1. Project to improve quality of drug administration Salas E, Bastida M, Grau S, Vilar Mª J, Ferrández O, Portabella J, Ortiz P, Miro M, Rubio L, Cuixart I, Cabello M

2. Background NY:New York;UC:Utah and Colorado;A:Australia;L:London;D:Denmark NZ:New Zealand;CA:Canada;S:Spain Incidence of patients suffering adverse healthcare-related events

3. Background  At the point of drug administration, errors have traditionally been more difficult to detect and clearly, the consequences of error more serious  Administration errors in hospitals 41 errors per 100 opportunities for error Lisby M, Nielsen LP, Mainz J. Qual health care 2005; 17:15-22.

4. Background In Spain -retrospective study in 24 hospitals -hospitalised patients who had a case record and were discharged during June 4-10, 2005 -identification of possible AE: Screening Guide from the Adverse event Identification Project (IDEA) RESULTS 5,624 case records -8.4% patients with AE related to hospital care - 37.4% of the AE were related to medication Aranaz JM, Aibar C, Vitaller J, Ruiz P. Estudio Nacional sobre los Efectos Adversos ligados a la hospitalización. ENEAS, 2005.

5. Background - Drug administration is the last step of the therapeutic care and one potential source of errors - Implementation of strategies affecting this step could be relevant for reducing errors related to drug administration

6. Objective Assessment of nurses’ knowledge of drug administration to provide them with information through a computer tool

7. Design  It was performed in a 900-bed hospital trust, IMAS (Esperança, Psiquiatric, Mar, Geriàtric) in Barcelona It was performed in a 900-bed hospital trust, IMAS (Esperança, Psiquiatric, Mar, Geriàtric) in Barcelona  The study period was from February to June 2006  Multidisciplinary team: pharmacists, nurses and computer programmers  Statistical  analysis -Student t test for parametrical variables -Chi-square test and “U” Mann Whitney test for non parametrical variables -CI 95% and p<0.05 for significance  A survey of 44 questions was handed out to a randomized number of nurses from different medical wards and shifts A survey of 44 questions was handed out to a randomized number of nurses from different medical wards and shifts

8. Hospital TRUST IMAS

9. Hospital de la Esperança 219-bed hospital 61,658 stays per year 11.76 doses per stay Specialities Ophtalmology Palliatives cures Convalescence Rehabilitation Radiotherapy Orthopaedic surgery Chronic patients

10. Hospital del Mar 431-bed university hospital 154,684 stays per year 9.77 doses per stay acute specialities

11. Geriàtric 206-bed hospital 10,696 stays per year 9.86 doses per stay chronic institution Psiquiàtric 83-bed hospital 13,056 stays per year 8.49 doses per stay psychiatric patients

12. Design  1.General questions: The survey included: - drug guide and protocol availability -adverse drug event record -overall points related to drugs 2.Oral and tube feeding drug administration 3.Parenteral drug administration 4. Errors related to medication 5.Drugs difficult to administer -pharmacological activity -administration route -adverse events Degree of concern and involvement of nurses

13. Design 127 surveys were given out HOSPITAL TRUST

14.  125/127 surveys were answered Results -awareness of drug guide and protocol availabilityawareness of drug guide and protocol availability -adverse drug event recordadverse drug event record -oral drug administrationoral drug administration -reconstitution, dilution, administration and stability of parenteral drugs (M vs E, G and P; p<0.001) -errors related to medicationerrors related to medication -awareness of a medication errors reporting systemawareness of a medication errors reporting system Statistical differences between hospitals:

15. AWARENESS OF DRUG GUIDE AND PROTOCOL AVAILABILITY p<0.001

16. ADVERSE DRUG EVENT RECORD P=0.009

17. ORAL DRUG ADMINISTRATION

18. ERRORS RELATED TO DRUGS p=0.039

19. AWARENESS OF MEDICATION ERRORS REPORTING SYSTEM p<0.001

20. Results Statistical differences between nurse shifts: -oral drug administrationoral drug administration -reconstitution, dilution, administration and stability of parenteral drugs (N vs M and A; p<0.001)

21. ORAL DRUG ADMINISTRATION

22. Results Drug classes whose administration was problematic: antimicrobials parenteral drugs opiates Differences were not found between different hospitals or shifts

23. Interventions According to the obtained results, pharmacists introduced information about drug administration drug administration paper chart drug administration computerized chart

24. Information included Parenteral drugs -Reconstitution -Dilution -Compatibility with fluids -Administration rate -Stability -Photosensitivity Oral drugs -Drug-food and beverages interactions -Drug-herbal medicines interactions -Possibility of crushing

25. Information sources Databases Micromedex Medline Iowa Books -Borgsdorf LR, Cada DJ, Cirigliano M, Covington TR, Generali JA, Hussar DA et al, editors. Drug facts and comparisons. St Louis:Facts and comparisons;2006. -Seetman SC, editor. Martindale: the complet drug reference. London:Pharmaceutical Press;2004. -Trissel LA. Handbook on injectable drugs. Bethesda:American Society of Health-System Pharmacists;2005. -McEvoy GK, Miller J, Litvak K, Dewey DR, Bollinger LA, Shick J et al, editors. AHFS Drug Information. Bethesda:American Society of Health-System Pharmacists;2004. - Baxter K, editor. Stockley’s drug interactions. London: Pharmaceutical Press;2006.

26. Information sources Articles -Dickerson RN, Melnik G. Osmolality of oral drug solutions and suspensions. American Journal of health-system pharmacy 1988;45:832-4. -Gámez M, Clopés A, Cardona D, Farré R, Castro I, Bonal J. Importancia de las características fisico-químicas de los fármacos para su administración por sonda nasoentérica o enterostomía. Farm Hosp 1998;22:137-43. -Schmidt LE, Dalhoff K.Food-drug interactions.Drugs 2002;62:1481-502 -Beckwith MC, Feddema SS, Barton RG, Graves C. A guide to drug therapy in patients with enteral feeding tubes:dosage form selection and administration methods.Hosp Pharm 2004;3:225-37. -Magnuson BL, Clifford TM, Hoskins LA, Bernard AC. Enteral nutrition and drug administration, interactions, and complications. Nutr Clin Pract 2005;20:618-24.. Information from manufacturers

27. Interventions According to the obtained results, pharmacists introduced information about drug administration drug administration paper chart drug administration computerized chart

28. MEDICACIO DOSI Hora Dill. Dima. Dime. Dijo. Dive. Diss. Dium. ----------------------------------------------------------- INDAPAMIDA RETARD 1.5 MG COMP 1 COR/CADA 24 HORES/OR No triturar els comprimits. Administrar sense tenir en compte els àpats. PANTOPRAZOL 40 MG COMP 1 COM/CADA 24 HORES/OR No triturar els comprimits. Administrar sense tenir en compte els àpats i amb un got d'aigua. PARACETAMOL 1G IV VIAL 1 VIA/CADA 8 HORES/IV Administrar en 15min

29. Useful information for drug administration Urgent information for drug administration

32. Conclusions A different knowledge profile in drug administration has been detected between nurses from different hospitals Different clinical characteristics of patients assisted in every center The introduction of strategies to improve security in drug administration is essential