Hospital prescribing errors: epidemiological assessment of predictors

Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study

OBJECTIVES

Prescribing errors can lead to inconvenience, morbidity and mortality. It is therefore crucial to educate doctors to prescribe safely, efficiently and effectively. To create an effective educational programme, it is essential to understand which errors are made and by whom. The aim of this study is to explore if the experience level of the doctor influences how many and which prescribing errors are made in a European academic teaching hospital, where a computerised physician order entry system (CPOE) with a clinical decision support system (CDSS) is exclusively used.

METHODS

Prescriptions for all inpatients in an academic teaching hospital were collected in June 2021. All prescriptions with an alert generated by the CDSS which could not be handled by a pharmacy technician according to local protocol were checked for errors. Identified errors were categorised by type and severity.

RESULTS

A total of 130 538 prescriptions were newly made or altered by doctors. Of these prescriptions, 1914 (1.5%) were retained for a check by the pharmacist. These contained 430 prescribing errors (0.3% of total prescriptions). Doctors not in specialty training and those in specialty training made more prescribing errors than consultants (0.5% and 0.5% vs 0.1%; p<0.001). Doctors in specialty training made relatively more drug-drug interaction errors than consultants (n=31 (16%) vs n=3 (3%), p<0.05). No significant difference was found regarding the severity of the errors.

CONCLUSIONS

Doctors not in specialty training and doctors in specialty training, who are the less experienced doctors, make more prescribing errors than consultants, even with the use of a CPOE combined with CDSS. The type of errors differ between doctors of different experience levels. This finding provides a solid basis for specific additional education to medical students, doctors not in specialty training and doctors in specialty training.

Does formative assessment help students to acquire prescribing skills?

PURPOSE

Formative assessments can help motivate students and ease students' learning through feedback. There is a pressing need for improvement of clinical pharmacotherapy (CPT) education since junior doctors make many prescribing errors. The aim of this study was to determine whether a formative assessment with personalized narrative feedback helps medical students to increase their prescribing skills.

METHODS

This retrospective cohort study was conducted among masters' medical students at Erasmus Medical Centre, The Netherlands. Students made a formative and a summative skill-based prescription assessment, both during clerkships as part of their regular curriculum. Errors in both assessments were categorized by type and possible consequence and compared with each other.

RESULTS

A total of 388 students made 1964 errors in the formative assessment and 1016 in the summative assessment. Most improvements after the formative assessment were seen for mentioning the weight of a child on the prescription (n = 242, 19%). Most new and repeated errors in the summative assessment were missing usage instructions (n = 82, 16% and n = 121, 41%).

CONCLUSIONS

This formative assessment with personalized and individual narrative feedback has helped students to increase the technical correctness of their prescriptions. However, errors repeated after the feedback were predominantly errors showing that only one formative assessment has not yet enhanced the clinical prescribing enough.

Impact of a policy to improve the management of oral medications when patients are fasting before a procedure: an interrupted time series analysis

Background

Managing medications inappropriately when patients have oral intake restrictions can cause patient harm. This study evaluated the impact of a medication policy separating fasting from nil by mouth with respect to giving oral medications in patients fasting before a diagnostic or interventional procedure.

Methods

The policy stipulated that ‘fasting’ means oral medications should be given with a sip of water up to 1 hour before a procedure, unless there is a clinical reason to withhold, while ‘nil by mouth’ means nothing to be given orally, including medications.

The policy was implemented in Surgical areas in February 2015 and Medical areas in March 2015 at a tertiary referral hospital in Melbourne, Australia, and included bedside signs, clinical champions and education sessions.

The study was conducted in 2020. Admission and medication records were matched for non-elective procedure patients from January 2014 to May 2016. The monthly proportion of doses omitted inappropriately and overall omissions pre/post-policy implementation were compared using segmented regression.

Results

Pre-implementation, the proportion of doses withheld inappropriately and total omissions in medical areas were 18.1% and 28.0%, respectively. Post-implementation, an absolute reduction of 13.4% (95% CI 9.0% to 17.7%) and 11.1% (95% CI 2.6% to 19.6%), respectively, was seen. Post-implementation linear trend showed a 0.3% (95% CI 0.0% to 0.6%) increase in inappropriate omissions but not overall omissions.

In Surgical areas, pre-implementation proportions for inappropriate and overall omissions were lower than Medical areas’. Post-implementation, there was an absolute decrease in doses withheld inappropriately (8.3%, 95% CI 0.8% to 15.7%, from 11.9% pre-implementation) but not total omissions.

Conclusions

Distinguishing fasting from nil by mouth appeared to provide clarity for some staff: a reduction in inappropriate omissions was seen post-implementation. Although the small increase in post-implementation linear trend for inappropriate omissions in Medical areas suggests sustainability issues, total omissions were sustained. The policy’s concepts require verification beyond our institution.

Prescribing Errors With Low-Molecular-Weight Heparins

BACKGROUND

Low-molecular-weight heparins (LMWHs) are used in the prevention and treatment of venous thromboembolism (VTE). Bleeding is the primary major complication of LMWH therapy, which is associated with dose. The administration of appropriate dosages of LMWHs depends on the patient's risk of VTE, risk of bleeding, bodyweight, and renal function. Therefore, LMWH prescribing is prone to errors. However, no earlier study has explored the frequency of prescribing errors with LMWH.

PURPOSE

The aim of the study was to determine the frequency and determinants of in-hospital LMWH-prescribing errors.

METHODS

A cross-sectional study was conducted to examine the frequency and determinants of LMWH prescribing errors between April and August 2014. We randomly selected 500 patients 18 years and older with at least one LMWH prescription during inpatient hospitalization. A prescribing error was a deviation from the internal hospital guidelines. Logistic regression estimated determinants of prescribing error.

RESULTS

A prescribing error was present with 34% of all LMWH users. The most frequently recorded error was a dose that was not adjusted to body weight and/or renal function (85%). Prophylactic LMWH prescribing in medical wards was associated with a higher risk of prescribing error as compared with surgical wards.

CONCLUSIONS

The frequency of prescribing errors was 34% in a tertiary care hospital. Being a patient with prophylactic LMWH use on a medical ward is a determinant for LMWH prescribing error. Interventions that will lead to better electronic recording of body weight and more awareness among medical doctors may reduce the total number of prescribing errors.

Antibiotic allergy as a cause of hospitalization in adults: a hospital-based study in Ukraine

Background:

Antibiotic allergy is an important clinical and social-economical issue.

Objective:

The main objectives of this study were to determine the incidence, causative drugs, and risk groups of antibiotic allergy as a reason for hospitalization. The secondary objective was to evaluate the treatment of antibiotic allergy through the identification of drug related problems (DRPs).

Methods:

This retrospective hospital-based study was carried out in one of Lviv city hospitals (Ukraine) from January 2015 to December 2017. Patients with antibiotic allergy as a cause for hospitalization were included in this study.

Results:

In this study the incidence of antibiotic allergy was 2.0% (95%CI 1.6:2.4) of all admissions to the Unit that provides special medical care for adult inpatients with allergy diseases and allergy reactions. The mean age of patients was 48.5 years (SD=17.0; range 18-83 years) with female predominance (78.2%; 95%CI 68.9:85.2). Antibiotic hypersensitivity reactions manifested as urticaria with angioedema (52.5%; 95%CI 42.3:62.5), urticaria (36.6%; 95%CI 27.8:46.8) or angioedema (10.9%; 95%CI 5.6:18.7). Beta-lactams (48.5%; 95%CI 38.5:58.7), fluoroquinolones (13.9%; 95%CI 7.8%:22.2%) and macrolides (7.9%; 95%CI 3.5:15.0) were specified as the main causative drugs. All patients during hospitalization (a mean of 8.2 days; SD=2.2; range 2-13 days) took at least 3 medicines (a mean of 5.4 medicines per patient; SD=1.2; range 3-12 medicines). The total number of identified DRPs was 400, a mean of 4.0 DRPs per patient (SD=1.8). The most frequently identified type of DRPs was inappropriate route of drug administration (25.0%; 95%CI 20.8:29.5). This was followed by duplicate prescriptions (23.5%; 95%CI 19.4:28.0) and insufficient frequency of drug administration (19.0%; 95%CI 15.3:23.2). Potential drug-drug interactions and inappropriate drug prescriptions each accounted for 16.0% (95% CI 12.6:20.0) of all DRPs. Comparing all above items in 2015, 2016 and 2017 showed no statistically significant changes (p>0.05).

Conclusions:

Antibiotic allergy is a common reason for admissions. The treatment of antibiotic allergy is associated with numerous DRPs. Our results could be useful for development of strategies for improving the safety and quality of pharmacotherapy.

Impact of a preoperative pharmaceutical consultation in scheduled orthopedic surgery on admission: a prospective observational study

BACKGROUND

Medication errors have a high prevalence in surgery and management of home medication is strongly involved in these errors. In scheduled surgery, the preoperative consultation is a privileged time to inform the patient about the management of her/his home medication before admission. This study assessed the impact of a pre-anesthesia best possible medication history (PA-BPMH) on admission. The PA-BPMH was performed by a clinical pharmacist prior to the anesthesia consultation for anesthesiologists to prescribe admission medical orders for scheduled orthopedic surgery patients.

METHODS

This was a prospective observational study which was carried out in an orthopedic surgery department. All patients over 18 years old with an elective orthopedic surgery were eligible except ambulatory surgery patients. The pharmacist registered the PA-BPMH into the software making it available for anesthesiologists for the pre-admission medication order. Finally, a medication reconciliation was performed at admission. The main outcome was the percentage of patients with at least one unintended medication discrepancy (UMD) at admission. The nature, potential clinical impact and acceptance rate of each UMD detected were assessed. Also, the PA-BPMH process was described and patients and anesthesiologists satisfaction was evaluated.

RESULTS

A total of 455 patients had a pharmaceutical consultation. Medication reconciliation was performed at admission for 360 patients. Overall, at least one UMD was observed in 13.0% of patients (n = 47). A total of 63 UMD were detected. The most common type of UMD was omission (25.4%) and incorrect drug (23.8%).Two UMD (3.2%) were evaluated as life threatening. All the UMD detected were corrected on the admission medication order.

CONCLUSION

A preoperative pharmacist-anesthesiologist teamwork seems to improve the safety of perioperative management of home medication for scheduled orthopedic surgery patients. This process needs a randomized clinical trial across a wider range of surgeries before its implementation.

Prescribing errors in electronic prescriptions for outpatients intercepted by pharmacists and the impact of prescribing workload on error rate in a Chinese tertiary-care women and children's hospital

BACKGROUND

Prescribing errors may, influenced by some risk factors, cause adverse drug events. Most studies in this field focus on errors in prescriptions for hospital inpatients, with only a few on those for outpatients. Our study aimed to explore the incidence of prescribing errors in electronic prescriptions and illustrate the trend of prescribing workload and error rate over time.

METHODS

The cross-section study was performed between September, 2015 and November, 2015. Prescribing errors were intercepted by pharmacists using a prescription reviewing system under which prescriptions with errors were transferred to a specific computer and recorded by another pharmacist and the incidence of total prescribing errors and severe errors was then calculated. A subgroup analysis was conducted in accordance to the number of drug orders, the age group of patients, the seniority of physicians, the specialty of physicians, the working day when prescriptions were issued, and the prescribing workload of physicians. A time-series analysis was employed to analyze the trend of prescribing workload and error rate, and the correlation between them.

RESULTS

Totally, 65,407 patients were included in this study and 150,611 prescriptions with 294,564 drug orders (including 584 different drugs) were reviewed for identification of errors. A total of 534 prescribing errors (an error rate of 0.34%) were identified. Severe errors accounted for 13.62% of total errors. The subgroup analysis showed prescriptions of multiple drug orders, for pediatric patients aged 29 days to 12 years, from physicians specializing in ophthalmology and otorhinolaryngology, or prescribing on weekdays were more susceptible to errors. A time-series analysis demonstrated no correlation between prescribing workload and error rate which increased at the end of each working shift while prescribing workload decreased.

CONCLUSION

Less than 1% of the studied prescriptions came with errors among which one in seven were severe ones. But prescribing errors were in no relation to workloads. What's more, further studies are needed to investigate pharmacist-led intervention to reduce prescribing errors.

Medication Review and Patient Outcomes in an Orthopedic Department: A Randomized Controlled Study

OBJECTIVE

We investigated the health-related effect of systematic medication review performed by a clinical pharmacist and a clinical pharmacologist on nonelective elderly orthopedic patients.

METHODS

This is a nonblinded randomized controlled study of 108 patients 65 years or older treated with at least 4 drugs. For the intervention, the clinical pharmacist reviewed the participants' medication after completion of the usual medication routine. Information was collected from medical charts, interviews with participants, and database registrations of drug purchase. Results were conferred with the clinical pharmacologist, and recommendations were delivered directly to the ward physicians. The control was usual medication routine, that is, physicians prescribing admitting orders. The primary outcome was time to the first unplanned contact to a physician after discharge (i.e., general practitioner, emergency department visit, or readmission) during 3-month follow-up. Secondary outcomes included other health-related outcomes, for example, length of in-hospital stay, mortality, and quality of life.

RESULTS

Time to the first unplanned contact to a physician was 14.9 days (95% confidence interval, 8.9-21.0) in the intervention group compared with 27.3 days (95% confidence interval, 18.9-35.7) in the controls (P = 0.05). Overall, no statistically significant differences were seen in the secondary outcomes apart from "number of" and "time to first" emergency department visits, which were in favor of the intervention group. A marked hesitation of the ward physicians to comply with recommendations was noted (18%).

CONCLUSIONS

The study showed that the patients receiving usual care had a significantly longer time to the first unplanned contact to a physician after discharge; however, the fact that less than 1 of 5 recommendations was adopted by the physicians raises concerns as to whether this finding could be attributable to the intervention.

A prescription audit using the World Health Organization-recommended core drug use indicators in a rural hospital of Delhi

INTRODUCTION

The inappropriate use of drugs is a global health problem, especially in developing country like India. Irrational prescriptions have an ill effect on health as well as health-care expenditure. Prescription auditing is an important tool to improve the quality of prescriptions, which in turn improves the quality of health care provided. The present study was conducted to investigate the rational use of drugs for completeness, legibility, and against the World Health Organization (WHO)-recommended core drug use indicators.

MATERIALS AND METHODS

A cross-sectional, outpatient department-based study was carried out in a rural hospital of Delhi wherein 120 prescriptions were randomly sampled, irrespective of patient characteristics and diagnosis over a period of 1 month. All the prescriptions were analyzed for general details, medical components, and WHO core drug use indicators. The data obtained were summed up and presented as descriptive statistics using the Microsoft Excel and were analyzed using SPSS version 16.

RESULTS

All the prescriptions had general details mentioned in it. The diagnosis was mentioned in 64.2% of prescriptions, and 85.8% of drugs were prescribed by generic name. An average of 3.02 drugs per encounter was prescribed. The average consultation time and dispensing time were 2.8 min and 1.2 min, respectively. Only half of the patients had correct knowledge of dose.

CONCLUSIONS

Our study highlights the need to train our prescribing doctors on writing rational prescriptions for quality improvement.

Prediction of clinically relevant adverse drug events in surgical patients

BACKGROUND

Risk stratification of hospital patients for adverse drug events would enable targeting patients who may benefit from interventions aimed at reducing drug-related morbidity. It would support clinicians and hospital pharmacists in selecting patients to deliver a more efficient health care service. This study aimed to develop a prediction model that helps to identify patients on the day of hospital admission who are at increased risk of developing a clinically relevant, preventable adverse drug event during their stay on a surgical ward.

METHODS

Data of the pre-intervention measurement period of the P-REVIEW study were used. This study was designed to assess the impact of a multifaceted educational intervention on clinically relevant, preventable adverse drug events in surgical patients. Thirty-nine variables were evaluated in a univariate and multivariate logistic regression analysis, respectively. Model performance was expressed in the Area Under the Receiver Operating Characteristics. Bootstrapping was used for model validation.

RESULTS

6780 admissions of patients at surgical wards were included during the pre-intervention period of the PREVIEW trial. 102 patients experienced a clinically relevant, adverse drug event during their hospital stay. The prediction model comprised five variables: age, number of biochemical tests ordered, heparin/LMWH in therapeutic dose, use of opioids, and use of cardiovascular drugs. The AUROC was 0.86 (95% CI 0.83-0.88). The model had a sensitivity of 80.4% and a specificity of 73.4%. The positive and negative predictive values were 4.5% and 99.6%, respectively. Bootstrapping generated parameters in the same boundaries.

CONCLUSIONS

The combined use of a limited set of easily ascertainable patient characteristics can help physicians and pharmacists to identify, at the time of admission, surgical patients who are at increased risk of developing ADEs during their hospital stay. This may serve as a basis for taking extra precautions to ensure medication safety in those patients.

Key Learning Outcomes for Clinical Pharmacology and Therapeutics Education in Europe: A Modified Delphi Study

Harmonizing clinical pharmacology and therapeutics (CPT) education in Europe is necessary to ensure that the prescribing competency of future doctors is of a uniform high standard. As there are currently no uniform requirements, our aim was to achieve consensus on key learning outcomes for undergraduate CPT education in Europe. We used a modified Delphi method consisting of three questionnaire rounds and a panel meeting. A total of 129 experts from 27 European countries were asked to rate 307 learning outcomes. In all, 92 experts (71%) completed all three questionnaire rounds, and 33 experts (26%) attended the meeting. 232 learning outcomes from the original list, 15 newly suggested and 5 rephrased outcomes were included. These 252 learning outcomes should be included in undergraduate CPT curricula to ensure that European graduates are able to prescribe safely and effectively. We provide a blueprint of a European core curriculum describing when and how the learning outcomes might be acquired.

Detection and correction of prescription errors by an emergency department pharmacy service

OBJECTIVES

Emergency departments (EDs) are recognized as a high-risk setting for prescription errors. Pharmacist involvement may be important in reviewing prescriptions to identify and correct errors. The objectives of this study were to describe the frequency and type of prescription errors detected by pharmacists in EDs, determine the proportion of errors that could be corrected, and identify factors associated with prescription errors.

METHODS

This prospective observational study was conducted in a tertiary care teaching ED on 25 consecutive weekdays. Pharmacists reviewed all documented prescriptions and flagged and corrected errors for patients in the ED. We collected information on patient demographics, details on prescription errors, and the pharmacists' recommendations.

RESULTS

A total of 3,136 ED prescriptions were reviewed. The proportion of prescriptions in which a pharmacist identified an error was 3.2% (99 of 3,136; 95% confidence interval [CI] 2.5-3.8). The types of identified errors were wrong dose (28 of 99, 28.3%), incomplete prescription (27 of 99, 27.3%), wrong frequency (15 of 99, 15.2%), wrong drug (11 of 99, 11.1%), wrong route (1 of 99, 1.0%), and other (17 of 99, 17.2%). The pharmacy service intervened and corrected 78 (78 of 99, 78.8%) errors. Factors associated with prescription errors were patient age over 65 (odds ratio [OR] 2.34; 95% CI 1.32-4.13), prescriptions with more than one medication (OR 5.03; 95% CI 2.54-9.96), and those written by emergency medicine residents compared to attending emergency physicians (OR 2.21, 95% CI 1.18-4.14).

CONCLUSIONS

Pharmacists in a tertiary ED are able to correct the majority of prescriptions in which they find errors. Errors are more likely to be identified in prescriptions written for older patients, those containing multiple medication orders, and those prescribed by emergency residents.

Risk factors for potential drug-drug interactions in intensive care unit patients

PURPOSE

To determine risk factors for each severity-based category of potential drug-drug interactions (DDIs) encountered at intensive care unit (ICU) patients.

METHODS

This was a retrospective cohort analysis of patients treated at the ICU of the Clinical Center Kragujevac, a public tertiary care hospital in Kragujevac, Serbia. Three interaction checkers were used to reveal drug-drug interactions: Medscape, Epocrates and Micromedex.

RESULTS

The study included 201 patients, 66.19±16.11 years of age. Average number of DDIs per patient ranged from 10.49±8.80 (Micromedex) to 29.43±21.51 (Medscape). Antiarrhythmic or anticonvulsant drug prescription, Charlson Comorbidity Index, male sex, length of hospitalization, number of drugs or therapeutic groups prescribed and surgery increased the risk of DDIs in ICU patients, while presence of delirium or dementia and transfer from emergency department to ICU protected against.

CONCLUSIONS

The rate of the DDIs in ICU patients at a tertiary care hospital is high, and adversely influenced by number of drugs or drug groups prescribed per patient, antiarrhythmic or anticonvulsant drug prescription, comorbidities, length of hospitalization and surgery. On the other hand, presence of cognitive deficit and transfer from emergency department to ICU protect ICU patients from the DDIs.

Assessment of drug-related problems in pediatric ward of Zewditu Memorial Referral Hospital, Addis Ababa, Ethiopia

Background Although medications play a vital role in the cure, palliation, and inhibition of disease, they also expose patients to drug-related problems (DRPs). DRPs are common in hospitalized patients. Specifically, pediatrics population are easily affected by DRPs, as dynamic and kinetic behaviors of drugs in this population are usually different than  in adults. Objectives To assess the prevalence of DRPs and associated factors in a pediatric setting in Ethiopia. Setting Pediatric ward of Zewditu Memorial Referral Hospital, Addis Abbeba, Ethiopia. Methods A cross-sectional study was conducted on 285 randomly selected patients. Data were obtained through review of physician medication orders and patient files. The prevalence and type of DRPs were studied and documented using the Pharmaceutical Care Network Europe Foundation classification system. The results were summarized using descriptive statistics including frequency, mean, and standard deviation. To identify the independent predicators of DRPs, logistic regression analysis was run and a P value ≤0.05 was considered as statistically significant. Main outcome measure DRPs, types of DRPs, drugs that are frequently involved in DRPs, and factors associated with DRPs. Main outcome measure Number of DRPs. Results Of the 1055 medication orders reviewed, a total of 106 DRPs were identified in 90 patients. This gives an overall rate of drug-related problems of 31.57%. The most frequently identified DRPs were dosing problems, with dose too low being 34.9% and dose too high being 7.5%. This was followed by drug-drug interactions (38.67%) and adverse drug reactions (8.49%). The number of prescribed drugs (AOR 2.3, 95% CI 1.3-4.3, P = 0.007) and total number of disease conditions (AOR 4.8, 95% CI 1.9, 12.1, P = 0.001) were potential risk factors for occurrence of DRPs. Conclusion The present study demonstrated that DRPs were common at the pediatric ward of Zewditu Memorial Referral Hospital and that it needs great attention. The most frequently identified DRPs were dosing problems, followed by drug-drug interactions and adverse drug reaction. Poly-pharmacy and number of disease conditions have been identified as important risk factors for occurrence of DRPs. The investigators recommend establishing a system for reporting DRPs in the pediatric ward of the hospital as it may facilitate appropriate measures for prospective interventions, such as training the healthcare team, as well as detail precautions to be followed by the practitioners. In addition to this, improving communication between the healthcare team members such as physicians, pharmacists, nurses, and other healthcare workers in the hospital is recommended.

Methods to reduce prescribing errors in elderly patients with multimorbidity

The global population of multimorbid older people is growing steadily. Multimorbidity is the principal cause of complex polypharmacy, which in turn is the prime risk factor for inappropriate prescribing and adverse drug reactions and events. Those who prescribe for older frailer multimorbid people are particularly prone to committing prescribing errors of various kinds. The causes of prescribing errors in this patient population are multifaceted and complex, including prescribers' lack of knowledge of aging physiology, geriatric medicine, and geriatric pharmacotherapy, overprescribing that frequently leads to major polypharmacy, inappropriate prescribing, and inappropriate drug omission. This review examines the various ways of minimizing prescribing errors in multimorbid older people. The role of education in physician prescribers and clinical pharmacists, the use of implicit and explicit prescribing criteria designed to improve medication appropriateness in older people, and the application of information and communication-technology systems to minimize errors are discussed in detail. Although evidence to support any single intervention to prevent prescribing errors in multimorbid elderly people is inconclusive or lacking, published data support focused prescriber education in geriatric pharmacotherapy, routine application of STOPP/START (screening tool of older people's prescriptions/screening tool to alert to right treatment) criteria for potentially inappropriate prescribing, electronic prescribing, and close liaison between clinical pharmacists and physicians in relation to structured medication review and reconciliation. Carrying out a structured medication review aimed at optimizing pharmacotherapy in this vulnerable patient population presents a major challenge. Another challenge is to design, build, validate, and test by clinical trials suitably versatile and efficient software engines that can reliably and swiftly perform complex medication reviews in older multimorbid people. The European Union-funded SENATOR and OPERAM clinical trials commencing in 2016 will examine the impact of customized software engines in reducing medication-related morbidity, avoidable excess cost, and rehospitalization in older multimorbid people.

Continuation Rate of Atypical Antipsychotics After Discharge When Initiated in the Intensive Care Unit

Purpose:

The frequency with which atypical antipsychotics initiated in the intensive care unit (ICU) is unknown. While there is lack of evidence to support the exact duration of treatment, antipsychotics should not be continued chronically for agitation and psychosis related to critical illness. The objective of this study was to determine whether atypical antipsychotics initiated in the ICU at a large tertiary academic medical center were continued after hospital discharge. Safety outcomes were also assessed.

Materials:

A total of 1023 patients who received atypical antipsychotics during ICU stay were identified. Patients were assessed in a pseudo-randomized fashion until a sample of 191 patients was reached. After review of the exclusion criteria, the final study population was 100 patients. When antipsychotics were discontinued, progress notes were reviewed to identify the reason for discontinuation. Safety outcomes were assessed based on physician documentation in the medical charts.

Results:

Atypical antipsychotics were continued in 23% of patients. Atypical antipsychotics were discontinued in 1 patient due to QTc prolongation.

Conclusions:

Atypical antipsychotics initiated in the ICU are frequently continued after hospital discharge. Given the known risks associated with extended therapy, initiatives are needed to prevent inappropriate continuation.

An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit

Aim

To assess the impact of the implementation of a Computerized Physician Order Entry (CPOE) associated with a pharmaceutical checking of medication orders on medication errors in the 3 stages of drug management (i.e. prescription, dispensing and administration) in an orthopaedic surgery unit.

Methods

A before-after observational study was conducted in the 66-bed orthopaedic surgery unit of a teaching hospital (700 beds) in Paris France. Direct disguised observation was used to detect errors in prescription, dispensing and administration of drugs, before and after the introduction of computerized prescriptions. Compliance between dispensing and administration on the one hand and the medical prescription on the other hand was studied. The frequencies and types of errors in prescribing, dispensing and administration were investigated.

Results

During the pre and post-CPOE period (two days for each period) 111 and 86 patients were observed, respectively, with corresponding 1,593 and 1,388 prescribed drugs. The use of electronic prescribing led to a significant 92% decrease in prescribing errors (479/1593 prescribed drugs (30.1%) vs 33/1388 (2.4%), p < 0.0001) and to a 17.5% significant decrease in administration errors (209/1222 opportunities (17.1%) vs 200/1413 (14.2%), p < 0.05). No significant difference was found in regards to dispensing errors (430/1219 opportunities (35.3%) vs 449/1407 (31.9%), p = 0.07).

Conclusion

The use of CPOE and a pharmacist checking medication orders in an orthopaedic surgery unit reduced the incidence of medication errors in the prescribing and administration stages. The study results suggest that CPOE is a convenient system for improving the quality and safety of drug management.

Making pharmacogenomic-based prescribing alerts more effective: A scenario-based pilot study with physicians

To facilitate personalized drug dosing (PDD), this pilot study explored the communication effectiveness and clinical impact of using a prototype clinical decision support (CDS) system embedded in an electronic health record (EHR) to deliver pharmacogenomic (PGx) information to physicians. We employed a conceptual framework and measurement model to access the impact of physician characteristics (previous experience, awareness, relative advantage, perceived usefulness), technology characteristics (methods of implementation-semi-active/active, actionability-low/high) and a task characteristic (drug prescribed) on communication effectiveness (usefulness, confidence in prescribing decision), and clinical impact (uptake, prescribing intent, change in drug dosing). Physicians performed prescribing tasks using five simulated clinical case scenarios, presented in random order within the prototype PGx-CDS system. Twenty-two physicians completed the study. The proportion of physicians that saw a relative advantage to using PGx-CDS was 83% at the start and 94% at the conclusion of our study. Physicians used semi-active alerts 74-88% of the time. There was no association between previous experience with, awareness of, and belief in a relative advantage of using PGx-CDS and improved uptake. The proportion of physicians reporting confidence in their prescribing decisions decreased significantly after using the prototype PGx-CDS system (p=0.02). Despite decreases in confidence, physicians perceived a relative advantage to using PGx-CDS, viewed semi-active alerts on most occasions, and more frequently changed doses toward doses supported by published evidence. Specifically, sixty-five percent of physicians reduced their dosing, significantly for capecitabine (p=0.002) and mercaptopurine/thioguanine (p=0.03). These findings suggest a need to improve our prototype such that PGx CDS content is more useful and delivered in a way that improves physician's confidence in their prescribing decisions. The greatest increases in communication effectiveness and clinical impact of PGx-CDS are likely to be realized through continued focus on content, content delivery, and tailoring to physician characteristics.

Analysis of Out Door Patients' Prescriptions According to World Health Organization (WHO) Prescribing Indicators Among Private Hospitals in Western India

BACKGROUND

Prescription is document through which doctor, patient and pharmacist are communicated. Many a times if these documents are not properly written or misinterpreted it can affect management of patients. WHO established prescribing indicators to analyse prescription and promoted rational use of drugs and better management of patients.

AIM

To study the prescription pattern according to WHO prescribing indicators among private hospitals.

SETTINGS AND DESIGN

The observational, prospective study carried out at different private hospitals at metro city in Western India to study the prescription pattern among private hospital.

MATERIALS AND METHODS

Study was conducted at different private hospitals of metro city. A total of 250 prescriptions of outdoor patients from various departments of private hospitals were collected for a period of three months (August to October) 2012 and evaluated.

STATISTICAL ANALYSIS

The study was analysed using Z-test.

RESULTS

Patient details like age and gender was not written in all (100%) prescriptions. It was noticed that dose, direction of drug and duration of treatment was not completely written in 90%, 74% and 80% of prescriptions respectively. Abbreviations were used in all (100%) prescriptions. Doctor's medical registration number was mentioned in 0% prescriptions. Total 869 drugs were prescribed in 250 prescriptions. Average number of drug prescribed was 3.38±1.79 (Mean±SD). It was reported that Group II (3 to 4 encoutner) was significantly higher as compared to Group I (less than or equal to 2 encoutner) and Group III( more than four encounter). It was significantly (p<0.05) prescribed brand name prescriptions (93.33%) as compared to generic name prescriptions (6.7%). Percentage of encounter with antibiotics and injections was 54% and 18% respectively. Approximately 70% drugs were prescribed according to Essential Medicine List (EML) of State. Antibiotics accounted 30% of prescribed drugs which was significantly higher as compared to other group of prescribed drugs.

CONCLUSION

Our study revealed that prescription errors were most commonly observed at private hospitals and antibiotics was commonly prescribed in private sector. Therefore, strict policy to good prescribing practice and strict antibiotic policy in outdoor patients are required to promote rational use of drugs.

Improving pre-operative medicines reconciliation

An audit of 143 surgical admissions showed that only 30% of general surgery and urology patients have complete medication charts on the day of surgery prior to going to theatre, compared to 94% of orthopaedic patients. This was despite having been seen previously in the pre-operative assessment clinic (POAC). These patients went to the wards post-operatively, where many then missed doses of their life-sustaining medications. Orthopaedic patients see a prescribing pharmacist in POAC who undertakes medicines reconciliation; this is performed by junior doctors for surgical patients.

We designed three interventions to improve drug chart completion by junior doctors, and gathered prospective data for 22 weeks in the POAC. We also recorded attendance of junior doctors in the POAC and reasons for absence. Daily and weekly percentages of drug chart completion were plotted on a run chart.

The baseline completion rate was 43%. This rose to 45% after the first and second interventions, and 51% after the third intervention. However, the completion rate remained markedly below our target of 94%. Junior doctors attended only 44% of POACs. They reported being “too busy to attend” 41% of the time, and could not be contacted on 11% of occasions.

Junior doctors reported that they were unable to attend to both unwell inpatients and the POAC, the latter seeming less of a priority. This was despite a rota allocating doctors to attend POAC sessions free from clinical or teaching commitments.

We were unable to increase the rate of drug chart completion with the resources available. We therefore recommend the employment of prescribing pharmacists in the POAC for general surgery and urology patients.

Prescribing errors in hospital practice

Prescribing errors that occur in hospitals have been a source of concern for decades. This narrative review describes some of the recent work in this field. There is considerable heterogeneity in definitions and methods used in research on prescribing errors. There are three definitions that are used most frequently (one for prescribing errors specifically and two for the broader arena of medication errors), although many others have also been used. Research methods used focus primarily on investigating either the prescribing process (such as errors in the dose prescribed) or the outcomes for the patient (such as preventable adverse drug events). This complicates attempts to calculate the overall prevalence or incidence of errors. Errors have been reported in handwritten descriptions of almost 15% and with electronic prescribing of up to 8% of orders. Errors are more likely to be identified on admission to hospital than at any other time (usually failure to continue ongoing medication) and errors of dose occur most commonly throughout the patients' stay. Although there is evidence that electronic prescribing reduces the number of errors, new types of errors also occur. The literature on causes of error shows some commonality with both handwritten and electronic prescribing but there are also causes that are unique to each. A greater understanding of the prevalence of the complex causal pathways found and the differences between the pathways of minor and severe errors is necessary. Such an understanding would underpin theoretically-based interventions to reduce the occurrence of prescribing errors.

Avoidable interruptions during drug administration in an intensive rehabilitation ward: improvement project

AIMS

To record the frequency of interruptions and their causes, to identify 'avoidable' interruptions and to build an improvement project to reduce 'avoidable' interruptions.

BACKGROUND

In Italy each year 30,000-35,000 deaths per year are attributed to health-care system errors, of which 19% are caused by medication errors. The factors that contribute to drug management error also include interruptions and carelessness during treatment administration.

METHODS

A descriptive study design was used to record the frequency of interruptions and their causes and to identify 'avoidable' interruptions in an intensive rehabilitation ward in Northern Italy. A data collection grid was used to record the data over a 6-month period.

RESULTS

A total of 3000 work hours were observed. During the study period 1170 interruptions were observed. The study identified 14 causes of interruption.

CONCLUSIONS

The study shows that of the 14 cases of interruptions at least nine can be defined as 'avoidable'. An improvement project has been proposed to reduce unnecessary interruptions and distractions to avoid making errors.

IMPLICATIONS FOR NURSING MANAGEMENT

An additional useful step to reduce the incidence of treatment errors would be to implement the use of a single patient medication sheet for the recording of drug prescription, preparation and administration and also the incident reporting.

Appropriateness of ambulatory prescriptions in Taiwan: translating claims data into initiatives

BACKGROUND

Appropriate prescribing is fundamental to successful pharmacotherapy. The status of current ambulatory medication practices in medicine and pharmacy would be better understood through an analysis of community pharmacy prescription claims.

OBJECTIVE

The aims of the study were to investigate patterns of the types of prescriptions claimed by community pharmacies, undetected prescription errors by community pharmacists, and associated factors of prescription errors.

SETTING

A population-based claims database of prescriptions dispensed by community pharmacies in Taiwan.

METHODS

Ambulatory prescriptions were randomly sampled and reassessed for prescribing appropriateness by medical center pharmacists using explicit criteria. Demographics of patients, physicians, care facilities, and prescription/dispensing details were assessed and used to identify associated factors for prescription errors using descriptive analyses as well as logistic regression.

MAIN OUTCOME MEASURES

Erroneous prescriptions prescribed by physicians, and dispensed and claimed through community pharmacies.

RESULTS

The study included analyses of 3065 prescriptions dispensed in community pharmacies resulting from 1003 patient visits, mostly to physician or dental clinics (99.5%). Prescribing characteristics, patterns, and examples of prescription errors are described. Prescription errors were identified in 18.3% (n = 560) of prescriptions and 34.9% (n = 350) of patient visits. Potential prescribing errors included errors of omission (25.5%), errors of commission (53.4%), and others (21.1%). The top three errors were incorrect dosage (27.5%), missing indication (23.6%), and insufficient or unavailable drug information (18.9%). Drugs most frequently associated with prescription errors included antihistamines, hormones, and gastrointestinal agents. Prescription were also higher in the central and eastern regions of Taiwan. Pediatricians accounted for a disproportionate number of prescription errors.

CONCLUSION

Prescription errors are prevalent in ambulatory care in Taiwan, and differential practice standards exist between community and hospital services. This disparity needs to be reconciled by pertinent initiatives to enhance community-hospital and pharmacist-general practitioner communication and interprofessional educational efforts to improve medication use and safety.

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital

BACKGROUND

Pharmacists have an essential role in improving drug usage and preventing prescribing errors (PEs). PEs at the interface of care are common, sometimes leading to adverse drug events (ADEs). This was the first study to investigate, using a computerized search method, the number, types, severity, pharmacists' impact on PEs and predictors of PEs in the context of electronic prescribing (e-prescribing) at hospital discharge.

METHOD

This was a retrospective, observational, 4-week study, carried out in 2008 in the Medical and Elderly Care wards of a 904-bed teaching hospital in the northwest of England, operating an e-prescribing system at discharge. Details were obtained, using a systematic computerized search of the system, of medication orders either entered by doctors and discontinued by pharmacists or entered by pharmacists. Meetings were conducted within 5 days of data extraction with pharmacists doing their routine clinical work, who categorized the occurrence, type and severity of their interventions using a scale. An independent senior pharmacist retrospectively rated the severity and potential impact, and subjectively judged, based on experience, whether any error was a computer-related error (CRE). Discrepancies were resolved by multidisciplinary discussion. The Statistical Package for Social Sciences was used for descriptive data analysis. For the PE predictors, a multivariate logistic regression was performed using STATA 7. Nine predictors were selected a priori from available prescribers', patients' and drug data.

RESULTS

There were 7920 medication orders entered for 1038 patients (doctors entered 7712 orders; pharmacists entered 208 omitted orders). There were 675 (8.5% of 7920) interventions by pharmacists; 11 were not associated with PEs. Incidences of erroneous orders and patients with error were 8.0% (95% CI 7.4, 8.5 [n = 630/7920]) and 20.4% (95% CI 18.1, 22.9 [n = 212/1038]), respectively. The PE incidence was 8.4% (95% CI 7.8, 9.0 [n = 664/7920]). The top three medications associated with PEs were paracetamol (acetaminophen; 30 [4.8%]), salbutamol (albuterol; 28 [4.4%]) and omeprazole (25 [4.0%]). Pharmacists intercepted 524 (83.2%) erroneous orders without referring to doctors, and 70% of erroneous orders within 24 hours. Omission (31.0%), drug selection (29.4%) and dosage regimen (18.1%) error types accounted for >75% of PEs. There were 18 (2.9%) serious, 481 (76.3%) significant and 131 (20.8%) minor erroneous orders. Most erroneous orders (469 [74.4%]) were rated as of significant severity and significant impact of pharmacists on PEs. CREs (n = 279) accounted for 44.3% of erroneous orders. There was a significant difference in severity between CREs and non-CREs (χ2 = 38.88; df = 4; p < 0.001), with CREs being less severe than non-CREs. Drugs with multiple oral formulations (odds ratio [OR] 2.1; 95% CI 1.25, 3.37; p = 0.004) and prescribing by junior doctors (OR 2.54; 95% CI 1.08, 5.99; p = 0.03) were significant predictors of PEs.

CONCLUSIONS

PEs commonly occur at hospital discharge, even with the use of an e-prescribing system. User and computer factors both appeared to contribute to the high error rate. The e-prescribing system facilitated the systematic extraction of data to investigate PEs in hospital practice. Pharmacists play an important role in rapidly documenting and preventing PEs before they reach and possibly harm patients. Pharmacists should understand CREs, so they complement, rather than duplicate, the e-prescribing system's strengths.

The pathophysiology of medication errors: how and where they arise

1. Errors arise when an action is intended but not performed; errors that arise from poor planning or inadequate knowledge are characterized as mistakes; those that arise from imperfect execution of well-formulated plans are called slips when an erroneous act is committed and lapses when a correct act is omitted. 2. Some tasks are intrinsically prone to error. Examples are tasks that are unfamiliar to the operator or performed under pressure. Tasks that require the calculation of a dosage or dilution are especially susceptible to error. 3. The tasks of prescribing, preparation, and administration of medicines are complex, and are carried out within a complex system; errors can occur at each of many steps and the error rate for the overall process is therefore high. 4. The error rate increases when health-care professionals are inexperienced, inattentive, rushed, distracted, fatigued, or depressed; orthopaedic surgeons and nurses may be more likely than other health-care professionals to make medication errors. 5. Medication error rates in hospital are higher in paediatric departments and intensive care units than elsewhere. 6. Rates of medication errors may be higher in very young or very old patients. 7. Intravenous antibiotics are the drugs most commonly involved in medication errors in hospital; antiplatelet agents, diuretics, and non-steroidal anti-inflammatory drugs are most likely to account for 'preventable admissions'. 8. Computers effectively reduce the rates of easily counted errors. It is not clear whether they can save lives lost through rare but dangerous errors in the medication process.

Prescription quality in an acute medical ward

PURPOSE

Prescribing is an effective and economical means of delivering health care. The aim of this study is to assess the quality of prescriptions in an Acute Medical Assessment Unit (AMAU) at Aberdeen Royal Infirmary (ARI).

METHODS

Prescription data were collected from all available medication charts of patients admitted to the ward over a 2-week period. Prescription quality indicators were divided into two categories: prescription chart related (e.g. complete patient information and absence of drug-drug interactions (DDIs)) and medication related (e.g. legibility of handwriting, generic prescribing and adherence to hospital's formulary).

RESULTS

Patient identifiers were omitted in 4% (n = 8) of the medication charts included in assessing prescribing quality. Patient allergies were omitted in 36% (n = 76) of charts. At least one DDI was detected in 26% (n = 55) of the charts. The mean number of medications prescribed per patient was seven (95%CI, 6.53-7.65). The median number of medication-related prescribing errors per medication chart was two (interquartile range (IQR), 1-3). The distribution of these errors was significantly higher in charts with five or more medications (p < 0.001).

CONCLUSION

This study demonstrates a relatively acceptable level of prescription quality compared to the published literature. However, the number of DDIs and level of allergy documentation are of concern emphasising the need for continued education in this field.

Drug Use and Dosing in Chronic Kidney Disease

One of the most important drug-related problems in patients with chronic kidney disease (CKD) is medication dosing errors. Many medications and their metabolites are eliminated through the kidney. Thus, adequate renal function is important to avoid toxicity. Patients with renal impairment often have alterations in their pharmacokinetic and pharmacodynamic pa-rameters. The clearance of drugs eliminated primarily by renal filtration is decreased by renal disease. Therefore, special consideration should be taken when these drugs are prescribed to patients with impaired renal function. Despite the importance of dosage adjustment in patients with CKD, such adjustments are sometimes ignored. Physicians and pharmacists can work together to accomplish safe drug prescribing. This task can be complex and require a stepwise approach to ensure effectiveness, minimise further damage and prevent drug nephrotoxicity. Key words: Dosage adjustment, Renal impairment, Stepwise approach

The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review

Prescribing errors are common, they result in adverse events and harm to patients and it is unclear how best to prevent them because recommendations are more often based on surmized rather than empirically collected data. The aim of this systematic review was to identify all informative published evidence concerning the causes of and factors associated with prescribing errors in specialist and non-specialist hospitals, collate it, analyse it qualitatively and synthesize conclusions from it. Seven electronic databases were searched for articles published between 1985-July 2008. The reference lists of all informative studies were searched for additional citations. To be included, a study had to be of handwritten prescriptions for adult or child inpatients that reported empirically collected data on the causes of or factors associated with errors. Publications in languages other than English and studies that evaluated errors for only one disease, one route of administration or one type of prescribing error were excluded. Seventeen papers reporting 16 studies, selected from 1268 papers identified by the search, were included in the review. Studies from the US and the UK in university-affiliated hospitals predominated (10/16 [62%]). The definition of a prescribing error varied widely and the included studies were highly heterogeneous. Causes were grouped according to Reason's model of accident causation into active failures, error-provoking conditions and latent conditions. The active failure most frequently cited was a mistake due to inadequate knowledge of the drug or the patient. Skills-based slips and memory lapses were also common. Where error-provoking conditions were reported, there was at least one per error. These included lack of training or experience, fatigue, stress, high workload for the prescriber and inadequate communication between healthcare professionals. Latent conditions included reluctance to question senior colleagues and inadequate provision of training. Prescribing errors are often multifactorial, with several active failures and error-provoking conditions often acting together to cause them. In the face of such complexity, solutions addressing a single cause, such as lack of knowledge, are likely to have only limited benefit. Further rigorous study, seeking potential ways of reducing error, needs to be conducted. Multifactorial interventions across many parts of the system are likely to be required.

A literature review of the individual and systems factors that contribute to medication errors in nursing practice

AIM

This paper reports a review of the empirical literature on factors that contribute to medication errors.

BACKGROUND

Medication errors are a significant cause of morbidity and mortality in hospitalized patients. This creates an imperative to reduce medication errors to deliver safe and ethical care to patients.

METHOD

The databases CINAHL, PubMed, Science Direct and Synergy were searched from 1988 to 2007 using the keywords medication errors, medication management, medication reconciliation, medication knowledge and mathematical skills, and reporting medication errors. RESULTS Contributory factors to nursing medication errors are manifold, and include both individual and systems issues. These include medication reconciliation, the types of drug distribution system, the quality of prescriptions, and deviation from procedures including distractions during administration, excessive workloads, and nurse's knowledge of medications.

IMPLICATIONS FOR NURSING MANAGEMENT

It is imperative that managers implement strategies to reduce medication errors including the establishment of reporting mechanisms at international and national levels to include the evaluation and audit of practice at a local level. Systematic approaches to medication reconciliation can also reduce medication error significantly. Promoting consistency between health care professionals as to what constitutes medication error will contribute to increased accuracy and compliance in reporting of medication errors, thereby informing health care policies aimed at reducing the occurrence of medication errors. Acquisition and maintenance of mathematical competency for nurses in practice is an important issue in the prevention of medication error. The health care industry can benefit from learning from other high-risk industries such as aviation in the prevention and management of systems errors.

[Assessment of inappropriate prescriptions in psychiatric in-patients]

OBJECTIVE

To evaluate occurrence of the inappropriate prescriptions in a psychiatric department.

METHODOLOGY

In this prospective survey over a two-month period, the medical orders were analysed. Inappropriate prescription was defined as any discrepancy with summary of product characteristics (SPC) or our hospital treatment guidelines.

RESULTS

One hundred inpatients (72 women, mean age 37.5+/-15 years) were included. We reviewed 495 medication orders, which represent 1875 prescribed drugs. We found 2636 discrepancies with SPC or our hospital treatment guidelines. The proportion of discrepancies related to legal informations was 21.28% and them related to pharmacotherapy was 55.04%. The proportion of discrepancy per patient was estimated to 4.93%.

CONCLUSION

Our study shows a high proportion of inappropriate prescriptions, none of them having induced adverse-drug effects.

Impact of a Renal Drug Dosing Service on Dose Adjustment in Hospitalized Patients with Chronic Kidney Disease

Background:

Appropriate drug selection and dosing for patients with chronic kidney disease (CKD) is important to avoid unwanted drug effects and ensure optimal patient outcomes.

Objective:

To assess the rate of inappropriate dosing in patients with CKD in a nephrology unit and to evaluate the impact on dose adjustment, adverse drug events (ADEs), and drug cost of having a pharmacist accompany a team of physicians on their rounds.

Methods:

This was a comparative study with a preintervention and postintervention design. The preintervention phase served as the control; it was prospective and observational only and was conducted from the beginning of February to the end of May 2007. The second phase (intervention phase) was conducted from the beginning of March to the end of June 2008. Two random samples of 300 patients with an estimated creatinine clearance less than or equal to 50 mL/min were included. During the intervention phase, a clinical pharmacist made rounds with the nephrology unit team and gave dosing adjustment recommendations when needed. A collection of reliable and up-to-date drug information references that are commonly used globally were used during the intervention.

Results:

In the preintervention group, drug dosage adjustment or avoidance, based on renal function, was necessary in 607 of 2814 (21.6%) prescriptions. Of these, 322 (53.0%) did not comply with guidelines. In the intervention group, adjustment was necessary for 640 of 2981 (21.5%) prescriptions. The pharmacist made 388 recommendations related to dosing adjustment, 212 (54.6%) of which were accepted by physicians. Clinicians' noncompliance with dosing guidelines decreased to 176 (27.5%) (p < 0.001). In the preintervention group, 64 (21.3%) patients had a suspected ADE, with a total of 73 events. In the intervention group, this number was significantly lower with 49 events in 48 (16.0%) patients (p < 0.05). The intervention resulted in drug cost savings of $2250 US.

Conclusions:

A renal drug dosing service for patients hospitalized with CKD can increase the proportion of drug dosing that is adjusted to take into account renal function. This can save drug costs and may prevent ADEs.

Interns' knowledge of clinical pharmacology and therapeutics after undergraduate and on-going internship training in Nigeria: a pilot study

BACKGROUND

A sound knowledge of pathophysiology of a disease and clinical pharmacology and therapeutics (CPT) of a drug is required for safe and rational prescribing. The aim of this study was therefore to assess how adequately the undergraduate CPT teaching had prepared interns in Nigeria for safe and rational prescribing and retrospectively, to know how they wanted the undergraduate curriculum to be modified so as to improve appropriate prescribing. The effect of internship training on the prescribing ability of the interns was also sought.

METHODS

A total of 100 interns were randomly selected from the Lagos State University Teaching Hospital (LASUTH), Ikeja; Lagos University Teaching Hospital (LUTH), Idiaraba; General Hospital Lagos (GHL); the EKO Hospital, Ikeja; and Havana Specialist Hospital, Surulere. A structured questionnaire was the instrument of study. The questionnaire sought information about the demographics of the interns, their undergraduate CPT teaching, experience of adverse drug reactions (ADRs) and drug interactions since starting work, confidence in drug usage and, in retrospect; any perceived deficiencies in their undergraduate CPT teaching.

RESULTS

The response rate was 81%. All the respondents graduated from universities in Nigeria. The ability of the interns to prescribe rationally (66, 81.4%) and safely (47, 58%) was provided by undergraduate CPT teaching. Forty two (51.8%) respondents had problems with prescription writing. The interns would likely prescribe antibiotics (71, 87.6%), nonsteroidal analgesics (66, 81.4%), diuretics (55, 67.9%), sedatives (52, 62.9%), and insulin and oral hypoglycaemics (43, 53%) with confidence and unsupervised. The higher the numbers of clinical rotations done, the more confident were the respondents to prescribe unsupervised (chi2 = 19.98, P < 0.001). Similarly, respondents who had rotated through the four major clinical rotations and at least a special posting (chi2 = 11.57, P < 0.001) or four major clinical rotations only (chi2 = 11.25, P < 0.001) were significantly more confident to prescribe drugs unsupervised.

CONCLUSION

Undergraduate CPT teaching in Nigeria appears to be deficient. Principles of rational prescribing, drug dose calculation in children and pharmacovigilance should be the focus of undergraduate CPT teaching and should be taught both theoretically and practically. Medical students and interns should be periodically assessed on prescribing knowledge and skills during their training as a means of minimizing prescribing errors.

Medication reconciliation performed by pharmacy technicians at the time of preoperative screening

BACKGROUND

Medication errors occur regularly in surgical patients, especially due to transfer problems at the time of hospital admission. A method for decreasing the error rate is medication reconciliation by hospital pharmacists as part of a preoperative clinic. The role of pharmacy technicians in this process has not been studied.

OBJECTIVE

To study the use of pharmacy technicians in medication reconciliation by measuring the effect of early reconciliation in the preoperative clinic on medication and allergy discrepancies and on inadvertent continuation of antithrombotics. A secondary objective was to study the effect of community pharmacist follow-up on recommendations to discontinue antithrombotic therapy.

METHODS

During the preintervention measurement period, patients received usual care by anesthesiologists, who recorded the medication and documented allergies of the patient. The intervention consisted of the addition of a pharmacy technician to the preoperative screening clinic to perform the same tasks as anesthesiologists as related to medication reconciliation. If necessary, the patient was advised on stopping the antithrombotic. On the day that the patient was supposed to stop the antithrombotic, that person's community pharmacist contacted the patient to determine whether this had been done. The main outcome measures were the proportions of patients with one or more medication discrepancy, one or more allergy discrepancy, and one or more antithrombotic error.

RESULTS

In the preintervention period, 204 patients were evaluated; 93 were included in the postintervention analysis. The proportion of patients with one or more medication discrepancy (RR 0.29; 95% CI 0.12 to 0.71) was statistically significantly reduced in the postintervention group. The proportions of patients with one or more allergy discrepancy (RR 0.76; 95% CI 0.35 to 1.64) and one or more antithrombotic errors (RR 0.18; 95% CI 0.02 to 1.33) were reduced, but not significantly. Follow-up by the community pharmacist did not identify any patients who had not followed the preoperative clinic's advice on temporarily withholding their antithrombotics.

CONCLUSIONS

The results of this study show that pharmacy technicians can be successfully assigned to a preoperative clinic, resulting in a statistically significant decrease in medication discrepancies.