Linda Graudins

Long-term Reduction in Adverse Drug Events: An Evidence-Based Improvement Model

OBJECTIVES: To develop and test an evidence-based model for reducing medication errors and harm in hospitalized children. METHODS: Prospective interrupted time series study evaluating the effectiveness of a multifaceted, staged intervention over 4 years in a major urban pediatric referral hospital. Guidelines for safe pediatric prescribing were implemented by using an evidence-based model. Key components included early clinician engagement and improved multidisciplinary communication, consensus development, interactive education, and timely data feedback by using iterative Plan-Do-Study-Act cycles. Impact on medication error and harm (adverse drug events, [ADEs]) was measured by using standard definitions and a multimethod approach. Prospective data from voluntary reports by nursing, medical, and pharmacy staff and intensive chart review were combined. All data were reviewed by a multidisciplinary panel, including causality assessments for ADEs. RESULTS: Reviewed over 3 time periods were 1011 patients with 6651 medication orders. Total ADEs decreased by > 50% in the first year and this was maintained at 4 years. Greatest improvements were in potential ADEs, which decreased from 12.26 per 100 patients at baseline to 4.60 per 100 patients at 4 years (P < .05). Total medication errors decreased from 4.51 per 100 orders at baseline to 2.78 per 100 orders at 4 years (P < .05). Prescribing errors decreased by 65%, from 4.07 per 100 orders at baseline to 2.05 orders at 4 years (P < .05). CONCLUSIONS: A multifaceted, evidence-based model for safe prescribing guideline implementation, engaging multidisciplinary clinicians, was effective in reducing medication error and harm in hospitalized children, resulting in sustained long-term improvement.

SHPA Standards of Practice for Drug Use Evaluation in Australian Hospitals: SHPA Committee of Specialty Practice in Drug Use Evaluation

INTRODUCTION Drug use evaluation (DUE) is a systematic quality improvement activity. The purpose of DUE is to improve the quality and cost-effectiveness of drug (medicine) use, and thereby improve patient care. DUE may be applied to a drug, therapeutic class, disease state or condition, a drug use process or specific outcomes.1 It may be applied in various practice settings, including hospitals, other health facilities, and community practice environments.2 DUE is an essential component of pharmacy service provision, clinical pharmacy practice and pharmacy quality assurance and management programs. These standards supersede the previously published SHP A Standards of Practice for DUE in Australian hospitals. 3

Changes in anticonvulsant prescribing for Australian children: implications for Quality Use of Medicines.

Aims:  The evidence‐base guiding choices between newer versus established anticonvulsants in children is limited. Inappropriate use exposes children to potentially ineffective and/or harmful medicines. Our objective is to describe recent anticonvulsant prescribing patterns in the Australian paediatric population, evaluating overall trends and extent of off‐label prescribing of newer agents.

Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study).

Objectives: To determine the nature, prevalence and description accuracy of recorded antibiotic allergy labels (AALs) in a cohort of general medical inpatients, and to assess the feasibility of an oral antibiotic re‐challenge study.

SHPA Standards of Practice in Emergency Medicine Pharmacy Practice

These standards describe the activities consistent with good practice for the provision of clinical pharmacy services in the specialty area of emergency medicine (EM). They should be read in conjunction with the current Society of Hospital Pharmacists of Australia (SHPA) Standards of Practice for Clinical Services. EM pharmacy practice encompasses clinical care for patients in the emergency department (ED) and may include pre-hospital care, toxicology and disaster planning. An ED is defined as a unit managing acute, urgent and time-critical aspects of illness and injury presenting from the community. Approximately one-quarter of patients who present to an ED will require an inpatient admission. EM pharmacists may therefore provide early pharmaceutical care to both patients who are admitted to hospital and those who are discharged back to community care directly from the ED. EM pharmacists have been shown to reduce hospital admissions. Associated with many EDs are short-stay units, the specific names of which vary and include ‘Emergency Medical Unit’, ‘Medical Admission Planning Unit’ and ‘ShortStay Observation Unit’. Typically, patients in such units are admitted for up to 24 or 48 h. The pharmacist responsible for the overall EM service is referred to as the EM pharmacist. OBJECTIVES

More than skin deep. Ten year follow-up of delayed cutaneous adverse drug reactions (CADR).

AIMS To determine the gaps in practice regarding appropriate ADR documentation and risk communication for patients diagnosed with severe cutaneous adverse drug reactions (CADR). METHODS This was a retrospective observational cohort study conducted using hospital coding and databases to identify inpatients diagnosed with CADR from January 2004 to August 2014. Hospital discharge summaries, ADR reports and pharmacy dispensing records were reviewed for ADR documentation. Patients still living in Australia and who did not opt out of being contacted were invited to be surveyed by telephone to determine their understanding of recommendations, re-exposure rates and long-term effects. RESULTS Of 85 patients identified, median age was 59 (IQR 44-72) years and 47.1% were male. The most common diagnosis was TENS (49.4%). Ten patients (11.8%) died as inpatients. Of the 81 patients with a drug-related causality, 47 (58%) had appropriate documentation in all three required medical record platforms. Of the 56 eligible patients, 38 (67.9%) were surveyed; 13% had no information provided upon discharge and 26.3% patients had a mismatch in knowledge of implicated medications. No surveyed patient had a relapse of CADR, but 23.7% had a subsequent unrelated allergic reaction. Thirteen patients (34.2%) reported long-term effects. CONCLUSIONS We found gaps in the accuracy of ADR documentation and communication of risk at discharge, which indicated risks to patient safety. Electronic systems are being developed to improve documentation. Written information about CADR is being provided at discharge to improve patient understanding and knowledge.

Celecoxib use and overuse - too much 'celebration'?

Aim: To characterise indications for celecoxib use in a hospital population and to evaluate whether hospital prescribing of celecoxib was consistent with agreed hospital guidelines.

Drug‐induced liver injury is frequently associated with severe cutaneous adverse drug reactions: experience from two Australian tertiary hospitals

Drug‐induced liver injury (DILI) can be associated with certain cutaneous adverse drug reaction (cADR).

Adverse Drug Reactions Reported by Healthcare Professionals: Reaction Characteristics and Time to Reporting

We describe adverse drug reaction (ADR) reporting characteristics and factors contributing to length of time to report by healthcare professionals. This is a retrospective study of voluntary reports to an Australian healthcare ADR Review Committee over a 2‐year period (2015–2016). Descriptive and univariate models were used for outcomes, employing standardized ADR definitions. Hospital pharmacists reported 84.8% of the 555 ADRs: 70.3% were hospital onset reactions, and 71.7% were at least of moderate severity. Immunologically mediated reactions were most commonly reported (409, 73.7%). The median time to submit an ADR report was 3 (interquartile range 1–10) days. Longer median times to reporting were associated with multiple implicated agents and delayed hypersensitivity reactions, especially severe cutaneous adverse reactions. A total of 650 medications were implicated that involved multiple agents in 165/555 (29.7%) reports. Antimicrobials were the most commonly implicated agents. Immunologically mediated reactions were most commonly associated with antimicrobials and radiocontrast agents (P < .0001, odds ratio [OR] 3.6, 95%CI 2.4–5.5, and P = .04, OR 4.2, 95%CI 1.2–18.2, respectively). Opioids and psychoactive medications were more commonly implicated in nonimmunological reported ADRs (P = .0002, OR 3.9, 95%CI 1.9–7.9, and P < .0001, OR 11.4, 95%CI 4.6–27.8, respectively). Due to the predominant reporting of immunologically mediated reactions, a targeted education program is being planned to improve identification and accuracy of ADR reports, with the overall aim of improved management to ensure quality service provision and patient safety.

Medication-related anaphylaxis treated in hospital: Agents implicated, patient outcomes, and management lessons

On background of increasing medication‐related anaphylaxis rates in Australia, our aim was to determine epidemiology, outcomes, adverse drug reaction (ADR) reporting rates, and accuracy of coding in patients treated for nonantimicrobial medication‐related anaphylaxis in our hospital network.