Page 27/44 · Protocol Development & Quality Improvement

Data Tables

Protocol Development & Quality Improvement

Jaime Robenolt Gray ~2 min read Module 4 of 20

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Protocol Development and Quality Improvement

Assess value of innovative practices

Meet quality or regulatory standards

Minimize costs

These should be considered together with the impact of the medication or medication use process on

patients and the medication use system as a whole to prioritize the highest-impact MUEs.

Medications selected for an MUE may be based on the following:

High risk

2High volume

ADEs

Preventable ADEs

Near-miss and harmful medication errors

Formulary review, including addition (non-formulary use), retention, or deletion

Pharmacy intervention data

Treatment failures

Physician or nurse identification or request

10Patient concerns

11Off-label use

12High cost

13Beneficial when used a specific way

14Drug shortages, recalls, or safety alerts

Examples of medication use processes in critically ill patients that may be selected for an MUE can be found

in Box 1.

K.Ideally, MUEs should be performed proactively and used to identify any gaps in practice or patient safety.

An interventional MUE is completed concurrently or prospectively, and if the criteria are not met,

an intervention by the pharmacist should be made to improve the use of the medication and patient

outcomes.

2A noninterventional MUE is completed concurrently or retrospectively by a medical record review, and

data are collected but criteria are not met. The review is retrospective, and there is no pharmacist-to-

prescriber interaction during the review process.

L.MUEs should have specific criteria set – These criteria are best determined by a multidisciplinary team of

medication or disease experts.

M.MUE criteria may be approved by the P&T committee. The P&T committee may create an MUE

subcommittee. Other hospital committees such as the QI committee may also request that an MUE be

performed. Other names for the MUE committees may include formulary, drug safety, therapeutic

assessment, medication safety, and drug use review committees.

N.The MUE subcommittee should be multidisciplinary and may be composed of the following:

Clinical pharmacists

2Physicians, nurse practitioners, and physician assistants

Nurses

Administrators

PI/QA representatives

Risk management representatives

Respiratory therapists, nutritionists, and other ancillary support staff

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