Application of the Failure Mode and Effects Analysis (FMEA) to identify vulnerabilities and opportunities for improvement prior to implementing a computerized prescription order entry (CPOE) system in a university hospital oncology clinic.

INTRODUCTION: Prior to implementing a new computerized prescription order entry (CPOE) application, the potential risks associated with this system were assessed and compared to those of paper-based prescriptions. The goal of this study is to identify the vulnerabilities of the CPOE process in order to adapt its design and prevent these potential risks. METHODS AND MATERIALS: Failure mode and effects analysis (FMEA) was used as a prospective risk-management technique to evaluate the chemotherapy medication process in a university hospital oncology clinic. A multidisciplinary team assessed the process and compared the critical steps of a newly developed CPOE application versus paper-based prescriptions. The potential severity, occurrence and detectability were assessed prior to the implementation of the CPOE application in the clinical setting. RESULTS: The FMEA led to the identification of 24 process steps that could theoretically be vulnerable, therefore called failure modes. These failure modes were grouped into four categories of potential risk factors: prescription writing, patient scheduling, treatment dispensing and patient follow-up. Criticality scores were calculated and compared for both strategies. Three failure modes were prioritized and led to modification of the CPOE design. Overall, the CPOE pathway showed a potential risk reduction of 51% compared to paper-based prescriptions. CONCLUSION: FMEA was found to be a useful approach to identify potential risks in the chemotherapy medication process using either CPOE or paper-based prescriptions. The e-prescription mode was estimated to result in less risk than the traditional paper mode.

A pharmacist-physician intervention model using a computerized alert system to reduce high-risk medication use in primary care.

PURPOSE: Potentially inappropriate medications (PIMs) have been associated with a greater risk of adverse drug events and hospitalizations. To reduce PIMs use, a family health team (FHT) implemented a knowledge translation (KT) strategy that included a pharmacist-physician intervention model based on alerts from a computerized alert system (CAS). METHODS: Our pragmatic, single-site, pilot study was conducted in an FHT clinic in Quebec, Canada. We included community-dwelling older adults (≥ 65 years), with at least 1 alert for selected PIMs and a medical appointment during the study period. PIMs were selected from the Beers and STOPP criteria. The primary outcome was PIMs cessation, decreased dose, or replacement. The secondary outcome was the clinical relevance of the alerts as assessed by the pharmacists. RESULTS: During the 134 days of the study, the CAS screened 369 individuals leading to the identification of 65 (18%) patients with at least 1 new alert. For those 65 patients, the mean age was 77 years, men accounted for 29% of the group and 55% were prescribed 10 or more drugs. One or more clinically relevant alerts were generated for 27 of 65 included patients for an overall clinical relevance of the alerts of 42%. Of the 27 patients with at least 1 relevant alert, 17 (63%) had at least 1 medication change as suggested by the pharmacist. CONCLUSION: An interdisciplinary pharmacist-physician intervention model, based on alerts generated by a CAS, reduced the use of PIMs in community-dwelling older adults followed by an FHT.

Reduction in targeted potentially inappropriate medication use in elderly inpatients: a pragmatic randomized controlled trial.

PURPOSE: The use of potentially inappropriate medications (PIMs) in hospitalized older adults is a complex problem, but the use of computerized alert systems (CAS) has shown some potential. The study's objective is to assess the change in PIM use with a CAS-based pharmacist-physician intervention model compared to usual clinical care. METHODS: Pragmatic single-site randomized controlled trial was conducted at a university teaching hospital. Hospitalizations identified with selected Beers or STOPP criteria were randomized to usual clinical care or to the CAS-based pharmacist-physician intervention. The primary outcome was PIM drug cessation or dosage decrease. Clinical relevance of the CAS alerts was assessed. RESULTS: Analyses included 231 patients who had 128 and 126 hospitalizations in the control and intervention groups, respectively. Patients had a mean age of 81, and 60% were female. In the intervention compared to the control group, drug cessation or dosage decrease were more frequent at 48 h post-alert (45.8 vs 15.9%; absolute difference 30.0%; 95%CI 13.8 to 46.1%) and at discharge from the hospital (48.1 vs 27.3%; absolute difference 20.8%; 95%CI 4.6 to 37.0%). In a post hoc analysis of all alerts, regardless of their clinical relevance, the absolute difference in drug cessation or dosage decrease between the intervention and control groups was 16.2% (95%CI 2.9 to 29.6%) at 48 h and 8.0% (95%CI -4.0 to 20.0%) at discharge from the hospital. CONCLUSIONS: In hospitalized older adults, a CAS-based pharmacist-physician intervention, compared to usual clinical care, resulted in significant higher number of drug cessation and dosage reductions for targeted PIMs.

Knowledge Translation Strategy to Reduce the Use of Potentially Inappropriate Medications in Hospitalized Elderly Adults.

OBJECTIVES: To evaluate the effect of a knowledge translation (KT) strategy to reduce potentially inappropriate medication (PIM) use in hospitalized elderly adults. DESIGN: Segmented regression analysis of an interrupted time series. SETTING: Teaching hospital. PARTICIPANTS: Individuals aged 75 and older discharged from the hospital in 2013/14 (mean age 83.3, 54.5% female). INTERVENTION: The KT strategy comprises the distribution of educational materials, presentations by geriatricians, pharmacist-physician interventions based on alerts from a computerized alert system, and comprehensive geriatric assessments. MEASUREMENTS: Rate of PIM use (number of patient-days with use of at least one PIM/number of patient-days of hospitalization for individuals aged ≥75). RESULTS: For 8,622 patients with 14,071 admissions, a total of 145,061 patient-days were analyzed. One or more PIMs were prescribed on 28,776 (19.8%) patient-days; a higher rate was found for individuals aged 75 to 84 (24.0%) than for those aged 85 and older (14.4%) (P < .001), and in women (20.8%) than in men (18.6%) (P < .001). The drug classes most frequently accounting for the PIM were gastrointestinal agents (21%), antihistamines (18%), and antidepressants (17%). An absolute decrease of 3.5% (P < .001) of patient-days with at least one PIM was observed immediately after the intervention. CONCLUSION: A KT strategy resulted in decreased use of PIM in elderly adults in the hospital. Additional interventions will be implemented to maintain or further reduce PIM use.

A Pharmacist-Physician Intervention Model Using a Computerized Alert System to Reduce High-Risk Medication Use in Elderly Inpatients.

BACKGROUND: Prescription is a complex challenge facing clinicians caring for elderly inpatients. Potentially inappropriate medication (PIM) use frequently leads to adverse drug events and geriatric syndromes. Strategies to reduce PIM use are thus urgently needed. OBJECTIVES: The objectives of this study were to assess (1) the applicability of a pharmacist-physician intervention model to reduce the use of high-risk medications; and (2) the clinical relevance of the alerts generated by a computerized alert system (CAS). METHODS: The study was conducted in patients aged 65 years or older admitted to a teaching hospital between April and June 2014. In the intervention model, the pharmacist determined the clinical relevance of the Beers criteria-based CAS alerts, analyzed the patient's pharmacotherapy, and developed a geriatric pharmacotherapeutic plan to be discussed with the treating physician. The main outcome was the change rate, defined as the number of patient-days with a change in at least one medication out of the number of patient-days with a pharmacist intervention. RESULTS: The CAS identified at least one alert in 200 patient-days, i.e., 4.3% of screened patient-days. In 74.5% of those patient-days, at least one alert was judged to be clinically relevant. The change rate was 77.7%. The most frequent changes were drug discontinuation (42.4%) and dose reduction (29.1%). The inpatient geriatric consultation team was involved in only 24% of the hospitalizations with at least one change in medication. CONCLUSION: The intervention model reduced high-risk medication use in older inpatients. Most of the vulnerable inpatients identified by CAS alerts would not have otherwise had a geriatric medication review.

Does hospitalization influence patients' medication adherence and community pharmacists' interventions?

BACKGROUND: Medication adherence reduces disease morbidity. Data regarding changes in a patient's adherence before and after hospitalization and how this hospitalization influences a pharmacist's interventions are scarce. OBJECTIVE: To assess changes in adherence to cardiovascular and respiratory medications in the year preceding and following a hospitalization; explore patients' perceptions about medication adherence and the pharmacist's role; and describe pharmacists' interventions regarding medication adherence. METHODS: This cohort study included patients hospitalized for acute coronary syndrome, acute worsening of heart failure, or acute COPD exacerbations. Adherence to cardiovascular and respiratory medications was measured by calculating the proportion of days covered (PDC) from prescription refills. Patient interviews were completed to explore their perceptions about medication adherence and the role of the pharmacist. Community pharmacists were invited to complete an online survey and to participate in focus groups to discuss interventions to improve medication adherence. RESULTS: Medication adherence was assessed for 61 patients; the mean PDC was 69.8% 12 months before hospitalization and 72.4% 12 months following hospitalization. Patients reported that they felt the need to take their medications to prevent worsening of their disease. They were satisfied with current pharmaceutical services. A total of 136 questionnaires completed by pharmacists were analyzed and 9 participants attended the focus groups. Most pharmacists reported monitoring prescription renewals to assess adherence, with no significant influence from the hospitalization itself. The patient's interest was reported to be an important facilitator, whereas a lack of time and face-to-face interaction with patients who had their medication delivered to their home was reported a main barrier to interventions. This study was limited by a small sample size. CONCLUSIONS: Patient medication adherence did not significantly change following hospitalization. Hospitalization does not appear to significantly influence patient and pharmacist behavior towards medication adherence.