Types and severity of medication errors in Iran; a review of the current literature

Medication error (ME) is the most common single preventable cause of adverse drug events which negatively affects patient safety. ME prevalence is a valuable safety indicator in healthcare system. Inadequate studies on ME, shortage of high-quality studies and wide variations in estimations from developing countries including Iran, decreases the reliability of ME evaluations. In order to clarify the status of MEs, we aimed to review current available literature on this subject from Iran. We searched Scopus, Web of Science, PubMed, CINAHL, EBSCOHOST and also Persian databases (IranMedex, and SID) up to October 2012 to find studies on adults and children about prescription, transcription, dispensing, and administration errors. Two authors independently selected and one of them reviewed and extracted data for types, definitions and severity of MEs. The results were classified based on different stages of drug delivery process. Eighteen articles (11 Persian and 7 English) were included in our review. All study designs were cross-sectional and conducted in hospital settings. Nursing staff and students were the most frequent populations under observation (12 studies; 66.7%). Most of studies did not report the overall frequency of MEs aside from ME types. Most of studies (15; 83.3%) reported prevalence of administration errors between 14.3%-70.0%. Prescribing error prevalence ranged from 29.8%-47.8%. The prevalence of dispensing and transcribing errors were from 11.3%-33.6% and 10.0%-51.8% respectively. We did not find any follow up or repeated studies. Only three studies reported findings on severity of MEs. The most reported types of and the highest percentages for any type of ME in Iran were administration errors. Studying ME in Iran is a new area considering the duration and number of publications. Wide ranges of estimations for MEs in different stages may be because of the poor quality of studies with diversity in definitions, methods, and populations. For gaining better insights into ME in Iran, we suggest studying sources, underreporting of, and preventive measures for MEs

Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundDisorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.MethodsWe estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.FindingsGlobally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378–521), affecting 3·40 billion (3·20–3·62) individuals (43·1%, 40·5–45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7–26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6–38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5–32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7–2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.InterpretationAs the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

A bibliometric study of publication patterns in rational use of medicines in Iran

Background - Inappropriate use of drugs is commonly observed in health care system throughout the world especially in developing countries. The consequences of irrational use of drugs are enormous for patients and communities. Proper interventions would have important financial and public health benefits. Several studies have been performed about rational use of drugs in Iran. Objective - The objective of this study was to assess scientific output on rational use of drugs in Iran using a bibliometric analysis of publications. Methods - A systematic search was conducted for finding all papers (English and Persian) using Pubmed, Web of Science, Google Scholar, CINAHL, Proquest, International Pharmaceutical Abstract and Persian databases including SID, Iran Medex and MagIran. Retrieved articles were categorized by research topics and year of publication. Impact Factor of the journals, citation analysis of first authors, most cited topics and average citations per item were analyzed. Results - A total of 668 articles were retrieved from all search engines after excluding irrelevant, 466 articles were included in the review. Number of publications increased dramatically after 2001(more than 10 times). Evaluation of prescribing pattern (15%), self-medication (11.3%) and adverse drug reaction (9.1%) were among the most studied topics. From the total of 165 journals, 60 of them had Impact factors and 125 articles were published in these journals. Antimicrobial resistance and adverse drug reaction were the most cited topic. Conclusion - Publication of articles on rational use of drugs research in Iran has undergone an important increase during last decade. Further analysis of research outputs is necessary to achieve rational use of medicines goal

Letter to the Editor: Assessment and reporting considerations for medication knowledge and adherence studies

To the Editor, We read the article by Okuyan et al. with great interest. Assessing medication knowledge in different contexts and its relationship with medication adherence will help us obtain valuable insights for better research actions in our country. But there are a few points in need for clarification by the authors; we try to mention them in no order of preference..

Imatinib Efficacy, Safety and Resistance in Iranian Patients with Chronic Myeloid Leukemia: A Review of Literature

Background: Imatinib is the gold standard in the treatment of chronic myeloid leukemia (CML) patients. Resistance to imatinib is interfering with patients’ responses and their survival. Materials and Methods: We designed a systematic search to find relevant studies by applying appropriate keywords in PubMed, Web of Science, Scopus, Ovid, ProQuest, Science Direct, and Google scholar for English studies. We also investigated the aforementioned terms’ correspondence in Magiran, Scientific information database (SID), and Google scholar for Persian articles. Results: 25 studies were selected for final analysis. Reported hematologic responses from adult studies ranged 86-99% and major molecular responses were estimated in 38.84% of our patients within 12 months of treatment. The most frequently reported adverse drug reactions (ADRs) were edema (n=5 studies, 100%) and fatigue and nausea (n=4 studies, 80%); ADR per capita ratio was 1.46. Only one study informed ADRs in pediatrics demonstrating 93% of patients experienced ADRs after receiving imatinib. Most of the Studies (n=4, 67% from 7 studies) considered BCR/ABL point mutation as the main reason for imatinib resistance. Drug-binding sites and P-loop regions were two common sites for BCR/ABL point mutation. Conclusion: Imatinib as the first-line treatment for CML has been associated with proper and durable responses in Iranian adults and children CML patients. Moreover, Imatinib life-threatening adverse effects were reported as uncommon. Various responses to modified regimens have been reported in resistant patients; therefore, individualized treatment based on mutation type could be recommended.

Prescribing pattern and prescription-writing quality of antineoplastic agents in the capital city of a middle-income developing country

Objective: Cancer is a global health concern with growing incidence worldwide. Chemotherapy is the main treatment modality in many malignancies. This study aimed at evaluation of antineoplastic prescribing pattern and prescription-writing quality in the capital city of Iran. Methods: All dispensed chemotherapy prescriptions by four main authorized pharmacies in Tehran during 1 month were targeted. Prescriptions with no antineoplastic medications or written by specialties other than oncology-related fields were excluded from the study. From the total 10,944 eligible prescriptions, 2736 (25%) prescriptions were selected randomly for data extraction. Findings: Total 5784 antineoplastic medications were written by 239 physicians; most of them were adult hematologist–oncologist (69.0%) and male (86.6%). Each prescription contained an average of 1.8 (±0.9) antineoplastic medications. The most widely prescribed antineoplastic agents were cyclophosphamide (16.2%), fluorouracil (15.2%), doxorubicin (12.8%), and oxaliplatin (11.0%). The quality of prescription writing was poor; diagnosis, drug dosing, treatment schedule, and instructions were mostly absent. Sixty percent of drugs were written in brand names. Conclusion: The prescribing writing quality was poor and patients were at great risk of medication errors. Prompt action including policies and educational strategies should be taken to assure effective and safe patient treatment with antineoplastic medications

Diversity of Physicians’ Handwriting and Name Stamp in Chemotherapy Prescriptions: Potential Target for Fraud

Backgrounds: Verification and authentication of the paper-based handwritten prescriptions is of great importance for antineoplastic medications that are good targets for forgery and fraud. Pharmacists usually investigate handwriting, signature and name stamp of prescribers to verify prescriptions in Iran. Anecdotal reports of variations in handwriting and name stamp of physicians who wrote antineoplastic prescriptions raised concerns in this regard. The aim of the study was to investigate the reported diversity and evaluate the quality of writing physician identity and required items in antineoplastic prescriptions. Methods: All insured hand-written prescriptions contained at least one antineoplastic medication and were dispensed by four main authorized community pharmacies dispensing antineoplastic medications in Tehran during one month were included. Prescriptions that were written by specialties other than oncology-related fields were excluded. Prescriptions of each physician were evaluated considering handwriting and name stamp by experienced pharmacy staff and the frequency of detected handwriting and name stamp types was recorded. Results: Of the 11022 included prescriptions, 10944 were eligible and written by 241 physicians. Median (third quartile) number of physicians’ prescriptions was 17 (51). Maximum number of observed handwriting and name stamp types were eight and six respectively. High prescribers tended to have several handwriting and name stamp types. Conclusion: The observed diversity and variation in handwriting and name stamp of the physicians in antineoplastic prescriptions may facilitate the entrance of forged prescription and makes fraud detection difficult. Administrative and regulatory interventions in addition to notification of health care professionals about the observed potential might be necessary