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  ID Week
Oct 8-12 2014
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In-Hospital Antiretroviral Errors Correctly Quickly With Two-Pronged Strategy
  IDWeek 2014, October 8-12, 2014, Philadelphia
Mark Mascolini
Two thirds of in-hospital antiretroviral medication errors were corrected within 24 hours and no error went uncorrected, thanks to implementation of a unified electronic medical record (EMR) and pharmacist reconciliation in a 186-admission US study [1]. The new approach also greatly reduced the error rate compared with an earlier period at the same hospital.
Medication errors remain common when HIV-positive people get admitted to the hospital. Previous work by a team at the University of Nebraska Medical Center found a 35% antiretroviral error rate from 2009 through 2011, and 55% of those errors never got corrected [2]. To limit such errors and speed their correction, the Nebraska group developed a medication reconciliation process with an HIV pharmacist and the institution adopted a unified EMR. Researchers conducted this prospective study to determine the impact of those changes.
This medical record review involved HIV-positive people admitted to the hospital for more than 24 hours between March 2013 and March 2014. An HIV pharmacist reconciled outpatient antiretroviral prescriptions with inpatient orders within 24 hours of admission. The researchers determined error rates and time to correction compared with historical data through logistic regression models.
In the 2009-2011 retrospective review, there were 416 admissions, 289 of which (69%) involved 340 prescription errors, and errors were more frequent with African-American patients than with whites (relative risk [RR] 1.53, 95% confidence interval 1.16 to 2.03). In the current pharmacist-intervention period, there were 186 admissions, 31 of which (17%) involved 43 errors, and error rates did not differ by race or gender. The largest share of errors in the pharmacist-intervention period involved incorrect scheduling (42%), followed by omission (21%), drug-drug interactions (19%), incorrect dosing (16%), and incorrect therapy (2%).
In the pharmacist-intervention period, error rates were similar among nucleosides, nonnucleosides, and protease inhibitors (PIs), but much lower with coformulated antiretrovirals. Compared with coformulated agents, prescription error risk was higher with nucleosides (RR 3.91, 95% confidence interval [CI] 1.14 to 13.4) and PIs (RR 3.6, 95% CI 1.1 to 11.7). Using coformulated antiretrovirals lowered the risk of errors about 75% when compared with either nucleosides (RR 0.26, 95% CI 0.07 to 0.88) or PIs (RR 0.28, 95% CI 0.09 to 0.91), but not compared with nonnucleosides or integrase inhibitors.
In the 2009-2011 retrospective review, 30.8% of errors got corrected within 24 hours, 7.6% within 48 hours, 6.6% after 48 hours, and 55% never. With pharmacist intervention, 67% of errors got corrected within 24 hours, 14% within 48 hours, and all the rest after 48 hours.
A logistic regression model to determine chance of any prescription error in the combined 3-year retrospective review and the pharmacist-intervention period figured that black race inflated the odds of an error more than 70% (odds ratio [OR] 1.715, 95% CI 1.145 to 2.570, P = 0.009), while electronic medical records lowered the odds more than 60% (OR 0.388, 95% CI 0.250 to 0.604, P < 0.001). Gender did not affect odds of prescription error detection.
Logistic regression to identify associations with correcting all errors within 24 hours of hospital admission also included both study periods. Having one or more drug omission errors raised the odds of correcting all errors within 24 hours more than 6 times (OR 6.431, 95% CI 2.349 to 17.609, P < 0.001), while pharmacy review improved odds more than 9 times (OR 9.441, 95% CI 3.013 to 29.578, P < 0.001). In contrast, more total errors halved odds that all would be corrected within 24 hours (OR 0.513, 95% CI 0.345 to 0.764, P = 0.001).
The University of Nebraska team concluded that using electronic medical records sliced prescription error rates more than 50%, "but the pharmacist intervention was key to timely error correction." Even with improvements gained through electronic medical records and pharmacist intervention, the researchers stressed, antiretroviral prescription errors were common--though quickly corrected.
1. Batra R, Wolbach-Lowes J, Swindells S, et al. Antiretroviral prescription errors among hospitalized HIV-infected patients. IDWeek 2014. October 8-12, 2014, Philadelphia. Abstract 1557.
2. Commers T, Swindells S, Sayles H, Gross AE, Devetten M, Sandkovsky U. Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients. J Antimicrob Chemother. 2014;69:262-267. http://jac.oxfordjournals.org/content/69/1/262.abstract