Adriano Max Moreira Reis

Adverse drug events in an intensive care unit of a university hospital

PurposeAdverse drug events (ADEs) are harmful and occur with alarming frequency in critically ill patients. Complex pharmacotherapy with multiple medications increases the probability of a drug interaction (DI) and ADEs in patients in intensive care units (ICUs). The objective of the study is to determine the frequency of ADEs among patients in the ICU of a university hospital and the drugs implicated. Also, factors associated with ADEs are investigated.MethodsThis cross-sectional study investigated 299 medical records of patients hospitalized for 5 or more days in an ICU. ADEs were identified through intensive monitoring adopted in hospital pharmacovigilance and also ADE triggers. Adverse drug reactions (ADR) causality was classified using the Naranjo algorithm. Data were analyzed through descriptive analysis, and through univariate and multiple logistic regression.ResultsThe most frequent ADEs were ADRs type A, of possible causality and moderate severity. The most frequent ADR was drug-induced acute kidney injury. Patients with ADEs related to DIs corresponded to 7% of the sample. The multiple logistic regression showed that length of hospitalization (OR = 1.06) and administration of cardiovascular drugs (OR = 2.2) were associated with the occurrence of ADEs.ConclusionAdverse drug reactions of clinical significance were the most frequent ADEs in the ICU studied, which reduces patient safety. The number of ADEs related to drug interactions was small, suggesting that clinical manifestations of drug interactions that harm patients are not frequent in ICUs.

Prevalence of potential drug interactions in patients in an intensive care unit of a university hospital in Brazil.

OBJECTIVES: To investigate the prevalence of potential drug interactions at the intensive care unit of a university hospital in Brazil and to analyze their clinical significance. METHODS: This cross‐sectional retrospective study included 299 patients who had been hospitalized in the intensive care unit of the hospital. The drugs administered during the first 24 hours of hospitalization, in the 50th length‐of‐stay percentile and at the time of discharge were analyzed to identify potential drug‐drug and drug‐enteral nutrition interactions using DRUG‐REAX® software. The drugs were classified according to the anatomical therapeutic chemical classification. RESULTS: The median number of medications per patient was smaller at the time of discharge than in the 50th length‐of‐stay percentile and in the first 24 hours of hospitalization. There was a 70% prevalence of potential drug interactions at the intensive care unit at the studied time points of hospitalization. Most of the drug interactions were either severe or moderate, and the scientific evidence for the interactions was, in general, either good or excellent. Pharmacodynamic interactions presented a subtle predominance in relation to pharmacokinetic interactions. The occurrence of potential drug interactions was associated with the number of medications administered and the length of stay. Medications that induced cytochrome P450, drugs that prolong the QT interval and cardiovascular drugs were pharmacotherapy factors associated with potential drug interactions. CONCLUSION: The study showed that potential drug interactions were prevalent in the intensive care unit due to the complexity of the pharmacotherapies administered. The interactions were associated with the number of drugs, the length of stay and the characteristics of the administered medications.

Evaluation of three brands of drug interaction software for use in intensive care units

Objective To evaluate drug interaction software programs and determine their accuracy in identifying drug-drug interactions that may occur in intensive care units. Setting The study was developed in Brazil. Method Drug interaction software programs were identified through a bibliographic search in PUBMED and in LILACS (database related to the health sciences published in Latin American and Caribbean countries). The programs’ sensitivity, specificity, and positive and negative predictive values were determined to assess their accuracy in detecting drug–drug interactions. The accuracy of the software programs identified was determined using 100 clinically important interactions and 100 clinically unimportant ones. Stockley’s Drug Interactions 8th edition was employed as the gold standard in the identification of drug-drug interaction. Main outcome Sensitivity, specificity, positive and negative predictive values. Results The programs studied were: Drug Interaction Checker (DIC), Drug-Reax (DR), and Lexi-Interact (LI). DR displayed the highest sensitivity (0.88) and DIC showed the lowest (0.69). A close similarity was observed among the programs regarding specificity (0.88–0.92) and positive predictive values (0.88–0.89). The DIC had the lowest negative predictive value (0.75) and DR the highest (0.91). Conclusion The DR and LI programs displayed appropriate sensitivity and specificity for identifying drug–drug interactions of interest in intensive care units. Drug interaction software programs help pharmacists and health care teams in the prevention and recognition of drug–drug interactions and optimize safety and quality of care delivered in intensive care units.

Adverse drug events in a sentinel hospital in the State of Goiás, Brazil

This was a retrospective, descriptive and documental study with the aim of identifying adverse drug events which occurred in the medication administration process and to classify these medication errors. This study was developed in the internal medicine unit of a general hospital of Goiás, Brazil. Report books used by nursing staff from the period 2002 to 2007, were analyzed. A total of 230 medication errors were identified, most of which occurred in the preparation and administration of the medications (64.3%). Medication errors were of omission (50.9%), of dose (16.5%), of schedule (13.5%) and of administration technique (12.2%) and were more frequent with antineoplastic and immunomodulating agents (24.3%) and anti-infective agents (20.9%). It was found that 37.4% of drugs were high alert medications. Considering the medication errors detected it is important to promote a culture of safety in the hospital.Trata-se de estudo retrospectivo, documental e descritivo que teve como objetivo identificar os eventos adversos a medicamentos, ocorridos no processo administracao de medicamentos, e classificar os erros de medicacao. Este estudo foi desenvolvido na unidade de clinica medica de um hospital geral de Goias, Brasil. Foram analisados os livros utilizados pela equipe de enfermagem, no periodo de 2002 a 2007, para registros de passagem de plantao. Identificaram-se 230 erros de medicacao, sendo a maioria no preparo e administracao de medicamentos (64,3%). Os erros de medicacao foram de omissao (50,9%), de dose (16,5%), de horario (13,5%) e de tecnica de administracao (12,2%), sendo mais frequentes com antineoplasicos e imunomoduladores (24,3%) e anti-infecciosos (20,9%). Constatou-se que 37,4% dos medicamentos eram potencialmente perigosos. Considerando os erros de medicacao detectados, e importante promover cultura de seguranca no hospital.

Desabastecimento de medicamentos: determinantes, conseqüências e gerenciamento

The present study analyzes drug shortage as a problem reaching beyond the logistic aspect of the health field and discusses its consequences with respect to quality, safety and cost of health care delivery. The pharmaceutical supply chain and the factors that determine the distribution and availability of drugs are discussed. The contribution of the Pharmacy and Therapeutics Committee in preventing and managing drug shortage in health institutions is stressed and measures for drug shortage management are suggested. Finally it is emphasized that drugs should be considered health products rather than consumer goods and as such be given a different treatment by the supply chain.

Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study

OBJECTIVE: To analyze the prevalence and types of prescribing and dispensing errors occurring with high-alert medications and to propose preventive measures to avoid errors with these medications. INTRODUCTION: The prevalence of adverse events in health care has increased, and medication errors are probably the most common cause of these events. Pediatric patients are known to be a high-risk group and are an important target in medication error prevention. METHODS: Observers collected data on prescribing and dispensing errors occurring with high-alert medications for pediatric inpatients in a university hospital. In addition to classifying the types of error that occurred, we identified cases of concomitant prescribing and dispensing errors. RESULTS: One or more prescribing errors, totaling 1,632 errors, were found in 632 (89.6%) of the 705 high-alert medications that were prescribed and dispensed. We also identified at least one dispensing error in each high-alert medication dispensed, totaling 1,707 errors. Among these dispensing errors, 723 (42.4%) content errors occurred concomitantly with the prescribing errors. A subset of dispensing errors may have occurred because of poor prescription quality. The observed concomitancy should be examined carefully because improvements in the prescribing process could potentially prevent these problems. CONCLUSION: The system of drug prescribing and dispensing at the hospital investigated in this study should be improved by incorporating the best practices of medication safety and preventing medication errors. High-alert medications may be used as triggers for improving the safety of the drug-utilization system.

Errors in medicine administration - profile of medicines: knowing and preventing

Objectives: To describe the pharmacological characteristics of medicines involved in administration errors and determine the frequency of errors with potentially dangerous medicines and low therapeutic index, in clinical units of five teaching hospitals, in Brazil. Methods: Multicentric study, descriptive and exploratory, using the non-participant observation technique (during the administration of 4958 doses of medicines) and the anatomical therapeutic chemical classification (ATC). Results: Of that total, 1500 administration errors were identified (30.3%). The administration of pharmacological groups - ATC (cardiovascular system, nervous system, alimentary tract and metabolism system and anti-infectives for systemic use) showed a higher frequency of errors. In 13.0% of errors were involved potentially dangerous medicines and in 12.2% medicines with low therapeutic index. Conclusion: The knowledge of the pharmacological profile could be an important strategy to be used in the prevention medication errors in health institutions.OBJETIVOS: Descrever as caracteristicas farmacologicas dos medicamentos envolvidos em erros de administracao e determinar a frequencia desses erros com medicamentos potencialmente perigosos e de baixo indice terapeutico em unidades de clinica medica de cinco hospitais de ensino brasileiros. METODOS: Estudo multicentrico, descritivo/exploratorio utilizando a tecnica de observacao nao participante durante a administracao de 4958 doses de medicamentos e a classificacao anatomica terapeutica quimica (ATC). RESULTADOS: Dentre esse total, foram identificados 1500 erros de administracao de medicamentos (30,3%). A administracao dos farmacos dos grupos ATC - sistema cardiovascular, sistema nervoso, trato alimentar e metabolismo e antinfecciosos de uso sistemico apresentou maior frequencia de erros. Em 13,0% dos erros estavam envolvidos medicamentos potencialmente perigosos e em 12,2% medicamentos de baixo indice terapeutico. CONCLUSAO: O conhecimento do perfil farmacologico pode ser uma importante estrategia a ser utilizada na prevencao de erros de medicacao em instituicoes de saude.

Eventos adversos a medicamentos em um hospital sentinela do Estado de Goiás, Brasil

This was a retrospective, descriptive and documental study with the aim of identifying adverse drug events which occurred in the medication administration process and to classify these medication errors. This study was developed in the internal medicine unit of a general hospital of Goiás, Brazil. Report books used by nursing staff from the period 2002 to 2007, were analyzed. A total of 230 medication errors were identified, most of which occurred in the preparation and administration of the medications (64.3%). Medication errors were of omission (50.9%), of dose (16.5%), of schedule (13.5%) and of administration technique (12.2%) and were more frequent with antineoplastic and immunomodulating agents (24.3%) and anti-infective agents (20.9%). It was found that 37.4% of drugs were high alert medications. Considering the medication errors detected it is important to promote a culture of safety in the hospital.Trata-se de estudo retrospectivo, documental e descritivo que teve como objetivo identificar os eventos adversos a medicamentos, ocorridos no processo administracao de medicamentos, e classificar os erros de medicacao. Este estudo foi desenvolvido na unidade de clinica medica de um hospital geral de Goias, Brasil. Foram analisados os livros utilizados pela equipe de enfermagem, no periodo de 2002 a 2007, para registros de passagem de plantao. Identificaram-se 230 erros de medicacao, sendo a maioria no preparo e administracao de medicamentos (64,3%). Os erros de medicacao foram de omissao (50,9%), de dose (16,5%), de horario (13,5%) e de tecnica de administracao (12,2%), sendo mais frequentes com antineoplasicos e imunomoduladores (24,3%) e anti-infecciosos (20,9%). Constatou-se que 37,4% dos medicamentos eram potencialmente perigosos. Considerando os erros de medicacao detectados, e importante promover cultura de seguranca no hospital.

Erros de administração de antimicrobianos identificados em estudo multicêntrico brasileiro

Medication administration errors (MAE) are the most frequent kind of medication errors. Errors with antimicrobial drugs (AD) are relevant because they may interfere in patient safety and in the development of microbial resistance. The aim of this study is to analyze the AD errors detected in a Brazilian multicentric study of MAE. It was a descriptive and exploratory study carried out in clinical units in five Brazilian teaching hospitals. The hospitals were investigated during 30 days. MAE were detected by observation technique. MAE were classified in categories: wrong route(WR), wrong patient(WP), wrong dose(WD) wrong time (WT) and unordered drug (UD). AD with MAE were classified by Anatomical-Therapeutical-Chemical Classification System. AD with narrow therapeutic index (NTI) were identified. A descriptive statistical analysis was performed using SPSS version 11.5 software. A total of 1500 errors were observed, 277 (18.5%) of them were errors with AD. The types of AD error were: WT 87.7%, WD 6.9%, WR 1.5%, UD 3.2% and WP 0.7%. The number of AD found was 36. The mostly ATC class were fluoroquinolones 13.9%, combinations of penicillin 13.9%, macrolides 8.3% and third-generation cephalosporins 5.6%. The parenteral drug dosage form was associated with 55.6% of AD. 16.7% of AD were NTI. 47.4% of WD and 21.8% WT were with NTI drugs. This study shows that these errors should be considered potential areas for improvement in the medication process and patient safety plus there is requirement to develop rational drug use of AD.

Drug-Induced Nephrotoxicity and Dose Adjustment Recommendations: Agreement Among Four Drug Information Sources.

Hospitalized patients require the use of a variety of drugs, many of which individually or in combination have the potential to cause kidney damage. The use of potentially nephrotoxic drugs is often unavoidable, and the need for dose adjustment should be evaluated. This study is aimed at assessing concordance in information on drug-induced nephrotoxicity and dose adjustment recommendations by comparing four drug information sources (DRUGDEX®, UpToDate®, Medscape® and the Brazilian Therapeutic Formulary) using the formulary of a Brazilian public hospital. A total of 218 drugs were investigated. The global Fleiss’ kappa coefficient was 0.265 for nephrotoxicity (p < 0.001; CI 95%, 0.211–0.319) and 0.346 for recommendations (p < 0.001; CI 95%, 0.292–0.401), indicating fair concordance among the sources. Anti-infectives and anti-hypertensives were the main drugs cited as nephrotoxic by the different sources. There were no clear definitions for qualitative data or quantitative values for dose adjustments among the four information sources. There was no advice for dosing for a large number of the drugs in the international databases. The National Therapeutic Formulary offered imprecise dose adjustment recommendations for many nephrotoxic drugs. Discrepancies among information sources may have a clinical impact on patient care and contribute to drug-related morbidity and mortality.