Medication-use Process Research Articles

Practice-enhancing publications about the medication-use process in 2019.

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change. A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation. It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.

Vulnerabilities for Drug Diversion in the Handling, Data Entry, and Verification Tasks of 2 Inpatient Hospital Pharmacies: Clinical Observations and Healthcare Failure Mode and Effect Analysis.

Inpatient hospital pharmacies have a central role in managing controlled substances (CS) throughout the hospital medication use process (MUP). Our objectives were to identify vulnerabilities for diversion in the MUPs of 2 inpatient pharmacies, explore differences between the sites, and characterize the types of vulnerabilities identified. We conducted clinical observations in 2 pharmacies to map their MUPs and performed a healthcare failure mode and effect analysis to proactively identify (1) the critical failure modes (CFMs) that make them vulnerable to diversion and (2) the controls that prevent, mitigate, or enhance the detectability of CFMs. We conducted 99 hours of observations between May-June and September-October 2018. We observed 36 pharmacy technicians, 4 pharmacists, and 1 clerk as they conducted tasks involving 4 processes common to both sites: procuring CS, receiving CS deliveries to the pharmacy, unit-dose packaging CS oral solids, and distributing CS to hospital units. The tasks and subtasks we mapped in the process flow diagrams led to the identification of 220 failure modes. Of these, 34 were deemed CFMs and were categorized as related to handling CS, data entry, or verification tasks. Three of the CFMs were unique to one site, given that the other site had a control for the CFM. Multiple vulnerabilities for diversion exist in inpatient pharmacy processes. Our results provide some much needed detail about how specific vulnerabilities in MUP tasks and subtasks lead to an increased risk of diversion.

Demystifying artificial intelligence in pharmacy.

To provide pharmacists and other clinicians with a basic understanding of the underlying principles and practical applications of artificial intelligence (AI) in the medication-use process. "Artificial intelligence" is a general term used to describe the theory and development of computer systems to perform tasks that normally would require human cognition, such as perception, language understanding, reasoning, learning, planning, and problem solving. Following the fundamental theorem of informatics, a better term for AI would be "augmented intelligence," or leveraging the strengths of computers and the strengths of clinicians together to obtain improved outcomes for patients. Understanding the vocabulary of and methods used in AI will help clinicians productively communicate with data scientists to collaborate on developing models that augment patient care. This primer includes discussion of approaches to identifying problems in practice that could benefit from application of AI and those that would not, as well as methods of training, validating, implementing, evaluating, and maintaining AI models. Some key limitations of AI related to the medication-use process are also discussed. As medication-use domain experts, pharmacists play a key role in developing and evaluating AI in healthcare. An understanding of the core concepts of AI is necessary to engage in collaboration with data scientists and critically evaluating its place in patient care, especially as clinical practice continues to evolve and develop.

Practice-enhancing publications about the medication-use process in 2018.

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2018 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following steps: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness toward daily practice change. A PubMed search was conducted in February 2019 for articles published in calendar year 2018 using targeted Medical Subject Headings (MeSH) keywords, targeted non-MeSH keywords, and the table of contents of selected pharmacy journals, providing a total of 43,977 articles. A thorough review identified 62 potentially significant articles: 9 for prescribing/transcribing, 12 for dispensing, 13 for administration, and 28 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why they are important within health-system pharmacy. The other articles are listed for further review and evaluation. It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing recent impactful contributions to the MUP literature. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of significant published studies can assist in changing practice at the institutional level.

ALFs, Meds, and Transitions

ALFs, Meds, and Transitions

Allergy-Related Medication Error Reports Submitted to a Large Patient Safety Reporting System

Medication allergies can and do cause patient harm. Managing a patient’s allergies is a challenge for institutionsbecause failures can happen throughout the medication-use process. A total of 854 Medication Error events associated with patient allergies that occurred between July 2016 and June 2018 were reported through a large event reporting database. Analysts categorized these events into the following five stages: obtaining information from the patient, documenting allergies in the record, ordering medications, verifying orders, and administering medications. More than half (56.3%; n = 481) of the events reached the patient. Most likely to reach patients were events involving breakdowns when obtaining information from the patient (74.7%, n = 68 of 91) and administering medications (97.6%, n = 281 of 288). In reports that indicated allergies were properly documented, the majority (87.3%, n = 289 of 331) of the events that reached patients passed through two or more stages. Organizations may use this information to inform proactive efforts to implement system-based strategies to improve the medication-use process. Keywords: drug allergy, drug reaction, medication errors, medication safety, patient safety

Pediatric medication safety considerations for pharmacists in an adult hospital setting

Risks and vulnerabilities of the medication-use process in nonpediatric institutions that also serve pediatric patients are reviewed, and guidance on risk mitigation strategies is provided. There are many risks and vulnerabilities in the medication-use process as it relates to pharmacotherapy for pediatric patients admitted to adult institutions. Mitigation of these risks is critical and should encompass various available resources and strategies. Special emphasis should be placed on use of technology to improve overall safety. Available literature recommends optimization of technology and resource use, institutional support for pediatric pharmacists' involvement in managing pediatric medication use, and provision of early exposure to pediatric patients in pharmacist training programs as additional methods of mitigating risks associated with pediatric medication use in adult institutions. Adult hospitals that provide care for pediatric patients should assess their processes in order to identify hospital-specific interventions to promote pediatric medication safety. Pediatric medication safety frameworks in U.S. adult institutions vary widely. Treating pediatric patients involves risks in all areas of the medication-use process. Optimizing technology, utilizing external resources, supporting a pediatric pharmacist, and providing early-career exposure to pediatric patients are methods to mitigate risks in institutions that primarily serve adult patients.

Implementation of an internal check of oral oncolytics: a single-center, specialty pharmacy safety initiative

Background: Oral oncolytic therapies (OOT) for patients with cancer continue to pose unique safety challenges. Unlike infusion therapies, there are few best practice recommendations for checking OOT. A multicenter review of four oncology clinics in the United States, estimated 8.1 errors in medications per 100 clinic visit identified. 1 The American Society of Health-System Pharmacists identify administration and ordering were the most common phases of the medication-use process where errors occur. 2 Despite the high-risk nature of OOT and high error-rate in these particular phases, with pharmacist surveillance, there continues to be little consensus for oral oncolytic safety to guide specialty pharmacists (SPs). Aims: The objectives of this single-center, quality improvement study was to review the quality metrics of the implementation of an oral oncolytic check process, in the specialty and ambulatory setting as a method to enhance medication safety and improve vigilance. Methods: The study was approved by the Institutional Review Board at the Hospital of the University of Pennsylvania. A standardized check process and documentation of capecitabine and temozolomide was implemented beginning in December 2016 for an adult oncology population. SPs have direct communication to pharmacy specialists and provider teams through the electronic medical record via Epic. Upon receipt of a new prescription, the SP reviews the prescription for: prescriber, chemotherapy regimen, indication, body surface area, dose verification, appropriate day supply/refills, laboratory values, allergy evaluation, drug interactions, and pre-medications. The SP documents this review as an intervention in Epic for every capecitabine and temozolomide prescriptions before processing. Intervention data between December 2016 and September 2018 was queried and quantified. Results: Over 22 months, a total of 1,619 intervention documents were reviewed with 551 intervention documents requiring intervention (34%). A total of 639 actionable interventions were identified. The top three categories were missing pre-medications (54.1%), missing/abnormal laboratory results (19.6%), and drug-drug interactions (13.6%). Rare interventions included dose clarification requests (3.6%), dose change requests (1.4%), and quantity supply requests (2.7%). A SP referred to a pharmacy specialist or provider outside of Epic communication in 21.2% of cases and 3.7% of cases respectively. The average time by the SP per intervention was 12.1 minutes (Range: 10-45 minutes). Conclusions: OOT is exponentially growing with unique risks associated when prescribing, with the SP being the last line of defense. Implementing an internal checking tool of oral oncolytics creates a standardized safety check and promotes active communication with oncology care teams. Addition of all OOT to incorporate mandatory documentation is ongoing.

Medication related litigation in Ireland: A 6-year review.

The primary aims of the study were to identify those medications most frequently associated with clinical litigation in Ireland and to quantify the cost of such litigation. Secondary aims were to identify where in the medication-use process claims were most likely to arise, the medication incident types involved and the primary injury alleged. The National Incident Management System (NIMS) for incident and claims management was searched to identify all medication-related claims finalised from 2011 to 2016 (inclusive). The physical case files were obtained and additional data not available on NIMS was extracted in order to build a detailed picture of the incident and subsequent claim. The search identified 79 relevant claims, of which 48 closed with a payment to the plaintiff. These 48 claims involved 54 medications. Medication groups identified included general anaesthetics (n=7), opioids (n=6), penicillins, antithrombotics and local anaesthetics (all n=5). The errors alleged occurred exclusively at the administration (58%) and prescribing (42%) stages of the medication-use process. Medication incident types included wrong dose/strength (n=17), wrong drug (n=7) and adverse drug reaction (n=6). The most commonly pleaded primary injuries were allergic reaction (n=9), deterioration in clinical status (n=9) and post-traumatic stress disorder (n=8). The median total cost of these claims was €60991, including median damages of €33858. This study links data on medication incidents, actual harm to patients and litigation costs. Thus, it presents a comprehensive picture of the consequences of medication error.

Clinical observations and a Healthcare Failure Mode and Effect Analysis to identify vulnerabilities in the security and accounting of medications in Ontario hospitals: a study protocol

IntroductionAn increasing number of opioids and other controlled substances are being stolen from healthcare facilities, diverting medications from their intended medical use to be used or sold illicitly. Many incidents...

ASHP guidelines on perioperative pharmacy services.

Historically, pharmacy involvement in perioperative areas primarily consisted of providing medication stock for access by operating room (OR) staff, confirming appropriate storage conditions, checking expiration dates, submitting billing, and maintaining controlled substance accountability. In the early 1980s, pharmacists recognized the need for increased involvement and OR satellite pharmacies began to appear, particularly in academic institutions.1 Even so, the focus remained primarily on medication distribution and regulatory compliance. Evolving standards from regulatory and accrediting agencies as well as the need for improved charge capture and greater controlled substance accountability over the last decade drove increased pharmacy involvement in the perioperative medication-use process. Ongoing rapid changes in healthcare now demand that our attention be turned toward incorporating additional activities, such as supporting institutional quality and safety goals, developing perioperative treatment algorithms and order sets, and collaborating with the perioperative team to provide patient-centered, medication-related care in inpatient and outpatient settings. Finally, the challenge of cost-effective perioperative medication use has never been greater, with the movement from fee-for-service payment to value-based payment systems.

Evaluating Pharmacy Practice in Hospital Settings in Jeddah City, Saudi Arabia: Prescribing and Transcribing-2018.

Purpose: The aim of this study was to evaluate the prescription and transcription processes in hospital settings in Jeddah city, Saudi Arabia. Method: A customized version of the original American Society of Health-System Pharmacists (ASHP) survey was distributed to a total of 26 hospitals in Jeddah city that fits our criteria starting from December 2017. Hospitals' names were adopted from the Ministry of Health and Jeddah Municipality websites. All questionnaires were collected in June 2018. After that, they were classified according to the type of care provided by the hospital, size, ownership, teaching affiliation, and accreditation. Data were entered electronically using Google forms, and then Microsoft Excel was used to conduct descriptive statistics. Results: The survey had a response rate of 57%. A strict formulary system was adopted in 53.3% of hospitals, and clinical practice guidelines were used to optimize medication use in 86.7% of hospitals. Pharmacists do not have the authority to write medication orders in about 86.7% of hospitals and only 40.0% of hospitals have pharmacists routinely assigned to patient care units. However, Pharmacists actively provided consultation, mostly in drug information (80.0%). Computerized prescriber order entry (CPOE) is used to receive medication orders electronically in 80.0% of hospitals, and electronic health record (EHR) is used in about 53.3% of hospitals and 50.0% of those hospitals have pharmacists who document their clinical intervention in EHR. Conclusion: Survey results suggest that pharmacists in hospital settings have not yet been positioned to improve the prescribing and transcribing components of the medication-use process.

Practice-enhancing publications about the medication use process in 2017.

This article identifies, prioritizes, and summarizes published literature on the medication use process (MUP) from calendar year 2017 that can impact health-system pharmacists' daily practice. The MUP is the foundational system that provides the framework for safe medication use within the health care environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness toward daily practice change. A PubMed search was conducted in March 2018 for calendar year 2017 using targeted Medical Subject Headings (MeSH) keywords, providing a total of 2,288 articles. A thorough review identified 45 potentially significant articles: 19 for prescribing/transcribing, 5 for dispensing, 4 for administration, and 17 for monitoring. Peer review ranking for importance led to the selection of key articles from each category. The highest ranked articles are briefly summarized, with a mention of why this article is important within health-system pharmacy. The other articles are listed for further review and evaluation. It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing those that are most impactful. Health-system pharmacists have an active role in improving the MUP in their institution and awareness of the significant published studies can assist in changing practice at the institutional level.

Process improvement strategy to prepare and administer bacillus Calmette-Guérin vaccine in compliance with United States Pharmacopeia chapter 800 standards.

This case study describes a multidisciplinary initiative to promote the safe use, preparation, and administration of bacillus Calmette-Guérin (BCG) in patients with bladder cancer that is in compliance with United States Pharmacopeia chapter 800. After an evaluation of a hospital's medication-use process for the preparation and administration of BCG identified inconsistencies with guideline-based procedures for the safe handling and manipulation of hazardous drug products, a revised medication-use process promoting the inclusion of pharmacy services was developed by pharmacy and urology clinic leaders. Implementation of the enhanced medication-use process included (1) the shift of BCG vaccine preparation from urology clinic nurses to a pharmacy equipped with the appropriate engineering controls for the safe preparation of hazardous product, (2) greater involvement by pharmacists in BCG order justification and verification, and (3) a process that ensured just-in-time preparation and delivery of medication for enhanced patient satisfaction. After initial process changes resulted in increased turnaround time from preparation to administration, a study on time to preparation, delivery, and administration was conducted and resulted in complete reduction of turnaround times and increased patient satisfaction. Through a multidisciplinary initiative involving pharmacists, physicians, nurses, and leadership, a new process to promote the safe preparation and administration of the tuberculosis vaccine Mycobacterium bovis BCG was developed and implemented. The results of a post-implementation time study indicated that a standardized approach to scheduling, preparing, and administering BCG was effective in managing the operations of BCG through having high clinic and patient satisfaction.

Diversion of Controlled Drugs in Hospitals: A Scoping Review of Contributors and Safeguards.

Drug losses and theft from the healthcare system are accelerating; hospitals are pressured to implement safeguards to prevent drug diversion. Thus far, no reviews summarize all known risks and potential safeguards for hospital diversion. Past incidents of hospital drug diversion have impacted patient and staff safety, increased hospital costs, and resulted in infectious disease outbreaks. We searched MEDLINE, Embase, PsycINFO, CINAHL, Scopus, and Web of Science databases and the gray literature for articles published between January 2005 and June 2018. Articles were included if they focused on hospital settings and discussed either: (1) drug security or accounting practices (any drug) or (2) medication errors, healthcare worker substance use disorder, or incident reports (only with reference to controlled drugs). We included 312 articles and extracted four categories of data: (1) article characteristics (eg, author location), (2) article focus (eg, clinical areas discussed), (3) contributors to diversion (eg, factors enabling drug theft), and (4) diversion safeguards. Literature reveals a large number of contributors to drug diversion in all stages of the medication-use process. All health professions and clinical units are at risk. This review provides insights into known methods of diversion and the safeguards hospitals must consider to prevent them. Careful configuration of healthcare technologies and processes in the hospital environment can reduce the opportunity for diversion. These system-based strategies broaden the response to diversion beyond that of individual accountability. Further evidence is urgently needed to address the vulnerabilities outlined in this review and prevent harm.

Improving the medication-use process for 23.4% sodium chloride.

Results of a study to evaluate medication storage, distribution, and safety outcomes after addition of 23.4% sodium chloride to a hospital formulary and development of a novel distribution process incorporating safeguards allowing for urgent medication removal from an automated dispensing cabinet (ADC) are reported. A retrospective review of 23.4% sodium chloride injection doses dispensed during a 38-month period was performed at an academic medical center to evaluate times from order entry to pharmacist verification, dispensing, and administration; adverse events related to dispensing or administration; and other outcomes. Seventy doses of 23.4% sodium chloride injection were administered to 60 patients during the study period. The mean times from order entry to pharmacist verification, medication removal from an ADC, and administration were 8, 25, and 43 minutes, respectively, when the ADC override function was not used. After 23.4% sodium chloride injection's addition to the ADC override list, 16 of 30 doses were removed "on override," with order entry performed retrospectively for 9 of these doses. There were no documented adverse events related to medication distribution and 2 adverse effects possibly related to medication administration. Novel storage and distribution processes for 23.4% sodium chloride injection were implemented at a large academic medical center to optimize safety related to the medication-use process. A retrospective review of 70 administered doses found the process of maintaining this medication in ADCs to be a safe and efficient method of storing and dispensing a high-alert medication.

Systematic review of computerized prescriber order entry and clinical decision support.

Results of a systematic review of published data on the effect of computerized prescriber order entry (CPOE) with clinical decision support on medication error (ME) and adverse drug event (ADE) rates are presented. Literature searches of MEDLINE, Embase, and other databases were conducted to identify English- and Spanish-language articles on selected CPOE outcomes published from 1995 through 2016; in addition, 5 specific journals were searched for pertinent articles published during the period 2010-16. Publications on controlled prospective studies and before-and-after studies that assessed MEs and/or ADEs as main outcomes were selected for inclusion in the review. Nineteen studies met the inclusion criteria. Data on MEs and ADEs could not be pooled, mainly due to heterogeneity in outcome definitions and study methodologies. The reviewed evidence indicated that CPOE implementation led to an overall reduction in errors at the prescription stage of the medication-use process (relative risk reduction, 0.29 [95% confidence interval, 0.10-0.85]; I 2 = 99%) and reductions in most types of prescription errors, but CPOE also resulted in the emergence of other types of errors. CPOE reduces the overall ME rate in the prescription process, as well as specific types of errors, such as wrong dose or strength, wrong drug, frequency, administration route, and drug-drug interaction errors. The implementation of CPOE can lead to new errors, such as wrong drug selection from drop-down menus.

Utilization of neonatal medication error prevention strategies: a clinical practice survey of Australian and New Zealand neonatal units.

Medication errors are common in neonatal care and can lead to significant harm. We sought to explore utilization of various medication error prevention strategies across Australian and New Zealand neonatal units (NNUs) through a clinical practice survey. An electronic survey was distributed in October 2016 to relevant staff at each of the 29 level III NNUs identified as members of the Australian and New Zealand Neonatal Network (ANZNN). The survey contained questions relating to a range of medication error prevention strategies identified from a previous systematic review on the topic. The evaluated interventions targeted different aspects of the medication-use process including prescribing, evaluation/checking of orders by clinical pharmacists, transmission, preparation and dispensing of orders, storage of medications, and medication administration. From the 20 respondents, the evidence-based strategies most commonly utilized were use of smart pumps (n = 18; 90%), and ward-based clinical pharmacists (n = 17; 85%). Interventions least commonly utilized included barcode scanning with medication administration (n = 0; 0%), electronic prescribing and clinical decision support (n = 1; 5%), and dedicated medication administration nurse (n = 2; 10%). The total number of evidence-based medication error prevention strategies utilized in each NNU ranged from 2 to 10 (median = 7), 10 of 16 strategies were utilized by less than 50% of NNUs. While evidence supports utilization of a number of medication error prevention strategies, these appear inconsistently utilized across current practice settings.

Assessment of medication use process in adult oncology unit of Tikur Anbesa Specialized Hospital

Abstract Background: Chemotherapy errors affect several steps of medication-use process. A reduction of errors and toxicities, and an increase in error awareness, dose verification, proper documentation, and appropriateness of supportive care treatment are important. The present study was conducted to assess the medication-use process and dose-related errors in an outpatient adult oncology unit of Tikur Anbesa Specialized Hospital. Methods: An institutional-based cross-sectional study was conducted in an oncology outpatient adult oncology unit of Tikur Anbesa Specialized Hospital between May 1 and June 30, 2012. A total of 212 patient records for 583 chemotherapy administrations were reviewed during the study period. Results: The overall dose-related error rate was found to be 228 (39.1%). Specific rate of dose-related errors were (under dosing 58 (25.4%), overdosing 52 (22.8%), inaccurately reconstituted doses 106 (46.5%), and inappropriately adjusted doses 12 (5.3%). Dose labeling and documentation of appropriate time of administration for each chemotherapy preparation were not evident in the unit records. Only 3/14 dose verifications and 3 dose documentation processes were found. Supportive care treatment was not performed according to the recommended standards. Of the 23 equipment and supplies needed for chemotherapy preparation and administration, only 8 were available. Conclusions: The findings of our study indicate that the medication-use process in an outpatient adult oncology unit was below expected standards in 2012. The hospital and the school of pharmacy should give emphasis on the establishment of pharmacist run oncology pharmacy for chemotherapy preparation. Policies and guidelines for chemotherapy mixing and administration service and standardization of the process workflow should be developed.

Impact on process results of clinical decision support systems (CDSSs) applied to medication use: overview of systematic reviews.

Objective:The purpose of this overview (systematic review of systematic reviews) is to evaluate the impact of clinical decision support systems (CDSS) applied to medication use in the care process.Methods:A search for systematic reviews that address CDSS was performed on Medline following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane recommendations. Terms related to CDSS and systematic reviews were used in combination with Boolean operators and search field tags to build the electronic search strategy. There was no limitation of date or language for inclusion. We included revisions that investigated, as a main or secondary objective, changes in process outcomes. The Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) score was used to evaluate the quality of the studies.Results:The search retrieved 954 articles. Five articles were added through manual search, totaling an initial sample of 959 articles. After screening and reading in full, 44 systematic reviews met the inclusion criteria. In the medication-use processes where CDSS was used, the most common stages were prescribing (n=38 (86.36%) and administering (n=12 (27.27%)). Most of the systematic reviews demonstrated improvement in the health care process (30/44 – 68.2%). The main positive results were related to improvement of the quality of prescription by the physicians (14/30 – 46.6%) and reduction of errors in prescribing (5/30 - 16.6%). However, the quality of the studies was poor, according to the score used.Conclusion:CDSSs represent a promising technology to optimize the medication-use process, especially related to improvement in the quality of prescriptions and reduction of prescribing errors, although higher quality studies are needed to establish the predictors of success in these systems.