Hospital program reduces ART errors by 50 percent
Adherence improves as a result
Even with computerized patient records, a hospital located in an ethnically diverse area of the country had medication errors among HIV patients.
"One of the reasons why errors could still occur is because while everything was computerized, you still needed a human component to make sure everything is accurate," says Andrea Odwin-Clarke, NP, an HIV nurse practitioner at Elmhurst Hospital Center in Elmhurst, NY.
The hospital's solution to reducing medication errors, which in turn would improve antiretroviral therapy adherence, was to assign staff to review prescriptions and patient records.
The program resulted in a 50 percent reduction in antiretroviral prescription errors, according to a study that looked at 291 HIV-infected inpatient charts in 2004.1
Odwin-Clarke was hired in 2004 on a research grant, and her specific main function was to improve the statistics with antiretroviral and hospital inpatient adherence, she says.
Her first task was to assess the current situation, which included 1,000 HIV patients in the clinic.
Among the clinic's patients are people who have become noncompliant or who have had HIV for a significantly long time and have advanced AIDS or a secondary diagnosis, Odwin-Clarke notes.
"So what I did was look at the current ordering system," Odwin-Clarke explains.
Since the system is completely computerized in the clinic, she could see which patients were clinic patients, what medications they were on, and view their medical record, including allergies and other important information that could impact adherence, she says.
"What would happen is that once a patient was hospitalized, the pharmacy would call me and I would review the patient's record," Odwin-Clarke says. "I would verify whether the patient was on antiretrovirals or not."
The project had the full support of the hospital's chief of medicine, who also is an infectious diseases physician and the director of the infectious diseases department, Odwin-Clarke notes.
"So it was easy to get things expedited with their full cooperation," she says.
"Pharmacy will call me, find out what antiretrovirals the patient is on — either by communicating directly or going to the hard copy chart, since it's not computerized," Odwin-Clarke explains. "I will make a decision about what the patient is on and whether it's appropriate, basing this on the current clinical situation."
For instance, if the patient was having an allergic reaction, hypersensitivity, or lactic acidosis, then the patient wouldn't be blindly put back on antiretrovirals, Odwin-Clarke says.
"If the patient was compliant with antiretroviral therapy [ART], based on the medical record and verbal communication with the attending physician, then the patient would be put back on ART," she adds.
The new process helped significantly in reducing the type of errors occurring when dosages were not within the recommended guidelines, Odwin-Clarke says.
"For example, a drug might be prescribed for three times a day when the standard dose was once a day," she says.
When residents see an HIV patient admission, they'll prescribe medication, which is put into the computer and picked up by the pharmacy department, Odwin-Clarke explains.
"Then the pharmacy department will call me and ask if it's appropriate, and I'll review the chart and give them an answer," she says.
Residents generally are there for general surgery or a specialty that does not include familiarity with antiretroviral medications, she says.
"So we rely on an infectious disease specialist to give the approval for the medications, and if I'm not there, then the infectious disease fellow or attending will give the approval," Odwin-Clarke adds.
The system has worked well since implemented, she notes.
"What we found when we did the study, which consisted of reviewing 18 to 23 charts, is we were able to intervene early if there was something incorrect with the prescription," Odwin-Clarke says. "We've found errors in dosing, frequency, drugs, and misspellings."
This double-check system ensures that there is excellent patient care for all HIV patients, and it ensures they have good adherence with the correct medications, she says.
"In addition to checking with the pharmacy, I also make visits to the floor, and I check with the patient to make sure they have, in fact, been getting their medication," Odwin-Clarke says.
The floor visits are where Odwin-Clarke inquires about a patient's experience with side effects and adherence.
"We also have an adherence team down in our tour clinic so that if the patient has literacy or language problems, our adherence team can be helpful in addressing those with pre-pouring medications and pill boxes, and those sorts of things," Odwin-Clarke says.
"And of course it really helps to have face-to-face contact with the person," she notes. "It helps with compliance, appointments, and the doctor/nurse/counselor-patient relationship."
The program also includes education for nurses and residents about what types of antiretrovirals can be used in combinations.
"I do inservices for new nurses once a month and inservices for residents twice a year," Odwin-Clarke says.
"We try to make this an environment where it's collaborative and provides support, so residents can call me about any questions they have about a newly-diagnosed HIV-positive person and AIDS testing," Odwin-Clarke says. "We find this is conducive to error reduction."
Odwin-Clarke's beeper number is given out by the chief of medicine as a resource to residents, so if they have an HIV-positive patient they can call her with any questions.
Another change resulting from the program was the way computer prompts work.
"What we found is when doctors were ordering medications they had to type in the medications, each letter for medications for that order," Odwin-Clarke says. "And we found that if you put in the recommended dosages for medications [on the computer prompt] then it's much easier for them to order because the prompt would come up."
The dosages were decided in collaboration with the director of medicine and infectious diseases doctor, and they're based on weight and creatine clearance. Physicians are given choices on the prompt, and they have to select from those choices, she adds.
Reference
- Odwin-Clarke A, Policar M. ARV error reduction and improved ARV adherence in the hospital setting. Abstract presented at the XVI International AIDS Conference, held Aug. 13-18, 2006, in Toronto, Canada.
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