Patient Safety

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    Title: Understanding Type II Diabetes Insulin Management During The COVID-19 Pandemic: Findings from a Hospital and a Clinic
    (2023) Opara, Chinemerem; White, Annesha; Xiao, Yan; Jodray, Megan; Fulda, Kimberly
    Purpose: COVID-19 disrupted the care of people with diabetes. It is not clear how the disrupted care impacted medication safety and diabetic control outcomes. During the pandemic, questions emerged regarding whether patients experienced changes in care that led to higher glucose levels, inappropriate medication changes and poorer health outcomes. The role of strategies to control glucose, such as the use of antidiabetic drugs has been established. We examined safety issues related to the association between insulin use and diabetic control among diabetic patients during COVID-19. Results: After examining 42 patient cases, it is noted that most (55%) patients had controlled A1C (pre-Covid vs Covid-era). (55%) of patients whose A1C was < 8% (pre-Covid vs Covid era) were prescribed insulin compared to (45%) of patients who had an A1C >8% (pre-Covid vs Covid era). The cease in insulin prescribing (pre-Covid vs Covid era) increased the A1C levels for uncontrollable patients. Conclusion: During the COVID pandemic, gaps in insulin prescriptions were associated with occurrences of diabetic control status changing to uncontrolled status, indicating patient safety issues. Monitoring insulin prescribing among diabetic patients during the pandemic may identify care gaps and help to improve patient care outcomes.
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    Inadequate Administration of Post-Intubation Sedation and Analgesia in the Pediatric Emergency Department (PED)
    (2023) Oad, Shayrin; Wolf, Haley; Hamby, Tyler; Sainna, Ruth; Selby, Sam
    Purpose: Previous adult studies demonstrate patients in emergency departments (ED) often do not receive subsequent sedative or analgesic medications within the intubation medication’s duration of action (DOA). These patients can experience pain or remember events while still being under the effects of the paralytic medication. Inadequate sedation following intubation increases rates of adverse events. The purpose of this project was to evaluate if pediatric patients intubated in the Cook Children’s Medical Center ED (CCMC ED) are administered timely post-intubation sedation and analgesia. Methods: Chart review was performed for patients intubated in the CCMC ED between June and December 2021. Exclusion criteria included intubation at another facility and charts with incomplete data. Data were collected for medications administered, time of medication administration, and intubation time. Results: There were 106 patients intubated in the CCMC ED meeting inclusion criteria. Following intubation, 17 (16%) patients were provided with a sedative or analgesic within the DOA of the sedative or analgesic used for induction, while the remaining 89 (84%) were inadequately medicated. Thirty-one patients (29%) did receive a sedative or analgesic following intubation but not within the DOA of the initial agent. The remaining 58 (55%) patients were inadequately medicated due to a lack of medication administration before intubation, following intubation, or both. Conclusions: The majority of intubations in the CCMC ED were not adequately medicated with sedatives and/or analgesics after intubation. Thus, these patients were at risk of suboptimal levels of sedation while paralyzed following intubation. Given the adverse effects of inadequate sedation seen in previous studies, timely administration of further sedation and analgesia after intubation may lead to decreased adverse events. Quality improvement interventions are being implemented in the CCMC ED to improve post-intubation sedation and analgesia administration.
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    Medication Management of Children with ADHD: Communication Strategies to Improve Safety
    (2023) Kehinde, Ganiat; White, Annesha
    BACKGROUND: Attention Deficit and Hyperactivity Disorder (ADHD) is a common neurologic disorder that affects children and adolescents and can persist into adulthood. According to the National Center for Health Statistics, there is an estimated prevalence of 4.4% to 5.2% in the general U.S population, but 7.8% of the school-age population (more than 6 million children in the U.S.). Getting children to follow a treatment regimen can be challenging and medication adherence is an essential determinant of clinical success. Pharmacist-comanaged ADHD programs may provide an improvement in medication management strategies in children. The objective of this study was to systematically review medication management models that provide safe and effective care to children and adolescents with ADHD. METHODS: A comprehensive and systematic literature search using PubMed from 2013-2023 was performed and included search terms: "Attention Deficit Disorder with Hyperactivity/diagnosis”, "Practice Guideline”, "Attention Deficit Disorder with Hyperactivity/drug therapy", "Stimulant”, "Non-Stimulant”, "Protocols”, "Models”, "Safety”, "Pharmacist”, and "Treatment”. Article abstracts were reviewed and considered for inclusion if they used an appropriate ADHD rating scale to measure efficacy of therapy and evaluated relevant therapy. After reviewing the selected articles each article was graded based on the CEBM levels of evidence. Two authors independently reviewed the titles and abstracts for inclusion of relevant studies. Full text was reviewed to determine final inclusion. If confusion existed regarding article inclusion/exclusion, it was resolved by discussion between two authors. Results were reported according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA). A table was developed to record findings from each included article and contained year of publication, author, title, research design, interventions, findings, source, and grade. RESULTS: A total of 22 articles were included in this review. A variety of guidelines exist regarding ADHD diagnosis. Most follow DSM-V although no clear consensus has been developed. Based on a patient's age, stimulants are a typical first line therapy in treating children and adolescents with ADHD. Stimulants pose a variety of safety concerns including reduced appetite, insomnia, and cardiovascular events. Based on stigma regarding stimulant use, parents have sought nonpharmacologic options to therapy. Characteristics of pharmacist co-managed ADHD programs include a standardized protocol for assessment, referral, and follow-up, psychosocial intervention, titration and monitoring of medications/adverse effects, and a communication plan. Successful programs include medication management provided via in-person as well as telehealth visits and a majority of patients with a current Health Plan membership. CONCLUSION: Pharmacist co-managed ADHD programs have been shown to be effective in the improvement of safety outcomes for children and adolescents with ADHD. ADHD remains a prevalent and growing topic among parents, teachers, caregivers, and healthcare providers. Further research, including highlighting outcomes associated with combined pharmacological and psychosocial treatments, is warranted to improve safety. Depending on the patient’s current health status, medical history, and use of other medications, parents need to work with their physician and pharmacist to determine the best treatment.