Medication errors in cancer therapy: Reports from German hospital pharmacists between 2008 and 2019.

OBJECTIVE: Since medication errors can have severe consequences, the development of methods to improve patient safety is becoming increasingly important. The aim of this evaluation was to identify frequent medication errors in oncology as well as characteristic correlations in the various error patterns. In addition, the implementation rate of the proposed pharmaceutical intervention was determined in order to assess the benefit of a clinical pharmacist in the field of oncology. METHODS: The evaluation was based on a data-set from a national documentation system for medication errors and interventions (DokuPIK) used by hospital pharmacists in the field of oncology from 2008 to 2019, namely 6684 reported cases in oncology, representing about 5% of all reports in DokuPIK. RESULTS: The most frequently reported errors were incorrect doses (22% of reported errors), followed by interactions (14%); in 10% of errors the prescription/documentation was incomplete/incorrect. The intervention suggested by the pharmacist was implemented in 97% of the cases. Based on the respective Anatomical Therapeutical Chemical Classification (ATC codes), drugs (or groups of drugs) were identified that were reported frequently in connection with medication errors, namely carboplatin and cyclophosphamide as anticancer drugs pantoprazole as non-anticancer drug. CONCLUSION: Frequently occurring medication errors in the field of oncology were identified, facilitating the development of specific recommendations for action and prevention strategies. The implementation of an electronic prescription software is particularly recommended for the avoidance of dosage errors in chemotherapy.

Clinical pharmacists' interventions across German hospitals: results from a repetitive cross-sectional study.

Background Pharmacists' interventions (PI) are suitable to improve medication safety and optimise patient outcome. However, in Germany, clinical pharmacy services are not yet available nationwide. Aim To gain prospective data on the extent and the composition of routine PI with special focus on intervention rates among German hospital pharmacists during two intervention weeks. Methods Within a repetitive cross-sectional study, clinical pharmacists documented all PIs on five days during a one-month period (intervention week) in 2017 and 2019 using the validated online-database ADKA-DokuPIK. Additionally, data regarding the supply structure/level of medical care, the extent of clinical pharmacy services and their professional experience were collected. All data were anonymised before analysis. Results In total, 2,282 PI from 62 pharmacists (2017) and 2578 PI from 52 pharmacists (2019) were entered. Intervention rate increased from 27.5 PI/100 patient days in 2017 to 38.5 PI/100 patient days in 2019 (p = 0.0097). Frequency of clinical pharmacy services on a daily basis significantly increased from 60% (2017) to 83% (2019). Reasons for PIs from the categories "drugs" (e.g. indication, choice, documentation/transcription) and "dose" were most common in both intervention weeks. The vast majority of underlying medication errors in both intervention weeks were categorised as "error, no harm" (80.3 vs. 78.6%), while the proportion of errors which did not reach the patient, doubled to 39.8% in IW-2019. Conclusion Regular and daily clinical pharmacy services become more established in Germany and clinical pharmacists are increasingly involved in solving drug related problems proactively and early during the medication management process.

[Polypharmacy - Solutions for Enhanced Drug Safety]. / Polypharmazie ­ Lösungswege für eine verbesserte Arzneimitteltherapiesicherheit.

Polypharmacy (≥ 5 drugs) is common among older people and may lead to falls, ADEs and delirium. Adherence is an important part in the medication management. Simple questions (i. e. for OTC, handling and omission of drugs) are effective. As most old people are treated by general practitioners (GP), they play a key role for drug safety and reducing polypharmacy. The involvement of pharmacists in analyzing one patient's drugs can enhance solutions for drug problems ("two-man rule"). An IT-based medication plan acts as an important communication tool for an enhanced team work between doctors, pharmacists and nursing care.

[Therapy of a common otitis media in the infancy]. / Antibiotika bei unkomplizierter Otitis media im Kindesalter?

The therapy of an acute otitis media has been questioned due to increasing bacterial resistance during the last years. Two recent studies dealing with efficiency of the antibiotic treatment regarding diseased children younger tha 2 or 3 years are recommending antibiotic drugs compared to the use of placebo. How are the results of the studies to be interpreted?

[Hepatitis A vaccination three days before departure to Eastern Europe?]. / Hepatitis-A-Impfung drei Tage vor Reiseantritt?

Vaccination against hepatitis A is indicated for travellers who visit areas with a high exposure to this type of virus. Beside tropical areas an active vaccination is indicated for the whole Mediterranean Area and Eastern Europe. This active vaccination is effective even short before departure due to the long incubation period of hepatitis A.

[SSRI-associated bleeding risk]. / Blutungsneigung unter selektiven Serotonin-Wiederaufnahmehemmern?

Secondary to their antidepressive effect, selective serotonin reuptake inhibitors (SSRI) also lead to a diminished platelet aggregation, which results in an increased risk of bleeding. This adverse effect is added to the therapeutic effects of antiplatelet drugs. Furthermore, combination with nonsteroidal antirheumatic drugs (NSAID) increases the risk of bleeding, particularly in the gastrointestinal tract. Given the widespread use of SSRI, antiplatelet drugs and NSAID, pharmacists and doctors should turn their attention to bleeding as adverse effect and interaction, respectively.

[Gingival hyperplasia]. / Gingivahyperplasie.

Gingival hyperplasia is a typical adverse reaction of certain drugs (phenytoin, calcium antagonists and cyclosporine). Also oral contraceptives and presumably hormone replacement therapy may rarely lead to gingival hyperplasia. By differential diagnosis a paraneoplastic syndrome has to be taken into account. Drug induced gingival hyperplasia is reversible when the therapy is stopped or modified. If a change of medication is not possible oral hygiene and prophylaxis is critical.

[Allergic reaction after intravenous application of vitamin B12]. / Allergische Reaktion nach i.v. Gabe von Vitamin B12.

Allergic reactions of parenteral vitamin B12 (cobalamin) for therapy of pernicious anaemia are very rare, but repeatedly described in the literature. In case of allergic reactions oral instead of intravenous substitution of vitamin B12 is tolerated. Very high dosages of vitamin B12 (1,000-2,000 microg per day) are necessary due to the underlying vitamin B12 malabsorption.

[Lactose-containing tablets for patients with lactose intolerance?]. / Lactosealtige Tabletten bei Lactose-Intoleranz?

Lactose is often used as an excipient in tablets because of its ideal characteristics. Most patients with lactose intolerance tolerate small amounts of lactose. However, the nocebo effect must be considered. Thus, patients should be informed about the very small amounts of lactose in the medication. If the patient is still suffering from gastrointestinal symptoms and there is no lactose-free alternative, the enzyme lactase can be substituted individually.

[Protective use of calcium in case of osteoporosis versus calcium oxalate stones]. / Calcium gegen Osteoporose trotz Calciumoxalat-Nierensteinen?

In patients with calcium-containing kidney stones calcium supplements are officially contraindicated. Recent studies showed a protective effect by calcium-supplementation when taken with meals, analogous to the decreased risk of kidney stones by dietary calcium due to binding of oxalate. However, because of the poor compliance, costs and the official contraindication for calcium supplements in patients with kidney stones, dietary calcium intake should be preferred whenever feasible.

[Accidental acetaminophen overdose]. / Akzidentielle Paracetamol-Uberdosierung.

Acetaminophen is an OTC medication and amongst the most used pain relievers. It is the analgesic of first choice in pregnancy. Because of its low therapeutic index, accidental and suicidal acetaminophen intoxication is one of the most common causes of acute liver failure. Thus, face-to-face counselling of patients on the proper use of acetaminophen is essential for drug safety.

[Creatine kinase increase under simvastatin--therapeutic consequences?]. / Creatinkinase-anstieg unter Simvastatin. Therapeutische Konsequenzen?

Myopathy is the most serious, dose dependent adverse reaction of statins and may lead to rhabdomyolysis and death. Clinical symptoms are muscle pain, weakness and muscle cramps, main laboratory finding is an increase in serum creatine kinase (CK). If myopathy symptoms are present or CK levels are greater than 5 times the upper limits of normal, statin therapy should be discontinued. In case of an asymptomatic CK increase below 5 times the upper limits of normal, therapy can be continued with CK monitoring.

[Prescription of rimonabant in the early stage of pregnancy?]. / Rimonabant in der Frühschwangerschaft? Ein Lehrbeispiel zur Arzneimitteltherapie bei Frauen im gebärfahigen Alter.

Rimonabant should not be prescribed in pregnancy because no sufficient data on the teratogenic/ embryotoxic risk are available. A preventive termination of pregnancy is not indicated. Women in childbearing age should take only low-risk drugs. Otherwise dedicated information, in doubt pregnancy test, and strict contraception is required.

[Are AT1 receptor antagonists an alternative to ACE inhibitors in angioedema?]. / Angiotensin-II-Antagonisten alternativ zu ACE-Hemmern bei Angioödem?

History of angioedema is a contraindication for ACE-inhibitors. Angioedema is caused by: 1. a decreased degradation of bradykinin, 2. a defect in C 1-esterase-inhibitor with the increased generation of bradykinin or 3. other trigger mechanisms as food, pollen and stress. AT1 receptor antagonists do not inhibit the degradation of bradykinin. Thus angioedema is no contraindication for AT1 receptor antagonists. In patients with an anamnestic angioedema or ACE-induced angioedema AT1 receptor antagonists can be given under close monitoring provided that there is strong indication for inhibition of the renin-angiotensin system.

[Splitting of tablets: small pieces a risk]. / Tablettenteilung: stückchenweise riskant?

For economic reasons physicians prescribe more and more multiunit tablets. Splitting of multiunit tablets depends on the physical-chemical properties of the agents, the galenic of the dosage form, the size and contour of the tablet and the shape of the score. Tablets with one or more scores are prepared to be divided for a single/multiple dose. How easily and exact a tablet can be divided depends heavily on the physical shape, its size and the outfit of the score. The fragments have to fulfil the requirements according to the European Pharmacopoeia: Uniformity of multiunit tablets. Since exact dosing is guaranteed only if tablets are divided properly, information and guidance of the patients by the physician and pharmacist is of critical importance.