Daniel J. Cobaugh

Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel

PURPOSEnConsensus recommendations to help ensure safe insulin use in hospitalized patients are presented.nnnSUMMARYnInsulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panels consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use.nnnCONCLUSIONnA 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.

Communicating non-steroidal anti-inflammatory drug risks: Verbal counseling, written medicine information, and patients’ risk awareness

OBJECTIVEnTo assess potential associations among physician counseling, pharmacist counseling, written medicine information (WMI) and patient awareness of non-steroidal anti-inflammatory drug (NSAID) risks.nnnMETHODSnThree-hundred and eighty-two older, white and African American patients prescribed NSAIDs were surveyed regarding their NSAID risk awareness defined as an index score ranging from zero to four correctly identified risks (i.e., gastrointestinal bleeding, heart attack, hypertension, and kidney disease). Associations among NSAID risk awareness and patient-reported physician counseling, pharmacist counseling, and reading of WMI were evaluated in multivariable ordered logistic regression models and confirmed using path analysis.nnnRESULTSnPhysician counseling was positively associated with reading WMI (p<0.001) and NSAID risk awareness (p<0.001). Pharmacist counseling was not associated with reading WMI (p=0.622) and neither pharmacist counseling (p=0.366) nor reading WMI (p=0.916) was associated with NSAID risk awareness.nnnCONCLUSIONSnPhysicians play a prominent role in facilitating NSAID risk awareness whereas pharmacist counseling and WMI may have limited impact.nnnPRACTICE IMPLICATIONSnThe lack of significant associations among pharmacist counseling and reading WMI with NSAID risk awareness suggests a missed opportunity to improve patient understanding. There is a need for coordinated and effective strategies to communicate risk information among physicians and pharmacists and to better integrate WMI into this process.

ASHP-SHM Joint Statement on Hospitalist-Pharmacist Collaboration.

The American Society of Health-System Pharmacists (ASHP) and the Society for Hospital Medicine (SHM) believe that the rapidly emerging hospitalist model of inpatient care offers new and significant opportunities to optimize patient care through collaboration among hospitalists, hospital pharmacists

Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS)

BackgroundUnresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation.MethodsSix U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders.DiscussionAt baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes.Trial registrationClinicaltrials.gov identifier NCT01337063

Effect of racial differences on ability to afford prescription medications

PURPOSEnThe association of race with not filling prescription medications because of cost for African-American and white patients 65 years or older was examined.nnnMETHODSnAfrican-American and white patients age 65 years or older were recruited from the practices of 48 Alabama primary care physicians participating in the Alabama Nonsteroidal Antiinflammatory Drug Patient Safety Study. All eligible patients were asked questions related to their ability to pay for prescription medications, comorbidities, insurance status, and socioeconomic status. Baseline and follow-up telephone surveys were completed between August 2005 and April 2006. Mediation analysis was conducted to determine whether patients perceived income inadequacy mediated the association between race and not filling medications using staged logistic regression models and adjusting for age, comorbidities, and traditional markers of socioeconomic position (income, education, and insurance status).nnnRESULTSnOf 399 participants, 32% were African-American, 74% were women, and 53% had an annual household income of <

The Role of Health Literacy and Written Medicine Information in Nonsteroidal Antiinflammatory Drug Risk Awareness

15,000. Patients not filling prescription medications were more likely to be African-American (50% versus 25%) and to report inadequate income to meet basic needs (61% versus 17%) (p < 0.001 for both comparisons). After adjusting for all covariates except the mediator, the odds ratio (OR) for African Americans not filling a prescription medication was 2.3 when compared with white patients. Adding the mediator (perceived income inadequacy) to the model reduced the OR to 1.4.nnnCONCLUSIONnAfrican Americans reported markedly greater difficulty in affording prescription medications than did white patients, even after accounting for income, education, health insurance status, and comorbidities. The inability of African Americans to afford prescription medications may be better predicted by perceived income inadequacy than more traditional measures of socioeconomic status.

Patient-reported communications with pharmacy staff at community pharmacies: The Alabama NSAID Patient Safety Study, 2005–2007

Background: Despite widespread use of prescription nonsteroidal antiinflammatory drugs (NSAIDs), patients are commonly unaware of their risks. Pharmacies regularly distribute written medicine information (WMI) describing the risks and benefits of NSAID therapy at the time of dispensing. Objective: To clarify the relationship among common sociodemographic factors, education, health literacy, reading of WMI routinefy distributed at pharmacies, and NSAID risk awareness. Methods: Generalized linear latent and mixed models (GLLAMM) ordered logistic regression and confirmatory path analysis were used to evaluate multivariable relationships in a cross-sectional dataset of 382 patients in the second phase of the Alabama NSAID Patient Safety Study. Results: The majority of the analytical sample was female (72.0%) with 38.7% African American, 38.1% age 65 years or older, and 43.3% reporting at least some college education. Health literacy was positively associated with reading of WMI (p = 0.001) and NSAID risk awareness (p = 0.025), while age was negatively associated with reading WMI (p = 0.001) and NSAID risk awareness (p = 0.005). Medicaid/uninsured status was negatively associated with risk awareness (p = 0.013). Reading of WMI was not associated with NSAID risk awareness (p = 0.659). The final path model demonstrated excellent fit. Conclusions: The lack of relationship between reading of WMI and NSAID risk awareness questions the current strategy of distribution of patient-targeted print education materials at pharmacies. To maximize limited resources, future research should identify more effective strategies to deliver risk information to patients and ensure its retention, especially in high-risk groups such as the elderly, the indigent, and those with inadequate health literacy.

Using single-item health literacy screening questions to identify patients who read written nonsteroidal anti-inflammatory medicine information provided at pharmacies

OBJECTIVESnTo examine the prevalence of patient-pharmacy staff communication about medications for pain and arthritis and to assess disparities in communication by demographic, socioeconomic, and health indicators.nnnDESIGNnDescriptive, nonexperimental, cross-sectional study.nnnSETTINGnAlabama between 2005 and 2007.nnnPATIENTSn687 Patients participating in the Alabama NSAID Patient Safety Study (age >or=50 years and currently taking a prescription nonsteroidal anti-inflammatory drug [NSAID]).nnnINTERVENTIONnNot applicable.nnnMAIN OUTCOME MEASURESnCommunication with pharmacy staff about prescription and over-the-counter (OTC) NSAIDs was examined before and after adjustment for demographic, socioeconomic, and health indicators.nnnRESULTSnFor the entire cohort (n = 687), mean (+/-SD) age was 68.3 +/- 10.0 years, 72.8% were women, 36.4% were black, and 31.2% discussed use of prescription pain/arthritis medications with pharmacy staff. Discussing use of prescription pain/arthritis medications with pharmacy staff differed by race/gender (P < 0.001): white men (40.3%), white women (34.6%), black men (30.2%), and black women (19.8%). Even after multivariable adjustment, black women had the lowest odds of discussing their medications with pharmacy staff (odds ratio 0.40 [95% CI 0.24-0.56]) compared with white men. For the 63.0% of participants with recently overlapping prescription and OTC NSAID use, communication with pharmacy staff about OTC NSAIDs use was only 13.7% and did not vary significantly by race/gender group.nnnCONCLUSIONnGiven the complex risks and benefits of chronic NSAID use, pharmacists, pharmacy staff, and patients all are missing an important opportunity to avoid unsafe prescribing and decrease medication adverse events.

Understanding research principles: Giving our patients the care they deserve

Our goal was to assess the relationships between single-item health literacy screening questions and reading prescription nonsteroidal anti-inflammatory drug (NSAID) written medicine information (WMI) provided at pharmacies. The health literacy of 382 patients from primary care physician practices in Alabama was estimated using validated health literacy screening questions related to understanding written medical information (SQ1); confidence in completing medical forms alone (SQ2); and need for assistance in reading hospital materials (SQ3). Reading WMI was measured by a “Yes” response to the question, “Often the drug store gives you written information such as pamphlets or handouts along with your prescription. Have you read about the risks of NSAIDs in this written material provided by the drug store?” Relationships were assessed using generalized linear latent and mixed models. Two-thirds (67.6%) of patients read WMI. Higher estimated health literacy was associated with increased odds of reading WMI. Adjusted odds ratios (95% CI) were 2.08 (1.08–4.03); 2.09 (1.12–3.91); and 1.98 (1.04–3.77) using SQ1–SQ3. Current WMI may be unable to meet the needs of those with inadequate health literacy. Health literacy screening questions can be used to triage patients at risk for not reading WMI so they can be assisted with supplemental educational strategies.

Screening Questions for Nonsteroidal Anti-inflammatory Drug Risk Knowledge

Pharmacists play a pivotal role in the U.S health care system by providing evidence-based care, generating new knowledge, educating future generations of practitioners, and participating in policy development. In the current edition of AJHP , Schumock and Pickard[1][1] provide a comprehensive