Expansion of Pharmacy Services During COVID-19: Pharmacists and Pharmacy Extenders Filling the Gaps Through Telehealth Services.

Purpose: The Coronavirus 2019 (COVID-19) pandemic created a significant disruption in healthcare. In our health-system located in New York City, the provision of care in the ambulatory care setting moved to a remote model virtually overnight. We describe interventions made during the pandemic to transform ambulatory care pharmacy through expansion of telehealth services. Summary: In March of 2020, the closure of primary care clinics and provider appointment cancellations due to inpatient redeployment created a void. Collaboration with other health care providers and development of standardized telehealth workflows served as a conduit for creating new roles and opportunities for pharmacy team members. Three main interventions where the pharmacy team filled gaps include; (1) Expansion of pharmacist telemedicine visits for high-risk patients to improve access to primary care visits, (2) Partnership with nursing to create a centralized refill call center workflow, (3) Integration of pharmacy extenders into the prior authorization process to prevent medication access issues. Existing collaborative practice agreements for chronic disease management were utilized. A virtual pharmacist model for patient care contributed to an increase in telehealth visits from 51 in 2019 to 2997 total visits in 2020. In addition, the health-system refill call center expanded its services through collaboration with our pharmacy team. Pharmacists and pharmacy interns partnered with nurse practitioners to improve the call center workflow and address the significant increase in refill requests during the outbreak. Furthermore, a prior authorization process was created across multiple ambulatory care clinics to expedite medication access and prevent delays in therapy. Conclusion: Our ambulatory care pharmacy team leveraged technology, innovative workflows, and collaborative teamwork to catalyze a shift in pharmacists' and pharmacy extenders' roles in healthcare delivery to expeditiously meet patients' needs during a pandemic.

Pain Management Stewardship Programs, Part I: A Review of Legislative and Regulatory Changes.

Background: Opioid use is classified as an epidemic by many due to the impact of these medications on society. Federal and state laws for prescribing and dispensing opioids have changed rapidly in a short period of time to hopefully balance proper pain control with their use. Pharmacy directors must be informed of these rapid changes to effectively work as part of any opioid stewardship team. Objective: The objective of this study was to provide foundational leadership guidance to pharmacy directors on current opioid legislation, literature, and best practices to assist in improving opioid use. Methods: A review of the literature from 2003 to the present was conducted along with collating important up to date resources and other publications that provide foundational information to help support a comprehensive management of opioid use. A summary of these data has been collated into an easy to use table and summarized throughout this article. Conclusion: The information provided in this article helps to properly inform pharmacy leaders to the resources available to improve the prescribing, dispensing, and monitoring of opioids and alternatives.

Impact of Hospitalist-Led Interdisciplinary Antimicrobial Stewardship Interventions at an Academic Medical Center.

BACKGROUND: Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes. METHODS: A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5). RESULTS: Total antibiotic use decreased by 16.8% (p < 0.001), 6.8% (p = 0.08), and 33.0% (p < 0.001) on Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Broad-spectrum antibiotic use decreased by 26.2% (p < 0.001), 7.8% (p = 0.09), and 32.4% (p < 0.001) on the Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Duration of inpatient antibiotic therapy decreased from 4 to 3 days on the Ed+IMPharmDx5 team (p = 0.01). Length of stay for patients who received any antibiotic decreased from 9 to 7 days on the Ed-only team (p < 0.001) and from 9 to 6 days on the Ed+IMPharmDx5 team (p < 0.001). There was no significant change in 30-day readmission to the same facility, transfer to ICU, or in-hospital mortality for any team. CONCLUSION: Multidisciplinary, frontline provider-driven approaches to antimicrobial stewardship may contribute to reduced antibiotic use and length of hospital stay.

Engaging hospital patients in the medication reconciliation process using tablet computers.

Objective: Unintentional medication discrepancies contribute to preventable adverse drug events in patients. Patient engagement in medication safety beyond verbal participation in medication reconciliation is limited. We conducted a pilot study to determine whether patients' use of an electronic home medication review tool could improve medication safety during hospitalization. Materials and Methods: Patients were randomized to use a tool before or after hospital admission medication reconciliation to review and modify their home medication list. We assessed the quantity, potential severity, and potential harm of patients' and clinicians' medication changes. We also surveyed clinicians to assess the tool's usefulness. Results: Of 76 patients approached, 65 (86%) participated. Forty-eight (74%) made changes to their home medication list [before: 29 (81%), after: 19 (66%), p = .170]. Before group participants identified 57 changes that clinicians subsequently missed on admission medication reconciliation. Thirty-nine (74%) had a significant or greater potential severity, and 19 (36%) had a greater than 50-50 chance of harm. After group patients identified 68 additional changes to their reconciled medication lists. Fifty-one (75%) had a significant or greater potential severity, and 33 (49%) had a greater than 50-50 chance of harm. Clinicians reported believing that the tool would save time, and patients would supply useful information. Discussion: The results demonstrate a high willingness of patients to engage in medication reconciliation, and show that patients were able to identify important medication discrepancies and often changes that clinicians missed. Conclusion: Engaging patients in admission medication reconciliation using an electronic home medication review tool may improve medication safety during hospitalization.

Randomized controlled evaluation of an insulin pen storage policy.

PURPOSE: Results of a quality-improvement project to enhance safeguards against "wrong-pen-to-patient" insulin pen errors by permitting secure bedside storage of insulin pens are reported. METHODS: A cluster-randomized controlled evaluation was conducted at an academic medical center to assess adherence with institutional policy on insulin pen storage before and after implementation of a revised policy allowing pen storage in locking boxes in patient rooms. In phase 1 of the study, baseline data on policy adherence were captured for 8 patient care units (4 designated as intervention units and 4 designated as control units). In phase 2, policy adherence was assessed through direct observation during weekly audits after lock boxes were installed on intervention units and education on proper insulin pen storage was provided to nurses in all 8 units. RESULTS: Phase 1 rates of adherence to insulin pen storage policy were 59% in the intervention units and 49% in the control units (p = 0.56). During phase 2, there was no significant change from baseline in control unit adherence (67%, p = 0.26), but adherence in intervention units improved significantly, to 89% (p = 0.005). Common types of observed nonadherence included pens being unsecured in patient rooms or nurses' pockets or left in patient-specific medication drawers after patient discharge. CONCLUSION: An institutional policy change permitting secure storage of insulin pens close to the point of care, paired with nurse education, increased adherence more than education alone.

Expansion of inpatient clinical pharmacy services through reallocation of pharmacists.

PURPOSE: The redesign of an inpatient pharmacy practice model through reallocation of pharmacy resources in order to expand clinical services is described. METHODS: A pharmacy practice model change was implemented at a nonprofit academic medical center to meet the increasing demand for direct patient care services. In order to accomplish this change, the following steps were completed: reevaluation of daily tasks and responsibilities, reallocation of remaining tasks to the most appropriate pharmacy staff member, determination of the ideal number of positions needed to complete each task, and reorganization of the model into a collection of teams. Data were collected in both the preimplementation and postimplementation periods to assess the impact of the model change on operational workflow and clinical service expansion. RESULTS: The mean ± S.D. times to order verification were 17 ± 52 minutes during the preimplementation period and 21 ± 70 minutes in the postimplementation period (p < 0.001). During the 3 months before and after implementation of the model change, the mean number of medication reconciliations performed increased from 114 to 144. After implementation of the model change, total interventions increased 194%. Notably, there was a 736% increase in the number of interventions focused on facilitating safe discharge. CONCLUSION: A pharmacy practice model change was successfully implemented by reallocating existing pharmacist and technician roles and increasing incorporation of pharmacy residents and students. This change led to an expansion of direct patient care coordination services without negatively affecting the operational responsibilities of the pharmacy or the need to hire additional staff.

Implementation of an emergency department-based clinical pharmacist transitions-of-care program.

PURPOSE: The implementation of an emergency department (ED)-based clinical pharmacist transitions-of-care (TOC) program is described. SUMMARY: The intervention program consisted of collaboration between ED and ambulatory care pharmacists to provide patient-specific comprehensive medication review and education in the ED setting and to help ensure a coordinated transition to the ambulatory care setting by scheduling an ambulatory pharmacy clinic or home-based visit. Patients who sought care at an adult ED for an exacerbation of asthma, chronic obstructive pulmonary disease (COPD), or congestive heart failure (CHF) were assessed for issues with medication adherence or administration technique, patient-specific concerns regarding medication use, access to medications at discharge, the need for modification of chronic therapy, contraindicated medications, and vaccination status, if applicable. The pharmacist then referred the patient to follow up in an ambulatory care pharmacy clinic or with the home-based medication management (HBMM) program. Of the 18 program participants who were referred to follow-up care, 5 successfully followed up with a pharmacist after ED discharge. The mean time from the ED visit to follow-up for these 5 patients was 16.6 ± 8.6 days. In addition, 5 patients followed up with their primary care provider within 30 days of the initial ED visit; 2 of these patients also followed up with a pharmacist. Within 30 days of the initial ED encounter, 4 patients had ED revisits. CONCLUSION: A TOC pharmacist-led program targeting patients who arrived at the ED with the chief complaint of asthma exacerbation, COPD, or CHF provided interventions from an ED or ambulatory care pharmacist as well as follow-up opportunities at outpatient clinics or an HBMM program.

Prescriber knowledge and attitudes regarding non-administration of prescribed pharmacologic venous thromboembolism prophylaxis.

Pharmacologic venous thromboembolism (VTE) prophylaxis is important patient safety practice in hospitalized patients. However, a substantial number of ordered doses are not administered. Patient and nursing attitudes and behaviors can influence whether a patient receives a dose. The objective of this single center study was to evaluate prescriber knowledge and attitudes regarding missed doses of pharmacologic VTE prophylaxis. An anonymous, 9-question survey was administered to internal medicine and general surgery resident physicians. The survey captured prescriber opinions on issues related to non-administration of VTE prophylaxis. Thirty-two percent of medicine residents compared with 3 % of surgery residents felt pharmacologic VTE prophylaxis was not necessary in an independently ambulating patient (P < 0.001). Medicine residents were more likely to agree that it is appropriate for nurses to make clinical decisions to determine whether a dose of pharmacologic VTE prophylaxis should be administered to a patient (24 vs. 0 %, P < 0.001). Study findings indicate the need for additional resident physician education. Further investigation is needed to assess these beliefs and ensure patients receive necessary VTE prophylaxis.

Evaluation of a Nurse-Managed Insulin Infusion Protocol.

BACKGROUND: The purpose of this study was to evaluate the performance of an insulin infusion protocol targeting a blood glucose (BG) level of 140-180 mg/dL and to characterize protocol adherence. MATERIALS AND METHODS: This was a retrospective observational cohort study including patients for whom the protocol was ordered from January 2012 to May 2013. Performance metrics were assessed in all patients and in patients with an initial BG level of ≥200 mg/dL. Protocol adherence was assessed in a random subset of 50 patients without hypoglycemia and in all hypoglycemic patients. RESULTS: In patients with an initial BG level of ≥200 mg/dL, the mean time to goal was 7.1 h. The rate of decline of BG level in the first 6 h was 16.4 mg/dL/h. Mean BG level was 167 mg/dL, with 43.9% of BG values within goal and 80.3% between 80 and 199 mg/dL. The rate of hypoglycemic events was 0.14 per 100 h. The mean protocol violation rate was higher in patients with hypoglycemia compared with those without (39.8 vs. 23.5 per 100 h, P = 0.002), and 60.7% of hypoglycemic events were attributable to protocol violations. The protocol violation rate (42.8 vs. 17.6 per 100 h; P < 0.001) and the odds of hypoglycemia (odds ratio = 5.2; 95% confidence interval, 1.6, 16.5) were higher in the cardiac surgery patients compared with other patients. CONCLUSIONS: This protocol provides adequate BG control within the clinically acceptable range of 80-199 mg/dL but not within the narrower range of 140-180 mg/dL, with a low incidence of hypoglycemia. Risk factors for hypoglycemia and barriers to protocol adherence in the cardiac surgery population should be elucidated.

Hidden Barriers to Delivery of Pharmacological Venous Thromboembolism Prophylaxis: The Role of Nursing Beliefs and Practices.

BACKGROUND: Standardized electronic order sets for venous thromboembolism prophylaxis have increased the proportion of patients receiving venous thromboembolism prophylaxis. However, ordering venous thromboembolism prophylaxis does not ensure consistent administration. OBJECTIVE: To explore causes of variability in the rate of administration of ordered doses of pharmacological venous thromboembolism prophylaxis among hospital units. DESIGN: Mixed methods study, including qualitative observation and quantitative nursing survey administration. SUBJECTS: Nurses included in observations were practicing on an inpatient unit, caring for patients with orders to receive venous thromboembolism prophylaxis consisting of low-dose unfractionated heparin or low-molecular weight heparin. Nurses on 12 inpatient units with disparate rates of administration were included in the survey. MEASURES: Qualitative observation data were collected until thematic saturation was achieved. Survey was conducted to identify beliefs and practices surrounding nursing administration of venous thromboembolism prophylaxis. RESULTS: During observations, some nurses presented pharmacological venous thromboembolism prophylaxis to their patients as an optional therapy. Nurses on low-performing units are more likely to believe that pharmacological venous thromboembolism prophylaxis is ordered for patients who do not require it. More often, they also acknowledge that nurses use their clinical decision-making skills to determine when to omit unnecessary doses of prescribed venous thromboembolism prophylaxis. CONCLUSIONS: Nurses on units with low administration rates often believe they have the skills to determine which patients require pharmacological venous thromboembolism prophylaxis. They are also more likely to believe that ordered doses are discretionary and offer the medication as optional to patients.

Implementation of transitions-of-care services through acute care and outpatient pharmacy collaboration.

PURPOSE: The implementation of a practice model designed to reduce hospital readmissions through optimal deployment of pharmacy staff on multidisciplinary care collaboration teams is described. SUMMARY: In response to Affordable Care Act provisions aimed at reducing preventable hospital readmissions, the pharmacy department at The Johns Hopkins Hospital (JHH) led the implementation of a new pharmacy services model spanning both inpatient and outpatient settings. Key components of the model include (1) increased pharmacist participation in multidisciplinary rounds, (2) targeted medication reconciliation and patient education, (3) postdischarge phone monitoring of selected patients, and (4) bedside discharge medication delivery performed by a "transitions pharmacist extender." Incorporation of care coordination activities into the daily workflow has increased the rate of patient education on high-risk medications and allowed for affordable and effective medication regimens to be designed and prescriptions to be filled prior to patient discharge. The ultimate goal is enhanced multidisciplinary collaboration to decrease hospital readmissions by increasing medication adherence and patients' understanding of medications. CONCLUSION: The inpatient and outpatient pharmacy teams at JHH collaborated to improve their understanding of patients' medication use prior to admission through targeted medication reconciliation, education of patients on high-risk medications initiated during admission, and development of affordable and practical medication regimens that patients would receive in hand on discharge. A pharmacy team model was developed to ensure that these services are adequately provided and enhance patient understanding of the importance of medications for acute and chronic disease state management.

Development and implementation of a postdischarge home-based medication management service.

PURPOSE: The development and implementation of a postdischarge home-based, pharmacist-provided medication management service are described. SUMMARY: A work group composed of pharmacy administrators, clinical specialists, physicians, and nursing leadership developed the structure and training requirements to implement the service. Eligible patients were identified during their hospital admission by acute care pharmacists and consented for study participation. Pharmacists and pharmacy residents visited the patient at home after discharge and conducted medication reconciliation, provided patient education, and completed a comprehensive medication review. Recommendations for medication optimization were communicated to the patient's primary care provider, and a reconciled medication list was faxed to the patient's community pharmacy. Demographic and medication-related data were collected to characterize patients receiving the home-based service. A total of 50 patients were seen by pharmacists in the home. Patient education provided by the home-based pharmacists included monitoring instructions, adherence reinforcement, therapeutic lifestyle changes, administration instructions, and medication disposal instructions. Pharmacists provided the following recommendations to providers to optimize medication regimens: adjust dosage, suggest laboratory tests, add medication, discontinue medication, need prescription for refills, and change product formulation. Pharmacists identified a median of two medication discrepancies per patient and made a median of two recommendations for medication optimization to patients' primary care providers. CONCLUSION: The implementation of a post-discharge, pharmacist-provided home-based medication management service enhanced the continuity of patient care during the transition from hospital to home. Pharmacists identified and resolved medication discrepancies, educated patients about their medications, and provided primary care providers and community pharmacies with a complete and reconciled medication list.

Impact of a pharmacy-based glucose management program on glycemic control in an inpatient general medicine population.

OBJECTIVE: A pharmacy-based glucose management program was evaluated to determine whether improved glycemic control could be achieved in an inpatient general medicine patient population. METHODS: A retrospective chart review of 151 patients with blood glucose (BG) values outside the range of 70 to 180 mg/dL within a 24-hour period was conducted. Observations for the baseline group with no pharmacy program in place were collected from admissions during July 2010 and for the intervention group in October 2010. The primary goal of the study was to determine if the pharmacy program improved patient days within the BG range of 70 to 250 mg/dL. The odds of poor glycemic control for patients in the intervention versus baseline groups were assessed by multivariate generalized estimating equations. These methods were also used to assess patient characteristics associated with poor glycemic control. RESULTS: No evidence was observed that the pharmacy program decreased the number of days spent out of the targeted blood glucose range (70-250 mg/dL; odds ratio, 1.08; 95% CI, 0.88-1.24). However, the subgroup of patients whose admission BG was < 200 mg/dL (49% of the intervention group) experienced a significant reduction in days spent out of the BG range (70-250 mg/dL; odds ratio, 0.42; 95% CI, 0.22-0.82). No improvement in glycemic control was observed in patients with an admission BG ≥ 200 mg/dL; these patients had more disease- and social-related factors associated with poor glycemic control. CONCLUSION: The primary finding of this analysis was that there was no global benefit of the pharmacy-based glucose management program for improving BG values compared with usual care. Patients whose admission glucose was < 200 mg/dL experienced improvement in glycemic control in the pharmacy-based program. Maintaining the BG level of the remaining patients was generally more complicated from a disease-state and social perspective and patients experienced no improvement. These patients may require a more intense, multidisciplinary approach that is better matched to the constellation of factors responsible for their condition.

Patterns of non-administration of ordered doses of venous thromboembolism prophylaxis: implications for novel intervention strategies.

BACKGROUND: Recent studies have documented high rates of non-administration of ordered venous thromboembolism (VTE) prophylaxis doses. Intervention strategies that target all patients have been effective, but prohibitively resource-intensive. We aimed to identify efficient intervention strategies based on patterns of non-administration of ordered VTE prophylaxis. METHODS AND FINDINGS: In this retrospective review of electronic medication administration records, we included adult hospitalized patients who were ordered pharmacologic VTE prophylaxis with unfractionated heparin or enoxaparin over a seven-month period. The primary measure was the proportion of ordered doses of VTE prophylaxis not administered, assessed at the patient, floor, and floor type levels. Differences in non-administration rates between groups were assessed using generalized estimating equations. A total of 103,160 ordered VTE prophylaxis doses during 10,516 patient visits on twenty-nine patient floors were analyzed. Overall, 11.9% of ordered doses were not administered. Approximately 19% of patients missed at least one quarter and 8% of patients missed over one half of ordered doses. There was marked heterogeneity in non-administration rate at the floor level (range: 5-27%). Patients on medicine floors missed a significantly larger proportion (18%) of ordered doses compared to patients on other floor types (8%, Odds Ratio: 2.4, p<0.0001). However, more than half of patients received at least 86% of their ordered doses, even on the lowest performing floor. The 20% of patients who missed at least two ordered doses accounted for 80% of all missed doses. CONCLUSIONS: A substantial proportion of ordered doses of VTE prophylaxis were not administered. The heterogeneity in non-administration rate between patients, floors, and floor types can be used to target interventions. The small proportion of patients that missed multiple ordered doses accounted for a large majority of non-administered doses. This recognition of the Pareto principle provides opportunity to efficiently target a relatively small group of patients for intervention.

Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice.

BACKGROUND: Strategies for successful implementation of hospitalwide glucose control efforts were addressed in a conceptual model for the development and implementation of an institutional inpatient glucose management program. CONCEPTUAL MODEL COMPONENTS: The Glucose Steering Committee incrementally developed and implemented hospitalwide glucose policies, coupled with targeted education and clinical decision support to facilitate policy acceptance and uptake by staffwhile incorporating process and outcome measures to objectively assess the effectiveness of quality improvement efforts. The model includes four components: (1) engaging staff and hospital executives in the importance of inpatient glycemic management, (2) educating staff involved in the care of patients with diabetes through structured knowledge dissemination, (3) executing evidence-based inpatient glucose management through development of policies and clinical decision aids, and (4) evaluating intervention effectiveness through assessing process measures, intermediary glucometric outcomes, and clinical and economic outcomes. An educational curriculum for nursing, provider, and pharmacist diabetes education programs and current glucometrics were also developed. OUTCOMES: Overall the average patient-day-weighted mean blood glucose (PDWMBG) was below the currently recommended maximum of 180 mg/dL in patients with diabetes and hyperglycemia, with a significant decrease in PDWMBG of 7.8 mg/dL in patients with hyperglycemia. The program resulted in an 18.8% reduction in hypoglycemia event rates, which was sustained. CONCLUSION: Inpatient glucose management remains an important area for patient safety, quality improvement, and clinical research, and the implementation model should guide other hospitals in their glucose management initiatives.

Impact of an antimicrobial stewardship intervention on shortening the duration of therapy for community-acquired pneumonia.

BACKGROUND: Initial management of community-acquired pneumonia (CAP) has been a Centers for Medicare and Medicaid Services performance measure for a decade. We hypothesized that an intervention directed at management of CAP that assesses areas not covered by the performance measures-treatment duration and antimicrobial selection after additional microbiology data are available--would further improve CAP management. METHODS: We performed a single-center, prospective study to compare management of adult inpatients with presumed CAP before (from 1 January 2008 through 31 March 2008) and after (from 1 February 2010 through 10 May 2010) an intervention consisting of education and prospective feedback to teams regarding antibiotic choice and duration. The primary outcome measure was duration of antibiotic therapy in the 2 periods. RESULTS: There were 62 patients in the preintervention period and 65 patients in the intervention period. The duration of antibiotic therapy decreased from a median of 10 to 7 days (P < .001), with 148 fewer days of antibiotic therapy. The median lengths of stay were similar in the 2 groups (4 vs 5 days). A causative pathogen was identified less frequently during the intervention period (14% vs 34%); however, antibiotics were more frequently narrowed or modified on the basis of susceptibility results during the intervention period (67% vs 19%). Fewer patients received duplicate therapy within 24 hours in the intervention period (90% vs 55%). CONCLUSIONS: The duration of therapy for CAP was excessive at our institution and was decreased with a stewardship intervention. Confirmatory studies at other institutions are needed; efforts to assess and reduce duration of therapy for CAP should be strongly considered.

Nurse-pharmacist collaboration on medication reconciliation prevents potential harm.

BACKGROUND: Medication reconciliation can prevent some adverse drug events (ADEs). Our prospective study explored whether an easily replicable nurse-pharmacist led medication reconciliation process could efficiently and inexpensively prevent potential ADEs. METHODS: Nurses at a 1000 bed urban, tertiary care hospital developed the home medication list (HML) through patient interview. If a patient was not able to provide a written HML or recall medications, the nurses reviewed the electronic record along with other sources. The nurses then compared the HML to the patient's active inpatient medications and judged whether the discrepancies were intentional or potentially unintentional. This was repeated at discharge as well. If the prescriber changed the order when contacted about a potential unintentional discrepancy, it was categorized as unintentional and rated on a 1-3 potential harm scale. RESULTS: The study included 563 patients. HML information gathering averaged 29 minutes. Two hundred twenty-five patients (40%; 95% confidence interval [CI], 36%-44%) had at least 1 unintended discrepancy on admission or discharge. One hundred sixty-two of the 225 patients had an unintended discrepancy ranked 2 or 3 on the harm scale. It cost $113.64 to find 1 potentially harmful discrepancy. Based on the 2008 cost of an ADE, preventing 1 discrepancy in every 290 patient encounters would offset the intervention costs. We potentially averted 81 ADEs for every 290 patients. CONCLUSION: Potentially harmful medication discrepancies occurred frequently at both admission and discharge. A nurse-pharmacist collaboration allowed many discrepancies to be reconciled before causing harm. The collaboration was efficient and cost-effective, and the process potentially improves patient safety.

Fondaparinux for thromboembolic treatment and prophylaxis of heparin-induced thrombocytopenia.

OBJECTIVE: To review literature evaluating the use of fondaparinux for thromboembolic treatment and prophylaxis in patients with heparin-induced thrombocytopenia (HIT). DATA SOURCES: A MEDLINE search (1966-February 2006) was conducted using the search terms fondaparinux, heparin, low-molecular-weight heparin, and thrombocytopenia to identify English-language articles. Additional sources were identified from bibliographies of select articles and the manufacturer. DATA SYNTHESIS: Fondaparinux, a pentasaccharide that selectively inhibits factor Xa, has been reported to have negligible or no cross-reactivity in vitro with HIT antibodies. Thromboembolic treatment and prophylaxis with fondaparinux in patients with HIT has been described. Three cases reported patients who were successfully treated for thromboembolic events with fondaparinux after developing HIT during therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). Another report showed positive outcomes using fondaparinux for prophylaxis in a patient who had previously developed HIT after receiving UFH. Moreover, 2 case series, one using fondaparinux for prophylaxis in patients with a previous diagnosis of HIT and the other using fondaparinux for treatment in patients who developed HIT while receiving UFH or LMWH, reported normal platelet counts during fondaparinux treatment. Finally, results of a retrospective review demonstrated that fondaparinux prevented thromboembolic events or recurrent thrombocytopenia in patients with a prior HIT diagnosis. CONCLUSIONS: Limited data support the use of fondaparinux for thromboembolic treatment or prophylaxis in patients with antibody assay-confirmed HIT who do not have a contraindication for fondaparinux use. Randomized controlled trials have not been published; therefore, questions remain regarding efficacy, safety, optimal doses, treatment duration, and incidence of thromboembolic events when fondaparinux is used in this setting. Prospective trials evaluating the efficacy and safety of fondaparinux in this patient population need to be conducted to answer these questions.