Unauthorized medication collections on inpatient units.

BACKGROUND: Unauthorized medication collections (UMCs) on inpatient (IP) units represent a potential source of medication errors. UMCs are collections of medications not approved for storage and immediate access on IP units. We sought to establish whether UMCs were present on IP units in a suburban acute care hospital and to document the characteristics of any UMCs found. METHODS: In this descriptive study, we searched all of the IP units in the hospital for unauthorized medications. We checked all medications found against current ward-stock lists to determine whether they were authorized, and we classified unauthorized medications into the following categories: high-alert, easily confused, expired and improperly stored medications, and controlled substances. All unauthorized medications found in various locations on a unit were considered one collection. We counted the number of unique products and total number of medications and calculated the total dollar value of the medications in each UMC. RESULTS: A UMC was found on each of the 17 IP units in the study hospital, resulting in a total of 656 unauthorized medications constituting 163 unique products. We documented high-alert, easily confused and expired medications and controlled substances. No unauthorized medications were improperly stored. DISCUSSION: Investigations are needed to determine why these UMCs exist and to formulate mechanisms to eliminate them. Knowing that UMCs may be present, nurses should search their workspace and remove any UMCs they find. They should also examine their nursing practice to determine if they are contributing to this unsafe practice.

Advanced cutaneous malignant melanoma: a systematic review of economic and quality-of-life studies.

OBJECTIVE: Metastatic melanoma (MM), a major concern for health-care providers, is increasing. We systematically reviewed published articles describing the impact of interventions (drugs and screening) on quality of life (QoL) in patients with MM, and articles that measured QoL in MM. METHODS: We searched secondary databases including MEDLINE, Embase, CINAHL, Cochrane, and DARE from inception to 2006 using MESH terms "melanoma" and "metastases." Economic articles were subject to established quality assessment procedures. RESULTS: We found 13 QoL and five economic studies (three cost-effectiveness, two cost-utility; average quality = 83% +/- 7%). No strong evidence was found in this review for cost-effectiveness of interferons in Canada (incremental cost-effectiveness ratio [ICER] = $55,090/quality-adjusted life-year) or temozolomide in the United States (ICER = $36,990/Life-year gained based on nonsignificant efficacy differences). Melanoma screening was not cost-effective in the United States ($150,000-931,000/life-saved) or Germany (no survival benefit). From the 13 QoL studies,eight measured baseline QoL; six studied the same population, generating similar results using different approaches/outcomes. Tools used included GLQ-8, QLQ-C30, QLQ-36, QWB-SA, and SF-36. Baseline scores QoL scores ranged from 0.60 to 0.69. Another five studies (N = 959 patients) were randomized trials analyzing QoL in patients treated with dacarbazine alone, dacarbazine +/- interferon, dacarbazine + fotemustine, interleukin +/- histamine, and temozolomide. Little difference was found in QoL scores between drugs or between baseline and end point. CONCLUSIONS: Cost-effectiveness has not been widely demonstrated for treatment of MM. Only two studies with unimpressive results exist for treatments. Screening was not cost-effective in the United States or Germany. Generally, no significant improvements in QoL were found for any alternative for treating MM. A need exists for effective treatments that improve duration and QoL.

Treatments for metastatic melanoma: synthesis of evidence from randomized trials.

BACKGROUND: Advanced melanomas (non-resectable Stage-III/IV) are fatal, with few effective treatments. It remains unclear if other drugs offer improvements over the standard, dacarbazine. PURPOSE: We quantified objective response rates (Complete+Partial response) of dacarbazine versus comparators for advanced cutaneous melanoma. METHODS: We retrieved all head-to-head randomized controlled trials involving dacarbazine and other drugs/combinations. Two reviewers searched MEDLINE (1966-Jan 2006), EMBASE (1980-2006), CINAHL (1982-2006) and Cochrane library, then compared results. Differences were resolved through consensus. Rates were combined using random effects meta-analysis. chi2 tested heterogeneity; points from Jadad's method were assessed to examine study quality. RESULTS: We found 48 studies having 111 active treatment arms [24 with dacarbazine monotherapy (n=1390), 75 with dacarbazine combinations (n=4962), and 12 with non-dacarbazine treatments (n=783)] treating 7135 patients. Overall, study quality was poor. Response to dacarbazine monotherapy ranged between 5.3% and 28.0% (average 15.3%), OR=1.31, CI(95%): 1.06-1.61; N=3356. Partial responses comprised 73% of successes. Only adding interferons improved response rates (OR=1.69, CI(95%): 1.07-2.68, N=778) but survival duration was not significantly longer (P=0.32), and trials with larger sample sizes found lower success rates. All other treatments alone or in combination were ineffective P>0.05. CONCLUSIONS: Dacarbazine generally produces poor outcomes. Adding other therapies offers minimal clinical advantages (possibly with interferons). In general, study quality was poor and sample sizes were small. This meta-analysis highlights the unmet need for effective treatment options for advanced melanoma.

Risk factors for new-onset diabetes mellitus in patients receiving protease inhibitor therapy.

BACKGROUND: Metabolic complications including diabetes mellitus (DM) have been associated with protease inhibitor (PI) therapy. Risk factors for the development of DM are not well-defined. OBJECTIVES: To determine risk factors for the development of new-onset DM in patients initiated on PI therapy. METHODS: A retrospective cohort study was conducted to identify predictors of developing DM in subjects started on PI therapy between January 1997 and January 2003. Diabetes cases were defined as physician documentation of DM in the outpatient medical chart and/or those subjects receiving an antidiabetic agent. Logistic regression was used to examine the relationship between new-onset DM and demographic characteristics, and between new-onset DM and total treatment days with PI therapy. Body mass index could not be entered into the model due to missing height measurements. RESULTS: A total of 496 subjects on PI therapy were included, of which 18 (3.6%) developed DM. The mean age of the subjects was 43.4+/-9.4 years (range 19 to 77) and the mean duration of therapy was 3.0+/-1.9 years (range 0.17 to 7.9). In the multivariate model, older subjects were more likely to develop DM (OR 1.12, 95% CI 1.05 to 1.19; P=0.001). This corresponds to a 12% increased risk of DM for each one-year increase in age. Subjects that weighed more had an increased risk (OR 1.06, 95% CI 1.03 to 1.10; P=0.001), as did those belonging to a non-Aboriginal minority group when compared with Caucasians (OR 6.67, 95% CI 1.56 to 28.41; P=0.01). A longer duration of PI therapy was also significantly associated with developing DM (OR 1.52, 95% CI 1.07 to 2.17; P=0.02). CONCLUSION: A longer duration of PI therapy is associated with an increased risk of developing DM. As with HIV-negative subjects, demographic characteristics such as age, weight and ethnicity were important predictors of developing DM in the present study.

Medications prescribed and occurrence of falls in general medicine inpatients.

BACKGROUND: Although falls are multifactorial, medications are a key risk factor that may be modifiable. Falls were among the most common occurrences entered into a risk identification system at the authors' hospital. OBJECTIVES: To identify whether general medicine inpatients who had experienced a fall were taking any medications known to be associated with falls. METHODS: The literature was reviewed to develop a list of high-risk medications that have been associated with falls. In a retrospective quality-improvement database-based study, information from the risk identification system was merged with data from the pharmacy dispensing system for general medicine inpatients who had experienced a fall. The primary end point was the percentage of patients with a documented fall who had a prescription for a high-risk medication. The number of such medications that had been prescribed for patients who fell was also calculated. RESULTS: Eighty-one unique medications were found to be associated with falls. During the study period (April 1, 2008, to March 31, 2009), 151 patients experienced a fall. Of those, 144 (95.4%) were taking at least one high-risk medication. The mean number of high-risk medications per patient who experienced a fall was 2.2. Of all documented falls, a new high-risk medication had been started within 7 days before the fall for 74 (49.0%) and within 24 h before the fall for 17 (11.3%). The most commonly prescribed drugs during all time periods (i.e., within 24 h or 7 days before the fall or since the patient's admission) were lorazepam and zopiclone. The pharmacy database did not track administration of medications, so it is possible that some of the drugs prescribed were not actually taken by the patient. CONCLUSION: Almost all inpatients who experienced a fall during the hospital stay had a prescription for at least one medication associated with a high risk for falls. Lorazepam and zopiclone were the drugs most commonly associated with falls in this hospital, and their use should be reviewed.

Acute renal failure, gastrointestinal bleeding, and cardiac arrhythmia after administration of arsenic trioxide for acute promyelocytic leukemia.

PURPOSE: The case of a patient who developed acute renal failure, gastrointestinal bleeding, and cardiac arrhythmia after receiving arsenic trioxide for the treatment of acute promyelocytic leukemia (APL) is described. SUMMARY: An 84-year-old Caucasian woman with a history of osteoarthritis sought medical attention for relapse of her APL, which had initially been diagnosed approximately 30 months earlier. Complete remission was accomplished with three cycles of i.v. daunorubicin for 3 days and oral tretinoin for 28 days. After 19 months in remission, she was noted to have increased bruising and blood test values consistent with APL relapse. Two additional trials of oral tretinoin were unsuccessful, and arsenic trioxide was initiated at a daily dosage of 0.15 mg/kg of actual body weight. Less than 24 hours after receiving arsenic trioxide, the patient had "bile-like emesis" and her hemoglobin level decreased. Upper gastrointestinal bleeding was suspected and managed aggressively with transfusions of platelets and fresh frozen plasma and i.v. desmopressin. She became anuric, and her serum creatinine level more than doubled. Hemodialysis was started due to a sudden increase in potassium and fluid overload that did not respond to i.v. furosemide. One hour after hemodialysis, the patient was found pulseless and unresponsive by nursing staff. The cardiac arrest team rapidly responded and noted atrial fibrillation with a fast ventricular rate. Postresuscitation, the patient was transferred to the intensive care unit. Despite aggressive life-support therapy, the patient remained unresponsive. CONCLUSION: An 84-year-old woman developed acute renal failure, gastrointestinal bleeding, and cardiac arrhythmia after receiving arsenic trioxide for the treatment of APL.