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1

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• guilherme_at_lexxa.com.br

2
Importância de Reações Adversas a Medicamentos
(RAM)

• 2 milhões de RAM anualmente nos EUA
• Cem mil mortes por ano
• Quarta causa de morte nos EUA (na frente de
  doenças pulmonares, diabetes, AIDS, acidentes
  automobilísticos
• RAM ambulatorial incidência não estimada
• RAM em clínicas para idosos 350 mil por ano

3
Custos associados a RAM

• 136 bilhões de US anualmente
• Maior do que custos com moléstias
  cardiovasculares ou tratamento de diabetes
• RAM responsável por 20 de danos ou mortes por
  ano em pacientes hospitalizados
• Custo hospitalar o dobro em relação a demais
  pacientes

4
Por que há tantos RAM?

• Dois terços de consultas médicas geram uma
  receita
• 2.8 bilhões de receitas no ano 2000 (10 por
  habitante dos EUA)
• RAM aumenta exponencialmente com 4 ou mais
  medicações

5
Interações Medicamentosas

• Representam 3-5 das internações de RAM que podem
  ser evitadas
• Importante causa no número de atendimentos
  ambulatórios

6
Por que há tantos RAM?

• Dois terços de consultas médicas geram uma
  receita
• 2.8 bilhões de receitas no ano 2000 (10 por
  habitante dos EUA)
• RAM aumenta exponencialmente com 4 ou mais
  medicações

7
Reported serious events vs outpatient
prescriptions, 1998-2005.
Serious Adverse Drug Events Reported to the Food
and Drug Administration, 1998-2005 - ARCH INTERN
MED/VOL 167 (NO. 16), SEP 10, 2007
8
Estados Unidos - Idosos

• 12 da população
• 31 das prescrições
• 18 consomem pelo menos uma medicação considerada
  não apropriada para a idade

9
Creatinine clearance and drug prescriptions for
the elderly. A study of 419 patients older than
70 years admitted through the emergency
department Viallon A, Guyomarch P, Marjollet O,
Belin M, Robert F, Berger C, Guyomarch S,
Bertrand JC.Service d'Urgence et de Reanimation,
Hopital Bellevue, Saint-Etienne.
alain.viallon_at_univ-st-etienne.fr INTRODUCTION
The incidence of drug-related adverse events
increases with age. In approximately 20 of
cases, these events necessitate hospitalization.
By taking into account the physiological changes
associated with aging when prescribing drugs,
physicians can prevent some of these events. The
objective of this study was to analyze the
prescriptions written by general practitioners
for elderly patients admitted to the emergency
department in relation to the patient's
creatinine clearance. PATIENTS AND METHODS Of
968 consecutive patients older than 70 years, 419
underwent a plasma creatinine assay on admission
and were included in this study. Creatinine
clearance was calculated with Cockcroft's
formula. The patients were classified into two
groups according to creatinine clearancelt30
mL/min (group I) and gtor30 mL/min (group II).
RESULTS Creatinine clearance waslt30 mL/min in 84
of the 419 patients (group I) and gtor30 mL/min
in 335 (group II). Mean age was significantly
higher in group I than in group II (87 /- 6 vs
81 /- 6 years, plt0.001), as was mean plasma
creatinine concentration (113 /- 23 vs 83 /- 19
mmol/L, plt0.001), while mean weight was
significantly lower (57 /- 10 vs 69 /- 13 kg,
plt0.001. In group I, 82 drugs with precautions
concerning renal function had been prescribed for
69 (82) patients, and in group II, 331 such
drugs for 174 (52) patients. Of the 82 drugs
prescribed in group I that required precaution,
47 (57) were contraindicated or prescribed at an
inappropriate dose in view of the creatinine
clearance. Irrespective of pharmacokinetic
parameters, the mean number of drugs taken per
patient was 5 /- 2 in group I and 6 /-2 in
group II. CONCLUSION In prescribing drugs for
elderly patients, especially those whose weight
is low, careful attention should be paid to renal
function.
10
Am J Geriatr Pharmacother. 2010
Dec8(6)562-70. Incident use and outcomes
associated with potentially inappropriate
medication use in older adults. Dedhiya SD,
Hancock E, Craig BA, Doebbeling CC, Thomas J
3rd. Source School of Pharmacy and
Pharmaceutical Sciences, Purdue University, West
Lafayette, Indiana, USA. Abstract BACKGROUND
Most studies of potentially inappropriate
medication (PIM) use among older adults have
focused on prevalence rather than
incidence. OBJECTIVES The goals of this study
were to determine the 1-year incidence of PIM use
among elderly Indiana Medicaid residents of
nursing homes and to examine associations between
incident PIM use and hospitalization and
mortality. METHODS A retrospective analysis was
conducted using Indiana Medicaid enrollment and
administrative claims files. Individuals were
included if they were Medicaid eligible and aged
65 years as of January 2003 and received nursing
home services in each month of 2003 or until
death in 2003. Individuals also had to receive
nursing home services from October 2002 through
December 2002 for inclusion in the sample. To
focus analysis on incident PIM use, individuals
who received any PIM prescription medication from
October 2002 through December 2002 were excluded
from the sample, as were those not prescribed any
new medication in 2003. PIMs were identified
using the 2003 Beers criteria. Associations
between incident PIM use and hospitalization and
mortality were assessed using logistic regression
models after controlling for other risk factors.
Potential selection bias was examined using
bivariate probit models. RESULTS The study
sample consisted of 7594 individuals (mean age,
83.07 years). A majority of the sample was female
(76.5), white (89.7), and widowed (58.8). Most
individuals received care in nursing homes
located in urban areas (5306 69.9) and in the
central region of Indiana (2838 37.4).
One-year incidence of PIM use was 42.1. Incident
PIM users were more likely to be hospitalized
(odds ratio OR 1.27 95 CI, 1.10-C1.46) and
more likely to die (OR 1.46 95 CI,
1.31-C1.62) in the 12 months after first
receiving a PIM than nonusers, even after
adjusting for demographic and clinical risk
factors. CONCLUSIONS Incident PIM use was high
among these elderly Indiana Medicaid residents of
nursing homes. Individuals who began use of a PIM
were at a higher risk of hospitalization and of
dying.
11
Comment. Advances in critical care medicine have
led to a greater number of elderly ICU survivors.
These survivors experience polypharmacy and
numerous transitions in care during
hospitalization and are at high risk of adverse
drug effects after hospital discharge. In the
present study, 85 of elderly ICU survivors were
discharged from the hospital with 1 or more PIM.
A unique aspect of our study, and a concerning
finding, was that more than half of these
patients were discharged with 1 or more AIM,
medications deemed more harmful than beneficial
to the patient. Similarly, Hajjar et al found
that 44 of elderly veterans were prescribed at
least 1 AIM at hospital discharge.
12
Inappropriate prescribing in an older ED
population

• Fredric M. Hustey MD, Nicole Wallis MD, Jonathan
  Miller MD
• Department of Emergency Medicine, Cleveland
  Clinic, Cleveland, OH 44195, USA
• Cleveland Clinic Lerner College of Medicine, Case
  Western Reserve University, Cleveland, OH 44195,
  USA
• Department of Emergency Medicine, MetroHealth
  Medica
• American Journal of Emergency Medicine (2007) 25,
  804807

13
Inappropriate prescribing in an older ED
population

• The objective of this study was to determine the
  prevalence of potentially inappropriate
  medication (PIMs) use in older emergency
  department (ED) patients based on the updated
  2002 Beers criteria. This was a retrospective
  analysis of 352 consecutive ED visits by patients
  aged 65 years and older. The mean number of
  medications taken was 8.4 per patient. In the
  study population, 111 (32 95 confidence
  interval CI, 27-36) of 352 patients were taking
  at least 1 PIM at ED presentation.

14
Inappropriate prescribing in an older ED
population

• Among 101 of 193 patients discharged home from
  the ED with a new prescription, 13 (13 95 CI,
  6-19) were also given PIMs.

15
Inappropriate prescribing in the elderly

• Journal of Clinical Pharmacy and Therapeutics
  (2007) 32, 113121

16
Inappropriate prescribing in the elderly

• Prescription of potentially inappropriate
  medications to older people is highly prevalent
  in the United States and Europe, ranging from 12
  in community-dwelling elderly to 40 in nursing
  home residents.

17
Australas J Ageing. 2011 Sep30(3)124-9. doi
10.1111/j.1741-6612.2010.00458.x. Epub 2010 Aug
19. Medication-related problems in patients
referred to aged care and memory clinics at a
tertiary care hospital. Elliott RA, Woodward
MC. Source Pharmacy Department, Austin Health,
Heidelberg. rohan.elliott_at_austin.org.au Abstract
AIM To investigate the prevalence of
medication-related problems (MRPs) in patients
attending aged care and memory disorder clinics
and explore the potential role of a clinical
pharmacist to obtain medication histories and
identify unresolved MRPs. METHODS The clinical
pharmacist interviewed patients and reviewed
their medication regimens in the outpatient
clinics. Clinical significance of
pharmacist-identified MRPs was rated by an
independent expert panel using validated
criteria. RESULTS Forty-six patients (mean age
82 years) were reviewed. They took a median of
nine medications, of which three were not
recorded in the medical record. One hundred and
thirteen MRPs (median 2.0 per patient) were
identified by the pharmacist. Independent review
rated 35 of MRPs as high or extreme risk.
Thirty-seven (33) MRPs related to medications
not recorded in the medical record. CONCLUSIONS
Medication-related problems were present for
most patients. Involvement of a clinical
pharmacist resulted in a more comprehensive
medication history and identified unresolved
MRPs.
18
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• Jérôme Tourret, Isabelle Tostivint,1 Sophie
  Tézenas Du Montcel,2 Svetlana Karie,1 Vincent
  Launay-Vacher,1 Cécile Vigneau,3 Christel
  Bessette,1 Gilbert Deray,1 and Corinne Isnard
  Bagnis1 Nephrology and 2Biostatistics
  Departments, Groupe Hospitalier
  Pitié-Salpêtrière, and 3Nephrology Department,
  Hôpital Tenon, Assistance Publique-Hôpitaux de
  Paris, and 4INSERM U722, Université Paris 7 Denis
  Diderot, Site Xavier Bichat, Paris, France
• Clinical Infectious Diseases 2007 4577984

19
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• Background. Several studies have revealed the
  frequency of antiretroviral (ARV) drug
  prescription errors. We nalyzed highly active
  antiretroviral therapy (HAART) prescribing
  practices for human immunodeficiency virus
  (HIV)infected patients undergoing hemodialysis
  in France.

20
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• Methods. Prescribed ARV drug doses in our cohort
  (consisting of all HIV-infected patients who
  underwent hemodialysis from 1 January 2002 and
  were prospectively followed up until 1 January
  2004) were compared with the recommended doses
  for patients undergoing hemodialysis. The
  log-rank test was used to compare the outcomes
  among different groups of treated patients.

21
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• Results. One hundred seven of the 129 patients in
  our cohort received a total of 317 ARV drugs, 59
  of which were improperly prescribed.

22
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• The dosing was too low for 18 of the patients
  and too high for 39 of the patients.
  Twenty-eight patients (26) did not receive any
  of their ARV drugs at the recommended dose.

23
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• Among the patients who received HAART, those who
  were prescribed an insufficient dose of a PI were
  not statistically distinguishable from the others
  in terms of age, sex, ethnicity, diabetic
  comorbidity, HIVassociated nephropathy diagnosis,
  hepatitis B virus and/or hepatitis C virus
  coinfections, duration of dialysis, and duration
  of HIV infection.

24
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis
No underprescribed PI
1.00 0.75 0.50 0.25 0.00
Underprescribed PI
Proportion of patients who survived
0 6 12
18 24
Time, months
No. Of patients at risk Underprescribed PI
30 28 24
23 23 No underprescribed PI 66
66 63 62
60
Antiretroviral Drug Dosing Errors in HIV-Infected
Patients Undergoing Hemodialysis - HIV/AIDS CID
200745 (15 September)
25
Antiretroviral Drug Dosing Errors in
HIV-InfectedPatients Undergoing Hemodialysis

• For dialyzable ARV drugs, the delay between ARV
  drug receipt by the patients and dialysis
  sessions was not respected in 9 of cases, and in
  73 of cases, it was not known whether the
  patients took the ARV drugs before or after
  dialysis sessions.

26
HIV Med. 2011 Sep12(8)494-9. doi
10.1111/j.1468-1293.2011.00915.x. Epub 2011 Mar
13. Evaluation of antiretroviral-related errors
and interventions by the clinical pharmacist in
hospitalized HIV-infected patients. Carcelero E,
Tuset M, Martin M, De Lazzari E, Codina C, Miró
J, Gatell J. Source Department of Pharmacy,
Hospital Clinic, Barcelona, Spain.
ecarcelero_at_yahoo.es Abstract OBJECTIVES The aim
of the study was to identify antiretroviral-relate
d errors in the prescribing of medication to
HIV-infected inpatients and to ascertain the
degree of acceptance of the pharmacist's
interventions. METHODS An observational,
prospective, 1-year study was conducted in a
750-bed tertiary-care teaching hospital by a
pharmacist trained in HIV pharmacotherapy.
Interactions with antiretrovirals were checked
for contraindicated combinations. Inpatient
antiretroviral prescriptions were compared with
outpatient dispensing records for reconciliation.
Renal and hepatic function was monitored to
determine the need for dose adjustments. RESULTS
The prescriptions for 247 admissions (189
patients) were reviewed. Sixty antiretroviral-rela
ted problems were identified in 41 patients
(21.7). The most common problem was
contraindicated combinations (n20 33.3),
followed by incorrect dose (n10 16.7), dose
omission (n9 15), lack of dosage reduction in
patients with renal or hepatic impairment (n6
10 and n1 1.7, respectively), omission of an
antiretroviral (n6 10), addition of an
alternative antiretroviral (n5 8.3) and
incorrect schedule according to outpatient
treatment (n3 5). Fifteen out of 20 errors
were made during admission. A multivariate
analysis showed that factors associated with an
increased risk of antiretroviral-related problems
included renal impairment odds ratio (OR) 3.95
95 confidence interval (CI) 1.39-11.23,
treatment with atazanavir (OR 3.53 95 CI
1.61-7.76) and admission to a unit other than an
infectious diseases unit (OR 2.50 95 CI
1.28-4.88). Use of a nonnucleoside reverse
transcriptase inhibitor was a protective factor
(OR 0.33 95 CI 0.13-0.81). Ninety-two per cent
of the pharmacist's interventions were
accepted. CONCLUSION Antiretroviral-related
errors affected more than one-in-five patients.
The most common causes of error were
contraindicated or not recommended drug-drug
combinations and dose-related errors. A clinical
pharmacist trained in HIV pharmacotherapy could
help to detect errors and reduce the duration of
their effect.
27
Pharmacoeconomics. 201028(1)23-34. The cost
and incidence of prescribing errors among
privately insured HIV patients. Hellinger FJ,
Encinosa WE. Center for Delivery, Organization,
and Markets, Agency for Healthcare Research and
Quality, Rockville, Maryland 20850, USA.
BACKGROUND With the rapid growth in the volume
of HIV-related studies that address drug
interactions, appropriate medication regimens,
and when and how to alter drug regimens, it is
challenging for physicians to stay informed.
Physicians require knowledge about all drugs
taken by HIV patients in order to assess
accurately the benefits and risks of various drug
combinations. OBJECTIVE To examine the cost and
frequency of antiretroviral prescribing errors
among a sample of privately insured patients with
HIV disease. METHODS Data were obtained from the
MarketScan Commercial Claims and Encounter
Database created by the Medstat Group Inc. The
MarketScan database contains claims data for
inpatient care, outpatient care, physician
services and prescription drugs in benefit plans
sponsored by gt50 large employers in the US. This
study compared data from the 1999-2000 MarketScan
database with those from the 2005 MarketScan
database. The 2005 MarketScan database includes
12,226 HIV enrollees who received antiretroviral
drugs. This study compared the claims experience
of HIV patients who filled a prescription for a
drug combination that is not recommended by the
US Department of Health and Human Services Panel
on Antiretroviral Guidelines for Adults and
Adolescents with the claims experience of
patients who did not receive such a prescription.
RESULTS In the 1999-2000 database the most
common inappropriate drug combination involved
the co-administration of a protease inhibitor
(PI) and the lipid-lowering drug simvastatin, and
1 of patients experienced this type of error. In
the 2005 database, only 0.4 of patients (46 of
12,226) experienced an inappropriate combination
of simvastatin and a PI while 5.3 of patients
(644 of 12,226) received atazanavir and tenofovir
without ritonavir (referred to herein as
'boosting errors'). Patients who experienced a
boosting error incurred higher annual costs than
patients who took ritonavir along with tenofovir
and atazanavir (US 20,927 vs US 16,704).
Because atazanavir was approved by the US FDA in
June 2003, medication errors involving atazanavir
were not relevant in 1999 and 2000. Overall, it
was found that HIV patients were three times as
likely to experience an inappropriate drug
combination in 2005 than they were in either 1999
or 2000 (5.9 vs 1.9), and that this increase is
attributable to boosting errors. In addition, the
prevalence rate of HIV in the 2005 MarketScan
database was almost triple that in the 1999
MarketScan database (0.14 vs 0.05). CONCLUSION
This study indicates that those who provide care
to HIV patients must be vigilant in their efforts
to provide patients with a drug therapy regimen
that minimizes the chance of an adverse reaction
and maximizes the potential to control viral
replication.
28
Prehosp Emerg Care. 2012 Jan16(1)59-66. Epub
2011 Oct 14. Medication dosing errors in
pediatric patients treated by emergency medical
services. Hoyle JD, Davis AT, Putman KK, Trytko
JA, Fales WD. Source Emergency Department, Helen
DeVos Children's Hospital/Michigan State
University College of Human Medicine, Grand
Rapids, Michigan 49503, USA. jdhoyle_at_hotmail.com
Abstract BAKGROUND Medication dosing errors
occur in up to 17.8 of hospitalized children.
There are limited data to describe pediatric
medication errors by emergency medical services
(EMS) paramedics. It has been shown that
paramedics have infrequent encounters with
pediatric patients. OBJECTIVE To characterize
medication dosing errors in children treated by
EMS. METHODS We studied patients aged 11
years who were treated by paramedics from eight
Michigan EMS agencies from January 2004 through
March 2006. We defined a medication dosing error
as 20 deviation from the weight-appropriate
dose, as determined by the patient's reported
weight in the prehospital medical record or by
use of the Broselow-Luten tape (BLT). We studied
errors in administering six EMS medications
commonly given to children albuterol, atropine,
dextrose, diphenhydramine, epinephrine, and
naloxone. RESULTS There were 5,547 children
aged 11 years who were treated during the study
period, of whom 230 (4.1) received drugs and had
a documented weight. These patients received a
total of 360 medication administrations. Multiple
drug administrations occurred in 73 cases.
Medication dosing errors occurred in 125 of the
360 drug administrations (34.7 95 confidence
interval CI 30.0, 39.8). Relative drug dosage
errors (with 95 CI) were as follows albuterol
23.3 (18.4, 29.1), atropine 48.8 (34.3, 63.5),
diphenhydramine 53.8 (29.1, 76.8), and
epinephrine 60.9 (49.9, 73.9). The mean error (
standard deviation) for intravenous/intraosseous
11000 epinephrine overdoses was 808 428. The
mean error ( standard deviation) for
intravenous/intraosseous 11000 epinephrine
underdoses was 35.5 27.4. CONCLUSIONS
Medications delivered in the prehospital care of
children were frequently administered outside of
the proper dose range when compared with patient
weights recorded in the prehospital medical
record. EMS systems should develop strategies to
reduce pediatric medication dosing errors.
29
Arch Dis Child. 2010 Feb95(2)113-8. Epub 2010
Feb 4. The incidence and nature of prescribing
and medication administration errors in
paediatric inpatients. Ghaleb MA, Barber N,
Franklin BD, Wong IC. Department of Practice and
Policy, The School of Pharmacy, University of
Hertfordshire, Hatfield AL10 9AB, UK
m.ghaleb_at_herts.ac.uk. Objectives To determine
the incidence and nature of prescribing and
medication administration errors in paediatric
inpatients. Design Prospective review of drug
charts to identify prescribing errors and
prospective observation of nurses preparing and
administering drugs to identify medication
administration errors. In addition, incident
reports were collected for each ward studied.
Participants Paediatric patients admitted to
hospitals and nurses administering medications to
these patients. Setting 11 wards (prescribing
errors) and 10 wards (medication administration
errors) across five hospitals (one specialist
children's teaching hospital, one nonteaching
hospital and three teaching hospitals) in the
London area (UK). Main outcome measures Number,
types and incidence of prescribing and medication
administration errors, using practitioner-based
definitions. Results 391 prescribing errors were
identified, giving an overall prescribing error
rate of 13.2 of medication orders (95 CI 12.0
to 14.5). There was great variation in
prescribing error rates between wards. Incomplete
prescriptions were the most common type of
prescribing error, and dosing errors the third
most common. 429 medication administration errors
were identified giving an overall incidence of
19.1 (95 CI 17.5 to 20.7) erroneous
administrations. Errors in drug preparation were
the most common, followed by incorrect rates of
intravenous administration. Conclusions
Prescribing and medication administration errors
are not uncommon in paediatrics, partly as a
result of the extra challenges in prescribing and
administering medication to this patient group.
The causes and extent of these errors need to be
explored locally and improvement strategies
pursued.
30
Pediatrics. 2012 Jan 23. Intravenous
Acetaminophen in the United States Iatrogenic
Dosing Errors. Dart RC, Rumack BH. Source aRocky
Mountain Poison and Drug Center, Denver Health,
Denver, Colorado Abstract An intravenous
formulation of acetaminophen was introduced to
the United States in 2011. Experience from Europe
indicates that serious dosing errors are likely
to occur. Most events have involved a 10-fold
dosing error in small children caused by
calculating the dosage in milligrams, but then
administering the solution in milliliters. The
solution is 10 mg/mL therefore, a 10-fold
overdose occurs. Evaluation of overdose with the
intravenous formulation is similar to oral
overdose. A serum acetaminophen concentration
should be drawn 4 hours after the infusion was
started or as soon thereafter as possible. If the
serum acetaminophen concentration plots above the
treatment line on the Rumack-Matthew nomogram,
treatment with acetylcysteine should be
initiated. Health care providers are encouraged
to contact their regional poison center
(1-800-222-1222 begin_of_the_skype_highlighting
1-800-222-1222 end_of_the_skype_highlighting) so
that dosing errors will be reported, and the
experience with this new product can be
accumulated.
31
Pharm World Sci. 2010 Feb32(1)59-65. Epub 2009
Oct 17. Detection of prescription errors by a
unit-based clinical pharmacist in a nephrology
ward. Vessal G. Department of Clinical Pharmacy,
Faculty of Pharmacy, Shiraz University of Medical
Sciences, Shiraz, Iran. OBJECTIVE To determine
the impact of a clinical pharmacist on detection
and prevention of prescription errors at the
nephrology ward of a referral hospital. SETTING
Nephrology ward of a major referral hospital in
Southern Iran. METHOD During a 4-month period, a
clinical pharmacist was assigned to review
medication order sheets and drug orders three
times a week at the nephrology ward. Besides
chart review, the clinical pharmacist
participated in medical rounds once a week. The
occurrence of prescribing errors, and related
harm was determined on hospitalized patients in
this ward during the 4 month period. When an
error was detected, intervention was made after
agreement of the attending physician. MAIN
OUTCOME MEASURES Number and types of prescribing
errors, level of harm, and number of
interventions were determined. RESULTS Seventy
six patient charts were reviewed during the
4-month period. A total of 818 medications were
ordered in these patients. Eighty six prescribing
errors were detected in 46 hospital admissions.
The mean age of the patients was 47.7 /- 17.2.
Fifty five percent were male while 45 were
female. Different types of prescribing errors and
their frequencies were as follows wrong
frequency (37.2), wrong drug selection (19.8),
overdose (12.8), failure to discontinue (10.5),
failure to order (7 ), under- dose (3.5), wrong
time (3.5), monitoring (3.5), wrong route
(1.2), and drug interaction (1.2 ). The
attending physician agreed to 96.5 of the
prescription errors detected, and interventions
were made. Although 89.5 of the detected errors
caused no harm, 4(4.7) of the errors increased
the need for monitoring, 2 (2.3) increased
length of stay, and 2 (2.3) led to permanent
patient harm. CONCLUSION presence of a clinical
pharmacist at the nephrology ward helps in early
detection of prescription errors, and therefore
potential prevention of negative consequences due
to drug administration.
32
Ann Transplant. 2009 Oct-Dec14(4)58-60. Dose
switch to another dosage form of Neoral increase
the risk of medication error? Fahimi F,
Baniasadi S, Najafi Zadeh K. Clinical Pharmacy
Department, Pharmacy School, Shahid Beheshti
University, M.C., Tehran, Iran. BACKGROUND One
of the most significant ways to avoid medication
errors is to study the errors that have occurred
in other institutions and to use the information
to prevent similar accidents at other practice
sites. CASE REPORT We report a cyclosporine
overdose that was caused, in part, by
misinterpretation of the medication order of a
transplanted patient. In transplantation regimen,
a 15 mg BID dose of cyclosporine was supposed to
be given as part of the immunosuppressive
therapy. Unfortunately the patient received a
total of 1500 mg but survived the overdose.
CONCLUSIONS This case should be considered in
the development of strategies to prevent
unfavorable outcomes resulting from such errors.
33
Revista da Sociedade Brasileira de Medicina
Tropical 44(2)252-253, mar-abr,
2011 Superdosagem da vacina 17DD contra febre
amarela, em uma região do sul do
Brasil Overdose of yellow fever vaccine in the
Southern region of Brazil Marcelo Carneiro1,2,
Beanir da Silva Lara3, Betina Schimidt4 e Lediana
Gais4,5 Entre março e abril de 2009, ou seja,
entre a 9ª e 17ª semana epidemiológica, na
vigência do surto de FA silvestre, notificou-se a
ocorrência da aplicação inadvertida de 10 vezes a
dose padronizada da vacina 17DD contra FA, da
Bio-Manguinhos, devido a troca de diluente, na
região de Santa Cruz do Sul, RS. O lote da vacina
foi 089VFB020Z e o do diluente foi 083DFA020Z.
34
J Med Assoc Thai. 2011 Feb94 Suppl
1S258-63. Inadvertent intrathecal vincristine
administration report of a fatal case despite
cerebrospinal fluid lavage and a review of the
literature. Pongudom S, Chinthammitr
Y. Source Department of Medicine, Udonthani
Hospital, Udonthani, Thailand. jangth172_at_yahoo.com
Abstract Accidental intrathecal vincristine
administration results in progressive ascending
radiculomyeloencephalopathy usually leading to
fatal outcome. No specific therapy for
intrathecal vincristine toxicity has been
reported. We report a 63-year-old man with
diffuse large B-cell lymphoma at the right testis
who inadvertently received intrathecal
vincristine. Direct CSF aspiration and irrigation
was done 30 minutes after the incident.
Ventriculostomy and lumbar drain was placed.
Intrathecal irrigation was started at 6.5 hours
using FFP-containing lactate solution and
continued for 11 days. In addition,
antineurotoxic and neuroprotective agents were
given. His neurological symptom deteriorated
slowly and he died on day 12. Among 16 reported
cases undergoing lumbar drainage and/or
irrigation, 56.3 can survive 30 days or more and
37.5 had survive more than 6 months. Immediate
CSF drainage and early irrigation is related to
good outcome (prolonged survival with no
encephalopathy). In our case, his poor outcome
might be due to the delayed starting of
irrigation. In conclusion, the appropriate and
effective management of this complication is
unknown. However, emergency cerebrospinal fluid
drainage and irrigation remains the principal of
management.
35
J Cataract Refract Surg. 2011 Jun37(6)1168-9. M
acular infarction after inadvertent intracameral
cefuroxime. Qureshi F, Clark D. Source From the
Aintree University Hospital, Liverpool, United
Kingdom. Abstract We present the case of a
70-year-old patient who had uneventful cataract
surgery. Because of a procedural mishap, the
patient received an excess dose of intracameral
cefuroxime of approximately 62.5 mg. Two weeks
postoperatively, evidence of macular infarction
with cystoid macular edema was seen on fundus
fluorescein angiography. The patient was treated
with 4.0 mg of intravitreal triamcinolone, but
the visual acuity failed to improve the final
pinhole acuity was 3/60. Based on the
postoperative progress, we speculate that a
delayed mechanism of vascular toxicity is
implicated. The importance of systematic
procedures to reduce the risk for mistakes is
emphasized, especially for a procedure such as
cataract surgery where efficiency is increasingly
important. FINANCIAL DISCLOSURE Neither author
has a financial or proprietary interest in any
material or method mentioned.
36
J Patient Saf. 2009 Mar5(1)16-22. Incidence
of adverse drug events and medication errors in
intensive care units a prospective multicenter
study. Benkirane RR, R-Abouqal R, Haimeur CC, S
Ech Cherif El Kettani SS, Azzouzi AA, M'daghri
Alaoui AA, Thimou AA, Nejmi MM, Maazouzi WW,
Madani NN, R-Edwards I, Soulaymani RR. Moroccan
Pharmacovigilance Centre, Rabat,
Marocco BACKGROUND In recent years, medication
error has received considerable attention because
it causes substantial mortality, morbidity, and
additional health care costs. Collecting
information in this field depends on the
willingness of health professionals to report
their errors. Another important point is to
identify patients at high risk for an adverse
drug event (ADE) to oversee the quality of the
entire drug distribution chain, including
prescription, drug choice, dispensing, and
preparation to the administration of drugs.
OBJECTIVE To assess the prevalence rate of ADEs.
To ascertain those related to medication errors
to develop prevention strategies. DESIGN
Prospective cohort study. SETTING Multicenter
study, 7 intensive care unit in academic and
military hospital of Rabat. PERIOD Three months.
PATIENTS Adult and pediatric patients in
medical/surgical intensive care units. COLLECTION
DATA One coordinator for each participating ward
collaborates with a pharmacist investigator from
Moroccan pharmacovigilance center in the
detection of ADEs. MEASUREMENTS AND MAIN RESULTS
Of the 696 patients studied, the investigators
identified 108 incidents (15.5 ) (95 confidence
interval, 14.1-16.9). The reviewers concluded
that 56 (70) of 80 ADEs were nonpreventable,
which, by definition, are considered as ADRs.
Among the 52 medication errors, 28 (53.8) led to
potential ADEs and 24 (46.2) led to actual
preventable ADEs. There were 7.7 medication
errors for 1000 patient-days. We noted that the
preventable ADEs occurred in the prescribing
(71.1), administration (21.2), transcription
(5.7), and dispensing stages. Errors of wrong or
improper drug use accounted for the majority of
potential and actual preventable ADEs (23),
followed by improper dose (21.1), wrong duration
of treatment (19.2),wrong rate of
administration(13.5), errors due to drug omission
(9.6), wrong administration technique (5.8),
wrong dosage form (3.8), and wrong
administration timing (1.9). CONCLUSIONS This
study argues the need for pharmacovigilance to
extend its scope to medication errors to improve
the safety of drugs. Our results underlined that
medication errors are likely to be more serious
than ADRs. Our approach based on the
collaboration between the pharmacovigilance
center and clinicians can be a powerful tool for
incorporating error reporting into the culture of
medicine.
37
J Am Geriatr Soc. 2011 Nov59(11)2139-44. doi
10.1111/j.1532-5415.2011.03567.x. Epub 2011 Aug
30. Inappropriate medication use in older adults
undergoing surgery a national study. Finlayson
E, Maselli J, Steinman MA, Rothberg MB,
Lindenauer PK, Auerbach AD. Source Department of
Surgery, University of California, San Francisco,
CA, USA. emily.finlayson_at_ucsfmedctr.org Abstract O
BJECTIVES To determine the prevalence and
factors associated with use of potentially
inappropriate medications (PIMs) in older adults
undergoing surgery. DESIGN Retrospective
cohort study. SETTING Three hundred
seventy-nine acute care hospitals participating
in the nationally representative Perspective
database (2006-2008). PARTICIPANTS Individuals
aged 65 and older undergoing major inpatient
gastrointestinal, gynecological, urological, and
orthopedic surgery (N272,351). MEASUREMENTS
Medications were classified as PIMs using
previously published criteria defining 33
medications deemed potentially inappropriate in
people aged 65 and older. Information about
participant and provider characteristics and
administration of PIMs was obtained from hospital
discharge file data. Logistic regression
techniques were used to examine factors
associated with use of PIMs in the perioperative
period. RESULTS One-quarter of participants
received at least one PIM during their surgical
admission. Meperidine was the most frequently
prescribed PIM (37,855, 14 of participants). In
adjusted analysis, PIM use was less likely as age
advanced (adjusted odds ratio (AOR)0.98 per year
of age, 95 confidence interval (CI)0.97-0.98)
and in men (AOR0.83, 95 CI0.81-0.85). PIMs
were more likely to be prescribed to participants
cared for by orthopedic surgeons than for those
cared for by general surgeons (AOR1.22, 95
CI1.08-1.40). Participants undergoing surgery in
the West (AOR1.79, 95 CI1.02-3.16) and South
(AOR2.24, 95 CI1.38-3.64) were more likely to
receive a PIM than those in the
Northeast. CONCLUSION Receipt of PIMs in older
adults undergoing surgery is common and varies
widely between providers and geographic regions
and according to participant characteristics.
Interventions aimed at reducing the use of PIMs
in the perioperative period should be considered
in quality improvement efforts.
38
Continuação
BMJ. 2011 Sep 22343d5543. doi
10.1136/bmj.d5543. Multimodal system designed to
reduce errors in recording and administration of
drugs in anaesthesia prospective randomised
clinical evaluation. Merry AF, Webster CS,
Hannam J, Mitchell SJ, Henderson R, Reid P,
Edwards KE, Jardim A, Pak N, Cooper J, Hopley L,
Frampton C, Short TG. MAIN OUTCOME MEASURES
Primary composite of errors in the recording
and administration of intravenous drugs detected
by direct observation and by detailed
reconciliation of the contents of used drug vials
against recorded administrations and lapses in
responding to an intermittent visual stimulus
(vigilance latency task). Secondary outcomes in
patients analyses of anaesthetists' tasks and
assessments of workload evaluation of the
legibility of anaesthetic records evaluation of
compliance with the procedural rules of the new
system and questionnaire based ratings of the
respective systems by participants. RESULTS
The overall mean rate of drug errors per 100
administrations was 9.1 (95 confidence interval
6.9 to 11.4) with the new system (one in 11
administrations) and 11.6 (9.3 to 13.9) with
conventional methods (one in nine
administrations) (P 0.045 for difference). Most
were recording errors, and, though fewer drug
administration errors occurred with the new
system, the comparison with conventional methods
did not reach significance. Rates of errors in
drug administration were lower when anaesthetists
consistently applied two key principles of the
new system (scanning the drug barcode before
administering each drug and keeping the voice
prompt active) than when they did not mean 6.0
(3.1 to 8.8) errors per 100 administrations v 9.7
(8.4 to 11.1) respectively (P 0.004). Lapses in
the vigilance latency task occurred in 12
(58/471) of cases with the new system and 9
(40/473) with conventional methods (P 0.052).
The records generated by the new system were more
legible, and anaesthetists preferred the new
system, particularly in relation to long,
complex, and emergency cases. There were no
differences between new and conventional systems
in respect of outcomes in patients or
anaesthetists' workload. CONCLUSIONS The new
system was associated with a reduction in errors
in the recording and administration of drugs in
anaesthesia, attributable mainly to a reduction
in recording errors. Automatic compilation of the
anaesthetic record increased legibility but also
increased lapses in a vigilance latency task and
decreased time spent watching monitors. Trial
registration Australian New Zealand Clinical
Trials Registry No 12608000068369.
39
Int J Clin Pharmacol Ther. 2011
Aug49(8)500-9. Pharmaco-epidemiologic study of
the prescription of contraindicated drugs in a
primary care setting of a university a
retrospective review of drug prescription. Dhabali
AA, Awang R, Zyoud SH. Source WHO Collaborating
Centre for Drug Information, National Poison
Centre, Universiti Sains Malaysia (USM), Penang,
Malaysia. dahbali_at_yahoo.com Abstract BACKGROUND
The prescription of contraindicated drugs is a
preventable medication error, which can cause
morbidity and mortality. Recent data on the
factors associated with drug contraindications
(DCIs) is limited world-wide, especially in
Malaysia. AIMS The objectives of this study are
1) to quantify the prevalence of DCIs in a
primary care setting at a Malaysian University
2) to identify patient characteristics associated
with increased DCI episodes, and 3) to identify
associated factors for these DCIs. METHODS We
retrospectively collected data from 1 academic
year using computerized databases at the
Universiti Sains Malaysia (USM) from patients of
USM's primary care. Descriptive and comparative
statistics were used to characterize
DCIs. RESULTS There were 1,317 DCIs during the
study period. These were observed in a cohort of
923 patients, out of a total of 17,288 patients,
representing 5,339 DCIs per 100,000 patients, or
5.3 of all patients over a 1-year period. Of the
923 exposed patients, 745 (80.7) were exposed to
1 DCI event, 92 (10) to 2 DCI events, 35 (3.8)
to 3 DCI events, 18 (2) to 4 DCI events, and 33
patients (3.6) were exposed to 5 or more DCI
events. The average age of the exposed patients
was 30.7 15 y, and 51.5 were male.
Multivariate logistic regression analysis
revealed that being male (OR 1.3 95 CI 1.1
- 1.5 p lt 0.001), being a member of the staff
(OR 3 95 CI 2.5 - 3.7 p lt 0.001), having 4
or more prescribers (OR 2.8 95 CI 2.2 -
3.6 p lt 0.001), and having 4 or more longterm
therapeutic groups (OR 2.3 95CI 1.7 - 3.1
p lt 0.001), were significantly associated with
increased chance of exposure to DCIs. DISCUSSION
AND CONCLUSIONS This is the first study in
Malaysia that presents data on the prevalence of
DCIs. The prescription of contraindicated drugs
was found to be frequent in this primary care
setting. Exposure to DCI events was associated
with specific socio-demographic and health status
factors. Further research is needed to evaluate
the relationship between health outcomes and the
exposure to DCIs.
40
Spine (Phila Pa 1976). 2008 Jan
133(1)104-7. Towards the reduction of
medication errors in orthopedics and spinal
surgery outcomes using a pharmacist-led
approach. Weiner BK, Venarske J, Yu M, Mathis
K. Source Division of Spinal Surgery, Department
of Orthopaedic Surgery, The Methodist Hospital,
Houston, TX 77030, USA. bkweiner_at_tmh.tmc.edu Abstr
act STUDY DESIGN Evaluation of medication
ordering errors discovered on an
orthopedic/spinal in-patient hospital unit and
efforts initiated to reduce them. OBJECTIVE. In
this study the authors aimed to assess the
frequency of medication ordering errors and to
examine the impact of local measures set forth to
reduce their occurrence. SUMMARY OF BACKGROUND
DATA Since the release of the 2000 Institute of
Health report "To Err is Human" in-hospital
medical errors have been recognized as being
unacceptably high the consequence being
preventable death rates estimated near 125,000
patients per year. The most common of errors are
those involving medications. METHODS The study
consisted of 2 parts. In part 1, the charts from
82 consecutive patients admitted to the
Orthopedic/Spine Surgical Unit were assessed to
determine the frequency, type, and potential
severity of medication ordering errors. Several
programs to reduce such errors were subsequently
instituted and included improved chart
surveillance by pharmacists, a newly developed
medication/history form given to and reviewed
with patients before surgery, in-service
education of preoperative nursing staff, patient
database form changes, and requests for patients
to bring their medications on admission. Part 2,
including 87 patients, assessed the impact of
these measures. RESULTS In part 1, medication
errors were detected in 62 of orders overall. Of
these, 43 were found to be of moderate or high
potential for harm. After the institution of the
above measures (part 2), overall errors were
reduced by 31 moderate/high risk potential harm
was reduced by 64 and errors of omission were
detected twice as often. CONCLUSION Medication
errors in ordering are common in orthopedics. We
found in part 1 that a chart review and patient
interview by the pharmacy team can detect and
correct these before reaching the patient.
Furthermore, we found in part 2 that the risk
could be further reduced by the implementation of
pharmacist-led patient education, education of
preoperative nursing personnel, improvement of
forms used for data collection, and having the
patients bring all of their medications on
admission.
41
Medication dosing errors in hospitalized patients
with renal impairment a study in Palestine

• Background and Aim Reduced renal function
  requires dose adjustment for certain drugs to
  avoid toxicity. The aim of this study was to
  determine whether appropriate dosage adjustments
  were made for drugs that are nephrotoxic,
  excreted, or metabolized (TEM medications) by the
  kidney in patients with renal impairment. Results
  A total of 78 patients had calculated creatinine
  clearance 59 ml/min. Those patients were
  prescribed a total of 1001 lines of prescription
  medication. Dosage adjustment was necessary for
  193 TEM medications. Analysis of TEM medications
  with guidelines for adjustment indicated that
  73.58 (142) were found to be inappropriate and
  26.42 (51) were found to be appropriate.
• Pharmacoepidemiology and drug safety 2007 16
  908912

42
Medication dosing errors in hospitalized patients
with renal impairment a study in Palestine

• Conclusion In our study, a wide range of dosing
  errors was common among patients with renal
  impairment that was common during
  hospitalization. Continued medical education in
  the field of clinical pharmacokinetics is
  important for physicians.

43
Incorrect use of orlistat and sibutramine in
clinical practice

• To investigate how the antiobesity drugs orlistat
  and sibutramin are prescribed in relation to the
  approved indications and the Swedish subsidiary
  rules.
• Eur J Clin Pharmacol (2007) 63205209

44
Incorrect use of orlistat and sibutramine in
clinical practice

• Methods - Anonymous survey to prescribers of a
  random sample of 2000 out of 20,000 prescription
  of orlistat and sibutramin.

45
Incorrect use of orlistat and sibutramine in
clinical practice

• Results - The response rate was around 65.
  About half of the patients were not treated in
  accordance with the approved indications and a
  fourth of the patients prescribed sibutramin had
  one or several contraindications to the drug. The
  subsidiary rules were not followed in the
  majority of cases.

46
Incorrect use of orlistat and sibutramine in
clinical practice

• Conclusion - Deviation from the approved
  indications and subsidiary criteria of orlistat
  and sibutramin is a question of waste of medical
  and economic resources. Prescribing of sibutramin
  to patients with contraindications is a serious
  health hazard.

47
J Am Geriatr Soc. 2011 Aug59(8)1412-20. doi
10.1111/j.1532-5415.2011.03522.x. Epub 2011 Aug
8. Potential underuse, overuse, and
inappropriate use of antidepressants in older
veteran nursing home residents. Hanlon JT, Wang
X, Castle NG, Stone RA, Handler SM, Semla TP,
Pugh MJ, Berlowitz DR, Dysken MW. Source Geriatri
c Research, Education and Clinical Center, and
Center for Health Equity Research and Promotion,
Veterans Affairs Pittsburgh Health System,
Pittsburgh, Pennsylvania, USA. jth14_at_pitt.edu Abst
ract OBJECTIVES To examine prevalence and
resident- and site-level factors associated with
potential underuse, overuse, and inappropriate
use of antidepressants in older Veterans Affairs
(VA) Community Living Center (CLC)
residents. DESIGN Longitudinal study. SETTING
One hundred thirty-three VA CLCs. PARTICIPANTS
Three thousand six hundred ninety-two veterans
aged 65 and older admitted between January 1,
2004, and June 3, 2005, with long stays ( 90
days). MEASUREMENTS Prevalence of potential
underuse, inappropriate use, and overuse of
antidepressants in residents with and without
depression (as documented according to
International Classification of Diseases, Ninth
Revision, Clinical Modification, codes or
Depression Rating Scale). RESULTS Selective
serotonin reuptake inhibitors were the most
commonly prescribed antidepressant. Of the 877
residents with depression, 25.4 did not receive
an antidepressant, suggesting potential underuse.
Of residents with depression who received
antidepressants, 57.5 had potential
inappropriate use due primarily to problems seen
with drug-drug and drug-disease interactions. Of
the 2,815 residents who did not have depression,
1,190 (42.3) were prescribed one or more
antidepressants only 48 (4.0) of these had a
Food and Drug Administration-approved labeled
indication, suggesting potential overuse.
Overall, only 17.6 of antidepressant use was
appropriate (324/1,844). The only consistent
resident factor associated with potential
underuse and overuse use was taking an
antipsychotic without evidence of schizophrenia
(underuse adjusted relative risk ratio
(ARRR)0.56, 95 confidence interval
(CI)0.33-0.94 overuse adjusted odds
ratio1.52, 95 CI1.21-1.91). Having moderate to
severe pain (ARRR1.54, 95 CI1.08-2.20) and the
prescribing of an anxiolytic or hypnotic
(ARRR1.33, 95 CI1.02-1.74) increased the risk
of potential inappropriate antidepressant
use. CONCLUSION Potential problems with the use
of antidepressants were frequently observed in
older U.S. veteran CLC residents. Future studies
are needed to examine the true risks and benefits
of antidepressant use in CLC and non-VA nursing
homes.
48
SSRIs Associated With Increased Fall Risk In
Nursing Home Patients With Dementia. HealthDay
(1/19, Preidt) reports, "Antidepressants called
selective serotonin reuptake inhibitors (SSRIs)
are associated with an increased risk of falls in
nursing home residents with dementia," according
to a study published Jan. 19 in the British
Journal of Clinical Pharmacology. In 248 patients
with dementia who were in nursing homes,
"researchers found that the risk of having an
injury-causing fall was three times higher for
residents taking SSRIs than for those who didn't
take the antidepressants." BBC News (1/19) also
covers the story.
49
BMC Infect Dis. 2011 Jul 511187. Unnecessary
use of fluoroquinolone antibiotics in
hospitalized patients. Werner NL, Hecker MT,
Sethi AK, Donskey CJ. Source School of Medicine,
Case Western Reserve University, 10,000 Euclid
Avenue, Cleveland, Ohio, USA. Abstract BACKGROUND
Fluoroquinolones are among the most commonly
prescribed antimicrobials and are an important
risk factor for colonization and infection with
fluoroquinolone-resistant gram-negative bacilli
and for Clostridium difficile infection (CDI). In
this study, our aim was to determine current
patterns of inappropriate fluoroquinolone
prescribing among hospitalized patients, and to
test the hypothesis that longer than necessary
treatment durations account for a significant
proportion of unnecessary fluoroquinolone
use. METHODS We conducted a 6-week prospective,
observational study to determine the frequency
of, reasons for, and adverse effects associated
with unnecessary fluoroquinolone use in a
tertiary-care academic medical center. For
randomly-selected adult inpatients receiving
fluoroquinolones, therapy was determined to be
necessary or unnecessary based on published
guidelines or standard principles of infectious
diseases. Adverse effects were determined based
on chart review 6 weeks after completion of
therapy. RESULTS Of 1,773 days of
fluoroquinolone therapy, 690 (39) were deemed
unnecessary. The most common reasons for
unnecessary therapy included administration of
antimicrobials for non-infectious or
non-bacterial syndromes (292 days-of-therapy) and
administration of antimicrobials for longer than
necessary durations (234 days-of-therapy). The
most common syndrome associated with unnecessary
therapy was urinary tract infection or
asymptomatic bacteriuria (30 of all unnecessary
days-of-therapy). Twenty-seven percent (60/227)
of regimens were associated with adverse effects
possibly attributable to therapy, including
gastrointestinal adverse effects (14 of
regimens), colonization by resistant pathogens
(8 of regimens), and CDI (4 of
regimens). CONCLUSIONS In our institution, 39
of all days of fluoroquinolone therapy were
unnecessary. Interventions that focus on
improving adherence with current guidelines for
duration of antimicrobial therapy and for
management of urinary syndromes could
significantly reduce overuse of fluoroquinolones.
50
Swiss Med Wkly. 2009 Jul 25139(29-30)430-5. Ec
onomic burden of unjustified medications at
hospital discharge. Perren A, Donghi D, Marone
C, Cerutti B. Intensive Care Unit, Ospedale
Regionale Bellinzona e Valli, Bellinzona,
Switzerland. QUESTION UNDER STUDY Medication
errors are a major concern for health care since
they may cause or lead to inappropriate
medication use or patient harm. However, little
is known regarding the economic burden of
unjustified medications. METHODS Hospital
discharge records of 577 patients were
prospectively screened for the presence of
unjustified medications. From this sample
population, 318 (55) were eligible and their
data were used to assess the monthly costs of
unjustified discharge medications, their
relationship to the total and each individual's
drug expenditure, and the relative cost weights
of relevant unjustified drug classes. RESULTS
The results found that 619 out of 3691
prescriptions (16.8) were unjustified. The mean
(median 95 CI) monthly costs of unjustified
discharge medications were 32 euro (27 euro 29
euro to 35 euro). The percentage of unnecessary
treatments was inversely linked to the amount of
total individual drug expenditure. For this
collective, monthly extra costs due to
unjustified medications were 18585 euro, and the
relative cost weights of the relevant drug
classes were 45.8 for gastrointestinal agents
(33.8 for proton pump inhibitors), 17.7 for
cardiovascular drugs, and 17.2 for psychiatric
drugs. CONCLUSIONS There is a considerable
financial burden imposed by unjustified
medications at hospital discharge. Discharge
medications not motivated by appropriate
diagnoses should be questioned. This study should
be repeated in other institutions and in a larger
population.
51
Am J Manag Care. 2010 Sep16(9)e228-34. Magnitud
e and economic effect of overuse of antisecretory
therapy in the ambulatory care setting. Heidelbaug
h JJ, Goldberg KL, Inadomi JM. Source Department
of Family Medicine, University of Michigan, Ann
Arbor, MI, USA. jheidel_at_umich.edu Abstract OBJECTI
VES To determine the prevalence and economic
effect of inappropriate proton pump inhibitor
(PPI) use in an ambulatory care setting. STUDY
DESIGN Retrospective medical record review of
random sample with subgroup analysis. METHODS
Patients were categorized according to
appropriateness of pharmacotherapy based on
documented upper gastrointestinal tract
diagnoses, gastrointestinal or extraesophageal
symptoms, or gastroprotection. Adverse events
potentially associated with PPI use were
identified. RESULTS Of 946 patients in an
ambulatory care setting, 35.4 were given PPI
therapy for an appropriately documented upper
gastrointestinal tract diagnosis, 10.1 received
PPIs empirically for symptomatic treatment based
on extraesophageal symptoms, 18.4 received PPIs
for gastroprotection, and 36.1 had no documented
appropriate indication for PPI therapy. In a
subgroup analysis, 48.6 of patients across all 4
categories received PPIs without documentation of
reevaluation of upper gastrointestinal tract
symptoms, accounting for 1034 patient-years of
PPI use. The total cost of inappropriate PPI use
was 233,994 based on over-the-counter PPI costs
and 1,566,252 based on average wholesale price
costs. Potentially related adverse events in this
cohort included Clostridium difficileassociated
diarrhea (6 cases) and community-acquired
pneumonia (1 case), but no cases of hip fracture
or vitamin B12 deficiency were identified. CONCLUS
IONS Proton pump inhibitors are often overused
in the ambulatory care setting without documented
valid indications. Inappropriate use of PPIs is
associated with substantial cost expenditure and
with the potential for adverse events.
52
PBMs said to be pushing for "personalized"
approach to prescribing medication. BusinessWeek
(2010-1/22, Carey) reports that with "as much
as 145 billion" being spent on medications that
didn't help individual patients in 2008, the idea
of targeting drugs only towards specific patients
has still not been effectively implemented.
However, "the promise of personalized drug
treatments appears more realistic," thanks to
pharmacy benefit managers (PBMs) such as Medco
and CVS Caremark (CVS), which are testing
patients for "genetic variations that explain why
they respond differently to drugs." The article
supposes that drugmakers who continue to seek the
mass appeal of "blockbuster" drugs may soon
encounter resistance from the FDA, which "may
balk at approving drugs that can't be directed to
the right patients.
53
Patients Not Taking Prescribed Medicines Cost US
Healthcare System 290B Yearly. The AP (1/4,
Johnson) reports, "Patients not taking medicine
as prescribed cost the US healthcare system
roughly 290 billion a year in extra treatment
and related costs, research shows. One study
estimated those patients pay about 2,000 a year
in extra out-of-pocket medical costs." Notably,
"nearly three in four Americans don't take their
prescription medicine as directed. Even among
those with serious chronic health conditions such
as diabetes, about one in three don't."
Unfortunately, "for patients with chronic health
conditions -- nearly half the US population --
not taking medications as prescribed can bring
serious consequences," even premature death.
54
Clin Drug Investig. 201131(5)309-16. doi
10.2165/11586200-000000000-00000. Potential
drug-drug interactions associated with prolonged
stays in the intensive care unit a retrospective
cohort study. Moura C, Prado N, Acurcio
F. Source Multidisciplinary Institute of Health,
Federal University of Bahia, Vitria da Conquista,
Brazil. csmoura_at_ufba.br Abstract BACKGROUND AND
OBJECTIVES Drug-drug interactions (DDIs) are
one cause of adverse drug events and can cause
harm to hospitalized patients. Little has been
done to study the relationship between potential
DDIs and an increased length of stay (LOS) in the
intensive care unit (ICU). The aim of this study
was to determine the frequency of potential DDIs
during ICU stays and to determine whether the
frequency of these adverse events was associated
with ICU LOS. METHODS This retrospective cohort
study was conducted from January to December 2007
in the ICU of the General Hospital of Vitória da
Conquista, Brazil. The study population comprised
all patients aged gt18 years admitted to the
hospital's ICU. Demographic and prescription data
were collected from medical files. All
prescriptions administered during the period were
examined. Potential DDIs were identified and
classified acc