A comprehensive study of prescribing, administering and drug handling medication errors in ten wards of a university hospital after implementation of electronic prescribing, clinical pharmacists or medication reconciliation

Background and aim: Medication errors lead to preventable risks. Preventing strategies such as e-prescribing, clinical pharmacists and medication reconciliation have been implemented in recent years. However, information on long-term medication error rates in routine procedures is missing. Investigations: We aimed to identify predefined medication errors in ten wards of a university hospital where e-prescribing, clinical pharmacists and medication reconciliation have been partially implemented. Patient files were reviewed and routine processes were monitored for drug prescription errors (missing, unclear, outdated information), administration errors (wrong dispensed drugs) and drug handling errors (no light-, moisture-protection, wrong splitting, no separation of drugs, which ought to be taken by an empty stomach). Results: We analyzed 959 prescriptions with 933 solid peroral drugs for 182 patients (98 female, median age 66.5 years [Q25-Q75: 56-78 years]; the median number of drugs was 5 [Q25-Q75: 3-7]). The most frequent prescription error was a not specified drug form (91.1%). The most common administration error was a not adequately provided release dose formulation (72.7%). The lack of light protection for observed photosensitive drugs was the most frequent drug handling error (100%). We found a significantly higher amount of complete drug prescriptions with one of the implemented measurements e-prescribing, medication reconciliation and clinical pharmacists (Fisher's exact test two tailed, each p<0.001; CI 95%). Drug administration errors and drug handling errors were not significantly improved. Among the most frequently involved drug were drugs for acid-related disorders, immunosuppressant, and antineoplastic drugs. Conclusions: In the nearly 1,000 prescriptions and drugs analyzed, medication errors were still common. Various preventive strategies had been implemented in recent years, positively influencing the predefined errors rates.

A clinical-pharmaceutical medication reconciliation with patient interview for a medication review to identify drug-related problems in elective patients during hospital admission

Background and aim: Drug-related problems (DRPs), e.g.drug-drug interactions (DDI), can lead to adversedrug reactions (ADRs) and thus complications during hospitalization. For this reason, such DRP, DDI and ADR should be identified and characterized as early as possible during hospital admission. We aimed to perform a clinical-pharmaceutical medication reconciliation in which patient-related information was collected and compared to drug-related information in a medication review. Investigations: During a 24-week-period, we consecutively invited patients electively admitted to Urology, Otolaryngology, Oral and Maxillofacial Surgery, General and Visceral Surgery, and Oncology Departments of a 300-bed hospital. A clinical pharmacist performed a patient interview asking for medication, ADR, and adherence. The medication reconciliation considered packages for a brown-bag analysis, medication lists, and data from the clinical information-system (CIS). In a medication review, we matched patient-related information to drug-related information from the drug label, guidelines, drug-databases and websites to identify DRPs. Results: In the study, 356 patients (median age: 58 years) taking 1,712 drugs participated. Of all patients, 7.3% reported ADR and 10.7% missing adherence. 5.3% brought packages that enabled a brown-bag analysis and 21.1% a medication list. In 76.7% of patients, information from CIS was incomplete or not up-to-date. Among the most frequently identified DRPs were "Medication without diagnosis" (31.2%) and "Inappropriate timing of administration" (11.5%). The proportion of patients affected by severe DDI ranged from 0.8%-16.6%, depending on the drug information source. Conclusions: Incomplete patient data, frequently identified DRPs and inconsistent drug-based information make pharmaceutical involvement in medication reconciliation on admission a necessity.

An online cross-sectional survey of community pharmacists to assess information needs for evidence-based self-medication counselling

BACKGROUND

Community pharmacists play an important role in healthcare. They are frequently visited by patients to receive advice on self-medication products. Little research has been conducted to investigate pharmacists' information needs for evidence-based self-medication counselling.

AIM

To assess community pharmacists' information needs in five predefined areas: general and specific individual needs, quality needs, utilisation needs, implication needs, and access needs for evidence based self-medication counselling.

METHOD

After ethical approval, we conducted an exploratory, semi-quantitative, cross-sectional online survey. Members of three different chambers of pharmacists in Germany were invited to participate anonymously in the survey. They gave informed consent and received no incentive for their participation. Quantitative outcome: Frequency of relevance / importance of items within predefined information needs areas, except for access needs. Qualitative outcome: Open-text responses concerning all information needs.

RESULTS

We analysed data from a total of 823 participants who completed the survey. General and specific information such as dosage (74.2% [611/823]) and when to refer to a physician (64.6% [532/823]) as well as an over-the-counter product's effectiveness according to medical guidelines (71.4% [588/823]) were rated as very important. Participants reported to prefer digital information sources (50.5% [416/823] strongly agreed), especially in the form of an easily accessible database (61.6% [507/823] strongly agreed) that contains regularly updated, manufacturer-independent, critically appraised, concise information.

CONCLUSION

Community pharmacists expressed distinct information needs for evidence-based self-medication counselling. Further information services on essential evidence-based pharmacy knowledge may be necessary to support implementation.

How do parents perceive their children's epileptic seizures? Experiences of the first seizure and changes during the course of the epilepsy

PROBLEM

Experiencing a child's seizure can be challenging for parents.

METHODS

We investigated parental experiences of their child's first seizure and how their perception and management of seizures changed over time. From September 2020 to March 2021, we invited parents who had witnessed at least two of their child's seizures to take part in a semi-structured interview. Parents whose children experienced solely absence seizures were excluded.

RESULTS

Of the parents, 52/74 (70%) did not recognize their child's first epileptic seizure and assumed the event to be due to a different cause, for instance teething. Parents overwhelmingly reported fear (48/74; 65%) and surprise (13/74; 18%) as the predominant emotional responses to the first seizure. In response to the most recently observed seizure parents reported feelings related to fear (33/74; 45%) and happiness (16/74; 22%), with regard to the latter, especially "being calm" or "feeling safe". Asked for thoughts in response to the first seizure, 22/74 (30%) reported concerns about their child's future, with regard to the most recent seizure, 15/74 (20%) expressed such thoughts. Of the parents, 53/74 (72%) did not know how to respond to the first seizure. Concerning the most recent seizure, 48/74 (65%) said they felt confident in managing the seizure.

CONCLUSION

Experiencing the child's first seizure was very challenging for parents. During the course of the epilepsy, changes were observed in both parental perception of and confidence in managing the seizures. Physicians should consider these changes when counselling parents in order to better target their evolving needs.

An Observational Study to Identify Drug-related Problems (DRP) in Routine Care and An Expert Panel Assessment to Rate Clinical Risk and Preventability by Unit-dose Dispensing Systems (UDDS) with Computerized Physician Order Entry (CPOE) and Clinical Decision-Support Systems (CDSS)

Background and aim: Drug-related problems (DRP) jeopardize patient safety. Unit-dose dispensing systems (UDDS) with computerized-physician-order-entry (CPOE) and clinical-decision-support-systems (CDSS) were reported as a promising concept for preventing DRP. We aimed at identifying and categorizing DRP in peroral drug administration considering their clinical risk and preventability by UDSS/CPOE/CDSS. Investigations: In surgical and internal-medicine departments, we observed routine procedures in peroral drug administration for DRP. An expert panel including pharmaceutical and nursing expertise categorized the identified 18 DRP categories into three levels: DRP that have not yet resulted in medication errors (ME) (Level-I), DRP where ME have occurred but have not yet reached the patient (Level-II), and DRP where ME have occurred and have reached the patient (Level-III). Additionally, the panel categorized DRP according to their clinical risk and whether the implementation of UDSS/CPOE/CDSS can prevent them. Results: In 77 surgical patients, 1,849 peroral drug administration procedures, and in 149 internal-medicine patients, 1,405 procedures were observed. The 18 DRP categories were identified with a frequency of 0.6%-26.7% (Level-I), 0.1%-21.5% (Level-II), and 0.0%-1.0% (Level-III). Of those, four categories were considered of high clinical risk: "Name of the medication is not readable", "Prescribed medication is not prepared for administration", "An incorrect or non-prescribed medication is prepared", and "A medication is prepared for the wrong patient (mix-up)". Twelve DRP categories were categorized as highly preventable by UDSS/CPOE/CDSS. Conclusions:Under routine conditions, we identified a substantial number of DRPs. An expert panel categorized many of those DRPs as clinically highly relevant and highly preventable by UDSS/CPOE/CDSS.

Knowledge and attitudes towards epilepsy: A survey of people with epilepsy

PROBLEM

Many studies focus on knowledge and attitudes of unaffected people towards epilepsy and people with epilepsy (PWE). The perspective of PWE themselves is much less explored.

METHODS

We invited PWE in Germany to answer a questionnaire on their knowledge and attitudes towards epilepsy and PWE.

RESULTS

The questionnaire was completed by 230 PWE (median age: 40 years; min./max.: 19/83; 66 % female). Of PWE, 22 % thought that PWE are more helpful, and 10 % thought that PWE are friendlier than other people. Nevertheless, reservations about relationships and friendships with other PWE existed: of the participants, only 74 % would definitely go on a date with another PWE, and 90 % would definitely include another PWE they liked into their circle of friends. Swimming was judged as more dangerous for PWE than for healthy people by 71 % of PWE. Of PWE, 86 % correctly assumed it was not useful to hold a person having a seizure to the ground. Putting a solid object in the mouth was considered not useful by 85 % of PWE. Of PWE, 20 % would definitely administer an available emergency medication if another PWE had a seizure. For 67 % of PWE, certain preconditions should have to be fulfilled such as an available document with instructions. Of PWE, 11 % stated they would not administer an available emergency medication if another PWE had a seizure.

CONCLUSION

Although positive attitudes of PWE towards other PWE exist, we also found some reservations calling for psychosocial support. Most PWE had sufficient knowledge about risks of certain activities and about measures to be taken during a seizure. Nevertheless, a small group of PWE showed knowledge gaps. Thus, educational support still seems essential.

Determine the impact of a structured pharmacist-led medication review - a controlled intervention study to optimise medication safety for residents in long-term care facilities

Background

Medication reviews contribute to protecting long-term care (LTC) residents from drug related problems (DRPs). However, few controlled studies have examined the impact on patient-relevant outcomes so far.

Objective

We examined the impact of a one-time, pharmacist-led medication review on medication changes (primary endpoint) including discontinued medication, the number of chronic medications, hospital admissions, falls, and deaths (secondary endpoints).

Methods

A prospective, controlled intervention study was performed in three LTC facilities. In the intervention group (IG), after performing a medication review, a pharmacist gave recommendations for resolving DRPs to physicians, nurses and community pharmacists. The control group (CG) received usual care without a medication review. (i) We assessed the number of medication changes and the secondary endpoints in both groups before (t0) and after (t1, t2) the intervention. (ii) Additionally, the medication review was evaluated in the IG with regard to identified DRPs, the healthcare professional’s feedback on the forwarded pharmacist recommendations and whether DRPs were finally resolved.

Results

107 (IG) and 104 (CG) residents were enrolled. (i) More medication changes were identified in the IG than in the CG at t1 (p = 0.001). However, no significant difference was identified at t2 (p = 0.680). Mainly, medication was discontinued in those medication changes. Chronic medications increased in the CG (p = 0.005) at t2 while hospital admissions, falls, and deaths showed no differences. (ii) Overall, 1252 DRPs (median: 10; minimum-maximum: 2–39) were identified. Recommendations for 82% of relevant DRPs were forwarded to healthcare professionals, of which 61% were accepted or clarified. 22% were not accepted, 12% required further review and 6% remained without feedback. 51% of forwarded DRPs were finally resolved.

Conclusions

We found more medication changes in the IG compared to controls. Mostly, medication was discontinued. This suggests that our intervention was successful in discontinuing unnecessary medication. Other clinical outcomes such as falls, hospitalisations, and deaths were not improved due to the one-time intervention. The medication review further identified a high prevalence of DRPs in the IG, half of which were finally resolved.

Trial registration

German Clinical Trials Register, DRKS00026120 (www.drks.de, retrospectively registered 07/09/2021).

QTc-time-prolongating drugs and additional risk factors for long-QT-syndrome at hospital admission of surgical patients - risk assessment by pharmacists

Drugs can cause long-QTc-syndrome (LQTS), thereby elevating the risk for palpitations, syncopes, and sudden cardiac death. Additional risk factors such as the intake of more than one QTc-prolongating drug (QTPD) and surgery (cardiac and non-cardiac) increase the risk considerably. Therefore, a good knowledge of patientś perioperative risk is important. Data concerning this issue in surgical patients is, however, scarce. We aimed to determine the number of surgical patients taking QTPD at hospital admission and to assess the presence of additional risk factors for LQTS. In addition, we determined the LQTS-risk at hospital admission by calculating the Tisdale Risk Score, enabling early detection of patients at risk. In a retrospective study, the pre-hospital medication of a 4-month cohort of surgical patients admitted to a tertiary teaching hospital was evaluated for QTPD-intake. For these patients, additional risk factors for LQTS were assessed and the Tisdale Risk Score was calculated. Of 837 surgical patients, 419 (50%) took at least one QTPD. In total, 3,376 drugs were taken and 723 (21%) classified as QTPD with a median number of 2 (range 1-8) per patient. The median number of LQTS-risk factors for these patients at hospital admission was 2 (range 0-5). The Tisdale Risk Score classified 23 patients (5%) as high, 187 (45%) as moderate, and 209 (50%) as low risk. These findings indicate a high number of surgical patients with QTPD and additional risk factors. The Tisdale Risk Score can be used as a screening instrument for patients at risk for QTc-prolongation during medication reconciliation by pharmacists at hospital admission. Patients identified as high and moderate risk should be evaluated for adjustable risk factors and monitored adequately. Medical treatment needs to be chosen carefully in view of in-hospital patient safety.

Knowledge of epilepsy among German pharmacists

PROBLEM

Pharmacists can have a large impact on attitude, acceptance and adherence in patients with long-term conditions. They should be able to give appropriate advice.

METHODS

We invited pharmacists in Mecklenburg-Vorpommern and Saxony, Germany, to complete a questionnaire mainly containing multiple-choice-questions.

RESULTS

Overall, 238 pharmacists took part in the survey. 199 (84%) said they were insecure counselling people with epilepsy or had no experience at all. 205 (86%) rightly assumed a seizure can result in death. Concerning an acute seizure, administration of a rescue medication was considered as possible useful measure by 127 (53%) participants. Of the participants, 206 (87%) stated a physician should be consulted for every first afebrile seizure, 188 (79%) for every first febrile seizure. Exanthema as especially clinically relevant adverse drug event was rightly chosen for carbamazepine by 18 (8%) and for lamotrigine by 12 (5%) participants. 60 (25%) rightly chose liver toxicity for valproate. The increase of carbamazepine plasma concentration when adding erythromycin was chosen by 66 (28%) of pharmacists. 13 (5%) knew about the reduction of effectiveness of lamotrigine when adding hormonal contraceptives. For valproate, 201 (84%) stated that it is important to counsel patients concerning contraception.

CONCLUSION

Pharmacists are insecure counselling people with epilepsy. Some of them would not suggest to seek medical advice for every first seizure. This can lead to reduced patient safety. The adverse drug events of valproate are well known, important adverse drug events and interactions of other anticonvulsants are less present to the pharmacists and should be regularly addressed in training courses.

Elderly drivers with dementia – how do experts and relatives assess their safety risk?

Background

Demographic change increases the proportion of car drivers over the age of 70. With increasing age, the likelihood of developing a form of dementia increases. In Germany, about 1.6 million people suffer from dementia. Surveys among dementia patients showed that about two-thirds said they held a valid driving licence and just under half reported still actively driving. We explored whether and to what extent motorists with dementia are putting road safety at risk and how relatives deal with the driving behaviour of their elders.

Methods

Semi-structured qualitative interviews were conducted with seven experts from the fields of police, gerontology and geriatrics as well as with 16 relatives of patients with different stages of dementia. All interviews were then transcribed. The analyses based on the qualitative content analysis (Mayring 2015) with MAXQDA.

Results

The experts regarded elderly drivers with dementia as a public health relevant safety risk. Among those elders who are affected by dementia the awareness of the problem often is limited and not rarely they are characterized by an unsafe driving style. Experts from Austria and Switzerland supported the concept of a mandatory dementia assessment for elderly drivers while experts from Germany did not. Relatives reported very similar descriptions of their elderly’s driving characteristics. Furthermore, the cognitive and motor limitations associated with dementia often are not noticed by both patients themselves and their relatives.

Conclusions

Representative studies are needed to test which measures, such as a mandatory dementia check from retirement age, are likely to improve the safety of older drivers with dementia. Family doctors and GPs should address and educate dementia patients in relation to their risk of accidents. Relatives should receive information material on how to communicate with their elderlys on this topic to maximize safety while avoiding conflict.

Key messages

The prevalence of elderly drivers with dementia is unknown. Representative studies are needed to test best practice appoaches for harm reduction in drivers with dementia.

A prospective follow-up study on the role of clinical pharmacists in sustainably optimized pain measurement and pain therapy consequences

Appropriate analgesic therapy requires adequate pain measurement. A few studies have already demonstrated benefits of clinical pharmacists supporting physicians' prescribing. Nevertheless, there are still open questions about pharmaceutical interventions at the nursing level in order to optimise pain therapy sustainably. We performed a prospective controlled follow-up intervention study to analyse the sustainability of improved pain measurement performance (PMP) and its therapeutic consequences. Half a year after a successful guidance implementation in two study units (control and intervention unit), pharmacists performed an individual coaching for nurses only in the intervention unit. We consecutively monitored patient-nurse contacts and evaluated PMP with a 7-point scale (from 0: no pain measurement to 6: optimal pain measurement) in three 4-week periods (t₁ : before guidance implementation, t₂ : directly after guidance implementation, t₃ : half a year after guidance implementation) on both units. Therapeutic consequences of PMP were evaluated in a post-hoc patient chart review. In the t₁ period, we found a median PMP of 0 in both units which rose to 6 (control unit) vs. 5 (intervention unit) in t₂ period due to guidance implementation in both units. In the t₃ period, we found a decrease of PMP to 0 in controls vs. to 4 in the intervention unit (p<0.001). We also found, that improved PMP did not lead to a more individualised analgesic prescribing and administration of more on-demand analgesics. A coaching concept of clinical pharmacists improved the sustainability of nurses' PMP after a successful guidance implementation. Our results illustrate the potential of including clinical pharmacist in interprofessional pain therapy teams.

Incompatibilities in paediatric intensive care - pitfalls in drug information

Drug incompatibilities can lead to loss of effectiveness of drugs or to increased risk for undesirable effects that can even be life-threatening. Especially children are at high risk. Databases are an important source of information in routine care to avoid incompatibilities. However, they were supposedly developed considering drugs for use in adults. Thus, we analysed to what extent databases are appropriate for the identification of incompatibilities in intravenous (i.v.) drug therapy in paediatric intensive care. We analysed the information provided by two databases (Database A and B) on all pairs of two drugs prescribed to be administered via the same i.v. access line in a university paediatric intensive care unit during the study period of 50 days. A total of 50 different i.v. drugs was prescribed in 318 different combinations (drug pairs). We found information on (in)compatibilities in 23.0 % (73/318) in Database A and in 31.1 % (99/318) in Database B. Only in 11.0 % (35/318) of the drug pairs, both databases provided information. Considering those drug pairs, in 17.1 % (6/35) Database B indicated compatibility whereas Database A indicated incompatibility. Compatibility information delivered by databases on drugs used in paediatric intensive care is incomplete, heterogeneous, and partly contradictory. Thus, an increased awareness on the strengths and limitations of different databases is necessary to avoid patient harm.

How do parents perceive adverse drug events of their children's anticonvulsant medication?

BACKGROUND

The main source of knowledge on adverse drug events (ADE) are physicians' reports in controlled clinical trials. In contrast, little is known about the parents' perception of ADE of anticonvulsants their children receive.

METHODS

After approval by the local ethics committee, we performed a survey in a neuropediatric outpatient clinic of a university hospital. Based on a structured questionnaire, we interviewed parents of children with current anticonvulsant treatment regarding (i) their fears about potential ADE, (ii) experienced ADE according to parents, and (iii) implications of ADE on the child's life.

RESULTS

Parents of 150 patients took part in the interview. (i) 95 (63.3%) parents expressed fears concerning ADE, mostly liver injury/liver failure (33 [22%]). (ii) 129 (86%) parents reported experienced ADE, mostly sedation (65 [43.3%]) and abnormal behavior (54 [36%]). (iii) Parents reported substantial implications of ADE on the child's daily life for 84 (56%) children, and 63 (42%) parents expressed a negative impact on the child's development.

CONCLUSION

We recognized a great discrepancy between those ADE that were feared and those that were experienced. Parents feared life-threatening ADE and experienced less severe ADE that nevertheless have a negative impact on the child's daily life.

[Discharge medication - what do patients know about their medication on discharge?]

BACKGROUND

Patients' lack of knowledge about their discharge medication can endanger patients' safety after their hospital stay. This is especially the case with regard to medications that were newly prescribed during the hospital stay and are intended to be used after discharge or medications with an increased risk for adverse drug reactions (high-risk drugs). The aim of this study was to analyse the patients' level of knowledge about their discharge medication and to identify influence factors.

METHODS

In a bicentric survey patients were interviewed prior to their discharge from an acute and a geriatric rehabilitation hospital. They were asked about their discharge medication in a structured interview. Influence factors were statistically analysed by Tobit regression.

RESULTS

In total, 179 patients were interviewed. On average, patients named 48% of their discharge medication correctly (95% CI: 46-50%). Influence factors for knowledge deficits were the lack of a medication plan, an older age, the hospitalization in a rehabilitation hospital and a long hospitalization. 81% of the patients had at least one drug in their discharge medication, which was newly prescribed during the hospital stay. 11% of those drugs were named correctly, the potency was named correctly in 6%, the indication in 8%. For almost two-thirds of the patients at least one high-risk drug was recommended in the discharge letter, among them most frequently oral anticoagulants and opioid analgesics. 38% of these high-risk drugs were named correctly.

CONCLUSION

Our results demonstrate an urgent need to train patients about their discharge medication, especially if medications are included that were newly prescribed during the hospital stay and recommended for further use after discharge or medications with an increased risk of adverse drug reactions. Particularly older patients and patients of a rehabilitation hospital after long hospitalization should be intensively counselled and obtain a medication plan upon discharge.

Biomonitoring of prenatal analgesic intake and correlation with infantile anti-aeroallergens IgE

An association between prenatal acetaminophen or ibuprofen intake and an increased risk of asthma and increased IgE level in children is discussed in various epidemiological studies. Although the molecular mechanistic link is still unknown, the question whether or not acetaminophen and/or ibuprofen are safe pain medications during pregnancy arose. In this study, we associate maternal acetaminophen and ibuprofen intake during pregnancy and breastfeeding to infantile asthma phenotypes and elevated IgE level. Therefore, we analysed questionnaires from a local mother-child cohort and monitored drug intake by LC-MS biomonitoring in urine. No association was found between drug intake and any analysed health outcome using questionnaire data. For the information obtained from biomonitoring, no association was found for ibuprofen and acetaminophen intakes during breastfeeding. However, an association between prenatal acetaminophen intake and increased infantile IgEs related to aeroallergens was statistically detected, but not for asthma phenotypes.

[Pain assessment in routine care : A prospective observational study in an orthopedic unit]

INTRODUCTION

Although well-established guidelines give advice on how to use analgesics, measure pain, and organize pain treatment, many patients still suffer from avoidable severe pain. We assume one reason for this is that pain is inadequately addressed in routine patient contacts. Thus, we aimed to evaluate the extent to which pain was addressed during patient contacts in routine orthopedic care.

MATERIALS AND METHODS

In a prospective observational study in an orthopedic unit of a university hospital, we invited physicians and nurses during their routine patient contacts to be observed by independent, trained monitors. The monitors systematically assessed all pain-related aspects, which were analyzed descriptively afterwards.

RESULTS

The monitors documented 572 physician-patient contacts with 7 physicians and 108 patients and 578 nurse-patient contacts with 12 nurses and 102 patients. Physicians and nurses asked their patients about pain in 20 and 16 % of the patient contacts, respectively. While in physician-patient contacts, patients most frequently addressed their current pain situation (in 35 % of contacts), in nurse-patient contacts, patients most frequently addressed their need for analgesics (52 %). Patients rated their pain intensity in 16 % of physician-patient contacts vs. 17 % of nurse-patient contacts.

CONCLUSIONS

Using a comprehensive external monitoring procedure, we found that systematic pain assessment was not optimally standardized and implemented for systematic, individualized pain therapy by physicians or nurses in our routine care setting.

Drug handling in a paediatric intensive care unit--can errors be prevented by a three-step intervention?

BACKGROUND

Drug handling in paediatric intensive care units (PICU) is prone to medication errors. We aimed to identify type and prevalence of those errors and to assess preventative interventions.

METHODS

Prospective intervention study investigating a 3-step intervention for preventing errors in drug handling in a 10-bed PICU of a university hospital. Nurses' drug handling was monitored in daily routine to identify the number of patients affected by errors and overall prevalence and types of errors in drug handling. We implemented a comprehensive intervention consisting of an information handout, a training course, and a 76-page reference book tailored to reduce the prevalence.

RESULTS

The prevalence of errors in drug handling decreased from 83 % (555 errors/668 processes)to 63 % (554/883; p < 0.001) after the intervention. The number of affected patients remained unchanged (95 % vs. 89 %, p = 0.370).Peroral (PO) drugs (1.33 errors/process) were more error-prone than intravenous (IV) drugs(0.64), despite being used less frequently (27 % vs.73 % of all processes, p < 0.001). The interventions decreased the prevalence to 0.77 errors/process(p < 0.001) in PO and to 0.52 in IV drugs (p = 0.025).

CONCLUSION

Errors in drug handling were alarmingly frequent. PO drugs were frequently subject to errors, even though being used less frequently. The implementation of a comprehensive intervention succeeded in reducing the prevalence of errors. Yet further refinements are necessary to decrease also the number of affected patients.

[Off-label drug prescriptions among outpatient children and adolescents in Germany--a database analysis]

BACKGROUND

Due to lack of respective studies children often receive medication that is applied beyond the approved indication. The consequence of this off-label use is often an increased risk of unexpected and undesirable side effects. This study deals with the amount of off-label drug prescriptions among children and adolescents receiving outpatient treatment in Germany. The aim is to outline age-, gender-, region-, and insurance specific differences and to determine risk factors for an off-label prescription.

METHODS

This is a retrospective study that has been conducted by means of the IMS Patient Database Disease Analyzer for the year 2010 considering three therapy classes (analgesics, antibiotics and antidepressants). The evaluation of the risk factors for an off-label prescription resulted from a multivariate logistic regression. Age- and dose-specific prescriptions were analyzed but not indication-specific prescriptions.

RESULTS

In total 189,285 children and adolescents with analgesics-, 147,089 with antibiotics-, and 15,405 with antidepressants prescriptions were identified. The percentage of patients with off-label prescriptions amounted to 0.9 % for analgesics, 2.5 % for antibiotics and 8.5 % for antidepressants. The off-label prescriptions made by general practitioners were significantly higher than those made by pediatricians and child psychiatrists. The number of off-label prescriptions in country sides was higher than in cities. In eastern states more off-label prescriptions were made than in western states of Germany.

CONCLUSION

The study shows that outpatient treatment of children and adolescents occurs widely with drugs corresponding to age and dosage. Off-label prescriptions not conform to indication were not determined. However, off-label drug use should be reduced further for outpatient treatment to ensure a safe and low-risk medical treatment for children and adolescents.

[HeiCare®: a project aiming to improve medication communication across health care sectors]

BACKGROUND AND OBJECTIVE

Changes between health care sectors represent a critical phase in long-term pharmacotherapy. The aim of the Hei CARE(®) project was to close the communication gap at the interface between primary care physicians (PCP), hospital physicians and patients, and to improve quality and safety of pharmacotherapy.

METHODS

Physicians who enrolled patients with long-term pharmacotherapy were able to participate in the Hei CARE(®) project. After enrolment the patient's medication was entered in the internet-based medication knowledge data base AiD PRAXIS and checked for medication interactions and optimized if necessary. At hospitalisation medication was transferred electronically to the hospital (AiD KLINIK(®)) and on discharge integrated in the discharge letter and faxed to the primary care physician (PCP). The project was evaluated using quantitative and qualitative methods. Hei CARE(®) -cases, in which medication was transferred electronically as planned, were compared with the other cases. PCPs' experiences were collected in focus groups.

RESULTS

One thousand and three chronically ill patients of 56 primary care practices participated. 259 patients were hospitalized between October 2005 and March 2009 of which entrance and discharge medication were transferred both ways via the electronic prescribing platform in 67 cases. The number of changes in medication was reduced in comparison to the other cases. Participating PCPs reported positive changes through Hei CARE(®) as well as further potential for optimizing communication across health care sectors.

CONCLUSION

Use of a common internet-based medication knowledge data base (Hei CARE(®) ) in both health care sectors reduced the number of changes in pharmacotherapy. Seamless care in chronically ill patients was thereby improved. The project also demonstrated that improving communication across health care sectors is a slow process.

Patient-specific electronic decision support reduces prescription of excessive doses

OBJECTIVES

Prescription of excessive doses is the most common prescription error, provoking dose-dependent adverse drug reactions. Clinical decision support systems (CDSS) can prevent prescription errors especially when mainly clinically relevant warnings are issued. We have built and evaluated a CDSS providing upper dose limits personalised to individual patient characteristics thus guaranteeing for specific warnings.

METHODS

For 170 compounds, detailed information on upper dose limits (according to the drug label) was compiled. A comprehensive software-algorithm extracted relevant patient information from the electronic chart (eg, age, renal function, comedication). The CDSS was integrated into the local prescribing platform for outpatients and patients at discharge, providing immediate dosage feedback. Its impact was evaluated in a 90-day intervention study (phase 1: baseline; phase 2: intervention). Outcome measures were frequency of excessive doses before and after intervention considering potential induction of new medication errors. Moreover, predictors for alert adherence were analysed.

RESULTS

In phase 1, 552 of 12,197 (4.5%) prescriptions exceeded upper dose limits. In phase 2, initially 559 warnings were triggered (4.8%, p=0.37). Physicians were responsive to one in four warnings mostly adjusting dosages. Thus, the final prescription rate of excessive doses was reduced to 3.6%, with 20% less excessive doses compared with baseline (p<0.001). No new manifest prescription errors were induced. Physicians' alert adherence correlated with patients' age, prescribed drug class, and reason for the alert.

CONCLUSION

During the 90-day study, implementation of a highly specific algorithm-based CDSS substantially improved prescribing quality with a high acceptance rate compared with previous studies.

Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents

BACKGROUND

Drug administration in children is an error-prone task for nurses and parents because individual dose adjustment is often necessary, and suitable formulations for children are frequently lacking. Hence, in the absence of measures for their prevention, medication errors are likely to occur.

OBJECTIVE

To assess the error prevalence in drug administration by mouth or gastric tube before and after implementing a programme for quality improvement for nurses and parents.

DESIGN, SETTING AND PARTICIPANTS

Prospective, two-period cohort intervention study on a paediatric neurology ward of a university hospital where drug administration procedures of nurses and parents were consecutively monitored during the routine drug administration hours.

MAIN OUTCOMES MEASURE

Prevalence of administration errors before and after implementing instructions for appropriate drug administration, and a teaching and training programme supported by information pamphlets.

RESULTS

Altogether, 1164 predefined administration tasks were assessed, 675 before and 489 after the intervention. Of these, 95.7% (after the

INTERVENTION

92.6%) were performed by nurses. Errors addressed by the intervention were reduced from 261/646 tasks (40.4%) to 36/453 (7.9%, p<0.001) in nurses and from 28/29 (96.6%) to 2/36 (5.6%, p<0.001) in parents. Errors in predefined categories concerning tablet dissolution, tablet storage, oral liquids, tablet splitting, administration by gastric tube and others were all considerably less frequent after the intervention (each p<0.001).

CONCLUSION

Errors of drug administration by mouth and gastric tube represent a considerable and often neglected drug-related problem in paediatric inpatients. Targeted quality-improvement programmes can substantially and rapidly reduce error prevalence. Appropriate teaching and training of both nurses and parents supported by pamphlets was a highly efficient way to reduce error prevalence.

[Patient safety based on computer-assisted drug therapy. Electronic check-up of the patient]

Patients in internal medicine frequently experience adverse drug events. Many of those events, however, are avoidable because they are caused by medication errors, which are particularly frequent in drug prescribing. Therefore, practical concepts are needed to make the rapidly growing knowledge on drugs available already during prescription. But also when deviations from standards are intended access to up-to-date information is required. Computer-based systems can offer support for prescribing clinicians to meet these claims and thus improve the quality of pharmacotherapy. To reach this goal, such systems have to be interlinked among each other and with systems of primary, secondary, and tertiary care. They must be based on scientific published evidence and should consider as many factors as possible for individualization of drug therapy. Individualization and focusing on relevant information are prerequisites to prevent inappropriate alerts (over-alerting) and thus to increase acceptance in practical use.

Detection and prevention of prescriptions with excessive doses in electronic prescribing systems

INTRODUCTION

Dose dependent adverse drug reactions are often caused by prescribing errors ignoring upper dose limits. Thus, computerised physician order entry incorporating maximum recommended therapeutic doses (MRTDs) might reduce prescriptions of excessive doses. We evaluated the suitability of MRTD information as published in the Summary of Product Characteristics (SPC) (MRTD(SPC)) or by the US Food and Drug Administration (MRTD(FDA)) and the value of Defined Daily Doses (DDD, World Health Organisation) as knowledge bases for an alerting system.

METHODS

In a large set of critical-dose drugs (N = 140) we compared MRTD(FDA) and DDD values with the corresponding German MRTD(SPC). We then retrospectively assessed a set of 633 electronically prescribed drugs (EPDs) issued at a university hospital and calculated prescription rates of excessive doses.

RESULTS

MRTD(FDA) was similar to MRTD(SPC) in 37% (N = 140), higher in 32%, and lower in 31% of drugs. On average, available DDD values (N = 129) were 1.6 times lower than MRTD(SPC), with 64% being lower, 33% similar, and 3% larger than MRTD(SPC). Prescription rates of excessive doses according to MRTD(FDA) were 2.5-fold higher (6.1%) than according to MRTD(SPC) (2.5%) (p < 0.01). However, only one in four EPDs categorised as overdosed according to MRTD(FDA) exceeded MRTD(SPC), and MRTD(FDA) values were available only for 67% of all assessed EPDs.

CONCLUSION

Our study revealed a remarkable number of prescriptions with doses exceeding approved limits. Their prevention appears feasible but the choice of an appropriate database for MRTDs is essential, and differences between available information sources are large.

Arzneimittelanwendung in der Therapie chronischer Schmerzen

Die Wahl der geeigneten Arzneiform ist maßgeblich für den Therapieerfolg. Tabletten, Kapseln und perorale Liquida stehen als klassische Applikationsformen in der Schmerztherapie zur Verfügung. Retardgaleniken haben die Therapie chronischer Schmerzen verbessert und bieten die Möglichkeit der peroralen Basismedikation mit nur zwei Applikationen pro Tag. Transdermale Systeme mit stark wirksamen Opioiden bieten Vorteile zur Therapie insbesondere chronischer und stabiler Schmerzzustände. Orotransmukosale Systeme sind eine Option für eine schnell wirksame Rescuemedikation. Suppositorien sind wegen geringer Patientenakzeptanz und schlecht reproduzierbarer Bioverfügbarkeit keine Applikationsformen der ersten Wahl. Eine PCA (patient controlled analgesia) ist den Patienten vorbehalten, die mit den genannten Applikationsformen nicht adäquat therapierbar sind. Für viele dieser Applikationsformen sind spezifische Informationen zu Verordnung und Anwendung notwendig, um gute Therapieergebnisse sicher zu stellen.

Arzneimittel in Schwangerschaft und Stillzeit

BACKGROUND AND OBJECTIVE

In selecting drugs for treatment during pregnancy and breastfeeding it is essential to be certain of their safety. But categories are lacking that systematically relate the current state of knowledge of individual substances--rather than just drug classes--to each trimester of pregnancy. As such a stratification of risk would be helpful, it was the aim of this study to propose a new and more differentiated classification.

METHODS

Internationally available literature and electronic data bases providing details on adverse effects of individual drugs during pregnancy and breastfeeding as well as summaries of product characteristics of the drugs served as comprehensive sources of information. Account was taken of compound-specific data on toxicity during the reproductive and developmental stages, genotoxicity and carcinogenicity (in animals and in-vitro experiments) and drug-specific experience as documented in women during pregnancy and breastfeeding.

RESULTS

A new risk classification and appropriate recommendations for clinical management were developed to ensure the safety of drugs given during pregnancy and breastfeeding, taking into account the varying risks during the three trimesters of pregnancy and the perinatal period. Antibiotics were selected as a model for drugs in general and classified according to the new system.

CONCLUSION

The proposed new classification of risk makes it possible to select safe agents in the treatment of pregnant and/or breastfeeding women. It is based on the current state of knowledge about a particular substance, also in relationship to the developmental phase of the breastfed child.

An in-vitro screening assay for the detection of inhibitors of proinflammatory cytokine synthesis: a useful tool for the development of new antiarthritic and disease modifying drugs

OBJECTIVE

This work targets the development of a new tool to help develop new anticytokine drugs that prevent or reduce the progression of arthritic diseases. The specific aim of our study was to establish a fast and reliable in vitro screening assay of cytokine synthesis inhibitors (TNFalpha, IL-1beta) which shows better correlation with enzyme assays than previously reported in vitro assays. The test system should be able to detect p38-MAP kinase inhibitors.

MATERIAL AND METHODS

Human peripheral blood mononuclear cells (PBMCs) were isolated by Ficoll density gradient centrifugation from human EDTA-potassium whole blood. Cells were adjusted at 1 x 10(6) cells/ml. PBMCs were stimulated with lipopolysaccharide (LPS; E. coli serotype 026:B6: 1 microg/ml) in the presence of test compound (10(-5)-10(-8)M) for 4h at 37 degrees C in a 5% CO(2)-incubator. Induced TNFalpha and IL-1beta protein were measured by ELISA.

RESULTS

The following are representative examples of inhibitors which effect cytokine synthesis. Corticoid Dexamethasone inhibits IL-1beta and TNFalpha synthesis at IC(50) of 38 nM and 25 nM, respectively. ERK1/ERK2 inhibitor U0126 effects cytokine synthesis at IC(50) of 0.34 microM for IL-1beta production and 0.26 microM for TNFalpha synthesis.p38-MAP kinase inhibitor SB 203580 inhibits IL-1beta- and TNF-alpha-synthesis (IC(50)sof 0.052 microM and 0.46 microM) in the same degree as p38-MAP kinase activity (IC(50): 0.34 microM). Same results could be shown for SB 210313, which had same efficacy on IL-1beta and TNFalpha biosynthesis (IC(50)'s: 1.88 microM and 1.01 microM) and on p38-MAP kinase (IC(50): 6.85 microM). Also for SB 202190 this correlation in inhibition of IL-1beta and TNFalpha synthesis (IC(50)'s: 0.055 microM and 1.01 microM) and p38-MAP kinase inhibition (IC(50): 0.088 microM) could be shown.

CONCLUSION

This study shows the screening assay using PBMCs stimulated with LPS for IL-1beta and TNFalpha synthesis is a reliable test system for the quantification of the effectiveness of new drugs modulating IL-1beta and TNFalpha synthesis which is mainly mediated by p38-MAP Kinase. These assay allows fast detection of IL-1beta and TNFalpha synthesis inhibitors with different modes of action, including p38-MAP kinase inhibitors. The results obtained with our in-vitro screening assay show good correlation with results from enzyme assays.

Stimulation of leukotriene synthesis in intact polymorphonuclear cells by the 5-lipoxygenase inhibitor 3-oxo-tirucallic acid

Commercially available extracts from Boswellia serrata resin used as anti-inflammatory drugs or phytonutrients show paradoxical concentration-dependent potentiating and inhibitory actions on 5-lipoxygenase (5-LO) product synthesis in stimulated PMNs. In our attempt to characterize the stimulating constituents, we identified the tetracyclic triterpene 3-oxo-tirucallic acid (3-oxo-TA), which, in the range from 2.5 to 15 microM, enhanced 5-LO product formation in ionophore-challenged polymorphonuclear cells (PMNs) (e.g., from 1981 +/- 177 to 3042 +/- 208 pmol at 10 microM 3-oxo-TA), and initiated Ca(2+) mobilization, MEK-1/2 phosphorylation, 5-LO translocation, and 5-LO product formation in resting cells (534 +/- 394 pmol/5 x 10(6) PMNs). In cell-free 5-LO assays, 3-oxo-TA acted only inhibitory (IC(50) value of about 3 microM), demonstrating the pivotal role of intact cell structure for its activating property. In 3-oxo-TA-challenged PMNs, the mitogen-activated protein kinase kinase (MEK)-1/2 inhibitor PD098059 abolished 5-LO product formation, along with inhibition of MEK-1/2 phosphorylation and 5-LO translocation. The 3-acetoxy derivative of 3-oxo-TA acted like 3-oxo-TA in intact PMNs, whereas 3-hydroxy-TA barely stimulated MEK phosphorylation in resting cells and showed only inhibition on ionophore-induced 5-LO product synthesis. Steroid-type tetracycles neither induced 5-LO activation nor had enhancing or inhibitory effects. In summary, defined natural tetracyclic triterpenes, which act as inhibitors of the 5-LO in the cell-free assay, initiate 5-LO activation by a MEK-inhibitor sensitive mechanism and potentiate stimulated product synthesis in intact cells. Because TAs contribute significantly to the overall biological effects of B. serrata resin extracts, special precaution for standardization is recommended when using B. serrata preparations as drugs or dietary supplements.

MEK-1/2 inhibition prevents 5-lipoxygenase translocation in N-formylpeptide-challenged human neutrophils

In order to elucidate the role of mitogen-activated protein kinase kinase (MEK-1/2) in 5-lipoxygenase (5-LO) activation we studied the N-formyl-methionyl-leucyl-phenylalanine (fMLP)-induced 5-LO translocation in human blood neutrophils (PMNs). In non-primed, Ca(2+)-repleted PMNs, fMLP consistently stimulated MEK-1/2 phosphorylation, but induced 5-LO translocation and product formation (430+/-128 pmol; SEM, n=13) only in 13 of 18 PMN preparations from different healthy donors. In fMLP-responsive cells, the MEK-1/2 inhibitor PD098059 (50 microM) attenuated MEK phosphorylation and abolished 5-LO activation at the translocation step. The fMLP-mediated 5-LO product formation was also sensitive to MEK inhibition by U0126 and to p38 inhibition by SB203580. But in contrast to PD098059, U0126 at 10 microM and SB203580 at 20-50 microM impaired 5-LO activity in the cell-free assay setting, suggesting direct actions of higher concentrations of U0126 and SB203580 on 5-LO apart from MEK and p38 inhibition, respectively. These data show that fMLP initiates 5-LO product formation in non-primed, Ca(2+)-repleted human blood PMNs from healthy donors, and that MEK signaling is pivotal, but not sufficient for 5-LO activation in response to the receptor agonist fMLP.