Drug Omission Research Articles

Antiretroviral therapy prescribing in hospitalized HIV clinic patients

Antiretroviral therapy (ART) medication prescribing errors in hospitalized patients still remain common. This study aimed to examine the initial prescribing of antiretroviral drug regimens for HIV clinic patients admitted to an urban academic teaching hospital. A retrospective chart review of all patients with a discharge diagnosis of HIV or AIDS was performed. Only patients actively managed by the hospital out-patient HIV clinic at the time of discharge were included in the final analysis. We compared the ART initially prescribed during hospitalization with the clinic records. Medication errors were separated by type and the prescriber's area of specialty was noted. From 1 January 2009 to 31 December 2009, 90 admissions in 62 patients were included in the final analysis. In 47 of those admissions, the patient had an initial regimen considered to be incorrectly prescribed; in 17 of these 47 admissions, the patient was not prescribed any ART, and in the remainder the errors were related to drug omissions, incorrect frequency/dose, and prescription of the wrong drug. The majority of admissions were by an internal medicine or non-infectious disease (ID) specialist. Average time to ART initiation was comparable among all prescribers. No statistically significant correlation was found between the number of admissions per patient or the prescriber's area of specialty and the percentage of incorrect regimens ordered. Hospital HIV medication management still remains an area of focus because of the complexity of regimens, poor medication reconciliation and limited non-HIV/ID specialist knowledge.

Computer alerts help avoid drug omissions

Computer alerts help avoid drug omissions

Computer alerts help avoid drug omissions

Computer alerts help avoid drug omissions

Medicines Reconciliation Using a Shared Electronic Health Care Record

: This study aimed to evaluate the use of a shared electronic primary health care record (EHR) to assist with medicines reconciliation in the hospital from admission to discharge. : This is a prospective cross-sectional, comparison evaluation for 2 phases, in a short-term elderly admissions ward in the United Kingdom. In phase 1, full reconciliation of the medication history was attempted, using conventional methods, before accessing the EHR, and then the EHR was used to verify the reconciliation. In phase 2, the EHR was the initial method of retrieving the medication history-validated by conventional methods. : Where reconciliation was led by conventional methods, and before any access to the EHR was attempted, 28 (28%) of hospital prescriptions were found to contain errors. Of 99 prescriptions subsequently checked using the EHR, only 50 (50%) matched the EHR. Of the remainder, 25% of prescriptions contained errors when verified by the EHR. However, 26% of patients had an incorrect list of current medications on the EHR.Using the EHR as the primary method of reconciliation, 33 (32%) of 102 prescriptions matched the EHR. Of those that did not match, 39 (38%) of prescriptions were found to contain errors. Furthermore, 37 (36%) of patients had an incorrect list of current medications on the EHR.The most common error type on the discharge prescription was drug omission; and on the EHR, wrong drug. Common potentially serious errors were related to unidentified allergies and adverse drug reactions. : The EHR can reduce medication errors. However, the EHR should be seen as one of a range of information sources for reconciliation; the primary source being the patient or their carer. Both primary care and hospital clinicians should have read-and-write access to the EHR to reduce errors at care transitions. We recommend further evaluation studies.

Sources of pre-admission medication information: observational study of accuracy and availability

To identify the accessibility of sources of pre-admission medication (PAM) information, to quantify agreement between the PAM list and the 'gold-standard' PAM list (GS-PAML) and to categorise disagreements. A random selection of patients with chronic illness admitted via accident and emergency to one of two study hospitals in the Republic of Ireland were recruited. For each patient, a GS-PAML was compiled and PAM lists were obtained from each relevant source, including patient own medications, general practitioner (GP) referral letter, past inpatient prescription (Kardex) and discharge summary, nursing home letter and personal communication with GP staff, community pharmacy staff and nursing home staff. Data were collected regarding availability for use of each source and allergy status. The GS-PAML was compared to each PAM, and disagreements were identified and categorised. Data were collected for 134 patients. Community pharmacy and nursing home staff were most accessible to researchers when undertaking the medication history (>90%), followed by GP staff (66%). Except for nursing home sources, agreement between PAML and GS-PAML was low (2-17% of patients, 44-77% of medications). The community pharmacy PAML most frequently agreed with the GS-PAML (17% of patients, 77% of medications) followed by GP staff (10% of patients, 69% of medications). Previous (within the last 6 months) discharge summaries (3% of patients, 49% of medications) and GP referral letters (2% of patients, 44% medications) agreed least frequently. Nursing home (100%) and GP (91%) staff provided most accurate allergy information. Drug omission (>35%) was the most common disagreement for all sources except nursing home staff. GP staff and community pharmacy PAMLs contained a considerable proportion of commission discrepancies. Community pharmacy and GP staff were identified as the most available and accurate sources of PAM information and should be prioritised when undertaking admission medication reconciliation in a busy clinical environment.

Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals

Potentially inappropriate prescribing is common in older people presenting to hospital with acute illness in Ireland. The aim of this study was to determine if this phenomenon is unique to Ireland or whether it is a more widespread problem in hospitals across Europe. Prospective data were collected from 900 consecutive older patients admitted to six university teaching hospitals (150 patients per centre) in Geneva (Switzerland), Madrid (Spain), Oostende (Belgium), Perugia (Italy), Prague (Czech Republic) and Cork (Ireland). Age, gender, comorbidity, cognitive status, prescription medicines taken before admission and baseline haematological, biochemical and electrocardiographic data were recorded. STOPP and Beers' criteria were applied to detect potentially inappropriate medicines (PIMs). START criteria were applied to detect potentially inappropriate prescribing omissions (PPOs). The overall PIM prevalence rate was 51.3% using STOPP criteria, varying from 34.7% in Prague to 77.3% in Geneva, and 30.4% using Beer's criteria, varying from 22.7% in Prague to 43.3% in Geneva. Using START criteria, the overall PPO prevalence rate was 59.4%, ranging from 51.3% in Cork to 72.7% in Perugia. Polypharmacy predicted the presence of PIMs using STOPP criteria [with >10 medications: odds ratio (OR) 7.22, 95% confidence interval (CI) 4.30-12.12, p < 0.001] and Beers' criteria (with >10 medications: OR 4.87, 95% CI 3.00-7.90, p < 0.001). Increasing co-morbidity (Charlson Index ≥2) and age ≥85years significantly predicted PPOs. Potentially inappropriate drug prescribing and the omission of beneficial drugs are highly prevalent in acutely ill hospitalized older people in six European centres.

A simple tool to improve medication reconciliation at the emergency department

Background Medication histories acquired upon admission are often incomplete. Using a standardized approach warrants more complete medication reconciliation, however, this is too time consuming to be performed. Other strategies guaranteeing complete medication histories should be explored. We developed a limited list of standardized questions and assessed its impact on completeness of medication histories. Methods This prospective study enrolled adults presenting to a tertiary care emergency department. In the control group, medication histories were conducted by physicians of general internal medicine conform standard care. In the intervention group, the physicians were obliged to use, besides the standard care, the ‘limited questions list’ for medication history acquisition. The clinical pharmacist re-obtained medication histories of the patients in both groups using a standardized approach. The primary outcome was the impact of the use of a ‘limited questions list’ on the frequency of drug omissions in medication histories. Results 260 consecutive patients were enrolled: 130 in the intervention group and 130 in the control group. There was a significant reduction of 49.3% in drug omissions in the intervention group. The omission rate per medication history was 1.1 for the control group, which was significantly lower (0.6) in the intervention group. Antithrombotics were most frequently forgotten in the control care group as opposed to dietary supplements in the intervention group. Conclusion Drug omission rate in medication histories can be significantly reduced if a limited list of simple questions is used during anamnesis. Widespread use of this tool should be considered to be implemented.

An In-Depth Analysis of Medication Errors in Hospitalized Patients with HIV

It is well recognized that medication errors occur and can affect success in treating patients with HIV/AIDS. However, little information is available describing the prevalence, nature, and causes of medication errors. To determine the incidence of combination antiretroviral therapy (ART)- and opportunistic infection (OI)-related medication errors and describe the nature and cause(s) of errors to guide future interventions. A daily antiretroviral utilization report was used to identify adults who were receiving ART and had been admitted to a tertiary care teaching hospital during 2 consecutive months in 2005. Patients' charts, medication profiles, and medication administration records were reviewed for medication errors such as improper dosing, interactions, drug omissions, and missing doses. Once identified, etiology and cause were further investigated through provider interviews. An interdisciplinary team reviewed each case to establish validity of the error, severity, and cause. Sixty-nine combined ART- and OI-related medication errors were identified in 20 of 26 (77%) evaluated patients, with 2.7 medication errors per patient. Fifty-four percent of the errors occurred within the first 24 hours after admission. Inadequate medication reconciliation on admission caused 21 of 37 (57%) admission-related errors. The most prevalent error types included missing doses (20%), underdosing (13%), overdosing (13%), therapy omission (13%), and drug-drug interaction (12%). The primary cause of errors was provider lack of knowledge. Prospective investigation of medication errors provided in-depth insight into the diverse nature of HIV-related medication errors, risk factors, and potential preventive strategies. System changes such as hard stops in the clinical decision support software and improved medication reconciliation training, and changes in cart-fill time could prevent specific types of errors. Further studies are warranted to evaluate the impact of various strategies for preventing medication errors in the HIV population.

When do medication administration errors happen to hospital inpatients?

Abstract The aim of this study was to determine when medication administration errors (MAEs) are most likely to occur. MAEs were identified by observing nurses preparing and administering medication on a care of the elderly ward during two eight-day periods. The exposure of individual patients to MAEs was also determined. A total of 119 MAEs was identified during the observation of 2,170 opportunities for error, representing an error rate of 5.5 per cent (95 per cent confidence interval, 4.5 per cent to 6.4 per cent). The omission of drugs that were not available on the ward was the predominant type of error. Of the 56 study patients, 35 experienced at least one MAE during the study period. Errors occurred at an average rate of at least 0.3 errors per patient day. The MAE rate was significantly higher on weekdays (6.4 per cent) than during weekends (4.0 per cent) and higher during pharmacy opening hours (7.8 per cent) than when the pharmacy was closed (4.6 per cent). Patients were at greatest risk of MAEs in the first 48 hours of admission and in the first 48 hours after prescribing. A multidisciplinary approach is required to design safer systems.

Neuroprotection by Minocycline Caused by Direct and Specific Scavenging of Peroxynitrite

Minocycline prevents oxidative protein modifications and damage in disease models associated with inflammatory glial activation and oxidative stress. Although the drug has been assumed to act by preventing the up-regulation of proinflammatory enzymes, we probed here its direct chemical interaction with reactive oxygen species. The antibiotic did not react with superoxide or (•)NO radicals, but peroxynitrite (PON) was scavenged in the range of ∼1 μm minocycline and below. The interaction of pharmacologically relevant minocycline concentrations with PON was corroborated in several assay systems and significantly exceeded the efficacy of other antibiotics. Minocycline was degraded during the reaction with PON, and the resultant products lacked antioxidant properties. The antioxidant activity of minocycline extended to cellular systems, because it prevented neuronal mitochondrial DNA damage and glutathione depletion. Maintenance of neuronal viability under PON stress was shown to be solely dependent on direct chemical scavenging by minocycline. We chose α-synuclein (ASYN), known from Parkinsonian pathology as a biologically relevant target in chemical and cellular nitration reactions. Submicromolar concentrations of minocycline prevented tyrosine nitration of ASYN by PON. Mass spectrometric analysis revealed that minocycline impeded nitrations more effectively than methionine oxidations and dimerizations of ASYN, which are secondary reactions under PON stress. Thus, PON scavenging at low concentrations is a novel feature of minocycline and may help to explain its pharmacological activity.

Validating reasons for medication discontinuation in electronic patient records at hospital discharge

The accuracy of health care professionals in reporting safety events determines their usefulness for both system improvement and research. The study objectives were to: (1) validate (assess the accuracy of) the reasons recorded by doctors and pharmacists for discontinuing medication orders at discharge in a hospital's electronic patient records (EPR); (2) investigate the causes of any detected recording inaccuracy; and (3) collect preliminary data on the frequency and types of medication discontinuation. This was a validation study in one English hospital. The study comprised two steps: extraction of discontinued medication orders from the EPR followed by short structured interviews with doctors and pharmacists who made the discontinuation. A total of 104 discontinued orders were discussed during 15 face-to-face and six telephone interviews. The software package spss was used for data analysis. Duplication of therapy (27, 25.2%), omission of drug (23, 21.5%) and dosage regimen change (19, 17.8%) were the three most frequent reasons given for discontinuing medications. The majority of recorded discontinuation reasons were correct (100, 96.2%) and complete (101, 97.1%), and hence were judged accurate (97, 93.3%). The difference in accurate recording between doctors (15, 88.2%) and pharmacists (82, 94.3%) was not statistically significant. Potential causes of recording inaccuracy included: slip or lapse, lack of training, carelessness and electronic system rigidity. This study showed that doctors and pharmacists recorded accurate reasons for the majority of the discontinued medication orders. It also showed that utilizing pharmacists' recorded reasons during clinical interventions using EPR was beneficial in understanding and characterizing prescribing errors. Although they require further research, the reasons identified present preliminary data about the most prevalent types of pharmacists' interventions during hospital discharge.

Inability to Tolerate Standard Therapy Is a Major Reason for Poor Outcome In Older Adults with Acute Lymphoblastic Leukemia (ALL): Results From the International MRC/ECOG Trial

AbstractAbstract 493The International MRC UKALL XII/ECOG E2993 trial for adults with newly diagnosed acute lymphoblastic leukemia (ALL) recruited 1,914 patients to the main part of the trial from 1995 up to its closure in 2006, of whom 100 were over the age of 55 years (median 57, range 55–65). Beginning in 2003 (MRC) or 2004 (ECOG), patients with Philadelphia chromosome positive (Ph+ve) disease were entered into an Imatinib sub-study. We report here baseline characteristics, treatment course and outcomes, and discuss implications for future management strategies.Direct comparison of the 100 patients over 55 yrs with 1,814 under 55 yrs showed that the groups are comparable for gender, immunophenotype and white cell count but there is an indication that more elderly patients had Ph+ve disease (28% aged ≥55 vs 17% aged <55 of those entered before the start of the Imatinib trial; p=0.02).All patients in this trial received a 2 stage induction regimen, consisting of Daunorubicin, Vincristine, Asparaginase and Steroid followed by Cyclophosphamide, Cytarabine, 6-Mercaptopurine and Methotrexate. CNS prophylaxis with IT Methotrexate and Cytarabine was given during both phases. There was a randomisation to autograft or chemotherapy, but only a small number of patients in this age group were randomised (13 autograft and 13 consolidation chemotherapy).OutcomesComplete remission (CR) rate, event-free survival (EFS) and overall survival (OS) were all worse in the over 55 age group, and even after achieving CR, the 5-year OS rate was reduced. There were more infections in phase I induction (67% vs 45%, p<0.0001) and more deaths during induction chemotherapy (18% vs 4% p<0.0001). Excluding those who died in induction, 47% had drug dose reductions in phase I or phase II vs 27% <55 yrs (P=0.0006). Of these, Asparaginase was the most common in those aged ≥55 years, usually due to hepatotoxicity.Agep-value <55 vs ≥55<55≥55Number1814100CRNo v Yes p<0.0001No131 (7%)27 (27%)No (died in induction)70 (4%)18 (18%)No (but survived induction)61 (3%)9 (9%)Yes1641 (90%)70 (70%)Unknown42 (2%)3 (3%)Deaths1112/1814 (61%)78/100 (78%)Relapses750/1683 (45%)36/73 (49%)Overall survival at 5 years (95% CI)41% (38–43%)21% (12–29%)p<0.0001Event free survival at 5 years (95% CI)37% (34–39%)19% (10–27%)p<0.0001Relapse free survival at 5 years (95% CI)50% (48–53%)38% (25–52%)p=0.08Overall survival at 5 years (95% CI) in those who achieved CR44% (41–46%)30% (18–41%)p=0.03In those patients aged ≥55 years, baseline factors causing a significantly worse 5-yr EFS were Ph-positivity (0% vs 23%, p=0.005), unfavourable vs standard cytogenetic risk (7% vs 26%, p=0.02) and a presenting WCC >50 × 109/l (0% vs 25% for WCC between 10 and 49.9 × 109/l and 23% for WCC <10 × 109/l, p=0.003). Infection during induction chemotherapy predicted for worse EFS; this was especially significant in those who had infection in both phases of induction (6% vs 38%, p=0.007).In those patients who received chemotherapy and were not transplanted, the differences in outcome were smaller: 5-yr OS 25% in ≥55 years vs 38% in <55 years (p=0.06), 5-yr EFS 22% vs 32% (p>0.1). ConclusionOlder adults fared significantly worse than younger adults both in terms of achieving an initial CR and long-term survival. This difference cannot be explained solely by a difference in disease characteristics, and the marked increase in infection and deaths during induction reflect the inability of many older patients to tolerate the intensive level of treatment. This is also supported by the large numbers of drug omissions or dose reductions seen. Our data show that this inability to tolerate induction chemotherapy is a major contributor to the poor outcomes seen in this age group.The less marked differences between age groups when transplant patients are excluded, indicates the significant mortality associated with these procedures in older patients.Alternative approaches to consider in this group include less intensive induction with a steroid and vinca alkaloid combination, in conjunction with targeted therapies (eg Rituximab in B-lineage CD20+ disease, Imatinib Mesylate in Ph+ disease). Even amongst those patients who do achieve CR however, the long-term outcome is worse. Reduced intensity allografts may play a role in carefully selected patients in this age group, and the emerging use of MRD monitoring may also assist in selecting patients for more or less intensive approaches. [Display omitted] Disclosures:McMillan: EUSA: Honoraria. Goldstone: Roche: Honoraria, Speakers Bureau.

Medication Safety in the Elderly: Translating Research Into Practice

In 1999, the Institute of Medicine (IOM) reported that medication errors are the most common error in health care. If medication-related problems were ranked as a disease by cause of death, it would be the fifth cause of death in the United States. The elderly, a rapidly increasing segment of the population, are at greatest risk for adverse drug events. Suboptimal prescribing in the elderly may involve overuse (poly-pharmacy), the use of inappropriate drugs, and/or omission of drugs that are indicated. The provision of quality care requires that clinicians recognize and prevent drug-related problems in the elderly.

Order Scanning Systems may Simultaneously Pull Multiple Pages; Through the Scanner, Leading to Drug Omissions; Dangerous Name Pair; Be Clear When Teaching People to Use Their Inhalers; Inaccurate Dosing If Insulin Withdrawn from a Pen Cartridge

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Chronology of prescribing error during the hospital stay and prediction of pharmacist's alerts overriding: a prospective analysis.

BackgroundDrug prescribing errors are frequent in the hospital setting and pharmacists play an important role in detection of these errors. The objectives of this study are (1) to describe the drug prescribing errors rate during the patient's stay, (2) to find which characteristics for a prescribing error are the most predictive of their reproduction the next day despite pharmacist's alert (i.e. override the alert).MethodsWe prospectively collected all medication order lines and prescribing errors during 18 days in 7 medical wards' using computerized physician order entry. We described and modelled the errors rate according to the chronology of hospital stay. We performed a classification and regression tree analysis to find which characteristics of alerts were predictive of their overriding (i.e. prescribing error repeated).Results12 533 order lines were reviewed, 117 errors (errors rate 0.9%) were observed and 51% of these errors occurred on the first day of the hospital stay. The risk of a prescribing error decreased over time. 52% of the alerts were overridden (i.e error uncorrected by prescribers on the following day. Drug omissions were the most frequently taken into account by prescribers. The classification and regression tree analysis showed that overriding pharmacist's alerts is first related to the ward of the prescriber and then to either Anatomical Therapeutic Chemical class of the drug or the type of error.ConclusionsSince 51% of prescribing errors occurred on the first day of stay, pharmacist should concentrate his analysis of drug prescriptions on this day. The difference of overriding behavior between wards and according drug Anatomical Therapeutic Chemical class or type of error could also guide the validation tasks and programming of electronic alerts.

Medication Errors Recovered by Emergency Department Pharmacists

We assess the impact of emergency department (ED) pharmacists on reducing potentially harmful medication errors. We conducted this observational study in 4 academic EDs. Trained pharmacy residents observed a convenience sample of ED pharmacists' activities. The primary outcome was medication errors recovered by pharmacists, including errors intercepted before reaching the patient (near miss or potential adverse drug event), caught after reaching the patient but before causing harm (mitigated adverse drug event), or caught after some harm but before further or worsening harm (ameliorated adverse drug event). Pairs of physician and pharmacist reviewers confirmed recovered medication errors and assessed their potential for harm. Observers were unblinded and clinical outcomes were not evaluated. We conducted 226 observation sessions spanning 787 hours and observed pharmacists reviewing 17,320 medications ordered or administered to 6,471 patients. We identified 504 recovered medication errors, or 7.8 per 100 patients and 2.9 per 100 medications. Most of the recovered medication errors were intercepted potential adverse drug events (90.3%), with fewer mitigated adverse drug events (3.9%) and ameliorated adverse drug events (0.2%). The potential severities of the recovered errors were most often serious (47.8%) or significant (36.2%). The most common medication classes associated with recovered medication errors were antimicrobial agents (32.1%), central nervous system agents (16.2%), and anticoagulant and thrombolytic agents (14.1%). The most common error types were dosing errors, drug omission, and wrong frequency errors. ED pharmacists can identify and prevent potentially harmful medication errors. Controlled trials are necessary to determine the net costs and benefits of ED pharmacist staffing on safety, quality, and costs, especially important considerations for smaller EDs and pharmacy departments.

Potentially inappropriate prescribing in an Irish elderly population in primary care

* Potentially inappropriate prescribing in older people is a well-documented problem and has been associated with adverse drug reactions and hospitalization. * Beers' criteria, Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) are screening tools that have been formulated to help physicians and pharmacists identify potentially inappropriate prescribing and potential prescribing omissions. * The prevalence of potentially inappropriate prescribing and prescribing omissions in the elderly population presenting to hospital with acute illness is high according to STOPP and START criteria. * Potential errors of prescribing and of omission of medicines are prevalent among medically stable older people in primary care. * Screening tools should be incorporated into the everyday practice of primary care doctors and community pharmacists as a means of preventing potential errors of prescribing commission and prescribing omission in older people. Screening tools have been formulated to identify potentially inappropriate prescribing (IP) in older people. Beers' criteria are the most widely used but have disadvantages when used in Europe. New IP screening tools called Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) have been developed to identify potential IP and potential prescribing omissions (PPOs). The aim was to measure the prevalence rates of potential IP and PPOs in primary care using Beers' criteria, STOPP and START. Case records of 1329 patients >or=65 years old from three general practices in one region of southern Ireland were studied. The mean age +/- SD of the patients was 74.9 +/- 6.4 years, 60.9% were female. Patients' current diagnoses and prescription medicines were reviewed and the Beers' criteria, STOPP and START tools applied. The total number of medicines prescribed was 6684; median number of medicines per patient was five (range 1-19). Overall, Beers' criteria identified 286 potentially inappropriate prescriptions in 18.3% (243) of patients, whilst the corresponding IP rate identified by STOPP was 21.4% (284), in respect of 346 potentially inappropriate prescriptions. A total of 333 PPOs were identified in 22.7% (302) of patients using the START tool. Potentially inappropriate drug prescribing and errors of drug omission are highly prevalent among older people living in the community. Prevention strategies should involve primary care doctors and community pharmacists.

Drug administration errors in paediatric wards: a direct observation approach

Paediatric patients are more vulnerable to drug administration errors due to a lack of appropriate drug dosages and strengths for use in this group of patients. Therefore, the aim of the present study was to determine the extent and types of drug administration errors in two paediatric wards and to identify measures to reduce such errors. A researcher was stationed in two paediatric wards of a teaching hospital to observe all drugs administered to paediatric inpatients in each of the ward, for 1 day in a week over ten consecutive weeks. All data were recorded in a data collection form and then compared with the actual drugs and dosages prescribed for the patients. Of the 857 drug administrations observed, 100 doses had errors, and this gave an error rate of 11.7% [95% confidence interval (CI) 9.5-13.9%]. If wrong time administration errors were excluded, the error rate reduced to 7.8% (95% CI 6.0-9.6%). The most common types of drug administration errors were incorrect time of administration (28.8%), followed by incorrect drug preparation (26%), omission errors (16.3%) and incorrect dose (11.5%). None of the errors observed were considered as potentially life threatening, although 40.4% could possibly cause patient harm. Drug administration errors are as common in paediatric wards in Malaysia as in other countries. Double-checking should be conducted, as this could reduce drug administration errors by about 20%, but collaborative efforts between all healthcare professionals are essential.

Use and cost of branded and generic drugs in patients with coronary heart disease--results from a prospective survey of 1008 patients in two London hospitals

Combination therapy with three classes of drug, antiplatelet, cholesterol and blood pressure lowering treatment markedly reduce the risk of recurrent cardiovascular events in patients with coronary heart disease (CHD). Within each class, generic and branded (patented) drugs are available which have similar efficacy but differ in cost. (i) To assess the extent to which preventive medical drugs are prescribed in patients with CHD and to examine the reasons for drug omissions and (ii) to assess the relative use of branded and generic drugs and the reasons for drug selection. The medication charts and hospital notes of consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at a large cardiothoracic centre were reviewed over a 3-month period. Interviews with patients, attending cardiologists and general practitioners were undertaken to establish why drugs were and were not prescribed. Among 1008 patients (755 who had PCI and 253 who had CABG) the use of aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), beta blockers and calcium channel blockers were, respectively, 97, 98, 81, 76 and 18%. The combination of any 4 classes of drug were used in 65% of patients. Almost all patients who did not receive aspirin or a statin had clinical contraindications and were on alternative drugs. In about 12% of patients without an ACE inhibitor (or ARB) and 7% of patients without a beta blocker, no reason to withhold such treatment was identified. Branded drugs were used in 52% of patients; the most commonly prescribed being atorvastatin in 33%. Clinical reasons for using branded rather than generic drugs were identified in 13% of cases. Our results show a high rate of use of secondary preventive cardiac medications in patients undergoing coronary revascularization procedures, but the use of ACE inhibitors or beta blockers is still overlooked in about 1 in 10 patients. Branded drugs are prescribed in about half of all patients undergoing PCI and CABG, but in almost 90% of cases, a generic equivalent could have been used to achieve similar risk reduction. If our results reflect wider practice, an estimated 11 million pounds a year would be saved by the National Health Service by switching to generic alternative drugs.

Omitted and unjustified medications in the discharge summary

Background:Limited information exists in regard to drug omissions and unjustified medications in the hospital discharge summary (DS).Objective:To evaluate the incidence and types of drug omissions and unjustified medications in the...