2024 Eastern States Conference

TITLE: Psychotropic stewardship: Impact of a pharmacist on reducing long-acting injectable antipsychotic-related medication errors
AUTHORS: Kevin Chen, Sara Girgis, Germin Fahim, Scott Mathis, Megan Maroney
OBJECTIVE:To analyze the impact of pharmacist review and intervention to reduce LAI-related medication errors
SELF ASSESSMENT QUESTION: A patient was admitted to the inpatient psychiatric unit and a once-monthly LAI formulation of risperidone was administered on day 3 of their admission. However, this patient had just received a dose of the same LAI 2 days prior to admission, which was not known until after it was given.
Which of the following is true about this scenario?
a) This is not a medication error, as duplicate dosing of LAIs is unlikely to cause patient harm
b) This error is the patient’s fault because they should have known they had just recently received an LAI
c) This error could not have been prevented, as errors will inevitably occur with high-risk LAI formulations
d) This error could have been prevented if the patient’s medication history was reviewed by a psychiatric pharmacist.
BACKGROUND: Long-acting injectable (LAI) antipsychotic formulations can improve outcomes related to poor adherence in psychiatric patients. However, LAIs are known to be high-risk medications that are prone to medication errors. Psychotropic stewardship efforts focused on implementing operational changes may reduce the likelihood of medication errors occurring with LAIs.
METHODS: In this single-center quality improvement-focused pre-post study, we aimed to assess the impact of pharmacist-led psychotropic stewardship efforts to implement standards related to LAIs to reduce the risk of medication incidents, including daily review of a report that captures all psychiatric inpatients who received documented administrations of LAIs, implementation of physician requirement to input "last-dose verification" when ordering LAIs, standardized utilization of intradepartmental handoffs for LAIs, and provision of formal education to providers and pharmacists regarding reviewing transitions of care documentation within the electronic health record. The primary endpoint was the change in frequency of LAI-related medication errors that reached patients. Secondary endpoints include reduction in the total number of medication incidents, reduction in total number of incidents that reached the patient associated with medication reconciliation, incomplete loading dose regimens, or oral overlap, and the reduction in number of incidents within each of the Health Performance Improvement Safety Event Classification categories.
RESULTS: A total of 80 encounters were analyzed in the pre-group and a total of 75 encounters were analyzed in the post-group. There was a difference seen in the prescribing habits of LAIs in the pre-group and post-group, with more encounters in the pre-group involving paliperidone palmitate extended-release once monthly injection (p = 0.007) and more encounters in the post-group involving risperidone extended-release subcutaneous injection (p <0.001). The number of medication incidents that reached the patient was 11 in the pre-group and 5 in the post-group (p = 0.19). The secondary endpoints were also not statistically significant, though an absolute reduction was seen in all secondary endpoints.
CONCLUSIONS: In this single-center quality improvement-focused pre-post study, a non-statistically significant decrease in patient-reaching medication incidents was observed after implementing pharmacist-led psychotropic stewardship efforts. Further efforts such as patient review at discharge and standardized pharmacist workflow changes at verification are being considered to further improve medication safety with LAIs.