Medication errors in community pharmacy: an investigation into the types and potential causes

Objectives To establish the nature of medication errors occurring within community pharmacy and analyse common error patterns. To identify factors which influence the occurrence of medication errors and near misses, with the intention of designing systems or strategies to reduce the occurrence of these events. Setting Fifteen community pharmacies situated within Brighton and Hove City Primary Care Trust, East Sussex, between January and March 2004. Method A self‐reporting form was designed, piloted and administered to pharmacists, which gathered information on the detection of an error or near miss in the dispensing process. Key findings One‐hundred and thirteen near misses and thirty‐two medication errors were reported. The majority of near misses were detected by the pharmacist at the final check, and the majority of medication errors were detected by the patient or patient's representative. Selection errors were most common, with similar drug names and packaging cited as the main contributory factors. ‘Business’ was frequently cited as the circumstance surrounding the error. Conclusion This study demonstrates that pharmacists do have an important part to play and the positive impact of community pharmacists in preventing, detecting and correcting errors and thus preventing harm to patients in the primary care setting. However, medication errors do occur, and therefore a multifactorial approach by manufacturers, marketing and packaging personnel, in addition to input from pharmacists, may be an effective permanent solution in reducing the errors made.     

A longitudinal study of adolescent mental health service use

This study examines longitudinal mental health service use patterns of a school-based sample of adolescents. Based on the Center for Epidemiologic Studies Depression Scale scores, a stratified sample of middle-school students was interviewed using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children: cycle one (n = 579; mean age 12.83) and cycle two (n = 490; mean age 18.65). Service use also was assessed by mailed questionnaire: cycle three (n = 330; mean age 20.60). Service use decreased over time. Whites and males received significantly more treatment in the first cycle. In the second cycle, service use by race and gender was equal; in the third cycle, females received more treatment. Those with a psychiatric diagnosis (first cycle 54%; second cycle, 33%) received treatment in the prior year. Under-treatment of youth with psychiatric diagnoses is a significant problem, with differences in service use by race and gender over time.     

A STRATEGY FOR RAPID IDENTIFICATION OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS NASAL CARRIER STATUS

Methicillin Resistant Staphylococcus aureus (MRSA) is a multi drug resistant organism responsible for severe outbreaks of life threatening infections in hospitals which are difficult to treat They are spread by nasal carriage among the hospitalised patients, staff and visitors. Mannitol cloxacillin salt agar (MCSA) is a single tube method to identify MRSA. However, tubes showing growth and change in colour on biochemical characterisation often do not prove to be MRSA. In this study we have combined two strategies for the rapid identification and isolation of MRSA by culture in MCSA and multiplex PCR for mecA and femB genes. Anterior nasal swabs obtained from nursing staff and patients admitted to a large referral hospital, were inoculated into MCSA. Of the 100 tubes inoculated, 8 tubes showed change in colour and growth. On conventional testing 4 were MRSA, 3 were methicillin sensitive S aureus (MSSA) and 1 was Methicillin Sensitive Coagulase Negative S aureus (MSCNS). Genotyping by multiplex PCR revealed 5 MRSA, 2 MSSA and 1 MRCNS. The Multiplex PCR technique to rapidly identify presence of mecA and femB genes showed presence of both mecA and femB bands in all MRSA. The methicillin sensitive organisms showed absence of mecA gene while coagulase negative organisms showed absence of the fern B gene. Combining MSCA with multiplex PCR for mec A and fem B genes made the test both rapid and specific. Use of this strategy would enable rapid screening of nasal carriers and early implementation of hospital infection control measures.KEY WORDS: Mannitol cloxacillin salt agar, Methicillin Resistant S aureus, Methicillin Sensitive Coagulase Negative S aureus, Methicillin Sensitive S aureus     

InterMiG: international differences in the therapeutic approach to migraine patients in specialized headache centers

BackgroundThere is currently a wide therapeutic arsenal for migraine patients, without a single first-line preventive drug and we choose the different available alternatives taking into account comorbidities, national guidelines, previous treatments and personal experiences.Our objective was to evaluate the differences in the use of migraine treatments between neurologists from different countries.MethodsThis is a multi-centre observational study carried out by neurologists from specialized headache units in seven countries, retrospective with consecutive inclusion of all patients presenting with a migraine diagnosis, over a period of three months.ResultsA total of 734 patients were recruited but only 600 were considered in the analysis in order to homogenize the patient cohorts from countries: 200 Spain (ES), 100 Italy (IT), 85 Russia (RUS), 80 Germany (DE), 60 Portugal (PT), 45 Poland (PL) and 30 Australia (AU). 85.4 % of patients were women with a mean age of 42.6 ± 11.8 years. Considering previous and current preventive treatment, the order of use was: antidepressants (69.3 %), antiepileptic drugs (54.7 %), beta-blockers and antihypertensive drugs (49.7 %), OnabotulinumtoxinA (44.0 %) and others (36.2 %).Statistically significant differences were found between all pharmacological classes: antidepressants were commonly used in all countries, with the exception of Poland (AU: 76.7 %, IT: 71.0 %, DE: 60.0 %, PL: 31.1 %, PT: 71.7 %, RUS: 70.6 %, ES: 78.5 %; p < 0.0001); antiepileptic drugs were more frequently prescribed in Portugal, Australia and Spain (AU: 73.3 %, IT: 40.0 %, DE: 37.5 %, PL: 48.9 %, PT: 85.0 %, RUS: 29.4 % and ES: 69.0 %; p < 0.0001); beta-blockers and antihypertensive drugs were frequently used in all countries except Italy (AU: 60.0 %, IT: 14.0 %, DE: 53.8 %, PL: 48.9 %, PT: 68.3 %, RUS: 49.4 % and ES: 59.0 %; p < 0.0001); BTX-A were predominately used in Spain, Italy and Australia (AU:56.7 %, IT:58.0 %, DE:20.0 %, PL: 42.2 %, PT: 26.7 %, RUS: 24.7 % and ES: 58.5 %; p < 0.0001) and others were most frequently used in Poland (AU: 0.0 %, IT: 19.0 %, DE: 42.5 %, PL: 95.6 %, PT: 31.7 %, RUS: 3.5 % and ES: 49.5 %; p < 0.0001). If only patients without comorbidities are considered (200/600), statistically differences between countries persist in all preventive treatments.ConclusionsThere is heterogeneity in the choice of preventive treatment between different countries. Prospective comparative studies of the different oral and subcutaneous alternatives would help to create a global therapeutic algorithm that would guarantee the best option for our patients.     

Supraorbital neuralgia: a clinical study

A series of 18 patients suffering from supraorbital neuralgia have been studied through a seven year period. Appropriate investigations ruled out other headaches. There was a female (67%) preponderance. Mean age at onset was 51.6 years. The mean headache duration was 5.9 years. Five patients had a history of ipsilateral forehead trauma. The main areas of pain were the forehead and orbit. The pain was dull with short sharp or burning exacerbations. The temporal pattern was either remitting (n = 7) or chronic continuous (n = 11). Autonomic accompaniments were generally lacking. Neurological assessment was normal in all but 4 patients who were found to have signs/symptoms of sensory dysfunction in the forehead of the symptomatic side. Trials of different drugs, including migraine and anti-neuralgic drugs, only provided slight relief. Anaesthetic nerve blocks of the supraorbital nerve provided an absolute but transitory relief of pain. Although aetiology and pathogenesis of supraorbital neuralgia is largely unknown, entrapment of the supraorbital nerve at its outlet and successful decompressive surgery have been previously reported. This and other pathogenic hypotheses are discussed.     

Observational study of regional aortic size referenced to body size: production of a cardiovascular magnetic resonance nomogram

Background

Cardiovascular magnetic resonance (CMR) is regarded as the gold standard for clinical assessment of the aorta, but normal dimensions are usually referenced to echocardiographic and computed tomography data and no large CMR normal reference range exists. As a result we aimed to 1) produce a normal CMR reference range of aortic diameters and 2) investigate the relationship between regional aortic size and body surface area (BSA) in a large group of healthy subjects with no vascular risk factors.

Methods

447 subjects (208 male, aged 19–70 years) without identifiable cardiac risk factors (BMI range 15.7–52.6 kg/m²) underwent CMR at 1.5 T to determine aortic diameter at three levels: the ascending aorta (Ao) and proximal descending aorta (PDA) at the level of the pulmonary artery, and the abdominal aorta (DDA), at a level 12 cm distal to the PDA. In addition, 201 of these subjects had aortic root imaging, allowing for measurements at the level of the aortic valve annulus (AV), aortic sinuses and sinotubular junction (STJ).

Results

Normal diameters (mean ±2 SD) were; AV annulus male(♂) 24.4 ± 5.4, female (♀) 21.0 ± 3.6 mm, aortic sinus♂32.4 ± 7.7, ♀27.6 ± 5.8 mm, ST-junction ♂25.0 ± 7.4, ♀21.8 ± 5.4 mm, Ao ♂26.7 ± 7.7, ♀25.5 ± 7.4 mm, PDA ♂20.6 ± 5.6, +18.9 ± 4.0 mm, DDA ♂17.6 ± 5.1, ♀16.4 ± 4.0 mm. Aortic root and thoracic aortic diameters increased at all levels measured with BSA. No gender difference was seen in the degree of dilatation with increasing BSA (p > 0.5 for all analyses).

Conclusion

Across both genders, increasing body size is characterized by a modest degree of aortic dilatation, even in the absence of traditional cardiovascular risk factors.     

Study of the radio-opacity of base and liner dental materials using a digital radiography system

Objectives:

This study investigated the radio-opacity of commercially available glass ionomer cements (GICs), flowable resin composites (FRCs) and calcium hydroxide cements (CHCs) and compared this with the radio-opacity of enamel, dentine and aluminium stepwedge. 16 GICs, 8 FRCs and 4 CHCs were analysed.

Methods:

Three sets of three samples were prepared: 1 mm, 2 mm and 3 mm thickness for GIC and FRC and 1 mm thickness for CHC. Specimens of enamel and dentine with the same thicknesses were obtained. As a control, an aluminium stepwedge was used. Radiographs were taken with a digital Kodak RVG 5000 (0.32 s, 30 cm). The images were analysed using the Image Tool^® program (v. 2.00; The University of Texas Health Science Center, San Antonio, TV) to obtain the mean grey values.

Results:

Analysis of variance was used to investigate the significance of differences among the groups. For pairwise comparisons, the Tukey test was applied (p < 0.05). The GICs Ionomaster (Wilcos, Petrópolis, Brazil), Maxxion (FGM, Joinville, Brazil), Bioglass R (Biodinâmica, Ibiporã, Brazil), Bioglass F (Biodinâmica), Vidrion R (SS White, Rio de Janerio, Brazil) and Vidrion F (SS White), presented radio-opacity lower than that of dentine. All FRCs and CHCs studied showed radio-opacity higher than that of dentine. Vitro Fil (DFL, Rio de Janeiro, Brazil), Magic Glass (Vigodent, Rio de Janeiro, Brazil), Vitrebond (3M, Sumaré SP, Brazil), Riva Self Cure (SDI, Victoria, Australia), Riva Light Cure (SDI), Fill Magic (Vigodent), Opallis (FGM, Joinville, Brazil), Surefil SDR (Dentsply, Milford, DE), Tetric N (Ivoclar Vivadent, Schaan, Lichtenstein), Tetric (Ivoclar Vivadent), Hydro C (Dentsply, Petrópolis, Brazil), Hydcal (Technew, Madalena, Portugal) and Liner (Vigodent) showed radio-opacity similar to or greater than that of enamel for all thicknesses.

Conclusions:

The increased thickness of the materials studied increases their radio-opacity. Some commercially available GICs used as a base and liner for restorations have a very low radio-opacity (Ionomaster, Maxxion, Bioglass R, Bioglass F, Vidrion R and Vidrion F).