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

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..

Evaluation of Plasma Concentration and Hepatotoxicity of Voriconazole in Pediatric Patients following Hematopoietic Stem Cell Transplantation

Background: Invasive fungal infection is one of the most important causes of morbidity and mortality in pediatric patients undergoing Hematopoietic stem cell transplantation (HSCT). Voriconazole as a broad-spectrum anti-fungal agent which has been used widely for prevention and treatment of invasive fungal infections in immunocompromised patients. Alteration in voriconazole plasma concentrations may be resulted in lack of efficacy and some adverse effects. Methods: This observational cohort study assessed the therapeutic plasma concentration of voriconazole and its relationship with hepatotoxic adverse effect in pediatric patients undergoing HSCT. Plasma concentration of voriconazole was measured by High-performance liquid chromatography (HPLC) assay with technique extracted from Khoschsorur et al. Results: Among a total of 14 pediatric patients,5 patients received voriconazole orally and 9 patients received voriconazole intravenously. The median plasma concentration of voriconazole was 1.8 mcg/ml (range, 0.75-5.54 mcg/ml). There was no correlation between voriconazole dose and plasma concentration of voriconazole(p=0.166). Trough concentration of ≥ 4 mcg/ml was observed in 2 of 3 patients who experienced severe hepatic dysfunction. The plasma concentration of voriconazole did not significantly differ in patients with or without hepatotoxicity(p=0.406). Conclusions: Our study showed that trough levels of voriconazole were sub-therapeutic in 21.4% of children. Furthermore, hepatic enzyme abnormalities were observed in half of pediatric patients following voriconazole initiation during hospitalization. We didn’t find any correlation between plasma concentration of voriconazole and the incidence of hepatotoxicity. We also didn’t observe any correlation between voriconazole dose and plasma concentration of voriconazole, but the correlation was linear after exclusion of outlier data

Comments on "Agreement between patients' self-report and physicians' prescriptions on nonsteroidal anti-inflammatory drugs and other drugs used in musculoskeletal disorders"

We read the article by Grimaldi-Bensouda et al.[1] carefully and with interest, and we would like to make the following comments. [1]: Grimaldi-Bensouda L, Rossignol M, Aubrun E, et al. Agreement between patients' self-report and physicians' prescriptions on nonsteroidal anti-inflammatory drugs and other drugs used in musculoskeletal disorders: the international Pharmacoepidemiologic General Research eXtension database. Pharmacoepidemiol Drug Saf 2012; 21: 753–759

Predictive performance of Vancomycin population pharmacokinetic models in Iranian patients underwent hematopoietic stem cell transplantation

Objective: Many hematopoietic stem cell transplantation (HSCT) patients receive vancomycin empirically during febrile neutropenia. There are several models for estimation of vancomycin pharmacokinetic parameters and calculation of initial dosing regimen accordingly. However, the performance of these methods in HSCT patients remained to be evaluated. The aim of the study was to determine which of the vancomycin population pharmacokinetic methods best fit Iranian HSCT patients. Methods: In order to evaluate predicted performance of seven vancomycin population pharmacokinetic models, the pharmacokinetic parameters of patients were estimated using each model’s equations. Then the predicted steady-state trough vancomycin concentration was calculated based on each model’s parameters and using a formula based on Sawchuk–Zaske method. The predicted steady-state trough vancomycin concentration and the real measured concentrations were compared to see which method was the most precise and least biased using mean squared error (MSE) and mean prediction error (ME) respectively. Findings: Forty-six patients (65% men) were included in the study. Calculated metrics showed a range of 38% under-prediction bias with Rodvold to 34% over-prediction bias with Matzke and Burton models. Birt and revised Burton methods showed no significant bias (ME [95% confidence interval (CI)]: –0.067 [–0.235–0.101] and 0.066 [–0.105–0.238]). Birt and revised Burton were not different significantly considering MSE (95% CI) of 0.385 (0.227–0.544) and 0.401 (0.255–0.546), respectively. Comparisons of precision with naive predictors revealed a delta MSE (95% CI) of –0.128 (–1.379–1.890) for Birt and 0.026 (–0.596–0.940) for revised Burton models. Conclusion: Although the Birt and Burton revised methods performed well, none of the studied models showed acceptable performance to be implemented as a routine method for initial dose calculation in HSCT patients. A vancomycin pharmacokinetic model specific for this high-risk subpopulation of Iranian patients should be designed and validated

Vancomycin Utilization Review in Patients Undergoing Bone MarrowTransplantation

Background:  Infections  in  neutropenic  patients  are  considered  as  major  causes  of  mortality and the emergence of drug resistance. Gram positive bacterial infections are crucially important to be covered if indicated. Vancomycin is active against most Gram positive bacteria including Methicillin Resistant Staphylococcus Aureus (MRSA). In this study, we evaluated the appropriate utilization of this agent in bone marrow transplantation (BMT) patients. Methods: In a cross sectional study, all patients who received vancomycin in a seven months period at bone marrow transplantation research center in Shariati teaching hospital in Tehran, Iran, were entered to the study. Clinical and preclinical parameters such as serum creatinine, microbial culture, antibacterial sensitivity, WBC count and fever were collected and recorded for analysis. We also measured vancomycin trough level after administration of three doses. Results: Fifty one patients were entered in the study and reviewed in two adult BMT wards. The age range was 18 to 65 years. Most patients received allogenic versus autologous transplantation (56.9%, 43.1%). About 80% of the vancomycin used for the patients with febrile neutropenia was compatible with National Comprehensive Cancer Network (NCCN) guideline. 21.6% of patients received appropriate doses. Vancomycin trough serum concentration range was 15.0±11.9 μg/mL. Conclusion: Vancomycin is an antibiotic used to treat resistant gram-positive infections and must be prescribed by a specialist. Vancomycin wrong dosing or initiation prescribing with dose 1 gr/q12h increases the resistance and toxicity to drug, and cause an inappropriate response to the drug

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.

The risk factors for cytomegalovirus reactivation following stem cell transplantation

Objective: Opportunistic infections like cytomegalovirus (CMV) are among the primary causes of morbidity and mortality in patients undergoing hematipoetic stem cell transplantation (HSCT). This infection is frequently seen in early postengraftment period. So we determined to find the risk factors associated with CMV reactivation. Methods: We retrospectively evaluated the medical records of 126 consecutive patients who underwent allogenic-HSCT from peripheral blood stem cells from August 2011 to February 2013 in Shariati Hospital. We included HSCT patients with 15 years of age or older, who survived at least 100 days after transplantation. CMV reactivation was detected based on the weekly PP65 assessment. Patients with 10 or more positive cells per 50,000 cells were defined as having high-level antigenemia. Findings: From 126 patients which included in this study, 76 were male (60%). CMV antigenemia was documented in 43 patients (34%). The median time to CMV infection was 40 days (range: 3–77) after transplantation. The incidence of high-level antigenemia during the first 100 days following HSCT was 11%. Conclusion: We found that the significant risk factor for CMV antigenemia in multivariate analysis was prior graft-versus-host disease (GVHD) experience and higher donor age. For high-level antigenemia, GVHD or duration of its treatment was significant determinant

Evaluation of Antioxidants in Bone Mineral Density of Iranian

AbstractObjective(s) Bone is a dynamic tissue that is continuously renewed throughout life by the process of bone remodeling. Antioxidant system might be involved in the pathogenesis of bone loss, so the aim of this study was to evaluate the total antioxidant capacity (TAC), vitamin C and vitamin E levels of plasma besides measuring enzymatic antioxidants, superoxide dismutase (SOD), catalase (CAT) and glutathione reductase (GR) enzymes activity in Iranian osteoporotic women comparing to the control group.Materials and MethodsBone mineral density (BMD) of the femoral neck and lumbar spine was measured by dual x-ray absorptiometry. The participants were divided into groups: a) total participants (-3.9 ≤ T–score ≤ 3.6) including 192 women, b) the control group (T-score ≥ -1) including 76 women, c) the total patients (T-score < -1) including 76 women. Then, plasma TAC, vitamin C levels, SOD and GR activities, erythrocyte CAT were measured using spectrophotometrical methods separately, and for vitamin E by HPLC analysis.ResultsComparing the control group and osteoporotic women showed that: a) plasma levels for vitamin C and erythrocyte CAT were markedly lower in the patients than in the controls, but plasma activity of TAC, SOD and GR were significantly higher, respectively. b) the differences were higher between control and patients with severe disease (T-score <-1.7) comparing to patients in the group with milder disease (-1.7 ≤ T-score <-1). c) Femoral neck BMD adjusted with age and BMI showed a positive and significant correlation with plasma levels of vitamin C in all subjects, but this relation was reverse or negative for TAC, SOD and GR.ConclusionIt seems that a physiologic increase in the amount of some antioxidants occurs in osteoporosis; even though this amount may not be sufficient for the human body requirements