Pharmacist-led medication safety interventions to reduce long-acting injectable-related medication incidents during community-to-inpatient transitions of care

Introduction

Long-acting injectable (LAI) antipsychotic formulations can improve patient outcomes by reducing risk of symptom relapse and hospital readmissions in comparison to oral antipsychotics.^1-3 As they become more frequently used, it has become increasingly common for patients to receive these medications in the inpatient setting.⁴

Medication errors are a significant cause of preventable morbidity and mortality in all health care settings, including the psychiatric inpatient setting.^5,6 LAIs are known to be particularly high-risk medications that are prone to medication errors as noted in the August 2023 edition of the Medication Safety Alert! newsletter published by the Institute for Safe Medication Practices.⁷ Whereas some of the potential for medication errors is related to administration, medication reconciliation and documentation are key areas in which operational changes can improve safety,⁸ and pharmacist involvement may help reduce these errors.^6,9 As such, pharmacist-led medication safety interventions were implemented to review, optimize, and manage the use of LAIs in a multiunit psychiatric facility to reduce medication errors in community-to-inpatient transitions of care.

Description of Practice and Intervention

This pharmacist-led medication safety effort took place at a 63-bed inpatient behavioral health facility within an academic medical center in New Jersey. The facility consists of 3 units: an involuntary adult unit, a child and adolescent unit, and a voluntary adult unit. The hospital’s electronic health record (EHR) is Epic Hyperspace.

Prior to these efforts, the date and the specific product of the last LAI administered (which is henceforth referred to as LAI history) was discovered through a combination of nurse-led medication reconciliation, collateral information obtained by clinical social workers, and the attending psychiatrist’s initial evaluation. Each clinician reconciled medications using patient interview and outpatient prescription dispense history; however, the latter was often unreliable due to lack of crossover between EHRs from external facilities. Pharmacist involvement was limited to 1 clinical psychiatric pharmacist reviewing admission medication reconciliations within 72 hours of admission only when on duty. As such, pharmacists were not routinely involved during admission medication reconciliations. Whereas inpatient staff pharmacists reviewed LAI orders, no protocol existed to ensure key details were reviewed. To increase pharmacist involvement and reduce the risk of medication errors, the below interventions were implemented.

Last-Dose Verification

A “last-dose verification” order panel was integrated into Epic that prompts the provider to enter the date of the last administered LAI and provides a side panel that displays information related to recent LAI administrations documented in the medication administration record (Figure). The provider inputs are then displayed on the pharmacist order verification screen. This order question was drafted by an Epic analyst and approved by the necessary committees at the health system prior to being rolled out.

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Methods

The interventions were implemented between September 2023 and November 2023 though risperidone microsphere use was continued until January 2024 to use up remaining inventory. A pre-post review was conducted to identify the effectiveness of the interventions by evaluating the difference in the occurrence of LAI medication errors (LAIMEs) related to medication reconciliation that reached a patient. LAIMEs were identified through chart review and included LAI maintenance doses that were administered too early or too late due to incomplete or delayed medication reconciliation or were omitted during admission without documented evidence of intentional discontinuation. Other types of errors, including incorrect dose or incorrect product, were also evaluated if they occurred because of improper medication reconciliation. All adult inpatient psychiatric unit encounters between May 2023 and August 2023 were screened for inclusion in the preintervention group (pregroup), and those between December 2023 and March 2024 were screened for inclusion in the postintervention group (postgroup). Encounters in which the patient had any documented history of having received an LAI were included in the analysis. The change in event count was calculated utilizing the Fisher exact test with statistical significance defined as p < 0.05.

Results

A total of 278 patients were screened for inclusion in the pregroup and 293 patients in the postgroup. After excluding patients who did not have documentation of receiving an LAI, the final groups included 80 and 75 patients, respectively.

The number of LAIMEs decreased from 4 to 0 though the difference was not statistically significant (p = 0.12) (Table). Errors identified in the pregroup included the following: 1 patient was overdue for a paliperidone palmitate extended-release injectable suspension (PP-1M) maintenance dose by 10 days, which was not identified until day 4 of admission, delaying treatment; 1 patient received a scheduled PP-1M 234 mg maintenance dose, but it was mistaken for an initiation dose, leading to an extra 156 mg dose 1 week later; 2 patients were due for PP-1M within a week prior to admission, but this was not addressed during their admission.

TABLEPre-post study results

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Whereas no errors reached the patient during the postgroup, 2 near-miss events (NMEs) were identified: 1 patient was ordered PP-1M despite receiving a maintenance dose 2 weeks prior to admission, but the dose was not administered due to the verifying pharmacist seeing the recent administration in the handoff; another patient received an inpatient dose of aripiprazole extended-release injectable suspension only for it to be ordered again 8 days later, and it was caught and prevented by the pharmacist during order verification.

The postgroup also saw an increase in the utilization of RER-SQ (p < 0.001) and a decrease in the utilization of PP-1M (p < 0.048) compared with the pregroup (Table).

Discussion

The pharmacy-led interventions in this study resulted in no LAIMEs occurring in the postgroup, and whereas statistical significance was not found due to the small sample size, the reduction in medication errors was seen as a positive finding. Furthermore, the interventions were feasible with limited resources and could be easily adopted by other facilities facing similar challenges.

A comparison of pregroup and postgroup incidents highlights the potential impact of the interventions. Due to the increased availability and visibility of LAI history, the 2 documented NMEs in the postgroup were stopped at pharmacist order verification, and undocumented NMEs—such as a physician recognizing duplication of therapy due to the LAI last-dose verification panel—may also have occurred. The differences in which LAI products were utilized (ie, increased RER-SQ and decreased PP-1M) could also have contributed to the lower number of medication incidents in the postgroup as 1 of the errors in the pregroup was explicitly related to a PP-1M maintenance dose being mistaken for an initiation dose. Although risperidone microspheres had been removed from the formulary, remaining inventory led to continued use during the postgroup, and the full impact of its removal was likely not seen.

Since implementing these LAI medication safety interventions, cascading effects have been seen throughout the facility with processes becoming more multidisciplinary and aligned with psychotropic stewardship principles.¹⁰ The increased oversight of LAIs led to increased vigilance among all clinicians, and interdepartmental efforts between nursing, pharmacy, and physicians continue to prevent future LAIMEs from occurring. One such intervention that was subsequently implemented was a standardized procedure for sharing patient-specific LAI information between the clinical psychiatric pharmacist and the charge nurse on the involuntary unit. When either party discovered that a patient had an LAI history, the information was added to an ongoing Epic chat. The charge nurse then informed the treatment team during the daily morning report.

Psychiatric pharmacists play a key role in promoting medication safety of LAIs by establishing interdisciplinary stewardship efforts to improve medication utilization of these high-risk, high-reward dosage forms. The endeavors described in this study were primarily pharmacy-led and included routine surveillance of LAI history, the development of an order question to prompt careful prescribing, and medication safety–oriented formulary adjustments. Despite the lack of statistical significance found, these initial interventions were necessary to increase awareness across disciplines and foster collaboration and improvement of medication safety.