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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: Pharmacist‐assisted prescribing (also known as pharmacist charting) has been adopted widely across Australia. The perspectives of medical and nursing staff, however, is poorly understood. Aim: To explore the perceived benefits and drawbacks of pharmacist‐assisted prescribing on admission and discharge, from the perspective of hospital medical officers (HMOs) and nurses. Methods: Face‐to‐face, semi‐structured interviews were conducted with orthopaedic junior HMOs, the orthogeriatric HMO and nurses during a study evaluating pharmacist‐assisted prescribing in an orthopaedic unit. Participants were individually interviewed to explore the perceived impacts of pharmacist‐assisted prescribing on patient safety, workflow and HMO skill development. Interviews were audio‐recorded and verbatim transcriptions were analysed independently by two investigators using a simple thematic analysis. Results: Interviews were conducted with six HMOs and six nurses. Emergent themes highlighted various factors which may affect the ability of HMOs to prescribe medications accurately and in a timely manner when there is no pharmacist assisting with prescribing, and the impact of pharmacist‐assisted prescribing on patient flow, safety and staff workload. Participants felt that having a pharmacist assist with prescribing improved patient safety by reducing prescribing errors and admission charting delays, and assisted with patient flow by reducing delays in discharging patients. Participants felt that pharmacist‐assisted prescribing reduced their workload. They noted a drawback was the potential to de‐skill HMOs, but felt this was outweighed by the benefits. Conclusions: Hospital medical officers and nurses reported that pharmacist‐assisted prescribing had benefits on patient safety, patient flow and workload and that these outweigh the potential drawbacks of potentially de‐skilling junior HMOs. [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]

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]

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]

Aim To examine the efficacy and safety of (1) midazolam-droperidol versus droperidol and (2) midazolam-droperidol versus olanzapine for methamphetamine-related acute agitation. Design and setting A multi-centre, randomized, double-blind, controlled, clinical trial was conducted in two Australian emergency departments, between October 2014 and September 2015. Participants Three hundred and sixty-one patients, aged 18-65 years, requiring intravenous medication sedation for acute agitation, were enrolled into this study. We report the results of a subgroup of 92 methamphetamine-affected patients. Intervention and comparator Patients were assigned randomly to receive either an intravenous bolus of midazolam 5 mg-droperidol 5 mg combined, droperidol 10 mg or olanzapine 10 mg. Two additional doses were administered, if required: midazolam 5 mg, droperidol 5 mg or olanzapine 5 mg, respectively. Measurements The primary outcome was the proportion of patients sedated adequately at 10 minutes. Odds ratios with 95% confidence intervals (ORs, 95% CI) were estimated. Findings The baseline characteristics of patients in the three groups were similar. At 10 minutes, significantly more patients in the midazolam-droperidol group [29 of 34 (85.3%)] were sedated adequately compared with the droperidol group [14 of 30 (46.7%), OR = 6.63, 95% CI = 2.02-21.78] or with the olanzapine group [14 of 28 (50.0%), OR 5.80, 95% CI = 1.74-19.33]. The number of patients who experienced an adverse event (AE) in the midazolam-droperidol, droperidol and olanzapine groups was seven of 34, two of 30 and six of 28, respectively. The most common AE was oxygen desaturation. Conclusion A midazolam-droperidol combination appears to provide more rapid sedation of patients with methamphetamine-related acute agitation than droperidol or olanzapine alone. [ABSTRACT FROM AUTHOR]

ABSTRACT: Despite having well-established clinical roles in many specialties, hospital pharmacists have not traditionally provided clinical services in the operating suite (OS). This paper describes the introduction of a clinical pharmacy service in the OS of a large metropolitan public hospital network. The initial focus of the service was on non-clinical issues that were priorities for pharmacy and OS staff, such as medication supply, waste minimisation, expenditure, inter-departmental communication and legal compliance. Once ongoing funding for the positions was secured, cognitive clinical pharmacy services have become the focus. Benefits of the service have been demonstrated in medication safety, antibiotic stewardship and quality use of medicines. The 2 pharmacists have now become essential members of the OS. Work is underway to further develop pharmacists' roles in areas such as perioperative antimicrobial prescribing and perioperative management of patient's regular medication regimens to optimise the continuum of care. [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]

Rationale, Aims, and Objectives: Whilst many dose omissions cause no patient harm, inappropriate dose omissions have been associated with increased length of hospital stay, risk of sepsis, and mortality. This study aimed to comprehensively describe the prevalence and nature of omitted doses overall and of high risk medication dose omissions in an organization using an electronic Medication Management System., Methods: A retrospective cross-sectional study was undertaken in an Australian tertiary referral health service. All routinely documented electronic inpatient dose administration records from 1 st July 2014 to 30 th June 2015 were included. Period prevalence and characteristics of dose omissions overall and of high-risk medication dose omissions were determined., Results: During the study period, 3.3 million inpatient doses were scheduled for administration, with doses endorsed as "not given" comprising 6.2% of all scheduled doses. Non-valid dose omissions (medication not available or no justification documented) comprised 1.2% of scheduled doses. Patient refusal accounted for one third of all dose omissions, while for 12% no explanation was provided and 7% were endorsed "medication not available". High-risk medications accounted for 20% of all dose omissions. One in 20 antimicrobial doses scheduled were omitted, and of these, 17% were due to patient refusal., Conclusion: The period prevalence of dose omissions in this large study after electronic Medication Management System implementation is similar to that found when paper charts were used. Although most dose omissions appear appropriate, many orders were not given due to patient refusal or with no documented justification. Interventions to minimize unintentional dose omissions are indicated., (© 2018 John Wiley & Sons, Ltd.)