Robert Likić

Medication errors: problems and recommendations from a consensus meeting.

Here we discuss 15 recommendations for reducing the risks of medication errors: 1. Provision of sufficient undergraduate learning opportunities to make medical students safe prescribers. 2. Provision of opportunities for students to practise skills that help to reduce errors. 3. Education of students about common types of medication errors and how to avoid them. 4. Education of prescribers in taking accurate drug histories. 5. Assessment in medical schools of prescribing knowledge and skills and demonstration that newly qualified doctors are safe prescribers. 6. European harmonization of prescribing and safety recommendations and regulatory measures, with regular feedback about rational drug use. 7. Comprehensive assessment of elderly patients for declining function. 8. Exploration of low-dose regimens for elderly patients and preparation of special formulations as required. 9. Training for all health-care professionals in drug use, adverse effects, and medication errors in elderly people. 10. More involvement of pharmacists in clinical practice. 11. Introduction of integrated prescription forms and national implementation in individual countries. 12. Development of better monitoring systems for detecting medication errors, based on classification and analysis of spontaneous reports of previous reactions, and for investigating the possible role of medication errors when patients die. 13. Use of IT systems, when available, to provide methods of avoiding medication errors; standardization, proper evaluation, and certification of clinical information systems. 14. Nonjudgmental communication with patients about their concerns and elicitation of symptoms that they perceive to be adverse drug reactions. 15. Avoidance of defensive reactions if patients mention symptoms resulting from medication errors.

Essential competencies in prescribing: A first european cross‐sectional study among 895 final‐year medical students

European medical students should have acquired adequate prescribing competencies before graduation, but it is not known whether this is the case. In this international multicenter study, we evaluated the essential knowledge, skills, and attitudes in clinical pharmacology and therapeutics (CPT) of final‐year medical students across Europe. In a cross‐sectional design, 26 medical schools from 17 European countries were asked to administer a standardized assessment and questionnaire to 50 final‐year students. Although there were differences between schools, our results show an overall lack of essential prescribing competencies among final‐year students in Europe. Students had a poor knowledge of drug interactions and contraindications, and chose inappropriate therapies for common diseases or made prescribing errors. Our results suggest that undergraduate teaching in CPT is inadequate in many European schools, leading to incompetent prescribers and potentially unsafe patient care. A European core curriculum with clear learning outcomes and assessments should be urgently developed.

Clinical pharmacology consultation: a better answer to safety issues of drug therapy during pregnancy?

PurposeDrug safety classifications give a very basic estimation of risk and should only be used as general guideline when assessing risk of pregnancy-related drug exposure or planning treatment. We conducted a study to assess the strength of association between both the clinical pharmacologists’ risk assessment and the FDA risk categorization, and adverse pregnancy outcomes.MethodsWe retrospectively reviewed records of 1,076 patients consecutively referred to the clinical pharmacology outpatient clinic for pregnancy-related drug exposure (2000–2008). Clinical pharmacologists’ risk assessments were reviewed in relation to FDA drug categorization and available pregnancy outcomes.ResultsOverall, clinical pharmacologists’ risk estimation was in agreement with the FDA risk categorization system in only 28% of consulted women, and in only 9% of women with high-risk exposure (FDA DX). Clinical pharmacologists’ risk assessment confirming high-risk drug exposure had a better positive predictive value for adverse pregnancy outcomes than the FDA DX categorization (25% vs 14% respectively), while the negative predictive values were similar (92% vs 94% respectively). Clinical pharmacologists’ risk assessment was a better predictor of adverse pregnancy outcomes compared with FDA risk categorization (OR 2.11 [95%CI 1.5-3.1; p < 0.001] vs OR 1.52 [95%CI 1.1-2.1; p = 0.014] respectively).ConclusionsAdditional evaluation beyond the FDA drug classification is essential for safer and more rational drug use in pregnancy. Clinical pharmacologists who have undergone rigorous medical training are ideally placed to consult on administration of medicines in pregnant women, thus making the prescribing of treatments in that patient category substantially safer and more rational.

The effects of problem-based learning integration in a course on rational drug use: a comparative study between two Croatian medical schools.

PurposeYoung doctors write prescriptions regularly from their first day of practice. We investigated final-semester students’ perceptions of their training in relation to prescribing in two Croatian medical schools with different clinical pharmacology (CPT) teaching styles (Zagreb: problem-based and Rijeka: lecture-based course).MethodsA total of 315 students (220 in Zagreb, 95 in Rijeka) underwent a 4-week-long course in CPT in the academic year 2006/2007. We compared the impact of different educational methods on student performance using an MCQ assessment. After the training, students completed a paper questionnaire on prescribing skills and knowledge of pharmacotherapy.ResultsStudents in Rijeka were significantly more satisfied with their traditional lecture-based course. Only 56% of Zagreb students and 54% of students from Rijeka felt confident about their prescription-writing skills. Only 8% of Zagreb and none of Rijeka students had written more than six prescriptions during their entire medical curriculum. There was no difference in the participants’ levels of factual knowledge of rational pharmacotherapy.ConclusionThe style of learning about medicines did not affect students’ factual knowledge. Only half of the student cohort felt confident about their ability to prescribe medicines, and few had practiced this skill during their medical training.

Distributed lags time series analysis versus linear correlation analysis (Pearson's r) in identifying the relationship between antipseudomonal antibiotic consumption and the susceptibility of Pseudomonas aeruginosa isolates in a single Intensive Care Unit of a tertiary hospital

The relationship between antibiotic consumption and selection of resistant strains has been studied mainly by employing conventional statistical methods. A time delay in effect must be anticipated and this has rarely been taken into account in previous studies. Therefore, distributed lags time series analysis and simple linear correlation were compared in their ability to evaluate this relationship. Data on monthly antibiotic consumption for ciprofloxacin, piperacillin/tazobactam, carbapenems and cefepime as well as Pseudomonas aeruginosa susceptibility were retrospectively collected for the period April 2006 to July 2007. Using distributed lags analysis, a significant temporal relationship was identified between ciprofloxacin, meropenem and cefepime consumption and the resistance rates of P. aeruginosa isolates to these antibiotics. This effect was lagged for ciprofloxacin and cefepime [1 month (R=0.827, P=0.039) and 2 months (R=0.962, P=0.001), respectively] and was simultaneous for meropenem (lag 0, R=0.876, P=0.002). Furthermore, a significant concomitant effect of meropenem consumption on the appearance of multidrug-resistant P. aeruginosa strains (resistant to three or more representatives of classes of antibiotics) was identified (lag 0, R=0.992, P<0.001). This effect was not delayed and it was therefore identified both by distributed lags analysis and the Pearsons correlation coefficient. Correlation coefficient analysis was not able to identify relationships between antibiotic consumption and bacterial resistance when the effect was delayed. These results indicate that the use of diverse statistical methods can yield significantly different results, thus leading to the introduction of possibly inappropriate infection control measures.

Key learning outcomes for clinical pharmacology and therapeutics education in Europe: a modified Delphi study

Harmonizing clinical pharmacology and therapeutics (CPT) education in Europe is necessary to ensure that the prescribing competency of future doctors is of a uniform high standard. As there are currently no uniform requirements, our aim was to achieve consensus on key learning outcomes for undergraduate CPT education in Europe. We used a modified Delphi method consisting of three questionnaire rounds and a panel meeting. A total of 129 experts from 27 European countries were asked to rate 307 learning outcomes. In all, 92 experts (71%) completed all three questionnaire rounds, and 33 experts (26%) attended the meeting. 232 learning outcomes from the original list, 15 newly suggested and 5 rephrased outcomes were included. These 252 learning outcomes should be included in undergraduate CPT curricula to ensure that European graduates are able to prescribe safely and effectively. We provide a blueprint of a European core curriculum describing when and how the learning outcomes might be acquired.

Brain drain: final year medical students’ intentions of training abroad

Background In Croatia, a new European Union (EU) member state since July 2013, there is already a shortage of around 3280 doctors to reach the European average. Objectives To investigate the emigration intentions of the current cohort of final year medical students at Zabreb School of Medicine. Methods An electronic questionnaire was used in June 2013 to assess the attitudes of 232 final year medical students towards working conditions abroad and expectations for career opportunities in Croatia following accession to the EU. Results With an overall response rate of 87%, more than half of the surveyed students (106/202, 53%) intended to travel abroad, either for specialty (52/202, 26%) or subspecialty (54/202, 27%) training. More female students (58/135, 43%) than male students (17/62, 27%) indicated they would not emigrate. Most attractive emigration destinations were: Germany (34/121, 28%), USA (19/121, 16%), the UK (19/121, 16%), Switzerland (16/121, 13%) and Canada (11/121, 9%). The most important goals that respondents aimed to achieve through training abroad were to excel professionally (45/120, 38%), to prosper financially (20/120, 17%) and to acquire new experiences and international exposure (31/120, 26%). Conclusions Students’ motivating factors, goals for and positive beliefs about training abroad, as well as negative expectations regarding career opportunities in Croatia, may point towards actions that could be taken to help make Croatia a country that facilitates medical education and professional career development of young doctors.

Emigration-related attitudes of the final year medical students in Croatia: a cross-sectional study at the dawn of the EU accession.

Aim To investigate the emigration-related attitudes of final year medical students in Croatia at the dawn of the EU accession in 2013. Methods All final-year medical students at four Croatian medical schools (Zagreb, Rijeka, Split, and Osijek) were invited to participate in a cross-sectional survey on emigration attitudes. Results Among 260 respondents (response rate 61%), 90 students (35%) reported readiness for permanent emigration, expecting better quality of life (N = 22, 31%), better health care organization (N = 17, 24%), more professional challenges (N = 10, 14%), or simply to get a job (N = 8, 11%), while the least common expectation were greater earnings (N = 7, 10%). The most common target countries were Germany (N = 36, 40%), USA and Canada (N = 15, 17%), and UK (N = 10, 11%). In a multivariate analysis, readiness for permanent emigration was associated with an interest in undertaking a temporary training abroad (odds ratio [OR] 6.87; 95% confidence interval [CI] 2.83-16.72), while the belief that the preferred specialty could be obtained in Croatia appeared protective against emigration (OR 0.26; 95% CI 0.12-0.59). Conclusion Despite shortages of health care workers in Croatia, the percentage of students with emigration propensity was rather high. Prevalent negative perception of the Croatian health care and recent Croatian accession to the EU pose a threat of losing newly graduated physicians to EU countries.

The impact of tobacco cessation training of medical students on their attitude towards smoking

In their 2008 MPOWER Report, The World Health Organization (WHO) placed the responsibility for managing and solving the tobacco epidemic on healthcare systems (WHO 2008). Counseling by healthcare workers and availability of inexpensive pharmacologic therapy were named as two crucial interventions for tobacco cessation (WHO 2008). At the University of Michigan Medical School (UMMS), students undergo training with Standardized Patients regarding tobacco cessation counseling, while at the University of Zagreb Medical School (UZMS), students are not offered such training. In order to investigate the impact of different teaching approaches in these schools, an adjusted online version of the Global Health Professions Student Survey (GHPSS) was electronically distributed to 340 clinical year medical students at UMMS and 256 students at UZMS at an equivalent level of clinical training (Warren et al. 2011). Response rates were 37% and 40%, respectively. Subsequent data analysis revealed statistically significant differences concerning smoking habits with 23% of UZMS and only 7% of UMMS students stating that they are currently smoking. Furthermore, UZMS students reported higher second-hand smoke exposure. Greater percentage of UMMS responders believed their patients considered them as role models (97% versus 63%) and that they should routinely advise them to quit smoking (98% versus 94%). In order to create a generation of confident physicians able to accurately counsel patients, medical schools must prioritize smoking cessation in their curriculums. If there were more emphasis in Croatian medical training regarding physician influence on patient behavior, perhaps students would think more seriously about quitting in an effort to be more effective motivators for their patient’s cessation.

IS REFERRING PATIENTS WITH A POSITIVE HISTORY OF ALLERGIC DRUG REACTIONS OR ATOPY FOR ALLERGY TESTING TO LOCAL ANESTHETICS JUSTIFIED

Although no more than 1% of adverse reactions to local anesthetics (LA) are thought to be immunologically mediated, many patients continue to be referred to allergy clinics for allergy workup. We evaluated the impact of a history of drug hypersensitivity or atopy on results of allergy testing to LA, with the aim of determining the appropriateness of allergy testing to LA in such patients. We retrospectively analyzed medical records of 112 consecutive patients referred for allergy testing to LA in a 9-year period (1996-2005). Intradermal tests with diluted (1:10) LA were performed to identify patients at risk for immunoglobulin E (IgE)-mediated hypersensitivity reaction. The odds for being testpositive were calculated with regard to the defined risk factors (atopy, history of adverse reactions to LA or other drugs, underlying autoimmune disease). Eleven of 112 patients (9.8%) tested positive for allergy to LA. Atopy, history of adverse reactions to LA or other drugs and underlying autoimmune disease did not increase the odds for being test-positive. The prevalence of multiple drug hypersensitivity, IgE values and eosinophil count were not significantly higher among the patients who tested positive as compared to the patients who tested negative. According to our data, allergy testing to LA is not justified in patients with atopy or histories of adverse drug reactions other than to LA. Further studies using validated methods of allergy testing to LA coupled with analysis of defined risk factors are needed to definitively establish the indications for referral of patients for allergy testing to LA.