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Improving medication management in the emergency department at

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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
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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
п‚і 65 years old or п‚і 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
P H A R M A C Y : A D M IS S IO N M E D IC A T IO N S
T h e p h arm acist h as con firm ed th e adm issio n m ed ication histo ry via:
P a tie n t In te rv ie w
O w n M e d ic a tio ns
P a tie n t L is t
A ll Y es /N o
N /H o m e ...........… .… . P h ........… .
R ela tiv es
W e bs te rp a k
G P ...........… … … .. P h ........…
P h a rm a c y...........… … ..… P h ........…
P rev A d m .....… … /… ./.....
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 r a m
Distribution of unintentional errors
30
25
Freque ncy
P
a
t
i
e
n
t
s
20
15
10
5
0
0
2
4
U n in t e 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:пЃ®
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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
M edication preadm ission
T egretol C R 400m g m an e
T egretol C R 500m g n octe
T opiram ate 100m g bd
Ran itidin e 150m g bd
A torvastatin 20m g n octe
A m itriptylin e 50m g n octe
N orethisteron e 5m g n octe
Ergocalciferol 1000m g bd
V itam in C 500m g m an e
Lactulose 20m l m an e
Paraffin liquid 40m l m an e
Lacrilube apply prn
M icrolax en em a 1 pr alt days
O estradiol gel ap pv n octe
M edication charted
Ph en ytoin 400m g m an e
Ph en ytoin 500m g n octe
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U nintentional
in correct drug
in correct drug
r/v asp pn eum
Intentional
M edication preadm ission
A torvastatin 10m g n octe
Sotalol 120m g bd
Sertralin e 50m g m an e
Pan toprazole E C 40m g
Prazosin 2m g bd
A spirin 100m g E C
M edication charted
A torvastatin 40m g n octe
Sotalol 80m g bd
Prazosin 2m g bd
A spirin 100m g E C
V en lafaxin e X R 75m g
M on oplus 20/12.5m g
Frusem ide 40m g m an e
U nintentional
in correct dose
in correct dose
drug om itted
drug om itted
Intentional
drug com m ission
drug com m ission
n ew m ed
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
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