Development of a Perioperative Medication-Related Clinical Decision Support Tool to Prevent Medication Errors: An Analysis of User Feedback

Objectives Medication use in the perioperative setting presents many patient safety challenges that may be improved with electronic clinical decision support (CDS). The objective of this paper is to describe the development and analysis of user feedback for a robust, real-time medication-related CDS application designed to provide patient-specific dosing information and alerts to warn of medication errors in the operating room (OR). Methods We designed a novel perioperative medication-related CDS application in four phases: (1) identification of need, (2) alert algorithm development, (3) system design, and (4) user interface design. We conducted group and individual design feedback sessions with front-line clinician leaders and subject matter experts to gather feedback about user requirements for alert content and system usability. Participants were clinicians who provide anesthesia (attending anesthesiologists, nurse anesthetists, and house staff), OR pharmacists, and nurses. Results We performed two group and eight individual design feedback sessions, with a total of 35 participants. We identified 20 feedback themes, corresponding to 19 system changes. Key requirements for user acceptance were: Use hard stops only when necessary; provide as much information as feasible about the rationale behind alerts and patient/clinical context; and allow users to edit fields such as units, time, and baseline values (e.g., baseline blood pressure). Conclusion We incorporated user-centered design principles to build a perioperative medication-related CDS application that uses real-time patient data to provide patient-specific dosing information and alerts. Emphasis on early user involvement to elicit user requirements, workflow considerations, and preferences during application development can result in time and money efficiencies and a safer and more usable system.

The Nuts and Bolts of a Successful Non-Narcotic Perioperative ERAS Protocol

Background Enhanced recovery after surgery (ERAS) protocols are widely utilized approaches to perioperative care that advocate preoperative counseling, multimodal perioperative medication management, and early postoperative mobilization to improve post-surgical patient outcomes and satisfaction. Objectives This article aims to elucidate the mechanism by which each medication utilized in the senior author’s ERAS protocol acts, determine the efficacy of this protocol in postoperative pain management, and reveal other factors that may play a role in patient’s degree of postoperative pain. Methods A literature review was performed on the medications utilized in the senior author’s ERAS protocol. Evidence from the author’s previous study on the efficacy of this regimen and anecdotal evidence regarding the psychological component of pain was also compiled. Results There is evidence that an ERAS protocol is as effective if not more effective than regimens involving opioid medications in management of postoperative pain. These medications act synergistically to block perception of pain by multiple pathways, while minimizing adverse effects that may be associated with high doses of a single medication and are affordable for both the patient and the surgeon and. Conclusions ERAS protocols effectively manage postoperative pain while avoiding the adverse effects associated with opioid medications. While an emphasis has often been placed on the medications involved in various protocols and avoidance of opioid medications, appropriate counseling on patients’ expectations concerning postoperative “pain” or discomfort and a systemic shift in the approach to perioperative pain are perhaps the most important components to holistic non-narcotic postoperative care.

Drug-allergy investigation, provocation tests

The authors present the in vivo investigation options in drug allergy. In suspicion of drug induced hypersensitivity reaction prick testing, intradermal testing and patch testing are recommended according to the assumed immuno-mechanism. If these examinations are negative, the next step is the drug provocation test, which is the gold standard in the diagnosis of drug allergy. We summarize methods, indications and contraindications and the evaluationof each test, focusing on issues concerning antibiotics, perioperative medication, local anesthetics and biological agents. There are increasing number of patients presenting hypersensitivity reactions who require proper identification of the culprit drug.

Process Risks in Perioperative Medication Delivery

One anesthesia provider is often responsible for prescribing, formulating, dispensing, administering, and documenting medications in the operating room. Unlike other hospital units, there are few safety interventions. Systems engineering approaches can provide important insights into improving patient safety during medication delivery processes (Kaplan et al., 2013; Reid et al., 2005). This study observed anesthesia medication delivery during 20 anesthetic cases in the OR and interviewed 10 anesthesia providers in a large midatlantic academic hospital using a Systems Engineering Initiative for Patient Safety (SEIPS) framework to identify process risk in perioperative medication delivery (Holden et al., 2013). Anesthesia attendings, fellows, residents, and certified resident nurse anesthetists (CRNAs) were sampled based on who was in the OR during observations and who volunteered for interviews. Interviews were transcribed and coded through a consensus procedure. The medication delivery process was described using a SEIPS-based process map. Tasks were separated based on the anesthesia phase, though the tasks and phases are not linear; e.g: a provider may prepare for the next case during the maintenance phase.

The impact of implementation of a hysterectomy enhanced recovery pathway on anesthetic medication costs

Aim: To evaluate the effect of implementation of a hysterectomy Enhanced Recovery After Surgery (ERAS) protocol on perioperative anesthetic medication costs. Patients & methods: Historical cohort study of 84 adult patients who underwent a hysterectomy. Forty-two patients who underwent surgery before protocol implementation comprised the pre-ERAS group. Forty-two patients who underwent surgery after protocol implementation comprised the post-ERAS group. Data on anesthetic medication costs and outcomes were analyzed. Results: Compared with the pre-ERAS group, the post-ERAS group’s total medication cost was significantly lower (median: 325.20 USD; interquartile range [IQR]: 256.12–430.65 USD vs median: 273.10 USD; IQR: 220.63–370.59 USD, median difference: -40.76, 95% CI: -130.39, 16.99, p = 0.047). Length of stay was significantly longer in pre-ERAS when compared with post-ERAS groups (median: 5.0 days; IQR: 4.0–7.0 days vs median: 3.0 days; IQR: 3.0–4.0 days, median difference: -2.0 days, 95% CI: -2.5581, -1.4419, p < 0.0001). Conclusion: ERAS protocols may reduce perioperative medication costs.

Does tooth extraction and perioperative medication affect PT-INR of patients taking warfarin?

Background: Various antibiotics and analgesics have been reported to interact with warfarin. Reports that investigate the effects of medication taken for just a few days during tooth extraction on the prothrombin time-international normalized ratio (PT-INR) are rare. Methods: A total of 110 patients receiving long-term stable warfarin therapy underwent tooth extraction without interruption of warfarin treatment. INR values were measured one month before the tooth extraction, the day of the extraction, and one week after the extraction. We investigated the changes of INR values between the day of extraction and one week after the extraction, as well as the various risk factors for increases in INR values.Results: Before and after tooth extraction, the number of patients taking cefcapene pivoxil, amoxicillin, and azithromycin was 57, 36, and 8, respectively. Nine patients were administered ampicillin before tooth extraction and received amoxicillin after their tooth extraction. One week after tooth extraction, the INR values increased beyond the therapeutic range in 3 out of 110 patients (2.7%). The INR values before tooth extraction in these three patients were close to 3.0. The INR value increased by more than twice as much in 1 of 110 patients (0.9%).Conclusion: When a tooth extraction is performed in patients taking warfarin, certain factors could increase the INR, such as interaction between warfarin and antibiotics or analgesics, post-extraction inflammation or infection, and eating disorders due to post-extraction pain. However, our results suggest that it has little effect on the INR values one week after extraction.