Medication-related Harm Research Articles

Medication-related harm and the newspapers - what has been communicated to the public in Ireland: A systematic content analysis

Abstract Introduction Reducing the global prevalence of severe, avoidable medication-related harm (MRH) by 50% by the end of 2022 is the WHO’s third global patient safety challenge [1]. MRH is reported frequently in the academic literature, with increasing age being a key risk factor. The WHO have highlighted the need to improve public health literacy and knowledge about medications. Little is known about the frequency and nature of Irish newspaper reports about MRH. This study sought to address this gap and to examine reporting during the calendar years 2019 and 2009. Methods In this mixed-methods study, LexisNexis® [2], an online newspaper archive database, was searched for newspaper articles reporting on MRH, published in the Republic of Ireland during the calendar years 2019 and 2009. The search strategy focussed on “medication” AND “harm” AND “patient”. Quantitative data extraction aimed to describe the frequency (by count of articles) of reporting of MRH and the nature by describing the publishing newspaper titles and the reported details of: drug class(es), demographics (age or life stage, gender) of those experiencing harm and the severity of harm. Qualitatively, a systematic content analysis, using inductive coding is ongoing and will be reported separately. Research ethics committee approval for this study is not required because this is an analysis of material in the public domain. Results In total, 7098 newspaper articles were identified through database searching for 2019 (n=3217) and 2009 (n=3881). To date, 54% (3867: n=3217, 45% 2019, n=650, 9% 2009) of these were screened, of which 63 newspaper articles (n=44 2019, n=19 2009) were included and quantitative data were extracted. Within these 63 articles, 71 cases of individual people experiencing MRH were reported (52 in 2019 and 19 in 2009). The newspapers most commonly reporting MRH were Irish Daily Mail (31/63: 27 in 2019 and 4 in 2009) and Irish Times (17/63:9 in 2019 and 8 in 2009). Drug classes most frequently reported as causing MRH were central nervous system drugs (antiepileptics n=10, opioid analgesics n=5, antidepressants n=9, and anxiolytics n=1), cancer chemotherapy (23 cases) and non-steroidal anti-inflammatories (n=3). MRH was reported as being fatal (13 /71:8 in 2019 and 5 in 2009) and non-fatal (58/71), with seven cases (5 in 2019 and 2 in 2009) of permanent harm. Among the 71 individual cases of MRH, the majority were adults aged 18–64 years (n=36), children (n=7), older adults (n=8), foetus (n=3) and newborn (n=1), while the remainder did not report the person’s age. Conclusion MRH is frequently reported to the public through Irish newspapers. The study is limited by focus on newsprint media with the exclusion of other forms of digital or social media and restriction to two calendar years in a single country, which likely stifles the generalisability of findings to other contexts. Future work could explore this issue across a wider range of media platforms and examine changes in reporting over time. The study findings may support an agenda to improve the general public's exposure to information and knowledge of MRH and medication safety.

Designing a continuous data-driven feedback and learning initiative to improve electronic prescribing: an interdisciplinary quality improvement study

Abstract Introduction The WHO Global Patient Safety Challenge aims to reduce severe avoidable medication-related harm by 50% by 2023[1]. Research suggests that providing timely, trusted feedback that incorporates relevant action can improve practice. However, a key barrier is lack of prescribing error data. Hospital electronic prescribing (EP) data may help address this gap. Aims To explore approaches for continuously monitoring medication safety signals using existing or new EP data, and to deliver personalised prescribing feedback and learning to improve patient safety. Methods We conducted a feasibility study (November 2019 - February 2020) on a 28-bed adult gastroenterology. This ward was chosen because of a high prescribing error rate. All foundation year 1 and 2 doctors, and pharmacists on the ward, participated in the study. The study team comprised pharmacists, doctors, quality improvement experts and clinical analysts, and used a quality improvement approach to design and test (i) methods for extracting electronic data to calculate prescribing accuracy rates, (ii) ways to refine a paper-prototype of an electronic pharmacists’ interventions form, (iii) potential digital medication safety indicators, and (iv) approaches for feedback for doctors to augment existing verbal feedback from pharmacists. Data were documented in accordance with local information governance and analysed using Excel. Acceptability and usability was assessed through verbal feedback from participants during weekly huddles. Outcome measures: feasibility of using EP to determine prescribing accuracy, user acceptability and usability of data collection, feedback and learning by pharmacists and doctors. We also measured changes in prescribing accuracy rate, pharmacists’ interventions, and quality of prescribing for targeted problematic medications. Results Extracting EP data required multiple data linkages to be configured and validated, and not all required data were available. Potential digital medication safety indicators: utility of the reason code ‘prescribed in error’ and actions by pharmacists to modify medications were limited by underuse and lack of data granularity. After testing different ways to extract relevant EP data, we eventually used a combination of EP and manual retrospective review of electronic patient records to determine prescribing accuracy rates. An intervention form was redesigned to tally interventions and capture details for contextual learning for email feedback to doctors and weekly prescribing improvement huddles. Doctors reported emails as timely and helpful for gaining new prescribing- and system-related knowledge. Pharmacists reported intervention data as providing invaluable evidence to drive improvement. Statistical process control charts showed no special cause variation around a mean prescription accuracy rate of 98% for inpatient orders, and 87% for discharge orders. By contrast, pharmacists recorded a mean of 10 interventions/day with 7 special cause variation (above upper control limit of 19) in the first two months. Omission of venous thromboembolism prophylaxis was identified as a priority medication issue. Specific prescriber- and system-based improvements were suggested (Jan 2020), some implemented (Feb 2020) and others fed back to the thrombosis committee (Feb 2020). Conclusion Harnessing the potential of EP data to improve medication safety requires the workforce to have a deeper understanding of the EP data structure and processes. Using a quality improvement approach, we developed a feedback and learning model that is acceptable and useful to pharmacists and doctors. Further research should explore adapting the approach to other clinical areas. Reference 1. Sheikh, A., Dhingra-Kumar, N., Kelley, E., Kieny, M. and Donaldson, L. The Third Global Patient Safety Challenge: Tackling Medication-Related Harm. Bulletin of the World Health Organization. World Health Organisation. 2017;95:546-546A.

Hospital admissions to geriatric ward related to adverse drug events: a cross-sectional study from the Czech Republic.

Background Geriatric patients represent a vulnerable population in terms of adverse drug events (ADEs). Objective The aims of this study were to determine the prevalence and preventability of hospital admissions to a geriatric ward related to ADEs, to identify medications involved in these ADEs and to describe potential preventability aspects of ADE-related admissions. Setting University Hospital Hradec Králové, Czech Republic. Methods This cross-sectional study evaluated acute hospital admissions to the geriatric ward of University Hospital Hradec Králové over a period of nine months (April-December 2017). Medication reviews were performed in order to identify ADE-related hospital admissions. Causality was assessed using the World Health Organization-Uppsala Monitoring Centre criteria. Modified Schumock-Thornton algorithm was used to assess the preventability of ADEs. Main outcome measure 9-month-prevalence of ADE-related hospital admissions. Results A total of 366 hospital admissions were included. The 9-month-prevalence of ADE-related hospital admissions was 11.75% [95% confidence interval 8.45-15.05]. Antithrombotic agents and diuretics represented the most common medication classes associated with ADEs (30.2% each). Electrolyte disturbances and gastrointestinal haemorrhages and ulcerations were the most frequently observed ADEs associated with hospital admission. Out of 43 ADE-related hospitalisations, 23 (53.5%) were considered potentially preventable. Conclusion The contribution of ADEs to hospital admission to the geriatric ward was not negligible. Our results also suggest that 53.5% of identified ADE-related admissions could be potentially prevented. This finding demonstrates just how important the research on the preventability of medication-related hospitalisations is. Further studies and implementations are still needed aiming to minimize the risk of medication-related harm.

Clinical Utility of Pharmacogenomic Data Collected by a Health-System Biobank to Predict and Prevent Adverse Drug Events.

Medication-related harm represents a significant issue for patient safety and quality of care. One strategy to avoid preventable adverse drug events is to utilize patient-specific factors such as pharmacogenomics (PGx) to individualize therapy. We measured the number of patients enrolled in a health-system biobank with actionable PGx results who received relevant medications and assessed the incidence of adverse drug events (ADEs) that might have been prevented had the PGx results been used to inform prescribing. Patients with actionable PGx results in the following four genes with Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines were identified: HLA-A*31:01, HLA-B*15:02, TPMT, and VKORC1. The patients who received interacting medications (carbamazepine, oxcarbazepine, thiopurines, or warfarin) were identified, and electronic health records were reviewed to determine the incidence of potentially preventable ADEs. Of 36,424 patients with PGx results, 2327 (6.4%) were HLA-A*31:01 positive; 3543 (9.7%) were HLA-B*15:02 positive; 2893 (7.9%) were TPMT intermediate metabolizers; and 4249 (11.7%) were homozygous for the VKORC1 c.1639 G>A variant. Among patients positive for one of the HLA variants who received carbamazepine or oxcarbazepine (n=92), four (4.3%) experienced a rash that warranted drug discontinuation. Among the TPMT intermediate metabolizers who received a thiopurine (n=56), 11 (19.6%) experienced severe myelosuppression that warranted drug discontinuation. Among patients homozygous for the VKORC1 c.1639 G>A variant who received warfarin (n=379), 85 (22.4%) experienced active bleeding and/or international normalized ratio (INR) >5 that warranted drug discontinuation or dose reduction. Patients with actionable PGx results from a health-system biobank who received relevant medications experienced predictable ADEs. These ADEs may have been prevented if the patients' PGx results were available in the electronic health record with clinical decision support prior to prescribing.

Caregivers' experiences of medication management advice for people living with dementia at discharge.

Caregivers of people living with dementia play an essential role in managing medications across transitions of care. Adequate caregiver medication management guidance at hospital discharge is important to ensure optimal outcomes from medication use. This qualitative study explores the experiences and perspectives of caregivers about the medication management guidance provided at hospital discharge. A qualitative approach using semi-structured, telephone interviews was conducted with 31 caregivers of people with dementia across Australia. Purposive sampling was used to ensure maximum variation of diverse experiences and perspectives. Caregivers' experiences of medication guidance for people with dementia at discharge were described in three themes including: (a) inadequate information about medication management at discharge; (b) limited caregiver engagement in medication management decisions; and (c) difficulties ensuring medication supply post discharge. Most participants indicated they would like to be included in discussions at discharge. However, participation was influenced by caregivers being overwhelmed by discharge processes; proactively seeking information on medication-related harm; and belief in advocacy as part of their caregiver role. Caregivers reported they would like to receive a tailored medication list for people with dementia which included information on medications that may impact on the patient's cognition, and for hospital staff to communicate with both the community pharmacist and primary care physician, to improve co-ordination post transition. In our study of caregivers of people with dementia, we identified key recommendations to facilitate regular participation of people living with dementia and their caregiver around medication guidance at discharge.

The extent of polypharmacy and use of 'fall risk increasing drugs' in the oldest old admitted to a regional New South Wales hospital.

Polypharmacy is associated with significant morbidity including cognitive decline and falls. We sought to quantify the extent of polypharmacy and use of medications associated with fall risk in the very old admitted to a regional NSW hospital. Cross-sectional study of patients aged over 80years admitted to a regional NSW hospital from September to October 2019. Demographic data and medication usage on admission were collected. Polypharmacy was defined as regular use of five or more medications. A total of 401 patients were included: mean age was 87.2 (±4.6) years and 56.9% were female. Of the participations, 82.9% experienced polypharmacy, and the mean number of medications was 8.2 (±4.2). Of the patients, 91.6% utilised medications associated with risk of falls. There was no association between age and number of preadmission regular medications. Polypharmacy is extremely common prior to acute hospitalisation for regional older individuals. This highlights the importance of medication rationalisation to reduce medication-related harm.

Attitudes of ambulatory care older Nepalese patients towards deprescribing and predictors of their willingness to deprescribe.

Introduction:Older adults continue to receive potentially inappropriate medications necessitating the need for medication optimization, by deprescribing. To ensure a holistic approach to deprescribing, it is essential to understand the perception of older adults towards deprescribing. This study aimed to assess the attitude of older ambulatory patients towards deprescribing and to identify factors predicting their willingness to deprescribe.Methods:A cross-sectional survey was conducted in central Nepal between March and September 2019 among 385 older ambulatory care patients (aged ⩾65 years) who were taking at least one regular medicine. The perception of patients towards deprescribing was assessed using the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire via a face-to-face interview method. Descriptive statistics were performed to describe patients’ characteristics and their attitudes towards deprescribing. A multivariate logistic regression analysis was used to determine predictors of the willingness of older ambulatory patients towards deprescribing.Results:The median [interquartile range (IQR)] age of patients was 72 (8) years. Nearly three in five patients (64.9%) had hypertension, with 11.2% having polypharmacy. More than half of the patients (57.4%) would be willing to stop one or more of their regular medicines if their doctor said it was possible to do so. Regression analysis showed that age [odds ratio (OR) 0.946; 95% CI 0.913, 0.981; p = 0.003] and concerns about stopping medicine score (OR 0.541; 95% CI 0.334, 0.876; p = 0.013) were predictors of the willingness of the older patients towards deprescribing.Conclusion:One in two older ambulatory care patients in Nepal would be willing to have one or more of their medicines deprescribed. The factors predicting their willingness to deprescribe are their age and concerns about stopping medicines. Clinicians should consider discussing the possibility of deprescribing with older patients for the prevention of potential medication-related harms.Plain Language SummaryWhat do older Nepalese patients think about withdrawal or dose reduction of an inappropriate medication?Introduction: Research suggests that older adults (aged ⩾65 years) continue to receive medications that have the potential for harm rather than a benefit. This necessitates the need for withdrawal or dose reduction of such inappropriate medications, the process known as deprescribing. Understanding what older patients think about this process could be a stepping-stone to the general approach for its implementation. Data on deprescribing is lacking from Nepal. Therefore, we designed a survey to explore the attitude of older patients towards deprescribing and factors that could predict their willingness to deprescribe.Methods: This study was conducted between March to September 2019 among 385 older patients who were taking at least one regular medicine and were visiting selected hospitals of Nepal for outpatient services. We performed a face-to-face interview to assess the attitude of patients towards deprescribing using a validated tool called revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire that quantified the response through scoring. The data were subjected to statistical analysis to determine the attitudes of Nepalese older patients towards deprescribing and to develop a model to predict their willingness to deprescribe.Results: The average age of the participant was 72 years with 65% having hypertension and 11% using more than five medications. Our data suggested that one in two older Nepalese patients would be willing to stop one or more of their regular medications if their doctors said it was possible to do so. Their willingness to deprescribe could be predicted from their age and concerns about stopping medications.Conclusion: Clinicians should consider discussing the possibility of deprescribing with older patients for the prevention of potential medication-related harms.

Source of Purchased Medications and Its Impact on Medication Mistakes and Hospitalizations: The NHATS 2017

Older adults self-administer prescribed medication regimens to treat chronic diseases which can lead to mismanagement, medication related harm and hospitalizations. We examined the extent to which source of purchased medications influenced the occurrence of self-reported medication mistakes and hospitalizations in community-dwelling participants who managed medications independently (N= 3899). The majority (65%) picked-up medications, 18% had medications delivered, and 17% used both (picked-up and delivery). Compared to those picking up their medications, those using delivery only were less likely to have a hospital stay (OR=0.691 [95% CI 0.507-0.943]) and no difference in odds of medication mistakes (OR=1.051 [95% CI 0.764-1.445]), while those using both methods were more likely to report hospital stays (OR=1.429 [95% CI 1.106-1.846]) and medication mistakes (OR = 1.576[95% CI 1.078-2.304]). Older adults who picked-up medications from a local pharmacy and had medications delivered were more likely to report medication mistakes and hospitalizations.

Engaging Pharmacists in Interprofessional Programs to Support Older Residents of HUD-Assisted Housing

Medications are one of the pillar 4Ms of an age-friendly healthcare system. Ensuring that benefits of a medication regimen outweigh the risks and that medications are not contributing to meaningful outcomes such as functional or cognitive decline is a challenge for our healthcare system, particularly for older persons experiencing adverse social determinants of health, health disparities or uncoordinated care. More fully engaging pharmacists in the older person’s health care team is one strategy to improve clinical, humanistic and economic outcomes. This workshop reports findings on medication management capacity among older residents of five low-income apartment buildings in urban Richmond, VA, indicating that this population experiences challenges in managing medications as measured by MedMaIDE. The second presentation describes a pilot partnership between an independent community pharmacy and a local area agency on aging to provide medication coaching to residents of six affordable housing buildings in Seattle, WA, demonstrating feasibility of engaging pharmacists in the healthcare team and resulting in an average of five interventions per resident. The third presentation describes an interprofessional educational intervention based in two low-income apartment buildings for older persons in underserved West Baltimore, MD involving pharmacy students, to better prepare pharmacists to engage in interprofessional team care and meet the needs of a low income culturally diverse older adult population. Discussion will focus on barriers and opportunities to more fully engage pharmacists to support urban residents of low-income housing buildings to optimize medication outcomes and reduce medication-related harm.

Health in Men Study: is frailty a predictor of medication-related hospitalization?

Older adults are at high risk of medication-related hospitalizations. Frailty is a phenotype commonly observed in older people due to declining physiological functions. To examine the association of frailty with medication-related hospitalization among community dwelling older men. A prospective observational cohort study was conducted among community dwelling older men (mean age 75.6 years SD 5.9) from Western Australia (4324) who participated in the Health in Men Study. Participants were followed-up at 12 and 24 months to determine adverse drug event-related hospitalization, hospitalizations for other causes and mortality. The prevalence of frailty was 13.2%. At baseline, frailty was associated with exposure to polypharmacy, potentially inappropriate medication use and potential adverse drug-drug interactions with unadjusted odds ratios; [4.13 (3.48-4.89) P < 0.001], [2.46 (1.91-3.17) P < 0.001], [3.85 (3.03-4.90) P < 0.001], respectively. In unadjusted models, frail men were more likely to have non-accidental falls [OR 3.16 (2.51-3.99) P < 0.001], acute kidney injury [OR 3.37 (2.35-4.82) P < 0.001], ADE-related hospitalizations at 12 months [OR 6.83 (4.91-9.51)] and non-ADE-related hospitalizations [OR 2.63 (2.01-3.45)], or to be dead at 12 months [OR 2.97 (1.79-4.92)] and at 24 months [OR 3.14 (2.28-4.33)] when compared with non-frail men. After adjusting for age, living alone, cognitive decline, smoking status and comorbidity, frailty remained associated with ADE-related hospitalization [OR 3.60 (2.41-5.37)], non-ADE-related hospitalizations [OR 1.74 (1.29-2.36)] and death [OR 1.67 (1.15-2.41)]. The study suggests that frailty is a predictor of medication-related harm with poorer clinical outcomes including mortality.

Prevalent medication-related harm identified in patients admitted to a geriatric ward: cross-sectional and survival based contributors.

Medication‑related harm (MRH) has been recognized as a global public health issue. This study aimed to assess the prevalence and causes of MRH in geriatric patients. Another objective of the study was to recognize how MRH and drugs prescribed after geriatric interventions affect survival. It was a cross‑sectional study of 301 geriatric patients admitted to the hospital for any cause, combined with a 2‑year survival analysis. Altogether, 71 drug items were included. Medication‑related harm was defined based on clinical reasoning. Logistic regression models were applied to identify the explanatory variables for each type of MRH. The Cox proportional hazards model was used to determine the association of MRH and postdischarge medications with patient survival. Medication‑related harms were identified in 35.2% of the study patients. Those included, among others, hypotension (19.3%), hypoglycemia (13.3%), parkinsonism (4.3%), and benzodiazepine addiction (5.7%). Logistic regression, applied to estimate the impact of drugs before admission on MRH of any type, demonstrated an independent negative effect of typical neuroleptics, antidiabetic medication, benzodiazepines, and supplements, except vitamin D. After geriatric interventions, 4 drug classes showed a positive association with survival: thiazides (hazard ratio [HR], 0.45; 95% CI, 0.22-0.93), selective serotonin reuptake inhibitors (SSRIs; HR, 0.51; 95% CI, 0.34-0.75), paracetamol (HR, 0.54; 95% CI, 0.33-0.88), and angiotensin‑converting enzyme inhibitors (ACEIs; HR, 0.59; 95% CI, 0.4-0.89). Geriatric-based deprescribing and drug optimization mitigate the negative impacts of MRH on patient survival and may decrease the rehospitalization rate and healthcare costs. Thiazides, ACEIs, SSRIs, and paracetamol, if indicated, were associated with better survival in geriatric patients.

Characterizing Potential Medication Related Harm in the 30-Days Following Hospitalization Using Linked Provincial Administrative Health Data

IntroductionPatients transitioning between hospital and home are at risk of experiencing adverse drug events. Hospital-based care teams require a better understanding of how therapeutic decisions and patient risk factors impact adverse health outcomes following discharge.&#x0D; Objectives and ApproachThe objective was to describe medications prescribed at discharge and quantify the association between these medication classes and risk of emergency department (ED) visits within 30 days. A retrospective, population-based cohort study was conducted using linked health administrative databases of adults discharged from hospital to the community between April 2016-March 2017, in Ontario, Canada. To distinguish medications prescribed at discharge from those by community providers, we examined medications dispensed in the 30-days following hospitalization but prior to another healthcare encounter (physician visit, ED visit, or rehospitalization). Adjusted logistic regression was used to determine the association between medication classes at discharge and ED visits in 30 days post discharge.&#x0D; ResultsOur study cohort included 214, 011 patients. Median age was 76 (IQR:66-82), 52% were females, 92% were discharged home and 8% were discharged to long term care. Patients were dispensed a median of 3 medications (IQR: 2-6). The most common medications included hydromorphone (16% of all patients, 71% of which represented new use), pantoprazole (15% of patients, 40% new use), furosemide (13% of patients, 34% new use), amlodipine (10% of patients, 35% new use) and oxycodone (9% of patients, 70% new use). To account for confounding by indication, we adjusted for age, sex, discharge service, discharge disposition, in hospital diagnoses and length of stay. Medications which were most highly associated with an increased risk of ED visits included antipsychotics, antiepileptics, anti-infectives, systemic corticosteroids, antihypertensives and cardiac stimulants.&#x0D; Conclusion / ImplicationsCharacterizing potential medication related harm in the 30-days following hospitalization is an important first step in understanding which patients may benefit most from hospital-based medication related interventions.

Preventable medication harm across health care settings: a systematic review and meta-analysis

BackgroundMitigating or reducing the risk of medication harm is a global policy priority. But evidence reflecting preventable medication harm in medical care and the factors that derive this harm remain unknown. Therefore, we aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings.MethodsWe performed a systematic review and meta-analysis of observational studies to compare the prevalence of preventable medication harm. Searches were carried out in Medline, Cochrane library, CINAHL, Embase and PsycINFO from 2000 to 27 January 2020. Data extraction and critical appraisal was undertaken by two independent reviewers. Random-effects meta-analysis was employed followed by univariable and multivariable meta-regression. Heterogeneity was quantified using the I2 statistic, and publication bias was evaluated. PROSPERO: CRD42020164156.ResultsOf the 7780 articles, 81 studies involving 285,687 patients were included. The pooled prevalence for preventable medication harm was 3% (95% confidence interval (CI) 2 to 4%, I2 = 99%) and for overall medication harm was 9% (95% CI 7 to 11%, I2 = 99.5%) of all patient incidence records. The highest rates of preventable medication harm were seen in elderly patient care settings (11%, 95% 7 to 15%, n = 7), intensive care (7%, 4 to 12%, n = 6), highly specialised or surgical care (6%, 3 to 11%, n = 13) and emergency medicine (5%, 2 to 12%, n = 12). The proportion of mild preventable medication harm was 39% (28 to 51%, n = 20, I2 = 96.4%), moderate preventable harm 40% (31 to 49%, n = 22, I2 = 93.6%) and clinically severe or life-threatening preventable harm 26% (15 to 37%, n = 28, I2 = 97%). The source of the highest prevalence rates of preventable harm were at the prescribing (58%, 42 to 73%, n = 9, I2 = 94%) and monitoring (47%, 21 to 73%, n = 8, I2 = 99%) stages of medication use. Preventable harm was greatest in medicines affecting the ‘central nervous system’ and ‘cardiovascular system’.ConclusionsThis is the largest meta-analysis to assess preventable medication harm. We conclude that around one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Our results support the World Health Organisation’s push for the detection and mitigation of medication-related harm as being a top priority, whilst highlighting other key potential targets for remedial intervention that should be a priority focus for future research.

High-Risk Medication Use in Older Residents of Long-Term Care Facilities: Prevalence, Harms, and Strategies to Mitigate Risks and Enhance Use.

Older residents of long-term care facilities (LTCFs), also known as nursing homes, care homes, or residential aged care facilities, often have multiple health conditions and are exposed to polypharmacy. Use of high-risk medications such as opioids, glucose-lowering medications, antithrombotics, and antipsychotics is prevalent among residents of LTCFs. Ensuring appropriate use of high-risk medications is important to minimize the risk of medication-related harm in this vulnerable population. This paper provides an overview of the prevalence and factors associated with high-risk medication use among residents of LTCFs. Evidencebased strategies to optimize the use of high-risk medications and enhance resident outcomes are also discussed.

High-Risk Medication Use in Older Residents of Long-Term Care Facilities: Prevalence, Harms, and Strategies to Mitigate Risks and Enhance Use

Older residents of long-term care facilities (LTCFs), also known as nursing homes, care homes, or residential aged care facilities, often have multiple health conditions and are exposed to polypharmacy. Use of high-risk medications such as opioids, glucose-lowering medications, antithrombotics, and antipsychotics is prevalent among residents of LTCFs. Ensuring appropriate use of high-risk medications is important to minimize the risk of medication-related harm in this vulnerable population. This paper provides an overview of the prevalence and factors associated with high-risk medication use among residents of LTCFs. Evidencebased strategies to optimize the use of high-risk medications and enhance resident outcomes are also discussed.

Introduction of medication review and medication report in Swedish hospital and primary care, using a theory-based implementation strategy

BackgroundThe development of routines regarding medication is important to avoid medication-related harm. Medication review and medication reports have earlier been found to be effective, but their implementation is not always successful. The aim of this study was to evaluate the introduction of medication review/medication report in hospital and primary care, in terms of perceptions of the implementation strategy, adoption and sustainability, in one Swedish county.MethodsThe study included 105 clinics. Data was collected from interviews with managers immediately after implementation, survey data and registry data collected five years later. Quantitative data was analysed using non-parametric statistical tests. Open-ended questions were analysed with qualitative methods.ResultsThe implementation activities were found satisfying, and managers were satisfied with their own influence over the process. After five years medication review and medication reports were reported mainly implemented by the managers. Facilitating factors reported were routines, staff influence, dedication, reminders, and a stable workforce, while hindering factors reported were organizational factors, less commitment and flaws in reporting. Registry data showed that performance of medication review was very limited in primary care. In hospital care medication review was registered in about one fifth of the patients, while medication reports, only relevant for hospital care, was registered in half of the patients.ConclusionsThe managers’ perceptions of the implementation process were mainly positive, and they found the new practices of medication review/medication report implemented. Implementation success, however, was not supported by registry data, showing the need for reliable outcome measures for implementation.

P54 Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

AimsProblems with medication account for 10–20% of all adverse healthcare events in the NHS, costing between £200–400 million per year.1 Children are more likely to experience medication related harm.2 International reviews of the prevalence of drug-related problems are over ten years old.3 There is a need for a focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK to support the development and targeting of interventions to improve medication safety.4MethodsNine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to September 2018. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children, and quality appraisal of the studies was conducted.Results26 studies were included; none of which specifically reported on the prevalence of ADEs. Three ADR studies reported a median prevalence of 28.3% of patients (IQR 13); &gt;70% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors and the median prescribing error rate in all paediatric contexts was 10.7% of prescriptions (IQR 6) Seven studies explored prescribing errors in PICU and the prevalence was twice that in non-ICU areas (11.1% prescriptions; IQR 2.9 versus 6.5% prescriptions; IQR 4.3). The median rate of dose prescribing errors was 11.1% doses prescribed (IQR 10.6). Four studies reported administration errors of which three used consistent methods. Across these three studies, a median prevalence of 12.4% of administrations (IQR 7.3) was found. Administration technique errors represented 53% of these errors (IQR 14.7). Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 33% (IQR 13) of prescribed medication with 70.3% (IQR 14) classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors.ConclusionsChildren are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm, there is an urgent need for outcome-focussed research on preventable ADEs in paediatric hospital settings in the UK. A deeper understanding of medication processes for children in hospital from a systems and theoretical perspective will also support the development and tragetting of effective interventions to improve patient safety.ReferencesChief Medical Officer. An Organisation With a Memory. London; 2000.Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114–2120.Ghaleb MA, Barber N, Franklin BD, Yeung VWS, Khaki ZF, Wong ICK. Systematic review of medication errors in pediatric patients. Ann Pharmacother 2006;40:1766–1776.

The clinical and educational outcomes of an inter-professional student-led medication review team, a pilot study

AimsThe involvement of an inter-professional healthcare student team in the review of medications used by geriatric patients could not only provide patients with optimized therapy but also provide students with a valuable inter-professional learning experience. We describe and evaluate the clinical and learning outcomes of an inter-professional student-run mediation review program (ISP).Subject and methodA variable team consisting of students in medicine, pharmacy, master advanced nursing practice, and master physician assistant reviewed the medication lists of patients attending a specialized geriatric outpatient clinic.ResultsDuring 32 outpatient visits, 188 medications were reviewed. The students identified 14 medication-related problems, of which 4 were not recognized by healthcare professionals. The ISP team advised 95 medication changes, of which 68 (71.6%) were directly implemented. Students evaluated this pilot program positively and considered it educational (median score 4 out of 5) and thought it would contribute to their future inter-professional relationships.ConclusionAn inter-professional team of healthcare students is an innovative healthcare improvement for (academic) hospitals to increase medication safety. Most formulated advices were directly incorporated in daily practice and could prevent future medication-related harm. The ISP also offers students a first opportunity to work in an inter-professional manner and get insight into the perspectives and qualities of their future colleagues.

Medication Management in Frail Older People: Consensus Principles for Clinical Practice, Research, and Education

Frailty is a geriatric condition associated with increased vulnerability to adverse drug events and medication-related harm. Existing clinical practice guidelines rarely provide medication management recommendations specific to frail older people. This report presents international consensus principles, generated by the Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network, related to medication management in frail older people. This consensus comprises 7 principles for clinical practice, 6 principles for research, and 4 principles for education. Principles for clinical practice include (1) perform medication reconciliation and maintain an up-to-date medication list; (2) assess and plan based on individual's capacity to self-manage medications; (3) ensure appropriate prescribing and deprescribing; (4) simplify medication regimens when appropriate to reduce unnecessary burden; (5) be alert to the contribution of medications to geriatric syndromes; (6) regularly review medication regimens to align with changing goals of care; and (7) facilitate multidisciplinary communication among patients, caregivers, and healthcare teams. Principles for research include (1) include frail older people in randomized controlled trials; (2) consider frailty status as an effect modifier; (3) ensure collection and reporting of outcome measures important in frailty; (4) assess impact of frailty on pharmacokinetics and pharmacodynamics; (5) encourage frailty research in under-researched settings; and (6) utilize routinely collected linked health data. Principles for education include (1) provide undergraduate and postgraduate education on frailty; (2) minimize low-value care related to medication management; (3) improve health and medication literacy; and (4) incorporate evidence in relation to frailty into clinical practice guidelines. These principles for clinical practice, research and education highlight different considerations for optimizing medication management in frail older people. These principles can be used in conjunction with existing best practice guidelines to help achieve optimal health outcomes for this vulnerable population. Implementation of the principles will require multidisciplinary collaboration between healthcare professionals, researchers, educators, organizational leaders, and policymakers.

Interventions to ensure medication safety in acute care: an umbrella review.

Medication errors are one of the leading avoidable sources of harm to hospital patients. In hospitals, a range of interventions have been used to reduce the risk of errors at each of the points they may occur, such as prescription, dispensing and/or administration. Systematic reviews have been conducted on many of these interventions; however, it is difficult to compare the clinical utility of any of the separate interventions without the use of a rigorous umbrella review methodology. The aim of this umbrella review was to synthesize the evidence from all systematic reviews investigating the effectiveness of medication safety interventions, in comparison to any or no comparator, for preventing medication errors, medication-related harms and death in acute care patients. The review considered quantitative systematic reviews with participants who were healthcare workers involved in prescribing, dispensing or administering medications. These healthcare workers were registered nurses, enrolled or licensed vocational nurses, midwives, pharmacists or medical doctors. Interventions of interest were those designed to prevent medication error in acute care settings. Eligible systematic reviews reported medication errors, medication-related harms and medication-related death as measured by error rates, numbers of adverse events and numbers of medication-related deaths. To qualify for inclusion, systematic reviews needed to provide a clearly articulated and comprehensive search strategy, and evidence of critical appraisal of the included studies using a standardized tool. Systematic reviews published in English since 2007 were included until present (March 2020). We searched a range of databases such MEDLINE, CINAHL, Web of Science, EMBASE, and The Cochrane Library for potentially eligible reviews. Identified citations were screened by two reviewers working independently. Potentially eligible articles were retrieved and assessed against the inclusion criteria and those meeting the criteria were then critically appraised using the JBI SUMARI instrument for assessing the methodological quality of systematic reviews and research syntheses. A predetermined quality threshold was used to exclude studies based on their reported methods. Following critical appraisal, data were extracted from the included studies by two independent reviewers using the relevant instrument in JBI SUMARI. Extracted findings were synthesized narratively and presented in tables to illustrate the reported outcomes for each intervention. The strength of the evidence for each intervention was indicated using 'traffic light' colors: green for effective interventions, amber for interventions with no evidence of an effect and red for interventions less effective than the comparison. A total of 23 systematic reviews were included in this umbrella review. Most reviews did not report the number of participants in their included studies. Interventions targeted pharmacists, medical doctors, medical students and nurses, or were nonspecific about the participants. The majority of included reviews examined single interventions. All reviews were published and in English. Four interventions, medication administration education, medication reconciliation or review, specialist pharmacists' roles and physical or design modifications, reported effectiveness in reducing errors; however, heterogeneity between the included studies in these reviews was high. For some interventions, there are strong indications of effectiveness in reducing medication errors in the inpatient setting. Government initiatives, policy makers and practitioners interested in improving medication safety are encouraged to adopt those interventions.