Drug-related admissions to an Australian hospital

This study was conducted to determine the prevalence of drug-related hospital admissions in southern Tasmania, Australia. The causes of consecutive admissions to medical wards of the Royal Hobart Hospital were reviewed. Comprehensive data were collected over a 10-week period on 691 admissions (median age: 67 years and range: 11–97 years; 50.8% males). Sixty-eight (9-8%) of the admissions were classified as being either probably or definitely drug-related. Most of these admissions were attributable to intentional overdose (38.2%) or an adverse drug reaction (30.9%). The overdoses often involved benzodiazepines or antipsychotics. Gastrointestinal bleeding related to the use of nonsteroidal anti-inflammatory drugs was the most common adverse drug reaction (38.1% of all reactions). Other drug-related admission categories were poor compliance (14.7%), dosage decrease or therapy cessation by a doctor producing an exacerbation of symptoms (7.4%), substance abuse (4.4%) and drug interaction (4.4%). Patients with a drug-related admission were, on average, younger than the other medical admissions, with no significant difference in gender. Patients admitted due to an overdose or substance abuse were younger than other drug-related admissions and non-drug related admissions. In conclusion, this study has determined that almost 10% of medical admissions to the hospital are drug-related and it is estimated that 40 to 50 elderly people are admitted each year suffering from gastrointestinal bleeding related to nonsteroidal anti-inflammatory drugs.     

One nurse's transfer to hospital information services

This first article of a series details a personal account of a career change within the nursing profession. Through her own reflections and analysis, the evolution of a psychiatric clinical nurse specialist into an information services nurse liaison is traced and detailed from its beginning. The motivation for and difficulties in seeking such a drastic change are explored. Readers are invited to share the experiences of a nurse who takes a risk and ventures into the complex and completely different world of data processing while trying to maintain her identity as a nurse.     

Patient knowledge and information concerning medication on discharge from hospital

This study aimed to establish whether patients had sufficient knowledge and information concerning their medications on discharge from hospital The purpose was also to identify who educated and provided patients with information and in what form it came The study was carried out in five medical wards of a large teaching hospital, where patients were interviewed on the morning of discharge By using a medication checklist the findings of this study appeared to indicate that the patients interviewed had relatively little knowledge or information regarding their discharge medications However, overall their knowledge and information concerning their discharge medications had improved in relation to that of their admission medications Despite this finding, there remains a definite need for structured medication teaching programmes with appropriate assessment of patients needs on admission to hospital     

Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo,Norway

Objective: We describe the drug-related problems (DRPs) identified during medication reviews (MRs) and the changes in drug utilization after MRs at nursing homes in Oslo, Norway. We explored predictors for the observed changes.

Design: Observational before-after study.

Setting: Forty-one nursing homes.

Intervention: MRs performed by multidisciplinary teams during November 2011 to February 2014.

Subjects: In all, 2465 long-term care patients.

Main outcome measures: DRPs identified by explicit criteria (STOPP/START and NORGEP) and drug–drug interaction database; interventions to resolve DRPs; drug use changes after MR.

Results: A total of 6158 DRPs were identified, an average of 2.6 DRPs/patient, 2.0 for regular and 0.6 for pro re nata (prn) drugs. Of these patients, 17.3% had no DRPs. The remaining 82.7% of the patients had on average 3.0 DRPs/patient. Use of unnecessary drugs (43.5%), excess dosing (12.5%) and lack of monitoring of the drug use (11%) were the most frequent DRPs. Opioids and psychotropic drugs were involved in 34.4% of all DRPs. The mean number of drugs decreased after the MR from 6.8 to 6.3 for regular drugs and from 3.0 to 2.6 for prn drugs. Patients with DRPs experienced a decrease of 1.1 drugs after MR (0.5 for regular and 0.6 for prn drugs). The reduction was most pronounced for the regular use of antipsychotics, antidepressants, hypnotics/sedatives, diuretics, antithrombotic agents, antacid drugs; and for prn use of anxiolytics, opioids, hypnotics/sedatives, metoclopramide and NSAIDs.

Conclusion: The medication review resulted in less drug use, especially opioids and psychotropic drugs.     

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.     

Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events

BackgroundMedication reconciliation (MR) has proven to be a problematic task for many hospitals to accomplish. It is important to know the clinical impact of physician- versus pharmacist-initiated MR in the resource-limited hospital environment.MethodsThis quasi-experimental study took place from December 2005 to February 2006 at an urban US Veterans Affairs hospital. MR was implemented on 2 similar general medical units: one received physician-initiated MR and the other received pharmacist-initiated MR. Adverse drug events (ADEs) and a 72-hour medication-prescribing risk score were ascertained by research pharmacists for all admitted patients by structured record review. Multivariable models were tested for intervention effect, accounting for quasi-experimental design and clustered observations, and were adjusted for patient and encounter covariates.ResultsPharmacists completed the MR process in 102 admissions and physicians completed the process in 116 admissions. In completing the MR process, pharmacists documented statistically more admission medication changes than physicians (3.6 vs 0.8; P < 0.001). The adjusted odds of an ADE caused by an admission prescribing change with pharmacist-initiated MR compared with a physician-initiated MR were 1.04 with a 95% CI of 0.53 to 2.0. The adjusted odds of an ADE caused by an admission prescribing change that was a prescribing error with pharmacist-initiated MR compared with a physician-initiated MR were 0.38 with a confidence interval of 0.14 to 1.05. No difference was observed in 72-hour prescribing risk score (coefficient = 0.10; 95% CI, ?0.54 to 0.75).ConclusionMR performed by pharmacists versus physicians was more comprehensive and was followed by lower odds of ADEs from admission prescribing errors but with similar odds of all types of ADEs. Further research is warranted to examine how MR tasks may be optimally divided among clinicians and the mechanisms by which MR affects the likelihood of subsequent ADEs. ClinicalTrials.gov identifier: NCT00370916.     

Risk for acute confusion on hospital admission

Elderly individuals are at risk for acute confusion (AC) during hospitalization. Using a prospective design, this study assessed the relationship between admission risk factors and subsequent development of AC in 117 elderly hospitalized patients. AC was ascertained using the NEECHAM Confusion Scale. Other measures included demographic data, cognitive status, physical function, laboratory data, medications, infections, activity, pain, and nursing acuity. The cumulative incidence estimate was 14%. Patients who developed AC were more likely to be admitted to the hospital from somewhere other than home, to have lower admission NEECHAM and MMSE scores, and to have restricted activity levels, an infection, and abnormal lab values. These patients were more cognitively and physically frail and may have been chronically undernourished and dehydrated on admission to the hospital. Nurses can be trained to routinely assess for acute confusion using easily implemented instruments incorporated into a research-based protocol.     

Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation)

Rationale  Medication errors can lead to preventable adverse drug events (pADEs) that have significant cost and health implications. Errors often occur at care interfaces, and various interventions have been devised to reduce medication errors at the point of admission to hospital. The aim of this study is to assess the incremental costs and effects [measured as quality adjusted life years (QALYs)] of a range of such interventions for which evidence of effectiveness exists.
Methods  A previously published medication errors model was adapted to describe the pathway of errors occurring at admission through to the occurrence of pADEs. The baseline model was populated using literature-based values, and then calibrated to observed outputs. Evidence of effects was derived from a systematic review of interventions aimed at preventing medication error at hospital admission.
Results  All five interventions, for which evidence of effectiveness was identified, are estimated to be extremely cost-effective when compared with the baseline scenario. Pharmacist-led reconciliation intervention has the highest expected net benefits, and a probability of being cost-effective of over 60% by a QALY value of £10 000.
Conclusions  The medication errors model provides reasonably strong evidence that some form of intervention to improve medicines reconciliation is a cost-effective use of NHS resources. The variation in the reported effectiveness of the few identified studies of medication error interventions illustrates the need for extreme attention to detail in the development of interventions, but also in their evaluation and may justify the primary evaluation of more than one specification of included interventions.