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3
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 high- priority target medication classes
Objective: • Evaluate iVents involving opioid prescribing practices within CS- Link by classifying trends in errors and identify areas of improvement of current prescribing practices
Study Period:
January 2014- March 2014
4
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
5
Opioid Prescribing Errors by Medication
1%
11%
HYDROMORPHONE 18%
2%MORPHINE 19%
1%1%
OXYCODONE 15%
3%
13%
FENTANYL 17% BELLADONNA ALKALOIDS-OPIUM
HYDROCODONE-ACETAMINOPHEN
HYDROMORPHONE
METHADONE
MORPHINE
NALOXONE
OPIUM TINCTURE
OXYCODONE
OXYCODONE-ACETAMINOPHEN
TRAMADOL
FENTANYL
6
Opioid Prescribing Errors by Specialty
Obstetrics & Gynecology Physical Medicine & Rehab
Surgery-Colo-rectalCertified Nurse-Midwife
Emergency MedicineIM/Cardiology
IM/Gastroenterology IM/Hematology/Oncology
Nurse PractitionerPeds - NeonatologyPhysician Assistant
Thoracic Surgery Urology
IM/NephrologyUnknown
Neurosurgery Surgery-General Surgery
OrthopedicsPediatrics
AnesthesiologyGeneral Internal Medicine
0 5 10 15 20 25
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
5
6
7
11
12
25
Number of Errors
Prov
ider
Spe
cial
ty
7
Opioid Prescribing Errors by Department
4-NE
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-M
ICU
6S-CSICU
ASAP EMERG
ENCY D
EPT
8-SE
3-N M
FCU
3N-U
NIV
5-NE
5N-SICU
5-NW
5-SE
6-NE
7-PACU
7S-RICU
8S-NSICU
7-SW
0
1
2
3
4
5
6
7
8
99 9
6
5 5 5
4 4 4 4
3 3 3
2 2 2 2 2 2 2 2 2 2
1 1 1 1 1 1 1 1 1 1 1
Patient Department
Num
ber o
f iVe
nts
8
Opioid Prescribing Errors by Type
Duplicate Thera
py
Wro
ng Dose
Recommended D
iscontinuation of T
herapy
Wro
ng Frequency
Incomplete O
rder
Allerg
y
Drug-D
rug In
teracti
on
Recommended In
itiation of Medica
tion
Wro
ng Medica
tion Ord
ered
Wro
ng Route
Wro
ng Concentra
tion
Wro
ng Dosa
ge Form
Wro
ng Dura
tion
Wro
ng Rate
0
2
4
6
8
10
12
14
16
1818
16
1312
65
4 4 43
2 21 1
Num
ber o
f Err
ors
9
Type of Error and Medications Involved
Duplicate Therapy Wrong Dose Recommended Discontinuation of
Therapy
Wrong Frequency 0
2
4
6
8
10
12
14
16
18
20BELLADONNA AL-KALOIDS-OPIUM
OPIUM TINCTURE
MORPHINE
FENTANYL
TRAMADOL
OXYCODONE-APAP
OXYCODONE
METHADONE
HYDROMORPHONE
HYDROCODONE-ACETAMINOPHEN
Num
ber
of P
resc
ribi
ng E
rror
s
10
Life-Threatening Opioid iVents: 4%
Problem Identified Pharmacist Recommendation
Outcome Avoided
Wrong RouteFentanyl 12.5mg IV Q2hr prn mild pain
Clarified route with MD as MD's note the day before stated fentanyl 12 mcg patch (patient was on fentanyl patch 2 days ago)
Avoided ADE
Wrong Dose Hydromorphone 4 mg/mL solnMD changing from morphine didn't decrease the dose for higher potency
Change dose to 1 mg Avoided ADE
Wrong doseFentanyl 1000 mcg/mL ordered ivp
Change dose to 100 mcg Avoided ADE
Wrong doseMorphine 2 mg/mL IV CRTGMD ordered 1 mg/kg
Change dose to 1 mg Avoided ADE
11
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 conversiono 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 IVo Weight based dosing: Best Practice Alert when order
exceeds 40-50 kgo Educate staff on importance of evaluating all pediatric
orders (wrong patient)
12
Overview
• Emergency Department Medication Reconciliation Evaluation (1)
• Order Verification and Staffing Model (2)
• Transitions of Care Literature Review
14
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
15
Emergency Department Medication Reconciliation Evaluation
Inclusion: Patients admitted from the ED during the week of 5/12/14-5/16/2014 with admission date and time on record.
Exclusion: Patients admitted to:
Demographics: 415 patients evaluated • 5/12: 95 patients• 5/13: 80 patients• 5/14: 83 patients• 5/15: 88 patients• 5/16: 69 patients
SICU OR Pre-op PACU AHSP-PACU/Pre-
op CVIC CT tapr GI lab
MRI tapr NUC MD Tapr Rad intervention
US Tapr Vas U/S Tapr
16
Emergency Department Medication Reconciliation Evaluation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240
2
4
6
8
10
12ED Med Rec 5/12/14 (n=95)
ED med rec NOT completed
ED med rec completed
Time (hours)
Nu
mb
er
of
Pa
tie
nts
Staffing on 5/12/14: 13 med recs completed (14%)
• Pharmacist: 1100-1930
• Pharmacy Technician: 1100-1930• Pharmacy Resident: 1700-2100
17
Emergency Department Medication Reconciliation Evaluation
Staffing on 5/13/14: 17 med recs completed (21%)
• Pharmacist: 1100-1930
• Pharmacist: 1630-0200
• Pharmacy Technician: 1100-1930• Pharmacy Resident: 1700-2100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240
1
2
3
4
5
6
7
8ED Med Rec 5/13/14 (n=80)
ED med rec NOT completed
ED med rec completed
Time (hours)
Nu
mb
er
of
Pa
tie
nts
18
Emergency Department Medication Reconciliation Evaluation
Staffing on 5/14/14: 31 med recs completed (37%)
• Pharmacist: 1100-1930
• Pharmacist: 2030-0200
• Pharmacy Technician: 1100-1930• Pharmacy Resident: 1700-2100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240
1
2
3
4
5
6
7ED Med Rec 5/14/14 (n=83)
ED med rec NOT completed
ED med rec completed
Time (hours)
Nu
mb
er
of
Pa
tie
nts
19
Staffing on 5/15/14: 25 med recs completed (28%)
• Pharmacist: 1100-1930
• Pharmacist: 1600-0100
• Pharmacy Technician: 1100-1930• Pharmacy Resident: 1700-2100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240
1
2
3
4
5
6
7
8 ED Med Rec 5/15/14 (n=88)ED med rec NOT completed
ED med rec completed
Time (hours)
Nu
mb
er
of
Pa
tie
nts
Emergency Department Medication Reconciliation Evaluation
20
Staffing on 5/16/14: 18 med recs completed (26%)
• Pharmacist: 1100-1930
• Pharmacy Technician: 1100-1930• Pharmacy Resident: 1700-2100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240
1
2
3
4
5
6 ED Med Rec 5/16/14 (n=69)
ED med rec NOT completed
ED med rec completed
Time (hours)
Nu
mb
er
of
Pa
tie
nts
Emergency Department Medication Reconciliation Evaluation
21
Emergency Department Medication Reconciliation Evaluation
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240
5
10
15
20
25
30
35
ED Admission Summary 5/12/14 to 5/16/14 (n=415)
Med Rec Completed
Med Rec NOT completed
Time (Hours)
Nu
mb
er
of
Pa
tie
nts 17%
6% 18%
17% 9%
12%
60%
43%
44%
38%
46%
39%43%
13%
29%
16%
13% 23%
22
Emergency Department Medication Reconciliation Evaluation Recommendations
• Proposed weekday coverage for ED medication reconciliation staffing:
• Proposed weekend (Saturday or Sunday, to be determined based on weekend analysis) 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
• 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
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
25
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
26
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:
Order Verification and Staffing Model
Microsoft Office Excel 97-2003 Worksheet
27
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
Order Verification and Staffing Model Recommendations
28
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)
30
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
31
iVents Evaluated:
• 200 iVents were included in the analysis⁻ 11 Life-Threatening⁻ 189 Serious/Significant
Apixaban<1%
Dabigatran3%
Heparin Flush4%
Enoxaparin Tx8%
Warfarin8%
Rivaroxaban11%
Enoxaparin PPX14%
Heparin Tx19%
Heparin PPX35%
Anticoagulant Prescribing Errors by Medication and Use:
Anticoagulant iVent Analysis
32
Anticoagulant iVent Analysis
GIM
Gener
al S
urge
ry
IM/C
ardi
olog
y
Neuro
surg
ery
Orthop
edics
Anest
hesio
logy
Other
Nurse
Pra
ctiti
oner
Emer
genc
y Med
icine
Nephr
olog
y
Infe
ctio
us D
iseas
es
Hemat
olog
y/Onc
olog
y
Phys
ician
Ass
istan
t
Pedi
atric
s
Neuro
logy
Obste
trics
& G
ynec
olog
y
Pulm
onar
y Med
icine
0
10
20
30
40
50
60
70
80
9078
12 12 11 11 11 11 105 5 4 4 3 3 3 3 3
Prescribing Errors by Specialty
Nu
mb
er
of
Err
ors
33
Anticoagulant iVent Analysis
Allergy
Wrong Concentration
Drug Drug interaction
Wrong Rate
Omission of Medication on Transfer
Recommended Initiation of Medication
Recommended Discontinuation of Therapy
0 10 20 30 40 50
1
1
1
1
6
1
2
1, 13
4
4
5
17
2236
49
45Anticoagulant Prescribing Errors by Type
Life Threatening
34
Anticoagulant iVent Analysis
Tre
atm
en
t a
nd
PPX
A
nti
coa
gu
lati
on
Du
plic
ate
Tre
at-
me
nt
An
tico
ag
ula-
tio
n
Du
plic
ate
Do
se o
f A
nti
coa
gu
lan
t
Du
plic
ate
an
ti-co
ag
ula
nt
pro
-p
hyla
xis
Duplicate Therapy
0102030
29
9 7 6
Categories of Duplicate Therapy (n=51)
35
Anticoagulant iVent Analysis
INR T
herp
eutic
Plat
elet
s Dro
ppin
g
Proc
edur
e
Other
Supr
athe
rape
utic
INR
Bleed
Renal
func
tion
HIT0
4
8
1213
108
5 5 53
1
Reasons for Recommending Discontinuation of Therapy (n=50)
36
Renal
func
tion
Inco
rrec
t rivar
oxab
an d
ose
High
dose
Wei
ght
PTA
Wro
ng fl
ush
dose
Low d
ose
0
2
4
6
8
10
12
3
9
2
31
5
3 4
12
31
Types of Wrong Doses (n=37)
HeparinEnoxaparinDabigatranRivaroxaban
Anticoagulant iVent Analysis
37
Anticoagulant iVent Analysis
Problem IdentifiedRX
Recommendation
Outcome Avoided
Severity Ranking
Patient with anaphylaxis allergy to heparin was
ordered heparin prophylaxis
Discontinue therapy
Anaphylaxis
Life Threatening
Patient that received TPA was ordered heparin prophylaxis
Discontinue therapy
Hemorrhage
Heparin 10 units/mL was ordered for infant as PICC line
flush
Correct concentration
Hemorrhage
Heparin order placed for 600 units/kg/hour
Correct rate Hemorrhage
Patient continued on heparin flush with positive PF4
Discontinue heparin
Thrombus
Duplicate treatment dose anticoagulant orders
2 Rivaroxaban and heparin drip
2 Dabigatran and heparin drip
Rivaroxaban and tx enoxaparin
Dabigatran and tx enoxaparin
Discontinue one of the therapies
Hemorrhage; inhibiting multiple
anticoagulation pathways
38
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.
40
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
$478,988.50Objective: To evaluate daptomycin use
Methods: Retrospective review of daptomycin orders in April 2014 to evaluate for proper dose and indication
Study Period:
April 2014
41
Daptomycin Medication Use Evaluation
Daptomycin MUE DemographicsNumber of Patients (#) 28Average Age (years) 63 ± 13Gender 14 males, 14 femalesAverage number of doses (#) 5 ± 3.4
Unit breakdown (%)
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
42
Daptomycin Medication Use Evaluation
Summary of inpatient daptomycin Use N=25
# of patients followed by ID physician (%) 25/25 (100%)
# of treatment courses meeting criteria 0/25
# of treatment courses with an acceptable indication or dose 21/25 (84%)
# of treatment courses approved by AUR (%) 9/25 (36%)
43
Daptomycin Medication Use Evaluation
Patient Error Indication Dose Total
doses
Approved by AUR
1 Incorrect Dose
MRSA joint infection with vancomycin
allergy described as flushing, PVCs, SOB
2.3-6 mg/kg 7 No
2 Incorrect Indication
Neutropenic patient spiking fever on
vancomycin (likely drug fever) with no
culture growth
5mg/kg 9 No
3 Incorrect Indication
Prosthetic joint infection with no
culture growth; MRSA and VRE screens
negative
6mg/kg 9 No
4 Incorrect Dose MRSA osteomyelitis 5mg/kg 2 No
44
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%)
45
Daptomycin Medication Use Evaluation
Bacte
rem
ia
Cellu
litis
Osteo
mye
litis
Join
t Inf
ectio
nJo
int
UTI
Surg
ical P
roph
ylax
is
Neutro
peni
c Fe
ver
Abdom
inal
Infe
ctio
n
Seps
is0
2
4
6
8
10
Daptomycin Indication and Culture Summary (n=28)
VREOther/No growthMRSA
46
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.
48
Risk Assessment of Procedural Areas
Background:
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.”
Objective: To evaluate medication stock of all procedural areas for compliance with TJC standards
49
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
50
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
51
Risk Assessment of Procedural Areas
7STONE; 35
8IR; 45
Blood Donor Cen-ter; 19
Bronch Lab; 18
Cath Lab; 93
GI Lab; 63
Non-Invasive Cardio; 23
PROCCTR Cart Stock; 5
PROCCTR Pyxis; 56Puml Fxn Lab; 6
Summary of number of medications per pro-cedural area
52
Risk Assessment of Procedural Areas
Reason for Lack of Pharmacist Review*
Reason# of
MedicationsMedication
Location
Managed by LIP65
medications
Nursing Protocol15
medications
Urgent Medication157
medications
No longer stocked 1 medications Ammonia Inhalant GI Lab
No indication 7 medications
Acetylcysteine 600mg capsules Cath Lab
Ibuprofen Pediatric suspension
Procedure Center Pyxis
Ibuprofen 400mg tabletProcedure Center
PyxisMethylprednisolone sodium 1000mg IV
solution7Stone Pyxis
Prednisone 5mg tabletProcedure Center
PyxisRanitidine 150mg tablet Cath Lab
Triamcinolone 0.1% topical cream
Procedure Center Pyxis
*Please note that some medications have multiple reasons
53
Medications NOT Meetings TJC Standards
Medication Indication Location Comments
Acetylcysteine 600mg capsules
IV contrast nephrotoxici
ty prophylaxis
Cath Lab Not urgent, should be verified by
pharmacist
Ibuprofen Pediatric suspension
Pain, feverProcedure
Center Pyxis
Oral pain medication not urgent Pyxis optimization report shows no use in
the last year
Ibuprofen 400mg tablet
Pain, feverProcedure
Center Pyxis
Oral pain medication not urgent Pyxis optimization report shows last use is
6/21/2013
Methylprednisolone 1000mg IV solution
Unclear7Stone Pyxis
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
Prednisone 5mg tablet
UnclearProcedure
Center Pyxis
Procedural center RNs unsure of indication Pyxis optimization report shows no use
since December 2013Ranitidine 150mg tablet
Heartburn, ulcer prophy
Cath Lab Oral medication not urgent; IV ranitidine is
available for urgent use
Triamcinolone 0.1% topical cream
Skin irritation
Procedure Center Pyxis
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.
53
54
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
56
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
57
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
58
Ready-to-Administer Dosage Form Analysis
Optha
lmic
drop
s
Topi
cal O
intm
ent
Inje
ctab
le sol
utio
n
Oral s
olut
ion
Topi
cal S
olut
ion
Topi
cal s
pray
Oral r
inse
Otic d
rop
Topi
cal J
elly
Mou
th w
ash
Optha
lmic
gel
Topi
cal lot
ion
Optha
lmic
Ointm
ent
0
4
8
12
1616 15 15
11
7 6 5 53 3 3 3 3 2 2 2 2 1 1 1 1 1 1 1 1
Bulk Dosage Forms Dispensed Jan 29th-31st, 2014
59
Ready-to-Administer Dosage Form Analysis
Summary of bulk order compliance with TJC Standards
Compliance with TJC Standards
Description of ComplianceNumber of Products (n=111)
Yes
Dispensed smallest commercially available product size, unable to unit dose
69
Unit dosed 16Dispensed from Pyxis 6Compounded product 5Size dispensed required for order 3Other
Medrol dose pack Chlorhexidine solution
2
NoProducts with
recommendations for change
10
60
Ready-to-Administer Dosage Form Analysis
Summary of products not in compliance with TJC standards
ProductQuality
dispensed
Proposed dispensed product
Cost Difference
1Bacitracin-polymyxin B (POLYSPORIN) ointment
1 oz tube 0.5 oz tube -$1,176.53
2 Bacitracin ointment 1 oz tube 0.5 oz tube $8,555.81
3Phenol throat spray (CHLORASEPTIC) spray
4 oz bottle 1 oz bottle $12,360.30
4Trypsin-balsam-castor oil (GRANULEX) topical spray 1 spray
4 oz spray bottle
2 oz spray bottle
$1,130.49
5Ketorolac (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
7Multivits-mins-coenzyme Q10 (AQUADEKS) 400 mcg/mL oral drops
10mL bottle Unit dose
8Pediatric multivitamin (POLY-VI-SOL) oral drop
10mL bottle Unit dose
9Pediatric multivitamin-iron (POLY-VI-SOL with IRON) drop
10mL bottle Unit dose
10
Pediatric ferrous sulfate oral solution10mL bottle Unit dose
61
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
63
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.
64
Readmission Prediction Score Analysis
Hospitalized patients with a Readmission Prediction score of ≥23 Analysis A
(n=25)Analysis B
(n=43)Patients with score ≥23
who met pharmacist criteria for medication
reconciliation
15/25 (60%) 28/43 (65%)
Patients meeting pharmacist criteria for
medication reconciliation received one during their
admission
8/15 (53%)
12/28 (43%)5 patients were assessed for MedAL:
3/5 qualified for post DC follow-up
65
Readmission Prediction Score Analysis
Hospitalized patients with a Readmission Prediction score of <23 (n=275)
Patients with score <23 who met pharmacist criteria for medication reconciliation 127/275 (46%)
Phar
macist
inclusion
criteria
On >10 medications PTA 116/127 (91%)
On anticoagulants and >10 medications PTA 11/127 (9%)
66
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-the-counter 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.
68
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.
69
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
70
Naloxone MUE and Screening Tool
Study Demographics (n=15)
Average age (years) ±SD 57 ± 20Weight (kg) ±SD 72.5 ±17Gender 8 females/7 males
Naloxone Dose
0.04 mg 1 patient0.1 mg 1 patient0.2 mg 3 patients0.4 mg 9 patients0.5 mg 1 patient
Patient identified as an airway risk using current protocol
Yes 2 No 10
Not Assessed 3Average 24 hour Morphine Milligram Equivalent (MME)
79 (0-300)
71
Naloxone MUE and Screening Tool
Seda
tives
in p
ast 2
4 ho
urs
Surg
ery in la
st 2
4 ho
urs
Conco
mita
nt O
pioids
*
Opioid
naive
Age
≥60
Scr ≥
1.3
Smok
ing
Histor
y
Cardio/
Pulm
onar
y Dise
ase
BMI >
30
Histor
y of
sleep
apn
ea-113579
111315
12 11 11 108 7 6 5
31
Patient Risk Factors (n=15)
Nu
mb
er
of
pati
en
ts
* received intermittent/ scheduled/ combination intermittent & scheduled IV/PO opioids
72
Naloxone MUE and Screening Tool
Summary of naloxone response
Vital SignPrior to naloxone administration
After naloxone administration
Average Heart Rate (n=13)
91.4 (80-114) 103.6 (80-136)
Average Respiratory rate (n=15)
18 (6-30) 24 (10-39)
Average O2 sat (n=13) 99 (94-100) 98 (89-100)
Average Pain score (n=4) 1.75 (0-4) 2.5 (0-10)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
73
Naloxone MUE and Screening Tool
Alte
red
men
tal s
tatu
s (A
MS)
Som
nolenc
e
Extu
batio
n
Low O
2 sa
tura
tion
Hypot
ensio
n
Unclear
Strid
or0123456
3
1 1 1
2
22
11 1
Indication of Naloxone Use
n/a Yes No
# o
f P
ati
en
ts
Response:
74
Proposed Screening Tool
Risk Factors: (yes/no)
Opioid Naïve
Scr ≥1.3
Age ≥60
years
Smoking
history
Surgery in last
24hrs
Concomitant* Opioids
Cardio/ pulmonary disease
Sedatives in past 24
hrs
MME in past
24hrs
Yes or No answers
are recorded
# for cases
reviewed (n=16)
10 7 8 6 11 11 5 1280
(0-300)
Average number of risk factors per patient = 4.7 (3-7)*received intermittent/ scheduled/ combination intermittent & scheduled IV/PO opioids
75
Proposed Screening Tool
Vital signs prior to naloxone administration Vital signs after naloxone administration
Pulse Ox (y/n) O2 sat HR RR Pain Score O2 sat HR RR Pain Score
76
Naloxone MUE and Screening ToolSummary 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.
77
Naloxone MUE and Screening ToolRecommendations
• 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.