Case Study: Using Electronic Medication Administration Record to Enhance Medication Safety and Improve Efficiency in Long-Term Care Facilities.

The electronic medication administration record (eMAR) has been used in hospitals and acute care facilities in Canada for over a decade. Unfortunately, the Canadian continuing care sector has been slow to adopt eMAR usage. Medication delivery in long-term care has traditionally been through paper-based orders and manual documentation in the paper medication administration record. The effectiveness of this manual system as it relates to medication incidents, patient safety and nursing efficiency is not well understood because most of the information is based on anecdotal evidence. Peer-reviewed scientific literature supports the premise that the eMAR, compared to the MAR, is more efficient, significantly reduces medication incidents, promotes patient safety and improves workflow efficiency. In April 2016, the Brenda Strafford Foundation committed to implementing the eMAR at each of our three long-term care facilities to improve medication delivery, reducing and eliminating medication incidents and evaluating the benefits of the electronic system. Under the direction of the clinical team, including nurses, physicians, pharmacists, and the software provider/vendor, an electronic system was developed and new processes for medication delivery were instituted within eight months of starting the project. Since the past year, the evaluation of the eMAR at the Brenda Strafford Foundation demonstrated a reduction in medication delivery time allowing for more time for direct care and a decrease in medication incidents, which directly affects resident health and safety. Nursing and the healthcare aides trained in medication management were surveyed and indicated that the eMAR provides a holistic view of the resident and provides important information readily available to improve the quality of resident care.

Self-micro emulsifying drug delivery systems: a strategy to improve oral bioavailability / Sistema de administración de fármacos autoemulsionante: una estrategia para mejorar la biodisponibilidad oral

Aim: Oral route has always been the favorite route of drug administration in many diseases and till today it is the first way investigated in the development of new dosage forms. The major problem in oral drug formulations is low and erratic bioavailability, which mainly results from poor aqueous solubility, thereby pose problems in their formulation. For the therapeutic delivery of lipophilic active moieties (BCS class II drugs), lipid based formulations are inviting increasing attention. Methods: To that aim, from the web sites of PubMed, HCAplus, Thomson, and Registry were used as the main sources to perform the search for the most significant research articles published on the subject. The information was then carefully analyzed, highlighting the most important results in the formulation and development of self-micro emulsifying drug delivery systems as well as its therapeutic activity. Results: Self-emulsifying drug delivery system (SMEDDS) has gained more attention due to enhanced oral bio-availability enabling reduction in dose, more consistent temporal profiles of drug absorption, selective targeting of drug(s) toward specific absorption window in GIT, and protection of drug(s) from the unreceptive environment in gut. Conclusions: This article gives a complete overview of SMEDDS as a promising approach to effectively deal with the problem of poorly soluble molecules

Objetivo: La vía oral siempre ha sido la ruta preferida de administración de fármacos en muchas enfermedades y hasta hoy es la primera forma investigada en el desarrollo de nuevas formas de dosificación. El principal problema en las formulaciones de fármacos orales es la baja y errática biodisponibilidad, lo que resulta fundamentalmente por la escasa solubilidad en agua, con lo que plantean problemas en su formulación. Para la administración terapéutica de los grupos activos lipófilos (BCS clase II drogas), las formulaciones a base de lípidos están teniendo cada vez más atención. Métodos: Con ese objetivo, a partir de los sitios web de PubMed, HCAplus, Thomson, y sus registros se utilizaron como fuentes principales para llevar a cabo la búsqueda de los artículos de investigación más importantes publicados sobre el tema. A continuación, la información fue analizada cuidadosamente, poniendo de relieve los resultados más importantes en la formulación y desarrollo de sistemas de administración de fármacos auto-emulsionante micro, así como su actividad terapéutica. Resultados: El sistema de administración de fármacos autoemulsionante (SMEDDS) ha ganado más atención debido a la mejorada que permite la reducción de la biodisponibilidad oral en dosis, los perfiles temporales más consistentes de la absorción del fármaco, la orientación selectiva de fármaco (s) hacia la ventana de absorción específica en el tracto gastrointestinal, y la protección del fármaco (s) desde el entorno poco receptivo en el intestino. Conclusiones: Este artículo proporciona una visión completa de SMEDDS como un enfoque prometedor para abordar eficazmente el problema de moléculas poco solubles

Re-assessing community-directed treatment: evidence from Mazabuka District, Zambia.

Cross-sectional surveys with carers, health workers, community drug distributors (CDDs) and neighbourhood health committees were conducted to identify factors associated with utilization of community-directed treatment (ComDT) of soil-transmitted helminths in children aged 12-59 months in Mazabuka district, Zambia. The surveys took place in December 2006 and December 2007. In addition child treatment records were reviewed. The factors that were found to be significantly associated (p < 0.05) with treatment of children by the CDDs were: (1) the perception of soil-transmitted helminth infections as having significant health importance, (2) the community-based decision to launch and subsequently implement ComDT, (3) the use of the door-to-door method of drug distribution, (4) CDDs being visited by a supervisor, (5) CDDs receiving assistance in mobilizing community members for treatment, (6) CDDs having access to a bicycle and (7) CDDs having received assistance in collecting drugs from the health centre. Despite the effectiveness of ComDT in raising treatment coverage there are factors in the implementation process that will still affect whether children and their carers utilize the ComDT approach. Identification and understanding of these factors is paramount to achieving the desired levels of utilization of such interventions.

A multi-disciplinary approach to medication safety and the implication for nursing education and practice.

BACKGROUND: Medication management is a complex multi-stage and multi-disciplinary process, involving doctors, pharmacists, nurses and patients. Errors can occur at any stage from prescribing, dispensing and administering, to recording and reporting. There are a number of safety mechanisms built into the medication management system and it is recognised that nurses are the final stage of defence. However, medication error still remains a major challenge to patient safety globally. OBJECTIVES: This paper aims to illustrate two main aspects of medication safety practices that have been elicited from an action research study in a Scottish Health Board and three local Higher Education Institutions: firstly current medication safety practices in two clinical settings; and secondly pre and post-registration nursing education and teaching on medication safety. METHOD: This paper is based on Phase One and Two of an Action Research project. An ethnography-style observational method, influenced by an Appreciative Inquiry (AI) approach was adapted to study the everyday medication management systems and practices of two hospital wards. This was supplemented by seven in-depth interviews with nursing staff, numerous informal discussions with healthcare professionals, two focus-groups, one peer-interview and two in-depth individual interviews with final year nursing students from three Higher Education Institutions in Scotland. RESULT: This paper highlights the current positive practical efforts in medication safety practices in the chosen clinical areas. Nursing staff do employ the traditional 'five right' principles - right patient, right medication, right dose, right route and right time - for safe administration. Nursing students are taught these principles in their pre-registration nursing education. However, there are some other challenges remaining: these include the establishment of a complete medication history (reconciliation) when patients come to hospital, the provision of an in-depth training in pharmacological knowledge to junior nursing staff and pre-registration nursing students. CONCLUSION: This paper argues that the 'five rights' principle during medication administration is not enough for holistic medication safety and explains two reasons why there is a need for strengthened multi-disciplinary team-work to achieve greater patient safety. To accomplish this, nurses need to have sufficient knowledge of pharmacology and medication safety issues. These findings have important educational implications and point to the requirement for the incorporation of medication management and pharmacology in to the teaching curriculum for nursing students. There is also a call for continuing professional development opportunities for nurses working in clinical settings.

Use of a computerized order set to increase prescription of calcium and vitamin D supplementation in patients receiving glucocorticoids.

BACKGROUND: American College of Rheumatology guidelines recommend that patients taking glucocorticoids also take calcium and vitamin D supplements, regardless of the dose or intended duration of glucocorticoid use, to decrease their risk of glucocorticoid-induced osteopenia or osteoporosis (GIOP). OBJECTIVE: To increase the number of prescriptions made for calcium and vitamin D in patients who receive a prescription for glucocorticoids using an automated, computerized order set. DESIGN: Pre-post test design. PATIENTS: A total of 1,041 outpatients receiving care at a single VA medical center. INTERVENTION/MAIN MEASURES: We developed an automated order set in which calcium and vitamin D were automatically co-ordered with glucocorticoid prescriptions of at least 2-week duration. We tested the impact of the order set by comparing the number of calcium and vitamin D prescriptions in patients taking glucocorticoids during a 12-month period before (T1) and after (T2) implementation. The automated order set could be modified by the treating physician, and it was not generated for patients with hypercalcemia. KEY RESULTS: A total of 535 patients during T1 and 506 patients during T2 had a glucocorticoid prescription of at least 2-week duration. The percent of co-prescriptions for calcium increased from 37 to 49% and vitamin D from 38 to 53% (both p < 0.0001) after the new automated order set was implemented. CONCLUSIONS: Implementation of an automatic prescription for calcium and vitamin D supplementation modestly increases the number of patients on glucocorticoids who are prescribed calcium and vitamin D supplementation.

Medicines management programme for non-medical prescribers.

The National Prescribing Centre has developed a single competency framework for all prescribers, including medical and dental prescribers. The framework demonstrates the need for keeping up to date with the knowledge and skills associated with medicines management and prescribing. The reorganisation of NHS community services in north west London led to the creation of an integrated care organisation, offering the opportunity to review the medicines management support provided to non-medical prescribers (NMPs) in the community and to develop a continuing professional development programme for community NMP staff. This article describes the design, delivery and evaluation of the programme, which is delivered by a team of pharmacists in collaboration with senior nurses.

Racionalidade terapêutica: elementos médico-sanitários nas demandas judiciais de medicamentos / Rational therapeutics: health-related elements in lawsuits demanding medicines / Racionalidad terapéutica: elementos medico-sanitarios en las demandas judiciales de medicamento

OBJETIVO: Caracterizar os principais elementos processuais, médico-científicos e sanitários que respaldam as decisões das demandas judiciais individuais por medicamentos consideradas essenciais. MÉTODOS: Estudo descritivo retrospectivo com base em 27 ações julgadas em 2ª instância no Estado do Rio de Janeiro em 2006. Os processos originais foram solicitados ao Arquivo Central do Tribunal de Justiça do Estado do Rio de Janeiro, fotografados e analisados na íntegra. RESULTADOS: Todas as ações incluíram prescrição e atestado médicos. As prescrições estavam em desacordo com a legislação. Não houve perícia médica em nenhuma das ações e em 7,4 por cento constavam exames complementares. Apesar da escassa informação médica contida nos autos, todos os pedidos foram deferidos. CONCLUSÕES: O acolhimento de demandas judiciais carentes de subsídios clínicos e diagnósticos traz embaraços de ordem gerencial e sanitária ao sistema de saúde, pois comprometem a assistência farmacêutica regular e fomentam o uso irracional de medicamentos.

OBJECTIVE: To characterize the main medical, scientific and health-related procedural elements upon which decisions are made in individual lawsuits demanding medicines that are considered essential to the Court of Justice. METHODS: Retrospective descriptive study based on 27 cases ruled on by the Court of Appeals in Rio de Janeiro, Southeastern Brazil, in 2006. The original proceedings were solicited from the Central Archive of the Court of Justice of the State of Rio de Janeiro and were photographed and analyzed in full. RESULTS: Prescriptions and medical certificates were present in 100 percent of the lawsuits. All prescriptions lacked conformity to legislation. No expert medical reports were added, and only 7.4 percent of the lawsuits presented complementary examinations. In spite of the scarcity of medical information present in the records, all of the demands were granted. CONCLUSIONS: The admission of judicial demands devoid of clinical and diagnostic substantiation results in managerial and health-related constraints on the health system. Besides creating havoc in standard pharmaceutical services, badly justified medicine demands may compromise rational drug use.

OBJETIVO: Caracterizar los principales elementos procesales, medico-científicos y sanitarios que respaldan las decisiones de las demandas judiciales individuales por medicamentos consideradas esenciales. MÉTODOS: Estudio descriptivo retrospectivo con base en 27 acciones juzgadas en 2ª instancia en el estado de Rio de Janeiro, Sureste de Brasil, en 2006. Los procesos originales fueron solicitados al Archivo Central del Tribunal de Justicia del Estado de Rio de Janeiro, fotografiados y analizados de forma íntegra. RESULTADOS: Todas las acciones incluyeron prescripción y atestados médicos. Las prescripciones estaban en desacuerdo con la legislación. No hubo pericia médica en ninguna de las acciones y en 7,4 por ciento constaban exámenes complementarios. A pesar de la escasa información médica contenida en los autos, todos los pedidos fueron deferidos. CONCLUSIONES: El acogimiento de demandas judiciales carentes de subsidios clínicos y diagnósticos trae complicaciones de tipo gerencial y sanitaria al sistema de salud, ya que comprometen la asistencia farmacéutica regular y fomentan el uso irracional de medicamentos.

Análise técnica para a tomada de decisão do fornecimento de medicamentos pela via judicial / A technical analysis of medicines request-related decision making in Brazilian courts / Análisis técnico para la toma de decisiones de abastecimiento de medicamentos por la vía judicial

OBJETIVO: Analisar a solicitação judicial de medicamentos previstos nos componentes da assistência farmacêutica no Sistema Único de Saúde. MÉTODOS: Foram analisados 81 processos judiciais para fornecimento de medicamentos no Estado de São Paulo, entre 2005 e 2009. As informações dos processos foram obtidas do Tribunal de Justiça do Estado de São Paulo. Portarias que regulamentam a assistência farmacêutica foram consultadas para identificar a solicitação judicial de medicamentos incorporados pelo Sistema Único de Saúde. Para análise do nível de evidência dos medicamentos nas indicações clínicas referidas, foi consultada a base de dados Thomson Micromedex®. RESULTADOS: O número de medicamentos solicitados em cada processo variou entre um e sete itens, nos quais foram identificados 77 fármacos diferentes. Dos medicamentos solicitados, 14,3 por cento deveriam estar disponíveis na atenção básica do Sistema Único de Saúde, 19,5 por cento no componente de medicamentos de dispensação excepcional e 66,2 por cento não pertenciam a nenhuma lista oficial. Medicamentos do componente de dispensação excepcional apresentaram melhor evidência clínica quando indicados no tratamento de doenças cobertas pelos Protocolos Clínicos e Diretrizes Terapêuticas do Ministério da Saúde. CONCLUSÕES: A via judicial tem sido utilizada para garantir o acesso a medicamentos cujo fornecimento está previsto no Sistema Único de Saúde e para solicitar aqueles não incorporados por ele. A avaliação do nível de evidência reforça a necessidade de análise técnica para a tomada de decisão do fornecimento de medicamentos pela via judicial.

OBJECTIVE: To analyze judicial requests for medications that are covered by the pharmaceutical assistance components of the Sistema Único de Saúde (SUS - Brazilian Unified Health System). METHODS: We analyzed 81 judicial requests for medications in the State of São Paulo between 2005 and 2009. The details of these cases were obtained electronically from the Court of Justice of the State of São Paulo. Directives that regulate pharmaceutical assistance were consulted to identify judicially requested medications that are covered by the SUS. To assess the level of evidence supporting the use of these medications to treat the clinical indications described, we consulted the Thomson Micromedex® database. RESULTS: The number of individual medications requested in each case ranged from 1 to 7; in total, 77 different pharmaceuticals agents were identified. Of the medications requested, 14.3 percent should have been available through SUS primary care, 19.5 percent were classified under the exceptionally dispensed medications component of the SUS, and 66.2 percent were not on any official list. Medications of the exceptionally dispensed medications component showed better clinical evidence when indicated for the treatment of medical conditions covered by the Clinical Protocols and Therapeutic Guidelines of Brazil's Ministry of Health. CONCLUSIONS: The judicial process has been used to ensure access to medications that are covered by the SUS and to request access to those that are not covered. Our assessment of the level of available evidence reinforces the need for technical analysis in the decision-making process in cases of judicially requested medications.

OBJETIVO: Analizar la solicitud judicial de medicamentos previstos en los componentes de la asistencia farmacéutica en el Sistema Único de Salud. MÉTODOS: Se analizaron 81 procesos judiciales para abastecimiento de medicamentos en el Estado de Sao Paulo, Sureste de Brasil, entre 2005 y 2009. Las informaciones de los procesos fueron obtenidas en el Tribunal de Justicia del Estado de Sao Paulo. Los documentos administrativos legales que regulan la asistencia farmacéutica fueron consultados para identificar la solicitud judicial de medicamentos incorporados por el Sistema Único de Salud. Para análisis del nivel de evidencia de los medicamentos en las indicaciones clínicas referidas, fue consultada la base de datos Thomson Micromedex®. RESULTADOS: El número de medicamentos solicitados en cada proceso varió entre uno y siete ítems, en los cuales fueron identificados 77 fármacos diferentes. De los medicamentos solicitados, 14,3 por ciento deberían estar disponibles en la atención básica del Sistema Único de Salud, 19,5 por ciento en el componente de medicamentos de dispensación excepcional y 66,2 por ciento no pertenecían a ninguna lista oficial. Medicamentos del componente de dispensación excepcional presentaron mejor evidencia clínica al ser indicados en el tratamiento de enfermedades cubiertas por los Protocolos Clínicos y Directrices Terapéuticas del Ministerio de la Salud. CONCLUSIONES: La vía judicial ha sido utilizada para garantizar el acceso a medicamentos cuyo abastecimiento está previsto en el Sistema Único de Salud y para solicitar aquellos no incorporados por él. La evaluación del nivel de evidencia refuerza la necesidad de análisis técnica para la toma de decisión del abastecimiento de medicamentos por la vía judicial.

A technical analysis of medicines request-related decision making in Brazilian courts.

OBJECTIVE: To analyze judicial requests for medications that are covered by the pharmaceutical assistance components of the Sistema Único de Saúde (SUS - Brazilian Unified Health System). METHODS: We analyzed 81 judicial requests for medications in the State of São Paulo between 2005 and 2009. The details of these cases were obtained electronically from the Court of Justice of the State of São Paulo. Directives that regulate pharmaceutical assistance were consulted to identify judicially requested medications that are covered by the SUS. To assess the level of evidence supporting the use of these medications to treat the clinical indications described, we consulted the Thomson Micromedex® database. RESULTS: The number of individual medications requested in each case ranged from 1 to 7; in total, 77 different pharmaceuticals agents were identified. Of the medications requested, 14.3% should have been available through SUS primary care, 19.5% were classified under the exceptionally dispensed medications component of the SUS, and 66.2% were not on any official list. Medications of the exceptionally dispensed medications component showed better clinical evidence when indicated for the treatment of medical conditions covered by the Clinical Protocols and Therapeutic Guidelines of Brazil's Ministry of Health. CONCLUSIONS: The judicial process has been used to ensure access to medications that are covered by the SUS and to request access to those that are not covered. Our assessment of the level of available evidence reinforces the need for technical analysis in the decision-making process in cases of judicially requested medications.

Rational therapeutics: health-related elements in lawsuits demanding medicines.

OBJECTIVE: To characterize the main medical, scientific and health-related procedural elements upon which decisions are made in individual lawsuits demanding medicines that are considered essential to the Court of Justice. METHODS: Retrospective descriptive study based on 27 cases ruled on by the Court of Appeals in Rio de Janeiro, Southeastern Brazil, in 2006. The original proceedings were solicited from the Central Archive of the Court of Justice of the State of Rio de Janeiro and were photographed and analyzed in full. RESULTS: Prescriptions and medical certificates were present in 100% of the lawsuits. All prescriptions lacked conformity to legislation. No expert medical reports were added, and only 7.4% of the lawsuits presented complementary examinations. In spite of the scarcity of medical information present in the records, all of the demands were granted. CONCLUSIONS: The admission of judicial demands devoid of clinical and diagnostic substantiation results in managerial and health-related constraints on the health system. Besides creating havoc in standard pharmaceutical services, badly justified medicine demands may compromise rational drug use.

Care or custody? An evaluation of palliative care in prisons in North West England.

This study aimed to evaluate health professionals' views about palliative care provision in prisons in the counties of Cumbria and Lancashire in the North West of England. Seventeen prison healthcare staff and nine specialist palliative care staff participated in semi-structured interviews and 16 prison healthcare staff completed a questionnaire designed to measure knowledge, skills and confidence in relation to palliative care. The findings highlighted tensions between the philosophies of care and custody, and the many challenges in providing palliative care in a custodial setting. This paper presents two illustrative case study examples, and suggests ways in which some of these challenges can be overcome in practice.

Evaluation of a pharmacist-managed diabetes medication therapy adherence clinic / Evaluación de una clínica farmacéutica para el cumplimiento del tratamiento en diabetes

Patient adherence to prescribed medication regimens is important in diabetes care to prevent or delay microvascular and macrovascular complications such as retinopathy, nephropathy and myocardial infarction. In Penang Hospital, Malaysia, pharmacists collaborate with physicians in diabetes care through a pharmacist-managed Diabetes Medication Therapy Adherence Clinic (DMTAC) in the Endocrine Clinic, in operation since 2006. Objective: To evaluate the effectiveness of the pharmacist-managed DMTAC program in improving glycaemic control, lipid parameters and patients´ medication adherence. Method: A retrospective study among patients enrolled in the DMTAC program was conducted between September 2007 and December 2008. Data was included from patients with a glycosylated haemoglobin (HbA1c) >8% and who had completed eight visits with the pharmacists. Medical records and DMTAC forms that provided patients´ demographics, medication regimens, adherence and laboratory parameters as well as pharmacists´ interventions were reviewed. HbA1c, fasting blood glucose (FBG), low-density lipoprotein cholesterol (LDL), triglycerides (TG) and high-density lipoprotein cholesterol (HDL) were evaluated. Documented data of patients´ adherence to medication regimen [Modified Morisky Medication Adherence Score (MMMAS); high adherence if score >8, medium adherence if score 6 to <8 and low adherence if score <6] was also evaluated. Results: A total of 43 patients (53.5% females; 46.5% Malays, 44.2% Chinese and 9.3% Indians) were included in the analysis. A mean reduction in HbA1c of 1.73% (p<0.001), mean reduction in FBG of 2.65mmol/l (p=0.01) and mean reduction in LDL cholesterol of 0.38mmol/l (p=0.007) were achieved. The difference in TG and HDL cholesterol were not significant. Patients´ adherence to medication regimens improved significantly with an increase in the mean MMMAS score from 7.00 to 10.84 (p<0.001) after completion of the DMTAC program. Conclusion: The pharmacist-managed DMTAC program resulted in significant improvements in HbA1c, glucose and LDL cholesterol levels as well as medication adherence in patients with diabetes (AU)

El cumplimiento de la medicación en los pacientes diabéticos es importante para prevenir o retrasar complicaciones micro y macrovasculares tales como retinopatía, neuropatía e infarto de miocardio. En el Hospital de Penang, Malasia, los farmacéuticos colaboran con los médicos en diabetes a través de una clínica farmacéutica para el cumplimiento del tratamiento en diabetes (DMTAC) en la clínica endocrinológica, operando desde 2006. Objetivo: Evaluar la efectividad del programa de la DMTAC en la mejora del control glucémico, de parámetros lipídicos y de cumplimiento de la medicación por los pacientes. Métodos: Entre septiembre 2007 y diciembre 2008 se realizó un estudio retrospectivo entre los pacientes atendidos en el programa de la DMTAC. Se incluyeron datos de pacientes con hemoglobina glicosilada (HbA1c) >8% y que habían completado 8 visitas con el farmacéutico. Se revisaron los historiales médicos y los formularios de la DMTAC que proporcionaron datos demográficos de los pacientes, medicación, cumplimiento y parámetros de laboratorio, así como las intervenciones de los farmacéuticos. La HbA1c, glucemia en ayuno, colesterol de lipoproteínas de baja densidad (LDL), triglicéridos (TG) y colesterol de lipoproteínas de alta densidad (HDL). También se evaluaron los datos de cumplimiento de los pacientes [Modified Morisky Medication Adherence Score (MMMAS); alto cumplimiento si la puntuación >8, cumplimiento medio si puntuación de 6 a 8 y bajo cumplimiento si puntuación <6]. Resultados: Se incluyó en el análisis un total de 43 pacientes (53,5% mujeres; 46.5% Malayos, 44.2% Chinos and 9.3% Indios). Se obtuvo una reducción media de HbA1c de 1,73% (p<0,001), de glucemia de 2,65 mmol/l (p=0,01) y de colesterol LDL de 0.38 mmol/l (p=0,007). La diferencia en TG y colesterol HDL no fue significativa. Después de completar el programa de la DMTAC, el cumplimiento de los pacientes de su medicación mejoró significativamente con un aumento en la puntuación del MMMAS de 7,00 a 10,84 (p<0,001). Conclusión: el programa farmacéutico de la DMTAC produjo mejorías significativas en los niveles de HbA1c, glucosa y colesterol LDL, así como en el cumplimiento de la medicación de los pacientes con diabetes (AU)

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.

Medication errors are a major source of morbidity and mortality. Inadequate laboratory monitoring of high-risk medications after initial prescription is a medical error that contributes to preventable adverse drug events. Health information technology (HIT)-based clinical decision support may improve patient safety by improving the laboratory monitoring of high-risk medications, but the effectiveness of such interventions is unclear. Therefore, the authors conducted a systematic review to identify studies that evaluate the independent effect of HIT interventions on improving laboratory monitoring for high-risk medications in the ambulatory setting using a Medline search from January 1, 1980 through January 1, 2009 and a manual review of relevant bibliographies. All anticoagulation monitoring studies were excluded. Eight articles met the inclusion criteria, including six randomized controlled trials and two pre-post intervention studies. Six of the studies were conducted in two large, integrated healthcare delivery systems in the USA. Overall, five of the eight studies reported statistically significant, but small, improvements in laboratory monitoring; only half of the randomized controlled trials reported statistically significant improvements. Studies that found no improvement were more likely to have used analytic strategies that addressed clustering and confounding. Whether HIT improves laboratory monitoring of certain high-risk medications for ambulatory patients remains unclear, and further research is needed to clarify this important question.

Comprensión de la información recibida por el paciente en la primera prescripción: intervención farmacéutica / Understanding of the information received by the patient in the first prescription of a medicine: pharmacist intervention

INTRODUCCIÓN.- Nuestro objetivo ha sido valorar el conocimiento que tiene el paciente del tratamiento prescrito por primera vez, en función de la información recibida en la consulta médica. MATERIAL Y MÉTODOS.- Estudio observacional transversal, realizado en 10 oficinas de farmacia de las provincias de Albacete y Jaén del 1 de abril al 31 de mayo del 2009 entre pacientes o cuidadores que acudieron con un inicio de tratamiento. A dichos sujetos se les realizó una encuesta para cada uno de los medicamentos prescritos y los datos se analizaron con SPSS. RESULTADOS.- Tuvieron validez un total de 318 encuestas y, de éstas, sólo un 44% de los casos demostraron tener un total conocimiento del tratamiento. La intervención del farmacéutico fue requerida principalmente para aclarar posología (35,4%) y duración del tratamiento (33,9%). El grado de conocimiento aumentó cuando la información era escrita, apreciándose un aumento significativo si se acompañaba de oral, y cuando se la proporcionaba el especialista. Disminuyó a mayor edad del paciente y menor nivel de estudios. DISCUSIÓN.- El moderado conocimiento del tratamiento podría ser debido a la presión ejercida por la masificación de las consultas, que provocaría que el médico general no pueda atender al paciente el tiempo suficiente. Además, el paciente acude al especialista para ser tratado de patologías más graves y lo hace con menor frecuencia, lo que podría suponer que ponga mayor interés en conocer el tratamiento. El menor conocimiento de los ancianos se explicaría porque se trata de pacientes habitualmente polimedicados y con problemas cognitivos(AU)

INTRODUCTION.- Our aim has been to evaluate the knowledge that a patient has regarding a treatment newly prescribed, according to the information given in the medical consultation. METHODOLOGY.- Cross-sectional study, carried out in 10 community pharmacies of Albacete and Jaén, from 1st of April to 31st of May 2009. Data was obtained from a survey completed by the patients or their carers for each one of the new treatments started. Information obtained was analyzed with SPSS. RESULTS.- 318 valid surveys, only 44% of these cases proved a total knowledge of the treatment. Pharmacist intervention was mainly needed to clarify the dosage (35,4%) and the duration of the treatment (33,9%). The degree of knowledge increased when the information was given by a consultant and also when was written information. More over it was seen a significant increase of knowledge when written information was accompanied by verbal. In the other hand, it decreased in elderly patients and in them with lower level of education. DISCUSION.- The moderate knowledge of the treatment could be due to the limited time GP have for each patient. Also, patients normally attend to the consultant for more serious illness and less often, probably paying more attention to the information about the treatment prescribed. The lower level of knowledge in the elderly could be explained for the high number of medicines they take and the cognitive problems(AU)

Estudo da evolução das unidades de Estratégia Saúde da Família na participação do Programa Remédio em Casa na Supervisão Técnica de Saúde Pirituba/Perus / Study of the Evolution of Health Strategy Unit in the Family Involvement Program Home Remedy Technical Supervision in Health Pirituba / Perus

Os resultados mostram um crescimento da participação das Unidades PSF nos resultados do Programa Remédio em Casa. A estratégia Saúde da Família faz um melhor acompanhamento dos pacientes, favorecendo maior adesão e melhor resultado no número de ativos sobre cadastrados. As UBS tradicionais atualmente enfrentam maior dificuldade em manter seus pacientes ativos, pois a re-inclusão após seis meses depende da consulta médica. No cumprimento das metas, as unidades PSF são favorecidas pelo trabalho em equipe multidisciplinar e incentivo mútuo entre as equipes.(AU)

Risk factors of self-reported adverse drug events among Medicare enrollees before and after Medicare Part D / Factores de riesgo de eventos adversas medicamentosos autoreportados entre asegurados en Medicare antes y después de Medicare Part D

Objectives: Quantify risk factors for self-reported adverse drug events (ADEs) after the implementation of Medicare Part D, quantify self-reported ADEs before and after Medicare Part D and quantify the association between self-reported ADEs and increased use of prescription medication. Methods: The design was a longitudinal study including an internet survey before Medicare Part D in 2005 (n=1220) and a follow-up survey in 2007 (n=1024), with n=436 responding to both surveys. Harris Interactive® invited individuals in their online panel to participate in this study. Individuals who were 65 or older, English speakers, US residents and enrolled in Medicare were included. Data collected and used in analysis included self-reported ADE, socio-demographics, self-rated health, number of medications, symptoms experienced, concern and necessity beliefs about medicines, number of pharmacies, and whether doses were skipped or stopped to save money. Results: In 2007, reporting an ADE was related to concern beliefs, symptoms experienced and age. ADEs were experienced by 18% of respondents in 2005 and 20.4% in 2007. The average number of medications increased from 3.82 (SD=2.82) in 2005 to 4.32 (SD=3.20) in 2007 (t= -5.77, p<0.001). Among respondents who answered both surveys (n=436), 18.4% reported an ADE in 2005 while 24.3% reported an ADE in 2007. The increase in self-reported ADE was related to concern beliefs (OR=1.12, 95%CI=1.05, 1.19) and symptoms experienced (OR= 3.27, 95%CI=1.60, 6.69), not number of medications (OR=1.04, 95%CI=0.77, 1.41). Conclusion: Discussing elderly patients' beliefs about their medicines may affect their medication expectations, symptom interpretation and attributions and future medication attributions (AU)

Objetivos: Cuantificar los factores de riesgo para eventos adversos medicamentosos (ADE) auto-reportados después de la implantación de Medicare Part D, cuantificar los ADE auto-reportados antes y después de Medicare Part D, y cuantificar la asociación entre ADE auto-reportados y el aumento del uso de medicamentos prescritos. Métodos: El diseño fue un estudio longitudinal incluyendo un cuestionario por internet antes de Medicare Part D en 2005 (n=1220) y una investigación de seguimiento en 2007 (n=1024), con n=436 que respondieron a los dos cuestionarios. Harris Interactive® invitó a individuos de su panel on-line a participar en este estudio. Se incluyó a individuos que tenían 65 o más 65 años, anglo-parlantes, residentes en USA y beneficiarios de Medicare. Los datos recogidos y utilizados en el análisis incluyeron los ADE auto-reportados, socio-demografía, salud auto-relatada, número de medicamentos, síntomas que sufrían, preocupaciones y creencia de la necesidad de medicinas, número de farmacias, y si se saltaban dosis o abandonaban para ahorrar dinero. Resultados: En 2007, las ADE comunicadas estaban relacionadas con creencias de problemas, síntomas manifestados y la edad. Los ADE fueron padecidos por un 18% de los respondentes en 2005 y 20,4% en 2007. La media de medicamentos aumentó de 3,82 (SD=2,82) en 2005 a 4,32 (SD=3,20) en 2007 (t= -5.77, p<0.001). Entre los respondentes que contestaron los dos cuestionarios (n=436), el 18,4% comunicó un ADE en 2005 mientras que el 24,3% comunicó un ADE en 2007. El aumento de ADE auto-reportados estaba relacionado con las creencias de problemas (OR=1.12, 95%CI=1.05, 1.19) y los síntomas manifestados (OR= 3.27, 95%CI=1.60, 6.69), pero no con el número de medicamentos (OR=1.04, 95%CI=0.77, 1.41). Conclusión: Discutir con los ancianos sus creencias sobre medicamentos puede afectar sus expectativas sobre su medicación, interpretación y atribuciones de síntomas, y futuras atribuciones de medicación (AU)

One kidney transplant center's experience: linking process improvements and Medicare/Medicaid conditions of participation.

CONTEXT: An institutional priority toward transplantation, dedicated team dynamics, aggressive clinical growth, and optimal care practices are essential for delivering exceptional care to transplant patients. The importance of multidisciplinary integration of these priorities throughout the continuum of patient care is widely recognized in the transplant arena as well as by the Centers for Medicare and Medicaid Services (CMS). In fact, it is the collaboration within these aspects of care that is necessary for certification by CMS. OBJECTIVES: To establish institution-wide practices, systems, and mechanisms to optimize performance of transplant centers through the use of evidence-based protocols, clinical innovation, and data-driven quality improvements. To develop training programs and competency based orientation addressing the topics needed for transplant nurses, multidisciplinary caregivers, and clinical transplant coordinators who provide care to transplant patients. To comply with the CMS conditions of participation for transplant centers. METHODS: Formation of a renal transplant council and multidisciplinary care team. Flow chart of hospital course from admission to discharge, carefully examining patients' progression through the continuum of care, assessing for barriers to care and knowledge deficits of transplant practitioners. RESULTS: Development of multiple clinical process improvements resulting in the creation of an environment for continuous learning, optimal transplant care, and exceptional outcomes in transplantation as well as compliance with CMS conditions of participation for transplant centers.

[Evaluation of the pilot program of medicine dispensation in customized doses in Galicia [Spain]]. / Evaluación del Programa Piloto de Dispensación de Medicamentos en Dosis Personalizada en Galicia.

OBJECTIVE: To quantify, from an economic perspective, the results of the Pilot Program of Dispensation of Medicines in Unitary Dose in Galicia, Spain. PATIENTS AND METHODS: Retrospective study from 35,923 antibiotic prescriptions in customized doses corresponding to 5 active principles (amoxicillin, amoxicilin/clavulanic, claritromicin, cefuroxima axetil and ciprofloxacin). The program, which worked during 12 months, included 292 physicians from 46 units of primary care of the Galician Health Service and 167 offices of pharmacy. RESULTS: 60.57% of the prescribed treatments did not adjust exactly to the conventional presentations existing in the market. Savings in units of antibiotic of the dispensation in customized doses compared with the conventional one has been of 14.32%. Registered economic saving has been of 29.94%. The inclusion of 2 new presentations in amoxiciline and amoxiciline/clavulanic (of 15 and 21 tablets) and of one in the other 3 (cefuroxime and ciprofloxacin of 14 tablets and clarithromycin of 16) would avoid 86.5% of the leftover units without having to implement individualized dispensation. CONCLUSIONS: An important antibiotic stock is being generated in home medicine cabinets as a result of the leftovers of prescribed treatments that in the case of Galicia are equivalent to more than 1,800,000 doses of antibiotic in 2004. This problem could be reduced with the dispensation in customized dose and partially with new presentations.

Evaluación del Programa Piloto de Dispensación de Medicamentos en Dosis Personalizada en Galicia / Evaluation of the Pilot Program of Medicine Dispensation in Customized Doses in Galicia

Objetivo: Evaluar, desde una perspectiva económica, los resultados del Programa Piloto de Dispensación de Medicamentos en Dosis Personalizada en Galicia. Pacientes y métodos: Estudio retrospectivo de las 35.923 recetas de antibióticos (amoxicilina, amoxicilina/clavulánico, claritromicina, cefuroxima axetilo y ciprofloxacino) en dosis personalizada generadas en el programa de 12 meses de duración en el que participaron 292 médicos de familia de 46 unidades de atención primaria del Servicio Gallego de Salud y 167 oficinas de farmacia. Resultados: El 60,57% de los tratamientos prescritos no se ajustaba de manera exacta a las presentaciones disponibles en el mercado. El ahorro, en número de unidades, de la dispensación en dosis personalizada frente a la convencional fue del 14,32%. El ahorro económico fue del 29,94%, lo que supondría un 0,46% de la facturación en Galicia. La inclusión de 2 presentaciones nuevas en amoxicilina y amoxicilina/clavulánico (de 15 y 21 comprimidos) y de una en los otros 3 (cefuroxima y ciprofloxacino de 14 comprimidos y claritromicina de 16) evitaría el 86,5% de las unidades sobrantes. Conclusiones: El importante sobrante de tratamientos prescritos (1.800.000 dosis de antibiótico en 2004 para el caso de Galicia) podría reducirse con la dispensación en dosis personalizada y, parcialmente, con la entrada en el mercado de nuevas presentaciones

Objective: To quantify, from an economic perspective, the results of the Pilot Program of Dispensation of Medicines in Unitary Dose in Galicia, Spain. Patients and methods: Retrospective study from 35,923 antibiotic prescriptions in customized doses corresponding to 5 active principles (amoxicillin, amoxicilin/clavulanic, claritromicin, cefuroxima axetil and ciprofloxacin). The program, which worked during 12 months, included 292 physicians from 46 units of primary care of the Galician Health Service and 167 offices of pharmacy. Results: 60.57% of the prescribed treatments did not adjust exactly to the conventional presentations existing in the market. Savings in units of antibiotic of the dispensation in customized doses forehead to the conventional one has been of 14.32%. Registered economic saving has been of 29.94%. The inclusion of 2 new presentations in amoxiciline and amoxiciline/ clavulanic (of 15 and 21 tablets) and of one in the other 3 (cefuroxima and ciprofloxacine of 14 tablets and claritromicine of 16) would avoid 86.5% of the leftover units without having to implement individualized dispensation. Conclusions: An important antibiotic stock is being generated in the domestic medicine kits as a result of the leftovers of prescribed treatments that in the case of Galicia are equivalent to more than 1,800,000 doses of antibiotic in 2004. This problem could be reduced with the dispensation in customized dose and partially with new presentations