A conceptual framework for identifying and managing system vulnerabilities for diversion of controlled substances in healthcare.

Purpose: Diversion or theft of controlled substances is a recognized problem affecting healthcare systems globally. The purpose of this study was to develop a framework for identifying and characterizing system factors leading to vulnerabilities for diversion within hospitals.

Methods: We applied a qualitative framework method, which involved 1) compiling a list of critical diversion vulnerabilities through observations and proactive risk analyses in the inpatient pharmacy, emergency department and intensive care unit of two Canadian hospitals; 2) coding the vulnerabilities into deductively and inductively derived themes and subthemes; and 3) building a conceptual framework.

Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada.

Objective: To collect medication error (ME) data during the perianesthetic period from small animal clinics.

Sample: 6 small animal general practice veterinary clinics.

Methods: Small animal general practice veterinary clinics were recruited in this prospective observational study, with staff given a presentation on medical errors and instructed on how to submit medication error reports to an online reporting system.

Coordination of oral anticoagulant care at hospital discharge (COACHeD): pilot randomised controlled trial.

Objectives: To evaluate whether a focused, expert medication management intervention is feasible and potentially effective in preventing anticoagulation-related adverse events for patients transitioning from hospital to home.

Design: Randomised, parallel design.

Setting: Medical wards at six hospital sites in southern Ontario, Canada.

Improving medication prescribing-related outcomes for vulnerable elderly in transitions on high-risk medications (IMPROVE-IT HRM): a pilot randomized trial protocol.

Background: Seniors with recurrent hospitalizations who are taking multiple medications including high-risk medications are at particular risk for serious adverse medication events. We will assess whether an expert Clinical Pharmacology and Toxicology (CPT) medication management intervention during hospitalization with follow-up post-discharge and communication with circle of care is feasible and can decrease drug therapy problems amongst this group.

Methods: The design is a pragmatic pilot randomized trial with 1:1 patient-level concealed randomization with blinded outcome assessment and data analysis.

From design to action: participatory approach to capacity building needs for local overdose response plans.

Background: In response to the rise in opioid-related deaths, communities across Ontario have developed opioid or overdose response plans to address issues at the local level. Public Health Ontario (PHO) leads the Community Opioid / Overdose Capacity Building (COM-CAP) project, which aims to reduce overdose-related harms at the community level by working with communities to identify, develop, and evaluate capacity building supports for local needs around overdose planning. The 'From Design to Action' co-design workshop used a participatory design approach to engage communities in identifying the requirements for capacity building support.

Coordination of Oral Anticoagulant Care at Hospital Discharge (COACHeD): protocol for a pilot randomised controlled trial.

Background: Oral anticoagulants (OACs) are commonly prescribed, have well-documented benefits for important clinical outcomes but have serious harms as well. Rates of OAC-related adverse events including thromboembolic and hemorrhagic events are especially high shortly after hospital discharge. Expert OAC management involving virtual care is a research priority given its potential to reach remote communities in a more feasible, timely, and less costly way than in-person care.

Supporting community overdose response planning in Ontario, Canada: Findings from a situational assessment.

Background: Many communities across North America are coming together to develop comprehensive plans to address and respond to the escalating overdose crisis, largely driven by an increasingly toxic unregulated drug supply. As there is a need to build capacity for successful implementation, the objective of our mixed methods study was to identify the current planning and implementation practices, needs, and priority areas of support for community overdose response plans in Ontario, Canada.

Methods: We used a situational assessment methodology to collect data on current planning and implementation practices, needs, and challenges related to community overdose response plans in Ontario, consisting of three components.

Vulnerabilities for Drug Diversion in the Handling, Data Entry, and Verification Tasks of 2 Inpatient Hospital Pharmacies: Clinical Observations and Healthcare Failure Mode and Effect Analysis.

Objectives: Inpatient hospital pharmacies have a central role in managing controlled substances (CS) throughout the hospital medication use process (MUP). Our objectives were to identify vulnerabilities for diversion in the MUPs of 2 inpatient pharmacies, explore differences between the sites, and characterize the types of vulnerabilities identified.

Methods: We conducted clinical observations in 2 pharmacies to map their MUPs and performed a healthcare failure mode and effect analysis to proactively identify (1) the critical failure modes (CFMs) that make them vulnerable to diversion and (2) the controls that prevent, mitigate, or enhance the detectability of CFMs.

Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review.

Context: Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed.

Opioid losses in terms of dosage and value, January 2012 to September 2017: a retrospective analysis of Health Canada data.

Background: Canadian health care facilities must report losses or thefts of opioids to Health Canada. To broaden the understanding of opioid loss in Canada, we analyzed data describing these losses to estimate the amount of opioid lost, estimate the wholesale and street value, compare the distribution of loss types between facility types and compare loss trends.

Methods: We analyzed Health Canada records of losses of codeine, fentanyl, hydromorphone, morphine and oxycodone reported by Canadian facilities from January 2012 to September 2017.

Evaluation of a Novel Audit Tool for Medication Reconciliation at Hospital Discharge.

Background: Discharge medication reconciliation (MedRec) is designed to reduce medication errors and inform patients and key postdischarge providers, but it has been difficult to implement routinely in Canadian hospitals.

Objectives: To evaluate and optimize a new discharge MedRec quality audit tool and to use it at 3 urban teaching hospitals.

Methods: The discharge MedRec quality audit tool, developed by the Canadian Patient Safety Institute and the Institute for Safe Medication Practices Canada, was assessed and modified to improve comprehensiveness, clarity, and quality.

Clinical observations and a ealthcare ailure ode and ffect nalysis to identify vulnerabilities in the security and accounting of medications in Ontario hospitals: a study protocol.

Introduction: An increasing number of opioids and other controlled substances are being stolen from healthcare facilities, diverting medications from their intended medical use to be used or sold illicitly. Many incidents of medication loss from Canadian hospitals are reported as unexplained losses. Together, this suggests not only that vulnerabilities for diversion exist within current medication-use processes (MUPs), but that hospitals lack robust mechanisms to accurately track and account for discrepancies and loss in inventory.

Diversion of Controlled Drugs in Hospitals: A Scoping Review of Contributors and Safeguards.

Drug losses and theft from the healthcare system are accelerating; hospitals are pressured to implement safeguards to prevent drug diversion. Thus far, no reviews summarize all known risks and potential safeguards for hospital diversion. Past incidents of hospital drug diversion have impacted patient and staff safety, increased hospital costs, and resulted in infectious disease outbreaks.

Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting.

Objectives: Assess interventions' impact on preventing IV infusion identification and disconnection mix-ups.

Design: Experimental study with repeated measures design.

Setting: High fidelity simulated adult ICU.

Medical Assistance in Dying: A Review of Canadian Nursing Regulatory Documents.

Canada's legalization of Medical Assistance in Dying (MAiD) in 2016 has had important implications for nursing regulators. Evidence indicates that registered nurses perform key roles in ensuring high-quality care for patients receiving MAiD. Further, Canada is the first country to recognize nurse practitioners as MAiD assessors and providers.

Quality-related events reported by community pharmacies in Nova Scotia over a 7-year period: a descriptive analysis.

Background: Quality-related events are defined as medication errors that reach the patient (e.g., incorrect drug, dose and quantity), in addition to medication errors that are intercepted before dispensing (i.

Developing recommendations for the safe handling of oral anti-cancer drugs in community pharmacies: A pan-Canadian consensus approach.

Purpose: To create a set of consensus-based and evidence-informed recommendations to provide guidance around the safe dispensing and handling of oral anti-cancer drugs in low-volume settings unique to the community pharmacy setting.

Methods: A review of published and grey literature (published in non-commercial domains such as national organizations and associations) documents and nine key informant interviews were conducted and a modified Delphi approach was taken to achieve consensus. The final list of 47 candidate recommendations was reviewed by a task force and validated by multi-disciplinary stakeholders.

Improving opioid safety practices in primary care: protocol for the development and evaluation of a multifaceted, theory-informed pilot intervention for healthcare providers.

Introduction: In North America, drug overdose deaths are reaching unprecedented levels, largely driven by increasing prescription opioid-related deaths. Despite the development of several opioid guidelines, prescribing behaviours still contribute to poor patient outcomes and societal harm. Factors at the provider and system level may hinder or facilitate the application of evidence-based guidelines; interventions designed to address such factors are needed.

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series.

Background: Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies.

Methods: In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine.

Medication reconciliation interventions in ambulatory care: A scoping review.

Purpose: The published literature on medication reconciliation (MR) interventions, outcomes, and facilitators in ambulatory care settings is reviewed.

Methods: A scoping review was conducted to characterize ambulatory care-based MR research in terms of study design, elements of interventions, and outcomes examined. English-language articles on comparative studies of MR programs targeting adults in ambulatory care settings were identified using data sources including MEDLINE, PreMEDLINE, EMBASE, and International Pharmaceutical Abstracts.

Pictograms for Safer Medication Management by Health Care Workers.

Background: Inherent risks are associated with the preparation and administration of medications. As such, a key aspect of medication safety is to ensure safe medication management practices.

Objective: To identify key medication safety issues and high-alert drug classes that might benefit from implementation of pictograms, for use by health care providers, to enhance medication administration safety.