pharmacy administration rotation presentation pharmacy resident june 26 th, 2014

Pharmacy Administration Rotation Presentation

Pharmacy Resident

June 26th, 2014

Opioid iVent Analysis

3


Background: • The Joint Commission 2012 Sentinel Event Alert • Centers for Medicare and Medicaid Services (CMS) 2014 Clinical Standards list opioids as one of the three high- priority target medication classes

Objective: • Evaluate iVents involving opioid prescribing practices within CS- Link by classifying trends in errors and identify areas of improvement of current prescribing practices

Study Period:

January 2014- March 2014

4


Methods: Retrospective review• To evaluate trends in inappropriate prescribing practices opioid iVents were categorized based on type of error and medication involved• To evaluate trends in units/departments involved opioid iVents were categorized based on physician specialty and location of order verification

Inclusion: All life threatening and serious/significant iVents involving an opioid as documented in Epic during the study timeframe

Exclusion: All iVents involving non-opioid medications, documented as low capacity for harm or unable to determine were excluded from data collection

Sample Size 95 iVents

5

Opioid Prescribing Errors by Medication

1%

11%

HYDROMORPHONE 18%

2%MORPHINE 19%

1%1%

OXYCODONE 15%

3%

13%

FENTANYL 17% BELLADONNA ALKALOIDS-OPIUM

HYDROCODONE-ACETAMINOPHEN

HYDROMORPHONE

METHADONE

MORPHINE

NALOXONE

OPIUM TINCTURE

OXYCODONE

OXYCODONE-ACETAMINOPHEN

TRAMADOL

FENTANYL

6

Opioid Prescribing Errors by Specialty

Obstetrics & Gynecology Physical Medicine & Rehab

Surgery-Colo-rectalCertified Nurse-Midwife

Emergency MedicineIM/Cardiology

IM/Gastroenterology IM/Hematology/Oncology

Nurse PractitionerPeds - NeonatologyPhysician Assistant

Thoracic Surgery Urology

IM/NephrologyUnknown

Neurosurgery Surgery-General Surgery

OrthopedicsPediatrics

AnesthesiologyGeneral Internal Medicine

0 5 10 15 20 25

1

1

1

2

2

2

2

2

2

2

2

2

2

3

3

5

6

7

11

12

25

Number of Errors

Prov

ider

Spe

cial

ty

7

Opioid Prescribing Errors by Department

4-NE

7-SE

8-NW

7-NW

6-SW

4S-PICU

6-NW

4-SW

AHSP PACU

4-SE

8-SW

7-NE

4N-CICU

8-NE

6N-CSICU

5S-SICU

3-LDR

4-NICU

4-NW

7N-M

ICU

6S-CSICU

ASAP EMERG

ENCY D

EPT

8-SE

3-N M

FCU

3N-U

NIV

5-NE

5N-SICU

5-NW

5-SE

6-NE

7-PACU

7S-RICU

8S-NSICU

7-SW

0

1

2

3

4

5

6

7

8

99 9

6

5 5 5

4 4 4 4

3 3 3

2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1 1

Patient Department

Num

ber o

f iVe

nts

8

Opioid Prescribing Errors by Type

Duplicate Thera

py

Wro

ng Dose

Recommended D

iscontinuation of T

herapy

Wro

ng Frequency

Incomplete O

rder

Allerg

y

Drug-D

rug In

teracti

on

Recommended In

itiation of Medica

tion

Wro

ng Medica

tion Ord

ered

Wro

ng Route

Wro

ng Concentra

tion

Wro

ng Dosa

ge Form

Wro

ng Dura

tion

Wro

ng Rate

0

2

4

6

8

10

12

14

16

1818

16

1312

65

4 4 43

2 21 1

Num

ber o

f Err

ors

9

Type of Error and Medications Involved

Duplicate Therapy Wrong Dose Recommended Discontinuation of

Therapy

Wrong Frequency 0

2

4

6

8

10

12

14

16

18

20BELLADONNA AL-KALOIDS-OPIUM

OPIUM TINCTURE

MORPHINE

FENTANYL

TRAMADOL

OXYCODONE-APAP

OXYCODONE

METHADONE

HYDROMORPHONE

HYDROCODONE-ACETAMINOPHEN

Num

ber

of P

resc

ribi

ng E

rror

s

10

Life-Threatening Opioid iVents: 4%

Problem Identified Pharmacist Recommendation

Outcome Avoided

Wrong RouteFentanyl 12.5mg IV Q2hr prn mild pain

Clarified route with MD as MD's note the day before stated fentanyl 12 mcg patch (patient was on fentanyl patch 2 days ago)

Avoided ADE

Wrong Dose Hydromorphone 4 mg/mL solnMD changing from morphine didn't decrease the dose for higher potency

Change dose to 1 mg Avoided ADE

Wrong doseFentanyl 1000 mcg/mL ordered ivp

Change dose to 100 mcg Avoided ADE

Wrong doseMorphine 2 mg/mL IV CRTGMD ordered 1 mg/kg

Change dose to 1 mg Avoided ADE

11

Recommendations

Wrong dose due to lack of opioid equivalent knowledge can be improved upon by removing hydromorphone 4 mg button in Epic

Reinforce PharmD pain mgmt. principles with questions in Health Stream Competency o Dilaudid conversiono Appropriateness of fentanyl order (duplication of opioid due

to fentanyl patch not being removed) o Allergies o Special Populations health competency questions – post-op,

elderly, pediatrics Pediatrics

o PCA Narcan Default order for overdose (respiratory depression)

o Morphine: change default from SQ to IVo Weight based dosing: Best Practice Alert when order

exceeds 40-50 kgo Educate staff on importance of evaluating all pediatric

orders (wrong patient)

12

Overview

• Emergency Department Medication Reconciliation Evaluation (1)

• Order Verification and Staffing Model (2)

• Transitions of Care Literature Review

13

1. Emergency Department Medication Reconciliation

Evaluation

14

Emergency Department Medication Reconciliation Evaluation

Background: Emergency department (ED) medication reconciliation is currently being performed by pharmacists, pharmacy technicians and pharmacy residents on weekdays with varying hours of operation.

Objective: To evaluate gaps in the current transitions of care staffing model in emergency department medication reconciliation to optimize staffing resources.

Methods: A list of ED admissions during the week of 5/12/14-5/16/14 was compiled and evaluated for completion of ED medication reconciliation.

Study Period:

May 12th, 2014- May 16th, 2014

15


Inclusion: Patients admitted from the ED during the week of 5/12/14-5/16/2014 with admission date and time on record.

Exclusion: Patients admitted to:

Demographics: 415 patients evaluated • 5/12: 95 patients• 5/13: 80 patients• 5/14: 83 patients• 5/15: 88 patients• 5/16: 69 patients

SICU OR Pre-op PACU AHSP-PACU/Pre-

op CVIC CT tapr GI lab

MRI tapr NUC MD Tapr Rad intervention

US Tapr Vas U/S Tapr

16


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

2

4

6

8

10

12ED Med Rec 5/12/14 (n=95)

ED med rec NOT completed

ED med rec completed

Time (hours)

Nu

mb

er

of

Pa

tie

nts

Staffing on 5/12/14: 13 med recs completed (14%)

• Pharmacist: 1100-1930

• Pharmacy Technician: 1100-1930• Pharmacy Resident: 1700-2100

17






1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

1

2

3

4

5

6

7

8ED Med Rec 5/13/14 (n=80)



Time (hours)

Nu

mb

er

of

Pa

tie

nts

18






1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

1

2

3

4

5

6

7ED Med Rec 5/14/14 (n=83)



Time (hours)

Nu

mb

er

of

Pa

tie

nts

19





1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

1

2

3

4

5

6

7

8 ED Med Rec 5/15/14 (n=88)ED med rec NOT completed


Time (hours)

Nu

mb

er

of

Pa

tie

nts


20




1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

1

2

3

4

5

6 ED Med Rec 5/16/14 (n=69)



Time (hours)

Nu

mb

er

of

Pa

tie

nts


21


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

5

10

15

20

25

30

35

ED Admission Summary 5/12/14 to 5/16/14 (n=415)

Med Rec Completed

Med Rec NOT completed

Time (Hours)

Nu

mb

er

of

Pa

tie

nts 17%

6% 18%

17% 9%

12%

60%

43%

44%

38%

46%

39%43%

13%

29%

16%

13% 23%

22

Emergency Department Medication Reconciliation Evaluation Recommendations

• Proposed weekday coverage for ED medication reconciliation staffing:

• Proposed weekend (Saturday or Sunday, to be determined based on weekend analysis) coverage for ED medication reconciliation staffing:

PharmD:• 1 FTE 0900-1730• 1 FTE 1100-1930• 1 FTE 1730-0200

Pharmacy tech:• 1 FTE 0800-1630• 1 FTE 1530-0000

Pharmacy Residents:• M-F 1700-2100

• PharmD: TOC pharmacist staffing every 3rd weekend 1100-1930

• Pharmacy tech: 1100-1930

• Pharmacy Residents: One day weekend coverage/month

• Pharmacy interns: to be determined

23

2. Order Verification and Staffing Model

Order Verification and Staffing Model

Background: • An evaluation of the current staffing model is needed to ensure trends in workload demands are matched with the appropriate resource allocation and staffing responsibilities.

• Per labor laws, when an employee works for a period of more than five hours, a meal period must be provided no later than the end of the employee’s fifth hour of work.

Objective: Objectively evaluate the current inpatient pharmacy staffing model based on order verification demands to improve workflow using existing resources.

Study Period: Weekdays from April 1, 2014 – April 30, 2014

25


Methods:

• A medication order verification report for April 2014 was extracted from Epic

• Weekend, pediatric, oncology and ICU order verifications for the month of April were removed from the report

• The number of pharmacists working each hour was entered into the data collection spreadsheet using the pharmacist staffing model available for April 2014

• The average number of orders verified per pharmacist per hour was calculated using the total number of pharmacists scheduled per hour and the total daily verifications per hour

Inclusion:

Medication order verifications from weekdays in April 2014

Exclusion:

• Orders verified for pediatrics, AHSP, Oncology (4SW, OCC), ICU beds (Saperstein)

• Staffing pharmacists for areas excluded from the analysis

26

Results: • On average, the most order verifications on weekdays occur between 1500-1800 (ranging from 264-304 order verifications/hour/day)

• On average, the most order verifications per pharmacist per hour occurs from 1800-2000 (19-27 orders per pharmacist) and 0000-0200 (19-22 orders per pharmacist)

Results are summarized in the attached spreadsheet:


Microsoft Office Excel 97-2003 Worksheet

27

Recommendations:

• Recommend scheduling lunch for med/surg AM staff in 2 shifts:

₋ 1st shift: 1145-1230

₋ 2nd shift: 1245-1330• Recommend scheduling lunch for

med/surg PM staff in 2 shifts:

₋ 1st shift: 1600-1645

₋ 2nd shift: 1645-1730

Order Verification and Staffing Model Recommendations

28

Overview

• Anticoagulation iVent Analysis (3)• Daptomycin Medication Use

Evaluation (4)• Risk Assessment of Procedural

Areas (5)• Ready to Administer Dosage

Forms Analysis (6)• Readmission Prediction Score

Analysis (7)• Naloxone Medication Use

Evaluation and Screening Tool (8)

29

3. Anticoagulation iVent Analysis

30

Anticoagulant iVent Analysis

Background: • Although anticoagulants can be life-saving therapies, there are serious risks associated with improper use

• By evaluating anticoagulation prescribing errors intercepted by pharmacists, the value of pharmacy services can be demonstrated and common errors can be evaluated for prevention strategies.

Objective: To evaluate iVents involving anticoagulants, classify trends in errors and identify areas of improvement for current prescribing practices.

Methods: Retrospective review of all life-threatening and serious/significant iVents involving anticoagulants as documented in Epic

Study Period:

January 1st, 2014 through March 31st, 2014

31

iVents Evaluated:

• 200 iVents were included in the analysis⁻ 11 Life-Threatening⁻ 189 Serious/Significant

Apixaban<1%

Dabigatran3%

Heparin Flush4%

Enoxaparin Tx8%

Warfarin8%

Rivaroxaban11%

Enoxaparin PPX14%

Heparin Tx19%

Heparin PPX35%

Anticoagulant Prescribing Errors by Medication and Use:


32


GIM

Gener

al S

urge

ry

IM/C

ardi

olog

y

Neuro

surg

ery

Orthop

edics

Anest

hesio

logy

Other

Nurse

Pra

ctiti

oner

Emer

genc

y Med

icine

Nephr

olog

y

Infe

ctio

us D

iseas

es

Hemat

olog

y/Onc

olog

y

Phys

ician

Ass

istan

t

Pedi

atric

s

Neuro

logy

Obste

trics

& G

ynec

olog

y

Pulm

onar

y Med

icine

0

10

20

30

40

50

60

70

80

9078

12 12 11 11 11 11 105 5 4 4 3 3 3 3 3

Prescribing Errors by Specialty

Nu

mb

er

of

Err

ors

33


Allergy

Wrong Concentration

Drug Drug interaction

Wrong Rate

Omission of Medication on Transfer

Recommended Initiation of Medication

Recommended Discontinuation of Therapy

0 10 20 30 40 50

1

1

1

1

6

1

2

1, 13

4

4

5

17

2236

49

45Anticoagulant Prescribing Errors by Type

Life Threatening

34


Tre

atm

en

t a

nd

PPX

A

nti

coa

gu

lati

on

Du

plic

ate

Tre

at-

me

nt

An

tico

ag

ula-

tio

n

Du

plic

ate

Do

se o

f A

nti

coa

gu

lan

t

Du

plic

ate

an

ti-co

ag

ula

nt

pro

-p

hyla

xis

Duplicate Therapy

0102030

29

9 7 6

Categories of Duplicate Therapy (n=51)

35


INR T

herp

eutic

Plat

elet

s Dro

ppin

g

Proc

edur

e

Other

Supr

athe

rape

utic

INR

Bleed

Renal

func

tion

HIT0

4

8

1213

108

5 5 53

1

Reasons for Recommending Discontinuation of Therapy (n=50)

36

Renal

func

tion

Inco

rrec

t rivar

oxab

an d

ose

High

dose

Wei

ght

PTA

Wro

ng fl

ush

dose

Low d

ose

0

2

4

6

8

10

12

3

9

2

31

5

3 4

12

31

Types of Wrong Doses (n=37)

HeparinEnoxaparinDabigatranRivaroxaban


37


Problem IdentifiedRX

Recommendation

Outcome Avoided

Severity Ranking

Patient with anaphylaxis allergy to heparin was

ordered heparin prophylaxis

Discontinue therapy

Anaphylaxis

Life Threatening

Patient that received TPA was ordered heparin prophylaxis

Discontinue therapy

Hemorrhage

Heparin 10 units/mL was ordered for infant as PICC line

flush

Correct concentration

Hemorrhage

Heparin order placed for 600 units/kg/hour

Correct rate Hemorrhage

Patient continued on heparin flush with positive PF4

Discontinue heparin

Thrombus

Duplicate treatment dose anticoagulant orders

2 Rivaroxaban and heparin drip

2 Dabigatran and heparin drip

Rivaroxaban and tx enoxaparin

Dabigatran and tx enoxaparin

Discontinue one of the therapies

Hemorrhage; inhibiting multiple

anticoagulation pathways

38

Anticoagulant iVent Analysis Recommendations

1. Allow pharmacists to discontinue prophylactic heparin or enoxaparin when treatment anticoagulation is initiated (i.e. dabigatran, rivaroxaban, and apixaban)

2. In patients on warfarin and heparin/LMWH per pharmacy, allow pharmacists to discontinue heparin drip/LMWH in the setting of a therapeutic INR for two days and at least 5 days of overlapping therapy

3. Continued education for providers, especially for the General Internal Medicine service

4. Pharmacists should initiate and discontinue ordering of “No IM injections”, “No ASA >162mg” and “RN to notify physician and pharmacists for signs/symptoms of bleeding” when all anticoagulation is ordered or discontinued.

39

4. Daptomycin Medication Use Evaluation

40

Daptomycin Medication Use Evaluation

Background:

• Daptomycin is a bactericidal, lipopeptide antibiotic used for the treatment of serious gram-positive infections

• Daptomycin is currently restricted for use in:₋ MRSA bacteremia/right-sided endocarditis and

severe vancomycin allergy₋ Documented MRSA SSTI and severe allergy to

vancomycin• In FY13, the total daptomycin expenditure was

$478,988.50Objective: To evaluate daptomycin use

Methods: Retrospective review of daptomycin orders in April 2014 to evaluate for proper dose and indication

Study Period:

April 2014

41


Daptomycin MUE DemographicsNumber of Patients (#) 28Average Age (years) 63 ± 13Gender 14 males, 14 femalesAverage number of doses (#) 5 ± 3.4

Unit breakdown (%)

Inpatient (89%): ICU: 5 patients 4th floor: 3 patients 5th floor: 4 patients 6th floor: 3 patients 7th floor: 6 patients 8th floor: 4 patients

Outpatient (11%) Procedure Center: 3

patients

42


Summary of inpatient daptomycin Use N=25

# of patients followed by ID physician (%) 25/25 (100%)

# of treatment courses meeting criteria 0/25

# of treatment courses with an acceptable indication or dose 21/25 (84%)

# of treatment courses approved by AUR (%) 9/25 (36%)

43


Patient Error Indication Dose Total

doses

Approved by AUR

1 Incorrect Dose

MRSA joint infection with vancomycin

allergy described as flushing, PVCs, SOB

2.3-6 mg/kg 7 No

2 Incorrect Indication

Neutropenic patient spiking fever on

vancomycin (likely drug fever) with no

culture growth

5mg/kg 9 No

3 Incorrect Indication

Prosthetic joint infection with no

culture growth; MRSA and VRE screens

negative

6mg/kg 9 No

4 Incorrect Dose MRSA osteomyelitis 5mg/kg 2 No

44


Daptomycin has been shown to cause myopathy and the manufacturer recommends creatine

phosphokinase (CPK) monitoring at least weekly.

Analysis of weekly CPK Monitoring for orders > 7 days

Patients with CPK monitoring Yes 3/7 (43%)

45


Bacte

rem

ia

Cellu

litis

Osteo

mye

litis

Join

t Inf

ectio

nJo

int

UTI

Surg

ical P

roph

ylax

is

Neutro

peni

c Fe

ver

Abdom

inal

Infe

ctio

n

Seps

is0

2

4

6

8

10

Daptomycin Indication and Culture Summary (n=28)

VREOther/No growthMRSA

46

Daptomycin Medication Use Evaluation Recommendations

• The following changes to the daptomycin use criteria are recommended:– Remove “Documented MRSA SSTI and severe

allergy to vancomycin” indication– Add “Documented infection with VRE and

resistant to ampicillin/penicillin/linezolid or severe allergy to linezolid”

• Reinforce requirement of pharmacy staff to call AUR for approval of all daptomycin orders that do not meet CSMC criteria.

• Future directions: Reevaluate the drug-drug interaction severity between linezolid and other serotonergic medications.

47

5. Risk Assessment of Procedural Areas

48

Risk Assessment of Procedural Areas

Background:

The Joint Commission (TJC) in its Hospital Program, Medication Management Chapter, Standard: MM.05.01.01 EP1 states:

“Before dispensing or removing medications from floor stock or from an automated storage and distribution device, a pharmacist reviews all medication orders or prescriptions unless a licensed independent practitioner controls the ordering, preparation, and administration of the medication or when a delay would harm the patient in an urgent situation (including sudden changes in a patient's clinical status), in accordance with law and regulation.”

Objective: To evaluate medication stock of all procedural areas for compliance with TJC standards

49


Methods: • Floorstock lists for all included procedural areas were reviewed for indication and compliance with TJC standards.

• Any questions were clarified with pharmacy and nursing staff of the procedural areas.

• A Pyxis optimization report was utilized to determine the use requirements of questionable medications

Study Period:

April 2014

50


Summary of procedural area medications evaluated

Total number of medication formulations evaluated (#)

199

Summary of medication dosage forms

38 oral agents 4 capsules 8 suspensions 26 tablets

21 topical products 124 injectable agents 12 inhaled products 4 suppositories

51


7STONE; 35

8IR; 45

Blood Donor Cen-ter; 19

Bronch Lab; 18

Cath Lab; 93

GI Lab; 63

Non-Invasive Cardio; 23

PROCCTR Cart Stock; 5

PROCCTR Pyxis; 56Puml Fxn Lab; 6

Summary of number of medications per pro-cedural area

52


Reason for Lack of Pharmacist Review*

Reason# of

MedicationsMedication

Location

Managed by LIP65

medications

Nursing Protocol15

medications

Urgent Medication157

medications

No longer stocked 1 medications Ammonia Inhalant GI Lab

No indication 7 medications

Acetylcysteine 600mg capsules Cath Lab

Ibuprofen Pediatric suspension

Procedure Center Pyxis

Ibuprofen 400mg tabletProcedure Center

PyxisMethylprednisolone sodium 1000mg IV

solution7Stone Pyxis

Prednisone 5mg tabletProcedure Center

PyxisRanitidine 150mg tablet Cath Lab

Triamcinolone 0.1% topical cream


*Please note that some medications have multiple reasons

53

Medications NOT Meetings TJC Standards

Medication Indication Location Comments

Acetylcysteine 600mg capsules

IV contrast nephrotoxici

ty prophylaxis

Cath Lab Not urgent, should be verified by

pharmacist

Ibuprofen Pediatric suspension

Pain, feverProcedure

Center Pyxis

Oral pain medication not urgent Pyxis optimization report shows no use in

the last year

Ibuprofen 400mg tablet

Pain, feverProcedure

Center Pyxis

Oral pain medication not urgent Pyxis optimization report shows last use is

6/21/2013

Methylprednisolone 1000mg IV solution

Unclear7Stone Pyxis

Procedural center RNs unsure of indication and need in procedural area

Pyxis optimization report shows medication was first stocked 9/17/13 and has not been used since

Prednisone 5mg tablet

UnclearProcedure

Center Pyxis

Procedural center RNs unsure of indication Pyxis optimization report shows no use

since December 2013Ranitidine 150mg tablet

Heartburn, ulcer prophy

Cath Lab Oral medication not urgent; IV ranitidine is

available for urgent use

Triamcinolone 0.1% topical cream

Skin irritation


Topical product is not urgent and is verified by pharmacists occasionally

Pyxis optimization report shows product was used 6 times in past year. Last used in April.

53

54

Risk Assessment of Procedural Areas Recommendations

• Recommend removing ammonia inhalant from procedural area floorstock list on intranet

• Recommend removal of the following medications from procedure center floor stock:– Ibuprofen Pediatric suspension– Ibuprofen 400mg tablet– Methylprednisolone sodium 1,000mg IV

solution– Prednisone 5mg tablet– Ranitidine 150mg tablet– Triamcinolone 0.1% topical cream

• Recommend development of an Acetylcysteine use protocol

55

6. Ready-to-Administer Dosage Form Analysis

56

Ready-to-Administer Dosage Form Analysis

Background:

The Joint Commission (TJC) update to its Hospital Program, Medication Management Chapter, Standard: MM.03.01.01 released in December 2013 states:

“Medications in patient care areas are available in the most ready-to-administer forms commercially available or, if feasible, in unit doses that have been repackaged by the pharmacy or a licensed repackager.”

Objective: To evaluate medications dispensed to patient care areas to ensure compliance with TJC standards.

Methods: Daily dispense reports for January 29th through January 31st, 2014 were run and filtered for bulk and bulk liquid medication dispenses. Each bulk medication dispensed was evaluated for compliance to TJC standards

Study Period:

January 29th, 2014-January 31st, 2014

57


Results are summarized on the following slides:

• 589 bulk orders were dispensed from January 29th to January 31st

• 111 bulk medications were reviewed

58


Optha

lmic

drop

s

Topi

cal O

intm

ent

Inje

ctab

le sol

utio

n

Oral s

olut

ion

Topi

cal S

olut

ion

Topi

cal s

pray

Oral r

inse

Otic d

rop

Topi

cal J

elly

Mou

th w

ash

Optha

lmic

gel

Topi

cal lot

ion

Optha

lmic

Ointm

ent

0

4

8

12

1616 15 15

11

7 6 5 53 3 3 3 3 2 2 2 2 1 1 1 1 1 1 1 1

Bulk Dosage Forms Dispensed Jan 29th-31st, 2014

59


Summary of bulk order compliance with TJC Standards

Compliance with TJC Standards

Description of ComplianceNumber of Products (n=111)

Yes

Dispensed smallest commercially available product size, unable to unit dose

69

Unit dosed 16Dispensed from Pyxis 6Compounded product 5Size dispensed required for order 3Other

Medrol dose pack Chlorhexidine solution

2

NoProducts with

recommendations for change

10

60


Summary of products not in compliance with TJC standards

ProductQuality

dispensed

Proposed dispensed product

Cost Difference

1Bacitracin-polymyxin B (POLYSPORIN) ointment

1 oz tube 0.5 oz tube -$1,176.53

2 Bacitracin ointment 1 oz tube 0.5 oz tube $8,555.81

3Phenol throat spray (CHLORASEPTIC) spray

4 oz bottle 1 oz bottle $12,360.30

4Trypsin-balsam-castor oil (GRANULEX) topical spray 1 spray

4 oz spray bottle

2 oz spray bottle

$1,130.49

5Ketorolac (ACULAR) Ophthalmic Solution 0.5%

5 mL drop bottle

3 mL drop bottle-$34.48 to $327.58

6 Lidocaine (XYLOCAINE) 2 % jelly 30 mL tube 5 mL tube $32,458.3 to $43,572.78

7Multivits-mins-coenzyme Q10 (AQUADEKS) 400 mcg/mL oral drops

10mL bottle Unit dose

8Pediatric multivitamin (POLY-VI-SOL) oral drop


9Pediatric multivitamin-iron (POLY-VI-SOL with IRON) drop


10

Pediatric ferrous sulfate oral solution10mL bottle Unit dose

61

Ready-to-Administer Dosage Form Analysis Recommendations

• Smaller product sizes should be purchased for:– Bacitracin-polymyxin B (Polysporin®) ointment– Bacitracin ointment, phenol throat spray– Trypsin-balsam-castor oil (Granulex®) topical spray– Ketorolac ophthalmic solution

• Smaller lidocaine 2% jelly tubes (5mL) should be purchased for procedural areas and emergency department to limit use on multiple patients

62

7. Readmission Prediction Score Analysis

63

Readmission Prediction Score Analysis

Background:

• Organization has developed a 30 day readmission prediction score containing 9 patient specific variables: Number of prior to admission (PTA)

medications Use of opioids, anticoagulants, digoxin Dialysis dependency Oncology diagnosis Last hemoglobin Last blood sodium Recent emergency department visits/hospital

admissions• A score of ≥ 23 is considered High Risk of 30 day

hospital readmission in the model. Objective: To determine the utility of the Readmission

Prediction Daily Report for pharmacy staff use in transitions of care services.

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Hospitalized patients with a Readmission Prediction score of ≥23 Analysis A

(n=25)Analysis B

(n=43)Patients with score ≥23

who met pharmacist criteria for medication

reconciliation

15/25 (60%) 28/43 (65%)

Patients meeting pharmacist criteria for

medication reconciliation received one during their

admission

8/15 (53%)

12/28 (43%)5 patients were assessed for MedAL:

3/5 qualified for post DC follow-up

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Hospitalized patients with a Readmission Prediction score of <23 (n=275)

Patients with score <23 who met pharmacist criteria for medication reconciliation 127/275 (46%)

Phar

macist

inclusion

criteria

On >10 medications PTA 116/127 (91%)

On anticoagulants and >10 medications PTA 11/127 (9%)

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Conclusion: • Only ~60% of patients with score ≥23 meet pharmacist criteria for medication reconciliation.

• The Readmission Prediction Score includes all over-the-counter medications, duplicate medications and as needed medications in the number of PTA medications

• Current pharmacist medication reconciliation criteria identifies more medication related high risk patients while not including patients that are at high risk of readmission for non-medication related problems.

Recommendation:

Pharmacists should continue to utilize inpatient medication reconciliation criteria. As more resources are allocated to enhanced transitions of care pharmacy services, we will be better able to prevent medication related readmissions.

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8. Naloxone Medication Use Evaluation and Screening Tool

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Naloxone Medication Use Evaluation and Screening Tool

Background:

• The Joint Commission 2012 Sentinel Event Alert as well as the Centers for Medicare and Medicaid Services (CMS) 2014 Clinical Standards focused on the need for safe opioid prescribing practices and the risk associated with opioid use.

• Naloxone is a pure opioid antagonist used to counter the effects of opioid overdose

• By evaluating the use of naloxone ,we can evaluate preventable prescribing errors associated with opioid use and determine if naloxone is being used correctly

• Currently, all patients at must be evaluated by nursing for airway risk to determine their risk of respiratory depression following administration of opioids.

Objective: To evaluate the use of naloxone and develop a simple screening tool to assess patients from naloxone usage reports and compliance to all regulatory requirements.

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Naloxone MUE and Screening Tool

Study Period:

May 2014

Methods: Naloxone intravenous (IV) push usage reports were processed for May 2014. All naloxone IV push administrations were evaluated for patient risk factors and indication.

Results: • 23 naxolone IV push administrations occurred in May 2014

• 8 of which were not included in the analysis because the naloxone was administered for nausea/vomiting or itching

• Results are summarized in the following slides

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Study Demographics (n=15)

Average age (years) ±SD 57 ± 20Weight (kg) ±SD 72.5 ±17Gender 8 females/7 males

Naloxone Dose

0.04 mg 1 patient0.1 mg 1 patient0.2 mg 3 patients0.4 mg 9 patients0.5 mg 1 patient

Patient identified as an airway risk using current protocol

Yes 2 No 10

Not Assessed 3Average 24 hour Morphine Milligram Equivalent (MME)

79 (0-300)

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Seda

tives

in p

ast 2

4 ho

urs

Surg

ery in la

st 2

4 ho

urs

Conco

mita

nt O

pioids

*

Opioid

naive

Age

≥60

Scr ≥

1.3

Smok

ing

Histor

y

Cardio/

Pulm

onar

y Dise

ase

BMI >

30

Histor

y of

sleep

apn

ea-113579

111315

12 11 11 108 7 6 5

31

Patient Risk Factors (n=15)

Nu

mb

er

of

pati

en

ts

* received intermittent/ scheduled/ combination intermittent & scheduled IV/PO opioids

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Summary of naloxone response

Vital SignPrior to naloxone administration

After naloxone administration

Average Heart Rate (n=13)

91.4 (80-114) 103.6 (80-136)

Average Respiratory rate (n=15)

18 (6-30) 24 (10-39)

Average O2 sat (n=13) 99 (94-100) 98 (89-100)

Average Pain score (n=4) 1.75 (0-4) 2.5 (0-10)Attempted to assess sedation scale pre- and post-naloxone

administration:Pre-naloxone administration:

3 patients assessed with Aldrete Score

4 patients with GCS 1 patient with RASS 7 not assessed

Post-naloxone administration: 1 patient assessed with Aldrete

Score 6 patients with GCS 1 patient with RASS 7 patients not assessed

73


Alte

red

men

tal s

tatu

s (A

MS)

Som

nolenc

e

Extu

batio

n

Low O

2 sa

tura

tion

Hypot

ensio

n

Unclear

Strid

or0123456

3

1 1 1

2

22

11 1

Indication of Naloxone Use

n/a Yes No

# o

f P

ati

en

ts

Response:

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Proposed Screening Tool

Risk Factors: (yes/no)

Opioid Naïve

Scr ≥1.3

Age ≥60

years

Smoking

history

Surgery in last

24hrs

Concomitant* Opioids

Cardio/ pulmonary disease

Sedatives in past 24

hrs

MME in past

24hrs

Yes or No answers

are recorded

# for cases

reviewed (n=16)

10 7 8 6 11 11 5 1280

(0-300)

Average number of risk factors per patient = 4.7 (3-7)*received intermittent/ scheduled/ combination intermittent & scheduled IV/PO opioids

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Proposed Screening Tool

Vital signs prior to naloxone administration Vital signs after naloxone administration

Pulse Ox (y/n) O2 sat HR RR Pain Score O2 sat HR RR Pain Score

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Naloxone MUE and Screening ToolSummary of Findings

• Evaluation of the naloxone IV push administration records in May 2014, showed limited evidence that over-prescribing of opioids at CSMC is contributing to naloxone use

• The Airway Risk assessment tool currently being used does not accurately identify patients at high risk of respiratory depression secondary to opioid use

• Patient vital signs prior to and immediately after naloxone administration are inconsistently documented

• Naloxone indication and time of administration can be difficult to obtain from a retrospective chart review

• Use and type of sedation scale varies when patients are assessed for AMS secondary to opioid use.

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Naloxone MUE and Screening ToolRecommendations

• Naloxone orders should require a drop-down menu to specify indication for use

• Pain management should be consulted to establish a naloxone use policy. The policy should include:• Naloxone use criteria• Required naloxone vital sign documentation and

standardized sedation scale• New risk assessment tool to accurately identify

patients at risk for respiratory depression following opioid use

• Nursing should be educated on need for complete and consistent vital sign documentation in patients requiring naloxone use.

• Daily naloxone use reports should be validated and filtered to not include administrations for itching and nausea/vomiting.

pharmacy administration rotation presentation pharmacy resident june 26 th, 2014

Documents

opioid prescribing errors

type slide

opioid prescribing practices

lifethreatening opioid

mgavoided ade slide

nonopioid medications

opioid ivent analysis

wrong route fentanyl