Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients

Comparison of Error Incidence Between Single-Tablet Versus Multiple-Tablet INSTI-Based Regimens in the Inpatient Setting

BACKGROUND

Errors related to antiretroviral therapy (ART) occur in up to 86% of hospitalized patients living with human immunodeficiency virus (HIV) and may contribute to treatment failure, drug resistance, adverse effects, and toxicity. ART can be administered as a single-tablet regimen (STR) or multiple-tablet regimen (MTR), with limited data on whether the number of tablets affects inpatient error incidence.

OBJECTIVE

The purpose of this study was to determine the error rate of substituting dolutegravir-based STRs to an MTR while admitted.

METHODS

This multicenter, retrospective, observational study in adult inpatients receiving ART for HIV evaluated continuation of bictegravir-based STR versus dolutegravir-based STR given as an MTR. The primary outcome was the composite error incidence when ART was dispensed as an STR versus MTR. Secondary endpoints included number of errors per patient encounter, between-group error types, time to error correction and pharmacist involvement, and conversion back to STR at discharge.

RESULTS

Of 514 patient encounters (257 bictegravir-based STR; 257 dolutegravir-based MTR), there was a significantly lower composite incidence of errors in the STR group versus the MTR group (23% vs 31.5%; P = 0.029). A significantly higher incidence of dose-related errors in the MTR group occurred related to renal or hepatic dose adjustments, which was the only significantly different between-group error type identified. Approximately one error per encounter was identified in both groups, with median time to error correction slightly over 1 day. Multiple-tablet regimens were converted back to an STR at discharge in 89.9% of admissions.

CONCLUSION AND RELEVANCE

Providing INSTI-based ART as an STR while admitted may reduce ART-related medication errors and has potential to improve patient care; however, use of an STR may not address errors related to inappropriate dosing in organ dysfunction. Increased vigilance for medication errors is warranted when substituting with MTRs in inpatient settings.

Reducing medication errors in HIV-positive patients: Influence of a clinical pharmacist

Background

The roll-out of antiretroviral medicines has improved life expectancy in people living with HIV (PLHIV). This has resulted in more patients being hospitalised for non-communicable diseases, increasing risk for medication errors (MEs). Pharmacists, through medication reconciliation, may identify and reduce MEs in this population.

Objectives

To describe the importance of a pharmacist's involvement in identifying and quantifying types of MEs.

Method

A quantitative, prospective observational study was conducted over 14 weeks. A pharmacist reviewed HIV-positive, hospitalised patients' files, using a data collection instrument, to determine the prevalence of MEs in PLHIV. The study pharmacist recommended appropriate actions to the prescriber to resolve MEs and documented resolution of the MEs.

Results

The study population of n = 180 patient files were reviewed 453 times, identifying 466 MEs. Medication errors included incorrect medication reconciliation from history (19; 4.1%), prescription omission (17; 3.7%), duplication of therapy (10; 2.2%), missed doses (265; 57.1%), incorrect dosing (103; 22.2%), incorrect administration frequency (2; 0.4%), incorrect duration of therapy (15; 3.2%) and drug-drug interactions (18; 3.9%). More than half (58.2%) of the MEs were resolved in less than 24 h, with involvement of the pharmacist.

Conclusion

This study demonstrates the magnitude of MEs experienced in hospitalised PLHIV and highlights the role clinical pharmacists play in identifying and resolving MEs to improve patient outcomes.

Designing an electronic medical record alert to identify hospitalised patients with HIV: successes and challenges

Objectives

Electronic medical record (EMR) tools can identify specific populations among hospitalised patients, allowing targeted interventions to improve care quality and safety. We created an EMR alert using readily available data elements to identify hospitalised people with HIV (PWH) to facilitate a quality improvement study intended to address two quality/safety concerns (connecting hospitalised PWH to outpatient HIV care and reducing medication errors). Here, we describe the design and implementation of the alert and analyse its accuracy of identifying PWH.

Methods

The EMR alert was designed to trigger for at least one of four criteria: (1) an HIV ICD-10-CM code in a problem list, (2) HIV antiretroviral medication(s) on medication lists, (3) an HIV-1 RNA assay ordered or (4) a positive HIV-antibody result. We used manual chart reviews and an EMR database search to determine the sensitivity and positive predictive value (PPV) of the overall alert and its individual criteria.

Results

Over a 24-month period, the alert functioned as intended, notifying an intervention team and a data abstraction team about admissions of PWH. Manual review of 1634 hospitalisations identified 18 PWH hospitalisations, all captured by the alert (sensitivity 100%, 95% CI 82.4% to 100.0%). Over the 24 months, the alert triggered for 1191 hospitalisations. Of these, 1004 were PWH hospitalisations, PPV=84.3% (95% CI 82.2% to 86.4%). Using fewer criteria (eg, using only ICD-10-CM codes) identified fewer PWH but increased PPV.

Conclusion

An EMR alert effectively identified hospitalised PWH for a quality improvement intervention. Similar alerts might be adapted as tools to facilitate interventions for other chronic diseases.

The transformation of HIV therapy: One pill once a day

A co-formulated, one pill once a day antiretroviral regimen (single-tablet regimen), containing efavirenz, emtricitabine, and tenofovir disoproxyl fumarate ( Atripla), revolutionized the antiretroviral therapy landscape. Single-tablet regimens provide not only dosing convenience but help optimize adherence and persistence with antiretroviral therapy to achieve durably suppressed viremia with both individual and societal benefits. Given the many excellent options available now, single-tablet regimens are the preferred choice for initiating antiretroviral therapy in almost all patients with rare exceptions for drug interactions and pregnancy, and for simplification of more complex antiretroviral therapy to a single-tablet regimen. In this special commemorative article, we celebrate this astounding advancement in antiretroviral therapy, championed by John C. Martin while CEO of Gilead Sciences, and its transformative impact on HIV care nationally and globally.

Impact of Pharmacist-Driven Antiretroviral Stewardship and Transitions of Care Interventions on Persons With Human Immunodeficiency Virus

Background

Persons with human immunodeficiency virus (HIV) experience high rates of medication-related errors when admitted to the inpatient setting. Data are lacking on the impact of a combined antiretroviral (ARV) stewardship and transitions of care (TOC) program. We investigated the impact of a pharmacist-driven ARV stewardship and TOC program in persons with HIV.

Methods

This was a retrospective, quasi-experimental analysis evaluating the impact of an HIV-trained clinical pharmacist on hospitalized persons with HIV. Patients included in the study were adults following up, or planning to follow up, at the University of Illinois (UI) outpatient clinics for HIV care and admitted to the University of Illinois Hospital. Data were collected between July 1, 2017 and December 31, 2017 for the preimplementation phase and between July 1, 2018 and December 31, 2018 for the postimplementation phase. Primary and secondary endpoints included medication error rates related to antiretroviral therapy (ART) and opportunistic infection (OI) medications, all-cause readmission rates, medication access at time of hospital discharge, and linkage to care rates.

Results

A total of 128 patients were included in the study: 60 in the preimplementation phase and 68 in the postimplementation phase. After the implementation of this program, medication error rates associated with ART and OI medications decreased from 17% (10 of 60) to 6% (4 of 68) (P = .051), 30-day all-cause readmission rates decreased significantly from 27% (16 of 60) to 12% (8 of 68) (P = .03), and linkage to care rates increased significantly from 78% (46 of 59) to 92% (61 of 66) (P = .02).

Conclusions

A pharmacist-led ARV stewardship and TOC program improved overall care of persons with HIV through reduction in medication error rates, all-cause readmission rates, and an improvement in linkage to care rates.

Economic Barriers to Antiretroviral Therapy in Nursing Homes

OBJECTIVES

Our aim was to clarify if persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have adequate economic access to antiretroviral therapy (ART) when admitted to nursing homes (NHs). Medicare Part A pays NHs a bundled skilled nursing rate that includes prescription drugs for up to 100 days, after which individuals are responsible for the costs.

DESIGN

A cross-sectional study.

SETTING

NHs.

PARTICIPANTS

A total of 694 newly admitted long-stay (>100 d) NH residents with HIV.

MEASUREMENTS

We used Minimum Dataset v.3.0, pharmacy dispensing data, NH provider surveys, and Medicare claims from 2011 to 2013. We assessed receipt of any HIV antiretrovirals or recommended combinations (ART), as defined by national care guidelines, and the source of payment. We identified predictors of antiretroviral use with risk-adjusted generalized estimating equation logistic models.

RESULTS

All study persons living with HIV/AIDS in NHs had prescription drug coverage through Medicare's Part D program, and ART was 100% covered. However, only 63.9% received recommended ART, and 15.2% never received any antiretrovirals during their NH stay. The strongest predictor of not receiving antiretrovirals was the first 100 days of a long NH stay (odds ratio [OR] = .44; 95% confidence interval [CI] = .24-.80). The strongest predictor of receiving recommended ART was health acuity (OR = 1.51; 95% CI = 1.20-1.88).

CONCLUSION

People living with HIV in NHs do not always receive lifesaving ART, but the reasons are unclear and appear unrelated to economic barriers. J Am Geriatr Soc 68:777-782, 2020.

Impact of an Antimicrobial Stewardship Team on Reducing Antiretroviral Medication Errors

Background: Numerous interventions have been used to reduce medication errors related to antiretroviral (ARV) therapy for hospitalized patients with HIV. Objective: This study assessed the impact of an antimicrobial stewardship (ASP) team intervention on reducing the rate of ARV therapy errors in patients admitted to an academic medical center. Methods: This observational, retrospective study included patients who received ARV therapy from June 2016 to December 2017. The primary outcome was evaluation of ASP team performance in detecting ARV medication errors in the inpatient setting. Errors were further categorized by type (interaction, dosing, regimen). The Mann-Whitney U test and χ² tests were utilized to analyze continuous and categorical data, respectively. Results: Medication errors occurred in 51% of patients in the preintervention group (n = 152) and 48% of patients in the postintervention group (n = 203; P = 0.43). The most frequent medication error type was drug interactions in both groups, involving integrase strand transfer inhibitors and polyvalent cations (64% vs 67%). There was a significant difference between preintervention and postintervention groups regarding number of errors detected (13 vs 106, P < 0.001), corrected (12 vs 86, P < 0.001), and persisting at discharge (106 vs 18, P < 0.001). Conclusion and Relevance: Review of ARV regimens by an ASP team significantly decreased medication errors. Drug interactions are the most common medication error found in HIV-positive patients admitted to our academic center.

An Evaluation of Pharmacist-Led Interventions for Inpatient HIV-Related Medication Errors

Background: Inpatient HIV-related medication errors occur in up to 86% of patients. Objective: To evaluate the number of antiretroviral therapy (ART)- and opportunistic infection (OI)-related medication errors following the implementation of pharmacist-directed interventions. Methods: This quasi-experiment assessed adult patients with HIV who received ART, OI prophylaxis, or both from December 1, 2014, to February 28, 2017 (pre-intervention) or December 1, 2017, to February 28, 2018 (post-intervention). Pre-intervention patients were assessed retrospectively; verbal and written education were provided (intervention); prospective audit and feedback was conducted for post-intervention patients. The primary outcome was rate of ART errors between groups. Secondary outcomes included rate of OI errors, time to resolution of ART and OI errors, types of errors, and rate of recommendation acceptance. Results: Sixty-seven patients were included in each group. ART errors occurred in 44.8% and 32.8% (P = .156), respectively. OI prophylaxis errors occurred in 11.9% versus 9% (P = .572), respectively. Medication omission decreased significantly in the post-intervention group (31.3% vs 11.9%; P = .006). Pharmacist-based interventions increased in the post-intervention group (6.3% vs 52.9%; P = .001). No statistical difference was found in time to error resolution (72 vs 48 hours; P = .123), but errors resolved during admission significantly increased (50% vs 86.8%; P < .001). No difference was found in rate of intervention acceptance (100% vs 97%). Conclusion and Relevance: ART and OI prophylaxis errors resolved a day faster in the pharmacist-led, post-intervention period, and there was a trend toward error reduction. Future interventions should target prescribing errors on admission using follow-up education and evaluation of medication reconciliation practices in HIV-infected patients.

Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease

Importance

Dementia is common in Parkinson disease, but few data exist on dementia treatment patterns or the concurrent use of acetylcholinesterase inhibitors (ACHEIs) and anticholinergic medications, a frank prescribing error.

Objectives

To describe dementia treatment patterns, and to determine the extent to which the concurrent use of ACHEIs and drugs with strong anticholinergic activity occurs among individuals with Parkinson disease in the United States.

Design, Setting, and Participants

This cross-sectional analysis included adult Medicare beneficiaries (aged 65 years or older) with Parkinson disease diagnosis with 12 consecutive months of inpatient, outpatient, and prescription drug coverage from January 1, 2014, through December 31, 2014. Beneficiaries with other parkinsonian syndromes were excluded. Demographic, geographic, prescription claims, and other data were extracted from the 2014 Carrier, Beneficiary Summary, and Prescription Drug Event research identifiable files of the Centers for Medicare & Medicaid Services. Data analysis was conducted from August 1, 2017, to November 30, 2017.

Main Outcomes and Measures

Primary outcomes were use of dementia drug, specific dementia medication, and concurrent exposure to a high-potency anticholinergic drug and an ACHEI. Descriptive analyses and multivariable logistic regression models determined the extent to which patient characteristics and comorbid conditions were associated with dementia treatment or with a high-potency anticholinergic and ACHEI never event.

Results

Of 268 407 Medicare beneficiaries with Parkinson disease (mean [SD] age, 78.9 [7.5]; 134 575 male [50.1%]), most were identified in the files as white (232 831 [86.7%]), followed by black (14 629 [5.5%]), Hispanic (7176 [2.7%]), Asian (7115 [2.7%]), and Native American (874 [0.3%]). Among these beneficiaries, 73 093 (27.2%) were given a prescription for at least 1 antidementia medication. The most commonly prescribed medication was donepezil hydrochloride (46 027 [63.0%] users), followed by memantine hydrochloride (30 578 [41.8%] users) and rivastigmine tartrate (19 278 [26.4%] users). Dementia drugs were more likely to be prescribed to black (adjusted odds ratio [AOR], 1.33; 95% CI, 1.28-1.38) and Hispanic (AOR, 1.28; 95% CI, 1.22-1.35) beneficiaries and less likely for Native American beneficiaries (AOR, 0.62; 95% CI, 0.51-0.74). Women were less likely than men to be given a prescription for dementia medication (AOR, 0.85; 95% CI, 0.84-0.87). Of the 64 017 beneficiaries receiving an ACHEI, 28 495 (44.5%) experienced at least 1 high-potency anticholinergic-ACHEI event. Hispanic (AOR, 1.11; 95% CI, 1.00-1.23) and women (AOR, 1.30; 95% CI, 1.25-1.35) beneficiaries had greater odds of experiencing this never event. Statistically significant clusters of the prevalence of this prescribing error were observed across the United States (Moran I = 0.24; P < .001), with clusters of high prevalence in the southern and midwestern states.

Conclusions and Relevance

Dementia medication use by persons with Parkinson disease varies by race/ethnicity and sex; potentially inappropriate prescribing is common among those being treated for cognitive impairment and varies by race/ethnicity, sex, and geography. These findings may serve as national and local targets for improving care quality and outcomes for persons with Parkinson disease.

Impact of an Antiretroviral Stewardship Team on the Care of Patients With Human Immunodeficiency Virus Infection Admitted to an Academic Medical Center

BACKGROUND

Interdisciplinary antiretroviral stewardship teams, comprising a human immunodeficiency virus pharmacist specialist, an infectious diseases physician, and associated learners, have the ability to assist in identification and correction of inpatient antiretroviral-related errors.

METHODS

Electronic medical records of patients with antiretroviral orders admitted to our hospital were evaluated for the number of interventions made by the stewardship team, number of admissions with errors identified, risk factors for occurrence of errors, and cost savings. Risk factors were analyzed by means of multivariable logistic regression. Cost savings were estimated by the documentation system Clinical Measures.

RESULTS

A total of 567 admissions were included for analysis in a 1-year study period. Forty-three percent of admissions (245 of 567) had ≥1 intervention, with 336 interventions in total. The following were identified as risk factors for error: multitablet inpatient regimen (odds ratio, 1.834; 95% confidence interval, 1.160-2.899; P = .009), admission to the intensive care unit (2.803; 1.280-6.136; P = .01), care provided by a surgery service (1.762; 1.082-2.868; P = .02), increased number of days reviewed (1.061; 1.008-1.117; P = .02), and noninstitutional outpatient provider (1.375; .972-1.946; P = .07). The 1-year cost savings were estimated to be $263 428.

CONCLUSIONS

Antiretroviral stewardship teams optimize patient care through identification and correction of antiretroviral-related errors. Errors may be more common in patients with multitablet inpatient regimens, admission to the intensive care unit, care provided by a surgery service, and increased number of hospital days reviewed. Once antiretroviral-related errors are identified, the ability to correct them provides cost savings.

Accuracy of Antiretroviral Prescribing in a Community Teaching Hospital: A Medication Use Evaluation

BACKGROUND

Medication errors account for nearly 250 000 deaths in the United States annually, with approximately 60% of errors occurring during transitions of care. Previous studies demonstrated that almost 80% of participants with human immunodeficiency virus (HIV) have experienced a medication error related to their antiretroviral therapy (ART).

OBJECTIVE

This retrospective chart review examines propensity and type of ART-related errors and further seeks to identify risk factors associated with higher error rates.

METHODS

Participants were identified as hospitalized adults ≥18 years old with preexisting HIV diagnosis receiving home ART from July 2015 to June 2017. Medication error categories included delays in therapy, dosing errors, scheduling conflicts, and miscellaneous errors. Logistic regression was used to examine risk factors for medication errors.

RESULTS

Mean age was 49 years, 76.5% were men, and 72.1% used hospital-supplied medication. For the primary outcome, 60.3% (41/68) of participants had at least 1 error, with 31.3% attributed to delays in therapy. Logistic regression demonstrated multiple tablet regimens (odds ratio [OR]: 3.40, 95% confidence interval [CI]: 1.22-9.48, P = .019) and serum creatinine (SCr) ≥1.5 mg/dL (OR: 8.87, 95% CI: 1.07-73.45, P = .043) were predictive for risk of medication errors. Regimens with significant drug-drug interactions (eg, cobicistat-containing regimens) were not significantly associated with increased risk of medication errors.

CONCLUSIONS AND RELEVANCE

ART-related medication error rates remain prevalent and exceeded 60%. Independent risk factors for medication errors include use of multiple tablet regimens and SCr ≥1.5 mg/dL.

Reducing medication errors involving antiretroviral therapy with targeted electronic medical record modifications

Medication errors are common among HIV-infected patients on anti-retroviral therapy (ART), especially when transitioning to the inpatient setting. In previous studies, medication error rates among hospitalized patients on ART have been reported to exceed 50%. When patients receiving ART are admitted to the hospital, medication errors can be prevented through optimization of administration instructions and dosing defaults in order-entry screens in the electronic medical record (EMR). We sought to evaluate the impact of EMR modifications (defaulted doses, frequencies, and administration instructions) implemented to improve the order-entry process and reduce errors. All adult patients admitted between 10/1/2010-3/31/2012 (pre-EMR modification) and 10/1/2013-3/31/2014 (post-EMR modification) that continued on ART upon admission were included. The primary outcome was the overall rate of medication errors identified through review by the antimicrobial stewardship program (ASP). We also characterized the types of medication errors identified during the two time periods. Following EMR modifications, the medication error rate identified through ASP review was reduced from 50.2% to 28.2% (P < 0.01). The number of medication related errors relating to dosage (regimens requiring dose optimization, renal dose adjustment, and dose timing) were reduced by 22% (P < 0.01). Modifications at the anti-retroviral medication order-entry screens in the EMR significantly reduced medication errors, particularly with respect to dosing and dose timing.

To Assess the Success of Computerized Order Sets and Pharmacy Education Modules in Improving Antiretroviral Prescribing

PURPOSE

To assess the success of order set and pharmacist training improvement (OSPTI) in improving prescription of antiretroviral therapy (ART) in a tertiary care, public, teaching hospital.

METHODS

In this pre-OSPTI (January 2012 through June 2013) and post-OSPTI study (July 2013 through September 2014), an infectious disease pharmacist reviewed all patients on ART. A review of intervention data in July 2013 led to order-set changes in the hospital's computerized order entry system for frequently intervened on antiretrovirals: ritonavir, tenofovir, emtricitabine/tenofovir disoproxil fumarate (FTC/TDF), and lamivudine. Concurrently, case-based education modules were conducted to help pharmacists identify ART errors. The number of patients on ART, number of interventions, and types of ritonavir interventions were compared between pre- and post-OSPTI periods.

RESULTS

In the pre-OSPTI period, an average of 239 patients were reviewed per quarter compared to an average of 216 per quarter in the post-OSPTI period. After implementing enhanced order sets, the number of interventions decreased by approximately 34% ( P < .0001). The number of ritonavir interventions decreased on average by 45% ( P < .0001), although the types of ritonavir interventions were similar.

CONCLUSION

Enhanced antiretroviral order sets and pharmacy education modules improved ART prescription by reducing the overall number of antiretroviral interventions required per quarter. This modality was effective in improving prescribing of ART and reducing the need for pharmacist interventions.

HIV Pharmacist's Impact on Inpatient Antiretroviral Errors

OBJECTIVES

Transitions in care between out-patient and in-patient settings provide ample opportunity for medication errors to occur in HIV-infected patients. The purpose of this study was to examine the effectiveness of an HIV pharmacist monitoring service in decreasing antiretroviral medication errors in a large south central teaching hospital in the USA.

METHODS

A retrospective, observational study was conducted to examine the frequency of antiretroviral medication errors in HIV-seropositive patients with hospital admissions between 1 September 2011 and 30 September 2013 at a single tertiary care centre in Oklahoma. Patient assignment to the 12-month pre-intervention and intervention study periods was determined by admission date. Demographic, laboratory, and in-patient medication data were collected. Bivariate analyses were conducted using χ² analysis with the Yates correction factor for continuity to examine frequencies in specific antiretroviral classes and error categories. A multivariable Poisson regression was employed to examine the frequency of medication errors before and after initiation of the pharmacist service.

RESULTS

Medication errors were examined in a total of 330 patient admissions during the 2-year study period. A multivariable-adjusted decrease of 73.9% in the number of errors was observed between the pre-intervention and intervention periods (P < 0.001). Patients on protease inhibitor regimens or with impaired renal function had 2.6-fold and 2.8-fold higher numbers of errors, respectively (P < 0.001).

CONCLUSIONS

HIV pharmacist monitoring can decrease medication errors in HIV-infected patients as they transition between out-patient and in-patient care. Patients receiving protease inhibitor-based therapy or with renal insufficiency are at higher risk for medication errors upon admission.

Computerized pharmacy surveillance and alert system for drug-related problems

WHAT IS KNOWN AND OBJECTIVE

Because of the impact of drug-related problems (DRPs) on morbidity and mortality, there is a need for computerized strategies to increase drug safety. The detection and identification of the causes of potential DRPs can be facilitated by the incorporation of a pharmacy warning system (PWS) in the computerized prescriber order entry (CPOE) and its application in the routine validation of inpatient drug therapy. A limited number of studies have evaluated a clinical decision support system to monitor drug treatment. Most of these applications have utilized a small range of drugs with alerts and/or types of alert. The objective of this study was to describe the implementation of a PWS integrated in the electronic medical record (EMR).

METHODS

The PWS was developed in 2003-2004. Pharmacological information to generate drug alerts was entered on demographic data, drug dosage, laboratory tests related to the prescribed drug and drug combinations (interactions, duplications and necessary combinations). The PWS was applied in the prescription reviews conducted in patients admitted to the hospital in 2012.

RESULTS AND DISCUSSION

Information on 83% of the drugs included in the pharmacopeia was introduced into the PWS, allowing detection of 2808 potential DRPs, representing 79·1% of all potential DRPs detected during the study period. Twenty per cent of PWS DRPs were clinically relevant, requiring pharmacist intervention.

WHAT IS NEW AND CONCLUSION

The PWS detected most potential DRPs, thus increasing inpatient safety. The detection ability of the PWS was higher than that reported for other tools described in the literature.

Design and validation of a predictive model for 1-year hospital admission in HIV patients on antiretroviral treatment

Objectives

To develop and validate a model for predicting the risk of hospital admission within 1 year in the HIV population under antiretroviral treatment.

Methods

We conducted a retrospective observational study. Patients receiving antiretroviral treatment for at least 1 year who were followed by the pharmacy service in a Spanish-speaking hospital between January 2008 and December 2012 were included. Demographics, and clinical and pharmacotherapy variables, were included in the model design. To find prognostic factors for hospital admission a multivariate logistic regression model was created after performing a univariate analysis. Model validity was determined by the shrinkage method and the model discrimination by Harrell's C-index.

Results

442 patients were included in the study. The variables 'CD4 count <200 (cells/µL)', 'drug/alcohol use', 'detectable viral load (>50 copies/mL)', 'number of previous admissions', and 'number of drugs different from antiretroviral treatment' were the independent predictors of risk of hospital admission. Probabilities predicted by the model showed an R²=0.98 for the development sample and an R²=0.86 for the validation sample. The Harrell's C index for the development and validation data were 0.82 (95% CI 0.77 to 0.87) and 0.80 (95% CI 0.73 to 0.88), respectively.

Conclusions

The model developed in this study may be useful in daily practice for identifying HIV patients at high risk of 1-year hospital admission.

Evaluation of the occurrence and type of antiretroviral and opportunistic infection medication errors within the inpatient setting

Background:

Previous data reports inpatient antiretroviral (ARV) and opportunistic infection (OI) medication errors in as many as 86% of patients, with averages ranging from 1.16-2.7 errors/patient.

Objective:

To determine the occurrence and type of inpatient ARV and OI medication errors at our institution.

Methods:

A retrospective, observational, electronic medical chart review of patients with HIV/AIDS admitted between February 15, 2011- May 22, 2012 was conducted to assess the occurrence and type of ARV and OI medication errors. Secondary outcomes included assessing each medication with an error and evaluating its potential for a medication error, calculating a medication error rate per patient, evaluating whether a non-formulary (NF) medication impacted the error potential, determining whether a clinical pharmacist on service decreased the medication error rate, and assessing whether patients who experienced an error were more likely to have a longer length of stay (LOS). Analysis included descriptive statistics, averages, and Spearmen rank correlation.

Results:

There were 344 patients included in this analysis, 132 (38%) experienced 190 medication errors (1.44 errors/patient). An omitted order was the most frequent ARV error and accounted for 30% (n=57) of total errors. There were 166 patients requiring OI medications, 37 patients experienced 39 medication errors. Omitting OI prophylaxis accounted for 31 errors. Only 45 of 190 (24%) errors were corrected prior to discharge. Being prescribed at least 1 NF medication was correlated with increased errors (n=193 patients “on NF medication”, p<0.025, r=0.12). Coverage of a service by a clinical pharmacist did not affect the number of errors. Patients experiencing an error had a longer LOS (p=0.02).

Conclusions:

Errors relating to ARV and OI medications are frequent in HIV-infected inpatients. More errors occurred in patients receiving NF medications. Suggested interventions include formulary revision, education, and training. Dedicated HIV clinicians with adequate training and credentialing may improve the management of this specialized disease state.

Impact of an electronic medical record on the incidence of antiretroviral prescription errors and HIV pharmacist reconciliation on error correction among hospitalized HIV-infected patients

BACKGROUND

Previous review of admissions from 2009-2011 in our institution found a 35.1% error rate in antiretroviral (ART) prescribing, with 55% of errors never corrected. Subsequently, our institution implemented a unified electronic medical record (EMR) and we developed a medication reconciliation process with an HIV pharmacist. We report the impact of the EMR on incidence of errors and of the pharmacist intervention on time to error correction.

METHODS

Prospective medical record review of HIV-infected patients hospitalized for >24 h between 9 March 2013 and 10 March 2014. An HIV pharmacist reconciled outpatient ART prescriptions with inpatient orders within 24 h of admission. Prescribing errors were classified and time to error correction recorded. Error rates and time to correction were compared to historical data using relative risks (RR) and logistic regression models.

RESULTS

43 medication errors were identified in 31/186 admissions (16.7%). The incidence of errors decreased significantly after EMR (RR 0.47, 95% CI 0.34, 0.67). Logistic regression adjusting for gender and race/ethnicity found that errors were 61% less likely to occur using the EMR (95% CI 40%, 75%; P<0.001). All identified errors were corrected, 65% within 24 h and 81.4% within 48 h. Compared to historical data where only 31% of errors were corrected in <24 h and 55% were never corrected, errors were 9.4× more likely to be corrected within 24 h with HIV pharmacist intervention (P<0.001).

CONCLUSIONS

Use of an EMR decreased the error rate by more than 50% but despite this, ART errors remained common. HIV pharmacist intervention was key to timely error correction.

Antiretroviral and Medication Errors in Hospitalized HIV-Positive Patients

Objective: To summarize the literature regarding antiretroviral and other medication errors in hospitalized HIV-positive patients and to discuss potential interventions and solutions that have been studied to minimize drug error. Data Sources: A systematic search of MEDLINE, PubMed, and EMBASE (2000-April 2014) was conducted. Search terms included HIV/AIDS, HAART, hospitalization, patient admission, inpatient, patient transfer, medication error, inappropriate prescribing, drug interaction, drug omission, drug toxicity, and contraindication. Study Selection and Data Extraction: English-language research articles, case reports, conference abstracts, and letters to the editor were reviewed. Data Synthesis: A high overall medication error rate was reported in HIV-positive inpatients. Errors occurred mainly at the time of prescribing on admission but were also detected throughout hospitalization and at discharge. Errors in the antiretroviral regimen, dosing, scheduling, and drug-drug and drug-food interactions were the most common. The most successful interventions involved a clinical pharmacist, who specializes in infectious diseases and/or HIV, completing medication reconciliation on admission, reviewing orders daily, and screening for errors at discharge. Conclusions: Although studies varied greatly in methodology, overall, a large number of medication errors occurred in this patient population. This underscores the important role the pharmacist has in optimizing care to hospitalized HIV-positive patients and provides further insights into the types of medication errors that occur and proposed solutions to reduce these errors. Because medication errors are multifactorial, ongoing initiatives to improve the quality of medication reconciliation processes, educate the health care team on antiretroviral medications, and improve the drug distribution system are required.