[Medication safety in Switzerland: Where are we today?] / Medikationssicherheit: Wo steht die Schweiz?

Empirical research shows that medication safety is an urgent area of concern in the Swiss healthcare system. Adverse drug events and medication errors are common and risks such as polypharmacy are widespread. No comprehensive national strategy explicitly dedicated to medication safety exists in Switzerland. The federalist system of government with relative autonomy of the cantons relating to healthcare laws influences the implementation of national healthcare reforms, also to the disadvantage of medication safety. Direct dispensing of drugs by the prescribing physician is permitted in almost all German-speaking cantons. This special feature of the Swiss system implies specific challenges for medication safety. Nonetheless, there is an increasing number of national activities dealing with various aspects of medication safety, such as the "progress!" programmes within the National Quality Strategy. Within the National Research Programme "Smarter Health Care" (NRP 74) of the Swiss National Science Foundation, several research projects are currently focusing on medication safety. Clinical pharmacy activities in hospitals are relatively widespread. In the primary care sector, pharmaceutical care practice and the corresponding competencies for pharmacists are being further developed. However, a comprehensive strategy, priority-setting and effectiveness studies involving all stakeholders are required in order for the Swiss healthcare system, to meet the challenges facing medication safety in a forward-looking manner.

[Selected safety-relevant medication processes in Swiss nursing homes: Current state of affairs and optimization potentials]. / Ausgewählte sicherheitsrelevante Medikationsprozesse in Schweizer Alters- und Pflegeheimen: Status quo und Optimierungspotenziale.

BACKGROUND: Reducing adverse drug events in nursing homes is a central patient safety concern. The aim of this study was to assess how often selected medication processes to increase medication safety are already implemented in Swiss nursing homes and to examine how nursing homes that have not yet implemented these processes can be characterized based on their organizational features. METHODS: Cross-sectional survey study among directors of nursing in Swiss nursing homes. RESULTS: 420 of 1,525 invited individuals participated in the survey (response rate: 27.5 %). Of these, 65.0 % stated that regular systematic medication reviews have been provided in their institution. 9.5 % of the nursing homes use a list to identify potentially inappropriate medication, and 6.7 % of the nursing homes have a standardized process to monitor side effects of medications. 66.0 % of the participating nursing homes have implemented at least one of these three processes, 34.0 % of the participating nursing homes have not implemented any of the three processes. Statistically significant differences in process implementation were found according to the geographical location of the nursing home, the type of documentation used for medications, the physician model, the number of external general practitioners, as well as the medication supply channel and the legal obligation to cooperate with pharmacists. No differences were found with regard to the nursing home size. CONCLUSION: In Swiss nursing homes, central safety-relevant medication processes have not yet been implemented nationwide. In particular, implementation is not widespread in nursing homes where medical care for their residents is provided by many different external general practitioners. The organizational features need to be taken into account to successfully implement quality improvement measures.

Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward.

OBJECTIVE: Medication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including a best possible medication history (BPMH) compared with a standard medication history in patients admitted to an internal medicine ward. DESIGN: Prospective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model. SETTING: Internal medicine ward in a secondary care hospital in Southern Switzerland. PARTICIPANTS: The first 100 consecutive patients admitted in an internal medicine ward. PRIMARY AND SECONDARY OUTCOME MEASURES: Medication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified. RESULTS: The median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model. CONCLUSION: Even in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to avoid a notable number of clinically relevant discrepancies and potential adverse drug events.

Implications of involving pharmacy technicians in obtaining a best possible medication history from the perspectives of pharmaceutical, medical and nursing staff: a qualitative study.

OBJECTIVES: In recent years, the involvement of pharmacy technicians in medication reconciliation has increasingly been investigated. The aim of this study was to assess the implications on professional roles and collaboration when a best possible medication history (BPMH) at admission is obtained by pharmacy technicians. DESIGN: Qualitative study with semistructured interviews. Data were analysed using a qualitative content analysis approach. SETTING: Internal medicine units in two mid-sized Swiss hospitals. PARTICIPANTS: 21 staff members working at the two sites (6 pharmacy technicians, 2 pharmacists, 6 nurses, 5 physician residents and 2 senior physicians). RESULTS: Pharmacy technicians generally appreciated their new tasks in obtaining a BPMH. However, they also experienced challenges associated with their new role. Interviewees reported unease with direct patient interaction and challenges with integrating the new BPMH tasks into their regular daily duties. We found that pharmacists played a key role in the BPMH process, since they act as coaches for pharmacy technicians, transmit information to the physicians and reconcile preadmission medication lists with admission orders. Physicians stated that they benefitted from the delegation of administrative tasks to pharmacy technicians. Regarding the interprofessional collaboration, we found that pharmacy technicians in the study acted on a preliminary administrative level and did not become part of the larger treatment team. There was no direct interaction between pharmacy technicians and physicians, but rather, the supervising pharmacists acted as intermediaries. CONCLUSION: The tasks assumed by pharmacy technicians need to be clearly defined and fully integrated into existing processes. Engaging pharmacy technicians may generate new patient safety risks and inefficiencies due to process fragmentation. Communication and information flow at the interfaces between professional groups therefore need to be well organised. More research is needed to understand if and under which circumstances such a model can be efficient and contribute to improving medication safety.

Conflicts of interest among authors of medical guidelines: an analysis of guidelines produced by German specialist societies.

BACKGROUND: Conflicts of interest can bias the recommendations of clinical guidelines. In 2010, the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) revised its rules about how conflicts of interest in guidelines should be managed. METHODS: All S2 and S3 guidelines in the AWMF database that were created in the years 2009-2011 were independently examined by two reviewers each (TL, MG, SC, BW, LF, SS). Information on conflicts of interest was extracted and descriptively analyzed. The effects of the new AWMF rules were studied with a before-and-after comparison. RESULTS: 60 (20%) of the 297 guidelines studied contained explicit declarations of conflict of interest by their authors. 680 authors (49%) stated that they had financial relationships that constituted a conflict of interest; 86% declared conflicts arising from membership in specialty societies or professional associations. From 2009 to 2011, there was a substantial rise in the frequency of conflict-of-interest declarations in guidelines (8% of 256 guidelines that were created before the AWMF revised its rules in 2010 and 95% of 41 guidelines created afterward). The percentage of persons declaring financial conflicts of interest rose after the new rules were introduced, while the mode of documentation of conflict-of-interest evaluation and of any measures that might have been taken as a result remained unchanged. CONCLUSION: From 2011 onward, all conflict-of-interest declarations by guideline authors have been published in the AWMF database. There is no current standard for the evaluation and management of conflicts of interest in guideline-creating groups, and this situation urgently needs to be remedied.

[Diversity in spite of standards: the special features of NDGMs]. / Trotz Standards--Vielfalt im Programm: Die Besonderheiten der NVL.

For seven years the German National Disease Management Guidelines Programme (NDMG Programme) has been supported by its funding bodies: the German Medical Association, the National Association of Statutory Health Insurance Physicians, and the Association of Scientific Medical Societies. The objectives of the NDMG Programme are to develop and to implement comprehensive national clinical guidelines for the management of selected illnesses. Key points of NDMG methodology are the strict adherence to the principles of evidence-based medicine as well as the avoidance of contradictory recommendations by means of neutrally facilitated consensus rounds. Despite the standardised NDMG methodology each guideline has individual structural and content features that make it unique. For example, the complex illness type 2 diabetes is presented in topic- and problem-oriented NDMG modules. For unipolar depression, the NDMG was simultaneously developed as a S3 guideline. Furthermore each NDMG group was faced with its own content-based challenges. For instance, in the case of the NDMG Low-back Pain the guideline group intensely and controversially discussed the definition of unspecific low-back pain. The NDMG Asthma does not solely address adults, but also children and adolescents, and the NDMG Heart Failure for the first time covers other health care relevant aspects such as multimorbidity and psychosocial factors in detail. The following article aims to deliver insight into the diversity of the development of National Disease Management Guidelines and to demonstrate the complexity of guideline development.

[After 15 years of ÄZQ: 10 years of safety for patients]. / 15 Jahre ÄZQ--10 Jahre Patientensicherheit am ÄZQ.

The German Agency for Quality in Medicine (ÄZQ) has been actively addressing the topic patient safety for ten years. ÄZQ's work in the field has focused on establishing a patient safety expert circle, publishing various articles on the subject, developing a patient safety continuing education curriculum, setting up a patient safety internet forum, and participating in the WHO initiative "Action on Patient Safety: High 5s". Furthermore, "CIRSmedical.de", a reporting and learning system for German medical professionals supported and maintained by ÄZQ, developed into the nationwide "CIRSmedical.de Network". In the following article these activities and how they relate to other national and international patient safety programs are described.

Bronchial asthma: diagnosis and long-term treatment in adults.

INTRODUCTION: Bronchial asthma is a serious global health problem. 5% to 10% of persons of all ages suffer from this chronic airway disorder. This review article presents important considerations of diagnosis and treatment in view of the current national and international asthma guidelines. METHODS: Selective literature review, with attention to the current national and international guidelines. RESULTS/DISCUSSION: Bronchial asthma is a chronic inflammatory disease of the airways characterized by bronchial hyperreactivity and a variable degree of airway obstruction. It is diagnosed on the basis of the clinical history, physical examination, and pulmonary function tests, including reversibility testing and measurement of bronchial reactivity. The goal of treatment is to control the symptoms of the disease effectively and in lasting fashion. Long-term treatment with inhaled corticosteroids is the basis of asthma treatment, alongside preventive measures and patient education. Bronchodilators such as beta2 sympathomimetics are used for rapid symptomatic relief of acute attacks.