R. Fijn

Frequency and determinants of drug administration errors in the intensive care unit

Objective The study aimed to identify both the frequency and the determinants of drug administration errors in the intensive care unit. Design Administration errors were detected by using the disguised-observation technique (observation of medication administrations by nurses, without revealing the aim of this observation to the nurses). Setting Two Dutch hospitals. Patients The drug administrations to patients in the intensive care units of two Dutch hospitals were observed during five consecutive days. Interventions None. Measurements and Main Results A total of 233 medications for 24 patients were observed to be administered (whether ordered or not) or were observed to be omitted. When wrong time errors were included, 104 administrations with at least one error were observed (frequency, 44.6%), and when they were excluded, 77 administrations with at least one error were observed (frequency, 33.0%). When we included wrong time errors, day of the week (Monday, odds ratio [OR] 2.69, confidence interval [CI] 1.42–5.10), time of day (6–10 pm, OR 0.28, CI 0.10–0.78), and drug class (gastrointestinal, OR 2.94, CI 1.48–5.85; blood, OR 0.12, CI 0.03–0.54; and cardiovascular, OR 0.38, CI, 0.16–0.90) were associated with the occurrence of errors. When we excluded wrong time errors, day of the week (Monday, OR 3.14, CI 1.66–5.94), drug class (gastrointestinal, OR 3.47, CI 1.76–6.82; blood, OR 0.21, CI 0.05–0.91; and respiratory, OR 0.22, CI 0.08–0.60), and route of administration (oral by gastric tube, OR 5.60, CI 1.70–18.49) were associated with the occurrence of errors. In the hospital without full-time specialized intensive care physicians (which also lacks pharmacy-provided protocols for the preparation of parenteral drugs), more administration errors occurred, both when we included (OR 5.45, CI 3.04–9.78) and excluded wrong time errors (OR 4.22, CI 2.36–7.54). Conclusions Efforts to reduce drug administration errors in the intensive care unit should be aimed at the risk factors we identified in this study. Especially, focusing on system differences between the two intensive care units (e.g., presence or absence of full-time specialized intensive care physicians, presence or absence of protocols for the preparation of all parenteral drugs) may help reduce suboptimal drug administration.

Cost-Benefit Analysis of the Detection of Prescribing Errors by Hospital Pharmacy Staff

AbstractObjective: Prescribing errors are a major cause of iatrogenic patient morbidity and therefore interventions aimed at preventing the adverse outcomes of these errors are likely to result in cost reduction. However, it is unclear whether the costs associated with these preventive measures are outweighed by the cost reductions (benefits). Therefore, a study was set up to analyse costs and benefits of detecting prescribing errors by hospital pharmacy staff. Design: During 5 consecutive days in two Dutch hospitals in February 2000 all medication orders, in which prescribing errors were detected, were analysed. A cost-benefit analysis was performed, based on direct medical costs only. The benefit-to-cost ratio was calculated by taking into account the net time hospital pharmacy staff needed for the prevention of the error (this included potential time saving for nursing staff, when an error was prevented by hospital pharmacy staff instead of nursing staff), as well as taking into account the possible consequences of the prescribing error (were the error not prevented). Results: A total of 3540 orders, of which 351 contained prescribing errors (9.9%), were analysed. During the 1-week period investigated, time-investment of the pharmacy staff had net costs of EUR285 (2000 values). During the same period estimated benefits related to this investment were EUR9867. The finding of higher benefits than costs was robust in sensitivity analysis. Conclusions: From this study it can be concluded that prevention of prescribing errors by hospital pharmacy staff results in higher benefits than the costs related to the net time investment.

Prevention of heterotopic ossification after total hip replacement with NSAIDs.

Introduction: non steroidal anti‐inflammatory drugs ((NSAIDs) and prophylactic radiotherapy can prevent ectopic bone formation around the hip after total hip arthroplasty. Methods: We retrieved from Medline, Embase and the Cochrane Register (clinical)) trials and other relevant literature on the prevention of heterotopic ossification (HO) from 1990‐2002 for further review.Results: Review of these clinical trials shows that HO is effectively prevented by a postoperative NSAID treatment with indomethacin for at least seven days. The best evidence is available for indomethacin, although naproxen, diclofenac and ibuprofen are also well documented. Short term use of ibuprofen is not effective. If NSAIDs are contraindicated, preoperative or postoperative radiotherapy is a very effective therapeutic option to prevent HO. Discussion and conclusion: Because of the potential of serious gastrointestinal side effects of NSAIDs and their interaction with anticoagulant drugs, rofecoxib and other COX‐2 specific NSAIDs may be a safer option for the treatment of HO. However, randomised controlled studies are needed to confirm the results of the rofecoxib study.

Rational pharmacotherapy and clinical practice guidelines - Theories and perspectives on implementing pharmacotherapeutic treatment guidelines

Several theories behind implementing clinical guidelines have been described within the literature. At first sight, these may seem different. However, there are similarities and eventually they are rather complementary than mutually exclusive. This article integrates several theoretical views on implementation of pharmacotherapeutic treatment guidelines and subsequently addresses some empirical considerations. Furthermore, specific limitations and potential harms of implementating guidelines are addressed. Several checklists are provided in order to make pharmacists, pharmacologists and clinicians aware of perspectives on dissemination, implementation, and subsequent application of pharmacotherapeutic treatment guidelines.