Occurrence Of Adverse Drug Events Research Articles

Increased risk of hip fracture among older people using antidepressants subtitle: A nationwide cohort study in Norway

Introduction.– Behavioural disorders are awell-established component of dementia and a frequent cause of hospitalisation. In some cases, theymay be of iatrogenic aetiology. The aim of the studywas to identify risk factors for the occurrence of adverse drug events (ADE) in elderlypatientswith cognitive impairment, hospitalised in an acute ward specialised in the management of dementia-related behaviour disorders. Methods.– A cross-sectional epidemiological study was performed in the acute geriatric medicine ward, specialised in the management of dementia disorders, at the University hospitals of Reims, France, betweenMay 2010 andNovember 2011. Demographic data (age, sex, place of residence), biological data and results of comprehensive geriatric assessmentwere recorded. Occurrence of ADE was recorded at admission and during the in-hospital phase in all patients,with double assessment (geriatricmedicine physician and pharmacovigilance physician). Risk factors for ADE were identified by logistic regression. Results.– In total, 293 patients aged 82±8years were included; the majority were women (61%). Cognitive evaluation found a Mini Mental State Examination (MMSE) score of 13±8; 245 (84%) were taking at least 5 different drugs at admission. Severe comorbidity was present in 183 (62%) (i.e. > 5 points on the Charlson index). Among the 293 patients, 70 (24%) experienced at least 1 ADE, of which half were considered as serious. The risk of ADE was significantly higher in case of polymedication (OR=3.8; 95%CI: 1.1–13.3), and in case of dependence (i.e. loss of at least 1 activity of daily living) (OR=2.8; 95%CI: 1.1–6.8). Patients aged over 85years had a significantly lower risk of adverse events than those aged <85 (OR=0.5; 95%CI: 0.2–0.9). Conclusion.–Polymedication anddependence as definedby theADL are risk factors for ADE. Older age appears to be a protective factor. This could be due to the prescription of drugs with a low iatrogenic risk in the oldest patients.

Adverse drug events in older hospitalized patients: results and reliability of a comprehensive and structured identification strategy.

BackgroundOlder patients are at high risk for experiencing Adverse Drug Events (ADEs) during hospitalization. To be able to reduce ADEs in these vulnerable patients, hospitals first need to measure the occurrence of ADEs, especially those that are preventable. However, data on preventable ADEs (pADEs) occurring during hospitalization in older patients are scarce, and no ‘gold standard’ for the identification of ADEs exists.MethodologyThe study was conducted in three hospitals in the Netherlands in 2007. ADEs were retrospectively identified by a team of experts using a comprehensive and structured patient chart review (PCR) combined with a trigger-tool as an aid. This ADE identification strategy was applied to a cohort of 250 older hospitalized patients. To estimate the intra- and inter-rater reliabilities, Cohen’s kappa values were calculated.Principal FindingsIn total, 118 ADEs were detected which occurred in 62 patients. This ADE yield was 1.1 to 2.7 times higher in comparison to other ADE studies in older hospitalized patients. Of the 118 ADEs, 83 (70.3%) were pADEs; 51 pADEs (43.2% of all ADEs identified) caused serious patient harm. Patient harm caused by ADEs resulted in various events. The overall intra-rater agreement of the developed strategy was substantial (κ = 0.74); the overall inter-rater agreement was only fair (κ = 0.24).Conclusions/SignificanceThe ADE identification strategy provided a detailed insight into the scope of ADEs occurring in older hospitalized patients, and showed that the majority of (serious) ADEs can be prevented. Several strategy related aspects, as well as setting/study specific aspects, may have contributed to the results gained. These aspects should be considered whenever ADE measurements need to be conducted. The results regarding pADEs can be used to design tailored interventions to effectively reduce harm caused by medication errors. Improvement of the inter-rater reliability of a PCR remains challenging.

Adverse drug events in surgical patients: an observational multicentre study

Errors occurring during different steps of the medication process can lead to adverse drug events (ADEs). Surgical patients are expected to have an increased risk for ADEs during hospitalization. However, detailed information about ADEs in the surgical patient is lacking. In this study, we aim to measure the incidence and nature of (preventable) ADEs, potential risk factors for and outcome parameters of (preventable) ADEs in surgical patients. Observational multicentre cohort study in which eight surgical wards participated from three Dutch hospitals, all using computerized physician order entry (CPOE) systems with clinical decision support. Electively admitted surgical patients of the participating wards were included from March until June 2009. ADEs were measured using a standardized method with expert judgment. Incidence, severity, preventability and accountable medication were assessed. Poisson regression analysis was applied to determine the associations between possible risk factors and the occurrence of ADEs, expressed as incidence rate ratio (IRR). Also outcomes of ADEs in surgical patients were measured. The incidence and nature of (preventable) ADEs in surgical patients. A total of 567 surgical patients were included. We found an incidence of 27.5 ADEs and 4.2 preventable ADEs (pADEs) per 100 admissions (15.4 %). A quarter of the pADEs were severe or life-threatening. Opioids and anti-coagulation medication play a major role in the occurrence of ADEs and pADEs respectively. Univariate analysis revealed an American Society of Anesthesiologists classification of III or more as a risk factor for ADEs. Patients older than 65 years [IRR 2.77 (1.14-6.72)], with cardiovascular comorbidity [IRR 2.87 (1.13-7.28)], or undergoing vascular surgery [IRR 2.32 (1.01-5.32)] were at risk for pADEs. Patients experiencing an ADE had a significant longer duration of admission than patients without an ADE. Surgical patients are at considerable risk of experiencing one or more ADEs during their admission, also in CPOE-hospitals. Risk factors for pADEs are age older than 65 years, cardiovascular comorbidity, and vascular surgery. Intensified monitoring may be needed in patients with a higher than average risk for pADEs.

Safety monitoring of artemisinin combination therapy through a national pharmacovigilance system in an endemic malaria setting

BackgroundThe National Malaria Control Programme in Senegal, introduced since 2006, artemisinin-based combination therapy (ACT administration) for the treatment of uncomplicated malaria cases. In this framework, an anti-malarial pharmacovigilance plan was developed and implemented in all public health services. This study investigated the occurrence of Adverse Drug Events (ADEs) after ACT.MethodsThe study was conducted between January 2007 and December 2009. It was based on spontaneous reports of ADEs in public health facilities. Data on patient demographic characteristics, dispensing facility, adverse signs and symptoms and causality were collected from a total of 123 patients.ResultsThe age range of these patients was six months to 93 years with a mean of 25.9 years. Of the reported symptoms, 46.7% were related to the abdomen and the digestive system. Symptoms related to the nervous system, skin and subcutaneous tissue, circulatory and respiratory systems and general symptoms and signs were 7%, 9.7%, 3.5% and 31.3%, respectively. Causality results linked 14.3% of symptoms to Falcimon® (Artesunate-Amodiaquine) with certainty. Effects were classified as mild and severe in 69.1% and 7.3% of cases respectively while 23.6% were serious. All patients with serious ADEs were hospitalized. One death was reported in a patient who had taken 24 pills at once.ConclusionThese results confirm the need to develop and implement pharmacovigilance systems in malaria endemic countries in order to monitor the safety of anti-malarial treatments.

Adverse drug events in a paediatric intensive care unit: a prospective cohort

ObjectivesTo describe adverse drug events (ADEs) in children under intensive care, identify risk factors and tools that can detect ADEs early, and the impact on length of stay (LOS).DesignA prospective...

Optimising drug prescribing and dispensing in subjects at risk for drug errors due to renal impairment: improving drug safety in primary healthcare by low eGFR alerts

ObjectivesTo assess the risk of medication errors in subjects with renal impairment (defined as an estimated glomerular filtration rate (eGFR) ≤40 ml/min/1.73 m2) and the effectiveness of automatic eGFR ≤40-alerts...

Multimorbidity, polypharmacy, referrals, and adverse drug events: are we doing things well?

The consequences of multimorbidity include polypharmacy and repeated referrals for specialised care, which may increase the risk of adverse drug events (ADEs). The objective of this study was to analyse the influence of multimorbidity, polypharmacy, and multiple referrals on the frequency of ADEs, as an indicator of therapeutic safety, in the context of a national healthcare system. This was a multicentre, retrospective, observational study of 79 089 adult patients treated during 2008 in primary care centres. The explanatory patient variables sex, age, level of multimorbidity, polypharmacy, number of primary care physician visits, and number of different specialties attended were analysed. The response variable was the occurrence of ADEs. Logistic regression models were used to identify associations among the analysed variables. The prevalence of individuals with at least one ADE was 0.88%. Multivariate analysis identified the following variables as risk factors for the occurrence of ADE in descending order of effect size: multimorbidity level (odds ratio [OR]Veryhigh/Low = 45.26; ORHigh/Low = 17.58; ORModerate/Low = 4.25), polypharmacy (OR = 1.34), female sex (OR = 1.31), number of different specialties (OR = 1.20), and number of primary care physician visits (OR = 1.01). Age, however, did not show statistical significance (OR = 1.00; 95% confidence interval = 0.996 to 1.005). The results of this study demonstrate that multimorbidity is strongly related to the occurrence of ADEs, insofar as it requires the intervention of multiple specialties and the prescription of multiple medications. Further research should shed light on the causal pathway between multimorbidity and increased risk of adverse events.

The Economic Burden of Inappropriate Drug Prescribing, Lack of Adherence and Compliance, Adverse Drug Events in Older People

Adverse drug events (ADEs) are an increasingly relevant issue for healthcare systems as they are associated with poorer health outcomes and avoidable misuse of resources. The rates of ADEs are higher in the elderly population, as many older patients have comorbidities, multiple drug prescriptions and deteriorated physical and cognitive functioning. The occurrence of ADEs can lead to a perceived lack of therapy efficacy and further underuse or suboptimal adherence in elderly people, with detrimental clinical outcomes. The present article systematically reviews the studies evaluating the economic impact of ADEs occurring as consequence of poor therapy adherence, inappropriate drug use, underuse of effective treatments and poor adherence, medication errors, drug-drug and drug-disease interactions.A Medline systematic literature review of studies evaluating the economic consequences of inappropriate drug prescribing, lack of adherence and compliance, ADEs in older people was performed. English-language articles were screened through a three-step approach (title review, abstract review, full article review) to select pertinent studies quantitatively evaluating costs. We systematically reviewed evidence from767 articles. After title, abstract and full text review, 21 articles were found to measure economic implications ofADEs, inappropriate drug prescribing and poor adherence in elderly patients. Studies suggested that the economic impact of these undesired effects is substantial: hospital costs were the main cost driver, with a relevant part of them being preventable (consequences of inappropriate prescribing). Healthcare costs for unused drug wastage and destruction were also surprisingly high.Although economic evidence in elderly patients is still limited, all studies seemed to confirm that the financial burden due to pharmacological treatment issues is relevant in elderly people. Including economic effects of adverse events in pharmacoeconomic analysis would be beneficial to improve the reliability of results. Preliminary evidence suggests that programmes aimed at comprehensively assessing geriatric conditions, detecting 'high-risk' prescriptions and training patients to comply with prescribed therapies could be costeffective measures to reduce the burden of ADEs.

A profile of adverse drug reactions with risk factors among geriatric patients in a tertiary care teaching rural hospital in India

Aims & Objective: To study the adverse drug reaction profile, its causality, severity, associated risk factors and preventability in geriatric patients in a tertiary care teaching rural hospital. Materials and methods: Four hundred geriatric patients from various inpatient and outpatient departments were observed for occurrence of adverse drug events (ADEs) during August 2007 to October 2009. ADEs were either spontaneously reported or elucidated from personal interviews and analyzed. Results: In forty seven (11.75%) patients, 57 events occurred of which 75.43% occurred in indoor and 24.56% in outdoor patients. Most patients (74.46%) were in the age range of 65 to 74 years. The male to female ratio was 1.47: 1. Majority of ADEs involved gastrointestinal system (43.85%), followed by cardiovascular system (14.03%), endocrine system (12.28%) and skin and mucous membranes (12.28%). 142 drugs were suspected to cause these ADEs. Chemotherapeutic agents were the most commonly suspected drugs followed by cardiovascular drugs, drugs acting on CNS and steroids. On assessing causality, majority of events were rated as ‘possible’ by both WHO-UMC (66.66%) and Naranjo’s criteria (68.42%). Severity assessment (Hartwig scale) showed that 19.29%, 68.42% and 12.28% ADEs were severe, moderately severe and mild respectively. Risk factors for ADR development found were socioeconomic status (p=0.000), number of diseases suffered (p=0.002), number of medicines taken per day (p=0.000), compliance (p=0.048) and inappropriate prescribing (p=0.004). 36.84% ADRs were definitely preventable and 17.54% were probably preventable by modified Schumock and Thornton scale. Conclusion: ADRs is a major problem prevalent in geriatric patients and is significantly associated with socioeconomic status, number of diseases, number of medicines consumed per day, compliance to therapy and inappropriate prescribing.

Adverse drug events in an intensive care unit of a university hospital

Adverse drug events (ADEs) are harmful and occur with alarming frequency in critically ill patients. Complex pharmacotherapy with multiple medications increases the probability of a drug interaction (DI) and ADEs in patients in intensive care units (ICUs). The objective of the study is to determine the frequency of ADEs among patients in the ICU of a university hospital and the drugs implicated. Also, factors associated with ADEs are investigated. This cross-sectional study investigated 299 medical records of patients hospitalized for 5 or more days in an ICU. ADEs were identified through intensive monitoring adopted in hospital pharmacovigilance and also ADE triggers. Adverse drug reactions (ADR) causality was classified using the Naranjo algorithm. Data were analyzed through descriptive analysis, and through univariate and multiple logistic regression. The most frequent ADEs were ADRs type A, of possible causality and moderate severity. The most frequent ADR was drug-induced acute kidney injury. Patients with ADEs related to DIs corresponded to 7% of the sample. The multiple logistic regression showed that length of hospitalization (OR = 1.06) and administration of cardiovascular drugs (OR = 2.2) were associated with the occurrence of ADEs. Adverse drug reactions of clinical significance were the most frequent ADEs in the ICU studied, which reduces patient safety. The number of ADEs related to drug interactions was small, suggesting that clinical manifestations of drug interactions that harm patients are not frequent in ICUs.

Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code-assisted medication administration system

The risk of adverse drug events (ADEs) in neonates treated with opioids and the effect of a bar-code-assisted medication administration (BCMA) system were studied. A prospective cohort study of neonates in a neonatal intensive care unit (NICU) was conducted. A BCMA system was operative for 50% of the study period. Structured medical record audits were conducted to identify medication errors and preventable ADEs. Stratified frequency distribution and Cox proportional hazards analyses were used. Of 618 patients, 78 (12.6%) received postoperative care, 280 (45.3%) required assisted ventilation, and 72 (11.7%) were treated with opioids during their hospitalization. A total of 32 first preventable ADEs occurred. Univariate analyses demonstrated that postoperative status, assisted ventilation, and opioid administration were each significantly associated with ADEs. However, stratified frequency distribution analyses indicated that opioid administration during hospitalization was associated with preventable ADEs, controlling for postoperative status (p = 0.0019) or assisted ventilation (p = 0.0007). The odds ratio for any preventable ADE occurrence in a patient treated with an opioid was 4.74 compared with an infant not treated with an opioid. Patients who were treated with an opioid in the absence of a BCMA system had a 10% probability of an ADE after hospitalization for six days. Infants in a NICU who were treated with opioids were at greater risk of a preventable ADE than other patients, adjusted for two medical conditions, assisted ventilation and postoperative status. A BCMA system reduced the risk of harm from an opioid medication error.

Misuse of over-the-counter medications among community-dwelling older adults and associated adverse drug events

Objectives The objective of this study was to examine the rates of occurrence of misuse of over-the-counter (OTC) medications in community-dwelling older adults. In addition we examined whether those who misused OTC medications had higher numbers of adverse drug events (ADEs). Methods The study was a cross-sectional study conducted in retirement homes and senior community centres in Houston, Texas, USA. Participants were community-dwelling older adults who (1) resided in retirement homes or visited senior community centres, (2) were responsible for managing their own medication regimens and (3) consumed OTC medications. Information regarding the use of OTC medications, conditions for which the OTC medication was used, ADEs and demographics was obtained using a combination of a self-administered questionnaire and a series of open-ended questions. Key findings Data were analysed using descriptive statistics, and chi-square and t tests. The response rate for the study was 66.5%. Approximately 18% of respondents misused OTC medications, and 23% experienced at least one ADE following consumption of OTC medications. Occurrence of ADEs was higher in patients who misused OTCs compared to those who did not. Conclusions Analyses indicated that older adults participating in this study misused OTC medications. As expected, those who misused OTC medications had higher numbers of ADEs. Results from this study highlight the need to monitor the appropriateness of use of OTC medications in community-dwelling older adults. This will enable more effective medication management in the older adult population.

Adaptação dos critérios de avaliação de eventos adversos a medicamentos para uso em um hospital público no Estado do Rio de Janeiro

To adapt the methodology, criteria and instruments for tracing adverse drug events proposed by the Institute for Healthcare Improvement and to evaluate the occurrence of adverse drug events in a specialized hospital. The method selected for the identification of adverse drug events was an adjustment proposed by the Institute for Healthcare Improvement based on the retrospective review of medical charts conducted through explicit tracing criteria. The adjustment process for tracing criteria for adverse drug events was carried out by a panel of specialists based on the analysis of aspects related to validation, viability and relevance. This analysis was carried out from a sample of 112 patients. 21 tracing criteria for the detection of adverse drug events were selected. The incidence of adverse drug events in the analyzed hospital was 14.3%. In 25% of the cases there was a need for life-support intervention. Tracing criteria for adverse drug events enable monitoring events through time, allowing to evaluate if the strategies implemented in the medication system could show results for a better quality of care.

Electronic health records and adverse drug events after patient transfer

Our objective was to examine the frequencies of medication error and adverse drug events (ADEs) at the time of patient transfer in a system with an electronic health record (EHR) as compared with a system without an EHR. It was hypothesised that the frequencies of these events would be lower in the EHR system because of better information exchange across sites of care. 469 patients transferred between seven nursing homes and three hospitals in New York and Connecticut between 1999 and 2005 were followed retrospectively. Two groups of patients were compared: US Veterans Affairs (VA) patients, with an EHR, and non-VA patients, without an EHR, on the following measures: (1) medication prescribing discrepancies at nursing home/hospital transfer, (2) high-risk medication discrepancies and (3) ADEs caused by medication discrepancies according to structured medical record review by pairs of physician and pharmacist raters. The overall incidence of ADE caused by medication discrepancies was 0.20 per hospitalisation episode. After controlling for demographic and clinical covariates, there were no significant differences between VA and non-VA groups in medication discrepancies (mean difference 0.02; 95% CI -0.81 to 0.85), high-risk medication discrepancies (-0.18; 95%CI -0.22 to 0.58) or occurrence of an ADE caused by a medication discrepancy (OR 0.96; 95% CI 0.18 to 5.01). There was no difference, with and without an EHR, in the occurrence of medication discrepancies or ADEs caused by medication discrepancies at the time of transfer between sites of care. Reducing such problems may require specialised computer tools to facilitate medication review.

Evaluation of intramuscular fosphenytoin vs intravenous phenytoin loading in the ED

Objective A comparison of length of stay in an emergency department (ED) after loading patients at risk for seizures with either intravenous (IV) phenytoin or intramuscular (IM) fosphenytoin was studied. Methods This was a retrospective observational cohort study that was conducted over a 24-month period in an academic teaching hospital (693 beds). Patients included were 18 years or older, discharged from the ED without hospital admission, and loaded with either IV phenytoin or IM fosphenytoin. The primary end point was the comparison of length of stay in the ED until discharge after loading. Characterization of seizure etiology, cardiac risk factors, and adverse drug events were also observed. Results A total of 51 patients were evaluated who received IV phenytoin compared with 59 for IM fosphenytoin. The median time-to-discharge difference between IV phenytoin vs IM fosphenytoin was 1:49 hours (95% confidence interval, 1:24-2:24 hours; P < .001). There was no statistical difference in cardiac risk factors and occurrence of adverse drug events between groups. Conclusions This study found that patients were discharged from the ED earlier with the loading of IM fosphenytoin compared to IV phenytoin.

Tailoring adverse drug event surveillance to the paediatric inpatient

IntroductionAlthough paediatric patients have an increased risk for adverse drug events, few detection methodologies target this population. To utilise computerised adverse event surveillance, specialised trigger rules are required to accommodate the unique needs of children. The aim was to develop new, tailored rules sustainable for review and robust enough to support aggregate event rate monitoring.MethodsThe authors utilised a voluntary staff incident-reporting system, lab values and physician insight to design trigger rules. During Phase 1, problem areas were identified by reviewing 5 years of paediatric voluntary incident reports. Based on these findings, historical lab electrolyte values were analysed to devise critical value thresholds. This evidence informed Phase 2 rule development. For 3 months, surveillance alerts were evaluated for occurrence of adverse drug events.ResultsIn Phase 1, replacement preparations and total parenteral nutrition comprised the majority (36.6%) of adverse drug events in 353 paediatric patients. During Phase 2, nine new trigger rules produced 225 alerts in 103 paediatric inpatients. Of these, 14 adverse drug events were found by the paediatric hypoglycaemia rule, but all other electrolyte trigger rules were ineffective. Compared with the adult-focused hypoglycaemia rule, the new, tailored version increased the paediatric event detection rate from 0.43 to 1.51 events per 1000 patient days.ConclusionsRelying solely on absolute lab values to detect electrolyte-related adverse drug events did not meet our goals. Use of compound rule logic improved detection of hypoglycaemia. More success may be found in designing real-time rules that leverage lab trends and additional clinical information.

Adverse Drug Events in Adult Patients Leading to Emergency Department Visits

Adverse drug events (ADEs) occurring in the community and treated in emergency departments (EDs) have not been well studied. To determine the prevalence, severity, and preventability of ADEs in patients presenting at EDs in 2 university-affiliated tertiary care hospitals in the Canadian province of Newfoundland and Labrador. A retrospective chart review was conducted on a stratified random sample (n = 1458) of adults (> or =18 y) who presented to EDs from January 1 to December 31, 2005. Prior to the chart review, the sample frame was developed by first eliminating visits that were clearly not the result of an ADE. The ED summary of each patient was initially reviewed by 2 trained reviewers in order to identify probable ADEs. All eligible charts were subsequently reviewed by a clinical team, consisting of 2 pharmacists and 2 ED physicians, to identify ADEs and determine their severity and preventability. Of the 1458 patients presenting to the 2 EDs, 55 were determined to have an ADE or a possible ADE (PADE). After a sample-weight adjustment, the prevalence of ADEs/PADEs was found to be 2.4%. Prevalence increased with age (0.7%, 18-44 y; 1.9%, 45-64 y; 7.8%, > or =65 y) and the mean age for patients with ADEs was higher than for those with no ADEs (69.9 vs 63.8 y; p < 0.01). A higher number of comorbidities and medications was associated with drug-related visits. Approximately 29% of the ADEs/PADEs identified were considered to be preventable, with 42% requiring hospitalization. Cardiovascular agents (37.4%) were the most common drug class associated with ADEs/PADEs. Adult ADE-related ED visits are frequent in Newfoundland and Labrador, and in many cases are preventable. Further efforts are needed to reduce the occurrence of preventable ADEs leading to ED visits.

Best Possible Medication History by a Pharmacy Technician at a Tertiary Care Hospital

INTRODUCTION At all interfaces of care during a hospital stay (admission, transfer, and discharge), the potential exists for inaccurate information about a patient’s drug therapy to be used for various purposes. If inaccurate information is used in establishing or modifying therapy, adverse drug events may occur. Such adverse events may span the range of drug-related problems, from inappropriate initiation or discontinuation to inappropriate route or dose. Medication reconciliation upon admission to hospital has been recognized as an important process in preventing adverse drug events at one interface of care.1 Conceptually, medication reconciliation on admission involves compiling an accurate list of the patient’s medications before admission (the best possible medication history [BPMH]) and ensuring that any subsequent therapy does not result in new drug-related problems. For optimal therapeutic transition, the BPMH would be obtained before any admission orders were written. However, many factors, such as cognitive impairment or a need to stabilize the patient’s condition, can prevent completion of the BPMH before in-hospital initiation of therapy. An alternative approach would be to compare the BPMH with therapy prescribed in hospital at some point after admission. This would allow prompt and efficient initiation of drug therapy but would also ensure subsequent review to identify and resolve any discrepancies. Such a comparison between the BPMH and admission orders ensures continuation of all appropriate medications while the patient is in hospital. Because medication reconciliation will be a requirement for hospital accreditation by 2010,1 it was necessary to devise a strategy for implementing this process at the authors’ hospital. Until now, physicians and nurses have reviewed each patient’s history at the time of admission, although neither discipline has medication use as the primary focus of these investigations. Pharmacists have extensive knowledge about medications, as well as the patient-interviewing skills required for high-quality assessment of patients’ drug therapy needs during transitions of care. However, pharmacists’ expertise would be better used in assessing the appropriateness of therapy rather than performing the technical task of compiling a BPMH. Because of resource constraints leading to inadequate attention or time on the part of physicians, nurses, and pharmacists, an alternative method of obtaining the BPMH was required. Although some institutions have assisted the admitting physicians or nurses by developing a standardized documentation form for use during the admission process, such forms have not been demonstrated to improve the rate of identified discrepancies upon admission.2 The use of pharmacy students for medication reconciliation has been reported, but the need to ensure a continuous supply of students and to provide training for new students limits the applicability of this method for most institutions.3 Several centres have studied the participation of pharmacy technicians in the medication reconciliation process.4-7 In these studies and others, the technicians were able to complete the BPMH with a 95% accuracy rate (B. Tugwood, Trillium Health Centre, personal communication by e-mail, January 29, 2008), and their involvement in medication reconciliation reduced the time spent by physicians, nurses, and pharmacists at the time of admission (L. Saulnier, South-East Regional Health Authority, personal communication by e-mail, August 14, 2007). When working in conjunction with a pharmacist, technicians can obtain the information necessary for timely identification and reconciliation of discrepancies, thus helping to prevent the occurrence of adverse drug events. Pharmacy technicians appear to be suitable candidates for completing medication histories. They are familiar with the dosage forms, strengths, and usual dosing schedules of a wide range of medications. In addition, they have received training about the medications that can be obtained without a prescription, which facilitates the identification of medications not included in prescription databases, such as the BC PharmaNet. Although lacking a pharmacist’s understanding of the indications, side effects, and combinations of medications, pharmacy technicians have many skills that allow identification of medications used on an outpatient basis. The study reported here was undertaken to demonstrate the feasibility of training a hospital pharmacy technician to obtain the BPMH and to communicate discrepancies to the pharmacist for patients who had been admitted to a tertiary care hospital.

Identifying Missed Opportunities to Curtail Antimicrobial Therapy for Presumed Ventilator-Associated Pneumonia Using the Clinical Pulmonary Infection Score

Early discontinuation of antimicrobial therapy for ventilator-associated pneumonia can reduce the emergence of antimicrobial resistance, the occurrence of adverse drug events, and the cost of therapy. Evidence suggests that discontinuation of therapy by day 3 may be appropriate for patients with a clinical pulmonary infection score of 6 or less at baseline and on day 3. To determine the proportion of patients eligible for antimicrobial discontinuation on day 3 and day 7 of therapy and to determine the proportion of eligible patients for whom antimicrobials were discontinued within these timeframes. A 6-month observational study was conducted from October 3, 2005, to March 31, 2006, in a 27-bed medical-surgical tertiary care intensive care unit. Clinical pharmacists attended daily rounds and prospectively identified patients for inclusion in the study. A study pharmacist retrospectively calculated clinical pulmonary infection scores. Other data were obtained from the quality-improvement database and patient health records for the intensive care unit. Ninety-two patients were treated for ventilator-associated pneumonia during the study period, of whom 49 were included in the analysis. At day 3, 17 (35%) of the 49 patients were eligible for early discontinuation of antimicrobial therapy, but therapy was discontinued for only 2 (12%) of these 17 patients. At day 7, 10 (32%) of 31 patients were eligible for antimicrobial discontinuation, but therapy was discontinued for only 1 (10%) of these 10 patients. A significant opportunity exists at the authors' institution to develop and implement an antimicrobial discontinuation policy that uses the clinical pulmonary infection score to guide antimicrobial use for patients with ventilator-associated pneumonia.

Adverse drug events in hospitals: a systematic review

The objective of this study was to evaluate studies on the occurrence of adverse drug events (ADEs) in hospitals in order to learn about their frequency and characteristics, comparing the methods for identifying them and the various definitions. A search was conducted on MEDLINE and identified studies published from 2000 to 2009. Inclusion criteria were: studies in populations not selected for specific diseases or drugs and ADEs that occurred during hospitalization. Twenty-nine studies were selected, displaying multiple sources of heterogeneity, including differences in the study populations, surveillance techniques, definitions of ADEs, and indicators. The proportion of patients with ADEs ranged from 1.6% to 41.4% of inpatients and the rates ranged from 1.7 to 51.8 events/100 admissions. A considerable share of these events could have been avoided. The findings show that ADEs in inpatients are a public health problem. However, further studies are needed to monitor these adverse events in order to effectively promote safe drug use.