[From treatment history to patient follow-up: the role of the pharmacist]. / De l'historique médicamenteux au suivi du patient. Rôle du pharmacien.

Pharmacists and physicians have complementary roles. Indeed, pharmacists have specific knowledge of medications and a particular relationship with patients, especially in the community. Integration of pharmacists within medical teams, based on the North-American model, helps to ensure close collaboration founded on mutual trust and face-to-face contacts. This role of the pharmacist is appreciated by physicians, notably because it helps them to verify their prescriptions. It is essential to determine patients' relationships with their medications, through a knowledge of their treatment history. The French educational model of clinical pharmacy, based on the fifth hospital year, is inspired by this experience. The challenge is now to prove the benefits both for patients, physicians and nurses, of integrating a pharmacist within the medical team. This educational model helps to develop the pharmacist's role within the community and facilitates relationships between the hospital and the community.

Automated drug dispensing system reduces medication errors in an intensive care setting.

OBJECTIVES: We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction. DESIGN: Preintervention and postintervention study involving a control and an intervention medical intensive care unit. SETTING: Two medical intensive care units in the same department of a 2,000-bed university hospital. PATIENTS: Adult medical intensive care patients. INTERVENTIONS: After a 2-month observation period, we implemented an automated dispensing system in one of the units (study unit) chosen randomly, with the other unit being the control. MEASUREMENTS AND MAIN RESULTS: The overall error rate was expressed as a percentage of total opportunities for error. The severity of errors was classified according to National Coordinating Council for Medication Error Reporting and Prevention categories by an expert committee. User satisfaction was assessed through self-administered questionnaires completed by nurses. A total of 1,476 medications for 115 patients were observed. After automated dispensing system implementation, we observed a reduced percentage of total opportunities for error in the study compared to the control unit (13.5% and 18.6%, respectively; p<.05); however, no significant difference was observed before automated dispensing system implementation (20.4% and 19.3%, respectively; not significant). Before-and-after comparisons in the study unit also showed a significantly reduced percentage of total opportunities for error (20.4% and 13.5%; p<.01). An analysis of detailed opportunities for error showed a significant impact of the automated dispensing system in reducing preparation errors (p<.05). Most errors caused no harm (National Coordinating Council for Medication Error Reporting and Prevention category C). The automated dispensing system did not reduce errors causing harm. Finally, the mean for working conditions improved from 1.0±0.8 to 2.5±0.8 on the four-point Likert scale. CONCLUSIONS: The implementation of an automated dispensing system reduced overall medication errors related to picking, preparation, and administration of drugs in the intensive care unit. Furthermore, most nurses favored the new drug dispensation organization.

[Diffusion of pharmacist interventions within the framework of clinical pharmacy activity in the clinical ward]. / Diffusion des opinions pharmaceutiques dans le cadre d'une activité de pharmacie clinique en unité de soins.

BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors. OBJECTIVES: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance. METHODS: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital. RESULTS: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01). CONCLUSION: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.

Compliance with guidelines on antibiotic prophylaxis in total hip replacement surgery: results of a retrospective study of 416 patients in a teaching hospital.

OBJECTIVE: To assess compliance of anesthesiologist practices in antibiotic prophylaxis during total hip replacement (THR) surgery with the French Society of Anesthesiology and Intensive Care consensus-based guidelines. DESIGN: Retrospective review of medical records. Compliance of anesthesiologist practices with the guidelines was assessed according to antibiotic prophylaxis use, antimicrobial agent, dosage of first injection, time from first dose to incision, and total duration of antibiotic prophylaxis. SETTING: Orthopedic surgery wards in a 2,200-bed French teaching hospital. PATIENTS: A random sample of 416 patients undergoing THR from January 1999 to December 2000. RESULTS: Three hundred eighty-six (93%) of the sampled medical records were usable. Antibiotic prophylaxis was used for 366 (95%) of the patients. Total duration of prophylaxis did not exceed 48 hours in 98% (359 of 366) of the patients. Drug selection complied with national guidelines in 259 (71%) of the patients. Dosage and timing of the first injection were appropriate in 98% (290 of 296) and 80% (236 of 296) of the patients, respectively, who received one of the recommended antibiotics. Overall, 53% (203 of 386) of the patients met all five criteria. In multivariate analysis, there was a significant anesthesiologist effect on overall compliance with the guidelines (likelihood ratio chi-square with 9 degrees of freedom, 25.7; P < .01). Undergoing surgery during 2000 was the only patient characteristic associated with an increased rate of appropriate practices (adjusted OR, 1.56; CI95 1.02-2.38). CONCLUSION: The overall compliance rate should be improved by disseminating the guidelines and the results of this study following audit and feedback.

Pharmacy education in Vietnam.

Pharmacy education programs in Vietnam are complex and offer various career pathways. All include theory and laboratory modules in general, foundation, and pharmaceutical knowledge; placements in health facilities; and a final examination. The various pharmacy degree programs allow specialization in 1 or more of 5 main fields: (1) drug management and supply, (2) drug development and production, (3) pharmacology and clinical pharmacy, (4) traditional medicine and pharmacognosy, and (5) drug quality control, which are offered as main specialization options during the reformed undergraduate and postgraduate programs. However, pharmacy education in Vietnam in general remains product oriented and clinical pharmacy training has not received adequate attention. Only students who have obtained the bachelor of pharmacy degree, which requires a minimum of 5 years of study, are considered as fully qualified pharmacists. In contrast, an elementary diploma in pharmacy awarded after 1 year of pharmacy study permits entry into more junior pharmacy positions. Since the 2000s, there has been a surge in the number and types of schools offering pharmacy qualifications at various levels.

Identification of drug-related problems in ambulatory chronic kidney disease patients: a 6-month prospective study.

BACKGROUND: Drug-related problems (DRPs) are common in chronic kidney disease (CKD) patients. We developed a 2-step consultation including a clinical pharmacist (CP) session and a nephrologist conventional care consultation to explore the feasibility of a pilot drug-oriented disease management program in controlling iatrogenic side effects. METHODS: Drug inventory was estimated by a CP before each nephrology consultation. CP interventions were based on the French Society of Clinical Pharmacy intervention tools. RESULTS: In this 6-month prospective study, 67 CKD patients were enrolled: 77% with stage 3 or 4 CKD (by Kidney Disease Improving Global Outcomes criteria), 66% males, 76% with diabetes, median age 70 years (range 59-75), with a mean 2.6 ± 1.2 comorbidities and 10 ± 3.5 medications. We registered 142 DRPs, in 93% of patients, which mainly concerned untreated indications (31.7%) and incorrect dosages (19%). The most frequent pharmaceutical interventions concerned addition of drug (34%) and adaptation of dose (25.5%). The main drugs involved concerned the cardiovascular (33%), digestive-metabolic (26.9%) and hematopoietic (19.9%) systems. DRPs correlated significantly with a higher number of medications (p=0.049) and with older patient age (p=0.0027). Furthermore, patients' knowledge was evaluated in 41 patients (61%) by the CP with a systematic questionnaire. Three at-risk situations were described: 80.5% of patients interviewed were unaware of the beneficial impact of their treatment, 85% were not aware of medical situations at risk and 68% declared self-medication habits. CONCLUSION: A formatted CP evaluation coupled with a renal consultation was able to detect a higher level of DRPs, to reinforce educational messages and to propose immediate changes in the therapeutic project.

Pharmaceutical care in chronic kidney disease: experience at Grenoble University Hospital from 2006 to 2010.

BACKGROUND: Clinical pharmacists (CPs) specifically manage lab-test follow-up, adapt drug dosage according to guidelines and evaluate cardiovascular risk factors and decline in renal function. The aim of this study was to assess the impact of clinical pharmacy services in outpatient nephrology clinics. METHOD: For each patient, medical history and current treatment were obtained. Each intervention was classified according to the Act-IP document of the French Society of Clinical Pharmacy. This tool contains identifications and guidelines for prevention and resolution of drug-related problems (DRPs). RESULTS: From January 2008 until April 2009, 42 patients seen by the CP on at least 2 visits were included in the study. We observed 350 pharmaceutical consultations and 263 interventions. The pharmaceutical interventions concerned: untreated indication (30%), underdosage (25.9%) and overdosage (18.3%). The CP interventions consisted of: adapting doses (42.2%) and adding treatments (31.9%). The main drugs involved concerned the cardiovascular (33.1%), digestive-metabolic (28.6%) and hematopoietic (21.6%) systems. CONCLUSION: The inclusion of a CP in the management of chronic kidney disease (CKD) patients is necessary for identification and prevention of DRPs. Besides the medical improvement of CKD patients, the CP participates in the development of prescription recommendations and therapeutic education programs for patients. Moreover, redefining roles and practices of members of a clinical team proved its efficiency in optimizing the medical care of CKD patients. Furthermore, patient entry into dialysis is postponed, which leads to a reduction in costs for health care insurance.

Computerized physician order entry system combined with on-ward pharmacist: analysis of pharmacists' interventions.

RATIONALE, AIMS AND OBJECTIVES: To analyse pharmacists' interventions in a setting where a computerized physician order entry system (CPOE) is in use and a pharmacist works on the ward. METHOD: A prospective cohort study was conducted in seven wards of a French teaching hospital using CPOE along with the presence of a full-time on-ward pharmacy resident. We documented the characteristics of pharmacists' interventions communicated to physicians during the medication order validation process whenever a drug-related problem was identified. Independent predictors of the physician's acceptance of the pharmacist's intervention were assessed using multiple logistic regression analysis. RESULTS: The 448 pharmacists' interventions concerned: non-conformity to guidelines or contraindications (22%), too high doses (19%), drug interactions (15%) and improper administration (15%). The interventions consisted of changes in drug choice (41%), dose adjustment (23%), drug monitoring (19%) and optimization of administration (17%). Interventions were communicated via the CPOE in 57% of cases and 43% orally. The rate of physicians' acceptance was 79.2%. In multivariate analysis, acceptance was significantly associated with the physician's status [higher for residents vs. seniors: OR = 7.23, CI 95 (2.37-22.10), P < 0.01], method of communication [higher for oral vs. computer communication: OR = 12.5, CI 95 (4.16-37.57), P < 0.01] and type of recommendation [higher for drug monitoring vs. drug choice recommendations: OR = 10.32, CI 95 (3.20-33.29), P < 0.01]. CONCLUSIONS: When a clinical pharmacist is present on a ward in which a CPOE is in use, the pharmacists' interventions are well accepted by physicians. Specific predictors of the acceptance by physicians emerge, but further research as to the impact of CPOE on pharmacist-physician communication is needed.

Physicians' perception of CPOE implementation.

OBJECTIVE: To identify perceptions held by physicians of the benefits of computerized physician order entry (CPOE) and factors influencing its successful implementation in the context of the increased presence of a clinical pharmacist on ward. SETTING: A 2000-bed University Hospital. METHOD: A cross-section opinion survey was conducted of all permanent physicians of the hospital to determine their perception on the benefits, or otherwise, of CPOE. Questionnaires, built upon the analysis of 10 preliminary semi-structured interviews with physicians, were sent to physicians by electronic and paper mail. It comprised three sections with a 4 level Likert scale: general perception of CPOE benefits (items 1.1-1.8); opinion on the introduction of the CPOE system in the hospital (item 2); opinion on the presence of a pharmacist on ward (item 3). A fourth section recorded the respondent's profile. MAIN OUTCOME MEASURES: Level of agreement on the items describing the general perception of CPOE benefits; opinion on the introduction of a CPOE system in the hospital; and opinion on the pharmacist's presence on ward. A Principal Component Analysis (PCA) was conducted on sections one and two. Analysis of this PCA representation in terms of the respondents' profile was performed. RESULTS: One hundred and one physicians (18%) participated in the survey. Most (83%) physicians favoured the implementation of a CPOE (item 2). Among the advantages of CPOE, the greatest agreement concerned items related to safety and regulatory issues (from 80 to 76% agreement). Other items related to management issues were perceived as less tangible benefits (from 50 to 67% agreement). The increased presence of a pharmacist on the ward was supported by 94% of physicians. The PCA representation using profile items produced a 2-factor solution, accounting for 68% of the variance, with former experience of collaboration with a pharmacist (P = 0.002) and senior physician status (P = 0.013) positively influencing the perception of the CPOE. CONCLUSION: Endorsement by senior physicians and the presence of a clinical pharmacist on ward promote a positive attitude towards CPOE and facilitate its implementation.

Educating diabetic children: integrating representations by children aged 7 to 11 and their parents.

OBJECTIVE: A patient living with a chronic disease develops illness-related knowledge, representations, and specific behaviour leading to attitudes. Our objective was to assess the interaction between representations from diabetic children 7 to 11 years of age and their parents, on the disease and its treatment, in order to improve the therapeutic education process. METHOD: A qualitative approach was developed. Semi-structured interviews and free association technique were used on 10 children 7 to 11 years of age and 10 parents, in the Toulouse Hospital, France. Qualitative and quantitative (Alceste(R) software) discourse analysis relating to representations was performed (distribution, frequency, and meaning of word sequences were compared). RESULTS: Children seemed to cope naturally with their environment in order to manage their disease. Their attitudes were neutral and their behaviour pragmatic. The parents' representations were more conceptual and negative. They expressed their fear of the disease, their difficulty to endorse the responsibilities and overcome everyday constraints. CONCLUSION: The educator must adapt his language level to integrate the child's universe and facilitate assimilation of knowledge. The therapeutic education process for diabetic children should integrate a specific support and training for parents. These results have influenced our choice of a strategy involving continuous group education focusing parents.