Katja Taxis

Incidence and nature of medication errors in neonatal intensive care with strategies to improve safety - A review of the current literature

Neonates are highly vulnerable to medication errors because of their extensive exposure to medications in the neonatal intensive care unit (NICU), the general lack of evidence on pharmacotherapeutic interventions in neonates and the lack of neonate-specific formulations. We searched PubMed and EMBASE to identify relevant original studies published in the English language. Eleven studies were identified on the frequency of medication errors in the NICU. The highest rate was 5.5 medication errors per 100 prescriptions; however, medication error rates varied widely between studies, partly due to differences in the definition of an error and the rigor of the method used to identify medication errors. Furthermore, studies were difficult to compare because medication error rates were calculated differently. Most studies did not assess the potential clinical impact of the errors. The majority of studies identified dose errors as the most common type of error. Computerised physician order entry and interventions by clinical pharmacists (e.g. the participation of pharmacists in ward rounds and review of patients’ prescriptions prior to dispensing) were the most common interventions suggested to improve medication safety in the NICU. However, only very limited data were available on evaluation of the effects of such interventions in NICUs. More research is needed to determine the frequency and types of medication errors in NICUs and to develop evidence-based interventions to improve medication safety in the NICU setting. Some of these research efforts need to be directed to the establishment of clear definitions of medication errors and agreement on the methods that should be used to measure medication error rates and their potential clinical impact.

A study of medication reviews to identify drug-related problems of polypharmacy patients in the Dutch nursing home setting

Background:  Little is known about the extent of drug‐related problems of polypharmacy patients in Dutch nursing homes.

A systematic review of instruments to measure depressive symptoms in patients with schizophrenia

BACKGROUND Depressive symptoms require accurate recognition and monitoring in clinical practice of patients with schizophrenia. Depression instruments developed for use in depressed patients may not discriminate depressive symptoms from negative psychotic symptoms. OBJECTIVE We reviewed depression instruments on their reliability and validity in patients with schizophrenia. METHODOLOGY A systematic literature search was carried out in three electronic databases. Psychometric properties were extracted for those instruments of which reliability, divergent, concurrent and predictive validity were reported in one or more publications. RESULTS Forty-eight publications described the reliability and validity of six depression instruments in patients with schizophrenia. The only self-report was the Beck Depression Inventory (BDI). The Brief Psychiatric Rating Scale-Depression subscale (BPRS-D), Positive and Negative Syndrome Scale-Depression subscale (PANSS-D), Hamilton Rating Scale for Depression (HAMD), Montgomery Asberg Depression Rating Scale (MADRS) and Calgary Depression Scale for Schizophrenia (CDSS) were clinician rated. All instruments were reliable for the measurement of depressive symptoms in patients with schizophrenia. The CDSS most accurately differentiated depressive symptoms from other symptoms of schizophrenia (divergent validity), correlated well with other depression instruments (concurrent validity), and was least likely to miss cases of depression or misdiagnose depression (predictive validity). CONCLUSIONS We would recommend to use the CDSS for the measurement of depressive symptoms in research and in daily clinical practice of patients with schizophrenia. A valid self-report instrument is to be developed for the use in clinical practice.

The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care

Objective To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU). Design Prospective study with a preintervention and postintervention measurement using direct observation. Setting NICU in a tertiary hospital in the Netherlands. Intervention A multifaceted educational intervention including teaching and self-study. Main outcome measures The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts. Results The incidence of errors decreased from 49% (43–54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25–36%). Preintervention, 0.3% (0–2%) medications contained severe errors, 26% (21–31%) moderate and 23% (18–28%) minor errors; postintervention, none 0% (0–2%) was severe, 23% (18–28%) moderate and 8% (5–12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29–0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)). Conclusions The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.

The incidence of metabolic syndrome and its reversal in a cohort of schizophrenic patients followed for one year

Cross-sectional studies showed a high prevalence of metabolic syndrome in patients with schizophrenia.This study aimed to identify the incidence of metabolic syndrome and its reversal in a non-preselected cohort of chronic psychotic patients in routine practice in one year follow-up and to find variables to describe development and reversal of metabolic syndrome. This cohort study was conducted as part of a disease management program and patients were included if they had two complete assessments in a one year follow-up. We conducted two logistic regressions to find variables to describe the development of metabolic syndrome and the reversal of metabolic syndrome. At the time of the first assessment 35% (n=92) of the 260 included patients had metabolic syndrome. Within one year 21 patients developed metabolic syndrome and 30 patients had it reversed. This was an incidence of 13% (21/168) and a reversal of 33% (30/92). Smoking, family history of cardiovascular diseases, and duration of disease >6 years was associated with a higher risk of developing metabolic syndrome as well as abdominal obesity and dyslipidemia. Patients with abdominal obesity had a smaller chance of reversing metabolic syndrome. Other variables included in the logistic regression such as receiving cardiovascular/antidiabetic drug treatment or duration of disease >6 years did not alter the risk of reversing the metabolic syndrome. Our study showed that the natural course of metabolic syndrome is dynamic. A considerable number of patients developed or reversed the metabolic syndrome in one year follow-up.

The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study

Background Little is known about interventions to reduce intravenous medication administration errors in hospitals, especially in low- and middle-income countries. Objective To assess the effect of a clinical pharmacist-led training programme on clinically relevant errors during intravenous medication preparation and administration in a Vietnamese hospital. Methods A controlled before and after study with baseline and follow-up measurements was conducted in an intensive care unit (ICU) and a post-surgical unit (PSU). The intervention comprised lectures, practical ward-based teaching sessions and protocols/guidelines, and was conducted by a clinical pharmacist and a nurse. Data on intravenous medication preparation and administration errors were collected by direct observation 12 h/day for seven consecutive days. Generalised estimating equations (GEE) were used to assess the effect of the intervention on the prevalence of clinically relevant erroneous doses, corrected for confounding factors. Results 1204 intravenous doses were included, 516 during the baseline period (236 on ICU and 280 on PSU) and 688 during the follow-up period (407 on ICU and 281 on PSU). The prevalence of clinically relevant erroneous doses decreased significantly on the intervention ward (ICU) from 64.0% to 48.9% (p<0.001) but was unchanged on the control ward (PSU) (57.9% vs 64.1%; p=0.132). GEE analysis showed that doses on the intervention ward were 2.60 (1.27–5.31) times less likely to have clinically relevant errors (p=0.013). Conclusions The pharmacist-led training programme was effective, but the error rate remained relatively high. Further quality improvement strategies are needed, including changes to the working environment and promotion of a safety culture.

Estimating Dopamine D-2 Receptor Occupancy for Doses of 8 Antipsychotics: A Meta-Analysis A Reply

Rationale: Dose equivalents based on dopamine D2 receptor occupancy can be used to compare antipsychotics on D2 receptor-mediated (adverse) effects such as extrapyramidal symptoms and altered emotional experiences. Previous meta-analyses modeling the dose-occupancy relationship hardly addressed potential heterogeneity of the imaging data. Objectives: To model the relationship between dose and D2 receptor occupancy for a series of frequently prescribed antipsychotics while addressing the potential heterogeneity of the imaging data. Methods: We conducted a meta-analysis on published D2 receptor occupancy data (positron emission tomography and single-photon emission computed tomography) in patients with schizophrenia treated with antipsychotics. A nonlinear mixed effects model estimated the median D2 receptor occupancy for a given antipsychotic dose. Heterogeneity between studies was investigated by incorporating study as a random effect in the model, in addition to patient- and study-specific explanatory variables. Results: Included were 51 studies, describing 606 patients (mean T SD age, 32.2 T10.8 years; 25.7% female). The models described the doseoccupancy relationship with narrow confidence bands around the therapeutic dose range. Maximum occupancy (95% confidence interval [CI]) was estimated for haloperidol (91.9%; 95% CI, 86.1Y97.8), risperidone (92.4%; 95% CI, 81.8Y100), olanzapine (96.5%; 95% CI, 85.8Y100), clozapine (61.7%; 95% CI, 49.2Y74.2), quetiapine (49.1%; 95% CI, 18.7Y79.6), aripiprazole (86.9%; 95% CI, 78.2Y95.7), ziprasidone (82.9%; 95% CI, 44.9Y100), and amisulpride (85.0%; 95% CI, 68.5Y100). Interindividual differences explained most of the variability in occupancy values, besides significant heterogeneity between studies. Conclusions: Dose-occupancy functions estimated the median level of dopamine D2 receptor occupancy for 8 frequently prescribed antipsychotics in patients with schizophrenia. These dose equivalents can be

Measuring anticholinergic drug exposure in older community-dwelling Australian men: a comparison of four different measures

AIMS Anticholinergic drug exposure is associated with adverse outcomes in older people. While a number of tools have been developed to measure anticholinergic drug exposure, there is limited information about the agreement and overlap between the various scales. The aim of this study was to investigate the agreement and overlap between different measures of anticholinergic drug exposure in a cohort of community-dwelling older men. METHODS A cross-sectional study was used to compare anticholinergic drug exposure calculated using the Anticholinergic Risk Scale (ARS), the Anticholinergic Drug Scale (ADS), the Anticholinergic Cognitive Burden (ACB) and the Drug Burden Index anticholinergic subscale (DBI-ACH) in a cohort of community-dwelling men aged 70 years and older (n = 1696). Statistical agreement, expressed as Cohens kappa (κ), between these measurements was calculated. RESULTS Differences were found between the tools regarding the classification of anticholinergic drug exposure for individual participants. Thirteen percent of the population used a drug listed as anticholinergic on the ARS, 39% used a drug listed on the ADS and the ACB, and 18% of the population used one or more anticholinergic drugs listed on the DBI-ACH. While agreement was good between the ACB and ADS (κ = 0.628, 95% CI 0.593, 0.664), little agreement was found between remaining tools (κ = 0.091-0.264). CONCLUSIONS With the exception of the ACB and ADS, there was poor agreement regarding anticholinergic drug exposure among the four tools compared in this study. Great care should be taken when interpreting anticholinergic drug exposure using existing scales due to the wide variability between the different scales.

Is the principle of a stable heinrich ratio a myth? - A multimethod analysis

AbstractBackground: Safety improvements are sometimes based on the premise that introducing measures to combat minor or no-harm incidents proportionately reduces the incidence of major incidents involving harm. This is in line with the principle of the Heinrich ratio, which asserts that there is a relatively fixed ratio between the incidence of no-harm incidents, minor incidents and major incidents. This principle has been advocated as a means of targeting and evaluating new safety initiatives. Research Methodology: Both thought experimentation and analysis of empirical data were used to examine the plausibility of this principle. A descriptive statistical analysis was carried out using triangle plots to display the relative frequencies of the occurrence of safety incidents classified as minor, moderate or severe. Findings: Thought experiments indicated that the principle of a fixed Heinrich ratio has a dubious logical foundation. Analysis of emergency department attendance and studies of medication errors demonstrated marked variation in the relative ratios of different outcomes. Triangle plots of UK road traffic accident data revealed a hitherto unrecognized systematic pattern of change that contradicts the principle of the Heinrich ratio. Interpretation: This study of the principle of a fixed Heinrich ratio invalidates it: introducing measures to reduce the incidence of minor incidents will not inevitably reduce the incidence of major incidents pro rata. Any safety policies based on the assumption that the Heinrich ratio is true need to be rethought.

Quantification of anticholinergic and sedative drug load with the Drug Burden Index: a review of outcomes and methodological quality of studies

PurposeThe Drug Burden Index (DBI) is a non-invasive method to quantify patients’ anticholinergic and sedative drug burden from their prescriptions. This systematic review aimed to summarise the evidence on the associations between the DBI and clinical outcomes and methodological quality of studies.MethodsA search in PubMed and Embase (search terms: ‘drug’, ‘burden’, and ‘index’) was performed and experts were contacted. We excluded publications that did not report empirical results or clinical outcomes. Methodological quality was assessed using the Newcastle-Ottawa Scale. Potential omissions of relevant clinical outcomes and populations were studied.ResultsOf the 2998 identified publications, 21 were eligible. Overall, methodological quality of studies was good. In all but one study, adjustment was made for prevalent co-morbidity. The DBI was examined in diverse older individuals, i.e. both males and females from different settings and countries. However, no studies were conducted in other relevant patient groups, e.g. psychiatric patients. Exposure to anticholinergic and sedative drugs was thoroughly ascertained, though the specific calculation of the DBI differed across studies. Outcomes were assessed from medical records, record linkage or validated objective tests or questionnaires. Many studies found associations between the DBI and outcomes including hospitalisation, physical and cognitive function. Cognitive function and quality of life were understudied and the number and scope of longitudinal studies was limited.ConclusionsAn accumulating body of evidence supports the validity of the DBI. Longitudinal studies of cognitive function and quality of life and in other patient groups, e.g. psychiatric patients, are warranted.