Preventable Drug-related Morbidity Research Articles

Intersecting care through specialized pharmacists: A case report of residency rotation focused on the new horizon of cardio-oncology

Background and purposeCardio-oncology is a nascent discipline in the synergy of clinical cardiology and oncology, aiming to improve antineoplastic therapies, whilst minimizing cardiovascular toxicities. It requires a multidisciplinary approach with particular knowledge to build individualized care for patients. As part of multidisciplinary teams, pharmacists are uniquely positioned to play a role in the management of these patients, being responsible for monitoring adverse reactions and having an active approach in preventing drug-related morbidity. However, despite the existence of oncology and cardiology residency pharmacy programs, and the burden of cancer and cardiovascular diseases, there is a lack of data regarding pharmacists training focusing on cardio-oncology. Educational activity and settingA 15-days rotation was built to develop knowledge and clinical skills on pharmacological cardiovascular management of patients in a hemato-oncology residency program. The hospital where the rotation was offered is a 900-bed university hospital in Porto Alegre, south of Brazil. The rotation was designed for a postgraduate year 2 (PGY2) onco-hematology pharmacy resident and mentored by two staff clinical pharmacists from the cardiology field. The rotation schedule was distributed to reach three different approaches of learning: theoretical, practical-theoretical and practical. Activities were proposed aiming to provide experiences in cardiac care for the PGY2 resident, and clinical activities with patients were developed in both inpatient and outpatient settings. After the end of the 15 days rotation period, an evaluation was carried out by the PGY2 resident together with the staff menthors. FindingsThis is the first cardio-oncology pharmacist rotation described in our country. The rotation was considered positive by residents evaluation on providing a clinical experience through cardiotoxicity management of oncology protocols. SummaryCollaborations between cardiology and oncology clinical pharmacy teams, and the multidisciplinary teams as well, can help provide structured cardio-oncology rotation opportunities for pharmacy residents.being the team's specialist on antineoplastic agents monitoring and preventable drug related morbidity, the pharmacist can contribute to achieve better outcomes to patients with cancer.

Preventable drug-related morbidity in community pharmacy: commentary on the implications for practice and policy of a novel intervention

This commentary relates to a paper on the development and piloting of a risk management intervention in Portuguese community pharmacy, based on validated preventable drug-related morbidity indicators. In the paper we presented the research programme and implications for future evaluation. However, we believe that the intervention may be seen as important for patient safety without further evaluation. Therefore in this commentary we discuss considerations for service roll-out, by revisiting some issues already presented and by introducing aspects such as service definition and remuneration. We argue that in the absence of service remuneration, redesign of care processes through IT support and inter-professional collaboration, and coaching to encourage the aforementioned efforts it is unlikely that the proposed risk management intervention will succeed in preventing drug-related morbidity.

Modelling drug-related morbidity in Sweden using an expert panel of pharmacists’

Drug-related morbidity (DRM) is common and to some extent preventable, and associated with considerable costs in patients attending hospital. In outpatients and in the general public corresponding data are limited, but pharmacists' expert opinion has suggested high rates of DRM also in US ambulatory care. It is unknown if the results are applicable in Sweden today. To estimate the proportions of patients with DRM and preventable DRM and the cost-of-illness (COI) of DRM in Sweden based on pharmacists' expert opinion. Swedish healthcare. The study applied a conceptual model of DRM based on a decision tree. An expert panel of pharmacists determined the probabilities of therapeutic outcomes of medication therapy. The COI analysis included direct costs from the healthcare perspective. Sensitivity analyses were performed for variations in probabilities and pathway costs. DRM included new medical problems (adverse drug reactions, drug dependence and intoxications) and therapeutic failures (insufficient effects of medicines and morbidity due to untreated indication). The expert panel estimated that 61 ± 14 % (mean ± SD) of all patients attending healthcare suffered from DRM, of which 29 ± 8 % suffered from new medical problems, 18 ± 6 % from therapeutic failures, and 15 ± 7 % from a combination of both. The DRM was considered preventable in 45 ± 15 % of the patients with DRM. The estimated COI was EUR 997 per patient attending healthcare, corresponding to an annual cost of EUR 6,600 million to the Swedish healthcare system. The COI ranged from EUR 490 to EUR 1,314 when varying the participants' probabilities of DRM and clinical outcomes from the first to the third quartile. Of the pathway costs, the COI was most sensitive to variation in the cost of prolonged hospital stay (COI range EUR 953-1,306). According to pharmacists' expert opinion, a large proportion of patients in Sweden experience DRM and preventable DRM, and the estimated COI of DRM is extensive. Since observational studies have not addressed the burden of DRM to the general public, this study adds the pharmacists' perception on DRM. Other healthcare professionals' perceptions on DRM need to be investigated in future studies.

High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved?

The safety of medication use in primary care is an area of increasing concern for health systems internationally. Systematic reviews estimate that 3-4% of all unplanned hospital admissions are due to preventable drug-related morbidity, the majority of which have been attributed to shortcomings in the prescribing and monitoring stages of the medication use process. We define high-risk prescribing as medication prescription by professionals, for which there is evidence of significant risk of harm to patients, and which should therefore either be avoided or (if avoidance is not possible) closely monitored and regularly reviewed for continued appropriateness. Although prevalence estimates vary depending on the instrument used, cross-sectional studies conducted in primary care equivocally show that it is common and there is evidence that it can be reduced. Quality improvement strategies, such as clinical decision support, performance feedback and pharmacist-led interventions have been shown to be effective in reducing prescribing outcomes but evidence of improved patient outcomes remains limited. The increasing implementation of electronic medical records in primary care offer new opportunities to combine different strategies to improve medication safety in primary care and to integrate services provided by different stakeholders. In this review article, we describe the spectrum of high-risk medication use in primary care, review approaches to its measurement and summarize research into its prevalence. Based on previously developed interventions to change professional practice, we propose a systematic approach to improve the safety of medication use in primary care and highlight areas for future research.

Preventable drug-related morbidity in community pharmacy: development and piloting of a complex intervention

Preventable drug-related morbidity (PDRM) arising in the community is a problem of unacceptable magnitude. Effective interventions to reduce this problem will avoid unnecessary patient harm and waste of resources for the health care system. To develop and pilot an intervention to manage the risk of PDRM in community pharmacy, underpinned by validated PDRM indicators. Setting Portuguese community pharmacy. Our work was informed by the Medical Research Council framework for the development and evaluation of complex interventions. Human error theory was considered as a theoretical framework for developing the intervention. Additionally, this stage consisted of a literature review, followed by two focus groups (17 community pharmacists) and interviews with 8 professional leaders. A 4-component intervention, was developed: (1) operationalisation of 4 validated PDRM indicators in dispensing encounters ('dispensing' indicators), and operationalisation of 25 validated indicators in patients enrolled in pharmaceutical care programmes ('follow-up' indicators), (2) pharmacist resource pack, (3) pharmacists' training and (4) support scheme. Piloting consisted of a feasibility study in 15 community pharmacies and an acceptability study with participating pharmacists (n = 16). Main outcome measures Proportion of cases with counselling (dispensing indicators); proportion of cases assessable, proportion of cases at risk and proportion of cases with risk minimisation actions (follow-up indicators). Operationalization of dispensing indicators resulted in counselling in 44.1 % of cases (n = 666). Factors influencing acceptability included pharmacists' perceptions of patients' characteristics, interest and informational needs, as well as perceptions on the relevance of safety information. For follow-up indicators, data were available to assess most cases (93/105, 88.6 %). About half of the assessable cases were at risk of a PDRM event (n = 49; 51.6 %); pharmacists undertook risk minimization actions in 23 cases (46.9 %). Lack of time and inter-professional issues emerged as important factors influencing acceptability. A novel risk management intervention was developed. Feasibility and acceptability of the 4-component intervention in Portuguese community pharmacy provided 'proof of concept', whilst highlighting aspects that need further refinement to better measure and maximise efficacy in future evaluative research.

Modelling drug-related morbidity in Sweden using an expert panel of physicians

In modelling studies using pharmacists' opinions, drug-related morbidity (DRM) and preventable DRM have been more common than in observational studies, and the resulting costs are extensive. Modelling studies' estimates may vary depending on informants' profession. The purpose of this modelling study was to estimate the proportion of patients with DRM and preventable DRM and the cost of illness (COI) of DRM in Sweden based on physicians' expert opinions. A conceptual model of DRM was modified from previous studies. Using a modified Delphi technique, a panel of physicians (n = 19) estimated the probabilities of DRM, preventable DRM, and clinical outcomes of DRM separately for outpatients and inpatients. DRM included new medical problems (adverse drug reactions, drug dependence, and intoxications by overdose) and therapeutic failure (insufficient effects of medicines, and morbidity due to untreated indication). A COI analysis included the direct costs of DRM. Physicians estimated that 51 ± 22% [mean ± standard deviation (SD)] of outpatients experience DRM and 12 ± 8% preventable DRM. Of inpatients, 54 ± 17% was estimated to experience DRM and 16 ± 7% preventable DRM. Of outpatients with DRM, 24 ± 11% was estimated to experience preventable DRM, whereas this proportion for inpatients was 31 ± 15%. The estimated COI was 376 euros per outpatient and 838 euros per inpatient. Swedish physicians estimated that every other outpatient and inpatient experiences DRM, which is often preventable and costly. As physicians' estimates on the proportion of patients with DRM were higher than in observational studies in restricted subpopulations, DRM may be more common in the general population than observational studies suggest.

Quality and safety of medication use in primary care: consensus validation of a new set of explicit medication assessment criteria and prioritisation of topics for improvement

BackgroundAddressing the problem of preventable drug related morbidity (PDRM) in primary care is a challenge for health care systems internationally. The increasing implementation of clinical information systems in the UK and internationally provide new opportunities to systematically identify patients at risk of PDRM for targeted medication review. The objectives of this study were (1) to develop a set of explicit medication assessment criteria to identify patients with sub-optimally effective or high-risk medication use from electronic medical records and (2) to identify medication use topics that are perceived by UK primary care clinicians to be priorities for quality and safety improvement initiatives.MethodsFor objective (1), a 2-round consensus process based on the RAND/UCLA Appropriateness Method (RAM) was conducted, in which candidate criteria were identified from the literature and scored by a panel of 10 experts for 'appropriateness' and 'necessity'. A set of final criteria was generated from candidates accepted at each level. For objective (2), thematically related final criteria were clustered into 'topics', from which a panel of 26 UK primary care clinicians identified priorities for quality improvement in a 2-round Delphi exercise.Results(1) The RAM process yielded a final set of 176 medication assessment criteria organised under the domains 'quality' and 'safety', each classified as targeting 'appropriate/necessary to do' (quality) or 'inappropriate/necessary to avoid' (safety) medication use. Fifty-two final 'quality' assessment criteria target patients with unmet indications, sub-optimal selection or intensity of beneficial drug treatments. A total of 124 'safety' assessment criteria target patients with unmet needs for risk-mitigating agents, high-risk drug selection, excessive dose or duration, inconsistent monitoring or dosing instructions. (2) The UK Delphi panel identified 11 (23%) of 47 scored topics as 'high priority' for quality improvement initiatives in primary care.ConclusionsThe developed criteria set complements existing medication assessment instruments in that it is not limited to the elderly, can be implemented in electronic data sets and focuses on drug groups and conditions implicated in common and/or severe PDRM in primary care. Identified priorities for quality and safety improvement can guide the selection of targets for initiatives to address the PDRM problem in primary care.

Drug advertising directed to pharmacists in Brazil: information or sales promotion?

Analyses of drug advertising reveal important social and cultural values and attitudes at a certain point in history. The purpose of this paper was to investigate how pharmaceutical industry communicates with pharmacists in Brazil, using drug promotion as a valuable tool. The point of departure was the analysis of a series of drug advertisements published in three Brazilian technical journals targeted at pharmacists and other health professionals. For the present study, the focus was on the content of the messages directed to pharmacists, in order to critically analyze the role attributed to these professionals as portrayed by the ads, and to discuss it in the context of pharmaceutical care. The collection and analysis of the data followed Anvisa's methodology. Pharmacists' social responsibility includes the reduction of preventable drug-related morbidity and mortality, but the information provided by the ads only refers to sales growth and profitability. Pharmacists are portrayed as salesmen, rather than health professionals, and encouraged to sell pharmaceutical drugs which are being heavily advertised to medical doctors. Consequences for pharmaceutical care are discussed.

Preventing drug-related morbidity: determining valid indicators

AbstractFocal points

Description of a multifaceted strategy for recruiting general practitioners and community pharmacists to talk about medication errors

Abstract Objective To describe the use of a multifaceted strategy for recruiting general practitioners (GPs) and community pharmacists to talk about medication errors which have resulted in preventable drug-related admissions to hospital. This is a potentially sensitive subject with medicolegal implications. Setting Four primary care trusts and one teaching hospital in the UK. Method Letters were mailed to community pharmacists and general practitioners asking for provisional consent to be interviewed and permission to contact them again should a patient be admitted to hospital as a result of a medication error. In addition, GPs were asked for permission to approach their patients should they be admitted to hospital. A multifaceted approach to recruitment was used including gaining support for the study from professional defence agencies and local champions. Key findings Eighty-five percent (310/385) of GPs and 62% (93/149) of community pharmacists responded to the letters. Eighty-five percent (266/310) of GPs who responded and 81% (75/93) of community pharmacists who responded gave provisional consent to participate in interviews. All GPs (14 out of 14) and community pharmacists (10 out of 10) who were subsequently asked to participate, when patients were admitted to hospital, agreed to be interviewed. Conclusion The multifaceted approach to recruitment was associated with an impressive response when asking healthcare professionals to be interviewed about medication errors which have resulted in preventable drug-related morbidity.

Indicators for preventable drug‐related morbidity. Practical application in home‐based care

The aim of this study is of evaluating Morris' PDRM indicator system in the Italian Health Care System, especially in the context of home-based health care assistance, so as to assess the reliability of such a system to detect preventable events of drug-related morbidity (DRM). This is a pilot study which has been carried out on a control group of patients. The results, which have been obtained, have then been used to calculate the incidence of the preventable drug-related morbidity (PDRM) in the entire population. The sample of patients was taken from the Health District of Chivasso (Local Health Unit 7 in Piedmont). The subjects had all been inserted in the Integrated Home Healthcare Assistance programme in the period from 1st January to 31st December 2004. The PDRM is equal to 32, with an incidence of 15.6% in the entire population (205). Seven indicators out of 19 were able to identify PDRM. Of these, the indicator which showed the best detection rate scored 72%. The study revealed that this indicator system has the capability of detecting events of PDRM. In addition to this, the version of the system which has been approved by the expert panel has proved executable in the Italian healthcare system, especially in home-based healthcare.

Development of clinical indicators for type 2 diabetes

Background/Objective:Preventable drug-related morbidity in patients with type 2 diabetes is a major concern. Our objective was to develop a set of Canadian clinical indicators of preventable drug-related morbidity (PDRM) and preventable care-related morbidity (PCRM) for type 2 diabetes.Methods:Each study partner (Dalhousie University, Nova Scotia Department of Health, Diabetes Care Program of Nova Scotia, and Sobeys Pharmacy Group) was asked to identify the priorities of medication-related diabetes care from the Canadian Diabetes Association 2003 clinical practice guidelines using the nominal group technique. Based on the priorities identified, a survey was constructed listing the clinical outcome and pattern of care related to a number of possible PDRMs/PCRMs in patients with type 2 diabetes. Using the Delphi technique, an interdisciplinary panel of 10 experts scored each clinical indicator in an attempt to achieve consensus.Results:Education/reinforcement of targets was identified by the nominal group t...

Preventable drug-related morbidity: determining valid indicators for primary care in Portugal

Preventable drug-related morbidity (PDRM) indicators are operational measures of therapeutic risk management. These clinical indicators, which cover a wide range of drugs, combine process and outcome in the same instrument. They were developed in the US and have been validated for primary care settings in the US, UK and Canada. This study is part of a research programme; it aimed to determine a valid set of PDRM indicators for adult patients in primary care in Portugal. Face validity of 61 US and UK-derived indicators translated to Portuguese was preliminarily determined by means of a postal questionnaire using a purposive sample of four Portuguese pharmacists with different backgrounds. Preliminary content validity of indicators approved in the previous stage was determined by cross-checking each definition of PDRM with standard drug information sources in Portugal. Face and content validity of indicators yielded by preliminary work were then established by a 37 expert panel (20 community pharmacists and 17 general practitioners) using a two-round Delphi survey. Data were analysed using SPSS release 11.5. Nineteen indicators were ruled out in preliminary validation. Changes were made in the content of eight of the remaining 42 indicators; these were related to differences in the drugs being marketed and patterns of drug monitoring between countries. Thirty-five indicators were consensus approved as PDRM for adult patients in Portuguese primary care by the Delphi panel.

Applying preventable drug-related morbidity indicators to the electronic patient record in UK primary care: methodological development

Measuring and assessing the quality of health care services is an issue of high international importance. Providing data can be reliably extracted, making use of the electronic patient record (EPR) could help practitioners fulfil clinical governance obligations and ultimately improve the quality of patient care. The objective of this paper is to describe (i) the process used to apply a series of clinical indicators for preventable drug-related morbidity (PDRM) in the EPR, (ii) problems encountered and (iii) our attempts to resolve them. The PDRM indicators were applied retrospectively in the EPR of all patients aged 18 years and over in nine general practices using the Morbidity Information and Query Export Syntax (MIQUEST) computer software programme. Issues identified as requiring attention when attempting to extract data from the EPR include considering the ranges to be used for age and biochemical test results, accuracy of diagnosis and drug coding, the level of complexity of the information needed, and how best to manipulate the resulting data. Practical difficulties encountered were ensuring the query coding schemes were sufficiently robust and comprehensive to secure reliable data extraction, the number of MIQUEST queries required to express each indicator, the time-consuming nature of the stages involved in the data manipulation process. Despite some practical difficulties, we have successfully used MIQUEST to identify potential preventable drug-related morbidities from the EPR. The quality of information that can be extracted from the EPR is obviously limited by the accuracy and completeness of the data on the system and the ability of the enquirer to reliably extract and manipulate that data. Although some of the problems encountered were specific to the MIQUEST software, many, including considering appropriate ranges for age and biochemical test results and paying careful attention to the reliability of drug and diagnosis coding, are relevant whenever data are extracted from the EPR for any purpose.

Current status of prospective drug utilization review.

The Omnibus Budget Reconciliation Act of 1990 offered the promise that prospective drug utilization review (pDUR) systems would improve the quality of drug prescribing and patient drug use. There is little evidence that this promise has been fulfilled. To the contrary, there is growing evidence that suboptimal use of drugs (in terms of preventable drug-related morbidity) is at least as costly as the prescription drugs themselves. Online computerized pDUR has been the subject of numerous critical examinations in the pharmacy and medical literature. Recent publications have sought to illustrate perceived shortcomings in the DUR systems currently in use. We focus on the state of the art with regard to pDUR, what is known about its effectiveness, and how emerging technologies may change pDUR and consider the work that may be needed to establish its effectiveness. A growing body of literature documents numerous problems and concerns with respect to the quality of DUR criteria, DUR alerts, and the response of health care professionals to these alerts. Problems with the current pDUR "system" can be grouped into those involving technical aspects (e.g., duplicate messaging from in-store and online systems, or message text limitations) and into those involving human aspects, specifically how pharmacists and other health care providers interpret and respond to potential drug therapy problem alerts generated by the electronic systems. DUR is a quality assurance system that holds promise as a tool that, if implemented effectively, could enhance appropriate drug use. We believe a more systematic approach to DUR is needed. Evaluation and management of public and private pDUR systems must link documentation of processes of care, such as pharmacists. cognitive services, patient interventions, etc. To address technical aspects, we strongly recommend (a) a national effort to validate DUR screen criteria relying upon evidence-based studies and (b) adoption of a minimal set of.critical. pDUR screen criteria by pharmacy service providers and third-party intermediaries, including pharmacy benefit managers. To address the human component of pDUR systems, we advocate (a) adoption of performance standards for pharmacists and (b) explicit remuneration for time spent identifying and responding to drug therapy problems.

Indicators for preventable drug related morbidity: application in primary care.

To apply in practice a series of validated indicators for preventable drug related morbidity (PDRM). A pilot study to identify retrospectively potential PDRM events over a 2 year 3 month time frame using the MIQUEST computer software program. The electronic patient record of all patients aged 18 years and over in nine English general practices. The number of potential PDRM events identified, as defined by the indicators. Five hundred and seven potential PDRM events were identified from 49 658 electronic patient records, giving an overall incidence of 1.0%. A small number of the indicators (n = 4) accounted for approximately 60% of the events, while for many indicators few events were identified. The most common events related to the use of non-steroidal anti-inflammatory drugs in patients with congestive heart failure or hypertension, lack of monitoring in patients prescribed angiotensin converting enzyme inhibitors, and the use of hypnotic-anxiolytic agents. A small number of indicators contributed to the majority of the PDRM events. Interrogation of electronic patient records in primary care using computerised queries shows potential for detecting PDRM.

Validation of four clinical indicators of preventable drug-related morbidity.

Clinical indicators are tools that assess quality issues related to the use of medicines. At this time, validated clinical indicators for preventable drug-related morbidity (PDRM) are lacking. To assess the validity and reliability of using population administrative claims data to identify the extent of PDRM in older adults in Canada. Four indicators of PDRM related to cerebrovascular and cardiovascular care were chosen for validation. A random sample of cases that represented the indicators and fit the criteria (hits) for PDRM from the retrospective operationalization of the study database and those that did not fit the criteria (near hits) were selected for chart review. One-page abstracts of the cases were prepared for review by a panel of 5 clinical pharmacists. Validity was assessed by calculating sensitivity, specificity, and positive and negative predictive value. Reliability was assessed using reviewers' agreement scores (kappa statistics). Overall, 119 case abstracts were reviewed by each panelist. The sensitivity ranged from 33% to 100% and the specificity from 51% to 71%. Predictive values ranged from 5.3% to 43% (positive) and 90% to 100% (negative). The overall kappa statistic was fair (0.21). The validity of the 4 assessed PDRM indicators varied. The reliability was fair; however, these indicators may be useful to screen older adults for PDRM.

Preventing drug-related morbidity--the development of quality indicators.

To describe the process that has been undertaken to (i) validate further UK indicators for preventable drug-related morbidity (PDRM) generated by a previous study and (ii) develop additional new indicators derived from UK clinical practice. A two-round Delphi questionnaire survey. A UK study based in primary care. A purposively selected sample of primary care pharmacists (n = 9) and general practitioners (n = 8). The establishment of consensus among the panel as to whether an indicator represented a PDRM. The pre-defined level of consensus was achieved for 24 indicators (59%; 24 of 41). We have identified that although mechanisms exist for identifying 'the outcome' component of PDRM indicators, identifying the 'pattern of care' that is needed to prevent their occurrence is far more challenging. Nonetheless, we have taken considerable steps along the path of validating such indicators. Future operationalization in a general practice setting should help to facilitate improvements in medicine management in primary care and ultimately benefit patients.

Indicators of preventable drug-related morbidity in older adults 2. Use within a managed care organization.

To determine the incidence of preventable drug-related morbidity (PDRM) in older adults in a provider-sponsored network and identify risk factors for PDRM. The study was based on a retrospective review of an integrated health care database, using 52 newly developed clinical indicators of PDRM. The incidence of PDRM was determined by identifying individuals in the database who matched an outcome and pattern of care associated with an indicator. Risk factors were determined through a forward inclusion logistic regression model. The subjects in this study were 3,365 older adults enrolled in a hospital-based health care system in Florida in 1997. The principal outcome measure was identification of individuals who matched a PDRM indicator and risk factors for PDRM. Ninety-seven enrollees who matched one or more of 52 PDRM indicators were found in 3,365 older adults, for an overall incidence rate of 28.8 per 1000. The top 5 indicators of PDRM were responsible for 46.8% of all PDRMs found. Regression analysis identified 5 risk factors: 4 or more recorded diagnoses, 4 or more prescribers, 6 or more prescription medications, antihypertensive drug use, and male gender. This study demonstrated that clinical indicators can be used in a managed care organization to identify seniors who have experienced a PDRM. The risk model should better prepare managed care organizations to proactively identify patients at risk for PDRM and to optimize medication use in older adults.

Development of a list of consensus-approved clinical indicators of preventable drug-related morbidity in older adults

Background: Older patients (aged ⪢65 years) may experience drug-related problems that, if unrecognized, can result in drug-related morbidities (DRMs). According to the literature, 49% to 76% of all DRMs may be preventable; however, there is little consensus as to which are preventable and which are not. Objective: The aim of this study was to develop consensus-approved clinical indicators of preventable DRM (PDRM) in older adults. Geriatricians, clinical pharmacologists, general practitioners, and clinical pharmacists were included in the consensus-building process. Methods: In 2001, a survey containing potential indicators of PDRM was prepared based on previous research and the input of 2 clinical pharmacists. The survey was administered concurrently via the Delphi technique to 2 separate specialist panels (6 geriatricians and 6 clinical pharmacologists) to generate clinical indicators of PDRMs in older adults. Subsequently, a focus group of 12 general practitioners (GPs) assessed these PDRM indicators in Nova Scotia, Canada. Results: The specialist panels generated 58 consensus-approved clinical indicators of PDRMs in older adults after 2 rounds of the Delphi technique. The GPs agreed with 52 (90%) of these PDRM indicators. Conclusions: This study generated consensus-approved indicators of PDRMs in older adults, which could be used by health professionals to identify patients at risk for PDRMs. The indicators could also have a role in quality measurement systems and in epidemiologic research. Furthermore, the indicators could complement existing clinical indicators and establish an important link between patterns of care and clinical outcomes.