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Studies Target High Rates of HIV Medication Errors Among Hospitalized Patients
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Download the PDF here
Download the PDF here
Findings Among the Research Featured at First IDWeek Conference
"The use of hospital EMR to maintain outpatient HIV clinic antiretroviral regimens decreased error rate by 93% and cost of medication errors by 85%, approximately $25,000. Continuous maintenance of ARV regimens within the hospital EMR allows for accurate medication reconciliation with hospitalized HIV positive patients."
San Diego, CA (October 19, 2012) - Research presented at IDWeek 2012™ concludes that despite advances in electronic medical records, mistakes are still commonly made in the prescription of antiretroviral medications for hospitalized HIV-positive patients. At the same time, a trio of studies suggests however, that electronic records in combination with increased clinical education can help to greatly decrease medical errors.
The three studies are among the significant research being discussed at the inaugural IDWeek meeting, taking place through Sunday October 21 in San Diego. With the theme Advancing Science, Improving Care, IDWeek will feature the latest science and bench-to-bedside approaches in prevention, diagnosis, treatment, and epidemiology of infectious diseases, including HIV, across the lifespan. More than 1,500 abstractsfrom national and international scientists will be highlighted over five days.
"Treatment of HIV infection is complex, involving the administration of multiple drugs that often have the potential for major interactions," noted Joel E. Gallant, MD, IDWeek chair for the HIV Medicine Association. "Hospitalized patients are at risk for serious medication errors, especially when drugs are added or changed by physicians without HIV expertise. These studies emphasize the critical importance of electronic medical records and early expert consultation in hospitalized HIV-infected patients to prevent dangerous and costly medication errors."
Antiretroviral therapy, or HAART, combines three to four powerful drugs to prevent HIV resistance. These drugs can cause toxicity and serious side effects and improper administration can also lead to decreased efficacy.
Two studies featured at IDWeek describe the challenges that hospitals face in ensuring that patients infected with HIV are not put at risk of treatment failure or drug toxicity through dosage, timing and/or other errors with these medications.
In one study, researchers at the Cleveland Clinic looked retrospectively at the charts for 162 admissions of HIV patients over a 10-month period in 2011. The rate of prescription errors in their HAART regimens was 50 percent, and two-thirds of those mistakes were not identified and resolved before the patients were discharged.
Lead researcher Elizabeth Neuner, PharmD, an infectious disease clinical pharmacist at the clinic, points to the changing nature of HIV care as one explanation. Many hospital physicians are less familiar with HAART regimens because so much HIV care is now administered in outpatient settings, she said.
"The number and complexity of medications used to treat HIV and an unfamiliarity with seeing patients with these medications can lead to errors," Neuner said.
Since the study, the Cleveland Clinic has implemented numerous quality improvement measures, including increased education about potential drug interactions with antiretroviral medications and greater coordination of care between inpatient and outpatient settings. The clinic also added dosing and frequency alerts to its electronic medical records system.
Similar error rates were seen over an 18-month period by the University of Chicago Medical Center. Researchers in this second study reviewed 155 HAART regimens, which had been evaluated within 24 hours of the patients' admission. Nearly half of the initial hospital-prescribed HAART regimens required intervention, most typically so that dosages could be modified.
Lead researcher Natasha Pettit, PharmD, a clinical pharmacy specialist with University of Chicago Medicine, suggests that teaching hospitals could have high error rates in part because their medical and pharmacy residents do not have much experience with HIV drugs early in their training. "A first-year resident may not know the nuances related to administering these medications appropriately," she said.
"Data indicate that hospitals need to provide additional educational trainings and create innovative ways to catch and prevent these errors," Pettit added. The University of Chicago Medical Center responded to the findings by developing dosing cards with cautions on drug interactions, timing recommendations and other safety points. They are planning a more detailed evaluation as a step toward modifying HAART medication order entry in their electronic records system.
A third study in Michigan looked at the impact on medication mistakes when an HIV outpatient clinic worked to actively maintain patients' antiretroviral prescriptions in a major hospital's electronic records system. The result: The error rate plunged -- by 93 percent -- among clinic patients who were later admitted to the hospital.
The approach required extensive preparation by Special Immunology Services, the HIV clinic at Saint Mary's Health Care. Although the two are affiliated, their electronic medical records systems don't communicate, and the drug records of nearly 900 clinic patients had to be individually uploaded and then continually updated in the hospital system. Through much of 2010, meetings followed with emergency room physicians. Educational notices went out through various hospital communications to other physicians, nurses, and other departments.
"It resulted in better care for our patients when they were hospitalized," said lead researcher Jean Lee, PharmD, a clinical pharmacist for HIV medicine at Special Immunology Services. In addition, based on a sample of 20 HIV-positive patients, the researchers found that the direct cost of medication errors fell by 85 percent. "We demonstrated that we can improve patient safety and show a financial benefit," said Lee.
Antiretroviral Medication Errors in Hospitalized Patients with HIV Infection
Elizabeth Neuner1, Jennifer Sekeres1, Ramona Davis1, Al Taege2Department of Pharmacy, Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
Conclusions
Medication errors with antiretrovirals and opportunistic infection medications occurred during 50% of admissions to the hospital during the study period
A majority of errors (65%) were neither recognized nor resolved during the admission
Errors were more likely to be resolved when patients received an Infectious Diseases consult
Opportunities exist for improving medication use in HIV patients receiving antiretrovirals and opportunistic infection medications
ABSTRACT
Background: HIV patients prescribed highly active antiretroviral therapy (HAART) are at high risk for medication errors. We sought to determine the rate at our institution.
Methods: Retrospective chart review of patients admitted between 1/1/2011 and 10/31/2011 prescribed antiretroviral therapy. Patients treated with monotherapy lamivudine or tenofovir for hepatitis B were excluded. Rates and types of errors with HAART or opportunistic infection treatment/prophylaxis were determined by the infectious diseases clinical pharmacist. Drug interaction classifications were defined per Micromedex®.
Results: During the 10 month study period, 162 admissions with a median stay of 4 days (range 1-35). Median CD4 count was 272 cells/uL (3-2234) and median viral load log10 copies/ml 2.07. Rate of medication errors was 50%, 81 of 162 admissions had at least 1 error. Total of 126 errors, average 1.6 errors/admission. 35% of errors were resolved during admission, average time to resolution 67.4 hrs. 65% of errors were not resolved, average time from error to discharge 78.7 hrs. Most common errors were major drug interaction 26%, dosing 20%, contraindicated drug interaction 12%, frequency 11%, and incomplete regimen 11%. Baseline characteristics that occurred more frequently in the patients with errors were female gender (44% in error group vs. 28% in no-error group, p=0.049) and hemodialysis (17% in error group vs. 5% in no error group, P=0.022). Infectious Diseases (ID) was consulted in 53% of admissions. Errors occurred in 58% of admissions in which ID was consulted and 41% without (p=0.04). Significantly more errors were resolved when ID was consulted 47% compared to when ID was not involved only 15% were resolved (p=0.002).
Conclusions: Medication errors were common (50%) in HIV patients admitted to the hospital. A significant number of errors (65%) were neither recognized nor resolved during admission. Quality improvement measures have focused on education, modification of electronic drug files, and targeted stewardship efforts between ID and pharmacy.
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Reducing Antiretroviral Medication Errors Utilizing an Electronic Medical Record in Hospitalized HIV Positive Patients
Jean C Lee1, Nnaemeka E Egwuatu1,3, Andrea D Goodrich2, Kymberlee A Moline2, Terry K Kirkpatrick2, David D Baumgartner1,3, Minerva A Galang1,3 1Special Immunology Services, Saint Mary's Health Care, Grand Rapids, MI, 2Depatment of Pharmacy Services, Saint Mary's Health Care, Grand Rapids, MI 3College of Human Medicine, Michigan State University, Grand Rapids, MI
ABSTRACT
Background: Antiretroviral (ARV) medication errors occur in all settings including during the admission process with medication reconciliation. These medication errors may lead to toxicity and decreased efficacy of ARVs, leading to potential development of viral mutations to current ARV therapy and thus, limiting future treatment options. Hospital electronic medical records (EMR) may be utilized to provide accurate ARV regimens to reduce medication errors and aid in medication reconciliation.
Methods: All ARVs were updated in the hospital EMR and maintained with any changes from the HIV clinic. ARV error rate, cost of errors and cost of pharmacist time to resolve errors were determined from a sample of 20 HIV positive hospitalized patients. Post-intervention metrics were compared to baseline and 6 months later for sustainability. Errors were categorized as: wrong dose, wrong time, drug interaction, ARV not ordered, wrong drug or wrong frequency. Cost of pharmacist time was based on an average pharmacist wages. Cost of error was based on activity definitions from a benchmarking system on cost of medication errors.
Results: Post-intervention, ARV error rate reduced from baseline by 93% (16.0% vs. 1.1%, p=0.002) and was sustained 6 months later (16.0% vs. 1.1%, p=0.004). Comparing baseline to post-intervention, the most common ARV error was wrong time (14 vs. 1), followed by wrong dose (4 vs. 1), drug interaction (4 vs. 1), missing ARV (4 vs. 1), wrong drug (3 vs. 0) and wrong frequency (2 vs. 0). The cost of these errors was reduced by 85% at approximately $25000. Cost of pharmacist time to resolve these errors was reduced by 87% at $338.
Conclusions: The use of hospital EMR to maintain outpatient HIV clinic antiretroviral regimens decreased error rate by 93% and cost of medication errors by 85%, approximately $25,000. Continuous maintenance of ARV regimens within the hospital EMR allows for accurate medication reconciliation with hospitalized HIV positive patients.
Table 1: Comparison of error rates and costs
Medication Errors in Inpatient Highly Active Anti-Retroviral (HAART) Therapy
Natasha N. Pettit, PharmD, BCPS1, Benjamin D. Brielmaier, PharmD1, Emily Landon, MD2, Jennifer C. Pisano, MD3 and Allison H. Bartlett, MD4, (1)Pharmaceutical Services, The University of Chicago Medicine, Chicago, IL, (2)Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, (3)Department of Medicine, Section of Infectious Diseases and Global Health, The University of Chicago Medical Center, Chicago, IL, (4)Pediatrics, Baylor College of Medicine, Houston, TX
Background: Medication related errors (MRE) are common among HIV-infected patients on HAART due to the complexity of the regimens, especially when transitioning to the inpatient setting. Missed doses or inadvertent changes in therapy can quickly lead to resistance or toxicity. The purpose of this analysis was to review errors associated with HAART in the inpatient setting.
Methods: At a large academic medical center the medication profile of all HIV-infected patients receiving HAART are reviewed by an Infectious Diseases clinical pharmacist within 12-24 hours of admission. Patients are identified through a daily report of all patients receiving antimicrobials, including anti-retrovirals.
Results: 155 individual HAART regimens were evaluated between October 2010 to March 2012. 75 of the regimens required one or more interventions as outlined in table 1. The majority of interventions (47.4%) were related to dosage modification. Only 5% of interventions were related to addressing drug-interactions.
Conclusion: Dosing errors in HAART were common in admitted HIV-infected patients. Almost 50% of inpatient HAART regimens required intervention. It is clear that review of these agents is necessary but even evaluation within 12-24 hours may not be sufficient to prevent resistance or toxicity.
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