Case Study: Review of Medication Orders for Appropriateness at Satguru Singh Apollo Hospitals, Ludhiana, India
By Dr. Geeta Chaudhary, Clinical Pharmacologist, Satguru Partap Singh Apollo Hospitals, Ludhiana, India (chaudhary_g@hotmail.com )
Abstract: One of the important components to improve medication safety is the review of medication orders by trained professionals prior to administration. Setting up an audit team in a country where clinical pharmacy is in nascent stage was challenging. This case study highlights the strategies adopted to review medication orders for appropriateness and how the process has benefited Satguru Partap Singh Apollo Hospitals. Satguru Partap Singh Apollo Hospitals was accredited by Joint Commission International in February 2010.
Providing health care needs of the highest standard in a safe and protective environment is of the utmost priority to leadership and staff at Satguru Partap Singh (SPS) Apollo Hospitals in Ludhiana, India. This priority is evident from the fact that the hospital opted for Joint Commission International accreditation within 2 years of its inception, and truly reflects SPS’ commitment to high-quality healthcare.
Medication Management—The SPS Focus Area
The initiative to overhaul the medication management program at SPS began in the year 2005. The objective was to establish safer medication practices so that patients can receive the right drug, at right dose, at right time by an efficient system. The medication management process at SPS was restructured and new check points were added so that all stages of the medication use process—selection, storage, ordering, dispensing, administration, and monitoring, as defined by Joint Commission International (JCI) requirements—are appropriately integrated into a comprehensive medication management system.
One of the JCI requirements in the medication use process is the prospective audit of the medication orders for appropriateness by trained professionals prior to administration. This is one of the most critical steps in the medication management use process. However, setting up the system was a real challenge for SPS because of the unavailability of trained manpower.
Clinical pharmacy is not widely taught or well recognized in India. It has been taught in this country only since the 1990s and very few colleges offer courses in it below the postgraduate level. Therefore, finding trained human resources in clinical pharmacy is an arduous job in itself.
Implementing Process for Review of Medication Orders for Appropriateness
Setting up the team
A total of ten candidates were chosen in March 2006 for the audit team from a pool of candidates who adequately completed their course work in pharmacy. A training module was developed and the team was trained in-house for a period of three months by the clinical pharmacologist.
Training included theory classes and the practice sessions. Several topics were covered, including the following:
• Pharmacology
• Concepts of pharmacodynamics and pharmacokinetics
• Individualization of drug therapy
• Adverse drug reaction reporting
• Dose calculations
• Drug risk classification in pregnancy
• Drug-drug, drug-food, and drug-disease interactions
• Drug compatibility and stability
• Photosensitive drugs
• Safety protocols on high-risk drugs
• Medication management protocols in the hospital, including error reporting
Candidates were also trained on the use of resources, including using data from evidence-based practices. The trainee pharmacists were assessed for competency for reviewing drug orders. Out of ten candidates, seven cleared the competency assessment after three months of training and were enrolled as full time staff.
Once chosen selected for full-time status as a clinical pharmacist, the pharmacists are assessed for their performance annually. Seminars and journal clubs—collective discussion groups on the latest literature from the field—are required for all clinical pharmacists.
Information access for the team
Changes were introduced in the hospital information system software so that the pharmacists performing the audit has access to patient’s laboratory reports, current medication list, pregnancy and lactation status, and other medical record data. To ensure that maximum information is available to the pharmacist reviewing drug orders, all the parameters that constitute a complete drug order are included in the pharmacy transcribing module, including the following:
• Drug name
• Route of administration (how the drug enters the body
• Dose
• Frequency
• Infusion rates and diluents (for intravenous drug infusions)
• Types of orders (stat/routine)
• Allergy status of the patient
• Demographic data of the patient
Drop-down menus were created with drug names tagged with available strengths.
Sources of drug information
The team was given round-the-clock access to books and the latest online drug resources, including the following:
• The Pharmacological Basis of Therapeutics, by Goodman and Gilman
• Pharmacology by Rang and Dale
• Basic and Clinical Pharmacology by Katzung
• Lippincott’s Illustrated Reviews: Pharmacology
• The Sanford Guide to Antimicrobial Therapy
• Monthly Index of Medical Specialties
• Physicians’ Desk Reference
• Drug Interaction (Facts & Comparisons)
• Drug Identifier (Facts & Comparisons)
Restructured Medication Use Process at the Hospital
After setting up team and the methodology for reviewing medication orders for appropriateness, SPS committed to strengthen its medication use process by instituting new “check points” in its procedures. Figure 1 details the restructured medication process of the hospital depicting the various check points including the medication order review by pharmacist.
Figure 1. Medication Use Process Flow Depicting Cross Checks in the System
Source: Satguru Partap Singh Apollo Hospitals, Ludhiana, India. Used with permission.
Once the drug therapy is indicated for the patient, the physician prescribes the therapy on the drug order sheet, mentioning all the parameters that constitute a complete order. The prescription is then transcribed by the nurse on the pharmacy module and transmitted online. In the pharmacy, the drug orders are verified for accuracy and appropriateness by the pharmacist. Only after clearance, the dispensing pharmacists dispense the drugs to the patient care areas. The drugs are stored in the patient’s bedside locker until administered by nurses, using seven rights of drug administration—right patient, right drug, right dose, right route, right time, right technique, and right documentation.
Process for Review of Medication Orders for Appropriateness
Review of medication orders for appropriateness by the pharmacist is a critical step in ensuring patient safety in the medication use process. Once the drug order is received at the pharmacy, the pharmacist evaluates the order for appropriateness as detailed in Figure 2.
Figure 2. Medication Use Process Flow Depicting Cross Checks in the System
Source: Satguru Partap Singh Apollo Hospitals, Ludhiana, India. Used with permission.
If the pharmacist finds any discrepancy, the pharmacist calls the staff nurse to confirm the order via the drug order sheet. This conversation is documented for the record. If the discrepancy persists, the prescribing physician is contacted to resolve the query. Only after the clearance by the clinical pharmacist are the drugs dispensed. Any error that the pharmacist discovers during the process is documented, mentioning the error details, action taken, and outcome. These errors are compiled at the end of the month, trended, and analyzed for quality improvement.
How Medication Order Review for Appropriateness Benefits SPS
Introducing the medication order review by pharmacist before drug administration has helped SPS immensely in raising the safety bar on use of medicines, including the following:
• Interception of errors. The new process helps us identify and intercept errors before they reach the patient, thereby increasing patient
safety.
• Reducing medication errors. The literature suggests that detecting errors and rectifying the systems is very important since processes
resulting in minor errors can later lead to other more serious errors. Our data analysis on medication errors intercepted by the team
revealed that the number of transcription errors was quiet high. A multidisciplinary team was formulated to review the transcription
process and find the causes for the transcription errors. The team recommended modifying the transcription process to eliminate
vulnerable areas, and as a result, the following interventions, among others, were instituted:
—Dedicated pharmacists were recruited for transcribing the drug orders in wards.
—Training on computer skills was enhanced.
—More double checks were added in the pharmacy module at critical steps.
These interventions led to significant decrease in transcription errors, from 43.2 errors per 1,000 orders to 5.2 errors per 1000 orders within 12 months from January 2009 to December 2009.
• Strengthening drug safety measures. The procedures followed during the medication order review process strengthen the safety
measures with regards to medication use. Measures include the following:
—Safety alerts for various classes of drugs, including high-risk drugs, look-alike sound alike drugs, and photosensitive drugs
—Increased attention to the medication orders of special population (renally and hepatically impaired, elderly, pediatric, pregnant, and
lactating population) and patients with allergy history
—Alerts to the physicians for any clinically significant interactions and contraindications and the precautions to be taken thereafter
• Improve compliance with safer practices. SPS has been able to improve compliance with a number of safe practices the following:
—Dosage adjustments for special population by the physicians
—Re-assessing the patient’s allergy status prior to prescribing
—A more complete order on intravenous drug infusions
—Eliminating extended-release and enteric-coated tablets from being crushed at the time of administration
Improved compliance is evident by the fact that the number of prescription errors related to nonadjustments of drug dosage for special populations—which constituted 15% of total prescription errors at the start of the review process—dropped to 3.4 % after two years. Similarly, number of patients prescribed the drugs to which they were allergic fell from 18% to 6%.
Below are examples of errors intercepted by the pharmacy during the medication order review process.
Sample Case 1
A 70-year-old male patient, with a known case of hypertension, diabetes mellitus type-2, and coronary artery disease, was admitted in the hospital complaining of being unable to walk for 3 weeks. The patient was taking an oral antidiabetic drug prior to admission and was initially prescribed another antidiabetic drug after admission. On review of the prescription by the pharmacist in the clinical pharmacology unit, the pharmacist discovered that both of the pre- and postadmission drugs contain gliclazide, and that the combined dose of these two drugs could have put the patient at an increased risk of hypoglycemia.
Sample Case 2
A 30-year-old male patient was admitted to the hospital and was diagnosed with a case of cryptococcal meningitis. The patient was prescribed an antifungal drug, dose 500 mg, route intravenous, duration of infusion 6 hours, with normal saline as diluent. The drug order was intercepted by the pharmacist because of drug-fluid incompatibility. The prescribed drug is incompatible in normal saline, which on dilution may precipitate, resulting in the loss of potency, increase in toxicity, or other adverse affects. This incompatibility was brought to the attention of the physician and the diluent was changed as per the recommendations of the manufacturer.
Sample Case 3
The 40-year-old male patient was admitted in hospital and diagnosed with alcoholic liver disease and acute pancreatitis. The patient had an upper and lower gastrointestinal bleed, for which the patient was prescribed terlipressin, 0.5 mg, duration of infusion 6 hours. However, when the orders were written on the new chart the next day by the ward physician, the order was incorrectly copied as 5 mg, 6 hourly, a ten-times-higher dose. The order was intercepted by the pharmacist as the dose mentioned was much higher than the recommended dose. The error could have caused the patient serious adverse effects with systemic circulation.
Conclusion
Review of medication orders for appropriateness is one of the most challenging parts of the medication management use. At SPS, we achieved our objective by focused human resource training and designing and implementing effective systems. It was a step towards increasing the overall quality of drug therapy and medication use safety in the organization.