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Background: Obtaining accurate medication histories at transitions of care is challenging, but important for patient safety. Prescription exchange services (PES) securely transfer electronic prescription and dispensing records between prescribers and pharmacies, which is potentially useful data for determining medication histories. Aim: To evaluate the accuracy of PES‐derived medication histories. Methods: Prospective observational study, at two Australian tertiary‐referral health services. A convenience sample of adult inpatients was recruited. The main outcome measure was: proportion of patients with ≥1 errors in their PES‐derived pre‐admission medication histories, compared with gold‐standard best‐possible medication histories, including prescribed and non‐prescribed medications, obtained by pharmacists using multiple sources including patient/carer interview. Results: Of 154 patients (median age 76 years; interquartile range (IQR) 64–84 years; median 10.0 pre‐admission medications; IQR 6.0–14.0), 153 (99.4%) had ≥1 errors in their PES‐derived medication history (median 6.0 errors per patient; IQR 4.0–9.0). Excluding when‐required medications, 146 (94.8%) patients had >1 errors (median 4.0 errors per patient; IQR 2.0–6.0). Omission was the most common error, affecting 549 (33.3%) of 1648 current medications (median 3.0; IQR 1.0–5.0 per patient); 396 (72.1%) omissions were over‐the‐counter medicines. Dose‐regimen errors affected 276 (25.1%) of 1099 current medications captured in PES‐derived medication histories (median 1.0 error per patient; IQR 0.0–3.0). Commission errors (medications in PES‐derived histories that were not current) affected 224 (16.9%) of 1323 medications (median 1.0 error per patient; IQR 1.0–2.0). Conclusions: Medication histories derived solely from a cloud‐based medication record repository had a high error rate compared with patients' actual medication use. Like all medication history sources, data from cloud‐based repositories need to be verified with additional sources including the patient and/or their carer. [ABSTRACT FROM AUTHOR]

Background: Problems with continuity of medication administration after discharge from hospitals to residential care facilities (RCFs) have been reported in Australia and internationally. The MedGap study in 2009 reported a significant decline in post‐discharge missed or delayed doses and locum doctor call‐outs at RCFs following implementation of a hospital pharmacy‐prepared interim residential care medication administration chart (IRCMAC). Aim: To determine whether reductions in missed or delayed doses and locum doctor call‐outs were sustained nearly 10 years after the IRCMAC was implemented, and evaluate RCFs' use of IRCMACs and discharge medications supplied in original packaging. Method: Structured telephone interviews with nurses at 52 RCFs were conducted approximately 48‐h after discharge for randomly selected patients discharged from hospitals within a major metropolitan health service in Melbourne, Australia in 2018. Results were compared with pre‐ and post‐intervention data collected using the same method in 2009. Primary endpoints were the proportion of patients for whom the RCF used the hospital‐supplied IRCMAC and discharge medications, and the incidence of missed or significantly delayed medication doses in the first 24 h post‐discharge. The number of locum doctor call‐outs was a secondary endpoint. Results: RCFs received IRCMACs for 71/73 (97.3%) patients and used them for 61/71 (85.9%). Hospital‐supplied medication, in original packaging, was received for 65/73 (89.0%) patients and used for 59/65 (90.8%). One or more doses were missed or significantly delayed for 2/73 (2.7%) patients and locum doctors were called for nine patients (12.3%), which was similar to the 2009 post‐intervention study (6/226, 2.7% and 25/226, 11.1%, respectively) and significantly lower than the 2009 pre‐intervention study (37/202, 18.3% and 66/202, 32.7%, respectively; P < 0.01 for both endpoints). Nearly 100% of RCF staff believed IRCMACs and hospital‐supplied medication improved continuity of care. Conclusion: Hospital pharmacy‐prepared IRCMACs and discharge medication in original packaging were highly used and valued by RCF staff, and associated with sustained low rates of missed and delayed doses and locum doctor call‐outs. [ABSTRACT FROM AUTHOR]

Objective: Patients present to EDs with various medication‐related problems (MRPs). MRPs are also associated with ED care, occurring during ED presentation or shortly afterwards. The aim of the present study is to describe the prevalence and nature of MRPs that occur prior to, during or shortly after leaving ED. Methods: We undertook a prospective, observational study in nine Australian EDs. Blocks of 10 consecutive adult patients who were not seen by a pharmacist in ED and who presented at pre‐specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine their medication history, patients' understanding of treatment, potential MRP risk factors and manage any identified MRPs. Results: A total of 904 patients were recruited: 14.8% aged ≥80 years, 18.9% taking more than eight regular medications; 581 MRPs were identified; 287 (49.4%, 95% confidence interval [CI] 45.3–53.5%) of moderate‐high significance. Most highly significant MRPs involved high‐risk medications, particularly strong opioids, insulin and anti‐coagulants. The most common types of MRPs were prescribing errors (46.8%), patient adherence/knowledge issues (31.2%) and adverse drug reactions (7.4%). Of all patients, 381 (42.1%, 95% CI 38.9–45.5%) had at least one MRP; 31.4% (95% CI 28.4–34.6%) had MRPs that could be identified or managed by screening at ED presentation and 12.4% (95% CI 10.4–14.8%) had MRPs that could be identified or managed by screening at ED discharge. Conclusions: Patients experienced a range of MRPs throughout the ED continuum of care. From these data, screening tools will be developed so that ED clinicians may identify patients at greatest risk of MRPs. [ABSTRACT FROM AUTHOR]

Objective: The objective was to describe the incidence, nature, and risk factors for adverse events (AEs) among patients who received parenteral sedation for acute agitation in an emergency department (ED) setting. Methods: We undertook a prospective observational study and a clinical trial of parenteral sedation for the management of acute agitation. We included agitated adult patients who required parenteral sedation from 2014 to 2017 in 12 Australian EDs, excluding those with incomplete information or aged under 18 years. The primary outcome was the number of patients who experienced at least one AE. Multivariable logistic regression was used to determine factors associated with AEs. Results: A total of 904 patients were included in the analyses (62.3% male; median age = 34 years, range = 18 to 95 years). Of these, 144 (15.9%) patients experienced at least one AE. The most common AEs were oxygen desaturation (7.4%), airway obstruction (3.6%), bradycardia (1.9%), hypotension (1.7%), and prolonged QTc interval (1.3%). No deaths or serious AEs were reported. The following factors had an increased adjusted odds ratio (OR) for experiencing an AE: age 65 years and older (OR = 2.8, 95% confidence interval [CI] = 1.2 to 7.2), more than one type of parenteral sedation administered within 60 minutes (OR = 2.1, 95% CI = 1.4 to 3.1), and alcohol intoxication (OR = 1.8, 95% CI = 1.2 to 2.6). Conclusions: Sedation‐related AEs are common, especially respiratory events. Elderly patients, sedation with multiple sedatives within 60 minutes, and alcohol intoxication increased the risk. [ABSTRACT FROM AUTHOR]

Background: Behavioural emergencies (BEs) are complex situations in the emergency department (ED) setting. Treatment decisions always must be made within a limited time and are based on incomplete patient data. As a result of the urgency and complexity, patients often are exposed to increased risk of harm. Aim: The aim of this paper is to describe the prescribing patterns and adverse events (AEs) associated with parenteral sedation for the management of BEs in Australian EDs. Methods: Ten Australian EDs enrolled a convenience sample of adult patients (aged ≥18 years) requiring parenteral sedative medication for BEs. Data were collected prospectively between March 2015 and April 2017 using a designated case report form. Results: In all, 564 cases were enrolled in this study. Incomplete cases (n = 17; 3%) were excluded. Of the 547 remaining cases, 63% were male and the median age was 34 years (range 18–95 years). Approximately half the patients (n = 230; 42.1%) required mechanical restraint and parenteral sedation to manage their BEs. Intramuscular monotherapy was administered in most cases (n = 390; 71.3%). The main sedative medications used as monotherapy were droperidol (n = 381; 69.7%), midazolam (n = 54; 9.9%) and olanzapine (n = 26; 4.8%). The most common combination therapy was midazolam + droperidol (n = 36; 6.6%). The incidence of AEs from sedative administration was 13.5%. No deaths or irreversible AEs were reported. Conclusions: Overall, the participating EDs provided safe pharmacological management for BEs. AEs following parenteral sedation are common, although serious AEs are rare. Because all patients receiving parenteral sedation for BEs are at risk of AEs, ongoing monitoring of vital signs after parenteral sedation should be a standard protocol in all EDs. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To assess the accuracy of medication information sources available for adult patients presenting to the ED, compared to a best possible medication history (BPMH). Methods: This prospective observational study was undertaken in the ED of a major tertiary‐referral teaching hospital. A convenience sample of consecutive adult patients taking one or more regular medications was included. A BPMH was ascertained using patient/carer interviews, where available, and confirmed with one or more other sources. For residential care facility (RCF) patients, the RCF medication chart and at least one other source were used. Information sources compared with the BPMH were community pharmacy dispensing history, patient's own medications, patient's medication list, general practitioner letter, medications stored in and labelled on dose administration aids (DAAs) and the RCF chart. Number of discrepancies per patient for each source was determined by comparing medications and dose regimens to those documented in the BPMH. Results: A total of 455 patients (median age 71 years) took a median of six ‘regular’ and two ‘as required’ medications. The median number (range) of discrepancies per patient for regular medication names and dosages were RCF chart 0 (0–3), DAA contents 2.0 (0–9), patient's medication list 2.5 (0–16), DAA medications label 3.0 (0–7), community pharmacy history 3.0 (0–19), general practitioner letter 3.0 (0–18) and patient's own medications 4.0 (0–16). Overall, 40.4% of discrepancies were deemed ‘moderate’ or ‘high’ clinical significance. Omission errors accounted for 55.6% of discrepancies. Conclusions: A combination of sources is essential to determine the BPMH. RCF charts provided the most accurate information. Other sources had two to four regular medication‐related discrepancies per patient. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Inpatient bed access decreases when ward discharge is delayed. This contributes to prolonged emergency department (ED) length of stay (LOS) which has been associated with increased hospital LOS and mortality. Delays in preparation of discharge medication prescriptions by ward doctors may contribute to delayed ward discharge. This project aimed to evaluate the effect on patient flow of having a pharmacist collaborate with ward doctors to prepare discharge prescriptions at a hospital with an electronic prescribing system. Method Eight-week pre- and post-intervention study on two surgical wards at a major metropolitan Australian hospital. During the intervention, a project pharmacist (PP) electronically prepared discharge prescriptions, in consultation with ward doctors, which were reviewed by the regular ward pharmacist before being dispensed. Outcome measures, based on hospital performance indicators, included: * Percentage of patients transferred to wards from ED within four and six hours of presentation; * Median time (minutes) past 9 am that patients were discharged from the wards; * Percentage of patients discharged from wards by 9 am; * Staff satisfaction. Results Pre- and post-intervention, there were 259 and 246 patients transferred from ED to the study wards, respectively. The percentage of patients transferred within four and six hours of presentation did not change. There were 320 and 341 patients discharged, pre- and post-intervention, respectively, who required a discharge prescription. The PP prepared 273 (80%) prescriptions during the post-intervention period. Patients were discharged 57 minutes earlier with the intervention (median 211 vs. 154 minutes past 9 am, P = 0.01). The percentage of patients discharged before 9 am increased from 6% to 12% (P = 0.01). All 26 health-professional respondents (79% response rate) were satisfied with the service and recommended its continuation. Conclusions Pharmacist collaboration with doctors to prepare discharge prescriptions did not impact upon ED access targets, but resulted in patients being discharged earlier. [ABSTRACT FROM AUTHOR]

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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]

We aimed to determine factors that are significantly associated with a high level of patient satisfaction with their pain management. We undertook an observational study in a large metropolitan ED. Adult patients with a triage pain score of ≥4 (0-10 scale) were enrolled. Data collected included demographics, presenting complaint, pain scores every 30 min, whether nurse-initiated analgesia was administered, the nature of the pain relief administered, time to first dose of analgesia, elements of staff communication and whether 'adequate analgesia' was provided (defined as a decrease in pain score to <4 and a decrease from the triage pain score of ≥2). The primary end-point, determined at follow up within 48 h, was the level of satisfaction with pain management (6-point scale: very unsatisfied-very satisfied). One hundred and sixty-seven (82.7%) of 202 enrolled patients were followed up - mean (SD) age 46.4 (18.3) years, 75 (44.9%) men. Eighty-one (48.5%) patients were very satisfied with their pain management. Only two clinical variables were significantly associated with a high level of satisfaction: receipt of 'adequate analgesia' (as defined) and specific communication regarding pain management. Forty-four (58.7%) versus 37 (40.2%) patients who did/did not receive 'adequate analgesia', respectively, were very satisfied (difference 18.5%, 95% CI 2.3-34.7, P= 0.027). Seventy-seven (53.9%) and four (16.7%) patients who were/were not advised by ED staff that their pain management was important, respectively, were very satisfied (difference 37.2%, 95% CI 17.7-56.6, P= 0.002). Our 'adequate analgesia' definition might provide a useful clinical target, which, combined with adequate communication, might help maximize patient satisfaction. [ABSTRACT FROM AUTHOR]