Pediatric medication safety considerations for pharmacists in an adult hospital setting.

PURPOSE: 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. SUMMARY: 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. CONCLUSION: 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 a new method to track propofol in an endoscopy unit.

AIM: Propofol is a widely used anesthesia induction agent and is easily accessible in most healthcare facilities. Unlike regulated or schedule drugs, propofol is inconsistently tracked, leading to inaccurate inventories, incorrect billing, and unrecognized diversion. The goal of this project was to implement a new method of tracking propofol in a single setting, with the aim of accounting for 100% of the drug. METHODS: For two, 2-week observation periods, data were extracted from an automated medication management system or pharmacy inventory system, anesthesia records, and pharmacy billing sheets for cases in a Gastrointestinal (GI) Endoscopy Unit, and compared pre-implementation and post-implementation of a new tracking and accounting protocol. Variables included amount of propofol inventoried, dispensed, administered, returned, billed, wasted, and missing. RESULTS: Pre-implementation (n = 300), 10% cases had no record of propofol removal from the automated medication system. Of the 90% that did, 25% had an amount signed out that did not match the amount administered. Thirty-one percent of all propofol was unaccounted for during this 2-week period. Furthermore, 19.7% of cases did not have a billing form located. Post-implementation of the process change, unaccounted for propofol decreased to 26% of all cases (P = ns). The percentage of missing billing forms decreased from 19.7 to 5.8% (P = 0.00). CONCLUSION: Data suggest notable amounts of propofol were unaccounted for and not billed for in the GI Endoscopy Unit prior to the protocol change. Post-protocol change data reveal modest improved accounting of the medication and significant cost-capture. Improvements may enhance inventory reconciliation, availability of drug stock, and potentially result in a decreased risk of unrecognized diversion.

Information system technologies' role in augmenting dermatologists' knowledge of prescription medication costs.

OBJECTIVES: Despite the recent rising costs of once affordable dermatologic prescription medications, a survey measuring dermatologists' attitudes, beliefs, and knowledge of the cost of drugs they commonly prescribe has not been conducted. Awareness of drug costs is hindered by a lack of access to data about the prices of medicines. No surveys of physicians have addressed this issue by proposing new information system technologies that augment prescription medication price transparency and measuring how receptive physicians are to using these novel solutions in their daily clinical practice. Our research aims to investigate these topics with a survey of physicians in dermatology. METHODS: Members of the North Carolina Dermatology Association were contacted through their electronic mailing list and asked to take an online survey. The survey asked several questions about dermatologists' attitudes and beliefs about drug costs. To measure their knowledge of prescription medications, the National Average Drug Acquisition Cost was used as an authoritative price that was compared to the survey takers' price estimates of drugs commonly used in dermatology. Physicians' willingness to use four distinct information system technologies that increase drug price transparency was also assessed. RESULTS: Dermatologists believe drug costs are an important factor in patient care and believe access to price information would allow them to provide a higher quality of care. Dermatologists' knowledge of the costs of medicines they commonly prescribe is poor, but they want to utilize information system technologies that increase access to drug pricing information. CONCLUSIONS: There is an unmet demand for information system technologies which increase price transparency of medications in dermatology. Physicians and IT professionals have the opportunity to create novel information systems that can be utilized to help guide cost conscious clinical decision making.

Coping with information silos: an examination of the medication management process in residential aged care facilities (RACFs).

The aim of this study was to examine the actions of geographically dispersed process stakeholders (doctors, community pharmacists and RACFs) in order to cope with the information silos that exist within and across different settings. The study setting involved three metropolitan RACFs in Sydney, Australia and employed a qualitative approach using semi-structured interviews, non-participant observations and artefact analysis. Findings showed that medication information was stored in silos which required specific actions by each setting to translate this information to fit their local requirements. A salient example of this was the way in which community pharmacists used the RACF medication charts to prepare residents' pharmaceutical records. This translation of medication information across settings was often accompanied by telephone or face-to-face conversations to cross-check, validate or obtain new information. Findings highlighted that technological interventions that work in silos can negatively impact the quality of medication management processes in RACF settings. The implementation of commercial software applications like electronic medication charts need to be appropriately integrated to satisfy the collaborative information requirements of the RACF medication process.

Impact of an online prescription management account on medication adherence.

OBJECTIVES: To assess medication adherence rates of patients utilizing an online prescription management account compared with nonusers. STUDY DESIGN: A retrospective analysis was conducted using de-identified pharmacy claims data from a pharmacy benefit manager covering the period from April 1, 2009, to March 31, 2011. Patients who were continuously eligible throughout the study period and that had at least 1 prescription fill for any of the 8 therapeutic groups examined in the study were selected for inclusion. METHODS: Adherence was assessed by measuring the proportion of days covered (PDC). Propensity score matching was utilized to minimize differences in age, gender, chronic condition score, copay, household income, and urban locality between the users and nonusers groups. Results were reported for all therapeutic groups combined, as well as by individual therapeutic group. RESULTS: Overall, patients utilizing the online account had a significantly higher weighted average PDC (73.19% vs 61.64%, P <.0001). Users also had a higher average PDC for each individual therapeutic group, although the beta-blocker group was not statistically significant. The percentage of patients achieving an average PDC of >80% was also found to be greater in the users group across each therapeutic group and overall. CONCLUSIONS: Patients who utilized an online prescription management account had higher rates of medication adherence as compared with nonusers. Additional studies are needed to assess which specific components of the prescription management account have the biggest impact on adherence.

Use of antiparkinson medications among elderly Medicare beneficiaries with Parkinson's disease.

BACKGROUND: Antiparkinson drugs (APDs) are the mainstay in the management of Parkinson's disease (PD). However, the use of APDs has not been investigated in a nationally representative sample. OBJECTIVES: This study aimed to describe the prevalence and patterns of APD use and to identify determinants of APD use among elderly Medicare beneficiaries with PD. METHODS: Data from the Medicare Current Beneficiary Survey and Medicare claims from 2000 to 2003 were used to identify beneficiaries ≥65 years of age with PD. The APDs included in the study were levodopa, dopamine agonists, monoamine oxidase-B inhibitors, amantadine, anticholinergic agents, and catechol-O-methyltransferase inhibitors. The annual prevalence of APD use was calculated; patterns of APD use were measured by drug class and type of drug regimens (monotherapy or combination therapy). Potential determinants of APD use included sociodemographic characteristics (age, sex, race, education, marital status, and annual income), self-reported health status, residential status (institution or community), prescription drug coverage, disability (functional, physical, and mental), and disease-specific factors (dementia, depression, and other comorbidities). Multivariate logistic regression analyses with generalized estimating equations were used to estimate odds ratios (ORs) of any APD use associated with the determinants. RESULTS: The data revealed 571 beneficiaries with PD (30.1% aged ≥85 years, 55.0% female, 88.3% white), who were observed for a total of 924 person-years. The annual prevalence of APD use was 58.2% (538/924). Levodopa was the most frequently used agent, either as monotherapy or in combination with other APDs (85.5%; 460/538). Multivariate analyses found that patients 65 to 74 years of age (OR = 0.70; 95% CI, 0.49-0.99; P < 0.05) and those ≥85 years of age (OR = 0.57; 95% CI, 0.40-0.81; P < 0.01) were less likely to use APDs than were patients aged 75 to 84 years of age. Patients who had attained a high level of education (more than a high school diploma) were more likely to use APDs than were patients with a low level of education (a high school diploma or less) (OR = 1.51; 95% CI, 1.04-2.19; P < 0.05). In addition, institutionalization (OR = 1.78; 95% CI, 1.17-2.71; P < 0.01), prescription drug coverage (OR = 1.50; 95% CI, 1.15-1.94; P < 0.01), activities of daily living (ADLs) (OR = 1.47; 95% CI, 1.16-1.87; P < 0.01), and depression (OR = 1.25; 95% CI, 1.02-1.53; P < 0.05) were significantly associated with use of APDs. The probability of APD use was lower among those with dementia than among those without dementia (OR = 0.62; 95% CI, 0.48-0.80; P < 0.001). CONCLUSIONS: Almost half of the elderly Medicare beneficiaries with PD in this study did not use any APD between 2000 and 2003. Levodopa was the most frequently used APD, either as monotherapy or in combination with other APDs. The identified determinants of APD use (age, education, prescription drug coverage, ADLs, dementia, depression, and residing in an institution) may be helpful in developing interventions for this population.

Geriatric drug therapy: neglecting the inevitable majority.

Demographic evolution will considerably increase the number of people aged 65 years and beyond in the coming decades. The elderly not only represent the most heterogeneous population, but also are a major user group for prescribed medicines, a predominance that will continue to further increase. Medicines and medication management are much more complex and challenging in the elderly and can only be addressed through a multidisciplinary approach. There is strong evidence that the elderly are able to properly manage their medication; however, their medications require different features than the standard medications used by adults. The elderly are exposed to several chronic disease conditions and their treatments, as well as experience age-related changes and limitations that need to be reflected in their medication management strategies. Geriatric drug therapy remains a multidisciplinary task. The health care industry, physicians, pharmacists, nurses and care givers provide and guide the patient's therapy according to individual needs, while the health care system and regulatory authorities build the necessary framework of support and resources.Any realistic and significant enhancement to the elderly patients' medicines and medication management needs to be addressed by all disciplines and stakeholders involved since the absence of any of the stakeholders in the overall process negatively impacts the achievable enhancement in geriatric drug therapy.

Assessment of informatization for the dispensing of medications at a university hospital.

INTRODUCTION: Informatics and automation are important tools for the reduction of work, errors and costs in a hospital pharmacy. OBJECTIVES: To describe the structuring and function of an informatized system for the dispensing of medications and to assess its effect on nursing and pharmacy services during the period from 1997 to 2003. MATERIALS AND METHODS: In this descriptive and retrospective study, we performed an analysis of documents addressing the structuring and implementation of the informatized medication dispensing system. In addition, we analyzed the perceptions of nurses, pharmacists and pharmacy assistants who participated in the structuring phase of the system when interviewed about the effect of informatization on administrative aspects (e.g., requisition of medications, presentation of the dispensed medication and system operationalization). RESULTS: The major advantages provided by the new system were 1) the elimination of manual transcripts for prescribed medications, 2) increased speed, 3) better identification of the doses prescribed by physicians, 4) medication labels containing all necessary identification and 5) practicality and safety of optical bar code-based verification of the requested and dispensed medications. CONCLUSIONS: The great majority of the interviewees considered the informatized medication supply system to be of good quality. Analysis of the data provided information that could contribute to the expansion and refinement of the system, provide support for studies regarding the utilization of medications and offer new perspectives for work and productivity.

The impact of pharmacy computerised clinical decision support on prescribing, clinical and patient outcomes: a systematic review of the literature.

OBJECTIVES: Computerised clinical decision support systems (CDSSs) are being used increasingly to support evidence-based decision-making by health care professionals. This systematic review evaluated the impact of CDSSs targeting pharmacists on physician prescribing, clinical and patient outcomes. We compared the impact of CDSSs addressing safety concerns (drug interactions, contraindications, dose monitoring and adjustment) and those focusing on medicines use in line with guideline recommendations (hereafter referred to as Quality Use of Medicines, or QUM). We also examined the influence of clinical setting (institutional versus ambulatory care), system- or user-initiation of CDSS, prescribing versus clinical outcomes reported and use of multi-faceted versus single interventions on system effectiveness. METHODS: We searched Medline, Embase, CINAHL and PsycINFO (1990-2009) for methodologically adequate studies (experiments and strong quasi-experiments) comparing a CDSS with usual pharmacy care. Individual study results are reported as positive trends or statistically significant results in the direction of the intentions of the CDSS being tested. Studies are aggregated and compared as the proportions of studies showing the effectiveness of the CDSS on the majority (> or = 50%) of outcomes reported in the individual study. KEY FINDINGS: Of 21 eligible studies, 11 addressed safety and 10 QUM issues. CDSSs addressing safety issues were more effective than CDSSs focusing on QUM (10/11 versus 4/10 studies reporting statistically significant improvements in favour of CDSSs on > or = 50% of all outcomes reported; P = 0.01). A number of QUM studies noted the limited contact between pharmacists and physicians relating to QUM treatment recommendations. More studies demonstrated CDSS benefits on prescribing outcomes than clinical outcomes (10/10 versus 0/3 studies; P = 0.002). There were too few studies to assess the impact of system- versus user-initiated CDSS, the influence of setting or multi-faceted interventions on CDSS effectiveness. CONCLUSIONS: Our study demonstrated greater effectiveness of safety-focused compared with QUM-focused CDSSs. Medicine safety issues are traditional areas of pharmacy activity. Without good communication between pharmacists and physicians, the full benefits of QUM-focused CDSSs may not be realised. Developments in pharmacy-based CDSSs need to consider these inter-professional relationships as well as computer-system enhancements.

Assessment of informatization for the dispensing of medications at a university hospital

INTRODUCTION: Informatics and automation are important tools for the reduction of work, errors and costs in a hospital pharmacy. OBJECTIVES: To describe the structuring and function of an informatized system for the dispensing of medications and to assess its effect on nursing and pharmacy services during the period from 1997 to 2003. MATERIALS AND METHODS: In this descriptive and retrospective study, we performed an analysis of documents addressing the structuring and implementation of the informatized medication dispensing system. In addition, we analyzed the perceptions of nurses, pharmacists and pharmacy assistants who participated in the structuring phase of the system when interviewed about the effect of informatization on administrative aspects (e.g., requisition of medications, presentation of the dispensed medication and system operationalization). RESULTS: The major advantages provided by the new system were 1) the elimination of manual transcripts for prescribed medications, 2) increased speed, 3) better identification of the doses prescribed by physicians, 4) medication labels containing all necessary identification and 5) practicality and safety of optical bar code-based verification of the requested and dispensed medications. CONCLUSIONS: The great majority of the interviewees considered the informatized medication supply system to be of good quality. Analysis of the data provided information that could contribute to the expansion and refinement of the system, provide support for studies regarding the utilization of medications and offer new perspectives for work and productivity.

Tele-pharmacy in remote medical practice: the Royal Flying Doctor Service Medical Chest Program.

In recent times remote medical practice has been developed into a unique discipline in its own right with telehealth one of the eight defining key features. Since 1942, the telemedicine consultation service provided by the Royal Flying Doctor Service in Australia has been supported by a tele-pharmacy program known as the Medical Chest Program. The contents of the chest comprise more than 85 items, including medications and equipment which can be prescribed during a telehealth consultation to cover both emergency care and definitive treatment for less serious conditions. By 2006 there were 3500 medical chests placed throughout Australia. Specifically, the state of Queensland had 21 470 telehealth consultations from 1 July 2005 to 30 June 2006, resulting in the prescription of at least one medical chest item in 2938 (13.7%) consultations. Queensland data regarding medication indicate that antibiotics (26%), analgesics (23%) and gastrointestinal medications (12%) were the most common categories of dispensed medications, and that the most common clinical diagnostic categories for the consultation resulting in dispensed medications were respiratory (17%), skin (15%) and abdominal conditions (13%). In summary, the RFDS medical chest program continues to be a successful large scale provider of medications to those living in remote Australia, enabling early access to medications for both emergencies and definitive care, while minimising the need for mail-order pharmacy or patient travel. This model of care may provide an important template for those designing service delivery models in other remote jurisdictions.

Developing and promoting an intranet site for a drug information service.

PURPOSE: The development and promotion of a drug information service (DIS) intranet site are described. SUMMARY: Stanford Hospital and Clinics (SHC) is an acute and tertiary care facility with 613 licensed inpatient beds and 48 outpatient clinics. A DIS intranet site was developed to allow better accessibility to pharmacy forms and products (e.g., drug shortage list, reference guides) and to reduce repetitive requests to the DIS. The goal was to continue to provide information to SHC health care providers but allow the drug information specialist to focus on answering clinical questions. The intranet site was completed over a four-month period. The intranet site was divided into seven webpages: DIS overview, pharmacy and therapeutics, frequently asked questions, quick drug reference guide, ask the pharmacist, drug information resources, and referral center. The preparation for and implementation of the promotional phase took approximately two months. Promotional strategies included the creation and dissemination of brochures and stickers. The intranet site went live on January 1, 2007, and the advertising campaign began one month later. The utility of the site was measured for five months by tracking the number of visits to the site, the number of visits to each webpage, and the number of downloaded files. Request volume, caller affiliation, and question types received by the DIS call center were also recorded. CONCLUSION: Establishing a DIS intranet site required a considerable time investment and a willingness to work with existing infrastructures, such as the marketing and communications department and Web marketing staff.