Updating formulations for compounded oral liquid medications in a university health system.

PURPOSE: The development of a compounded oral liquid medication formulary and subsequent implementation of revised standard formulations in a university health system are described. METHODS: A standard assessment form was developed to direct evaluation of published literature and current compounding resources for all oral liquid formulations prepared by health-system pharmacies. Specific variables reviewed included concentration, components, beyond-use dating, and storage recommendations. After their review and approval, revised formulations were typed into distinct templates that incorporated additional safety features. An online departmental repository was developed to house the revised formulations. RESULTS: Modifications were made to 136 (78%) of the 175 compounded formulations reviewed. Changes in storage conditions and extension of beyond-use dating were the most common revisions in 77 (44%) and 42 (24%) of compounds, respectively. In addition, strawberry syrup was removed as a component of 38 (22%) formulations, reducing exposure of pediatric patients to red dye. Presentations were given at several forums to inform pharmacy staff of the goals of the project and details regarding implementation. In addition, e-mail communications were sent to share the online location of the updated formulations and compounding sheets. Nursing, medical, and pharmacy staff were notified of concentration changes through the pharmacy newsletter and e-mail. CONCLUSION: A comprehensive review resulted in updates to over 75% of oral liquid medications prepared by pharmacies in a university health system. Revised formulations were made available through an online repository, ensuring consistency of compounding procedures with respect to concentrations, components, and storage requirements.

The relationship between diabetes mellitus and 30-day readmission rates.

BACKGROUND: It is estimated that 9.3% of the population in the United States have diabetes mellitus (DM), 28% of which are undiagnosed. The high prevalence of DM makes it a common comorbid condition in hospitalized patients. In recent years, government agencies and healthcare systems have increasingly focused on 30-day readmission rates to determine the complexity of their patient populations and to improve quality. Thirty-day readmission rates for hospitalized patients with DM are reported to be between 14.4 and 22.7%, much higher than the rate for all hospitalized patients (8.5-13.5%). The objectives of this study were to (1) determine the incidence and causes of 30-day readmission rates for patients with diabetes listed as either the primary reason for the index admission or with diabetes listed as a secondary diagnosis compared to those without DM and (2) evaluate the impact on readmission of two specialized inpatient DM services: the Hyperglycemic Intensive Insulin Program (HIIP) and Endocrine Consults (ENDO). METHODS: For this study, DM was defined as any ICD-9 discharge diagnosis (principal or secondary) of 250.xx. Readmissions were defined as any unscheduled inpatient admission, emergency department (ED) visit, or observation unit stay. We analyzed two separate sets of patient data. The first pilot study was a retrospective chart review of all patients with a principle or secondary admission diagnosis of diabetes admitted to any adult service within the University of Michigan Health System (UMHS) between October 1, 2013 and December 31, 2013. We then did further uncontrolled analysis of the patients with a principal admitting diagnosis of diabetes. The second larger retrospective study included all adults discharged from UMHS between October 1, 2013 and September 30, 2014 with principal or secondary discharge diagnosis of DM (ICD-9-CM: 250.xx). RESULTS: In the pilot study of 7763 admissions, the readmission rate was 26% for patients with DM and 22% for patients without DM. In patients with a primary diagnosis of DM on index admission, the most common cause for readmission was DM-related. In the larger study were 37,702 adult inpatient discharges between October 1, 2013 and September 30, 2014. Of these, 20.9% had DM listed as an encounter diagnosis. Rates for all encounters (inpatient, ED and Observation care) were 24.3% in patients with DM compared to 17.7% in those without DM (p < 0.001). The most common cause for readmission in patients with DM as a secondary diagnosis to the index admission was infection-related. During the index hospital stay, only a small proportion of patients with DM (approximately 12%) received any DM service consult. Those who received a DM consult had a higher case mix index compared to those who did not. Despite the higher acuity, there was a lower rate of ED /observation readmission in patients followed by the DM services (6.6% HIIP or ENDO vs. 9.6% no HIIP or ENDO, p = 0.0012), though no difference in the inpatient readmission rates (17.6% HIIP or ENDO vs. 17.4% no HIIP or ENDO, p = 0.89) was noted. CONCLUSIONS: Patients with both a primary or secondary diagnosis of DM have higher readmission rates. The reasons for readmission vary; patients with a principal diagnosis of DM have more DM related readmissions and those with secondary diagnosis having more infection-related readmissions. DM services were used in a small proportion of patients and may have contributed to lower DM related ED revisits. Further prospective studies evaluating the role of these services in terms of glucose management, patient education and outpatient follow up on readmission are needed to identify interventions important to reducing readmission rates.

Standardization of compounded oral liquids for pediatric patients in Michigan.

PURPOSE: The development, dissemination, and adoption of standard concentrations for compounded oral liquids for pediatric patients in Michigan are described. SUMMARY: A baseline assessment of current practices in Michigan revealed significant variations in the concentrations of commonly used oral liquid medicines for pediatric patients. A statewide collaborative initiative in Michigan was created to standardize the concentrations of compounded oral liquids for pediatric patients. Standard concentrations were proposed and adopted by key stakeholders. These standards were then disseminated across the state to prescribers and pharmacists, with encouragement to voluntarily adopt the standards as a patient safety measure. A follow-up survey was conducted to evaluate adoption of the standards. A total of 263 pharmacists responded to the survey. Standardization of the concentrations of compounded oral liquids in Michigan was welcomed by most pharmacies and is perceived to have reduced the risk for errors at transitions of care for children receiving compounded oral liquids. Awareness of the standardization initiative was acknowledged by 77% of survey respondents, and adoption of the standards was observed to some degree by 57% of survey respondents. In addition, 70% of survey respondents agreed or strongly agreed that adoption of the standards has improved patient safety in Michigan. CONCLUSION: Standard drug concentrations for compounded oral liquids were developed for pediatric patients in Michigan. A survey after dissemination of the recommended standards confirmed general awareness of the initiative and adoption of the standards by a substantial proportion of respondents. Most respondents indicated a belief that creation of the standards improved patient safety.

Nursing, Pharmacy, and Prescriber Knowledge and Perceptions of High-Alert Medications in a Large, Academic Medical Hospital.

BACKGROUND: High-alert medications pose a greater risk of causing significant harm to patients if used in error. The Joint Commission requires that hospitals define institution-specific high-alert medications and implement processes to ensure safe medication use. METHOD: Nursing, pharmacy, and prescribers were asked to voluntarily complete a 34-question survey to assess their knowledge, experience, and perceptions regarding high-alert medications in an academic hospital. RESULTS: The majority of respondents identified the organization's high-alert medications, the consequences of an error involving a high-alert medication, and the reversal agent. Most of the risk-reduction strategies within the institution were viewed as being effective by respondents. Forty-five percent of the respondents utilized a high-alert medication in the previous 24 hours. Only 14.2% had experienced an error with a high-alert medication in the previous 12 months, with 46% being near misses. The survey found the 5 rights for medication administration were not being utilized consistently. Respondents indicated that work experience or hospital orientation is the preferred learning experience for high-alert medications. CONCLUSIONS: This study assessed all disciplines involved in the medication use process. Perceptions about high-alert medications differ between disciplines. Ongoing discipline-specific education is required to ensure that individuals accept accountability in the medication use process and to close knowledge gaps on high-alert medications and risk-reduction strategies.

Variability in compounding of oral liquids for pediatric patients: a patient safety concern.

OBJECTIVE: To determine the degree in variation of oral liquid pediatric compounding practices in Michigan pharmacies. DESIGN: Cross-sectional survey study. SETTING: All types of inpatient and outpatient pharmacies across the state of Michigan, excluding nuclear pharmacies and long-term care facilities. PARTICIPANTS: 244 Michigan pharmacies. INTERVENTION: An online survey tool was used to assess the current compounding practices of 147 oral liquid pediatric medications. The survey was e-mailed or faxed to hospitals, chain pharmacies, and independent pharmacies. Pharmacists were also mailed a follow-up postcard, and the Michigan Pharmacists Association publicized the project through its journal and annual meeting. MAIN OUTCOME MEASURES: Pharmacy demographics; number of compounding pharmacies; number of medications compounded; awareness of compounding errors; results of compounding errors; and number of concentrations compounded per medication. RESULTS: The majority of respondents were from outpatient pharmacies, but inpatient and other types of pharmacies were also represented. The majority of participating pharmacies compound fewer than five oral liquid medications per week. Awareness of errors was low overall, with no errors believed to result in permanent harm or death. The number of concentrations compounded per medication ranged from 1 to 9, with the majority of pharmacies compounding more than 3 concentrations per medication. CONCLUSION: There is a considerable degree of variation in current oral pediatric liquid compounding practices in Michigan pharmacies. This variability poses a significant risk to patient safety.

Medication safety in obstetrics and gynecology.

The safe prescribing, use, administration, and monitoring of medications are an important component of patient safety efforts and are of particular importance to the obstetrician/gynecologist. Safe use of medications requires a team-based approach focused on medication safety with effective 2-way communication, use of technology to prevent and identify errors, diligent monitoring of the medication's effects on the patient, and use of standardized protocols to decrease the likelihood of a medication error.