Medication For Individual Patient Research Articles

Exploring near miss errors associated with split-pack robotic dispensing

Abstract Introduction Pharmacy automation using dispensing robots for the supply of medicines is not new. Improved dispensing efficiencies, maximised storage capacity and reduced dispensing errors are cited as key benefits.1 Published articles describe the impact of automation on dispensing error rates and types for original-pack dispensing2 with a paucity of literature on split-packs. Split-pack dispensing cannot be entirely eradicated: the ability to barcode and return to the robot facilitates the storage of medicines locally where dispensary footprint is limited; a manual process and one that is subject to human error. With anecdotal reports of split-pack robotic dispensing errors, there is an opportunity to explore near-miss errors as part of routine monitoring undertaken. Aim To establish the incidence and type of near-miss dispensing errors associated with split-pack robotic dispensing. Methods Approval was obtained from the Trust Pharmacy Research Committee. The need for ethical submission was waived. Near-miss dispensing errors were recorded in real-time via direct observations using a standardised data collection tool adapted from the Royal Pharmaceutical Society Near Miss Error Log3; with additional data collected on whether prescription requests were for original or split-pack quantities and storage location. All drugs dispensed/ checked in the dispensary between 09:00-17:00 were included (4 days in January 2023). All prescription types for individual patient medication orders were included. Stock drugs and outpatient prescriptions were excluded. A manual count of all items dispensed/ checked was undertaken each day to provide the denominator. Data was entered into Microsoft excel and analysed. Results Overall near-miss dispensing error incidence of 3.5% (72 near-misses/ 2035 items dispensed). Fourteen of fifty-eight (24.1%) erroneously dispensed items had two near-misses identified. Near-miss incidence associated with original-pack dispensing of 3.1% (50 near-misses/ 1590 items dispensed) compared with split-pack dispensing of 4.9% (22 near-misses/ 445 items dispensed). Chi square (with Yate’s correction) did not identify a statistical significant difference between the overall near-miss error rate between the two (p> 0.06). Most common original-pack dispensing error types were ‘wrong instructions on label’ (n=29/50), ‘wrong quantity on label and dispensed’ (n= 6/50), and ‘missing label’ on item (n=5/50). For split-pack dispensing, ‘wrong instructions on label’ (n=9/22), ‘wrong quantity dispensed’ (n=8/22), and ‘wrong quantity labelled’ (n=5/22) were most common. Discussion/Conclusion Local prevalence of near-misses is higher than in reported published literature1. Whilst direct comparisons are difficult to make due to differences in research methods, definitions, and operating systems; the incidence of near-miss errors associated with split-packs was notably higher than original-pack dispensing despite no statistical difference. Similar near-miss error types were identified for original/ split-pack dispensing with ‘wrong instructions on the label’ being the most common. This is consistent with published literature1 on errors with pharmacy automation. With split-pack robotic dispensing, it was noted that the quantity were not always as identified on the barcode label due to the manual returns process. Direct observations have indicated that missing patient information leaflets are a common problem for split-pack dispensing, although not recorded in this study. Further work should focus on causes/ contributory factors to split-pack robotic dispensing errors.

Impact of community pharmacist-led intensive education on the control of serum phosphate levels in haemodialysis patients.

Background Administration of phosphate binders can decrease serum phosphate levels and improve the prognosis of patients on dialysis. However, patients are often non-adherent to phosphate binder medication. Although community pharmacist-led education could be effective in the maintenance of adherence to phosphate binder medication, its impact has not been evaluated. Objective We aimed to evaluate the impact of community pharmacist-led intensive education focusing on phosphate binders for patients receiving haemodialysis. Setting The study comprising three phases (baseline phase, intervention phase, and follow-up phase) was conducted at the Yamauchi Pharmacy, Japan. Method Six pharmacists provided intensive education focusing on phosphate binders to patients receiving haemodialysis. As intensive education, a sheet containing checks for the remaining phosphate binders and information advising the patients on the use of the drugs was issued. Using the check sheet filled in by the patient, the pharmacists repeatedly provided education appropriate to the individual patient's medication status and level of understanding to encourage the correct use of phosphate binders for 8weeks (intervention phase). We investigated their serum phosphate levels from their medical records from 2months before the start of intensive education (baseline phase) to 8months after the end of the education (follow-up phase). Main outcome measure Serum phosphate levels in patients receiving haemodialysis after intensive education by community pharmacists. Results Fifty patients were enrolled in this study. During the intervention phase, serum phosphate levels in the patients with high and the highest serum phosphate level (6-7mg/dL and ≥ 7mg/dL, respectively) significantly decreased by 6.9% (P = 0.007) and 10.9% (P = 0.034), respectively. The levels remained below the baseline value throughout the follow-up phase in patients with the highest serum phosphate level. Conclusion Community pharmacist-led education focusing on phosphate binders affects short- and long-term management of serum phosphate levels in patients receiving haemodialysis, especially the patients whose levels were initially high.

Demand for Interpretation of a Urine Drug Testing Panel Reflects the Changing Landscape of Clinical Needs; Opportunities for the Laboratory to Provide Added Clinical Value.

The direct detection of drugs and metabolites in urine using a targeted panel offers sensitive and specific detection in comparison to the traditional approach to urine drug testing (screen with reflex of samples with positive results to confirmation testing). The purpose of this study was to evaluate changes in clinical demand for the laboratory to provide interpretation of patient adherence and abstinence, based on reconciling laboratory results and individual patient medication information provided by the clinician. The shifts in toxicology testing likely reflect the inherent complexity of the data and associated interpretation. Retrospective testing results associated with a targeted urine drug panel and its related interpretation were collected from our laboratory. We examined the associated testing volume and positivity rates of each reported analyte over 5 consecutive years (2015-2019). Requests from clinicians for consultation regarding this test and use of interpretive comments for the most recent year (2019), as well as access to publicly available educational resources over two years (2018-2019) were collected. The changes in test ordering patterns demonstrate shifting of clinical demands for toxicology testing, by increased adoption of a targeted panel for which laboratory-based interpretation is provided. Positivity rates reflect national shifts in controlled substance prescriptions. Several consultative services were accessed by clinicians suggesting interest and need. The value of clinical urine drug testing is improved by providing laboratory-based result interpretation and consultative services.

Medication review service implementation in community pharmacy settings: Scoping review with focus on implementation studies.

Medication reviews are a structured clinical intervention with the general goals of improving patient drug knowledge and detecting and resolving drug-related problems in an individual patient's medication regimen. A variety of barriers entrenched in the traditional drug distribution and dispensing model of pharmacy business has continued to challenge the implementation efforts of medication review services worldwide in the community pharmacy setting. MAIN OBJECTIVES: i) Characterize original research studies that sought to enhance medication review service implementation in community pharmacy settings. ii) Categorize the broader corpus of scientific literature (beyond original implementation studies) on medication review service implementation in community pharmacy settings. A broad systematic search strategy was applied to ovid MEDLINE, Embase, CINAHL and Cochrane Library to create an over-arching view and extensively ordered bibliography of the diverse research publication types dealing with the topic of medication review service implementation in the community pharmacy setting. A scoping review was subsequently conducted on original research studies that utilized various strategies to enhance the implementation of this service in community pharmacies. Data-charting evaluated the location of implementation studies, the strategies undertaken, the scale of implementation strategies, the use of DII (Dissemination, Implementation and Improvement) science theory, sample sizes, and DII outcomes. Of 5947 records screened, 419 fulfilled the inclusion criteria (from abstract screening) to be deemed suitable for categorization and inclusion into the broader survey on this topic. Of these 419 publications, only 75 were original research specifically focused on enhancing the implementation of medication reviews in community pharmacy. A large majority of the publications were qualitative studies (n = 203). The remaining articles were improvement studies (n = 36), descriptive observational studies (n = 49), reviews (n = 69) and methodology papers (n = 16). Twenty-nine of these articles were deemed suitable for inclusion in more than one category. After full-text screening, 41 of the 75 implementation publications, representing 40 original studies, published between 1999 and 2019, were eligible for data-charting. The majority of these studies occurred in North America (n = 30), used some form of education as the most common implementation strategy (n = 22) and measured 'adoption' (extent or frequency of medication reviews delivered) most frequently as an implementation outcome (n = 30). Just over half of the studies used a multi-faceted implementation strategy (n = 21). Only 9 studies used a theory, model or framework at any point in the research process to test hypotheses or explain empirical findings. There is an abundance of publications addressing various issues surrounding medication review implementation in community pharmacies. However, the literature appears disproportionately represented by qualitative studies. There is also a need for more rigorously conducted implementation studies on medication review services in community pharmacy.

Prescription auditing in rural area

Prescription is an order written by a physician, dentist or any other medical practitioner to the pharmacist to compound and dispense a specific medication for individual patient. Prescription auditing is a quality improvement process that seeks to improve patient care. The parameters which has to analyzed in the process of prescription auditing are, patient demographics, clinical diagnosis, department, prescribing standards, doctors name and signature. It is a prospective survey carried out in a rural area. About 50 prescription was collected. The study provides the effect of prescription auditing. Patients age sex, date of prescription ,drugs name and signature of the prescriber, dose, dosage form, duration of treatment was collected and analyzed. About 96% of prescription contain patient name, 88% contain patient age, all of these prescription are written in brand names and 96% are written in small letter. About 60% of the prescription contain dose of the drug and 90% of drug dosage forms are included. Among 50 prescription, 36% are eligible for reading, 48% are partially eligible and 16% are not eligible for reading. Prescription audits is an educational activity, which promotes high-quality patient care and which should carried out regularly.. A prescription auidit is to designed to measure the compliance with the standards of the proven clinical practice and to record the required and the documented changes in the clinical practice, which are shown by the re-audits.

Pharmacists' role in glycemic management in the inpatient setting: An opinion of the endocrine and metabolism practice and research network of the American College of Clinical Pharmacy

The objective of this opinion paper was to identify and describe the role of pharmacists in ensuring safe and optimal management of patients with glycemic excursions in the inpatient setting. The role of the pharmacist includes involvement in admission medication history and reconciliation, formulary management of glucose‐lowering medications and devices, individual patient medication management, discharge transition of care, and interprofessional collaboration with other health care providers. Recommendations are based on review of published guidelines and literature focusing on the management of patients with hypo‐ and hyperglycemia in the hospital as well as during the time of transition to and from the inpatient setting.

Assessing the extent of drug interactions among patients with multimorbidity in primary and secondary care in the West Midlands (UK): a study protocol for the Mixed Methods Multimorbidity Study (MiMMS)

IntroductionThe numbers of patients with three or more chronic conditions (multimorbidity) are increasing, and will rise to 2.9 million by 2018 in the UK alone. Currently in the UK, conditions...

Which role for brexpiprazole, a new dopamine D2 partial agonist, in the treatment of schizophrenia?

ABSTRACT FROM: Correll CU, Skuban A, Ouyang J, et al . Efficacy and safety of brexpiprazole for the treatment of acute schizophrenia: a 6-Week Randomized, Double-Blind, Placebo-Controlled Trial. Am J...

Impact of an expanded ward pharmacy technician role on service-delivery and workforce outcomes in a subacute aged care service

Background Ward pharmacy technicians (WPTs) support hospital pharmacists in the provision of clinical pharmacy services, however they are under-utilised in Australia. Aim To evaluate the impact of an expanded WPT role within a 56-bed subacute aged care inpatient service. Method The expanded WPT role included increased hours (from approximately 15.2 to 38 h/week) and an expanded scope of practice. WPT tasks included: assisting with individual patient medication supply, screening medication charts for changes, assisting with medication reconciliation and recording laboratory data for review by the pharmacist. The impact of the redesigned role on workforce and service-delivery outcomes was evaluated in a prospective before–after study. Data were collected using self-report, time-and-motion studies, dispensing reports and surveys. Results WPT assistance with individual patient medication supply increased from 80%. In the new workforce model, the WPT assisted with medication reconciliation and recording laboratory data on admission for more than 80% patients. The proportion of pharmacist time spent on clinical tasks increased from 58.0% to 73.9% (p < 0.0001), and unpaid pharmacist overtime fell from a median of 58.4 to 13.4 min/day (p < 0.0001). The median number of pharmacist interventions to resolve medication-related problems increased from 4 to 9/day (p < 0.0001), and interventions were made earlier in the admission. There were improvements in ward staff satisfaction with some aspects of the pharmacy service, and in the pharmacist's and WPT’s satisfaction with their roles. Conclusion An expanded WPT role improved clinical pharmacy service-delivery, staff satisfaction and patient care.

Pre‐habilitation (i): aggregation of marginal gains

Pre‐habilitation (i): aggregation of marginal gains

Pharmacogenetics in perioperative medicine

This review will discuss the most recent developments in pharmacogenetics of commonly used perioperative medications, new collaboration networks in the field of personalized medicine, and future clinical implications of pharmacogenetics. Evidence now suggests that pharmacogenetics has a role in the effects of analgesic, sedative, beta-blocker, local anesthetic, antiemetic, and obstetric medications. Variants in the μ opioid receptor gene change the analgesic effects of morphine. Additional opioids recently studied include remifentanil, methadone, tramadol, and codeine. Ibuprofen's clearance varies with CYP2C9*3 genotype. Midazolam is primarily metabolized by the CYP3A4/CYP3A5 enzymes. Enzyme induction was found to be about 50% greater with CYP3A5*3 homozygous genotype. Variations in minimum alveolar concentrations of volatile anesthetics and subcutaneous lidocaine efficacy have been attributed in part to melanocortin-1 receptor variants. Metoprolol achieved different effects in patients with CYP2D6 and beta1-receptor polymorphisms. Genetic background of the beta2-receptor contributes to susceptibility for experiencing preterm labor. The Pharmacogenomics Research Network and the Clinical Pharmacogenetics Implementation Consortium are partnerships of researchers who are dedicated to elucidating how the genome contributes to an individual patient's medication responses. In the near future, pharmacogenetic approaches may facilitate personalized perioperative intervention trials.

Practice-based pharmaceutical services: a systematic review

AbstractBackgroundGeneral practice-based pharmaceutical services are increasingly common, ranging from global medication changes (eg, generic switch) to individual patient medication review and educational interventions.AimTo conduct a systematic review of the effectiveness of practice-based pharmaceutical interventions.DesignA systematic review of general practice-based pharmaceutical services.SettingGeneral practice in the UK, Australia, Canada, Scandinavia and the US.Outcome measuresThe effect and cost of practice-based pharmaceutical services.MethodsElectronic databases were searched and pharmaceutical organisations were contacted. Studies fulfilling the review criteria were considered for inclusion. Duplicate independent data screening and abstraction was undertaken. Three indicators were used to assess the quality of included studies: method of random allocation; allocation concealment; and proportion of subjects followed to the end of the study.ResultsA total of 2,707 references were identified: 256 full publications were retrieved and 16 randomised, controlled trials (RCTs) met the inclusion criteria. Included studies assessed either the professional interface (educational outreach and general prescribing advice) or the patient interface (medication review and patient-specific prescribing advice). Three trials included all three quality markers. Most studies were effective in achieving one or more of the desired outcomes from pharmaceutical intervention. Two trials showed no statistically significant differences between the study and control groups post intervention.ConclusionsMany evaluations of practice-based pharmaceutical s***érvices have been published but few meet recognised standards of trial methodology. The results of this review suggest that practice-based pharmaceutical services are effective in achieving desired changes; however, more robust evidence is needed to confirm whether they are effective, efficient and sustainable.

Convergence of tuberculosis and diabetes mellitus: time to individualise pharmaceutical care

To assess the feasibility of providing a pharmacist-led pharmaceutical care service to patients with tuberculosis and diabetes mellitus. The study was conducted at a tertiary hospital in the northern region of Peninsular Malaysia. Methods Action research methodology was used. Pharmaceutical care issues. The prevalence of diabetes mellitus among newly diagnosed tuberculosis patients was 15% (53/352). Out of 53 patients identified, 35 participated in the study. Patients' ages ranged between 29 and 73 years (mean of 52 ± 10 years). The male: female ratio was 1.7:1. Pharmaceutical care issues identified by pharmacists were nonadherence, uncontrolled diabetes mellitus, adverse drug reactions and individual patient's medication related problems. Pharmacists were able to intervene and resolve some of the pharmaceutical care issues. Pharmacists played an important role in integrating the provision of care for tuberculosis and diabetes mellitus by providing individualised pharmaceutical care management. There still remains a need to address logistic barriers that impinged on the ability to conduct the pharmaceutical care service to its full potential.

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008

BackgroundThis paper presents Part 2 of a literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care, updating the 2002 national report on medication safety. Part 2 of the review examined the Australian evidence base for approaches to build safer medication systems in acute care.MethodsA literature search was conducted to identify Australian studies and programs published from 2002 to 2008 which examined strategies and activities for improving medication safety in acute care.Results and conclusionSince 2002 there has been significant progress in strategies to improve prescription writing in hospitals with the introduction of a National Inpatient Medication Chart. There are also systems in place to ensure a nationally coordinated approach to the ongoing optimisation of the chart. Progress has been made with Australian research examining the implementation of computerised prescribing systems with clinical decision support. These studies have highlighted barriers and facilitators to the introduction of such systems that can inform wider implementation. However, Australian studies assessing outcomes of this strategy on medication incidents or patient outcomes are still lacking. In studies assessing education for reducing medication errors, academic detailing has been demonstrated to reduce errors in prescriptions for Schedule 8 medicines and a program was shown to be effective in reducing error prone prescribing abbreviations. Published studies continue to support the role of clinical pharmacist services in improving medication safety. Studies on strategies to improve communication between different care settings, such as liaison pharmacist services, have focussed on implementation issues now that funding is available for community-based services. Double checking versus single-checking by nurses and patient self-administration in hospital has been assessed in small studies. No new studies were located assessing the impact of individual patient medication supply, adverse drug event alerts or bar coding. There is still limited research assessing the impact of an integrated systems approach on medication safety in Australian acute care.

Combination Therapy Versus Monotherapy for Bipolar Disorder

Patients experiencing breakthrough manic or mixed episodes during maintenance therapy for bipolar disorder should first be assessed to ensure they are receiving an optimal dose of the first-line medication. If further intervention is needed, one option is to combine an atypical antipsychotic and a mood stabilizer. The decision to use a particular combination should be made on the basis of the efficacy, tolerability, and safety of each medication for individual patients. Psychosocial therapy as an adjunct to medication is also useful in delaying relapse.

Optimizing patient safety by preventing combined use of intramuscular olanzapine and parenteral benzodiazepines

A formalized policy was developed to warn of the potential for adverse events associated with the use of intramuscular olanzapine in combination with injectable benzodiazepines. Administrators in the psychiatry department at Lutheran Hospital proposed that concomitantly active orders for both intramuscular olanzapine and parenteral benzodiazepines be prohibited as a matter of policy; this decision was supported by the institution's pharmacy and therapeutics and medical executive committees. The pharmacy department subsequently examined its processes as they related to the two medications, and changes were implemented in the areas of order processing and floor-stock provision. Before policy implementation, injectable olanzapine was stored as floor stock in several automated medication cabinets for use in urgent situations. Injectable lorazepam was also included in the stock inventory for most patient care areas. After policy implementation, intramuscular olanzapine was removed from the general floor stock on all hospital units. The drug is now only available after a pharmacist's review and approval of each individual order. Upon receipt of an order for intramuscular olanzapine, the pharmacist is required to conduct a prospective review of the individual patient's medication profile to determine if an active order for an injectable benzodiazepine exists. In the event that the prescriber cannot be reached in a timely fashion, the new order is held until a physician's clarification can be obtained. Implementation of a policy that increased pharmacist surveillance and regulation of the use of intramuscular olanzapine reduced the potential for coadministration of the agent with parenteral benzodiazepines in a community hospital.

Understanding the meaning of medications for patients: The medication experience

Objective: To understand and describe the meaning of medications for patients. Methods: A metasynthesis of three different, yet complementary qualitative research studies, was conducted by two researchers. The first study was a phenomenological study of patients’ medication experiences that used unstructured interviews. The second study was an ethnographic study of pharmaceutical care practice, which included participant observation, in-depth interviews and focus groups with patients of pharmaceutical care. The third was a phenomenological study of the chronic illness experience of medically uninsured individuals in the United States and included an explicit aim to understand the medication experience within that context. The two researchers who conducted these three qualitative studies that examined the medication experience performed the meta-synthesis. The process began with the researchers reviewing the themes of the medication experience for each study. The researchers then aggregated the themes to identify the overlapping and similar themes of the medication experience and which themes are sub-themes within another theme versus a unique theme of the medication experience. The researchers then used the analytic technique, “free imaginative variation” to determine the essential, structural themes of the medication experience. Results: The meaning of medications for patients was captured as four themes of the medication experience: a meaningful encounter; bodily effects; unremitting nature; and exerting control. The medication experience is an individual’s subjective experience of taking a medication in his daily life. It begins as an encounter with a medication. It is an encounter that is given meaning before it occurs. The experience may include positive or negative bodily effects. The unremitting nature of a chronic medication often causes an individual to question the need for the medication. Subsequently, the individual may exert control by altering the way he takes the medication and often in part because of the gained expertise with the medication in his own body. Conclusion: The medication experience is a practice concept that serves to understand patients’ experiences and to understand an individual patient’s medication experience and medication-taking behaviors in order to meet his or her medication-related needs.

Conducting research in individual patients: lessons learnt from two series of N-of-1 trials

BackgroundDouble-blind randomised N-of-1 trials (N-of-1 trials) may help with decisions concerning treatment when there is doubt regarding the effectiveness and suitability of medication for individual patients. The patient is his or her own control, and receives the experimental and the control treatment during several periods of time in random order. Reports of N-of-1 trials are still relatively scarce, and the research methodology is not as firmly established as that of RCTs. Recently, we have conducted two series of N-of-1 trials in general practice. Before, during, and after data-collection, difficulties regarding outcome assessment, analysis of the results, the withdrawal of patients, and the follow-up had to be dealt with. These difficulties are described and our solutions are discussed.DiscussionTo prevent or anticipate difficulties in N-of-1 trials, we argue that that it is important to individualise the outcome measures, and to carefully consider the objective, type of randomisation and the analysis. It is recommended to use the same dosages and dosage forms that the patient used before the trial, to start the trial with a run-in period, to formulate both general and individualised decision rules regarding the efficacy of treatment, to adjust treatment policies immediately after the trial, and to provide adequate instructions and support if treatment is adjusted.SummaryBecause of the specific characteristics of N-of-1 trials it is difficult to formulate general 'how to do it' guidelines for designing N-of-1 trials. However, when the design of each N-of-1 trial is tailored to the specific characteristics of each individual patient and the underlying medical problem, most difficulties in N-of-1 trials can be prevented or overcome. In this way, N-of-1 trials may be of help when deciding on drug treatment for individual patients.

Strategies to reduce medication errors with reference to older adults

This information on best practice is based on a systematic review (Hodglkinson et a/ 2006) conducted by the Australian Centre for Evidence Based Aged Care, formerly a collaborating centre of the Joanna Briggs Institute (JBI). The primary references on which this information is based are available online via Blackwell Synergy: www.blackwell-synergy.com and to members of the institute via the web site: www.joannabriggs.edu.au. This information sheet discusses the following: Types and causes of medication errors. Interventions, including computerised systems, individual patient medication supply, education and training, use of pharmacists and nursing care models. Implications for practice and research. Recommendations.

Reminders of Drug Effects on Laboratory Test Results

Drug effects on laboratory test results are difficult to take into account without an online decision support system. In this study, drug effects on hormone test results were coded using a drug-laboratory effect (DLE) code. The criteria that trigger the reminders were defined. To issue reminders, it was necessary to write a computer program linking the DLE knowledge base with databases containing individual patient medication and laboratory test results. During the first 10 months, 11% of the results from hormone samples were accompanied by one or more DLE reminders. The most common drugs to trigger reminders were glucocorticoids, furosemide, and metoclopramide. Physicians facing the reminders completed a questionnaire on the usefulness of the reminders. All respondents considered them useful. In addition, DLE reminders had caused 74% of respondents to refrain from additional, usually performed examinations. In conclusion, drug effects on laboratory tests should always be considered when interpreting laboratory results. An online reminder system is useful in displaying potential drug effects alongside test results.