Background:Methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with high rates of mortality and morbidity. Vancomycin is widely used for the treatment of pneumonia and bacteremia due to MRSA, despite treatment failure rates between 21% and 50%. Given the high rates of treatment failure with vancomycin, it is hypothesized that such failure may add a substantial burden to the health care system. Objectives:To estimate the hospital costs for patients treated with vancomycin for MRSA pneumonia and/or bacteremia, comparing costs between those who experienced treatment failure and those who experienced treatment success. Methods:This retrospective cohort study involved patients admitted to a Canadian hospital between 2014 and 2018 with MRSA pneumonia and/or bacteremia who were treated with vancomycin. Direct and indirect hospital costs and additional clinical data were obtained from the hospital database. All costs were inflated to 2024 Canadian dollars using the Consumer Price Index. A generalized linear model was used to estimate the adjusted difference in hospital costs between patients with and without treatment failure. Results:A total of 128 patients were included in the cohort, of whom 43 (34%) were identified as having treatment failure. Treatment failure was associated with significantly higher costs than treatment success, with an adjusted mean difference in total cost of $43 082 (95% confidence interval $2065 to $84 098). Those with treatment failure had higher rates of vasopressor use, greater need for intensive care, higher sequential organ failure assessment scores, greater need for mechanical ventilation, and higher rates of nephrotoxicity. Conclusions:Failure of vancomycin treatment for MRSA pneumonia and/or bacteremia significantly increased hospital costs.
Background:Hypotension is common among preterm and term neonates in the neonatal intensive care unit, particularly those with very low birth weight, sepsis, or hypoxic-ischemic encephalopathy. Some remain hypotensive despite volume expansion and vasopressors, possibly due to relative adrenal insufficiency. Hydrocortisone is proposed as adjunct therapy, but its effect on mortality is uncertain. Objective:To evaluate whether IV hydrocortisone reduces all-cause mortality in neonates with hypotension. Methods:The MEDLINE, Embase, CENTRAL, and Scopus databases were searched up to March 30, 2025, for randomized controlled trials (RCTs) that compared IV hydrocortisone with placebo and reported mortality. Two reviewers independently screened the studies, extracted data, and assessed bias. A fixed-effects Mantel-Haenszel meta-analysis was used, based on the degree of heterogeneity. Results:Five RCTs (with a total of 239 neonates) were included. Heterogeneity was low (I 2 = 0%). Hydrocortisone significantly reduced mortality (odds ratio 0.48, 95% confidence interval 0.24-0.96). Conclusions:IV hydrocortisone may reduce mortality in refractory neonatal hypotension. However, larger trials are needed to confirm this finding.
Background:To foster equity for vulnerable populations, hospital pharmacists should be motivated to acquire new knowledge in geriatrics. No tool specifically designed to assess their motivation in this area exists. Objectives:To assess the motivation of clinical pharmacists in Quebec university hospital centres who are not experts in geriatrics to participate in a knowledge transfer strategy developed by geriatric experts. Methods:A survey, constructed using a Delphi method, was conducted from July to October 2022. The topics covered by the survey included participants' perceptions, barriers faced, and openness to participating in a knowledge transfer strategy in geriatrics. Results:Of the 703 pharmacists invited to participate, 202 (28.7%) responded to the questionnaire. The average motivation score was 78.9/108 (standard deviation 5.8). No statistically significant difference was observed between pharmacists in critical care and those in other sectors, nor were there differences related to year of graduation. Conclusions:Clinical pharmacists working in Quebec university hospital centres seemed motivated to improve their knowledge in geriatrics.
Background:Involvement of pharmacists in discharge medication reconciliation (DMR) reduces readmissions when DMR is delivered as part of a medication management bundle. With current staffing and workload, pharmacists are unable to complete DMR for every inpatient. Consequently, it is necessary to prioritize patients for DMR interventions according to clinical need and risk. Objectives:To describe how pharmacists prioritize patients for DMR at a tertiary hospital; to identify facilitators of and barriers to pharmacist involvement in DMR; and to compare pharmacists' patient-priority assessment with scores derived using the Epic risk-of-unplanned-readmission, PRIME, and PADR-EC risk assessment tools. Methods:Pharmacists involved in DMR participated in focus groups to explore their DMR practices, including factors considered in patient prioritization, as well as facilitators of and barriers to their involvement in DMR. For patients on their service with an expectation of discharge within 48 hours, pharmacists used a questionnaire to rank DMR priority and indicate their intent to complete DMR. For each patient, the Epic, PRIME, and PADR-EC scores were collected and compared with the pharmacist's assessment. Results:A total of 13 pharmacists participated in 2 focus groups, and 11 of these pharmacists completed the questionnaire (for a total of 110 patients). Twenty-two unique factors and 27 subfactors for patient prioritization were identified. The top 5 factors were complex medication regimen, high-risk medications, medication changes, medication access, and length of stay. Facilitators and barriers were categorized into 6 themes: team dynamics, pharmacist workload, prior pharmacist involvement, process for DMR, discharge planning, and technology. Pharmacists' assessments appeared to differ from scores obtained with the 3 risk assessment tools. Conclusions:Pharmacists at the study institution lacked a consistent approach to prioritizing patients for DMR. Next steps will include developing and piloting a standardized process for prioritization.
Background:Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent and debilitating side effect that significantly reduces cancer patients' quality of life, limits treatment tolerance, and can compromise treatment efficacy. Accurate prediction of CIPN risk is crucial for targeted interventions. Objective:To develop and validate a risk prediction model, Foresight Neuro-Wing, for identifying patients at increased risk of CIPN during chemotherapy with common cytotoxic agents. Methods:A retrospective cohort study was used to analyze the electronic medical records of patients receiving chemotherapy at a single institution. Potential risk factors (demographic characteristics, as well as cancer-related and chemotherapy-related factors) were assessed using logistic regression. Model performance was evaluated using area under the receiver operating characteristic curve and calibration plots. Internal validation involved bootstrapping and cross-validation. A classified score model stratified patients into 4 risk groups. Results:A total of 346 patients met the inclusion criteria. The incidence of CIPN was 33.5% (n = 116). Significant predictors included sex, underlying disease, cancer type, previous and current chemotherapy regimens, and number of chemotherapy cycles. The scoring model achieved a predictive performance of 87.33%, and the classified score model had a predictive performance of 85.93%. Decision curve analysis demonstrated that using the model to guide intervention decisions provided a greater net benefit than treating all or treating none. Conclusions:The Foresight Neuro-Wing model effectively identified patients at increased risk of CIPN. This tool has the potential to inform clinical decision-making, enabling targeted monitoring and preventive strategies, ultimately improving patient outcomes and quality of life.
Background:The Clinical & Systems Transformation project implemented the Oracle Health (formerly Cerner) electronic health record system across 3 health organizations in British Columbia. Medication-related clinical decision support (CDS) alerts in such systems are intended to assist pharmacists during order verification but may contribute to alert fatigue. Objectives:To evaluate hospital pharmacists' perceptions of standard and custom CDS alerts within the pharmacist verification application of the new system, including their views on alert content, alert volume, and improvement opportunities. Methods:A cross-sectional survey was conducted in late 2023 at the 3 health organizations, targeting pharmacists with at least 6 months of experience using the system. Quantitative data were analyzed using descriptive statistics, and qualitative responses were grouped into common themes. Results:A total of 47 responses were suitable for analysis. The majority of respondents rated CDS alert content positively. However, perceptions about the volume of alerts and overall alert satisfaction were primarily neutral. Certain custom alerts, such as those for low renal function, were rated as having high impact but were infrequently encountered. Conclusions:These findings highlight the need for ongoing optimization of CDS alerts to better support pharmacists through reduction of unnecessary alerts and improved implementation of high-impact alerts.
Background:Various organizations recommend targeting a calculated ratio of area under the curve to minimum inhibitory concentration (AUC/MIC) of 400-600 for therapeutic drug monitoring (TDM) of vancomycin. Sites that have implemented AUC/MIC-based TDM for vancomycin have shown reduced vancomycin exposure, decreased nephrotoxicity rates, and fewer dosage adjustments relative to the use of trough monitoring. Objectives:To implement AUC/MIC-based TDM for vancomycin at a pediatric and obstetric tertiary care site and to assess pharmacists' knowledge and satisfaction before and 1 month after implementation and at 2-year follow-up. Methods:This quality improvement project involved the planning, implementation, and evaluation of AUC/MIC-based TDM for vancomycin. Anonymous electronic surveys were distributed to pharmacists before and after implementation and at 2-year follow-up, assessing practices, comfort, knowledge, and satisfaction with AUC/MIC-based TDM. Results:Implementation of AUC/MIC-based TDM for vancomycin occurred in April 2021, after 8 months of preparation during which educational sessions, a dosing calculator, guidelines, and written communications were developed and delivered. Surveys were partially or fully completed by 27 pharmacists before implementation, by 24 pharmacists at 1 month after implementation, and by 32 pharmacists at 2-year follow-up. At 1 month and 2 years after implementation, larger proportions of respondents felt knowledgeable (88% [n = 21] and 81% [n = 26], respectively, vs 22% [n = 6] before implementation) and comfortable (88% [n = 21] and 81% [n = 26], respectively, vs 19% [n = 5] before implementation) with AUC/MIC-based TDM. Respondents' satisfaction with implementation of AUC/MIC-based TDM was 88% (n = 21/24) at 1 month after implementation and 94% (n = 29/31) at the 2-year follow-up. Conclusions:AUC/MIC-based TDM for vancomycin was implemented with high pharmacist satisfaction. Future studies at this site should investigate clinical outcomes.
Background: The preparation of injectable chemotherapy drugs is a critical process, given their toxicity and the large number of stakeholders involved. As such, systematic and proactive risk assessment is required. Objective: To analyze the risks associated with the cytotoxic drug preparation process using the failure mode, effects, and criticality analysis (FMECA) method within a centralized cytotoxic drug preparation unit (CCDPU). Methods: An analytical study was conducted in a CCDPU over a 6-month period. The risk analysis was performed using the FMECA method. An action plan was developed to address critical scenarios. A second FMECA cycle was conducted to evaluate the effectiveness of the implemented actions. Results: A total of 189 failure modes were identified, of which 2% were deemed unacceptable and 30% were tolerable when controlled. An action plan was developed based on training, double visual inspection, and the implementation of analytical control. During the follow-up FMECA, a reduction of 23% in the overall criticality index was observed, with a significant improvement in criticality levels. Of the 60 actions, 73% were completed, and an updated action plan was proposed. Conclusion: These results demonstrate the CCDPU team's genuine commitment to risk management and the usefulness of the FMECA method in a continuous improvement approach to the cytotoxic preparation circuit.
Background:International pharmacy graduates (IPGs) are underrepresented in Canadian hospitals. It has been speculated that structural factors, particularly limited access to residency programs, may contribute to IPGs' disproportionate streaming toward community pharmacy practice. Objectives:To review the criteria of accredited hospital pharmacy residency programs in Canada to determine whether IPGs are eligible to apply, to examine the extent of IPGs' participation and success in securing hospital pharmacy residency positions, and to determine the factors that influence success in the matching process. Methods:A policy scan of accredited residency programs that participate in the Canadian Pharmacy Residency Board matching program was conducted in September 2023. In addition, a descriptive cross-sectional study was performed using available application data from the Pharmacy Residency Application and Matching Service in Canada for the 2022/23 matching cycle (January 2023 match). Results:Of the 40 participating residency programs, 7 (17.5%) required graduation from a North American-accredited institution, whereas the others accepted candidates with eligibility for licensure in any Canadian province. Only one program explicitly mentioned and encouraged IPGs to apply. In the matching data, only 19 (6.2%) of 308 applicants were IPGs, of whom 3 (16%) were successfully matched to a program, whereas 131 (45.3%) of 289 domestic graduates were matched. There was a significant association between country of graduation and residency matching, with lower odds of matching for IPGs (adjusted odds ratio 0.230, 95% confidence interval 0.063-0.845). Conclusion:These results show that IPGs are substantially underrepresented in the residency application and matching processes and provides insights into potential systemic barriers that need to be addressed by policy-makers and stakeholders.
Background:Hospital pharmacists are essential for the safe use of total parenteral nutrition (TPN), a complex high-alert medication. Errors may occur during TPN administration; for example, Y-site incompatibilities may cause embolism or thrombosis. Pediatric patients are especially vulnerable because of complex formulations and limited venous access. The stability of both TPN and any drugs administered concurrently depends on physicochemical properties. The American Society for Parenteral and Enteral Nutrition emphasizes the pharmacist's role in preventing such incompatibilities. Objective:To describe the role of pharmaceutical care in, and a systematic approach to, managing Y-site administration of medications with TPN in pediatric patients. Methods:A prospective observational study was conducted from May to October 2024 at a university children's hospital in Madrid, Spain. The study involved hospitalized pediatric patients who were receiving TPN by central venous catheter. A clinical pharmacist evaluated the compatibility of IV drugs with TPN using an evidence-based approach, with information from specialized sources and the literature. Each TPN-drug combination was classified as compatible, incompatible, contradictory, or unknown, and pharmacists' recommendations were documented in the electronic prescription system. Results:A total of 37 patients (accounting for 40 TPN episodes) were included. Their median age was 11 (interquartile range 2.9-12.8) years, and most were receiving oncological care. Pharmacists undertook 604 interventions; 311 (51.5%) involved compatible combinations, 100 (16.6%) involved incompatible combinations, 150 (24.8%) involved combinations lacking data, and 43 (7.1%) involved combinations with contradictory information. Of the 75 drugs that were reviewed, 25 (33.3%) were compatible with TPN, 15 (20.0%) were incompatible, 32 (42.7%) lacked data, and 3 (4.0%) had contradictory reports. Conclusions:Pharmacist-led assessment of Y-site compatibility in pediatric TPN is essential for medication safety and good outcomes. The high proportion of drugs with unknown or conflicting information about compatibility highlights the need for further research to support clinical decision-making.
Background:Mannequin-based simulations are widely used in health professional education; however, their adoption in pharmacy practice and education remains limited, especially outside critical care and emergency settings. Objectives:To evaluate perceptions, previous experiences, perceived benefits and barriers, and future interest regarding mannequin-based simulation among hospital pharmacists, pharmacy residents, and pharmacy leaders. Methods:A province-wide scoping survey was conducted in British Columbia from June to August 2024. The survey assessed previous exposure to, perceived benefits and barriers to participation in, and future interest in mannequin-based simulations. Descriptive analysis was performed on quantitative data, and thematic analysis was used for qualitative data. Results:Of 160 respondents, 146 submitted completed surveys suitable for analysis. Participants supported the use of mannequin-based simulation in pharmacy practice for creating a safe learning environment (n = 143, 98%), enhancing knowledge and skills (n = 125, 86%), and improving confidence (n = 123, 84%). Major barriers included limited access to mannequin-based simulation opportunities (n = 121, 83%) and perceived need for prior content knowledge (n = 96, 66%). The proportions of participants perceiving the specified benefits were 10%-15% higher among those with previous exposure to mannequin-based simulation than among those without previous exposure, whereas perceptions of barriers were similar in the 2 groups. Of the total group, 104 (71%) expressed interest in pharmacy-led mannequin-based simulations, with 96 (66%) supporting its integration into residency programs. Conclusions:Hospital pharmacists showed strong interest in mannequin-based simulations to improve clinical and nontechnical skills. Limited access remains the primary barrier and hinders understanding of the adaptability of such simulations to pharmacy practice. Structured pharmacy-led sessions could enhance exposure to and applicability of this learning method in pharmacy education and practice.
Background:The pharmacist staffing ratios required for comprehensive patient care are not well defined, particularly in pediatrics. Understanding optimal clinical pharmacist staffing ratios for pediatrics may help in advocating for appropriate staffing and optimizing patient outcomes. Objectives:The primary objective was to describe optimal pediatric clinical pharmacist staffing ratios in general pediatric, surgical, and hematology-oncology-bone marrow transplant (heme-onc-BMT) units in tertiary pediatric hospitals in Canada. The secondary objectives were to quantify how pediatric clinical pharmacists spend their time and to qualify their perspectives on current workload. Methods:Two electronic surveys were distributed. One survey, sent to leaders in tertiary pediatric health care centres, was designed to describe current staffing ratios. The second survey, sent to pediatric clinical pharmacists, aimed to estimate the frequency of and time spent on 13 comprehensive pharmaceutical care activities, as validated by a working group. The survey data were used to estimate pharmacist staffing ratios according to the World Health Organization workforce calculator. Results:Seven (50%) of the 14 sites responded to the management survey, and 33 clinical pharmacists responded to the clinical pharmacist survey. Optimal pharmacist-to-patient ratios (based on clinical pharmacist survey responses) were estimated to be 1:11 for general pediatric units, 1:14 for pediatric surgery units, and 1:6 for pediatric heme-onc-BMT units, with median lengths of stay of 4.9, 2.5, and 7 days, respectively. Conclusions:Further research is needed to validate these ratios in various pediatric clinical pharmacy settings.
Background:For patients with sepsis, timely administration of antimicrobials is imperative, with evidence demonstrating that delays may be associated with an increase in mortality. Objective:To determine whether antimicrobial administration is delayed among patients with sepsis admitted through the Queen Elizabeth II Health Sciences Centre Emergency Department (QEII-HSC-ED) in Halifax, Nova Scotia. Methods:A single-centre, retrospective health records review was conducted for adult patients with sepsis admitted through the QEII-HSC-ED between January 1, 2021, and December 31, 2022. Differences between groups with and without antimicrobial administration delays were compared by univariate analysis, and an adjusted multivariate regression was completed to examine associations between risk factors and significant delays. Results:A total of 275 patient encounters were included in the analysis, accounting for a total of 1208 antimicrobial doses: 275 first doses and 933 subsequent doses. Of the 275 patient encounters, 216 (78.5%) had at least one significant dose delay; 135 (49.1%) of the encounters had delay of the first dose, and 169 (61.5%) had delay of a subsequent dose. Of the 933 subsequent doses administered, 276 (29.6%) had a significant delay. Relative to patients admitted to a medicine service, surgical patients had reduced odds of experiencing significant delay of a subsequent dose (odds ratio 0.25, 95% confidence interval 0.08-0.77). Conclusions:Many patients with sepsis admitted through the QEII-HSC-ED experienced significant delays in administration of first and/or subsequent doses of antimicrobial therapy, which may have increased their risk of negative outcomes. These results can be used to develop future initiatives aimed at improving time to administration of antimicrobials for patients with sepsis admitted to the study institution.
Background:Hypomagnesemia, characterized by decreased levels of magnesium in the blood, is common among patients with cancer and may be related to the administration of proton pump inhibitors (PPIs) and/or platinum derivatives. Objective:To evaluate the safety and potential impact on serum magnesium levels of concomitant use of the PPI omeprazole in patients receiving a platinum derivative. Methods:This prospective, randomized, double-blind, single-dose, placebo-controlled study involved fixed doses of PPI administered on an outpatient basis. It spanned 4 cycles of platinum-based combination chemotherapy (21 days per cycle), and entailed a screening period (14 days before chemotherapy), 2 PPI treatment periods (total of 60 days), and a follow-up period (1 cycle). Patients recruited between May 2019 and March 2020 at 3 hospitals in Brazil were randomly assigned to receive placebo or PPI in a 1:1 ratio. Data analysis employed a linear mixed-effects model and Kaplan-Meier analysis. Results:A total of 164 patients were included in the study, 83 in the placebo group and 81 in the PPI group. Blood magnesium levels showed a modest decrease over time (by approximately 20%) across all patients. A correlation was observed between treatment duration and decrease in serum magnesium in the total sample (β = -0.035, 95% confidence interval [CI] -0.048 to -0.0021; p < 0.001). Compared with the placebo group, the PPI group showed a slightly greater decline (β = -0.121, 95% CI -0.231 to -0.011; p = 0.031). Additionally, no differences were noted between groups regarding the occurrence of neuropathy (p = 0.77), anorexia (p = 0.77), diarrhea (p = 0.34), or constipation (p = 0.39). Omeprazole use was associated with a lower incidence of nausea and vomiting (p = 0.005). Conclusion:These exploratory findings suggest that the concomitant use of omeprazole with platinum derivatives may be associated with a slightly faster rate of serum magnesium depletion than occurs with chemotherapy alone, but without clinical relevance or occurrence of frank hypomagnesemia. Clinical trial registration:Brazilian Registry of Clinical Trials (ReBEC) RBR-8vsb7k2.
Background:Open access publishing has broadened research dissemination, but it has also enabled the rise of predatory journals and conferences, posing challenges for health care professionals, including pharmacists. Objectives:To analyze unsolicited professional emails received by a hospital pharmacist and to characterize potentially predatory solicitations. Methods:All email messages received over a 31-day period in 2024 by a senior Canadian hospital pharmacist involved in research were reviewed and assessed according to 12 indicators of predation, including false impact factors, suggestion to submit manuscript by email, flattery, solicitation for an unrelated field, and short deadlines. Results:Of 1228 emails received over the study period, 453 (37%) contained at least one predatory indicator, with a total of 494 distinct solicitations: 347 (70%) for manuscript submission, 116 (24%) for conference attendance, 15 (3%) for republication of a previously published article, 11 (2%) for peer review, and 5 (1%) for webinar participation. The emails contained an average of 3.6 (standard deviation 1.7) indicators. Conclusions:One-third of the emails received were predatory in nature, highlighting the scale of the phenomenon.
Background:The introduction of electronic health records (EHRs) and computerized physician order entry has been associated with a reduction in medication errors due to the safety features of these systems. Objectives:To identify changes in medication errors-specifically related to the types and severity of errors documented and the numbers and types of errors by clinical program-before and after implementation of an EHR system and to identify medication safety initiatives. Methods:This retrospective observational study was conducted at a 2-campus, 500-bed Canadian community hospital before (April 10, 2019, to April 10, 2021) and after (April 11, 2021, to April 11, 2023) implementation of an EHR system. Data were categorized according to event type to ascertain changes in types of errors before and after EHR implementation by clinical program. Data were also collected to determine changes in the severity of errors, as well as changes in categories and changes in frequency of event types (e.g., barcode scanning, medications not ordered, incorrect orders). Results:Totals of 1379 and 1269 medication errors were reported before and after EHR implementation, respectively. The reduction in frequency of errors was statistically significant (z score = 2.14). Overall, statistically significant reductions were observed for errors that did not reach the patient and for errors that reached the patient and necessitated increased monitoring. There were statistically significant decreases in errors secondary to medication(s) not being ordered (197 before vs 121 after EHR implementation) and medications being administered to the incorrect patient (58 vs 20, respectively). Conclusion:Implementation of the EHR system was associated with a reduction in overall medication incidents at the study institution. Findings from this study allowed the medication safety committee to identify targeted medication safety initiatives focused on barcode scanning (of both medications and patient identification) to reduce the frequency of patients receiving incorrect medications.
Background:Pharmacological management of status epilepticus (SE) in children must be rapid and optimal to limit morbidity and mortality. Objectives:The primary objective was to compare SE management in children before and after the implementation of a drug treatment algorithm. The secondary objective was to describe the compliance of SE management with the algorithm following its implementation. Methods:This evaluative cross-sectional population study with retrospective chart review was performed in a 5-site teaching hospital, which included a tertiary pediatric hospital. Eligible patients were between 1 month and under 18 years of age, had a diagnosis of SE, and received antiseizure medication (ASM) between January 1, 2019, and April 1, 2023. Results:The study involved 108 patients, 60 treated before algorithm implementation and 48 treated after implementation. In both groups, most patients received a benzodiazepine (BZD) as first-line treatment (96% [52/54] and 100% [44/44], respectively). For second-line treatment, the proportion of patients receiving a BZD was greater before than after implementation (36% [10/28] and 26% [6/23], respectively). For first-line treatment, the mean lorazepam dose for patients weighing 40 kg or less was suboptimal (0.08 [standard deviation 0.03] mg/kg in both groups). Median time from hospital arrival to treatment was 7 minutes before and 6 minutes after implementation of the algorithm. For first-line treatment, the choice of ASM and the doses were compliant with the algorithm for 98% (43/44) and 53% (23/43) of patients, respectively. Conclusions:Implementation of the drug treatment algorithm brought limited changes at the study hospital. More specifically, choice of ASM and time between seizure onset and administration of ASM were similar before and after implementation. Weight-based doses of lorazepam remained suboptimal. Additional training should be given to clinicians.
