2026 Southeastern Residency Conference

Background: Concomitant administration of carbapenems and valproic acid (VPA) is a well-documented interaction that leads to rapid reductions in serum VPA concentrations with effects observed within 24 hours and persisting up to 7-10 days after discontinuation. This interaction increases the risk of breakthrough seizures, mood destabilization, and is associated with adverse clinical outcomes, including prolonged hospital stays and increased mortality, particularly in critically ill patients. Despite awareness, concomitant prescribing persists in large medical centers. At Grady Health System (GHS), prescribers and pharmacists receive a drug interaction warning when VPA and carbapenems are ordered together. Prior studies report only ~37% compliance with similar alerts, with over 50% of patients developing subtherapeutic VPA levels. Although drug interaction warnings are designed to mitigate this risk, it remains unclear whether these alerts effectively influence healthcare providers' behavior in hospitalized patients. This study aims to evaluate the clinical effectiveness of drug interaction warning targeting the co-administration of carbapenem and VPA and subsequent clinical sequelae at GHS.
Methods: This single-center, retrospective chart review included adults (≥18 years) admitted to GHS between January 1, 2020, and April 1, 2025, who received at least one overlapping dose of VPA and a carbapenem with a triggered drug interaction alert. Patients were excluded if discharged within 48 hours, receiving VPA and carbapenems prior to admission, or if clinical sequelae were documented prior to concomitant exposure. Data collected included demographics, indication for therapy, alert response, and resulting clinical actions (dose adjustment, discontinuation, or substitution). The primary outcome was the proportion of alerts with action versus no action at order entry or verification. Secondary outcomes included the type and frequency of resulting actions, incidence of clinical sequelae, hospital length of stay, duration of antimicrobial therapy, and documented indications for both VPA and carbapenem therapy Descriptive statistics were used, and chi-square and Fisher’s exact analysis evaluated associations between responder type and alert response.
Results: A total of 299 drug interaction alerts across 56 unique patients were analyzed. Clinical action was taken for 65 alerts (22%), while 234 alerts (78%) resulted in no action at order entry or pharmacist verification. Pharmacists were more likely than other providers to override alerts (84.0% vs 71.5%; χ² = 6.73, p = 0.009). Internal Medicine most frequently accounted for the provider responsible for the must-action (45.9%), followed by Infectious Diseases (12.6%). Given that carbapenems are restricted antimicrobials, Infectious Diseases consultation was commonly involved. At the patient level, clinical sequelae occurred in 40% of patients in the action group and 48% in the no-action group (Fisher’s exact p= 0.59). Median hospital length of stay was 22 versus 17 days, and median antibiotic duration was 3 versus 5 days, respectively. Agitation and behavioral changes were the most common sequelae in both groups, while breakthrough seizures and ICU transfer occurred less frequently and at similar rates. When action was taken, the most common interventions were switching the carbapenem, discontinuing valproic acid, or increasing the valproic acid dose.
Conclusions: Among 299 alerts, concomitant VPA and carbapenem use remained common, with alerts most often resulting in no action with no statically significant difference in clinical sequelae. Notably, nearly half of the patients in the no action group experienced adverse clinical outcomes, emphasizing clinical concern. Future research should assess pharmacist education, provider feedback, and alert optimization to improve compliance.

Background
Autoverification is the process in which a medication is automatically verified after provider order entry, without pharmacist review.  Autoverification of antimicrobials in the emergency department was implemented following health system integration to align with system-wide autoverification practices; however, this was subsequently reverted to reinstate pharmacist verification. Timely administration of antimicrobials has long been recognized as a cornerstone of improving patient outcomes, particularly in those with sepsis. While most autoverification studies focus on quality and process improvement, there is limited data on the impact on clinical outcomes. To address this gap, this study examined if there is a difference in timely administration between autoverified and pharmacist verified antimicrobials. 

Methods
A retrospective chart review of patients bedded in the adult and pediatric emergency departments who received an initial dose of oral or parenteral antimicrobial between November 16th, 2024 and January 16th, 2025, was conducted. Eligible patients were separated into two groups: the control group, during which autoverification of antimicrobials was permitted, and the intervention group, during which autoverification of antimicrobials was not allowed. The primary outcome was administration of antimicrobials within one hour of order entry. Secondary outcomes included pharmacist intervention rates and alerts per 100 orders.   

Results
A total of 300 orders from 235 patients were included in the analysis, 150 orders in the control group; 150 orders in the intervention group. Significant differences in patient demographics were observed for age, race, and infections (abdominal, bloodstream/catheter-related, empiric/unknown). A significant difference was also observed in the order characteristics for the dispense location. One hundred and three (68.7%) orders in the control group and 87 (58%) of orders in the intervention group were administered within one hour (x2 = 3.67, (p = 0.055)).  Compared with the control group, the intervention group observed higher rates of pharmacist intervention (1.33 vs 20 per 100 orders; IRR, 15; 95% CI, 3.58–62.7) and alerts (58 vs 104 per 100 orders; IRR, 1.79; 95% CI, 1.38–2.33). 

Conclusion
This study found no difference in administration of antimicrobials within one hour between the control and intervention groups. The intervention group generated more alerts and required greater pharmacist involvement. Together, these findings suggest that excluding antimicrobials from autoverification does not negatively impact timely administration of antimicrobials and may preserve the safety benefits associated with pharmacist verification. 



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Title: Impact of IV Electrolyte Autoverification Compared to Pharmacist Verification in the Emergency Department   

Authors: Raven Gadson, Brittany Onyeji, Kirsten DiPiro, Ambra Hannah 

Background/Purpose: Autoverification allows medication orders to bypass pharmacist review, which can improve efficiency but also introduces safety concerns. Studies show that removing high‑risk medications from autoverification increases pharmacist involvement and may reduce medication errors. The purpose of this study is to evaluate the safety and efficiency of pharmacist verification to autoverification for intravenous (IV) electrolyte orders in the emergency department setting (ED).  

Methods: A retrospective chart review was conducted from August 1, 2024, to March 1, 2025, to compare pharmacist verification with autoverification. Inclusion criteria were age ≥18 years and received an IV Piggyback (IVPB) in the ED of a Wellstar Health System facility that was stocked in the ED Omnicell. The primary end point was a comparison of error rates related to dosing, indication, duplication, drug interaction, and allergies. Secondary end points included the time to final verification and time to administration that occurred in each study group. 

Results: A total of 150 IVPB electrolyte orders were analyzed. Baseline demographics and order characteristics were similar between groups. No clinically significant ordering errors were identified in either group (P = 1). Time to final verification was significantly shorter with autoverification versus pharmacist verification (0 minutes vs 3 minutes, P < 0.001). However, time to administration did not differ between groups (40 minutes vs 40 minutes, P = 0.997). Provider order-entry alerts were infrequent and comparable. Among pharmacist‑verified orders, pharmacists received an alert for 18.7% of orders and documented a clinical intervention on 2.7%. 

Conclusion: Autoverification of IVPB electrolytes demonstrated no observed increase in ordering errors compared with pharmacist verification and significantly reduced time to final verification, without affecting time to administration. These findings suggest that, within a safeguarded ED workflow, selective autoverification of IVPB electrolyte orders such as those that are pre-mixed, standardized, or placed through an order set may be a safe and efficient strategy. Limitations include retrospective design, modest sample size, reliance on documented interventions, and analysis restricted to medications that were administered. Prospective studies with larger samples are warranted to confirm safety signals and to evaluate operational levers that influence administration time. 

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Background: 
Automated dispensing cabinet (ADC) overrides are intended for emergent medication access but introduce risk when medications are removed without an associated order. After a medication is pulled on override, a retrospective order should be placed in the electronic health record (EHR) and the override linked to that order.

Overrides unlinked to orders may reflect breakdowns in ordering workflows, verbal order reconciliation, or documentation practices, increasing the risk of inappropriate medication administration or incomplete clinical review. Additionally, medication administration without a documented provider order may carry legal and licensure implications, as it can be interpreted as practice outside established scope and authorization.

Override monitoring is a critical safety and policy component of ADC governance. A company-wide override dashboard was recently updated to pull data from the EHR instead of pulling data from the ADC. This allowed the additional visualization of overrides being linked to orders in the EHR. However, limitations in filtering functionality and data clarity reduced its effectiveness for identifying trends in overrides unlinked to orders.

Objective: 
To evaluate data integrity within a company-wide ADC override dashboard to enhance identification and review of unlinked overrides.

Methods: 
This quality improvement initiative evaluated override data without linked orders from AdventHealth Central Florida Division (CFD), consisting of 10 acute care campuses and 11 off-site emergency departments (OSEDs). An evaluation of dashboard performance was conducted to assess usability and data reliability.

Results: 
Dashboard filters were refined to allow more precise identification of overrides unlinked to medication orders, including improved medication-level and ADC-level stratification. Following implementation of revised filters, medications and ADCs commonly associated with unlinked overrides were more readily identifiable, enabling targeted analysis rather than broad, non-specific review. During detailed data review, a discrepancy was identified between data displayed and data exported. This prompted review of dashboard logic and strengthened confidence in data interpretation.

Medications and ADCs commonly associated with unlinked overrides were systematically identified, and focused analyses were performed to evaluate opportunities to improve override-to-order linking workflows. These finds were brought to the CFD interdisciplinary Medication Safety Committee to facilitate focused discussions on strategies to improve order linking workflows.

Conclusions:
Refinement and validation of a company-wide ADC override dashboard enhanced transparency, usability, and data reliability in monitoring unlinked overrides. Systematic dashboard optimization and multidisciplinary collaboration are essential to strengthening medication safety surveillance across large health systems.
  

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Title: Evaluation of the Medication Discrepancy Rate at Discharge
Purpose: Medication errors during hospital admissions have unfortunately followed patients out of the hospital. Many hospitals aim to resume accurate home medications within 24 hours of admission. However, medication discrepancies at the point of hospital discharge can be overlooked. The prevention of unnecessary or potentially harmful medications at discharge could reduce medication errors as well as provide a potential cost-savings opportunity for the health system. The purpose of this study is to evaluate the rate of medication discrepancies at hospital discharge by comparing prior-to-admission medication lists to discharge medication orders.
Methods: This study is an institutional review board approved, retrospective chart review. Patients discharged from Mobile Infirmary Medical Center between June 1st, 2025 to August 31st, 2025 will be randomized and evaluated by a manual chart review. Medication discrepancies are defined as intentional or unintentional differences between medication lists.  Patients will be excluded if they did not have a home medication list marked as “complete” during the admission, left the hospital admission against medical advice or had more than 2 readmissions during the study period. The primary outcome of this study is to identify the rate of medication discrepancies per medication in patients with a completed prior to admission list. Our secondary outcomes include 30-day readmission rates, types of medication discrepancies, and most common drug classes associated with errors. A subgroup analysis will be completed on patients with at least one unintentional discrepancy, focusing on average number of discrepancies per patient, average length of stay, and average number of home medications. Data that will be collected includes: patient demographics and types of medication discrepancies at the time of hospital discharge.
Results: A chart review was conducted on 350 patients. 137 were excluded, and our final included population was 213. Of the excluded patients, 77 had incomplete prior-to-admission (PTA) lists, 25 did not have any home medications on admission, 24 did not have a discharge medication reconciliation completed, and 11 were readmitted more than twice at the time of review. Baseline characteristics included a mean age of 67 + 14.5, 46% of our population were male, the mean length of stay was 14.3 [5] days, and the mean number of home medications was 6.3 + 4.2. The rate of unintentional medication discrepancies per medication was 6.6%. 87 out of 1345 medications screened had an unintentional discrepancy. The most common type of discrepancy was omission, which accounted for 54% of unintentional discrepancies. Dose was next at 16%, followed by frequency at 13%, other reasons at 9%, duplication at 5%, and route at 3%. Of our total population, 14% were readmitted within 30 days, and 21% of those readmitted had unintentional discrepancies. The top five most common drug classes were analgesics, insulin, statins, beta-blockers, and anticoagulants. 54 (25%) patients from our population had at least one unintentional discrepancy. We found that 85% of these patients had 1-2 discrepancies, 11% had 3-4 discrepancies, and 4% had 5-6 discrepancies. The mean number of discrepancies per patient was 1.6 + 1.1, the mean length of stay in this subgroup was 9.5 [5], and the mean number of home medications was 7.6 + 4.3.
Conclusion: Our study consisted of a thorough chart review of initially 350 patients. Based on exclusion criteria, the included sample size was 213, which is a decently sized sample. Our criteria allows for decent generalizability as it included any adult discharged from mobile infirmary in the span of 3 months, however it did exclude incomplete lists as to focus on discharge medications. We also had to assume that the completed reconciliation was as accurate as possible. This was also a single-center study, though at a large community hospital, and was retrospective, so there was a lack of true control. In conclusion, our study shows that medication discrepancies can still occur at discharge despite a completed prior to admission list, and the medications that have errors are high-risk medications. Future directions include scoring tools, artificial intelligence, and prioritizing the assessment of home medications while on disciplinary rounds. We are hopeful that this study procures a dedicated pharmacist-led reconciliation team and additional medication reconciliation protocols at discharge.

Title: Evaluation of an Institutional Inpatient Warfarin Policy Within an Academic Health System

Authors: Conner Correll Cain; Hannah Young; Gabrielle Iliff; Laura Holden

Background: Warfarin is a commonly used anticoagulant with a narrow therapeutic window that requires precise management to avoid complications. Pharmacist involvement has been shown to optimize warfarin therapy and improve patient outcomes; however, many institutions lack dedicated anticoagulation stewardship roles. This study aimed to evaluate compliance with an institutional anticoagulation monitoring policy for inpatient warfarin management to identify opportunities for a pharmacist-driven anticoagulation stewardship program.

Methods: This multicenter, retrospective cohort study evaluated adult patients administered warfarin at a Prisma Health inpatient facility between February 1, 2024 and August 1, 2024. The primary outcome was overall compliance with the institutional anticoagulation monitoring policy, defined as a composite of baseline international normalized ratio (INR) prior to the first scheduled warfarin dose, daily INR levels ordered until two consecutive therapeutic INRs were achieved on a stable dose, and weekly INR monitoring thereafter. Secondary outcomes included compliance with individual policy components, frequency of pharmacy consultation for warfarin management, time to therapeutic INR, incidence of supratherapeutic INR, warfarin reversal, appropriate bridge therapy, direct oral anticoagulant (DOAC) candidacy, prior to admission medication history, and discharge education.

Results: Of the 500 patient encounters reviewed, 418 met inclusion criteria. The vast majority (93.3%) were compliant with INR monitoring per institutional policy. Pharmacy consultation for warfarin management occurred in 49.8% of the encounters. Appropriate bridge therapy was significantly more common when pharmacy was consulted compared to no consultation (91.3% and 75.4%, p=0.01). Pharmacy completion of prior to admission medication histories occurred in fewer than half of the encounters, whereas warfarin discharge education was completed in over half of the encounters (48.9% and 62.9%).

Conclusions: There was widespread compliance with Prisma Health’s inpatient anticoagulation monitoring policy. Secondary outcomes suggest opportunities to improve pharmacy involvement during transitions of care.

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