Improve Drug Use Research Articles

Medication error prevention by pharmacists--an Israeli solution.

The purpose of this study was to record prospectively the frequency of medication order errors in a general hospital in Israel with the objective of assessing the impact of pharmacist intervention in preventing potential harm. The study was conducted during a 6-month period. A total of 160 medication order errors were detected at the hospital of which 60.6% were prescription errors and 39.4% were therapy ones. Principal types of errors detected were incorrect dosage (27.5%), interactions between drugs (20%), incorrect drug (12.5%), route (11.2%) and frequency (11.2%). Medication error rate by degree of severity was calculated per 100 patient days. The highest rate was found in Hemato-Oncology (2.48), followed by Intensive Care (0.82), Surgery (0.48) and Internal Medicine (0.26). Anti-infective drugs were the most prevalent class of drugs in which errors occurred (38.7%) followed by total parenteral nutrition preparations (21.8%), antineoplastics (15.6%) and anticoagulants (11.3%). Changes in medication orders due to pharmacists' intervention only occurred in 73.8% of error cases, most referring to dosage or route change (37.5%). This study underestimates the actual number of medication errors. However, it identified problem areas and trends so that better measures to improve drug use could be implemented.

Improving drug use: a case study of events which led to changes in use of flucloxacillin in Australia

Policy makers and health professionals charged with implementing policies to improve medication use require knowledge as to how to integrate and co-ordinate strategies and interventions which have been shown to be effective. Experimental methodologies are commonly used to assess the effectiveness of interventions to improve medication use and while valuable for determining the effectiveness of particular interventions, they do not add to our understanding of how to co-ordinate and integrate multiple initiatives to improve medication use. We argue that analyses of the overall system of events which are implemented to improve medication use are also needed. In this paper, we demonstrate how the case study analysed within the framework of the Transtheoretical Model of behaviour change can be used to provide an understanding of the relationship of events which result in changes in medication use. A case study of the sequence of events which led to changes in the utilisation of flucloxacillin in Australia is assessed. The analysis demonstrated that the effectiveness of individual interventions was dependent upon the initiatives which were implemented concurrently and those that had been implemented previously. Changes in the utilisation of flucloxacillin resulted from regulatory interventions and the promotion of appropriate alternative therapies. The effectiveness of this change was enhanced by previous interventions which had raised awareness amongst health professionals of the adverse hepatic reaction associated with the use of flucloxacillin. This methodology adds to those currently employed to study methods of improving use of medications. It provides an understanding of the role of each initiative in the overall system. This is valuable for policy makers, providing them with information on how to co-ordinate and orchestrate the myriad of activities which support quality use of medicines.

Intervention research in rational use of drugs: a review.

Many studies have been done to document drug use patterns, and indicate that overprescribing, multi-drug prescribing, misuse of drugs, use of unnecessary expensive drugs and overuse of antibiotics and injections are the most common problems of irrational drug use by prescribers as well as consumers. Improving drug use would have important financial and public health benefits. Many efforts have been undertaken to improve drug use, but few evaluations have been done in this field. This article provides an overview of 50 intervention studies to improve drug use in developing countries. It highlights what type of interventions exist and what is known about their impact. It reveals that commonly used interventions, such as an essential drug list and standard treatment guidelines, have rarely been systematically evaluated so far. The majority of intervention studies are focused on prescribers in a public health setting, while irrational use of drugs is also widespread in the private sector. Furthermore, the magnitude of inappropriate drug use at community level is often overlooked and few interventions address drug use from a consumer's perspective. More research on different types of intervention strategies in various health care settings is needed to draw conclusions on the effectiveness of a specific intervention strategy. Also more research is needed on socio-cultural factors influencing the impact of drug use interventions, particularly from a user perspective. To enhance evaluative research, more technical support will be needed for researchers in developing countries. The design of available studies from developing countries is generally weak, only six of the 50 studies included in this overview were randomized controlled studies. In order to provide technical support and coordination of future intervention research the establishment of an international resource centre for drug use intervention research is recommended.

Use of antimalarial drugs in Mali: policy versus reality.

Inappropriate use of antimalarial drugs undermines therapeutic efficacy and promotes the emergence and spread of drug-resistant malaria. Strategies for improving compliance require accurate information about current practices. Here we describe Knowledge-Attitude-Practice surveys conducted among health providers and consumers in two Malian villages, one rural and one periurban. All sanctioned providers limited their first choices of antimalarial drug to those recommended by the national malaria control program and reported using correct dosing regimens. However, the majority of consumers in the two villages chose non-recommended treatments for malaria and reported suboptimal treatment regimens when they did use recommended drugs. Antimalarial drugs were also widely available from unsanctioned sources, often accompanied by erroneous advice on dosing regimens. This study demonstrates that even when the most peripheral health providers are well-trained in correct use of antimalarial drugs, additional measures directly targeting consumers will be required to improve drug use practices.

Drug Prescribing in Rural Health Facilities in China: Implications for Service Quality and Cost

Overuse of drugs in rural areas of China has led to a growing concern regarding service quality and cost. The study found evidence of high levels of drug use in some rural health facilities in comparison with a number of other developing countries. Such a result was significantly associated with the government policy of financing health care, regulation and monitoring of health services, and users' attitudes and behaviour. It underlines the need for measures to be taken in China to improve drug use in order to allow its population access to effective care at reasonable cost.

Drug Use in Swedish Nursing Homes

To describe the overall drug use in Swedish nursing homes and to comment on the impact of regular multidisciplinary team interventions on the quantity of inappropriate medications. This randomised, controlled trial was carried out in a sample of 33 nursing homes, 15 experimental homes and 18 control homes, representing 5% of all Swedish nursing homes. The sample consisted of 1854 nursing home residents with an average age of 83 years. 70% of the residents were female and 42% had a documented diagnosis of dementia. An additional 5% had a psychotic disorder and 7% had a diagnosis of depression. Lists of each resident's prescriptions were collected 1 month before and 1 month after the 12-month intervention. Measures included the proportion of residents receiving any particular drug. The number of drugs classified by guidelines as inappropriate was also measured before and after the intervention period. The nursing home residents were prescribed on average 7.7 medications, the majority on a regular basis. The most frequently prescribed group of drugs was laxatives, followed by psychotropic agents and cardiovascular drugs. Some groups of drugs decreased in the intervention homes. Extensive and somewhat inappropriate drug use in Swedish nursing homes is a significant and serious problem. Careful monitoring is necessary to ensure well tolerated drug therapy in this frail population. Neither written information from the Medical Products Agency, nor the campaign in the pharmacies alone had an impact on drug use in Swedish nursing homes. Multidisciplinary team discussions contributed to improved drug use, but more research is needed to understand the mechanisms behind this finding.

Improving drug use in a capitated program for the poor.

Improving drug use in a capitated program for the poor.

Impact of managed care in pharmacy.

Implementation of managed care results in decreased reimbursement, decreased use of specialty services, and consolidation of providers. With these changes, pharmacy services have been affected in all settings. However, pharmacists do have opportunities to implement change in this new health care environment. Employee compensation usually represents over half of hospital expenses and is therefore often the target of efforts to decrease costs. For pharmacy, this translates to increased automation and expanded technician responsibilities. In response to these changes, pharmacists have broadened their scope of responsibility to improve drug use, with the goal of decreasing drug-related hospitalizations and providing quality care at a reasonable cost.

Cuba: improving use of medicines

As a result of the US economic blockade and the loss of trading partners after the collapse of the Soviet Union, Cuba's economy has weakened. On some health indices Cuba had been performing very well, among the South and Central American and Caribbean nations, but the downturn in the economy has taken its toll in terms of, for example, infectious disease. Access to drugs and other medical supplies has become difficult. In 1991 a national medicines programme had been set up to ensure the availability of essential drugs. In 1994, as the economic situation worsened, the programme was retuned to cover 343 drugs in 29 pharmacological classes. Cuba's local pharmaceutical industry can manufacture 87% of the products on the basic list of medicines. Since 1993 the Ministry of Health (MINSAP) in Havana, PAHO/WHO, and the Catalan Institute of Pharmacology (ICF) in Barcelona, Spain, have been working together to try to improve drug use in primary care. This collaboration began with a workshop held at the Cuban drug regulatory authority (CECMED), the object being to review drug registration procedures and make them consistent with the national medicines programme. One outcome was a formulary, which has since been distributed to 25 000 family doctors in Cuba and to the country's medical schools. This was followed by a course on the clinical pharmacological basis for the rational use of medicines, and subsequently more than 400 primary care physicians have been taking par in three research projects on drug use by pregnant women and on the treatment of asthma and uncontrolled hypertension. In 1996 MINSAP began to set up a network of centres, one for each of the country's 169 municipalities. These centres, coordinated by the newly established Centre for the Development of Pharmacoepidemiology, are staffed by one family doctor and one pharmacist, who have the following tasks: •Updating the national formulary by review of published material•Revising printed information on drugs and common therapeutic problems•Advising primary health care centres and local associations with a view to setting up protocols on the treatment of common diseases•Promoting and coordinating drug utilisation and pharmacoepidemiological studies•Organising courses and seminars on therapeutics The family doctors who will be in charge of these local centres are being trained in the pharmacoepidemiological aspects of 30 common problems seen in primary care in Cuba. Several Cuban family doctors and pharmacologists are also being trained in Barcelona. MINSAP in Havana provides the manpower and the office space while funding and technical support and training for this project come from PAHO/WHO's Havana office and from ICF, Barcelona.

Adverse Drug Events in Hospitalized Patients-Reply

In Reply. —Active surveillance for ADEs can prevent the unfortunate adversarial relationships between physicians and pharmacists that concern Dr Davis. Surveillance, rather than mandatory reporting, must be the core of the concerted multidisciplinary effort called for by Dr Rybacki. Using exactly this approach, we have published evidence that early notification of physicians can alert them to ongoing ADEs so that mild and moderate reactions don't progress to more serious conditions,1focused surveillance can reduce the incidence of certain types of ADEs,2and antibiotic management programs, including but not limited to computerized ordering, can reduce the incidence of ADEs to antibiotics by 75%.3,4Indeed, we are the only center to have developed and implemented broad-based programs that prevent ADEs. The major reason for our success has been our focus on improving drug use at the bedside rather than on elucidating and cataloging all sources of inconsequential drug errors. Dr Davis

Variations in practice patterns: antiviral drug use in hospitalized patients with herpes infections.

This study describes patterns of antiviral drug use for patients hospitalized with chickenpox, herpes simplex, and herpes zoster infections, and also for a subgroup of herpes patients with severe infections (systemic infections, eye infections, encephalitis, hemorrhagic pneumonitis, and other severe conditions). Our findings demonstrate that there is great deal of variation in the use of antiviral drugs for these herpes patients, and that much of this variation is apparently unrelated to medical indications for antiviral drug use. Instead, patterns of use are associated with patient characteristics (age, race) and with hospital characteristics (location, teaching status, number of beds). Because these drugs are effective when used properly, treatment guidelines and protocols may be needed so that improved drug use will produce better patient outcomes.

Improving drug use through continuing education: A randomized controlled trial in Zambia

The objective of this study was to evaluate the impact of three continuing education seminars (within a period of 4 months) on the quality of patient management and rational drug use. The study was designed as a randomized controlled trial. Prescribers in 16 general health centers were allocated to an intervention (eight health centers) or a control (eight health centers) group. A total of 5,685 patient cards was analyzed for quality of case management and rational drug use. In the intervention health centers the average number of drugs per patient decreased from 2.3 to 1.9 ( p = 0.005) and the proportion of patients managed with nonpharmacological treatment increased from 1 to 13.2%. Recorded history taking, examination, and diagnosis improved in the intervention health centers. More drugs were correctly chosen in the intervention health centers compared to control health centers ( p = 0.03). The proportion of patients prescribed antibiotics decreased and the proportion of patients adequately managed increased in the intervention health centers. Our conclusion is that continuing education in the form of repeated seminars is effective in influencing prescribers and in promoting rational drug use in primary care.

An iconoclastic perspective on progress in pharmacy practice.

Progress in pharmacy practice is examined and areas for improvement are identified. Data from surveys of hospital and health system pharmacy practice from 1957 to 1994 show that the steady progress from 1974 to 1985 was not sustained over the past decade. Changing to a profession in which all practitioners provide pharmaceutical care will be difficult when practice in hospitals, where the most acutely ill patients are treated, does not meet the profession's recommended standards. Many pharmacists may be resigned to a reality in which their services are viewed as ancillary. The number of medication misadventures that occur indicates that there is an unmet need for effective medication management. Pharmaceutical care offers the promise of better patient outcomes as well as "reprofessionalization" of pharmacists. To elevate the level of pharmacy practice, individual practitioners need will; too much attention has been given to skill. Many new practitioners have earned Pharm. D. degrees but not received enough nurturing from colleagues to develop into innovators who will continue the profession's progress. It is crucial that the pharmacy practice and education communities cooperate to prepare pharmacists to function in the changing health care system. Also, professional organizations must set aside their fragmented interests and focus together on pharmacists' survival. The restructuring and economic pressures in health care may offer pharmacists the opportunity for progress, since improving drug use would help to decrease health problems and cost.

Improving Drug Use Through Purchase Agreement Commitments

Improving Drug Use Through Purchase Agreement Commitments

Computer-Assisted Retrospective Clinical Activities Statistics (CARCAS) Program.

Clinical pharmacy services have been demonstrated to have a positive impact on patient care in the hospital setting. Accurate and complete documentation of interventions aimed at improving drug use is essential to assess workload characteristics, determine the impact of pharmacist activities, justify current programs and predict future clinical staffing requirements. The need for an improved system of collecting and analyzing clinical workload statistics led to the development of a Computer-Assisted Retrospective Clinical Activities Statistics (CARCAS) Program in our department. Using a pre-defined clinical activity coding system, pharmacist activities were efficiently documented on a daily basis using an existing distributional computer system. Training requirements and data entry time were minimal. The CARCAS Program appeared to capture more clinical pharmacist activities than the earlier manual system. The flexibility of the CARCAS Program should permit adaptation to other hospitals with similar computer systems regardless of the nature of their clinical programs.

Severity-Indexed, Incident Report-Based Medication Error-Reporting Program

A medication error-reporting program is described. Medication errors at a large teaching hospital are reported through traditional incident reports. Specific information on the errors is documented on an additional form; data captured include the type of error, system breakdown point, and class of drug involved. A severity ranking that reflects patient outcome is also assigned to each medication error. The data are entered into a relational database and analyzed. Reports are generated that show the overall error rate, the distribution of errors by severity ranking and drug class, and the error types, system breakdown points, and drug classes associated with errors of the highest severity rankings. Between January and December 1990, the number of medication error reports received per month ranged from 73 to 141, and the number of errors reported per month increased during the year. Although the incident report-based method underestimates the actual number of medication errors, the program has been effective in identifying problem areas and trends so that quality assurance and medical committees can implement measures to improve drug use. The use of a severity-indexed medication error-reporting program based on incident reports and managed through a relational database has revealed problems that are then addressed by other quality assurance measures.

Methadone Treatment and Legal Supervision: Individual and Joint Effects on the Behavior of Narcotics Addicts

This study investigated the individual and joint effects of methadone maintenance treatment and of legal supervision that included drug use testing (e.g., parole or probation) in improving the behaviors of narcotics addicts. Subjects were 202 clients selected from a sample of admissions to methadone clinics in southern California. The subjects selected had experienced all intervention conditions (methadone maintenance alone, legal supervision/drug testing alone, both interventions simultaneously, and neither intervention) in their addiction careers. Extensive interviewing of subjects provided longitudinal self-report data on various characteristics and behaviors. Repeated measures analysis of variance was used to test for statistical differences. Overall, the individual effect of methadone maintenance and of legal supervision was better than that of the no-intervention condition in improving drug use and criminal behavior by narcotics addicts. Methadone maintenance alone showed a broader range of improvement (e.g., in employment) and greater magnitude of improvement than did legal supervision alone. The combined effect of these two intervention conditions was not significantly better than that of methadone maintenance alone, except on abstinence from narcotics use.

Intervention research to promote clinically effective and economically efficient use of pharmaceuticals: The international network for rational use of drugs

Despite acceptance of the essential drug concept by over 100 countries, current drug use patterns frequently result in unsafe use, waste of scarce resources, non-compliance, excess adverse drug reactions and disease resistance. Even in countries where resources for research are available, most efforts to improve drug prescribing have never been properly evaluated. Proposed interventions should reflect the behavioral basis for current drug use, target priority public health areas, and be feasible in developing country contexts. Most importantly, they must be critically assessed for cost and effectiveness in well-controlled field trials. The International Network for Rational Use of Drugs (INRUD) is a cooperative organization of health professionals and researchers in developing countries whose aim is to promote improved quality of care through more clinically effective and economically efficient use of pharmaceuticals. To accomplish this, INRUD will strengthen regional and national capacities to develop and scientifically evaluate programs to improve drug use and disseminate information on practical strategies shown to be cost-effective.

Improving Medication Prescribing and Utilization in the Nursing Home

There is ample and compelling evidence to suggest that medications are frequently used inappropriately in the nursing home. The occurrence of avoidable adverse drug reactions is the most serious consequence of inappropriate prescribing; economic implications are also of interest. With increasing concern over the quality of care in nursing homes, and with the revision of regulations governing such care by the Health Care Financing Administration, it is important to consider the experience thus far in monitoring and improving drug use in nursing homes. A number of studies have investigated approaches designed to reduce inappropriate prescribing and drug utilization in this setting. In contrast to the wide range of approaches that have been evaluated and implemented in the hospital setting, interventions in the nursing home have centered primarily around consultant-pharmacist activities. Although these activities are now federally mandated in all nursing homes, there is little evidence from adequately controlled studies to document their impact or cost-effectiveness. By contrast, face-to-face educational interventions directed at physicians ("academic detailing") have been shown to be effective in improving prescribing for some medications. The prominent role played by the nursing staff in the utilization of many medications in the nursing home implies that an educational intervention excluding nursing staff would be insufficient to influence drug utilization positively in many situations (eg, psychoactive medications and laxatives). Future research efforts must pay greater attention to adequate study design considerations as well as to the clinical outcomes of such interventions and their cost-effectiveness.

Problems in the Prescription of Sustained-Release Theophylline

A prospective audit of 100 consecutive outpatient prescriptions for sustained-release theophylline was performed to evaluate clinical dosing practice. Forty-one of 98 evaluable prescriptions failed dosing criteria based on accepted guidelines. Documentation of dose, dosage form, or schedule was inadequate in 53% ofthe reviewed charts. Serum theophylline level determinations, when performed, were lower in the group with dosing below guidelines compared to those with appropriate dosing (mean ± SD serum theophylline level: 4.5 ± 4.6 vs 7.4 ± 5.8 μg/ml; p < 0.05), and 76% of all levels were subtherapeutic ( < 10 μg/ml). Clinical outcome was highly variable and seemed to depend on factors other than the use or dosage of theophylline. Pediatric asthma specialists prescribed theophylline with fewer errors than other pediatric staff physicians and residents. We conclude that current dosing practice for sustained-release theophylline in pediatric teaching hospitals may be suboptimal and recommend a combination of targeted education and modification of institutional policies to improve drug use.