Collaborative Medication Reviews to Identify Inappropriate Prescribing in Pre-Admission Medications at Emergency Department Short-Term Ward.

PURPOSE: Collaborative medication reviews (CMR) have been shown to reduce inappropriate prescribing (IP) in various settings. This study aimed at describing a CMR practice in an emergency department (ED) short-term ward in Finland to investigate IP in pre-admission medications. PATIENTS AND METHODS: Pre-admission medications were collaboratively reviewed for all the adult ED admissions within a 5-month study period in 2016. Types of IP were inductively categorized, and descriptive statistics were used to show the incidence and type of IP events. RESULTS: The pre-admission medications of 855 adult ED patients were reviewed by the pharmacist, with 113 IP events identified in 83 (9.7%) of the patients. The majority (81%, n=67) of these patients were older adults (≥65 years). Of these 94 IP events identified in 67 older patients, 58 (62%) were confirmed by the ED physicians. The following 3 main categories were inductively developed for the types of identified and confirmed IP events: 1) Misprescribing (prescription of medications that significantly increase the risk of adverse drug events); 2) Overprescribing (prescription of medications for which no clear clinical indications exist); and 3) Underprescribing (omission of potentially beneficial medications that are clinically indicated for treatment or prevention of a disease). Misprescribing was the most common type of IP identified (79% of the identified and 72% confirmed IP events). Benzodiazepines (29%) and antidepressants (28%) were involved in 33 out of 58 (57%) confirmed IP events. Medications with strong anticholinergic effects were involved in 19% of the confirmed IP events. CONCLUSION: The CMR practice was able to identify IP in pre-admission medications of about one-tenth of ED patients. Older patients using benzodiazepines and drugs with strong anticholinergic effects should be paid special attention to ED admissions.

Are Older People Aware of Potential Risks Related to Benzodiazepines They are Taking and Has Anything Changed in Risk Awareness Over Ten Years?

PURPOSE: The use of benzodiazepines and related drugs (BZD) is common among older adults although there is growing evidence of their harmful effects. This study investigated how well older people are aware of the potential risks related to the BZD they are taking and whether the risk awareness has changed in the years between 2004 and 2015. PATIENTS AND METHODS: The data were collected by interviewing BZD using home-dwelling patients aged ≥65 years with normal cognitive function (MMSE ≥20) who were admitted to the hospital within a 1 month study period in the years 2004 and 2015. Patients were asked whether they were aware of the ten main potential risks related to BZD use. A risk awareness score (range 0-10) was assessed for each patient, each known potential risk yielding one point. RESULTS: The study included 37 patients in 2004 and 31 patients in 2015. In 2004, 6/37 patients (16%), while 16/31 patients (52%) in 2015 had risk awareness scores between 6 and 10. Awareness of dependence (p=0.047), interaction with alcohol (p=0.001), dizziness (p=0.002) and developing tolerance (p=0.002) had improved, while awareness of the other potential risks remained unchanged, muscle weakness being the least known (3/37 in 2004 and 4/31 in 2015 were aware of it as a potential risk). Regular BZD use had declined (p=0.043) but pro re nata (PRN; when required) BZD use had increased (p=0.003) between the years 2004 and 2015. CONCLUSION: Older BZD users' awareness of some potential risks related to BZD use (dependence, interaction with alcohol, dizziness and developing tolerance) had improved between 2004 and 2015, while awareness of other potential risks remained unchanged.

Auditing Safety of Compounding and Reconstituting of Intravenous Medicines on Hospital Wards in Finland.

On the hospital wards in Finland, nurses generally reconstitute intravenous medicines, such as antibiotics, analgesics, and antiemetics prescribed by doctors. Medicine reconstitution is prone to many errors. Therefore, it is important to identify incorrect practices in the reconstitution of medicine to improve patient safety in hospitals. The aim of this study was to audit the compounding and reconstituting of intravenous medicines on hospital wards in a secondary-care hospital in Finland by using an assessment tool and microbiological testing for identifying issues posing patient safety risks. A hospital pharmacist conducted an external audit by using a validated 65-item assessment tool for safe-medicine compounding practices on 20 wards of the selected hospital. Also, three different microbiological samples were collected to assure the aseptics. Practices were evaluated using a four-point rating scale of "never performed," "rarely performed," "often performed," and "always performed," and were based on observation and interviews with nurses or ward pharmacists. In addition, glove-, settle plate-, and media fill-tests were collected. Associations between microbial sample results and audit-tool results were discussed. Altogether, only six out of the 65 items were fully implemented in all wards; these were related to logistic practices and quality assurance. More than half of the wards used incorrect practices ("rarely performed" or "never performed") for five items. Most of these obviated practices related to aseptic practices. All media-fill tests were clean but the number of colony forming units in glove samples and settle- plate samples varied from 0 to >100. More contamination was found in wards where environmental conditions were inadequate or the use of gloves was incorrect. Compounding practices were [mostly] quite well adapted, but the aseptic practices needed improvement. Attention should have been directed particularly to good aseptic techniques and compounding environment on the wards. These results can be used for updating the guidelines and for training nurses involved in compounding.

Incorrect aseptic techniques in medicine preparation and recommendations for safer practices: a systematic review.

OBJECTIVE: Many patient deaths have been reported because of administration of contaminated intravenous medicines due to incorrect aseptic techniques. Our aim was to review the literature for (1) incorrect practices in aseptic drug preparation and administration and (2) recommendations for safer practices in hospitals. METHODS: A systematic literature search was conducted in PubMed covering 2007-2015. Studies were included if they concerned aseptic medicine preparation and administration in hospitals by different healthcare professionals, assessed incorrect practices and made recommendations for safer aseptic preparation and administration. RESULTS: 26 studies were included of which 19 were original articles. 12 of the studies concerned description of incorrect practices that led to contamination. The studies reported 11 incorrect practices that increased the risk of contamination of parenteral medicines. The most reported incorrect practices were multiple use of phials and syringes (2/12 studies) and lack of overall disinfection during the aseptic preparation and administration (3/12 studies). 22 practices were recommended to avoid contamination, which were classified into six categories: equipment and medicines (7); disinfection (6); working environment (3); storing (3); catheter care (2) and quality of prepared medicines (1). The results indicate that pharmacists prepared syringes with less contamination than nurses because of the pharmacist's aseptic skills and environmental aspects in pharmacy units. CONCLUSIONS: The review discusses many appropriate and enhanced practices in aseptic drug preparation and administration. As the change for the better in contamination rates of administered medicines seems to be challenging to achieve in hospitals, better and possibly international procedures for safe parenteral practices need to be developed.

Development and content validation of an assessment tool for medicine compounding on hospital wards.

Background Medicines should be compounded by using an aseptic technique to assure patient safety. The parenteral administration of microbiologically contaminated doses can result in bacteriaemia, other morbidity and even death. Objective The purpose was to develop and content validate an assessment tool for medicine compounding on hospital wards suitable for self-assessment and external audit to ensure the safety of medicine compounding on wards. Setting Finland as setting. Method The first draft of the tool was based on ISMP "Guidelines for safe preparation of sterile compounds" and a systematic literature search. The tool was validated by using a two-rounded Delphi-method with a panel of 19 experts. Suitability and feasibility of each item was evaluated. Main outcome measure An agreement of ≥70% on each item was required. Results The final tool comprises of 64 items under the following topics: (1) general principles of good compounding practices (23 items), (2) recording and confirming medicine orders on the wards (5 items), (3) storage of medicines on the wards (7), (4) aseptic compounding of intravenous medicines (25 items) and (5) quality assurance (4 items). Most items related to General principles of good compounding practices and Compounding of IV medicines (36 and 38% of the items, respectively). Conclusion It was possible to develop and content validate, by the Delphi method, an assessment tool for safe aseptic compounding on hospital wards. A two-round Delphi process yielded consensus on 64 items for this purpose.

Adapting and remodelling the US Institute for Safe Medication Practices' Medication Safety Self-Assessment tool for hospitals to be used to support national medication safety initiatives in Finland.

BACKGROUND: The US Institute for Safe Medication Practices' (ISMP) Medication Safety Self-Assessment (MSSA) tool for hospitals is a comprehensive tool for assessing safe medication practices in hospitals. AIMS: To adapt and remodel the ISMP MSSA tool for hospitals so that it can be used in individual wards in order to support long-term medication safety initiatives in Finland. METHODS: The MSSA tool was first adapted for Finnish hospital settings by a four-round (applicability, desirability and feasibility were evaluated) Delphi consensus method (14 panellists), and then remodelled by organizing the items into a new order which is consistent with the order of the ward-based pharmacotherapy plan recommended by the Ministry of Social Affairs and Health. The adapted and remodelled tool was pilot tested in eight central hospital wards. KEY FINDINGS: The original MSSA tool (231 items under ten key elements) was modified preliminarily before the Delphi rounds and 117 items were discarded, leaving 114 items for Delphi evaluation. The panel suggested 36 new items of which 23 were accepted. A total of 114 items (including 91 original and 23 new items) were accepted and remodelled under six new components that were pilot tested. The pilot test found the tool time-consuming but useful. CONCLUSION: It was possible to adapt the ISMP's MSSA tool for another hospital setting. The modified tool can be used for a hospital pharmacy coordinated audit which supports long-term medication safety initiatives, particularly the establishment of ward-based pharmacotherapy plans as guided by the Ministry of Social Affairs and Health.