Reducing Medication Error Through a Collaborative Committee Structure: An Effort to Implement Change in a Community-Based Health System.

OBJECTIVES: This article describes a methodology for implementation and sustainment of continuous quality improvement initiatives through committee structures aimed at reducing medication error rates. METHODS: A committee structure was developed in a collaborative effort to analyze and reduce medication error rates. Interdisciplinary teams comprised of frontline staff met regularly to identify and resolve trending medication safety events and prepare and deliver education for staff. Continuous quality improvement initiatives supported by these committees included technical handling and administration of medication, medication reconciliation, and enhancements to standardized treatment protocols. Data were collected through a voluntary electronic safety event reporting system between March 2013 and March 2016, to evaluate the rate of medication errors and near-misses. RESULTS: A retrospective analysis of reported medication errors and near-misses was conducted. The medication error rate significantly declined over the study period as the rate of near-misses conversely increased. CONCLUSIONS: Initiatives supported by the oversight of collaborative committees were successful in decreasing medication error rates.

The Impact of Preventative Multimodal Analgesia on Postoperative Opioid Requirement and Pain Control in Patients Undergoing Lumbar Fusions.

STUDY DESIGN: A prospective observational study with a historical reference group. OBJECTIVES: The main objectives of this study were to determine the impact of preventative multimodal analgesia (PMA) on postoperative opioid requirements and analgesic effectiveness in patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: PMA addresses the multiple pathways of acute and chronic pain by interfering with peripheral and central sensitization and should provide a way to achieve safer and more effective pain management with reduced opioid medication use. MATERIALS AND METHODS: This study compared postoperative opioid requirement and analgesic effect in a total of 101 patients undergoing elective, 1-level or 2-level transforaminal lumbar interbody fusion surgeries for symptomatic lumbar degenerative disk disease. The PMA patient group included 51 consecutive patients who received 1000 mg of acetaminophen, 300-900 mg of gabapentin, and 200-400 mg of celecoxib 1 hour before their index procedure. The reference group included 50 patients who received 15 mg of morphine-equivalent dose (MED) preoperatively.Multiple linear regression was used to evaluate the effect of PMA on postoperative pain and MED over 4 postoperative days, while controlling for all variables likely to influence these outcomes, including age, sex, baseline opioid use, duration of surgery, postoperative intrathecal morphine use and the administration of muscle relaxants and anticonvulsants. RESULTS: The differences in opioid requirement and postoperative pain scores were statistically significant on all 4 postoperative days. The effect size varied from -0.54 to -0.99 (34.8%-54.2% MED reduction) for the postoperative opioid requirement and from -0.59 to -1.16 (28.9%-37.3% visual analog scale reduction) for postoperative pain indicating that these measures were reduced by about ½ to 1 SD in the PMA patient group. CONCLUSIONS: PMA is a highly effective and safe method for postoperative pain management in patients undergoing elective lumbar fusion surgeries by improving pain control and reducing opioid requirement. LEVEL OF EVIDENCE: Level III.

Implementation of a timed, electronic, assessment-driven potassium-replacement protocol.

PURPOSE: The adherence to and effectiveness and safety of a timed, electronic, assessment-driven potassium-replacement protocol (TARP) were compared with an electronic nurse-driven replacement protocol (NRP) are reported. METHODS: A retrospective observational study was conducted in a community hospital evaluating protocol adherence, effectiveness, and safety for 2 potassium-replacement protocols. All adults on medical units with an order for potassium replacement per protocol during the 3-month trial periods were reviewed. All patients requiring potassium replacement per protocol were included in the analysis. Adherence to the protocol was assessed by evaluating the dose of potassium administered and performance of reassessments. Effectiveness of the protocol was assessed by evaluating the time to achieve target potassium levels. Safety was assessed by evaluating the route of administration and occurrence of hyperkalemia. RESULTS: A total of 300 patients treated using potassium-replacement protocols required potassium replacement during the study period, with 148 patients in the NRP group requiring 491 instances of potassium replacement. In the TARP group a total of 564 instances requiring potassium replacement corresponded to 152 patients. Of the 491 instances requiring replacement in the NRP group, the correct dose was administered and reassessment performed 117 times (23.8%). Overall adherence (p < 0.05), correct dose given (p < 0.05), average time from blood draw to potassium replacement (p < 0.0001), use of oral replacement (p < 0.05), and time to achieve target potassium level within 12 hours (p < 0.05) were significantly improved in the TARP group. CONCLUSION: The TARP improved the effectiveness and safety of potassium-replacement therapy over the traditional NRP without negatively affecting timeliness of care.

A three-year reflective writing program as part of introductory pharmacy practice experiences.

OBJECTIVES: To implement and evaluate a 3-year reflective writing program incorporated into introductory pharmacy practice experiences (IPPEs) in the first- through third-year of a doctor of pharmacy (PharmD) program. DESIGN: Reflective writing was integrated into 6 IPPE courses to develop students' lifelong learning skills. In their writing, students were required to self-assess their performance in patient care activities, identify and describe how they would incorporate learning opportunities, and then evaluate their progress. Practitioners, faculty members, and fourth-year PharmD students served as writing preceptors. ASSESSMENT: The success of the writing program was assessed by reviewing class performance and surveying writing preceptor's opinions regarding the student's achievement of program objectives. Class pass rates averaged greater than 99% over the 8 years of the program and the large majority of the writing preceptors reported that student learning objectives were met. A support pool of 99 writing preceptors was created. CONCLUSIONS: A 3-year reflective writing program improved pharmacy students' reflection and reflective writing skills.

Quality of drug information database research for clinical decision support.

This commentary identifies studies that have compared commercially available DI databases, and discusses improvements in study methodology that might better guide clinicians in selecting resources for their practice setting. We also provide suggestions for future direction of research in this area with an eye towards clinical decision support systems (CDSS). The body of comparative research of commercially available DI databases is small, and provides little value to the average clinician when making purchasing decisions. Transparency of study methodology would allow readers to choose a database that best fits their practice needs. Future research must consider how DI resources are imbedded within CDSS, such that the alerts generated by the CDSS are consistent with the primary DI workhorse of the practice site. Cohesion between CDSS and DI resources needs to be a consideration in future DI resource comparative research.