Geriatric pharmacotherapy : optimisation through integrated approach in the hospital setting

Since older patients are more vulnerable to adverse drug-related events, there is a need to ensure appropriate prescribing in these patients in order to prevent misuse, overuse and underuse of drugs. Different tools and strategies have been developed to reduce inappropriate prescribing; the available measures can be divided into medication assessment tools, and specific interventions to reduce inappropriate prescribing. Implicit criteria of inappropriate prescribing focus on appropriate dosing, search for drug-drug interactions, and increase adherence. Explicit criteria are consensus-based standards focusing on drugs and diseases and include lists of drugs to avoid in general or lists combining drugs with clinical data. These criteria take into consideration differences between patients, and stand for a medication review, by using a systematic approach. Different types of interventions exist in order to reduce inappropriate prescribing in older patients, such as: educational interventions, computerized decision support systems, pharmacist-based interventions, and geriatric assessment. The effects of these interventions have been studied, sometimes in a multifaceted approach combining different techniques, and all types seem to have positive effects on appropriateness of prescribing. Interdisciplinary teamwork within the integrative pharmaceutical care is important for improving of outcomes and safety of drug therapy. The pharmaceutical care process consists offour steps, which are cyclic for an individual patient. These steps are pharmaceutical anamnesis, medication review, design and follow-up of a pharmaceutical care plan. A standardized approach is necessary for the adequate detection and evaluation of drug-related problems. Furthermore, it is clear that drug therapy should be reviewed in-depth, by having full access to medical records, laboratory values and nursing notes. Although clinical pharmacists perform the pharmaceutical care process to manage the patient’s drug therapy in every day clinical practice, the physician takes the ultimate responsibility for the care of the patient in close collaboration with nurses

Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries

Background Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries. Methods A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included. Results Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5–16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists’ interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists’ recommendations. Conclusions Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.Peer reviewe

Information technology for detecting medication errors and adverse drug events

It is estimated that over three-quarters of a million people are injured or die in hospitals ‎each year from adverse drug events (ADE’s). The majority of medical errors result form ‎poorly designed healthcare systems rather than from negligence on the part of healthcare ‎providers. In general, healthcare systems rely on voluntary reporting, which seriously ‎underestimates the number of medication errors and ADE’s by as much as 90%. This ‎paper reviews the causes and impact of medication errors and ADE\u27s. It also reports ‎studies that have used information technology (IT) to detect and prevent medication ‎errors and ADE’s. Significant reduction of medication errors and ADE’s requires ‎systemic implementation of IT, improvements in the reporting of errors, and integration ‎of the components of the healthcare systems’ information systems. At the present time, ‎most healthcare systems should be able to use IT to detect and prevent ADE’s.

Costs of Adverse Drug Events in German Hospitals—A Microcosting Study

AbstractObjectiveIn Germany, only limited data are available to quantify the attributable resource utilization associated with adverse drug events (ADEs). The aim of this study was twofold: first, to calculate the direct treatment costs associated with ADEs leading to hospitalization and, second, to derive the excess costs and extra hospital days attributable to ADEs of inpatient treatments in selected German hospitals.MethodsThis was a retrospective and medical record–based study performed from the hospitals' perspective based on administrative accounting data from three hospitals (49,462 patients) in Germany. Total treatment costs (“analysis 1”) and excess costs (i.e., incremental resource utilization) between patients suffering from an ADE and those without ADEs were calculated by means of a propensity score–based matching algorithm (“analysis 2”).ResultsMean treatment costs (“analysis 1”) of ADEs leading to hospitalization (n = 564) were €1,978 ± 2,036 (range €191–18,147; median €1,446; €843–2,480 [Q1–Q3]). In analysis 2, the mean costs of inpatients suffering from an ADE (n = 1,891) as a concomitant disease or complication (€5,113 ± 10,059; range €179–246,288; median €2,701; €1,636–5,111 [Q1–Q3]) were significantly higher (€970; P < 0.0001) than those of non-ADE inpatients (€4,143 ± 6,968; range €154–148,479; median €2,387; €1,432–4,701 [Q1–Q3]). Mean inpatient length of stay of ADE patients (12.7 ± 17.2 days) and non-ADE patients (9.8 ± 11.6 days) differed by 2.9 days (P < 0.0001). A nationwide extrapolation resulted in annual total treatment costs of €1.058 billion.ConclusionsThis is one of the first administrative data–based analyses calculating the economic consequences of ADEs in Germany. Further efforts are necessary to improve pharmacotherapy and relieve health care payers of preventable treatment costs

Outcomes of integrating a clinical pharmacist in the pediatric cardiology ward

To date, very limited data are available on clinical pharmacist's services in pediatric cardiology. The aim of this review was to assess "drug-related problems" (DRPs) and patient outcomes during the involvement of the clinical pharmacist in the pediatric cardiology ward. Studies published between January 2000 and November 2021 were searched across Medline, PubMed, Google Scholar, Elsevier, and ScienceDirect for “DRPs” and “patient outcome” with “clinical pharmacist” and “pediatric cardiology”. Results revealed that the incorporation of clinical pharmacists in the multidisciplinary team can detect and resolve DRPs, reduce the overall burden of healthcare costs, and improve drug safety in pediatric cardiology patients. Most DRPs identified and interventions proposed by the clinical pharmacists were accepted by the physicians. Studies have also reported a positive impact on patient outcomes, including: shorter hospital stay, fewer disease events, optimal anticoagulation levels, lipid levels, and blood pressure. Moreover; pharmacist-led discharge medication counseling resulted in better medication adherence, fewer medication discrepancies, and a lower incidence of cardiovascular-associated hospital readmissions. In summary, there is growing evidence that integration and interventions of clinical pharmacists into cardiology ward has a positive influence on DRPs and patient outcomes

Computerized Alert System Use in Clinical Medicine

Conference PaperBiomedical Informatic

Off-label drug use, medication errors and adverse drug events : among Swedish pediatric inpatients

Background: In pediatrics, treatment with drugs is an important and fully integrated part of everyday medical practice. However, authorized drugs specified to be used in children are often lacking which leads to off-label use, i.e. outside of approved product monographs. Another challenge is medication errors (ME) which is an important cause of adverse drug events (ADE) in hospitalized children. The consequences and effects of these conditions are largely unknown. Studies within the field of pediatric, and especially neonatal, drug safety are lacking. Unsafe drug use may be an important and unrecognized contributor to suboptimal health in this vulnerable group with limited capacity for drug metabolism and excretion. Aim: The general aim of the thesis was to explore the magnitude of drug safety issues within Swedish pediatric inpatients. More specifically we aimed to investigate; I. National extent of off-label drug-use, II. Contents in national ME incident reports, III. Type of ADEs in a pediatric inpatient setting and IV. The views of pediatricians on a clinical decision support system (CDSS) to aid in prescribing drugs. Methods: In the four papers we used different study approaches. In paper I we performed a descriptive cross-sectional study based on collection of drug charts during two time-points. In paper II we used an analytic cross-sectional register-based study on Lex Maria incident reports and complaints from the Health and Social Care Inspectorate. In paper III we carried out a cohort study using a chart review with a pediatric trigger tool covering 600 admissions stratified in four different units, and in paper IV we used qualitative semi-structured interviews with pediatricians. Results: Paper I showed that half of all drug orders received by pediatric inpatients was outside approved product monographs, extemporaneously prepared or unlicensed. In paper II the ME reports indicated frequent occurrence of substances from three previously known high-alert lists with specified error characteristics among the different drug handling processes. In paper III we showed that skin/tissue/vascular harm, omission of analgesic drug therapy and hospital acquired infections are the most abundant ADEs as identified by an extended set of medical record triggers. In paper IV the CDSS-experiences of pediatricians emerged into six categories being: use, benefit, confidence, situations of disregards, misgivings/risks and development potential. Conclusions: Paper I found a similar situation in Sweden regarding off-label and unlicensed drug use as in many other countries. Paper II found that the existing high-alert lists are relevant for pediatric inpatients and suggested the use of process dependent high-alert lists. Paper III found that ADEs are common in pediatric inpatients and that the incidence varied with ADE-type, depending on ward and time after admission. In paper IV the experiences of pediatricians after the implementation of a CDSS gave insights on usability and the need for future developments

Computerized surveillance of opioid-related adverse drug events in perioperative care: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Given the complexity of surgical care, perioperative patients are at high risk of opioid-related adverse drug events. Existing methods of detection, such as trigger tools and manual chart review, are time-intensive which makes sustainability challenging. Using strategic rule design, computerized surveillance may be an efficient, pharmacist-driven model for event detection that leverages existing staff resources.</p> <p>Methods</p> <p>Computerized adverse drug event surveillance uses a logic-based rules engine to identify potential adverse drug events or evolving unsafe clinical conditions. We extended an inpatient rule (administration of naloxone) to detect opioid-related oversedation and respiratory depression to perioperative care at a large academic medical center. Our primary endpoint was the adverse drug event rate. For all patients with a naloxone alert, manual chart review was performed by a perioperative clinical pharmacist to assess patient harm. In patients with confirmed oversedation, other patient safety event databases were queried to determine if they could detect duplicate, prior, or subsequent opioid-related events.</p> <p>Results</p> <p>We identified 419 cases of perioperative naloxone administration. Of these, 101 were given postoperatively and 69 were confirmed as adverse drug events after chart review yielding a rate of 1.89 adverse drug events/1000 surgical encounters across both the inpatient and ambulatory settings. Our ability to detect inpatient opioid adverse drug events increased 22.7% by expanding surveillance into perioperative care. Analysis of historical surveillance data as well as a voluntary reporting database revealed that 11 of our perioperative patients had prior or subsequent harmful oversedation. Nine of these cases received intraoperative naloxone, and 2 had received naloxone in the post-anesthesia care unit. Pharmacist effort was approximately 3 hours per week to evaluate naloxone alerts and confirm adverse drug events.</p> <p>Conclusion</p> <p>A small investment of resources into a pharmacist-driven surveillance model gave great gains in organizational adverse drug event detection. The patients who experienced multiple events are particularly relevant to future studies seeking risk factors for opioid induced respiratory depression. Computerized surveillance is an efficient, impactful, and sustainable model for ongoing capture and analysis of these rare, but potentially serious events.</p

Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial

INTRODUCTION: Medication errors in the intensive care unit (ICU) are frequent and lead to attributable patient morbidity and mortality, increased length of ICU stay and substantial extra costs. We investigated if the introduction of a computerized ICU system (Centricity Critical Care Clinisoft, GE Healthcare) reduced the incidence and severity of medication prescription errors (MPEs). METHODS: A prospective trial was conducted in a paper-based unit (PB-U) versus a computerized unit (C-U) in a 22-bed ICU of a tertiary university hospital. Every medication order and medication prescription error was validated by a clinical pharmacist. The registration of different classes of MPE was done according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. An independent panel evaluated the severity of MPEs. We identified three groups: minor MPEs (no potential to cause harm); intercepted MPEs (potential to cause harm but intercepted on time); and serious MPEs (non-intercepted potential adverse drug events (ADE) or ADEs, being MPEs with potential to cause, or actually causing, patient harm). RESULTS: The C-U and the PB-U each contained 80 patient-days, and a total of 2,510 medication prescriptions were evaluated. The clinical pharmacist identified 375 MPEs. The incidence of MPEs was significantly lower in the C-U compared with the PB-U (44/1286 (3.4%) versus 331/1224 (27.0%); P < 0.001). There were significantly less minor MPEs in the C-U than in the PB-U (9 versus 225; P < 0.001). Intercepted MPEs were also lower in the C-U (12 versus 46; P < 0.001), as well as the non-intercepted potential ADEs (21 versus 48; P < 0.001). There was also a reduction of ADEs (2 in the C-U versus 12 in the PB-U; P < 0.01). No fatal errors occurred. The most frequent drug classes involved were cardiovascular medication and antibiotics in both groups. Patients with renal failure experienced less dosing errors in the C-U versus the PB-U (12 versus 35 serious MPEs; P < 0.001). CONCLUSION: The ICU computerization, including the medication order entry, resulted in a significant decrease in the occurrence and severity of medication errors in the ICU