Computerized pharmaceutical intervention to reduce reconciliation errors at hospital discharge in Spain: an interrupted time-series study.

WHAT IS KNOWN AND OBJECTIVE: It is well known that medication reconciliation at discharge is a key strategy to ensure proper drug prescription and the effectiveness and safety of any treatment. Different types of interventions to reduce reconciliation errors at discharge have been tested, many of which are based on the use of electronic tools as they are useful to optimize the medication reconciliation process. However, not all countries are progressing at the same speed in this task and not all tools are equally effective. So it is important to collate updated country-specific data in order to identify possible strategies for improvement in each particular region. Our aim therefore was to analyse the effectiveness of a computerized pharmaceutical intervention to reduce reconciliation errors at discharge in Spain. METHODS: A quasi-experimental interrupted time-series study was carried out in the cardio-pneumology unit of a general hospital from February to April 2013. The study consisted of three phases: pre-intervention, intervention and post-intervention, each involving 23 days of observations. At the intervention period, a pharmacist was included in the medical team and entered the patient's pre-admission medication in a computerized tool integrated into the electronic clinical history of the patient. The effectiveness was evaluated by the differences between the mean percentages of reconciliation errors in each period using a Mann-Whitney U test accompanied by Bonferroni correction, eliminating autocorrelation of the data by first using an ARIMA analysis. In addition, the types of error identified and their potential seriousness were analysed. RESULTS AND DISCUSSION: A total of 321 patients (119, 105 and 97 in each phase, respectively) were included in the study. For the 3966 medicaments recorded, 1087 reconciliation errors were identified in 77·9% of the patients. The mean percentage of reconciliation errors per patient in the first period of the study was 42·18%, falling to 19·82% during the intervention period (P = 0·000). When the intervention was withdrawn, the mean percentage of reconciliation errors increased again to 27·72% (P = 0·008). The difference between the percentages of pre- and post-intervention periods was statistically significant (P = 0·000). Most reconciliation errors were due to omission (46·7%) or incomplete prescription (43·8%), and 35·3% of which could have caused harm to the patient. WHAT IS NEW AND CONCLUSION: A computerized pharmaceutical intervention is shown to reduce reconciliation errors in the context of a high incidence of such errors.

[Risk prescription associated to treatment at home of the elderly patient when admitted to the hospital]. / Prescripciones de riesgo asociadas al tratamiento domiciliario del paciente anciano al ingreso hospitalario.

OBJECTIVE: To determine the prevalence, the incidence of error, and the potential harm associated to particular prescriptions identified as a risk for medication error in the home treatment of elderly patients admitted to the hospital, as well as factors associated to their occurrence. MATERIAL AND METHODS: Cross-sectional, descriptive study. Patients aged 65 years and older, being admitted to the hospital from the emergency department in the last quarter of 2009. The SPSS software version 15.0 was used for the statistical analysis. RESULTS: 324 patients were included in the study. 1,176 (47%) prescriptions were identified as risk prescriptions in 91% of the patients. The most relevant risk prescription was prescription of high-risk medications (51.5% patients) that accounted for an error incidence of 88/100 patients with high-risk medications, being severe in 68 patients. Factors associated to the occurrence of moderate/high risk error due to risk prescriptions were suffering from a chronic respiratory illness, diabetes or polymedication. CONCLUSIONS: Actions aimed at decreasing the errors due to high risk medications should be prioritized.

Objetivo: Determinar la prevalencia, la incidencia de error y el daño potencial asociado a determinadas prescripciones señaladas como de riesgo de error de medicación en el tratamiento domiciliario de pacientes ancianos que ingresan en el hospital, así como los factores asociados a su aparición. Material y métodos: Estudio transversal descriptivo. Se incluyeron los pacientes de edad igual o mayor a 65 años que ingresaron en el hospital desde el servicio de urgencias durante el último trimestre de 2009.Para el análisis estadístico se utilizó el programa SPSSv15.0. Resultados: Se incluyeron en el estudio 324 pacientes. Se identificaron 1176 (47%) prescripciones de riesgo en el 91% de los pacientes. La prescripción de riesgo más relevante fue la prescripción de medicamentos de alto riesgo (51.5% pacientes) que presentó una incidencia de error de 88/100 pacientes con medicamentos de alto riesgo, de los cuales en 68 pacientes fue grave. Los factores asociados a la presencia de error grave/moderado ocasionado por prescripciones de riesgo fueron tener enfermedad respiratoria crónica o diabetes y la polimedicación. Conclusiones: Se deben priorizar actuaciones dirigidas a disminuir errores por medicamentos de alto riesgo.

[Analysis of the drug interactions associated to domiciliary drug therapy in elderly hospitalized patients]. / Análisis de las interacciones medicamentosas asociadas a la farmacoterapia domiciliaria en pacientes ancianos hospitalizados.

OBJECTIVE: To determine the prevalence of potentially relevant drug-drug interactions associated with chronic treatment of elderly patients over 64-years of age on hospital admission and the factors associated with an increased presence of these. SUBJECTS AND METHODS: Cross-sectional observational study in a hospital referral area. All patients aged 65 or over admitted to the hospital in the last three months in 2009 were included. Based on the drug database of the General Council of Colleges of Pharmacy (BOT), drug-drug interactions and their potential clinical relevance were identified. To identify the variables associated with a higher prevalence of drug-drug interactions, analyses of correlation and of univariable linear regression and uni-and multivariable logistic regression analyses were performed using the SPSS, version 15.0. RESULTS: We analyzed the drug prescription data of 382 patients, whose mean age was 7.7 years. A total of 45.3% of patients had comorbidities and 78.8% had taken 5 or more drugs. We identified 272 clinically relevant drug-drug interactions that involved 159 patients (41.6%). Seven pharmacological groups accounted for 80.6% of the drug-drug interactions. The variables that had a statistically significant association to a higher prevalence of relevant interactions were polypharmacy, respiratory insufficiency, and treatment with proton-pump inhibitors, vitamin K antagonists, diuretics or anti-platelet drugs. CONCLUSIONS: A high prevalence of relevant drug-drug interactions was found in elderly hospitalized patients. Our findings suggest that prevention strategies should be implemented to avoid their associated adverse events, especially in high risk populations.

[Cross-hypersensitivity syndrome between antiepileptic drugs: report of a case]. / Síndrome de hipersensibilidad cruzado entre antiepilépticos: a propósito de un caso.

Antiepileptic hypersensitivity syndrome (SHA) is a rare (1/1.000 to 1/10.000 in new exposures) but potentially life-threatening syndrome that occurs after exposure to an anticonvulsant, most commonly the aromatic ones such as phenytoin, carbamazepine or phenobarbital. Clinical features of this syndrome include cutaneous reactions, fever, lymphadenopaties, eosinophilia and internal organ involvement (mainly liver, but also kidney, CNS, heart or lung). We present a case report of a 61-year-old woman treated with phenobarbital who developed a cutaneous eruption attributed to this drug. Treatment was changed to phenytoin and after 17 days the patient developed cutaneous rash, eosinophilia and an increase in transaminase levels. The high rate of cross-sensitivity between aromatic anticonvulsants (40-80%) suggests a link between a hypersensitivity reaction to phenytoin and the previous reaction to phenobarbital.

[Assessing the use of low-molecular-weight heparins fo venous thromboembolism prophylaxis in internal medicine patients]. / Evaluación de la utilización de heparinas de bajo peso molecular como profilaxis de tromboembolismo venoso en pacientes de medicina interna.

BACKGROUND: Sufficient evidence exists to recommend routine thromboembolic disease prophylaxis for medical inpatients with risk factors --with low-molecular-weight-- heparins being (LMWH) the most suitable treatment option. The objective is to determine the thromboembolic risk level of Internal Medicine patients with LMWH prophylaxis, prescription habits and their adequacy to hospital's standards, as well as prevalence of non-treated patients at risk. MATERIAL AND METHODS: Descriptive and prospective study of internal medicine patients for 2 months. Patients with prophylactic LMWH prescription were chosen, and their thromboembolic risk level and suitable LMWH dose was determined according to the hospital's "thromboembolic disease prevention standards". On the other hand, patients with no LMWH prophylaxis were analysed in order to judge their candidacy. RESULTS: 30% of patients had a prophylactical LMWH prescription, with 43.5% of these prescriptions being adequate to the risk level. The main risk factors were: age, bed-stay, hypertension, cardiopathy with risk factors, diabetes mellitus, dislipemias and COPD. Chi2(0.05) test between risk level and prescribed LMWH revealed no association. 72% of patients without LMWH prescription had a moderate or high risk level. CONCLUSIONS: 1. A high proportion of the patients studied have a considerable thromboembolic risk level. 2. There is not a statistical relationship between thromboembolic risk level and LMWH prescription. 3. There is a high percentage of patients with no LMWH prophylaxis which could be eligible for it. 4. A pharmaceutical intervention would be useful to approach pharmacological prophylaxis to each patient's risk.

[Intravenous inmunoglobulins in pediatrics]. / Inmunoglobulinas intravenosas en pediatría.

The use of intravenous immunoglobulins remains controversial after their introduction in therapeutics during the 80s. Their mechanism of action remains unexplained for certain pathologies, but their application to new indications and their economical impact makes them a target of many studies and protocols of use. Intravenous immunoglobulins are administred as substitution therapy in primary and secondary immunodeficiencies. On the other hand, their immunomodulating effect is the basis of their use on a great variety of autoimmune diseases and inflammatory processes, although not always following the authorised indications. This study reviews the use of intravenous immunoglobulins in pediatric population, making the distinction between the indications authorised by the regulatory authorities, and those non-authorised but supported by scientific publications.

[An analysis of patient information sheets for obtaining informed consent in clinical trials]. / Análisis de las hojas de información al paciente para la obtención de su consentimiento informado en ensayos clínicos.

BACKGROUND: The written information provided to the potential participants in a clinical trial must have certain qualitative and quantitative characteristics to reach the ethical requirements governing the theory of the informed consent. MATERIAL AND METHODS: In a sample of 101 clinical trial protocols approved in two Spanish university general hospitals, the following items were evaluated: a) the amount and quality of the written information given to the patient, in accordance with the established in the Spanish legislation; b) the formal readability of this written forms, by means of the Flesch method, and c) the level of complexity of the vocabulary, by means of the number of non-comprehensible words for two volunteers unaware of the health professions, with high studies. RESULTS: The balance of benefits and risks, the identification and the way of contact with the main investigator, the description of the alternative treatments and the specification of the compensations in case of lesions were the items with highest noncompliance. The mean global readability by means of the index of Flesch was of -12.7 (text with a high level of complexity). The mean percentage of words non-comprehensible for the volunteers that analyzed the texts was 0.3%. CONCLUSIONS: The written form of information provided to the patient in the clinical trials developed in Spain has serious deficiencies, either in their formal readability (complexity of the linguistic structure) or in the amount and quality of the information that provides. These deficiencies could have a wrong influence in the appropriate obtention of the informed consent from the patients.