Use of an Anti-Infective Medication Assignment 12 –

Use of an Anti-Infective Medication Assignment 12
Use of an Anti-Infective Medication Assignment 12
Use of an Anti-Infective Medication Review Process at Hospital Discharge to Identify Medication Errors and Optimize Therapy
Christy P. Su, PharmD, BCPS 1 , Levita Hidayat, PharmD
2 ,
Shafiqur Rahman, MD 3 , and Veena Venugopalan, PharmD, BCPS, AQ-ID
Abstract Background: Medication reconciliation is a major patient safety concern, and the impact of a structured process to evaluate anti- infective agents at hospital discharge warrants further review. Objective: The aim of this study was to (1) describe a structured, multidisciplinary approach to review anti-infectives at discharge and (2) measure the impact of a stewardship-initiated anti- microbial review process in identifying and preventing anti-infective-related medication errors (MEs) at discharge. Methods: A prospective study to evaluate adult patients discharged on anti-infectives was conducted from October 2013 to May 2014. The antimicrobial stewardship program (ASP) classified interventions on anti-infective regimens into predefined ME categories. Results: Forty-five patients who were discharged on 59 anti-infective prescriptions were included in the study. The most common indications for anti-infective regimens at discharge were pneumonia (22%, n ¼ 10), bacteremia (18%, n ¼ 8), and skin and soft tissue infections (16%, n ¼ 7). An ME was identified in 42% (n ¼ 19/45) of anti-infective regimens. Seventy percentage of ASP team recommendations were accepted which resulted in an avoidance of MEs in 68% (n ¼ 13/19) of patients with an ME prior to discharge. Conclusion: This study describes the outcomes of a stewardship-initiated review process in preventing MEs at discharge. Developing a systematic process for a multidisciplinary ASP team to review all anti-infectives can be a valuable tool in preventing MEs at hospital discharge.
Keywords antimicrobial stewardship, transitions of care, hospital discharge, medication errors, medication reconciliation
Transition of care from hospital to community can be a high-
risk period for medication errors (MEs). 1
The National
Coordinating Council for Medication Error Reporting and
Prevention (NCCMERP) defines ME as any preventable event
that may cause or lead to inappropriate medication use or
patient harm, while the medication is in the control of the
health-care provider, patient, or consumer. 2
Forster and col-
leagues noted that 66% of adverse events (AEs) occurring in patients following hospital discharge were medication related
and could be prevented in 27% of cases. Furthermore, anti- infective agents were identified as one of the most common
medication classes associated with adverse drug events with a
reported rate of 5.1 AE per 100 prescriptions. 3,4 Use of an Anti-Infective Medication Assignment 12
ME prevention is a major patient safety concern which has
received national attention. 5
Many patients who receive anti-
microbials in hospitals are also discharged on antimicrobial
therapy, to complete the treatment course at home, in long-
term acute care centers, skilled nursing facilities, outpatient
infusion centers, or dialysis centers. 6,7
In the absence of anti-
microbial stewardship oversight at these transitions of care
points, patients may be discharged from hospitals on
inappropriate therapy. This presents a unique opportunity for
antimicrobial stewardship programs (ASP) to be involved in
the discharge process. We conducted a pilot study at The
Brooklyn Hospital Center (TBHC), a 416-bed community
teaching facility in Brooklyn, New York. The objectives of this
study were to (1) describe a structured, multidisciplinary
approach to review anti-infective prescriptions at discharge and
(2) measure the impact of a stewardship-initiated anti-infective
review process in identifying and preventing anti-infective-
related MEs at discharge. The experience gained from this
1 Department of Pharmacy, Memorial Hermann Greater Heights Hospital,
Houston, TX, USA 2 Global Health Science, The Medicines Company, Parsipanny, NJ, USA 3 Division of Infectious Diseases, The Brooklyn Hospital Center, Brooklyn, NY,
USA 4 Department of Pharmacotherapy and Translational Research, College of
Pharmacy, University of Florida, Gainesville, FL, USA
Corresponding Author:
Christy P. Su, Department of Pharmacy, Memorial Hermann Greater Heights
Hospital, 1635 North Loop West, Houston, TX 77008, USA.
Email: [email protected]
Journal of Pharmacy Practice 2019, Vol. 32(5) 488-492 ª The Author(s) 2018 Article reuse guidelines: DOI: 10.1177/0897190018761411
mailto:[email protected]:// is critical in identifying institutional resources needed to
implement an anti-infective review process and sustain it to
produce desired outcomes. Use of an Anti-Infective Medication Assignment 12
A single-center prospective study was conducted at TBHC
from October 2013 to May 2014. TBHC has a centralized
pharmacy model. Pharmacists in the central inpatient pharmacy
provide distributional services and primarily serve in a drug
dispensing role. There are also clinical pharmacy specialists
integrated into the patient care teams within the medical inten-
sive care, family medicine, and pediatrics units. These pharma-
cists perform a combination of clinical and distributional
activities. At the time of this study, the pharmacy department
operated with 11 clinical pharmacy specialists which included
coverage for inpatient and outpatient clinical services. The
ASP was established in 2004 and comprised of infectious dis-
eases (ID) physicians, ID clinical pharmacists, and a PGY-2 ID
resident. The ASP was actively involved in prospective anti-
infective review during hospitalization; however, no process
was in place for the assessment of discharge treatment.
To begin the development of a systematic process to review
anti-infective agents at discharge, one hospital service was
selected during this study period, with future plans to expand
the initiative hospital-wide. Patients greater than 18 years of age
who were discharged from the family medicine service on intra-
venous (IV) or oral anti-infective therapy were included in this
initiative. MEs were identified according to NCCMERP and
were classified into the following predefined categories by
Heintz and colleagues: safety, efficacy, or simplification. 8
interventions included those related to ordering laboratory tests,
adjusting doses due to renal dysfunction, avoiding central line
placement, avoiding unnecessary anti-infective agents, reassess-
ment of patient’s stability, or adjusting therapy due to drug
interactions. Efficacy interventions included those related to
anti-infective selection, dose, or extending the duration of ther-
apy. Simplification interventions included those related to reduc-
ing the frequency of dosing, performing IV to oral interchange,
reducing the number of anti-infective agents prescribed, or short-
ening the duration of therapy (Table 1). Each anti-infective agent
prescribed could have more than 1 type of intervention.
The stepwise process of implementing the review process is
depicted in Figure 1.  Use of an Anti-Infective Medication Assignment 12The ASP clinical pharmacist contacted the
family medicine team daily for a list of patients with an anticipated
discharge within 48 hours. The ASP team then screened these
patients for anti-infective prescriptions through electronic medi-
cal records. Patients who had a prescribed anti-infective agent
were evaluated by the ASP team for appropriateness based on
evidence-based practice guidelines. Potential interventions that
were identified were then verbally communicated and discussed
with the primary team physician. However, if a patient received an
ID consultation during hospital admission, the ID consultant
would be contacted and changes to treatment regimens were made
collaboratively with the ASP team. All recommendations were
made prior to patient discharge and the number of accepted inter-
ventions and types were quantified. Descriptive statistics were
used to present the results. This study was conducted in compli-
ance with the hospital’s institutional review board.
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