Improving Medication Safety in Psychiatry - A Controlled Intervention Study of Nurse Involvement in Avoidance of Potentially Inappropriate Prescriptions

Patient Safety Strategies in Psychiatry and How They Construct the Notion of Preventable Harm: A Scoping Review

OBJECTIVES

The literature on patient safety in psychiatry has not been explored systematically in terms of what interventions are used, how they are used, and what type of (preventable) harm is targeted. The aims of this scoping review are to explore patient safety strategies used in psychiatry and determine how they construct the notion of preventable harm.

METHOD

A scoping review of literature on patient safety in psychiatry published in English between 2000 and 2019 was conducted using Scopus, MEDLINE, PsycInfo, and CINAHL. Keywords of patient safety strategies and possible outcomes were coded from the results, discussion, or conclusion. Patient safety strategies were inductively categorized into themes according to the focus of the strategy.

RESULTS

The review introduces 7 focus areas of patient safety strategies identified within the psychiatric literature: "risk management," "healthcare practitioners," "patient observation," "patient involvement," "computerized methods," "admission and discharge," and "security." The result shows that patient safety strategies mainly aim to reduce suicide, self-harm, violence, and falls and present a large diversity of measures, often aimed at reducing variability while increasing standardization.

CONCLUSIONS

The strategies that are supported in the literature to achieve safer psychiatry mainly arise from linear cause-effect models and rely on staff performance, competence, and compliance. Contemporary safety science acknowledges the performance variability of everyday normal work and sees risk as the dynamic migration of these daily activities. The field of psychiatry has not yet included this view of safety in the strategic actions to reduce preventable harm.

Structured Interventions to Optimize Polypharmacy in Psychiatric Treatment and Nursing Homes: A Systematic Review

BACKGROUND

Polypharmacy is a common clinical issue. It increases in prevalence with older age and comorbidities of patients and has been recognized as a major cause for treatment complications. In psychiatry, polypharmacy is also commonly seen in younger patients and can lead to reduced treatment satisfaction and incompliance. A variety of structured polypharmacy interventions have been investigated. This systematic review provides a comprehensive overview of the field and identifies research gaps.

METHODS

We conducted a systematic review on structured interventions aimed at optimizing polypharmacy of psychotropic and somatic medication in psychiatric inpatient and outpatient settings as well as nursing homes. A search protocol was registered with PROSPERO (CRD42020187304). Data were synthesized narratively.

RESULTS

Fifty-eight studies with a total of 30,554 participants met the inclusion criteria. Interventions were most commonly guided by self-developed or national guidelines, drug assessment scores, and lists of potentially inappropriate medications. Tools to identify underprescribing were less commonly used. Most frequently reported outcomes were quantitative drug-related measures; clinical outcomes such as falls, hospital admission, cognitive status, and neuropsychiatric symptom severity were reported less commonly. Reduction of polypharmacy and improvement of medication appropriateness were shown by most studies.

CONCLUSIONS

Improvement of drug-related outcomes can be achieved by interventions such as individualized medication review and educational approaches in psychiatric settings and nursing homes. Changes in clinical outcomes, however, are often nonsubstantial and generally underreported. Patient selection and intervention procedures are highly heterogeneous. Future investigations should establish standards in intervention procedures, identify and assess patient-relevant outcome measures, and consider long-term follow-up assessments.

Leading 20 drug-drug interactions, polypharmacy, and analysis of the nature of risk factors due to QT interval prolonging drug use and potentially inappropriate psychotropic use in elderly psychiatry outpatients

BACKGROUND

Psychotropic medications extend corrected QT (QTc) period in the electrocardiogram (ECG). Psychiatric patients exposed to ⩾1 psychotropic medication(s) represent a group with marked probability of drug-activated QTc-prolongation. Prolonged QTc interval in elderly patients (age > 60 years) is connected to greater risk of all-cause and coronary heart disease deaths. This study aimed at investigating pattern of utilization of QTc-interval protracting medications, QT-extending drug interactions, and prevalence of QTc-interval extending hazard factors in elderly patients.

METHODS

This was a cross-sectional, prospective study at the Psychiatry OPD at All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India from 1 October 2017 to 30 August 2019 employing the pertinent prescriptions.

RESULTS

A total of 832 elderly patients (age 60 years or more) visiting the Psychiatry OPD during the aforementioned study duration were investigated. About 420 (50.5%) patients were males while 412 (49.5%) were females. Of the 832 patients, 588 (70.7%) were using interacting agents with capacity to produce TdP. Almost 1152 interacting torsadogenic medication pairs were unraveled. As per AzCERT/CredibleMeds Classification, 1016 (48.8%), 724 (34.8%), and 248 (12%) agents with potential to interact were identified with 'known', 'possible', and 'conditional risk of TdP', respectively. The common interacting medications belonged to antidepressant (288), proton pump inhibitor (364), antipsychotic (340), antinausea (184), antimicrobial (156), and H₂ receptor antagonist (60) therapeutic categories. The all-inclusive frequency of potentially inappropriate psychotropic (PIP) agents administered was 62% (1343/2166) with Beers Criteria 2019, and 46% (997/2166) with STOPP Criteria 2015.

CONCLUSION

Many geriatric patients were administered drugs and drug combinations with heightened proclivity toward QT-interval prolongation. Furthermore, reliable evidence-based online drug knowledge resources, such as AzCERT/CredibleMeds Drug Lists, Medscape Drug Interactions Checker, Epocrates Online Interaction Check, and Drugs.com Drug Interactions Checker, can facilitate clinical professionals in selecting drugs for psychiatric patients. A wise choice of medications is imperative to preclude serious adverse sequelae. Therefore, we need to exigently embrace precautionary safety means, be vigilant, and forestall QT-extension and TdP in clinical environments.

Nurses' responsibilities and tasks in pharmaceutical care: A scoping review

Aim

To provide an overview of responsibilities and tasks of nurses in pharmaceutical care.

Design

Scoping review.

Methods

Two databases were systematically searched (MEDLINE and Scopus) for recent original research papers concerning nurses’ responsibilities and tasks in pharmaceutical care. The definition of responsibility was based on literature, moral and ethical discussions. Existing responsibilities and tasks beyond preparation and administration of medication were collected and synthesized. This main study outcome was extracted from titles and abstracts only. Results were reported in accordance with PRISMA‐ScR guidelines.

Results

Of the 3,805 titles and abstracts reviewed, 453 abstracts were included. A total of seven responsibilities were identified: (a) management of therapeutic and adverse effects of medication, (b) management of medication adherence, (c) management of patient medication self‐management, (d) management of patient education and information about medication, (e) prescription management, (f) medication safety management and (g) (transition of) care coordination. Within these responsibilities, all tasks performed by nurses were described.

Clonazepam tops the list of potentially inappropriate psychotropic (PIP) medications in older adults with psychiatric illness: A cross-sectional study based on Beers criteria 2019 vs STOPP criteria 2015

BACKGROUND

In older adults, polypharmacy and potentially inappropriate psychotropic (PIP) medication use are prominent prescription challenges. However, there is limited information available on the use of PIP medication in older adults having psychiatry illness.

OBJECTIVE

To find out the most commonly prescribed PIP in tertiary care hospitals of developing countries with respect to Beers criteria 2019 and Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) and predictors of PIP.

METHODS

A cross-sectional analysis of 456 patients of either sex with a median age of 65 years visiting the outpatient department of psychiatry was performed at the tertiary care hospital of North India with respect to Beers criteria 2019 and STOPP criteria 2015. Bivariate logistic regression was used to figure out the predictors of PIP medication.

RESULTS

Results of the study reflects a staggering number of older adults, (more than 91 % and 73 %) out of total 456 patients were prescribed with at least one PIP medication as per Beers criteria and STOPP criteria, respectively. Long-acting benzodiazepine like clonazepam, chlordiazepoxide were identified as one of the most commonly prescribed PIP medications with respect to the both set of criteria. Further analysis revealed that polypharmacy (≥5 medications with odds Ratio (OR) 17.33, 95% Confidence Interval (CI) 1.42-210.66, P-0.025) as the sole important predictor for PIP medication.

CONCLUSION

According to the Beers criterion and the STOPP criteria, the use of PIP medicine is very prevalent among older adults with psychiatric illness. The Beers criteria dramatically diagnose more PIP medication than STOPP criteria.