Does formative assessment help students to acquire prescribing skills?

PURPOSE: Formative assessments can help motivate students and ease students' learning through feedback. There is a pressing need for improvement of clinical pharmacotherapy (CPT) education since junior doctors make many prescribing errors. The aim of this study was to determine whether a formative assessment with personalized narrative feedback helps medical students to increase their prescribing skills. METHODS: This retrospective cohort study was conducted among masters' medical students at Erasmus Medical Centre, The Netherlands. Students made a formative and a summative skill-based prescription assessment, both during clerkships as part of their regular curriculum. Errors in both assessments were categorized by type and possible consequence and compared with each other. RESULTS: A total of 388 students made 1964 errors in the formative assessment and 1016 in the summative assessment. Most improvements after the formative assessment were seen for mentioning the weight of a child on the prescription (n = 242, 19%). Most new and repeated errors in the summative assessment were missing usage instructions (n = 82, 16% and n = 121, 41%). CONCLUSIONS: This formative assessment with personalized and individual narrative feedback has helped students to increase the technical correctness of their prescriptions. However, errors repeated after the feedback were predominantly errors showing that only one formative assessment has not yet enhanced the clinical prescribing enough.

Effects of training physicians in electronic prescribing in the outpatient setting on clinical, learning and behavioural outcomes: a cluster randomized trial.

AIMS: Electronic prescribing systems may improve medication safety, but only when used appropriately. The effects of task analysis-based training on clinical, learning and behavioural outcomes were evaluated in the outpatient setting, compared with the usual educational approach. METHODS: This was a multicentre, cluster randomized trial [EDUCATional intervention for IT-mediated MEDication management (MEDUCATE trial)], with physicians as the unit of analysis. It took place in the outpatient clinics of two academic hospitals. Participants comprised specialists and residents (specialty trainees, in the UK) and their patients. Training took the form of a small-group session and an e-learning. The primary outcome was the proportion of medication discrepancies per physician, measured as discrepancies between medications registered by physicians in the electronic prescribing system and those reported by patients. Clinical consequences were estimated by the proportion of patients per physician with at least one missed drug-drug interaction with the potential for causing adverse drug events. A questionnaire assessed physicians' knowledge and skills. RESULTS: Among 124 participating physicians, primary outcome data for 115 (93%) were available. A total of 1094 patients were included. A mean of 48% of registered medications per physician were discrepant with the medications that their patients reported in both groups (P = 0.14). Due to registration omissions, a mean of 4% of patients per physician had one or more missed drug-drug interactions with the potential to cause a clinically relevant adverse drug event in the intervention group, and 7% in controls (P = 0.11). The percentages of correct answers on the knowledge and skills test were higher in the intervention group (57%) compared with controls (51%; P = 0.01). CONCLUSION: The training equipped outpatient physicians with the knowledge and skills for appropriate use of electronic prescribing systems, but had no effect on medication discrepancies.

Drug-drug interactions in pediatric oncology patients.

BACKGROUND: Drug-drug interactions (DDIs) can negatively affect pharmacotherapy. However, pediatric DDI studies are scarce. We undertook an exploratory study to investigate prevalence and clinical relevance of DDIs between cytostatic and noncytostatic drugs in outpatient pediatric oncology patients. PROCEDURE: After informed consent and inclusion, the following information was collected: currently prescribed noncytostatic and cytostatic drugs, comorbidities, and use of over-the-counter (OTC) drugs, complementary and alternative medicines (CAMs), and dietary supplements. All medication was screened for DDIs according to two databases: Micromedex® Solutions and the Dutch drug database G-Standard. The researcher presented DDIs with an associated potential for adverse outcome and a proposal for intervention to three independent experts. If the experts considered a DDI to be potentially clinically relevant and requiring intervention, the physician was notified. RESULTS: Seventy-three patients were included (median age 8.9 years). A total of 67 different DDIs were counted (66 in Micromedex® Solutions, 14 in G-Standard, and 13 DDIs in both databases). The medication reviews resulted in 35 interventions related to 11 different DDIs. The majority of DDIs concerned noncytostatic drugs (25/35) and one third occurred between cytostatic and noncytostatic drugs (10/35). The use of QTc-interval-prolonging drugs resulted in one intervention. The use of OTC drugs, CAM, or dietary supplements did not lead to DDIs. CONCLUSIONS: This study resulted in a selection of 11 potentially clinically relevant DDIs for 73 outpatients in our pediatric oncology department. Interventions were formulated in close collaboration between physicians and clinical pharmacists. Future research should focus on assessing DDIs concerning QTc-interval prolongation.

[The treatment of hypomagnesemia]. / De behandeling van hypomagnesiëmie.

Hypomagnesemia is seen in 11% of the normal hospital population and in up to 65% of severely ill patients, and can have many causes. The clinical picture may comprise the signs of Chvostek and Trousseau, paraesthesias, tremor and convulsions, although asymptomatic hypomagnesemia is seen most often. Hypomagnesemia can be treated by parenteral or oral administration of magnesium, guided by the serum magnesium level. Parenteral magnesium suppletion is indicated if the concentration is below 0.5 mmol/l or in the presence of symptoms of hypomagnesemia. In patients with magnesium concentrations between 0.5 and 0.7 mmol/l and a deficient diet or malabsorption, prolonged therapy is sometimes necessary. In such cases, oral Mg-containing antacids in a normal dosage regimen may be a good choice, but clinical proof is still lacking. In case of renal insufficiency or constipation the magnesium dose should be lowered, while in hypophosphatemia oral antacids are contra-indicated.

[The treatment of drug extravasation]. / De behandeling van extravasaties van geneesmiddelen.

An extravasation is the unintentional leakage of an intravenously-administered drug into the surrounding tissue. Extravasation can cause serious tissue injury. Risk factors for tissue injury can be divided in patient-related factors (age, site of extravasation, comorbidities, physical condition of the patient) and drug-related factors (mechanical injury, pharmacological properties, physicochemical properties). If the right treatment strategy (expectative policy, pharmacological or surgical intervention) is chosen at an early stage, tissue injury can largely be avoided. Comprehensive multidisciplinary approach and communication between nursing staff, the treating physician, the plastic surgeon and the hospital pharmacist is mandatory for the treatment of a patient with extravasation.

Antiviral drugs: present status and future prospects.

1. There is a limited number of antiviral drugs available for therapy. Many investigations and new analytical techniques have unraveled the development and progression of a viral infection. Nowadays there is a good understanding of the multiplication cycle of viruses, including the human immunodeficiency virus. 2. In this article the currently available antiviral drugs are presented arranged by their mode of action that can be understood by the multiplication cycle of the virus. 3. Clinical use and side-effects are discussed as well as place in current therapy. Some attention is paid on promising investigational antivirals.

Population pharmacokinetics of flucytosine: comparison and validation of three models using STS, NPEM, and NONMEM.

The objective of this study is to compare and validate three models of flucytosine (5-FC) population pharmacokinetics using three methods of analysis to elucidate which model describes 5-FC pharmacokinetics most accurately and which method is the most suitable for this purpose. Retrospectively, demographic and clinical data of two similar sets of a total of 88 intensive care unit (ICU) patients were gathered for calculation and validation of 5-FC pharmacokinetics respectively. Three pharmacokinetic models were analyzed: a one-compartment with renal elimination (renal model), a one-compartment with renal and metabolic elimination (mixed model), and a two-compartment with renal elimination (two-compartment model). Population pharmacokinetic parameters were calculated using the standard two-stage method (STS), NONMEM, and NPEM. Furthermore, a covariate model was built by NONMEM. Validation of the 10 calculated pharmacokinetic models showed that NONMEM is most suitable for predicting 5-FC population pharmacokinetics. Based upon AIC values, bias and precision, the best results are obtained using a two-compartment model with renal elimination (k(elr) = 0.000858 +/- 0.000143 l/h per mL per min, k12 = 0.0313 +/- 0.0168 h(-1), k21 = 0.0353 +/- 0.0145 h(-1), and Vd = 0.541 +/- 0.084 L/kg; bias = -13.16; 95% CI = -16.77; -9.55; precision = 30.50; 95% CI = 27.47; 33.26) or a two-compartment covariate model as built by NONMEM [Vd (L) = 0.572 x WT, Cl(5FC) (L/h) = 1.69 + 0.0273 x (Cl(cr) (mL/min) - 52.5), k12 = 0.0235 +/- 0.0107 h(-1), and k21 = 0.0375 +/- 0.0147 h(-1); bias = -8.29; 95% CI = -11.63; -4.95; precision = 26.77; 95% CI = 24.24; 29.07]. In conclusion, this study shows that a two-compartment model with renal elimination best describes 5-FC population pharmacokinetics and NONMEM is able to build a two-compartment covariate model that predicts 5-FC levels equally well in our population of ICU patients. Furthermore, NONMEM appeared to be the most suitable method of population pharmacokinetics in our population and for this purpose it offers more reliable and accurate results than NPEM or the STS method.