Optimising ePrescribing in hospitals through the interoperability of systems and processes: a qualitative study in the UK, US, Norway and the Netherlands.

BACKGROUND: Investment in the implementation of hospital ePrescribing systems has been a priority in many economically-developed countries in order to modernise the delivery of healthcare. However, maximum gains in the safety, quality and efficiency of care are unlikely to be fully realised unless ePrescribing systems are further optimised in a local context. Typical barriers to optimal use are often encountered in relation to a lack of systemic capacity and preparedness to meet various levels of interoperability requirements, including at the data, systems and services levels. This lack of systemic interoperability may in turn limit the opportunities and benefits potentially arising from implementing novel digital heath systems. METHODS: We undertook n = 54 qualitative interviews with key stakeholders at nine digitally advanced hospital sites across the UK, US, Norway and the Netherlands. We included hospitals featuring 'standalone, best of breed' systems, which were interfaced locally, and multi-component and integrated electronic health record enterprise systems. We analysed the data inductively, looking at strategies and constraints for ePrescribing interoperability within and beyond hospital systems. RESULTS: Our thematic analysis identified 4 main drivers for increasing ePrescribing systems interoperability: (1) improving patient safety (2) improving integration & continuity of care (3) optimising care pathways and providing tailored decision support to meet local and contextualised care priorities and (4) to enable full patient care services interoperability in a variety of settings and contexts. These 4 interoperability dimensions were not always pursued equally at each implementation site, and these were often dependent on the specific national, policy, organisational or technical contexts of the ePrescribing implementations. Safety and efficiency objectives drove optimisation targeted at infrastructure and governance at all levels. Constraints to interoperability came from factors such as legacy systems, but barriers to interoperability of processes came from system capability, hospital policy and staff culture. CONCLUSIONS: Achieving interoperability is key in making ePrescribing systems both safe and useable. Data resources exist at macro, meso and micro levels, as do the governance interventions necessary to achieve system interoperability. Strategic objectives, most notably improved safety, often motivated hospitals to push for evolution across the entire data architecture of which they formed a part. However, hospitals negotiated this terrain with varying degrees of centralised coordination. Hospitals were heavily reliant on staff buy-in to ensure that systems interoperability was built upon to achieve effective data sharing and use. Positive outcomes were founded on a culture of agreement about the usefulness of access by stakeholders, including prescribers, policymakers, vendors and lab technicians, which was reflected in an alignment of governance goals with system design.

E-prescribing and access to prescription medicines during lockdown: experience of patients in Aotearoa/New Zealand.

BACKGROUND: Health services internationally have been compelled to change their methods of service delivery in response to the global COVID-19 pandemic, to mitigate the spread of infection amongst health professionals and patients. In Aotearoa/New Zealand, widespread electronic delivery of prescriptions (e-prescribing) was enabled. The aim of the research was to explore patients' experiences of how lockdown, changes to prescribing and the interface between general practices and community pharmacy affected access to prescription medications. METHOD: The research employed a mixed-method approach. This included an online survey (n = 1,010) and in-depth interviews with a subset of survey respondents (n = 38) during the first COVID-19 lockdown (March-May 2020). Respondents were recruited through a snowballing approach, starting with social media and email list contacts of the research team. In keeping with the approach, descriptive statistics of survey data and thematic analysis of qualitative interview and open-ended questions in survey data were combined. RESULTS: For most respondents who received a prescription during lockdown, this was sent directly to the pharmacy. Most people picked up their medication from the pharmacy; home delivery of medication was rare (4%). Survey and interview respondents wanted e-prescribing to continue post-lockdown and described where things worked well and where they encountered delays in the process of acquiring prescription medication. CONCLUSIONS: E-prescribing has the potential to improve access to prescription medication and is convenient for patients. The increase in e-prescribing during lockdown highlighted how the system could be improved, through better feedback about errors, more consistency across practices and pharmacies, more proactive communication with patients, and equitable prescribing costs.

Pharmacist-led, prescription intervention system-assisted feedback to reduce prescribing errors: A retrospective study.

WHAT IS KNOWN AND OBJECTIVE: Prescribing errors are prevalent in hospital settings, with provision of feedback recommended to support prescribing by doctors. To evaluate the impact of a pharmacist-led prescription intervention system on prescribing error rates and to measure intervention efficiency. METHODS: All prescribers in Shandong Provincial Third Hospital received feedback from ward pharmacists using a pharmacist-led prescription intervention system. The prescribing error rate was calculated from Oct 2019 to December 2020. After the intervention was applied, the rates of PASS 1 (System pass), PASS 2 (Pharmacist pass) and PASS 3 (Pharmacist-doctor pass) events and the feedback time were calculated each month. RESULTS AND DISCUSSION: Irrational use of drugs was reduced and the prescription rate increased significantly. The error rate reduced from 6.94% to 1.96%, representing an estimated 71.76% decrease overall (p < 0.05). The PASS 1 rate gradually increased from 88% to 96% (p < 0.05), the PASS 2 rate gradually decreased from 5.06% to 2.04% (p < 0.05), the PASS 3 rate gradually decreased from 6.94% to 1.96% (p < 0.05). WHAT IS NEW AND CONCLUSION: The pharmacist-led prescription intervention system has the potential to reduce prescribing errors and improve prescribing outcomes and patient safety.

Incidence and Variables Associated With Inconsistencies in Opioid Prescribing at Hospital Discharge and Its Associated Adverse Drug Outcomes.

OBJECTIVES: Opioid-related medication errors (MEs) can have a significant impact on patient health and contribute to opioid misuse. The objective of this study was to estimate the incidence of and variables associated with the receipt of an opioid prescription and opioid-related MEs (omissions, duplications, or dose changes) at hospital discharge. We also determined rates of adverse drug events and risks of emergency department visits, readmissions, or death 30 days and 90 days post discharge associated with MEs. METHODS: A cohort of hospitalized patients discharged from the McGill University Health Centre between 2014 and 2016 was assembled. The impact of opioid-related MEs was assessed in a propensity score-adjusted logistic regression models. Multivariable logistic regression was used to determine characteristics associated with MEs and discharge opioid prescription. RESULTS: A total of 1530 (43.9%) of 3486 patients were prescribed opioids, of which 13.4% (n = 205) of patients had at least 1 opioid-related ME. Rates of MEs were higher in handwritten prescriptions compared to the electronic reconciliation discharge prescription group (20.6% vs 1.2%). Computer-based prescriptions were associated with a 69% lower risk of opioid-related MEs (adjusted odds ratio: 0.31, 95% confidence interval: 0.14-0.65) as well as 63% lower risk of receiving an opioid prescription. Opioid-related MEs were associated with a 2.3 times increased risk of healthcare utilization in the 30 days postdischarge period (adjusted odds ratio: 2.32, 95% confidence interval: 1.24-4.32). CONCLUSIONS: Opioid-related MEs are common in handwritten discharge prescriptions. Our findings highlight the need for computer-based prescribing platforms and careful review of medications during critical periods of care such as hospital transitions.

Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors.

Importance: Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). Previous research shows that interruptive solutions, such as electronic patient verification forms or alerts, can reduce these types of errors but may be time-consuming and cause alert fatigue. Objective: To evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors. Design, Setting, and Participants: In this cohort study, data collected as part of care for patients visiting the ED of a large tertiary academic urban hospital in Boston, Massachusetts, between July 1, 2017, and June 31, 2019, were analyzed. Exposures: In a quality improvement initiative, the ED staff encouraged patients to have their photographs taken by informing them of the intended safety impact. Main Outcomes and Measures: The rate of WPOE errors (measured using the retract-and-reorder method) for orders placed when the patient's photograph was displayed in the banner of the EHR vs the rate for patients without a photograph displayed. The primary analysis focused on orders placed in the ED; a secondary analysis included orders placed in any care setting. Results: A total of 2 558 746 orders were placed for 71 851 unique patients (mean [SD] age, 49.2 [19.1] years; 42 677 (59.4%) female; 55 109 (76.7%) non-Hispanic). The risk of WPOE errors was significantly lower when the patient's photograph was displayed in the EHR (odds ratio, 0.72; 95% CI, 0.57-0.89). After this risk was adjusted for potential confounders using multivariable logistic regression, the effect size remained essentially the same (odds ratio, 0.57; 95% CI, 0.52-0.61). Risk of error was significantly lower in patients with higher acuity levels and among patients whose race was documented as White. Conclusions and Relevance: This cohort study suggests that displaying patient photographs in the EHR provides decision support functionality for enhancing patient identification and reducing WPOE errors while being noninterruptive with minimal risk of alert fatigue. Successful implementation of such a program in an ED setting involves a modest financial investment and requires appropriate engagement of patients and staff.

Thunderstorm asthma medication management during an external emergency (Code Brown): An observational study of the impact of electronic prescribing and clinical documentation.

BACKGROUND: On 21 November 2016, during a thunderstorm asthma event, an external disaster was called in our Emergency Department (ED), the first since comprehensive implementation of electronic clinical documentation. This study compared medication ordering and administration documentation during surge (thunderstorm asthma) and non-surge (control) conditions. METHODS: Retrospective audit of ED patients presenting with asthma between 21 and 23 November 2016 (72-h thunderstorm asthma period) and equivalent 72-h periods of the preceding three weeks (control period). Demographic details, medical history and treatment were extracted from Cerner Millennium. RESULTS: During the thunderstorm asthma and control periods, 318 and 164 patients presented with respiratory symptoms; 302 (95.0%) and 27 (16.5%) were due to asthma, respectively. Salbutamol was ordered and administration signed on the Medication Administration Record for 122/302 (40.4%) thunderstorm asthma and 21/27 (77.8%) control patients (p<0.01). During the thunderstorm asthma period, 52/302 (17.2%) patients had no documentation on the Medication Administration Record or any ED notes of receiving salbutamol, whilst during the control periods 2/27 (7.4%) patients had no such documentation. Similar disparities with corticosteroids and ipratropium were identified. CONCLUSION: Quality of medication documentation declined during surge conditions. These data have informed policies for future surge events, when higher risk medications might be required.

Ifema hospital model. Implementation and start-up of the Pharmacy Department.

On the 20th of March 2020, triggered by the public health emergency declared,  the Health Authorities in Madrid reported a legal instruction (Orden 371/2020)  indicating the organization of a provisional hospital to admit patients with  COVID-19 at the Trade Fair Institution (IFEMA). Several pharmacists working in  the Pharmacy and Medical Devices Department of the Madrid Regional Health  Service were called to manage the Pharmacy Department of the  abovementioned hospital. Required permissions to set up a PD were here  authorized urgently. Tackling human and material resources, and computer  systems for drug purchase and electronic prescription, were some of the initial  issues that hindered the pharmaceutical provision required for patients from the  very day one. Once the purchase was assured, mainly by direct purchase from suppliers, drug dispensing up to 1,250 hospitalized patients (25 nursing units) and 8 ICU patients was taken on. Dispensing was carried out  through either drug stocks in the nursing units or individual patient dispensing  for certain drugs. Moreover, safety issues related to prescription were  considered, and as the electronic prescription was implemented we attained  100% prescriptions review and validation. The constitution of a multidisciplinary  Pharmacy and Therapeutics Committee let agree to a pharmacotherapy guide,  pres cription protocols, therapeutic equivalences, interactions, and drug  dispensing circuits. The Pharmacy Department strategy was to ensure a very  quick response to basic tasks keeping the aim to offer a pharmaceutical care of  the highest quality whenever possible. Working under a health emergency  situation, with many uncertainties and continuous pressure was a plight.  However, the spirit of collaboration in and out of the Pharmacy Department was  aligned with the whole hospital motivation to offer the highest quality of  healthcare. These were possibly the keys to allow caring for almost 4,000  patients during the 42 days that the hospital lasted.

El día 20 de marzo de 2020 la Consejería de Sanidad publicó una Orden  (371/2020) para la apertura de un centro hospitalario provisional para atender a  pacientes COVID-19 en la Institución Ferial de Madrid (IFEMA), por razón de  emergencia sanitaria. Se dispuso un equipo de farmacéuticos de la Subdirección  General de Farmacia y Productos Sanitarios para la apertura de un Servicio de  Farmacia, que obtuvo la autorización correspondiente por el órgano competente, con carácter de urgencia. La gestión de recursos humanos,  materiales y de herramientas informáticas para la adquisición y prescripción  electrónica fueron unas de las primeras dificultades que se solaparon con el  primer reto de garantizar la prestación farmacéutica a los pacientes que atendía  el hospital desde el mismo día uno. Asegurada la adquisición, fundamentalmente  mediante la compra directa a proveedores, se planteó la  dispensación para un máximo de 1.250 pacientes de hospitalización (25  controles de enfermería) y una Unidad de Cuidados Intensivos de 8 pacientes;  se establecieron botiquines en las unidades de enfermería y circuitos  individualizados de dispensación para determinados medicamentos. A su vez,  desde el primer momento se trabajó en la seguridad en la prescripción, llegando  a la revisión y validación del 100% de los tratamientos, una vez instaurada la  prescripción electrónica. La creación de una  Comisión de Farmacia y Terapéutica multidisciplinar permitió consensuar la guía farmacoterapéutica, protocolos de  prescripción, equivalencias terapéuticas, interacciones y circuitos de  dispensación de medicamentos. La estrategia del Servicio de Farmacia se basó  en asegurar una respuesta rápida en las funciones básicas, sin perder la visión  de incorporar una atención farmacéutica de la máxima calidad posible a medida  que iba siendo factible. A pesar de un escenario adverso, de incertidumbre y  presión continuas por la emergencia sanitaria, se ha mantenido un espíritu de  colaboración y contribución dentro y fuera del Servicio de Farmacia, alineado con un objetivo común de trabajo en equipo para brindar una atención sanitaria rápida y de la mayor calidad posible. Posiblemente éstas han sido las claves del  éxito que han permitido atender a casi 4.000 pacientes en los 42 días de vida  del hospital.

Integrating patient-centric indications into the prescribing process: Experience at a tertiary academic medical center.

PURPOSE: To describe the development of and implementation of a patient-centric clinical indications library (CIL) into the prescribing process and determine the operational and humanistic outcomes (from prescriber, pharmacist, and patient perspectives) of including indications on outpatient prescription labels. METHODS: A descriptive retrospective data analysis was conducted. Multiple stakeholder groups were engaged to develop and integrate the CIL into the prescription package. After CIL integration, prescribers, pharmacists, and patients were surveyed. A focus group discussion consisting of Veterans and caregivers was held. RESULTS: Following implementation of the CIL, the proportion of prescriptions associated with an indication increased from 88% to 96%. Surveyed clinicians responded that indications helped them better understand a patient's profile (61.1% of prescribers and 100% of pharmacists). Among surveyed pharmacists, 61.5% and 53.8%, respectively, believed that indications helped them catch instances of wrong medications and wrong doses ordered. Veterans surveyed found that indications on their prescription labels helped them know what their medications were for (91.0% of respondents) and why it is important to take their medications (70.7%). In focus group discussions, Veterans and family members and/or caregivers expressed a preference to see indications that describe how a medication works (eg, "to lower blood sugar" vs "for diabetes") because they felt that type of phrasing is measurable, action oriented (which was appealing due to Veterans' military background), provides surreptitious education, and tells the users what to expect. CONCLUSION: Engaging multidisciplinary stakeholder groups, optimizing the electronic health record system, and authorizing pharmacists to add known indications to prescriptions increased the number of prescriptions with indications, decreased the perceived time spent on order entry and verification, and enabled better understanding of each medication's purpose by providers and patients.

The impact of a computerised decision support system on antibiotic usage in an English hospital.

Background Antimicrobial resistance is correlated with the inappropriate use of antibiotics. Computerised decision support systems may help practitioners to make evidence-based decisions when prescribing antibiotics. Objective This study aimed to evaluate the impact of computerized decision support systems on the volume of antibiotics used. Setting A very large 1200-bed teaching hospital in Birmingham, England. Main outcome measure The primary outcome measure was the defined daily doses/1000 occupied bed-days. Method A retrospective longitudinal study was conducted to examine the impact of computerised decision support systems on the volume of antibiotic use. The study compared two periods: one with computerised decision support systems, which lasted for 2 years versus one without which lasted for 2 years after the withdrawal of computerised decision support systems. Antibiotic use data from June 2012 to June 2016 were analysed (comprising 2 years with computerised decision support systems immediately followed by 2 years where computerised decision support systems had been withdrawn). Regression analysis was applied to assess the change in antibiotic consumption through the period of the study. Result From June 2012 to June 2016, total antibiotic usage increased by 13.1% from 1436 to 1625 defined daily doses/1000 bed-days: this trend of increased antibiotic prescribing was more pronounced following the withdrawal of structured prescribing (computerised decision support systems). There was a difference of means of - 110.14 defined daily doses/1000 bed days of the total usage of antibiotics in the period with and without structured prescribing, and this was statistically significant (p = 0.026). From June 2012 to June 2016, the dominant antibiotic class used was penicillins. The trends for the total consumption of all antibiotics demonstrated an increase of use for all antibiotic classes except for tetracyclines, quinolones, and anti-mycobacterial drugs, whereas aminoglycoside usage remained stable. Conclusion The implementation of computerised decision support systems appears to influence the use of antibiotics by reducing their consumption. Further research is required to determine the specific features of computerised decision support systems, which influence increased higher adoption and uptake of this technology.

Analgesic Outcomes in a Danish Acute Care Hospital Following Electronic Prescribing and Analgesic Self-Administration.

BACKGROUND: Despite the long-term consequences of poorly controlled postoperative pain, inadequate pain control remains a problem. AIMS: To improve the quality of postoperative pain management, the study site, an acute care hospital in Denmark, introduced electronic prescribing with standard order-sets, and allowed patients to self-administer analgesia. This study aimed to describe analgesic prescribing, prescriptions for multimodal analgesia, analgesic administration, and patients' pain experience, in this context. DESIGN: Point-prevalence survey. SETTINGS: One Danish regional hospital. PARTICIPANTS: Consecutive sample of 286 surgical inpatients comprising 65 orthopaedic, 41 gynaecological, 57 urology and 123 gastrointestinal patients. METHODS: We evaluated the quality of postoperative pain management on four postoperative surgical wards using: (1) the Revised American Pain Society Patient Outcome Questionnaire; and (2) patient chart audit. RESULTS: Overall, 89.2% of patients were prescribed a fixed analgesic and 71.7% were prescribed fixed analgesics in multimodal combination. Patterns of multimodal prescribing and administration varied significantly across surgical groups. Patients received 87.7% of available fixed prescriptions and 22.5% of available analgesics prescribed 'as needed'. However, patients' worst pain intensity was high (mean = 5.8/10, SD = 2) and 73.4% reported moderate-to-severe worst pain during the previous 24-hours. Patients who self-administered medications used significantly more fixed-schedule paracetamol (p = .018), non-steroidal anti-inflammatory drugs (p = .001), weak (p = .035) and strong (p < .001) opioids. CONCLUSIONS: The availability of multimodal analgesia was high following the introduction of electronic prescribing. However, gaps remain in the administration of both fixed and 'as needed' analgesics for postoperative patients. Findings suggested that allowing patients to self-administer analgesia may increase compliance with fixed schedule prescriptions.

Optimising electronic prescribing in hospitals: a scoping review protocol.

INTRODUCTION: Electronic prescribing (ePrescribing) systems can improve the quality of prescribing decisions and substantially reduce the risk of serious medication errors in hospitals. However, realising these benefits depends on ensuring that relevant sociotechnical considerations are addressed. Optimising ePrescribing systems is essential to maximise the associated benefits and minimise the accompanying risks of these large-scale and expensive health informatics infrastructures. METHODS: We will undertake a systematic scoping review of the literature to identify strategies to achieve optimisation of ePrescribing systems. We will search Medline, Embase and CINAHL for the period 1 January 2010 to 1 June 2019 and the grey literature by using Google Scholar. Independent reviewers will screen the results using predefined inclusion and exclusion criteria and will extract data for narrative and thematic synthesis. DISCUSSION: This work will be published in a peer-reviewed journal and we will ensure that the findings are both accessible and interpretable to the public, academics, policymakers and National Health Service leaders.

Modelo hospital de IFEMA. Implantación y puesta en marcha de su Servicio de Farmacia / Ifema hospital model. Implementation and start-up of the Pharmacy Department

El día 20 de marzo de 2020 la Consejería de Sanidad publicó una Orden (371/2020) para la apertura de un centro hospitalario provisional para atender a pacientes COVID-19 en la Institución Ferial de Madrid (IFEMA), por razón de emergencia sanitaria. Se dispuso un equipo de farmacéuticos de la Subdirección General de Farmacia y Productos Sanitarios para la apertura de un Servicio de Farmacia, que obtuvo la autorización correspondiente por el órgano competente, con carácter de urgencia. La gestión de recursos humanos, materiales y de herramientas informáticas para la adquisición y prescripción electrónica fueron unas de las primeras dificultades que se solaparon con el primer reto de garantizar la prestación farmacéutica a los pacientes que atendía el hospital desde el mismo día uno. Asegurada la adquisición, fundamentalmente mediante la compra directa a proveedores, se planteó la dispensación para un máximo de 1.250 pacientes de hospitalización (25 controles de enfermería) y una Unidad de Cuidados Intensivos de 8 pacientes; se establecieron botiquines en las unidades de enfermería y circuitos individualizados de dispensación para determinados medicamentos. A su vez, desde el primer momento se trabajó en la seguridad en la prescripción, llegando a la revisión y validación del 100% de los tratamientos, una vez instaurada la prescripción electrónica. La creación de una omisión de Farmacia y Terapéutica multidisciplinar permitió consensuar la guía farmacoterapéutica, protocolos de prescripción, equivalencias terapéuticas, interacciones y circuitos de dispensación de medicamentos. La estrategia del Servicio de Farmacia se basó en asegurar una res-puesta rápida en las funciones básicas, sin perder la visión de incorporar una atención farmacéutica de la máxima calidad posible a medida que iba siendo factible. A pesar de un escenario adverso, de incertidumbre y presión continuas por la emergencia sanitaria, se ha mantenido un espíritu de colaboración y contribución dentro y fuera del Servicio de Farmacia, alineado con un objetivo común de trabajo en equipo para brindar una atención sanitaria rápida y de la mayor calidad posible. Posiblemente éstas han sido las claves del éxito que han permitido atender a casi 4.000 pacientes en los 42 días de vida del hospital

On the 20th of March 2020, triggered by the public health emergency declared, the Health Authorities in Madrid reported a legal instruction (Orden 371/2020) indicating the organization of a provisional hospital to admit patients with COVID-19 at the Trade Fair Institution (IFEMA).Several pharmacists working in the Pharmacy and Medical Devices Department of the Madrid Regional Health Service were called to manage the Pharmacy Department of the abovementioned hospital. Required permissions to set up a PD were here authorized urgently. Tackling human and material resources, and computer systems for drug purchase and electronic prescription, were some of the initial issues that hindered the pharmaceutical provision required for patients from the very day one. Once the purchase was assured, mainly by direct purchase from suppliers, drug dispensing up to 1,250 hospitalized patients (25 nursing units) and 8 ICU patients was taken on. Dispensing was carried out through either drug stocks in the nursing units or individual patient dispensing for certain drugs. Moreover, safety issues related to prescription were considered, and as the electronic prescription was implemented we attained 100% prescriptions review and validation. The constitution of a multidisciplinary Pharmacy and Therapeutics Committee let agree to a pharmacotherapy guide, prescription protocols, therapeutic equivalences, interactions, and drug dispensing circuits. The Pharmacy Department strategy was to ensure a very quick response to basic tasks keeping the aim to offer a pharmaceutical care of the highest quality whenever possible. Working under a health emergency situation, with many uncertainties and continuous pressure was a plight. However, the spirit of collaboration in and out of the Pharmacy Department was aligned with the whole hospital motivation to offer the highest quality of healthcare. These were possibly the keys to allow caring for almost 4,000 patients during the 42 days that the hospital lasted

Electronic prescription: frequency and severity of medication errors.

OBJECTIVE: To assess the frequency and severity of prescriptions errors with potentially dangerous drugs (heparin and potassium chloride for injection concentrate) before and after the introduction of a computerized provider order entry (CPOE) system. METHODS: This is a retrospective study that compared errors in manual/pre-typed prescriptions in 2007 (Stage 1) with CPOE prescriptions in 2014 (Stage 2) (Total = 1,028 prescriptions), in two high-complexity hospitals of Belo Horizonte, Brasil. RESULTS: An increase of 25% in the frequency of errors in Hospital 1 was observed after the intervention (p<0.001). In contrast, a decreased error frequency of 85% was observed in Hospital 2 (p<0.001). Regarding potassium chloride, the error rate remained unchanged in Hospital 1 (p>0.05). In Hospital 2, a significant decrease was recorded in Stage 2 (p<0.001). A reduced error severity with heparin (p<0.001) was noted, while potassium chloride-related prescription severity remain unchanged (p> 0.05). CONCLUSIONS: The frequency and severity of medication errors after the introduction of CPOE was affected differently in the two hospitals, which shows a need for thorough observation when the prescription system is modified. Control of new potential errors introduced and their causes for the adoption of measures to prevent these events must be in place during and after the implementation of this technology.

Electronic prescription: frequency and severity of medication errors

SUMMARY OBJECTIVE: To assess the frequency and severity of prescriptions errors with potentially dangerous drugs (heparin and potassium chloride for injection concentrate) before and after the introduction of a computerized provider order entry (CPOE) system. METHODS: This is a retrospective study that compared errors in manual/pre-typed prescriptions in 2007 (Stage 1) with CPOE prescriptions in 2014 (Stage 2) (Total = 1,028 prescriptions), in two high-complexity hospitals of Belo Horizonte, Brasil. RESULTS: An increase of 25% in the frequency of errors in Hospital 1 was observed after the intervention (p<0.001). In contrast, a decreased error frequency of 85% was observed in Hospital 2 (p<0.001). Regarding potassium chloride, the error rate remained unchanged in Hospital 1 (p>0.05). In Hospital 2, a significant decrease was recorded in Stage 2 (p<0.001). A reduced error severity with heparin (p<0.001) was noted, while potassium chloride-related prescription severity remain unchanged (p> 0.05). CONCLUSIONS: The frequency and severity of medication errors after the introduction of CPOE was affected differently in the two hospitals, which shows a need for thorough observation when the prescription system is modified. Control of new potential errors introduced and their causes for the adoption of measures to prevent these events must be in place during and after the implementation of this technology.

RESUMO OBJETIVO: Avaliar a frequência e a gravidade de erros em prescrições envolvendo medicamentos potencialmente perigosos (heparina e cloreto de potássio concentrado injetável) antes e após a introdução de um sistema de prescrição eletrônica. MÉTODOS: Trata-se de estudo retrospectivo que comparou erros em prescrições manuais e pré-digitadas de 2007 (Fase 1) com prescrições eletrônicas de 2014 (Fase 2) (total = 1.028 prescrições), em dois hospitais de alta complexidade de Belo Horizonte. RESULTADOS: Foi observado no hospital 1 aumento de 25% dos erros depois da intervenção (p<0,001), e no hospital 2 foi verificada redução de 85% (p<0,001). Para o cloreto de potássio, a frequência de erros permaneceu a mesma no hospital 1 (p>0,05), independentemente da fase e, no hospital 2, ocorreu redução significativa na fase 2 (p<0,001). Foi identificada redução da gravidade dos erros com a heparina (p<0,001), mas não houve alteração na gravidade dos erros com cloreto de potássio (p>0,05). CONCLUSÕES: A frequência e a gravidade dos erros de medicação após a introdução de prescrição eletrônica foram impactadas de forma diferente nos dois hospitais, demonstrando necessidade de observação criteriosa quando o sistema de prescrição é modificado. Durante e após a implantação dessa tecnologia, deve existir controle dos novos erros potenciais introduzidos e suas causas para a adoção de medidas de prevenção desses eventos.

Why do Belgian Community Pharmacists Still Treat Electronic Prescriptions as Paper-Based?

Belgium is in a transition phase from paper-based prescriptions to electronic prescriptions (ePrescriptions) during which both the paper and electronic format are valid. Since patients still get a paper proof of the ePrescription, sometimes pharmacists use the ePrescription as paper-based prescription. When the government demands a complete dematerialization, i.e. no more paper-based prescriptions, this will no longer be possible. Therefore, we questioned the frequency and reasons for treating an ePrescription as paper-based. The logged interactions in the national database were used to identify possible reasons. The tarification service Koninklijk Limburgs Apothekers Verbond (KLAV) provided prescriptions of June 2018. KLAV supports tarification for community pharmacies all over Belgium, thereby providing a representative sample for the Belgian community pharmacies. A two-stage cluster random sampling technique was applied to retrieve a subset of 10,000 prescriptions. In this subset we identified 4961 ePrescriptions (49.61%) of which 226 (4.56%, in total 2.26%) were treated as paper-based. Reasons observed for this incorrect handling are (1) non-compliance of the community pharmacist; (2) errors in software or handling of the community pharmacist; (3) errors at the prescriber side or patient tries to fraud; (4) incorrectly revoking the ePrescription; and (5) errors in software of prescriber. The main reasons for treating ePrescriptions as paper-based are non-compliance of the community pharmacist (n = 124, 54.87%) by ignoring its digital nature, and errors in software or handling of the community pharmacist (n = 85, 37.61%). Future research is necessary to investigate user opinions and to measure the impact of introducing ePrescribing in the daily routine.

Effect of New York State Electronic Prescribing Mandate on Opioid Prescribing Patterns.

BACKGROUND: Drug overdose was the leading cause of injury and death in 2013, with drug misuse and abuse causing approximately 2.5 million emergency department (ED) visits in 2011. The Electronic Prescriptions for Controlled Substances (EPCS) program was created with the goal of decreasing rates of prescription opioid addiction, abuse, diversion, and death by making it more difficult to "doctor-shop" and alter prescriptions. OBJECTIVE: In this study, we describe the opioid-prescribing patterns of emergency physicians after the introduction of the New York State EPCS mandate. METHODS: We conducted a retrospective, single-center, descriptive study with a pre-/post-test design. The pre-implementation period used for comparison was April 1-July 31, 2015 and the post-implementation period was April 1-July 31, 2016. All ED discharge prescriptions for opioid medications prior to and after the initiation of New York State EPCS were identified. RESULTS: During the pre-implementation study period, 22,221 patient visits were identified with 1366 patients receiving an opioid prescription. During the post-implementation study period, 22,405 patient visits were identified with 642 patients receiving an opioid prescription. This represented an absolute decrease of 724 (53%) opioid prescriptions (p < 0.0001), which is an absolute difference of 2.3% (95% confidence interval 2.0-2.6%). CONCLUSIONS: There was a significant decline in the overall number of opioid prescriptions after implementation of the New York EPCS mandate.

¿Por qué los pacientes no retiran todos los medicamentos y productos sanitarios que les son prescritos por el médico? / Why do patients not withdraw all the medicines and health products prescribed to them by the doctor?

Introducción: la e-receta finalizó su implantación en la Comunidad Valenciana (CV) en septiembre de 2013, observándose que el paciente no retiraba parte de los medicamentos que tenía prescritos, por lo que se diseña un estudio para estudiar las diversas incidencias que pudieran ser la causa. Objetivos: analizar y cuantificar las incidencias detectadas en la dispensación de las e-receta prescritas a los pacientes en farmacia comunitaria de la CV. Métodos: estudio observacional, transversal, prospectivo multicéntrico de base poblacional de las incidencias detectadas en las dispensaciones de las e-receta. Población diana: pacientes mayores de 18 años o cuidadores. Resultados: se registraron 22.983 solicitudes de medicamentos o productos sanitarios (MPS) correspondientes a 6.621 pacientes. De los MPS disponibles para ser dispensados se rechazaron un 12,0 %. Las discrepancias entre lo que el médico prescribió y el paciente entendió supusieron el 19,0 % de los rechazos. Las distintas razones relacionadas con el inccumplimiento fueron el 32,3 % de los medicamentos rechazados (MR). En aquellos medicamentos en los que el paciente debía pagar una aportación el rechazo fue ligeramente mayor (12,2 %) que en el caso de los que no. Conclusiones: La dispensación de MPS prescritos a través de la e-receta permite identificar problemas relacionados con medicamentos (PRM) que inciden sobre la falta de adherencia y las discrepancias con lo prescrito en la receta electrónica

Introduction: The e-receipt finished its implantation in the Valencian Community (CV) in September 2013, observing that the patient did not withdraw part of the medicines prescribed, so a study is designed to find out the various incidents that could be the cause. Objectives: To analyze and quantify the incidences detected in the dispensation of the e-recipes prescribed to patients in community pharmacy (FC) de la CV. Methods: Observational, cross-sectional, prospective multicenter population-based study of the incidences detected in the dispensations of the e-recipes. The target population: patients over 18 years of age, or caregivers. Results: 22,983 requests for medicines or health products (HP) were recorded for 6,621 patients. Of the medicines or HP available for dispensing, 12.0% were rejected. • Discrepancies between what the doctor prescribed and what the patient understood accounted for 19.0% of refusals. • The different reasons related to non-compliance were 32.3% of medicines or health products (HP). In those medicines where the patient had to pay a contribution, the rejection was slightly higher (12.2%) than in the case of those who did not. Conclusions: The dispensing of prescribed medicines/HP through the e-prescription makes it possible to identify drug related problem DRPs that affect the lack of adherence and discrepancies with what is prescribed in the electronic prescription

Unavailable prescriptions at Danish community pharmacies: A descriptive study.

Background Handling of unavailable prescriptions, i.e. prescriptions missing on the online server, is considered troublesome and time-consuming by community pharmacy staff and may result in both patient dissatisfaction and non-compliance. Objective To describe the occurrence and reasons for unavailable prescriptions at Danish community pharmacies as well as the types of drugs involved. Method An online 11-item questionnaire was developed and distributed to 24 community pharmacies across Denmark which each collected data on unavailable prescriptions handled within a 3-week period. Results Out of 194,358 prescriptions dispensed during the study period, a total of 2765 (1.4%) unavailable prescriptions were registered. Of these, 51.1% (n = 1412) occurred when a patient expected a new prescription after having consulted a physician, most often the patient's general practitioner (75.6%; n = 1067). Of all unavailable prescriptions, 68.1% (n = 1882) concerned prescriptions on regular drugs for treatment of a chronic condition, with the patient not having any medication left in 27.9% (n = 526) of these cases. Unavailable prescriptions most frequently concerned cardiovascular drugs (15.8%; n = 437) followed by nervous system drugs (14.4%; n = 399). Conclusion Unavailable prescriptions occur in approximately 1% of all dispensing at Danish community pharmacies. Miscommunication between the patient and general practitioner seems to be the primary source of unavailable prescriptions.

Reglamento General de Protección de Datos. ¿Qué novedades presenta? / General Data Protection Regulation. What is new?

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