordi Stira More articles by this author Beatrice Turchi More articles by this author Alessandro Guercio More articles by this author Riccardo Lombardo More articles by this author Antonio Cicione More articles by this author Olivia Alessandra Voglino More articles by this author Valeria Baldassarri More articles by this author Giorgio Guarnotta More articles by this author Elisa Mancini More articles by this author Antonio Franco More articles by this author Simone D'Annunzio More articles by this author Andrea Tubaro More articles by this author Cosimo De Nunzio More articles by this author Expand All Advertisement PDF DownloadLoading ...

Characterizing the temporal changes in association between modifiable risk factors and acute kidney injury with multi-view analysis

BackgroundAcute kidney injury (AKI) is a common life-threatening clinical syndrome in hospitalized patients. Advances in machine learning has demonstrated success in AKI risk prediction using electronic health records (EHRs). However, to prevent AKI, it is critical to identify clinically modifiable factors and understand their impact at different prevention windows. MethodWe extracted 4129 clinical variables including demographics, social history, past diagnoses, procedures, labs, medications, vitals from EHRs for a cohort of 144,084 eligible inpatient encounters. We developed a multi-view learning framework for XGBoost (MV-XGB) to enhance algorithm attention on modifiable factors. To study effects of modifiable factors at different time points, we built AKI prediction models at 24-hours, 48-hours, 72-hours before AKI onset. To characterize the temporal changes in effect of modifiable factors on AKI, we derived two indicators, inter-class score-difference and exposed-score-difference, based on SHAP values to compare effects of modifiable factors in different windows. ResultMV-XGB effectively increased attention on modifiable factors (explained 92.4%-94.1% inter-class score-difference, i.e., predictive difference between AKI and non-AKI samples) while maintaining good predictive performance (AUROCs were 0.854, 0.798, 0.765 in models for 24–48-72 h AKI prediction respectively). We observed that 62% of predicted odds-ratio difference between AKI and non-AKI patients in 24 h can be explained by factors occurring between 24 and 72 h. Among the important modifiable factors, electrolyte balance explained 38.3% of the inter-class score difference increase between 24 h and 72 h, followed by high-risk medications (13.7%), care strategy (12.1%), blood pressure (10%), infection (7.8%), and anemia (5.4%). Effects of cardiac surgery or condition, respiratory ventilation, and anemia remained important longer than 72 h. ConclusionBetter understanding of the clinically modifiable factors is important to AKI prevention. The proposed multi-view learning approach improved the identification of modifiable factors of AKI and allowed characterization of the temporal dynamics of their potential benefit in intervention.

Overcoming Decisional Gaps in High-Risk Prescribing by Junior Physicians Using Simulation-Based Training: Protocol for a Randomized Controlled Trial.

BackgroundGaps between rational thought and actual decisions are increasingly recognized as a reason why people make suboptimal choices in states of heightened emotion, such as stress. These observations may help explain why high-risk medications continue to be prescribed to acutely ill hospitalized older adults despite widely accepted recommendations against these practices. Role playing and other efforts, such as simulation training, have demonstrated benefits to help people avoid decisional gaps but have not been tested to reduce overprescribing of high-risk medications.ObjectiveThis study aims to evaluate the impact of a simulation-based training program designed to address decisional gaps on prescribing of high-risk medications compared with control.MethodsIn this 2-arm pragmatic trial, we are randomizing at least 36 first-year medical resident physicians (ie, interns) who provide care on inpatient general medicine services at a large academic medical center to either intervention (simulation-based training) or control (online educational training). The intervention comprises a 40-minute immersive individual simulation training consisting of a reality-based patient care scenario in a simulated environment at the beginning of their inpatient service rotation. The simulation focuses on 3 types of high-risk medications, including benzodiazepines, antipsychotics, and sedative hypnotics (Z-drugs), in older adults, and is specifically designed to help the physicians identify their reactions and prescribing decisions in stressful situations that are common in the inpatient setting. The simulation scenario is followed by a semistructured debriefing with an expert facilitator. The trial’s primary outcome is the number of medication doses for any of the high-risk medications prescribed by the interns to patients aged 65 years or older who were not taking one of the medications upon admission. Secondary outcomes include prescribing by all providers on the care team, being discharged on 1 of the medications, and prescribing of related medications (eg, melatonin, trazodone), or the medications of interest for the control intervention. These outcomes will be measured using electronic health record data.ResultsRecruitment of interns began on March 29, 2021. Recruitment for the trial ended in Q42021, with follow-up completed by Q12022.ConclusionsThis trial will evaluate the impact of a simulation-based training program designed using behavioral science principles on prescribing of high-risk medications by junior physicians. If the intervention is shown to be effective, this approach could potentially be reproducible by others and for a broader set of behaviors.Trial RegistrationClinicalTrials.gov NCT04668248; https://clinicaltrials.gov/ct2/show/NCT04668248International Registered Report Identifier (IRRID)PRR1-10.2196/31464

Evaluation of a Pharmacist-Led Telephonic Medication Therapy Management Program in Rural Arizona: Implications for Community Health Practice

This study evaluated a pharmacist-led telephonic Medication Therapy Management (MTM) program for rural patients in Arizona with poor access to healthcare services. A pharmacist provided telephonic MTM services to eligible adult patients living in rural Arizona communities with a diagnosis of diabetes and/or hypertension. Data were collected and summarized descriptively for demographic and health conditions, clinical values, and medication-related problems (MRPs) at the initial consultation, and follow-up data collected at 1 and 3 months. A total of 33 patients had baseline and one-month follow-up data, while 15 patients also had three-month follow-up data. At the initial consultation, the following MRPs were identified: medication adherence issues, dose-related concerns, adverse drug events (ADE), high-risk medications, and therapeutic duplications. Recommendations were made for patients to have the influenza, herpes zoster, and pneumonia vaccines; and to initiate a statin, angiotensin converting enzyme inhibitor, angiotensin receptor blocker, beta-blocker, and/or rescue inhaler. In conclusion, this study demonstrated that while pharmacists can identify and make clinical recommendations to patients, the value of these interventions is not fully realized due to recommendations not being implemented and difficulties with patient follow-up, which may have been due to the COVID-19 pandemic. Additional efforts to address these shortcomings are therefore required.

Administration of High-Risk Medication: A Hospital Based Prospective Study

Background: High-risk medicines are outlined as those medicines that have a high risk of inflicting pain or death once employed to patients in error. Hence, this work was done to identify key parameters of mishandling observed by the administration on high-risk medication.&#x0D; Methods: The audit team conjointly assessed compliance with policies and tips associated with the administration of medication. Moreover, key documents including several of the nursing ability checklists were reviewed. The major attributes are taken as ICU, ER, Wards, Pre-Post-Operative &amp; CCU. The measurable elements include documented policies, and procedures for medication administration; close monitoring on records for adverse drug incidents. Analysis revealed that a significant improvement in high-risk medicine accessibility along with the provision of a list of drugs, high-risk medicines were still found at patient bedside in few scenarios. Nurses were found to be highly knowledgeable regarding high-risk medications policies but fall short in executing them at workstations.&#x0D; Results: Findings suggest that there is a need for revision in policies concerning high-risk medicines placement and storage; and also, they must be separated from the usually used medicines; timely training programs should be conducted for staff and individual attention. Documentation related to high-risk medicines starting from prescription, double authentication, verification, pre-, and post-administration should be improvised. Special attention needs to be paid to reporting medication errors like prescription errors; adverse drug reactions related to high-risk medicine administration.

Cocreating the ICU-PAUSE Tool for Intensive Care Unit-Ward Transitions.

BackgroundIntensive care unit (ICU)–ward patient transfers are inherently high risk, and clinician miscommunication has been linked to adverse events and negative outcomes. Despite these risks, few educational tools exist to improve resident handoff communication at ICU–ward transfer.ObjectiveWe used human-centered design (HCD) methods to cocreate a novel electronic health record ICU–ward transfer tool alongside Internal Medicine residents at three academic hospitals.MethodsWe conducted HCD workshops at each hospital, performing process mapping, brainstorming, and rapid prototyping. We performed thematic analysis on verbatim-transcribed workshop audio recordings to inform development and adaptation of the final resident prototype into the ICU-PAUSE tool.ResultsICU-PAUSE focuses on reasons for ICU admission and problem-based ICU course (I); Code status, goals of care, and family contacts (C); a diagnostic pause acknowledging Uncertainty (U); Pending tests (P); Active consultants (A); high-risk medications, including medications to be Unprescribed (U); Summary of problems and to-dos (S); and a current physical Exam (E).ConclusionWe used HCD to cocreate a novel, more user-friendly electronic ICU–ward transfer tool, ICU-PAUSE, alongside Internal Medicine trainees. Future steps will involve formal usability testing, evidence-driven implementation, and clinical evaluation of ICU-PAUSE across multiple hospitals.

Potentially Harmful Medication Dispenses After a Fall or Hip Fracture: A Mixed Methods Study of a Commonly Used Quality Measure.

High-risk medication dispenses to patients with a prior fall or hip fracture represent a potentially dangerous disease-drug interaction among older adults. The research team quantified the prevalence, identified risk factors, and generated patient and provider insights into high-risk medication dispenses in a large, community-based integrated health system using a commonly used quality measure. This was a mixed methods study with a convergent design combining a retrospective cohort study using electronic health record (EHR) data, individual interviews of primary care physicians, and a focus group of patient advisors. Of 113,809 patients ≥ 65 years with a fall/fracture in 2009-2015, 35.4% had a potentially harmful medication dispensed after their fall/fracture. Most medications were prescribed by primary care providers. Older age, male gender, and race/ethnicity other than non-Hispanic White were associated with a reduced risk of high-risk medication dispenses. Patients with a pre-fall/fracture medication dispense were substantially more likely to have a post-fall/fracture medication dispense (hazard ratio [HR] = 13.26, 95% confidence interval [CI] = 12.91-13.61). Both patients and providers noted that providers may be unaware of patient falls due to inconsistent assessments and patient reluctance to disclose falls. Providers also noted the lack of a standard location to document falls and limited decision support alerts within the EHR. High-risk medication dispenses are common among older patients with a history of falls/fractures. Future interventions should explore improved assessment and documentation of falls, decision support, clinician training strategies, patient educational resources, building trusting patient-clinician relationships to facilitate long-term medication discontinuation among persistent medication users, and a focus on fall prevention.

Identifying Potential Drug-Related Problems Among Geriatric Patients With Use of an Integrated Clinical Decision Support Tool.

Background: Drug-related problems (DRPs) which arise from potentially inappropriate medications (PIMs) are a common problem in older people with multi-morbidity and polypharmacy. Aim: To develop an integrated PIM clinical decision support tool for identification of DRPs in geriatric multi-morbid polypharmacy patients, using the EU(7)-PIM and EURO-FORTA lists, with a focus on high-risk medications. Methods: The integrated PIM tool used the information on PIMs in both databases—the EU(7)-PIM and EURO-FORTA. PIMs were classified into four color groups based on risk profile: high-risk PIMs (should be avoided in older patients) as red, moderate-risk PIMs (require dose and/or treatment duration adjustment) as yellow, low-risk PIMs (low DRP risk) as green, and questionable PIMs (incomplete/missing information) as grey. Results: The summarized list of the high-risk (red and some grey) PIMs contained 81 active substances and medication classes. According to the ATC classification, most of the high-risk PIMs (n = 60, 74.1%) belong to the A, C, and N medication groups and 50.6% (n = 41) of the high-risk PIMs have currently marketing authorization in Estonia. The preliminary list of the moderate- and low-risk (yellow, green, and other grey) PIMs contained 240 active substances and medication classes, but sub-classification of this category into one or another group depends mainly on an individual patient´s clinical characteristics in a concrete analyzed study sample and needs further research. Conclusion: The integrated clinical decision support tool based on the EU(7)-PIM and EURO-FORTA criteria addresses the need for more efficient identification of DRPs. It can be applied to identify PIMs and geriatric prescribing problems in different health care settings, and also in a context of little clinical information available.

Impact of an electronic health record alert on inappropriate prescribing of high-risk medications to patients with concurrent "do not give" orders.

To evaluate the effectiveness of clinical decision support (CDS) alerts tied to high-risk medications at a Michigan health system by determining the true prescriber action rate in response to select "do not give" (DNG) alerts. A retrospective review of prescriber actions in response to CDS alerts was conducted to evaluate the effectiveness of alerts designed to prevent prescribing of high-risk medications to patients with concurrent DNG orders. The primary endpoint was the overall action rate, determined by totaling orders cancelled within the alert display and orders modified shortly after an alert. The overall action rate was hypothesized to significantly exceed the action rate estimated on the basis of alert overrides alone. Following the initial review, changes were made to the alert format and preset documentation choices ("acknowledgement comments"), and it was hypothesized that these changes would increase the overall action rate. A repeat analysis was conducted to evaluate the impact of these changes. Across a total of 506 CDS alerts over 14 months, 78% resulted in prescribers modifying orders to comply with alert recommendations. Prescribers cancelled orders in response to only 26% of alerts, often overriding alerts prior to modifying orders. Documentation of rationale or approval for overrides was inconsistent, and while requiring acknowledgement comments facilitated documentation of prescriber rationale, it did not consistently improve overall action rates. These findings demonstrate that override rates alone are not good markers for the true effectiveness of CDS alerts and support the need for frequent evaluation of alerts at the institutional level. CDS alerts remain a valuable tool to prevent inappropriate prescribing of high-risk medications and for promoting patient safety.

Activity-Based Checks (ABCs) of Pain: A Functional Pain Scale Used by Surgical Patients.

IntroductionIncreased rates of surgery, combined with concerns about high-risk pain medications, have highlighted the need for improved methods of meaningfully assessing pain. In response to lack of medical context and functional data in existing scales, the Activity-Based Checks (ABCs) was developed.MethodsThis prospective, cohort study was deployed at a single-institution, academic center. The primary outcome was to correlate the ABCs to the 0 – 10 numeric rating scale (NRS) in post-operative general surgery patients. Secondary outcomes included assessing the impact of patient factors and prescribing patterns on opioid consumption, in milligrams of morphine equivalents (MME), after discharge.ResultsThe function that correlated most to the NRS at discharge was “Out of Bed to Chair”. Indicators of better mental health were correlated inversely with MME consumption. Interestingly, the largest predictor of MME taken was MME prescribed. Over 40% of prescribed opioids goes unused.ConclusionsFunctional pain scales, like the ABCs, may be useful adjuncts to evaluate pain. Individual functions, such as, “Out of Bed to Chair”, may be of particular importance. Clinicians must be aware that the strongest predictor of MMEs taken by patients was MMEs prescribed, highlighting the importance of better pain assessments and opioid stewardship.

Health Equity in an Age-Friendly Health System: Identifying Potential Care Gaps.

The Age-Friendly Health Systems (AFHS) initiative uses a 4Ms framework-What Matters, Mentation, Medication, and Mobility-to encourage patient-centered care for older adults. Many health systems have implemented the core elements of AFHS with the goal to uniformly apply them to all patients 65 years and older. However, equity in AFHS delivery has not yet been examined. Five health equity factors-gender, race, ethnicity, preferred language, and electronic patient portal (MyChart) activation-were cross-sectionally analyzed against the 4Ms framework for patients in an academic internal medicine clinic seen between April 2020 and April 2021 (N = 3 370). Bivariate analysis and multiple logistic regression models analyzed the relationship of health equity variables to the 4Ms metrics and were represented with odds ratios and 95% confidence intervals. Preferred language, gender, and MyChart activation yielded significant 4M metric pairings. Females were 1.22 times more likely than males, and English-speaking patients were 2.27 times more likely than non-English-speaking patients to receive advance care planning (p < .01). Females and patients with MyChart activation were about 2 times more likely to have a high-risk medication on their medication list compared to males and patients without MyChart activation (p < .01). Patients with MyChart activation were 2.08 times more likely than patients without MyChart activation to get cognitive screening (p < .001). This study, the first to incorporate demographic data into AFHS outcomes, suggests a need to develop best practices for equitable Age-Friendly care at the clinical team and institutional policy levels.