Identification of diagnostic biomarkers used in the diagnosis of cardiovascular diseases and diabetes mellitus: A systematic review of quantitative studies.

AIMS: To perform a systematic review of studies that sought to identify diagnostic biomarkers for the diagnosis of cardiovascular diseases (CVDs) and diabetes mellitus (DM), which could be used in low- and middle-income countries (LMICs) where there is a lack of diagnostic equipment, treatments and training. MATERIALS AND METHODS: Papers were sourced from six databases: the British Nursing Index, Google Scholar, PubMed, Sage, Science Direct and Scopus. Articles published between January 2002 and January 2023 were systematically reviewed by three reviewers and appropriate search terms and inclusion/exclusion criteria were applied. RESULTS: A total of 18 studies were yielded, as well as 234 diagnostic biomarkers (74 for CVD and 160 for DM). Primary biomarkers for the diagnosis of CVDs included growth differentiation factor 15 and neurogenic locus notch homologue protein 1 (Notch1). For the diagnosis of DM, alpha-2-macroglobulin, C-peptides, isoleucine, glucose, tyrosine, linoleic acid and valine were frequently reported across the included studies. Advanced analytical techniques, such as liquid chromatography mass spectrometry, enzyme-linked immunosorbent assays and vibrational spectroscopy, were also repeatedly reported in the included studies and were utilized in combination with traditional and alternative matrices such as fingernails, hair and saliva. CONCLUSIONS: While advanced analytical techniques are expensive, laboratories in LMICs should carry out a cost-benefit analysis of their use. Alternatively, laboratories may want to explore emerging techniques such as infrared, Fourier transform-infrared and near-infrared spectroscopy, which allow sensitive noninvasive analysis.

Medicine use and medicine-related problems in patients with liver cirrhosis: a systematic review of quantitative and qualitative studies.

PURPOSE: This review aimed to determine the prevalence, causes and risk factors of medicine-related problems (MRPs) in patients with liver cirrhosis. METHODS: Eight online databases were searched up to 30 September 2018 with no start date. Appropriate Critical Appraisal Skills Programme tools were used to assess the quality of included studies. RESULTS: An overall 16 quantitative and 11 qualitative studies were included in the review. Methodological quality of the included studies was variable. Mean frequency of MRPs reported in the quantitative studies ranged from 14 to 23.4%. The most frequent causes of MRPs included drug interactions, inappropriate dosing and use of contraindicated drugs. The qualitative analysis identified three themes: patient-related factors, healthcare professionals' related factors and stigma associated with liver cirrhosis. CONCLUSION: MRPs were found to be prevalent in patients with liver cirrhosis. Factors contributing to MRPs in liver cirrhosis were not limited to medicines' effects and interactions but included healthcare systems and patients. Therefore, management of liver cirrhosis should not be limited to providing an effective medicine therapy and should take into account the patients' behaviour towards the condition.

A systematic review of hospitalization resulting from medicine-related problems in adult patients.

AIMS: Medicine-related problems (MRPs) represent a major issue leading to hospitalization, especially in adult and elderly patients. The aims of this review are to investigate the prevalence, causes and major risk factors for MRPs leading to hospitalization in adult patients and to identify the main medicine classes involved. METHODS: Studies were identified through electronic searches of Medline, Embase, Scopus and International Pharmaceutical Abstracts between January 2000 and May 2013. A systematic review was conducted of both retrospective and prospective studies. Studies included were those involving hospitalization resulting from MRPs in adults (≥18 years old), whereas studies excluded were those investigating drug misuse and abuse and studies investigating MRPs in hospitalized patients. Data analysis was performed using SPSS version 20. RESULTS: Forty-five studies were identified, including 21 that investigated hospitalization resulting from adverse drug reactions, six studies that investigated hospitalization due to adverse drug events and 18 studies that investigated hospitalization due to MRPs. The median prevalence rates of hospitalization resulting from adverse drug reactions, adverse drug events and MRPs were 7% (interquartile range, 2.4-14.9%), 4.6% (interquartile range, 2.85-16.6%) and 12.1% (interquartile range, 6.43-22.2%), respectively. The major causes contributing to MRPs were adverse drug reactions and noncompliance. In addition, the major risk factors associated with MRPs were old age, polypharmacy and comorbidities. Moreover, the main classes of medicines implicated were medicines used to treat cardiovascular diseases and diabetes. CONCLUSIONS: Hospitalization due to MRPs had a high prevalence, in the range of 4.6-12.1%. Most MRPs encountered were prevalent among adult patients taking medicines for cardiovascular diseases and diabetes.

Perceptions and Practices of Saudi Hospital Pharmacists Towards Reporting Medication Errors Including Near Misses.

OBJECTIVES: Medication errors (MEs) represent a patient safety concern that can have negative consequences on patients in the short and long term. Community pharmacists play an important role in the medication management process, which urges the need for their role in managing MEs. Therefore, this study aimed to investigate the perceptions and attitudes of Saudi pharmacists towards reporting MEs. METHODOLOGY: A cross-sectional study was conducted using a semi-structured questionnaire that was distributed to Saudi pharmacists. The questionnaire was distributed to pharmacists via email after they had provided their consent to take part in the study. Data from the questionnaire were analysed using Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. RESULTS: The findings showed that most pharmacists appreciated the importance of reporting MEs and the role the reporting played in improving the quality of healthcare delivery. However, pharmacists raised many concerns regarding barriers to reporting. Such barriers to reporting included blaming patients or healthcare professionals, underdeveloped protocols, and the lack of standard procedures for ME reporting. Moreover, inadequate communication between healthcare professionals (for example, between pharmacists and doctors) represented an additional barrier to reporting MEs. CONCLUSIONS: MEs and near misses are underreported among Saudi pharmacists due to many operational and communication challenges. These findings are useful for healthcare authorities involved in developing patient safety frameworks for reporting MEs and near misses. Future work can also determine the attitudes of other healthcare professionals involved in the medication management process.

Understanding factors influencing the implementation of medicine risk communications by healthcare professionals in clinical practice: a systematic review using the Theoretical Domains Framework.

BACKGROUND: Adverse drug reactions (ADRs) are known to cause hospitalisation, longer hospital stays, as well as higher healthcare costs and mortality. Unrecognised ADRs are anticipated throughout the medicine lifecycle as, before the medicine reaches the market, clinical trials are conducted for a short period on a limited number of people, who might underrepresent the actual population. After the medicine reaches the market, emergent information that could affect its benefit-to-risk balance is usually shared by regulatory agencies and pharmaceutical companies through medicine risk communications. Medicines risk communications aim to prevent harm to patients by targeting their behaviour, knowledge, and attitudes, as well as those of health care professionals (HCPs). Despite their important role in translating these communications into their clinical practice, HCPs do not always adhere to the recommendations provided in risk communications. Measurement of medicine risk communications' effectiveness does not necessarily guarantee their implementation, cost-effectiveness, or transferability in real-world situations. To enhance the impact of drug regulatory interventions, implementation science has been encouraged. However, implementation science was not previously used to identify factors affecting HCPs' implementation of medicines risk communications. A recently widely used framework is the Theoretical Domain Framework (TDF). In this systematic review, the TDF was employed to categorise a range of different factors that could affect HCPs' implementation of medicine risk communications within their clinical contexts. METHODS: The search strategy involved a set of predefined search terms and fifteen databases, such as EMBASE, PubMed, Web of Science and CINAHL PLUS. Searches were conducted from April to May 2018 and updated in June 2021 using PubMed, Scopus, and CINAHL PLUS. A second reviewer independently conducted the screening process of the initial search. The total number of records screened was 10,475. A study was included if it reported any factors influencing HCPs' uptake of medicine risk communications. Only studies with English or Arabic abstracts were included. Those studies that did not include pharmacovigilance-related medicine risk communications were excluded. Additionally, studies only assessing HCPs' practice or evaluating the effectiveness of risk minimisation measures were excluded. Likewise, studies related to occupational hazards, case reports, interventional studies, and studies not involving HCPs were excluded. In case the published information was insufficient to decide whether to include or exclude a study, the authors were contacted. Furthermore, the authors of seven eligible abstracts were contacted for full-text articles. The mixed method appraisal tool (MMAT) was used to evaluate the quality of the included studies. All included studies were assessed by one reviewer, and a total of 16 studies were assessed by two reviewers independently. Disagreements were resolved through discussion. Using thematic analysis and concept mapping, a narrative synthesis was performed, followed by a critical reflection on the synthesis process. This review presents the results of the concept mapping, which involved matching the identified factors to the TDF. RESULTS: A total of 28 studies were included. Eleven domains influenced HCPs' implementation of medicine risk communications. A large number of studies included factors related to the "Knowledge" domain (n = 23), followed by "Beliefs about Consequences" (n = 13), "Memory, Attention and Decision Processes" (n = 12) and "Environmental Context and Resources" domains (n = 12). Seven studies reported "social influences" and six studies included factors relating to "Goals", followed by four studies involving factors related to "Social/Professional Role and Identity". Underrepresented domains included "Emotion" (n = 2), "Beliefs about Capabilities" (n = 2), "Behavioural Regulation" (n = 1), and "Reinforcement" (n = 1). On the other hand, none of the identified factors were related to the "Skills", "Optimism", or "Intentions" domains. Except for "Beliefs about Consequences", most studies contributing to the other three most commonly reported domains ("Knowledge"; "Environmental Context and Resources"; and "Memory, Attention and Decision Processes") scored low (1 or 2 out of 5) on the MMAT quality assessment. Moreover, the same number of studies (n = 5) contributing to the "Beliefs about Consequences" domain had low (1 or 2 out of 5), and intermediate (3 out of 5) scores on the MMAT. CONCLUSION: Medicines risk communications are important tools for disseminating information that may influence the benefit-to-risk balance of medicines. Even though HCPs are required to implement the recommendations of these communications, they do not always adhere to them. Using the TDF enabled the categorization of the range of factors that affect whether or not HCPs implement the recommendations provided in a medicine risk communication. However, most of these factors relate to four domains only ("Knowledge"; "Beliefs about Consequences"; "Memory, Attention and Decision Processes"; and "Environmental Context and Resources"). Additionally, most of the studies contributing to three of these four domains were of low quality. Future research should focus on using implementation science to identify target behaviours for actionable medicine risk communications. Regulators should use such science to develop cost-effective strategies for improving the implementation of medicines risk communication by HCPs.

Antibiotic resistance before, during, and after the COVID-19 pandemic: a retrospective study.

INTRODUCTION: Prevalence of antibiotic resistance (AR) during the coronavirus 2019 (COVID-19) pandemic was higher than pre-pandemic times. This study determined the prevalence and patterns of AR among Gram-positive and negative bacteria before, during and after COVID-19 in Saudi Arabia and identified the associated factors. METHODOLOGY: A retrospective cross-sectional study was employed to identify patients with positive AR bacteria between March 2019 and March 2022. The bacterial isolates and patients' data were identified from laboratory and medical records departments retrospectively. Binary logistic regression analysis was performed to identify the factors associated with AR and deaths. Multinominal logistic regression was applied to confirm the factors associated with AR classification. RESULTS: AR Gram-negative bacteria decreased during and after the pandemic. However, S. aureus showed a negligible increase in resistance rate after pandemic, while E. faecium, recorded a higher-than-average resistance rate during the pandemic. The prevalence of pan drug resistance (PDR) during the pandemic (85.7%) was higher than before (0%) and after (14.3%), p = 0.001. The length of stay and time were significant predictors for AR classification. The odds of multi drug resistance (MDR) development to PDR during the pandemic were 6 times higher than before and after (OR = 6.133, CI =, p = 0.020). Age, nationality, COVID-19 infection, smoking, liver disease, and type and number of bacteria were associated with death of patients with positive AR. CONCLUSIONS: Further studies are recommended to explore the prevalence of PDR and to justify the increased rates of E. faecium AR during the COVID-19 pandemic.

Gender Bias in Diagnosis, Prevention, and Treatment of Cardiovascular Diseases: A Systematic Review.

Cardiovascular disease (CVDs) has been perceived as a 'man's disease', and this impacted women's referral to CVD diagnosis and treatment. This study systematically reviewed the evidence regarding gender bias in the diagnosis, prevention, and treatment of CVDs. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. We searched CINAHL, PubMed, Medline, Web of Science, British Nursing Index, Scopus, and Google Scholar. The included studies were assessed for quality using risk bias tools. Data extracted from the included studies were exported into Statistical Product and Service Solutions (SPSS, v26; IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. A total of 19 studies were analysed. CVDs were less reported among women who either showed milder symptoms than men or had their symptoms misdiagnosed as gastrointestinal or anxiety-related symptoms. Hence, women had their risk factors under-considered by physicians (especially by male physicians). Subsequently, women were offered fewer diagnostic tests, such as coronary angiography, ergometry, electrocardiogram (ECG), and cardiac enzymes, and were referred to less to cardiologists and/or hospitalisation. Furthermore, if hospitalised, women were less likely to receive a coronary intervention. Similarly, women were prescribed cardiovascular medicines than men, with the exception of antihypertensive and anti-anginal medicines. When it comes to the perception of CVD, women considered themselves at lower risk of CVDs than men. This systematic review showed that women were offered fewer diagnostic tests for CVDs and medicines than men and that in turn influenced their disease outcomes. This could be attributed to the inadequate knowledge regarding the differences in manifestations among both genders.

Factors influencing the implementation of medicine risk communications by healthcare professionals in clinical practice: A systematic review.

BACKGROUND: Regulatory medicines risk communications aim to prevent patient harm through the dissemination of safety information to healthcare professionals (HCPs), patients, and the public. Evidence suggests that in addition to implementing the required changes, HCPs also respond to these communications through unintended and unwarranted actions and behaviours such as stopping medicine courses unnecessarily, and blanket actions spilling over to unintended patients' populations. Misunderstanding and mis-implementation of medicines risk communications could jeopardise patients' safety and clinical outcomes. Therefore, it is important to understand the determinants that affect HCPs responses to medicines risk communications. This systematic review aims to identify the factors that affect the implementation of risk communications by healthcare professionals. METHODS: Fifteen databases, including EMBASE, PubMed, Scopus, Web of science, CINAHL PLUS were searched in April-May 2018, and the search was updated again in June 2021 to identify studies reporting on factors influencing HCPs' uptake of medicine risk alerts. We used keywords such as risk communication, safety update, and safety regulation. Studies were excluded if they did not involve pharmacovigilance or patient safety alerts; or if they only focused on measuring HCPs' practice after alerts; or evaluating the effectiveness of risk minimisation measures without reporting on factors affecting HCPs' actions. Studies relating to occupational hazards, case reports, interventional studies, and studies not involving HCPs were also excluded. The Mixed Method Appraisal Tool (MMAT) was used to assess the quality of the included studies. A Narrative synthesis approach was undertaken using thematic analysis and concept mapping, followed by a critical reflection of the synthesis. RESULTS: Twenty-eight studies met our criteria and were included in the synthesis. We identified four themes summarising the factors influencing HCPs' implementation of risk communications. These include HCPs: knowledge of medicine alerts; perceptions of alerts; attitudes, and concerns regarding medicine alerts; and the self-reported impact of these alerts. Our concept mapping exercise identified key interactions between different stakeholders, and these interactions determine HCPs' implementation of medicine risk communications. These stakeholders comprise of alert developers, including the sources and senders of safety information, and the receivers of safety information including health care institutions, HCPs, patients and their carers. CONCLUSIONS: Healthcare professionals are crucial to translating risk communication messages into clinical practice. However, if they have inadequate information about the content of the alert, and have inaccurate perceptions about the alert, they may not implement the required clinical changes as intended. Communication of medicine risk alerts does not always translate into improved patient care, due to a complex interaction between stakeholders involved in the creation and implementation of these alerts. These complex interactions should be the subject of future research efforts to understand the alert-implementation trajectory and identify the mediators for change and interventions to improve implementation.

Exploring e-psychonauts perspectives towards cocaine effects and toxicity.

BACKGROUND: According to the World Drug Report, cocaine is the second most used drug globally after cannabis. Online discussion forums enable the understanding of authentic drug users' experience as it is anonymous. Therefore, this study determined the uses, effects and toxicity of cocaine from the perspectives' of e-psychonauts. METHODS: A qualitative study was conducted using six popular discussion forums. From these discussion forums, 1229 posts from 50 threads were subject to thematic analysis. Hence, the information from these threads were examined carefully for patterns and codes among the data. The codes were then collated into subthemes and themes. RESULTS: The four main themes emerging from the study were related to cocaine characteristics and use, e-psychonauts' knowledge and experience, desired effects and adverse events. The main characteristic associated with cocaine use was purity that was highest in the US being nearest to the source. The most common cutting agent encountered in cocaine samples was levamisole that increased the chances of immunosuppression and cardiovascular toxicity. Purity depended on the source of purchase that included street dealers, dark web and surface web. Hence, e-psychonauts recommended purchase of cocaine from known dealers rather than websites with unknown sources. E-psychonauts mainly used cocaine in social context and parties or to self-medicate against anxiety and depression. Effects desired from cocaine use were mainly euphoria and increased energy. However, tachycardia and myocardial infarction were the main adverse events. It is noteworthy to mention that myocardial infarction was idiosyncratic and was often lethal. Myocardial infarction was more often reported when cocaine was combined with alcohol due to the production of cocaethylene. Social harm was also reported as a consequence for the use of cocaine that resulted in homelessness and broken relationships. CONCLUSION: Online discussion forums allowed the understanding of e-psychonauts' experience with cocaine use. Not only it informed about the sources and modalities of use of cocaine but also about the adverse events and social harm associated with cocaine use. The present findings serve as useful information for practitioners and healthcare professionals dealing with cocaine users.

Diabetes Self-management Apps: Systematic Review of Adoption Determinants and Future Research Agenda.

BACKGROUND: Most diabetes management involves self-management. Effective self-management of the condition improves diabetes control, reduces the risk of complications, and improves patient outcomes. Mobile apps for diabetes self-management (DSM) can enhance patients' self-management activities. However, they are only effective if clinicians recommend them, and patients use them. OBJECTIVE: This study aimed to explore the determinants of DSM apps' use by patients and their recommendations by health care professionals (HCPs). It also outlines the future research agenda for using DSM apps in diabetes care. METHODS: We systematically reviewed the factors affecting the adoption of DSM apps by both patients and HCPs. Searches were performed using PubMed, Scopus, CINAHL, Cochrane Central, ACM, and Xplore digital libraries for articles published from 2008 to 2020. The search terms were diabetes, mobile apps, and self-management. Relevant data were extracted from the included studies and analyzed using a thematic synthesis approach. RESULTS: A total of 28 studies met the inclusion criteria. We identified a range of determinants related to patients' and HCPs' characteristics, experiences, and preferences. Young female patients were more likely to adopt DSM apps. Patients' perceptions of the benefits of apps, ease of use, and recommendations by patients and other HCPs strongly affect their intention to use DSM apps. HCPs are less likely to recommend these apps if they do not perceive their benefits and may not recommend their use if they are unaware of their existence or credibility. Young and technology-savvy HCPs were more likely to recommend DSM apps. CONCLUSIONS: Despite the potential of DSM apps to improve patients' self-care activities and diabetes outcomes, HCPs and patients remain hesitant to use them. However, the COVID-19 pandemic may hasten the integration of technology into diabetes care. The use of DSM apps may become a part of the new normal.

Exploring the adverse effects of chemotherapeutic agents used in the treatment of cervical and ovarian cancer from the patients' perspective: a content analysis of the online discussion forums.

OBJECTIVES: This study aimed to explore the adverse effects of chemotherapeutic agents used in the treatment of ovarian and cervical cancer by analysing patients' views posted in online discussion forums. METHOD: UK-centred online discussion forums were used to identify discussion threads on ovarian and cervical cancer between 2008 and 2017. The study was approved by the University of Bournemouth ethics committee. 272 discussion threads with 644 participants from four online discussion forums (Cancer Research UK, Macmillan, Ovacome and Jo's Cervical Cancer Trust) were identified. The threads were exported into NVivo and a thematic content analysis was conducted to identify study themes. RESULTS: Of the 644 participants, 19.4% had a diagnosis of cervical cancer and 80.6% had a diagnosis of ovarian cancer. Four main themes related to: (1) treatment plan, (2) adverse effects, (3) perception of treatment and (4) hospitalisation were identified. Patients' perceptions about their treatment were reported to be positive across all chemotherapeutic agents. 312 adverse effects were reported by patients with cervical cancer taking cisplatin, with fatigue (52.1%) and nausea (30.6%) being the two most frequently reported adverse effects. With regard to the treatment of ovarian cancer, 402 adverse effects were reported by patients on carboplatin and paclitaxel, with neuropathy (29.3%) and fatigue (28.0%) being the two most commonly reported adverse effects. CONCLUSION: The online discussion forums allowed patients to express their concerns in a blame-free environment that provided novel insight into the impact of chemotherapy-associated adverse effects on patients with cervical and ovarian cancers. Real-life experiences shared by patients can help the healthcare professionals to find the right balance between prolonged survival and quality of life.

Relevance of physicochemical properties and functional pharmacology data to predict the clinical safety profile of direct oral anticoagulants.

Direct oral anticoagulants (DOACs) have rapidly become the drug class of choice for anticoagulation therapy in secondary care. It is known that gastrointestinal hemorrhage are potential side effects of the DOAC drug class. In this study we have investigated the relevance of molecular structure and on/off-target pharmacology as a predictor of adverse drug reactions (ADRs) for the DOAC drug class. Use of the Reaxys MedChem module allowed for data mining of all possible reported off-target effects of the DOAC class members. For the first time, the MHRA Yellow card database in combination with prescribing rates in the United Kingdom (data for n = 30 566 936 DOAC Rx (up to 2017) and ADR data n = 22 275 (up to 2018)) were used for our data comparison of DOACs. From the underlying reported data, we were able to rank the DOACs in terms of the likely adverse events we would expect to observe. We identified potential risks of ADRs based on the DOACs pharmacology including the expected GI hemorrhage, but also the unexpected risk of stroke, pulmonary embolism and kidney injury. Statistically significant (P < .001) differences were found between all DOACs and their total number of ADRs. Although the risks are small, strong statistical correlation between observed pharmacology and national ADR data is observed in three out of the five areas of concern.

Interventions to improve spontaneous adverse drug reaction reporting by healthcare professionals and patients: systematic review and meta-analysis.

INTRODUCTION: The aim of this study was to evaluate the effectiveness of interventions used for improving ADR reporting by patients and healthcare professionals. AREAS COVERED: A systematic review of literature was conducted by searching Medline, Embase and Cochrane Central Register of Controlled of Trials. Meta-analysis of randomized controlled trials (RCTs; n = 5) was conducted to estimate the pooled risk ratio for the effectiveness of interventions on ADR reporting rates. Data from observational studies were synthesized using narrative synthesis approach. EXPERT OPINION: A total of 28 studies were included. All except one study targeted healthcare professionals using educational, technological, policy, financial and/or mixed interventions. The results showed that financial and face-to-face educational interventions improved quality and quantity of ADR reporting when compared with interventions not involving face-to-face interactions. However, the quality of studies was generally low. Meta-analysis showed a statistically significant 3.5-fold overall increase in reporting of ADRs [RR 3.53; 95% CI (1.77,7.06)] in the intervention group compared to the control. There was a lack of consideration of theory and sustainability in the design of the interventions. There is a need to develop and test theory-based interventions and target patient reporting. More research needs to be conducted in the low- and middle-income countries.

An exploration of patient safety culture in Kuwait hospitals: a qualitative study of healthcare professionals' perspectives.

OBJECTIVE: Patient safety culture (PSC) represents a key component of the quality of care offered by healthcare professionals. Therefore, it is crucial to understand the factors that influence the implementation of a safe culture. This study explored the knowledge and attitudes of healthcare professionals in Kuwait towards the factors that might affect the PSC. METHODS: A qualitative study using semi-structured interviews with healthcare professionals was conducted between February and June 2018 at two major hospitals in Kuwait. Both hospitals had been accredited and have been applying the safety programmes recommended by the Kuwaiti Ministry of Health. Participants were purposively selected where 20 healthcare professionals were interviewed. The interviewees comprised of six physicians, six clinical pharmacists, six nurses and two members of the patient safety committee. Inclusion criteria involved healthcare professionals who had more than 1-year clinical experience, have interest in patient safety and had a good level of English. Interviews were audio-recorded and transcribed verbatim. Thematic analysis of the interview transcripts was conducted to identify the emergent themes. KEY FINDINGS: Thematic analysis of the interviews yielded three major themes related to 'management', 'regulations and policies' and 'healthcare professionals'. Management issues included managerial support, resources, safety environment and staff training. Regulations and policies highlighted issues related to policies and procedures and incident reporting system. Healthcare professionals' theme covered factors related to knowledge, communication and teamwork among healthcare professionals. CONCLUSIONS: This study gave insight into how healthcare professionals perceive the current PSC in Kuwait. Despite their positive attitudes and knowledge towards patient safety, various barriers were reported that hinder optimal PSC. These barriers were related to support, staffing, resources and response to error.

Causes, Nature and Toxicology of Fentanyl-Associated Deaths: A Systematic Review of Deaths Reported in Peer-Reviewed Literature.

PURPOSE: Fentanyl poisoning has been widely reported, yet there is a lack of systematic evaluation of the nature and toxicology of associated deaths in the published literature. This article aims to systematically review the nature, causes, routes of administration and toxicology of fentanyl-associated deaths using case studies and case series in peer-reviewed published literature. METHODS: Four electronic databases including Embase, Medline (via Ovid), Scopus and Google Scholar were searched from inception until October 2019 to identify the studies reporting fentanyl related deaths. Two independent reviewers screened and selected the titles and then evaluated the full texts. Only case studies and case series were included. A structured data extraction tool was used to extract data on the number of deaths, routes of administration, concomitant drug use and toxicological data. The Joanna Briggs Institute quality assessment tool was used to evaluate the quality of included studies. Data were synthesized narratively. RESULTS: Of 1251 articles identified during initial search, 8 case reports and 9 case series met the inclusion criteria. A total of 1969 deaths were reported in the included studies. Deaths were concentrated in the north American region (n = 1946) and the Nordic region (n = 22). Reported causes of death included fentanyl overdose (n = 321, 56.4%), mixed drug toxicity (n = 196, 34.5%), natural (n = 28, 4.9%), other drug toxicity (n = 10, 1.8%), fentanyl and ethanol intoxication (n = 8, 1.4%), incidental (n = 5, <1%) and aspiration (n = 1). Most common routes of use were intravenous (70.5%) and transdermal routes (23.0%). Deaths came swiftly via the intravenous route. Mean level of blood fentanyl amongst all reported deaths was 0.024 µg/mL. CONCLUSION: Literature related to fentanyl-associated deaths predominantly come from North America. Deaths are comparatively lower or not reported in peer-reviewed publications from the rest of the world. Abuse through intravenous administration, mixed drug toxicities and self-treatment of breakthrough pain are mainly responsible for majority of the reported deaths.

Medical errors: Healthcare professionals' perspective at a tertiary hospital in Kuwait.

Medical errors are of economic importance and can contribute to serious adverse events for patients. Medical errors refer to preventable events resulting from healthcare interactions, whether these events harm the patient or not. In Kuwait, there is a paucity literature detailing the causes, forms, and risks of medical errors in their state-funded healthcare facilities. This study aimed to explore medical errors, their causes and preventive strategies in a Kuwait tertiary hospital based on the perceptions and experience of a cross-section of healthcare professionals using a questionnaire with 27 open (n = 10) and closed (n = 17) questions. The recruited healthcare professionals in this study included pharmacists, nurses, physicians, dentists, radiographers, hospital administrators, surgeons, nutritionists, and physiotherapists. The collected data were analysed quantitatively using descriptive statistics. A total of 203 participants filled and completed the survey questionnaire. The frequency of medical errors in Kuwait was found to be high at 60.3% ranging from incidences of prolonged hospital stays (32.9%), adverse events and life-threatening complications (32.3%), and fatalities (20.9%). The common medical errors result from incomplete instructions, incorrect dosage, and incorrect route of administration, diagnosis errors, and labelling errors. The perceived causes of these medical errors include high workload, lack of support systems, stress, medical negligence, inadequate training, miscommunication, poor collaboration, and non-adherence to safety guidelines among the healthcare professionals.

Factors contributing to medicine-related problems in adult patients with diabetes and/or cardiovascular diseases in Saudi Arabia: a qualitative study.

OBJECTIVES: To investigate the factors contributing to medicine-related problems (MRPs) among patients with cardiovascular diseases (CVDs) and/or diabetes in Saudi Arabia. DESIGN: Qualitative semistructured interviews were conducted. Interviews were audio recorded then transcribed into Microsoft Word. The transcribed interviews were then imported into the qualitative analysis software NVivo where thematic analysis was applied. Thematic synthesis was achieved by coding and developing subthemes/themes from the findings of the interviews. SETTING: Five healthcare centres in Najran, Saudi Arabia. PARTICIPANTS: 25 adult patients with diabetes and/or CVDs. RESULTS: The study cohort included 16 men and 9 women with a median age of 61.8 years (40-85 years). Diabetes was the main condition encountered among 23 patients and CVDs were reported among 18 patients. Perceived factors leading to MRPs were of four types and related to: patient-, healthcare system-, clinical (condition-) and medicine-related factors. Patient-related factors were related to living situation, religious practices, diet/exercise and patients' behaviour towards the condition and medicines. Healthcare system-related factors comprised sources and availability of medicines, ease of access to healthcare system and patient satisfaction with healthcare providers. Clinical (condition-) related factors associated with both the knowledge and control over condition, and effects of the condition among medicines intake. Medicine-related factors included lack of knowledge about medicines and medicine use. CONCLUSIONS: The results of this study uncovered many factors associated with MRPs among patients with CVDs and diabetes in Saudi Arabia, especially in reference to lifestyle and medicine use. Improving communication with healthcare professional alongside the introduction of national clinical guidance would mitigate the unwanted health complications related to medicine use.

Hospitalisation Resulting from Medicine-Related Problems in Adult Patients with Cardiovascular Diseases and Diabetes in the United Kingdom and Saudi Arabia.

Cardiovascular diseases (CVDs) and diabetes (DM) are two interrelated conditions that have a heavy morbidity and mortality burden worldwide. Patients with the two conditions usually take multiple medicines and thus are more susceptible to medicine-related problems (MRPs). MRPs can occur at any stage of the treatment process and in many cases can lead to unplanned hospitalisations. The aim of the study was to determine the prevalence of hospitalisation resulting from MRPs in adult patients with CVDs and/or DM and to identify the main causes, risk factors, and medicine classes involved. A retrospective study included 300 adult patients from two hospitals, one in the United Kingdom and one in Saudi Arabia. To identify MRPs, medical records were reviewed for demographic data, clinical data, laboratory assay, and prescription records. A total of 197 (65.7%) patients had MRPs, of which less than 10% were severe. The main problems were lack of treatment effectiveness and adverse drug reactions. Moreover, polypharmacy and patient non-adherence were the main risk factors contributing to MRPs. The main medicine classes associated with MRPs were insulin and antihypertensive medicines. Further research should address the pharmaceutical care processes employed in treating CVDs and DM, and to empower patients/healthcare providers in tackling MRPs.