Reducing Medication Errors by Adopting Automatic Dispensing Cabinets in Critical Care Units.

Medication errors can have severe consequences and threaten patient safety. The patient safety-related benefits of automated dispensing cabinets (ADCs) have been reported by several previous studies, including a reduction in medication errors in intensive care units (ICUs) and emergency departments. However, the benefits of ADCs need to be assessed, given the different healthcare practice models. This study aimed to compare the rates of medication errors, including prescription, dispensing, and administrative, before and after using ADCs in intensive care units. The prescription, dispensing, and administrative error data before and after the adoption of ADCs were retrospectively collected from the medication error report system. The severity of medication errors was classified according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. The study outcome was the rate of medication errors. After the adoption of ADCs in the intensive care units, the rates of prescription and dispensing errors reduced from 3.03 to 1.75 per 100,000 prescriptions and 3.87 to 0 per 100,000 dispensations, respectively. The administrative error rate decreased from 0.046 to 0.026%. The ADCs decreased National Coordinating Council for Medication Error Reporting and Prevention category B and D errors by 75% and category C errors by 43%. To improve medication safety, multidisciplinary collaboration and strategies, such as the use of automated dispensing cabinets, education, and training programs from a systems perspective, are warranted.

An investigation of the potential association between retinal detachment and oral fluoroquinolones: a self-controlled case series study.

OBJECTIVES: A study reported a significant association between oral fluoroquinolones and the development of retinal detachment among current users of oral fluoroquinolones (Etminan M, Forooghian F, Brophy JM et al. JAMA 2012; 307: 1414-9). However, other published studies have discordant results. This study aimed to investigate this association and to estimate the absolute risk of developing retinal detachment in patients exposed to oral fluoroquinolones. METHODS: A self-controlled case series study was conducted with data retrieved from the Hong Kong Clinical Data Analysis and Reporting System database and the Taiwan National Health Insurance Research Database. Hong Kong and Taiwanese patients who had prescriptions for oral fluoroquinolones and a procedure for retinal detachment between 2001 and 2012 and between 2000 and 2010, respectively, were defined as cases and included in the analysis. RESULTS: A total of 9 events were found during the fluoroquinolone-exposed period and 1407 events were found during the non-exposed period. The adjusted incidence rate ratio in the combined model was 1.26 (0.65-2.47). The crude absolute risk of experiencing retinal detachment whilst on oral fluoroquinolones was ∼1.3 per 200 000 prescriptions. CONCLUSIONS: Our study does not support the association between the use of fluoroquinolones and the development of retinal detachment and our findings are strikingly similar to that of the study conducted in Denmark. Doubt is cast on the association between the use of fluoroquinolones and the development of retinal detachment. Therefore, the use of fluoroquinolones should not be precluded based on the current evidence on the risk of retinal detachment. The impact of different ethnicities on the response to fluoroquinolones should also be investigated.

Acute urinary retention increases the risk of complications after transurethral resection of the prostate: a population-based study.

UNLABELLED: Study Type--Prognosis (cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Higher mortality and morbidity rates in men presenting with AUR have been reported in previous studies. This study has comprehensive comparisons of post-TURP complications between patients with and without AUR. Furthermore, it shows that AUR is associated with increased risk of complications after TURP. OBJECTIVE: • To assess the association between a history of acute urinary retention (AUR) and complications after transurethral resection of prostate (TURP). PATIENTS AND METHODS: • We conducted a retrospective, national, population-based study using Taiwan's National Health Insurance Research Database. • We included men > 50 years old, diagnosed with benign prostatic hyperplasia (BPH) and divided these into two groups: an AUR(+) group--those with AUR who underwent TURP between 2002 and 2004; and an AUR(-) group--those without AUR who underwent TURP between those dates. • Prostate cancer, Parkinsonism and multiple sclerosis were exclusion criteria. • Postoperative complications, e.g. re-catheterization, haematuria or urinary tract infection (UTI), were compared using crude odds ratios (ORs), 95% confidence intervals (CIs), and Student's t-test. • A chi-squared test was used for potential confounding factors: preoperative UTI and anticoagulant use. • Univariate and multivariate analysis on medical expenses were conducted. RESULTS: • The AUR(+) group contained 3305 men; the AUR(-) group contained 1062. • Re-catheterization (13.8%), septicaemia (1.1%) and shock (0.3%) were found only in the AUR(+) group. • The AUR(+) group had more UTIs (18.9% vs. 15.6%, OR: 1.26, 95% CI: 1.05-1.52), more lower urinary tract symptoms (22.8% vs. 16.9%, OR: 1.45, 95% CI: 1.21-1.73), fewer blood transfusions (3.2% vs. 1.5%, OR: 2.19, 95% CI: 1.29-3.72) and higher medical expenses. • There were no significant differences in haematuria, lower urinary tract stricture, or re-surgical intervention of the prostate and second-line antibiotic use. CONCLUSION: • Patients in Taiwan with BPH with AUR who were treated by TURP were associated with a higher risk of complications, longer hospital stay and more comorbidities than those without AUR and a preoperative warning is warranted for these patients.

Validation of the National Health Insurance Research Database with ischemic stroke cases in Taiwan.

OBJECTIVE: The National Health Insurance Research Database (NHIRD) is commonly used for pharmacoepidemiological research in Taiwan. This study evaluated the validity of the database for patients with a principal diagnosis of ischemic stroke. STUDY DESIGN AND METHODS: This cross-sectional study compares records in the NHIRD with those in one medical center. Patients hospitalized for ischemic stroke in 1999 were identified from both databases. The discharge notes, laboratory data, and medication orders during admission and the first discharge visit were reviewed to validate ischemic stroke diagnoses and aspirin prescribing in the NHIRD. Agreement between the two databases in comorbidities of ischemic stroke diagnosis was evaluated using ICD-9 codes. RESULTS: Three hundred and seventy two cases were identified from the NHIRD; among them, 364 cases (97.85%) were confirmed as ischemic stroke by radiology examination and clinical presentation. Among these confirmed cases, 344 (94.51%) were assigned 'ischemic stroke' as the principal diagnosis in the NHIRD. The overall agreement of comorbid diagnoses between the databases was 48.39%. The PPV for selected conditions also varied widely, from 0.50 for fracture to 1.00 for colon cancer. The accuracy of recorded aspirin prescriptions was higher in first post-discharge visits (PPV = 0.94) than during hospitalization (PPV = 0.88). CONCLUSION: The accuracy of the NHIRD in recording ischemic stroke diagnoses and aspirin prescriptions was high, and the NHIRD appears to be a valid resource for population research in ischemic stroke.

Applying a common data model to Asian databases for multinational pharmacoepidemiologic studies: opportunities and challenges.

OBJECTIVE: The goal of the Asian Pharmacoepidemiology Network is to study the effectiveness and safety of medications commonly used in Asia using databases from individual Asian countries. An efficient infrastructure to support multinational pharmacoepidemiologic studies is critical to this effort. STUDY DESIGN AND SETTING: We converted data from the Japan Medical Data Center database, Taiwan's National Health Insurance Research Database, Hong Kong's Clinical Data Analysis and Reporting System, South Korea's Ajou University School of Medicine database, and the US Medicare 5% sample to the Observational Medical Outcome Partnership common data model (CDM). RESULTS: We completed and documented the process for the CDM conversion. The coordinating center and participating sites reviewed the documents and refined the conversions based on the comments. The time required to convert data to the CDM varied widely across sites and included conversion to standard terminology codes and refinements of the conversion based on reviews. We mapped 97.2%, 86.7%, 92.6%, and 80.1% of domestic drug codes from the USA, Taiwan, Hong Kong, and Korea to RxNorm, respectively. The mapping rate from Japanese domestic drug codes to RxNorm (70.7%) was lower than from other countries, and we mapped remaining unmapped drugs to Anatomical Therapeutic Chemical Classification System codes. Because the native databases used international procedure coding systems for which mapping tables have been established, we were able to map >90% of diagnosis and procedure codes to standard terminology codes. CONCLUSION: The CDM established the foundation and reinforced collaboration for multinational pharmacoepidemiologic studies in Asia. Mapping of terminology codes was the greatest challenge, because of differences in health systems, cultures, and coding systems.

Differences in the prescription patterns of anti-asthmatic medications for children by pediatricians, family physicians and physicians of other specialties.

BACKGROUND: Prescription patterns of anti-asthma medications in children vary among doctors in different disciplines and settings, and may reflect differences in treatment outcome. The purpose of this study was to analyze the prescribing patterns of anti-asthma drugs by pediatricians, family physicians and other practitioners. METHODS: Data for a total of 225,537 anti-asthma prescriptions were collected from the National Health Insurance Research Database for the period from January 1, 2002 to March 31, 2002. These medications included inhaled and oral adrenergics, inhaled and oral corticosteroids, xanthine derivatives, and leukotriene receptor antagonists prescribed by general pediatricians, family physicians and physicians in other disciplines. RESULTS: Oral beta2-agonist was the most commonly prescribed drug used as monotherapy, with prescription rates of 70.4%, 46.9% and 58.0% by pediatricians, family physicians and other physicians, respectively. A xanthine derivative was the next most commonly prescribed monotherapy. Oral corticosteroid combined with oral beta2-agonist, followed by oral beta2-agonist combined with a xanthine derivative were the two most commonly prescribed dual-agent combined therapies by all three physician categories. The prescription rate for inhaled corticosteroid monotherapy was 7.8% by pediatricians, 5.6% by family physicians, and 8.0% by other physicians. The prescription rate for inhaled adrenergic was the highest in family physicians (14.9%), followed by the other physicians (7.2%), and was lowest in pediatricians (3.1%). CONCLUSION: Pediatricians and family physicians appeared to share similar opinions on the medical management of children with asthma in that both most commonly prescribed oral beta2-agonists and xanthine derivatives, either alone or in combination. Family physicians were least likely to prescribe an inhaled corticosteroid and most likely to prescribe an inhaled adrenergic agent.

Pharmaceutical care of elderly patients with poorly controlled type 2 diabetes mellitus: a randomized controlled trial.

BACKGROUND: Care of the elderly with diabetes is more complicated than that for other age groups. The elderly and/or those with multiple comorbidities are often excluded from randomized controlled trials of treatments for diabetes. The heterogeneity of health status of the elderly also increases the difficulty in diabetes care; therefore, diabetes care for the elderly should be individualized. Motivated patients educated about diabetes benefit the most from collaborating with a multidisciplinary patient-care team. A pharmacist is an important team member by serving as an educator, coach, healthcare manager, and pharmaceutical care provider. OBJECTIVE: To evaluate the effects of pharmaceutical care on glycemic control of ambulatory elderly patients with type 2 diabetes. SETTING: A 421-bed district hospital in Nantou City, Taiwan. METHOD: We conducted a randomized controlled clinical trial involving 100 patients with type 2 diabetes with poor glycemic control (HbA1c levels of ≥9.0 %) aged ≥65 years over 6 months. Participants were randomly assigned to a standard-care (control, n = 50) or pharmaceutical-care (intervention, n = 50) group. Pharmaceutical care was provided by a certified diabetes-educator pharmacist who identified and resolved drug-related problems and established a procedure for consultations pertaining to medication. The Mann­Whitney test was used to evaluate nonparametric quantitative data. Statistical significance was defined as P < 0.05. MAIN OUTCOME MEASURE: The change in the mean HbA1c level from the baseline to the next level within 6 months after recruiting. RESULTS: Nonparametric data (Mann­Whitney test) showed that the mean HbA1c level significantly decreased (0.83 %) after 6 months for the intervention group compared with an increase of 0.43 % for the control group (P ≤ 0.001). Medical expenses between groups did not significantly differ (−624.06 vs. −418.7, P = 0.767). There was no significant difference in hospitalization rates between groups. CONCLUSION: The pharmacist intervention program provided pharmaceutical services that improved long-term, safe control of blood sugar levels for ambulatory elderly patients with diabetes and did not increase medical expenses.

Prescribing patterns of anti-asthma drugs in pediatric patients.

Guidelines from the Global Initiative for Asthma (GINA) mention several medications for the treatment of asthma. These medications include oral and inhaled beta-2 agonists, oral and inhaled corticosteroids, xanthines, leukotriene receptor antagonists, and their combinations. In addition to asthma, these drugs are commonly prescribed to treat other respiratory diseases, such as acute bronchitis, chronic cough, lower respiratory infection, or even bronchopneumonia. We analyzed differences in prescribing patterns between pediatric patients with and those without asthma, as coded in the claim records from the National Health Insurance Research Database. Oral beta-2 agonists were the most frequently monotherapy in both groups of patients (52.6-77.6% vs 62.8-84. 8%). Oral beta-2 agonists combined with xanthines or oral corticosteroids combined with an oral beta-2 agonist were the most frequent combination therapies in both groups. Inhaled corticosteroids were used in 3.1-11.0% of patients with asthma; the rate varied by patient age. In conclusion, prescribing patterns were similar in pediatric patients with and those without asthma.

Health-care utilization and costs in Taiwanese pediatric patients with asthma.

BACKGROUND: In many countries, the burden of asthma is sufficient to warrant recognition as a high-priority disorder in governmental health strategies. However, the components of the total health-care costs for pediatric patients with asthma have not been well studied, and an overall understanding of health-care utilization patterns in this population is lacking in Taiwan. METHODS: A total of 33 461 patients aged 3-17 years who were enrolled in the National Health Insurance Research database from 1 January to 31 December 2002 were evaluated. Health-care utilization and costs, including those related to office, outpatient hospital, emergency department, and inpatient hospital visits were compared between pediatric patients with and without asthma. RESULTS: In 2002, the period prevalence of treated asthma was 6.0%. Pediatric patients with asthma used substantially more services than did those without asthma in all categories. Hospital outpatient visits and overall health-care expenditure for patients with asthma were 2.2-fold higher than those of patients without asthma. Asthma care represented 20% of all health-care services that patients with asthma received, while the remaining 80% were for non-asthma care. Almost three-fourths of all asthma-related costs were attributable to office and hospital outpatient visits; one-fourth was attributable to urgent care and hospitalizations. CONCLUSIONS: These findings may serve as baseline data for future evaluation of changes in health-care utilization and expenditure among pediatric patients with asthma.