Evaluation and Enhancement of a Comprehensive Controlled Substances Management Process at an Academic Medical Center

2021 ◽  
pp. 089719002110222
Author(s):  
Bailey E Eason ◽  
Tyler A Vest ◽  
Katherine D. Mieure ◽  
Danielle Neal ◽  
Jennifer Tryon
Keyword(s):  
Direct Observation ◽  
Gap Analysis ◽  
Work Group ◽  
Medical Center ◽  
Phase 1 ◽  
Academic Medical Center ◽  
Compliance Rate ◽  
Analysis Tool ◽  
Controlled Substances ◽  
Current State

Purpose: Controlled substances management is highly regulated, and requires institutions to have processes in place to maintain a closed-loop. This study was conducted to comprehensively evaluate the current state of controlled substances management, propose optimization opportunities, and implement steps to align the medication use process (MUP) to a defined desired state. Methods: This evaluation was conducted in 2 phases. In phase 1, the current state of controlled substances management was assessed in order to develop a gap analysis tool and failure mode and effects analysis (FMEA). In phase 2, a work group was assembled to address opportunities within the FMEA. The work group prioritized opportunities using the risk priority number (RPN), and formulated action steps to align processes with the defined desired state. Results: Through the literature evaluation, a desired state, consisting of 86 segments, was defined and compared with a gap analysis tool. Direct observation of the MUP allowed for development of 13 process maps depicting current state. Of the 86 segments, it was determined the study institution had a compliance rate of 62%. The remaining 38% correlated with 55 actionable process opportunities that were included in the FMEA. To date, 31 of the 55 (56%) opportunities have been successfully addressed by the work group. Conclusion: Use of direct observation to formulate a gap analysis tool and FMEA is an effective modality to evaluate controlled substances processes. These tools allow for pharmacy departments to identify and prioritize opportunities to optimize controlled substances management within an academic medication center

PIVC Best Practices: A Path to Performance Improvement

2021 ◽  
Author(s):  
Erin Davidson ◽  
Prachi Arora
Keyword(s):  
Dwell Time ◽  
Medical Center ◽  
Phase 1 ◽  
Compliance Rate ◽  
Phase 3 ◽  
Improvement Project ◽  
Vascular Access Devices ◽  
Current State ◽  
The Impact ◽  
Current Standards

Highlights Abstract Background: Insertion of peripheral vascular access devices (PIVC) is fundamental to patient care and may affect patient outcomes. Baseline data of PIVC insertions at a large medical center revealed that catheters required multiple insertion attempts, catheter hubs were manipulated to place extension sets, increasing the risk of complications, dwell times did not meet current standards, nurses experienced blood-exposure risk, and overall compliance with the hospital documentation policy was suboptimal. A 3-phase quality improvement project was conducted to address these concerns. Methods: In Phase 1, an assessment of the current state of PIVC insertions and care was conducted using a mixed-methods approach consisting of an observational audit of insertion and maintenance practices, and retrospective chart reviews. In Phase 2, PIVC policies and practices were updated to reflect current standards. A new advanced design PIVC device was adopted, and education was provided to all staff. In Phase 3, the impact of these changes on key PIVC measures was assessed 1 year later. Results: The analysis of the data found several improvements following implementation of an integrated IV catheter system: first-stick success rate increased from 73% to 84%, staff blood exposure was reduced from 46.67% to 0% (P = .01), improper securement of PIVC catheters was reduced from 11% to 0% (P = .002), and documentation compliance rate increased from 68% to 80%. The median PIVC dwell time doubled (from 2 days to 4 days). Conclusion: Changes to policy, practices, and products plus education can improve the PIVC first-stick success, dwell time, documentation, and staff safety.

Implementation of a Clinical Pathway to Reduce Rates of Postextubation Stridor

2018 ◽  
Vol 38 (5) ◽  
pp. 34-41
Author(s):  
Megan Lange ◽  
Neeraj Badjatia ◽  
Wan-Tsu Chang
Keyword(s):  
Clinical Pathway ◽  
Neurocritical Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Compliance Rate ◽  
Hospital Costs ◽  
Hospital Length ◽  
Laryngeal Edema ◽  
Implementation Phase ◽  
Postextubation Stridor

Background Unsuccessful extubation is associated with increased intensive care unit and hospital length of stays, hospital costs, morbidity, and mortality. The most common cause of reintubation is laryngeal edema, often evidenced by postextubation stridor. Objective To reduce the rates of postextubation stridor and reintubation in the neurocritical care unit at a large urban academic medical center. Methods A clinical pathway was created to aid in detecting patients expected to experience postextubation stridor and to guide prophylactic treatment. During the 12-week implementation phase, the pathway was completed on all intubated patients daily. Results The 12-week trial included a total of 606 days of mechanical ventilation. Checklists were completed for 531 days, a compliance rate of 88% for use of the clinical pathway. Of the 56 patients who were extubated during the trial, 54 had a checklist completed, for 96% compliance on the day of extubation. Outcomes after all nonpalliative extubations (n = 43) during the 12 weeks before and after implementation of the pathway (n = 56 periods) were evaluated by using χ2 tests. Implementation of the pathway was associated with a significant reduction in rates of postextubation stridor (χ2 = 6.2; P = .01), reintubation (χ2 = 5.5; P = .02), and reintubation due to postextubation stridor (χ2 = 8.3; P = .004). Conclusion The clinical pathway implemented in the neurocritical care unit was safe and effective in reducing rates of reintubation and reintubation due to postextubation stridor.

scholarly journals Quality improvement and reconciliation process for automated dispensing cabinet medication overrides

2021 ◽  
Author(s):  
James A M Rhodes ◽  
Deborah S Bondi ◽  
Laura Celmins ◽  
Charlene Hope ◽  
Randall W Knoebel
Keyword(s):  
Quality Improvement ◽  
Medical Center ◽  
Academic Medical Center ◽  
Compliance Rate ◽  
Medication Use ◽  
Governance Structure ◽  
Dosage Forms ◽  
Academic Medical ◽  
Dispensing Practices ◽  
Reconciliation Process

Abstract Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To describe a pharmacist-led reconciliation process for automated dispensing cabinet (ADC) medication override setting maintenance at an academic medical center. Summary ADC override management requires alignment of people, processes, and technology. This evaluation describes system-wide improvements to enhance institutional medication override policy compliance by establishing a formalized evaluation and defined roles to streamline ADC dispense setting management. A pharmacist-led quality improvement initiative revised the institutional medication override list to improve medication dispensing practices across an academic medical center campus with a pediatric hospital and 2 adult hospitals. This initiative included removal of patient care unit designations from the medication override list, revision of institutional override policy, creation of an online submission form, and selection of ADC override metrics for surveillance. A conceptual framework guided decisions for unique dosage forms and interdisciplinary engagement. Employing this framework revised workflows for stakeholders in the medication-use process through clinical pharmacist evaluation, existing shared governance structure communication, and pharmacy automation support. The revised policy increased the number of medications available for override from 80 to 106 (33% increase) and unique dosage forms from 166 to 191 (15% increase). The total number of medication dispense settings was reduced from 5,600 to 541 (90% decrease). The proportion of override dispenses compliant with policy increased from 59% to 98% (P < 0.001). Median monthly ADC overrides remained unchanged following policy revision (P = 0.995). ADC override rate reduction was observed across the institution, with the rate decreasing from 1.4% to 1.2% (P < 0.001). Similar ADC override rate reductions were observed for adult, pediatric, and emergency department ADCs. Conclusion This initiative highlights pharmacists’ role in leading institutional policy changes that influence the medication-use process through ADC dispensing practices. A pharmacist-led reconciliation process that removed practice area designations from our medication override policy streamlined ADC setting maintenance, increased the compliance rate of ADC override transactions, and provided a formalized process for future evaluation of medication overrides.

scholarly journals The Prescribing and Education of Naloxone in a Large Academic Medical Center

Pharmacy ◽  
2020 ◽  
Vol 8 (1) ◽  
pp. 31
Author(s):  
Sabrina Miller ◽  
Lauren Williams ◽  
Amy N. Thompson
Keyword(s):  
Medical Center ◽  
Demographic Data ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Reversal Agents ◽  
Outpatient Prescription ◽  
Current State ◽  
Academic Medical ◽  
History Of ◽  
Improvement Measures

The opioid epidemic has led to increased needs for opioid reversal agents which require education and counseling for proper use. The purpose of this study was to evaluate outpatient naloxone prescribing and education practices at an academic medical center to understand the current state and inform quality improvement measures. This retrospective chart review study included 439 patients that were at least 18 years old and received an outpatient prescription for naloxone between 1 July 2017 and 30 June 2018. Descriptive and demographic data were collected. The primary endpoint was whether an indication for naloxone and education on administration were documented when naloxone was initially prescribed to patients. Overall, 39% of naloxone prescriptions did not have an indication for prescribing listed in the medical record. Of those with a documented indication, concomitant benzodiazepines and history of overdose or substance abuse were most common (22% and 14%). The average morphine milligram equivalents were 165. Additionally, 69% of dispenses did not have documentation that the patient or a caregiver received education regarding the use and administration of naloxone. These findings suggest that patients are receiving naloxone for appropriate indications. Documentation of medication education is needed to ensure it is occurring and that patients are informed.

Medication Histories in Critically Ill Patients Completed by Pharmacy Personnel

2019 ◽  
Vol 53 (6) ◽  
pp. 596-602
Author(s):  
Bridgette L. Kram ◽  
Morgan A. Trammel ◽  
Shawn J. Kram ◽  
Sandy E. Wheeley ◽  
Ben G. Mancheril ◽  
...  
Keyword(s):  
Critically Ill ◽  
Medical Center ◽  
Phase 1 ◽  
Academic Medical Center ◽  
Median Number ◽  
Phase 2 ◽  
Medication History ◽  
Medication Discrepancies ◽  
Critically Ill Adults ◽  
Ill Adults

Background: Although critically ill adults often have extended hospital lengths of stay and are at high risk of having medication-related adverse events, the value of medication histories in these patients remains underreported. Objective: To assess the feasibility of performing medication histories in critically ill adults and to establish the frequency of and characterize identified discrepancies. Methods: This prospective study included patients admitted to 4 intensive care units (ICUs) in a large academic medical center and was conducted in 2 phases. In phase 1, medication histories were conducted over a 5-week period by clinical pharmacists to assess feasibility. In phase 2, medication histories were conducted over a 3-week period by a pharmacy technician. Medication discrepancies, defined as any difference between the documented and pharmacy personnel–identified home medication list, were aggregated in both phases and adjudicated for severity. Results: In phase 1, 127 medication histories were completed (42.3% of admitted patients). Impaired cognition was the most common barrier encountered; however, 76% of patients were able to have a history completed if an attempt was made. In phase 2, a medication history was completed for 176 patients (58.9% of admitted patients). In aggregate, 1155 discrepancies were identified, with 78.2% of patients having a discrepancy. The median number of discrepancies per patient was 3 (interquartile range = 1-5); 11 life-threatening, 101 serious, and 326 significant discrepancies were identified. Conclusion and Relevance: A pharmacy personnel–based medication history program in the ICU is feasible and assists in the discovery of medication discrepancies with the potential for patient harm.

Decluttering the problem list in electronic health records

2021 ◽  
Author(s):  
Austin R Brown ◽  
Allison B McCoy ◽  
Adam Wright ◽  
Scott D Nelson
Keyword(s):  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Decision ◽  
Problem List ◽  
Snomed Ct ◽  
Face To Face ◽  
Current State ◽  
Academic Medical ◽  
Support Tools ◽  
Electronic Health

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The purpose of this study was to evaluate the current state of problem list maintenance at an academic medical center. Summary We included problem list data for patients who had at least 2 face-to-face encounters at Vanderbilt University Medical Center or its clinics between January 1, 2018, and December 31, 2019. We used the frequency of problem list additions, resolutions, deletions, duplicate problems (exact and SNOMED CT duplicates), inconsistencies (contradicting stages of disease state), and items that could be documented elsewhere in the electronic health record as surrogate markers of problem list maintenance. Descriptive statistics were used to summarize the results. A total of 546,510 patients met inclusion criteria. There were 3,762 (0.7%) patients who had the exact same active problem listed more than once. SNOMED CT code duplications occurred in the records for 56,399 (10.5%) patients. Of the patients with asthma, 2.5% (223/8,779) had contradicting asthma stages active on their problem list, and 6.4% (950/14,950) of patients with chronic kidney disease (CKD) had contradicting CKD stages. In addition, 17,205 (3.1%) patients had 20,365 active family history problems and 39,464 (7.2%) patients had an allergy documented on their problem list. On average, there were 43.7 (95% confidence interval [CI], 14-73.4) additions, 8.7 (95% CI, 0.1-17.4) resolutions, and 2.1 (95% CI, 0-4.6) deletions of problems per 100 face-to-face encounters, inpatient or outpatient. Conclusion Our study suggests areas for improvement for problem list maintenance. Further studies into semantic duplication and clinical decision support tools to encourage problem list maintenance and deduplication are needed.

Infusion reactions following administration of intravenous rolapitant at an academic medical center

2018 ◽  
Vol 25 (7) ◽  
pp. 1776-1783 ◽  
Author(s):  
Amanda S Cass ◽  
Johlee S Odinet ◽  
John M Valgus ◽  
Daniel J Crona
Keyword(s):  
Medical Center ◽  
Phase 1 ◽  
Objective Assessment ◽  
Academic Medical Center ◽  
Treatment Strategies ◽  
Significant Risk ◽  
Hepatic Metabolism ◽  
Bioequivalence Study ◽  
Hypersensitivity Reactions ◽  
The North

In 2017, due to a fluid shortage secondary to Hurricane Maria's devastation of Puerto Rico, hospitals and health-systems began to substitute rolapitant for fosaprepitant as part of chemotherapy-induced nausea and vomiting prevention and treatment strategies. However, despite advantageous pharmacologic and formulation (e.g. long half-life, quicker time to onset, and lack of first-pass hepatic metabolism) profiles, there seems to be significant risk of infusion-related hypersensitivity reactions associated with the administration of intravenous rolapitant. In January 2018, the U.S. FDA issued a Health Care Provider Letter stating that anaphylaxis, anaphylactic shock, and other serious hypersensitivity reactions have been reported in the postmarketing setting. Importantly, these reactions were observed at a higher rate than initially reported in the phase 1 bioequivalence study that led to FDA approval of intravenous rolapitant (2.8%), with many resulting in hospitalizations. At our institution, rolapitant-induced infusion-related reactions also occurred in more patients than expected (8.7%). Described herein are six cases of infusion-related hypersensitivity reactions with intravenous rolapitant at the North Carolina Cancer Hospital. Due to the quick onset of the infusion-related hypersensitivity reactions with intravenous rolapitant, interpatient differences in pharmacokinetics or pharmacodynamics are unlikely to be the cause. An objective assessment utilizing the Naranjo Causality Scale rates these infusion-related hypersensitivity reactions as definite adverse drug reactions.

Prospective Comparison of Acute Kidney Injury During Treatment With the Combination of Piperacillin-Tazobactam and Vancomycin Versus the Combination of Cefepime or Meropenem and Vancomycin

2016 ◽  
Vol 30 (2) ◽  
pp. 209-213 ◽  
Author(s):  
Vincent Peyko ◽  
Samantha Smalley ◽  
Henry Cohen
Keyword(s):  
Acute Kidney Injury ◽  
Work Group ◽  
Medical Center ◽  
Academic Medical Center ◽  
Kidney Injury ◽  
Adult Patients ◽  
Open Label ◽  
Prospective Comparison ◽  
Academic Medical ◽  
Vancomycin Group

Purpose: To prospectively evaluate the observed incidence of acute kidney injury (AKI) in adult patients receiving the combination of piperacillin-tazobactam and vancomycin versus the combination of cefepime or meropenem and vancomycin for greater than 72 hours. Methods: This was a prospective, open-label cohort study at a community academic medical center involving adult patients over a 3-month time period who received either the combination of piperacillin-tazobactam and vancomycin or the combination of cefepime or meropenem and vancomycin for greater than 72 hours. The patients were evaluated for AKI, defined using specific criteria introduced by Kidney Disease: Improving global outcomes (KDIGO) acute kidney injury work group in 2012. Results: A total of 85 patients receiving either antimicrobial combination were evaluated for AKI. The incidence of AKI was significantly higher in the piperacillin-tazobactam and vancomycin group (37.3%) compared with the cefepime or meropenem and vancomycin group (7.7%; χ2 = 7.80, P = .005). Conclusion: The result of this study suggests that the risk of developing AKI is increased in patients receiving the combination of piperacillin-tazobactam and vancomycin versus those receiving the combination of cefepime or meropenem and vancomycin.

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