Effects of stratified medication review in high-risk patients at admission to hospital: a randomised controlled trial.

BACKGROUND: Patients at high risk of medication errors will potentially benefit most from medication reviews. An algorithm, MERIS, can identify the patients who are at highest risk of medication errors. The aim of this study was to examine the effects of performing stratified medication reviews on patients who according to MERIS were at highest risk of medication errors. METHODS: A randomised controlled trial was performed at the Acute Admissions Unit, Aarhus University Hospital, Denmark. Patients were included at admission to the hospital and were randomised to control or intervention. The intervention consisted of stratified medication review at admission on patients with a high MERIS score. Clinical pharmacists and clinical pharmacologists performed the medication reviews; the clinical pharmacologists performed the reviews on patients with the highest MERIS score. The primary outcome measure was the number of prescribing errors during the hospitalisation. Secondary outcomes included self-experienced quality of life, health-care utilisation and mortality measured at follow-up 90 days after discharge. RESULTS: A total of 375 patients were included, of which medication reviews were performed in 64 patients. The medication reviews addressed 63 prescribing errors in 37 patients and 60 other drug-related problems. No difference in the number of prescribing errors during hospitalisation between the intervention group (n = 165) and control group (n = 153) was found, corresponding to 0.11 prescribing errors per drug (95% confidence interval (CI): 0.08-0.14) versus 0.13 per drug (95% CI: 0.09-0.16), respectively. No differences in secondary outcomes were observed. CONCLUSION: A stratified medication review approach based on the individual patient's risk of medication errors did not show impact on the chosen outcomes. PLAIN LANGUAGE SUMMARY: How does a medication review at admission affect patients who are in high risk of medication errors? Patients are at risk of medication errors at admission to hospital. Medication reviews aim to detect and solve these. Yet, due to limited resources in healthcare, it would be beneficial to detect the patients who are most at risk of medication errors and perform medication reviews on those patients.In this study we investigated whether an algorithm, MERIS, could detect patients who are at highest risk of medication errors; we also studied whether performing medication reviews on patients at highest risk of medication errors would have an effect on, for example, the number of medication errors during hospitalisation, qualify of life and number of readmissions. We included 375 patients in a Danish acute admission unit and they were divided into control group and intervention group. Patients in the intervention group received a medication review at admission if they were considered at high risk of medication errors, assessed with the aid of MERIS. In summary, 64 patients in the intervention group were most at risk of medication errors and therefore received a medication review.We conclude in the study that MERIS was useful in identifying relevant patients for medication reviews. Yet, the medication reviews performed at admission did not impact on the chosen outcomes.

A national drug related problems database: evaluation of use in practice, reliability and reproducibility.

BACKGROUND: A drug related problems database (DRP-database) was developed on request by clinical pharmacists. The information from the DRP-database has only been used locally e.g. to identify focus areas and to communicate identified DRPs to the hospital wards. Hence the quality of the data at the national level is unknown, which may compromise national analyses for benchmarking and identification of national focus areas. OBJECTIVE: The aim of the study was to evaluate the use in practice, reliability and reproducibility of the DRPs documented in the Danish drug related problems database. SETTING: Danish hospital pharmacies. METHODS: Practice use of the DRP-database was explored by an electronic questionnaire distributed to hospital pharmacies, and consisted of questions regarding current and previous use of the DRP-database. The reliability was evaluated by comparing the categorization of 24 cases by clinical pharmacists with categorization performed by the project group. Reproducibility was explored by re-categorization of a sample of existing records in the DRP-database by two project group members individually. MAIN OUTCOME MEASURES: Observed proportion of agreement and Fleiss' kappa as measures of inter-rater reliability and reproducibility. RESULTS: The practice use study of 12 hospital pharmacy locations revealed that when implementing the DRP-database, the majority of identified DRPs are documented in the DRP-database, however, some variations throughout the country exist. The interrater reliability study of 34 clinical pharmacists showed high inter-rater reliability with the project group (Fleiss' kappa = 0.79 with 95 % CI (0.70; 0.88)), and the reproducibility study also documented high inter-rater reliability of a sample of 379 records from the DRP-database re-categorized by two project group members (Fleiss' kappa = 0.81 with 95 % CI (0.78; 0.85)). CONCLUSION: The study showed high reliability and reproducibility of the DRP-database, however, some local variation in the use of the DRP-database throughout the country existed affecting the overall quality. These findings indicate that data in the DRP-database may be pooled, and national analyses may be conducted to explore development areas for common interest.

Characterization of drug-related problems identified by clinical pharmacy staff at Danish hospitals.

BACKGROUND: In 2010, a database of drug related problems (DRPs) was implemented to assist clinical pharmacy staff in documenting clinical pharmacy activities locally. A study of quality, reliability and generalisability showed that national analyses of the data could be conducted. Analyses at the national level may help identify and prevent DRPs by performing national interventions. OBJECTIVE: The aim of the study was to explore the DRP characteristics as documented by clinical pharmacy staff at hospital pharmacies in the Danish DRP-database during a 3-year period. SETTING: Danish hospital pharmacies. METHOD: Data documented in the DRP-database during the initial 3 years after implementation were analyzed retrospectively. The DRP-database contains DRPs reported at hospitals by clinical pharmacy staff. The analyses focused on DRP categories, implementation rates and drugs associated with the DRPs. MAIN OUTCOME MEASURE: Characteristics of DRPs. RESULTS: In total, 72,044 DRPs were documented in the DRP-database during the first 3 years of implementation, and the number of documented DRPs increased every year. An overall stable implementation rate of approximately 58 % was identified. The DRPs identified were multi-facetted, however evenly distributed for each of the 3 years. The most frequently identified DRP categories were: "Dose", followed by "Nonadherence to guidelines" and "Supplement to treatment". The highest implementation rates were found for the following DRP categories: "Non-adherence to guidelines" (79 %) followed by "Therapeutic duplication" (73 %) and "Dosing time and interval" (70 %). Even though the top 25 drugs were involved in 58 % of all DRPs, multiple drugs were associated with DRPs. The drugs most frequently involved in DRPs were paracetamol (4.6 % of all DRPs), simvastatin (3.0 %), lansoprazole (2.7 %), morphine (2.6 %) and alendronic acid (2.4 %). CONCLUSIONS: The study found that a national database on DRPs contained multi-facetted DRPs, however evenly distributed for each of the 3 years. Even though the top 25 drugs were involved in 58 % of all DRPs, multiple drugs were associated with DRPs. The study emphasizes the importance of detecting and intervening for DRPs.