Financial impact of medication reviews by clinical pharmacists to reduce in-hospital adverse drug events: a return-on-investment analysis.

BACKGROUND: Adverse drug events contribute to rising health care costs. Clinical pharmacists can reduce their risks by identifying and solving drug-related problems (DRPs) through medication review. AIM: To develop an economic model to determine whether medication reviews performed by clinical pharmacists could lead to a reduction in health care costs associated with the prevention of potential adverse drug events. METHOD: Two pharmacists performed medication reviews during ward rounds in an internal medicine setting over one year. Avoided costs were estimated by monetizing five categories of DRPs (improper drug selection, drug interactions, untreated indications, inadequate dosages, and drug use without an indication). An expert panel assessed potential adverse drug events and their probabilities of occurrence for 20 randomly selected DRPs in each category. The costs of adverse drug events were extracted from internal hospital financial data. A partial economic study from a hospital perspective then estimated the annual costs avoided by resolving DRPs identified by 3 part-time clinical pharmacists (0.9 full-time equivalent) from 2019 to 2020. The return on investment (ROI) of medication review was calculated. RESULTS: The estimated annual avoided costs associated with the potential adverse drug events induced by 676 DRPs detected was € 304,170. The cost of a 0.9 full-time equivalent clinical pharmacist was € 112,408. Extrapolated to 1 full-time equivalent, the annual net savings was € 213,069 or an ROI of 1-1.71. Sensitivity analyses showed that the economic model was robust. CONCLUSION: This economic model revealed the positive financial impact and favorable return on investment of a medication review intervention performed by clinical pharmacists. These findings should encourage the future deployment of a pharmacist-led adverse drug events prevention program.

Development and evaluation of a blended learning training programme for pharmacy technicians' continuing education.

OBJECTIVES: The role of the pharmacy technician (PT) has expanded in recent years, requiring new competencies, better communications skills and high-level knowledge about drugs. The objective of this study is to develop and evaluate a blended learning programme for PTs' continuing professional development. METHODS: A blended learning programme designed to enhance knowledge, skills and attitudes was created using a six-step approach to curriculum development for medical education. The first part included three short microlearning videos to improve knowledge; the second consisted of a 1.5 hour 'edutainment' session for groups of 5-6 PTs to deepen their knowledge and practice skills. Impacts on knowledge, degree of certainty and self-perceived competence were evaluated before training (pre-test), after the microlearning (post-test 1) and after the edutainment session (post-test 2). RESULTS: The three microlearnings were entitled 'Communication', 'Cut-crush a tablet/open a capsule' and 'Pharmacy website'. The edutainment session used team-based learning, game-based learning, peer instruction and simulation. Twenty-six PTs of mean±SD age 36±8 years participated. Pre-test and post-test 1 evaluation scores showed significant overall improvements in mean knowledge (9.1/18 vs 12.1/18, p<0.001), mean degree of certainty (3.4/5 vs 4.2/5, p<0.001) and mean self-perceived competence (58.6/100 vs 72.3/100, p<0.001). After post-test 2, mean knowledge (12.1/18 vs 13.1/18, p=0.010) and mean self-perceived competence (72.3/100 vs 81.1/100, p=0.001) scores had improved, but not mean degree of certainty (4.2/5 vs 4.4/5, p=0.105). All participants found the blended learning programme suitable for their continuing professional development. CONCLUSIONS: The present study showed the positive effects of using our blended learning programme to improve PTs' knowledge, degree of certainty and self-perceived competence, to their great satisfaction. This pedagogical format will be integrated into PTs' continuing professional development and include other educational topics.

WoCoVA consensus on the clinical use of in-line filtration during intravenous infusions: Current evidence and recommendations for future research.

The need for filtering intravenous infusions has long been recognized in the field of venous access, though hard scientific evidence about the actual indications for in-line filters has been scarce. In the last few years, several papers and a few clinical studies have raised again this issue, suggesting that the time has come for a proper definition of the type of filtration, of its potential benefit, and of its proper indications in clinical practice. The WoCoVA Foundation, whose goal is to increase the global awareness on the risk of intravenous access and on patients' safety, developed the project of a consensus on intravenous filtration. A panel of experts in different aspects of intravenous infusion was chosen to express the current state of knowledge about filtration and to indicate the direction of future research in this field. The present document reports the final conclusions of the panel.

NeoCheck: a prescription-screening tool to optimise pharmacotherapy for hospitalised neonates.

AIMS OF THE STUDY: To develop a screening tool to optimise neonatal drug prescription, which is often based on low-quality evidence. METHODS: Neonatal pharmacotherapy recommendations were identified by literature review and synthesised into NeoCheck tool statements. In a two-round modified Delphi process, experts from Swiss neonatal intensive care units (NICUs) rated their agreement with individual statements using a five-point Likert scale (5 = totally agree). Statements with >65% scores ≥4 in round 1 and >75% scores ≥4 in round 2 were selected. RESULTS: We identified 1375 clinical guidelines via literature review. After synthesis, 158 statements were submitted to 23 experts (1 clinical pharmacist, 22 neonatologists; 65% with >10 years neonatology practice) from 10 Swiss NICUs. Nineteen items did not reach the agreement threshold and were eliminated in the second Delphi round. The final NeoCheck tool comprises 141 statements in 11 medical domains concerning 49 neonatal diseases. Most (79%) statements concern all neonates, 13% concern preterm (<37 weeks gestational age) infants and 3% concern very preterm (<32 weeks gestational age) infants CONCLUSIONS: NeoCheck is the first prescription-screening tool developed to optimise neonatal pharmacotherapy. In a future prospective study, its effect on NICU prescription optimisation and the quality of care will be assessed.

Incidence and Causes of Infusion Alarms in a Neonatal and Pediatric Intensive Care Unit: A Prospective Pilot Study.

OBJECTIVES: To evaluate the incidence and causes of infusion alarms in a NICU/PICU setting. METHODS: We conducted a 90-day prospective analysis of event logs downloaded daily from infusion pumps (syringe and volumetric pumps). The details about conditions surrounding alarm events were described daily by bedside nurses on a standardized form. The occlusion pressure alarm was set at 300 mm Hg on each device. RESULTS: Forty-one pediatric patients including 12 neonates, mean weight 11.0 ± 11.3 kg (minimum-maximum, 0.48-50), were included for a total infusion time of 2164 hours. Eight hundred forty-three infusion alarms were documented (220 [26.1%] occlusion; 273 [32.4%] infusion completed; 324 [38.4%] door open/syringe disengagement; 26 [3.1%] air-in-line) resulting in an incidence of 4.7 infusion (1.2 occlusion) alarms per patient per day.Detailed conditions surrounding occlusion alarm events were documented in only 22.7% (50/220) of the cases. Of these, 36% (18/50) were related to closed or clamped lines, 4% (2/50) to syringe change, 16% (8/50) to drug injection, and 8% (4/50) to patient-related factors. The remaining 36% (18/50) occurred without any apparent external cause during ongoing infusion, among these drug incompatibilities were a potential cause for 12 events. CONCLUSION: Alarms from infusion pumps were frequent in the NICU/PICU setting, a quarter of them resulting from line occlusion. Other than well-known triggers (mechanical and patient factors), drug incompatibilities were identified as a potential cause for occlusion alarms in this pilot study.

E-Learning Training to Improve Pediatric Parenteral Nutrition Practice: A Pilot Study in Two University Hospitals.

BACKGROUND: Education and training may improve the prescription of pediatric parenteral nutrition. The aim was to evaluate the impact of an e-learning method on parenteral nutrition prescription skills among pediatric residents in 2 pediatric hospitals. METHODS: A randomized double-blind control study was conducted over a 9-month period among pediatric residents in HOSP1, Geneva, Switzerland, where physicians prescribe parenteral nutrition directly, and in HOSP2, Montreal, Canada, where physicians prescribe only occasionally because clinical pharmacists are devoted to this activity. The intervention consisted of an e-learning session about key issues of parenteral nutrition. Physician parenteral nutrition knowledge was evaluated with a standardized questionnaire based on clinical cases before and after the e-learning in the intervention groups; in the control groups, only the 2 tests were conducted. In HOSP1, participants also underwent iterative tests every 2 months to measure the retention of knowledge. RESULTS: Sixty-five physicians participated. Initial knowledge scores were higher in HOSP1 (pretest scores 180 ± 29 vs 133 ± 24, p < 0.001). Overall, there was no significant difference in the impact of the e-learning intervention between the control and e-learning groups (p > 0.05). A significant knowledge improvement was observed in HOSP2 in the e-learning group (p = 0.033). Iterative tests in HOSP1 showed persistence of knowledge without significant differences between the groups. E-learning satisfaction among the participants was outstanding (100%). CONCLUSION: E-learning seems to be an effective method for teaching parenteral nutrition among pediatric residents and fellows at the beginning of the training. High satisfaction with this teaching method was observed in this study.

Immunosuppressant therapeutic drug monitoring and trough level stabilisation after paediatric liver or kidney transplantation.

BACKGROUND: Immunosuppressive therapy must be guided by therapeutic drug monitoring (TDM) in paediatric liver (LT) and kidney transplantation (KT) patients to prevent under- and overdosing, which have clinical consequences. AIM: The purpose of our study was to analyse TDM results in our institutions and evaluate factors associated with blood level stabilisation after LT and KT. METHODS: Blood levels of immunosuppressants were measured by immunoassay analysis. We compared blood level stabilisation between LT and KT, and evaluated associated factors in a retrospective study in two Swiss university hospitals. RESULTS: Forty-six patients (27 LT [median age 1.0 y], 19 KT [15.1 y]) were included. During the first month after transplantation, 32.8% (LT) and 41.2% (KT) of tacrolimus, and 22.1% (KT) of ciclosporin trough levels (measured before the next dose) were within target. In KT, trough levels stabilised earlier for tacrolimus than for ciclosporin (p = 0.02). Intensive care and hospital discharge occurred earlier in KT patients (p <0.001). Living-donor LT was associated with an earlier intensive care discharge compared with deceased donor (5.5 vs 11 days, p = 0.02). Primary metabolic disease and graft/recipient weight-ratio ≥0.03 was associated with earlier tacrolimus level stabilisation (14 vs 18 days, p = 0.01 and 15 vs 22 days, p = 0.05, respectively). In KT, recipient age (≥15.1 years) and weight (≥39.4 kg) were associated with an earlier trough level stabilisation (both 13 days vs not reached, p <0.001), and age with earlier hospital discharge (10 vs 14 days, p = 0.02). CONCLUSION: Immunosuppressant trough levels were often outside the target range in the first month after LT and KT. Organ-specific factors were associated with trough stabilisation.

Evaluation of Incompatible Coadministration of Continuous Intravenous Infusions in a Pediatric/Neonatal Intensive Care Unit.

OBJECTIVES: We aimed to evaluate and quantify incompatible coadministrations of continuous intravenous medication in the daily clinical practice of a PICU/NICU. METHODS: We conducted a retrospective, observational study in the setting of an 18-bed PICU/NICU. All concurrently administered continuous infusions, including blood products and parenteral nutrition, were analyzed for 2 months. Raw electronic data were retrieved and subjected to quality controls. Infusion combinations were classified as compatible, incompatible, no data, or variable according to the internal hospital charts, Trissel's database, and the Swiss summary of product characteristics. For situations with incompatible coadministrations, we assessed alternative distributions of infusions among the currently available lumen. RESULTS: Data for 100 patients were analyzed. Patients were exposed to a mean of 6.9 ± 3.6 individual continuous infusions administered through 3.8 ± 1.8 lumina. Among the 1447 coadministered continuous infusions, we detected 146 incompatible combinations (10%), resulting in 105 individually relevant incompatible situations. Furthermore, 185 combinations (13%) were not covered by internal compatibility charts, and for 207 combinations (15%) no data on compatibility were available. We found that 58% of the incompatible situations could have been avoided by a redistribution of the infusions among the available lumina. CONCLUSIONS: Most infusion combinations in the studied PICU/NICU were compatible and covered by the internal compatibility charts. However, we also identified concurrent administrations of incompatible infusions or for which compatibility data are not available. A significant reduction of coadministrations of incompatible infusions could be achieved through optimal use of available lumina.

PIM-Check: development of an international prescription-screening checklist designed by a Delphi method for internal medicine patients.

OBJECTIVES: Potentially inappropriate medication (PIM) occurs frequently and is a well-known risk factor for adverse drug events, but its incidence is underestimated in internal medicine. The objective of this study was to develop an electronic prescription-screening checklist to assist residents and young healthcare professionals in PIM detection. DESIGN: Five-step study involving selection of medical domains, literature review and 17 semistructured interviews, a two-round Delphi survey, a forward/back-translation process and an electronic tool development. SETTING: 22 University and general hospitals from Canada, Belgium, France and Switzerland. PARTICIPANTS: 40 physicians and 25 clinical pharmacists were involved in the study.Agreement with the checklist statements and their usefulness for healthcare professional training were evaluated using two 6-point Likert scales (ranging from 0 to 5). PRIMARY AND SECONDARY OUTCOME MEASURES: Agreement and usefulness ratings were defined as: >65% of the experts giving the statement a rating of 4 or 5, during the first Delphi-round and >75% during the second. RESULTS: 166 statements were generated during the first two steps. Mean agreement and usefulness ratings were 4.32/5 (95% CI 4.28 to 4.36) and 4.11/5 (4.07 to 4.15), respectively, during the first Delphi-round and 4.53/5 (4.51 to 4.56) and 4.36/5 (4.33 to 4.39) during the second (p<0.001). The final checklist includes 160 statements in 17 medical domains and 56 pathologies. An algorithm of approximately 31 000 lines was developed including comorbidities and medications variables to create the electronic tool. CONCLUSION: PIM-Check is the first electronic prescription-screening checklist designed to detect PIM in internal medicine. It is intended to help young healthcare professionals in their clinical practice to detect PIM, to reduce medication errors and to improve patient safety.

Confusion between Two Amphotericin B Formulations Leading to a Paediatric Rehospitalisation.

A heavily immunosuppressed, 43-kg, 9-year-old patient was recovering from a bone marrow transplant. Primary prophylaxis against invasive fungal infections was liposomal amphotericin B (AmBisome®, 2.3 mg/kg [100 mg] two times per week). Once home, following a first amphotericin B infusion, he presented with strong diarrhoea and vomiting; this was repeated after the second infusion. The clinical situation worsened rapidly and the patient was rehospitalised. On admission, he presented with acute renal failure. During the 2-week hospitalisation, renal function recovered progressively. A few days after returning home, a new administration of amphotericin B was again followed by diarrhoea and vomiting, together with shivering and fever. The child was again rapidly rehospitalised. Investigation revealed that the community pharmacist, relying on drug software, had selected an inappropriate substitute drug: the patient had been administered amphotericin B deoxycholate (Fungizone®) and not liposomal amphotericin B. Depending on the indication, intravenous AmBisome® is usually administered at a dose between 3 and 5 mg/kg bodyweight; this dose can be increased to up to 10 mg/kg/day. Intravenous Fungizone®, however, should be administered using an initial dose of 0.25 mg/kg bodyweight, up to a recommended 1-mg/kg/day dose. The child had thus received 100 mg of Fungizone®, or ten times the recommended dose.

Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital discharge.

BACKGROUND: Discharging patients from hospital is a complex multidisciplinary process that can lead to non-compliance and medication-related problems. OBJECTIVE: To evaluate risks of discontinuity of pharmaceutical care at paediatric hospital discharge and assess potential improvement strategies, using two complementary methods: a prospective risk analysis and a spontaneous incident reporting system. SETTING: Geneva University hospitals and community pharmacies. METHODS: A multidisciplinary team analysed the paediatric medication discharge process applying the failure modes (FM), effects, and criticality analysis (FMECA), using ibuprofen, morphine, valganciclovir as model drugs. Over 46 months, incidents with discharge prescriptions, reported by community pharmacists, were classified according to FMECA's FM. MAIN OUTCOME MEASURES: FM, criticality indexes (CI), incidents. RESULTS: Twenty-four FM were identified. The highest criticality scores were given for prescribing the wrong dosage [mean criticality index (CI = 205)], early treatment discontinuation by the patient (CI = 195), and continuation of contraindicated treatment by the general practitioner (CI = 191). Implementation of eight improvement strategies covering the eight most critical FM led to a 64 % reduction in criticality scores (CI 496 vs 1,392). Improvement of the computerized-physician-order-entry system was the single most effective strategy (CI 843 vs 1,392). Only 52 incidents were spontaneously reported (17 for paediatric patients). Paediatric problems most frequently reported (lack of information, 35 %; delay in drug supply, 18 %) were consistent with the highest frequencies scored by FMECA. CONCLUSION: Spontaneous incident reporting leads to high levels of under-reporting, but highlighted similar problems at paediatric hospital discharge to FMECA. Using FMECA allowed estimations of criticalities at each step and the potential impact of safety improvement strategies. Proactive and reactive methods proved complementary and would help to set up effective targeted improvement strategies to improve medication process at paediatric hospital discharge.

Impact of clinical decision support guidelines on therapeutic drug monitoring of gentamicin in newborns.

BACKGROUND: Our institution's gentamicin dosing and therapeutic drug monitoring (TDM) practices for newborns were suspected to be very heterogeneous. Once-daily dosing (ODD) or extended-interval dosing (EID) and trough concentration measurement were recommended. Clinical decision support guidelines were developed and implemented as clinical decision support in the computerized prescriber order entry system. Impact on dosing, TDM practices, and blood sampling were evaluated. METHODS: A 1-year retrospective historically controlled study before (April 2008-March 2009) and after the implementation of guidelines (January 2010-December 2010) for newborns (<30 days of life) receiving gentamicin. Blood concentrations (% of peak concentrations sampled, % of patients with zero or one concentration sampled, % of trough concentrations ≤1 mg/L) and dose regimen (ODD/EID) were compared between groups. Factors potentially associated with gentamicin concentration were analyzed (multivariate analysis). RESULTS: One hundred thirty-two (postguidelines) versus 102 (preguidelines) patients were included (median gestational age: 34.3 versus 35.8 weeks, P > 0.05). After implementation of the guidelines, an ODD/EID regimen was almost exclusively used (97.7% versus 61.6%, P < 0.001), the percentage of peak concentrations (0.9% versus 17.2%, P < 0.001) and the number of blood samples per patient (87.1% having 0 or 1 concentration measured versus 48.0, P < 0.001) sharply reduced. A significantly higher percentage of trough concentrations were ≤1 mg/L (68.5% versus 33.0%, P < 0.001). The probability of a trough concentration ≤1 mg/L increased with an ODD/EID regimen (odds ratio, 7.23; 95% confidence interval: 3.48-15.0, P < 0.001) and in the postguidelines group (odds ratio, 2.02; 95% confidence interval: 1.01-4.02, P = 0.045). CONCLUSIONS: Guideline implementation generated a sharp reduction in blood sampling. Clinical benefits of better gentamicin dosing and TDM practices were evident. Cost-effectiveness and clinical benefit of reduced blood sampling should be evaluated.

Compatibility of intravenous medications with parenteral nutrition: in vitro evaluation.

BACKGROUND AND AIM: Hospitalized patients requiring parenteral nutrition (PN) often need to receive intravenous (IV) medications as well. Y-site administration is occasionally necessary, but physicochemical incompatibilities can occur between the medications and PN. The aim of the present study was to assess the physical compatibility between 25 frequently coadministered IV medications and a commercially available ready-to-use total PN. METHODS: PN (NuTRIflex Lipid Special; B. Braun Medical AG, Sempach, Switzerland) and medications were mixed in 1:1 (v/v) proportions, and the stability was assessed at the time of mixing and after 1 and 4 hours. The stability of lipid emulsion was observed by microscopic investigation, visual inspection, dynamic laser light scattering, and laser light obscuration. The binary admixtures of PN (without lipid emulsion) and medications were used to detect discoloration, visibly detectable precipitates, and subvisual particles. RESULTS: Two of 25 medications were incompatible with the lipid emulsion (serum albumin 20% and tropisetron), 2 showed signs of degradation (discoloration) over time (esomeprazole and pantoprazole), and 1 precipitated at high concentrations (5-fluorouracil). The other 20 medications were considered compatible when administered by Y-site. CONCLUSION: The present study validated the compatibility of 1 commercially available PN and 20 medications. These results offer new solutions to support the implementation of complex therapeutic schemes in practice, when coadministration via Y-site cannot be avoided.

Maximizing calcium and phosphate content in neonatal parenteral nutrition solutions using organic calcium and phosphate salts.

BACKGROUND: The provision of high amounts of calcium and phosphate in parenteral nutrition (PN) solution for neonates is important for bone mass accretion. Because of the risk of calcium phosphate precipitation, a well-documented incompatibility for inorganic salts, the concentrations of these electrolytes in PN are generally limited to 5 mmol/L. The aim of this study was to assess the risk of precipitation of calcium phosphate when organic calcium and phosphate salts are used instead of inorganic salts. METHODS: Precipitation curves were determined for inorganic and organic calcium and phosphate salts in a PN solution favorable to precipitation (low concentration of amino acids and glucose) using visual inspection and particle counts. RESULTS: The use of organic phosphate salt was associated with a decreased risk of precipitation of calcium phosphate. No precipitation occurred up to a concentration of 50 mmol/L of calcium and phosphate. In contrast, organic calcium salt only slightly decreased the risk of precipitation. CONCLUSION: Up to 50 mmol/L of organic calcium and phosphate salts can be safely mixed in PN, even in unstable conditions, making it possible to follow the current European recommendations for requirements in neonates.

Evaluation of tools to prevent drug incompatibilities in paediatric and neonatal intensive care units.

OBJECTIVE: Intravenous drug administration in neonatal (NICU) and paediatric intensive care units (PICU) is critical because of poor venous access, polymedication, fluid restriction and low infusion rate. Risk is further increased by inadequate information on the physicochemical compatibility of drugs. Eight decision-supporting tools were hence evaluated to improve the detection of drug incompatibilities in paediatric wards. SETTING: NICU and PICU, University hospital. METHOD: Eight tools (Thériaque 2007, Stabilis 3, Perfysi 2 databases; KIK 3.0 software; Neofax 2007 handbook; King 2008 Guide, CHUV 9.0, pH 2007 cross-tables) were assessed by two pharmacists using 40 drug pairs (20 incompatible; 20 compatible) frequently prescribed in PICUs and NICUs. Trissel's 14th Ed. handbook served as the gold standard. Four criteria were evaluated (each with a maximum of 250 points): accuracy (sensitivity, specificity, positive and negative predictive values), completeness (number of drug pairs documented), comprehensiveness (presence of 16 different items), and applicability (by combining the time needed by 7 pharmacists to classify 5 drug pairs, plus an evaluation of their design, usefulness, reliability and ergonomics, using visual analogy scales). The percentage of non-compliant answers (NCA) was calculated for both the performing pharmacists and the tools. MAIN OUTCOME MEASURE: Global score of drug incompatibilities (accuracy + completeness + comprehensiveness + applicability). RESULTS: Thériaque obtained the best global score (840/1000 points), followed by pH (807), CHUV (803), Perfysi (776), Neofax (678), King Guide (642), Stabilis (584) and KIK (523), respectively. The highest scores were reached by Thériaque for accuracy (234/250); Thériaque and pH for completeness (200/250); Thériaque and Perfysi for comprehensiveness (218/250); and pH for applicability (298/250). The range of pharmacists' NCAs was between 9% (4/45 NCAs) and 33% (15/45), whereas that for drug pairs was between 10% (6/63) and 30% (19/63). The range of NCAs for tools was between 6% (2/35, pH) and 49% (18/35, Perfysi). CONCLUSIONS: Thériaque proved outstanding as a drug-incompatibility tool. However, all resources showed some shortcomings. The large ranges of pharmacists' NCAs shows that such an assessment is subject to different interpretations. Standard operating procedures for drug-incompatibility assessment should be implemented in drug-information centres. Tools with low NCA percentage, such as the pH or CHUV tables, may be useful for nurses in ICUs.

Long-term physico-chemical stability of standard parenteral nutritions for neonates.

BACKGROUND & AIMS: Two ready-to-use parenteral nutritions (PN) have been developed, for the first days of life of the premature newborn, along with syringes of lipid emulsion with or without vitamins. Long-term physico-chemical stability for storage in wards was assessed. METHODS: Physico-chemical stability of PN: visual inspection, particle size, pH, osmolarity measurement, amino acids, glucose, and electrolytes dosages. Physico-chemical stability of lipid emulsion: visual inspection, globule size, peroxide level and vitamins A, E, and C dosages. Stability was studied for 12 weeks on refrigerated (2-8 °C) and room temperature (30 ± 2 °C) samples. RESULTS: No precipitation was detected in any PN. A brown coloration was observed in PN stored for four weeks at room temperature but not in the refrigerator. Concentrations of all the nutrients remained constant over the 12 week-study period. Phase separation of the lipid emulsion occurred after three weeks, but particle size complied with the USP limits for 12 weeks. Peroxide content increased only in the samples without vitamins at room temperature. Vitamins remained stable for one week under refrigeration. CONCLUSION: The PN did not present a detectable change of the tested properties when refrigerated for 12 weeks. The lipid emulsion with vitamins is stable for one week when refrigerated.

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

OBJECTIVE: To analyse safety risks in injectable medications. To assess the potential impact and pharmacoeconomic aspects of safety tools. DESIGN: The injectable drug process was prospectively assessed using a failure modes, effects and criticality analysis. Criticality indexes were estimated based on their likelihood of occurrence, detection probability and potential severity. The impact of 10 safety tools on the criticality index was calculated and extrapolated to all drugs injected daily. Yearly costs for a reduction in criticality by 1 point (=1 quali) per day were estimated. SETTING: Paediatric and neonatal intensive care units in a University Hospital. PARTICIPANTS: Two paediatric nurses, a neonatologist, three hospital pharmacists. INTERVENTIONS: Qualitative and quantitative risk assessment. MAIN OUTCOME MEASURES: Failure modes, criticality indexes, cost-efficacy ratios. RESULTS: Thirty-one failure modes identified, with the mean of their entire criticality indexes totalling 4540. The most critical failure mode was microbial contamination. The following gains were predicted: 1292 quali (46 500 per day by extrapolation) from ready-to-use syringes, 1201 (72 060) by employing a clinical pharmacist, 996 (59 780) from double check by nurses and 984 (59 040) with computerized physician order entry. The best cost-efficacy ratios were obtained for a clinical pharmacist (1 quali = 0.54 euros), double check (1 quali = 0.71 euros) and ready-to-use syringes (1 quali = 0.72 euros). Computerized physician order entry showed the worst cost-efficacy ratio due to a very high investment costs (1 quali = 22.47 euros). CONCLUSION: Based on our risk and pharmacoeconomic analyses, clinical pharmacy and ready-to-use syringes appear as the most promising safety tools.

Subcutaneous administration of drugs in the elderly: survey of practice and systematic literature review.

OBJECTIVES AND METHOD: Survey of subcutaneous drug use and hypodermoclysis with a standardized questionnaire to 27 nursing teams and 52 physicians in a geriatric hospital department (404 beds). Evaluation of license status (CH, F, D and UK) and systematic literature review of 34 drugs used in the geriatric setting. RESULTS: Subcutaneous route is used daily with drugs and fluids mostly for patients in palliative care (83%) or who are dehydrated (54%) when oral or IV administration is impossible (73%, 68% respectively). Morphine (98%), haloperidol (90%), furosemide (69%) and hydromorphone (56%) by bolus (36%) or slow injection over 5 min (82%) are the main drugs used and NaCI 0.9% (95%), and glucose 5%/NaCI 0.9% (31 %) are commonly used for rehydration. Among the 34 drugs reviewed, only 13 (38%) are licensed for subcutaneous use in CH, UK, F or D, and only, morphine (14 articles of 68) and rehydration (six articles) are evaluated in high level studies. Haloperidol and furosemide are used off-label and there are no well-designed studies supporting their subcutaneous use. CONCLUSION: There is a lack of information on drugs widely used by subcutaneous route in the elderly. In that context, physicians carry responsibility for the prescription.

Quality assessment of the visits of pharmaceutical company representatives to hospital pharmacists.

OBJECTIVES: To evaluate whether the quality of pharmaceutical company representatives' (PCRs) visits to hospital pharmacists can be improved by written communication of the results of an evaluation of their visits. METHODS: Pilot study with prospective evaluation of overall visit quality and strength of request for adding drugs to the hospital formulary, and of the scientific quality of products presentations using a standardized form. Two one-year study periods (59 vs. 61 visits) separated by the intervention (global results of the first period sent to each drug company). RESULTS: No difference was observed between both periods in overall visit quality (VAS 0 = null, 10 = excellent: mean 4.7 (2.1 SD) vs. 5.2 (2.1) or strength of request for adding drug to hospital formulary (VAS 0 = null, 10 = extreme: 7.0 [2.6] vs. 7.2 [2.7]). Clarity and scientific value of products' presentations and scientific value of responses were better during the second study period, as a sign of quality improvement. CONCLUSIONS: This study suggests that systematic quality evaluation of PCRs visits and communication of results to drug companies may improve the scientific quality of products' presentation.