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El-Bosily HM, Abd El Meguid KR, Sabri NA, Ahmed MA. Physicians Adherence to Evidence-Based Guidelines as a Major Predictor to Anticoagulant-related Medication Errors Incidence and Severity. Br J Clin Pharmacol 2022; 88:3730-3740. [PMID: 35293625 DOI: 10.1111/bcp.15314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 01/16/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022] Open
Abstract
AIM Anticoagulants represent a main source of medication errors (MEs) and complications that cause catastrophic implications posing an obligation on health care providers to assess anticoagulant related MEs and factors affecting their occurrence. This study investigates the occurrence and severity of prescribing MEs in patients on anticoagulants and explores their potential predictors. METHODS a prospective cohort study in a tertiary hospital on 116 patients with a total of 2166 anticoagulant doses. RESULTS Forty-four percent of prescribed anticoagulant doses resulted in MEs with low molecular weight heparin (LMWH) and unfractionated heparin (UFH) causing 61% and 34% respectively of the total MEs. More than 50% of all MEs were incorrect doses (high and low) shared between heparin and tinzaparin. The highest severity of error was Category D followed by Category F and C. Poisson regression analysis model revealed that female (IRR 1.32, 95% CI 1.13-1.54, p<0.001), bridging (IRR 1.52; 95% CI 1.10 - 2.09; p=0.011), VTE prophylaxis (IRR 7.65; 95% CI 4.88 - 12.02; p<0.001), physician non-adherence (IRR 2.71; 95% CI 2.22 - 3.29; p<0.001), and polypharmacy (IRR 1.68; 95% CI 1.26 - 2.23; p=0.036) were predictors of the higher incidence of MEs. Ordinal logistic regression analysis demonstrated that physician non-adherence (OR 24.67; 95% CI 5.54 - 207; p<0.001) was the main predictor of increased error severity. CONCLUSION The major predictor in increasing both MEs incidence and severity is physician adherence to evidence-based guidelines (EBG). Strict regulations of anticoagulant prescribing through an anticoagulant stewardship program are a necessity.
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Affiliation(s)
- Heba M El-Bosily
- Clinical Pharmacy Department, El-Sheikh Zayed Specialized Hospital, Giza, Egypt
| | | | - Nagwa A Sabri
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain-Shams University, Cairo, Egypt
| | - Marwa Adel Ahmed
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain-Shams University, Cairo, Egypt
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Quintens C, Verhamme P, Vanassche T, Vandenbriele C, Van den Bosch B, Peetermans WE, Van der Linden L, Spriet I. Improving appropriate use of anticoagulants in hospitalised patients: a pharmacist-led Check of Medication Appropriateness intervention. Br J Clin Pharmacol 2021; 88:2959-2968. [PMID: 34913184 DOI: 10.1111/bcp.15184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/13/2021] [Accepted: 12/05/2021] [Indexed: 11/29/2022] Open
Abstract
AIM Inappropriate anticoagulant use increases the risk of bleeding and thrombotic events. We implemented clinical decision rules to promote judicious medication use, as part of the 'Check of Medication Appropriateness' (CMA). The CMA concerns a pharmacist-led review service, targeting potentially inappropriate prescriptions (PIPs). In this analysis, we aimed to evaluate the impact of the CMA on anticoagulant prescribing. METHODS The number of anticoagulant-related PIPs was evaluated before and after implementation of the intervention in a quasi-experimental interrupted time series analysis. The pre-implementation cohort received usual care. The anticoagulant-focused CMA, comprising 13 clinical rules pertaining to anticoagulation therapies, was implemented in the post-implementation cohort. Segmented regression analysis was used to assess the impact of the intervention on the number of residual PIPs. A residual PIP was defined as a PIP which persisted up to 48h after the CMA intervention. Total number of recommendations and acceptance rate were documented for the 2-year post-implementation period. RESULTS Pre-implementation, we observed 501 PIPs in 466 inpatients on 36 days, with a median proportion of 78.5% (range: 46.2%-100%) residual PIPs per day. Post-implementation, 538 PIPs were detected in 485 patients over the same number of days. The CMA intervention reduced the median proportion to 18.2% (range: 0-100%) per day. The effect coincided with an immediate relative reduction of 70% (95%CI 0.19-0.46) in anticoagulant-related residual PIPs. Post-implementation, 2778 recommendations were provided and 75.1% were accepted. CONCLUSION Our CMA approach significantly reduced anticoagulant-related PIPs. Implementing a pharmacist-led intervention, based on clinical rules, may support safer prescribing of anticoagulants.
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Affiliation(s)
- Charlotte Quintens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Bart Van den Bosch
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Department of Information Technology, University Hospitals Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
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Frazer A, Rowland J, Mudge A, Barras M, Martin J, Donovan P. Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients. Eur J Clin Pharmacol 2019; 75:1645-1657. [PMID: 31511939 DOI: 10.1007/s00228-019-02752-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/23/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Anticoagulation-associated adverse drug events are common in hospitalised patients and result in morbidity, mortality, increased length of hospital stay and higher costs of care. Many are preventable. We reviewed the literature to identify and assess interventions intended to improve safety or quality anticoagulant prescribing. METHODS A systematic search of EMBASE, MEDLINE, the Cochrane Library, Pretty Darn Quick-Evidence and Health Systems Evidence was undertaken to identify controlled studies assessing system-level interventions to improve prescribing of oral or parenteral therapeutic anticoagulation for any indication in hospitalised adults. Data were extracted for safety and quality outcomes, with studies grouped by intervention type for meta-analysis and narrative review. RESULTS Of 10,640 records screened, 19 trials evaluating 12,742 participants were included for analysis. No study specifically evaluated prescribing of low molecular weight heparins (LMWHs) or direct acting oral anticoagulants (DOACs). Our findings suggest that physician-led anticoagulation consultation services may reduce bleeding rates in high-risk patients. On meta-analysis, decision supported warfarin dosing resulted in higher proportion of time with international normalised ratio in therapeutic range (p = 0.0007). Studies of other clinical decision support systems and heparin monitoring systems did not demonstrate improved safety, and quality findings were inconsistent. Systematic education and feedback programs were not efficacious. CONCLUSIONS There is currently insufficient high-quality evidence to recommend any reviewed intervention, though several warrant closer evaluation. Adequately powered controlled trials assessing safety outcomes and evidence-based quality markers in high-risk patient groups and studies of interventions to improve safety of LMWH and DOAC prescribing are needed.
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Affiliation(s)
- Andrew Frazer
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia.
| | - James Rowland
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Alison Mudge
- Department of Internal Medicine and Aged Care, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Michael Barras
- University of Queensland School of Pharmacy, 20 Cornwall Street, Woolloongabba, QLD, 4102, Australia
| | - Jennifer Martin
- Chair of Clinical Pharmacology, University of Newcastle School of Medicine and Public Health, University Drive, Callaghan, NSW, 2308, Australia
| | - Peter Donovan
- Director of Clinical Pharmacology, The Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
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The effect of hospital-based antithrombotic stewardship on adherence to anticoagulant guidelines. Int J Clin Pharm 2019; 41:691-699. [PMID: 31020598 PMCID: PMC6554262 DOI: 10.1007/s11096-019-00834-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/10/2019] [Indexed: 10/27/2022]
Abstract
Background Anticoagulant therapy is associated with a high risk of complications. Adherence to anticoagulant therapy protocols may lower this risk but adherence is often suboptimal. The introduction of a multidisciplinary antithrombotic team may improve adherence to anticoagulant guidelines among physicians. Objective To determine the effect of hospital-based multidisciplinary antithrombotic stewardship on adherence to anticoagulant guidelines among prescribing physicians. Setting This prospective non-randomised before-and-after study was conducted in patients hospitalized between October 2015 and December 2017 and treated with anticoagulant therapy. Method A multidisciplinary antithrombotic team focusing on education, medication reviews, drafting of local anticoagulant therapy protocols, patient counseling and medication reconciliation at admission and discharge was implemented in two Dutch hospitals. Main outcome measure Primary outcome was the proportion of the admitted patients in which the prescribing physician did adhere to the anticoagulant guidelines. Results The study comprised 1886 patients, of which 941 patients were included in the usual care period and 945 patients in the intervention period. Multivariable logistic regression analysis indicated that adherence was observed significantly more often during the intervention period (adjusted odds ratio [ORadj] 1.58, 95% confidence interval [95% CI] 1.21-2.05). Detailed analysis identified that the significantly higher overall adherence in the intervention period was attributed to dosing of LMWHs (odds ratio [OR] 1.58, 95% CI 1.16-2.14). Conclusion This study shows that introduction of a multidisciplinary antithrombotic stewardship leads to a significantly higher overall adherence to anticoagulant guidelines among prescribing physicians, mainly based on the improvement of dosing of low-molecular-weight-heparins.
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Rwabihama JP, Audureau E, Laurent M, Rakotoarisoa L, Jegou M, Saddedine S, Krypciak S, Herbaud S, Benzengli H, Segaux L, Guery E, Ambime G, Rabus MT, Perilliat JG, David JP, Paillaud E. Prophylaxis of Venous Thromboembolism in Geriatric Settings: A Cluster-Randomized Multicomponent Interventional Trial. J Am Med Dir Assoc 2018; 19:497-503. [PMID: 29580885 DOI: 10.1016/j.jamda.2018.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/07/2018] [Accepted: 02/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the efficacy of an intervention on the practice of venous thromboembolism prevention. DESIGN A multicenter, prospective, controlled, cluster-randomized, multifaceted intervention trial consisting of educational lectures, posters, and pocket cards reminding physicians of the guidelines for thromboprophylaxis use. SETTINGS Twelve geriatric departments with 1861 beds total, of which 202, 803, and 856 in acute care, post-acute care, and long-term care wards, respectively. PARTICIPANTS Patients hospitalized between January 1 and May 31, 2015, in participating departments. MEASUREMENTS The primary endpoint was the overall adequacy of thromboprophylaxis prescription at the patient level, defined as a composite endpoint consisting of indication, regimen, and duration of treatment. Geriatric departments were divided into an intervention group (6 departments) and control group (6 departments). The preintervention period was 1 month to provide baseline practice levels, the intervention period 2 months, and the postintervention period 1 month in acute care and post-acute care wards or 2 months in long-term care wards. Multivariable regression was used to analyze factors associated with the composite outcome. RESULTS We included 2962 patients (1426 preintervention and 1536 postintervention), with median age 85 [79;90] years. For the overall 18.9% rate of inadequate thromboprophylaxis, 11.1% was attributable to underuse and 7.9% overuse. Intervention effects were more apparent in post-acute and long-term care wards although not significantly [odds ratio 1.44 (95% confidence interval 0.78;2.66), P = .241; and 1.44 (0.68, 3.06), P = .345]. Adequacy rates significantly improved in the postintervention period for the intervention group overall (from 78.9% to 83.4%; P = .027) and in post-acute care (from 75.4% to 86.3%; P = .004) and long-term care (from 87.0% to 91.7%; P = .050) wards, with no significant trend observed in the control group. CONCLUSIONS/IMPLICATIONS This study failed to demonstrate improvement in prophylaxis adequacy with our intervention. However, the intervention seemed to improve practices in post-acute and long-term care but not acute care wards.
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Affiliation(s)
- Jean Paul Rwabihama
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France.
| | - Etienne Audureau
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Marie Laurent
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Albert Chenevier-Henri Mondor, Créteil, France
| | - Lalaina Rakotoarisoa
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital George Clemenceau, Champceuil, France
| | - Marc Jegou
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Sofiane Saddedine
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Sébastien Krypciak
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
| | - Stéphane Herbaud
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
| | - Hind Benzengli
- Assistance Publique-Hôpitaux de Paris, Service de Pharmacie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Lauriane Segaux
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Esther Guery
- Assistance Publique-Hôpitaux de Paris, Service de Santé Publique, Hôpital Henri Mondor, Créteil, France
| | - Gabin Ambime
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Marie-Thérèse Rabus
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Jean-Guy Perilliat
- Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Joffre-Dupuytren, Draveil, France
| | - Jean-Philippe David
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Emile Roux, Limeil Brévannes, France
| | - Elena Paillaud
- Université Paris-Est, UPEC, DHU A-TVB, IMRB-EA 7376 CEpiA (Clinical Epidemiology and Aging Unit), Créteil, France; Assistance Publique-Hôpitaux de Paris, Service de Gériatrie, Hôpital Henri Mondor, Créteil, France
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