Level of concordance between two risk-assessment models for predicting venous thromboembolism in medical patients at admission.

OBJECTIVES: To evaluate the level of concordance between the 2007 PRETEMED guidelines and the 2012 American College of Chest Physicians (ACCP) guidelines in medical patients at admission. METHODS: A cross-sectional, observational and descriptive study was designed and included all adult medical patients admitted from an emergency department. Firstly, patients classified as low-moderate risk and high risk according to PRETEMED were compared to those classified by ACCP as low and high risk. Secondly, the same analysis was performed but this time low and moderate-high risk patients according to PRETEMED were compared to ACCP low and high risk patients. The level of concordance was calculated using the kappa concordance index. The study was approved by the Ethics Committee for Clinical Research of the hospital. RESULTS: The analysis was performed with 207 patients; 53.1% were male and the median age was 75.3 years (minimum 18, maximum 100 years old). The most common diagnosis at admission was related to a respiratory disease (37.2%). The level of concordance was 0.59 (95% CI 0.48 to 0.70) when moderate risk patients were grouped with low-risk patients and 0.53 (95% CI 0.42 to 0.65) when moderate risk patients were grouped with high-risk patients. CONCLUSIONS: The level of concordance between both guides is moderate. It would be helpful to confirm whether the level of agreement improves when the patient's condition stabilises after several days of hospitalisation.

Medication reconciliation: passing phase or real need?

Medication reconciliation errors occur across transitions in patient care. Of all medication errors in a hospital, 25 % in hospitalised patients are caused by a failure to reconcile new prescriptions with ongoing home treatments. These errors are more common at discharge, but the critical moment for detecting and resolving them is at the time of admission. This commentary reviews the different ways in which reconciliation errors can be prevented. The reconciliation process should be standardised and implemented in daily practice as a routine part of healthcare provision. To achieve this, professional development of hospital pharmacists is of paramount importance. The commentary goes on to describe the factors that affect the reconciliation process and the stages involved in its implementation. Finally, we discuss the use of information technology as a means to help integrating medication reconciliation into clinical practice.

Prescribing errors intercepted by clinical pharmacists in paediatrics and obstetrics in a tertiary hospital in Spain.

PURPOSE: To assess the main differences in clinical significance of the prescribing errors intercepted by clinical pharmacists in paediatrics and obstetrics and the reasons for these prescribing errors, as well as the differences in pharmacists' activity indicators. METHODS: The was a cross-sectional epidemiological study analysing the activities of paediatric pharmacists in a maternity and children's hospital with 180 paediatric beds and 138 obstetrics and gynaecology beds between January 2007 and December 2009. The following variables were analysed: clinical significance of prescribing errors intercepted, reason for the error, impact of the intervention by pharmacist, acceptance rate of the recommendation made, medication involved, intervention detection date and observations. RESULTS: A total of 2,449 interventions in medical orders were recorded. Interventions that were not accepted by doctors were excluded, leaving 43 cases (2.1%) of extremely significant interventions and 170 (8.4%) very significant interventions. Interventions in what were deemed to be error-free situations were excluded. Significance testing (based on 2,035 errors detected) showed that 1.7% of the detected errors were potentially lethal (35 cases), while 10.2% (210 cases) were clinically serious. The main reason for the interventions was the detection of a dosage between 1.5- and tenfold higher than the recommended dosage. The overall rate of acceptance of the pharmacist's suggestions was 92.2%. Pharmacists carried out an average of 0.016 interventions/patient-day throughout the study period. CONCLUSIONS: Paediatric patients had a fourfold higher risk of serious errors than the maternity population. Pharmacist intervention had a major impact on reducing prescribing errors in the study period, thus improving the quality and efficiency of care provided.

Impact of clinical pharmacist interventions in reducing paediatric prescribing errors.

OBJECTIVE: To assess the impact of pharmacist intervention in reducing prescribing errors in paediatrics, and to analyse the clinical significance and reasons behind the errors detected. METHODS: Cross-sectional epidemiological study analysing the activities of the paediatric pharmacist in a maternity and children's hospital with 180 paediatric beds, between January 2007 and December 2009. The following variables were analysed: impact of the pharmacist's recommendation on patient care, reason for the intervention, clinical significance, type of negative outcome associated with the medication, acceptance rate, medication involved, intervention detection date and observations. RESULTS: A total of 1475 interventions in medical orders for 14,713 paediatric patients were recorded (40 (2.9%) extremely significant interventions and 155 (11.1%) very significant interventions). There were 1357 prescribing errors, 833 of which were dosing errors. 2.2% of the errors detected were potentially fatal (30 cases) and 14.3% (194 cases) were clinically serious. The main reason for interventions was detection of a dosage between 1.5 and 10 times higher than that recommended. The overall rate of acceptance of the pharmacist's suggestions was 94.3%. The pharmacist carried out an average of 0.019 interventions per patient day throughout the study period. CONCLUSION: Interventions by a clinical pharmacist had a major impact on reducing prescribing errors in the study period, thus improving the quality and safety of care provided.

Prevalence of medication administration errors in two medical units with automated prescription and dispensing.

OBJECTIVE: To identify the frequency of medication administration errors and their potential risk factors in units using a computerized prescription order entry program and profiled automated dispensing cabinets. DESIGN: Prospective observational study conducted within two clinical units of the Gastroenterology Department in a 1537-bed tertiary teaching hospital in Madrid (Spain). MEASUREMENTS: Medication errors were measured using the disguised observation technique. Types of medication errors and their potential severity were described. The correlation between potential risk factors and medication errors was studied to identify potential causes. RESULTS: In total, 2314 medication administrations to 73 patients were observed: 509 errors were recorded (22.0%)-68 (13.4%) in preparation and 441 (86.6%) in administration. The most frequent errors were use of wrong administration techniques (especially concerning food intake (13.9%)), wrong reconstitution/dilution (1.7%), omission (1.4%), and wrong infusion speed (1.2%). Errors were classified as no damage (95.7%), no damage but monitoring required (2.3%), and temporary damage (0.4%). Potential clinical severity could not be assessed in 1.6% of cases. The potential risk factors morning shift, evening shift, Anatomical Therapeutic Chemical medication class antacids, prokinetics, antibiotics and immunosuppressants, oral administration, and intravenous administration were associated with a higher risk of administration errors. No association was found with variables related to understaffing or nurse's experience. CONCLUSIONS: Medication administration errors persist in units with automated prescription and dispensing. We identified a need to improve nurses' working procedures and to implement a Clinical Decision Support tool that generates recommendations about scheduling according to dietary restrictions, preparation of medication before parenteral administration, and adequate infusion rates.

Developing a programme for medication reconciliation at the time of admission into hospital.

The aim of this article is to describe the methods used to develop the medication reconciliation programme implemented in a tertiary care hospital, and to discuss the main problems encountered and lessons learned during the process. A quasi-experimental study was carried out, analysing discrepancies between routine medication and drugs prescribed in the hospital, before and after an electronic reconciliation tool was introduced at admission. This tool was integrated into the computerized provider order entry system. The implementation of the electronic reconciliation tool has shown a reduction of the rate of discrepancies, decreasing from 7.24% (CI 95% 6.0-8.5) before the intervention to 4.18% (CI 95% 3.2-5.1) afterwards. Projects like this are costly, but this study has made it possible to detect numerous areas where interventions could be useful and proved the importance of a medication reconciliation programme.

Literature review on the structure and operation of Pharmacy and Therapeutics Committees.

AIM OF THE REVIEW: To review the literature on the structure and operation of hospital Pharmacy and Therapeutics Committees from an international point of view and examine the factors that influence decision-making of these committees. METHOD: We performed a literature search in the Medline and Embase databases from 1997 to January 2009 with the search terms: formulary system decision making, pharmacy and therapeutics committee, formularies hospital, drug formulary, survey, drug selection and outcome assessment health care. Inclusion criteria were the following: studies analyzing Pharmacy and Therapeutics Committees published in English or Spanish from 1997 to January 2009. Exclusion criteria were: publications which were editorials or opinion pieces, studies relating to one hospital, and studies where full text could not be attained. The analysis was divided into structural/organizational data and data on factors affecting the decision-making process. RESULTS: Seventeen studies met the inclusion criteria. Pharmacy and Therapeutics Committees and formularies were present in more than 90% of the hospitals in four of the five countries examined. Therapeutic interchange programs existed only in two of these countries. The mean number of committee members ranged between six and eight. More than 89% of the committees included a pharmacist. Standard operating procedures were implemented by 89% of the committees. The most influential factors in the decision-making were clinical trial results or drug costs rather than pharmacoeconomic studies. Other local organization-dependent factors were also important. CONCLUSIONS: The structure and operating procedures of Hospital Pharmacy and Therapeutics Committees are similar in select Western countries. Information from clinical trials is the most influential factor in the decision-making process.

Structure and procedures of the pharmacy and therapeutic committees in Spanish hospitals.

OBJECTIVE: Define the structure and working procedures of the Pharmacy and Therapeutic Committees (P&T Committees) in Spanish hospitals. SETTING: Hospitals over 75 beds located in all regions of the Spanish State. METHOD: A cross-sectional descriptive study based on the completion of a questionnaire that consisted of 138 questions. The participants were recruited by post, e-mail and telephone between November 2007 and January 2008. The Hospitals were classified according to their size and public or private and university or non-university status. MAIN OUTCOME MEASURES: They are related with the structure and composition of the P&T Committees, performance, drug evaluation process, working methods and the results of their activity. RESULTS: A total of 200 hospitals answered the questionnaire (response rate of 39.0% of hospitals and 57.1% of the beds in Spain). All the hospitals have P&T Committees, 99.5% have a Drug Formulary, 71.0% have a Therapeutic Interchange Programme and 91.0% have a document determining the mission, objectives and functions of the P&T Committee. Almost all hospitals (95.5%) have established a formal application for the inclusion of a drug in the hospital, while 80.5% have established a model for evaluation reports. The mean (SD) number of participants in P&T Committees was 11.84 (3.82). The annual mean of drugs evaluated per hospital was 10.35 (7.45). The proportion of assessments that concludes the inclusion, rejection or deferral of the decision was 75.3, 21.4 and 3.2%, respectively. CONCLUSION: Spanish P&T Committees have a similar structure and function, a multi-disciplinary professional composition to carry out an important assessment activity. This activity is higher in large hospitals and in university hospitals. The proportion of the approved and rejected drugs is similar in different types of hospital. The Therapeutic Interchange Guidelines, the use of application models and the reports follow the indications of scientific collaborative groups, thus being used more in Spain than in other countries.