Impact of a multidisciplinary medication reconciliation program on clinical outcomes: A pre-post intervention study in surgical patients.

BACKGROUND: Previous studies have evaluated the effects of medication reconciliation (MR) and suggest that it is effective in decreasing medication discrepancies. Nevertheless, a recent overview of systematic reviews concluded that there is no clear evidence in favor of MR in patient-related outcomes and healthcare utilization, and further research about it is needed. OBJECTIVE: To evaluate the impact of a multidisciplinary MR program on clinical outcomes in patients with colorectal cancer presenting other chronic diseases, undergoing elective colorectal surgery. METHODS: We performed a pre-post study. Adult patients scheduled for elective colorectal cancer surgery were included if they presented at least one "high-risk" criteria. The MR program was developed by internists, pharmacists and surgeons, and ended with the obtention of the patient's pre-admission medication list and follow-up care until discharge. The primary outcome was the length of stay (LOS). Secondly, we evaluated mortality, preventable surgery cancellations and risk factors for complications. RESULTS: Three hundred and eight patients were enrolled. Only one patient in the pre-intervention group suffered a preventable surgery cancellation (p = 0.317). The mean LOS was 13 ± 12 vs. 11 ± 5 days in the pre-intervention and the intervention cohort, respectively (p = 0.435). A difference in favor of the intervention group in patients with cardiovascular disease (p = 0.038) and those >75 years old (p = 0.043) was observed. No difference was detected in the mortality rate (p = 0.999) neither most of the indicators of risk factors for complications. However, the management of preoperative systolic blood pressure of hypertensive patients (p = 0.004) and insulin reconciliation in patients with treated diabetes (p = 0.003) were statistically better in the intervention group. CONCLUSIONS: No statistically significant change was observed in the mean global LOS. A statistically significant positive effect on LOS was observed in vulnerable populations: patients >75 years old and those with cardiovascular disease, who presented a 5-day reduction in the mean LOS.

Impact of medication reconciliation on health outcomes: An overview of systematic reviews.

BACKGROUND: Recent systematic reviews and meta-analyses suggest that medication reconciliation (MR) is effective in decreasing the risk of medication discrepancies. Nevertheless, the association between MR and subsequent improved healthcare outcomes is not well established. OBJECTIVES: This systematic review of reviews set out to identify published systematic reviews on the impact of MR programs on health outcomes and to describe key components of the intervention, the health outcomes assessed and any associations between MR and health outcomes. METHODS: PubMed, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and SCOPUS were searched from inception to May 2019. Systematic reviews of all study designs, populations, intervention providers and settings that measured patient-related outcomes or healthcare utilization were considered. Methodological quality was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). Two investigators performed study selection, quality assessment and data collection independently. RESULTS: Five systematic reviews met the inclusion criteria: 2 were rated as low quality and 3 as critically low quality. Reviews included primary studies in different settings (hospitals, the community and residential aged care facilities) that reported the impact of MR on mortality, length of stay, Emergency Department (ED) visits, readmissions, physician visits and healthcare utilization. Only one review reported results on mortality. However, healthcare utilization, which usually included ED visits and readmissions, was communicated in all reviews. Meta-analyses were conducted in all reviews except one. Medication reconciliation was not consistently found to be associated with improvements in health outcomes. CONCLUSIONS: Few systematic reviews support the value of MR in achieving good patient-related outcomes and healthcare utilization improvements. The quality of the systematic reviews was low and the primary studies included commonly involved additional activities related to MR. There was no clear evidence in favor of intervention in mortality, length of stay, ED visits, unplanned readmissions, physician visits and healthcare utilization.

[Failure mode effect analysis applied to preparation of intravenous cytostatics]. / Análisis modal de fallos y efectos aplicado a la elaboración de citostáticos intravenosos.

OBJECTIVE: To proactively identify risks in the preparation of intravenous cytostatic drugs, and to prioritise and establish measures to improve safety procedures. MATERIAL AND METHODS: Failure Mode Effect Analysis methodology was used. A multidisciplinary team identified potential failure modes of the procedure through a brainstorming session. The impact associated with each failure mode was assessed with the Risk Priority Number (RPN), which involves three variables: occurrence, severity, and detectability. Improvement measures were established for all identified failure modes, with those with RPN>100 considered critical. The final RPN (theoretical) that would result from the proposed measures was also calculated and the process was redesigned. RESULTS: A total of 34 failure modes were identified. The initial accumulated RPN was 3022 (range: 3-252), and after recommended actions the final RPN was 1292 (range: 3-189). RPN scores >100 were obtained in 13 failure modes; only the dispensing sub-process was free of critical points (RPN>100). A final reduction of RPN>50% was achieved in 9 failure modes. CONCLUSIONS: This prospective risk analysis methodology allows the weaknesses of the procedure to be prioritised, optimize use of resources, and a substantial improvement in the safety of the preparation of cytostatic drugs through the introduction of double checking and intermediate product labelling.

[Visa at a tertiary hospital]. / El visado en un hospital de tercer nivel.

OBJECTIVE: To analyze the visa application process and his activity at a tertiary hosipital. MATERIAL AND METHODS: Descriptive study of the drug s visa activity during the period April 2011-April 2012. We designed a database and defined categories on the study variables: patients and recipes. For patients admitted to the Visa Unit, issues detected were recorded based on a previously established classification. RESULTS: 6738 patients were included. They involved the visa of 8,465 recipes. The visa was applied to 170 drugs and nutrition products different, being the majority Tacrolimus. During this period, we detected a total of 420 incidents being the most frequent «No clinical document¼ (46.67%) and the «Formal completion errors¼ (28.57%). CONCLUSIONS: This work has allowed a more detailed analysis of the activity, the types of incidents and the identification of areas for improvement.

Objetivo: Analizar el procedimiento de visado y su actividad en un hospital de tercer nivel. Material y métodos: Estudio descriptivo del procedimiento de visado durante el período abril 2011-abril 2012. Se diseñó una base de datos y se definieron categorías relativas a las variables de estudio: pacientes y recetas. Para los pacientes atendidos en la Unidad de Visado se registraron las incidencias detectadas en base a una clasificación previamente establecida. Resultados: Se incluyeron 6.738 pacientes (8.465 recetas visadas). Se visaron 170 medicamentos y productos de nutrición diferentes, siendo el mayoritario Tacrolimus. Se detectaron un total de 420 incidencias, siendo las más frecuentes la «Ausencia de documento clínico¼ (46,67 %) y los «Errores formales de cumplimentación¼ (28,57%). Conclusiones: El presente trabajo ha permitido un conocimiento más pormenorizado de la actividad, los tipos de incidencias y la identificación de áreas de mejora.

Cuestionario ISMP-España y estrategia de mejora en el uso seguro del medicamento dentro del Servicio Andaluz de Salud / ISMP-Spain questionnaire and strategy for improving good medication practices in the andalusian health system

Objetivo: Describir la estrategia seguida en los hospitales del Servicio Andaluz de Salud para potenciar el uso seguro del medicamento utilizando como herramienta base el cuestionario de autoevaluación de la seguridad del sistema de utilización de los medicamentos en los hospitales, adaptado por el Instituto para el Uso Seguro de los Medicamentos en España. Material y métodos La estrategia se desarrolló en varias fases. Un análisis del informe de evaluación de la seguridad del sistema de utilización de los medicamentos en los hospitales públicos de Andalucía publicado por el ministerio de Sanidad y Consumo en 2008 seguido del establecimiento de un diagnóstico de partida del grado de seguridad en el uso de los medicamentos en los hospitales andaluces y priorización de las áreas de mejora. El desarrollo de un catálogo de buenas prácticas disponibles en el entorno web del observatorio para la seguridad del paciente de la agencia de calidad sanitaria andaluza, difusión de la estrategia a través de talleres formativos y la puesta en marcha de un sistema de evaluación del grado de cumplimiento de cada una de las buenas prácticas dirigido a hospitales a partir del cual componer un mapa de centros de referencia, completan las actuaciones realizadas. Resultados Se detectaron áreas de mejora en varios de los criterios esenciales del cuestionario. Estas áreas de mejora se relacionaron con procesos habituales que sigue el medicamento en la práctica clínica habitual. Así, se elaboraron 7 guías de buena práctica que recogen de forma transversal todos los elementos de evaluación del cuestionario relacionados con el proceso clínico a mejorar. Conclusiones El cuestionario de autoevaluación adaptado por ISMP-España constituye una buena herramienta para diseñar una intervención sistemática y racional en el uso seguro del medicamento dirigida a un grupo de hospitales que comparten los mismos valores (AU)

Objective: To describe the strategy employed by Andalusian public health service hospitals to foster safe medication use. The self-evaluation questionnaire on drug system safety in hospitals, adapted by the Spanish Institute for Safe Medication Practices was used as a fundamental tool to that end. Material and method: The strategy is developed in several phases. We analyse the report evaluating drug system safety in Andalusian public hospitals published by the Spanish Ministry of Health and Consumption in 2008 and establish a grading system to assess safe medication practices in Andalusian hospitals and prioritise areas needing improvement. We developed a catalogue of best practices available in the web environment belonging to the Andalusian health care quality agency’s patient safety observatory. We publicised the strategy through training seminars and implemented a system allowing hospitals to evaluate the degree of compliance for each of the best practices, and based on that system, we were able to draw up a map of centres of reference. Results: We found areas for improvement among several of the questionnaire’s fundamental criteria. These areas for improvement were related to normal medication procedures in daily clinical practice. We therefore wrote 7 best practice guides that provide a cross-section of the assessment components of the questionnaire related to the clinical process needing improvement. Conclusions: The self-evaluation questionnaire adapted by ISMP-Spain is a good tool for designing a systematic, rational intervention to promote safe medication practices and intended for a group of hospitals that share the same values (AU)

[ISMP-Spain questionnaire and strategy for improving good medication practices in the Andalusian health system]. / Cuestionario ISMP-España y estrategia de mejora en el uso seguro del medicamento dentro del Servicio Andaluz de Salud.

OBJECTIVE: To describe the strategy employed by Andalusian public health service hospitals to foster safe medication use. The self-evaluation questionnaire on drug system safety in hospitals, adapted by the Spanish Institute for Safe Medication Practices was used as a fundamental tool to that end. MATERIAL AND METHOD: The strategy is developed in several phases. We analyse the report evaluating drug system safety in Andalusian public hospitals published by the Spanish Ministry of Health and Consumption in 2008 and establish a grading system to assess safe medication practices in Andalusian hospitals and prioritise areas needing improvement. We developed a catalogue of best practices available in the web environment belonging to the Andalusian health care quality agency's patient safety observatory. We publicised the strategy through training seminars and implemented a system allowing hospitals to evaluate the degree of compliance for each of the best practices, and based on that system, we were able to draw up a map of centres of reference. RESULTS: We found areas for improvement among several of the questionnaire's fundamental criteria. These areas for improvement were related to normal medication procedures in daily clinical practice. We therefore wrote 7 best practice guides that provide a cross-section of the assessment components of the questionnaire related to the clinical process needing improvement. CONCLUSIONS: The self-evaluation questionnaire adapted by ISMP-Spain is a good tool for designing a systematic, rational intervention to promote safe medication practices and intended for a group of hospitals that share the same values.

[Work of a multidisciplinary team in the control of the prescription of ertapenem]. / Actuación de un equipo multidisplinario en el control de la prescripción de ertapenem.

OBJECTIVE: To determine the effectiveness of the intervention of a multidiscipline antimicrobial control group in the correct prescription of Ertapenem. METHOD: A four-month long, prospective study into prescriptions for Ertapenem was carried out in a third-level hospital. Assessment into the degree of suitability of each prescription according to the infections commission usage criteria. In the situation where prescriptions were not suitable, recommendations were given and acceptance of this was recorded. The effectiveness of the antimicrobial treatment used was assessed and treatment was considered effective when there was remission of the signs and symptoms of the infection when the treatment was completed. The treatment was considered to have failed when the signs and symptoms of infection persisted or progressed, requiring the addition of another antimicrobial agent, changing antibiotics or the prolongation of the treatment for longer than 2 weeks. Lastly, the differences in the average length of stay and the duration of the antibiotic treatment between groups were analysed. RESULTS: Forty-eight prescriptions were assessed. The usage criterion was adequate in 48 % of cases, with 78 % effectiveness in this group. In the cases where the prescription was not adequate, but a change in prescription was accepted, the effectiveness was 92 %, with 55.5 % of those cases not accepting recommendation for change. The average stay was higher in this last group (p = 0.07). The duration of the antibiotic treatment in the patients who accepted the change in prescription was significantly less than in those who did not accept it (2 vs 7.4 days, p < 0.0001). CONCLUSIONS: The control of Ertapenem prescriptions by a multidisciplinary team was effective.

Actuación de un equipo multidisplinario en el control de la prescripción de ertapenem* / Work of a multidisciplinary team in the control of the prescription of ertapenem

Objetivo: Determinar la efectividad de la intervención de un grupo multidisciplinario de control antimicrobiano en la correcta prescripción de ertapenem. Método: Estudio prospectivo, durante un período de 4 meses, de las prescripciones de ertapenem realizadas en un hospital de tercer nivel. Evaluación del grado de adecuación de cada prescripción a los criterios de utilización de la comisión de infecciones. En las situaciones en las que no se adecuaban, se emitió una recomendación y se registró la aceptación de éstas. Se evaluó la efectividad del tratamiento antimicrobiano utilizado; para ello, se consideró tratamiento efectivo cuando hubo remisión de los signos y los síntomas de la infección al finalizar el tratamiento. Se consideró fracaso del tratamiento cuando los signos y los síntomas de la infección persistieron o progresaron, requiriendo la adición de otro antimicrobiano, la sustitución por otro/s antibiótico/s o la prolongación del tratamiento más allá de 2 semanas. Finalmente, se analizaron las diferencias de estancia media y duración de tratamiento antibiótico entre los grupos. Resultados: Se evaluaron 48 prescripciones. Se adecuaron a los criterios de uso un 48 % de éstas, con una efectividad del 78 % en este grupo. En los casos en los que la prescripción no se adecuó, pero se aceptó un cambio de tratamiento, la efectividad fue del 92 %, y fue del 55,5 % en los casos en los que no se aceptó esta recomendación. La tendencia de la estancia media fue mayor en este último grupo (p = 0,07). La duración del tratamiento antibiótico en los pacientes en los que se aceptó el cambio fue significativamente menor que en los que no se aceptó (2 frente a 7,4 días; p < 0,0001). Conclusiones: El control de las prescripciones de ertapenem por un equipo multidisciplinario fue efectivo (AU)

Objective: To determine the effectiveness of the intervention of a multidiscipline antimicrobial control group in the correct prescription of Ertapenem.Method: A four-month long, prospective study into prescriptions for Ertapenem was carried out in a third-level hospital. Assessment into the degree of suitability of each prescription according to the infections commission usage criteria. In the situation where prescriptions were not suitable, recommendations were given and acceptance of this was recorded. The effectiveness of the antimicrobial treatment used was assessed and treatment was considered effective when there was remission of the signs and symptoms of the infection when the treatment was completed. The treatment was considered to have failed when the signs and symptoms of infection persisted or progressed, requiring the addition of another antimicrobial agent, changing antibiotics or the prolongation of the treatment for longer than 2 weeks. Lastly, the differences in the average length of stay and the duration of the antibiotic treatment between groups were analysed.Results: Forty-eight prescriptions were assessed. The usage criterion was adequate in 48 % of cases, with 78 % effectiveness in this group. In the cases where the prescription was not adequate, but a change in prescription was accepted, the effectiveness was 92 %, with 55.5 % of those cases not accepting recommendation for change. The average stay was higher in this last group (p = 0.07). The duration of the antibiotic treatment in the patients who accepted the change in prescription was signifi cantly less than in those who did not accept it (2 vs 7.4 days, p < 0.0001).Conclusions: The control of Ertapenem prescriptions by a multidisciplinary team was effective (AU)

[Assessment of safety practices for medication-use systems in Spanish hospitals (2007)]. / Evaluación de las prácticas de seguridad de los sistemas de utilización de medicamentos en los hospitales españoles (2007).

BACKGROUND AND OBJECTIVE: To examine the current status of safety practices for medication-use systems in Spanish hospitals and to identify major areas of risk. MATERIAL AND METHOD: Those hospitals that completed the "Medication use-system safety self-assessment for hospitals" between June 1 and July 15, 2007, were included in the study. The survey contained 232 items for evaluation grouped into 20 core characteristics. RESULTS: A total of 105 hospitals from the 17 autonomous communities in Spain participated in the study. The average aggregate score for the survey of all the participating hospitals was 612.7 (39.7% of the maximum possible score) and there were no differences found with regard to number of beds, training activity or type of hospital. When core characteristics were analyzed, there were 3 criteria with the lowest values (< 25%), associated with professional training, skills, and the establishment of a system for reporting errors. Another 9 criteria, with percentages between 25% and 50%, reflected practices related to: access to information regarding patients and medications; communication of medication orders; prevention of errors due to naming, labeling, and packaging problems; standardization of medication delivery devices; restriction of medications in patient care units; and safety culture and double-checking procedures. CONCLUSIONS: Many opportunities for improvement have been identified, particularly in areas related to training, risk management, incorporating new technologies and patient participation. The information obtained may prove useful for prioritizing practices when establishing patient safety strategies, and as a baseline for successfully monitoring the effectiveness of the initiatives and programs consequently set into motion.