Improving medication safety in the Intensive Care by identifying relevant drug-drug interactions - Results of a multicenter Delphi study

Purpose: Drug-drug interactions (DDIs) may cause adverse outcomes in patients admitted to the Intensive Care Unit (ICU). Computerized decision support systems (CDSSs) may help prevent DDIs by timely showing relevant warning alerts, but knowledge on which DDIs are clinically relevant in the ICU setting is limited. Therefore, the purpose of this study was to identify DDIs relevant for the ICU. Materials and methods: We conducted a modified Delphi procedure with a Dutch multidisciplinary expert panel consisting of intensivists and hospital pharmacists to assess the clinical relevance of DDIs for the ICU. The procedure consisted of two rounds, each included a questionnaire followed by a live consensus meeting. Results: In total the clinical relevance of 148 DDIs was assessed, of which agreement regarding the relevance was reached for 139 DDIs (94%). Of these 139 DDIs, 53 (38%) were considered not clinically relevant for the ICU setting. Conclusions: A list of clinically relevant DDIs for the ICU setting was established on a national level. The clinical value of CDSSs for medication safety could be improved by focusing on the identified clinically relevant DDIs, thereby avoiding alert fatigue

The effect of ICU-tailored drug-drug interaction alerts on medication prescribing and monitoring: Protocol for a cluster randomized stepped-wedge trial

Background: Drug-drug interactions (DDIs) can cause patient harm. Between 46 and 90% of patients admitted to the Intensive Care Unit (ICU) are exposed to potential DDIs (pDDIs). This rate is twice as high as patients on general wards. Clinical decision support systems (CDSSs) have shown their potential to prevent pDDIs. However, the literature shows that there is considerable room for improvement of CDSSs, in particular by increasing the clinical relevance of the pDDI alerts they generate and thereby reducing alert fatigue. However, consensus on which pDDIs are clinically relevant in the ICU setting is lacking. The primary aim of this study is to evaluate the effect of alerts based on only clinically relevant interactions for the ICU setting on the prevention of pDDIs among Dutch ICUs. Methods: To define the clinically relevant pDDIs, we will follow a rigorous two-step Delphi procedure in which a national expert panel will assess which pDDIs are perceived clinically relevant for the Dutch ICU setting. The intervention is the CDSS that generates alerts based on the clinically relevant pDDIs. The intervention will be evaluated in a stepped-wedge trial. A total of 12 Dutch adult ICUs using the same patient data management system, in which the CDSS will operate, were invited to participate in the trial. Of the 12 ICUs, 9 agreed to participate and will be enrolled in the trial. Our primary outcome measure is the incidence of clinically relevant pDDIs per 1000 medication administrations. Discussion: This study will identify pDDIs relevant for the ICU setting. It will also enhance our understanding of the effectiveness of alerts confined to clinically relevant pDDIs. Both of these contributions can facilitate the successful implementation of CDSSs in the ICU and in other domains as well. Trial registration: Nederlands Trial register Identifier: NL6762. Registered November 26, 2018

Clinically relevant potential drug-drug interactions in intensive care patients: a large retrospective observational multicenter study

Purpose: Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all pDDIs are clinically relevant. Clinical decision support systems (CDSSs) warning for irrelevant pDDIs could result in alert fatigue and overlooking important signals. Therefore, our aim was to describe the frequency of clinically relevant pDDIs (crpDDIs) to enable tailoring of CDSSs to the ICU setting. Materials & methods: In this multicenter retrospective observational study, we used medication administration data to identify pDDIs in ICU admissions from 13 ICUs. Clinical relevance was based on a Delphi study in which intensivists and hospital pharmacists assessed the clinical relevance of pDDIs for the ICU setting. Results: The mean number of pDDIs per 1000 medication administrations was 70.1, dropping to 31.0 when con -sidering only crpDDIs. Of 103,871 ICU patients, 38% was exposed to a crpDDI. The most frequently occurring crpDDIs involve QT-prolonging agents, digoxin, or NSAIDs. Conclusions: Considering clinical relevance of pDDIs in the ICU setting is important, as only half of the detected pDDIs were crpDDIs. Therefore, tailoring CDSSs to the ICU may reduce alert fatigue and improve medication safety in ICU patients. ? 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).Perioperative Medicine: Efficacy, Safety and Outcome (Anesthesiology/Intensive Care

Clinically relevant potential drug-drug interactions in intensive care patients: A large retrospective observational multicenter study

Purpose: Potential drug-drug interactions (pDDIs) may harm patients admitted to the Intensive Care Unit (ICU). Due to the patient's critical condition and continuous monitoring on the ICU, not all pDDIs are clinically relevant. Clinical decision support systems (CDSSs) warning for irrelevant pDDIs could result in alert fatigue and overlooking important signals. Therefore, our aim was to describe the frequency of clinically relevant pDDIs (crpDDIs) to enable tailoring of CDSSs to the ICU setting. Materials & methods: In this multicenter retrospective observational study, we used medication administration data to identify pDDIs in ICU admissions from 13 ICUs. Clinical relevance was based on a Delphi study in which intensivists and hospital pharmacists assessed the clinical relevance of pDDIs for the ICU setting. Results: The mean number of pDDIs per 1000 medication administrations was 70.1, dropping to 31.0 when considering only crpDDIs. Of 103,871 ICU patients, 38% was exposed to a crpDDI. The most frequently occurring crpDDIs involve QT-prolonging agents, digoxin, or NSAIDs. Conclusions: Considering clinical relevance of pDDIs in the ICU setting is important, as only half of the detected pDDIs were crpDDIs. Therefore, tailoring CDSSs to the ICU may reduce alert fatigue and improve medication safety in ICU patients

Medication safety in older inpatients: Measurement and intervention strategies

Older patients (65 years and older) experience far more adverse drug events (ADEs) compared with younger adults. Appropriate prescribing and recognition of ADEs in older inpatients is challenging endeavor because of often present polypharmacy, multimorbidity, and impaired cognitive and physical functions. The main objectives of this thesis were to determine medication safety in older inpatients by measuring ADEs, to develop and implement a multifaceted intervention strategy (MFIS), and to investigate the effect of this strategy on preventable ADEs and ADE recognition in older inpatients. In total 118 ADEs were identified in 250 included older inpatients (65 years and older and taking ≥ 5 medications on admission). Of the 118 ADEs, 71% was preventable and 43% caused serious preventable patient harm. Most preventable ADEs (86%) were ADEs caused by prescribing errors. Furthermore, of the ADEs already present upon hospital admission 20% was not recognized by the medical teams, and 20% of ADEs occurring during the hospital stay was also missed. The implementation of MFIS in three Dutch hospitals resulted in 51% reduction in the rate of preventable ADEs (pADEs) occurring during the hospital stay (P < 0.001), 63% reduction in the rate of serious pADEs (P < 0.001), and 52% reduction in the rate of unrecognized ADEs (P < 0.001). All rates were calculated per 100 hospitalizations. The MFIS consisted of a comprehensive medication review followed by face-to-face feedback on prescribing by hospital pharmacists, geriatric pharmacotherapy education, and a pocket-sized checklist of drug-related problems for internal medicine residents

RESCUE Metadata

This record contains meta-data on the RESCUE study, a retrospective observational study on drug-induced kidney injury in patients admitted to an Intensive Care Unit (ICU).  RESCUE dataset contains routinely collected data from Electronic Health Records of Intensive Care Units of 15 Dutch hospitals in the period 2010-2019. The data includes the following variables: medication administrations (with ATC code      and GPK code as identifier) laboratory findings ECG orders renal replacement therapy orders risk scores including RASS and GCS  vital signs including temperature, blood pressure measurements and heart rhythm medication safety alerts including potential drug-drug interactions alerts and duplicate orders alerts based on G-Standaard of Z-Index This data was enriched by linking it to Minimal Data Set (MDS) of National Intensive Care Evaluation (NICE) data delivered by the participating ICUs as part of national quality of care monitoring. Information about MDS of NICE can be found here: Data Dictionary (stichting-nice.nl)  For inquiries about re-use of RESCUE study dataset for research, please contact project leader from Amsterdam UMC (Dr. Joanna Klopotowska). The re-use of the dataset is possible upon reasonable request and subject to certain limitations. Conditions include but are not limited to: re-use of data for a scientifically valid and methodologically sound research project with an aim to publish in a peer-review journal, data will only be shared for collaborative efforts, not for use by third parties only, de-identified data may not leave control of Amsterdam UMC; anonymized data may also be used by a third party, contractual obligations regarding the rights of participating ICUs are respected (e.g. agreement to re-use, prior review of protocol and intended publications), legal rights of study participants are respected, re-use is always subject to applicable law, institutional regulations and review by the medical ethics committee, if applicable. Contact with the project leader can be sought via [email protected]</p

RESCUE Metadata

This record contains meta-data on the RESCUE study, a retrospective observational study on drug-induced kidney injury in patients admitted to an Intensive Care Unit (ICU).  RESCUE dataset contains routinely collected data from Electronic Health Records of Intensive Care Units of 15 Dutch hospitals in the period 2010-2019. The data includes the following variables: medication administrations (with ATC code      and GPK code as identifier) laboratory findings ECG orders renal replacement therapy orders risk scores including RASS and GCS  vital signs including temperature, blood pressure measurements and heart rhythm medication safety alerts including potential drug-drug interactions alerts and duplicate orders alerts based on G-Standaard of Z-Index This data was enriched by linking it to Minimal Data Set (MDS) of National Intensive Care Evaluation (NICE) data delivered by the participating ICUs as part of national quality of care monitoring. Information about MDS of NICE can be found here: Data Dictionary (stichting-nice.nl)  For inquiries about re-use of RESCUE study dataset for research, please contact project leader from Amsterdam UMC (Dr. Joanna Klopotowska). The re-use of the dataset is possible upon reasonable request and subject to certain limitations. Conditions include but are not limited to: re-use of data for a scientifically valid and methodologically sound research project with an aim to publish in a peer-review journal, data will only be shared for collaborative efforts, not for use by third parties only, de-identified data may not leave control of Amsterdam UMC; anonymized data may also be used by a third party, contractual obligations regarding the rights of participating ICUs are respected (e.g. agreement to re-use, prior review of protocol and intended publications), legal rights of study participants are respected, re-use is always subject to applicable law, institutional regulations and review by the medical ethics committee, if applicable. Contact with the project leader can be sought via [email protected]</p

Interruptions during intravenous medication administration: a multicenter observational study.

Aims: To determine the frequency and cause of interruptions during intravenous medication administration, which factors are associated with interruptions and to what extent interruptions influence protocol compliance. Background: Hospital nurses are frequently interrupted during medication administration, which contributes to the occurrence of administration errors. Errors with intravenous medication are especially worrisome, given their immediate therapeutic effects. However, knowledge about the extent and type of interruptions during intravenous medication administration is limited. Design: Multicenter observational study. Methods: Data were collected during two national evaluation studies (2011/2012 and 2015/2016). Nurses were directly observed during intravenous medication administration. An interruption was defined as a situation where a break during the administration was needed or where a nurse was distracted but could process without a break. Interruptions were categorized according to source and cause. Multilevel logistic regression analyses were conducted to assess the associations between explanatory variables and interruptions or complete protocol compliance. Results: In total, 2526 intravenous medication administration processes were observed. During 291 (12%) observations, nurses were interrupted 321 times. Most interruptions were externally initiated by other nurses (19%) or patients (19%). Less interruptions occurred during the evening (Odds Ratio: 0.23, (95%‐Confidence Interval: 0.08‐0.62). Do‐not‐disturb vests were worn by 61 (2%) nurses. No significant association was found between being interrupted and complete protocol compliance. Conclusion: An interruption occurred in every eight observed intravenous medication administration, mainly caused by other nurses or patients. One needs to critically consider which strategies effectively improve safety during the high‐risk nursing‐task of intravenous medication administration