Medication errors in acute cardiovascular and stroke patients: a scientific statement from the American Heart Association

Drug therapy problems among hospitalized patients with cardiovascular disease

BACKGROUND

Optimal utilization of cardiovascular drugs is crucial in reducing morbidity and mortality associated with cardiovascular diseases. However, the effectiveness of these drugs can be compromised by drug therapy problems. Hospitalized patients with cardiovascular diseases, particularly those with multiple comorbidities, polypharmacy, and advanced age, are more susceptible to experiencing drug therapy problems. However, little is known about drug therapy problems and their contributing factors among patients with cardiovascular disease in our setting. Therefore, our study aimed to investigate drug therapy problems and their contributing factors in patients with cardiovascular diseases.

METHOD

A prospective observational study was conducted among hospitalized patients with cardiovascular disease at Ayder Comprehensive Specialized Hospital in the Tigray region of Northern Ethiopia from December 2020 to May 2021. We collected the data through patient interviews and review of patients' medical records. We employed Cipolle's method to identify and categorize drug therapy problems and sought consensus from a panel of experts through review. Data analysis was performed using the Statistical Software Package SPSS version 22. Binary logistic regression analysis was performed to determine the contributing factors of drug therapy problems in patients with cardiovascular disease. Statistical significance was set at p < 0.05.

RESULTS

The study included a total of 222 patients, of whom 117 (52.7%) experienced one or more drug-related problems. We identified 177 drug therapy problems equating to 1.4 ± 0.7 drug therapy problems per patients. The most frequently identified DTP was the need for additional drug therapy (32.4%), followed by ineffective drug therapy (14%), and unnecessary drug therapy (13.1%). The predicting factors for drug therapy problems were old age (AOR: 3.97, 95%CI: 1.68-9.36) and number of medications ≥ 5 (AOR: 2.68, 95%CI: 1.47-5.11).

CONCLUSION

More than half of the patients experienced drug therapy problems in our study. Old age and number of medications were the predicting factors of drug therapy problems. Therefore, greater attention and focus should be given to patients who are at risk of developing drug therapy problems.

Physicians Adherence to Evidence-Based Guidelines as a Major Predictor to Anticoagulant-related Medication Errors Incidence and Severity

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.

Identification and solution of drug-related problems in the neurology unit of a tertiary hospital in China

BACKGROUND

The prevalence and characteristics of drug-related problems (DRPs) and factors associated with the occurrence of DRPs in the neurology unit in China remain unknown. This study aimed to determine the prevalence, characteristics and severity ratings of DRPs and identify factors associated with the occurrence of DRPs in the neurology unit of a tertiary care and academic teaching hospital in China.

METHODS

A retrospective study of DRPs and pharmacists' interventions for neurology patients was performed during a non-consecutive 24-month study period. Patient demographics and clinical characteristics, and pharmacist's intervention records were collected. The characteristics and severity ratings of DRPs were categorized using the Pharmaceutical Care Network Europe (PCNE) DRP classification tool V9.00 and the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) classification respectively.

RESULTS

A total of 242 DRPs were detected for 974 admitted patients, an average of 0.25 DRPs per patient. Treatment safety was the major type of DRPs (106;43.8%) followed by treatment effectiveness (78;32.2%). The primary causes of DRPs were drug selection (124;44.1%) and dose selection (92;32.7%). Clinical pharmacists provided 525 interventions, and most interventions occurred at the prescriber level (241;45.9%). A total of 91.4% of these interventions were accepted, contributing to solving 93.0% of the identified problems. The majority of DRPs (210;86.8%) were rated at severity categories B to D (causing no patient harm). Multiple logistic regression showed that creatinine clearance, number of medications used, nasogastric feeding, diabetes, and infectious diseases were associated with more frequent DRPs (p < 0.05).

CONCLUSIONS

DRPs are relatively common in the neurology unit in China, with primary causes of drug and dose selection, and clinical pharmacists can effectively reduce and prevent DRPs to optimize medication therapy.

An Iterative and Collaborative End-to-End Methodology Applied to Digital Mental Health

Artificial intelligence (AI) algorithms together with advances in data storage have recently made it possible to better characterize, predict, prevent, and treat a range of psychiatric illnesses. Amid the rapidly growing number of biological devices and the exponential accumulation of data in the mental health sector, the upcoming years are facing a need to homogenize research and development processes in academia as well as in the private sector and to centralize data into federalizing platforms. This has become even more important in light of the current global pandemic. Here, we propose an end-to-end methodology that optimizes and homogenizes digital research processes. Each step of the process is elaborated from project conception to knowledge extraction, with a focus on data analysis. The methodology is based on iterative processes, thus allowing an adaptation to the rate at which digital technologies evolve. The methodology also advocates for interdisciplinary (from mathematics to psychology) and intersectoral (from academia to the industry) collaborations to merge the gap between fundamental and applied research. We also pinpoint the ethical challenges and technical and human biases (from data recorded to the end user) associated with digital mental health. In conclusion, our work provides guidelines for upcoming digital mental health studies, which will accompany the translation of fundamental mental health research to digital technologies.

Bivalirudin versus unfractionated heparin during percutaneous coronary intervention in high-bleeding-risk patients with acute coronary syndrome in contemporary practice

BACKGROUND

Bivalirudin, as compared with unfractionated heparin (UFH), has been shown to reduce bleeding complications and supply a better safety profile among low/medium-bleeding-risk patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) in some previous studies. Whether this advantage persists in patients at high risk of bleeding according to contemporary practice characterized by frequent use of radial-artery access and novel P2Y₁₂ inhibitors, and low use of glycoprotein IIb/IIIa inhibitors (GPIs) is unclear.

AIM OF THE STUDY

This study aimed to assess the efficacy and safety of bivalirudin compared with UFH in high bleeding risk patients with ACS undergoing PCI in current practice.

MATERIALS AND METHODS

All consecutive high-bleeding-risk patients who underwent PCI for ACS at the First Affiliated Hospital of Zhengzhou University from January to September 2019 were retrospectively analyzed. The 30-day primary outcome was a composite of major bleeding, myocardial infarction, all-cause death, or stroke (net adverse clinical events [NACEs]), and the secondary outcomes at 30 days included a composite of myocardial infarction, stoke, or all-cause death (major adverse cardiovascular events [MACEs]), each component of the primary outcome, target vessel revascularization (TVR) and stent thrombosis (ST). Besides, we assessed angina-related health status at 30 days, the length of hospital stay, and hospitalization costs. A logistic regression model was used to adjust for baseline differences. Consistency of the treatment effect of bivalirudin for NACEs and MACEs compared with UFH was evaluated in 15 prespecified subgroups.

RESULTS

From January to September 2019, 823 patients (361 treated with bivalirudin and 462 treated with UFH) were enrolled in the study. GPIs, novel P2Y₁₂ inhibitors, and radial approach was used in 5.6 %, 66.1 %, and 89.7 % of the patients, respectively. After adjusting for baseline differences, bivalirudin was associated with significant reduction in NACEs, MACEs, major bleeding, and myocardial infarction at 30 days compared with UFH. The individual endpoints of death, stroke, ST and TVR did not differ significantly between the 2 groups after adjusting for covariates. Furthermore, bivalirudin consistently reduced the rates of NACEs and MACEs in the 15 prespecified subgroups compared with UFH. These benefits of bivalirudin can translate into improved angina-related health status, shorter hospital stays, and lower hospitalization costs.

CONCLUSIONS

The treatment of bivalirudin showed better efficacy and safety as compared to UFH among patients with ACS undergoing PCI at high risk of bleeding in contemporary practice.

Characteristics of drug-related problems among hospitalized ischemic stroke patients in China

Background Patients with ischemic stroke are often taking multiple medications and are at increased risk for drug-related problems (DRPs). However, the prevalence and nature of DRPs in these patients in China and the impact of pharmacist interventions to resolve DRPs in this population are unknown. Objective To investigate the prevalence and nature of DRPs in ischemic stroke patients. Setting A neurology ward at an academic teaching hospital in Shanghai, China. Methods This was a prospective observational study conducted from September to November 2017. A total of 274 ischemic stroke adult patients were included. Pharmacists provided pharmaceutical care activities in the multi-disciplinary team. DRPs were categorized by the Pharmaceutical Care Network Europe classification V8.0. Main outcome measure The number, types, and causes of DRPs. Results We identified 88 DRPs related to 89 causes, an average rate of 0.32 DRP per patient. The rates of DRPs were higher in patients with renal impairment (0.91), liver impairment (0.65), or patients younger than 60 years (0.39). The primary cause of the DRPs was drug selection (66.3%), and the most common problem was treatment safety (60.2%). Among the top medications associated with DRPs were proton pump inhibitors (17.2%) followed by cerebrovascular/nootropics (16.1%) and sedative-hypnotics (13.9%). The acceptance rate of pharmacists' inventions reached 94.0%, and 90.0% of these accepted inventions were fully implemented (DRP status solved). Conclusion Drug-related problems are relatively common in hospitalized ischemic stroke patients in China, and treatment safety is the major DRP type. Pharmacist intervention can identify and resolve pertinent DRPs to optimize medication therapy.

Stress hyperglycemia and electrolytes disturbance in patients with acute cerebrovascular stroke

Background

Stroke is a medical emergency and considered the 2nd leading cause of mortality worldwide. High morbidity and mortality of stroke are due to some complications like cerebral edema, infection, and associated heart disease. Stroke may cause stress hyperglycemia and electrolyte disturbance that may be independent predictors for increased morbidity and mortality. Data on electrolyte disorder in neurological conditions especially acute stroke are somewhat scanty and not frequently interpreted.

Objectives

The current study aimed to evaluate the effect of stress induced by acute stroke on the blood glucose and serum electrolytes and its relationship to the type, severity, and prognosis of stroke.

Subjects and methods

A total of 100 patients admitted with acute stroke were included in the study. After informed consent, fasting blood sugar, glycosylated hemoglobin, serum sodium, and potassium levels were measured simultaneously. Stroke severity and outcome were assessed using the Glasgow Coma Scale.

Results

Stress hyperglycemia was noted in 21 patients, out of which 62% presented with hemorrhagic stroke. Undiagnosed diabetes was found in 47% of cases. Also, 13 % of our patients had both stress hyperglycemia and electrolyte disturbance simultaneously. Mortality among hemorrhagic versus ischemic patients was 46% and 22%, respectively. The independent predictors of mortality were stress hyperglycemia, electrolytes disturbance, ischemic heart diseases, and type and admission severity of stroke.

Conclusion

Stress hyperglycemia and electrolyte disturbance after acute stroke were found in 21% and 47% of patients respectively and may adversely affect outcome of stroke especially those with cerebral hemorrhage.

Gaps, traps, bridges and props: a mixed-methods study of resilience in the medicines management system for patients with heart failure at hospital discharge

INTRODUCTION

Poor medicines management places patients at risk, particularly during care transitions. For patients with heart failure (HF), optimal medicines management is crucial to control symptoms and prevent hospital readmission. This study explored the concept of resilience using HF as an example condition to understand how the system compensates for known and unknown weaknesses.

METHODS

We explored resilience using a mixed-methods approach in four healthcare economies in the north of England. Data from hospital site observations, healthcare staff and patient interviews, and documentary analysis were collected between June 2016 and March 2017. Data were synthesised and analysed using framework analysis.

RESULTS

Interviews were conducted with 45 healthcare professionals, with 20 patients at three time points and 189 hours of observation were undertaken. We identified four primary inter-related themes concerning organisational resilience. These were named as gaps, traps, bridges and props. Gaps were discontinuities in processes that had the potential to result in poorly optimised medicines. Traps were features of the system that could produce errors or unintended adverse medication events. Bridges were features of the medicines management system that promoted safety and continuity which ensured that, despite varying conditions, care could be delivered successfully. Props were informal, temporary or impromptu actions taken by patients or healthcare staff to avoid potential adverse events.

CONCLUSION

The numerous opportunities for HF patient safety to be compromised and for suboptimal medicines management during this common care transition are mitigated by system resilience. Cross-organisational bridges and temporary fixes or 'props' put in place by patients and carers, healthcare teams and organisations are critical for safe and optimal care to be delivered in the face of continued system pressures.

[Radial approach in the elderly]

Due to the steady increase in life expectancy, the number of patients over 80 years of age proposed for coronary angioplasty is increasing significantly. The elderly patient is a patient at high cardiovascular risk and high risk of bleeding; whose severity of prognosis depends of comorbidities. The radial approach presents particularities and technical difficulties that have to be known in this part of the population, but reduce vascular and hemorrhagic complications, as well as mortality. Because of greater safety, the radial approach is therefore the first choice for the elderly.

Drug therapy problems and contributing factors in the management of heart failure patients in Jimma University Specialized Hospital, Southwest Ethiopia

BACKGROUND

Drug therapy problem (DTP) is any unwanted incident related to medication therapy that actually or potentially affects the desired goals of treatment. Heart failure (HF) patients are more likely to experience DTP owing to multiple prescriptions and comorbidities. Despite the serious negative impact of DTP on treatment outcomes, there is a dearth of study on DTP among HF patients in Ethiopia.

OBJECTIVE

The main aim of this study was to assess the prevalence and contributing factors of DTP among ambulatory HF patients in Jimma University Specialized Hospital, Ethiopia.

METHODS

A hospital based prospective observational study was conducted. Written informed consent was obtained from each patient after full explanation of the study. Data were collected through patient interview and expert review of medical, medication and laboratory records of one-year follow-up from May 2015 to April 2016. DTPs were identified using Cipolle's method followed by consensus review with experts. Binary logistic regression was performed to identify factors contributing to DTP. A p<0.05 was considered statistically significant in all analyses.

RESULT

Of 340 study participants; male to female ratio was equivalent, the mean (± SD = standard deviation) age was 50.5±15.6 years. Eight hundred eighty DTPs were identified equating 2.6 ±1.8 DTPs per patient. The frequently identified DTPs were dosage too low (27.8%), ineffective drug therapy (27.6%) and need additional drug therapy (27.4%). Most commonly implicated drugs were beta-blockers (34.4%), angiotensin converting enzyme inhibitors (24.8%), statins (16.5%) and antithrombotics (13.1%). Factors contributing to DTP were age >50 years (AOR [adjusted odd ratio] = 5.43, 95%CI [95% confidence interval] = 2.03-14.50); negative medication belief (AOR = 3.50, 95%CI = 1.22-10.05); poor involvement of patients in the therapeutic decision makings (AOR = 4.11, 95%CI = 1.91-8.88); number of co-morbidity≥2(AOR = 5.26, 95%CI = 2.38-11.65) and number of medications ≥5 (AOR = 3.68, 95%CI = 1.28-10.51).

CONCLUSION

DTPs are common among ambulatory care HF patients. Patients with older age, negative medication belief, polypharmacy, co-morbidities and those who were poorly involved in the therapeutic decision were more likely to experience DTP. Despite traditional prescription refilling, an integrated multidisciplinary approach involving patients and clinically trained pharmacists should be implemented in the patient care process at ambulatory care clinics in order to improve overall outcomes and reduce DTPs and associated burdens in HF patients.

Enoxaparin dosing errors in the emergency department

BACKGROUND

The study aimed to determine the frequency of enoxaparin dosing errors for patients who had a measured emergency department (ED) weight compared to those who did not have a measured ED weight, and to determine if demographic variables (e.g., weight, height, age, English-speaking, race) impact the likelihood of receiving an inappropriate dose.

METHODS

This is a retrospective, electronic chart review of patients who received a dose of enoxaparin in the ED between January 1, 2008 and July 1, 2013. We identified all patients >18 years who received a dose of enoxaparin while in the ED, were admitted, and had at least one inpatient weight within the first four days of hospitalization. Patients were excluded if they received enoxaparin for prophylaxis or a dose of more than 1.25 mg/kg.

RESULTS

A total of 1,944 patients were included. Patients were more likely to experience an error if they did not have a measured ED weight. Over-doses of >10 mg were more likely to occur in patients without a measured ED weight. Patients with no documented ED weight or with a staff-estimated ED weight were more likely to experience a dosing error than those with a patient-stated weight. Patients were more likely to experience an error if their first inpatient weight was more than 96 kg, they were more than 175-cm tall, or were English speaking.

CONCLUSION

Dosing errors are more likely to occur when patients are not weighed in the ED. Modifications to current workflows to incorporate weighing those patients who receive weight-dosed medications may be warranted.

Non–Health Care Facility Cardiovascular Medication Errors in the United States

Background: Prior studies have not examined national trends and characteristics of unintentional non–health care facility (HCF) medication errors associated with cardiovascular drugs. Objective: To investigate non-HCF medication errors associated with cardiovascular drugs reported to poison control centers in the United States. Methods: A retrospective analysis of non-HCF medication errors associated with cardiovascular drugs from 2000 to 2012 was conducted using the National Poison Data System database. Results: There were 278 444 medication errors associated with cardiovascular drugs reported to US poison control centers during the study period, averaging 21 419 exposures annually. The overall rate of cardiovascular medication errors per 100 000 population increased 104.6% from 2000 to 2012 ( P < 0.001) and the highest rates were among older adults. Most cases (83.6%) did not require treatment at a HCF. Serious medical outcomes were reported in 4.0% of exposures. The cardiovascular drugs most commonly implicated in medication errors were β-blockers (28.2%), calcium antagonists (17.7%), and angiotensin-converting enzyme inhibitors (15.9%). Most of the 114 deaths were associated with cardiac glycosides (47.4%) or calcium antagonists (29.8%). Most medication errors involved taking or being given a medication twice (52.6%). Conclusions: This study describes characteristics and trends of non-HCF cardiovascular medication errors over a 13-year period in the United States. The number and rate of cardiovascular medication errors increased steadily from 2000 to 2012, with the highest error rates among older adults. Further research is needed to identify prevention strategies for these errors, with a particular focus on the older adult population.

Clinical relevance of pharmacist intervention in an emergency department

OBJECTIVES

To evaluate the clinical relevance of pharmacist intervention on patient care in emergencies, to determine the severity of detected errors. Second, to analyse the most frequent types of interventions and type of drugs involved and to evaluate the clinical pharmacist's activity.

METHODS

A 6-month observational prospective study of pharmacist intervention in the Emergency Department (ED) at a 400-bed hospital in Spain was performed to record interventions carried out by the clinical pharmacists. We determined whether the intervention occurred in the process of medication reconciliation or another activity, and whether the drug involved belonged to the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. To evaluate the severity of the errors detected and clinical relevance of the pharmacist intervention, a modified assessment scale of Overhage and Lukes was used. Relationship between clinical relevance of pharmacist intervention and the severity of medication errors was assessed using ORs and Spearman's correlation coefficient.

RESULTS

During the observation period, pharmacists reviewed the pharmacotherapy history and medication orders of 2984 patients. A total of 991 interventions were recorded in 557 patients; 67.2% of the errors were detected during medication reconciliation. Medication errors were considered severe in 57.2% of cases and 64.9% of pharmacist intervention were considered relevant. About 10.9% of the drugs involved are in the High-Alert Medications ISMP list. The severity of the medication error and the clinical significance of the pharmacist intervention were correlated (Spearman's ρ=0.728/p<0.001).

CONCLUSIONS

In this single centre study, the clinical pharmacists identified and intervened on a high number of severe medication errors. This suggests that emergency services will benefit from pharmacist-provided drug therapy services.

Impact of Norepinephrine Weight-Based Dosing Compared With Non–Weight-Based Dosing in Achieving Time to Goal Mean Arterial Pressure in Obese Patients With Septic Shock

Background: Currently, a lack of standardization exists in norepinephrine dosing units, the first-line vasopressor for septic shock. Timely achievement of goal mean arterial pressure (MAP) is dependent on optimal vasopressor dosing. Objective: To determine if weight-based dosing (WBD) of norepinephrine leads to earlier time to goal MAP compared with non-WBD in obese patients with septic shock. Methods: This was a retrospective, multicenter cohort study. Patients had a body mass index (BMI) ≥30 kg/m2 and received norepinephrine for septic shock with either a non-WBD strategy (between December 2009 and January 2013) or WBD strategy (between January 2013 and December 2015). The primary outcome was time to goal MAP. Secondary outcomes were norepinephrine duration, dose requirements, and development of treatment-related complications. Results: A total of 287 patients were included (WBD 144; non-WBD 143). There was no difference in median time to goal MAP (WBD 58 minutes, interquartile range [IQR] = 16.8-118.5, vs non-WBD 60 minutes, IQR = 17.5-193.5; P = 0.28). However, there was a difference in median cumulative norepinephrine dose (WBD 12.6 mg, IQR = 4.9-45.9, vs non-WBD 10.5 mg, IQR = 3.9-25.6; P = 0.04) and time to norepinephrine discontinuation (WBD 33 hours, IQR = 15-69, vs non-WBD 27 hours, IQR = 12-51; P = 0.03). There was no difference in rates of atrial fibrillation (WBD 15.3% vs non-WBD 23.7%; P = 0.07) or mortality (WBD 23.6% vs non-WBD 23.1%; P = 0.92). Conclusion: WBD of norepinephrine does not achieve time to goal MAP earlier in obese patients with septic shock. However, WBD may lead to higher norepinephrine cumulative dose requirements and prolonged time until norepinephrine discontinuation.

Pharmacological reasons that may explain why randomized clinical trials have failed in acute heart failure syndromes

Acute heart failure (AHF) represents a clinical challenge as it encloses a heterogeneous group of syndromes (AHFS) with different pathophysiology, clinical presentations, prognosis and response to therapy. In the last 25years multiple therapeutic targets have been identified and numerous new drugs were evaluated but, up to now, all failed to demonstrate a consistent benefit on clinical outcomes. Moreover, a repeated finding has been the poor correlation between the encouraging results of preclinical and early clinical trials and the lack of effect on outcomes observed in phase III trials. We review several possible pharmacological reasons that may explain the lack of success to develop new drugs and the pharmacological challenges to overcome in the future to develop new more effective and safer drugs for the treatment of AHFS.

Cognitive biases associated with medical decisions: a systematic review

Background

Cognitive biases and personality traits (aversion to risk or ambiguity) may lead to diagnostic inaccuracies and medical errors resulting in mismanagement or inadequate utilization of resources. We conducted a systematic review with four objectives: 1) to identify the most common cognitive biases, 2) to evaluate the influence of cognitive biases on diagnostic accuracy or management errors, 3) to determine their impact on patient outcomes, and 4) to identify literature gaps.

Methods

We searched MEDLINE and the Cochrane Library databases for relevant articles on cognitive biases from 1980 to May 2015. We included studies conducted in physicians that evaluated at least one cognitive factor using case-vignettes or real scenarios and reported an associated outcome written in English. Data quality was assessed by the Newcastle-Ottawa scale. Among 114 publications, 20 studies comprising 6810 physicians met the inclusion criteria. Nineteen cognitive biases were identified.

Results

All studies found at least one cognitive bias or personality trait to affect physicians. Overconfidence, lower tolerance to risk, the anchoring effect, and information and availability biases were associated with diagnostic inaccuracies in 36.5 to 77 % of case-scenarios. Five out of seven (71.4 %) studies showed an association between cognitive biases and therapeutic or management errors. Of two (10 %) studies evaluating the impact of cognitive biases or personality traits on patient outcomes, only one showed that higher tolerance to ambiguity was associated with increased medical complications (9.7 % vs 6.5 %; p = .004). Most studies (60 %) targeted cognitive biases in diagnostic tasks, fewer focused on treatment or management (35 %) and on prognosis (10 %). Literature gaps include potentially relevant biases (e.g. aggregate bias, feedback sanction, hindsight bias) not investigated in the included studies. Moreover, only five (25 %) studies used clinical guidelines as the framework to determine diagnostic or treatment errors. Most studies (n = 12, 60 %) were classified as low quality.

Conclusions

Overconfidence, the anchoring effect, information and availability bias, and tolerance to risk may be associated with diagnostic inaccuracies or suboptimal management. More comprehensive studies are needed to determine the prevalence of cognitive biases and personality traits and their potential impact on physicians’ decisions, medical errors, and patient outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0377-1) contains supplementary material, which is available to authorized users.

A study of medication-related problems in stroke patients: A need for pharmaceutical care

Objective:

The study was aimed to assess the incidence and characteristics of drug-related problems (DRPs).

Methods:

A prospective, observational study was conducted among 133 patients with stroke disease who were aged 18 years or older and admitted to the general medicine ward. During the 6 months study period, the incidence of DRPs was identified using the Pharmaceutical Care Network Europe Foundation classification system, version 6.2.

Findings:

A total of 133 patients were screened for DRPs. Among them, 120 patients have at least one DRP. A total of 254 DRPs were identified (on average, 2.015 DRPs per each patient case).

Conclusion:

Increasing the evidence of the incidence of medication-related problems in tertiary care hospitals indicates the need for the establishment of a clinical pharmacist in hospital settings.

Fibrinolytic therapy in hospitals without percutaneous coronary intervention capabilities in China from 2001 to 2011: China PEACE-retrospective AMI study

BACKGROUND

Fibrinolytic therapy is the primary reperfusion strategy for ST-segment elevation myocardial infarction in China, and yet little is known about the quality of care regarding its use and whether it has changed over time. This issue is particularly important in hospitals without the capacity for cardiovascular intervention.

METHODS

Using a sequential cross-sectional study with two-stage random sampling in 2001, 2006, and 2011, we characterised the use, timing, type and dose of fibrinolytic therapy in a nationally representative sample of patients with ST-segment elevation myocardial infarction admitted to hospitals without the ability to perform percutaneous coronary intervention.

RESULTS

We identified 5306 patients; 2812 (53.0%) were admitted within 12 hours of symptom onset, of whom 2463 (87.6%) were ideal candidates for fibrinolytic therapy. The weighted proportion of ideal candidates receiving fibrinolytic therapy was 45.8% in 2001, 50.0% in 2006, and 53.0% in 2011 ( P_trend=0.0042). There were no regional differences in fibrinolytic therapy use. Almost all ideal patients (95.1%) were treated after admission to the hospital rather than in the emergency department. Median admission to needle time was 35 minutes (interquartile range 10-82) in 2011, which did not improve from 2006. Underdosing was common. Urokinase, with little evidence of efficacy, was used in 90.2% of patients.

CONCLUSIONS

Over the past decade in China, the potential benefits of fibrinolytic therapy were compromised by underuse, patient and hospital delays, underdosing and the predominant use of urokinase, an agent for which there is little clinical evidence. There are ample opportunities for improvement.

Norepinephrine Dosing in Obese and Nonobese Patients With Septic Shock

BACKGROUND

Whether or not norepinephrine infusions for support of hemodynamic status in patients with septic shock should be weight based is unknown. This situation is particularly pertinent in patients who are extremely overweight or obese.

OBJECTIVE

To compare dosing requirements and effect of norepinephrine on blood pressure in obese and nonobese patients with septic shock.

METHODS

In a retrospective cohort study, data on adult patients with septic shock who received norepinephrine infusion for support of hemodynamic status in a tertiary care, academic medical center were analyzed. Patients were categorized as obese (body mass index ≥ 30) or nonobese (body mass index < 30). The primary outcome was dosing requirements of norepinephrine at 60 minutes after the start of the infusion. The secondary outcome was the log-transformed ratio of mean arterial pressure to norepinephrine.

RESULTS

The final cohort consisted of 100 obese and 100 nonobese patients. Mean norepinephrine infusion rate at 60 minutes was 0.09 (SD, 0.08) μg/kg per minute in the obese group and 0.13 (SD, 0.14) μg/kg per minute in the nonobese group (P = .006). The non-weight-based dose at 60 minutes was 9 μg/min in obese patients and 8 μg/min in nonobese patients (P = .72). The log transformed mean arterial pressure to norepinephrine ratio at 60 minutes was 2.5 (SD, 0.9) in obese patients and 2.5 (SD, 0.8) in nonobese patients (P = .54) CONCLUSIONS: Compared with nonobese patients, obese patients with septic shock require lower weight-based doses of norepinephrine and similar total norepinephrine doses.

Toward phase 4 trials in heart failure: A social and corporate responsibility of the medical profession

Congestive heart failure (CHF) is a chronic condition, requiring polypharmacy, allied health supports and regular monitoring. All these factors are needed to ensure compliance and to deliver the positive outcomes demonstrated from randomized controlled trials. Unfortunately many centers around the world are unable to match trial level support. The outcomes for many communities are thus unclear. Research design factors in post-marketing surveillance to address this issue. Phase 4 studies is the name given to trials designed to obtain such community level data and thus address issues of external validity. CHF phase 4 studies are relatively underutilized. We feel the onus for this research lies with the health profession. In this commentary we provide arguments as to why phase 4 studies should be viewed as a social and corporate responsibility of health professional that care for clients with CHF.

What Lies behind the Ischemic Stroke: Aortic Dissection?

Introduction. Some cases with aortic dissection (AD) could present with various complaints other than pain, especially neurological and cardiovascular manifestations. AD involving the carotid arteries could be associated with many clinical presentations, ranging from stroke to nonspecific headache. Case Report. A 71-year-old woman was admitted to emergency department with vertigo which started within the previous one hour and progressed with deterioration of consciousness following speech disorder. On arrival, she was disoriented and uncooperative. Diffusion magnetic resonance imaging (MRI) of brain was consistent with acute ischemia in the cerebral hemisphere. Fibrinolytic treatment has been planned since symptoms started within two hours. Echocardiography has shown the dilatation of ascending aorta with a suspicion of flap. Computed tomography (CT) angiography has been applied and intimal flap has been detected which was consistent with aortic dissection, intramural hematoma of which was reaching from aortic arch to bilateral common carotid artery. Thereafter, treatment strategy has completely changed and surgical invention has been done. Conclusion. In patients who are admitted to the emergency department with the loss of consciousness and stroke, inadequacy of anamnesis and carotid artery involvement of aortic dissection should be kept in mind.

The golden hour Performing an acute ischemic stroke workup

Ischemic stroke is a medical emergency resulting from an embolic or thrombotic occlusion of an intracranial artery. The purpose of this article is to provide acute care nurse practitioners a summary of recent updates on the rapid evaluation and workup for patient selection and treatment with I.V. fibrinolysis.

An intervention to improve inpatient medication management: a before and after study

AIM

To optimise medication administration, prevent medication errors and improve inpatient safety.

BACKGROUND

Interventions are needed to reduce medication-related errors and to improve patient safety.

METHOD

A five-point management intervention strategy was developed and implemented. A quasi-experimental design was used to examine its effects.

RESULTS

Comparing pre-intervention data with post-intervention data, the rate of accurate compliance with medication policies and procedures increased from 86.7% (645/744 doses observed) to 97.5% (725/744). The success rate of medication administration procedures increased from 94.0% (466/496 doses observed) to 96.8% (480/496). Nurse-initiated medication error reports/total medication error reports increased from 77.1% (101/131) to 95.1% (58/61). Rate of inpatient satisfaction with medication increased from 92.1% (3427/3720) to 98.3% (3656/3720). Complaints related to nursing medication administration decreased from 23 to 6 (73.9% reduction).

CONCLUSION

The five-point management intervention strategy improved inpatient medication safety: medication errors were reduced, nurses' awareness and skills of medication safety enhanced, inpatient satisfaction improved. However, randomised controlled trials are needed to test its effectiveness.

IMPLICATIONS FOR NURSING MANAGEMENT

A systematic approach is vital to address the issues of medication errors and patient safety.

Transitions of care in anticoagulation management for patients with atrial fibrillation

Thromboprophylaxis with oral anticoagulants (OACs) is an important but underused element of atrial fibrillation (AF) treatment. Reduction of stroke risk with anticoagulants comes at the price of increased bleeding risk. Patients with AF receiving anticoagulants require heightened attention with transition from one care setting to another. Patients presenting for emergency care of anticoagulant-related bleeding should be triaged for the severity and source of the bleeding using appropriate measures, such as discontinuing the OAC, administering vitamin K, when appropriate, to reverse warfarin-induced bleeding, or administering clotting factors for emergent bleeding. Reversal of OACs in patients admitted to the hospital for surgery can be managed similarly to patients with bleeding, depending on the urgency of the surgical procedure. Patients with AF who are admitted for conditions unrelated to AF should be assessed for adequacy of stroke risk prophylaxis and bleeding risk. Newly diagnosed AF should be treated in nearly all patients with either warfarin or a newer anticoagulant. Patient education is critically important with all anticoagulants. Close adherence to the prescribed regimen, regular international normalized ratio testing for warfarin, and understanding the stroke risk conferred by both AF and aging are goals for all patients receiving OACs. Detailed handoff from the hospitalist to the patient's primary care physician is required for good continuity of care. Monitoring by an anticoagulation clinic is the best arrangement for most patients. The elderly, or particularly frail or debilitated patients who are transferring to long-term care, need a detailed transfer of information between settings, education for the patient and family, and medication reconciliation. Communication and coordination of care among outpatient, emergency, inpatient, and long-term care settings are vital for patients with AF who are receiving anticoagulants to balance stroke prevention and bleeding risk.

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm

Appropriate and safe use of medications is an important aspect of quality of care in nursing home patients. Because of their complex medication use process, anticoagulants are prone to medication errors in the frail elderly. Therefore, we designed this study to characterize anticoagulant medication errors and to evaluate their association with patient harm using individual medication error incidents reported by all North Carolina nursing homes to the Medication Error Quality Initiative (MEQI) during fiscal years 2010-2011. Characteristics, causes, and specific outcomes of harmful anticoagulant medication errors were reported as frequencies and proportions and compared between anticoagulant errors and other medication errors using chi-square tests. A multivariate logistic regression model explored the relationship between anticoagulant medication errors and patient harm, controlling for patient- and error-related factors.

Dosing practice of low molecular weight heparins and its efficacy and safety in cardiovascular inpatients: a retrospective study in a Chinese teaching hospital

Background

Low-molecular-weight heparins (LMWHs) are safe and effective anticoagulant options for cardiovascular patients when applied as body weight-adjusted doses. However, there are some barriers that make it difficult to implement weight-adjusted doses in clinical practice. Therefore, it is vital to learn the dosing practices of LMWH and its efficacy and safety in clinical practice.

Methods

A retrospective study was conducted in cardiovascular inpatients who had received at least one dose of LMWH during a 6-month period. Appropriateness of LMWH dosing was determined and major clinical outcomes (major adverse vascular events and major bleeding) during hospitalization were evaluated.

Results

A total of 376 admissions representing 364 patients received LMWH treatment. Of these, 17.0% (64/376) of admissions did not have body weight records. Of the 312 admissions included for the outcome study, only 34 cases (10.9%) received the recommended doses of LMWH, while 51 cases (16.3%) received mild underdoses, 223 cases (71.5%) received major underdoses and 4 (1.3%) received excess doses. There were 10 major adverse vascular events, which occurred more often in patients receiving excess doses of LMWH than in patients receiving recommended, mild or major underdoses (50%, 2.9%, 2.0% and 2.7%, respectively, P < 0.001). After multivariable analysis, severe renal insufficiency was an independent risk factor for major adverse vascular events [odds ratio (OR), 31.93; 95% confidence interval (CI), 5.99-170.30; P < 0.001]. No major bleeding was recorded.

Conclusions

Underdose of LMWH is commonly used in cardiovascular inpatients, which was suboptimal according to guidelines. Using LMWH at a fixed, low dose for treatment purposes in patients without severe renal insufficiency was not associated with a higher risk of adverse vascular events in the current study, though larger studies with extended follow-ups are required to fully assess the long-term consequences of LMWH underdosing.

Evaluation of dose requirements for prolonged bivalirudin administration in patients with renal insufficiency and suspected heparin-induced thrombocytopenia

Bivalirudin, a direct thrombin inhibitor, is indicated for patients with suspected heparin-induced thrombocytopenia (HIT) with anticipated percutaneous coronary intervention (PCI). Data is limited on dose selection among patients with renal insufficiency, particularly with prolonged infusion durations. The study cohort comprised 73 patients with renal dysfunction who received bivalirudin for suspected HIT with or without acute coronary syndrome. We reviewed individual pharmacy and medical records for laboratory and bivalirudin dosing information, medical comorbidities, and adverse clinical outcomes during administration. When estimated glomerular filtration rate (eGFR) was calculated by the Cockcroft-Gault (CG; ml/min) formula, the average bivalirudin dose (mg/kg/h) achieving a therapeutic activated partial thromboplastin time (aPTT) was 0.07 ± 0.04, 0.15 ± 0.08, and 0.16 ± 0.07 for patients with eGFR between 15-30, 31-60, and >60, respectively. When eGFR was calculated by the modification of diet in renal disease (MDRD; ml/min/1.73 m(2)) formula, the average bivalirudin dose achieving a therapeutic aPTT was 0.07 ± 0.04, 0.12 ± 0.07, and 0.20 ± 0.07 for patients with eGFR between 15-30, 31-60, >60, respectively. The difference between the dose achieving a therapeutic aPTT for patients with eGFR >60 when calculated by MDRD versus CG was completely abolished when obese patients were excluded from the CG cohort. The results of our series of patients with renal dysfunction receiving prolonged duration of bivalirudin in the setting of acute coronary syndrome (ACS) suggests that dose adjustment is safe and should be considered for patients with moderate to severe renal impairment (eGFR < 60 ml/min/1.73 m(2)).

Drug-related problems in patients with ischemic stroke in hospital

BACKGROUND

Drug therapy is getting more complex, thus making it more challenging to prescribe appropriate drug therapy. Accordingly, in clinical practice, a wide range of drug-related problems (DRP) may arise; they are relatively common in hospitalised patients and can result in patient morbidity and mortality, and increased costs.

OBJECTIVE

The objective was to investigate the nature and frequency of DRPs along with pharmaceutical interventions to address them in patients with ischemic stroke from hospital admission to discharge.

METHOD

From January to June 2011 patients with ischemic stroke, who were taking >2 drugs during hospital stay and at discharge, were recruited. A clinical pharmacist performed medication reconciliation on admission, and checked the medication records during the hospital stay regularly. DRPs were categorized by APS-Doc. Results In total, DRPs occurred in 105/155 (67.7 %) patients: Overall 271 DRPs were documented, with a mean of 1.8 ± 2.0 DRPs per patient. The DRPs occurred mainly in the categories "drug", "indication", and "dosage".

CONCLUSION

In conclusion, DRPs are relatively common in hospitalised patients and may occur at any part of the prescribing process. The clinical pharmacist can provide a valuable contribution in the multidisciplinary team to an optimized pharmacotherapy in patients with ischemic stroke.

Medication errors in patients with severe chronic kidney disease and acute coronary syndrome: the impact of computer-assisted decision support

OBJECTIVE

To evaluate the impact of computerized physician order entry (CPOE) with decision support on the frequency of antithrombotic medication errors in patients with chronic kidney disease (CKD) admitted with acute coronary syndrome (ACS) and to measure what effect it would have on in-hospital bleeding.

PATIENTS AND METHODS

We evaluated 80 patients with CKD who were admitted with ACS between January 1, 2009, and December 31, 2010, using either a standardized order set or CPOE with decision support to assess the frequency of medication errors and in-hospital bleeding.

RESULTS

Of the 80 patients, 47 were admitted with standard orders vs 33 with CPOE. In-hospital bleeding occurred in 13 patients: 10 in the standard orders group vs 3 in the CPOE group (P=.12). In-hospital bleeding occurred in 5 (63%) of 8 patients receiving a contraindicated antithrombotic medication compared with 8 (11%) of 72 patients receiving appropriate medications (P=.002); the corresponding length of stay was 12.0 days compared with 6.8 days (P=.10). Contraindicated medications were given to no patients in the CPOE group vs 8 patients (17%) in the standard orders group (P=.01).

CONCLUSION

Medication errors occur frequently in patients with CKD admitted with ACS and result in a high risk of in-hospital bleeding. Use of CPOE with decision support is feasible in the ACS setting and may lead to improved patient safety.

Heart disease and stroke statistics--2011 update: a report from the American Heart Association

Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2009 alone, the various Statistical Updates were cited ≈1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year’s edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing how family history and genetics play a role in cardiovascular disease (CVD) risk. Also, the 2011 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA’s 2020 Impact Goals. Below are a few highlights from this year’s Update.