Search

This study aimed to evaluate the impact of electronic communication of medication discontinuation from prescribers to pharmacies (CancelRx) on medication safety.We used electronic health record (EHR) data to identify medications that were e-prescribed from a pilot practice to a health system pharmacy and subsequently discontinued before or after CancelRx implementation (January 16-April 15, 2018 versus 2019). We matched these EHR data to pharmacy management software data to identify medications that were sold to patients in the 6 months after discontinuation. As a surrogate for unintended cancellation, we also identified medications refilled within 120 days of discontinuation. We conducted a medical record review to identify documentation of prescriber intent to discontinue these medications.CancelRx implementation prevented prescriptions from being sold after discontinuation in the EHR (42 of 392 [10.7%] versus 0 of 387 [0.0%], Plt; 0.0001), but only 15 of 42 (35.7%) had documented intent to discontinue the medication (15 of 392, or 3.8% overall). There was a nonsignificant increase in the proportion of discontinued medications reordered within 120 days (10.0% versus 12.7%, P = 0.23). Medical record review of reordered prescriptions after CancelRx implementation found that 10 of 49 (10 of 387, or 2.6% overall) might have been unintentionally canceled.Implementation of CancelRx eliminated the sale of e-prescribed medications after discontinuation in the EHR but might result in the unintentional cancellation of some prescriptions. Strategies to increase situational awareness of providers and pharmacy staff, including increased visibility of CancelRx, clear distinctions between active and expired prescriptions, and transmission of the reason for discontinuation, might reduce the risk of unintentional cancellations.

There is a lack of comprehensive lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) content in pre-licensure nursing curricula. LGBTQI+ people commonly experience mistreatment from nurses and healthcare providers due to a lack of knowledge or personal biases. To date, few instruments exist to guide LGBTQI+-specific curricular improvement.Johns Hopkins School of Nursing LGBTQI+ Health Initiative and Emory University School of Nursing developed the Tool for Assessing LGBTQI+ Health Training (TALHT) to assist in evaluating gaps and redundancies in LGBTQI+ health content within pre-licensure nursing curricula. Face and content validity were evaluated among experts in LGBTQI+ health, curricular development, nursing education, and measure development (N = 22). The TALHT was modified based on expert feedback and a pilot with pre-licensure faculty (N = 13) to evaluate utility and acceptability of the refined measure.Face and content validity evaluation of the 60-item iteration of the TALHT showed that the majority of items were consistently relevant among external expert reviewers. However, the clarity and readability of items were lacking. We triangulated the quantitative and qualitative data from experts to adapt and reduce the number of items in the TALHT to 20 items. Pilot testing of the revised 20-item measure found that utility and acceptability of the tool were rated highly among pre-licensure faculty.The validation of the TALHT comes at a time when this type of instrument is clearly needed. The Future of Nursing 2020-2030 report calls for nursing education to incorporate competencies in caring for diverse populations to promote health equity. The Essentials: Core Competencies for Professional Nursing Education calls for a transition to operationalization of competency-based nursing education. The TALHT provides faculty and programs with a valid and reliable means to operationalize implementation of those competencies as they pertain to LGBTQI+ health.

One of the most common interventions in health care is medication use. Although simple when contrasted against interventions such as surgery, the high incidence of adverse drug events highlights the complexity and risk inherent in the medication-use process. This process comprises multiple interconnected stages: prescribing, order processing, dispensing, administration, and monitoring. Not only is there considerable variation in how steps are executed across stages, but the interconnected nature of the stages may also mean that errors made in one stage often have a cascading effect on subsequent stages. This chapter offers guidelines for designing medication reconciliation technology and presents a mixed methods empirical study in medication reconciliation.

Summary Background Unfractionated heparin (UFH) is widely used to treat thromboembolic disease, but monitoring in children is challenging. Both activated partial thromboplastin time (aPTT) and anti-factor Xa activity (anti-Xa) are utilized, but a comparison of dosing nomograms has not been reported in pediatrics. Objective To compare the performance of aPTT and anti-Xa for UFH monitoring in pediatric patients. Design/methods A retrospective cohort study was conducted in patients ≤ 21 years old treated with UFH at Johns Hopkins Hospital from January 2009 to May 2011. For monitoring, an aPTT nomogram was used for the initial 15 months, and an anti-Xa nomogram was used for the subsequent 12 months. Clinical characteristics, laboratory data and outcomes were analyzed. Results Thirty-four patients were monitored with aPTT and 26 patients with anti-Xa. There was no significant difference in median time to therapeutic range (11.6 h aPTT, 95%CI = 6.0–17.0; 9.9 h anti-Xa, 95%CI = 7.3–20.7) or per cent of patients achieving therapeutic measurements at 24 (79% aPTT, 95%CI = 62–91; 73% anti-Xa, 95%CI = 52–88) and 48 h (88% aPTT, 95%CI = 73–97; 96% anti-Xa, 95%CI = 80–100). However, anti-Xa measurements were more frequently therapeutic than aPTT (74% [95%CI = 69–78] vs. 54% [95%CI = 50–59]). Variance between anti-Xa and aPTT measurements was high (R2 = 0.236). No significant difference was seen in bleeding incidence (9% aPTT, 95%CI = 2–24; 15% anti-Xa, 95%CI = 4–35). Conclusion The time to achieve therapeutic measures and bleeding outcomes were not significantly different between anti-Xa and aPTT nomograms. However, a small study size limits the power to detect clinically relevant differences. The results warrant larger prospective studies of UFH monitoring in children with thromboembolic disease.

OBJECTIVES: To inform pediatric cart-fill batch scheduling for reductions in pharmaceutical waste using a case study and simulation analysis. METHODS: A pre and post intervention and simulation analysis was conducted during 3 months at a 205-bed children's center. An algorithm was developed to detect wasted medication based on time-stamped computerized provider order entry information. The algorithm was used to quantify pharmaceutical waste and associated costs for both preintervention (1 batch per day) and postintervention (3 batches per day) schedules. Further, simulation was used to systematically test 108 batch schedules outlining general characteristics that have an impact on the likelihood for waste. RESULTS: Switching from a 1-batch-per-day to a 3-batch-per-day schedule resulted in a 31.3% decrease in pharmaceutical waste (28.7% to 19.7%) and annual cost savings of $183,380. Simulation results demonstrate how increasing batch frequency facilitates a more just-in-time process that reduces waste. The most substantial gains are realized by shifting from a schedule of 1 batch per day to at least 2 batches per day. The simulation exhibits how waste reduction is also achievable by avoiding batch preparation during daily time periods where medication administration or medication discontinuations are frequent. Last, the simulation was used to show how reducing batch preparation time per batch provides some, albeit minimal, opportunity to decrease waste. CONCLUSIONS: The case study and simulation analysis demonstrate characteristics of batch scheduling that may support pediatric pharmacy managers in redesign toward minimizing pharmaceutical waste.

Hospital relocation is a highly complex undertaking, which has the potential to interrupt operations and poses risks for patients, staff, and providers. Little is known how hospital relocation impacts on workflow and communication.Using existing Electronic Health Record (EHR) data we determined time from medication ordering to first dose administration as a proxy for well-being of the medication process during a five months window surrounding the relocation of a 205-bed children's hospital.Overall performance of the medication process has declined slightly. We identified regional (unit) differences with the pediatric intensive care unit, which had the most significant changes to its workflow, experiencing a more than doubling of the time from ordering to medication administration. Overall, there was no significant difference in time-sensitive medication administration times. Evaluating the medication ordering-dispensing-administration process through readily available EHR data demonstrated that the impact of a hospital' s relocation on workflow and communication can be successfully monitored.

Abstract 1171 Background: Heparin-induced thrombocytopenia (HIT) is characterized by the development of platelet-activating antibodies in response to heparin exposure, resulting in thrombocytopenia and a paradoxical risk for thrombotic complications. The diagnosis of HIT rests on clinical findings with supporting laboratory evaluation. The major features of HIT (thrombocytopenia and thrombosis after heparin exposure) are often seen in critically-ill children, but this is usually due to causes other than HIT. Clinical scoring systems (such as the 4T scoring system) to assess the pre-test probability of HIT are used widely in adults, but have yet to be fully validated in children. However, without prompt diagnosis and discontinuation of heparin, HIT can result in life and limb threatening thrombosis; on the other hand, overdiagnosis of HIT can lead to unnecessary exposure to alternative anticoagulants. Tests for HIT antibodies include ELISA immunoassays (EIA) for anti-PF4/heparin antibodies, which are widely available. The ELISA has high sensitivity but poor specificity with a high false positive rate. Functional tests, such as the 14C serotonin release assay (SRA), have high sensitivity and specificity, but are not routinely performed at most hospitals. In adults, higher antibody titers by ELISA are associated with SRA positivity and clinical manifestations of HIT. While the predictive value of these laboratory tests have been studied extensively for the diagnosis of HIT in adults, relatively little is known about their performance in the evaluation of pediatric patients. The aim of this study is to assess the utility of the ELISA and SRA tests, and clinical scoring systems to diagnosis HIT pediatric patients. Methods/Results: We identified 194 patients < 22 years of age who were referred for HIT testing between March 2001 and February 2010 at Johns Hopkins Hospital. 263 samples were evaluated by ELISA and/or SRA. ELISA was performed on 221 samples. Using the adult cut off value of 0.4 OD, 197 were negative, and 25 were positive (11%). SRA was performed on 39 samples and 3 were positive (8%). We found that positive SRA assays were found only in patients with ELISA OD values > 1.0. Two out of these three patients with SRA positivity had clinical HIT as diagnosed by treating physicians. The 4T Score (Warkentin, Br J Haem, 2003) and the HIT Expert Probability (Cuker, J Thromb Haemost, 2010) are pre-test scoring models that stratifies patients to high, intermediate, and low probability of HIT but have not been evaluated in pediatrics. A retrospective evaluation of utility of these scoring systems is currently underway. Conclusion: The utility of HIT antibody testing has not been formally evaluated in children. Only a subset of patients with positive ELISA tests will show SRA positivity. Higher titers of anti-PF4/heparin antibodies are associated with SRA positivity in pediatric patients, similar to adults. Further studies to validate predictive scoring systems in pediatic patients for the diagnosis of HIT is warranted. Disclosures: Streiff: BristolMyers Squibb: Research Funding; sanofi-aventis: Consultancy; Daiichi-Sankyo: Consultancy; Eisai:; sanofi-aventis: Honoraria.