Improving medication management in the emergency department at Royal Perth Hospital

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Improving medication management in the emergency
department at Royal Perth Hospital

• Lea Dias - ED Pharmacist
• Barry Jenkins, Chief Pharmacist
• Dr Frank Sanfilippo, Population Health, UWA
• Stephen Witney - ED Technician

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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

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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

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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

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Ongoing

• E-formulary trial
• POMBs
• roll-out rest of RPH
• Discussion with SJA.
• Possible use State-wide?
• Business case to continue the pharmacy service.

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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.

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Method

• Service
• 1FTE clinical pharmacist, 1FTE Technician
• Mon-Fri 800am-430pm
• 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)

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Method

• Role of the technician
• Record pre-admission medication information
• patients own medications/list or WebsterPak
• GP letters
• nursing home/pharmacy medication list
• previous admission at RPH
• discharge letters
• Record medications charted on admission

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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

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Method
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Method

• Introduced towards the end of the study.

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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

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Results
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Results 2
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Distribution of unintentional errors
Patients
Unintentional errors
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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

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Case 1

• 95yo, Italian lady
• presents with ?pulm oedema
• 3 errors identified
• dose incorrect frusemide
• irbesartan charted (drug commission)
• gliclazide charted (drug commission)
• withhold gliclazide and instructions to begin an
  insulin infusion
• no history of diabetes
• daughter/mother medication mix up
• discrepancies corrected in ED

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Case report 1 Medication Action Plan

• ED Pharmacist
• GP confirmed
• no history of diabetes
• daughter/mother medication mix up
• irbesartan ceased
• frusemide increased
• discussed digoxin/clarithromycin interaction
• blue notes indicated withhold gliclazide, begin
  insulin infusion (admitting team)
• discrepancies corrected in ED
• digoxin level 3.5
• Ward pharmacist
• follow up digoxin, allopurinol, ibuprofen

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Case report 2 Medication Action Plan

• ED Pharmacist
• patients own medications
• brand names used on the Websterpak
• meds charted by admitting team
• ceased phenytoin
• add carbamazepine
• discrepancies corrected in ED by admitting team
• Ward Pharmacist
• to follow up liquid paraffin in ? aspiration
  pneumonia

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Case report 3 Medication Action Plan

• ED Pharmacist
• GP confirmed
• recent discharge from Swan Elderley Mental Health
  Service 1 week ago
• changed antidepressant to sertraline at SEMHS
• increased dose of sotalol at SEMHS
• ceased fosinopril/hydrochlorothiazide in Nov 05
• dose of atorvastatin
• discrepancies corrected in ED by admitting team
• morning doses of venlafaxine and fosinopril had
  been given
• history obtained from a previous admission (Aug
  05)

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Case report 4 Medication Action Plan

• ED Pharmacist
• GP contacted 18/04/06 confirmed
• no medication changes communicated on discharge
  09/03/06
• patient had recommenced allopurinol, frusemide
  and diclofenac
• pantoprazole not continued
• Ward pharmacist
• warfarin counselling
• follow up allopurinol, diclofenac, frusemide

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Conclusion

• Primary objectiveTo 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 ObjectiveAssess 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

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Key messages

• Dont 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