A retrospective analysis of drug-related problems documented in a national database

Sedatives and analgesics are major contributors to potentially inappropriate duplicate prescriptions in geriatric psychiatry

BACKGROUND

This study sought to investigate the frequency and characteristics of duplicate prescriptions (DPs) in elderly psychiatric inpatients using a novel categorisation of DPs that differentiates between appropriate duplicate prescriptions (ADPs) and potentially inappropriate duplicate prescriptions (PIDPs).

METHODS

The study was conducted as a monocentric retrospective cross-sectional pilot study on the gerontopsychiatric ward of the Department of Psychiatry, Social Psychiatry and Psychotherapy of Hannover Medical School, a large university hospital in northern Germany. The outcome measures were the nature and frequency of PIDPs compared with the frequency of ADPs.

RESULTS

For 92 individual patients a total of 339 medication chart reviews were conducted between April 2021 and February 2022. The median age of the study population was 73 years (interquartile range (IQR) 68-82 years); 64.6% were female. Patients' medications comprised a median of eight drugs (IQR 6-11 drugs) and 43.1% of the study population were exposed to at least one PIDP (at least one grade-1 PIDP: 39.5%; at least one grade-2 PIDP: 5.0%; at least one grade-3 PIDP: 1.5%). Sedatives were most frequently responsible for grade-1 and grade-2 PIDPs, while grade-3 PIDPs were elicited exclusively by analgesics. Nearly half of the study population (49.0%) displayed at least one ADP.

CONCLUSION

Even though the clinical implications of PIDPs are not fully established to date, we recommend that physicians who treat elderly psychiatric patients pay special attention to PIDPs, especially PIDPs elicited by sedatives. Termination of PIDPs may prevent adverse drug reactions and save healthcare expenditures.

Duplicate prescriptions in the emergency department: a retrospective cohort study

PURPOSE

To determine the nature and frequency of duplicate prescriptions (DPs) in the emergency department (ED) by utilization of a novel categorization of DPs which differentiates between appropriate DPs (ADPs) and potentially inappropriate DPs (PIDPs).

METHODS

In this retrospective cohort study, adult patients who presented to the ED for internal medicine of a large university hospital in northern Germany in 2018 and 2019 were screened for the presence of DPs. Descriptive statistical methods were used to characterize the nature and frequency of PIDPs compared to the frequency of ADPs.

RESULTS

A total of 4208 patients were enrolled into the study. The median age of the study population was 63 years (interquartile range (IQR) 48-77), 53.9% were female. The patients took a median of 5 drugs (IQR 3-9). 10.9% of the study population were affected by at least one PIDP (at least one grade-1 PIDP: 6.1%; at least one grade-2 PIDP: 4.5%; at least one grade-3 PIDP: 1.1%). Non-opioid analgesics accounted for the majority of grade-1 PIDPs, while inhalatives were most frequently responsible for grade-2 and grade-3 PIDPs. Nearly half of the study population (48.6%) displayed at least one ADP.

CONCLUSION

PIDPs pose a frequent pharmacological challenge in the ED. The medication review should comprise a systematic screening for PIDPs with a particular focus on non-opioid analgesics and inhalatives. ADPs were detected more frequently than PIDPs, questioning the predominant notion in the medical literature that DPs are exclusively deleterious.

Current Knowledge about Providing Drug-Drug Interaction Services for Patients-A Scoping Review

Drug-drug interactions (DDIs) pose a major problem to patient safety. eHealth solutions have the potential to address this problem and generally improve medication management by providing digital services for health care professionals and patients. Clinical decision support systems (CDSS) to alert physicians or pharmacists about DDIs are common, and there is an extensive body of research about CDSS for professionals. Information about DDIs is commonly requested by patients, but little is known about providing similar support to patients. The aim of this scoping review was to explore and describe current knowledge about providing digital DDI services for patients. Using a broad search strategy and an established framework for scoping reviews, 19 papers were included. The results show that although some patients want to check for DDIs themselves, there are differences between patients, in terms of demands and ability. There are numerous DDI services available, but the existence of large variations regarding service quality implies potential safety issues. The review includes suggestions about design features but also indicates a substantial knowledge gap highlighting the need for further research about how to best design and provide digital DDI to patients without risking patient safety or having other unintended consequences.

Incidence, types and acceptability of pharmaceutical interventions about drug related problems in a general hospital: an open prospective cohort

OBJECTIVES

To evaluate the incidence and types of drug-related problems (DRP) in a general teaching hospital and to evaluate the acceptability of pharmaceutical interventions by the medical team.

DESIGN

Prospective cohort study during 2 years.

SETTING

Conducted in a Brazilian University Hospital.

PARTICIPANTS

The patient cohort consisted of 9303 patients with a total of 12 286 hospitalisation episodes.

PRIMARY OUTCOME MEASURES

DRP detected by pharmacists' review of 100% medication orders using Pharmaceutical Care Network Europe 6.2 classification.

RESULTS

Patients with a mean age of 52.6±17.7 years and 50.9% females. A total of 3373 DRP in 1903 hospital episodes were identified, corresponding to a cumulative incidence of 15.5%. 'Treatment ineffectiveness' (11.5%) and 'Treatment costs' (5.90%) were the most common DRP and 'Drug use process' (18.4%) and 'Treatment duration' (31.0%) the main causes of DRP. The medicines involved most often involved in DRP were anti-infectives (36.0%), mainly cephalosporins (20.2%), antiulcer (38.6%), analgesics/antipyretics (61.2%), propulsives (51.2%), opioids (38.5%) and antiemetics (57.4%). From 1939 pharmaceutical interventions, at least, 21.4% were not approved by the medical team.

CONCLUSION

DRP detected by 100% medication order review by hospital pharmacists occur in a significant proportion of hospital episodes, the most frequent being related to treatment effectiveness and treatment costs. The medications mostly involved were cephalosporins, penicillins, antidyspeptics, analgesics, antipyretics, opioids and antiemetics. Pharmaceutical interventions had low acceptability by the medical staff.

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.

Dispensing of Prescribed Medicines in Swiss Community Pharmacies-Observed Counselling Activities

BACKGROUND

Patient counselling and addressing drug-related problems are the pharmacist's key activities to ensure the safe and effective use of medicines. This study aimed to describe the dispensing practice of prescribed medicines in daily community pharmacy practice and to identify factors influencing counselling provision; Methods: An observational study was conducted in community pharmacies in Basel, Switzerland. One master student in pharmacy performed non-participatory observations for one day at each of the participating community pharmacies. Patient characteristics, counselling content, additional activities, and pharmaceutical interventions were documented on a structured checklist; Results: 556 prescription encounters (PE) in 18 participating community pharmacies were observed (269 first prescriptions; 287 refill prescriptions). Patients were regular customers (n = 523, 94.1%) and 53.8 ± 23.4 years old. Counselling was provided to 367 (66.0%) customers on 2.9 ± 3.1 themes per PE. Factors influencing counselling were dispensing by the pharmacist, new customer, customer who did not refuse counselling, customer with a first prescription, with a prescription resulting in a pharmaceutical intervention, and a prescription filled by carers. During 144 PEs, 203 interventions were documented. Pharmacists proposed few additional activities and performed no cognitive pharmaceutical service; Conclusions: Our study quantified counselling and additional services at the dispensing of prescribed medicines and identified influencing factors on counselling provision at the patient, prescription, and pharmacy level.

Consequences of non-medical switch among patients with type 2 diabetes

OBJECTIVE

This study aimed to describe real-world experiences following a non-medical switch among adults with type 2 diabetes mellitus (T2DM) in the United States.

METHODS

For this cross-sectional study, patients with T2DM (N = 451) provided data on demographics, and how a non-medical switch of their anti-hyperglycemic agent (AHA) affected their general health, HbA1c levels and medication management, via an Internet-based survey. Patients self-reported their level of satisfaction with the original medication and emotional reactions to the non-medical switch. Patients who recently experienced a non-medical switch of their AHA(s) (n = 379) were asked about the consequences of switching and their satisfaction with the switch (vs. the original) medication.

RESULTS

Patients most frequently reported feeling very/extremely frustrated, surprised, upset and angry in reaction to a non-medical switch. Patients were somewhat satisfied with their original medication. Between 20% and 30% of patients reported the non-medical switch had a moderate/major effect on their general health, diabetes, mental well-being and control over their health. The blood glucose levels of recent switchers were somewhat/much worse (20.7%) and medication management was somewhat/much worse (12.9%) on the switch (vs. the original) medication. Some recent switchers reported old symptoms returning (7.7%) and experiencing new side-effects (14.2%).

CONCLUSIONS

Approximately one in five patients reported a moderate/major negative impact on their blood glucose level, diabetes, mental well-being, general health and control over their health following a non-medical switch. Findings suggest that a non-medical switch may have unintended negative health consequences and results in considerable burden across multiple domains for a sizeable minority of patients with T2DM.

Consumer views on safety of over-the-counter drugs, preferred retailers and information sources in Sweden: after re-regulation of the pharmacy market

BACKGROUND

The availability of over-the-counter drugs (OTCs) has increased in Sweden since a re-regulation of the pharmacy market in 2009, through which non-pharmacy retailers became permitted to provide certain OTCs.

OBJECTIVE

To examine the adult general public's views on safety, purchasing and information channels, storage and disposal of OTCs in Sweden, three years after the re-regulation of the pharmacy market.

METHODS

A questionnaire study in 2012-13 in a stratified, random sample of all inhabitants in Sweden ≥ 18 years old.

RESULTS

Totally 8,302 people (42%) answered the questionnaire. Seven percent found OTCs completely harmless regardless of how they are being used, 18% felt they should be used only on health professionals' recommendation. Differences in how OTCs are perceived were however found with regards to respondents' country of birth, family type, educational level and income. The pharmacy was still the preferred OTC drug retailer by 83% of the respondents and preferred information source by 80% Reasons for preferred retailers were primarily due to out of habit (45%), counseling provided (35%), the product range (34%) and the confidence in staff (27%). Analgesics are the most common OTCs to have at home (90%). The bathroom cabinet is the primary site for storage (42%) and 16% throw their OTC leftovers in the trash.

CONCLUSIONS

The study population does not consider OTCs as harmless regardless of how they are used, but on the other hand feels they should not be taken on health professionals' recommendation only. The pharmacy is still the preferred retailer and information source, and there is room for further improvement in the storage and disposal of OTCs. A return of OTC drug leftovers to the pharmacy should be further encouraged. Due to several limitations, great caution should however be observed when generalizing the results to the adult population of Sweden.

Medication review in German community pharmacies - Post-hoc analysis of documented drug-related problems and subsequent interventions in the ATHINA-project

BACKGROUND

Any medication can cause drug-related problems (DRPs), which can often be detected by medication reviews. So far, only limited information is available on the practicability of systematic medication reviews in community pharmacies in daily routine and their value in Germany. Since 2012, the community pharmacy-centered medication review project "ATHINA - Arzneimitteltherapiesicherheit in Apotheken [medication safety in community pharmacies]" is endorsed by four Chambers of Pharmacists in Germany. The aim of this evaluation was to post-hoc analyze the nature of medication reviews performed in ATHINA.

METHODS

For this analysis, information from anonymized, structured documentation sheets of medication reviews performed from 2012 to 2015 were analyzed. Documentation sheets contained demographic information of the patient, the patient's medication, and structured information on any information need or DRP identified for a specific drug, the pharmacists' actions taken with regard to the identified problem (e.g. contact with a physician), and whether the problem was ultimately resolved completely, partly, or not at all.

RESULTS

Overall, 241 pharmacists documented 912 medication reviews with on average 10.8 ± 3.6 drugs. In 869 reviews (95.3%), the pharmacist documented at least one drug with information need or DRP. In 75.7% (N = 3972/5248) of the drugs with at least one information need or DRP, the pharmacists documented the action taken to solve the problem. At the end of the medication review, 359 (39.4%) of the cases had only drugs with resolved or no identified problems. Overall, the ratio of DRPs per drug regimen was reduced from 56% ± 22.7 drugs with at least one information need or DRP in the beginning to 28.9% ± 18.3 in the end.

CONCLUSION

This analysis indicates that community pharmacists can deliberately identify patients with information needs and DRPs and solve many of these problems in the course of a medication review.

Development and validation of the Slovenian drug-related problem classification system based on the PCNE classification V 6.2

Background Classifying drug-related problems increases pharmacists' awareness of patients' drug-related needs and supports the development of counselling skills through increased awareness of the nature and frequency of drug-related problems. No standardised classification system was used in daily pharmacy practice in Slovenia. Objective To translate, upgrade and validate the Pharmaceutical Care Network Europe (PCNE) classification V 6.2 for use in Slovenian community pharmacies. Setting Expert panel meetings at the Faculty of Pharmacy and home-based classification validation. Methods The PCNE classification V 6.2 was translated to Slovenian language by forward-backward translation procedure. An expert panel consisting of nine practicing pharmacists upgraded the content of the translated version. Thirty-one community pharmacists validated this version with the PCNE set of 18 patient cases by coding problems, risk factors and interventions they believed were present in each case. The expert panel discussed the results and upgraded the classification accordingly. Afterwards, 33 community pharmacists validated the upgraded version with a set of 40 actual Slovenian pharmacy patient cases. Based on the results, the expert panel formed a final version of the classification. Main outcome measure Coding consistency between community pharmacists. Results The expert panel performed some major modifications to the PCNE classification V 6.2: the potential problem was added as a sub domain to problems domain; the term adverse drug event was used instead of adverse drug reaction; the causes domain was renamed to risk factors and its sub domains were organized into prescribing, dispensing and use of drugs; dispensing errors were specified; use of drugs was organized into intentional and unintentional use of drugs; the sub domains in the interventions domain were divided according to the communication and agreement with the prescriber. The average coding consistencies in the first validation study were 75 % (±16 %) for problems, 74 % (±20 %) for risk factors and 94 % (±10 %) for interventions. The average coding consistencies in the second validation study were 83 % (±16 %) for problems, 85 % (±17 %) for risk factors and 80 % (±20 %) for interventions. Conclusion A drug-related problem classification for use in Slovenian community pharmacies was developed based on The PCNE classification V 6.2. The validation studies demonstrated high coding consistencies.

The understanding of core pharmacological concepts among health care students in their final semester

BACKGROUND

The overall aim of the study was to explore health care students´ understanding of core concepts in pharmacology.

METHOD

An interview study was conducted among twelve students in their final semester of the medical program (n = 4), the nursing program (n = 4), and the specialist nursing program in primary health care (n = 4) from two Swedish universities. The participants were individually presented with two pharmacological clinically relevant written patient cases, which they were to analyze and propose a solution to. Participants were allowed to use the Swedish national drug formulary. Immediately thereafter the students were interviewed about their assessments. The interviews were audio-recorded and transcribed verbatim. A thematic analysis was used to identify units of meaning in each interview. The units were organized into three clusters: pharmacodynamics, pharmacokinetics, and drug interactions. Subsequent procedure consisted of scoring the quality of students´ understanding of core concepts. Non-parametric statistics were employed.

RESULTS

The study participants were in general able to define pharmacological concepts, but showed less ability to discuss the meaning of the concepts in depth and to implement these in a clinical context. The participants found it easier to grasp concepts related to pharmacodynamics than pharmacokinetics and drug interactions.

CONCLUSION

These results indicate that education aiming to prepare future health care professionals for understanding of more complex pharmacological reasoning and decision-making needs to be more focused and effective.

Pharmacists' role in handling problems with prescriptions for antithrombotic medication in Belgian community pharmacies

BACKGROUND

Community pharmacists have an important task in the follow-up of patients treated with antithrombotics. When delivering these medicines, pharmacists can encounter drug-related problems (DRPs) with substantial clinical and economic impact.

OBJECTIVE

To investigate the amount and type of antithrombotic related DRPs as well as how community pharmacists handled these DRPs.

SETTING

Belgian community pharmacies.

METHODS

MSc pharmacy students of six Belgian universities collected data about all DRPs encountered by a pharmacist during ten half days of their pharmacy internship. Data were registered about DRPs detected at delivery and in an a posteriori setting, when consulting the medical history of the patient. Classification of the DRP, cause of the DRP, intervention and result of the intervention were registered.

MAIN OUTCOME MEASURE

Amount and type of antotrombitocs related DRPs occurring in community pharmacies, as well as how community pharmacists handled these DRPs.

RESULTS

3.1 % of the 15,952 registered DRPs concerned antithrombotics. 79.3 % of these DRPs were detected at delivery and 20.7 % were detected a posteriori. Most antithrombotic-related DRPs concerned problems with the choice of the drug (mainly because of drug-drug interactions) or concerned logistic problems. Almost 80 % of the antithrombotic-related DRPs were followed by an intervention of the pharmacist, mainly at the patient's level, resulting in 90.1 % of these DRPs partially or totally solved.

CONCLUSION

Different DRPs with antithrombotic medication occurred in Belgian community pharmacies. About 20 % was detected in an a posteriori setting, showing the benefit of medication review. Many of the encountered DRPs were of technical nature (60.7 %). These DRPs were time-consuming for the pharmacist to resolve and should be prevented. Most of the DRPs could be solved, demonstrating the added value of the community pharmacist as first line healthcare provider.

Development of an Aggregated System for Classifying Causes of Drug-Related Problems

Background: More than 20 different types of classification systems for drug-related problems (DRPs) and their causes have been developed. Classification is necessary to describe and assess clinical, organizational, and economic impacts of DRPs through documentation of collected data. However, many researchers have judged classification systems incomplete when describing their data, and have modified them or developed their own. This variability between systems has made study comparisons difficult. Objectives: To perform a category-by-category comparison of the content of selected DRP classification systems to construct an aggregated cause-of-DRP classification system containing the content of all systems. Method: DRP classification systems were identified after a literature review, with 7 chosen based on their use in varied health care settings, geographical diversity, frequency of use, and method of development. These systems were critically analyzed, and the content of each category was compared and aggregated where appropriate. A hierarchy of categories was constructed to include all content from all systems. Any modifications that previous studies may have made to the 7 systems were also cross-referenced to ensure that no concepts were missing from the newly aggregated system. Clinical examples to optimize application, and instructions for when or when not to use categories, were developed. Interrater agreement for classification of the causes of DRPs from 10 medication reviews was performed between 3 clinical pharmacists and the authors’ gold standard. Results: We found variation in developmental methods, category descriptions, number and types of categories, and validation methods between the 7 selected systems, together with intermingling of categories identified as causes of DRPs with DRPs themselves. A hierarchical classification system was constructed consisting of 9 cause-of-DRP categories, 33 subcategories, and 58 sub-subcategories, for which interrater agreements were 82.5%, 74.6%, and 58.8%, respectively. Conclusion: An aggregated classification system was constructed through a unique and transparent developmental process that may provide the most comprehensive description of causes of DRPs to date. This may facilitate teaching of pharmaceutical care, comparisons of clinical practice, and measurement of the effectiveness of pharmaceutical care interventions.

Potential drug related problems detected by electronic expert support system in patients with multi-dose drug dispensing

Background Drug related problems (DRPs) are frequent and cause suffering for patients and substantial costs for society. Multi-dose drug dispensing (MDDD) is a service by which patients receive their medication packed in bags with one unit for each dose occasion. The clinical decision support system (CDSS) electronic expert support (EES) analyses patients' prescriptions in the Swedish national e-prescription repository and provides alerts if potential DRPs are detected, i.e. drug-drug interactions, duplicate therapy, drug-disease contraindications, high dose, gender warnings, geriatric, and paediatric alerts. Objective To analyse potential DRPs in patients with MDDD, detected by means of EES. Setting A register study of all electronically stored prescriptions for patients with MDDD in Sweden (n = 180,059) March 5-June 5, 2013. Method Drug use and potential DRPs detected in the study population during the 3 month study period by EES were analysed. The potential DRPs were analysed in relation to patients' age, gender, number of drugs, and type of medication. Main outcome measure Prevalence of potential DRPs measured as EES alerts. Results The study population was on average 75.8 years of age (± 17.5, range 1-110) and had 10.0 different medications (± 4.7, range 1-53). EES alerted for potential DRPs in 76 % of the population with a mean of 2.2 alerts per patient (± 2.4, range 0-27). The older patients received a lower number of alerts compared to younger patients despite having a higher number of drugs. The most frequent alert categories were drug-drug interactions (37 % of all alerts), duplicate therapy (30 %), and geriatric warnings for high dose or inappropriate drugs (23 %). Psycholeptics, psychoanaleptics, antithrombotic agents, anti-epileptics, renin-angiotensin system agents, and analgesics represented 71 % of all drugs involved in alerts. Conclusions EES detected potential DRPs in the majority of patients with MDDD. The number of potential DRPs was associated with the number of drugs, age, gender, and type of medication. A CDSS such as EES might be a useful tool for physicians and pharmacists to assist in the important task of monitoring patients with MDDD for potential DRPs.