Avoidable Adverse Drug Reactions Research Articles

Impact of Antimicrobial Stewardship Program Intervention Acceptance on Hospital Length of Stay.

Background: Inappropriate antibiotic use is a major public health concern. Excessive exposure to antibiotics results in the proliferation of multidrug-resistant bacteria, increase in potentially avoidable adverse drug reactions, healthcare utilization, and cost. Currently, systematic reviews and controlled trials assessing the effects of antimicrobial stewardship programs (ASP) on hospital length of stay (LOS), mortality, and cost-savings are conflicting. Some studies reported a significant cost-savings driven by shorter hospital LOS while the others found no effect and, in some cases, prolonged LOS. Shortening the time to appropriate therapy and reducing unnecessary days of therapy have been shown to reduce hospital LOS. Objective: The purpose of this study was to evaluate the effects of prescriber acceptance to ASP interventions on hospital LOS. Methods: Between January 2018 and December 2019, 764 charts were retrospectively reviewed for patients who received antimicrobial treatment and in whom an ASP intervention was performed. Patients were allocated into 2 groups: those whose ASP interventions were accepted and those whose were rejected. Provider responses were then documented within 24 hours of being communicated. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates and inpatient antimicrobial duration of therapy (DOT). Results: There were 384 patients with an accepted ASP intervention and 380 with a denied intervention. Baseline characteristics were similar between both groups, except for a difference in the types of intervention performed (P < 0.001). The median hospital LOS for patients in the accepted intervention group was 6.5 days compared to 7 days in the rejected intervention group (P = 0.009). Antimicrobial DOT was also shorter in the accepted intervention group (5 vs 7 days; P < 0.001). There was no difference in 30-day readmission rates (P = 0.98). Conclusion: Prescriber acceptance to ASP interventions decreases hospital LOS and antimicrobial DOT without affecting 30-day readmission rates.

Time-Trends of Drug-Drug Interactions among Elderly Outpatients in the Piedmont Region (Italy): A Population-Based Study.

Adverse drug reactions (ADRs) are a major health problem in the primary care setting, particularly among the elderly population. While the high frequency of ADRs in the elderly has several causes, a major and common determinant is polypharmacy, which can in turn increase the risk of drug-drug interactions (DDIs). In this paper, we analyzed the drugs prescriptions dispensed to elderly outpatients, to assess changes in the prevalence of selected DDIs in the period 2013–2019. Overall, about 15% of the patients aged >65 years were poly-treated. Among them, a decreasing trend in prevalence was observed for the majority of DDIs during the study period. This trend was particularly noticeable for DDIs involving fluoroquinolones and vitamin K antagonists, where a sharp reduction of over 40% was observed. On the opposite, a small increase in prevalence was observed for the association of antidiabetics and beta-blocking agents and for that of clopidogrel and PPIs. While the occurrence of most of the considered DDIs among poly-treated elderly decreased over time, the prevalence of some of them is still worrying. The complexity of the national drug formularies, as well as the increased number of prescribing actors that are involved, further urges the update of DDI lists to be used to monitor drug appropriateness and reduce avoidable ADRs.

Association between potentially inappropriate medication and adverse drug reactions in hospitalized elderly patients.

The Beers, European Union (EU) and Screening Tool of Older Persons' potentially inappropriate Prescription (STOPP) criteria were developed to improve the safe use of medicines in the elderly. However, the predictive validity of existing criteria to detect adverse drug reactions (ADRs) remains unexplored. The objective of the current study was to determine whether the 2019 Beers, 2015 STOPP or 2015 EU potentially inappropriate medicine (PIM) criteria were associated with ADRs. A retrospective, cross-sectional investigation was conducted among older persons (≥60years of age) admitted to a tertiary hospital in China between April 2019 and December 2019. PIMs were identified as per the Beers, EU and STOPP criteria definitions. ADRs were retrospectively evaluated by two clinical pharmacists using the Naranjo algorithm. Multivariate logistic regression was used to evaluate the factors associated with ADRs in the hospitalized patients. The study participants included 560 hospitalized patients (mean age 72.05±8.15). The prevalence of patients receiving at least one PIM was 52.1%, 37.0% and 42.9% according to the Beers, EU and STOPP criteria, respectively. Univariate analysis showed that ADRs were associated with PIMs listed in the Beers criteria (OR: 2.093, 95% CI: 1.028-4.263, 0.042), but not with the STOPP-listed (OR: 0.536, 95% CI: 0.255-1.123, 0.098) and EU-listed PIMs (OR: 0.258, 95% CI: 0.118-0.563, 0.001). In contrast to the STOPP and EU criteria on PIMs, the Beers criteria were significantly associated with avoidable ADRs in hospitalized older persons.

A Time for Transitions

A Time for Transitions

Adverse drug reactions to anti-diabetic drugs are commonest in patients whose treatment do not adhere to diabetes management clinical guidelines: cross-sectional study in a tertiary care service in sub-Saharan Africa.

The study aimed to identify and describe adverse drug reactions and adherence to clinical guidelines in patients receiving treatment for type 2 diabetes mellitus (T2DM) in Cameroon. The method used was a cross-sectional study at a tertiary diabetes care service in Yaoundé, Cameroon. Adult T2DM patients attending the diabetes clinic were interviewed using a pre-structured data collection form. Adverse drug reactions (ADRs) were self-reported by the patients. Naranjo's algorithm and Hartwig and Siegel's scale were used for assessment of causality and severity of ADRs, respectively. A blinded senior endocrinologist assessed whether treatment pattern of patients was "adherent" or not to local clinical guidelines for the management of diabetes. Of a total of 350 patients enrolled into the study 61.1% were on oral hypoglycaemic agents only, 24.9% were on both oral hypoglycaemic agents and insulin, while 13.4% were on insulin alone. Metformin was used by 96.3% of the patients. Ninety patients reported 101 suspected ADRs. The proportion of ADRs among patients with poor adherence to clinical guidelines was higher than ADRs reported among adherent patients (Chi-square test = 7.3273; p= 0.007). Hypoglycaemia was more frequent ADR among non-adherent (25.7% of the suspected ADR) than adherent participants (11.6%). In the participants whose treatment pattern did not adhere to local clinical guidelines, ADRs were definite in 63.9%, probable in 16.6%, doubtful in 13.9% and possible in 5.6% of the cases. ADRs were moderate in 61.1% and severe in 19.4% of cases whose treatment pattern was non-adherent to clinical guidelines. Adverse drug reactions may be frequent in type 2 diabetes patients whose treatment pattern does not adhere to local clinical guidelines in Cameroon. Therefore, the promotion of active pharmacovigilance and the design of training activities to promote the appropriate use of medicines at hospital level in Cameroon could help to improve the management of diabetes and reduce the incidence of avoidable ADRs in the future.

Reducing harm to patients caused by avoidable adverse drug reactions.

Emeritus Professor Alan Glasper, from the University of Southampton, discusses a research report on the causes and effects of avoidable adverse drug reactions and drug errors on NHS patients in England.

Pharmacovigilance in pediatrics

The characteristics of pharmacology and drug evaluation in the pediatric age group highlight the necessity for the pharmacovigilance community to adjust to the specific features of children. At the time of marketing a medicinal product intended for children, the product's safety profile is sometimes less well known than for adults due to fewer or small sample clinical trials. Furthermore, the frequent off-labeled drug use, the use of unsuitable dosage forms and the need for continuous dose adjustments increase the risk of medication errors and thus lead to avoidable adverse drug reactions (ADRs). The occurrence of child-specific ADRs (such as growth disorders) or ADRs more commonly occurring in children than in adults make it necessary to monitor the safety of child-specific drugs. Pediatric pharmacovigilance includes also the consequences of in utero exposure, whether manifestations are present from birth or occur in early childhood (such as neurodevelopmental disorders). The incidence of ADRs varies with age, setting of medical care (in- or out-patients, pediatric specialties) and by country in which the study was carried out. The drugs most frequently reported with ADRs are those most commonly used in the pediatric age group, i.e. antibiotics and vaccines. The ADRs most often reported are skin, neurological and general disorders. As in adults, spontaneous notification is essential to generate alerts and child-specific pharmacoepidemiological studies are necessary and should be developed.

Preventable ADRs leading to hospitalization — results of a long-term prospective safety study with 6,427 ADR cases focusing on elderly patients

ABSTRACTBackground: Studies evaluating the impact of age and potentially inappropriate medication (PIM) on avoidable adverse drug reactions (ADRs) are scarce.Methods: In this prospective, multi-center, long-term (8.5 years) observational study, we analysed ADRs leading to hospitalization in departments of internal medicine. ADRs causality and preventability were assessed using standardised algorithms. PIM was defined based on the PRISCUS-list. Multivariate analyses and estimation of ADR incidence rates were conducted.Results: Of all 6,427 ADR patients, a preventable ADR was present in 1,253 (19.5%) patients (elderly patients ≥70 years: 828). Risk factors for preventable ADRs in elderly patients were multimorbidity, two to four ADR-causative drugs, and intake of particular compounds (e.g. spironolactone) but not sex, PIM usage, or the total number of drugs. Regarding particular compounds associated with preventable ADRs, highest incidence rates for preventable ADRs were found for patients aged ≥70 years for spironolactone (3.3 per 1,000 exposed persons (95% CI: 1.4–6.6)) and intermediate-acting insulin (3.3 per 1,000 exposed persons (95% CI: 1.6–6.1)).Conclusion: Avoiding PIM usage seems to be of limited value in increasing safety in elderly patients whereas our results underline the importance of an individualized medication review of the most commonly implicated drugs in preventable ADRs (supported by BfArM FoNr: V-11337/68605/2008–2010).

Adverse Drug Reactions in Children

Adverse drug reactions (ADRs) are a common clinical problem in both paediatric and adult medicine. ADRs are a frequent cause of hospitalization and one of the leading causes of morbidity and mortality. The aim of the study was to prospectively identify the ADRs causing hospital admission of children and identification of the risk factors and involved drugs. All patients aged 19 years or under admitted to hospital were included in the study, and all admissions for ADRs were prospectively screened for a period of 9 months. Suspected ADRs were subsequently evaluated, and causality assessment was undertaken to determine whether each suspected reaction was possible, probable or definite. The assessment of ADR causality was performed using the Naranjo algorithm, the Liverpool ADR Causality Assessment Tool and the Edwards and Aronson causality assessment method. During the study period, 2903 admissions were identified; of these, there were 143 admissions of patients with an oncological disease. Sixty-four admissions (2.2%) were caused by an ADR. Anticancer chemotherapy accounted for 35% of the cases, followed by antibiotics (18%). The use of different scoring systems does not lead to the differences in the numbers of ADR-diagnosed patient but may result in differences in the determination of the level of certainty. The majority of the ADR-diagnosed patient affected the hematopoietic and gastrointestinal systems; the drugs most frequently involved were cytotoxic agents and antibiotics. The most important risk factors identified were female sex and oncological disease. ADRs cause a small but substantial proportion of children’s hospital admissions. Preventing avoidable ADRs requires careful adherence to good prescribing practice.

A Systematic Approach to Assess the Burden of Drug Interactions in Adult Kidney Transplant Patients.

Renal transplant patients are frequently subject to polypharmacy and drug-drug interactions. However, no previous study has systematically assessed the risk of drug interactions and Adverse Drug Reactions (ADRs) in this population. A total of 138 consecutive adult kidney transplant recipients admitted to our hospital between August 2010 and February 2012 were prospectively and systematically assessed by our pharmacovigilance team, within 24 hours of admission, to identify potential drug-drug interactions and probable ADRs. As a consequence of the high number of medications per patient (7.8±0.2 drugs), a considerable number of drugdrug interactions were observed in this population, with an average of 5.6±0.4 drug interactions per patient. Moreover, a significant percentage of admissions (~10%) of kidney transplant patients were related to probable ADRs. Almost all these patients had at least one drug interaction that could have potentially contributed to the probable ADR. Of note, clinically significant (i.e. severe) drug interactions were more frequent among patients with ADRs (29% vs. 15%, p<0.01). Also, patients with ADRs were more likely to have started a medication 30 days before admission (38.5% vs. 10.4%, p < 0.01). Non-immunosuppressive drugs most commonly involved in severe interactions were omeprazole, magnesium sulphate, and statins. The most commonly observed interactions were: tacrolimus and omeprazole, mycophenolate and omeprazole, sirolimus and enalapril, mycophenolate and antivirals, and mycophenolate and magnesium sulphate. Drug interactions were extremely frequent among kidney transplant recipients, and responsible for potentially avoidable ADRs. They should be carefully considered when following kidney transplant recipients.

Prescribing Patterns and Perceptions of Health Care Professionals About Rational Drug use in a Specialist Hospital Clinic.

Irrational drug use is associated with adverse consequences including drug resistance and avoidable adverse drug reactions. Studies of rational drug use in psychiatric facilities are scanty. This study evaluated prescription practices and perception of health care professionals regarding causes of irrational drug use. A retrospective study conducted at the outpatient clinic of Federal Neuropsychiatric Hospital, Yaba, Lagos. Data on drug use indicators were analyzed. A cross-sectional assessment of perception of prescribers and dispensers regarding rational drug use was conducted. A total of 600 prescriptions were analyzed. Mean number of drugs per encounter was 3.5 and percentage generic prescribed was 58.5%. Poly-pharmacy (P=0.024, 95% CI=1.082-1.315) and non-generic prescribing (P=0.032, 95% CI=1.495-1.821) were significantly associated with young prescribers. Factors associated with irrational drug use include demand from patients, patients’ beliefs about injection drugs and influence of pharmaceutical sale representatives. Certain aspect of prescribers indicators are still poor in the hospital studied. Health care professionals identified possible associated factors for irrational drug use. Concerted efforts are required to ensure rational drug use especially in psychiatric facilities in Nigeria.

E‐SPC – delivering drug information in the 21st century: developing new approaches to deliver drug information to prescribers

e‐SPC – delivering drug information in the 21st century: developing new approaches to deliver drug information to prescribers

Global transcriptome analysis of the E. coli O157 response to Agrimonia pilosa extract

Antibiotics are certainly beneficial to treat the bacterial infection. However, inappropriate use puts patients at danger for avoidable adverse drug reactions. This inappropriate use accelerates the emergence of resistance and potentially increases overall health-care costs. In oriental pharmacology, herbal medicines had been used as an antibiotic drug, but its antibiotic mechanism has not yet been proved completely. Here, we studied the antibiotic effects of Agrimonia pilosa on E. coli O157:H7. Especially, it is noteworthy that the antibiotic efficacy of the herb extract on three proven targets for a main antibiotic drug: bacterial cell wall biosynthesis, protein synthesis and DNA replication and repair. The results show the antibiotic effects through the inhibition of bacterial cell wall synthesis, folic acid synthesis, and multidrug efflux.

Pharmacogenomics and adverse drug reactions.

Adverse drug reactions (ADRs) observed during drug development have been the cause for discontinuing development of many drugs. In addition, serious but rare ADRs observed after marketing have led to withdrawal of some drugs. A priori identification of individuals at risk of developing ADRs for a given drug will help develop strategies to reduce the risk for ADRs in these patients. US FDA initiatives and efforts at reducing ADRs to make drugs safer are described, including updating of drug labels to include genomic information intended to reduce ADRs. Pharmacogenomics can also be harnessed to identify individuals at risk of developing serious ADRs and to treat these individuals with alternative therapy, thus converting ADRs that are traditionally considered unavoidable to avoidable ADRs.

Avoidability of Adverse Drug Reactions Spontaneously Reported to a French Regional Drug Monitoring Centre

Adverse drug reactions (ADRs) are now recognized as a major category of iatrogenic illness in terms of morbidity and mortality. To describe the type and frequency of avoidable ADRs spontaneously reported to a regional drug monitoring centre following inappropriate prescribing, as a basis for preventive actions. A prospective, observational study of ADRs reported to the Regional Drug Monitoring Centre of Tours, France, between 26 November 2002 and 28 November 2003. The outcome measure was ADRs secondary to inappropriate prescribing that were defined as entirely or partly avoidable, i.e. at least one of the recommendations in various sections of the summary of product characteristics (SPC; indication, route of administration, dose, duration of treatment, dose adaptation, precautions for use, monitoring of treatment, absolute contraindications and contraindicated interactions) had not been respected. The link between the lack of conformity of the drug prescription with the SPC and occurrence of the ADR was evaluated by a working group using two criteria: (i) is nonconformity of the prescription of this drug a known and validated risk factor for this ADR?; and (ii) are there other aetiologies or other risk factors for this ADR? Three hundred and sixty ADRs in 294 adults and 66 children were analysed. The prescription was considered inappropriate for 213 of the 659 (32%) drugs implicated in ADRs, corresponding to 161 patients (45%). The ADR was adjudged entirely avoidable for 32 (9%) patients, partly avoidable for 28 (8%) patients and unavoidable for 300 (83%) patients. Not taking into account a history of allergy or altered renal function and not respecting the recommended dose were the most frequent causes of entirely avoidable ADRs. Allopurinol and lamotrigine were the drugs most frequently involved in serious avoidable ADRs. Preventive actions should focus on more systematic allergy checks when prescribing drugs and on dose adaptation in cases of altered renal function.

Hypersensitivity to intravenous ondansetron: a case report.

IntroductionOndansetron, a 5-hydroxytryptamine3 receptor antagonist widely used in the prevention and treatment of chemotherapy-induced nausea and vomiting, is associated with various unusual adverse drug reactions. In this paper, we describe a hypersensitivity reaction to a single intravenous dose of ondansetron.Case presentationA 19-year-old woman presented to the emergency department of our institute with 3–4 episodes of nausea, vomiting and epigastric distress. She had a diagnosis of polycystic ovarian disease and had been on treatment with cyproterone acetate 2 mg, ethinyl estradiol 0.035 mg, finasteride 5 mg and metformin 500 mg for a month. She had been taking oral roxithromycin 500 mg per day for the past 3 days for treatment of a mild upper respiratory tract infection. She also occasionally took rabeprazole 10 mg for gastritis which had worsened after treatment with roxithromycin. She was treated with a single 4 mg dose of ondansetron intravenously. She immediately developed urticaria, which was treated with intravenous dexamethasone 4 mg and chlorpheniramine maleate 20 mg. The reaction abated within a few minutes and she was discharged within an hour. She was asymptomatic at 72 hours of follow-up.She had no history of ondansetron exposure, or drug or food allergies. On the Naranjo's causality assessment scale, the adverse event was 6 indicating a "probable" reaction to ondansetron.Conclusion5-hydroxytryptamine3 receptor antagonists have been associated with life-threatening adverse reactions such as hypotension, seizures and anaphylaxis. The wide availability of these drugs in India has promoted their off label use in the treatment of gastritis, migraine and so on. Our case represents an off label use in a patient who could have been treated with a safer drug.Some authors have suggested that anaphylaxis may be a class effect while others think it may be drug specific. In our case, the reaction could be either anaphylaxis or anaphylactoid, but the latter seems more likely given the history of absence of prior sensitization. Other components of the drug, such as solvent, also need to be considered as a cause of this reaction. Considering all of the existing evidence, we need to be more cautious while using ondansetron and also to be aware of the various unusual side effects, especially when used in an out-of-hospital set-up.Our case report underscores the importance of physicians judiciously using the drug, particularly in the outpatient setting so as to reduce the incidence of avoidable adverse drug reactions.

Assessing general practitioners' prescribing behaviour in elderly patients with concealed renal failure

Many avoidable adverse drug reactions (ADR) in elderly patients are due to an absence of dose adjustment according to renal function [1]. Nephron loss is a normal ageing process, leading to a lower glomerular filtration rate (GFR). Many drugs and/or their metabolites are excreted through the kidney; thus, the risk of ADR is increased if dose is not adjusted as a function of creatinine clearance (CC). However, despite a lower GFR, serum creatinine concentration may be normal in elderly patients because the rate of production of creatinine is dependent on dietary intake and muscle mass [2]. Therefore, CC should be systematically estimated in this population. Physician prescribing behaviour has been assessed for hospitalized patients with concealed renal insufficiency (serum creatinine level within the normal range but low estimated GFR) [3–5], but not in general practice. We aimed to assess general practitioners' (GP) prescribing behaviour for elderly patients with concealed renal insufficiency and knowledge of drugs requiring dose adjustment. The study was carried out in a French departement (a French administrative unit). Fifty GPs were randomly selected from the telephone directory of physicians and were asked by phone to participate in the study. The same interviewer questioned the 50 GPs using a questionnaire based on two questions and two clinical cases. The use of a source of recommendations concerning dose adjustment for renal impairment was allowed. All 50 GPs agreed to participate and completed the questionnaire. This study group included 38 men (76%) and 12 women (24%). Twenty-two GPs worked in a town with a population of >10 000; nine worked in a town with 5000–10 000 people and 19 in a town of <5000 people. For the prescription of drugs in elderly patients, 80% claimed to take CC into account (formula), 14% took only the serum creatinine level into account and 6% considered both. Before prescribing medication to a 70-year-old patient, 28% of the GPs said they evaluated GFR for all new drugs, 32% only for certain drugs, and 51% regularly, even for repeat prescriptions. In the first clinical case, 14% of GPs calculated CC with the Cockroft and Gault formula and 86% only took serum creatinine concentration into account. Not all GPs would have prescribed the reduced dose of levofloxacin, allopurinol, digoxin and sotalol required for this patient with an estimated CC rate of 49.6 ml min−1 (Table 1). In the second clinical case, some GPs prescribed dextropropoxyphen, celecoxib, nadroparin and pravastatin for this patient with severe renal failure (CC of 25 ml min−1), despite contraindication in this situation, and prescribed amoxicillin and clarithromycin at normal doses, although a reduced dose was required (Table 1). Finally, only 13 GPs (26%) consulted the summary of product characteristics (SPC) of the drugs before answering the questions. Table 1 Prescribing behaviour of GP Although most GPs said that they take CC into account, few actually calculated it and most therefore underestimated the severity of renal impairment. Like physicians for hospitalized patients [3–5], GPs do not sufficiently consider renal function of elderly patients. Allopurinol, levofloxacin, digoxin and sotalol are often prescribed without dose adjustment. This oversight can lead to an overdose, with potentially serious adverse effects. Moreover, despite finding renal function to be normal, some GPs prescribed a reduced dose or did not prescribe these drugs at all. This study has revealed that GPs lack sufficient knowledge about some commonly prescribed drugs, such as dextropropoxyphen, which are contraindicated in cases of severe renal failure because of its potentially fatal consequences. However, this study has some limitations. First, the sample size is small for an epidemiological study, and it is difficult to draw any general conclusions about GP practice. Second, some GPs may not have adjusted the dose for the first case because the CC was just below 50 ml min−1. Awareness that a normal serum creatinine concentration in elderly patients does not exclude the possibility of renal impairment needs to be increased. Before prescribing medication to a patient with CC <60 ml min−1, the SPC, or any other source should be systematically consulted to check that dose adjustment is not necessary or that the drug is not contraindicated in particular situations. We now focus training for doctors in our region on prescribing behaviour for elderly patients with concealed renal insufficiency and on knowledge of drugs which require dose adjustment.

Prevalence, Clinical Features and Avoidability of Adverse Drug Reactions as Cause of Admission to??a??Geriatric Unit

Drug use increases with advancing age, and in older patients it is associated with an increase in adverse drug reactions (ADRs). ADRs are a primary cause of morbidity and mortality worldwide. To evaluate the prevalence, clinical characteristics and avoidability of ADR-related hospital admissions in elderly patients. From November 2004 to December 2005, all patients aged >or=65 years consecutively admitted to the Geriatric Unit of the Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo in Italy, were evaluated for enrolment in the study. ADRs were defined according to the WHO Adverse Reaction Terminology system. Drugs were classified according to Anatomical Therapeutic Chemical classification system. The Naranjo algorithm was used to evaluate the relationship between drug use and the ADR (definite, probable, possible or doubtful) and Hallas criteria were used to evaluate the avoidability of the ADR (definitely avoidable, possibly avoidable or unavoidable). All cases of a suspected ADR were discussed by a team trained in drug safety, including three geriatricians, one clinical pharmacologist and one pharmacist. Only cases of an ADR with an agreement >or=80% were included. Of the 1756 patients observed, 102 (5.8%, 42 males, 60 females, mean age 76.5 +/- 7.4 years, range 65-93 years) showed certain (6.8%) or probable (91.2%) ADR-related hospitalization. Gastrointestinal disorders (48 patients, 47.1%); platelet, bleeding and clotting disorders (20 patients, 19.6%); and cardiovascular disorders (13 patients, 12.7%) were the most frequent ADRs. NSAIDs (23.5%), oral anticoagulants (20.6%), low-dose aspirin (acetylsalicylic acid) [13.7%] and digoxin (12.7%) were the drugs most frequently involved in ADRs. Of the ADRs, 45.1% were defined as definitely avoidable, 31.4% as possibly avoidable, 18.6% as unavoidable and 4.9% as unclassifiable. Of 78 patients with definitely or possibly avoidable ADRs, 17 patients (21.8%) had received an inappropriate prescription, 29 patients (37.2%) had not received a prescription for an effective gastroprotective drug concomitantly with NSAID or low-dose aspirin treatment and 32 patients (41%) were not monitored during drug treatment. In the elderly, almost 6% of hospitalizations are ADR related. Most of these ADRs are potentially avoidable. Strategies that reduce inappropriate prescriptions and monitoring errors, as well as improving active prevention of ADRs, are needed in elderly subjects.

Educating European (Junior) Doctors for Safe Prescribing

Evidence of poor prescribing is widespread including overuse of medicines, underuse of effective medicines, avoidable adverse drug reactions and medication errors. Junior doctors who have recently graduated are responsible for much of the prescribing that takes place in hospitals and are implicated in many of the adverse medication events. Analysis of such events suggests that lack of knowledge and training underlies many of them and it has been shown that dedicated training can increase prescribing performance. In the context of these problems, it is a matter of increasing concern that recent changes to undergraduate medical education may have reduced exposure to clinical pharmacology, a discipline dedicated to optimal practice in relation to medicines. For this reason, the European Association of Clinical Pharmacology and Therapeutics (EACPT) and British Pharmacological Society (BPS) jointly organized a meeting to explore (i) the state of undergraduate education in clinical pharmacology in Europe, (ii) the knowledge and competencies in relation to medicines that should be expected of a new graduate, (iii) assessments that might demonstrate that this minimum standard had been reached, (iv) a curriculum that might help medical students to achieve this standard and (v) how competence can be developed in the postgraduate phase. It was agreed that the lack of exposure to clinical pharmacology is a cause for concern at a time when the challenges facing junior prescribers have never been greater. The potential for undertaking further research was discussed.

Wasted medicines and avoidable adverse events: a multibillion pound problem

SummaryFew studies assess the economic burden that potentially avoidable adverse drug reactions (ADRs) impose on the National Health Service. Therefore, we performed a first-order, hypothesis-generating heuristic estimate that suggested 392,000 acute admissions were due to ADRs during 2003/4, which accounted for about 0.7% of the Department of Health budget. We assumed that 59% of the ADRs were potentially preventable, equivalent to a potential saving of almost £369 million. Furthermore, we estimated that the community consultation costs reached £1 billion. Of these, 59% could have been prevented, equivalent to a potential saving of £600 million.We used liquid formulations as an example of how savings can offset the costs of initiatives to improve compliance, even using some very conservative assumptions about the downstream benefits. For example, preventing a single day's admission to a psychiatric hospital would fund liquid chlorpromazine instead of solid formulation for a year for three patients.More research is needed into the economics of noncompliance, competing formulations and the association between clinical outcomes and adherence. Furthermore, the analysis contains numerous assumptions and inferences. Nevertheless, we provisionally suggest that the total cost of potentially avoidable ADRs in the community and secondary care is approximately £1 billion a year.