Empowering Patients to Start a Conversation: 5 Questions to Ask about Your Medications.

This quality improvement initiative to help prevent known medication-related failures during transitions of care was co-led by Patients for Patient Safety Canada, the Institute for Safe Medication Practices Canada, the Canadian Patient Safety Institute, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists. Initially, the intervention was to develop, test, evaluate and disseminate a medication safety "checklist" for patients and healthcare providers. Through small tests of change, the checklist was redesigned as the "5 Questions to Ask about Your Medications." Collective results demonstrate a shared commitment among more than 200 organizations to empower patients with questions to ask about their medications.

Vasopressor stewardship: a case report and lesson shared.

A case report, focused on vasopressor use and presented in this article, is likely to resonate with many critical care nurses. In this article the authors describe opportunities to enhance safety with vasopressor therapy. Specifically, the goal of improving communication among physicians, nurses, and pharmacists around desired endpoints for vasopressor therapy, triggers for reassessment of the therapeutic strategy and cause of the patient's shock was identified as an area for improvement. A form piloted within an organization for use during multidisciplinary rounds and key findings is shared. Vasopressors constitute the mainstay of therapy for nearly every hemodynamically unstable patient in critical care. It is hoped that the lessons and information shared help empower critical care nurses to facilitate vasopressor stewardship within their facilities and, ultimately, enhance patient safety.

Improving medication prescribing-related outcomes for vulnerable elderly in transitions on high-risk medications (IMPROVE-IT HRM): a pilot randomized trial protocol.

BACKGROUND: Seniors with recurrent hospitalizations who are taking multiple medications including high-risk medications are at particular risk for serious adverse medication events. We will assess whether an expert Clinical Pharmacology and Toxicology (CPT) medication management intervention during hospitalization with follow-up post-discharge and communication with circle of care is feasible and can decrease drug therapy problems amongst this group. METHODS: The design is a pragmatic pilot randomized trial with 1:1 patient-level concealed randomization with blinded outcome assessment and data analysis. Participants will be adults 65 years and older admitted to internal medicine services for more than 2 days, who have had at least one other hospitalization in the prior year, taking five or more chronic medications including at least one high-risk medication. The CPT intervention identifies medication targets; completes consult, including priorities for improving prescribing negotiated with the patient; starts the care plan; ensures a detailed discharge medication reconciliation and circle-of-care communication; and sees the patient at least twice after hospital discharge via virtual visits to consolidate the care plan in the community. Control group receives usual care. Primary outcomes are feasibility - recruitment, retention, costs, and clinical - number of drug therapy problems improved, with secondary outcomes examining coordination of transitions in care, quality of life, and healthcare utilization and costs. Follow-up is to 3-month posthospital discharge. DISCUSSION: If results support feasibility of ramp-up and promising clinical outcomes, a follow-up definitive trial will be organized using a developing national platform and medication appropriateness network. Since the intervention allows a very scarce medical specialty expertise to be offered via virtual care, there is potential to improve the safety, outcomes, and cost of care widely. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT04077281.

Coordination of oral anticoagulant care at hospital discharge (COACHeD): pilot randomised controlled trial.

OBJECTIVES: To evaluate whether a focused, expert medication management intervention is feasible and potentially effective in preventing anticoagulation-related adverse events for patients transitioning from hospital to home. DESIGN: Randomised, parallel design. SETTING: Medical wards at six hospital sites in southern Ontario, Canada. PARTICIPANTS: Adults 18 years of age or older being discharged to home on an oral anticoagulant (OAC) to be taken for at least 4 weeks. INTERVENTIONS: Clinical pharmacologist-led intervention, including a detailed discharge medication management plan, a circle of care handover and early postdischarge virtual check-up visits to 1 month with 3-month follow-up. The control group received the usual care. OUTCOMES MEASURES: Primary outcomes were study feasibility outcomes (recruitment, retention and cost per patient). Secondary outcomes included adverse anticoagulant safety events composite, quality of transitional care, quality of life, anticoagulant knowledge, satisfaction with care, problems with medications and health resource utilisation. RESULTS: Extensive periods of restriction of recruitment plus difficulties accessing patients at the time of discharge negatively impacted feasibility, especially cost per patient recruited. Of 845 patients screened, 167 were eligible and 56 were randomised. The mean age (±SD) was 71.2±12.5 years, 42.9% females, with two lost to follow-up. Intervention patients were more likely to rate their ability to manage their OAC as improved (17/27 (63.0%) vs 7/22 (31.8%), OR 3.6 (95% CI 1.1 to 12.0)) and their continuity of care as improved (21/27 (77.8%) vs 2/22 (9.1%), OR 35.0 (95% CI 6.3 to 194.2)). Fewer intervention patients were taking one or more inappropriate medications (7 (22.5%) vs 15 (60%), OR 0.19 (95% CI 0.06 to 0.62)). CONCLUSION: This pilot randomised controlled trial suggests that a transitional care intervention at hospital discharge for older adults taking OACs was well received and potentially effective for some surrogate outcomes, but overly costly to proceed to a definitive large trial. TRIAL REGISTRATION NUMBER: NCT02777047.

Review article: improving drug safety for patients undergoing anesthesia and surgery.

PURPOSE: This article presents a summary of recent advances, including tools and interventions, that are designed to improve drug safety for patients in critical care settings, particularly those undergoing anesthesia and surgery. PRINCIPAL FINDINGS: Medication error remains a leading cause of adverse events among patients undergoing anesthesia. Misidentification of ampoules, vials, and syringes is a common source of error. Systems are now being engineered to reduce the likelihood of medication misidentification through approaches such as revision of standards for labelling of drug ampoules and vials and the development of bar code systems that allow "double checking" or drug verification in the operating room. Also, efforts are being made to improve medication reconciliation, a process for accurately communicating a patient's medication information during transitions from one healthcare setting to another. Finally, the opportunity exists for anesthesiologists to increase awareness about the rising problem of opioid addiction in patients for whom typical doses are initially prescribed for appropriate indications such as postoperative pain. CONCLUSIONS: There is a need to improve drug delivery systems in complex critical care environments, particularly the operating room. Anesthesiologists must continue to play a leading role in promoting drug safety in these environments.

Coordination of Oral Anticoagulant Care at Hospital Discharge (COACHeD): protocol for a pilot randomised controlled trial.

BACKGROUND: Oral anticoagulants (OACs) are commonly prescribed, have well-documented benefits for important clinical outcomes but have serious harms as well. Rates of OAC-related adverse events including thromboembolic and hemorrhagic events are especially high shortly after hospital discharge. Expert OAC management involving virtual care is a research priority given its potential to reach remote communities in a more feasible, timely, and less costly way than in-person care. Our objective is to test whether a focused, expert medication management intervention using a mix of in-person consultation and virtual care follow-up, is feasible and effective in preventing anticoagulation-related adverse events, for patients transitioning from hospital to home. METHODS AND ANALYSIS: A randomized, parallel, multicenter design enrolling consenting adult patients or the caregivers of cognitively impaired patients about to be discharged from medical wards with a discharge prescription for an OAC. The interdisciplinary multimodal intervention is led by a clinical pharmacologist and includes a detailed discharge medication reconciliation and management plan focused on oral anticoagulants at hospital discharge; a circle of care handover and coordination with patient, hospital team and community providers; and early post-discharge follow-up virtual medication check-up visits at 24 h, 1 week, and 1 month. The control group will receive usual care plus encouragement to use the Thrombosis Canada website. The primary feasibility outcomes include recruitment rate, participant retention rates, trial resources management, and the secondary clinical outcomes include adverse anticoagulant safety events composite (AASE), coordination and continuity of care, medication-related problems, quality of life, and healthcare resource utilization. Follow-up is 3 months. DISCUSSION: This pilot RCT tests whether there is sufficient feasibility and merit in coordinating oral anticoagulant care early post-hospital discharge to warrant a full sized RCT. TRIAL REGISTRATION: NCT02777047.

Drug name alert: potential for confusion between pradax and plavix.

In this article, the authors highlight an incident that involved a mix-up between the oral anticoagulant medication Pradax (dabigatran etexilate) and the antiplatelet medication Plavix (clopidogrel). Because critical care nurses may admit or care for patients who are receiving (or have received) one of these medications, it is important that they be aware of the potential for confusion between these two drug names throughout the medication-use process.

ALERT: mix-ups between conventional and lipid formulations of amphotericin B can be extremely dangerous.

In this column, the authors review Amphotericin B incidents reported Although amphotericin B may be less commonly used today because to ISMP Canada. In particular, we focus on incidents reported to have of alternative antifungal agents available, incident reports suggest resulted in patient harm due to mix-ups between the conventional there continues to be a need to alert practitioners to the different (non-lipid)formulation and lipid formulations of amphotericin B. formulations, and to implement system safety strategies.

Hospitals report on medication safety in Canada.

Measurement of safety can be difficult. Given that incident reporting systems rely primarily on voluntary reporting and some types of medication incidents may occur rarely, lack of reports about a particular type of incident cannot be interpreted as evidence that the underlying causes are resolved. Proxy measurements, such as the level of implementation of evidence-based practices known to reduce the risk of a particular incident, may provide an indication of progress toward safer systems. This article includes an overview of some proxy measurements influencing medication use systems in patient care areas, including critical care, as reported in the biennial Hospital Pharmacy in Canada survey.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review.

CONTEXT: Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined. OBJECTIVE: Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit. STUDY DESIGN: Systematic rapid realist review. DATASET: Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation. RESULTS: 95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion. CONCLUSIONS: Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.

ALERT: Revatio is another brand name for sildenafil.

In this column, the authors highlight a medication incident that occurred with Revatio (sildenafil), along with the learnings and recommendations from a previously published ISMP Canada Safety Bulletin. It is well-known to health care practitioners that use of nitroglycerin therapy is contraindicated in patients taking sildenafil (commonly known as Viagra). Many health care practitioners may be unaware that sildenafil is also marketed under the brand name Revatio for treatment of primary pulmonary hypertension or pulmonary hypertension secondary to connective tissue disease. The following incident signals the need to heighten the awareness that Revatio is a brand name for sildenafil.

Pharmaceutical bar coding: moving forward in Canada.

The purpose of this article is to provide an update on the status of automated identification (e.g., bar coding) of pharmaceutical products manufactured for distribution within Canada.

A near miss involving cyclophosphamide.

Reports of near miss incidents offer valuable learning opportunities. In this article, the authors highlight a near miss incident that occurred in an intensive care unit with the cytotoxic medication cyclophosphamide, for a non-oncology indication. The learning from this incident, including recommendations, is shared.

Preventing substitution errors involving high-concentration heparin products.

Critical care practitioners routinely administer heparin for various indications (e.g., treatment of acute coronary syndrome, venous thromboembolism prophylaxis, line maintenance) and by various routes (e.g., intravenously, subcutaneously). Knowledge of reported incidents involving high-concentration heparin products can increase practitioner awareness of risks for error-induced injury associated with storage and administration of anticoagulants, such as heparin. Substitution errors leading to administration of an incorrect dose of unfractionated heparin are highlighted and suggestions for system-based error prevention strategies are provided.

Desmopressin (dDAVP) incident signals the need for enhanced monitoring protocols.

In this article, the authors highlight the circumstances surrounding the death of a young adult neurosurgical patient, recently reported to ISMP Canada. The incident signals the need for enhanced safeguards for patients receiving desmopressin (also known as dDAVP) and intravenous therapy. The authors present information from a recent ISMP Canada Safety Bulletin relevant to critical care, including an outline of potential contributing factors and suggested recommendations.

Medication safety in the operating room: teaming up to improve patient safety.

A medication safety project for operating rooms (ORs) was initiated under the leadership of the Departments of Anesthesia and Nursing with a representative from the Canadian Anesthesiologists' Society and the Institute for Safe Medication Practices Canada. The aims of the collaborative project were twofold: (1) to identify areas of exposure to risk and make recommendations to enhance medication safety within the hospital and (2) to inform the development of a medication safety checklist specific to the OR setting. The strategies developed and implemented during this project were aimed at reducing the risk of injury induced by medications. Attempts were made to use feasible best practices and managerial support systems for defined areas - in this case, medication-use systems for the ORs and associated patient care areas. The learning from this project will also inform the development of a medication safety checklist for use by other hospitals and OR settings.

Using human factors methods to evaluate the labelling of injectable drugs.

Adverse drug events, including in-hospital medication errors, are a well-documented world-wide problem. This interdisciplinary team set out to examine the issues related to the labelling of injectable drugs. We sought answers to the following two questions: (1) To what extent do injectable drug labels adhere to existing Canadian design practice recommendations and regulations for labelling and (2) is there a need to make changes to the recommendations or regulations for labelling of injectable drugs in Canada? The project contained three phases. The first phase involved taking a sample of vials and ampoules from a hospital pharmacy and identifying adherence to the 1999 Canadian Standards Association standard for the labelling of drug ampoules, vials and prefilled syringes, as well as with the Canadian (Health Canada) Food and Drug Regulations for labelling. The second phase involved a failure mode and effects analysis of the label-reading process in order to identify information on the label considered critical for safe medication use. The third phase involved a preliminary human factors experiment addressing one problem identified with existing labels. Our finding is that existing injectable drug labels do not adhere sufficiently to available best design standards for labels and also do not adhere to all Canadian Food and Drug Regulations. Recommendations are made to inform future enhancements to labelling standards, guidelines and regulations.

Enhancing safety with potassium phosphates injection.

The inadvertent administration of concentrated potassium chloride resulting in patient death is well-documented in Canada and other countries. Vials of potassium phosphates contain more than twice the concentration of potassium compared to vials of potassium chloride concentrate. If inadequately diluted or administered too rapidly, intravenous potassium phosphate can also lead to serious patient harm. This article contains information reprinted with permission from an ISMP Canada Safety Bulletin (ISMP Canada, 2006, April 25) for the purpose of enhancing safety with potassium phosphates injection.

Epidural medications given intravenously may result in death.

Anesthetics, such as bupivacaine, intended for epidural analgesia can cause severe cardio- and neurotoxicity when inadvertently administered via the intravenous route. This article highlights a case report and the dangers associated with the inadvertent administration of an epidural solution intravenously. Multiple system-based strategies for prevention are provided.