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Opioid prescribing requires careful planning to minimise the risk of serious adverse outcomes. However, documentation of discharge opioid plans for patients and their general practitioners (GPs) is inconsistent, particularly when opioids are commenced in the emergency department or after surgery. We describe an initiative to promote consistent discharge opioid plan communication by implementing an opioid management plan (OMP) in our hospital's electronic medical record. Completion of an electronic form by the prescriber generates an OMP note in the medical history, which is used by the pharmacist to provide tailored opioid patient education. The OMP also populates the discharge summary that is sent to the GP and the Australian national digital health record platform, My Health Record. Preliminary evaluation shows incorporating OMP documentation into routine workflows has assisted prescribers to consistently document the plan for supplied opioids, supporting continuity of care. Workflow optimisation is ongoing to further improve discharge summary documentation and provision of patient‐friendly written information. This study was conducted as a quality improvement project and audits conducted as part of the project were approved by Austin Health's Office for Research (Project No: LNR/18/Austin/155). Informed patient consent was not required by Austin Health. [ABSTRACT FROM AUTHOR]

Aim: To evaluate whether pharmacist‐assisted electronic warfarin charting and monitoring reduces warfarin‐related errors and improves post‐discharge continuum of care. Method: Cardiology and medical patients admitted for at least 24 h and prescribed at least one warfarin dose were included in a pre/post‐intervention study. The intervention involved pharmacists proactively charting warfarin and ordering international normalised ratios (INRs) using electronic prescribing software, following discussion with medical doctors. Endpoints included: percentage of patients with one or more warfarin errors, INR > 5.0 during admission, readmission within 30 days for anticoagulant‐related issues and warfarin discharge plan (WDP) completeness (including documentation of next dose/s, and when and where the next INR was to be checked). Results: Pre‐ and post‐intervention groups comprised 130 and 108 patients, respectively. Post‐intervention, more patients received warfarin following heart valve replacement and fewer for venous thromboembolism. Post‐intervention, pharmacists ordered 130 doses (72 patients) and 98 INRs (59 patients). Percentage of patients with one or more warfarin errors declined from 27.7 to 7.4% (p < 0.01), with INR> 5.0 decreased from 7.7 to 2.8% (p = 0.17) and readmission within 30 days for anticoagulation problems occurred in 4 and 0 cases pre‐ and post‐intervention, respectively. While there was a non‐significant decline in the proportion of patients with a WDP post‐intervention, when patients had a WDP it was more comprehensively completed (p < 0.01). Conclusion: Pharmacists proactively charting and monitoring warfarin reduced warfarin‐related errors during hospitalisation and improved elements of post‐discharge communication. Closer multi‐disciplinary communication and 7‐day pharmacy services may result in further continuum of care improvements. [ABSTRACT FROM AUTHOR]

Background: An interim residential care medication administration chart (IRCMAC), usually handwritten by hospital medical officers, is provided by some hospitals to reduce the risk of medication administration delays and errors for patients discharged to residential care facilities (RCFs). Aim: To describe a novel method for IRCMAC preparation; and to determine the percentage of patients discharged from hospital to RCFs who received an IRCMAC, the accuracy of the IRCMAC, and the time IRCMAC preparation added to the pharmacy discharge process. Method: Software and processes were developed to enable integration of IRCMAC preparation into the pharmacy discharge process, with auto-population of the IRCMAC with patient, prescriber and medication data. The percentage of patients for whom RCF staff reported receiving an IRCMAC over a 3-month study period was determined by telephone interview 24 to 72 hours post-discharge. Accuracy was determined by retrospective comparison of a random sample of IRCMACs with pharmacist reviewed and reconciled discharge prescriptions to identify discrepancies. Time added to pharmacy discharge processes was recorded prospectively by pharmacy staff. Results: RCF staff reported receiving IRCMACs for 214/226 (95%) patients discharged to 84 RCFs. The medication discrepancy rate (excluding nutritional supplements) in 76 randomly selected IRCMACs was 9/877 (1%). The IRCMAC took a mean of 8.7 (SD 4.1) minutes to prepare. Conclusion: Accurate IRCMACs can be provided for a high percentage of patients discharged to RCFs by hospital pharmacists using a semi-automated process linked to dispensing software. [ABSTRACT FROM AUTHOR]

Aim: To investigate complementary and alternative medicines (CAM) knowledge and use in patients on warfarin and matched controls, and the association between CAM use and adverse events (bleeding or clotting). Method: A retrospective cohort study was undertaken in the emergency department of a Melbourne hospital. Patients in the warfarin and control groups were those taking/not taking warfarin, respectively (groups matched for age and gender). An investigator-administered questionnaire was used to collect data on CAM knowledge and use, and bleeding/clotting events during the previous 6 months. The international normalised ratio (INR) data during the previous 6 months were obtained from medical and pathology records. Results: 246 warfarin and 246 control group patients were enrolled. Approximately 50% in each group indicated that they knew of the potential for CAM-drug interactions. Only 60 (24%) patients in the warfarin group reported having been advised about CAM use. Compared to controls, a similar proportion of warfarin patients reported CAM use (29% vs 37%; p = 0.07) and significantly fewer used a CAM known to interact with warfarin ('interacting CAM') (11% vs 19%; p = 0.03). In the warfarin group, CAM users and non-users reported a similar number of events below and above their therapeutic INR range and when the INR exceeded 5. CAM users in the warfarin group tended to have more abnormal bleeding events (42% vs 30%; p = 0.06) but a similar number of clotting events (9% vs 10%; p = 0.8) than CAM non-users. Warfarin patients who used 'interacting CAM' had significantly more clotting events than those who used CAM not known to interact with warfarin (18% vs 2%; p = 0.02). Conclusion: CAM knowledge in people on warfarin was poor. 'Interacting CAM' used concomitantly with warfarin may be associated with increased rates of clotting events. [ABSTRACT FROM AUTHOR]