Deprescribing in older patients with advanced cancer referred to palliative care.

OBJECTIVES: This study aimed to explore the prevalence of potentially inappropriate medications (PIMs) in a cohort of older adults with advanced cancer referred to palliative care. Secondary objectives were to describe the categories of identified PIMs and assess risk factors associated with their presence in this population. METHODS: This retrospective, observational study evaluated patients with advanced cancer admitted to a tertiary university hospital in Madrid, Spain and referred to palliative care between 1 January 2020 and 30 June 2020. Demographic, clinical, and pharmacotherapeutic data were obtained from the electronic medical records and regional databases. PIMs were assessed using the Screening Tool of Older Persons Prescriptions in Frail adults (STOPPFrail) criteria, V1. RESULTS: Among 123 patients (median age 80 years (IQR 73.5-87), 64.2% male), 74% presented at least one PIM according to the STOPPFrail criteria. The most common categories of inappropriate medications were lipid-lowering therapies, proton pump inhibitors, calcium supplements, and oral antidiabetics. The number of chronic comedications was significantly associated with PIM presence. CONCLUSIONS: Our study found a high prevalence of PIM among a cohort of older adults with advanced cancer and short life expectancy. This underlines the need for a comprehensive medication review to optimise pharmacotherapy in this population.

Potentially inappropriate prescriptions and potential prescription omissions in older people living with HIV.

OBJECTIVES: This study aimed to determine the prevalence of potentially inappropriate prescriptions (PIPs) and potential prescription omissions (PPOs) in a Spanish cohort of people living with HIV (PLWH) aged ≥65 years and to identify risk factors for the presence of PIPs and PPOs. METHODS: This retrospective cross-sectional study was conducted across 10 public hospitals in the Autonomous Community of Madrid, Spain. Clinical and demographic data were cross-checked against hospital and community pharmacy dispensation registries. PIPs and PPOs were assessed using the American Geriatrics Society (AGS)/Beers and Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria. Risk factors for PIPs and PPOs and agreement between AGS/Beers and STOPP/START criteria were statistically analysed. RESULTS: This study included 313 PLWH (median age 72 years), of whom 80.5% were men. PIP prevalence rates were 29.4% and 44.4% based on the AGS/Beers and STOPP criteria, respectively. The concordance between AGS/Beers and STOPP criteria was moderate. Benzodiazepines and proton pump inhibitors were the chronic comedications most commonly involved in PIPs. PPOs were observed in 61.4% of the patients. The leading omissions were insufficient influenza and pneumococcal vaccine coverage and inadequate bone health-related treatments. The number of chronic comedications, female sex, neuropsychiatric disorders, and cancer diagnosis were risk factors for PIPs, whereas osteopenia and osteoporosis were risk factors for PPOs. CONCLUSIONS: A high prevalence of PIPs and PPOs was observed in our cohort of older PLWH. These findings emphasize the importance of comprehensive medication reviews in this population to reduce inappropriate medication use and address their specific and underserved therapeutic needs.

Analysis of adverse drug events as a way to improve cancer patient care.

PURPOSE: To define the signals that a new artificial intelligence (AI) system must emit to improve adverse drug events (ADEs) management in oral antineoplastic agents (OAA). METHODS: A multidisciplinary group of experts in patient safety was set up to define what signals the new AI system must emit to improve ADEs management in OAAs. The baseline data for the new AI system were generated through an observational and ambispective study carried out in a university hospital. All patients who met the inclusion criteria were selected consecutively every working day for 6 months. The ADEs were collected by interview and by the review of health records. The ADEs were categorised according to how they could be detected: patient, analysis, examination. RESULTS: The group defined what signals the AI system must emit to improve ADEs management in OAAs: a signal to educate the patient when the possible ADEs were categorised as patient, a signal as a reminder to request a blood test or a microbiological culture when the possible ADEs were categorised as analysis, and a signal as a reminder for the necessity of a clinical examination when the possible ADEs were categorised as examination. A total of 1652 ADEs were reported in the interviews (ADE-interview) with the pharmacist, and doctors noted 1989 ADEs in the health record (ADE-HR). The most frequent ADEs were identified in the patient category. CONCLUSION: This study opens a new way for better management of ADEs and is the first step in the development of a future technology, which will improve the quality of life of patients.

Grading the potential safety risk of medications used in hospital care.

OBJECTIVE: The aim of this study was to stratify medications used in hospital  care according to their potential risk. METHOD: The RAND/UCLA Appropriateness Method was used. Anatomical Therapeutic Chemical subgroups were classified according to their potential risk. A literature search, bulletins, and alerts issued by patient safety organizations were used to identify the potential safety risk of  these subgroups. Nine experts in patient/medication safety were selected to score the subgroups for their appropriateness in the classification. Two evaluation rounds were conducted: the first by email and the second by a  panel meeting. RESULTS: A total of 298 Anatomical Therapeutic Chemical subgroups were  evaluated. They were classified into three scenarios (low, medium, and high  risk). In the first round, 266 subgroups were classified as appropriate to the  assigned scenario, 32 were classified as uncertain, and none were classified as  inappropriate. In the second round, all subgroups were classified as appropriate.  The most frequent subgroups in the low-risk scenario belonged to  group A "Alimentary tract and metabolism" (44%); the most frequent in the  medium-risk scenario belonged to group J "Antiinfectives for systemic use"  (32%); and the most frequent in the high-risk scenario belonged to group L  "Antineoplastic and immunomodulating agents" (29%) and group N "Nervous  system" (26%). CONCLUSIONS: Based on the RAND/UCLA appropriateness method, Anatomical  Therapeutic Chemical subgroups used in hospital care were classified according  to their potential risk (low, medium, or high). These lists can be incorporated  into a risk-scoring tool for future patient/medication safety studies.

Objetivo: Estratificar los medicamentos utilizados en el ámbito hospitalario según el riesgo de provocar daño al paciente.Método: Se utilizó la metodología RAND/UCLA para clasificar los subgrupos terapéuticos del código Anatómica, Terapéutica, Química según el  riesgo de provocar daño al paciente. Para ello se realizó una revisión de la  evidencia disponible en publicaciones, boletines y alertas de organismos de  seguridad del paciente. A continuación se seleccionaron nueve expertos en  seguridad del paciente/medicamento para evaluar la clasificación de los  subgrupos terapéuticos: una primera ronda de evaluación por vía telemática y  una segunda ronda en una reunión presencial en la que se presentaron y  discutieron los resultados de la primera.Resultados: Se evaluaron 298 subgrupos terapéuticos. Se clasificaron en tres  escenarios (riesgo bajo, medio y alto). En la primera ronda se clasificaron 266  subgrupos como adecuados al escenario asignado, 32 subgrupos fueron  clasificados como inciertos y ninguno fue clasificado como inapropiado. En la  segunda ronda, todos los subgrupos fueron clasificados como adecuados. Los  subgrupos más frecuentes en el escenario de riesgo bajo pertenecieron al Grupo  A: "Tracto alimentario y metabolismo" (44%), en el de riesgo medio al Grupo J:  "Antiinfecciosos para uso sistémico" (32%), y en el de riesgo alto al Grupo L:  "Agentes antineoplásicos e inmunomoduladores" (29%) y al Grupo N: "Sistema  nervioso" (26%).Conclusiones: La metodología RAND/UCLA ha permitido estratificar los  subgrupos utilizados en el ámbito hospitalario según el riesgo potencial de  provocar daño al paciente. Esta estratificación puede servir como herramienta  para futuros estudios de seguridad en la utilización de medicamentos.

Technology-induced errors associated with computerized provider order entry software for older patients.

Background The introduction of new technologies in the prescribing process has seen the emergence of new types of medication errors. Objective To determine the prevalence and consequences of technology-induced prescription errors associated with a computerized provider order entry (CPOE) system in hospitalized older patients. Setting Patients 65 years or older admitted to the Departments of Internal Medicine, General Surgery, and Vascular Surgery of a tertiary hospital. Method Prospective observational 6-month study. Technology-induced errors were classified according to various taxonomies. Interrater reliability was measured. Consequences were assessed by interviewing patients and healthcare providers and classified according to their severity. Main outcome measure Prevalence of technology-induced errors. Results A total of 117 patients were included and 107 technology-induced errors were recorded. The prevalence of these errors was 3.65%. Half of the errors were clinical errors (n = 54) and the majority of these were classified as wrong dose, wrong strength, or wrong formulation. Clinical errors were 9 times more likely to be more severe than procedural errors (14.8 vs 1.9%; OR 9.04, 95% CI 1.09-75.07). Most of the errors did not reach the patient. Almost all errors were related to human-machine interactions due to wrong (n = 61) or partial (n = 41) entries. Conclusion Technology-induced errors are common and intrinsic to the implementation of new technologies such as CPOE. The majority of errors appear to be related to human-machine interactions and are of low severity. Prospective trials should be conducted to analyse in detail the way these errors occur and to establish strategies to solve them and increase patient safety.

Potential future risk of errors in medication administration recording.

RATIONALE, AIMS AND OBJECTIVES: The aim of this study is to adapt and assess the interrater reliability of a potential future risk matrix for medication errors in medication administration recording (ME-MAR). METHODS: The study was carried out in a teaching hospital. It was conducted in two phases. In the first phase, a consensus method was used in order to adapt the potential future risk matrix published by the National Patient Safety and Otero et al. to the ME-MAR. The consensus method consisted in a nominal group formed by four pharmacists. In the second phase, a multidisciplinary group of experts in patient safety assessed the reliability of the adapted matrix. Five raters evaluated 100 ME-MAR. Its reliability was evaluated using the kappa statistic. RESULTS: In the first phase, two meetings were necessary until consensus was reached to adapt the potential future risk matrix to the ME-MAR. For this purpose, the two following categories were defined: likelihood of ME-MAR's recurrence and most likely consequences of ME-MAR. The definition of each grade of likelihood of recurrence was based on the incidence of ME-MAR from an unpublished study carried out in our hospital. In order to determine the most likely consequences of ME-MAR, a two-dimensional matrix was designed, with severity per type of ME-MAR on one axis and the class of medication on the other. In the second phase, the reliability of the matrix was tested. The overall interrater agreement for the five raters was substantial at 0.68 (Confidence interval 95% 0.60-0.76). CONCLUSION: The adapted matrix of potential future risk to ME-MAR is reliable and can serve as a guide for future studies.