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.     

Patients' views of the value of “brown bag” medication reviews

Objective — To explore and describe patients' views of the value of brown bag medication reviews. Method — Semi‐structured, tape‐recorded interviews were conducted with 20 patients who had participated in a brown bag medication review scheme. Setting — A health authority area in south‐east inner London. Key findings — Patients perceived the following benefits from brown bag reviews: clinical problems resolved; better understanding of their medications, leading to increased confidence; and appreciation that an interest was being taken in their health care. Reviews had given patients a sense of empowerment, and had made them realise that they had a right to information about their medical treatment and medication. As a result they were likely to be more proactive in seeking information in future. Reviews had made patients realise that pharmacists were knowledgeable about medicines, where previously many had thought that only doctors had sufficient knowledge. Reviews had enhanced relationships between patients and pharmacists. However, some patients still perceived their doctor as the authoritative source of information about medicines. Patients' accounts indicated that much of the information provided by the pharmacist was new, raising the issue of what information was routinely being provided by pharmacists. Conclusions — Brown bag reviews were regarded by patients as beneficial and they wanted them to be available in the future. Patients' perceptions of pharmacists as health professionals and providers of information on medicines were enhanced by brown bag reviews.     

Haemodialysis patients' beliefs about treatment: implications for adherence to medication and fluid‐diet restrictions

Objectives — To assess haemodialysis patients' beliefs about treatment and to investigate which beliefs correlate with adherence to medication and fluid‐diet restrictions. Methods — Forty‐seven haemodialysis patients receiving intermittent hospital haemodialysis completed questionnaires assessing their beliefs about medication and fluid‐diet restrictions. Key findings — Adherence rates varied between and within patients, and were related to specific treatment beliefs in a logically consistent way. Reported intentional non‐adherence to medication correlated with concerns about the potential adverse effects of renal medication. Low adherence to fluid‐diet restrictions (assessed by inter‐dialysis weight gain) was associated with the personal belief that the restrictions were too strict. Most patients (90 per cent) agreed that medicines prescribed for their renal condition were necessary for maintaining health. However, 32 per cent harboured concerns about their medication, arising from beliefs about the potential for dependence, long‐term effects, or disruption of life. Concerns about renal medication correlated with more general beliefs that medicines as a whole are harmful, addictive poisons which are overused by doctors. Although specific treatment beliefs (medication or fluid‐diet restrictions) were related to specific adherence behaviours, these two areas of beliefs and behaviours were unrelated. Conclusions — Patients' perceptions of treatment merit further study. Eliciting and addressing patients' perceptions of treatment may be a target for pharmaceutical care and a foundation for partnership in medicine‐taking.     

Are health professionals ready for the new philosophy of concordance in medicine taking?

Objectives — To develop and administer a practical, valid and reliable tool to measure attitudes to concordance in medicine taking, a new concept where decisions depend on an equal partnership between patient and prescriber. Method — A postal questionnaire was devised comprising statements from the original concordance document, along with statements reflecting the orthodox model of medicine taking. There was a total of 22 statements. Respondents rated each statement on a four‐point Likert agreement scale. The questionnaire also included three scenarios of consultations involving medicine prescribing and taking, with associated statements for rating as true or false. Setting — A random sample of 207 medical, nursing and pharmacy graduates in the North of England at the time of qualification. We received 81 completed questionnaires (39 per cent) Key findings — Item analysis reduced the 22‐item scale to a 12‐item scale with good reliability (Cronbach's alpha = 0.79) and construct validity was demonstrated through correlation with responses to the scenarios. Although the typical respondent had a positive attitude towards concordance (mean = 2.3), 25 per cent of respondents had negative attitudes. Pharmacists showed the least favourable attitudes (P<0.05) Conclusions — The 12‐item Leeds Attitude Towards Concordance (LATCon) scale is a reliable and valid tool for assessing health care providers' attitudes to the new concept of concordance in medicine taking. Newly qualified doctors, nurses and pharmacists tended to hold favourable attitudes, although a significant minority — especially pharmacists — hold negative attitudes. These results have implications for undergraduate education and continuing professional education.     

A randomised controlled trial of a pharmaceutical care programme in high‐risk diabetic patients in an outpatient clinic

Objective — To determine the impact of a pharmaceutical care programme (PCP) in diabetic patients. Design — Randomised controlled study of high‐risk diabetic patients. Setting — Outpatient clinic at Fremantle hospital (FH), Western Australia. Method — Patients over 18 years of age who could communicate freely in English and fulfilled pre‐determined criteria for being high‐risk for the development of diabetic complications, were randomly assigned to the PCP or control groups in a ratio of 2:1. In the PCP arm, a clinical pharmacist reviewed and monitored all aspects of the patients' drug therapy in collaboration with other health care professionals at six‐weekly intervals for six months. The control patients received usual outpatient care. Main outcome measures — Glycosylated haemoglobin (HbA_1c), quality of life (QOL), patient satisfaction with health care providers and changes in drug therapy during the PCP. Results — Seventy‐three patients were recruited into the study, of whom 48 (66 per cent) were randomised to the PCP. There were no significant differences between the PCP (cases) and the control groups for demographic variables. The mean (±SD) HbA_1c for the cases was 8.4±1.4 per cent at the beginning and 8.2±1.5 per cent at the end of the study period (P>0.05). There was similarly no change in the control group (8.5±1.6 per cent to 8.1±1.6 % P>0.05). There were no significant changes in QOL for cases or controls over the period of the study. During the PCP, there was a significant increase in patient satisfaction with the care provided by the clinical pharmacist (P=0.007) and the provision of drug information (P=0.036). The clinical pharmacist facilitated 39 drug interventions in the 48 cases. A high level of complementary medicine usage was found in the PCP group (16.7 per cent). Conclusions — PCPs provide patients with important medication information and result in changes to drug therapy. However, in diabetic patients under specialist care, a six‐month PCP did not lead to an improvement in glycaemic control. The role for pharmacist intervention in primary care now needs to be evaluated.     

“I've not asked him,you see,and he's not said”: understanding lay explanatory models of illness is a prerequisite for concordant consultations

Method — An extended qualitative analysis of a single case. Objective — To illustrate the complexity of patients' explanatory models and their significance in underpinning experience of illness and response to disease. Key findings — The case demonstrates how lack of professional awareness and understanding of patient models limits the capacity to provide effective health care and reduces patients' ability to cope with the experience of illness or to participate constructively in the management of disease. The distance between patients and health professionals is likely to increase, as also is the rate of “non‐compliance”, if laypeople continue to become increasingly well informed outside the consulting room, but retain the traditional role of passive and acquiescent patient within it. Concordant consultations are characterised by attention to the patient's illness as well as disease. It is not enough that technical issues and disease problems should be dealt with. The patient's subjective experience of symptoms, and the personal significance of his or her illness should be set out. The interpretation of meaning should be a collaborative endeavour involving both doctor and patient. Increased professional awareness of patient models of illness and associated concerns could be an important lever in changing the culture of the consultation. Conclusion — Concordance offers a way of developing a more equal and meaningful relationship between patients and professionals and of generating more positive outcomes in medical consultations as a result.     

The development and evaluation of an extended adherence support programme by community pharmacists for elderly patients at home

Objective —To devise, implement and evaluate a medication adherence support service by community pharmacists for elderly patients living at home and at risk of non‐adherence. Method — Six community pharmacists identified patients who were 65 years of age and older, prescribed four or more regular medicines and living alone. A random sample of patients was visited at home and assessed for adherence‐related problems using a structured interview. The pharmacist then drew up an action plan in conjunction with the patient and general practitioner (GP), and returned for a second home visit, where the revised regime was delivered and explained. A self‐reported adherence questionnaire was also administered. After two months an independent researcher visited the patients at home to assess progress. Setting — Six community pharmacies in the city of Leeds, UK, and patients' homes. Key findings — A total of 143 patients were recruited and 441 medicine‐related problems were identified. Of these, 241 (55 per cent) required the provision of information and advice, 106 (24 per cent) required consultation with the GP and 86 (20 per cent) required changes in the presentation of the medicines. The median number of regular prescribed medicines fell from six to five (P<0.001). Overall, there was a reduction in the number of patients with one or more problems from 94 per cent to 58 per cent (P<0.001). The proportion of patients who reported non‐adherence fell from 38 per cent to 14 per cent (P<0.001). Conclusion — This study shows that community pharmacists can target patients at risk of medication non‐adherence and, using a structured approach, identify problems and implement solutions. The pharmacy patient medication record is an underutilised tool for identifying patients with adherence problems. The software needs enhancing to enable pharmacists to maximise their use of these records in adherence support. An adherence support programme needs to take more account of intentional non‐adherence and should be closely linked with the rest of the primary health care team.     

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.     

Adverse drug reaction monitoring by United Kingdom hospital pharmacy departments: impact of the introduction of “yellow card” reporting for pharmacists

Objective — To assess the impact of the introduction of hospital pharmacist “yellow card” adverse drug reaction (ADR) reporting on the operation of local schemes. Method — Prepiloted postal questionnaire sent to hospitals in 1998 following up a previous survey two years earlier. Setting — Clinical services managers for 200 hospital pharmacies that had been randomly selected for the previous survey. Key findings — One hundred and fifty usable questionnaires (75 per cent) were returned. Twenty-eight departments (18.9 per cent), compared with 26 departments (15.1 per cent) in 1996, operated ADR reporting schemes. Of a total of 440 local ADR reports made to participating departments, 70.0 per cent (312) were forwarded to the Committee on Safety of Medicines, a significantly higher percentage than the 14.9 per cent in the previous study (P=0.001). Only eight hospitals (5.4 per cent) had schemes for monitoring newly marketed or “black triangle” drugs. Ninety-four departments (62.3 per cent) had supported education and training activities. Of the hospitals without a scheme, 15 (12.5 per cent) said they had definite plans to introduce one in their hospital, 40 (33.3 per cent) had probable plans to introduce one and 65 (54.2 per cent) had no such plans. Conclusion — Pharmacists' involvement in the CSM yellow card scheme appears to have had little impact on local initiatives. In areas where these local schemes have been implemented and educational activities provided, drug information pharmacists appear to have a significant role. From the results of this study, even in hospitals with local or in-house schemes, gross under-reporting of ADRs remains a major problem.     

Prescribing new drugs: a survey of hospital consultants in the West Midlands

Objective — To investigate the factors that influence how consultants introduce new drugs into their clinical practice. Method — A postal questionnaire survey of hospital consultants. Setting — 169 consultants in medical specialties in six hospitals (general or teaching hospitals) in the West Midlands region, United Kingdom. Key findings — Ninety‐two completed questionnaires (54 per cent) were returned. Eighty consultants (87 per cent) reported using a new drug in the previous two years; 60 (65 per cent) had used either one or two new drugs and these were generally in their specialist field. There was no significant difference between hospitals in how easy it was to introduce a new drug. Sixty‐one consultants (67 per cent) said that the procedure required an application to the hospital drug and therapeutics committee. Consultants frequently asked patients' general practitioners to prescribe a new drug. Consultants rated independent sources of information more highly than non‐independent sources. The most important factors reported to influence prescribing decisions about new drugs were drug characteristics, such as efficacy and safety, and evidence from scientific literature. Sixty‐four respondents (70 per cent) saw drug company representatives up to once a week and 57 (62 per cent) had been involved in clinical trials of new drugs in the previous five years. Conclusion — In general, the consultants reported that they used only a small number of new drugs. There is considerable pressure on hospital doctors to control prescribing and costs of new drugs through policies that require approval by the drug and therapeutics committee. Although contact with the pharmaceutical industry was high, consultants reported that independent sources of information were more important. Factors such as clinical trial evidence and improved drug characteristics were said to be the most influential in reaching decisions to prescribe new drugs.     

Public perceptions of community pharmacists in Benin City,Nigeria

Objective — To determine public perceptions of community pharmacists and pharmacies in Benin City, Nigeria. Method — A self‐completion questionnaire was distributed to a stratified random sample of 1,500 households. Data were collected using a 22‐item, Likert‐type scale which was shown to have 0.77 reliability. The neutral point was assumed to be 66 on the scale of 22 to 110. Scores above 66 were interpreted as positive perception. Results — The response rate was 68.3 per cent (1,025/1500). Almost two‐thirds (64 per cent) of respondents perceived the community pharmacist as a health care provider, and 70 per cent agreed that community pharmacists are needed, especially in the area of medicinal product selection (76 per cent). However, 52 per cent believed pharmacists are profit motivated and only 43 per cent said they would be willing to pay for pharmacist consultation. Respondents reported difficulty in differentiating between pharmacists and pharmacy attendants, with only 58 per cent reporting that they could tell the difference. The pharmacists scored 76.37 ± 27.63, with 60 per cent of respondents scoring them above 66. Conclusion — This study found that community pharmacists received a moderately positive rating from the public. There is a need for community pharmacists to carve out a more distinct professional identity for themselves.     

Pharmacists solving problems in asthma management — experiences from a one‐year intervention programme in Finland

Objective — To study the effect of an intervention provided by community pharmacists on detection and resolution of problems in asthma patients' self‐management and to study patients' opinions about the perceived usefulness of the pharmacists' input. Method — A one‐year intervention study was conducted with scheduled visits and follow‐ups at baseline, four, eight and 12 months. Study patients (n=28) acted as their own controls. Setting — Four communities and community pharmacies in different parts of Finland. Key findings — At study baseline, all patients had at least one documented problem, the most commonly reported being problems with medication, side effects, problems with inhalation devices and not using asthma medicines according to the physician's instructions. On average, patients had five “intervention” consultations with the pharmacist during the one‐year study. After the intervention, half of the patients reported that their problems had been resolved. The most useful areas of advice were considered by the patients to be instructions about changing asthma medication according to asthma symptoms and management of asthma symptoms. Twenty‐five of the 28 patients reported that they were satisfied with the education and counselling provided by pharmacists, a higher number than for physicians or nurses. Conclusion — The findings from this small longitudinal study indicate that community pharmacists can improve asthma patients' treatment by consultations during which they identify and address problems in self‐management of asthma.     

Evaluation of mental health care interventions made by three community pharmacists — a pilot study

Objective — To assess the clinical significance of drug‐related interventions made by three community pharmacists (CPs) in the pharmaceutical care of 30 long‐term mentally ill patients in the UK. Method — Three CPs (“study pharmacists”) participated in a nine‐month study in which they collaborated with the community mental health team (CMHT) to provide pharmaceutical care for long‐term mentally ill patients in the community. In particular, they liaised with the patients' keyworkers, accompanying them on home visits. The pharmacists had previously attended a specially organised training course. Their primary tasks were to assess patient need and identify medication‐related problems, intervene as appropriate and document patient outcome. An expert review panel (two specialist hospital mental health pharmacists and a consultant psychiatrist) evaluated the appropriateness of the interventions and the level of clinical significance of the interventions (using a validated four‐point rating scale). Key findings — Thirty‐eight patients consented to participate in the study and 35 were contactable. Ninety‐four medication‐related problems were identified involving 30 patients (mean number of recorded problems per patient=3), of which full data were available for 92. Eighty‐four problems (91 % n=92) were said to have had appropriate interventions, and eight (9 per cent) inappropriate interventions. In 35 per cent of problems the three reviewers agreed that the interventions were clinically significant. Inter‐rater agreement for paired agreements (assessed by the kappa statistic) was fair in all cases except one, where it was poor. Conclusions — The reviewers considered the study pharmacists to have made a valuable pharmaceutical contribution to mental health care through clinically significant interventions, although they identified cases in which further clinically significant interventions could have been made. The reviewers saw the work undertaken as providing a positive way forward in primary mental health care.     

The use of serial point‐prevalence studies to investigate hospital anti‐infective prescribing

Objectives — To develop and test an efficient, reproducible method for the surveillance of hospital anti‐infective use; to use this method to investigate patterns of anti‐infective prescribing. Method — A series of three standardised point‐prevalence studies were carried out in which pharmacists recorded details of all inpatients prescribed systemic anti‐infectives. Time taken to collect, enter and analyse these data was documented. Parameters examined included: percentage of patients prescribed anti‐infectives, percentage of anti‐infectives that were for “reserved” use, percentage of these with appropriate approval, percentage of anti‐infectives administered intravenously, duration of therapy, and combinations of anti‐infectives used. Setting — All hospital inpatients in a large National Health Service (NHS) Trust comprising four sites. Key findings — For each study, an estimated 35 additional hours of pharmacists' time was required for data collection, cleaning and analysis, and 15 hours for data entry. The method developed was easily reproducible and results from the three studies were very similar. Overall, 33 per cent of 2,656 inpatients were prescribed at least one anti‐infective (mean 1.7 per patient); 48 per cent of anti‐infectives were given intravenously (IV), of which 34 per cent could have been given orally. Of the anti‐infectives used, 21 per cent were for “reserved” use. Of these, 65 per cent were used for an approved indication, and 11 per cent were not. The remaining 24 per cent had no indication documented in the medical notes. Conclusion — This is a practical method for studying hospital anti‐infective use in the absence of computerised prescribing. The database produced provides a wealth of information and various targets for intervention have been identified; these can now be evaluated against the baseline data collected. The methods developed could be used in other hospitals to provide benchmarking data.     

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.