Management of a parenteral opioid shortage using ASHP guidelines.

PURPOSE: Management of an acute shortage of parenteral opioid products at a large hospital through prescribing interventions and other guideline-recommended actions is described. SUMMARY: In early 2018, many hospitals were faced with a shortage of parenteral opioids that was predicted to last an entire year. The American Society of Health-System Pharmacists (ASHP) has published guidelines on managing drug product shortages. This article describes the application of these guidelines to manage the parenteral opioid shortage and the impact on opioid dispensing that occurred in 2018. Our approach paralleled that recommended in the ASHP guidelines. Daily dispensing reports generated from automated dispensing cabinets and from the electronic health record were used to capture dispenses of opioid medications. Opioid prescribing and utilization data were converted to morphine milligram equivalents (MME) to allow clinical leaders and hospital administrators to quickly evaluate opioid inventories and consumption. Action steps included utilization of substitute opioid therapies and conversion of opioid patient-controlled analgesia (PCA) and opioid infusions to intravenous bolus dose administration. Parenteral opioid supplies were successfully rationed so that surgical and elective procedures were not canceled or delayed. During the shortage, opioid dispensing decreased in the inpatient care areas from approximately 2.0 million MME to 1.4 million MME and in the operating rooms from 0.56 MME to 0.29 million MME. The combination of electronic health record alerts, increased utilization of intravenous acetaminophen and liposomal bupivacaine, and pharmacist interventions resulted in a 67% decline in PCA use and a 65% decline in opioid infusions. CONCLUSION: A multidisciplinary response is necessary for effective management of drug shortages through implementation of strategies and practices for notifying clinicians of shortages and identifying optimal alternative therapies.

Pharmacotherapy prevention and management of nutritional deficiencies post Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass is the most commonly performed bariatric procedure. It is associated with nutritional deficiencies due to gastric reduction, intestinal bypass, reduced caloric intake, avoidance of nutrient-rich foods, noncompliance with supplementation and poor food tolerability. Although there are multiple publications on this topic, there is a lack of consistent guidance for the healthcare practitioner caring for the bariatric patient. This article will encompass literature reviewing the pharmacotherapy approach to prevention and management of nutritional deficiencies since the American Society of Metabolic and Bariatric Surgery guidelines were published in 2008.

Bariatric surgery pharmacy consultation service.

Bariatric surgical patients often need changes in formulation and dosages of their medications. The literature contains minimal information regarding pharmaceutical care and consultation services for the bariatric surgery patient. Complex medication regimens and safety concerns initiated a collaborative effort between surgeons and pharmacists to manage more effectively bariatric patients perioperatively. The consultation service included patient identification, pharmacy referral, pharmacist consultation with the patient, communication of recommendations with surgeons, follow-up, and documentation. There were 124 consultations performed from February 2, 2009 to December 1, 2010 with an average of 7.7 medications optimized per patient. Every patient required a minimum of one adjustment to their regimen. The surgeons approved 98% of these recommendations. Of recommendations provided, the majority focused on changing the formulation of the medication in some manner. The collaborative effort between surgeons and pharmacists effected changes in medication transitioning perioperatively and resulted in improved pharmaceutical care for this patient population.

Impact of smart infusion technology on administration of anticoagulants (unfractionated Heparin, Argatroban, Lepirudin, and Bivalirudin).

This study reviewed 863 alerts generated from the infusion of anticoagulants in 355 patients from October 2003 to January 2005. Alerts were generated by smart infusion technology pumps and recorded in the devices' memory. The most common alerts were underdose alerts (59.8%), followed by overdose alerts (31.3%) and duplicate drug therapy alerts (8.9%). In response to the alerts, users' most frequent action was to cancel (46.5%) or reprogram (43.1%) the infusions. The highest percentage of alerts occurred from 2 to 4 p.m. During the study, there were 4 infusion rate errors, compared with 15 in the immediately preceding 16-month period. In conclusion, smart infusion technology intercepted keypad entry errors, thereby reducing the likelihood of intravenous anticoagulant overdose or underdose. Dose or infusion rate programming during intravenous anticoagulation is an important targets for medication safety interventions.

Creating an integrated patient safety team.

UNLABELLED: CREATING A PATIENT SAFETY TEAM: In May 2001 Brigham and Women's Hospital (Boston) created the Patient Safety Team, which was incorporated into the pre-existing safety and quality infrastructure. ESTABLISHING THE PATIENT SAFETY TEAM'S GOALS AND INITIATIVES: The goal was to create the safest possible environment for patients and staff by creating a culture of safety, increasing the capacity to measure and evaluate processes, committing to change unsafe processes, and adopting new technologies. To achieve this mission, the following initiatives were established: create a culture of safety, increase event identification, improve event analysis, close the feedback loop, assess risk proactively, improve medication safety, and involve the patient. DISCUSSION: Integrating the Patient Safety Team into pre-existing committees and departments facilitated its work while helping to reinforce the multidisciplinary nature of safety efforts. It is critical that pre-existing groups feel that patient safety represents value added and is not a threat to their current roles. SUMMARY AND CONCLUSIONS: If a patient safety strategy and team are to be effective, commitment from the organization's leaders is essential. This team should also work with individual departments and pre-existing quality structures to drive changes to the systems of care to enable health care to become as safe as possible.