Download Improving medication management in the emergency

Improving medication management
in the emergency department at
Royal Perth Hospital
Lea Dias - ED Pharmacist
Barry Jenkins, Chief Pharmacist
Dr Frank Sanfilippo, Population Health, UWA
Stephen Witney - ED Technician
Background
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ED is under-serviced by pharmacy at RPH
Significant medication safety concerns
Significant continuity of care issues
Funding obtained for a pharmacist and
technician from Oct 05 - June 06
Aim
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Introduce a comprehensive service
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patient own medication bags
frequent stock checks and analysis
access to a clinical pharmacist during business hrs
introduce an electronic drug formulary
investigate the role of the pharmacist & technician
Conduct a Pilot study
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assess the accuracy of medication history taking
assess the impact of pharmacy involvement
Achievements
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Patient Own Medication Bags (POMBs)
introduced and written into hospital policy
Drug protocols and administration guidelines
on ED intranet
Service to nursing & medical staff improved
Pilot study completed and analysed
Pilot study summary
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Primary objective:
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To compare the accuracy of medications recorded
on the medication chart against a validated
medication history taken by the pharmacist for
high-risk patients.
Secondary objective
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Assess the utility of the pharmacy service in
reviewing high risk patients and resolving
medication related problems.
Method
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Service
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1FTE clinical pharmacist, 1FTE Technician
Mon-Fri 8:00am-4:30pm
Sample - high risk patients
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Inclusion criteria
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Exclusion criteria
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admitted patients with a completed drug chart
 65 years old or  5 medications
nil medications pre-admission
Recruitment
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once or twice daily ward rounds in all ED areas
9th April - 30th May 06 (period of 7 weeks)
Method
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Role of the technician
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Record pre-admission medication information
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patient’s own medications/list or WebsterPak®
GP letters
nursing home/pharmacy medication list
previous admission at RPH
discharge letters
Record medications charted on admission
Method
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Role of the pharmacist
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Validate history with at least two sources
Reconcile pre-admission medication history with
charted medications
Classify discrepancy as;
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intentional (deliberate changes) eg. withheld, new or
cease drug, OR
unintentional (errors) eg. drug omission, drug
commission, or incorrect dose.
Communicate discrepancies
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written in blue notes
verbally with team or ward pharmacist
attach Medication Action Plan to chart
Method
PHARMACY: ADMISSION MEDICATIONS
The pharmacist has confirmed the admission medication history via:
Patient Interview
Patient List
Relatives
Own Medications All Yes/No
Websterpak
N/Home ...........….…. Ph........….
GP...........……….. Ph........…
Pharmacy...........……..… Ph........…
Prev Adm .....……/…./.....
Method
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Introduced towards
the end of the study.
Analysis
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Data analysed using SPSS
Lost to follow up
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subjects that satisfied the selection criteria but
were lost to the ward/discharged before being
seen by the ED Pharmacist
these subjects were not included in the results
Patients not screened
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lack of resources did not permit all high-risk pts to
be reviewed and included in the results.
sub-sample of these patients to test for selection
bias
Results
Demographics
N
females
males
age
Pre-admission Meds/pt
Discrepancies between preadmission medications and
charted medications
unintentional (errors/patient)
intentional (deliberate changes/patient)
106
50.9%
49.1%
66.2 (17.1) mean (sd)
7.8 (1-26) mean (range)
mean (95% CI)
2.1 (1.7,2.4)
0.9 (0.6,1.1)
Results 2
Discrepancies per preadmission
% unintentional (errors)
% intentional (deliberate changes)
Unintentional discrepancies follow-up
% Errors corrected by pharmacist in ED
% Errors communicated for follow-up
All discrepancies for review at discharge
% Errors (not corrected in ED) & deliberate
changes
% (95% CI)
26.5 (22.4,30.5)
10.9 (7.7,14.1)
% (95% CI)
36.3 (25.4,47.2)
63.7 (52.8,74.6)
% (95% CI)
27.8 (22.4,33.1)
H is to g ra m
Distribution of unintentional errors
30
25
Frequency
P
a
t
i
e
n
t
s
20
15
10
5
0
0
2
4
U n in te n t_ U
Unintentional errors
6
8
10
Discussion
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Unintentional discrepancies (errors)
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Intentional (deliberate) changes
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mean of 2.1 per patient
mean of 0.9 per patient
On discharge must account for:
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all errors not corrected in ED and
all deliberate changes initiated in ED and
all other discrepancies arising from the ward
Medication preadmission
Tegretol CR 400mg mane
Tegretol CR 500mg nocte
Topiramate 100mg bd
Ranitidine 150mg bd
Atorvastatin 20mg nocte
Amitriptyline 50mg nocte
Norethisterone 5mg nocte
Ergocalciferol 1000mg bd
Vitamin C 500mg mane
Lactulose 20ml mane
Paraffin liquid 40ml mane
Lacrilube apply prn
Microlax enema 1 pr alt days
Oestradiol gel ap pv nocte
Medication charted
Phenytoin 400mg mane
Phenytoin 500mg nocte
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Unintentional
incorrect drug
incorrect drug
r/v asp pneum
Intentional
Medication preadmission
Atorvastatin 10mg nocte
Sotalol 120mg bd
Sertraline 50mg mane
Pantoprazole EC 40mg
Prazosin 2mg bd
Aspirin 100mg EC
Medication charted
Atorvastatin 40mg nocte
Sotalol 80mg bd
Prazosin 2mg bd
Aspirin 100mg EC
Venlafaxine XR 75mg
Monoplus 20/12.5mg
Frusemide 40mg mane
Unintentional
incorrect dose
incorrect dose
drug omitted
drug omitted
Intentional
drug commission
drug commission
new med
Conclusion
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Primary objective
[To compare the accuracy of medications recorded on the medication
chart against a validated medication history taken by the pharmacist
for high-risk patients.]
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there is a high incidence of unintentional error in
admission medication histories for high-risk
patients
Secondary Objective
[Assess the utility of the pharmacy service in reviewing high risk
patients and resolving medication related problems]
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a pharmacist/technician based pharmacy service
identified, and in a third of cases, corrected,
unintentional medication errors
Key messages
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Don’t rely on old information - validate it
Accurate discharge letter is vital
Undetected errors made on admission may
go uncorrected at discharge
Medical and nursing staff benefit from clinical
pharmacy services
A dedicated ED pharmacy service improves
the medication management of admitted
patients