Safeguarding the process of drug administration with an emphasis on electronic support tools.

AIMS: The aim of this work is to understand the process of drug administration and identify points in the workflow that resulted in interventions by clinical information systems in order to improve patient safety. METHODS: To identify a generic way to structure the drug administration process we performed peer-group discussions and supplemented these discussions with a literature search for studies reporting errors in drug administration and strategies for their prevention. RESULTS: We concluded that the drug administration process might consist of up to 11 sub-steps, which can be grouped into the four sub-processes of preparation, personalization, application and follow-up. Errors in drug handling and administration are diverse and frequent and in many cases not caused by the patient him/herself, but by family members or nurses. Accordingly, different prevention strategies have been set in place with relatively few approaches involving e-health technology. CONCLUSIONS: A generic structuring of the administration process and particular error-prone sub-steps may facilitate the allocation of prevention strategies and help to identify research gaps.

Development of a standardized knowledge base to generate individualized medication plans automatically with drug administration recommendations.

AIMS: We aimed to develop a generic knowledge base with drug administration recommendations which allows the generation of a dynamic and comprehensive medication plan and to evaluate its comprehensibility and potential benefit in a qualitative pilot study with patients and physicians. METHODS: Based on a literature search and previously published medication plans, a prototype was developed and iteratively refined through qualitative evaluation (interviews with patients and focus group discussions with physicians). To develop the recommendations for safe administration of specific drugs we screened the summary of product characteristics (SmPC) of different exemplary brands, allocated the generated advice to groups with brands potentially requiring the same advice, and reviewed these allocations regarding applicability and appropriateness of the recommendations. RESULTS: For the recommendations, 411 SmPCs of 140 different active ingredients including all available galenic formulations, routes of administrations except infusions, and administration devices were screened. Finally, 515 distinct administration recommendations were included in the database. In 926 different generic groups, 29,879 allocations of brands to general advice, food advice, indications, step-by-step instructions, or combinations thereof were made. Thereby, 27,216 of the preselected allocations (91.1%) were confirmed as appropriate. In total, one third of the German drug market was labelled with information. CONCLUSIONS: Generic grouping of brands according to their active ingredient and other drug characteristics and allocation of standardized administration recommendations is feasible for a large drug market and can be integrated in a medication plan.

Contribution of oxycodone and its metabolites to the overall analgesic effect after oxycodone administration.

OBJECTIVE: Oxycodone (OC) is an opioid which exerts its analgesic effect through µ-receptors in the brain. It is metabolized through CYP450 enzymes and some of the metabolites show pharmacological activity. The aim of this investigation is to research the contribution of the metabolites of OC to its overall analgesic effect. A further aim was to elucidate the role of drug-drug interactions and CYP2D6 polymorphism. RESEARCH DESIGN AND METHODS: The authors performed a literature search to identify published information on: blood concentrations of OC and metabolites, protein binding, blood-brain-barrier behavior and opioid receptor affinity. The authors then calculated the contribution of OC and metabolites to the overall analgesic effect. RESULTS: OC itself is responsible for 83.02 and 94.76% of the analgesic effect during p.o. and i.v. administration, respectively. Oxymorphone (OM), which has a much higher affinity for the µ-receptor, only plays a minor role (15.77 and 4.52% for p.o. and i.v., respectively). Although the CYP2D6 genotype modulates OM pharmacokinetics, OC remains the major contributor to the overall analgesic effect. CONCLUSION: This article's calculations demonstrate that OC itself is responsible for the analgesic effect. Although OM and noroxymorphone have much higher µ-receptor affinity than the parent drug, the metabolite concentrations at the site of action are very low. This suggests that there is a minimal analgesic effect from these metabolites.

Opportunities to reduce medication regimen complexity: a retrospective analysis of patients discharged from a university hospital in Germany.

BACKGROUND: Numerous characteristics of a medication regimen can weaken patient adherence to drug therapy and thus impair clinical outcomes of drug therapy. OBJECTIVE: The aim of the study was to investigate the prevalence of medication regimen characteristics that are known to reduce patient adherence to drug therapy. Furthermore, we assessed to what extent complex medication regimens can possibly be simplified through different strategies. METHODS: We retrospectively evaluated the medication regimens of 500 consecutive patients discharged from the University Hospital of Heidelberg, Germany, in whom the dosages of all drugs were specified. The medication regimens were extracted from the discharge letters issued between 1 January 2007 and 29 December 2007. Each medication regimen was checked for the presence of seven regimen characteristics that are known to reduce patient adherence, and theoretical viable strategies to avoid four of the respective characteristics were identified. The extent of possible simplification through the identified strategies was evaluated for the overall study population and the subgroup of elderly patients (≥65 years) with polypharmacy (≥5 drugs). RESULTS: On average, every medication regimen in the overall study population had 2.9±1.7 (standard deviation) characteristics (range 0-7) known to impair patient adherence. In contrast, the medication regimens of elderly patients with polypharmacy contained 3.7±1.6 characteristics (range 0-7) known to impair patient adherence. The most prevalent complexity characteristics in the overall study population were prescription of ≥1 drug with multiple doses per day (441 patients), ≥3 drugs with different dosing intervals (349 patients), tablet splitting (223 patients), followed by ≥12 daily drug administrations (190 patients). Almost half of the prescribed tablet splitting could be prevented. Moreover, 17.9% of the multi-dose prescriptions could be switched to once-daily dosing, and thus reduced the number of drugs with different dosing intervals and the number of daily drug administrations. The combined intervention reduced the total number of potentially preventable complexity characteristics by 18.3% (from 2283 to 1865 characteristics) without reducing prescription quality. CONCLUSION: Almost one-fifth of all regimen complexity characteristics relevant for patient adherence were avoidable by simple modifications of the medication scheme, stressing the need for targeted interventions.

Do we prescribe what patients prefer? Pilot study to assess patient preferences for medication regimen characteristics.

BACKGROUND: The aim of this pilot study was to evaluate patients' self-reported attitudes towards medication-related factors known to impair adherence and to assess their prevalence in ambulatory care as an essential prerequisite to improve patient adherence. METHODS: We conducted a face-to-face interview with 110 primary care patients maintained on at least one drug. For each drug, the patient was asked to specify medication-related factors of interest, ie, dosage form, dosage interval, required relationship with food intake, and the planned time of day for intake, and to rate the individual relevance of each prevalent parameter on a three-point Likert scale (discriminating between prefer, neutral, and dislike). RESULTS: Tablets with a once-daily dosage frequency were the most preferred dosage form, with a high prevalence in the ambulatory setting. Drug intake in the morning and evening were most preferred, and drug intake at noon was least preferred, but also had a low prevalence in contrast with drug intake independent of meals that was most preferred. Interestingly, only one quarter (26.4%) of all the patients were able to indicate clear preferences or dislikes. CONCLUSION: When patients are asked to specify their preferences for relevant medication regimen characteristics, they clearly indicated regimens that have been associated with better adherence in earlier studies. Therefore, our results suggest that adaptation of drug regimens to individual preferences might be a promising strategy to improve adherence. Because the German health care system may differ from other systems in relevant aspects, our findings should be confirmed by evaluation of patient preferences in other health care systems. Once generalizability of the study results is shown, these findings could be a promising basis upon which to promote patient adherence right from the beginning of drug therapy.