Understanding the implementation, impact and sustainable use of an electronic pharmacy referral service at hospital discharge: A qualitative evaluation from a sociotechnical perspective.

INTRODUCTION: The transition of patients across care settings is associated with a high risk of errors and preventable medication-related harm. Ensuring effective communication of information between health professionals is considered important for improving patient safety. A National Health Service(NHS) organisation in the North West of England introduced an electronic transfer of care around medicines (TCAM) system which enabled hospital pharmacists to send information about patient's medications to their nominated community pharmacy. We aimed to understand the adoption, and the implications for sustainable use in practice of the TCAM service. METHODS: We evaluated the TCAM service in a Clinical Commissioning Group (CCG) and NHS Foundation Trust in Salford, United Kingdom (UK). Participants were opportunistically recruited to take part in qualitative interviews through stakeholder networks and during hospital admission, and included hospital pharmacists, hospital pharmacy technicians, community pharmacists, general practice-based pharmacists, patients and their carers. A thematic analysis, that was iterative and concurrent with data collection, was undertaken using a template approach. The interpretation of the data was informed by broad sociotechnical theory. RESULTS: Twenty-three interviews were conducted with health care professionals patients and carers. The ways in which the newly implemented TCAM intervention was adopted and used in practice and the perceptions of it from different stakeholders were conceptualised into four main thematic areas: The nature of the network and how it contributed to implementation, use and sustainability; The material properties of the system; How work practices for medicines safety were adapted and evolved; and The enhancement of medication safety activities. The TCAM intervention was perceived as effective in providing community pharmacists with timely, more accurate and enhanced information upon discharge. This allowed for pharmacists to enhance clinical services designed to ensure that accurate medication reconciliation was completed, and the correct medication was dispensed for the patient. CONCLUSIONS: By providing pharmacy teams with accurate and enhanced information the TCAM intervention supported healthcare professionals to establish and/or strengthen interprofessional networks in order to provide clinical services designed to ensure that accurate medication reconciliation and dispensing activities were completed. However, the intervention was implemented into a complex and at times fragmented network, and we recommend opportunities be explored to fully integrate this network to involve patients/carers, general practice pharmacists and two-way communication between primary and secondary care to further enhance the reach and impact of the TCAM service.

Antibiotic use and the development of inflammatory bowel disease: a national case-control study in Sweden.

BACKGROUND: Use of antibiotics in early life has been linked with childhood inflammatory bowel disease (IBD), but data for adults are mixed, and based on smaller investigations that did not compare risk among siblings with shared genetic or environmental risk factors. We aimed to investigate the association between antibiotic therapy and IBD in a large, population-based study. METHODS: In this prospective case-control study, we identified people living in Sweden aged 16 years or older, with a diagnosis of IBD based on histology and at least one diagnosis code for IBD or its subtypes (ulcerative colitis and Crohn's disease). We identified consecutive patients with incident IBD from the ESPRESSO (Epidemiology Strengthened by histoPathology Reports in Sweden) study, cross-referenced with the Swedish Patient Register and the Prescribed Drug Register. We accrued data for cumulative antibiotic dispensations until 1 year before time of matching for patients and up to five general population controls per patient (matched on the basis of age, sex, county, and calendar year). We also included unaffected full siblings as a secondary control group. Conditional logistic regression was used to estimate multivariable-adjusted odds ratios (aORs) and 95% CIs for diagnosis of incident IBD. FINDINGS: We identified 23 982 new patients with IBD (15 951 ulcerative colitis, 7898 Crohn's disease, 133 unclassified IBD) diagnosed between Jan 1, 2007, and Dec 31, 2016. 117 827 matched controls and 28 732 siblings were also identified. After adjusting for several risk factors, aOR in patients who had used antibiotics versus those who had never used antibiotics was 1·88 (95% CI 1·79-1·98) for diagnosis of incident IBD, 1·74 (1·64-1·85) for ulcerative colitis, and 2·27 (2·06-2·49) for Crohn's disease. aOR was higher in patients who had received one antibiotic dispensation (1·11, 1·07-1·15), two antibiotic dispensations (1·38, 1·32-1·44), and three or more antibiotic dispensations (1·55, 1·49-1·61) than patients who had none. Increased risk was noted for ulcerative colitis (aOR with three or more antibiotic dispensations 1·47, 95% CI 1·40-1·54) and Crohn's disease (1·64, 1·53-1·76) with higher estimates corresponding to broad-spectrum antibiotics. Similar but attenuated results were observed when siblings were used as the reference group, with an aOR of 1·35 (95% CI 1·28-1·43) for patients who had received three or more dispensations, compared with general population controls. INTERPRETATION: Higher cumulative exposure to systemic antibiotic therapy, particularly treatments with greater spectrum of microbial coverage, may be associated with a greater risk of new-onset IBD and its subtypes. The association between antimicrobial treatment and IBD did not appear to differ when predisposed siblings were used as the reference controls. Our findings, if substantiated by longer-term prospective studies in humans or mechanistic preclinical investigations, suggest the need to further emphasise antibiotic stewardship to prevent the rise in dysbiosis-related chronic diseases, including IBD. FUNDING: National Institutes of Health. Crohn's and Colitis Foundation.

Operating a patient medicines helpline: a survey study exploring current practice in England using the RE-AIM evaluation framework.

BACKGROUND: Patient medicines helplines provide a means of accessing medicines-related support following hospital discharge. However, it is unknown how many National Health Service (NHS) Trusts currently provide a helpline, nor how they are operated. Using the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance), we sought to obtain key data concerning the provision and use of patient medicines helplines in NHS Trusts in England. This included the extent to which the delivery of helplines meet with national standards that are endorsed by the Royal Pharmaceutical Society (standards pertaining to helpline access, availability, and promotion). METHODS: An online survey was sent to Medicines Information Pharmacists and Chief Pharmacists at all 226 acute, mental health, specialist, and community NHS Trusts in England in 2017. RESULTS: Adoption: Fifty-two percent of Trusts reported providing a patient medicines helpline (acute: 67%; specialist: 41%; mental health: 29%; community: 18%). Reach: Helplines were predominantly available for discharged inpatients, outpatients, and carers (98%, 95% and 93% of Trusts, respectively), and to a lesser extent, the local public (22% of Trusts). The median number of enquiries received per week was five. IMPLEMENTATION: For helpline access, 54% of Trusts reported complying with all 'satisfactory' standards, and 26% reported complying with all 'commendable' standards. For helpline availability, the percentages were 86% and 5%, respectively. For helpline promotion, these percentages were 3% and 40%. One Trust reported complying with all standards. Maintenance: The median number of years that helplines had been operating was six. Effectiveness: main perceived benefits included patients avoiding harm, and improving patients' medication adherence. CONCLUSIONS: Patient medicines helplines are provided by just over half of NHS Trusts in England. However, the proportion of mental health and community Trusts that operate a helpline is less than half of that of the acute Trusts, and there are regional variations in helpline provision. Adherence to the national standards could generally be improved, although the lowest adherence was regarding helpline promotion. Recommendations to increase the use of helplines include increasing the number of promotional methods used, the number of ways to contact the service, and the number of hours that the service is available.

Evaluation of medication dose omissions amongst inpatients in a hospital using an electronic Medication Management System.

RATIONALE, AIMS, AND OBJECTIVES: Whilst many dose omissions cause no patient harm, inappropriate dose omissions have been associated with increased length of hospital stay, risk of sepsis, and mortality. This study aimed to comprehensively describe the prevalence and nature of omitted doses overall and of high risk medication dose omissions in an organization using an electronic Medication Management System. METHODS: A retrospective cross-sectional study was undertaken in an Australian tertiary referral health service. All routinely documented electronic inpatient dose administration records from 1st July 2014 to 30th June 2015 were included. Period prevalence and characteristics of dose omissions overall and of high-risk medication dose omissions were determined. RESULTS: During the study period, 3.3 million inpatient doses were scheduled for administration, with doses endorsed as "not given" comprising 6.2% of all scheduled doses. Non-valid dose omissions (medication not available or no justification documented) comprised 1.2% of scheduled doses. Patient refusal accounted for one third of all dose omissions, while for 12% no explanation was provided and 7% were endorsed "medication not available". High-risk medications accounted for 20% of all dose omissions. One in 20 antimicrobial doses scheduled were omitted, and of these, 17% were due to patient refusal. CONCLUSION: The period prevalence of dose omissions in this large study after electronic Medication Management System implementation is similar to that found when paper charts were used. Although most dose omissions appear appropriate, many orders were not given due to patient refusal or with no documented justification. Interventions to minimize unintentional dose omissions are indicated.

The Electronic Pharmaceutical Record: A new method for medication reconciliation.

RATIONALE, AIM, AND OBJECTIVE: There are several ways to establish an accurate medication list in the hospital admission medication reconciliation (MedRec). The challenge for MedRec lies in the availability, reliability, and completeness of the data used. In France, the Electronic Pharmaceutical Record (ePR) was developed to register each medication taken by ambulatory patients, primarily to make dispensation in community pharmacies safe. We evaluated the suitability of this tool in the MedRec when patients were admitted to the hospital. METHOD: We conducted a 6-month pilot study of 249 MedRec files from a hospital diabetology department. The analysis was supplemented by the ePR for any patient for whom this information was recorded. The study evaluated the ePR as a new MedRec tool, as well as the clinical impact (CI) of the new data collected. RESULTS: The ePR was contributory for 28% of the patients. Discrepancies were associated with polypharmacy, most of which had a CI = 1. Medication omission was the most frequently found discrepancy (72%), but self-medication (8%) and lack of medication adherence (9%) were also observed. CONCLUSION: This tool provided added value for reconciliation, as it quickly identifies regular medications, adherence, and self-medication behaviour. The ePR is essential for conducting a thorough MedRec.

Factors Associated With Barcode Medication Administration Technology That Contribute to Patient Safety: An Integrative Review.

In an effort to prevent medication errors, barcode medication administration technology has been implemented in many health care organizations. An integrative review was conducted to understand the effect of barcode medication administration technology on medication errors, and characteristics of use demonstrated by nurses contribute to medication safety. Addressing poor system use may support improved patient safety through the reduction of medication administration errors.

Allopurinol Medication Adherence as a Mediator of Optimal Outcomes in Gout Management.

BACKGROUND: Patient and provider factors, including allopurinol medication adherence, affect gout treatment outcomes. OBJECTIVES: The aim of this study was to examine associations of patient and provider factors with optimal gout management. METHODS: Linking longitudinal health and pharmacy dispensing records to questionnaire data, we assessed patient and provider factors among 612 patients with gout receiving allopurinol during a recent 1-year period. Associations of patient (medication adherence and patient activation) and provider factors (dose escalation, low-dose initiation, and anti-inflammatory prophylaxis) with serum urate (SU) goal achievement of less than 6.0 mg/dL were examined using multivariable logistic regression. Medication adherence was assessed as a mediator of these factors with goal achievement. RESULTS: A majority of patients (63%) were adherent, whereas a minority received dose escalation (31%). Medication adherence was associated with initiation of daily allopurinol doses of 100 mg/d or less (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.20-2.76). In adjusted models, adherence (OR, 2.35; 95% CI, 1.50-3.68) and dose escalation (OR, 2.48; 95% CI, 2.48-4.25) were strongly associated with SU goal attainment. Low starting allopurinol dose was positively associated with SU goal attainment (OR, 1.11; 95% CI, 1.02-1.20) indirectly through early adherence, but also had a negative direct association with SU goal attainment (OR, 0.21; 95% CI, 0.12-0.37). CONCLUSIONS: Medication adherence and low starting dose combined with dose escalation represent promising targets for future gout quality improvement efforts. Low starting dose is associated with better SU goal attainment through increased medication adherence, but may be beneficial only in settings where appropriate dose escalation is implemented.

Effect of an electronic medication administration record application on patient safety.

RATIONALE, AIMS, AND OBJECTIVES: To evaluate the effect of an electronic medication administration record (eMAR) application on the rate of medication errors in medication administration recording (ME-MAR). METHODS: A before-and-after, quasiexperimental study was conducted in a university hospital that implemented the eMAR application in March 2014. Data collection was conducted in April 2012 (pre-) and June 2014 (post-) by two pharmacists. The ME-MARs were analysed by the staff involved to identify their cause. The two pharmacists independently classified the ME-MARs. In the case of disagreement, a research team examined the ME-MARs and categorized them by consensus. Three classifications were used: A classic medication error taxonomy and 2 technology-induced error taxonomies. RESULTS: The pharmacists analysed 2835 (pre-) and 2621 (post-) medication administration records (MAR), respectively. Overall, the ME-MAR rate decreased from 48.0% (pre-) to 36.9% (post-) (P < .05). The same types of ME-MAR were observed in both phases except for "MAR with incomplete information," which was not observed in the postimplementation phase. In both phases, the most frequent ME-MAR was "MAR at the wrong time" (MAR before or after medication administration) (31.6% vs 30.2%). The main cause of ME-MARs in both phases was the failure to follow work procedures. The potential future risk of ME-MARs significantly decreased after the eMAR implementation (P < .05). All ME-MARs were "use errors" because of human factors. New ME-MARs (1.24%; n = 12) were observed in the postimplementation phase. CONCLUSION: Use of the eMAR application significantly reduces the rate of ME-MAR and their potential risk. The main cause of ME-MAR was the failure to follow work procedures.

Gamification of Clinical Routine: The Dr. Fill Approach.

Gamification is used in clinical context in the health care education. Furthermore, it has shown great promises to improve the performance of the health care staff in their daily routine. In this work we focus on the medication sorting task, which is performed manually in hospitals. This task is very error prone and needs to be performed daily. Nevertheless, errors in the medication are crucial and lead to serious complications. In this work we present a real world gamification approach of the medication sorting task in a patient's daily pill organizer. The player of the game needs to sort the correct medication into the correct dispenser slots and is rewarded or punished in real time. At the end of the game, a score is given and the user can register in a leaderboard.

Organizational Benefits of Computerized Physican Order Entry (CPOE) System in Pakistan.

Electronic prescribing is also known as Computerized Physician Order Entry (CPOE). It is a computer-aided system which offers the health professionals a robust platform for entering the prescription electronically. Due to paucity of facilities in Pakistan which are available around the world, there is an observable overburden on the health professionals and practitioners. CPOE system has shown to be very effective in minimizing medication errors. CPOE is beneficial for both patient and health organizations. There is great deal of interest in the adoption of this system in our healthcare system. The results state clearly that this system is equally beneficial for organizations who want to adopt this system as perceived by the health professionals. It supports the idea of adoption and implementation of CPOE in healthcare facilities healthcare institutes. CPOE must be adopted to ease and optimize nursing services in Pakistani healthcare system.

An Assessment of the Application of Pharma Cloud System to the National Health Insurance Program of Taiwan and the Result in Hospitals.

National Health Insurance Administration established Pharma Cloud System in July 2014. The purpose is to decrease therapeutic duplications and enhance public medication safety. Comparison will be made among individual hospitals and the administering branches of National Health Insurance Bureau (NHIB) on the statistical data on the inquiry of the cloud medication history record system to understand the result of the installation and advocacy of this system. The results show (1) there were 2,329,846 entries of data collected from the branches of the NHIB from 2015 on cloud medication history record and 50,224 entries of data from individual hospitals. (2) The inquiry rate at the branches of the NHIB was 43.2% from January to April, 2015 and at individual hospitals was 18.8%. (3) The improvement rate at the branches of the NHIB was 32.5% and at the individual hospitals was 47.0% from January to April, 2015.

Assessment of Pharmacy Information System Performance in Three Hospitals in Eastern Province, Saudi Arabia.

The pharmacy information system is one of the central pillars of a hospital information system. This research evaluated a pharmacy information system according to six aspects of the medication process in three hospitals in Eastern Province, Saudi Arabia. System administrators were interviewed to determine availability of functionalities. Then, system users within the hospital were targeted to evaluate their level of usage of these functionalities. The study was cross-sectional. Two structured surveys were designed. The overall response rate of hospital users was 31.7 percent. In all three hospitals studied, the electronic health record is hybrid, implementation has been completed and the system is running, and the systems have computerized provider order entry and clinical decision support. Also, the pharmacy information systems are integrated with the electronic health record, and computerized provider order entry and almost all prescribing and transcription functionalities are available; however, drug dispensing is a mostly manual process. However, the study hospitals do not use barcode-assisted medication administration systems to verify patient identity and electronically check dose administration, and none of them have computerized adverse drug event monitoring that uses the electronic health record. The numbers of users who used different functionalities most or all of the time was generally low. The highest frequency of utilization was for patient administration records (56.8 percent), and the lowest was for linkage of the pharmacy information system to pharmacy stock (9.1 percent). Encouraging users to use different functionalities was highly recommended.

Antihypertensive drug class and adherence: an electronic monitoring study.

BACKGROUND: Medication adherence is essential to optimizing blood pressure (BP) control. Prior research has demonstrated differences in pharmacy refill patterns according to antihypertensive drug class. No prior study has assessed the association between drug class and day-to-day adherence. METHODS: Between 2011 and 2014, we enrolled a convenience sample of 149 patients with persistently uncontrolled hypertension from two inner-city clinics and concurrently measured adherence of up to four antihypertensive medications using electronic pillboxes during the interval between two primary care visits. The main outcome was mean percent of days adherent to each drug. Mixed effects regression analyses were used to assess the association between drug class and adherence adjusting for age, gender, race, ethnicity, education, health insurance, coronary artery disease, heart failure, chronic kidney disease, diabetes, number of medications, days monitored, and dosing frequency. RESULTS: The mean age was 64 years; 72% women, 75% Hispanic, 88% prescribed ≥ 1 BP medication. In unadjusted analyses, adherence was lower for beta-blockers (70.9%) compared to angiotensin receptor blocking agents (75.0%, P = 0.11), diuretics (75.9%, P < 0.001), calcium channel blockers (77.6%, P < 0.001) and angiotensin-converting enzyme inhibitors (78.0%, P < 0.0001). In the adjusted analysis, only dosing frequency (P = 0.0001) but not drug class (P = 0.71) was associated with medication adherence. CONCLUSIONS: Antihypertensive drug class was not associated with electronically measured adherence after accounting for dosing frequency amongst patients with uncontrolled hypertension. Low adherence to beta-blockers may have been due to the common practice of prescribing multiple daily dosing. Providers may consider using once daily formulations to optimize adherence and should assess adherence among all treated patients with uncontrolled hypertension.

Accuracy of the days' supply and the number of refills allowed recorded in Québec prescription claims databases for inhaled corticosteroids.

OBJECTIVES AND HYPOTHESES: Adherence to inhaled corticosteroids (ICS) is a major issue in asthma. This study aimed to estimate the accuracy of the days' supply and number of refills allowed, variables recorded in Québec claims databases and used to estimate adherence, and to develop correction factors, if required. We hypothesised that the accuracy of the days' supply for ICS would be low whereas the accuracy of the number of refills allowed would be high. SETTING: 40 community pharmacies in Québec (Canada) and a medication registry. PARTICIPANTS: We collected data for 1108 ICS original prescriptions stored in the 40 pharmacies (sample 1), and we obtained a second sample of 2676 ICS prescriptions selected from reMed, a medication registry (sample 2). PRIMARY AND SECONDARY OUTCOMES: We estimated the concordance of the days' supply and number of refills between Québec claims databases and the original prescription from sample 1. We developed a correction factor for the days' supply in sample 1 and validated it in sample 2. Analyses were stratified by age: 0-11 and 12-64 years. RESULTS: In sample 1, the concordance for the days' supply was 39.6% (95% CI 37.6% to 41.6%) in those aged 0-11 years and 56% (54.9% to 57.2%) in those aged 12-64 years. The concordance increased to 59.4% (58.2% to 60.5%) in those aged 0-11 years and 74.2% (73.5% to 74.9%) in those aged 12-64 years after applying the correction factors in sample 2. The concordance for the refills allowed was 92.1% (91% to 93.1%) in those aged 0-11 years and 93.1% (92.5% to 93.7%) in those aged 12-64 years in sample 1. CONCLUSIONS: The accuracy of the days' supply was moderate among those aged 0-11 years and substantial among those aged 12-64 years after applying the correction factors. The accuracy of the number of refills was almost perfect in both groups.

Estimation of severe drug-drug interaction warnings by medical specialist groups for Austrian nationwide eMedication.

OBJECTIVE: The objective of this study is to estimate the amount of severe drug-drug interaction warnings per medical specialist group triggered by prescribed drugs of a patient before and after the introduction of a nationwide eMedication system in Austria planned for 2015. METHODS: The estimations of interaction warnings are based on patients' prescriptions of a single health care professional per patient, as well as all patients' prescriptions from all visited health care professionals. We used a research database of the Main Association of Austrian Social Security Organizations that contains health claims data of the years 2006 and 2007. RESULTS: The study cohort consists of about 1 million patients, with 26.4 million prescribed drugs from about 3,400 different health care professionals. The estimation of interaction warnings show a heterogeneous pattern of severe drug-drug-interaction warnings across medical specialist groups. CONCLUSION: During an eMedication implementation it must be taken into consideration that different medical specialist groups require customized support.

Drug interaction alert override rates in the Meaningful Use era: no evidence of progress.

BACKGROUND: Interruptive drug interaction alerts may reduce adverse drug events and are required for Stage I Meaningful Use attestation. For the last decade override rates have been very high. Despite their widespread use in commercial EHR systems, previously described interventions to improve alert frequency and acceptance have not been well studied. OBJECTIVES: (1) To measure override rates of inpatient medication alerts within a commercial clinical decision support system, and assess the impact of local customization efforts. (2) To compare override rates between drug-drug interaction and drug-allergy interaction alerts, between attending and resident physicians, and between public and academic hospitals. (3) To measure the correlation between physicians' individual alert quantities and override rates as an indicator of potential alert fatigue. METHODS: We retrospectively analyzed physician responses to drug-drug and drug-allergy interaction alerts, as generated by a common decision support product in a large teaching hospital system. RESULTS: (1) Over four days, 461 different physicians entered 18,354 medication orders, resulting in 2,455 visible alerts; 2,280 alerts (93%) were overridden. (2) The drug-drug alert override rate was 95.1%, statistically higher than the rate for drug-allergy alerts (90.9%) (p < 0.001). There was no significant difference in override rates between attendings and residents, or between hospitals. (3) Physicians saw a mean of 1.3 alerts per day, and the number of alerts per physician was not significantly correlated with override rate (R2 = 0.03, p = 0.41). CONCLUSIONS: Despite intensive efforts to improve a commercial drug interaction alert system and to reduce alerting, override rates remain as high as reported over a decade ago. Alert fatigue does not seem to contribute. The results suggest the need to fundamentally question the premises of drug interaction alert systems.

Reduction in chemotherapy order errors with computerized physician order entry.

PURPOSE: To measure the number and type of errors associated with chemotherapy order composition associated with three sequential methods of ordering: handwritten orders, preprinted orders, and computerized physician order entry (CPOE) embedded in the electronic health record. MATERIALS AND METHODS: From 2008 to 2012, a sample of completed chemotherapy orders were reviewed by a pharmacist for the number and type of errors as part of routine performance improvement monitoring. Error frequencies for each of the three distinct methods of composing chemotherapy orders were compared using statistical methods. RESULTS: The rate of problematic order sets-those requiring significant rework for clarification-was reduced from 30.6% with handwritten orders to 12.6% with preprinted orders (preprinted v handwritten, P < .001) to 2.2% with CPOE (preprinted v CPOE, P < .001). The incidence of errors capable of causing harm was reduced from 4.2% with handwritten orders to 1.5% with preprinted orders (preprinted v handwritten, P < .001) to 0.1% with CPOE (CPOE v preprinted, P < .001). CONCLUSION: The number of problem- and error-containing chemotherapy orders was reduced sequentially by preprinted order sets and then by CPOE. CPOE is associated with low error rates, but it did not eliminate all errors, and the technology can introduce novel types of errors not seen with traditional handwritten or preprinted orders. Vigilance even with CPOE is still required to avoid patient harm.

Effectiveness of an electronic inpatient medication record in reducing medication errors in Singapore.

This study examined the effectiveness of an inpatient electronic medication record system in reducing medication errors in Singaporean hospitals. This pre- and post-intervention study involving a control group was undertaken in two Singaporean acute care hospitals. In one hospital the inpatient electronic medication record system was implemented while in another hospital the paper-based medication record system was used. The mean incidence difference in medication errors of 0.06 between pre-intervention (0.72 per 1000 patient days) and post-intervention (0.78 per 1000 patient days) for the two hospitals was not statistically significant (95%, CI: [0.26, 0.20]). The mean incidence differences in medication errors relating to prescription, dispensing, and administration were also not statistically different. Common system failures involved a lack of medication knowledge by health professionals and a lack of a systematic approach in identifying correct dosages. There was no difference in the incidence of medication errors following the introduction of the electronic medication record system. More work is needed on how this system can reduce medication error rates and improve medication safety.

Detection and correct handling of prescribing errors in Dutch hospital pharmacies using test patients.

BACKGROUND: Hospital pharmacists and pharmacy technicians play a major role in detecting prescribing errors by medication surveillance. At present the frequency of detected and correctly handled prescribing errors is unclear, as are factors associated with correct handling. OBJECTIVE: To examine the frequency of detection of prescribing errors and the frequency of correct handling, as well as factors associated with correct handling of prescribing errors by hospital pharmacists and pharmacy technicians. SETTING: This study was conducted in 57 Dutch hospital pharmacies. METHOD: Prospective observational study with test patients, using a case-control design to identify factors associated with correct handling. A questionnaire was used to collect the potential factors. Test patients containing prescribing errors were developed by an expert panel of hospital pharmacists (a total of 40 errors in nine medication records divided among three test patients; each test patient was used in 3 rounds; on average 4.5 prescribing error per patient per round). Prescribing errors were defined as dosing errors or therapeutic errors (contra-indication, drug-drug interaction, (pseudo)duplicate medication). The errors were selected on relevance and unequivocalness. The panel also defined how the errors should be handled in practice using national guidelines and this was defined as 'correct handling'. The test patients had to be treated as real patients while conducting medication surveillance. The pharmacists and technicians were asked to report detected errors to the investigator. MAIN OUTCOME MEASURE: The percentages of detected and correctly handled prescribing errors were the main outcome measures. Factors associated with correct handling were determined, using multivariate logistic regression analysis. RESULTS: Fifty-nine percent of the total number of intentionally added prescribing errors were detected and 57 % were handled correctly by the hospital pharmacists and technicians. The use of a computer system for medication surveillance compared to no computer system was independently associated with correct handling [odds ratio (OR) 15.39 (95 % confidence interval (CI) 3.62-65.50] for computerized physician order entry system; OR 15.40 (95 % CI 3.61-65.70) for order entry by pharmacy technicians), but because the reference category contained only one hospital these results can't be interpreted. Furthermore, manual screening of dosages in children with or without computerized surveillance compared to no dosage checks for children [OR 2.02 (95 % CI 1.06-3.84)], qualified pharmacy technicians compared to no qualified pharmacy technicians [OR 1.32 (95 % CI 1.03-1.67)] and pharmacy technicians using protocols compared to ones not using protocols [OR 1.30 (95 % CI 1.04-1.61)] were independently associated with correct handling. CONCLUSION: This study showed that the quality of medication surveillance in Dutch hospital pharmacies can be subject to improvement and the identified factors may give direction to such improvements.