National Hospital and Health-System Controlled Substances Drug Diversion Prevention & Surveillance Program Assessment Survey - 2021.

PURPOSE: To present and discuss the results of the National Hospital and Health-System Controlled Substances Drug Diversion Prevention & Surveillance Program Assessment Survey. METHODS: The survey was emailed to 1,529 chief pharmacy officers utilizing the list of directors of pharmacy from the American Society of Health-System Pharmacists. The survey opened September 15, 2021, and closed October 4, 2021. Forty-nine questions were included in 5 different sections, and participants were also given the option to respond to 39 additional questions. RESULTS: The survey response rate was 12.75%, with the results showing consistencies in practice around drug security and human resource management. Sixty-two percent of sites had a formalized drug diversion committee, half of which had been implemented since 2018. Adoption of electronic controlled substance systems continues to increase, with 50% of sites having implemented such a system in the previous 3 years. At the time of the survey, 18% of organizations did not have an electronic system, but 90% of sites had implemented or intended to implement one by 2023. Over 40% of sites that utilized an electronic system were looking to upgrade to a next-generation system. Most organizations had 0.5 to 1 full-time equivalent dedicated to diversion prevention, and two-thirds of sites had a formalized diversion committee. The majority of sites defined "significant loss" by utilizing professional judgement, based on the scenario, as a percentage of inventory or as a range of units. Community practice consensus is needed around auditing adjustments to controlled substance inventory and for perpetual inventory processes. Respondents reported 1 to 2 (29%), 3 to 5 (26%), and more than 10 (26%) formal drug diversion investigations annually. CONCLUSION: This first-time survey provided significant insight into the realities of drug diversion prevention practices in hospitals and health systems nationally.

A Human Factors Engineering Study of the Medication Delivery Process during an Anesthetic: Self-filled Syringes versus Prefilled Syringes.

BACKGROUND: Prefilled syringes (PFS) have been recommended by the Anesthesia Patient Safety Foundation. However, aspects in PFS systems compared with self-filled syringes (SFS) systems have never been explored. The aim of this study is to compare system vulnerabilities (SVs) in the two systems and understand the impact of PFS on medication safety and efficiency in the context of anesthesiology medication delivery in operating rooms. METHODS: This study is primarily qualitative research, with a quantitative portion. A work system analysis was conducted to analyze the complicated anesthesia work system using human factors principles and identify SVs. Anesthesia providers were shadowed: (1) during general surgery cases (n = 8) exclusively using SFS and (2) during general surgery cases (n = 9) using all commercially available PFS. A proactive risk assessment focus group was followed to understand the risk of each identified SV. RESULTS: PFS are superior to SFS in terms of the simplified work processes and the reduced number and associated risk of SVs. Eight SVs were found in the PFS system versus 21 in the SFS system. An SV example with high risk in the SFS system was a medication might need to be "drawn-up during surgery while completing other requests simultaneously." This SV added cognitive complexity during anesthesiology medication delivery. However, it did not exist in the PFS system. CONCLUSIONS: The inclusion of PFS into anesthesiology medication delivery has the potential to improve system safety and work efficiency. However, there were still opportunities for further improvement by addressing the remaining SVs and newly introduced complexity.

Cardiovascular Drug Shortages: Predominant Etiologies, Clinical Implications, and Management Strategies.

OBJECTIVE: To review the literature surrounding the incidence, significance, and management of cardiovascular (CV) drug shortages. DATA SOURCES: A literature search was conducted using all available indexing databases from January 1996 to August 2013, coupled with assessments of the ASHP (American Society of Health System Pharmacists) and Food and Drug Administration Web sites designated to drug shortages. Data were also gathered through a review of listservs discussing this topic. DATA SYNTHESIS: CV drug shortages are among the top 5 national drug class shortages that are posing a threat to patient care and public health. When a drug shortage occurs, it requires modifications to prescribing and the method medications are processed by the pharmacy. These necessary yet cumbersome changes can potentially result in less-than-desirable prescribing options and increases in personnel time because of administrative and dispensing obstacles. Any one of these has the potential to increase costs and/or lead to worse outcomes. Several factors have been shown to contribute to these shortages, including manufacturing delays, increased demand, medication discontinuations, and lack of raw materials. In this article, we review 13 of the critical CV drug shortages, describe their role in therapy, discuss the reasons for the shortage, define their impact on patient care, and recommend alternative therapies. CONCLUSIONS: CV drug shortages are common and can potentially lead to deleterious patient outcomes. Institutions should develop plans for early identification, management, and resolution to minimize the clinical sequelae associated with drug shortages.

Clinical management strategies and implications for parenteral nutrition drug shortages in adult patients.

Drug shortages affect every aspect of patient care, including and especially, nutrition therapy. The purpose of this review is to discuss current parenteral nutrition-related drug shortages, including causes and duration of the disruptions, and provide recommendations for managing specific nutritional shortages that minimize negative patient care outcomes. A general framework for the management of current and future shortages is presented.

Knowledge, skills, and resources for pharmacy informatics education.

Pharmacy has an established history of technology use to support business processes. Pharmacy informatics education within doctor of pharmacy programs, however, is inconsistent, despite its inclusion as a requirement in the 2007 Accreditation Council for Pharmacy Education Standards and Guidelines. This manuscript describes pharmacy informatics knowledge and skills that all graduating pharmacy students should possess, conceptualized within the framework of the medication use process. Additionally, we suggest core source materials and specific learning activities to support pharmacy informatics education. We conclude with a brief discussion of emerging changes in the practice model. These changes are facilitated by pharmacy informatics and will inevitably become commonplace in our graduates' practice environment.

Bar Code Medication Administration Technology: Characterization of High-Alert Medication Triggers and Clinician Workarounds.

BACKGROUND: Bar code medication administration (BCMA) technology is gaining acceptance for its ability to prevent medication administration errors. However, studies suggest that improper use of BCMA technology can yield unsatisfactory error prevention and introduction of new potential medication errors. OBJECTIVE: To evaluate the incidence of high-alert medication BCMA triggers and alert types and discuss the type of nursing and pharmacy workarounds occurring with the use of BCMA technology and the electronic medication administration record (eMAR). METHODS: Medication scanning and override reports from January 1, 2008, through November 30, 2008, for all adult medical/surgical units were retrospectively evaluated for high-alert medication system triggers, alert types, and override reason documentation. An observational study of nursing workarounds on an adult medicine step-down unit was performed and an analysis of potential pharmacy workarounds affecting BCMA and the eMAR was also conducted. RESULTS: Seventeen percent of scanned medications triggered an error alert of which 55% were for high-alert medications. Insulin aspart, NPH insulin, hydromorphone, potassium chloride, and morphine were the top 5 high-alert medications that generated alert messages. Clinician override reasons for alerts were documented in only 23% of administrations. Observational studies assessing for nursing workarounds revealed a median of 3 clinician workarounds per administration. Specific nursing workarounds included a failure to scan medications/patient armband and scanning the bar code once the dosage has been removed from the unit-dose packaging. Analysis of pharmacy order entry process workarounds revealed the potential for missed doses, duplicate doses, and doses being scheduled at the wrong time. CONCLUSIONS: BCMA has the potential to prevent high-alert medication errors by alerting clinicians through alert messages. Nursing and pharmacy workarounds can limit the recognition of optimal safety outcomes and therefore workflow processes must be continually analyzed and restructured to yield the intended full benefits of BCMA technology.

Hemodynamic and electrocardiographic effects of short-term Ginkgo biloba.

OBJECTIVE: To evaluate the immediate and short-term hemodynamic and electrocardiographic effects of Ginkgo biloba (ginkgo). METHODS: Healthy volunteers were randomized to receive ginkgo 120 mg or placebo twice daily for 7 days in this prospective, double blind trial. After at least a 7-day washout period, subjects were crossed over to an additional 7 days of alternate therapy. Blood pressure, heart rate, and 12-lead electrocardiograms were evaluated immediately before (baseline), and at 1, 3, and 5 hours after observed ingestion of study drug on days 1 and 7 of therapy. Electrocardiographic parameters (P wave and QRS complex duration; PR, QT, and QTc intervals) were measured in lead II by a blinded investigator. RESULTS: Ginkgo had no effect on any of the evaluated electrocardiographic parameters at any time point on days 1 or 7. Additionally, no changes in heart rate or systolic and diastolic blood pressure were found between the groups at any time point on any evaluative day. CONCLUSIONS: Commonly used doses of Ginkgo biloba do not have any immediate or short-term effects on blood pressure, heart rate, or electrocardiographic variables in young, healthy volunteers.