Changes to medication-use processes after overdose of U-500 regular insulin.

PURPOSE: Modifications made to medication-use processes after an overdose of U-500 regular insulin are described. SUMMARY: After a medication error occurred with U-500 regular insulin, a multidisciplinary team of physicians, nurses, advanced-practice nurses, and pharmacists was created to review and improve the ordering, dispensing, and administration processes associated with U-500 regular insulin. The group determined that current safety practices for managing insulin were inadequate. New safety processes specific to U-500 regular insulin were developed and implemented. Vials of U-500 regular insulin are no longer dispensed to nursing units and are stored only in the pharmacy and separated from other insulins. The ordering of U-500 regular insulin is limited to the endocrinology service, and all orders are written using a specialized U-500 regular insulin order set. The option for i.v. administration for U-500 regular insulin was removed from the pharmacy order-entry system; thus, only the subcutaneous route is entered by the pharmacist. In addition, patient-specific doses of U-500 regular insulin are prepared in the pharmacy using only tuberculin syringes that require a double check by two pharmacists. These syringes are delivered to patient care areas in a bag distinguishing the medication as "high alert." One last safety check involving a two-nurse check at the bedside to confirm correct medication administration is performed. Lastly, patient education material specifically for U-500 regular insulin is available online. CONCLUSION: A multidisciplinary team recommended modifications to the medication-use system regarding U-500 regular insulin after review of a medication error. No errors involving U-500 regular insulin have been reported since implementation of the changes.

Selection of a validated scale for measuring medication adherence.

OBJECTIVE: To evaluate literature describing medication adherence surveys/scales to gauge patient behaviors at the point of care. DATA SOURCES: Literature was identified via PubMed and Ovid (1950 to June 2009) using the search terms medication adherence, medication compliance, and medication persistence and combined with the terms questionnaire, survey, scale, or self-report. STUDY SELECTION: All articles in English with adherence scales validated in two or more diseases and containing 30 or fewer questions were selected. DATA SYNTHESIS: Five adherence scales were identified and reviewed by evaluating positive characteristics (short length, internal consistency, reliability, barriers to adherence, literacy appropriate, and self-efficacy), sensitivity, specificity, and diseases in which they have been validated. The Medication Adherence Questionnaire (MAQ) is the shortest scale and easiest to score. MAQ identifies barriers to nonadherence but not self-efficacy. The Self-efficacy for Appropriate Medication Use Scale (SEAMS) is a 13-question scale, and the Brief Medication Questionnaire (BMQ) has three main question headings and multiple subquestions. Both assess barriers and self-efficacy; however, scoring is difficult. The Hill-Bone Compliance Scale and Medication Adherence Rating Scale (MARS) address barriers and self-efficacy but are limited in their generalizability. The Hill-Bone Compliance Scale focuses on hypertensive patients, while MARS is specific to psychiatric populations. CONCLUSION: No gold-standard medication adherence scale exists. MAQ is most adaptable at the point of care and across populations. MAQ is the quickest to administer and score and has been validated in the broadest range of diseases. SEAMS, BMQ, and the Hill-Bone Compliance Scale allow self-efficacy to be assessed and therefore may be useful in medication management clinics. MARS is specific to psychiatric populations.

Influence of medications and diagnoses on fall risk in psychiatric inpatients.

PURPOSE: The influence of medications and diagnoses on fall risk in psychiatric inpatients was evaluated. METHODS: In this retrospective case-control study, psychiatric inpatients age 18 years or older with a documented fall that was reported served as study cases. These patients were matched to control patients from the same hospital (1:1) by admission year, sex, and age. Psychiatric diagnoses evaluated included major depressive disorder, schizophrenia or schizoaffective disorder, bipolar disorder, Alzheimer's disease and dementia, anxiety or neurosis, delirium, personality disorder, and obsessive-compulsive disorder. Medications assessed as independent variables were conventional antipsychotics, atypical antipsychotics, selective serotonin-reuptake inhibitors, tricyclic antidepressants, atypical antidepressants, monoamine oxidase inhibitors, lithium, anticonvulsants, benzodiazepines, nonbenzodiazepine sleep aids, Alzheimer's disease medications, antihistamines, antiarrhythmics, antihypertensives, benign prostatic hyperplasia medications, oral hypoglycemic agents, histamine H(2)-receptor blockers, laxatives and stool softeners, muscle relaxants, nonsteroidal antiinflammatory drugs, opioids, Parkinson's disease medications, and overactive bladder medications. Univariate logistic regression models were developed for each risk factor to determine its impact on fall risk. RESULTS: A total of 774 patient cases were matched with controls. Most falls occurred on the second day of hospitalization. Medications associated with a higher risk of falls were alpha-blockers, nonbenzodiazepine sleep aids, benzodiazepines, H(2)-blockers, lithium, antipsychotics, atypical antidepressants, anticonvulsants, and laxatives and stool softeners. Patients with a diagnosis of dementia and Alzheimer's disease also had an increased risk of falling. CONCLUSION: Alpha-blockers, nonbenzodiazepine sleep aids, benzodiazepines, H(2)-blockers, lithium, atypical antipsychotics, atypical antidepressants, anticonvulsants and mood stabilizers, conventional anti-psychotics, laxatives and stool softeners, and dementia and Alzheimer's disease were significant predictors of inpatient falls in a psychiatric population.

Effect of drug information request templates on pharmacy student compliance with the modified systematic approach to answering drug information questions.

BACKGROUND: The modified systematic approach to answering drug information questions is a technique used in drug information practice and in teaching pharmacy students to effectively provide drug information. Drug information request templates were developed to prompt students and other trainees to ask appropriate background questions and perform an effective search. OBJECTIVE: An evaluation was conducted to determine whether use of drug information templates by fourth-year pharmacy students during their drug information experiential rotation improved compliance with the modified systematic approach. METHODS: Fifty documented drug information requests, including 25 prior to template implementation (August 2005-August 2006) and 25 after template implementation (August 2007-August 2008), were randomly selected for evaluation. Each question was evaluated for completeness of background information obtained, categorization and identification of the ultimate question, completeness of references searched, and formulation of a concise response and an evidence-based recommendation. RESULTS: Background information was complete in 16% of pre-template questions and 92% of post-template questions (p < 0.001). Eighty-four percent of pre-template questions and 96% of post-template questions were appropriately categorized (p = 0.349). The requestor's ultimate question was clearly identified in 68% of pretemplate questions and 92% of post-template questions (p = 0.074). All necessary references were searched in 36% of pre-template questions and 88% of post-template questions (p < 0.001). A concise response was documented in 80% of pretemplate questions and 92% of post-template questions (p = 0.417). In questions determined to require a specific recommendation among the pre-template (n = 20) and post-template groups (n = 14), a clear and evidence-based recommendation was described in 40% (p = 0.038) and 79% (p = 0.038), respectively. CONCLUSIONS: Use of drug information request templates improves students' compliance with the modified systematic approach, most notably in obtaining background information and searching necessary references including primary literature.