An evaluation of the process‐related medication risks for elective surgery patients from pre‐operative assessment to discharge

Aim — To investigate where the process‐related medication risks occur in an elective surgery service with a pre‐operative assessment clinic (PAC) and make recommendations for how pharmacy services should best be provided. Method — The study involved identification of discrepancies in medication history taking, changes that occurred in patients' medication between PAC and admission, and changes that occurred between admission and discharge. Prescribing errors were identified and classified according to whether they occurred on admission, during the inpatient stay or on discharge, and whether they were identified and rectified by the existing pharmacy service. Setting — Seventy‐six patients recruited from the nurse‐led PAC of a 580‐bed London teaching hospital between May 2 and June 30, 2000. Key findings — The PAC nurse omitted 27 per cent of medications from the medication history; the admitting doctor omitted 37 per cent from the medication history documented in the medical notes and 47 per cent from the inpatient medication chart; the majority of the omissions were complementary and over‐the‐counter preparations. Twenty‐six per cent of patients had changes made to their medication between PAC and admission, and 85 per cent had changes made between admission and discharge. A total of 177 prescribing errors were identified (median of 1 error per patient; interquartile range 0–3), of which 38 per cent occurred on admission, 14 per cent during the inpatient stay and 48 per cent at discharge. Pharmacists made interventions to rectify 59 per cent of the errors. Conclusion — Given the large number of changes to patients' medication that occurred between PAC and admission, we would not support the writing of inpatient medication charts or the supply of medication at this stage. For this group of patients in the study hospital, the greatest process‐related medication risks occurred on admission and discharge, and pharmacy services should be provided accordingly.     

Medication compliance devices in primary care: activities of community‐based nurses

Objective — To investigate the workload, training and views of community‐based nurses in relation to medication compliance devices. Method — Postal questionnaires distributed to all nurse team leaders (n=57) and community‐based nurses (n=327) in the Grampian region of Scotland. Setting — Primary care. Key findings — Responses were received from 32 team leaders (56 per cent) and 153 nurses (47 per cent). Ninety‐six nurses (63 per cent) filled a total of 212 medication compliance devices per week for patients under their care — an activity which accounted for an estimated total of 121 hours per week (mean of 1.25 hours per nurse per week, range 0.5 to 7 hours) and for which they had received no formal training. One hundred devices (47 per cent) were filled to enable carers to administer medicines. Team leaders reported several areas of concern which had been raised by their staff, particularly relating to responsibility and accountability under professional body guidelines. Conclusion — Many community‐based nurses fill medication compliance devices, an activity which clearly causes much concern. There is an urgent need to develop and evaluate multidisciplinary models of care based around the needs of individual patients requiring medication compliance devices.     

Glaucoma patient receipt of information and instruction on how to use their eye drops

Objectives The objectives of the study are: (a) to describe the sources of glaucoma patient's medication information and instruction, and (b) to examine the influence of patient characteristics on the sources of medication information and instruction obtained. Setting Four geographically distinct ophthalmology practices in the US. Method A survey assessing receipt of information and instruction on how to use eye drops was completed by 324 patients. Multivariable logistic and ordinal regression were used to analyse the data. Key findings Fifteen per cent of patients stated that no‐one gave them information about their glaucoma medications, and 20% of patients stated that no‐one showed them how to use their glaucoma medications. Ophthalmologists were the individuals most likely and ophthalmic technicians were the second‐most likely to give the patients information and instruction on how to use their medications. Fourteen per cent of patients stated that pharmacists gave them information about their eye drops. Patients very rarely reported pharmacists or primary care physicians showing them how to use their glaucoma medications. Fourteen per cent of patients reported going to the internet for information. Younger patients were significantly more likely to receive information about glaucoma and glaucoma medications from the internet than older patients. Conclusion Patients are receiving information about glaucoma medications from numerous sources, yet almost one out of five glaucoma patients reported receiving no instruction on the instillation of their eye drops. Pharmacists have the opportunity to educate glaucoma patients about using their medications by giving them information and showing them how to administer the medications correctly.     

Literacy and perceived barriers to medication taking among homeless mothers and their children.

PURPOSE: The relation of medical literacy to women-reported barriers to taking medication themselves or giving medication to their children was studied. METHODS: Women in 18 homeless shelters in four counties in central North Carolina were recruited. Head-of-household homeless mothers with psychiatric or substance-abuse disorders and dependent children were eligible to participate. Trained interviewers administered a site-specific questionnaire on medication use. RESULTS: One hundred sixty-four homeless women participated. Forty-two percent of the women were currently taking a medication. Forty-six percent of the women stated that there was a barrier to taking their medications as prescribed. Medical literacy was not significantly related to whether women felt there were barriers to taking a medication. Seventy-five percent of the women reported having one or more children living with them. Thirty-seven percent reported having a child with asthma live with them, and 12% reported having a child with attention-deficit disorder. Forty percent reported a barrier to giving their child a needed medication. Taste was the most commonly reported barrier. Women with lower medical literacy and younger women were significantly more likely to report a barrier to giving their children a needed medication. Over 80% of women listed pharmacists as their first or second choice for receiving drug information orally. CONCLUSION: Race and perceived barriers to medication use affected the medication-taking behavior of homeless women, while their age and literacy level affected the reporting rates of the barriers to medication use for their children. Homeless women preferred receiving both written and oral drug information from a physician or a pharmacist.     

Impact of medication regimen reviews performed by community pharmacists for ambulatory patients through liaison with general medical practitioners

Objective — To evaluate the cost and clinical benefits of the provision of medication regimen reviews (MRRs) by community pharmacists for patients identified and referred by a general practitioner using a collaborative approach. Method — There were two cohorts of patients — 105 in stage 1 and 170 in stage 2 — from 34 GPs. The reviews were performed by 45 community pharmacists who had completed a training programme in MRR. The protocol was as follows: (1) a proforma MRR request form, including relevant clinical information and the patient's current regimen, was completed by the GP, (2) the review was conducted by the pharmacist and documented in a proforma report, (3) pharmacists and GPs met to discuss the review findings and recommendations for each patient, and (4) three months later, GPs were surveyed to verify any accepted recommendations and changes to medication regimen. A clinical panel estimated the clinical significance of the regimen changes for a subset of 141 cases. Key findings — The patients had an average of five diagnoses, with cardiovascular disease (34 per cent) and musculoskeletal disease (15 per cent) the most common conditions. A total of 2,220 medications were prescribed, representing a mean of eight per patient. In all, 869 changes to therapy were observed at the three‐month follow up: 47 per cent drug ceased; 17 per cent dose reduced; 11 per cent dose increased; and 12 per cent drug changed. Examining the impact of MRR on the mean number of medications per patient, the null hypothesis of no difference pre‐ and post‐MRR was rejected. There was a mean reduction of one medication per patient (P<0.001). As a consequence of this reduction, the average annual cost of medications was reduced by $A240 per patient. This translated to a projected annual cost saving for medication alone of $A90 per patient after offsetting the $A150 cost (professional remuneration) of the MRR. Considering health outcomes, overall, the reviewers rated at least 40 per cent of the MRR changes as leading to a positive effect on the patient's health. Conclusion — This study provides a good indication that MRR through GP‐pharmacist collaboration in the community can lead to positive clinical benefits and reduction in health care costs.     

Clinical medication review by a pharmacist of elderly patients on repeat medications in general practice — pharmacist interventions and review outcomes

Objectives — To describe the nature and rate of interventions made by a pharmacist conducting clinical medication reviews in general practice. Method — Patients, randomly allocated to the intervention group, in a randomised controlled trial of 1,188 patients, were invited to a pharmacist‐conducted medication review clinic at their general practice. Patients were seen over one year from June 1, 1999, to May 31, 2000. In the consultation an assessment was made of the patient, their clinical conditions and medication. Consultation outcomes for each patient and intervention outcomes for each medicine were evaluated. Setting — Patients were recruited from four randomly selected general practices in Leeds, UK. Patients were eligible if aged 65 years or over and on at least one repeat medicine. Key findings — Consultations were held with 590 patients in the intervention group (97 per cent). A recommendation for change was made in 44 per cent (258/591) of consultations. The most common outcome was a change in medication: 29 per cent of consultations (170/591). Doctor referral occurred for 28 patients (5 per cent) and nurse referral for 25 (4 per cent). Study patients were recorded as taking 2,927 repeat medications (mode of two per patient). Interventions were made for 21 per cent of medications (603). Clinically related interventions accounted for 71 per cent (430/603). Recommendations were spread evenly across therapy groups. At the study end, 90 per cent (433/484) of recommendations remained implemented. Conclusion — A pharmacist who clinically reviewed elderly patients, their conditions and their medications, intervened in nearly half the patients. The pharmacist was able to implement most interventions without referring the patient to a doctor or nurse.     

Contribution of a ward‐based technician service to delivering effective patient health care and reducing dispensary workload

Objective — To determine whether introduction of a ward‐based technician service reduces medication administration errors and decreases pharmacy workload. Method — Information on the incidence of unavailable medication administration errors (U‐MAEs), number of calls to pharmacy, volume of weekend medicine supply and workload of the non‐stock supply (NSS) pharmacist was compared during a two‐week period prior to the implementation of a ward‐based technician service (control period) and a two‐week period after the introduction of the service (study period). Setting — Five wards (two acute admission wards and three care of the elderly medical wards) at Bristol Royal Infirmary with a perceived high workload. Key findings — When a ward‐based technician service was implemented the number of U‐MAEs was almost halved (46 per cent reduction), and there was a 60 per cent reduction in the number of telephone calls from the five pilot wards to the dispensary. Overall, there was a decrease in the number of item requests during the weekend; however, the number of items requested from the non stock supply pharmacist increased from 51 to 58 (14 per cent). Conclusion — Following the introduction of the ward‐based technician service, patient care has improved as medicines are available more reliably, and the work life of the pharmacy team has benefited.     

The effects of a patients' own drugs scheme on the incidence and severity of medication administration errors

Background — Many UK hospitals are introducing patients' own drugs (PODs) schemes, in which patients' own medication is used during their stay. It has been suggested that these will reduce medication administration errors (MAEs), particularly those due to medication unavailability. Objective — To explore the effects of introducing a PODs system on the incidence and severity of MAEs. Method and setting — An observational method was used to identify MAEs before and after introducing a PODs system on one surgical and one medical ward in a teaching hospital in the United Kingdom. MAEs were classified as being due to unavailability (U‐MAEs) or other reasons (O‐MAEs). A validated severity assessment method was applied to the MAEs identified. Key results — The overall MAE rate for the traditional ward pharmacy system was 4.3 per cent and for the PODs system it was 4.2 per cent (P=0.99, chi square test). There were also no significant differences in U‐MAE or O‐MAE rates, types of MAE or their severity. There were several potential reasons why the PODs system did not reduce U‐MAEs. These included the informal use of patients' own medication in the traditional ward pharmacy system and one patient prescribed a non‐formulary drug who accounted for many of the U‐MAEs observed. Logistic regression analyses indicated that U‐MAE rates were affected by time of day and day of week, and O‐MAE rates by day of week and administering nurse. Conclusion — It was concluded that the introduction of a PODs system had little effect on MAEs.     

Cross‐sectional survey of medication used for headache in a general population

Objective To determine the level and types of medication used to treat headache in the general population and to compare this with current recommendations. Methods Cross‐sectional survey to an adult general population sample. A questionnaire gathered information on occurrence, characteristics of, and medication use for headaches in the previous three months. Setting Patients aged 18 years and over registered with five general practices in North Staffordshire, England. Key findings The response rate was 56%. Eighty‐five per cent of headache sufferers (60% of all questionnaire respondents) reported using medication for their headaches in the three months prior to the survey. Medication use was more likely to be reported by women, respondents aged 36 to 50 years, those reporting more painful and more disabling headaches, those experiencing at least five associated symptoms, and those whose untreated headaches lasted 4 to 24 hours. Paracetamol was by far the most widely used medication, with 74% of medication users taking it in the three‐month period. Fifty‐eight per cent of acute medication users took only one single therapy for their headaches. Only a small number of medication users (3%) took their headache medication before the pain began, with most (63%) taking it when the pain started and the remainder waiting until the pain was unbearable. Half of medication users (47%) reported that the medication completely relieved their headache, 51% obtained partial relief and 2% did not obtain relief. Conclusion Medication use for headache appears to be appropriate for most patients. Although only a minority used combination therapy, the high prevalence of headache means that this translates to substantial numbers in the population as a whole. Some headache sufferers might benefit from advice to make better use of the treatments available.     

Assessing patient adherence to anti‐hypertensive drug therapy: can a structured pharmacist‐conducted interview separate the wheat from the chaff?

Objective To identify determinants of adherence and assess the impact of structured pharmacist‐conducted interviews in determining patients' adherence to prescribed anti‐hypertensive medications in a secondary care setting in Nigeria. Method The study was conducted in a secondary care facility located in Ibadan, Southwestern Nigeria. Two methodological approaches were employed. The first phase was pharmacist‐conducted, pre‐physician consultation, cross‐sectional interviews of 400 hypertensive patients who presented at the study site within the 2‐month study period. The second phase was a follow‐up review of case notes of these patients after they had left the physician's office. Key findings The outcome of the pharmacist‐conducted pre‐physician consultation interview shows that financial difficulty was the most frequently identified factor responsible for patients' non‐adherence to anti‐hypertensive drug therapy (64%). A drug holiday, varying from 5–14 days per month, was the coping strategy adopted by patients to circumvent this difficulty. Only 48% (192) of patients were aware of the negative consequences of non‐adherence with anti‐hypertensive drug therapy, and of these, 75% were adherent. The level of awareness was significantly higher in adherent patients (P < 0.001). Sixty‐seven per cent (268) of patients use a daily medication reminder (DMR) to assist them in taking their anti‐hypertensive drugs, and of these 65.7% were adherent. The use of DMRs was significantly higher among adherent patients (P < 0.01). A meal time was the most frequently used DMR (88%). Forty‐one per cent (164) of patients had additional measurement of their blood pressure at pharmacies (65.9%) and neighbourhood private hospital (34.1%), and of these 75.6% were judged to be adherent with their prescribed drug therapy. Additional measurement of blood pressure was significantly higher in adherent patients (P < 0.001). Fifty‐one per cent of the cohort were judged by pharmacists as non‐adherent during pre‐consultation interviews (phase 1), while physicians judged 25% of the same cohort as non‐adherent during consultation (phase 2). The structured pharmacist‐conducted pre‐physician consultation interviews were significantly better at identifying patients who were non‐adherent with prescribed anti‐hypertensive drugs (P < 0.01). Conclusion A brief structured pharmacist‐conducted interview can be a valuable tool in assessing and/or identifying determinants of adherence with anti‐hypertensive drug therapy.     

Over‐the‐counter ibuprofen: how and why is it used?

Objectives — To pilot an over‐the‐counter (OTC) medicine pharmacovigilance project, using ibuprofen as a model. Method — All users of any tablet or capsule form of ibuprofen (excluding compound products) purchased from 61 participating community pharmacies, aged ≥18 years and able to give informed consent, were eligible to join the study. A postal questionnaire one week after the index purchase monitored the follow‐up rate, drug usage, past medical history, concurrent medication, symptoms and health service utilisation. Setting — Primary care: community pharmacies in Grampian, Scotland. Key findings — A total of 443/544 (81 per cent) questionnaires were completed. The recommended daily dose of OTC ibuprofen (1,200mg) was exceeded by 35 customers (8 per cent) on at least one day and the recommended maximum daily dose that can be prescribed by a physician (2,400mg) was exceeded on five occasions. During the seven days after the index purchase, ibuprofen was used by 15 customers (4 per cent) with an active or past history of peptic ulcer, and 30 (7 per cent) with an active or past history of asthma. Thirty‐eight per cent had purchased ibuprofen for a chronic condition and 32 per cent were still taking it at the end of the initial seven‐day period. Twenty‐eight of 412 customers (7 per cent) sought advice during the seven‐day period about at least one symptom: 13 consulted their general practitioner, 12 consulted a pharmacist, two consulted both their GP and a pharmacist, and one consulted a hospital doctor. Some of these consultations (23/28, 82 per cent) might have related to an adverse reaction to ibuprofen: 11 customers (3 per cent) consulted about lower abdominal symptoms, nine about gastric symptoms and three about wheeziness. Conclusions — This pilot study identifies instances of contraindicated and excessive use of OTC ibuprofen, indicating a need for pharmacovigilance studies of OTC medicines; it also demonstrates the feasibility of a major study.     

Does the concordance concept serve patient medication management?

Objectives — To assess how people with arthritis evaluate and calibrate their complex medication regimens. Building on these findings, to explore how the concept of concordance helps to describe a patient‐provider partnership model which can aid optimum medication regimen selection, calibration and management of chronic conditions. Method — A longitudinal study of 689 patients diagnosed with osteoarthritis (OA) or rheumatoid arthritis (RA) was conducted to identify patient perceptions, decision‐making and behaviour related to their medication management. Face to face interviews with the Brief Medication Questionnaire, health quality of life questionnaires (AIMS2 and SF‐36) and telephone interviews were conducted in waves centered around patient visits every six months for two years. Data about medication regimens were abstracted from the clinic medication profile record for each visit. Setting — Three rheumatology clinics in the United States: a university clinic, a private clinic and a Veterans Administration clinic. Key findings — About half of the patients in the sample had complex regimens with eight or more medications at any one time. The majority of physicians altered patients' medication orders every six months. The majority of patients reported that they evaluated the effectiveness and side effects of individual medicines based largely on symptoms. There were 248 reported deviations in the scheduled medications at baseline and the majority (61 per cent) were intentional, largely based on symptoms. Conclusion — Providers and patients each had unique expertise and were engaged in a dynamic process of calibrating patients' ever‐changing regimens. In the absence of a perfect static regimen for patients, the concept of concordance productively reflects the partnership and mutual respect needed for ongoing medication regimen selection, calibration and management for a long‐term condition.     

Drug‐related problems in the elders of the British Virgin Islands

Objective — To explore the extent of drug‐related problems in elderly patients in the Caribbean. Methods — Comprehensive medication reviews were carried out on a 1 in 20 sample of the elderly population of the British Virgin Islands, a UK dependent territory located in the Caribbean. Fifty non‐institutionalised patients, 65 years or older and taking at least one prescribed medicine, were interviewed for the study. Key findings — On average, 4.5 prescribed medications, 4.7 over‐the‐counter preparations and 3.3 herbal remedies/natural products were used by the sample. A mean of 5.9 potential drug‐related problems per patient were identified and a mean of 3.7 complications relating to the sub‐optimal use of medicines per patient were observed. Conclusion — This study has highlighted the need for a multidisciplinary review of the prescribing, dispensing and monitoring of elderly patients receiving prescribed medications. The pharmacist has a role to play in helping prescribers achieve this review, and in educating patients in ways in which they can get the best out of their medicines.     

Review of computerised patient medication records to determine potential clinical interventions in community pharmacy

The potential intervention rate for cardiovascular drugs dispensed in community pharmacy was investigated by a retrospective study of 300 patient medication records (PMRs) collected from 10 community pharmacies in Sydney, Australia. A medication review protocol and operational definitions were developed for 17 types of clinical intervention and three levels of clinical significance. Spearman's correlation coefficient (r_s) was used to examine the relationship between total number of potential interventions and predictor variables. From 5,271 medications dispensed, 1,509 (28.6 per cent) potential interventions were identified. The most frequent types of potential intervention were precautions (27.6 per cent), overutilisation (17 per cent) and dose discrepancy (16.3 per cent). Of the interventions classified as being of major clinical significance, 61.3 per cent were precautions, 19.7 per cent drug interactions and 19 per cent contraindications. The cardiovascular drug classes with the highest potential intervention rate were inotropics (93.2 per cent) and anticoagulants (89.5 per cent). There was a statistically significant correlation between the number of potential interventions per patient and the total number of medications dispensed per patient (r_s=0.68, P<0.001), the total number of cardiovascular drugs dispensed per patient (r_s=0.67, P<0.001) and the number of different prescribing doctors per patient (r_s=0.29, P<0.001). This study demonstrates the potential for community pharmacists to review computerised PMRs and intervene in patients' drug therapy, thereby reducing iatrogenic problems and improving health outcomes for patients.