Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study.

OBJECTIVES: Prescribing errors can lead to inconvenience, morbidity and mortality. It is therefore crucial to educate doctors to prescribe safely, efficiently and effectively. To create an effective educational programme, it is essential to understand which errors are made and by whom. The aim of this study is to explore if the experience level of the doctor influences how many and which prescribing errors are made in a European academic teaching hospital, where a computerised physician order entry system (CPOE) with a clinical decision support system (CDSS) is exclusively used. METHODS: Prescriptions for all inpatients in an academic teaching hospital were collected in June 2021. All prescriptions with an alert generated by the CDSS which could not be handled by a pharmacy technician according to local protocol were checked for errors. Identified errors were categorised by type and severity. RESULTS: A total of 130 538 prescriptions were newly made or altered by doctors. Of these prescriptions, 1914 (1.5%) were retained for a check by the pharmacist. These contained 430 prescribing errors (0.3% of total prescriptions). Doctors not in specialty training and those in specialty training made more prescribing errors than consultants (0.5% and 0.5% vs 0.1%; p<0.001). Doctors in specialty training made relatively more drug-drug interaction errors than consultants (n=31 (16%) vs n=3 (3%), p<0.05). No significant difference was found regarding the severity of the errors. CONCLUSIONS: Doctors not in specialty training and doctors in specialty training, who are the less experienced doctors, make more prescribing errors than consultants, even with the use of a CPOE combined with CDSS. The type of errors differ between doctors of different experience levels. This finding provides a solid basis for specific additional education to medical students, doctors not in specialty training and doctors in specialty training.

Inpatients' information needs about medication: A narrative systematic literature review.

OBJECTIVE: To provide an overview of inpatients' information needs about medication, including the best moment to provide this information, how, by whom and what patient characteristics influence these needs. METHODS: A systematic literature review was conducted. Studies that reported the information needs from inpatients about medication were included from Medline and Embase. The Crowe critical appraisal tool (CCAT) was used to assess the quality of the studies. RESULTS: Initially, 710 records were retrieved from Medline and Embase. After the forward search, another 609 records were screened and in total, 26 articles were included. The CCAT scores ranged from 17 to 34 points on a 40 point scale and two articles received 0 points. CONCLUSION: Inpatients main needs about medicine information are information about adverse and beneficial effects of medication, and general rules about how to take medication. Preferably, this information is printed and provided at the time of prescribing by a physician that already has a relationship with the patient. The most recent studies show that patients are open to the use of modern technology. PRACTICE IMPLICATIONS: This review provides a starting point for providing medicine information to inpatients. Further research should focus on patient characteristics influencing these information needs.

A meta-analysis of protein binding of flucloxacillin in healthy volunteers and hospitalized patients.

OBJECTIVES: The aim of this study was to develop a mechanistic protein-binding model to predict the unbound flucloxacillin concentrations in different patient populations. METHODS: A mechanistic protein-binding model was fitted to the data using non-linear mixed-effects modelling. Data were obtained from four datasets, containing 710 paired total and unbound flucloxacillin concentrations from healthy volunteers, non-critically ill and critically ill patients. A fifth dataset with data from hospitalized patients was used for evaluation of our model. The predictive performance of the mechanistic model was evaluated and compared with the calculation of the unbound concentration with a fixed unbound fraction of 5%. Finally, we performed a fit-for-use evaluation, verifying whether the model-predicted unbound flucloxacillin concentrations would lead to clinically incorrect dose adjustments. RESULTS: The mechanistic protein-binding model predicted the unbound flucloxacillin concentrations more accurately than assuming an unbound fraction of 5%. The mean prediction error varied between -26.2% to 27.8% for the mechanistic model and between -30.8% to 83% for calculation with a fixed factor of 5%. The normalized root mean squared error varied between 36.8% and 69% respectively between 57.1% and 134%. Predicting the unbound concentration with the use of the mechanistic model resulted in 6.1% incorrect dose adjustments versus 19.4% if calculated with a fixed unbound fraction of 5%. CONCLUSIONS: Estimating the unbound concentration with a mechanistic protein-binding model outperforms the calculation with the use of a fixed protein binding factor of 5%, but neither demonstrates acceptable performance. When performing dose individualization of flucloxacillin, this should be done based on measured unbound concentrations rather than on estimated unbound concentrations from the measured total concentrations. In the absence of an assay for unbound concentrations, the mechanistic binding model should be preferred over assuming a fixed unbound fraction of 5%.

A cost-benefit analysis of hospital-wide medication reviews: a period prevalence study.

Background For specific medical specialties it has been shown that clinical pharmacists can have a beneficial effect on the reduction of drug-related problems by performing medication reviews. However, little is known on the cost-benefit ratio of hospital-wide implementation of medication reviews. Aim To investigate the effect of conducting hospital-wide medication reviews on the detection and resolution of drug-related problems, and to calculate the cost-benefit ratio of the intervention. Method In this observational prospective period prevalence study, medication reviews were conducted during five consecutive working days in a Dutch university hospital. Patients admitted for more than 24 h were included. The cost-benefit ratio of conducting the medication reviews was calculated by dividing the total costs by the total savings. Results In 622 medication reviews, 709 potential drug-related problems (1.1 per patient) were detected. The most common advice was to stop medication (38.6%). Patients with a potentially drug-related problem were significantly older, had a higher median number of prescriptions, and the median number of days from admission to the time of medication reviews was longer. Conducting medication reviews showed a positive cost-benefit ratio of 9.7. Conclusions Hospital-wide medication reviews by clinical pharmacists have a positive cost-benefit ratio and contribute to the detection and the resolution of drug related problems (DRPs), mainly by reducing overtreatment.

Population pharmacokinetic modelling of total and unbound flucloxacillin in non-critically ill patients to devise a rational continuous dosing regimen.

OBJECTIVE: This study's objective was to describe the population pharmacokinetics of total and unbound flucloxacillin in non-critically ill patients, and to devise a rational continuous dosing regimen for this population. METHODS: Total and unbound flucloxacillin pharmacokinetics in 30 non-critically ill patients receiving intravenous flucloxacillin were analysed using non-linear mixed-effects modelling. Monte Carlo simulation was used to assess the fraction of the population reaching effective unbound flucloxacillin levels and the fraction reaching potential neurotoxic exposure for various continuous dosing regimens. RESULTS: The observed protein binding varied between 64.6-97.1%. The unbound fraction was significantly associated with serum albumin and was concentration-dependent. The parameter estimates of the final model were: Cltotal 122 L/h, Clrenal 1.41 L/h, Vc 190 L, Vp 33.9 L, Q 16.8 L/h, Kd 9.63 mg/L, θBmax 177 mg/L,θalb 0.054. A continuous dose of 6 g/24 hours was sufficient for 100% of the population to obtain a unbound concentration of > 0.25 mg/L. With 14 g/24 h, 91.2% of the population was predicted to reach concentrations of > 2 mg/L, the clinical breakpoint for Staphylococcus aureus. Potential toxic unbound flucloxacillin levels were reached in 2.0% of the population with 6 g/24 h, and 24.1% with 14 g/24 h. CONCLUSIONS: This study showed that a continuous infusion of 6 g/24 h flucloxacillin is sufficient to treat most infections in non-critically ill patients. With this dosing regimen, an unbound serum concentration flucloxacillin > 0.25 mg/L was reached in 100% of the patients, with minimal chance of neurotoxicity.

Adverse drug reaction reports of patients and healthcare professionals-differences in reported information.

PURPOSE: This study aims to explore the differences in reported information between adverse drug reaction (ADR) reports of patient and healthcare professionals (HCPs), and, in addition, to explore possible correlation between the reported elements of information. METHODS: This retrospective study compared the reported information between 200 ADR reports of patients and HCPs. Reports were rendered anonymous and scored for the presence or absence of predefined elements of information. These elements can be objective (e.g. start date of the ADR) or subjective (e.g. the impact or severity of the ADR). A two-sided Pearson's Chi-square test was used to detect statistically significant differences in the reported information. A Bonferroni correction was used to correct for multiple comparisons. Correlation between the elements of information was explored using categorical principal components analysis (CATPCA). RESULTS: Overall, HCPs had a higher score for the presence of objective and patients for subjective elements of information. Elements that were statistically significant more often reported by patients are the impact of the ADR and the patient's weight and height. HCPs statistically significant more often reported the medical history and the route of administration of the drug. CATPCA showed four clusters of elements of information that have fair correlation. CONCLUSIONS: This study demonstrates the differences in reported information between ADR reports of patients and HCPs. Patient reports are more focused on patient-related information and the impact of the reported ADRs, whereas reports from HCPs provide more clinically related information.

Important information regarding reporting of adverse drug reactions: a qualitative study.

OBJECTIVE: To give an overview of the views of different types of reporters (patients and healthcare professionals (HCPs)) and assessors of adverse drug reactions (ADRs) on what they consider important information regarding an ADR report. METHODS: A semi-structured interview was conducted among reporters and assessors of ADRs in the Netherlands. All interviews were audiotaped and transcribed verbatim. Content analysis was used on the data. All transcripts were coded individually by two researchers. A list was drafted of all elements of information mentioned during the interviews. KEY FINDINGS: In total 16 interviews were conducted. Elements of information that were explicitly brought up during the interviews were the impact of the ADR on the patient's daily life and information regarding causality. Furthermore, the correctness of reported information was found important by assessors of ADRs. Generally, patient reporting was seen as a very positive development for pharmacovigilance. CONCLUSION: Patients reported that the severity of ADRs and their impact on daily life were important subjects. In the interviews with HCPs, either reporters or assessors, the focus was mainly on causality. The correctness of the given information is considered by ADR assessors to be very important. Regarding patient reporting the overall view was positive. Because HCPs and patients have different views regarding ADR reporting, in daily practice it is important to receive reports from both groups to assess the true nature of the ADR.

A play-based intervention for children with ADHD: a pilot study.

INTRODUCTION: Many children with attention deficit hyperactivity disorder (ADHD) have serious social and peer difficulties that can lead to adverse outcomes in adolescence and adulthood. To date, psychosocial treatments have produced poor outcomes in reducing social impairments commonly associated with ADHD. This study aimed to examine the efficacy of a new intervention designed to improve the play and social skills of children with ADHD and their playmates within the natural context of play. METHODS: Participants included children (aged 5-11 years) diagnosed with ADHD, age-matched typically developing playmates (n=14/group) and parents of children with ADHD. The intervention involved seven weekly video-recorded free-play sessions; video feed-forward/feedback and therapist- and peer-modelling were used to promote social play. The Test of Playfulness was used as a pre-/post-test measure. Data were subjected to Rasch analysis to calculate measure scores on interval level; dependant sample t-test and Cohen-d calculations were used to measure effect. RESULTS: A dependant samples t-test revealed that both children with ADHD (t=8.1; d.f.=13; P<0.01) and their playmates (t=6.9; d.f.=13; P<0.01) improved in their social play. Results demonstrated a large effect in improving the social play of children with ADHD (d=1.5) and their playmates (d=1.3). DISCUSSION: Results support the use of play, video feed-forward/feedback techniques, therapist- and peer-modelling and parent involvement as an effective means to develop the social play skills of children with ADHD. Further larger-scale research is required.