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Pharmacy Administration
Rotation Presentation
Pharmacy Resident
June 26th, 2014
Opioid iVent Analysis
2
Opioid iVent Analysis
Background:
• The Joint Commission 2012 Sentinel Event Alert
• Centers for Medicare and Medicaid Services (CMS) 2014
Clinical Standards list opioids as one of the three highpriority target medication classes
Objective:
• Evaluate iVents involving opioid prescribing practices within CSLink by classifying trends in errors and identify areas of
improvement of current prescribing practices
Study Period:
January 2014- March 2014
3
Opioid iVent Analysis
Methods:
Retrospective review
• To evaluate trends in inappropriate prescribing practices opioid
iVents were categorized based on type of error and medication
involved
• To evaluate trends in units/departments involved opioid iVents
were categorized based on physician specialty and location of
order verification
Inclusion:
All life threatening and serious/significant iVents involving
an opioid as documented in Epic during the study
timeframe
Exclusion:
All iVents involving non-opioid medications, documented as
low capacity for harm or unable to determine were
excluded from data collection
Sample Size
95 iVents
4
Opioid Prescribing Errors by Medication
1%
FENTANYL 17%
BELLADONNA ALKALOIDS-OPIUM
10%
HYDROCODONE-ACETAMINOPHEN
HYDROMORPHONE
METHADONE
HYDROMORPHONE
18%
13%
MORPHINE
NALOXONE
3%
2%
MORPHINE 19%
OXYCODONE 15%
OPIUM TINCTURE
OXYCODONE
OXYCODONE-ACETAMINOPHEN
TRAMADOL
1% 1%
FENTANYL
5
Provider Specialty
Opioid Prescribing Errors by Specialty
General Internal Medicine
Anesthesiology
Pediatrics
Orthopedics
Surgery-General Surgery
Neurosurgery
Unknown
IM/Nephrology
Urology
Thoracic Surgery
Physician Assistant
Peds - Neonatology
Nurse Practitioner
IM/Hematology/Oncology
IM/Gastroenterology
IM/Cardiology
Emergency Medicine
Certified Nurse-Midwife
Surgery-Colo-rectal
Physical Medicine & Rehab
Obstetrics & Gynecology
25
12
11
7
6
5
3
3
2
2
2
2
2
2
2
2
2
2
1
1
1
0
5
10
15
20
25
Number of Errors
6
7
6
6
5
9
9
5
5
5
4
4
4
4
4
3
3
3
3
2
1
1
1
1
1
5-NE
5N-SICU
5-NW
5-SE
6-NE
7-PACU
7S-RICU
8S-NSICU
7-SW
1
7-SE
8-NW
7-NW
6-SW
4S-PICU
6-NW
4-SW
AHSP PACU
4-SE
8-SW
7-NE
4N-CICU
8-NE
6N-CSICU
5S-SICU
3-LDR
4-NICU
4-NW
7N-MICU
6S-CSICU
ASAP EMERGENCY DEPT
8-SE
1
3N-UNIV
0
1
1
1
3-N MFCU
1
1
4-NE
Patient Department
2
2
2
2
2
2
2
2
2
2
Number of iVents
Opioid Prescribing Errors by Department
9
8
7
Opioid Prescribing Errors by Type
18
18
16
Number of Errors
16
14
13
12
12
10
8
6
4
2
6
5
4
4
4
3
2
2
1
1
0
8
Type of Error and Medications Involved
BELLADONNA
ALKALOIDS-OPIUM
OPIUM TINCTURE
20
Number of Prescribing Errors
18
16
MORPHINE
14
FENTANYL
12
TRAMADOL
10
8
OXYCODONE-APAP
6
OXYCODONE
4
METHADONE
2
HYDROMORPHONE
0
Duplicate Therapy
Wrong Dose
Recommended Wrong Frequency
Discontinuation of
Therapy
HYDROCODONEACETAMINOPHEN
9
Life-Threatening Opioid iVents: 4%
Problem Identified
Pharmacist Recommendation
Outcome
Avoided
Wrong Route
Fentanyl 12.5mg IV Q2hr prn mild pain
Clarified route with MD as MD's note Avoided ADE
the day before stated fentanyl 12
mcg patch (patient was on fentanyl
patch 2 days ago)
Wrong Dose
Hydromorphone 4 mg/mL soln
MD changing from morphine didn't
decrease the dose for higher potency
Change dose to 1 mg
Avoided ADE
Wrong dose
Fentanyl 1000 mcg/mL ordered ivp
Change dose to 100 mcg
Avoided ADE
Wrong dose
Morphine 2 mg/mL IV CRTG
MD ordered 1 mg/kg
Change dose to 1 mg
Avoided ADE
10
Recommendations
 Wrong dose due to lack of opioid equivalent knowledge can be improved
upon by removing hydromorphone 4 mg button in Epic
 Reinforce PharmD pain mgmt. principles with questions in Health Stream
Competency
o Dilaudid conversion
o Appropriateness of fentanyl order (duplication of opioid due to fentanyl
patch not being removed)
o Allergies
o Special Populations health competency questions – post-op, elderly,
pediatrics
 Pediatrics
o PCA Narcan Default order for overdose (respiratory depression)
o Morphine: change default from SQ to IV
o Weight based dosing: Best Practice Alert when order exceeds 40-50 kg
o Educate staff on importance of evaluating all pediatric orders (wrong
patient)
11
Overview
•
Emergency Department Medication
Reconciliation Evaluation (1)
•
Order Verification and Staffing Model (2)
•
Transitions of Care Literature Review
12
1. Emergency Department
Medication Reconciliation Evaluation
13
Emergency Department Medication
Reconciliation Evaluation
Background:
Emergency department (ED) medication reconciliation is
currently being performed by pharmacists, pharmacy
technicians and pharmacy residents on weekdays with
varying hours of operation.
Objective:
To evaluate gaps in the current transitions of care staffing
model in emergency department medication reconciliation
to optimize staffing resources.
Methods:
A list of ED admissions during the week of 5/12/14-5/16/14
was compiled and evaluated for completion of ED
medication reconciliation.
Study Period:
May 12th, 2014- May 16th, 2014
14
Emergency Department Medication
Reconciliation Evaluation
Inclusion:
Patients admitted from the ED during the week of 5/12/145/16/2014 with admission date and time on record.
Exclusion:
Patients admitted to:




SICU
AHSP-PACU/Pre-op
MRI tapr
US Tapr
Demographics:




OR
 Pre-op
CVIC
 CT tapr
NUC
 MD Tapr
Vas U/S Tapr
 PACU
 GI lab
 Rad intervention
415 patients evaluated
• 5/12: 95 patients
• 5/13: 80 patients
• 5/14: 83 patients
• 5/15: 88 patients
• 5/16: 69 patients
15
Emergency Department Medication
Reconciliation Evaluation
ED Med Rec 5/12/14 (n=95)
Number of Patients
12
10
ED med rec NOT completed
8
ED med rec completed
6
4
2
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time (hours)
Staffing on 5/12/14: 13 med recs completed (14%)
• Pharmacist:
1100-1930
• Pharmacy Technician: 1100-1930
• Pharmacy Resident: 1700-2100
16
Emergency Department Medication
Reconciliation Evaluation
ED Med Rec 5/13/14 (n=80)
8
ED med rec NOT completed
Number of Patients
7
ED med rec completed
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time (hours)
Staffing on 5/13/14: 17 med recs completed (21%)
• Pharmacist:
1100-1930
• Pharmacist:
1630-0200
• Pharmacy Technician: 1100-1930
• Pharmacy Resident: 1700-2100
17
Emergency Department Medication
Reconciliation Evaluation
ED Med Rec 5/14/14 (n=83)
7
ED med rec NOT completed
Number of Patients
6
ED med rec completed
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time (hours)
Staffing on 5/14/14: 31 med recs completed (37%)
• Pharmacist:
1100-1930
• Pharmacist:
2030-0200
• Pharmacy Technician: 1100-1930
• Pharmacy Resident: 1700-2100
18
Emergency Department Medication
Reconciliation Evaluation
ED Med Rec 5/15/14 (n=88)
8
ED med rec NOT completed
Number of Patients
7
ED med rec completed
6
5
4
3
2
1
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time (hours)
Staffing on 5/15/14: 25 med recs completed (28%)
• Pharmacist:
1100-1930
• Pharmacist:
1600-0100
• Pharmacy Technician: 1100-1930
• Pharmacy Resident:
1700-2100
19
Emergency Department Medication
Reconciliation Evaluation
ED Med Rec 5/16/14 (n=69)
6
ED med rec NOT completed
Number of Patients
5
ED med rec completed
4
3
2
1
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time (hours)
Staffing on 5/16/14: 18 med recs completed (26%)
• Pharmacist:
1100-1930
• Pharmacy Technician: 1100-1930
• Pharmacy Resident: 1700-2100
20
Emergency Department Medication
Reconciliation Evaluation
ED Admission Summary 5/12/14 to 5/16/14 (n=415)
39%
43%
46%
30
Number of Patients
Med Rec NOT
completed
29%
35
25
Med Rec
Completed
17%
60%
20
6% 18%
15
12%
17%
9%
44%
43%
13%
13%
16%
23%
38%
10
5
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time (Hours)
21
Emergency Department Medication
Reconciliation Evaluation Recommendations
• Proposed weekday coverage for ED medication reconciliation staffing:
PharmD:
• 1 FTE 0900-1730
• 1 FTE 1100-1930
• 1 FTE 1730-0200
Pharmacy tech:
• 1 FTE 0800-1630
• 1 FTE 1530-0000
Pharmacy Residents:
• M-F 1700-2100
• Proposed weekend (Saturday or Sunday, to be determined based on
weekend analysis) coverage for ED medication reconciliation staffing:
• PharmD: TOC pharmacist staffing
every 3rd weekend 1100-1930
• Pharmacy tech: 1100-1930
• Pharmacy Residents: One day
weekend coverage/month
• Pharmacy interns: to be determined
22
2. Order Verification and
Staffing Model
23
Order Verification and Staffing Model
Background:
• An evaluation of the current staffing model is needed to
ensure trends in workload demands are matched with the
appropriate resource allocation and staffing
responsibilities.
• Per labor laws, when an employee works for a period of
more than five hours, a meal period must be provided no
later than the end of the employee’s fifth hour of work.
Objective:
Objectively evaluate the current inpatient pharmacy staffing
model based on order verification demands to improve
workflow using existing resources.
Study Period:
Weekdays from April 1, 2014 – April 30, 2014
Order Verification and Staffing Model
Methods:
• A medication order verification report for April 2014 was
extracted from Epic
• Weekend, pediatric, oncology and ICU order verifications for the
month of April were removed from the report
• The number of pharmacists working each hour was entered into
the data collection spreadsheet using the pharmacist staffing
model available for April 2014
• The average number of orders verified per pharmacist per hour
was calculated using the total number of pharmacists scheduled
per hour and the total daily verifications per hour
Inclusion:
Medication order verifications from weekdays in April 2014
Exclusion: • Orders verified for pediatrics, AHSP, Oncology (4SW, OCC), ICU
beds (Saperstein)
• Staffing pharmacists for areas excluded from the analysis
25
Order Verification and Staffing Model
Results:
• On average, the most order verifications on weekdays
occur between 1500-1800 (ranging from 264-304 order
verifications/hour/day)
• On average, the most order verifications per pharmacist
per hour occurs from 1800-2000 (19-27 orders per
pharmacist) and 0000-0200 (19-22 orders per
pharmacist)
Results are summarized in the attached spreadsheet:
26
Order Verification and Staffing Model
Recommendations
Recommendations:
• Recommend scheduling lunch for med/surg AM
staff in 2 shifts:
₋ 1st shift: 1145-1230
₋ 2nd shift: 1245-1330
• Recommend scheduling lunch for med/surg PM
staff in 2 shifts:
₋ 1st shift: 1600-1645
₋ 2nd shift: 1645-1730
27
Overview
•
•
•
•
•
•
Anticoagulation iVent Analysis (3)
Daptomycin Medication Use Evaluation (4)
Risk Assessment of Procedural Areas (5)
Ready to Administer Dosage Forms
Analysis (6)
Readmission Prediction Score Analysis (7)
Naloxone Medication Use Evaluation and
Screening Tool (8)
28
3. Anticoagulation iVent Analysis
29
Anticoagulant iVent Analysis
Background:
• Although anticoagulants can be life-saving therapies,
there are serious risks associated with improper use
• By evaluating anticoagulation prescribing errors
intercepted by pharmacists, the value of pharmacy
services can be demonstrated and common errors can be
evaluated for prevention strategies.
Objective:
To evaluate iVents involving anticoagulants, classify trends
in errors and identify areas of improvement for current
prescribing practices.
Methods:
Retrospective review of all life-threatening and
serious/significant iVents involving anticoagulants as
documented in Epic
Study Period:
January 1st, 2014 through March 31st, 2014
30
Anticoagulant iVent Analysis
iVents Evaluated:
• 200 iVents were included in the analysis
⁻ 11 Life-Threatening
⁻ 189 Serious/Significant
Anticoagulant Prescribing Errors by Medication and Use:
Heparin PPX
35%
Apixaban
<1%
Dabigatran
3%
Heparin Tx
19%
Heparin Flush
3%
Enoxaparin Tx
7%
Enoxaparin PPX
14%
Warfarin
8%
Rivaroxaban
11%
31
Anticoagulant iVent Analysis
Prescribing Errors by Specialty
90
Number of Errors
80
78
70
60
50
40
30
20
10
12
12
11
11
11
11
10
5
5
4
4
3
3
3
3
3
0
32
Anticoagulant iVent Analysis
Anticoagulant Prescribing Errors by Type
45
6
Duplicate Therapy
Recommended Discontinuation of Therapy
1
Wrong Dose
1
49
36
22
Recommended Initiation of Medication
Wrong Frequency
17
Omission of Medication on Transfer
5
Wrong Medication Ordered
4
Wrong Rate
4
Incomplete Order
3
1, 1
Life Threatening
2
Serious/Significant
Drug Drug interaction
Wrong Duration
Wrong Concentration
1
Wrong Patient
1
1
Allergy
0
10
20
30
40
50
33
Anticoagulant iVent Analysis
Categories of Duplicate Therapy (n=51)
35
30
29
25
20
15
9
10
7
6
Duplicate Dose of
Anticoagulant
Duplicate anticoagulant
prophylaxis
5
0
Treatment and PPX
Anticoagulation
Duplicate Treatment
Anticoagulation
Duplicate Therapy
34
Anticoagulant iVent Analysis
Reasons for Recommending Discontinuation of Therapy (n=50)
14
12
10
8
6
4
2
13
10
8
5
5
5
3
1
0
35
Anticoagulant iVent Analysis
Types of Wrong Doses (n=37)
12
10
8
6
5
Heparin
Enoxaparin
4
3
2
0
9
2
3
4
3
Renal
function
Weight
Rivaroxaban
3
2
Incorrect High dose
rivaroxaban
dose
Dabigatran
1
1
PTA
1
Wrong flush Low dose
dose
36
Anticoagulant iVent Analysis
Problem Identified
Patient with anaphylaxis allergy to
heparin was ordered heparin
prophylaxis
Patient that received TPA was
ordered heparin prophylaxis
Heparin 10 units/mL was ordered for
infant as PICC line flush
Heparin order placed for 600
units/kg/hour
Patient continued on heparin flush
with positive PF4




Duplicate treatment dose
anticoagulant orders
2 Rivaroxaban and heparin drip
2 Dabigatran and heparin drip
Rivaroxaban and tx enoxaparin
Dabigatran and tx enoxaparin
RX
Recommendation
Outcome Avoided
Discontinue therapy
Anaphylaxis
Discontinue therapy
Hemorrhage
Correct concentration
Hemorrhage
Correct rate
Hemorrhage
Discontinue heparin
Thrombus
Discontinue one of the
therapies
Hemorrhage; inhibiting
multiple anticoagulation
pathways
Severity Ranking
Life Threatening
37
Anticoagulant iVent Analysis Recommendations
1.
Allow pharmacists to discontinue prophylactic heparin or
enoxaparin when treatment anticoagulation is initiated (i.e.
dabigatran, rivaroxaban, and apixaban)
2. In patients on warfarin and heparin/LMWH per pharmacy, allow
pharmacists to discontinue heparin drip/LMWH in the setting of a
therapeutic INR for two days and at least 5 days of overlapping
therapy
3. Continued education for providers, especially for the General
Internal Medicine service
4. Pharmacists should initiate and discontinue ordering of “No IM
injections”, “No ASA >162mg” and “RN to notify physician and
pharmacists for signs/symptoms of bleeding” when all
anticoagulation is ordered or discontinued.
38
4. Daptomycin Medication Use
Evaluation
39
Daptomycin Medication Use Evaluation
Background:
• Daptomycin is a bactericidal, lipopeptide antibiotic used for
the treatment of serious gram-positive infections
• Daptomycin is currently restricted for use in:
₋ MRSA bacteremia/right-sided endocarditis and severe
vancomycin allergy
₋ Documented MRSA SSTI and severe allergy to
vancomycin
• In FY13, the total daptomycin expenditure was $478,988.50
Objective:
To evaluate daptomycin use
Methods:
Retrospective review of daptomycin orders in April 2014 to
evaluate for proper dose and indication
Study Period: April 2014
40
Daptomycin Medication Use Evaluation
Daptomycin MUE Demographics
Number of Patients (#)
Average Age (years)
Gender
Average number of doses (#)
Unit breakdown (%)







28
63 ± 13
14 males, 14 females
5 ± 3.4
Inpatient (89%):
ICU:
5 patients
4th floor:
3 patients
5th floor:
4 patients
6th floor:
3 patients
7th floor:
6 patients
8th floor:
4 patients
Outpatient (11%)
Procedure Center: 3 patients
41
Daptomycin Medication Use Evaluation
Summary of inpatient daptomycin Use
# of patients followed by ID physician (%)
# of treatment courses meeting criteria
N=25
25/25 (100%)
0/25
# of treatment courses with an acceptable indication
or dose
21/25 (84%)
# of treatment courses approved by AUR (%)
9/25 (36%)
42
Daptomycin Medication Use Evaluation
Patient
Error
1
Incorrect Dose
2
Incorrect Indication
3
Incorrect Indication
4
Incorrect Dose
Indication
MRSA joint infection with
vancomycin allergy
described as flushing,
PVCs, SOB
Neutropenic patient
spiking fever on
vancomycin (likely drug
fever) with no culture
growth
Prosthetic joint infection
with no culture growth;
MRSA and VRE screens
negative
MRSA osteomyelitis
Dose
Total
doses
Approved
by AUR
2.3-6
mg/kg
7
No
5mg/kg
9
No
6mg/kg
9
No
5mg/kg
2
No
43
Daptomycin Medication Use Evaluation
Daptomycin has been shown to cause myopathy and the
manufacturer recommends creatine phosphokinase (CPK)
monitoring at least weekly.
Analysis of weekly CPK Monitoring for orders > 7 days
Patients with CPK monitoring
Yes
3/7 (43%)
44
Daptomycin Medication Use Evaluation
Daptomycin Indication and Culture Summary (n=28)
10
9
8
7
6
5
4
3
2
1
0
VRE
Other/No growth
MRSA
45
Daptomycin Medication Use Evaluation
Recommendations
• The following changes to the daptomycin use criteria are
recommended:
– Remove “Documented MRSA SSTI and severe allergy to
vancomycin” indication
– Add “Documented infection with VRE and resistant to
ampicillin/penicillin/linezolid or severe allergy to linezolid”
• Reinforce requirement of pharmacy staff to call AUR for
approval of all daptomycin orders that do not meet CSMC
criteria.
• Future directions: Reevaluate the drug-drug interaction
severity between linezolid and other serotonergic
medications.
46
5. Risk Assessment of Procedural
Areas
47
Risk Assessment of Procedural Areas
Background:
Objective:
The Joint Commission (TJC) in its Hospital Program, Medication
Management Chapter, Standard: MM.05.01.01 EP1 states:
“Before dispensing or removing medications from floor
stock or from an automated storage and distribution device,
a pharmacist reviews all medication orders or prescriptions
unless a licensed independent practitioner controls the
ordering, preparation, and administration of the
medication or when a delay would harm the patient in an
urgent situation (including sudden changes in a patient's
clinical status), in accordance with law and regulation.”
To evaluate medication stock of all procedural areas for
compliance with TJC standards
48
Risk Assessment of Procedural Areas
Methods:
• Floorstock lists for all included procedural areas were
reviewed for indication and compliance with TJC
standards.
• Any questions were clarified with pharmacy and nursing
staff of the procedural areas.
• A Pyxis optimization report was utilized to determine
the use requirements of questionable medications
Study Period: April 2014
49
Risk Assessment of Procedural Areas
Summary of procedural area medications evaluated
Total number of medication formulations
evaluated (#)
199

Summary of medication dosage forms




38 oral agents
 4 capsules
 8 suspensions
 26 tablets
21 topical products
124 injectable agents
12 inhaled products
4 suppositories
50
Risk Assessment of Procedural Areas
Summary of number of medications per procedural area
Puml Fxn Lab, 6
PROCCTR
Cart Stock, 5
Non-Invasive
Cardio, 23
7STONE
, 35
PROCCTR
Pyxis, 56
8IR, 45
Blood Donor
Center, 19
GI Lab, 63
Bronch Lab, 18
Cath Lab, 93
51
Risk Assessment of Procedural Areas
Reason for Lack of Pharmacist Review*
Reason
# of Medications
Managed by LIP
65 medications
Nursing Protocol
15 medications
Urgent Medication
157 medications
No longer stocked
1 medications
No indication
7 medications
Medication
Location
Ammonia Inhalant
GI Lab
Acetylcysteine 600mg capsules
Cath Lab
Ibuprofen Pediatric suspension
Procedure Center Pyxis
Ibuprofen 400mg tablet
Methylprednisolone sodium
1000mg IV solution
Prednisone 5mg tablet
Ranitidine 150mg tablet
Triamcinolone 0.1% topical
cream
Procedure Center Pyxis
7Stone Pyxis
Procedure Center Pyxis
Cath Lab
Procedure Center Pyxis
*Please note that some medications have multiple reasons
52
Medications NOT Meetings TJC Standards
Medication
Acetylcysteine 600mg
capsules
Indication
IV contrast
nephrotoxicity
prophylaxis
Location
Cath Lab
Comments

Not urgent, should be verified by pharmacist


Oral pain medication not urgent
Pyxis optimization report shows no use in the last
year
Oral pain medication not urgent
Pyxis optimization report shows last use is 6/21/2013
Procedural center RNs unsure of indication and need
in procedural area
Pyxis optimization report shows medication was first
stocked 9/17/13 and has not been used since
Procedural center RNs unsure of indication
Pyxis optimization report shows no use since
December 2013
Oral medication not urgent; IV ranitidine is available
for urgent use
Topical product is not urgent and is verified by
pharmacists occasionally
Pyxis optimization report shows product was used 6
times in past year. Last used in April.
Ibuprofen Pediatric
suspension
Pain, fever
Procedure
Center Pyxis
Ibuprofen 400mg
tablet
Pain, fever
Procedure
Center Pyxis



Unclear
7Stone Pyxis

Unclear
Procedure
Center Pyxis
Heartburn,
ulcer prophy
Cath Lab
Methylprednisolone
1000mg IV solution
Prednisone 5mg tablet
Ranitidine 150mg
tablet




Triamcinolone 0.1%
topical cream
Skin irritation
Procedure
Center Pyxis

53
53
Risk Assessment of Procedural Areas
Recommendations
• Recommend removing ammonia inhalant from procedural area
floorstock list on intranet
• Recommend removal of the following medications from
procedure center floor stock:
– Ibuprofen Pediatric suspension
– Ibuprofen 400mg tablet
– Methylprednisolone sodium 1,000mg IV solution
– Prednisone 5mg tablet
– Ranitidine 150mg tablet
– Triamcinolone 0.1% topical cream
•
Recommend development of an Acetylcysteine use protocol
54
6. Ready-to-Administer Dosage
Form Analysis
55
Ready-to-Administer Dosage Form Analysis
Background:
The Joint Commission (TJC) update to its Hospital Program,
Medication Management Chapter, Standard: MM.03.01.01
released in December 2013 states:
“Medications in patient care areas are available in the most
ready-to-administer forms commercially available or, if
feasible, in unit doses that have been repackaged by the
pharmacy or a licensed repackager.”
Objective:
To evaluate medications dispensed to patient care areas to
ensure compliance with TJC standards.
Methods:
Daily dispense reports for January 29th through January 31st,
2014 were run and filtered for bulk and bulk liquid medication
dispenses. Each bulk medication dispensed was evaluated for
compliance to TJC standards
Study Period:
January 29th, 2014-January 31st, 2014
56
Ready-to-Administer Dosage Form Analysis
Results are summarized on the following slides:
• 589 bulk orders were dispensed from January 29th
to January 31st
• 111 bulk medications were reviewed
57
Ready-to-Administer Dosage Form Analysis
Bulk Dosage Forms Dispensed Jan 29th-31st, 2014
18
16
14
12
10
8
6
4
2
0
16
15 15
11
7
6
5
5
3
3
3
3
3
2
2
2
2
1
1
1
1
1
1
1
1
58
Ready-to-Administer Dosage Form Analysis
Summary of bulk order compliance with TJC Standards
Compliance with TJC
Standards
Yes
No
Description of Compliance
Dispensed smallest commercially
available product size, unable to unit dose
Unit dosed
Dispensed from Pyxis
Compounded product
Size dispensed required for order
Other
 Medrol dose pack
 Chlorhexidine solution
Products with recommendations
for change
Number of
Products (n=111)
69
16
6
5
3
2
10
59
Ready-to-Administer Dosage Form Analysis
Summary of products not in compliance with TJC standards
Product
Quality
dispensed
Proposed
dispensed product
Cost Difference
1 oz tube
0.5 oz tube
-$1,176.53
1 oz tube
0.5 oz tube
$8,555.81
4 oz bottle
1 oz bottle
$12,360.30
2
Bacitracin-polymyxin B (POLYSPORIN)
ointment
Bacitracin ointment
3
Phenol throat spray (CHLORASEPTIC) spray
4
Trypsin-balsam-castor oil (GRANULEX) topical
spray 1 spray
4 oz spray bottle
2 oz spray bottle
$1,130.49
5
Ketorolac (ACULAR) Ophthalmic Solution 0.5%
5 mL drop bottle
3 mL drop bottle
-$34.48 to $327.58
6
Lidocaine (XYLOCAINE) 2 % jelly
30 mL tube
5 mL tube
$32,458.3 to
$43,572.78
7
Multivits-mins-coenzyme Q10 (AQUADEKS)
400 mcg/mL oral drops
10mL bottle
Unit dose
8
Pediatric multivitamin (POLY-VI-SOL) oral drop
10mL bottle
Unit dose
10mL bottle
Unit dose
10mL bottle
Unit dose
1
Pediatric multivitamin-iron (POLY-VI-SOL with
IRON) drop
10 Pediatric ferrous sulfate oral solution
9
60
Ready-to-Administer Dosage Form Analysis
Recommendations
• Smaller product sizes should be purchased for:
– Bacitracin-polymyxin B (Polysporin®) ointment
– Bacitracin ointment, phenol throat spray
– Trypsin-balsam-castor oil (Granulex®) topical spray
– Ketorolac ophthalmic solution
• Smaller lidocaine 2% jelly tubes (5mL) should be purchased for
procedural areas and emergency department to limit use on multiple
patients
61
7. Readmission Prediction Score
Analysis
62
Readmission Prediction Score Analysis
Background:
• Organization has developed a 30 day readmission
prediction score containing 9 patient specific variables:
 Number of prior to admission (PTA) medications
 Use of opioids, anticoagulants, digoxin
 Dialysis dependency
 Oncology diagnosis
 Last hemoglobin
 Last blood sodium
 Recent emergency department visits/hospital
admissions
• A score of ≥ 23 is considered High Risk of 30 day hospital
readmission in the model.
Objective:
To determine the utility of the Readmission Prediction Daily
Report for pharmacy staff use in transitions of care services.
63
Readmission Prediction Score Analysis
Hospitalized patients with a Readmission Prediction score of ≥23
Analysis A
(n=25)
Patients with score ≥23 who met
pharmacist criteria for
medication reconciliation
Patients meeting pharmacist
criteria for medication
reconciliation received one
during their admission
15/25 (60%)
Analysis B
(n=43)
28/43 (65%)
8/15 (53%)
5 patients were assessed for
MedAL:
3/5 qualified for post DC
follow-up
12/28 (43%)
64
Readmission Prediction Score Analysis
Hospitalized patients with a Readmission Prediction score of <23 (n=275)
Pharmacist
inclusion criteria
Patients with score <23 who met pharmacist criteria for
medication reconciliation
127/275 (46%)
On >10 medications PTA
116/127 (91%)
On anticoagulants and >10 medications PTA
11/127 (9%)
65
Readmission Prediction Score Analysis
Conclusion:
• Only ~60% of patients with score ≥23 meet pharmacist
criteria for medication reconciliation.
• The Readmission Prediction Score includes all over-thecounter medications, duplicate medications and as
needed medications in the number of PTA medications
• Current pharmacist medication reconciliation criteria
identifies more medication related high risk patients
while not including patients that are at high risk of
readmission for non-medication related problems.
Recommendation:
Pharmacists should continue to utilize inpatient medication
reconciliation criteria. As more resources are allocated to
enhanced transitions of care pharmacy services, we will be
better able to prevent medication related readmissions.
66
8. Naloxone Medication Use
Evaluation and Screening Tool
67
Naloxone Medication Use Evaluation and
Screening Tool
Background:
• The Joint Commission 2012 Sentinel Event Alert as well as the
Centers for Medicare and Medicaid Services (CMS) 2014 Clinical
Standards focused on the need for safe opioid prescribing
practices and the risk associated with opioid use.
• Naloxone is a pure opioid antagonist used to counter the effects of
opioid overdose
• By evaluating the use of naloxone ,we can evaluate preventable
prescribing errors associated with opioid use and determine if
naloxone is being used correctly
• Currently, all patients at must be evaluated by nursing for airway
risk to determine their risk of respiratory depression following
administration of opioids.
Objective:
To evaluate the use of naloxone and develop a simple screening tool
to assess patients from naloxone usage reports and compliance to all
regulatory requirements.
68
Naloxone MUE and Screening Tool
Study Period:
May 2014
Methods:
Naloxone intravenous (IV) push usage reports were processed
for May 2014. All naloxone IV push administrations were
evaluated for patient risk factors and indication.
Results:
• 23 naxolone IV push administrations occurred in May 2014
• 8 of which were not included in the analysis because the
naloxone was administered for nausea/vomiting or itching
• Results are summarized in the following slides
69
Naloxone MUE and Screening Tool
Study Demographics (n=15)
Average age (years) ±SD
Weight (kg) ±SD
Gender
Naloxone Dose
Patient identified as an airway risk using
current protocol
Average 24 hour Morphine Milligram
Equivalent (MME)
57 ± 20
72.5 ±17
8 females/7 males
0.04 mg
1 patient
0.1 mg
1 patient
0.2 mg
3 patients
0.4 mg
9 patients
0.5 mg
1 patient
Yes
2
No
10
Not Assessed
3
79 (0-300)
70
Naloxone MUE and Screening Tool
Number of patients
Patient Risk Factors (n=15)
15
13
11
9
7
5
3
1
-1
12
11
11
10
8
7
6
5
3
1
* received intermittent/ scheduled/ combination intermittent & scheduled IV/PO opioids
71
Naloxone MUE and Screening Tool
Summary of naloxone response
Vital Sign
Average Heart Rate (n=13)
Prior to naloxone
administration
After naloxone
administration
91.4 (80-114)
103.6 (80-136)
18 (6-30)
24 (10-39)
99 (94-100)
98 (89-100)
1.75 (0-4)
2.5 (0-10)
Average Respiratory rate (n=15)
Average O2 sat (n=13)
Average Pain score (n=4)
Attempted to assess sedation scale pre- and post-naloxone administration:




Pre-naloxone administration:
3 patients assessed with Aldrete Score
4 patients with GCS
1 patient with RASS
7 not assessed




Post-naloxone administration:
1 patient assessed with Aldrete Score
6 patients with GCS
1 patient with RASS
7 patients not assessed
72
Naloxone MUE and Screening Tool
# of Patients
Indication of Naloxone Use
6
5
4
3
2
1
0
Response:
n/a
2
3
2
1
Yes
No
1
2
1
1
1
1
73
Proposed Screening Tool
Risk Factors: (yes/no)
Yes or No
answers are
recorded
# for cases
reviewed
(n=16)
Opioid
Naïve
Scr
≥1.3
Age
≥60
years
Smoking
history
Surgery
in last
24hrs
Concomitant*
Opioids
Cardio/
pulmonary
disease
10
7
8
6
11
11
5
Sedatives in MME in
past 24 hrs past 24hrs
12
80
(0-300)
Average number of risk factors per patient = 4.7 (3-7)
*received intermittent/ scheduled/ combination intermittent & scheduled IV/PO opioids
74
Proposed Screening Tool
Vital signs prior to naloxone
administration
Pulse Ox
(y/n)
O2 sat
HR
RR
Pain Score
Vital signs after naloxone administration
O2 sat
HR
RR
Pain Score
75
Naloxone MUE and Screening Tool
Summary of Findings
• Evaluation of the naloxone IV push administration records in May
2014, showed limited evidence that over-prescribing of opioids at
CSMC is contributing to naloxone use
• The Airway Risk assessment tool currently being used does not
accurately identify patients at high risk of respiratory depression
secondary to opioid use
• Patient vital signs prior to and immediately after naloxone
administration are inconsistently documented
• Naloxone indication and time of administration can be difficult to
obtain from a retrospective chart review
• Use and type of sedation scale varies when patients are assessed
for AMS secondary to opioid use.
76
Naloxone MUE and Screening Tool
Recommendations
• Naloxone orders should require a drop-down menu to specify
indication for use
• Pain management should be consulted to establish a naloxone use
policy. The policy should include:
• Naloxone use criteria
• Required naloxone vital sign documentation and standardized
sedation scale
• New risk assessment tool to accurately identify patients at risk
for respiratory depression following opioid use
• Nursing should be educated on need for complete and consistent
vital sign documentation in patients requiring naloxone use.
• Daily naloxone use reports should be validated and filtered to not
include administrations for itching and nausea/vomiting.
77
78