Evaluation of Medication Administration Timing-Are We Meeting Our Goals?

BACKGROUND: Per the Centers for Medicare and Medicaid Services (CMS) Code of Federal Regulations (CFR) 482.23(c) regarding medication administration, hospital policies and procedures must identify time-critical scheduled medications which must be administered within 30 minutes either before or after the scheduled dosing time, for a total administration window of 1 hour. OBJECTIVE: The general objective of this analysis was to determine whether there was a difference in meeting medication administration goals when comparing time-critical to non-time-critical scheduled medication administration in both intensive care units (ICUs) and general medical floors at a large, academic medical center. METHODS: Data were collected in 6 inpatient nursing units (3 general medical units and 3 ICUs) during the month of June 2017. Electronic medical record charge data for medications were used to evaluate timeliness of medication administration. RESULTS: In total, 69,794 medication administrations were evaluated. Of 389 administrations of time-critical scheduled medications, 268 (69%) were administered on time. Of 69,405 administrations of non-time-critical scheduled medications, 58,099 (84%) were administered on time (P < 0.001). ICUs had a higher percentage of on-time administrations than general medical units (89% vs 77%, P < 0.001), and nurses had a higher percentage of on-time administrations than respiratory therapists (84% vs 63%, P < 0.001). CONCLUSIONS: Non-time-critical scheduled medications were more commonly administered on time compared with time-critical scheduled medications. Staff education and optimizations to the electronic health record (EHR) are interventions that may improve administration of time-critical scheduled medications.

Hypoglycemic effects of tramadol analgesia in hospitalized patients: a case-control study.

BACKGROUND: In outpatient populations, hypoglycemia has been associated with tramadol. We sought to determine the magnitude of risk for hypoglycemia associated with tramadol use in hospitalized patients. METHODS: During a 2-year period of observation, adult inpatients who received ≥1 dose of tramadol were identified and their medical records were reviewed. Patients were included if they had blood or plasma glucose (BG) concentrations measured on at least two occasions within five days after the initial administration of tramadol. A contemporary comparator group of hospitalized oxycodone recipients was similarly reviewed. RESULTS: Tramadol was administered to 2927 patients who met inclusion criteria. Among these, hypoglycemia (BG ≤70 mg/dL) was documented in 22 (46.8%) of 47 patients with type 1 diabetes, 113 (16.8%) of 673 patients with type 2 diabetes, and 103 (4.7%) of 2207 patients who did not have a diabetes mellitus diagnosis. In those without a diabetes diagnosis, the causality association between hypoglycemia and tramadol use was probable in 77 patients (3.5%). By comparison, hypoglycemia was documented in 8 (1.1%) of 716 matched oxycodone recipients without diabetes (p = 0.002). As compared with tramadol recipients who did not develop low BG concentrations, those who experienced tramadol-related hypoglycemia were relatively young (mean age 52.0 versus 59.8 years; p = 0.027) and predominantly female (74.0% versus 59.8%; p = 0.012). CONCLUSIONS: Tramadol use was causally associated with hypoglycemia in hospitalized patients. The proportion of patients without diabetes who developed hypoglycemia was higher among those who received tramadol than among those who received oxycodone. TRIAL REGISTRATION: Colorado Multiple Institutional Review Board Protocol № 15-2215. Registered/approved 8 December 2015.

Stability of dronabinol capsules when stored frozen, refrigerated, or at room temperature.

PURPOSE: Results of a study to determine the 90-day stability of dronabinol capsules stored under various temperature conditions are reported. METHODS: High-performance liquid chromatography (HPLC) with ultraviolet (UV) detection was used to assess the stability of dronabinol capsules (synthetic delta-9-tetrahydrocannabinol [Δ9-THC] mixed with high-grade sesame oil and other inactive ingredients and encapsulated as soft gelatin capsules) that were frozen, refrigerated, or kept at room temperature for three months. The dronabinol capsules remained in the original foil-sealed blister packs until preparation for HPLC-UV assessment. The primary endpoint was the percentage of the initial Δ9-THC concentration remaining at multiple designated time points. The secondary aim was to perform forced-degradation studies under acidic conditions to demonstrate that the HPLC-UV method used was stability indicating. RESULTS: The appearance of the dronabinol capsules remained unaltered during frozen, cold, or room-temperature storage. Regardless of storage condition, the percentage of the initial Δ9-THC content remaining was greater than 97% for all evaluated samples at all time points over the three-month study. These experimental data indicate that the product packaging and the sesame oil used to formulate dronabinol capsules efficiently protect Δ9-THC from oxidative degradation to cannabinol; this suggests that pharmacies can store dronabinol capsules in nonrefrigerated automated dispensing systems, with a capsule expiration date of 90 days after removal from the refrigerator. CONCLUSION: Dronabinol capsules may be stored at room temperature in their original packaging for up to three months without compromising capsule appearance and with minimal reduction in Δ9-THC concentration.

Electronic inventory systems and barcode technology: impact on pharmacy technical accuracy and error liability.

PURPOSE: To measure the effects associated with sequential implementation of electronic medication storage and inventory systems and product verification devices on pharmacy technical accuracy and rates of potential medication dispensing errors in an academic medical center. METHODS: During four 28-day periods of observation, pharmacists recorded all technical errors identified at the final visual check of pharmaceuticals prior to dispensing. Technical filling errors involving deviations from order-specific selection of product, dosage form, strength, or quantity were documented when dispensing medications using (a) a conventional unit dose (UD) drug distribution system, (b) an electronic storage and inventory system utilizing automated dispensing cabinets (ADCs) within the pharmacy, (c) ADCs combined with barcode (BC) verification, and (d) ADCs and BC verification utilized with changes in product labeling and individualized personnel training in systems application. RESULTS: Using a conventional UD system, the overall incidence of technical error was 0.157% (24/15,271). Following implementation of ADCs, the comparative overall incidence of technical error was 0.135% (10/7,379; P = .841). Following implementation of BC scanning, the comparative overall incidence of technical error was 0.137% (27/19,708; P = .729). Subsequent changes in product labeling and intensified staff training in the use of BC systems was associated with a decrease in the rate of technical error to 0.050% (13/26,200; P = .002). CONCLUSIONS: Pharmacy ADCs and BC systems provide complementary effects that improve technical accuracy and reduce the incidence of potential medication dispensing errors if this technology is used with comprehensive personnel training.

Use of recalibrated serum creatinine concentrations for adjustment of drug dosages: determination of values compatible with conventional dosing recommendations.

BACKGROUND: Measurement of serum creatinine concentration is central to evaluation of kidney function. Recent efforts to increase the accuracy of this evaluation have led to recalibration of laboratory instruments. Recalibrated creatinine concentrations often are lower than previously reported. OBJECTIVES: To derive a method for converting recalibrated serum creatinine (RSCr) concentrations into values that are compatible with recommended equations for calculation of estimated creatinine clearance. METHODS: Beginning with a proprietary array of recalibrated and corresponding non-recalibrated serum creatinine (NR-SCr) numerical data provided by the instrument manufacturer, relationships were examined with exponential and linear regression analyses. The validity of derived values for NR-SCr obtained through these analyses was tested by comparison of proprietary and derived serum creatinine concentrations and calculated creatinine clearance values. RESULTS: Analyses revealed that relationships between R-SCr and NR-SCr creatinine were essentially linear. Rearranging and solving the equation for a straight line described this relationship as x = (y - b)/m, where x is the derived creatinine value, y is the R-SCr concentration, and, for our laboratory instrument, best parameters for m and b equal to 0.987 and -0.07, respectively. Use of these parameters to derive NR-SCr values was shown to significantly decrease positive bias in subsequent creatinine clearance calculations. CONCLUSIONS: As compared to R-SCr concentrations, use of derived NR-SCr values can improve the predictive performance of conventional equations used to calculate estimated creatinine clearance.

Management of diabetes mellitus in hospitalized patients: efficiency and effectiveness of sliding-scale insulin therapy.

STUDY OBJECTIVE: To determine the efficiency and effectiveness of current prescribing practices relative to short- and intermediate-acting insulins in the prevention or treatment of acute hyperglycemic episodes in hospitalized patients with diabetes mellitus or hyperglycemia, and to identify clinical findings that influence the effectiveness of insulin therapy in these patients. DESIGN: Retrospective observational study. SETTING: University-affiliated hospital. PATIENTS: Ninety consecutive adult inpatients who had orders placed for as-needed subcutaneous regular or lispro sliding-scale insulin. MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for patients' clinical characteristics and responses to administered insulin that were recorded during each of the first 5 days of hospitalization in which sliding-scale insulin therapy was used. Despite the immediate or bedside availability of both computerized and manual means to record finger-stick blood glucose levels and insulin injections, uncertainties or missing information related to execution, timing, blood glucose levels, or insulin dose were present in approximately 30% of all anticipated points of care involving insulin. Ten episodes of hypoglycemia in six patients were associated with sliding-scale insulin. Appropriately timed, successive glucose measurements documented a decrement in elevated blood glucose values to within the target range of 90-130 mg/dl after 76 (12%) of 621 sliding-scale insulin injections. Glucose levels remained elevated, and insulin effects were therefore subtherapeutic after 523 injections (84%). Despite blood glucose levels that remained persistently elevated, corresponding adjustments in either the timing or the dose of insulin were made infrequently. Sliding-scale insulin regimens were never adjusted in 73 patients (81%). Through 5 days of therapy, the proportion of patients who attained good glycemic control ranged from 2-10% (mean 6%). The mode of overall glycemic control was poor, with 51-68% of patients in this category on any given day. Overall, treated diabetic and hyperglycemic patients were more likely to be poorly controlled than relatively well controlled. CONCLUSION: Our findings reveal outcomes associated with sliding-scale insulin that are widely variable, often ineffectual, and prone to deficiencies in monitoring, documentation, and prescribing soundness. Efforts to improve glycemic control in hospitalized patients are clearly needed.

Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety.

OBJECTIVES: Evaluate potassium and phosphorus repletion in hospitalized patients. Assess the potential role for use of various methods, including healthcare information technology, to improve prescribing and patient safety. RESEARCH DESIGN AND METHODS: Inpatient medication profiles were screened to identify orders for potassium and phosphorus replacement products. Electronic laboratory and medical records were used to evaluate efficacy and safety. Eligibility for oral therapy was defined by the presence of other scheduled oral medications on the medication profile. Appropriateness of prescribing was based on adherence to the hospital guidelines for repletion. RESULTS: Overall, 134 orders for potassium in 92 patients and 36 orders for phosphorus in 27 patients were evaluated over a 3-week data collection period. Intravenous (IV) potassium was prescribed in 73% of replacement episodes (46% as single doses and 54% within large volume IV fluids), with 85% for normokalemia or mild-to-moderate cases of hypokalemia. Phosphorus orders involved single doses of IV potassium phosphate (mean 13.1 mmol) in 75% of cases. Approximately 85% of doses were for mild or moderate hypophosphatemia. Eligibility for oral therapy was evident in 74% of normokalemic or mild hypokalemic cases receiving IV potassium products and in 33% of cases receiving IV phosphorus replacement. Six cases of mild hyperkalemia were observed. No hyperphosphatemia was documented. Study limitations include use of a retrospective design, inability to discern whether some electrolyte doses were given with a preventative intent, potential overestimation of the number of patients eligible for oral repletion, and lack of data on the accessibility of the laboratory serum concentrations or the awareness of serum values to the prescribers. CONCLUSIONS: Intravenous potassium and phosphate products are commonly prescribed for mild or moderate cases of hypokalemia or hypophosphatemia. Many patients met eligibility for oral therapy. Efforts to enhance prescriber education and implement computerized prescribing and decision support systems have the potential to improve prescribing and reduce possibilities of adverse drug events and medication errors related to potassium and phosphate administration.

Living donor liver transplant recipients achieve relatively higher immunosuppressant blood levels than cadaveric recipients.

Two recent brief reports suggest that recipients of living donor liver transplants achieve higher levels of immunosuppressive agents than cadaveric (CAD) liver transplant recipients administered the same dose. These results could have important implications regarding the dosing of immunosuppressives in living donor liver transplant recipients. We report our findings relative to immunosuppressive doses and levels in a cohort of 46 living donor liver transplant recipients. Immunosuppressive blood levels and doses were recorded weeks 1, 2, 3, and 4 and months 2, 3, 4, 5, and 6 for 46 living donor liver transplant recipients and 66 matched CAD liver transplant recipients who underwent transplantation between August 1997 and May 2001. The ratio of level to dose also was recorded at each interval. The mean overall cyclosporine A dose was similar in living donor liver transplant recipients (323 mg/d) compared with CAD recipients (344 mg/d; P = not significant [NS]). The mean overall tacrolimus dose was 15% lower in patients who underwent living donor liver transplantation (LDLT; 5.7 mg/d) than CAD transplantation (6.7 mg/d), although statistical significance was not achieved (P =.08). The mean overall cyclosporine A level was 18% higher in those undergoing LDLT (275 ng/mL) than CAD transplantation (234 ng/mL; P =.015). The mean overall tacrolimus level was the same in living donor liver transplant recipients (10.8 ng/mL) and CAD recipients (10.2 ng/mL; P = NS). The overall cyclosporine A level-dose ratio was 26% higher for those undergoing LDLT (0.83) than CAD transplantation (0.66; P =.01). The overall tacrolimus level-dose ratio was 26% higher for those undergoing LDLT (1.82) than CAD transplantation (1.44; P =.01). In conclusion, (1) living donor liver transplant recipients achieve higher blood levels of tacrolimus and cyclosporine A for a given dose compared with CAD recipients, and (2) this difference is observed up to 6 months after transplantation, when hepatic regeneration is completed.