Problematic Prescriptions Research Articles

Understanding the role of law and the legal system in economic development requires more than a purely economic model

This article illustrates that an approach to law and economics which uses economic models and quantitative analysis without considering socio-cultural factors and lacks detailed legal understanding of the specific ‘laws’ being analysed can lead to problematic policy prescriptions. It shows that the ‘law and finance’ approach to law and economic development is flawed. More generally, the article demonstrates that law and economics cannot solely rely on the application of the techniques of economics but must also recognise the importance of culture in determining economic behaviour. The studies discussed utilise a New Institutional Economics model of the role of law and the legal system, draw on dimensional models of culture from cross-cultural psychology and utilise a Leximetric dataset containing more finely grained measures of creditor and investor protection indices than those used in earlier studies of the role of law in economic development. The evidence adduced suggests a strong and persistent transplant effect.

Factors associated with potentially problematic opioid prescriptions among individuals with private insurance and medicaid

If opioid analgesics are prescribed and used inappropriately, they can lead to addiction and other adverse effects. In this study, we (1) examine factors associated with potentially problematic opioid prescriptions and (2) quantify the link between potentially problematic prescriptions and the development of opioid use disorder. We found that older age; female sex; having back pain, arthritis, or migraine; hydrocodone prescription; previous pharmacotherapy for opioid use disorder; and frequent emergency department use were associated with problematic prescriptions among individuals with Medicaid and private insurance. Patients with commercial insurance and Medicaid who had potentially problematic opioid prescriptions were eight and three times more likely, respectively, to develop an opioid use disorder than patients without potentially problematic opioid prescriptions. Our findings help identify factors associated with problematic prescriptions and underscore the importance of targeted public health interventions.

Potentially Problematic Opioid Prescriptions Among Individuals With Private Insurance and Medicaid.

Opioid analgesics can be safe and effective when used properly. Reducing prescriptions that increase adverse outcomes is a focus for addressing the opioid crisis. In this study, the rate of potentially problematic opioid prescriptions was examined over 11 years in a large sample of U.S. patients. Claims from the IBM MarketScan commercial database (about 45 million) and multistate Medicaid database (about 7 million) from 2005 to 2015 were used to calculate rates of the following potentially problematic prescription practices: prescriptions for high-dose opioids for 90 days or more, prescriptions from multiple providers, prescriptions of long-acting or extended-release opioids for acute pain, overlap between prescriptions for opioids, and overlap between prescriptions for opioids and benzodiazepines. Among patients with an opioid prescription, about 8% of those with private insurance and about 14% of those with Medicaid coverage had at least two incidents of potentially problematic prescriptions per year. Over the study period, rates increased for some practices (opioid-benzodiazepine overlap) and decreased for others (prescriptions from multiple providers). Receipt of potentially problematic prescriptions was higher among older patients, female patients with private insurance, and whites and male patients covered by Medicaid. A significant percentage of patients who are prescribed opioids experience problematic prescription practices. Targeted policy and clinical interventions that reduce potentially problematic prescription could be a focus for addressing the U.S. opioid crisis.

Pattern of drug therapy problems and interventions in ambulatory patients receiving antiretroviral therapy in Nigeria.

We describe the frequency and types of drug therapy problems (DTPs), and interventions carried out to resolve them, among a cohort of HIV-infected patients on ART in Jos, Nigeria. A prospective pharmacists' intervention study was conducted between January and August 2012 at the outpatient HIV clinic of the Jos University Teaching Hospital (JUTH). Pharmacists identified DTPs and made recommendations to resolve them. The main outcome measures were number of DTPs encountered, interventions proposed and acceptance rate of recommendations. A total of 42,416 prescriptions were dispensed to 9339 patients during the eight months study. A total of 420 interventions (Intervention rate of 1 per 100 prescriptions) were made to resolve DTPs in 401 (4.3%) patients with a mean age of 41 (SD=10) years, and made up of 73% females. DTPs encountered were drug omission (n=89, 21.2%), unnecessary drug (n=55, 13.1%) and wrong drug indication (n=55, 13.1%). Recommendations offered included; Addition of another drug to the therapy (n=87, 20.7%), rectification of incomplete prescriptions (n=85, 20.2%), change of drug or dosage (n=67, 16.0%), and discontinuation of the offending drug (n=59, 14.0%). A total of 389 (93%) out of 420 of the recommendations were accepted. In all, 50.4% (212) of the problematic prescriptions were changed and dispensed, 22.2% (89) were clarified and dispensed, while wrong identities were corrected in 11.7% (49). However, 7.5% (30) prescriptions were dispensed as prescribed, 5.2% (21) were not dispensed, and 3% (12) were unresolved. Our findings suggest that pharmacists-initiated interventions can ameliorate DTPs in patients receiving ART given the high intervention acceptance rate recorded. The implication of this finding is that pharmacists with requisite training in HIV pharmacotherapy are an excellent resource in detecting and minimizing the effect of antiretroviral drug-related errors.

Risks to patient safety associated with implementation of electronic applications for medication management in ambulatory care--a systematic review.

BackgroundThe objective was to find evidence to substantiate assertions that electronic applications for medication management in ambulatory care (electronic prescribing, clinical decision support (CDSS), electronic health record, and computer generated paper prescriptions), while intended to reduce prescribing errors, can themselves result in errors that might harm patients or increase risks to patient safety.MethodsBecause a scoping search for adverse events in randomized controlled trials (RCTs) yielded few relevant results, we systematically searched nine databases, including MEDLINE, EMBASE, and The Cochrane Database of Systematic Reviews for systematic reviews and studies of a wide variety of designs that reported on implementation of the interventions. Studies that had safety and adverse events as outcomes, monitored for them, reported anecdotally adverse events or other events that might indicate a threat to patient safety were included.ResultsWe found no systematic reviews that examined adverse events or patient harm caused by organizational interventions. Of the 4056 titles and abstracts screened, 176 full-text articles were assessed for inclusion. Sixty-one studies with appropriate interventions, settings and participants but without patient safety, adverse event outcomes or monitoring for risks were excluded, along with 77 other non-eligible studies. Eighteen randomized controlled trials (RCTs), 5 non-randomized controlled trials (non-R,CTs) and 15 observational studies were included. The most common electronic intervention studied was CDSS and the most frequent clinical area was cardio-vascular, including anti-coagulants. No RCTS or non-R,CTS reported adverse event. Adverse events reported in observational studies occurred less frequently after implementation of CDSS. One RCT and one observational study reported an increase in problematic prescriptions with electronic prescribingConclusionsThe safety implications of electronic medication management in ambulatory care have not been established with results from studies included in this systematic review. Only a minority of studies that investigated these interventions included threats to patients’ safety as outcomes or monitored for adverse events. It is therefore not surprising that we found little evidence to substantiate fears of new risks to patient safety with their implementation. More research is needed to focus on the draw-backs and negative outcomes that implementation of these interventions might introduce.

Assessing the effect of providing a pharmacist with patient diagnosis on electronic prescription orders: A pilot study

As a result of the US Omnibus Reconciliation Act of 1990 (OBRA '90), pharmacists have the obligation to ensure that prescription orders are appropriate and are not likely to cause adverse events. However, patient diagnosis information is not a requirement for a legal prescription order in any state in the US. To compare a pharmacist's interventions before and after patient diagnosis is added by prescribers to their electronic prescription orders. This prospective, pre-post study was conducted during two consecutive 4-week periods in a community health center pharmacy. During the first data collection period, the clinical pharmacist prospectively evaluated e-prescriptions using a standard DUR protocol. All problematic prescriptions were documented using a medication intervention form. During the second data collection period, providers included the patient's diagnosis on each e-prescription and the same clinical pharmacist again evaluated prescribed therapy and documented interventions. Pharmacist intervention rates on e-prescription orders were significantly lower following addition of the patient diagnosis information to the e-prescription order (3.9% pre- vs. 1.0% post-, P<0.001). While preliminary, the results of this pilot suggest that the addition of patient diagnosis to the e-prescription order can reduce confusion and uncertainty on the part of a DUR pharmacist, thereby decreasing the overall number of interventions and the subsequent number of contacts with prescribers.

Exploring information chaos in community pharmacy handoffs

A handoff is the process of conveying necessary information in order to transfer primary responsibility for providing safe and effective drug therapy to a patient from one community pharmacist to another, typically during a shift change. The handoff information conveyed in pharmacies has been shown to be unstructured and variable, leading to pharmacist stress and frustration, prescription delays, and medication errors. The purpose of this study was to describe and categorize the information hazards present in handoffs in community pharmacies. A qualitative research approach was used to elicit the subjective experiences of community pharmacists. Community pharmacists who float or work in busy community pharmacies were recruited and participated in a face to face semi-structured interview. Using a systematic content data analysis, the study identified five categories of information hazards that can lead to information chaos, a framework grounded in human factors and ergonomics. Information hazards including erroneous information and information overload, underload, scatter, and conflict, are experienced routinely by community pharmacists during handoff communication and can result in information chaos. The consequences of information chaos include increased mental workload, which can precipitate problematic prescriptions "falling between the cracks." This can ultimately impact patient care and pharmacist quality of working life. The results suggest that handoffs in community pharmacies result in information hazards. These information hazards can distract pharmacists from their primary work of assessing prescriptions and educating their patients. Further research on how handoffs are conducted can produce information on how hazards in the system can be eliminated.

Standardized order form for investigational drugs: effect on completeness of the prescription.

To compare completeness and quality of orders written before and after introduction of a preprinted medication order form for investigational drugs. Completeness of physician's orders for investigational drugs was compared during two successive periods: before and after implementation of a preprinted form for these orders. Orders were checked for six elements: pharmaceutical company's identity, protocol's name, patient's identity (i.e., initials), investigator's signature, order's date, and drug designation. Each element was categorized according to three quality criteria: mistake (wrong information), omission, or imprecision (incomplete information). A total of 536 orders were evaluated corresponding to 268 orders and to 4824 quality criteria in each period. During the baseline study, 228 (85%) problematic prescriptions were detected. Of the 4824 quality criteria evaluated, 422 (8.7%) errors were recorded. Common types of errors were omission of pharmaceutical company's identity, mistaken protocol name, and omission of patient's identity. After the introduction of the order form, 13 (4.9%) prescriptions contained errors. Fifteen (0.3%) quality criteria were not in conformity with the standard. The common types of errors were omission of patient's identity and order date. Physician's orders for investigational drugs are more complete when they use a preprinted prescription form than when they use traditional orders. The introduction of a preprinted order form for investigational drugs prevents potential medication errors and contributes to patients' safety.

Outpatient-prescription-intervention-activities-by-pharmacists-in-a-teaching-hospital

Prescriptions with prescribing errors received by an outpatient pharmacy of a teaching hospital were sampled. The types of pharmacist interventions on problematic prescriptions and its outcome were identified and documented. From a total of 6340 prescriptions processed by the outpatient pharmacy in a one-week period, 43 prescriptions (0.68%) required interventions by the pharmacy staff. These included 54% of the prescriptions that were incomplete or inadequately written (errors of omission) and 46% that contained the wrong drug, dose regimen, strength and dosage form (errors of commission). A total of 62 types of action were taken by the pharmacy staff to resolve the 43 problematic prescriptions. These include contacting the prescribers concerned (24.2%), clarifying with the patient or his/her representative (19.4%), contacting the prescriber’s nurse (17.7%) and checking the patient’s appointment or identity card (4.8%). Of the 43 problematic prescriptions, 48.8% were clarified without any change and dispensed while 32.6% were changed and dispensed. The study reinforces the importance of prescription screening and interventions by pharmacists in minimising preventable adverse events attributed to medication errors. It also emphasizes the necessity of interdisciplinary communication and cooperation in identifying and resolving prescribing errors and irregularities in order to achieve optimal therapeutic outcomes for the patient.

An Exploration of Pharmacist-Initiated Queries on Problematic Prescriptions in Japanese Community Pharmacies

An Exploration of Pharmacist-Initiated Queries on Problematic Prescriptions in Japanese Community Pharmacies