Impact of the ENDORSE study results on thromboprophylaxis prescribing patterns in medical patients attending the emergency department.

AIMS: The aim of the study was to evaluate the impact of the ENDORSE study results on thromboprophylaxis prescribing patterns in medical patients attending the Emergency Department (ED) by assessing prescribing appropriateness at admission. METHODS: A cross-sectional, observational, descriptive study was designed and included all adult medical patients admitted from an ED between 20 November 2012 and 26 November 2012 at a large tertiary hospital. Patients to whom anticoagulants were prescribed for therapeutic purposes, patients admitted to Intensive Care Unit or maternity wards were excluded. Prescribing appropriateness was assessed using the Padua Prediction Score (ACCP 2012 guideline) for thromboembolic risk assessment and the NICE model to determine risk of bleeding. The primary end-point was the adequacy of thromboprophylaxis prescribed at the ED according to the ACCP 2012 guideline. RESULTS: A total of 393 patients were examined and 207 patients were included in the study (53.1% were male) with a median age of 75.3 years. The most common diagnosis at admission was related to a respiratory disease (41.1%). In 34.8% of the patients (72 patients), the recommendation of prophylaxis according to ACCP 2012 guideline did not match with the prophylaxis prescribed at admission. Reasons for non-concordance were undertreatment (14.5%) and overtreatment (20.3%). CONCLUSIONS: The adequacy of thromboprophylaxis in high risk patients for VTE has improved compared with the ENDORSE study. However, the percentage of patients with discordant prescriptions remains high. Despite the existence of treatment omissions, this percentage has been overcome by patients overtreated.

[Potentially inappropriate prescriptions in the ambulatory treatment of elderly patients]. / Prescripciones potencialmente inapropiadas en el tratamiento ambulatorio de pacientes ancianos.

INTRODUCTION: The aim of this study was to establish the percentage of potentially inappropriate prescriptions, according to STOPP/START criteria, in the ambulatory treatments of patients over 65 years admitted to an internal medicine unit, and to identify the most common prescription errors. MATERIAL AND METHODS: A prospective, observational study was performed between October and December 2012. The variable recorded were,age, gender, Charlson comorbidity index, reason for hospitalisation and pharmacological ambulatory treatment. RESULTS: Data from 131 patients were collected (Mean age: 80.2 years; 58.8% male, mean Charlson comorbidity index: 2; mean number of medications per patient: 8.6). Main reasons for hospitalisation: decompensated heart failure, respiratory infection, exacerbated COPD, urinary tract infection, pneumonia, and unintended weight loss. There were 121 potentially inappropriate prescriptions detected in 73 patients (55.7%). The most common STOPP criteria were therapeutic duplicities. The most common START criteria were the omission of statins and antiplatelets in primary prevention for cardiovascular risk in patients with diabetes mellitus and at least one cardiovascular risk factor. CONCLUSIONS: The percentage of patients with inappropriate prescriptions was similar to those obtained in similar studies. Over 50% of elderly patients had at least one inappropriate prescription. This warrants a joint search for errors by excess and by default in the prescription of medications, with the aim of performing a more complete evaluation of prescription practice and to achieve optimization of therapy in elderly patients, especially the most fragile.

Validation of a method for recording pharmaceutical interventions.

WHAT IS KNOWN AND OBJECTIVE: The validation of a method for recording pharmaceutical interventions measures the instrument's ability to provide consistent values when the same analysis is performed several times. Our aim was to validate the inter-rater reliability of the method used to record pharmaceutical interventions in our hospital. METHODS: We recorded interventions in a database, entering variables related to the patient, treatment and impact of the recommendation. We also recorded the type, cause and clinical significance of the negative outcome associated with use of the medicinal product (NOM). Twenty interventions performed during a 3-year study period (2007-2009) were randomly tested for consistency to analyse the kappa (κ) coefficient statistic of the recommendations as coded by nine senior and junior clinical pharmacists. RESULTS AND DISCUSSION: There were 87·8% global consistency for NOM cause, 66·1% for intervention impact and 95·0% for NOM type. Agreement was substantial for 'intervention reasons', with a κ value of 0·74 (95%CI 0·61-0·87), fair for 'intervention impact', with a κ value of 0·24 (95%CI 0·15-0·32) and excellent for 'NOM type', with a κ value of 0·87 (95%CI 0·71-1·00), respectively. Our results are globally good, especially with regard to the analysis of intervention reasons and NOM type, which matches other authors' findings. Furthermore, our validation method is suitable for recording and considering the impact of pharmaceutical interventions. WHAT IS NEW AND CONCLUSION: We describe a systematic method for clinical pharmacists to record their activities and assess their value. This methodology should help in the development of clinical pharmacy in Spain and should be translatable to other settings.

Variability in activity and results from drug assessments by pharmacy and therapeutics committees in Spanish hospitals.

OBJECTIVE: To quantify the Spanish Pharmacy and Therapeutics Committees (P&TC) activity with regard to assessing and selecting drugs and describing variability in decisions made to include them. METHOD: Descriptive, cross-sectional study based on a questionnaire aimed to 513 hospitals with more than 75 beds. We included questions referring to the P&TC resolutions, the therapeutic positioning and assessment reports. Recruitment was carried out between November 2007 and January 2008. Variability among P&TC conclusions were presented in five categories or levels of coincidence. RESULTS: One hundred and seventy-five hospitals participated, with a response rate of 34% (54% of beds). The mean (SD) number of drug-indications assessed per hospital was 10.35 (7.45). The proportion of assessments that conclude with drug inclusion or rejection was 75.3 and 21.4%, respectively. 16.2% concluded with therapeutic equivalence. Conditions for use were established for 64% of them, and 33% were included in a clinical guide. With regard to variability, 81.0% of assessments coincided with the conclusion to include or reject the drug. A contradictory decision was made for 19.0%. CONCLUSIONS: Drug assessment and selection activity in hospitals involve an amount of work. The proportion of drugs approved is similar in different types of hospitals. There is extensive variability as regards deciding upon inclusion and is similar to studies conducted in other countries. They indicate that a standardising methodology would be recommendable.

[Drug-related interventions made through a computerized prescription order entry system in an Internal Medicine unit]. / Intervenciones farmacoterapéuticas realizadas mediante un programa de prescripción electrónica en una unidad de medicina interna.

INTRODUCTION: The objective of this article is to describe the drug-related interventions made in the prescriptions with a computerized order entry system and to determine their frequency and clinical relevance in order to propose improvement actions. MATERIAL AND METHOD: Observational descriptive study. Drug-related interventions made in the inpatient's prescriptions of an Internal Medicine unit from January to May of 2007 were analyzed and recorded. The frequency of the intervention causes and of the drugs involved was determined.The clinical significance and impact of the recommendations were also determined. RESULTS: A total of 441 interventions were recorded, 0.73 per patient. The most frequent was the proposal of intravenous to oral conversion (45%), mainly with acetaminophen (63%) and protons pump inhibitors (24%). This was followed by replacement of drugs not included in the guide (15% of interventions), mainly involving cardiovascular and central nervous system drugs (23% each one). Educational actions proposed included a campaign to promote intravenous to oral conversion and a program involving therapeutic equivalent replacement. The most clinically significant interventions were due to dosage errors, therapeutic duplicities, off label medications and adverse events. A proposal was made to include a new module in the medical order entry system that alerts on the established maximum doses for each drug, and new protocols for the treatment of certain conditions. Sixty percent of the interventions achieved an improvement in efficiency. DISCUSSION: We conclude that drug therapy intervention analysis can identify items that can be improved, set educational actions for physicians and new protocols for certain conditions. Innovative actions can be introduced into the medical order entry system in order to improve drug safety.

[Perception of clinical practice derived risks compared to adverse effects detected in an internal medicine service]. / Percepción de riesgos derivados de la práctica clínica frente a los efectos adversos detectados en un servicio de medicina interna.

BACKGROUND AND OBJECTIVE: To know how the health care workers perceive the risks derived from the care practice. To estimate the most frequent adverse effects (AE) and establish differences and similarities between the perception of risks and the AE produced. MATERIAL AND METHOD: A self-administered questionnaire was applied to all the workers of an Internal Medicine Department of a General University Hospital on perception of risks and safety of the patient. After, and by using the screening guide of the IDEA project, edition 1, the clinical histories of the patients selected were analyzed by medical residents of preventive Medicine and Internal Medicine. RESULTS: Questionnaire. Fifty questionnaires we sent with a 42% response rate. Risks prioritized by obtaining a lower mean score: there is not action plan against catastrophes (2.79/10) and lack of spaces to report (3/10); those having greater percentage of open questions: long maintenance of urinary probes (47.61%) and inadequate prescription of antibiotics (33.33%). Study of AE. Incidence of patients with AE: 25% (95% CI 11.06-38.9). Incidence of AE: 26.6% (95% CI 12.6-40.6). 41.6% of AE was related to medication, 25% to nosocomial infection, 16.66% to technical problems in procedures and 16.66% were related to nursing cares. CONCLUSIONS: The perception of the health care workers on health care practice derived risks is different from the adverse events that really appear. The professionals are concerned about the information to patients than about scientific and technical quality. The most frequent adverse events produced are those related with medication. The only common point is concern for nosocomial infection.

[Patient safety]. / Seguridad del paciente.

Ensuring patient safety is essential for better heath care. Safety have gripped public attention ever since the release of the report "To Err is Human". To find strategies of promotion of patient safety has stimulated models that improve knowledge of adverse events. Adverse drug events are the most common cause of injury to hospitalized patients and are often preventable. Many tactics are available to make system changes to reduce errors and adverse events; they fall into five categories: Reduce complexity, optimise information processing, automate wisely, use constraints, and mitigate the unwanted side effects of change. These tactics can be deployed to support any of the three strategic components of error prevention, detection, and mitigation. Although progress has been slow, the pace of change is likely to accelerate, particularly in implementation of electronic health records and diffusion of safe practices.

Clinical pathway for hip arthroplasty six years after introduction.

PURPOSE: This paper seeks to analyse clinical pathways (CP) as a useful tool for the improvement of all aspects of quality in medical assistance - in this case, hip arthroplasty. DESIGN/METHODOLOGY/APPROACH: The study was carried out on patients who had undergone scheduled hip arthroplasty included in CP during the years 1999 to 2004. Data on demographics, lengths of stay, complications, process and result variables were gathered, coverage was calculated and the evolution of the indicators was compared. FINDINGS: A total of 487 patients were enrolled, with five leaving the pathway and with unequal coverage, leading to a maximum peak of 77 per cent in 1999. A statistically significant decrease exists in the consumption of overall stays and in the pre-surgical stay, which dropped from a mean of 19.41 days in the pre-pathway situation to 10.12 days in 2004 and 4.5 days pre-surgery to 1.08 days. As a process indicator, the performance should be highlighted of post-operation check-up radiographies, which have been gaining high levels of compliance (p < 0.05) since 2001. The rate of complications has remained stable over the years. ORIGINALITY/VALUE: Implementing the CP has meant a sustained saving of resources over the years and an improvement in the organization of work.