A Data-Driven Approach to Evaluate Barcode-Assisted Medication Preparation Alerts at a Large Academic Medical Center.

BACKGROUND: The purpose of this study was to develop a data-driven process to analyze barcode-assisted medication preparation alert data with a goal of minimizing inaccurate alerts. METHODS: Medication preparation data for the prior three-month period was obtained from an electronic health record system. A dashboard was developed to identify recurrent, high-volume alerts and associated medication records. A randomization tool was used to obtain a prespecified proportion of the alerts to review for appropriateness. Alert root causes were identified by chart review. Depending on the alert's cause(s), targeted informatics build changes, workflow and purchasing changes, and/or staff education were implemented. The rate of alerts was measured postintervention for select drugs. RESULTS: The institution averaged 31,000 medication preparation alerts per month. The "barcode not recognized" alert (13,000) was the highest volume over the study period. Eighty-five medication records were identified as contributing to a high volume of alerts (5,200/31,000), representing 49 unique drugs. Of the 85 medication records triggering alerts, 36 required staff education, 22 required informatics build changes, and 8 required workflow changes. Targeted interventions for 2 medications, resulted in reducing the rate of the "barcode not recognized" alert from 26.6% to 1.3% for polyethylene glycol and from 48.7% to 0% for cyproheptadine. CONCLUSION: This quality improvement project highlighted opportunities to improve medication purchasing, storage, and preparation through development of a standard process to evaluate barcode-assisted medication preparation alert data. A data-driven approach can help identify and minimize inaccurate alerts ("noise") and promote medication safety.

Analysis of medication-related triggers to determine adverse drug events.

PURPOSE: Voluntary event reporting systems continue to be the most common method used to identify adverse events in most US hospitals; however, this method fails to capture more than 90% of adverse drug events (ADEs). The purpose of this study is to examine which medication-related triggers have the highest positive predictive values (PPV) for detecting ADEs at a large academic medical centre. METHODS: A 1-year, single-centre, retrospective quality improvement study was conducted to assess the PPV of four medication-related triggers: flumazenil, naloxone, glucose <70 mg/dL or dextrose 50%. Retrospective chart review was conducted on a random sample of eligible patients to establish if an ADE occurred and determine its preventability. Assessed triggers were also compared against the hospital's voluntary event reporting system to determine whether the events were previously reported. RESULTS: A total of 161 triggers were reviewed. PPV values for detection of ADEs were 0.55, 0.58, 0.76 and 0.68 for flumazenil, naloxone, glucose <70 mg/dL and dextrose 50%, respectively. PPV values for detection of preventable ADEs were 0.09, 0.16, 0.32 and 0.34 for flumazenil, naloxone, glucose <70 mg/dL and dextrose 50%, respectively. Of the 107 ADEs identified, three events were reported through the hospital's voluntary event reporting system (2.8%). CONCLUSIONS: Trigger tools successfully detected both preventable and non-preventable ADEs. Events detected using trigger tools are unlikely to be reported through voluntary event reporting systems; therefore, trigger tools can serve as a useful adjunct for adverse event detection.

Use of failure modes and effects analysis to mitigate potential risks prior to implementation of an intravenous compounding technology.

PURPOSE: The purpose of this study was to identify potential failure points in a new chemotherapy preparation technology and to implement changes that prevent or minimize the consequences of those failures before they occur using the failure modes and effects analysis (FMEA) approach. METHODS: An FMEA was conducted by a team of medication safety pharmacists, oncology pharmacists and technicians, leadership from informatics, investigational drug, and medication safety services, and representatives from the technology vendor. Failure modes were scored using both Risk Priority Number (RPN) and Risk Hazard Index (RHI) scores. RESULTS: The chemotherapy preparation workflow was defined in a 41-step process with 16 failure modes. The RPN and RHI scores were identical for each failure mode because all failure modes were considered detectable. Five failure modes, all attributable to user error, were deemed to pose the highest risk. Mitigation strategies and system changes were identified for 2 failure modes, with subsequent system modifications resulting in reduced risk. CONCLUSION: The FMEA was a useful tool for risk mitigation and workflow optimization prior to implementation of an intravenous compounding technology. The process of conducting this study served as a collaborative and proactive approach to reducing the potential for medication errors upon adoption of new technology into the chemotherapy preparation process.

Current state of opioid stewardship.

PURPOSE: The opioid epidemic continues to result in significant morbidity and mortality even within hospitals where opioids are the second most common cause of adverse events. Opioid stewardship represents one model for hospitals to promote safe and rational prescribing of opioids to mitigate preventable adverse events in alliance with new Joint Commission standards. The purpose of this study was to identify the prevalence of current hospital practices to improve opioid use. METHODS: A cross-sectional survey of hospital best practices for opioid use was electronically distributed via electronic listservs in March 2018 to examine the presence of an opioid stewardship program and related practices, including formulary restrictions, specialist involvement for high-risk patients, types of risk factors screened, and educational activities. RESULTS: Among 133 included hospitals, 23% reported a stewardship program and 14% reported a prospective screening process to identify patients at high risk of opioid-related adverse events (ORAEs). Among those with a prospective screening process, there was variability in ORAE risk factor screening. Formulary restrictions were dependent on specific opioids and formulations. Patient-controlled analgesia was restricted at 45% of hospitals. Most hospitals reported having a pain management service (90%) and a palliative care service providing pain management (67%). CONCLUSION: The absence of opioid stewardship and prospectively screening ORAEs represents a gap in current practice at surveyed hospitals. Hospitals have an opportunity to implement and refine best practices such as access to pain management specialists, use of formulary restrictions, and retrospective and prospective monitoring of adverse events to improve opioid use.

The Effect of Performance Transparency on Adherence to Barcode Scanning During Order Preparation in an Adult Inpatient Satellite Pharmacy.

Purpose: The aim of this study was to investigate the effect of performance transparency and individualized feedback on pharmacy technician compliance with barcode verification technology during inpatient order preparation. Methods: Following the incorporation of barcode scanning technology into the workflow of pharmacy staff, a multiphasic intervention was employed to promote its use. The intervention included verbal feedback and publically posting performance metrics to increase accountability. An interrupted time-series analysis was conducted to ascertain trends and levels in the percent of orders that were dispensed using barcode verification, before and after the study intervention. Analyses were conducted by shift and overall for pharmacy workers in a single satellite pharmacy. Results: A significant increase in percent scanned orders was observed immediately following the intervention in our analysis of all pharmacy workers (+14.4%; P = .045; 95% confidence interval [CI]: 0.35-28.4). In the analysis of each shift, statistically significant increases in percent scanned orders were observed immediately following the intervention for both the evening shift (+5.1%; P = .024; 95% CI: 0.70-9.6) and the night shift (+29.9%; P = .025; 95% CI: 3.9-55.9), but not the day shift (+2.6; P = .707; 95% CI: -11.1 to 16.2). Conclusion: Increasing transparency of individual and team performance metrics in conjunction with targeted feedback is an effective intervention to improve compliance with barcode scanning technology.

A Multi-hospital Before-After Observational Study Using a Point-Prevalence Approach with an Infusion Safety Intervention Bundle to Reduce Intravenous Medication Administration Errors.

INTRODUCTION: We previously found a high rate of errors in the administration of intravenous medications using smart infusion pumps. OBJECTIVES/DESIGN: An infusion safety intervention bundle was developed in response to the high rate of identified errors. A before-after observational study with a prospective point-prevalence approach was conducted in nine hospitals to measure the preliminary effects of the intervention. MAIN OUTCOME MEASURES: Primary outcome measures were overall errors and medication errors, with the secondary outcome defined as potentially harmful error rates. RESULTS: We assessed a total of 418 patients with 972 medication administrations in the pre-intervention period and 422 patients with 1059 medication administrations in the post-intervention period. The overall error rate fell from 146 to 123 per 100 medication administrations (p < 0.0001), and the medication error rate also decreased from 39 to 29 per 100 medication administrations (p = 0.001). However, there was no significant change in the potentially harmful error rate (from 0.5 to 0.8 per 100 medication administrations, p = 0.37). An intervention component aiming to reduce labeling-not-completed errors was effective in reducing targeted error rates, but other components of the intervention bundle did not show significant improvement in the targeted errors. CONCLUSION: Development and implementation of the intervention bundle was successful at reducing overall and medication error rates, but some errors remained and the potentially harmful error rate did not change. The error-rate reductions were not always correlated with the specific individual interventions. Further investigation is needed to identify the best strategies to reduce the remaining errors. CLINICAL TRIALS REGISTRATION: Registered at ClinicalTrials.gov, identifier: NCT02359734.

Medication Errors and Trainees: Advice for Learners and Organizations.

Limited information exists regarding medication errors and trainees (students or residents). Yet during the experiential education component of their training, learners are expected to assume significant responsibilities in the medication use process. This commentary addresses both trainees and organization leaders on medication safety practices and the incorporation of learners into the organization's medication safety culture.