Pharmacotherapy Process Research Articles

Medication use review as a service for pharmaceutical care: Conditions for implementation in pharmacy practice


 
 
 Pharmaceutical care is an aggregated pharmaceutical service based on an innovative approach towards the patient’s pharmacotherapy process. It was introduced into the Polish pharmaceutical law system in 2008, but it was not until the end of 2020 that the list of activities included in this innovative health service was clarified. The delayed initiation of pharmaceutical care means that implementation procedures are lacking, making it difficult to fully implement it into pharmacy practice. The initiating service for pharmaceutical care in pharmacy practice is the medication use review (MUR), which, combined with the pharmacotherapy assessment, has the task of detecting and solving patients’ drug-related problems and thus ensuring safety in the pharmacotherapy process. Such important objectives for medication use review face organisational barriers that make its effective implementation difficult and practically impossible, limiting the scope of pharmaceutical care to the consultative aspect in practice. The aim of the article is to present the implementation conditions of medication use reviews in Polish pharmacy practice, which helped to identify the conditions for effective implementation of pharmaceutical care. Achieving the research objectives requires the use of a variety of research methods. To identify the conditions for effective implementation of medication use reviews, the method of analysis of legal acts was used. Apart from that, the analysis of literature and the method of examination of documents were also implemented, which made it possible to determine whether the Polish pharmaceutical law system creates conditions for effective provision of this service in pharmacy practice. The method of observation (the mystery shopper) was also used to indicate the territorial (subjective scope) scope of the provision of medication use review and to identify barriers to their implementation in Polish organisational and legal realities. All the methods applied made it possible to determine to what extent pharmacist shortages in the pharmacy limit the implementation process. The results of the study were subjected to statistical analysis.
 
 

Is there a need for standardization of medication counseling in community pharmacies?

Medication counseling is one of the most important duties in community pharmacies aiming to ensure rational pharmacotherapy and medication safety. However, based on research evidence, the quality of medication counseling in pharmacies is often low and shown to vary between different patient groups. This Commentary raises a question whether there is a need to standardize medication counseling in community pharmacies to ensure quality of care for every customer?The law obligates to counsel about medications when dispensing medicines in many countries, however, on a very general level. It seems clear that the general level in which medication counseling is required in law is not enough to ensure the quality of medication counseling, and thus, some standards are needed. However, these standards should take into account the multidisciplinary nature of the pharmacotherapy process as well as the different patient groups and situations that patients face. Most importantly, such standards should not inhibit interaction between the patient and the pharmacist, and they should encourage tailored medication counseling that is based on the individual needs of the patient.

Reasons for medication administration errors, barriers to reporting them and the number of reported medication administration errors from the perspective of nurses: A cross-sectional survey

The aim of the study was to identify the reasons for medication administration errors, describe the barriers in their reporting and estimate the number of reported medication administration errors. BackgroundProviding quality and safe healthcare is a key priority for all health systems. Medication administration error belongs to the more common mistakes committed in nursing practice. Prevention of medication administration errors must therefore be an integral part of nursing education. DesignA descriptive and cross-sectional design was used for this study. MethodsSociological representative research was carried out using the standardized Medication Administration Error Survey. The research study involved 1205 nurses working in hospitals in the Czech Republic. Field surveys were carried out in September and October 2021. Descriptive statistics, Pearson’s and Chi-square automatic interaction detection were used to analyze the data. The STROBE guideline was used. ResultsAmong the most frequent causes of medication administration errors belong name (4.1 ± 1.4) and packaging similarity between different drugs (3.7 ± 1.4), the substitution of brand drugs by cheaper generics (3.6 ± 1.5), frequent interruptions during the preparation and administration of drugs (3.6 ± 1.5) and illegible medical records (3.5 ± 1.5). Not all medication administration errors are reported by nurses. The reasons for non-reporting of such errors include fear of being blamed for a decline in patient health (3.5 ± 1.5), fear of negative feelings from patients or family towards the nurse or legal liability (3.5 ± 1.6) and repressive responses by hospital management (3.3 ± 1.5). Most nurses (two-thirds) stated that less than 20 % of medication administration errors were reported. Older nurses reported statistically significantly fewer medication administration errors concerning non-intravenous drugs than younger nurses (p < 0.001). At the same time, nurses with more clinical experience (≥ 21 years) give significantly lower estimates of medication administration errors than nurses with less clinical practice (p < 0.001). ConclusionPatient safety training should take place at all levels of nursing education. The standardized Medication Administration Error survey is useful for clinical practice managers. It allows for the identification of medication administration error causes and offers preventive and corrective measures that can be implemented. Measures to reduce medication administration errors include developing a non-punitive adverse event reporting system, introducing electronic prescriptions of medicines, involving clinical pharmacists in the pharmacotherapy process and providing nurses with regular comprehensive training.

Evaluation of medication errors in the hospital environment.

Healthcare is inherently associated with a risk to patient health. One risk is associated with medication-related errors, which are commonly reported adverse events. By analyzing the root causes of medication errors, effective preventive measures can be proposed to reduce their likelihood. This study aimed to identify the reasons of medication administration errors, determine the number of medication administration errors reported, and describe the barriers hindering reporting. The study used a standardized Questionnaire Medication Administration Error Survey (MAE survey) that was quantitatively analyzed. The study involved 112 nurses from four hospitals in the South Bohemian Region. Risk factors that increase the likelihood of medication administration errors include similarity of drug names (3.7 ± 1.3) and packaging (3.9 ± 1.5), frequent prescription changes for patients (3.2 ± 1.5), illegibility of written prescriptions (3.1 ± 1.6), a lack of clarity of medical records (2.6 ± 1.5). Only a proportion of medication administration errors are reported by nurses (16% to 21%). The reluctance of nurses to report medication administration errors is linked to fear of being blamed for the deterioration of the patients health (3.3 ± 1.7), fear of the doctors reaction to a medication administration error (2.6 ± 1.4), and repressive responses from hospital management to reported misconduct (2.9 ± 1.5). Measures to reduce the likelihood of medication administration errors include building a non-punitive system for reporting adverse events and medication errors, introducing electronic prescription systems, promoting open communication within the team, involving clinical pharmacists in the pharmacotherapy process, and regular comprehensive training of nursing staff.

Nutritional knowledge of patients diagnosed with endocrinopathies

Background: Thyroid diseases including Hashimoto's chronic lymphocytic thyroiditis represent an increasing epidemiological problem of the 21st century. Thyroid disease is estimated to affect approximately 7.0-9.0 per cent of the population up to the age of 60 years, and as much as 10.0-12.0 per cent after the age of 60 years. Hashimoto's disease is much more common among women of childbearing age, but it is also increasingly common among children and adolescents. The number of reported cases of autoimmune thyroiditis is steadily increasing. The aim of this study was to assess the nutritional knowledge of female patients with Hashimoto's disease in selected closed online support groups for patients with thyroid disease.Materials and methods: A self-administered online survey questionnaire was used to conduct the study.Results: 321 women were enrolled in the study. The largest group of respondents, aged between 20 and 40 years, lived in cities with more than 100 000 inhabitants and had a university education. Hypothyroidism along with Hashimoto's disease was declared by the largest number of respondents. The respondents' main source of nutritional knowledge was the media; the level of knowledge was assessed as insufficient.Conclusions: There is a need to increase nutritional education among patients in order to reduce the incidence of disease complications, the development of other comorbidities and will allow for health-promoting effects during the pharmacotherapy process.

Patient Safety in the Process of Pharmacotherapy Carried Out by Nurses-A Polish-Slovak Prospective Observational Study.

Pharmacotherapy, i.e., the use of medicines for combating a disease or its symptoms, is one of the crucial elements of patient care. Nursing workloads in the pharmacotherapy process prove that nurses spend 40% of their work on the management of medications. This study was aimed at the determination and comparison of safety levels at the nurse-managed stage of the pharmacotherapy process in Poland and Slovakia by identifying the key risk factors which directly affect patient safety. The study involved a group of 1774 nurses, of whom 1412 were from Poland and 362 were from Slovakia. The original Nursing Risk in Pharmacotherapy (acronym: NURIPH) tool was used. The survey questionnaire was made available online and distributed to nurses. The Cronbach’s alpha coefficient was 0.832. Nurses from Slovakia most often, i.e., for six out of nine factors (items: one, five, six, seven, eight, and nine), assessed the risk factors as “significant risk (3)”, and Polish nurses most often, i.e., for as many as eight out of nine risk factors (items: one, two, three, four, five, six, seven, and nine), assessed the risk factors as “very significant (5)”. It has been found that the safety of the pharmacotherapy process is assessed by Polish nurses to be much lower than by Slovak nurses.

Safety Assessment of the Pharmacotherapy Process at the Nurse and Midwife Level - An Observational Study.

PurposePharmacological errors are among the most common in the healthcare system. This study aimed to determine the level of safety of the pharmacotherapy process at the stage performed by nurses and midwives by indicating the key risk factors affecting patients’ safety.MethodsA group of 1276 nurses and 136 midwives in Poland participated in the study. The survey was conducted in the period from May 2019 to August 2019. The original Nursing Risk in Pharmacotherapy (NURIPH) tool was used.ResultsThe Cronbach alpha coefficient was 0.832. The low legibility of the medical orders (item 1) was indicated as the highest risk. A mean of 4.50 means that this factor’s significance is assessed between “very significant” and “significant.” The communication between physician, nurse and midwife, time pressure, and work organization were also rated high (Items 2, 3, and 4). The averages for these factors are higher than 4, so their evaluation is more than “significant.”.ConclusionNurses and midwives involved in the pharmacotherapy process are exposed to many ergonomic factors triggering risk. A huge problem is the lack of readability of medical orders, which may be a factor triggering a medical error.

Features of pharmacists professional roles realization in the Ukrainian realities

The rapid development of pharmacy in Ukraine needs rethinking and re-targeting of the professional roles (PR) of a pharmacist in society and the healthcare system, as he/she is not only manufactures and markets drugs, but is an equal participant in the pharmacotherapy process, a provider of pharmaceutical services and pharmaceutical information.Aim. To make an analysis of pharmacist PR implementation in domestic pharmaceutical practice.Materials and methods. The materials of the study were the provisions of the World Health Organization (the WHO), the International Pharmaceutical Federation (the FIP) and scientific works on the PR of pharmacist, an analysis of job descriptions on the websites work.ua and robota.ua among pharmacy networks (PhN). The methods of critical analysis, concretization and scientific generalization were used.Results. Analysis of scientific works, the WHO and the the FIP provisions regarding PR pharmacist, as well as the descriptions of pharmaceutical vacancies of 10 large PhN of Ukraine on the websites work.ua and robota.ua. Conclusions. Based on the study of the job description of 10 large PhN and a critical analysis of the literature data, it was found that nowadays PR of the domestic pharmacist are reduced to the role of a seller of drugs. It is necessary to fill the PR with Ukrainian pharmacists with the content that is characteristic of the world pharmaceutical community: to create such a training system that would allow the pharmacist successfully fulfill the roles required by their profession in the current context in the WHO and the FIP provisions; to develop new and improve the current national regulatory documents on pharmacist PR with the involvement of pharmacists and pharmaceutical self-regulatory organizations; to work out by the pharmaceutical self-regulatory organizations the medialinguistic technologies for formation of the positive image of pharmacist, that will help to restore the image of the pharmaceutical profession and in the long run will solve one of the most important problems of our time – the problem of trust in the pharmacy and pharmacists and, as a consequence will have a positive impact on the health of the population.

Medication safety risks to be managed in national implementation of automatic substitution of biological medicines: a qualitative study

ObjectivesTo explore relevant Finnish stakeholders’ perceptions on the automatic substitution of biological medicines with particular focus on medication safety and issues that need to be considered to create an appropriate...

As the twig is bent, so is the tree inclined: a survey of student attitudes toward interprofessional collaboration supported with the curricula analysis

ABSTRACTPharmaceutical care was legally introduced as an interprofessional service in Poland in 2009. However, a collaboration between physicians and pharmacists remains incidental. Proper education at the undergraduate level is necessary to shape the attitudes of students toward establishing interprofessional relations. The aim of the study was to assess the perception of physician-pharmacist collaboration among final-year medical and pharmacy students through questionnaires with both closed-ended and open-ended questions. The study also includes an analysis of medicine and pharmacy curricula in terms of promoting interprofessional collaboration between the two fields. The statistical analysis of data obtained from 502 respondents revealed significant differences between the perceived areas for such collaboration. Moreover, the division of roles and responsibilities during the pharmacotherapy process between both professions seems to be unclear. Importantly, only 10.14% of the respondents evaluated these professional relations as ‘good’ or ‘very good’. Also, 66.87% of the students emphasized the importance of educational interventions to improve interprofessional collaboration between pharmacists and physicians. Although 70% of medical and 87% of pharmacy students wish to establish such collaboration in the future, only 15% and 35%, respectively feel adequately prepared for the task. Understanding similarities and differences in this field appears to be the key to designing effective educational solutions for promoting interprofessional attitudes among healthcare undergraduates.

Neonatal Abstinence Syndrome: Update on Diagnostic and Therapeutic Strategies.

Substance use among pregnant women is a major public health issue. Both prescription opioid use and illicit opioid abuse have increased dramatically in recent years. Prolonged in utero drug exposure may result in neonatal abstinence syndrome (NAS), an acute multisystemic clinical entity that occurs in the first days of life. This syndrome is caused by abrupt discontinuation of fetal exposure to licit or illicit drugs chronically consumed by the mother during pregnancy and transmitted to the fetus through the placenta. It usually requires prolonged hospitalization and may have long-term effects. The interplay of many factors contributes to its clinical heterogeneity, and its pathophysiology has not been fully unveiled. The first step in NAS management consists of nonpharmacologic interventions and includes promoting breastfeeding when not contraindicated. If withdrawal signs become severe, pharmacotherapy is needed. The Finnegan scoring system supports care providers across the pharmacotherapy process from initiation through the monitoring phase, until weaning and discontinuation. However, a standardized approach to pharmacotherapy is still lacking. Morphine is usually the first-line agent to treat NAS. Methadone is a valid option, but its safety profile is not completely known. Phenobarbital, despite its lack of effect on gastrointestinal symptoms and unfavorable pharmacologic features, has been identified as a second-line agent to be used in infants unresponsive to opiates. Although buprenorphine and clonidine seem promising, their use requires further validation. Long-term developmental effects of NAS therapy call for more-comprehensive, longitudinal assessments. In this article, key points for use of recommended therapies are outlined, and directions for future research are suggested.

Diş Hekimliğinde Akılcı Farmakoterapi Düzenleme Süreci

Unnecessary or improper use of medications is a common worldwide problem. Inadequate approach of doctors to the rational use of medicine (RUM) principles and lack of its educational process are main reasons of this problem. RUM defined as “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community”. Dentists prescribe serious amount of medication, which is mostly analgesics and antibiotics. Therefore, informing dentists and dissemination of RUM among them is an urgent issue. This article points out, “how to manage overall treatment process based on RUM principles next by a patient on the dental practice”. In additionally, that is carried out by a simulation case requiring an analgesic drug treatment. Therefore, suitability of the drug with the patient, which is going to be prescribed after dental procedure with the correct diagnosis, will be assessed. Illness, treatment aim, participants and adaptation with the life style are explained to the patients. Dentist makes instructions and recommendations clearly about the pharmacotherapy process and informs the patient. Therefore, they integrate the patient to the overall treatment process and manage it.

Preventing medication errors in neonatology: Is it a dream?

Since 1999, the problem of patient safety has drawn particular attention, becoming a priority in health care. A "medication error" (ME) is any preventable event occurring at any phase of the pharmacotherapy process (ordering, transcribing, dispensing, administering, and monitoring) that leads to, or can lead to, harm to the patient. Hence, MEs can involve every professional of the clinical team. MEs range from those with severe consequences to those with little or no impact on the patient. Although a high ME rate has been found in neonatal wards, newborn safety issues have not been adequately studied until now. Healthcare professionals working in neonatal wards are particularly susceptible to committing MEs due to the peculiarities of newborn patients and of the neonatal intensive care unit (NICU) environment. Current neonatal prevention strategies for MEs have been borrowed from adult wards, but many factors such as high costs and organizational barriers have hindered their diffusion. In general, two types of strategies have been proposed: the first strategy consists of identifying human factors that result in errors and redesigning the work in the NICU in order to minimize them; the second one suggests to design and implement effective systems for preventing errors or intercepting them before reaching the patient. In the future, prevention strategies for MEs need to be improved and tailored to the special neonatal population and the NICU environment and, at the same time, every effort will have to be made to support their clinical application.

Mejora del proceso farmacoterapéutico del paciente hospitalizado mediante la metodología Lean Seis Sigma

Lean Six Sigma methodology has been used to improve care processes, eliminate waste, reduce costs, and increase patient satisfaction. To analyse the results obtained with Lean Six Sigma methodology in the diagnosis and improvement of the inpatient pharmacotherapy process during structural and organisational changes in a tertiary hospital. 1.000 beds tertiary hospital. prospective observational study. The define, measure, analyse, improve and control (DMAIC), were deployed from March to September 2011. An Initial Project Charter was updated as results were obtained. 131 patients with treatments prescribed within 24h after admission and with 4 drugs. safety indicators (medication errors), and efficiency indicators (complaints and time delays). Proportion of patients with a medication error was reduced from 61.0% (25/41 patients) to 55.7% (39/70 patients) in four months. Percentage of errors (regarding the opportunities for error) decreased in the different phases of the process: Prescription: from 5.1% (19/372 opportunities) to 3.3% (19/572 opportunities); Preparation: from 2.7% (14/525 opportunities) to 1.3% (11/847 opportunities); and administration: from 4.9% (16/329 opportunities) to 3.0% (13/433 opportunities). Nursing complaints decreased from 10.0% (2119/21038 patients) to 5.7% (1779/31097 patients). The estimated economic impact was 76,800 euros saved. An improvement in the pharmacotherapeutic process and a positive economic impact was observed, as well as enhancing patient safety and efficiency of the organization. Standardisation and professional training are future Lean Six Sigma candidate projects.

Analysis of medication errors in a private hospital: pharmacist interventions

BackgroundThe medication errors (ME) represent the largest single cause of errors in the hospital setting, and some of them result in serious patient morbidity/mortality. A knowledge of ME in every...

Consideration of patient preferences and challenges in storage and access of pharmacogenetic test results

PurposePharmacogenetic testing is one of the primary drivers of personalized medicine. The use of pharmacogenetic testing may provide a lifetime of benefits through tailoring drug dosing and selection of multiple medications to improve therapeutic outcomes and reduce adverse responses. We aimed to assess public interest and concerns regarding sharing and storage of pharmacogenetic test results that would facilitate the reuse of pharmacogenetic data across a lifetime of care. MethodsWe conducted a random-digit-dial phone survey of a sample of the US public. ResultsWe achieved an overall response rate of 42% (n = 1139). Most respondents indicated that they were extremely or somewhat comfortable allowing their pharmacogenetic test results to be shared with other doctors involved in their care management (90% ± 2.18%); significantly fewer respondents (74% ± 3.27%) indicated that they were extremely or somewhat comfortable sharing results with their pharmacist (P < 0.0001). ConclusionPatients, pharmacists, and physicians will all be critical players in the pharmacotherapy process. Patients are supportive of sharing pharmacogenetic test results with physicians and pharmacists and personally maintaining their test results. However, further study is needed to understand which options are needed for sharing, appropriate storage, and patient education about the relevance of pharmacogenetic test results to promote consideration of this information by other prescribing practitioners.

Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy

To analyze medication errors (MEs) in a multidisciplinary system with a Computerized Pharmacotherapy Process (CPP) in cancer patients. A longitudinal, prospective 2-year (January 2003 -to December 2004) cohort study was made in adult patients administered antineoplastic treatment in Services of Oncology and Haematology. MEs were identified by double cross-validation of each stage of the pharmacotherapeutic process (prescription, preparation, dispensing, administration, and follow-up) carried out by the multidisciplinary team (physician, pharmacist, nurse) with CPP assistance. Number of MEs per 1000 patient-days, percentage according to the stage of the pharmacotherapeutic process and the severity of intercepted ME (scored from 1 = no damage to the patient, to 5 = patient death). A total of 1311 patients were receiving treatment, and MEs were identified in 225. Out of a total of 13,158 patient-days, 276 MEs were detected, equivalent to 20.9 MEs per 1000 patient-days; of these, 16.8 MEs per 1000 patient-days (80%) were intercepted and did not affect any patient. The detected ME distribution according to pharmacotherapeutic stage was: prescription 75.7%, preparation 21.0%, dispensing 1.8%, administration 1.1%, and follow-up 0.4%. ME distribution according to severity was: grade 1 : 15.9%, grade 2 : 49.6%, grade 3 : 33.7%, grade 4 : 0.7%, and grade 5 : 0%. The system intercepted 98.9% of all MEs with severity >or=3 (MEs with a potential for causing patient damage). The multidisciplinary system with a well-established CPP detects 20.9 MEs per 1000 patient-days and intercepts 98.8% of all MEs with a potential for causing patient damage.

Rational Pharmacotherapy and Pharmacovigilance

Pharmacovigilance is defined as "the detection, evaluation, understanding and prevention of adverse drug reactions (ADRs)". The ultimate aim of pharmacovigilance is the optimization of the risk-benefit ratio of marketed drugs at the individual level (i.e. the choice of the most suitable treatment for a given patient) and at the population level (i.e. maintenance or removal of a drug from the market, informing prescribers of its potential risks, etc.). Prevalence of drug-related morbidity and mortality increase in correlation with the increase in drug use. Both physicians and patients prefer polypharmacy because of different reasons such as insufficient knowledge, lack of enough time for the patients, being misled by non-scientific newspaper/TV news, etc. Polypharmacy is among the major causes of drug-related morbidity and requires additional medication as treatment. On the other hand, adverse reactions might be minimized by adequate knowledge and rational prescribing, simply by reducing inappropriate polypharmacy. Therefore, physicians' prescribing habits based on rational pharmacotherapy processes which include choosing suitable drug(s), at an optimum dose and duration of use, among the effective and safe treatment alternatives, and informing patients about the diagnosis and treatment, can be a major contribution to optimize the risk-benefit ratio of drugs. As an essential step in the rational pharmacotherapy process, giving adequate information to the patients about their treatment (i.e. dosage, use instructions, warnings, effects, side effects, etc.) may prevent some of the drug-related problems. In addition, informed patients are more likely to seek advice from their physicians to seek advice for ADRs. In this review article, therefore, the influence of rational pharmacotherapy training on the pharmacovigilance of drugs will be discussed.

Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy

6136 Background: The aim of this study is to quantify medication errors (ME) in a multidisciplinary system with a Computerized Pharmacotherapy Process (CPP) in cancer patients. Methods: Longitudinal, prospective, and cohorts study during 2 years (January, 2003-December, 2004) in adult patients who received antineoplastic treatment in Oncology and Haematology services. ME were identified by double cross-validation of every stage of the pharmacotherapy process (prescription, preparation, dispensation, administration and follow-up) carried out by the multidisciplinary team (physician, pharmacist, nurse) with CPP assistance. Variables: number of ME for 1000 patients-day, % according to the stage of the process and severity (scale to 1 -not damage in the patient- to 5 -irreversible damage-) of ME intercepted. Results: 638 patients were on treatment and ME were identified in 225 (35%). On a total of 18,785 preparations and 13,206 patients-day, 276 ME were detected, equivalent to 20.9 ME by 1000 patients-day (95%CI: 18.5–23.5); of these 16.8 ME for 1000 patients-day (80.1%) were intercepted and did not reach a patient (95%CI: 14.6–19.1). ME detected distribution according to the stage were: prescription 75.7% (95%CI: 70.2–80.7), preparation 21.0% (95%CI: 16.4–26.3), dispensation 1.8% (95%CI: 0.6–4.2), administration 1.1% (95%CI: 0.2–3.1), and follow-up 0.4% (95%CI: 0.01–2.0). ME distribution according to the severity were: grade 1: 15.9% (95%CI: 11.8–20.8), grade 2: 49.6% (95%CI: 43.6–55.7), grade 3: 33.7% (95%CI: 28.1–39.6), grade 4: 0.7% (95%CI: 0.1–1.6) and none of grade 5. The system intercepted 98.9% (95%CI: 94.3–99.9) of ME with severity equal or greater than 3 -ME with potential to damage the patient- and 70.2% (95%CI: 62.9–76.7) of severity equal or minor to 2, ME without clinical significance. Conclusions: The multidisciplinary system with well-established CPP detects 20.9 ME for 1,000 patients-day and intercepts 98.8% of ME with potential to damage the oncology patient. No significant financial relationships to disclose.