Improving medication management in the emergency

department at Royal Perth Hospital

Lea Dias - ED Pharmacist Barry Jenkins, Chief Pharmacist

Dr Frank Sanfilippo, Population Health, UWAStephen Witney - ED Technician

Background

ED is under-serviced by pharmacy at RPH

Significant medication safety concerns Significant continuity of care issues Funding obtained for a pharmacist and

technician from Oct 05 - June 06

Aim

Introduce a comprehensive service patient own medication bags frequent stock checks and analysis access to a clinical pharmacist during business hrs introduce an electronic drug formulary investigate the role of the pharmacist & technician

Conduct a Pilot study assess the accuracy of medication history taking assess the impact of pharmacy involvement

Achievements

Patient Own Medication Bags (POMBs) introduced and written into hospital policy

Drug protocols and administration guidelines on ED intranet

Service to nursing & medical staff improved

Pilot study completed and analysed

Pilot study summary

Primary objective: To compare the accuracy of medications

recorded on the medication chart against a validated medication history taken by the pharmacist for high-risk patients.

Secondary objective Assess the utility of the pharmacy service in

reviewing high risk patients and resolving medication related problems.

Method Service

1FTE clinical pharmacist, 1FTE Technician Mon-Fri 8:00am-4:30pm

Sample - high risk patients Inclusion criteria

admitted patients with a completed drug chart 65 years old or 5 medications

Exclusion criteria nil medications pre-admission

Recruitment once or twice daily ward rounds in all ED areas 9th April - 30th May 06 (period of 7 weeks)

Method

Role of the technician Record pre-admission medication

information patient’s own medications/list or WebsterPak® GP letters nursing home/pharmacy medication list previous admission at RPH discharge letters

Record medications charted on admission

Method Role of the pharmacist

Validate history with at least two sources Reconcile pre-admission medication history with

charted medications Classify discrepancy as;

intentional (deliberate changes) eg. withheld, new or cease drug, OR

unintentional (errors) eg. drug omission, drug commission, or incorrect dose.

Communicate discrepancies written in blue notes verbally with team or ward pharmacist attach Medication Action Plan to chart

PHARMACY: ADMISSION MEDICATIONSThe pharmacist has confirmed the admission medication history via:

Patient Interview Patient List Relatives

Own Medications All Yes/No Websterpak

N/Home ...........….…. Ph........…. GP...........……….. Ph........…

Pharmacy...........……..… Ph........… Prev Adm .....……/…./.....

Method

Method

Introduced towards the end of the study.

Analysis

Data analysed using SPSS Lost to follow up

subjects that satisfied the selection criteria but were lost to the ward/discharged before being seen by the ED Pharmacist

these subjects were not included in the results Patients not screened

lack of resources did not permit all high-risk pts to be reviewed and included in the results.

sub-sample of these patients to test for selection bias

DemographicsN 106females 50.9%males 49.1%age 66.2 (17.1) mean (sd)

Pre-admission Meds/pt 7.8 (1-26) mean (range)

Discrepancies between preadmission medications and charted medications mean (95% CI)unintentional (errors/patient) 2.1 (1.7,2.4)intentional (deliberate changes/patient) 0.9 (0.6,1.1)

Results

Discrepancies per preadmission % (95% CI)

% unintentional (errors) 26.5 (22.4,30.5)% intentional (deliberate changes) 10.9 (7.7,14.1)

Unintentional discrepancies follow-up % (95% CI)

% Errors corrected by pharmacist in ED 36.3 (25.4,47.2)% Errors communicated for follow-up 63.7 (52.8,74.6)

All discrepancies for review at discharge % (95% CI)

% Errors (not corrected in ED) & deliberate changes 27.8 (22.4,33.1)

Results 2

1086420

Unintent_U

30

25

20

15

10

5

0

Freq

uenc

y

Mean =2.06Std. Dev. =1.805

N =108

Histogram

Unintentional errors

Patients

Distribution of unintentional errors

Discussion

Unintentional discrepancies (errors) mean of 2.1 per patient

Intentional (deliberate) changes mean of 0.9 per patient

On discharge must account for:- all errors not corrected in ED and all deliberate changes initiated in ED and all other discrepancies arising from the ward

Medication preadmission Medication charted Unintentional IntentionalTegretol CR 400mg mane Phenytoin 400mg mane incorrect drugTegretol CR 500mg nocte Phenytoin 500mg nocte incorrect drugTopiramate 100mg bd Ranitidine 150mg bd Atorvastatin 20mg nocte Amitriptyline 50mg nocte Norethisterone 5mg nocte Ergocalciferol 1000mg bd Vitamin C 500mg mane Lactulose 20ml mane Paraffin liquid 40ml mane r/v asp pneumLacrilube apply prn Microlax enema 1 pr alt days Oestradiol gel ap pv nocte

Medication preadmission Medication charted Unintentional IntentionalAtorvastatin 10mg nocte Atorvastatin 40mg nocte incorrect doseSotalol 120mg bd Sotalol 80mg bd incorrect doseSertraline 50mg mane drug omittedPantoprazole EC 40mg drug omittedPrazosin 2mg bd Prazosin 2mg bdAspirin 100mg EC Aspirin 100mg EC

Venlafaxine XR 75mg drug commissionMonoplus 20/12.5mg drug commissionFrusemide 40mg mane new med

Conclusion

Primary objective[To compare the accuracy of medications recorded on the medication chart against a validated medication history taken by the pharmacist for high-risk patients.]

there is a high incidence of unintentional error in admission medication histories for high-risk patients

Secondary Objective[Assess the utility of the pharmacy service in reviewing high risk patients and resolving medication related problems]

a pharmacist/technician based pharmacy service identified, and in a third of cases, corrected, unintentional medication errors

Key messages

Don’t rely on old information - validate it Accurate discharge letter is vital Undetected errors made on admission may

go uncorrected at discharge Medical and nursing staff benefit from

clinical pharmacy services A dedicated ED pharmacy service improves

the medication management of admitted patients