NCPDP recommendations for dose accumulation monitoring in the inpatient setting: Acetaminophen case model, version 1.0

Abstract

Purpose: Best practices and guidance are provided for improved electronic detection and alerting of inadvertent supratherapeutic cumulative doses of acetaminophen and other medications with narrow therapeutic ranges in inpatient settings.

Summary: Despite the use of medication safety technologies, overdosage and associated sentinel events continue to be serious problems in many inpatient settings. The tools needed to monitor and employ dose alerts, accumulators, and warning systems are available to reduce inadvertent overdose. Required are staff training and the implementation of processes that provide guidance and documentation of the drug reconciliation process from admittance to discharge for safe patient passage through the various transitions of care. Recommendations to achieve optimal patient safety outcomes include the adoption and integration of available technologies with full functionality configured to meet the institution's policies and processes, initial training and retraining of all staff who use these systems, continuing education of the patient care staff on the dosing safety requirements, and assigning a prominent role to the clinical pharmacist in the entire drug-use and reconciliation process.

Conclusion: The key factors contributing to inadvertent overdosage in inpatient settings include a lack of recognition of recommended maximum daily dosages; failure to optimally communicate medication information at transitions of care; failure to optimally implement medication safety technologies, particularly dose accumulator calculation features and associated alerts; and alert fatigue and override.

Figure 1

Errors in the medication cycle (National Council for Prescription Drug Programs).

Figure 2

Medication management process with current technologies. ADEs = adverse drug events. Reproduced, with permission, from David Classen and FCG.

Figure 5

Primary responsibility for medication regimen information. Reprinted, with permission, from Pedersen CA, Schneider PJ, Scheckelhoff DJ. 2012 ASHP national survey results: implications and trends for today’s practice. Paper presented at 2012 ASHP Midyear Clinical Meeting. Las Vegas, NV; 2012 Dec 5.

Figure 3

Proportion of inpatients monitored by pharmacists each day. Reprinted, with permission, from Pedersen CA, Schneider PJ, Scheckelhoff DJ. 2012 ASHP national survey results: implications and trends for today’s practice. Paper presented at 2012 ASHP Midyear Clinical Meeting. Las Vegas, NV; 2012 Dec 5.

Figure 4

Transitions of care processes used by pharmacists or pharmacy technicians. Reprinted, with permission, from Pedersen CA, Schneider PJ, Scheckelhoff DJ. 2012 ASHP national survey results: implications and trends for today’s practice. Paper presented at 2012 ASHP Midyear Clinical Meeting. Las Vegas, NV; 2012 Dec 5.