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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 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 Introduce a comprehensive service 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 assess the accuracy of medication history taking assess the impact of pharmacy involvement Achievements 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 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. Secondary objective Assess the utility of the pharmacy service in reviewing high risk patients and resolving medication related problems. Method Service 1FTE clinical pharmacist, 1FTE Technician Mon-Fri 8:00am-4:30pm Sample - high risk patients Inclusion criteria Exclusion criteria admitted patients with a completed drug chart 65 years old or 5 medications nil medications pre-admission Recruitment once or twice daily ward rounds in all ED areas 9th April - 30th May 06 (period of 7 weeks) Method Role of the technician Record pre-admission medication information 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 Role of the pharmacist Validate history with at least two sources Reconcile pre-admission medication history with charted medications Classify discrepancy as; intentional (deliberate changes) eg. withheld, new or cease drug, OR unintentional (errors) eg. drug omission, drug commission, or incorrect dose. Communicate discrepancies 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 Introduced towards the end of the study. Analysis Data analysed using SPSS Lost to follow up 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 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 Unintentional discrepancies (errors) Intentional (deliberate) changes mean of 2.1 per patient mean of 0.9 per patient On discharge must account for: 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 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 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.] 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] a pharmacist/technician based pharmacy service identified, and in a third of cases, corrected, unintentional medication errors Key messages 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