High-Risk,High-Alert Medication Management Practices in a Regional State Psychiatric Facility

Abstract

Background

The Joint Commission on Accreditation of Healthcare Organizations requires that health care organizations identify high-risk, high alert medications and develop specific processes for enhancing patient safety surrounding their use.

Purpose

Describe the development and implementation of a clinical pharmacy service, which identifies patients initiated on lithium, clozapine, and warfarin therapy to enable real-time consultation, decrease preventable adverse medication events, and improve the medication-use process. Methods: The facility identified lithium, clozapine, and warfarin for enhanced clinical monitoring. Lithium monitoring criteria include appropriate indication and testing for pregnancy, renal function, electrolyte levels, thyroid function, and serum drug levels. Clozapine monitoring criteria include informed consent, metabolic end points, appropriate indication, and complete blood count monitoring. Warfarin monitoring includes appropriate indication, screening for drug interactions, and international normalized ratio follow-up. Pharmacy and Laboratory information system flags were used to identify at-risk patients.

Results

For the initial 21 months of implementation, 419 lithium patients were evaluated, with 60.1 % meeting criteria preconsultation, and 95.7% meeting criteria postconsultation. Adverse drug reaction (ADR) reports involving lithium decreased from 6% preimplementation to 3% postimplementation.

A total of 76 clozapine-initiation patients were evaluated, with 75% of patients meeting all criteria preconsultation, and 96% meeting criteria postconsultation. Two percent of ADR reports involved clozapine preimplementation, with a decrease to 1% postimplementation.

Fifty-six warfarin-initiation therapy patients were followed, with 94.6% meeting all post-pharmacist review criteria. Significant changes were made in the medication dispensing system to prevent warfarin-dose administration errors.

Conclusion

Pharmacist-facilitated, high-alert medication monitoring plays a significant role in improving the medication-use process in this regional state psychiatric facility.

Keywords

medication safety medication therapy management psychiatric pharmacy

Get full access to this article

View all access options for this article.

References

Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals: The Official Handbook. 2004.

Joint Commission on Accreditation of Healthcare Organizations. High-Alert Medications and Patient Safety. Sentinel Event Alert; (11): November 19, 1999.

Kohn

L.T.

, Corrigan

J.M.

, Donaldson

eds. To Err is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999.

Bates

D.W.

, Cullen

D.J.

, Laird

. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995; 274: 29–34.

May

S.K.

Improving patient safety: one standard at a time. Hosp Pharm. 2005; 40: 921–924,928.

Rich

D.S.

New JCAHO medication management standards for 2004. Am J Health Syst Pharm. 2004;61: 1349–1358.

Rich

D.S.

Questions about the medication-related national patient safety goals. Hosp Pharm. 2003; 38: 170–174.

Institute for Safe Medication Practices. Institute for Safe Medication Practices Frequently Asked Questions. Available at: http://www.ismp.org/faq.asp#Question_7. Accessed March 9, 2007.

Leape

L.L.

, Brennan

T.A.

, Laird

. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324: 377–384.

10.

Classen

D.C.

, Pestotik

M.S.

, Evans

R.S.

, Loyd

J.F.

, Burke

J.P.

The nature of adverse events in hospitalized patients: excessive length of stay, extra costs, and attributable mortality. JAMA. 1997; 277: 301–306.

11.

American Psychiatric Association. APA Practice Guidelines for the Treatment of Psychiatric Disorders. Bipolar Disorder – Quick Reference Guide. Available at: http://www.psych.org/psych_pract/treatg/quick_ref_guide/BipolarDisorderQRG_04-15-05.pdf. Accessed March 9, 2007.