Medication errors in HIV-infected hospitalized patients: a pharmacist's impact

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.

Antiretroviral Stewardship: Top 10 Questions Encountered by Stewardship Teams and Solutions to Optimize Therapy

PURPOSE

Infectious disease pharmacists and physicians overseeing antimicrobial stewardship programs possess expertise and often advanced certification in management of antiretrovirals to treat HIV. Stewardship programs are responsible for managing facility formularies and must stay up to date with the latest antiretrovirals, including once daily formulations and depot injectables. Furthermore, stewardship program members need to understand drug-interactions, short-, and long-term toxicities of these regimens, including dyslipidemia and cardiovascular effects. Patients receiving chronic antiretroviral therapy may present to the acute care, ambulatory care, and long-term care settings. Like other antimicrobials, audit-and-feedback, drug monitoring, and dose-optimization are often required to prevent antiretroviral associated medication errors and minimize resistance.

METHODS

A narrative review was conducted on antiretroviral stewardship, addressing common clinical questions encountered by stewardship teams and best practices to optimize antiretroviral therapy and reduce the risk for treatment interruptions, resistance, drug interactions, long term toxicities, and other adverse effects.

FINDINGS

People living with HIV are often hospitalized and treated by medical teams without formal HIV training. For this reason, these patients are at greater risk for medication errors during hospitalization and between transitions of care. Many opportunities are present for antiretroviral stewardship to mitigate these errors. Frequent updates to simplify HIV regimen, maintain select patients on fixed-dose combination tablets, and strategies to minimize drug interactions make it difficult for even the seasoned clinician to keep up regularly.

IMPLICATIONS

Despite the availability of free online HIV resources and progress made in HIV management, significant opportunities for antiretroviral stewardship remain. Implementing electronic order entry updates, formulary upgrades, and formal pharmacy renal dose adjustments to optimize antiretroviral therapy will help clinicians harness these opportunities. Dedicated time and expertise for antiretroviral stewardship as part of local antimicrobial stewardship programs are needed.

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.

Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors

OBJECTIVES

The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP).

PRACTICE DESCRIPTION

This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods.

RESULTS

The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11).

CONCLUSION

Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

Clinical pharmacist input on HIV management may improve antiretroviral prescribing for psychiatric patients

PURPOSE

The results of a study to determine the difference in HIV management with clinical pharmacist input in an adult psychiatric hospitalized patient population are reported.

METHODS

Single-center, retrospective study of patients admitted to a psychiatric hospital on antiretroviral (ARV) medication(s) from October 2016 to March 2017 (phase I: no pharmacist involvement), October 2017 to March 2018 (phase II: partial pharmacist involvement), and November 2018 to January 2019 (phase III: consistent pharmacist involvement). Patients were excluded if less than 18 years of age, pregnant, incarcerated, or taking ARV medication(s) for non-HIV indications. The primary outcome was difference in appropriateness of ARV therapy prior to and during pharmacist involvement. Secondary outcomes were appropriateness of opportunistic infection (OI) prophylaxis, laboratory testing, and comprehensive HIV management.

RESULTS

Thirty-seven patients were included per phase. An increased number of appropriate ARV regimens were initiated in phase II compared to phase I (62% vs 32%; P = 0.01) and in phase III compared to phase II (84% vs 62%; P = 0.036). Increased laboratory monitoring was seen with partial and consistent pharmacist involvement. Among the patients requiring OI prophylaxis, appropriate prophylaxis was initiated in more patients in phase III (57%) than in phase II (50%) or phase I (11%). More patients had comprehensive HIV management in phase II compared to phase I (38% vs 5%; P < 0.001) and in phase III compared to phase II (46% vs 38%; P = 0.48).

CONCLUSION

Pharmacist involvement in HIV management in a psychiatric patient population increased appropriateness of ARV therapy, laboratory testing, and OI prophylaxis.

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.

A Call to Action: The Role of Antiretroviral Stewardship in Inpatient Practice, a Joint Policy Paper of the Infectious Diseases Society of America, HIV Medicine Association, and American Academy of HIV Medicine

Persons living with human immunodeficiency virus (HIV) and others receiving antiretrovirals are at risk for medication errors during hospitalization and at transitions of care. These errors may result in adverse effects or viral resistance, limiting future treatment options. A range of interventions is described in the literature to decrease the occurrence or duration of medication errors, including review of electronic health records, clinical checklists at care transitions, and daily review of medication lists. To reduce the risk of medication-related errors, antiretroviral stewardship programs (ARVSPs) are needed to enhance patient safety. This call to action, endorsed by the Infectious Diseases Society of America, the HIV Medicine Association, and the American Academy of HIV Medicine, is modeled upon the success of antimicrobial stewardship programs now mandated by the Joint Commission. Herein, we propose definitions of ARVSPs, suggest resources for ARVSP leadership, and provide a summary of published, successful strategies for ARVSP that healthcare facilities may use to develop locally appropriate programs.

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.

Impact of an HIV-trained clinical pharmacist intervention on error rates of antiretroviral and opportunistic infection medications in the inpatient setting

Background:

Based on a retrospective study performed at our institution, 38% of inpatients living with human immunodeficiency virus (HIV) were found to have a medication error involving their anti-retroviral (ARV) and/or opportunistic infection (OI) prophylaxis medications.

Objective:

To determine the impact of a dedicated HIV-trained clinical pharmacist on the ARV and OI prophylaxis medication error rates at our institution.

Methods:

A prospective quality improvement project was conducted over a six month period to assess the impact of a dedicated HIV-trained clinical pharmacist on the ARV and OI prophylaxis medication error rates. IRB approval received.

Results:

There were 144 patients included in this analysis, who experienced a combined 76 medication errors. Compared to historical control study conducted at our institution, the percent of patients who experienced a medication error remained stable (38% vs. 39%, respectively) and the error rate per patient was similar (1.44 vs. 1.36, p=NS). The percent of medication errors that were corrected prior to discharge increased from 24% to 70% and the median time to error correction decreased from 42 hours to 11.5 hours (p<0.0001).

Conclusions:

Errors relating to ARV or OI prophylaxis medications remain frequent in inpatient people living with HIV/AIDS. After multiple interventions were implemented, ARV and OI prophylaxis medication errors were corrected faster and with greater frequency prior to discharge, however, similar rates of errors for patients existed. Dedicated HIV clinicians with adequate training and credentialing are necessary to manage this specialized disease state and to reduce the overall number of medication errors associated with HIV/AIDS.

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.

Polypharmacy and drug-related problems among people living with HIV/AIDS: a single-center experience

Background/aim

The HIV-infected population is aging, and the concomitant comorbidities increase the likelihood of polypharmacy. There is a scarcity of data for determining drug-related problems in people living with HIV/AIDS (PLWHA).

Materials and methods

This cross-sectional study was carried out between 1 September 2015 and 1 July 2016. All patients underwent a face-to-face interview with a clinical pharmacist. PCNE Classification V 7.0 was used classify incident drug-related problems (DRPs).

Results

The mean age of the patients was 40.4 ± 13.06 years. The rate of polypharmacy was 66.1% in patients with comorbidities and 12.3% in those without comorbidities (P < 0.001). DRPs were more prominent in older patients (46 vs. 37 years, P < 0.001), those with longer durations of antiretroviral therapy (ART) (45 vs. 27 months, P = 0.014), and those with lower education levels (P = 0.013). Receiving >3 ART drugs was associated with more DRPs in the logistic regression model (odds ratio: 8.299, 95% confidence interval: 1.924–35.803). Fifty-eight interventions were performed in 45 (24.9%) patients. Clinical pharmacist interventions were performed in 18.9% of patients without polypharmacy and in 38.9% of patients with polypharmacy (P < 0.001).

Conclusion

DRPs and polypharmacy are common among elderly PLWHA. More interventions are warranted to boost the quality of life in aging PLWHA.

Impact of an antiretroviral stewardship strategy on medication error rates

PURPOSE

The impact of an antiretroviral stewardship strategy on medication error rates was evaluated.

METHODS

This single-center, retrospective, comparative cohort study included patients at least 18 years of age infected with human immunodeficiency virus (HIV) who were receiving antiretrovirals and admitted to the hospital. A multicomponent approach was developed and implemented and included modifications to the order-entry and verification system, pharmacist education, and a pharmacist-led antiretroviral therapy checklist. Pharmacists performed prospective audits using the checklist at the time of order verification. To assess the impact of the intervention, a retrospective review was performed before and after implementation to assess antiretroviral errors.

RESULTS

Totals of 208 and 24 errors were identified before and after the intervention, respectively, resulting in a significant reduction in the overall error rate (p < 0.001). In the postintervention group, significantly lower medication error rates were found in both patient admissions containing at least 1 medication error (p < 0.001) and those with 2 or more errors (p < 0.001). Significant reductions were also identified in each error type, including incorrect/incomplete medication regimen, incorrect dosing regimen, incorrect renal dose adjustment, incorrect administration, and the presence of a major drug-drug interaction. A regression tree selected ritonavir as the only specific medication that best predicted more errors preintervention (p < 0.001); however, no antiretrovirals reliably predicted errors postintervention.

CONCLUSION

An antiretroviral stewardship strategy for hospitalized HIV patients including prospective audit by staff pharmacists through use of an antiretroviral medication therapy checklist at the time of order verification decreased error rates.

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.

Pharmacists' impact on opportunistic infection prophylaxis in patients with HIV/AIDS

Pharmacists have demonstrated a positive impact on the care of patients with human immunodeficiency virus/acquired immunodeficiency syndrome through enhancing patient outcomes associated with antiretroviral therapy. This pre- and postintervention study assessed the impact of pharmacist intervention on improving the use of prophylactic medications for opportunistic infections (OI). Of the 139 patients screened, 42 patients were included in the prospective intervention group. A total of 27 interventions were made on 15 patients, and 24 recommendations (89%) were accepted by providers. Compared with the retrospective control group, prescribing of OI prophylaxis increased from 58% to 93% (P<0.001) with the addition of pharmacist intervention.

Antiretroviral Stewardship in a Pediatric HIV Clinic: Development, Implementation and Improved Clinical Outcomes

BACKGROUND

Antiretroviral (ARV) management in pediatrics is a challenging process in which multiple barriers to optimal therapy can lead to poor clinical outcomes. In a pediatric HIV clinic, we implemented a systematic ARV stewardship program to evaluate ARV regimens and make recommendations for optimization when indicated.

METHODS

A comprehensive assessment tool was used to screen for issues related to genotypic resistance, virologic/immunologic response, drug-drug interactions, side effects and potential for regimen simplification. The ARV stewardship team (AST) made recommendations to the HIV clinic provider, and followed patients prospectively to assess clinical outcomes at 6 and 12 months.

RESULTS

The most common interventions made by the AST included regimen optimization in patients on suboptimal regimens based on resistance mutations (35.4%), switching to safer ARVs (33.3%) and averting significant drug-drug interactions (10.4%). In patients anticipated to have a change in viral load (VL) as a result of the AST recommendations, we identified a significant benefit in virologic outcomes at 6 and 12 months when recommendations were implemented within 6 months of ARV review. Patients who had recommendations implemented within 6 months had a 7-fold higher probability of achieving a 0.7 log10 reduction in VL by 6 months, and this benefit remained significant after controlling for adherence [adjusted odds ratio: 6.8 (95% confidence interval: 1.03-44.9; P <0.05)].

CONCLUSIONS

A systematic ARV stewardship program implemented at a pediatric HIV clinic significantly improved clinical outcomes. ARV stewardship programs can be considered a core strategy for continuous quality improvement in the management of HIV-infected children and adolescents.

Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center: A 3-Year, Multiphase Study

BACKGROUND

There is a high prevalence of HIV infection in Newark, New Jersey, with University Hospital admitting approximately 600 HIV-infected patients per year. Medication errors involving antiretroviral therapy (ART) could significantly affect treatment outcomes. The goal of this study was to evaluate the effectiveness of various stewardship interventions in reducing the prevalence of prescribing errors involving ART.

METHODS

This was a retrospective review of all inpatients receiving ART for HIV treatment during three distinct 6-month intervals over a 3-year period. During the first year, the baseline prevalence of medication errors was determined. During the second year, physician and pharmacist education was provided, and a computerized order entry system with drug information resources and prescribing recommendations was implemented. Prospective audit of ART orders with feedback was conducted in the third year. Analyses and comparisons were made across the three phases of this study.

RESULTS

Of the 334 patients with HIV admitted in the first year, 45% had at least one antiretroviral medication error and 38% had uncorrected errors at the time of discharge. After education and computerized order entry, significant reductions in medication error rates were observed compared to baseline rates; 36% of 315 admissions had at least one error and 31% had uncorrected errors at discharge. While the prevalence of antiretroviral errors in year 3 was similar to that of year 2 (37% of 276 admissions), there was a significant decrease in the prevalence of uncorrected errors at discharge (12%) with the use of prospective review and intervention.

CONCLUSIONS

Interventions, such as education and guideline development, can aid in reducing ART medication errors, but a committed stewardship program is necessary to elicit the greatest impact.

National Incidence of Medication Error in Surgical Patients Before and After Accreditation Council for Graduate Medical Education Duty-Hour Reform

OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) established duty-hour regulations for accredited residency programs on July 1, 2003. It is unclear what changes occurred in the national incidence of medication errors in surgical patients before and after ACGME regulations.

DESIGN

Patient and hospital characteristics for pre- and post-duty-hour reform were evaluated, comparing teaching and nonteaching hospitals. A difference-in-differences study design was used to assess the association between duty-hour reform and medication errors in teaching hospitals.

SETTING

We used the Nationwide Inpatient Sample database, which consists of approximately annual 20% stratified sample of all the United States nonfederal hospital inpatient admissions.

PARTICIPANTS

A query of the database, including 4 years before (2000-2003) and 8 years after (2003-2011) the ACGME duty-hour reform of July 2003, was performed to extract surgical inpatient hospitalizations (N = 13,933,326). The years 2003 and 2004 were discarded in the analysis to allow for a wash-out period during duty-hour reform (though we still provide medication error rates).

RESULTS

The Nationwide Inpatient Sample estimated the total national surgical inpatients (N = 135,092,013) in nonfederal hospitals during these time periods with 68,736,863 patients in teaching hospitals and 66,355,150 in nonteaching hospitals. Shortly after duty-hour reform (2004 and 2006), teaching hospitals had a statistically significant increase in rate of medication error (p = 0.019 and 0.006, respectively) when compared with nonteaching hospitals even after accounting for trends across all hospitals during this period. After 2007, no further statistically significant difference was noted.

CONCLUSIONS

After ACGME duty-hour reform, medication error rates increased in teaching hospitals, which diminished over time. This decrease in errors may be related to changes in training program structure to accommodate duty-hour reform.

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.

Antimicrobial stewardship program to reduce antiretroviral medication errors in hospitalized patients with human immunodeficiency virus infection

OBJECTIVE

Evaluate antimicrobial stewardship interventions targeted to reduce highly active antiretroviral therapy (HAART)- or opportunistic infection (OI)-related medication errors and increase error resolution.

DESIGN

Retrospective before-after study.

SETTING

Academic medical center.

PATIENTS

Inpatients who were prescribed antiretroviral therapy before the intervention (January 1, 2011, to October 31, 2011) and after the intervention (July 1, 2012, to December 31, 2012). Patients treated with lamivudine or tenofovir monotherapy for hepatitis B were excluded.

METHODS

Antimicrobial stewardship interventions included education, modification of electronic medication records, collaboration with the infectious diseases (ID) department, and prospective audit and review of HAART and OI regimens by an ID clinical pharmacist.

RESULTS

Data for 162 admissions from the preintervention period and 110 admissions from the postintervention period were included. The number of admissions with a medication error was significantly reduced after the intervention (81 [50%] of 162 admissions vs 37 (34%) of 110 admissions; P < .00)1. A total of 124 errors occurred in the preintervention group (mean no. of errors, 1.5 per admission), and 43 errors occurred in the postintervention group (mean no. of errors, 1.2 per admission). The most common error types were major drug interactions and dosing in the preintervention group and renal adjustment and OI-related errors in the postintervention group. A significantly higher error resolution rate was observed in the postintervention group (36% vs 74%; P < .001). After adjustment for potential confounders with logistic regression, admission in the postintervention group was independently associated with fewer medication errors (odds ratio, 0.4 [95% confidence interval, 0.24-0.77]; P = .005). Overall, presence of an ID consultant demonstrated a higher error resolution rate (32% without a consultation vs 68% with a consultation; P = .002).

CONCLUSIONS

Multifaceted, multidisciplinary stewardship efforts reduced the rate and increased the overall resolution of HAART-related medication errors.