A comprehensive study of prescribing, administering and drug handling medication errors in ten wards of a university hospital after implementation of electronic prescribing, clinical pharmacists or medication reconciliation.

Background and aim: Medication errors lead to preventable risks. Preventing strategies such as e-prescribing, clinical pharmacists and medication reconciliation have been implemented in recent years. However, information on long-term medication error rates in routine procedures is missing. Investigations: We aimed to identify predefined medication errors in ten wards of a university hospital where e-prescribing, clinical pharmacists and medication reconciliation have been partially implemented. Patient files were reviewed and routine processes were monitored for drug prescription errors (missing, unclear, outdated information), administration errors (wrong dispensed drugs) and drug handling errors (no light-, moisture-protection, wrong splitting, no separation of drugs, which ought to be taken by an empty stomach). Results: We analyzed 959 prescriptions with 933 solid peroral drugs for 182 patients (98 female, median age 66.5 years [Q25-Q75: 56-78 years]; the median number of drugs was 5 [Q25-Q75: 3-7]). The most frequent prescription error was a not specified drug form (91.1%). The most common administration error was a not adequately provided release dose formulation (72.7%). The lack of light protection for observed photosensitive drugs was the most frequent drug handling error (100%). We found a significantly higher amount of complete drug prescriptions with one of the implemented measurements e-prescribing, medication reconciliation and clinical pharmacists (Fisher's exact test two tailed, each p<0.001; CI 95%). Drug administration errors and drug handling errors were not significantly improved. Among the most frequently involved drug were drugs for acid-related disorders, immunosuppressant, and antineoplastic drugs. Conclusions: In the nearly 1,000 prescriptions and drugs analyzed, medication errors were still common. Various preventive strategies had been implemented in recent years, positively influencing the predefined errors rates.

Determine the impact of a structured pharmacist-led medication review - a controlled intervention study to optimise medication safety for residents in long-term care facilities.

BACKGROUND: Medication reviews contribute to protecting long-term care (LTC) residents from drug related problems (DRPs). However, few controlled studies have examined the impact on patient-relevant outcomes so far. OBJECTIVE: We examined the impact of a one-time, pharmacist-led medication review on medication changes (primary endpoint) including discontinued medication, the number of chronic medications, hospital admissions, falls, and deaths (secondary endpoints). METHODS: A prospective, controlled intervention study was performed in three LTC facilities. In the intervention group (IG), after performing a medication review, a pharmacist gave recommendations for resolving DRPs to physicians, nurses and community pharmacists. The control group (CG) received usual care without a medication review. (i) We assessed the number of medication changes and the secondary endpoints in both groups before (t0) and after (t1, t2) the intervention. (ii) Additionally, the medication review was evaluated in the IG with regard to identified DRPs, the healthcare professional's feedback on the forwarded pharmacist recommendations and whether DRPs were finally resolved. RESULTS: 107 (IG) and 104 (CG) residents were enrolled. (i) More medication changes were identified in the IG than in the CG at t1 (p = 0.001). However, no significant difference was identified at t2 (p = 0.680). Mainly, medication was discontinued in those medication changes. Chronic medications increased in the CG (p = 0.005) at t2 while hospital admissions, falls, and deaths showed no differences. (ii) Overall, 1252 DRPs (median: 10; minimum-maximum: 2-39) were identified. Recommendations for 82% of relevant DRPs were forwarded to healthcare professionals, of which 61% were accepted or clarified. 22% were not accepted, 12% required further review and 6% remained without feedback. 51% of forwarded DRPs were finally resolved. CONCLUSIONS: We found more medication changes in the IG compared to controls. Mostly, medication was discontinued. This suggests that our intervention was successful in discontinuing unnecessary medication. Other clinical outcomes such as falls, hospitalisations, and deaths were not improved due to the one-time intervention. The medication review further identified a high prevalence of DRPs in the IG, half of which were finally resolved. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00026120 ( www.drks.de , retrospectively registered 07/09/2021).

QTc-time-prolongating drugs and additional risk factors for long-QT-syndrome at hospital admission of surgical patients - risk assessment by pharmacists.

Drugs can cause long-QTc-syndrome (LQTS), thereby elevating the risk for palpitations, syncopes, and sudden cardiac death. Additional risk factors such as the intake of more than one QTc-prolongating drug (QTPD) and surgery (cardiac and non-cardiac) increase the risk considerably. Therefore, a good knowledge of patients perioperative risk is important. Data concerning this issue in surgical patients is, however, scarce. We aimed to determine the number of surgical patients taking QTPD at hospital admission and to assess the presence of additional risk factors for LQTS. In addition, we determined the LQTS-risk at hospital admission by calculating the Tisdale Risk Score, enabling early detection of patients at risk. In a retrospective study, the pre-hospital medication of a 4-month cohort of surgical patients admitted to a tertiary teaching hospital was evaluated for QTPD-intake. For these patients, additional risk factors for LQTS were assessed and the Tisdale Risk Score was calculated. Of 837 surgical patients, 419 (50%) took at least one QTPD. In total, 3,376 drugs were taken and 723 (21%) classified as QTPD with a median number of 2 (range 1-8) per patient. The median number of LQTS-risk factors for these patients at hospital admission was 2 (range 0-5). The Tisdale Risk Score classified 23 patients (5%) as high, 187 (45%) as moderate, and 209 (50%) as low risk. These findings indicate a high number of surgical patients with QTPD and additional risk factors. The Tisdale Risk Score can be used as a screening instrument for patients at risk for QTc-prolongation during medication reconciliation by pharmacists at hospital admission. Patients identified as high and moderate risk should be evaluated for adjustable risk factors and monitored adequately. Medical treatment needs to be chosen carefully in view of in-hospital patient safety.

A prospective follow-up study on the role of clinical pharmacists in sustainably optimized pain measurement and pain therapy consequences.

Appropriate analgesic therapy requires adequate pain measurement. A few studies have already demonstrated benefits of clinical pharmacists supporting physicians' prescribing. Nevertheless, there are still open questions about pharmaceutical interventions at the nursing level in order to optimise pain therapy sustainably. We performed a prospective controlled follow-up intervention study to analyse the sustainability of improved pain measurement performance (PMP) and its therapeutic consequences. Half a year after a successful guidance implementation in two study units (control and intervention unit), pharmacists performed an individual coaching for nurses only in the intervention unit. We consecutively monitored patient-nurse contacts and evaluated PMP with a 7-point scale (from 0: no pain measurement to 6: optimal pain measurement) in three 4-week periods (t1 : before guidance implementation, t2 : directly after guidance implementation, t3 : half a year after guidance implementation) on both units. Therapeutic consequences of PMP were evaluated in a post-hoc patient chart review. In the t1 period, we found a median PMP of 0 in both units which rose to 6 (control unit) vs. 5 (intervention unit) in t2 period due to guidance implementation in both units. In the t3 period, we found a decrease of PMP to 0 in controls vs. to 4 in the intervention unit (p<0.001). We also found, that improved PMP did not lead to a more individualised analgesic prescribing and administration of more on-demand analgesics. A coaching concept of clinical pharmacists improved the sustainability of nurses' PMP after a successful guidance implementation. Our results illustrate the potential of including clinical pharmacist in interprofessional pain therapy teams.

[Discharge medication - what do patients know about their medication on discharge?]. / Entlassungsmedikation - Was weiß der Patient bei Entlassung über seine Arzneimittel?

BACKGROUND: Patients' lack of knowledge about their discharge medication can endanger patients' safety after their hospital stay. This is especially the case with regard to medications that were newly prescribed during the hospital stay and are intended to be used after discharge or medications with an increased risk for adverse drug reactions (high-risk drugs). The aim of this study was to analyse the patients' level of knowledge about their discharge medication and to identify influence factors. METHODS: In a bicentric survey patients were interviewed prior to their discharge from an acute and a geriatric rehabilitation hospital. They were asked about their discharge medication in a structured interview. Influence factors were statistically analysed by Tobit regression. RESULTS: In total, 179 patients were interviewed. On average, patients named 48% of their discharge medication correctly (95% CI: 46-50%). Influence factors for knowledge deficits were the lack of a medication plan, an older age, the hospitalization in a rehabilitation hospital and a long hospitalization. 81% of the patients had at least one drug in their discharge medication, which was newly prescribed during the hospital stay. 11% of those drugs were named correctly, the potency was named correctly in 6%, the indication in 8%. For almost two-thirds of the patients at least one high-risk drug was recommended in the discharge letter, among them most frequently oral anticoagulants and opioid analgesics. 38% of these high-risk drugs were named correctly. CONCLUSION: Our results demonstrate an urgent need to train patients about their discharge medication, especially if medications are included that were newly prescribed during the hospital stay and recommended for further use after discharge or medications with an increased risk of adverse drug reactions. Particularly older patients and patients of a rehabilitation hospital after long hospitalization should be intensively counselled and obtain a medication plan upon discharge.

[Pain assessment in routine care : A prospective observational study in an orthopedic unit]. / Schmerzerfassung in der Routineversorgung : Eine prospektive Beobachtungsstudie auf einer orthopädischen Station.

INTRODUCTION: Although well-established guidelines give advice on how to use analgesics, measure pain, and organize pain treatment, many patients still suffer from avoidable severe pain. We assume one reason for this is that pain is inadequately addressed in routine patient contacts. Thus, we aimed to evaluate the extent to which pain was addressed during patient contacts in routine orthopedic care. MATERIALS AND METHODS: In a prospective observational study in an orthopedic unit of a university hospital, we invited physicians and nurses during their routine patient contacts to be observed by independent, trained monitors. The monitors systematically assessed all pain-related aspects, which were analyzed descriptively afterwards. RESULTS: The monitors documented 572 physician-patient contacts with 7 physicians and 108 patients and 578 nurse-patient contacts with 12 nurses and 102 patients. Physicians and nurses asked their patients about pain in 20 and 16 % of the patient contacts, respectively. While in physician-patient contacts, patients most frequently addressed their current pain situation (in 35 % of contacts), in nurse-patient contacts, patients most frequently addressed their need for analgesics (52 %). Patients rated their pain intensity in 16 % of physician-patient contacts vs. 17 % of nurse-patient contacts. CONCLUSIONS: Using a comprehensive external monitoring procedure, we found that systematic pain assessment was not optimally standardized and implemented for systematic, individualized pain therapy by physicians or nurses in our routine care setting.