Identifying high-risk medication: a systematic literature review

Development, content validation and standardization of an adult patient prioritization tool for hospital clinical pharmacy services

BACKGROUND

Patient prioritization is a effective strategy to identify high risk patients for targeted Clinical Pharmacy Service (CPS) in hospital pharmacy. However, there is a paucity of patient prioritization tool to use in clinical practice.

OBJECTIVES

Describe the development, content validation and standardization of an adult patient prioritization tool for hospital CPS named, PrioFarClinH.

METHODS

The tool was developed using a stepwise design multi: Scoping Review to identify prioritization criteria/sub-criteria; Delphi technique to obtain consensus under the identified criteria/sub-criteria; Survey with pharmacists evaluating applicability of the criteria/sub-criteria obtained from Delphi; Definition of criteria/sub-criteria to be included in PrioFarClinH attribution of scores. Content validation was performed by a panel of experts evaluating relevance, feasibility, clarity and adequacy of the score. Content Validity Index (CVI) was calculated. Standardization occurred through a retrospective observational study carried out at 24 and 72 h and median of the patient's hospital stay. An intragroup norm was performed, determining percentile ranks of the instrument's total scores. Patients with a P90 score were classified with a high level of prioritization for CPS.

RESULTS

PrioFarClinH is divided into three sections, with prioritization criteria for health issues; therapeutic classes; laboratory parameters. It comprises 51 criteria with specific scores with simple total calculation. None of the criteria presented CVI <0.78, maintaining the items from the initial version of PrioFarClinH. The scores were adjusted per suggestions from the panel of judges. Data were collected from 393 patients. The P90 percentile in the three hospitalization stages (24 h, 72 h, and median) was found, respectively, in the following scores: 18.0, 20.0, and 22.6.

CONCLUSIONS

PrioFarClinH is a comprehensive tool to target and to prioritize adults patients most likely to benefit from CPS. Evidence for adequate content validity was provided. However, further validation of this tool is necessary to establish tool performance.

A quality improvement study of the implementation and initial results of a pragmatic clinical decision support system in the community pharmacy setting

BACKGROUND

A six year collaboration between academics, community pharmacists and informaticians, led to the development of nine guidelines for a clinical decision support system, enhancing community pharmacists' ability to address drug-related problems and improve care.

AIM

The objective of this study was to assess the effectiveness of clinical decision support system rules in enhancing medication management within the community pharmacy setting. This was achieved through retrospective monitoring of real-world usage and measuring the pharmacotherapeutic impact of the rules.

METHOD

In 2019, a retrospective observational evaluation appraised the acceptance rate of the clinical decision support system components in 490 Belgian pharmacies. Among these, 51 pharmacies underwent a longitudinal analysis involving (i) co-prescription of methotrexate and folic acid, (ii) gastroprotection with non-steroidal anti-inflammatory drugs, and (iii) drug combinations causing QT prolongation. The study period spanned one year pre-launch, one year post-launch, and two years post-launch.

RESULTS

Of the targeted pharmacies, 80% used 7 of the 9 rules. After four years, methotrexate-folic acid co-prescription increased 4%, reaching 79.8%. Gastroprotection improved by 3% among older patients and 7.47% in younger individuals (< 70 year) with multiple risk factors. The QT prolongation rules faced implementation difficulties.

CONCLUSION

Pharmacists' acceptance of the developed rules was high and coincided with a decline in drug-related problems, holding potential public health impact. This real-world data can inform the future implementation of such systems, as it demonstrated the need for more detailed data-gathering and more intensive training of pharmacists in the handling of more complex problems such as QT prolongation.

Clinical frailty and polypharmacy in older emergency critical care patients: a single-centre retrospective case series

BACKGROUND AND OBJECTIVES

Admission of complex and frail patients to critical care units is common. Little is known about the relationship between clinical frailty and polypharmacy measures in critical care patients or how a critical care admission affects polypharmacy.We sought to: (1) Describe the extent and relationship between clinical frailty and polypharmacy in a cohort of older emergency general critical care patients, and to (2) Describe the effect of the critical care pathway on patient polypharmacy measures.

METHODS

A retrospective evaluation was undertaken in all patients ≥70 years of age, admitted as emergencies to the general critical care units of a single large UK academic hospital, over a 2-year period (March 2016 to February 2018) (n=762). Patient Clinical Frailty Scale (CFS) and polypharmacy measures on admission were described and association was tested. Medication changes and documentation on care transitions were analysed in a randomly selected convenience cohort of critical care survivors (n=77).

RESULTS

On admission patients had a median of 9 (5;12) medicines, of which a median of 3 (2;5) were high-risk medicines. Polypharmacy (5-9 medicines) and hyperpolypharmacy (≥10 medicines) occurred in 80.7% (615/762) and 43.2% (329/762) of patients, respectively. A degree of frailty was the standard (median CFS 4 (3;5)) with 45.7% (348/762) CFS 4-5 and 20% (153/762) CFS ≥6. The patient median CFS increased by 1 with polypharmacy classification increments (p<0.001). In the survivor cohort, a median of 6 (4;8) and 5 (4;8) medication changes occurred on critical care and hospital discharges, respectively. A minority of patients had detailed medication continuity plans on care transitions.

CONCLUSIONS

Polypharmacy and frailty were very common in this UK single-centre cohort of older emergency critical care patients. There was a significant association between the degree of polypharmacy and frailty score. The critical care pathway created extensive changes in patient medication therapy. Medication changes on care transitions often lacked detailed documentation.

Prioritizing patients for medication review by emergency department pharmacists: a multi-method study

BACKGROUND

Little is known about how pharmacists think and act in the situation when they need to prioritize patients without prioritization tools.

AIM

To understand how Emergency Department (ED) pharmacists prioritize patients for medication review.

METHOD

A multi-method study with pharmacists working in one ED in Denmark. At the start of the study, non-clinical prioritization rules had been implemented at the ED to ensure that medication histories were available quickly. Qualitative participant observations of all seven pharmacists who work at the ED were carried out. Semi-structured interviews with six of the pharmacists were held near in time to the observations. Observations for each pharmacists' patients were analysed inductively looking for patterns and themes. The interviews were audiotaped, transcribed verbatim and analysed inductively.

RESULTS

The interviews shed light on the kinds of considerations pharmacists processed when prioritizing patients and how they used the ground rules (as set out in the PDSA process). The observations supplemented these data by showing some notable differences between pharmacists' prioritization procedures that linked to their clinical experience. The interviews highlighted the importance of collaboration with physicians and how pharmacists could be better integrated in the ward team.

CONCLUSION

Although the ward-established rules increased efficiency, they were handled differently by the pharmacists according to experience, and were not deemed helpful in detecting the clinically meaningful ED patients. A prioritization tool and sitting near to the physicians at the ward would enable pharmacists to become further integrated into patient care and improve prioritization of patients for medication reviews.

Evaluation of a multifaceted medication review in older patients in the outpatient setting: a before-and-after study

BACKGROUND

The prevalence of medication-related emergency department visits and acute hospital admissions in older patients is rising due to the ageing of the population and increasing prevalence of multimorbidity and associated polypharmacy.

AIM

To explore whether a combined medication review performed in the outpatient setting reduces the number of medication-related emergency department visits and hospital (re)admissions.

METHOD

All consecutive patients visiting the geriatric outpatient clinic underwent a multifaceted medication review (i.e. evaluation by at least a geriatrician, and/or pharmacist and use of clinical decision support system). Subsequently, we analysed the number of, and reason for, emergency department visits, acute hospital admissions and readmissions in the year prior to and the year following the index-date (date of first presentation and medication review).

RESULTS

A multifaceted medication review reduced the number of potentially medication-related emergency department visits (38.9% vs. 19.6%, p < 0.01), although the total number of ED visits or acute hospital admissions per patient in the year before and after medication review did not differ.

CONCLUSION

A multifaceted medication review performed in the outpatient clinic reduced the number of potentially medication-related emergency department visits and could therefore reduce negative health outcomes and healthcare costs.

Effectiveness and safety of selected traditional Chinese medicine injections in patients with combined diabetes mellitus and coronary heart disease: A systematic review and network meta-analysis of randomized clinical trials

Background: In view of the high morbidity and mortality of Diabetes mellitus-Coronary heart disease (DM-CHD) in diabetics, the combination therapy of traditional Chinese medicine injections (TCMIs) and conventional therapy (CT) is receiving extensive attention. Therefore, the effectiveness and security of conventional therapy with traditional Chinese medicine injections in the therapy of diabetes mellitus-coronary heart disease were compared by systematical review and network meta-analysis. Methods: According to the preset inclusion criteria and exclusion criteria, we searched seven electronic literature databases from their inception to JAN 5,2022, to obtain the relevant RCT literature on the therapy of diabetes mellitus-coronary heart disease with traditional Chinese medicine injections. Two researchers independently reviewed the papers, two other researchers worked in extracting data and quality assessment of the included literature. The primary outcomes were total effective rate. The secondary outcomes included electrocardiogram (EGG)effective rate, the effective rate of angina pectoris, fasting blood glucose (FBG), 2-h postprandial blood glucose (PBG), hemoglobinA1c (HbA1c), total cholesterol (TC) and triglycerides (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), frequency of angina pectoris, and duration of angina pectoris. We adopted stata16.0 software for the systematic review and network meta-analysis. Results: A total of 53 trials involved 4,619 patients and one of the following 16 traditional Chinese medicine injections: Danhong, Danshen, Gualoupi, Gegen, Chuanxiongqin, Danshenchuanxiongqin, Shenmai, Shenqi, Xixin, Xuesaitong, Shuxuetong, Guanxinning, Kudiezi, Ciwujia, Xingding, Shuxuening. The meta-analysis revealed that Chuanxiongqin injection was superior to all other therapies in improving the total effective rate, [vs. conventional therapy odds ratio (OR): 14.52, 95% confidence interval (CI): 4.13-51.02], vs. Xuesaitong injection (odds ratio: 7.61, confidence interval: 1.25-46.40), and vs. Danshenchuanxiongqin injection (odds ratio: 3.98, confidence interval: 1.03-15.28)]. Xixin injection + conventional therapy was superior to conventional therapy only for electrocardiogram effective rate (odds ratio: 5.44, confidence interval: 1.55-19.18). Shenmai injection + conventional therapy was superior to conventional therapy in effective rate of angina (odds ratio: 11.05, confidence interval: 2.76-44.28). There was not different significantly in the comparisons of frequency of angina pectoris and duration of angina pectoris, we considered that this may be due to the lack of sufficient data. As most of the included RCTs did not monitor Adverse Events, the safety of those traditional Chinese medicine injections remains to be further explored. Conclusion: Basing on our study, traditional Chinese medicine injections combined with conventional therapy takes important role in the treatment of diabetes mellitus-coronary heart disease, and its curative effect is better than conventional therapy. Nevertheless, properly designed RCTs are required to validate our conclusions in the future. Systematic Review Registration: [https://inplasy.com/inplasy-2021-12-0125/], identifier [INPLASY2021120125].

Drug-Related Problems in Bariatric Surgery: a Retrospective Study

BACKGROUND

With the rapid increase of bariatric surgery worldwide, drug-related problems (DRPs) in this area seem to be rising. This study aimed to investigate the incidence and characteristics of DRPs in patients undergoing bariatric surgery.

METHODS

Medication records for patients who underwent bariatric surgery were analysed retrospectively between January 2019 and December 2020 in our center. We classified and analysed DRPs using the Pharmaceutical Care Network Europe classification (PCNE version 9.0). Rating severity of these DRPs was based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) classification. Continuous variables were analysed by Student's t-test, and categorical variables were compared using the chi-square test. One-way ANOVA was used to compare the numbers of DRPs.

RESULTS

Totally 347 patients were reviewed, and 760 DRPs were identified with an average of 2.19 ± 1.36 DRPs for each patient. The most common DRPs were problems related to perioperative antibiotics accounting for 29.47%, 25.62% and 14.34% for hepatoprotection and proton-pump inhibitors (PPI), respectively. The leading causes of DRPs were inappropriate medications for antibiotics, hepatoprotection, ancillary drugs and PPI. 89.34% of the DRPs were rated at severity categories B-D (which means potential adverse reactions that may occur), whereas 10.66% were rated as categories E-H. There were relations between DRPs and older (32.22 ± 9.29 vs. 29.11 ± 6.53 years), fewer concomitant surgeries (1.89 ± 1.25 vs. 2.99 ± 1.31), longer postoperative fasting time (PFT) (1.18 ± 0.55 vs. 1.06 ± 0.24 days) and more comorbidities (6.71 ± 2.63 vs. 5.23 ± 1.46) (P < 0.05).

CONCLUSIONS

The incidence of DRPs in the perioperative period of bariatric surgery is high. Patients with fewer concomitant surgeries and longer PFT are prone to DRPs. It is necessary for clinical pharmacists to participate in medication monitoring and reviewing to facilitate enhanced recovery after bariatric surgery.

Analysis of medication and prescription background risk factors contributing to oral medication administration errors by nurses: A case-control study

Medication errors, including overdose and underdose, have a significant impact on patients and the medical economy. We need to prevent or avoid recurring medication errors. Therefore, we conducted a survey to identify medication and prescription background risk factors contributing to the administration of medication by nurses. This study surveyed cases of medication administration errors. This study was conducted at Higashinagoya National Hospital from April 1, 2018, to October 31, 2019. Patients' backgrounds and medication and prescription background risk factors were investigated. Three control cases were randomly selected for each medication error case. We defined the group of medication error cases as the medication error group and the group of control cases as the no-medication-error group. A logistic regression analysis was performed for factors related to medication errors. A total of 202 patients were included in the medication error group. The median age and number of medications were 78 years and 7, respectively. A total of 606 cases were included in the no-medication-error group. The median age and number of medications were 77 years and 6, respectively. The factors that exhibited a relationship with the medication error group were the number of administrations per day, dosing frequency on indicated days, prescription and start dates were the same, medications from multiple prescriptions, and continuous use of a medication received prior to admission. This study identified existing medication and prescription background risk factors. Overlapping risk factors from these groups might contribute to medication administration errors. Therefore, reviewing these factors is necessary to avoid recurring medication administration errors.

A prediction and interpretation machine learning framework of mortality risk among severe infection patients with pseudomonas aeruginosa

Pseudomonas aeruginosa is a ubiquitous opportunistic bacterial pathogen, which is a leading cause of nosocomial pneumonia. Early identification of the risk factors is urgently needed for severe infection patients with P. aeruginosa. However, no detailed relevant investigation based on machine learning has been reported, and little research has focused on exploring relationships between key risk clinical variables and clinical outcome of patients. In this study, we collected 571 severe infections with P. aeruginosa patients admitted to the Xijing Hospital of the Fourth Military Medical University from January 2010 to July 2021. Basic clinical information, clinical signs and symptoms, laboratory indicators, bacterial culture, and drug related were recorded. Machine learning algorithm of XGBoost was applied to build a model for predicting mortality risk of P. aeruginosa infection in severe patients. The performance of XGBoost model (AUROC = 0.94 ± 0.01, AUPRC = 0.94 ± 0.03) was greater than the performance of support vector machine (AUROC = 0.90 ± 0.03, AUPRC = 0.91 ± 0.02) and random forest (AUROC = 0.93 ± 0.03, AUPRC = 0.89 ± 0.04). This study also aimed to interpret the model and to explore the impact of clinical variables. The interpretation analysis highlighted the effects of age, high-alert drugs, and the number of drug varieties. Further stratification clarified the necessity of different treatment for severe infection for different populations.

Is a High Medication Risk Score Associated With Increased Risk of 30-Day Readmission? A Population-Based Cohort Study From CROSS-TRACKS

OBJECTIVES

The primary aim of this study was to evaluate whether a high Medication Risk Score (MERIS) upon admission to an emergency department is associated with increased risk of 30-day readmission in patients discharged directly home. Mortality, visit to general practitioner, and drug changes within 30 days were included as secondary outcomes.

METHODS

This is a historical cohort study with data from the Danish population-based open-cohort CROSS-TRACKS. Cox regression analyses were used to determine whether a high MERIS score was associated with increased risk of 30-day readmission and mortality. Visit to general practitioner and drug changes were tested with χ2 test and Wilcoxon rank sum test.

RESULTS

A total of 2106 patients were eligible: 2017 had a MERIS score lower than 14 (low-risk group), and 89 had a score of 14 or higher (high-risk group). The proportion of patients in the high-risk group who were readmitted was 21.3% compared with 16.3% in the low-risk group, resulting in a hazard ratio for readmission of 1.43 (95% confidence interval, 0.9-1.3). The hazard ratio for mortality was 8.3 (95% confidence interval, 3.0-22.8). No statistical significant difference was found in general practitioner visits; however, significantly more drug changes were observed in the high-risk group.

CONCLUSIONS

A high MERIS score was associated with increased risk of readmissions and can potentially assist healthcare professionals in the prioritizing of patients who may benefit from further exam, for example, additional medication review in acute care setting. Further investigation of MERIS and exploration of causal inferences between medication-related harm and medication-related readmissions are warranted.

Admission Medication Reconciliations in Pediatric Patients Admitted to an Inpatient Psychiatry Unit

OBJECTIVE

Medication errors resulting in adverse drug events may occur during transition of care. Most can be prevented with a medication reconciliation. California Senate Bill 1254 requires a pharmacist to perform an admission medication reconciliation (AMR) to obtain an accurate medication list for each high-risk patient upon hospital admission. Adult patient literature reveals that antidepressant, antipsychotic, and mood-stabilizing drugs are high-risk medications likely to cause errors. Therefore, the purpose of this analysis is to determine if pediatric psychiatry inpatients should be considered high risk, meriting an additional AMR by the pharmacy team.

METHODS

This was a retrospective, single-center analysis of pediatric patients admitted to the inpatient psychiatry unit at Rady Children's Hospital, San Diego between January 1 and 31, 2021. All newly admitted patients had an AMR performed by the medical team (physician-led AMR). High-risk patients (prescribed a high-risk medication or 3 or more medications of any kind prior to admission) had an additional AMR by the pharmacy team (pharmacy-led AMR). Differences between these 2 AMRs were examined.

RESULTS

Of the 58 patients admitted during the study period, 39 (67.2%) were identified as high risk, warranting an AMR by the pharmacy team. From the 170 medications reviewed, 51 differences (30%) were found between physician-led and pharmacy-led AMR, with 4 (2.4%) of the differences involving high-risk medications. No medications were incorrectly ordered, and no adverse drug events occurred.

CONCLUSIONS

Given that physician-led and pharmacy-led AMRs of high-risk prescription medications were only marginally different and no medications were incorrectly ordered, the existing AMR methodology used by psychiatrists at our institution is effective at creating a safe medication list.

Prescribing errors in post - COVID-19 patients: prevalence, severity, and risk factors in patients visiting a post - COVID-19 outpatient clinic

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has challenged healthcare globally. An acute increase in the number of hospitalized patients has necessitated a rigorous reorganization of hospital care, thereby creating circumstances that previously have been identified as facilitating prescribing errors (PEs), e.g. a demanding work environment, a high turnover of doctors, and prescribing beyond expertise. Hospitalized COVID-19 patients may be at risk of PEs, potentially resulting in patient harm. We determined the prevalence, severity, and risk factors for PEs in post–COVID-19 patients, hospitalized during the first wave of COVID-19 in the Netherlands, 3 months after discharge.

Methods

This prospective observational cohort study recruited patients who visited a post-COVID-19 outpatient clinic of an academic hospital in the Netherlands, 3 months after COVID-19 hospitalization, between June 1 and October 1 2020. All patients with appointments were eligible for inclusion. The prevalence and severity of PEs were assessed in a multidisciplinary consensus meeting. Odds ratios (ORs) were calculated by univariate and multivariate analysis to identify independent risk factors for PEs.

Results

Ninety-eight patients were included, of whom 92% had ≥1 PE and 8% experienced medication-related harm requiring an immediate change in medication therapy to prevent detoriation. Overall, 68% of all identified PEs were made during or after the COVID-19 related hospitalization. Multivariate analyses identified ICU admission (OR 6.08, 95% CI 2.16–17.09) and a medical history of COPD / asthma (OR 5.36, 95% CI 1.34–21.5) as independent risk factors for PEs.

Conclusions

PEs occurred frequently during the SARS-CoV-2 pandemic. Patients admitted to an ICU during COVID-19 hospitalization or who had a medical history of COPD / asthma were at risk of PEs. These risk factors can be used to identify high-risk patients and to implement targeted interventions. Awareness of prescribing safely is crucial to prevent harm in this new patient population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00588-7.

Knowledge, Attitude and Practice Survey Regarding High Alert Medication among Resident Doctors in a Tertiary Care Teaching Hospital in Eastern India

BACKGROUND

Medication errors are a reality in all settings where medicines are prescribed, dispensed and used. High Alert Medications (HAM) are those that bear a heightened risk of causing significant harm to the patient, if used erroneously. Though mishaps with HAM may not be more common than with other drugs, the consequences of error with them can be especially serious. We conducted a survey on knowledge, attitude and practice, among residents working in a teaching hospital, to assess the ground situation regarding HAM awareness and handling.

METHODS

We approached 492 residents among the approximately 600 residents currently working through purposive sampling. Residents in all disciplines (clinical, paraclinical and preclinical) were targeted. A structured questionnaire with 54 questions, pilot-tested on 20 volunteer residents, was used for data collection. The questionnaire was administered to residents through face-to-face interview, by two raters, while they were on duty, but not during rush hours.

RESULTS

Of the total 261 responses received, 32.33% respondents correctly defined or explained the meaning of the term 'medication error'. Knowledge regarding difference between medication error and adverse event did not get reflected in 68.38% of the participants, and only 16.86% were able to name relevant group of medicines as HAM. Regarding attitude in dealing with HAM, majority believed that taking the history of drug allergy and reconciling all prescription and over the counter (OTC) drugs already being used before prescribing or using a medicine, is important. In practice, most respondents followed protocols, but not routinely. Several potential errors in practice were identified.

CONCLUSION

The current situation requires corrective action. There is an urgent need for improving awareness regarding HAM for the sake of patient safety. The pharmacology department can take the lead in designing awareness campaign with support from the hospital administration.

Applicability of explicit potentially inappropriate medication lists to the Australian context: A systematic review

OBJECTIVES

To determine i) the similarity of potentially inappropriate medications specified in and between existing explicit lists and ii) the availability in Australia of medications included on existing lists to determine their applicability to the Australian context.

METHODS

This systematic review identified explicit potentially inappropriate medication lists that were published on EMBASE (1974 - April 2021), MEDLINE (1946 - April 2021) and Elsevier Scopus (2004 - April 2021). The reference lists of seven previously published systematic reviews were also manually reviewed. Lists were included if they were explicit, and the most recent version and the complete list were published in English. Lists based on existing lists were excluded if no new items were added. Potentially inappropriate medications identified on each list were extracted and compared to the medications available on the Australian Register of Therapeutic Goods and Australian Pharmaceutical Benefits Schemes.

RESULTS

Thirty-five explicit published lists were identified. A total of 645 unique potentially inappropriate medications were extracted, of which 416 (64%) were available in Australia and 262 (41%) were subsided by the general Pharmaceutical Benefits Scheme. Applicability of each explicit list ranged from 50-96% according to medications available in Australia and 25-83% according to medications available under subsidy.

CONCLUSIONS

Pooling data from different lists may help to identify potentially inappropriate medications that may be applicable to local settings. However, if selecting a list for use in the Australian context, consideration should also be given to the intended purpose and setting for application.

Assessment of Patients' Views on Drug Benefits and Risks: An Interview Study with Cardiovascular Patients

Better and balanced information strategies supporting cardiovascular patients' adherence are required. Cardiovascular drugs have outstanding morbidity and mortality benefits. This can be counteracted by patients' perceptions of risks. Drug information should help the patient but not fuel unwarranted fears. We performed a cross-sectional survey of patients admitted to a cardiology ward. We evaluated (i) the patients' general benefit-risk estimation of their pharmacotherapy; (ii) views on benefits; (iii) views on risks; and (iv) information sources. Additionally, we assessed aspects of anxiety and depression with the Patient Health Questionnaire-4 (PHQ-4). (i) 67 patients (66%) rated expected drug benefits higher than potential risks. (ii) 72% of benefits motivated the patients to take their medication as prescribed. Patients more frequently mentioned surrogate markers as benefits than clinical benefits (p < 0.001). (iii) 56% of risks mentioned were perceived as bothersome and 35% as concerning. Risks were more often perceived as bothersome and concerning by patients with higher PHQ-4 scores (p=0.016). (iv) Physicians were the most frequent information source of benefits (92% of patients) and risks (45%), and pharmacy staff for 27% and 14%, respectively. Laymen or media served as sources of information on benefits in 39%, for risks in 40%, and package leaflets in 26% and 36%. 42% of the patients would like to receive more information on benefits versus 27% on risks. Our results suggest that knowledge of benefits motivates patients to take their drugs as prescribed. There is already good information on surrogate markers for process control with active patient involvement. However, a lack of knowledge still exists in relation to clinical benefits. Regarding risks, it has been shown that patients with higher PHQ-4 scores are more likely to be bothered or concerned. Both emphases on clinical benefits and individualization depending on PHQ-4 scores may be valuable resources for patient counseling to support adherence.

Efficacy and Safety of TCMI in Patients With Combined Coronary Heart Disease and Heart Failure: A Systematic Review and Network Meta-Analysis

Objective: To compare the efficacy and safety of conventional treatments (CTs) to those that included traditional Chinese medicine injections (TCMIs) in patients with combined coronary heart disease and heart failure (CHD-HF). Methods: Eight electronic literature databases (PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, China National Knowledge Infrastructure Database, Chinese Scientific Journal Database, Wanfang Database, Chinese Biomedical Database) were searched from their inceptions to May 18, 2021, to identify relevant randomised controlled trials (RCTs). The primary outcomes analyzed included the total effectiveness rate and adverse events (ADRs). The secondary outcomes analyzed included the left ventricular ejection fraction (LVEF), N-terminal pro-brain natriuretic peptide (NT-proBNP), brain natriuretic peptide (BNP), and 6-min walk test (6MWT). Cochrane risk-of-bias tool was used to assess quality of the analyzed RCTs. Stata and OpenBUGS software were used to prior to the systematic review and network meta-analysis. Results: Sixty-one eligible trials involved 5,567 patients and one of the following 15 TCMIs: Shuxuetong, Shenmai, Shenfu, Shengmai, Danshenduofenyansuan, Danhong, Dazhuhongjingtian, Xinmailong, Dengzhanxixin, Gualoupi, Shuxuening, Xuesaitong, Yiqi Fumai, Shenqi Fuzheng, Huangqi. Network meta-analysis revealed that Shuxuetong injection + CT group was superior to CT only in improving the total effectiveness rate [odds ratio (OR): 7.8, 95% confidence interval (CI): 1.17-27.41]. Shenmai injection + CT was superior to CT only for LVEF (OR: 8.97, CI: 4.67-13.18), Xinmailong injection + CT was superior to CT only for NT-proBNP (OR: -317.70, CI: -331.10-303.10), Shenqi Fuzheng injection + CT was superior to CT only for BNP (OR: -257.30, CI: -308.40-242.80); and Danhong injection + CT was superior to CT only for 6MWT (OR: 84.40, CI: 62.62-106.20). Different TCMIs had different toxicity spectrums. Conclusion: TCMIs combined with CT are better than CT alone in treating CHD-HF. Different TCMIs improve different outcomes. Additional properly designed RCTs are needed to conduce a more refined comparison of various TCMIs. Systematic Review Registration: [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021258263].

The impact of treatment choices on potential drug-drug interactions in hypertensive patients

AIMS

The aim of this study was to analyse potential drug-drug interactions (pDDIs) and their potential adverse drug reactions (ADRs) among hypertensive patients. Moreover, we investigated the possibility of reducing pDDIs with different treatment choices.

METHODS

This was a cross-sectional study including all outpatients with hypertension and two or more medications, treated in a university hospital in Serbia. Lexicomp Interact (Lexi-Comp, Inc., Hudson, OH) was used for identification of pDDIs and potential ADRs. Treatment choices were explored according to patient characteristics, treatment guidelines and the interacting potential of drugs. Data were analysed using descriptive analysis and multiple logistic regression.

RESULTS

A total of 350 patients were included in this study, with average age (77 [36-98] years and 6.1 [2.5]) medications. The majority of patients (86.0%) had at least one clinically significant pDDI, and the average was 3.78 (3.90) (range 1-25). Suggestions for treatment change aimed mainly at eliminating drug duplications, reducing the use of thiazide diuretics, sulfonylureas, alpha-lipoic acid and pentoxifylline and increasing the use of calcium-channel blockers, when appropriate. pDDIs would have decreased to 2.10 (2.52), P <.001, yet male gender, ≥6 medications, cardiovascular diseases, diabetes, benign prostatic hyperplasia, would be predictive of two or more pDDIs. The main potential adverse outcomes of pDDIs were hypotension, renal failure, hypoglycaemia, bradycardia and lactic acidosis.

CONCLUSION

Careful choice of drugs can reduce but not eliminate pDDIs and their potential ADRs in hypertensive patients. Close monitoring for hypotension, renal failure, hypoglycaemia, bradycardia and lactic acidosis is necessary.

How to Identify Organizational High-Alert Medications

OBJECTIVES

High-alert medications may cause significant patient harm when used in error. Hospital-specific safety data should be used to customize high-alert medication lists to fit the local context. The aim of this study was to identify organizational high-alert medications by evaluating university hospital's data on adverse drug reaction (ADR) and medication error (ME).

METHODS

The Anatomical Therapeutic Chemical (ATC) codes and top active substances in ADR (n = 401) and ME (n = 11,668) reports of Helsinki University Hospital from 2015-2016 were analyzed and compared with hospitals' drug consumption and the Institute for Safe Medication Practices' (ISMP) list of high-alert medications.

RESULTS

The top ATC groups and active substances in ADR and ME reports were not similar. The most numerous ATC groups were L, antineoplastic and immunomodulating agents (30%) in ADRs and N, nervous system (26%) in MEs. According to ADR and ME reports, several high-alert medications from Institute for Safe Medication Practices' lists, such as antineoplastic agents, antithrombotics, opioids, and insulins, should be considered high-alert medications also in Helsinki University Hospital. Although no ADR reports of amphotericin B existed, it had the highest number of MEs causing severe/moderate harm or unexpected reactions relative to its consumption.

CONCLUSIONS

To identify organizational high-alert medications, both drug safety information and medication safety information should be used. Adverse drug reaction and ME data are needed to recognize high-alert medications, but these should also be combined with a literature search and local expert opinions.

Serious adverse drug reactions in sub-Saharan Africa in the era of antiretroviral treatment: A systematic review

We aimed to summarize and describe the burden of serious adverse drug reactions (ADRs) in sub-Saharan Africa (SSA) in the era of antiretroviral therapy. We searched Medline, CINAHL, Africa-Wide Information, Scopus, and Web of Science, without language restriction up to March 2021. We hand-searched reference lists, conference abstracts, and dissertation databases. We included studies reporting proportions of admissions attributed to ADRs, admissions prolonged by ADRs, or in-hospital deaths attributed to ADRs. Two reviewers independently screened the studies, reviewed the study quality using a previously published tool, and extracted the data. We tested for heterogeneity using I2 -statistics and summarized the study results using medians and interquartile ranges. Subgroup analyses summarized the results by study quality, setting, methodology, and population. From 1005 unique references identified, we included 15 studies. Median study quality was 7/10; heterogeneity was very high. Median [IQR] proportion of admissions attributed to ADRs was 4.8% [1.5% to 7.0%] (14 studies) and 6.4% [4.0% to 8.4%] in nine active surveillance studies in adults. Two pediatric studies reported the proportion of admissions prolonged by ADRs (0.29% and 0.99%). Three studies reported the proportion of in-hospital deaths attributed to ADRs (2.5%, 13%, and 16%). Antiretroviral and antituberculosis drugs were often implicated in serious ADRs. Evidence of the burden of serious ADRs in SSA is patchy and heterogeneous. A few high-quality studies suggest that the burden is considerable, and that it reflects the regional impact of the HIV pandemic. Further characterization of this burden is required, ideally in studies of standardized methodology.

What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?

OBJECTIVES

This study investigated severe medication errors (MEs) reported to the National Supervisory Authority for Welfare and Health (Valvira) in Finland and evaluated how the incident documentation applies to learning from errors.

METHODS

This study was a retrospective document analysis consisting of medication-related complaints and authoritative statements investigated by Valvira in 2013 to 2017 (n = 58).

RESULTS

Medication errors caused death or severe harm in 52% (n = 30) of the cases (n = 58). The majority (83%; n = 48) of the incidents concerned patients older than 60 years. Most likely, the errors occurred in prescribing (n = 38; 47%), followed by administration (n = 15; 19%) and monitoring (n = 14; 17%). The error process often included many failures (n = 24; 41%) or more than one health professional (n = 16; 28%). Antithrombotic agents (n = 17; 13%), opioids (n = 10; 8%), and antipsychotics (n = 10; 8%) were the therapeutic groups most commonly involved in the errors. Almost all error cases (91%; n = 53) were assessed as likely or potentially preventable. In 60% (n = 35) of the cases, the organization reported actions taken to improve medication safety after the occurrence of the investigated incident.

CONCLUSIONS

Medication errors reported to the national health care supervisory authority provide a valuable source of risk information and should be used for learning from severe errors at the level of health care systems. High age remains a key risk factor to severe MEs, which may be associated with a wide range of medications including those not typically perceived as high-alert medications or high-risk administration routes. Despite being complex processes, the severe MEs have a great potential to lead to developing systems, processes, resources, and competencies of health care organizations.

Clinical usefulness of prediction tools to identify adult hospitalized patients at risk of drug-related problems: A systematic review of clinical prediction models and risk assessment tools

AIMS

This study aimed to review systematically all available prediction tools identifying adult hospitalized patients at risk of drug-related problems, and to synthesize the evidence on performance and clinical usefulness.

METHODS

PubMed, Scopus, Web of Science, Embase, and CINAHL databases were searched for relevant studies. Titles, abstracts and full-text studies were sequentially screened for inclusion by two independent reviewers. The Prediction Model Risk of Bias Assessment Tool (PROBAST) and the Revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklists were used to assess risk of bias and applicability of prediction tools. A narrative synthesis was performed.

RESULTS

A total of 21 studies were included, 14 of which described the development of new prediction tools (four risk assessment tools and ten clinical prediction models) and six studies were validation based and one an impact study. There were variations in tool development processes, outcome measures and included predictors. Overall, tool performance had limitations in reporting and consistency, with the discriminatory ability based on area under the curve receiver operating characteristics (AUROC) ranging from poor to good (0.62-0.81), sensitivity and specificity ranging from 57.0% to 89.9% and 30.2% to 88.0%, respectively. The Medicines Optimisation Assessment tool and Assessment of Risk tool were prediction tools with the lowest risk of bias and low concern for applicability. Studies reporting external validation and impact on patient outcomes were scarce.

CONCLUSION

Most prediction tools have limitations in development and validation processes, as well as scarce evidence of clinical usefulness. Future studies should attempt to either refine currently available tools or apply a rigorous process capturing evidence of acceptance, usefulness, performance and outcomes.

Identifying High-alert Medications in a University Hospital by Applying Data From the Medication Error Reporting System

OBJECTIVES

To facilitate safe use of high-alert medications, lists of medications posing higher risks for medication errors (MEs) and harmful effects have been compiled. These lists can be general or reflect clinical practices in specific settings. Less common has been to compile a hospital-specific list applying data from the organization's ME reporting system. Our objective was to demonstrate a method for compiling such a high-alert medication list in a university hospital.

METHODS

Of the eighteen 136 MEs reported during 2007 to 2013, ME reports with medications coded as a contributing factor to the incident were included (n = 249). The involved medications were identified and compared with the hospital's drug consumption and Institute for Safe Medication Practice's List of High-Alert Medications. The report narratives of MEs with most reported and high-alert medications (120 reports) were qualitatively content analyzed.

RESULTS

The included 249 reports concerned 280 medications, of which 33% were classified as high-alert medications by the Institute for Safe Medication Practice. The most common therapeutic groups were antibacterials for systemic use (13%), psycholeptics (10%), analgesics (9%), and antithrombotic agents (9%). The most common high-alert medications were oxycodone (5%), enoxaparin (3%), and noradrenaline (3%). Serious patient harm (3%) was related to cefuroxime, enoxaparin, ibuprofen, midazolam, propofol, and warfarin. A half of the MEs were related to parenteral preparations. The qualitative content analysis revealed the key process safety risks of the most reported and high-alert medications.

CONCLUSIONS

The method is applicable for compiling a hospital-specific high-alert medication list and related analysis of key process safety risks contributing to MEs.

An investigation of new medications initiation during ambulatory care visits in patients with dementia

Background

Objectives

Methods

Results

Conclusion

•

What was already known?•

Dementia remains responsible for a large economic burden; research has shown that patients with dementia have increased utilization of ambulatory care visits before and after diagnosis.

•

Prior research in patients with dementia has focused on inappropriate prescribing, adverse drug interactions, and polypharmacy, but little work has been published investigating new medications prescribed at outpatient visits.

•

Opportunities exist for pharmacists to manage medications in the outpatient setting for patients with complex medication regimens.

•

What the study adds?•

Though fewer visits for patients with dementia provided new medications compared to visits for patients without dementia, there was no statistically significant difference in odds of a new medication being provided after adjustment for important confounders.

•

Some of the new medications more commonly provided to dementia patients include anticoagulants and antipsychotics that often require close monitoring and dosage adjustments.

•

Pharmacist led services would likely improve the care of the dementia population in an outpatient setting, but further investigation of new medication usage and the utility of pharmacists is needed.

Patient harm from cardiovascular medications

Background

Medication harm can lead to hospital admission, prolonged hospital stay and poor patient outcomes. Reducing medication harm is a priority for healthcare organisations worldwide. Recent Australian studies demonstrate cardiovascular (CV) medications are a leading cause of harm. However, they appear to receive less recognition as ‘high risk’ medications compared with those classified by the medication safety acronym, ‘APINCH’ (antimicrobials, potassium, insulin, narcotics, chemotherapeutics, heparin). Our aim was to determine the scale and type of medication harm caused by CV medications in healthcare.

Methods

A narrative review of adult (>16 years) medication harm literature identified from PubMed and CINAHL databases was undertaken. Studies with the primary outcome of measuring the incidence of medication harm were included. Harm caused by CV medications was described and ranked against other medication classes at four key stages of a patient’s healthcare journey. Where specified, the implicated medications and type of harm were investigated.

Results

A total of 75 studies were identified, including seven systematic reviews and three meta-analyses, with most focussing on harm causing hospital admission. CV medications were responsible for approximately 20% of medication harm; however, this proportion increased to 50% in older populations. CV medications were consistently ranked in the top five medication categories causing harm and were often listed as the leading cause.

Conclusion

CV medications are a leading cause of medication harm, particularly in older adults, and should be the focus of harm mitigation strategies. A practical approach to generate awareness among health professionals is to incorporate ‘C’ (for CV medications) into the ‘APINCH’ acronym.

Plain language summary

External validation of the Medication Risk Score in polypharmacy patients in general practice: A tool for prioritizing patients at greatest risk of potential drug-related problems

Drug-related problems are important causes of patient harm and increased healthcare costs. To assist general practitioners in prioritizing patients in need of a critical medication review, we aimed to assess the ability of the Medication Risk Score (MERIS) to stratify patients with polypharmacy in general practice according to their risk of drug-related problems. We conducted a cross-sectional multi-centre external validation study. Patients receiving more than five concomitant medications (polypharmacy) were eligible. The outcome was potentially serious drug-related problems as evaluated by expert consensus. Performance was assessed in terms of calibration and discrimination indices. Of 497 patients, 489 were included in the main analysis. The median age (interquartile range) was 70.5 years (60-79). In total, 372 potentially serious drug-related problems were observed in 253 patients (52%). The MERIS was well calibrated above a score level of 10. The area under the receiver operating characteristic curve was 0.70 (95% confidence interval: 0.65-0.74). The performance of the MERIS was fair in patients with polypharmacy in general practice. Given the scale of drug-related problems and the lack of efficient prioritization tools in this setting, the MERIS could be a useful risk indicator to complement usual practice.

The association of polypharmacy and high-risk drug classes with adverse health outcomes in the Scottish population with type 1 diabetes

AIMS/HYPOTHESIS

The aim of this work was to map the number of prescribed drugs over age, sex and area-based socioeconomic deprivation, and to examine the association between the number of drugs and particular high-risk drug classes with adverse health outcomes among a national cohort of individuals with type 1 diabetes.

METHODS

Utilising linked healthcare records from the population-based diabetes register of Scotland, we identified 28,245 individuals with a diagnosis of type 1 diabetes on 1 January 2017. For this population, we obtained information on health status, predominantly reflecting diabetes-related complications, and information on the total number of drugs and particular high-risk drug classes prescribed. We then studied the association of these baseline-level features with hospital admissions for falls, diabetic ketoacidosis (DKA), and hypoglycaemia or death within the subsequent year using multivariate Cox proportional hazards models.

RESULTS

Not considering insulin and treatment for hypoglycaemia, the mean number of prescribed drugs was 4.00 (SD 4.35). The proportion of individuals being prescribed five or more drugs at baseline consistently increased with age (proportion [95% CI]: 0-19 years 2.04% [1.60, 2.49]; 40-49 years 28.50% [27.08, 29.93]; 80+ years 76.04% [67.73, 84.84]). Controlling for age, sex, area-based socioeconomic deprivation and health status, each additional drug at baseline was associated with an increase in the hazard for hospitalisation for falls, hypoglycaemia and death but not for DKA admissions (HR [95% CI]: falls 1.03 [1.01, 1.06]; DKA 1.01 [1.00, 1.03]; hypoglycaemia 1.05 [1.02, 1.07]; death 1.04 [1.02, 1.06]). We found a number of drug classes to be associated with an increased hazard of one or more of these adverse health outcomes, including antithrombotic/anticoagulant agents, corticosteroids, opioids, antiepileptics, antipsychotics, hypnotics and sedatives, and antidepressants.

CONCLUSIONS

Polypharmacy is common among the Scottish population with type 1 diabetes and is strongly patterned by sociodemographic factors. The number of prescribed drugs and the prescription of particular high-risk drug classes are strong markers of an increased risk of adverse health outcomes, including acute complications of diabetes.

Poisoning among the elderly

OBJECTIVES

Poisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals.

METHODS

Retrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital.

RESULTS

A total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4).

CONCLUSIONS

The prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

Identifying Potential High-Risk Medication Errors Using Telepharmacy and a Web-Based Survey Tool

Background and Introduction:

Obtaining patient medication histories during emergency department (ED) admissions is an important step towards identifying potential errors that could otherwise remain in the patient’s active medication list. This is a descriptive report of a standardized, electronic data collection tool created to document potential medication errors in patients receiving high-risk medications during ED admissions.

Materials and Methods:

Trained pharmacy technicians completed a survey following medication history collection using a secure web platform called REDCap®. Data collected included patient-specific information, the number and type of high-risk medications, and potential medication errors identified in the collection process.

Results:

During a pilot period of April 2019 to October 2020, 191 patient records were completed using the survey tool. Out of a total of 1088 medications recorded, 41% were considered high-risk medications. 42% of potential medication errors were classified as high-risk medication errors. Results from this survey tool demonstrated that 58% of high-risk medication orders could potentially result in a medication error that can be carried through patient admission and discharge.

Discussion:

Accurate medication history and transitions of care can significantly impact patient quality of life. The cost of addressing a medication related-adverse event is also substantial. Based on published reports, annual gross savings to a hospital is estimated to be $4532 per harmful error in 2020, after adjusting for inflation. This equated to approximately $1,182,852 in estimated savings for Ascension Texas in 18 months. Nationwide, preventing potential medication errors in an outpatient setting can save on average $3.5 billion per year.

Conclusion:

This web-based survey tool has improved the quality and efficiency of potential error identification during medication history collection by pharmacy technicians. This information can be easily retrieved and aid in discussions regarding medication reconciliation at the leadership level and impact patient treatment outcomes by developing virtual processes that may result in fewer medication related events.

Harm Prevalence Due to Medication Errors Involving High-Alert Medications: A Systematic Review

OBJECTIVE

The aim of the study was to determine the prevalence and main types of harm caused by high-alert medication after medication errors (MEs) in hospitals.

METHOD

A literature systematic review was conducted on PubMed, Scopus, Web of Science, and Lilacs. Eligible studies published until June 2017 were included.

RESULT

Of 6244 studies identified through searching four electronic databases, five studies meeting the selection criteria of this study were analyzed. There was wide variation in the overall prevalence of harm due to MEs involving HAM, from 3.8% to 100%, whereas the pooled prevalence was 16.3%. Overall, 0.01% of harm caused by MEs involving HAM resulted in death. The severity of errors ranged from 0.1% to 19.2% for moderate errors, 0.2% to 15.4% for serious errors, and 1.9% lethal to the patients. The highest prevalences of harm occurred after errors involving potassium chloride 15%, insulin, and epoprostenol. The lowest prevalence of harm was related to errors of anticoagulants administration. The methodological heterogeneity limited direct comparisons among the studies.

CONCLUSIONS

Of the 15 drugs on the list of Institute for Safe Medication Practices HAMs in the United States and Brazil, nine did not present scientific evidence of the potential for harm. In general, few studies, characterized by methodological and conceptual heterogeneity, were performed to determine the harm prevalence resulting from errors involving these drugs.

Impact of Check of Medication Appropriateness (CMA) in optimizing analgesic prescribing: An interrupted time series analysis

BACKGROUND

Pain therapy in inpatients is regularly suboptimal and might be improved by clinical pharmacy services. In our hospital, we have implemented a software-supported 'Check of Medication Appropriateness' (CMA), which is a centralized pharmacist-led service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs), and a subsequent medication review by pharmacists. We aimed to investigate the impact of the CMA on pain-related prescribing.

METHODS

A quasi-experimental study was performed in a large teaching hospital, using an interrupted time series design. Pre-implementation, patients were exposed to standard of care. Afterwards, a pain-focused CMA comprising 12 specific clinical rules pertaining to analgesic prescribing were implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of pain-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the post-implementation period.

RESULTS

At baseline, a median number of 13.1 (range: 9.5-15.8) residual PIPs per day was observed. After the CMA intervention, the number was reduced to 2.2 (range: 0-9.5) per day. Clinical rules showed an immediate relative reduction of 66% (p < .0001) in pain-related residual PIPs. A significant decreasing time trend was observed during the post-implementation period. Post-implementation, 1683 recommendations were given over 1 year with an acceptance rate of 74.3%.

CONCLUSIONS

We proved that the CMA approach reduced the number of pain-related residual PIPs. More pharmacist involvement and the use of clinical rules during hospital stay should be further promoted to optimize appropriate prescribing of analgesics.

SIGNIFICANCE

Prescribing of analgesics should be improved in inpatients to optimize pain control and to reduce iatrogenic harm. The Check of Medication Appropriateness (CMA) approach, comprising a clinical rule-based screening for patients at risk and a targeted medication review by pharmacists, reduced the number of pain-related potentially inappropriate prescriptions in a highly significant and sustained manner. This study presents the opportunities of a centralized clinical pharmacy service to help clinicians to further improve analgesic prescribing.

Medication Risk Management in Routine Dispensing in Community Pharmacies

Community pharmacists have a duty to contribute to medication risk management in outpatient care. This study aimed to investigate the actions taken by pharmacists in routine dispensing to manage medication risks. The study was conducted as a national cross-sectional online survey targeted at all community pharmacies in Finland (n = 576) in October 2015. One pharmacist from each pharmacy was recommended to be the spokesperson for the outlet to describe their practices. Responses were received from 169 pharmacies (response rate of 29%). Pharmacists were oriented to solving poor adherence and technical problems in prescriptions, whereas responsibility for therapeutic risks was transferred to the patient to resolve them with the physician. Pharmacists have access to a wide range of electronic medication risk management tools, but they are rarely utilized in daily dispensing. Attention was paid to drug–drug interactions and the frequency of dispensing with regard to high-risk medicines. Pharmacies rarely had local agreements with other healthcare providers to solve medication-related risks. In routine dispensing, more attention needs to be given to the identification and solving of therapeutic risks in medications, especially those of older adults. Better participation of community pharmacists in medication risk management requires stronger integration and an explicit mandate to solve the therapeutic risks.

Poisoning among the elderly

OBJECTIVES

Poisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals.

METHODS

Retrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital.

RESULTS

A total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4).

CONCLUSIONS

The prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

Nature of adverse events with opioids in hospitalised patients: a post-hoc analysis of three patient record review studies

OBJECTIVE

Opioids are increasingly prescribed and frequently involved in adverse drug events (ADEs). The underlying nature of opioid-related ADEs (ORADEs) is however understudied. This hampers our understanding of risks related to opioid use during hospitalisation and when designing interventions. Therefore, we provided a description of the nature of ORADEs.

DESIGN

A post-hoc analysis of data collected during three retrospective patient record review studies (in 2008, 2011/2012 and 2015/2016).

SETTING

The three record review studies were conducted in 32 Dutch hospitals.

PARTICIPANTS

A total of 10 917 patient records were assessed by trained nurses and physicians.

OUTCOME MEASURES

Per identified ORADE, we described preventability, type of medication error, attributable factors and type of opioids involved. Moreover, the characteristics of preventable and non-preventable ORADEs were compared to identify risk factors.

RESULTS

Out of 10 917 patient records, 357 ADEs were identified, of which 28 (8%) involved opioids. Eleven ORADEs were assessed as preventable. Of these, 10 were caused by dosing errors and 4 probably contributed to patients' death. Attributable factors identified were mainly on patient and organisational levels. Morphine and oxycodone were the most frequently involved opioids. The risk for ORADEs was higher in elderly patients.

CONCLUSIONS

Only 8% of ADEs identified in our sample were related to opioids. Although the frequency is low, the risk of serious consequences is high. We recommend to use our findings to increase awareness among physicians and nurses. Future interventions should focus on safe dosing of opioids when prescribing and administering, especially in elderly patients.

Effects of stratified medication review in high-risk patients at admission to hospital: a randomised controlled trial

Background:

Patients at high risk of medication errors will potentially benefit most from medication reviews. An algorithm, MERIS, can identify the patients who are at highest risk of medication errors. The aim of this study was to examine the effects of performing stratified medication reviews on patients who according to MERIS were at highest risk of medication errors.

Methods:

A randomised controlled trial was performed at the Acute Admissions Unit, Aarhus University Hospital, Denmark. Patients were included at admission to the hospital and were randomised to control or intervention. The intervention consisted of stratified medication review at admission on patients with a high MERIS score. Clinical pharmacists and clinical pharmacologists performed the medication reviews; the clinical pharmacologists performed the reviews on patients with the highest MERIS score. The primary outcome measure was the number of prescribing errors during the hospitalisation. Secondary outcomes included self-experienced quality of life, health-care utilisation and mortality measured at follow-up 90 days after discharge.

Results:

A total of 375 patients were included, of which medication reviews were performed in 64 patients. The medication reviews addressed 63 prescribing errors in 37 patients and 60 other drug-related problems. No difference in the number of prescribing errors during hospitalisation between the intervention group (n = 165) and control group (n = 153) was found, corresponding to 0.11 prescribing errors per drug (95% confidence interval (CI): 0.08–0.14) versus 0.13 per drug (95% CI: 0.09–0.16), respectively. No differences in secondary outcomes were observed.

Conclusion:

A stratified medication review approach based on the individual patient’s risk of medication errors did not show impact on the chosen outcomes.

Plain language summary

How does a medication review at admission affect patients who are in high risk of medication errors?

Patients are at risk of medication errors at admission to hospital. Medication reviews aim to detect and solve these. Yet, due to limited resources in healthcare, it would be beneficial to detect the patients who are most at risk of medication errors and perform medication reviews on those patients.

In this study we investigated whether an algorithm, MERIS, could detect patients who are at highest risk of medication errors; we also studied whether performing medication reviews on patients at highest risk of medication errors would have an effect on, for example, the number of medication errors during hospitalisation, qualify of life and number of readmissions. We included 375 patients in a Danish acute admission unit and they were divided into control group and intervention group. Patients in the intervention group received a medication review at admission if they were considered at high risk of medication errors, assessed with the aid of MERIS. In summary, 64 patients in the intervention group were most at risk of medication errors and therefore received a medication review.

We conclude in the study that MERIS was useful in identifying relevant patients for medication reviews. Yet, the medication reviews performed at admission did not impact on the chosen outcomes.

Quality of clinical direct oral anticoagulant prescribing and identification of risk factors for inappropriate prescriptions

AIMS

Even though the use of direct oral anticoagulants (DOACs) is safe based on clinical outcomes, drug safety also depends on appropriateness of drug prescription, which is challenging for DOACs since many patient factors need to be considered. The aim of this study was to assess the appropriateness of DOAC prescriptions and to identify risk factors of determinants for inappropriate DOAC prescriptions.

METHODS

A retrospective study in a nonuniversity teaching hospital was performed of hospitalized patients (≥18 years) who received an initial DOAC prescription between February and August 2018. Appropriateness of prescribing was evaluated on 8 criteria by using a modified version of the medication appropriateness index.

RESULTS

A total of 770 initial DOAC prescriptions of inpatients were evaluated: 267 patients (34.6%) had at least met 1 inappropriate criterion for a DOAC prescription. The most frequent inappropriate criterion was dosage (17.4%). Of the 4 DOACs, dabigatran (21.6%) and apixaban (21.2%) were mostly inappropriate dosed. In a multivariable analysis, reduced renal function (estimated glomerular filtration rate <50 mL/min; odds ratio [OR] = 2.35; P < .001), a diagnosis of atrial fibrillation (OR = 1.87; P = .004), and 'prescribed by surgeons' (OR = 1.9; P = .013) were independently associated with inappropriateness of prescribing.

CONCLUSION

This study has highlighted a high degree of inappropriate prescribing of DOACs. These results underline the need for targeted interventions to improve DOAC prescribing.

Getting to Complete and Accurate Medication Lists During the Transition to Home Health Care

OBJECTIVES

Characterize the work that home health care (HHC) admission nurses complete as part of the medication reconciliation tasks, explore the impact of shared electronic medication data (interoperability) from the referral source on medication reconciliation, and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.

DESIGN

Observational field study.

SETTINGS AND PARTICIPANTS

Three diverse Pennsylvania HHC agencies; each used different electronic health record systems with different interoperability characteristics. Six nurses per site admitted 2 patients each (36 patients total).

METHODS

Researchers observed the admission process in the patient home and at the HHC agency. The nurses' tasks related to medication reconciliation were characterized by (1) number and change types (ie, medications dropped or added; changes to dose, frequency/administration time, or tablet types) made to the referrer medication list during and after the home visit, and (2) reasons that the nurse called the health provider (doctor, pharmacy) to resolve medication-related issues. Differences between interoperable and non-interoperable observations were explored.

RESULTS

Polypharmacy (on average, study patients were taking more than 12 medications) and high-risk medications (on average, more than 8 per patient) were pervasive. For 91% of patients, the number of medications decreased between pre- and post-reconciliation medication lists; 41% of the medications required changes. Nurses using interoperable systems needed to make fewer changes than nurses using non-interoperable systems. In two-thirds of observations, the nurse called a provider.

CONCLUSIONS AND IMPLICATIONS

Changes to the referrer medication list and calls to providers highlighted the nurses' effort to complete the medication reconciliation. Interoperability appeared to reduce the number of changes required, but did not eliminate changes or calls to providers. We highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.

Patient safety incidents involving transdermal opioids: data from the Danish Patient Safety Database

Background Transdermal opioids are widely used among elderly adults with chronic pain. However, transdermal patches may be involved in a significant proportion of opioid-related patient safety incidents, as the application process includes several subprocesses, each associated with an individual risk of error. Objective The aim was to obtain specific knowledge on patient safety incidents related to transdermal opioid treatment within both the primary care sector and the hospital sector in Denmark. Setting The study is descriptive with data provided by the Danish Patient Safety Database. Methods We manually retrieved all patient safety incidents concerning transdermal opioids reported for 2018 from (1) the hospital sector and (2) the primary care sector. Study data were collected and managed using REDCap electronic data capture tools. Main outcome measure The available information for each incident was sorted into the following categories: location, medication process, type of problem, outcome at time of reporting, and outcome classification. Results A total of 866 patient safety incidents involving transdermal opioids were reported to the Danish Patient Safety Database in 2018. No fatal incidents were present in the database. In 386 cases, the incidents were reported as harmful, and these 386 cases were analysed. Most reports came from the primary care sector (nursing home, home care or social housing). The majority of incidents were related to the administration of the patch in the medication process, and the most prevalent problem was the omission of doses. Conclusion This study has demonstrated that the administration of transdermal opioids is challenging and may cause harm, particularly in the primary care sector. To improve patient safety, optimized systems, including guidelines on drug management and the continuing education of healthcare personnel in transdermal opioid management, are necessary. These guidelines should preferably incorporate reminders and checklists, since the omission of doses was the most reported problem.

Drug-related problems and pharmacy interventions in non-prescription medication, with a focus on high-risk over-the-counter medications

Background The risks associated with over-the-counter medication are often underestimated by consumers. The incorrect use of certain medications can lead to significant patient harm. Inappropriate use can be prevented by pharmaceutical counselling. Objective To determine the number and nature of drug-related problems in over-the-counter medication with a special emphasis on high-risk over-the-counter medications. Setting Fifty-two community pharmacies in Finland. Method This observational study was conducted as a questionnaire survey. The pharmacists working in participating pharmacies documented the observed drug-related problems and pharmacy interventions in over-the-counter medication during 1 week using an electronic study form based on the Westerlund drug-related problem classification system. Main outcome measure The prevalence of drug-related problems and problem types in different medication categories. Results The 52 community pharmacies documented 339 drug-related problems in 0.6% of over-the-counter customers, the most common problem being “Uncertainty about the indication for the drug” (39.2%). A significant proportion of the documented problems (26.3%) concerned high-risk over-the-counter medications, and the majority of these cases were associated with non-steroidal anti-inflammatory drugs (21.8%). In total, pharmacies made 641 interventions to resolve the drug-related problems. For majority of drug-related problems (87%), pharmacist’s intervention involved counselling. In more than half of the problem cases, the pharmacy intervention was precautionary. Conclusion Pharmacists intervene in and prevent problems related to over-the-counter medications, including high-risk medications like analgesics, in which inappropriate use due to consumers’ lack of knowledge can lead to severe consequences. As the selection and use of over-the-counter medications is continuously increasing, pharmaceutical counselling should be readily available and actively provided for consumers to achieve safer self-medication.

High-risk medication in community care: a scoping review

PURPOSE

To review the international literature related to high-risk medication (HRM) in community care, in order to (1) define a definition of HRM and (2) list the medication that is considered HRM in community care.

METHODS

Scoping review: Five databases were systematically searched (MEDLINE, Scopus, CINAHL, Web Of Science, and Cochrane) and extended with a hand search of cited references. Two researchers reviewed the papers independently. All extracted definitions and lists of HRM were subjected to a self-developed quality appraisal. Data were extracted, analysed and summarised in tables. Critical attributes were extracted in order to analyse the definitions.

RESULTS

Of the 109 papers retrieved, 36 met the inclusion criteria and were included in this review. Definitions for HRM in community care were used inconsistently among the papers, and various recurrent attributes of the concept HRM were used. Taking the recurrent attributes and the quality score of the definitions into account, the following definition could be derived: "High-risk medication are medications with an increased risk of significant harm to the patient. The consequences of this harm can be more serious than those with other medications". A total of 66 specific medications or categories were extracted from the papers. Opioids, insulin, warfarin, heparin, hypnotics and sedatives, chemotherapeutic agents (excluding hormonal agents), methotrexate and hypoglycaemic agents were the most common reported HRM in community care.

CONCLUSION

The existing literature pertaining to HRM in community care was examined. The definitions and medicines reported as HRM in the literature are used inconsistently. We suggested a definition for more consistent use in future research and policy. Future research is needed to determine more precisely which definitions should be considered for HRM in community care.

Identifying risks areas related to medication administrations - text mining analysis using free-text descriptions of incident reports

BACKGROUND

Some medications carry increased risk of patient harm when they are given in error. In incident reports, names of the medications that are involved in errors could be found written both in a specific medication field and/or within the free text description of the incident. Analysing only the names of the medications implicated in a specific unstructured medication field does not give information of the associated factors and risk areas, but when analysing unstructured free text descriptions, the information about the medication involved and associated risk factors may be buried within other non-relevant text. Thus, the aim of this study was to extract medication names most commonly used in free text descriptions of medication administration incident reports to identify terms most frequently associated with risk for each of these medications using text mining.

METHOD

Free text descriptions of medication administration incidents (n = 72,390) reported in 2016 to the National Reporting and Learning System for England and Wales were analysed using SAS® Text miner. Analysis included text parsing and filtering free text to identify most commonly mentioned medications, followed by concept linking, and clustering to identify terms associated with commonly mentioned medications and the associated risk areas.

RESULTS

The following risk areas related to medications were identified: 1. Allergic reactions to antibacterial drugs, 2. Intravenous administration of antibacterial drugs, 3. Fentanyl patches, 4. Checking and documenting of analgesic doses, 5. Checking doses of anticoagulants, 6. Insulin doses and blood glucose, 7. Administration of intravenous infusions.

CONCLUSIONS

Interventions to increase medication administration safety should focus on checking patient allergies and medication doses, especially for intravenous and transdermal medications. High-risk medications include insulin, analgesics, antibacterial drugs, anticoagulants, and potassium chloride. Text mining may be useful for analysing large free text datasets and should be developed further.

High-risk medicines associated with clinically relevant medication-related problems in UK hospitals: A prospective observational study

The aim of this prospective observational study was to establish associations between the use of high-risk medicine groups and the study outcome: occurrence of at least 1 moderate or severe preventable medication-related problem. Data on medication-related problems, high-risk medicines, and other potential risk factors were collected from adults on medical wards in 2 UK hospitals. Logistic regression modelling was used to determine relationships between high-risk medicines and the study outcome. Among 1503 eligible admissions, 6 high-risk medicine groups were associated with the study outcome on univariable analysis; multivariable analysis found only systemic antimicrobials and epilepsy medicines to be independently associated with the outcome (adjusted odds ratio 1.44, 95% confidence interval 1.08-1.92 and adjusted odds ratio 1.61, 95% confidence interval 1.16-2.25 respectively). Identification of high-risk medicine groups has potential to permit targeting of patients at highest risk of avoidable medication-related harm, but multivariable analysis suggests risk is likely to be multifactorial.

Proactive risk assessment of vincristine use process in a teaching and referral hospital in Kenya and the implications

INTRODUCTION

The chemotherapy use process is potentially risky for cancer patients. Vincristine, a "High Alert" medicine, has been associated with fatal but preventable medication errors. Consequently, there is a need to improve the use of vincristine especially in lower- and middle-income countries where there are constraints with resources and often a lack of trained personnel to administer cancer medicines. However, where there is a rising prevalence of cancer cases. These concerns can be addressed by performing proactive risk assessments using Healthcare Failure Mode Effect Analysis (HFMEA) and implementing the findings.

METHODS

A multidisciplinary health team driven by pharmacists identified and evaluated potential failure modes based on a vincristine use process flow diagram using a hazard scoring matrix in a leading referral hospital in Kenya.

RESULTS

The processes evaluated were: prescribing, preparation and dispensing, transportation and storage, administration and monitoring of the use of vincristine. Seventy-seven failure modes were identified over the three-month study period, of which 25 were classified as high risk. Thirteen were adequately covered by existing control measures while 12 including one combined mode required new strategies. Two of the failure modes were single-point weaknesses. Recommendations were subsequently made for improving the administration of vincristine.

CONCLUSIONS

HFMEA is a useful tool to identify improvements to medication safety and reduction of patient harm. The HFMEA process brings together the multidisciplinary team involved in patient care in actively identifying potential failure modes and owning the recommendations made, which are now being actively followed up in this hospital. Pharmacists are a key part of this process.

Evaluation of drug-related problems and subsequent clinical pharmacists' interventions at a Swiss university hospital

WHAT IS KNOWN AND OBJECTIVE

The evaluation of clinical pharmacy services is essential for their further development and establishment. We analysed drug-related problems (DRPs) and subsequent clinical pharmacists' interventions (PIs) at a Swiss university hospital.

METHOD

We conducted a retrospective analysis of DRPs and subsequent PIs that were identified and implemented during interdisciplinary ward rounds in internal medicine at the University Hospital Basel, Switzerland, between 2015 and 2017. We estimated the potential clinical and economic impact of PIs using a validated evaluation tool (CLEO_de ).

RESULTS AND DISCUSSION

Based on medication reviews of 5441 patients, clinical pharmacists identified 5024 DRPs, of which 2892 DRPs (57.6%) were followed by a PI that was directly accepted and implemented by the physician in charge and included in the present analysis. The leading cause and type of PIs were inappropriate dose and dose adjustment, respectively. Overall, 97.8% of DRPs were followed by PIs with an expected clinical benefit for the patients (major: 11.1%; moderate: 27.6%; minor: 59.1%). The drugs most often involved in PIs of major clinical impact were antithrombotics, acid blockers and cardiovascular drugs. With regard to the economic impact, 40.7% of DRPs implied PIs resulting in an increase of immediate therapy costs, whereas 39.3% implied PIs resulting in a decrease of immediate therapy costs. The remaining PIs were cost-neutral.

WHAT IS NEW AND CONCLUSION

This study emphasizes that clinical pharmacists may help improve the effectiveness and safety of pharmacotherapy on acute care medical wards.

Canonical correlations between individual self-efficacy/organizational bottom-up approach and perceived barriers to reporting medication errors: a multicenter study

Background

Individual and organizational factors correlate with perceived barriers to error reporting. Understanding medication administration errors (MAEs) reduces confusion about error definitions, raises perceptions of MAEs, and allows healthcare providers to report perceived and identified errors more frequently. Therefore, an emphasis must be placed on medication competence, including medication administration knowledge and decision-making. It can be helpful to utilize an organizational approach, such as collaboration between nurses and physicians, but this type of approach is difficult to establish and maintain because patient-safety culture starts at the highest levels of the healthcare organization. This study aimed to examine the canonical correlations of an individual self-efficacy/bottom-up organizational approach variable set with perceived barriers to reporting MAEs among nurses.

Methods

We surveyed 218 staff nurses in Korea. The measurement tools included a questionnaire on knowledge of high-alert medication, nursing decision-making, nurse-physician collaboration satisfaction, and barriers to reporting MAEs. Descriptive statistics, t-tests, analysis of variance (ANOVA), Pearson’s correlation coefficient, and canonical correlations were used to analyze results.

Results

Two canonical variables were significant. The first variate indicated that less knowledge about medication administration (− 0.83) and a higher perception of nurse-physician collaboration (0.42) were related to higher disagreement over medication error (0.64). The second variate showed that intuitive clinical decision-making (− 0.57) and a higher perception of nurse-physician collaboration (0.84) were related to lower perceived barriers to reporting MAEs.

Conclusions

Enhancing positive collaboration among healthcare professionals and promoting analytic decision-making supported by sufficient knowledge could facilitate MAE reporting by nurses. In the clinical phase, providing medication administration education and improving collaboration may reduce disagreement about the occurrence of errors and facilitate MAE reporting. In the policy phase, developing an evidence-based reporting system that informs analytic decision-making may reduce the perceived barriers to MAE reporting.

Medication related litigation in Ireland: A 6-year review

AIMS

The primary aims of the study were to identify those medications most frequently associated with clinical litigation in Ireland and to quantify the cost of such litigation. Secondary aims were to identify where in the medication-use process claims were most likely to arise, the medication incident types involved and the primary injury alleged.

METHODS

The National Incident Management System (NIMS) for incident and claims management was searched to identify all medication-related claims finalised from 2011 to 2016 (inclusive). The physical case files were obtained and additional data not available on NIMS was extracted in order to build a detailed picture of the incident and subsequent claim.

RESULTS

The search identified 79 relevant claims, of which 48 closed with a payment to the plaintiff. These 48 claims involved 54 medications. Medication groups identified included general anaesthetics (n = 7), opioids (n = 6), penicillins, antithrombotics and local anaesthetics (all n = 5). The errors alleged occurred exclusively at the administration (58%) and prescribing (42%) stages of the medication-use process. Medication incident types included wrong dose/strength (n = 17), wrong drug (n = 7) and adverse drug reaction (n = 6). The most commonly pleaded primary injuries were allergic reaction (n = 9), deterioration in clinical status (n = 9) and post-traumatic stress disorder (n = 8). The median total cost of these claims was €60 991, including median damages of €33 858.

CONCLUSIONS

This study links data on medication incidents, actual harm to patients and litigation costs. Thus, it presents a comprehensive picture of the consequences of medication error.

Occurrence of Antithrombotic Related Adverse Events in Hospitalized Patients: Incidence and Clinical Context between 2008 and 2016

Antithrombotic drugs are consistently involved in medication-related adverse events (MRAEs) in hospitalized patients. We aimed to estimate the antithrombotic-related adverse event (ARAE) incidence between 2008 and 2016 and analyse their clinical context in hospitalized patients in The Netherlands. A post-hoc analysis of three national studies, aimed at adverse event (AE) identification, was performed. Previously identified AEs were screened for antithrombotic involvement. Crude and multi-level, case-mix adjusted ARAE and MRAE incidences were calculated. Various contextual ARAE characteristics were analysed. ARAE incidence between 2008 and 2016 decreased significantly in in-hospital deceased patients from 1.20% (95% confidence interval (CI): 0.63-2.27%) in 2008 to 0.54% (95% CI: 0.27-1.11%) in 2015/2016 (p = 0.02). In discharged patients ARAE incidence remained stable. By comparison, overall MRAE incidence remained stable for both deceased and discharged patients. Most ARAEs involved Vitamin-K antagonists (VKAs). Preventable ARAEs occurred more during weekends and with increasing multidisciplinary involvement. Antiplatelet and combined antithrombotic use seemed to be increasingly involved in ARAEs over time. ARAE incidence declined by 55% in deceased patients between 2008 and 2016. Opportunities for improving antithrombotic safety should target INR monitoring and care delivery aspects such as multidisciplinary involvement and weekend care. Future ARAE monitoring for the involvement of antiplatelet, combined antithrombotic and direct oral anticoagulant (DOAC) use is recommended.