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When medication administration record (MAR) "hold" capability is enabled in the electronic health record (EHR) during patient transfers, medication doses appear as "held" rather than due. We sought to quantify the incidence of delayed and missed doses of critical medications during MAR hold periods and to implement and evaluate interdisciplinary efforts and technical interventions to reduce missed medication doses during these periods. A list of critical medications was identified. MAR data were collected in patients with at least 1 critical medication dose due during the MAR hold period. MAR times were used to determine if delayed doses or missed doses occurred. Our interventions included: (1) implementation of a patient list indicator to retrospectively identify recently "held" medication doses, and (2) a report for operating room pharmacists to prospectively identify upcoming doses and ensure they were administered on time. Pre- and post-intervention period data were compared using a chi-squared test. During the pre-intervention study period, there were 1044 instances of delayed or missed doses during MAR hold. Most MAR times evaluated were on MAR hold during perioperative patient transfers. Delayed, missed, and multiple missed doses were defined in accordance with internal medication administration policies. There was no significant difference in the incidence of delayed and missed doses (69% vs 66%, P  = .31), however, there was a significant reduction in the number of critical medication doses missed multiple times (0.8% vs 6.7%, P  < .001) and all missed doses (35% vs 42%, P  = .05) between the pre- and post-intervention period. As demonstrated across in both the pre- and post-intervention period of our study, MAR hold is commonly associated with dose delays and missed doses, which has potential negative consequences on patient outcomes. Future considerations will include implementation of a best practice alert (BPA) that directs users to a MAR tab highlighting doses held during transfers., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Four-factor prothrombin complex concentrate (4F-PCC) is indicated for vitamin K antagonist (VKA) reversal but is associated with thrombotic events (TE). In 2018, the institution revised 4F-PCC dosing for VKA reversal from INR and weight-based dosing to a fixed-dose of 1500 units. Objective: The purpose of this study was to compare hemostatic efficacy and TE rate of fixed-dose 4PCC to weight-based dosing. Methods: This was a retrospective, single-center, quasi-experimental study of adult patients who received 4F-PCC for VKA reversal from January 2014 through May 2016 (INR and weight-based dosing) or April through October 2018 (fixed-dosing). The primary endpoint was hemostatic efficacy, defined by achieving an INR of ≤1.4, or an INR of ≤1.7 with evidence of hemostasis. The key secondary endpoint was TE within 14 days of 4F-PCC administration. Data were analyzed using descriptive statistics, chi-squared for nominal data and Mann-Whitney U for ordinal and continuous data. Results: The study included 163 patients who received weight-based dosing and 45 who received fixed-dose 4F-PCC. Hemostatic efficacy was 76.9% of patients in the weight-based group and 77.4% of patients in the fixed-dose group ( P = .229). TE occurred in 13.5% of the weight-based vs 6.7% of the fixed-dose group ( P = .181). Conclusion: This study found no difference in hemostatic efficacy with fixed-dose 4F-PCC for VKA reversal compared to INR and weight-based dosing. The occurrence of TE was reduced by 50% with the 4F-PCC fixed-dose strategy; however, this difference was not statistically significant. Further randomized studies are needed to confirm these results., Competing Interests: Declaration of Conflicting IinterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: A paucity of data exists on how transcatheter aortic valve implantation (TAVI) practice has evolved in Ireland. This study sought to analyse temporal trends in patient demographics, procedural characteristics, and clinical outcomes at an Irish tertiary referral centre., Methods: The prospective Mater TAVI database was divided into time tertiles based on when TAVI was performed: Group A, November 2008-April 2013; Group B, April 2013-September 2017; and Group C, September 2017-February 2022. Patient and procedural characteristics and clinical outcomes were compared across groups., Results: A total of 1063 (Group A, 59; Group B, 268; and Group C:, 736) patients were treated with TAVI during the study period (mean age 81.1±7.4, mean Society of Thoracic Surgeons score 5.9±5.1).Conscious sedation (Group A, 0%; Group B, 59.9%; and Group C, 90.2%, p<0.001) and femoral artery access (Group A, 76.3%; Group B, 90.7%; and Group C, 96.6%, p<0.001) were used more frequently over time. The median length of hospital stay reduced from 9 days (IQR 7, 18) in Group A to 2 days (IQR 2, 3) in Group C. In-hospital death was numerically higher in Group A compared with Group C (6.8% vs 1.9%, p=0.078). At 1-year follow-up, the rate of death and/or stroke was similar in Group A and Group C (20.3% vs 12.0%, adjusted HR 1.49, 95% CI (0.59 to 3.74))., Conclusion: There was exponential growth in TAVI procedural volume during the study period. A minimalist approach to TAVI emerged, and this was associated with significantly shorter procedure duration and hospital stay. Clinical outcomes at 1-year follow-up did not change significantly over time., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)