Incidence of adverse drug events and medication errors in Japan: the JADE study

Efficiency of computerized clinical decision support systems involving anticoagulants: A flashmob study in Dutch hospital pharmacies

AIMS

Computerized decision support systems (CDSSs) aim to prevent adverse drug events. However, these systems generate an overload of alerts that are not always clinically relevant. Anticoagulants are frequently involved in these alerts. The aim of this study was to investigate the efficiency of CDSS alerts on anticoagulants in Dutch hospital pharmacies.

METHODS

A multicentre, single-day, cross-sectional study was conducted using a flashmob design in Dutch hospital pharmacies, which have CDSSs that operate on both a national medication surveillance database and on self-developed clinical rules. Hospital pharmacists and pharmacy technicians collected data on the number and type of alerts and time needed for assessing these alerts. The primary outcome was the CDSS efficiency on anticoagulants, defined as the percentage of alerts on anticoagulants that led to an intervention. Secondary outcomes where among other CDSSs efficiency related to any medications and the time expenditure. Descriptive data-analysis was used.

RESULTS

Of the 69 hospital pharmacies invited, 42 (61%) participated. The efficiency of CDSS alerts on anticoagulants was 4.0% (interquartile range [IQR] 14.0%) for the national medication surveillance database alerts and 14.3% (IQR 40.0%) for alerts from clinical rules. For any medication, the efficiency was lower: 1.8% (IQR 7.5%) and 13.4% (IQR 21.5%) respectively. The median time for assessing the relevance of all alerts was 2 (IQR 1:21) h/day for pharmacists and 6 (IQR 5:01) h/day for pharmacy technicians.

CONCLUSION

CDSS efficiency is generally low, both for anticoagulants and any medication, while the time investment is high. Optimization of CDSSs is needed.

Efficacy and safety of oral semaglutide in older patients with type 2 diabetes: a retrospective observational study (the OTARU-SEMA study)

BACKGROUND

Oral semaglutide in older subjects with type 2 diabetes was as effective as in younger subjects, according to phase 3 clinical trials. However, its efficacy can be limited in very aged population, due to the presence of impaired cognitive function and the complex instructions for its use. Here, we investigated its efficacy and safety by further age bracket in older subjects in real-world.

METHODS

We retrospectively studied subjects > 65 years of age with type 2 diabetes who started oral semaglutide treatment. The primary outcome was the change in glycated hemoglobin (HbA1c) over 6 months. Adverse events and cognitive function were evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) and the Hasegawa Dementia Rating Scale-revised (HDS-R). The achievement rate of glycemic targets was evaluated based on the age, health status of subjects and their use of anti-diabetic agents which can cause hypoglycemia, with additional analysis between two subgroups; early (65-74) versus late (≥ 75) older. Furthermore, we evaluated the relationships between their improvements in HbA1c and the baseline characteristics of the subjects, including their cognitive function and insulin secretory capacity.

RESULTS

We studied the efficacy of the drug in 24 subjects. Their HbA1c and body weight significantly decreased (- 13.1 ± 7.5 mmol/mol and - 3.0 ± 2.4 kg, respectively; P < 0.01). Although cognitive function was lower in the late older group (r = -0.57, P < 0.01), changes in HbA1c showed no difference between the two subgroups (P = 0.66) and it correlated with the insulin secretory capacity rather than cognitive function (r = -0.49, P < 0.05). Glycemic targets were more likely to be achieved (P < 0.01), but HbA1c excessively decreased in late older subjects who were also using insulin or an insulin secretagogue. The frequency of adverse events was similar to that in the clinical trial, whereas discontinuation of medication were more frequent among the late older subjects (Early; n = 2, Late; n = 4).

CONCLUSIONS

Oral semaglutide improves the glycemic control of older subjects, but it might be a risk for potential hypoglycemia and discontinuation because of adverse events in subjects of ≥ 75 years. Attention should be paid to insulin secretory capacity and concomitant medications rather than concern about adherence.

Polypharmacy and Bleeding Outcomes After Percutaneous Coronary Intervention

BACKGROUND

Polypharmacy was reported to be associated with major bleeding in various populations. However, there are no data on polypharmacy and its association with bleeding in patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Among 12,291 patients in the CREDO-Kyoto PCI Registry Cohort-3, we evaluated the number of medications at discharge and compared major bleeding, defined as Bleeding Academic Research Consortium Type 3 or 5 bleeding, across tertiles (T1-3) of the number of medications. The median number of medications was 6, and 88.0% of patients were on ≥5 medications. The cumulative 5-year incidence of major bleeding increased incrementally with increasing number of medications (T1 [≤5 medications] 12.5%, T2 [6-7] 16.5%, and T3 [≥8] 20.4%; log-rank P<0.001). After adjusting for confounders, the risks for major bleeding of T2 (hazard ratio [HR] 1.21; 95% confidence interval [CI] 1.08-1.36; P=0.001) and T3 (HR 1.27; 95% CI 1.12-1.45; P<0.001) relative to T1 remained significant. The adjusted risks of T2 and T3 relative to T1 were not significant for a composite of myocardial infarction or ischemic stroke (HR 0.95 [95% CI 0.83-1.09; P=0.47] and HR 1.06 [95% CI 0.91-1.23; P=0.48], respectively).

CONCLUSIONS

In a real-world population of patients undergoing PCI, approximately 90% were on ≥5 medications. Increasing number of medications was associated with a higher adjusted risk for major bleeding, but not ischemic events.

Monitoring for adverse drug events of high-risk medications with a computerized clinical decision support system: a prospective cohort study

Monitoring is recommended to prevent severe adverse drug events, but such examinations are often missed. To increase the number of monitoring that should be ordered for high-risk medications, we introduced a clinical decision support system (CDSS) that alerts and orders the monitoring for high-risk medications in an outpatient setting. We conducted a 2-year prospective cohort study at a tertiary care teaching hospital before (phase 1) and after (phase 2) the activation of a CDSS. The CDSS automatically provided alerts for liver function tests for vildagliptin, thyroid function tests for immune checkpoint inhibitors (ICIs) and multikinase inhibitors (MKIs), and a slit-lamp examination of the eyes for oral amiodarone when outpatients were prescribed the medications but not examined for a fixed period. The order of laboratory tests automatically appeared if alert was accepted. The alerts were hidden and did not appear on the display before activation of the CDSS. The outcomes were the number of prescriptions with alerts and examinations. During the study period, 330 patients in phase 1 and 307 patients in phase 2 were prescribed vildagliptin, 20 patients in phase 1 and 19 patients in phase 2 were prescribed ICIs or MKIs, and 72 patients in phase 1 and 66 patients in phase 2 were prescribed oral amiodarone. The baseline characteristics were similar between the phases. In patients prescribed vildagliptin, the proportion of alerts decreased significantly (38% vs 27%, P < 0.0001), and the proportion of examinations increased significantly (0.9% vs 4.0%, P < 0.0001) after activation of the CDSS. In patients prescribed ICIs or MKIs, the proportion of alerts decreased significantly (43% vs 11%, P < 0.0001), and the proportion of examinations increased numerically, but not significantly (2.6% vs 7.0%, P = 0.13). In patients prescribed oral amiodarone, the proportion of alerts decreased (86% vs 81%, P = 0.055), and the proportion of examinations increased (2.2% and 3.0%, P = 0.47); neither was significant. The CDSS has potential to increase the monitoring for high-risk medications. Our study also highlighted the limited acceptance rate of monitoring by CDSS. Further studies are needed to explore the generalizability to other medications and the cause of the limited acceptance rates among physicians.

Identification of adverse drug reactions that may be related to pharmacogenetics in a public hospital in the South of Brazil

BACKGROUND

Adverse drug reactions (ADRs) are of great concern in clinical practice. Pharmacogenetics can identify individuals and groups at increased risk of developing ADRs, enabling treatment adjustments to improve outcomes. The study aimed to determine the prevalence of ADRs related to drugs with pharmacogenetic evidence level 1A in a public hospital in Southern Brazil.

RESEARCH DESIGN AND METHODS

ADR information was collected from the pharmaceutical registries from 2017 to 2019. Drugs that have pharmacogenetic evidence level 1A were selected. Public genomic databases were used to estimate the genotypes/phenotypes frequency.

RESULTS

During the period, 585 ADRs were spontaneously notified. Most were moderate (76.3%), whereas severe reactions accounted for 33.8%. Additionally, 109 ADRs caused by 41 drugs presented pharmacogenetic evidence level 1A, representing 18.6% of all notified reactions. Depending on the drug-gene pair, up to 35% of individuals from Southern Brazil could be at risk of developing ADRs.

CONCLUSIONS

Relevant amount of ADRs were related to drugs with pharmacogenetic recommendations on drug labels and/or guidelines. Genetic information could guide and improve clinical outcomes, decreasing ADR incidence and reducing treatment costs.

Multicenter prospective observational study on hospital pharmacist interventions to reduce inappropriate medications

Background: In Japan, the involvement of hospital pharmacists in inappropriate medications (IMs) practices has not been sufficiently reported. Therefore, this prospective study described the interventions of hospital pharmacists in discontinuing inappropriate drugs or reducing drug doses. Methods: We conducted a prospective, multicenter, observational study to investigate the intervention of hospital pharmacists in inappropriate prescriptions for inpatients in September 2018. Fifty pharmacists from 45 hospitals in Japan participated in this study. IMs were defined as medications that pharmacists deemed inappropriate for patient treatment. The subjects of the study were patients who interacted with the participating pharmacists. Results: During the study period, the median number of beds in hospitals where the 50 participating pharmacists worked was 380, and the average number of beds for which the pharmacists were responsible was 49. The enrolled hospital pharmacists recommended that doctors discontinue or reduce the doses of their regular drugs for 347 out of 1,415 (24.5%) patients. Among the 391 pharmacists' recommendations to reduce IMs for 347 patients, physicians accepted 368 (94.1%) recommendations, and 523 drugs were discontinued as a result. Pharmacist intervention also led to improvements in hypnotic sedation, delirium, and hypotension. The most common reasons for IMs identified by pharmacists were "long-term administration of irresponsible or aimless medications" (44.5%), "adverse effects caused by medications" (31.5%), and "medications-mediated duplication of the pharmacological effect" (15.3%). Approximately 90% of pharmacists' suggestions to reduce medications were accepted for each reason. The average number of regular medications used by patients involved in drug reduction was 8.2, and the average number of medications reduced was 1.7. A sub-analysis showed that patients using opioids tended to take more medications, and these patients were able to reduce the amount of medications taken. Interventions by pharmacists certified in palliative pharmacies tended to reduce adverse drug events. Conclusion: This was the first multicenter prospective observational study conducted in Japan to demonstrate hospital pharmacist intervention's effectiveness in promoting appropriate prescription and, consequently, a reduction in the number of medications in use and polypharmacy.

An Early Adverse Drug Event Detection Approach with False Discovery Rate Control

Adverse drug event (ADE) is a significant challenge in clinical practice. Many ADEs have not been identified timely after the approval of the corresponding drugs. Despite the use of drug similarity network demonstrates early success on improving ADE detection, false discovery rate (FDR) control remains unclear in its application. Additionally, performance of early ADE detection has not been explicitly investigated under the time-to-event framework. In this manuscript, we propose to use the drug similarity based posterior probability of null hypothesis for early ADE detection. The proposed approach is also able to control FDR for monitoring a large number of ADEs of multiple drugs. The proposed approach outperforms existing approaches on mining labeled ADEs in the US FDA's Adverse Event Reporting System (FAERS) data, especially in the first few years after the drug initial reporting time. Additionally, the proposed approach is able to identify more labeled ADEs and has significantly lower time to ADE detection. In simulation study, the proposed approach demonstrates proper FDR control, as well as has better true positive rate and an excellent true negative rate. In our exemplified FAERS analysis, the proposed approach detects new ADE signals and identifies ADE signals in a timelier fashion than existing approach. In conclusion, the proposed approach is able to both reduce the time and improve the FDR control for ADE detection.

Signal mining and analysis for central nervous system adverse events due to taking oxycodone based on FAERS database

OBJECTIVES

Central nervous system adverse events (AEs) occur when oxycodone is used in combination with benzodiazepines, antidepressants and anticonvulsants. There have been no reports of central nervous system AEs with oxycodone alone or in combination with oxycodone. Based on USA Food and Drug Administration Adverse Event Reporting System (FAERS) data, this study aims to explore the risk signals of central nervous system AEs with oxycodone alone or in combination with benzodiazepines, antidepressants and anticonvulsants, and to provide a reference for the safe and rational use of this drug.

METHODS

Extracted AEs data from the FAERS for oxycodone alone and in combination with benzodiazepines, antidepressants, and anticonvulsants from Q1 2004 to Q2 2021. The risk signal mining analysis of AEs was performed using the proportional imbalance method and Bayesian method. Number of reports ≥3 and lower 95% CI limit of reporting odds ratio (ROR)>1; number of reports ≥3, proportional reporting ratio (PRR)≥2 and χ2≥4; lower information components (IC) lower 95% CI limit (IC025)>0; empirical Bayes geometric mean (EBGM) lower 95% CI limit (EBGM05)>2, and N>0 were defined as positive signals.

RESULTS

A total of 5 793 reports of central nervous system AEs with oxycodone alone were tapped, and 366, 622, and 740 reports of combined benzodiazepines, antidepressants, and anticonvulsants, respectively. Consumers and physicians were the main reporting population. The age distribution of oxycodone alone was mainly from 61 to 80 years old. The age distribution of oxycodone in combination with related drugs was mainly from 46 to 60 years old. The risk of AEs was greater in women than in men, and the United States was the predominant reporting country. Oxycodone alone was strongly associated with myoclonus [ROR=2.92, 95% CI 2.28 to 3.76); PRR=2.92, χ2(77.49); IC=1.52, IC025(0.65); EBGM=2.89, EBGM05(2.33)], delirium [ROR=4.69, 95% CI 4.24 to 5.21; PRR=4.66, χ2(1 052.64); IC=2.17, IC025(1.81); EBGM=4.50, EBGM05 (4.13)], mental disorder [ROR=2.95, 95% CI 2.53 to 3.44; PRR=2.94, χ2(206.93); IC=1.56, IC025(0.96); EBGM=2.95, EBGM05(2.58)], and acute central respiratory depression [ROR=2.87, 95% CI 2.68 to 3.08); PRR=2.82, χ2(971.62); IC=1.52, IC025(1.33), EBGM=2.87, EBGM05 (2.76)]. Combination of benzodiazepines was most strongly associated with mental disorder [ROR=10.08, 95% CI 9.38 to 10.78; PRR=9.90, χ2(64.06); IC=3.33, IC025 (1.65); EBGM=10.08, EBGM05(5.61)], and tremor [ROR=3.09, 95% CI 2.76 to 3.42); PRR=3.08, χ2(48.93); IC=1.63, IC025 (1.17); EBGM=3.09, EBGM05(2.34)]. Combination of antidepressants was most strongly associated with delirium [ROR=13.23, 95% CI 12.23 to 14.23; PRR=12.87, χ2(43.86); IC=3.69, IC025(1.36); EBGM=12.23, EBGM05 (5.32)] and somnolence [ROR=6.74, 95% CI 6.15 to 7.33); PRR=6.73, χ2(53.42); IC=2.75, IC025(1.52); EBGM=6.73, EBGM05(4.10)]. Combination of anticonvulsants was most strongly associated with myoclonus [ROR=17.89, 95% CI 17.46 to 18.32; PRR=17.72, χ2(971.39); IC=4.16, IC025(2.70); EBGM=17.89, EBGM05(12.46)] and delirium [ROR=4.86, 95% CI 4.45 to 5.27); PRR=4.82, χ2(69.49); IC=2.28, IC025 (1.51); EBGM=4.86, EBGM05(3.44)].

CONCLUSIONS

Based on pharmacovigilance studies of the FAERS database, clinical medication monitoring of oxycodone alone and in combination with benzodiazepines, antidepressants, and anticonvulsants should be strengthened to be alert to the occurrence of central nervous system-related AEs.

Reporting Antimicrobial-Related Adverse Drug Events in Jordan: An Analysis from the VigiBase Database

This study aims to assess the reporting of antimicrobial-related adverse drug events (ADEs) in Jordan between 2003 and 2022. Data regarding the antimicrobial-related ADEs were extracted from the WHO's global database (VigiBase) by the Rational Drug Use and Pharmacovigilance Department at the Jordan Food and Drug Administration (JFDA). A total of 279 Individual Case Safety Reports (ICSRs) were recorded. The number of ICSRs increased from 2019 onwards (219 out of 279 cases). This increase in the reported ADEs was influenced by the actions of the JFDA, including the introduction of electronic reporting forms, updating the national pharmacovigilance guidelines, which encouraged adverse drug reactions reporting, the implementation of the AMR-national action plan, the encouragement to report due to COVID-19 vaccine, and the continuous awareness campaigns and training programs. Skin and subcutaneous tissue disorders (n = 105; 19.48%) were the most reported antimicrobial-related ADEs. The highest number of ADEs was reported for tetracyclines (n = 101; 18.74%) followed by fluoroquinolones (n = 54; 10.02%), third-generation cephalosporines (n = 48; 8.9%), and carbapenems (n = 42; 7.79%). From the top 10 consumed antibiotics, the number of ADEs in patients who consumed Watch group antibiotics (97 ADEs) was higher than those who consumed Access group antibiotics (28 ADEs). The findings highlight the need to monitor and rationalize the use of Watch antibiotics. Enhanced reporting of antimicrobial-related adverse drug reactions is needed to inform antimicrobial stewardship and improve the pharmacovigilance system in Jordan.

Incidence and Economic Burden of Adverse Drug Reactions in Hospitalization: A Prospective Study in Korea

BACKGROUND

Adverse drug reactions (ADRs) are escalating, and their socioeconomic burden is increasing. However, large-scale prospective studies investigating ADRs during hospitalization are rare in Korea. We prospectively investigated the incidence, characteristics, and economic burden of ADRs in hospitalized patients based on electronic medical records (EMRs).

METHODS

Among patients admitted to three hospitals from October 2016 to October 2017, 5,000 patients were randomly selected and prospectively observed during hospitalization. Research nurses monitored and detected patients who had symptoms, signs, or laboratory findings suspicious for ADRs using an EMR-based detection protocol. Next, allergy and ADR specialists reviewed the medical records to determine the relationship between adverse reactions and drugs. Cases in which a causal relationship was certain, probable/likely, or possible were included in the ADR cases. Clinically meaningful ADR cases or those leading to prolonged hospitalization were defined as significant ADRs.

RESULTS

ADRs occurred in 510 (10.2%) patients. The mean length of hospital stay was approximately 5 days longer in patients with ADRs. Opioids accounted for the highest percentage of total ADRs. Significant ADRs were observed in 148 (3.0%) patients. Antibiotics accounted for the highest percentage of significant ADRs. Drug hypersensitivity reactions (DHRs) occurred in 88 (1.8%) patients. Antibiotics accounted for the highest percentage of DHRs. The average medical expenses for one day of hospitalization per patient were highest in significant ADRs, followed by non-significant ADRs, and non-ADRs.

CONCLUSION

ADRs in hospitalized patients are an important clinical issue, resulting in a substantial socioeconomic burden. EMR-based strategy could be a useful tool for ADR monitoring and early detection.

Incidence and patterns of adverse drug reactions among adult patients hospitalized in the University of Gondar comprehensive specialized hospital: A prospective observational follow-up study

BACKGROUND

Adverse drug reactions (ADRs) have continued to be a public health challenge with significant clinical and healthcare costs. However, little is known regarding the incidence of ADR in Ethiopia, particularly in the study setting. Thus, this study aimed to assess the incidence and patterns of ADRs in patients admitted to the University of Gondar comprehensive specialized hospital (UoGCSH).

METHODS

A prospective observational follow-up study was conducted on admitted patients at the medical ward in the UoGCSH from May to August 2022. A multifaceted approach involving daily chart review and patient interviews was employed to collect the data. A standard Naranjo ADR Probability Scale measuring tool was used to characterize the probability of existing ADR. The data was analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Logistic regression analysis was employed to determine the association between the occurrence of ADRs and other variables. A p-value at the 95% confidence interval was considered statistically significant.

RESULTS

This study included 237 participants in total. The average length of follow-up was 16.4 (±5.2) days. Overall, 65 ADRs were identified, resulting an incidence rate of 27.4 (95% CI: 19.8-30.4) per 100 admissions. The most common ADRs were hypokalemia (10.7%), followed by constipation, diarrhea, hypotension, and rash (9.2% each). The majority of these ADRs (73.8%) were classified as "definite" by the Naranjo ADR probability scale. Gastrointestinal tract (GIT) (41.5%) and metabolic (18.6%) were the most frequently exposed systems for ADR. Antibiotics (26.2%) and cardiovascular medications (24.7%) were the most frequently implicated medications in existing ADRs. ADRs were significantly associated with age (p = 0.035), the presence of comorbidities (p = 0.021) and complications (p = 0.008), and receiving a higher number of medications (p = 0.04).

CONCLUSION

In this study, ADR was identified in about one-fourth of the participants. Older patients, patients with comorbidities and complications, and patients who received a higher number of medications were more likely exposed for ADRs. Healthcare providers should strictly follow the admitted patients to minimize ADRs.

Automatic Detection of Adverse Drug Events in Geriatric Care: Study Proposal

BACKGROUND

One-third of older inpatients experience adverse drug events (ADEs), which increase their mortality, morbidity, and health care use and costs. In particular, antithrombotic drugs are among the most at-risk medications for this population. Reporting systems have been implemented at the national, regional, and provider levels to monitor ADEs and design prevention strategies. Owing to their well-known limitations, automated detection technologies based on electronic medical records (EMRs) are being developed to routinely detect or predict ADEs.

OBJECTIVE

This study aims to develop and validate an automated detection tool for monitoring antithrombotic-related ADEs using EMRs from 4 large Swiss hospitals. We aim to assess cumulative incidences of hemorrhages and thromboses in older inpatients associated with the prescription of antithrombotic drugs, identify triggering factors, and propose improvements for clinical practice.

METHODS

This project is a multicenter, cross-sectional study based on 2015 to 2016 EMR data from 4 large hospitals in Switzerland: Lausanne, Geneva, and Zürich university hospitals, and Baden Cantonal Hospital. We have included inpatients aged ≥65 years who stayed at 1 of the 4 hospitals during 2015 or 2016, received at least one antithrombotic drug during their stay, and signed or were not opposed to a general consent for participation in research. First, clinical experts selected a list of relevant antithrombotic drugs along with their side effects, risks, and confounding factors. Second, administrative, clinical, prescription, and laboratory data available in the form of free text and structured data were extracted from study participants' EMRs. Third, several automated rule-based and machine learning-based algorithms are being developed, allowing for the identification of hemorrhage and thromboembolic events and their triggering factors from the extracted information. Finally, we plan to validate the developed detection tools (one per ADE type) through manual medical record review. Performance metrics for assessing internal validity will comprise the area under the receiver operating characteristic curve, F1-score, sensitivity, specificity, and positive and negative predictive values.

RESULTS

After accounting for the inclusion and exclusion criteria, we will include 34,522 residents aged ≥65 years. The data will be analyzed in 2022, and the research project will run until the end of 2022 to mid-2023.

CONCLUSIONS

This project will allow for the introduction of measures to improve safety in prescribing antithrombotic drugs, which today remain among the drugs most involved in ADEs. The findings will be implemented in clinical practice using indicators of adverse events for risk management and training for health care professionals; the tools and methodologies developed will be disseminated for new research in this field. The increased performance of natural language processing as an important complement to structured data will bring existing tools to another level of efficiency in the detection of ADEs. Currently, such systems are unavailable in Switzerland.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40456.

Two factors that can increase the length of hospital stay of patients with dementia

OBJECTIVES

Patients with dementia are at greater risk of a long hospital stay and this is associated with adverse outcomes. The aim of this service evaluation was to identify variables most predictive of increased length of hospital stay amongst patients with dementia.

METHODS/DESIGN

We conducted a retrospective analysis on a cross-sectional hospital dataset for the period January-December 2016. Excluding length of stay less than 24h and readmissions, the sample comprised of 1133 patients who had a dementia diagnosis on record.

RESULTS

The highest incidence rate ratio for length of stay in the dementia sample was: (a) discharge to a care home (IRR: 2.443, 95% CI 1.778-3.357), (b) falls without harm (IRR: 2.486, 95% CI 2.029-3.045).

CONCLUSIONS

Based on this dataset, we conclude that improvements made to falls prevention strategies in hospitals and discharge planning procedures can help to reduce the length of stay for patients with dementia.

Low Serum Total Protein at Admission Predicts in-Hospital Mortality Among General Inpatients: Historical Cohort Study

Purpose

Low total protein (TP) is associated with mortality among patients with specific diseases, but its association was uncertain among general patients. We evaluated the effects of low TP on in-hospital mortality among general inpatients.

Patients and Methods

We used data from the Japan Adverse Drug Events study series. We enrolled adult inpatients (≥ 16 years) admitted to a tertiary care hospital between September 1 and November 30, 2013. We excluded patients with multiple myeloma, pregnant women, and bone marrow graft donors. Patient data were extracted from electronic medical records. All patients were stratified into those with and without malignancy and divided into the low and normal TP groups. Low TP was defined as < 6.5 g/dL. We compared the in-hospital mortality of the low and normal TP groups stratified by the presence of malignancy.

Results

Among the 2235 enrolled patients (mean age, 67.8 years), the TP value was lower in 516 patients with malignancy than in 1719 patients without malignancy (6.6 g/dL vs 6.8 g/dL, P = 0.0002). Among patients without or with malignancy, 27% (462/1719) and 35% (183/516) were in the low TP group, respectively. Mortality was higher in the low TP group among patients without malignancy (23.2% vs 10.2%, P < 0.0001). Likewise, among patients with malignancy, mortality was higher in the low TP group (34.7% vs 11.3%, P = 0.0029). The adjusted hazard ratio of the low TP group was 1.75 (95% confidence interval, 1.04–2.96) in patients without malignancy and 2.45 (95% confidence interval, 1.12–5.37) in patients with malignancy, but the interaction was not significant (P = 0.23).

Conclusion

Low TP values were associated with higher in-hospital mortality among general inpatients, and this association was observed among patients with and those without malignancy. Routinely measured TP should be utilized to risk stratification on admission.

Systematic Review of Risk Factors Assessed in Predictive Scoring Tools for Drug-Related Problems in Inpatients

Drug-related problems (DRP, defined as adverse drug events/reactions and medication errors) are a common threat for patient safety. With the aim to aid improved allocation of specialist resources and to improve detection and prevention of DRP, numerous predictive scoring tools have been proposed. The external validation and evidence for the transferability of these tools still faces limitations. However, the proposed scoring tools include partly overlapping sets of similar factors, which may allow a new approach to estimate the external usability and validity of individual risk factors. Therefore, we conducted this systematic review and analysis. We identified 14 key studies that assessed 844 candidate risk factors for inclusion into predictive scoring tools. After consolidation to account for overlapping terminology and variable definitions, we assessed each risk factor in the number of studies it was assessed, and, if it was found to be a significant predictor of DRP, whether it was included in a final scoring tool. The latter included intake of ≥ 8 drugs, drugs of the Anatomical Therapeutic Chemical (ATC) class N, ≥1 comorbidity, an estimated glomerular filtration rate (eGFR) <30 mL/min and age ≥60 years. The methodological approach and the individual risk factors presented in this review may provide a new starting point for improved risk assessment.

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.

Incidence of adverse drug events in patients hospitalized in the medical wards of a teaching referral hospital in Ethiopia: a prospective observational study

BACKGROUND

Adverse drug events (ADEs) are an important public health problem with considerable clinical and economic costs. However there are limited studies of ADE incidence in adult inpatients in low-income countries, particularly in Ethiopia. Hence, this study aimed to assess the incidence of adverse drug events and associated factors in patients hospitalized in the medical wards of Wolaita Sodo University teaching referral hospital (WSUTRH).

METHODS

A prospective observational study was conducted involving 240 patients admitted to the medical wards of WSUTRH. A checklist was used for data collection, while standard tools were employed for assessing the probability and characterization of ADEs. A multifaceted approach involving daily chart review, patient interview, attendance at ward rounds and/or meetings, and staff reports were employed to collect the data. To identify factors independently associated with ADEs, logistic regression analysis was conducted using Stata version 15.

RESULTS

Patients were followed from ward admission to discharge, accounting for 2200 patient-days of hospital stay. Overall, 976 medications were ordered during the hospital stay. Sixty-four ADEs were identified with an incidence of approximately 27 per 100 admissions and 29 per 1000 patient days. Of the total ADEs, 59% were preventable. Regarding the severity, 2% of the ADEs were severe, while 54% were moderate. The risk of ADEs increased with longer hospital stay (LOHS) (p = 0.021), in patients with blood and immune disease diagnosis (p = 0.001), use of cardiovascular medicines (p = 0.028), and an increase in the number of medications prescribed (p = 0.021).

CONCLUSIONS

In this study, ADEs were identified in about one-quarter of the participants. Longer hospital stays, blood and immune diseases, cardiovascular medicines use, and multiple medication use had increased the likelihood of ADE occurrences. The majority of the ADEs were preventable, indicating the existence of a window of opportunity to ensure patient safety.

Medication Prescription Errors in the Intensive Care Unit: Prospective Observational Study

Introduction

The WHO launched a 5-year global initiative to address the problem of medication errors on March 29, 2017, targeting a decrease in severe and avoidable medication-related harm by 50% in all the countries. Since prescription errors are preventable, this study was conducted to determine incidence and severity of medication prescription errors (MPEs).

Settings and design

Intensive care unit of a tertiary care academic hospital, prospective observational study.

Methods and materials

For all patients admitted in a medical ICU, baseline data (demographic, APACHE II, length of ICU stay, and days of mechanical ventilation) were noted. Treatment charts were reviewed daily, and each prescription was compared against a master chart prepared using standardized references to study the incidence of prescription errors. Severity classification was done using National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) classification. Mean and median, along with standard deviation and interquartile range, were calculated for all quantitative variables. Multivariate linear regression analysis model was used.

Results

Out of the total 24,572 medication orders, 2,624 had prescription errors, an error rate of 10.7% (95% CI, 10.3–11.1). When analyzed for severity, 1,757 (7.15%) (95% CI, 6.8–7.5) MPEs did not result in patient harm and 867 (3.52%) (95% CI, 3.3–3.8) MPEs required interventions and/or resulted in patient harm. Patients with deranged creatinine (p <0.001) and INR (p = 0.024) had higher number of severe MPEs.

Conclusion

The incidence of MPEs in the medical ICU at the tertiary care hospital was 10.7%, 3.52% being severe errors.

How to cite this article

Kumar M, Sahni N, Shafiq N, Yaddanapudi LN. Medication Prescription Errors in the Intensive Care Unit: Prospective Observational Study. Indian J Crit Care Med 2022;26(5):555–559.

Epidemiology of adverse drug events and medication errors in four nursing homes in Japan: the Japan Adverse Drug Events (JADE) Study

BACKGROUND

Worldwide, the emergence of super-ageing societies has increased the number of older people requiring support for daily activities. Many elderly residents of nursing homes (NHs) take drugs to treat chronic conditions; however, there are few reports of medication safety in NHs, especially from non-western countries.

OBJECTIVE

We examined the incidence and nature of adverse drug events (ADEs) and medication errors (MEs) in NHs for the elderly in Japan.

DESIGN, SETTING, AND PARTICIPANTS

The Japan Adverse Drug Events Study for NHs is a prospective cohort study that was conducted among all residents, except for short-term admissions, at four NHs for older people in Japan for 1 year.

MEASUREMENTS

Trained physicians and psychologists, five and six in number, respectively, reviewed all charts of the residents to identify suspected ADEs and MEs, which were then classified by the physicians into ADEs, potential ADEs and other MEs after the exclusion of ineligible events, for the assessment of their severity and preventability. The kappa score for presence of an ADE and preventability were 0.89 and 0.79, respectively.

RESULTS

We enrolled 459 residents, and this yielded 3315 resident-months of observation time. We identified 1207 ADEs and 600 MEs (incidence: 36.4 and 18.1 per 100 resident-months, respectively) during the study period. About one-third of ADEs were preventable, and MEs were most frequently observed in the monitoring stage (72%, 433/600), with 71% of the MEs occurring due to inadequate observation following the physician's prescription.

CONCLUSION

In Japan, ADEs and MEs are common among elderly residents of NHs. The assessment and appropriate adjustment of medication preadmission and postadmission to NHs are needed to improve medication safety, especially when a single physician is responsible for prescribing most medications for the residents, as is usually the case in Japan.

A comprehensive method for the quantification of medication error probability based on fuzzy SLIM

Medication errors can endanger the health and safety of patients and need to be managed appropriately. This study aimed at developing a new and comprehensive method for estimating the probability of medication errors in hospitals. An extensive literature review was conducted to identify factors affecting medication errors. Success Likelihood Index Methodology was employed for calculating the probability of medication errors. For weighting and rating of factors, the Fuzzy multiple attributive group decision making methodology and Fuzzy analytical hierarchical process were used, respectively. A case study in an emergency department was conducted using the framework. A total number of 17 factors affecting medication error were identified. Workload, patient safety climate, and fatigue were the most important ones. The case study showed that subtasks requiring nurses to read the handwritten of other nurses and physicians are more prone to human error. As there is no specific method for assessing the risk of medication errors, the framework developed in this study can be very useful in this regard. The developed technique was very easy to administer.

An Analysis of Judicial Cases Concerning Analgesic-Related Medication Errors in the Republic of Korea

OBJECTIVES

Analgesic-related medication errors can be a threat to patient safety. This study aimed to identify and describe medication errors that can cause serious adverse drug events (ADEs) related to analgesic use.

METHODS

This retrospective, observational, medicolegal study analyzed closed cases concerning complications induced by medication errors involving 3 commonly used analgesics: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen (AAP). Cases closed between 1994 and 2019 that were available in the Korean Supreme Court judgment database system were included. Medication errors were categorized using a classification system (developed by our group) based on the stage of drug administration. Clinical characteristics and judgment statuses were analyzed.

RESULTS

A total of 71 cases were included in the final analysis (opioids, n = 30; NSAIDs, n = 35; AAP, n = 6). Among them, 43 claims (60.6%) resulted in payments to the plaintiffs, with a median payment of $86,607 (interquartile range, $34,554-$193,782). The severity of ADEs was high (National Association of Insurance Commissioners scale ≥6) in 88.7% (n = 63) of claims, with a total of 44 (62%) deaths. The most common types of ADEs associated with opioid, NSAID, and AAP use were respiratory depression, anaphylactic shock, and fulminant hepatitis, respectively. The most common recognized medication errors associated with opioid, NSAIDs, and AAP were inappropriate patient monitoring (n = 10; 33.3%), improper analgesic choice (n = 15; 42.9%), and inappropriate treatment after ADEs (n = 3; 50%), respectively.

CONCLUSIONS

Our findings indicate that efforts should be made to reduce medication errors related to analgesic use to prevent permanent injury and potential malpractice claims.

Medication Errors at a Tertiary Hospital Intensive Care Unit

Background

The intensive care unit (ICU) generates more medication prescriptions per patient day than any other unit in the hospital. The dynamics of the ICU environment, coupled with the complexity of patient pathology, increases the risk of medication errors. This study aimed to evaluate the incidence and spectrum of medication errors in an adult general ICU in Johannesburg, South Africa.

Methods

A retrospective chart review was conducted at a 19-bed ICU in a tertiary-level hospital in Johannesburg. Data were independently collected by two of the study investigators. The doctors’ prescription and the nurses’ administration section of patient bedside charts were scrutinized for drug prescription and administration errors.

Results

Of the 656 patient days studied, 3237 drugs (5.6 drugs per patient day) were prescribed. There were a total of 359 medication errors, comprising 237 (66.0%) prescription and 122 (34.0%) administration errors. The total error rate per 1000 patient days was 621.1, while the total error rate per 1000 drug prescriptions was 110.9. The most common errors were incorrect dose prescribed (n=69, 19.2%), incorrect dosing interval prescribed (n=48, 13.4%), incorrect dose administered (n=42, 11.7%) and failure to administer the prescribed drug (n=38, 10.6%).

Conclusion

The overall occurrence of medication errors is high but is in keeping with general international trends. Targeted interventions should be implemented to minimize the frequency of medication errors in the ICU and consequent risk to patients.

Patterns of adverse drug reactions (ADRs) in Saudi Arabia

Background

Pharmacovigilance enhances post-market drug safety. However, analytical reports of a pattern of adverse drug reactions (ADRs) experienced by patients in Saudi Arabia are demanded.

Objective

To describe patterns of ADRs submitted to the Saudi Central National Pharmacovigilance and Drug Safety Center (NPC), Saudi Food and Drug Administration (SFDA), from its inception in 2015 until the end of 2017 to understand the pattern of ADR reporting in Saudi Arabia.

Methods

In this retrospective study, data from cases reported to the NPC were used to determine ADRs and identify the most common associated drug classes based on anatomical therapeutic chemical (ATC) classification system.

Result

A total of 17,730 ADR cases were reported during study period. An annual increase in ADRs was clearly evident. Approximately 54% of the total ADRs reported were serious. Most commonly reported ATC drug classes were anti-infective agents for systemic use (22.27%), antineoplastic and immunomodulating agents (21.49%), alimentary tract and metabolism (15.48 %), cardiovascular system (11.11%) and nervous system (10.23%). Vancomycin (2.7%), ceftiraxone (1.8%), fingolimod (1.4%) and paracetamol (1.4%) were the most common drugs associated with serious ADRs.

Conclusion

This study provide valuable insights in hypothesis generation for future studies on drug-event interactions and amplification studies. The NPC educational programs and awareness campaigns to promote systematic reporting of ADRs among healthcare professionals and general public should be continued.

Characterization of Medication Errors in a Medical Intensive Care Unit of a University Teaching Hospital in South Korea

OBJECTIVES

The objective of this study was to characterize the current status of medication errors (MEs) throughout the medication therapy process from prescribing to use and monitoring in a medical intensive care unit (MICU) in Korea.

METHODS

Four trained research pharmacists collected data through retrospectively reviewing electronic medical records for adults hospitalized in the MICU in 2017. The occurrence of MEs was determined through interprofessional team discussion led by an academic faculty pharmacist and a medical intensivist based on the medication administration records (MARs). The type of MEs and the consequent ME-related outcome severity were categorized according to the Pharmaceutical Care Network Europe and the National Coordinating Council for Medication Error Reporting and Prevention, respectively.

RESULTS

Overall, electronic medical records for 293 patients with 78,761 MARs were reviewed in this study. At least one type of ME occurred in 271 patients (92.5%) in association with 16,203 MARs (21%), primarily caused by inappropriate dose (35.5%), drug (27.8%), and treatment duration (25.1%). Clinically significant harmful events occurred in 24 patients (8%), including life-threatening (n = 5) and death (n = 2) cases. The 2 patients died of enoxaparin-induced fatal hemorrhage and neutropenia associated with ganciclovir and cefepime. Antibiotics were the most common culprit medications leading to clinically significant harmful events.

CONCLUSIONS

In conclusion, MEs are prevalent in the MICU in Korea, most commonly prescribing errors. Although mostly benign, harmful events including deaths may occur due to MEs, mainly associated with antibiotics. Systematic strategies to minimize these potentially fatal MEs are urgently needed.

Association between induction of the self-management system for preventing readmission and disease severity and length of readmission in patients with heart failure

Objective

We recently developed the self-management system using the HF points and instructions to visit hospitals or clinics when the points exceed the pre-specified levels. We found that the self-management system decreased the hospitalization for HF with an increase in unplanned visits and early intervention in the outpatient department. However, it is unclear whether we managed severe HF outpatients who should have been hospitalized. In this study, we aimed to compare HF severity in rehospitalized patients with regard to self-management system use.

Results

We retrospectively enrolled 306 patients (153 patients each in the system user and non-user groups) using propensity scores (PS). We compared HF severity and length of readmission in rehospitalized patients in both groups. During the 1-year follow-up period, 24 system users and 43 non-system users in the PS-matched cohort were hospitalized. There were no significant differences between the groups in terms of brain natriuretic peptide levels at readmission, maximum daily intravenous furosemide dose, percentage of patients requiring intravenous inotropes, duration of hospital stay and in-hospital mortality. These results suggest that the HF severity in rehospitalized patients was not different between the two groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-021-05864-6.

Differences in adverse drug events and medication errors among pediatric inpatients aged <3 and ≥3 years: The JADE study

Background

Adverse drug events (ADEs) are defined as any injuries due to medication use. We hypothesized that the incidences of ADEs and medication errors (MEs) could be associated with linguistic skills of pediatric patients.

Methods

We analyzed data from the Japan Adverse Drug Events study on pediatric inpatients. This study included inpatients aged one months and older and less than seven years old. We compared the primary outcome of ADEs and MEs between patients aged under three years and three years and older as children typically do not acquire sufficient linguistic skills until around three years of age.

Results

This study included 639 patients; 412 (64%) patients aged under three years and 227 (36%) patients aged three years and older. We identified 241 ADEs in 639 patients; 152 ADEs among patients aged under three years (37 ADEs per 100 patients) and 89 ADEs among those aged three years and older (39 ADEs per 100 patients). ADEs among patients aged under three years were less likely to be found (49 ADEs) during their hospital stay than those aged three years and older (20 ADEs) ( P = 0.02). Among 172 MEs identified in 639 patients, 25 MEs (15%) resulted in ADEs; 23 (92%) occurred to those aged under three years and two (8%) occurred to those aged three years and older ( P = 0.0008).

Conclusion

ADEs were less likely to be found and MEs resulted in ADEs more frequently in patients under three years old, and these differences could be explained by differences in their linguistic skill levels.

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

Estimation of adverse drug reaction reporting in Iran: Correction for underreporting

PROPOSE

Underreporting of Adverse Drug Reactions (ADRs) reduces the sensitivity of pharmacovigilance systems. We described ADR reporting and its trend from 1999 to 2017 and estimated the ADR underreporting in the Iranian Pharmacovigilance Center.

METHODS

We expressed the number of ADR reporting per inhabitants and admissions and their possible trends. Finally, ADR underreporting percentages were estimated by three approaches: prospective studies, literature review, stratification of the country; and the trend of the proportion of ADR per inhabitants was corrected.

RESULTS

The proportion of ADR reporting was 15.3 per 100 000 inhabitants (95% CI: 15.2, 15.8) and 10.0 per 100 000 admissions (95% CI: 9.8, 10.2) in 2017, and its trend was increasing with 16.3% average change per annum during 19 years. The median of estimated percentages of underreporting was 76.0% (IQR: 64.32-81.35). After the correction, the mean proportion of ADR reporting for 19 years reached from 5.87 to 10.33 per 100 000 inhabitants.

CONCLUSIONS

The trend of ADRs reporting has been increasing over the 19 years but is still low. This study showed a considerable underreporting of ADR, and about one of four detected ADRs were reported to the pharmacovigilance center from 1999 to 2017.

Predicting Adverse Drug Events in Chinese Pediatric Inpatients With the Associated Risk Factors: A Machine Learning Study

The aim of this study was to apply machine learning methods to deeply explore the risk factors associated with adverse drug events (ADEs) and predict the occurrence of ADEs in Chinese pediatric inpatients. Data of 1,746 patients aged between 28 days and 18 years (mean age = 3.84 years) were included in the study from January 1, 2013, to December 31, 2015, in the Children’s Hospital of Chongqing Medical University. There were 247 cases of ADE occurrence, of which the most common drugs inducing ADEs were antibacterials. Seven algorithms, including eXtreme Gradient Boosting (XGBoost), CatBoost, AdaBoost, LightGBM, Random Forest (RF), Gradient Boosting Decision Tree (GBDT), and TPOT, were used to select the important risk factors, and GBDT was chosen to establish the prediction model with the best predicting abilities (precision = 44%, recall = 25%, F1 = 31.88%). The GBDT model has better performance than Global Trigger Tools (GTTs) for ADE prediction (precision 44 vs. 13.3%). In addition, multiple risk factors were identified via GBDT, such as the number of trigger true (TT) (+), number of doses, BMI, number of drugs, number of admission, height, length of hospital stay, weight, age, and number of diagnoses. The influencing directions of the risk factors on ADEs were displayed through Shapley Additive exPlanations (SHAP). This study provides a novel method to accurately predict adverse drug events in Chinese pediatric inpatients with the associated risk factors, which may be applicable in clinical practice in the future.

The Burden of Preventable Adverse Drug Events on Hospital Stay and Healthcare Costs in Japanese Pediatric Inpatients: The JADE Study

Background:

Adverse drug events (ADEs) are a burden to the healthcare system. Preventable ADEs, which was ADEs due to medication errors, could be reduced if medication errors can be prevent or ameliorate.

Objective:

We investigated the burden of preventable ADEs on the length of hospital stay (LOS) and costs, and estimated the national burden of preventable ADEs in pediatric inpatients in Japan.

Methods:

We analyzed data from the Japan Adverse Drug Events (JADE) study on pediatric patients and estimated the incidence of preventable ADEs and associated extended LOS. Costs attributable to extended LOS by preventable ADEs were calculated using a national statistics database and we calculated the effect of preventable ADEs on national cost excess.

Results:

We included 907 patients with 7377 patient-days. Among them, 31 patients (3.4%) experienced preventable ADEs during hospitalization. Preventable ADEs significantly increased the LOS by 14.1 days, adjusting for gender, age, ward, resident physician, surgery during hospitalization, cancer, and severe malformation at birth. The individual cost due to the extended LOS of 14.1 days was estimated as USD 8258. We calculated the annual extra expense for preventable ADEs in Japan as USD 329 676 760. Sensitivity analyses, considering the incidence of preventable ADEs and the length of hospital stay, showed that the expected range of annual extra expense for preventable ADEs in Japan is between USD 141 468 968 and 588 450 708.

Conclusion:

Preventable ADEs caused longer hospitalization and considerable extra healthcare costs in pediatric inpatients. Our results would encourage further efforts to prevent and ameliorate preventable ADEs.

Antipsychotic Polypharmacy Is Associated With Adverse Drug Events in Psychiatric Inpatients: The Japan Adverse Drug Events Study

BACKGROUND

Antipsychotic (AP) polypharmacy (APP), the coprescription of more than 1 AP, is frequently practiced in psychiatric inpatients and is considered to be a risk factor for adverse drug events (ADEs). However, the association between APP and ADEs among psychiatric inpatients has not been well investigated.

METHODS

The Japan Adverse Drug Events (JADE) study was a series of cohort studies conducted in several clinical settings. In particular, the JADE study for psychiatric inpatients was a retrospective cohort study of 448 psychiatric inpatients with a cumulative 22,733 patient-days. We investigated the relationship between APP, defined as a concurrent prescription of 2 or more APs and ADEs. We also assessed the relationship between potential risk factors for ADEs due to APs.

RESULTS

Among the 448 patients included in this study, 106 patients (24%) had APP and the remaining 342 patients were prescribed 1 AP or none. Risperidone was the most frequent drug (25%, 109/442 AP prescriptions) used, and levomepromazine was most frequently prescribed as a concurrent medication with other APs (91%, 29/32). The median number of ADEs among the patients with APP was significantly higher than in those without APP (P = 0.001). Antipsychotic polypharmacy was a risk factor for the occurrence of first (adjusted hazard ratio, 1.54; 95% confidence interval, 1.15-2.04) and second (adjusted hazard ratio, 1.99; 95% confidence interval, 1.40-2.79) ADEs.

CONCLUSIONS

Antipsychotic polypharmacy was a risk factor for the occurrence of single and multiple ADEs. Antipsychotic polypharmacy should be conservatively and minimally practiced.

Clinical Decision Support System with Renal Dose Adjustment Did Not Improve Subsequent Renal and Hepatic Function among Inpatients: The Japan Adverse Drug Event Study

Background  Medication dose adjustment is crucial for patients with renal dysfunction (RD). The assessment of renal function is generally mandatory; however, the renal function may change during the hospital stay and the manual assessment is sometimes challenging.

Objective  We developed the clinical decision support system (CDSS) that provided a recommended dose based on automated calculated renal function.

Methods  We conducted a prospective cohort study in a single teaching hospital in Japan. All hospitalized patients were included except for obstetrics/gynecology and pediatric wards between September 2013 and February 2015. The CDSS was implemented on December 2013. Renal and hepatic dysfunction (HD) were defined as changes in the estimated glomerular filtration rate (eGFR) and alanine aminotransferase or alkaline phosphatase levels based on these measurements during hospital stay. These measurements were obtained before (phase I), after (phase II), and 1 year after (phase III) the CDSS implementation.

Results  We included 6,767 patients (phase I: 2,205; phase II: 2,279; phase III: 2,283). The patients' characteristics were similar among phases. Changes in eGFR were similar among phases, but the incidence of RD increased in phase III (phase I: 228 [10.3%]; phase II: 260 [11.4%]; phase III: 296 [13.0%], p  = 0.02). However, the differences in incidences of RD were not statistically significant after adjusting for eGFR at baseline and age. The incidences of HD were also similar among phases (phase I: 175 [13.2%]; phase II: 171 [12.9%]; phase III: 167 [12.2%], p  = 0.72).

Conclusion  The CDSS implementation did not affect the incidence of renal and HD and changes in renal and hepatic function among hospitalized patients. The effectiveness of the CDSS with renal-guided doses should be investigated with respect to other endpoints.

Preventable medication harm across health care settings: a systematic review and meta-analysis

BACKGROUND

Mitigating or reducing the risk of medication harm is a global policy priority. But evidence reflecting preventable medication harm in medical care and the factors that derive this harm remain unknown. Therefore, we aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings.

METHODS

We performed a systematic review and meta-analysis of observational studies to compare the prevalence of preventable medication harm. Searches were carried out in Medline, Cochrane library, CINAHL, Embase and PsycINFO from 2000 to 27 January 2020. Data extraction and critical appraisal was undertaken by two independent reviewers. Random-effects meta-analysis was employed followed by univariable and multivariable meta-regression. Heterogeneity was quantified using the I² statistic, and publication bias was evaluated.

PROSPERO

CRD42020164156.

RESULTS

Of the 7780 articles, 81 studies involving 285,687 patients were included. The pooled prevalence for preventable medication harm was 3% (95% confidence interval (CI) 2 to 4%, I² = 99%) and for overall medication harm was 9% (95% CI 7 to 11%, I² = 99.5%) of all patient incidence records. The highest rates of preventable medication harm were seen in elderly patient care settings (11%, 95% 7 to 15%, n = 7), intensive care (7%, 4 to 12%, n = 6), highly specialised or surgical care (6%, 3 to 11%, n = 13) and emergency medicine (5%, 2 to 12%, n = 12). The proportion of mild preventable medication harm was 39% (28 to 51%, n = 20, I² = 96.4%), moderate preventable harm 40% (31 to 49%, n = 22, I² = 93.6%) and clinically severe or life-threatening preventable harm 26% (15 to 37%, n = 28, I² = 97%). The source of the highest prevalence rates of preventable harm were at the prescribing (58%, 42 to 73%, n = 9, I² = 94%) and monitoring (47%, 21 to 73%, n = 8, I² = 99%) stages of medication use. Preventable harm was greatest in medicines affecting the 'central nervous system' and 'cardiovascular system'.

CONCLUSIONS

This is the largest meta-analysis to assess preventable medication harm. We conclude that around one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Our results support the World Health Organisation's push for the detection and mitigation of medication-related harm as being a top priority, whilst highlighting other key potential targets for remedial intervention that should be a priority focus for future research.

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.

Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study

BACKGROUND

Medication errors are a serious and complex problem in clinical practice, especially in intensive care units whose patients can suffer potentially very serious consequences because of the critical nature of their diseases and the pharmacotherapy programs implemented in these patients. The origins of these errors discussed in the literature are wide-ranging, although far-reaching variables are of particular special interest to those involved in training nurses. The main objective of this research was to study if the level of knowledge that critical-care nurses have about the use and administration of medications is related to the most common medication errors.

METHODS

This was a mixed (multi-method) study with three phases that combined quantitative and qualitative techniques. In phase 1 patient medical records were reviewed; phase 2 consisted of an interview with a focus group; and an ad hoc questionnaire was carried out in phase 3.

RESULTS

The global medication error index was 1.93%. The main risk areas were errors in the interval of administration of antibiotics (8.15% error rate); high-risk medication dilution, concentration, and infusion-rate errors (2.94% error rate); and errors in the administration of medications via nasogastric tubes (11.16% error rate).

CONCLUSIONS

Nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU.

How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review

OBJECTIVES

Surgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied.

DESIGN

A multicentre retrospective patient record review.

SETTING AND PARTICIPANTS

Records from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level.

RESULTS

Preoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%-100%), international normalised ratio testing (range 21%-94%) and postoperative bridging (range 20%-88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients' weight.

CONCLUSIONS

Unsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.

Effect of baseline renal and hepatic function on the incidence of adverse drug events: the Japan Adverse Drug Events study

Background The impact of renal and hepatic dysfunction on the morbidity and mortality of inpatients with adverse drug events (ADEs) is uncertain in daily clinical practice. The objective of this study was to investigate the effect of renal and hepatic function on ADEs and inpatients' morbidity and mortality. Methods The Japan Adverse Drug Events (JADE) study was a prospective cohort study carried out at three tertiary-care teaching hospitals in Japan. Participants were consecutive inpatients (n=3459) aged 15 years or older. We evaluated the effect of renal and hepatic function on the occurrence of ADEs, and assessed how they affected length of hospital stay (LOS) and in-hospital mortality. We used the estimated glomerular filtration rate to quantify renal function and categorized patients into three groups (normal, ≥60 mL/min/1.73 mm; moderate, ≥30 and <60 mL/min/1.73 mm; severe, <30 mL/min/1.73 mm). We defined patients as having hepatic dysfunction when at least one data point (total bilirubin, aspartate aminotransferase, alanine aminotransferase, or gamma glutamyltransferase) was beyond a cutoff value. Results We analyzed the laboratory data of 2508 patients. There was a significant difference in the occurrence of ADEs among the three GFR categories (normal, 20%; moderate, 26%; severe, 22%; p=0.02). More ADEs occurred in patients with hepatic dysfunction (25% vs. 20%, p=0.01). LOS was significantly longer in those with ADEs stratified either by renal or by hepatic dysfunction (p<0.0001). ADEs were independently associated with in-hospital mortality, adjusting for renal and hepatic function (p<0.0001). Conclusions Inpatients' organ dysfunction increased ADEs, and ADEs were associated with both LOS and in-hospital mortality independently, irrespective of renal and hepatic function.

Association between heart rate on admission and in-hospital mortality among general inpatients: Insights from Japan Adverse Drug Events (JADE) study

Association between heart rate (HR) and in-hospital mortality in general patients irrespective of underlying diseases were not well scrutinized. We assessed the relationship between HR on admission and in-hospital mortality among general inpatients.We used data from Japan Adverse Drug Events (JADE) study, a prospective cohort study. One tertiary care hospital in Japan with 13 medical and 12 surgical wards, and an intensive care unit (ICU). Patients (n = 2360) were ≥12 years old and admitted to this hospital within 3 months; and pregnant women were excluded. We assessed the relationship between HR and mortality in five (<60, 60-79, 80-99, 100-119, ≥120 beats per minutes [bpm]) groups. We also compared the five HR groups according to the age (<70 years; ≥70 years) and wards (medical; surgical; ICU).We enrolled 2360 patients (median age, 71 [interquartile range (IQR) 58-81] years) including 1147, 1068, and 145 patients in the medical and surgical wards, and the ICU, respectively. The median (IQR) HR on admission was 78 (68-91) bpm. Ninety-five patients died during hospitalization. Mortalities in the <60, 60-79, 80-99, 100-119, and ≥120 bpm groups were 2.9% (5/175), 2.7% (28/1047), 3.4% (26/762), 8.2% (24/291), and 14.3% (12/84), respectively (P < .001). The adjusted odds ratios of in-hospital mortality was 3.64 (95% CI 1.88-7.05, P < .001) when HR was ≥100 bpm in the medical ward; and 5.69 (95% CI 1.72-18.82, P = .004) when HR ≥120 bpm in the surgical ward. There was no statistically significant relationship with the ICU.In conclusion, higher HR should be associated with in-hospital mortality among patients with general diseases. Even with less severe condition or outside ICU, HR should be directed attention to and patients with high HR on admission should be taken additional therapy to reduce the further risk of deterioration.

Pharmacist-Initiated Medication Error-Reporting and Monitoring Programme in a Developing Country Scenario

Medication errors (MEs) often prelude guilt and fear in health care professionals (HCPs), thereby resulting in under-reporting and further compromising patient safety. To improve patient safety, we conducted a study on the implementation of a voluntary medication error-reporting and monitoring programme. The ME reporting system was established using the principles based on prospective, voluntary, open, anonymous, and stand-alone surveillance in a tertiary care teaching hospital located in South India. A prospective observational study was carried out for three years and a voluntary Medication Error-reporting Form was developed to report medication errors MEs that had occurred in patients of either sex were included in the study, and the reporters were given the choice to remain anonymous. The analysis was carried out and discussed with HCPs to minimise the recurrence. A total of 1310 medication errors were reported among 20,256 hospitalised patients and the incidence was 6.4%. Common aetiologies were administration errors [501 (38.2%)], followed by prescribing and transcribing errors [363 (28%)]. Root-cause of these MEs were distractions, workload, and communications. Analgesics/antipyretics (19.4%) and antibiotics (15.7%) were the most commonly implicated classes of medications. A clinical pharmacist initiated non-punitive anonymous ME reporting system could improve patient safety.

Potential drug-related problems detected by routine pharmaceutical interventions: safety and economic contributions made by hospital pharmacists in Japan

Background

Pharmaceutical intervention enables safe and effective pharmacotherapy by avoiding of adverse drug reactions (ADRs) and efficacy attenuations. Many prescriptions require optimization, and pharmaceutical interventions are inextricably associated with the prevention of potential drug-related problems (DRPs). Although the analysis and understanding of pharmaceutical interventions can lead to improvement in prescription, the analysis of routine pharmaceutical interventions in Japan in insufficient. Thus, we conducted this study to understand potential DRPs by analyzing routine pharmaceutical interventions made by pharmacists in Japan.

Methods

Pharmacists register the details of pharmaceutical interventions (excluding personal patient information) in a web-based database. We classified data of pharmaceutical interventions into 13 DRP types, 43 DRP subtypes, and 10 intervention categories (e.g., avoidance of serious ADRs and renal dosing recommendations). These data were analyzed with a focus on renal dysfunction and polypharmacy.

Results

During the study period, 2376 pharmaceutical interventions were performed. Overall, 68.2% of pharmaceutical interventions were for patients aged over 65 years. The most frequently detected potential DRP was overdosage, followed by omission of prescription, contraindications, and duplication of a drug with similar effect. The main cause of contraindication and overdosage was renal function deterioration, and that of polypharmacy was duplication of a drug with similar effect. Using our original evidence-based approach, we found that 2376 pharmaceutical interventions prevented ADRs for 1678 drugs, with potential cost savings of up to USD 2,657,820.

Conclusions

Our results indicate that the analysis of routine pharmaceutical interventions is beneficial for detecting potential DRPs. Our findings also show that, in an aging society, pharmacists have an important role in providing medication safety, with potential cost savings.

Adverse drug events identified in hospitalized patients in Brazil by International Classification of Diseases (ICD-10) code listings

Studies of adverse drug events (ADEs) are important in order not to jeopardize the positive impact of pharmacotherapy. These events have substantial impact on the population morbidity profiles, and increasing health system operating costs. Administrative databases are an important source of information for public health purposes and for identifying ADEs. In order to contribute to learning about ADE in hospitalized patients, this study examined the potential of applying ICD-10 (10th revision of the International Classification of Diseases) codes to a national database of the public health care system (SIH-SUS). The study comprised retrospective assessment of ADEs in the SIH-SUS administrative database, from 2008 to 2012. For this, a list of ICD-10 codes relating to ADEs was built. This list was built up by examining lists drawn up by other authors identified by bibliographic search in the MEDLINE and LILACS and consultations with experts. In Brazil, 55,604,537 hospital admissions were recorded in the SIH-SUS, between 2008 and 2012, of which 273,440 (0.49%) were related to at least one ADE. The proportions and rates seem to hold constant over the study period. Fourteen out of 20 most frequent ADEs were identified in codes relating to mental disorders. Intoxications figure as the second most frequently recorded group of ADEs in the SIH-SUS, comprising 76,866 hospitalizations. Monitoring of ADEs in administrative databases using ICD-10 codes is feasible, even in countries with information systems under construction, and can be an innovative tool to complement drug surveillance strategies in place in Brazil, as well as in others countries.

Improving the assessment of adverse drug reactions using the Naranjo Algorithm in daily practice: The Japan Adverse Drug Events Study

It is difficult to determine adverse drug reactions (ADRs) in daily complicated clinical practice in which many kinds of drugs are prescribed. We evaluated how well the Naranjo Algorithm (NA) categorized ADRs among suspected ADRs. The Japan Adverse Drug Events (JADE) study was a prospective cohort study of 3459 inpatients. After all suspected ADRs were reported from research assistants, a single physician reviewer independently assigned an NA score to each. After all NA score of suspected ADRs were scored, two physician reviewers discussed and determined ADRs based on the literature. We investigated the sensitivity and specificity of NA and each component to categorize ADRs among suspected ADRs. A total of 1579 suspected ADRs were reported in 962 patients. Physician reviewers determined 997 ADRs. The percentage of ADRs was 94% if the total NA score reached 5. The modified NA consisted of 5 components that showed high classification abilities; its area under the curve (AUC) was 0.92 for categorizing ADRs, the same as the original. When we set the total NA score cut-off value to 5, specificity was 0.95 and sensitivity was 0.59. When we reclassified NA components as binary variables, the specificity increased to 0.98 with a cut-off value of 4 and yielded an AUC of 0.93. In conclusion, we showed that both NA and modified NA could categorize ADRs among suspected ADRs with a high likelihood in daily clinical practice.

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

BACKGROUND

Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries.

METHODS

A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included.

RESULTS

Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5-16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists' interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists' recommendations.

CONCLUSIONS

Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.

Incidence, causes, and consequences of preventable adverse drug reactions occurring in inpatients: A systematic review of systematic reviews

BACKGROUND

Preventable adverse drug reactions (PADRs) in inpatients are associated with harm, including increased length of stay and potential loss of life, and result in elevated costs of care. We conducted an overview of reviews (i.e., a systematic review of systematic reviews) to determine the incidence of PADRs experienced by inpatients. Secondary review objectives were related to assessment of the effects of patient age, setting, and clinical specialty on PADR incidence.

METHODS

The protocol was registered in PROSPERO (CRD42016043220). We performed a search of Medline, Embase, and the Cochrane Library, limiting languages of publication to English and French. We included published systematic reviews that reported quantitative data on the incidence of PADRs in patients receiving acute or ambulatory care in a hospital setting. The full texts of all primary studies for which PADR data were reported in the included reviews were obtained and data relevant to review objectives were extracted. Quality of the included reviews was assessed using the AMSTAR-2 tool. Both narrative summaries of findings and meta-analyses of primary study data were undertaken.

RESULTS

Thirteen systematic reviews encompassing 37 unique primary studies were included. Across primary studies, the PADR incidence was highly varied, ranging from 0.006 to 13.3 PADRs per 100 patients, with a pooled incidence estimate of 0.59 PADRs per 100 patients. Substantial heterogeneity was present across both reviews and primary studies with respect to review/study objectives, patient age, hospital setting, medical discipline, definitions and assessment tools used, event detection methods, endpoints of interest, and units of measure. Thirteen primary studies used prospective event detection methods and had a pooled PADR incidence of 3.13 (2.87-3.38) PADRs per 100 patients; however, extreme statistical heterogeneity (I2 = 97%) indicated this finding should be considered with caution. Subgroup meta-analyses demonstrated that PADR incidence varied significantly with event detection method (prospective > retrospective > voluntary reporting methods), hospital setting (ICU > wards), and medical discipline (medical > surgical). High statistical heterogeneity (I2 > 80%) was present across all analyses, indicating results should be interpreted with caution. Effects of patient age could not be assessed due to poor reporting of age groups used in primary studies.

DISCUSSION

The method of event detection appeared to significantly influence PADR incidence, with prospective methods having the highest reported PADR rate. This finding is in agreement with the background literature. High methodological and statistical heterogeneity across primary studies evaluating adverse drug events reduces the validity of the overall PADR incidence derived from the meta-analyses of the pooled data. Data pooled from studies using only prospective methods of event detection should provide an overall estimate closest to the true PADR incidence; however, our estimate should be considered with caution due to the statistical heterogeneity found in this group of studies. Future studies should employ prospective methods of detection. This review demonstrates that the true overall incidence of PADRs is likely much greater than the overall pooled incidence estimate of 0.59 PADRs per 100 patients obtained when event detection method was not taken into consideration.

Preventable Adverse Drug Events Among Inpatients: A Systematic Review

: media-1vid110.1542/5799876436001PEDS-VA_2018-0805Video Abstract CONTEXT: Patient harm resulting from medication errors drives prevention efforts, yet harm associated with medication errors in children has not been systematically reviewed.

OBJECTIVE

To review the incidence and severity of preventable adverse drug events (pADEs) resulting from medication errors in pediatric inpatient settings.

DATA SOURCES

Data sources included Cumulative Index of Nursing and Allied Health Literature, Medline, Scopus, the Cochrane Library, and Embase.

STUDY SELECTION

Selected studies were published between January 2000 and December 2017, written in the English language, and measured pADEs among pediatric hospital inpatients by chart review or direct observation.

DATA EXTRACTION

Data extracted were medication error and harm definitions, pADE incidence and severity rates, items required for quality assessment, and sample details.

RESULTS

Twenty-two studies were included. For children in general pediatric wards, incidence was at 0 to 17 pADEs per 1000 patient days or 1.3% of medication errors (of any type) compared with 0 to 29 pADEs per 1000 patient days or 1.5% of medication errors in ICUs. Hospital-wide studies contained reports of up to 74 pADEs per 1000 patient days or 2.6% of medication errors. The severity of pADEs was mainly minor.

LIMITATIONS

Limited literature on the severity of pADEs is available. Additional study will better illuminate differences among hospital wards and among those with or without health information technology.

CONCLUSIONS

Medication errors in pediatric settings seldom result in patient harm, and if they do, harm is predominantly of minor severity. Implementing health information technologies was associated with reduced incidence of harm.

Pharmacotherapeutic follow-up in a respiratory intensive care unit: description and analysis of results

Objective

To describe and evaluate the pharmacotherapeutic follow-up by a clinical pharmacist in an intensive care unit.

Methods

A descriptive and cross-sectional study carried out from August to October 2016. The data were collected through a form, and pharmacotherapeutic follow-up conducted by a clinical pharmacist at the respiratory intensive care unit of a tertiary hospital. The problems recorded in the prescriptions were quantified, classified and evaluated according to severity; the recommendations made by the pharmacist were analyzed considering the impact on pharmacotherapy. The medications involved in the problems were classified according to the Anatomical Therapeutic Chemical Classification System.

Results

Forty-six patients were followed up and 192 pharmacotherapy-related problems were registered. The most prevalent problems were missing information on the prescription (33.16%), and those with minor severity (37.5%). Of the recommendations made to optimize pharmacotherapy, 92.7% were accepted, particularly those on inclusion of infusion time (16.67%), and dose appropriateness (13.02%), with greater impact on toxicity (53.6%). Antimicrobials, in general, for systemic use were drug class most often related to problems in pharmacotherapy (53%).

Conclusion

Pharmacotherapeutic follow-up conducted by a pharmacist in a respiratory intensive care unit was able to detect problems in drug therapy and to make clinically relevant recommendations.