[Alerts system associated with computerized physician order entry: analysis and identification of improvement points]. / Sistema de alertas asociado a prescripción electrónica asistida: análisis e identificación de puntos de mejora.

OBJECTIVE: To make a quantitative analysis of the alerts associated with a computerized physician order entry system and identify opportunities to improve the system. METHOD: A retrospective observational study in a general hospital with 750 beds, 500 of which have a computerized physician order entry system installed. The frequency per type and medication of 525,691 alerts produced for a year in the prescription of drug treatments to 15,466 patients was analysed, entering these on a database. The system includes three categories of alert relating to the drug, the characteristics of the patient and the hospital medicine policy. By means of a failure mode and effects analysis, opportunities for improving the system were identified and corrective measures were suggested. RESULTS: It has been observed that from the total of 1,084 drugs, 20 of them produce 34% of alerts. The ten most frequently active ingredients involved are: potassium chloride, acenocumarol, imipenem, lorazepam, diazepam, mycophenolate, enoxaparin, tacrolimus, calcium carbonate and cyclosporine. The most frequent alerts generated during electronic prescription are associated with duplicated therapy (35.4%), renal failure (27.6%) and risk due to advanced age (17.2%), with these groups accounting for 80.2% of the total. The excess of alerts and information provided by the alerts were identified as priority improvement points. CONCLUSIONS: The system produced excessive alerts which led to the risk of them being ignored and reducing the capacity to prevent adverse drug events. Modifications are required for the design of the alert system, which also needs to be continuously updated.

[Pharmaceutical care self-assessment process for hospitalized patients through the Valor program]. / Autoevaluación del proceso de atención farmacéutica en pacientes hospitalizados a través del programa Valor.

OBJECTIVE: To assess the quality of pharmaceutical care for inpatients using qualitative criteria as established in the Valor program. METHOD: Evaluation study through 43 explicit structural, process, and outcome criteria within the Valor program, in which pharmacists in the Unit Dose Functional Unit may assess themselves along a compliance scale from 0 to 100%. This Unit provides daily individualized pharmaceutical care to 550 patients in an adult general and surgery hospital. Mean scores per pharmacist and item are estimated for the 2003-2005 period. RESULTS: Mean compliance assessments for all 14 interannual "structural items" were 53, 57, and 64%; those for all 13 "process items" were 52, 51, and 46%; and those for all 15 "outcome items" were 18, 28, and 26%. A variability of 20% was documented for structure and process evaluations, and of 50% for outcome assessments. CONCLUSIONS: Every autoevaluation raises to the equipment the necessity to establish improvements and to enhance communication, and the application of standardized procedures in the pharmaceutical care process.

Effects of IV morphine in central pain: a randomized placebo-controlled study.

OBJECTIVE: To investigate the effects of IV morphine on central pain syndromes through quantitative sensory testing and to assess the long-term benefit of oral morphine. METHODS: After an initial open titration phase aiming to determine the maximal tolerated dosage of IV morphine, the efficacy of morphine infusion (9-30 mg; mean dosage, 16 mg) was assessed in a double-blind, placebo-controlled and crossover fashion in 15 patients with poststroke- (6 patients) or spinal cord injury- (9 patients) related pain. All of the patients subsequently received sustained oral morphine. RESULTS: Morphine significantly reduced the intensity of brush-induced allodynia but had no effect on other evoked pains (i.e., static mechanical and thermal allodynia/hyperalgesia). The effects of morphine on ongoing pain were not significantly different from those of the placebo, but 7 patients (46%) responded to morphine. There was a correlation between the effects of morphine on spontaneous pain and the decrease of the responses to suprathreshold thermal stimuli on the nonpainful contralateral side, suggesting that these effects were related to the general antinociceptive activity of the drug. The effects of IV morphine were correlated with those of oral morphine at 1 month, but only 3 patients (20%) were still taking morphine after 1 year. CONCLUSIONS: IV morphine induces analgesic effects on some components of central neuropathic pain syndromes, but only a minority of patients may benefit from long-term opioid treatment.

Intravenous lidocaine in central pain: a double-blind, placebo-controlled, psychophysical study.

OBJECTIVE: To investigate the effects of systemic administration of lidocaine on different components of neuropathic central pains by quantitative sensory testing. METHODS: The efficacy of systemic lidocaine (5 mg/kg IV over 30 minutes) was evaluated in a double-blind, placebo-controlled, and cross-over fashion, on both spontaneous ongoing pain and evoked pains (allodynia and hyperalgesia) in 16 patients with chronic poststroke (n = 6) or spinal cord injury (n = 10) related pain. RESULTS: Lidocaine was significantly superior to the placebo (saline) in reducing the intensity of spontaneous ongoing pain for up to 45 minutes after the injection: 10 of 16 patients (62.5%) receiving lidocaine showed a significant reduction in spontaneous pain, whereas only six patients showed this after the placebo. Lidocaine also significantly reduced the intensity of brush-induced allodynia and mechanical hyperalgesia, but was no better than the placebo against thermal allodynia and hyperalgesia. In general, the side effects were moderate and consisted mainly of lightheadedness (44%). CONCLUSIONS: Systemic lidocaine can induce a significant and selective reduction of several components of pain caused by CNS injuries. The observed preferential antihyperalgesic and antiallodynic effects of this drug suggest a selective central action on the mechanisms underlying these evoked pains.

[Periodic evaluation of practices in postoperative pain management] . / Intérêt d'une évaluation périodique des pratiques de prise en charge de la douleur postopératoire.

OBJECTIVE: Periodical assessment of practices as part of a quality assurance program: impact on postoperative pain. PATIENTS: All patients evaluated from the first postoperative day during a week. METHODS: Two surveys performed at a six month interval after establishment of some corrective measures. Different items were evaluated: pre-anaesthesia information for patients, pain severity and satisfaction with pain treatment. Medical data were consulted concerning postoperative analgesic prescriptions, their realization, pain assessment by nurses. Between the two surveys, first survey results were presented to anaesthesiologists. Then guidelines for prescriptions were suggested and new monitoring guidelines were proposed to nurses in surgical ward. RESULTS: 94 patients were evaluated during each survey. Patients had undergone orthopaedic, visceral, urology, ophthalmology and vascular surgery. Half of the patients did not receive information about pain before surgery. 43% of patients had a pain scores = 30/100 during movements; no difference was found between the two evaluations. Satisfaction graded as "moderate or insufficient" decreased from 22% (1rst survey) to 10 (2nd survey) (p < 0.05). Non steroidal anti-inflammatory drugs and nefopam prescriptions increased between the two surveys (p < 0.05). Association of three or four analgesics increased between the two surveys and monotherapies decreased (p < 0.05). Concordance of prescriptions with guidelines was 55% during first survey and 62% during the second (NS). Pain severity was not recorded for 36% of patients at first survey and in 18% at the second (p < 0.05). CONCLUSION: Although anaesthesiologists and nurses changed their practice due to a quality insurance program concerning postoperative pain, its consequence on the severity of postoperative pain was not significant.

[Therapeutic interchange of drugs not included in the hospitals pharmacotherapeutic guide: a quality program]. / Programa de calidad aplicado a la sustitución de medicamentos no incluidos en la Guía Farmacoterapéutica del hospital.

BACKGROUND: Standardised substitution of those drugs not included in the hospitals formulary constitutes one of several methods used to improve therapeutic efficiency, due to reduction of variability in pharmaceutical practice and prevention of potential medication errors. OBJECTIVES: To evaluate quality of drug substitution procedures in those drugs not included in the hospital's formulary. METHODS: Assessment study in a surgical hospital with 314 beds, using structural, process and outcome criteria from 1998 to 2002. RESULTS: Compliance degree for structure, process and outcome criteria were 100, 89 and 35%, respectively, while the established standards were 100%. Prevalence values for patients with substituted medication, increased from 2.9 (95%CI, 2.4-3.6) in 1998 to 11.1% (95%CI, 10.2-12.1) in 2002. Non-substituted drugs annual cost decreased from 20,199 in 1998 to 12,356 Euro in 2002. Drug substitution made by the pharmacist had an acceptance degree of 82.5%. No interchange errors were found in 126 replaced drugs. CONCLUSIONS: The development of quality programs to improve drug prescription adherence to the hospitals formulary, specially those that promote therapeutic interchange under the Pharmacy Committee guidance, are helpful strategies to make a proficient management of patients pharmacotherapy.