Closed-Loop Medication Management with an Electronic Health Record System in U.S. and Finnish Hospitals.

Many medication errors in the hospital setting are due to manual, error-prone processes in the medication management system. Closed-loop Electronic Medication Management Systems (EMMSs) use technology to prevent medication errors by replacing manual steps with automated, electronic ones. As Finnish Helsinki University Hospital (HUS) establishes its first closed-loop EMMS with the new Epic-based Electronic Health Record system (APOTTI), it is helpful to consider the history of a more mature system: that of the United States. The U.S. approach evolved over time under unique policy, economic, and legal circumstances. Closed-loop EMMSs have arrived in many U.S. hospital locations, with myriad market-by-market manifestations typical of the U.S. healthcare system. This review describes and compares U.S. and Finnish hospitals' EMMS approaches and their impact on medication workflows and safety. Specifically, commonalities and nuanced differences in closed-loop EMMSs are explored from the perspectives of the care/nursing unit and hospital pharmacy operations perspectives. As the technologies are now fully implemented and destined for evolution in both countries, perhaps closed-loop EMMSs can be a topic of continued collaboration between the two countries. This review can also be used for benchmarking in other countries developing closed-loop EMMSs.

Developing an In-House Comprehensive Medication Review Training Program for Clinical Pharmacists in a Finnish Hospital Pharmacy.

Long-term continuing education programs have been a key factor in shifting toward more patient-centered clinical pharmacy services. This narrative review aims to describe the development of Helsinki University Hospital (HUS) Pharmacy's in-house Comprehensive Medication Review Training Program (CMRTP) and how it has impacted clinical pharmacy services in HUS. The CMRTP was developed during the years 2017-2020. The program focuses on developing the special skills and competencies needed in comprehensive medication reviews (CMRs), including interprofessional collaboration and pharmacotherapeutic knowledge. The program consists of two modules: (I) Pharmacist-Led Medication Reconciliation, and (II) CMR. The CMRTP includes teaching sessions, self-learning assignments, medication reconciliations, medication review cases, CMRs, a written final report, and a self-assessment of competence development. The one-year-long program is coordinated by a clinical teacher. The program is continuously developed based on the latest guidelines in evidence-based medicine and international benchmarking in cooperation with the University of Helsinki. With the CMRTP, we have adopted a more patient-centered role for our clinical pharmacists and remarkably expanded the services. This program may be benchmarked in other countries where the local education system does not cover clinical pharmacy competence well enough and in hospitals where the clinical pharmacy services are not yet very patient-oriented.

Implementing a New Electronic Health Record System in a University Hospital: The Effect on Reported Medication Errors.

Closed-loop electronic medication management systems (EMMS) have been seen as a potential technology to prevent medication errors (MEs), although the research on them is still limited. The aim of this paper was to describe the changes in reported MEs in Helsinki University Hospital (HUS) during and after implementing an EPIC-based electronic health record system (APOTTI), with the first features of a closed-loop EMMS. MEs reported from January 2018 to May 2021 were analysed to identify changes in ME trends with quantitative analysis. Severe MEs were also analysed via qualitative content analysis. A total of 30% (n = 23,492/79,272) of all reported patient safety incidents were MEs. Implementation phases momentarily increased the ME reporting, which soon decreased back to the earlier level. Administration and dispensing errors decreased, but medication reconciliation, ordering, and prescribing errors increased. The ranking of the TOP 10 medications related to MEs remained relatively stable. There were 92 severe MEs related to APOTTI (43% of all severe MEs). The majority of these (55%, n = 53) were related to use and user skills, 24% (n = 23) were technical failures and flaws, and 21% (n = 21) were related to both. Using EMMS required major changes in the medication process and new technical systems and technology. Our medication-use process is approaching a closed-loop system, which seems to provide safer dispensing and administration of medications. However, medication reconciliation, ordering, and prescribing still need to be improved.

Dose error reduction software in medication safety risk management - optimising the smart infusion pump dosing limits in neonatal intensive care unit prior to implementation.

BACKGROUND: Smart infusion pumps with dose error reduction software can be used to prevent harmful medication errors. The aim of this study was to develop a method for defining and assessing optimal dosing limits in a neonatal intensive care unit's smart infusion pump drug library by using simulation-type test cases developed based on medication error reports. METHODS: This mixed-methods study applied both qualitative and quantitative methods. First, wrong infusion rate-related medication errors reported in the neonatal intensive care unit during 2018-2019 were explored by quantitative descriptive analysis and qualitative content analysis to identify the error mechanisms. The researchers developed simulation-type test cases with potential errors, and a literature-based calculation formula was used to set upper soft limits to the drug library. The limits were evaluated by conducting programming of pumps without errors and with potential errors for two imaginary test patients (1 kg and 3.5 kg). RESULTS: Of all medication errors reported in the neonatal intensive care unit, 3.5% (n = 21/601) involved an error or near-miss related to wrong infusion rate. Based on the identified error mechanisms, 2-, 5-, and 10-fold infusion rates, as well as mix-ups between infusion rates of different drugs, were established as test cases. When conducting the pump programming for the test cases (n = 226), no alerts were triggered with infusion rates responding to the usual dosages (n = 32). 73% (n = 70/96) of the erroneous 2-, 5-, and 10-fold infusion rates caused an alert. Mix-ups between infusion rates triggered an alert only in 24% (n = 24/98) of the test cases. CONCLUSIONS: Simulation-type test cases can be applied to assess the appropriateness of dosing limits within the neonatal intensive care unit's drug library. In developing the test cases, combining hospital's medication error data to other prospective data collection methods is recommended to gain a comprehensive understanding on mechanisms of wrong infusion rate errors. After drug library implementation, the alert log data and drug library compliance should be studied to verify suitability of dosing limits.

Compounding Parenteral Products in Pediatric Wards-Effect of Environment and Aseptic Technique on Product Sterility.

Parenteral products must be compounded using an aseptic technique to ensure sterility of the medicine. We compared the effect of three clinical environments as compounding areas as well as different aseptic techniques on the sterility of the compounded parenteral product. Clinical pharmacists and pediatric nurses compounded 220 samples in total in three clinical environments: a patient room, a medicine room and biological safety cabinet. The study combined four methods: observation, environmental monitoring (settle plates), monitoring of personnel (finger dab plates) and sterility testing (membrane filtration). Of the compounded samples, 99% were sterile and no significant differences emerged between the clinical environments. Based on the settle plates, the biological safety cabinet was the only area that fulfilled the requirements for eliminating microbial contamination. Most of the steps on the observation form for aseptic techniques were followed. All participants disinfected their hands, wore gloves and disinfected the septum of the vial. Non-contaminated finger dab plates were mostly detected after compounding in the biological safety cabinet. Aseptic techniques were followed relatively well in all environments. However, these results emphasize the importance of good aseptic techniques and support the recommendation of compounding parenteral products in biological safety cabinets in clinical environments.

How to Identify Organizational High-Alert Medications.

OBJECTIVES: High-alert medications may cause significant patient harm when used in error. Hospital-specific safety data should be used to customize high-alert medication lists to fit the local context. The aim of this study was to identify organizational high-alert medications by evaluating university hospital's data on adverse drug reaction (ADR) and medication error (ME). METHODS: The Anatomical Therapeutic Chemical (ATC) codes and top active substances in ADR (n = 401) and ME (n = 11,668) reports of Helsinki University Hospital from 2015-2016 were analyzed and compared with hospitals' drug consumption and the Institute for Safe Medication Practices' (ISMP) list of high-alert medications. RESULTS: The top ATC groups and active substances in ADR and ME reports were not similar. The most numerous ATC groups were L, antineoplastic and immunomodulating agents (30%) in ADRs and N, nervous system (26%) in MEs. According to ADR and ME reports, several high-alert medications from Institute for Safe Medication Practices' lists, such as antineoplastic agents, antithrombotics, opioids, and insulins, should be considered high-alert medications also in Helsinki University Hospital. Although no ADR reports of amphotericin B existed, it had the highest number of MEs causing severe/moderate harm or unexpected reactions relative to its consumption. CONCLUSIONS: To identify organizational high-alert medications, both drug safety information and medication safety information should be used. Adverse drug reaction and ME data are needed to recognize high-alert medications, but these should also be combined with a literature search and local expert opinions.

Strategies for improving medication safety in hospitals: Evolution of clinical pharmacy services.

BACKGROUND: Medication safety risks are the most important preventable factors jeopardizing patient safety. To manage these risks, extending pharmacists' involvement in patient care and patient safety work has been systematically addressed in patient safety initiatives since the early 2000s. OBJECTIVE: To explore the extent and range of clinical pharmacy services in Finnish hospitals to promote medication safety: 1) in 2011, when the first National Patient Safety Strategy, the new Health Care Act and the Medicines Policy 2020 had been recently enacted; and 2) five years later in 2016. METHODS: The study was conducted in 2011 and 2016 as a national online survey targeted to hospital pharmacies (n = 24) and medical dispensaries (n = 131 in 2011; n = 28 in 2016). The questions were analyzed using descriptive statistics and qualitative content analysis. RESULTS: Overall response rate was 60% in 2011 and 52% in 2016. Clinical pharmacy services were provided by 51% of the responding units in 2011, whereas by 85% in 2016. The reported number of clinical pharmacists had increased during the five years. The most notable increase in reported tasks occurred in conducting medication reconciliations (+63% increase in the number of providing units). By 2016 pharmacists had extended their tasks particularly towards system-based medication safety work: e.g. developing instructions for medication-use (91% of the responding units), creating and updating medication safety plans (87%) and using medication error reports in developing the process of medication use safer (78%). Pharmacists' participation in long-term continuing education became more common in 2016, which was perceived as helpful in extending their responsibilities to improve medication safety. CONCLUSION: Pharmacists' involvement in patient care and system-based medication safety work was reported to become more common in Finnish hospitals during 2011-2016. This development is in line with patient safety policy initiatives and its impact on patient care outcomes should be followed up.

Medication reconciliation and review for older emergency patients requires improvement in Finland.

BACKGROUND: 10-30% of hospital stays by older patients are drug-related. The admission phase is important for identifying drug-related problems, but taking an incorrect medication history often leads to medication errors. OBJECTIVES: To enhance medication history recording and identify drug-related problems (DRPs) of older patients admitted to emergency departments (EDs). METHODS: DRPs were identified by pharmacists-led medication reconciliation and review procedures in two EDs in Finland; Helsinki University Hospital (HUS), and Kuopio University Hospital (KUH). One-hundred-and-fifty patients aged ≥65-years, living at home and using ≥6 medicines were studied. RESULTS: 100% of patients (N = 75) in HUS and 99% in KUH (N = 75), had discrepancies in their admission-medication chart recorded by the nurse or physician. Associations between admission-diagnosis and drug-related problems were found in 12 patients (16%) in HUS and 22 patients (29%) in KUH. Of these, high-alert medications (e.g. antithrombotics, cytostatics, opioids) were linked to eight patients (11%) in HUS and six patients (8%) in KUH. Other acute DRPs were identified in 19 patients (25%) in HUS and 54 patients (72%) in KUH. Furthermore, 67 patients (89%) in HUS and all patients in KUH had non-acute DRPs. CONCLUSIONS: Medication reconciliation and review at admission of older ED patients requires improvement in Finland.