Drug-related problems in medical wards with a computerized physician order entry system

Objective:  Identification and estimation, by clinical pharmacists participating in routine medical rounds, of drug-related problems (DRPs), arising despite the use of a computerized physician order entry (CPOE) system.
Methods:  An 18-month prospective study of DRPs through a CPOE was conducted by seven clinical pharmacists participating in ward activity. DRPs were identified by two independent pharmacists using a structured order review (French Society of Clinical Pharmacy instrument).
Results:  A total of 29 016 medication orders relating to 8152 patients were analysed, and 2669 DRPs, involving 1564 patients (56% female; mean age 72·6 years), were identified representing 33 DRPs per 100 admissions. The most commonly identified DRPs were non-conformity to guidelines or contra-indication (29·5%), improper administration (19·6%), drug interaction (16·7%) and overdosage (12·8%). There were 429 different drugs associated with these DRPs. Cardiovascular drugs were the most frequently implicated (22·2%), followed by antibiotics/anti-infectives (13·3%) and analgesics/antiinflammatory drugs (11·3%). Different types of DRPs were closely associated with specific classes of drugs.
Conclusions:  Drug-related problems are common even after implementation of CPOE. In this context, routine participation of clinical pharmacists in clinical medical rounds may facilitate identification of DRPs. Pharmacists should be able to enhance patient safety through such involvement.     

A retrospective study of drug‐related problems in Australian aged care homes: medication reviews involving pharmacists and general practitioners

Background Drug‐related problems (DRPs) in Australian aged care homes have been studied previously. However, little is known about the acceptance and implementation of pharmacists' recommendations by general practitioners (GPs) to resolve DRPs. Objectives The primary objective of this study was to investigate the number and nature of DRPs identified by accredited clinical pharmacists. The secondary objective was to study the GP acceptance and implementation of pharmacist recommendations to resolve DRPs. Methods This was a retrospective study of 500 randomly selected, de‐identified medication reviews performed by 10 accredited clinical pharmacists over 6 months across 62 aged care homes. The DRPs identified by pharmacists were subsequently classified by the drugs involved, types of problem (indication, effectiveness and safety) and medical diagnoses of the patient. GP written feedback on the medication review reports determined implementation of pharmacists' recommendations to resolve the DRPs. Results A total of 1433 DRPs were identified in 480 of the 500 residents. Potential DRPs were frequently classified as risk of adverse drug reactions, need for additional monitoring and inappropriate choice of a drug. Alimentary, cardiovascular, central nervous system and respiratory drugs were most frequently implicated, accounting for more than 75% of the DRPs. GPs' acceptance and implementation of pharmacists recommendations were 72.5% (95% CI; 70.2, 74.8) and 58.1% (95% CI; 55.5, 60.6), respectively. Conclusions Over 96% of the residents had potential DRPs identified by pharmacists. GP acceptance of pharmacists' recommendations was independent of the drug category, but not independent of the disease category.     

Appropriate prescribing in the elderly: an investigation of two screening tools, Beers criteria considering diagnosis and independent of diagnosis and improved prescribing in the elderly tool to identify inappropriate use of medicines in the elderly in primary care in Ireland

Background:  Elderly patients are particularly vulnerable to inappropriate prescribing, with increased risk of adverse drug reactions and consequently higher rates of morbidity and mortality. A large proportion of inappropriate prescribing is preventable by adherence to prescribing guidelines, suitable monitoring and regular medication review. As a result, screening tools have been developed to help clinicians improve their prescribing.
Objectives:  To compare identification rates of inappropriate prescribing in elderly patients in primary care using two validated screening tools: Beers' criteria and improved prescribing in the elderly tool (IPET); to calculate the net ingredient cost (NIC) per month (€) of the potentially inappropriate medicines in this population of patients.
Method:  A consecutive cohort of 500 patients 65 years of age and over were recruited prospectively from primary care over a 6 month period in a provincial town in Ireland. Patients' medical records (electronic and paper) were screened and all relevant information concerning current illnesses and medications was recorded on a standardized data collection form to which Beers' criteria [considering diagnosis (CD) and independent of diagnosis (ID)] and IPET tools were applied. The NIC was calculated from an edition of the Irish monthly index of medical specialities published concurrently with the data collection.
Results:  Beers' criteria identified a total of 69 medicines that were prescribed inappropriately (eight CD and 61 ID) in 65 patients (13%), costing €824·88 per month while IPET identified 63 potentially inappropriate medicines in 52 (10·4%) patients costing €381·28 per month.
Conclusions:  Potentially inappropriate medications are prescribed in a significant proportion of elderly people in primary care, with significant economic implications.     

Clinical Predictors of Appropriate Implantable-Cardioverter Defibrillator Discharge

Background : The implantable cardioverter-defibrillator (ICD) is the mainstay of treatment for ventricular tachyarrhythmias due to its impact on mortality. ICD discharges may be appropriate or inappropriate, and identification of patients at risk for ICD discharge is essential. We sought to determine the predictors of appropriate ICD discharge.
Methods : We analyzed data from 591 ICD recipients (mean age 67.9 ± 13.0 years; 474 men; mean follow-up 10.9 ± 13.8 months). The association between ICD discharges and multiple clinical variables, including age, gender, hypertension, diabetes, coronary artery bypass graft (CABG) surgery, syncope, atrial fibrillation (AF), prior coronary intervention, left ventricular ejection fraction (LVEF), left ventricular end diastolic dimension, left ventricular end systolic dimension (LVESD), and ambient drug therapy was examined.
Results : The rates of appropriate or inappropriate discharges, delivered to 155 patients, were 0.49 per follow-up year (F/Y). The median time-to-first appropriate discharge was 3.4 years. Among the discharges delivered, 97(63%) were appropriate and 58(37%) were inappropriate. Risk factors associated with a trend toward earlier appropriate discharges included age ≤65 years, and diuretic and digitalis use. By multiple variable analysis, no history of CABG and an enlarged LVESD were independent predictors of earlier appropriate ICD discharge.
Conclusions: Patients who did not have CABG revascularization were 2.8-fold more likely than those who underwent CABG, and patients with enlarged LVESD were 2.5-fold more likely than those with normal LVESD to receive appropriate ICD discharges. These patients deserve special vigilance and management in order to prevent the occurrence of ventricular tachyarrhythmias triggering ICD discharges.     

The impact of clinical pharmacists' consultations on physicians' geriatric drug prescribing. A randomized controlled trial.

The impact of clinical pharmacists' consultations on geriatric drug prescribing was studied in a prospective randomized controlled trial of patients 65 years of age and over discharged on 3 or more medications for chronic conditions from a 450-bed community hospital. The pharmacists provided consultation to experimental patients and their physicians at hospital discharge and at periodic intervals for 3 months postdischarge. Using a standardized tool, a physician-pharmacist panel, blinded to study group assignment of patients, evaluated the appropriateness of prescribing for a random sample of 236 patients. Eighty-eight percent had at least one or more clinically significant drug problems, and 22% had at least one potentially serious and life-threatening problem. Drug-therapy problems were divided into six categories: 1) inappropriate choice of therapy; 2) dosage; 3) schedule; 4) drug-drug interactions; 5) therapeutic duplication; and 6) allergy. Experimental patients were less likely to have one or more prescribing problems in any of the categories (P = 0.05) or in the appropriateness (P = 0.02) or dosage (P = 0.05) categories. A summary score, measuring the appropriateness of the patient's total drug regimen, indicated that experimental patients' regimens were more appropriate than those of controls (P = 0.01). Results of this trial reveal that clinical pharmacists can improve the appropriateness of geriatric drug prescribing in outpatient settings.     

Continuity of care and monitoring pain after discharge: patient perspective

Title.  Continuity of care and monitoring pain after discharge: patient perspective.
Aim.  This paper is a report of a study conducted to evaluate, from the patients' perspective, a Liaison and Continuity of Care Programme coordinating care provision between a hospital and primary care centres.
Background.  Promoting continuity of care between hospitals and primary care improves quality of care, patient satisfaction and decreases further hospitalizations. However, inadequate pain management is common after discharge.
Method.  A sample of patients from the Liaison and Continuity of Care Programme were included in a longitudinal study in 2007. We conducted standardized telephone interviews at 24 hours, 7 days, 1 and 3 months after discharge. Outcome measures included readmission, time between hospital discharge and readmission, information level at discharge, patient satisfaction, queries about care and information related to perceived state of health and pain.
Results.  Eighty-three adult patients (average age 69·3, 50·6% males) who needed continued care at discharge were followed. Ten participants died during follow-up, and seven required readmission. A total of 49·4% of patients stated that they had understood the information given at discharge very well or perfectly. At 24 hours after discharge, 30% already had doubts about their state of health and the management of their condition. In relation to perceived health, only 25·3% stated that this was good or very good. Prevalence of pain 24-hours after discharge was 58·3% in surgical patients and 17·1% in other patients.
Conclusion.  The preparation and education of patients and family members should be improved before discharge, and appropriate written information must be given, especially if a patient has pain or requires complex care.     

The potential for adverse drug reactions in elderly patients

This study examined inappropriately prescribed drugs, inappropriate dosages of drugs, inappropriate combinations of drugs, and numbers of drugs and their potential for causing adverse drug reactions (ADRs) in the elderly. The study also looked at whether the number of diagnoses made a difference in the drugs' potential to cause ADRs. A retrospective audit was made of 146 patients diagnosed with congestive heart failure (CHF) who were admitted to a suburban community agency. Significant correlations were found between the number of medications prescribed and the number of inappropriate medications, the number of medications prescribed and the number of inappropriate dosages of medications, and the number of medications prescribed and the number of potential drug interactions. Multiple diagnoses did not make a difference.     

The EMITT study: development and evaluation of a medication information transfer tool

BACKGROUND: Continuity of care is required as patients move from the care of one pharmacist to another. The appropriate transfer of medication information between pharmacists as well as to patients at these times is essential in order to prevent drug-related problems (DRPs). OBJECTIVE: To develop a tool to transfer medication information between various pharmacists caring for the same patients. Secondary objectives were to evaluate the tool based on utility in practice and satisfaction of pharmacists. METHODS: The project consisted of a needs assessment involving in-depth interviews with patients and pharmacists and a literature review. These data were used to develop an optimal tool for medication information transfer between pharmacists in different practice settings. The tool was evaluated in a feasibility pilot for potential utility and pharmacist satisfaction. RESULTS: The tool created called EMITT (electronic medication information transfer tool) facilitates the communication of information to outpatient pharmacists including a letter and an up-to-date list of the patient's drugs. A total of 187 medication issues were communicated within 40 transferred letters, 61 of which required active follow-up, which potentially prevented 348 DRPs if the receiver of the information acted on the information that was provided. The 3 most common issues that required follow-up were restarting a held medication (n = 13), adjustment of doses based on laboratory results (n = 11), and starting a new indicated medication in the future (n = 7). CONCLUSIONS: A tool can be created to help address the gap in communication between pharmacists when patients move between interfaces of care by evaluating the needs of healthcare professionals involved in the information transfer process. It is envisioned that the elements of our tool can be easily adapted to other institutions to improve medication information transfer.     

Identification of medication-related attendances at an A & E department

BACKGROUND: The use of medication is the most common medical intervention, but it has associated risks. These have been described as drug-related problems (DRPs). Other non-UK studies have reported DRPs to be the cause of 3-16% of hospital admissions and around 4% of attendances at emergency departments. The size of the problem in the UK has not been quantified. AIM: The aim of this study was to identify the number of patients attending a central London accident and emergency (A & E) department with symptoms or conditions caused by DRPs. METHOD: A 2-week retrospective, case-review study was conducted in the A & E department of St Thomas' Hospital, London, during March 1999. DRPs were identified using recognized criteria. Statistical analysis identified patient characteristics which could be associated with the incidence of DRPs. The types of DRP and the drugs involved were identified. RESULTS: During the study period, 106 patients attended the A & E department with a DRP. This equates to 4% of the A & E population. During this period the demographics of the A & E attenders were no different to the annual A & E cohort. The most common DRPs were adverse drug reactions and overdose. The most frequently involved drugs included analgesics, antibiotics, those with narrow therapeutic indices and illegal drugs. The mean age of this patient group was 38 years (non-significant). They attended significantly more frequently during the early hours of the morning and on Saturdays than the A & E general population (chi-squared P = 0.004 and P = 0.003, respectively). DISCUSSION: The incidence of DRP as a cause of attendance at A & E reflects that in the literature. No statistical association with a specific age group of patients could be made, but the mean age of 38 years is younger than previously reported. The demographic differences which were statistically significant can be explained by the increased incidence of DRP associated with the use of illegal drugs than reported in other studies. Other drug groups identified by this study are representative of other reports. CONCLUSION: DRPs account for 4% of attendances at a central London A & E Department.     

Preliminary reliability of an observer rating scale for assessing medication adherence on psychiatric wards

Objectives  Medication non-adherence is a major contributor to poor outcomes following discharge from psychiatric hospitals. It is therefore imperative that staff are able to accurately assess the extent to which patients have engaged with treatment. This study presents data on a new observer rating instrument of patient medication adherence.
Methods  Staff participating in a medication adherence training programme ('Medication Alliance') were given a brief overview of the Observer Rating of Medication Taking (ORMT) scale. Participants then watched six video vignettes of patient adherence behaviour and provided a rating on their scale for each vignette. Participant ratings were then compared with 'expert' ratings.
Results  Percentage agreement between 'experts' and participants ranged from a low of 68% through to 98% agreement. Only one vignette was rated significantly differently [ Mdiff  = 0.33, t (49) = 2.08, P  = 0.007], with 32% of people falling outside the expert rating range (all of those ratings being higher). This difference was attributed to between group differences, [ F (2,47) = 3.49, P  < 0.05] and post hoc assessment suggested that the differences between expert and trainee ratings for the vignette may be explained by trainee characteristics, as distinct from inherent characteristics of the rating scale.
Conclusion  The ORMT can help mental health professionals identify particular non-adherent behaviours thus facilitating identification and treatment of likely non-adherence before discharge. The scale appears to be accessible to a variety of professions with a range of experience and requires minimum training in order to be used reliably.