Soraya Dhillon

Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial.

OBJECTIVES: To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management (GEM) care on the appropriateness of prescribing.

Appropriateness of use of medicines in elderly inpatients: qualitative study

Abstract Objectives To explore the processes leading to inappropriate use of medicines for elderly patients admitted for acute care. Design Qualitative study with semistructured interviews with doctors, nurses, and pharmacists; focus groups with inpatients; and observation on the ward by clinical pharmacists for one month. Setting Five acute wards for care of the elderly in Belgium. Participants 5 doctors, 4 nurses, and 3 pharmacists from five acute wards for the interviews; all professionals and patients on two acute wards for the observation and 17 patients (from the same two wards) for the focus groups. Results Several factors contributed to inappropriate prescribing, counselling, and transfer of information on medicines to primary care. Firstly, review of treatment was driven by acute considerations, the transfer of information on medicines from primary to secondary care was limited, and prescribing was often not tailored to elderly patients. Secondly, some doctors had a passive attitude towards learning: they thought it would take too long to find the information they needed about medicines and lacked self directed learning. Finally, a paternalistic doctor-patient relationship and difficulties in sharing decisions about treatment between prescribers led to inappropriate use of medicines. Several factors, such as the input of geriatricians and good communication between members of the multidisciplinary geriatric team, led to better use of medicines. Conclusions In this setting, improvements targeted at the abilities of individuals, better doctor-patient and doctor-doctor relationships, and systems for transferring information between care settings will increase the appropriate use of medicines in elderly people.

Impact of community pharmacy diabetes monitoring and education programme on diabetes management: a randomized controlled study

Diabet. Med. 29, e326–e333 (2012)

Clinical handover incident reporting in one UK general hospital

OBJECTIVE To determine the prevalence and characteristics of clinical handover incidents that occurred across a medium-size UK hospital. DESIGN A retrospective review of 36 consecutive months of data from the hospital electronic database of critical incidents was conducted. MAIN OUTCOME MEASURES Number of incidents reported, characterization of handover incidents according to clinical setting, severity and type of incidents. RESULTS We identified 334 handover incidents. The number of reported incidents increased over the 3 years. The transfer of patient care within the same specialty accounted for 51% (170) of incidents of which 75% (143) occurred during a change of shift. The specialties reporting the highest number of adverse events were: Obstetrics and Gynaecology, 42% (140); Medicine for the Elderly, 12.2% (41) and General Medicine, 12% (40). The most common types of handover incident scenario were poor or incomplete handover, 45% (151) and no handover of a patient at all, 29% (98). Reported severity was generally low (99%). CONCLUSIONS Current reporting rate is low if compared with prospective studies highlighting an issue of under-reporting. Many incidents appear to be of modest harm for patients because of response time; however, further research is required to assess potential severity and level of harm linked to low-quality handovers.

An observational study of the prescribing and administration of intravenous drugs in a general hospital

The prescribing and administration of intravenous drugs on two surgical and one medical ward were studied to determine the number, type and causes of errors occurring. The errors were classified for potential to harm the patient and for implications for the system of supply, preparation and administration. Of the 154 patients, 46.7 per cent were prescribed intravenous drugs. Of the 178 prescriptions for intravenous drugs, 14 per cent failed to conform to the local policy on prescribing and 11.2 per cent were considered to be clinically inappropriate. Preparation and administration were observed for 41.5 per cent of all scheduled intravenous doses during the 39‐day study period. Excluding wrong time errors, the intravenous error rate was 26.9 per cent. Most errors were omissions (12.5 per cent of all observations), of which 45 per cent were due to lack of venous access and 22.5 per cent due to improper use of the drug chart. The latter also caused two errors of extra dosing. Fifty‐two per cent of doses were given at the wrong time. Of the 254 errors, 4.7 per cent were classed as of major consequence for the patient, 17.3 per cent classed as moderate and 77.9 per cent as minor. Although the majority of errors observed were of minor consequence for the patient, the intravenous medication error rate could be reduced by using knowledge of the causes observed to change or reinforce the existing system of intravenous drug supply, preparation and administration.

The prevalence and nature of prescribing and monitoring errors in English general practice: a retrospective case note review

BACKGROUND Relatively little is known about prescribing errors in general practice, or the factors associated with error. AIM To determine the prevalence and nature of prescribing and monitoring errors in general practices in England. DESIGN AND SETTING Retrospective case-note review of unique medication items prescribed over a 12-month period to a 2% random sample of patients. Fifteen general practices across three primary care trusts in England. METHOD A total of 6048 unique prescription items prescribed over the previous 12 months for 1777 patients were examined. The data were analysed by mixed effects logistic regression. The main outcome measures were prevalence of prescribing and monitoring errors, and severity of errors, using validated definitions. RESULTS Prescribing and/or monitoring errors were detected in 4.9% (296/6048) of all prescription items (95% confidence interval [CI] = 4.4% to 5.5%). The vast majority of errors were of mild to moderate severity, with 0.2% (11/6048) of items having a severe error. After adjusting for covariates, patient-related factors associated with an increased risk of prescribing and/or monitoring errors were: age <15 years (odds ratio [OR] = 1.87, 95% CI = 1.19 to 2.94, P = 0.006) or >64 years (OR = 1.68, 95% CI = 1.04 to 2.73, P = 0.035), and higher numbers of unique medication items prescribed (OR = 1.16, 95% CI = 1.12 to 1.19, P<0.001). CONCLUSION Prescribing and monitoring errors are common in English general practice, although severe errors are unusual. Many factors increase the risk of error. Having identified the most common and important errors, and the factors associated with these, strategies to prevent future errors should be developed, based on the study findings.

A comparative pharmacokinetic study of intravenous and intramuscular midazolam in patients with epilepsy

The pharmacokinetics of midazolam, a water soluble 1,4-benzodiazepine, has been studied in 12 patients (11 male, 1 female; age range 19-57 years) with epilepsy. All patients were taking hepatic enzyme inducing antiepileptic drugs (AEDs) on a regular basis. Midazolam (5 mg) was administered intravenously and 1 week later midazolam was administered intramuscularly, the dose used being dependent on the sedative response to the intravenous dose (10 mg, n = 2; 7 mg, n = 8; 5 mg, n = 2). Serial blood samples were collected at timed intervals for 5-7 h. After intravenous administration initial distribution was rapid with a mean half-life (t 1/2 alpha) of 0.06 +/- 0.03 h followed by a terminal half-life (t 1/2 beta or gamma) of 1.5 +/- 0.3 h. Volume of distribution was 0.62 +/- 0.27 l/kg. After intramuscular administration midazolam was rapidly absorbed with peak serum concentrations achieved at 25 +/- 23 min. Two patients showed delayed absorption. Mean terminal half-life was 2.8 +/- 1.7 h. The absolute bioavailability of intramuscular midazolam was calculated in 11 patients as 87 +/- 18%. Sedation was rapid (less than 1-2 min) but transient (7-75 min) after intravenous and slower (2-30 min) and for a longer period (20-120 min) after intramuscular administration. Since intravenous administration of AEDs including diazepam is not always feasible in status epilepticus there are obvious advantages in having an effective intramuscular formulation. Our data suggest that midazolam may be such a drug.

Comparative efficacy and tolerability of anti-epileptic drugs for refractory focal epilepsy: systematic review and network meta-analysis reveals the need for long term comparator trials

To evaluate the comparative efficacy (50% reduction in seizure frequency) and tolerability (premature withdrawal due to adverse events) of anti‐epileptic drugs (AEDs) for refractory epilepsy.

Pharmacokinetics of Bupropion and Its Metabolites in Haemodialysis Patients Who Smoke

To date, no study has investigated the effects of bupropion (BP) in renal-impaired humans. This study aims to identify the pharmacokinetics of BP and metabolites in haemodialysis patients who smoke, determine whether haemodialysis affects BP and metabolite clearance, and suggest the BP dose in haemodialysis. The pharmacokinetics of BP and two of its major metabolites, hydroxybupropion (HB) and threohydrobupropion (TB) were studied in 8 smokers with ESRD receiving haemodialysis. Following a single oral dose of 150 mg bupropion hydrochloride sustained-release, blood samples were taken over 7 days, which were assayed using HPLC-mass spectrometry. Pharmacokinetic analysis was undertaken by non-linear regression using MWPharm. The BP results were similar to those for individuals with normal renal function. The metabolites demonstrated increased areas under the curve, indicating accumulation. Dialysis clearance of HB is unlikely. The results suggest significant accumulation of the metabolites in renal failure. Clarification of the clinical importance of the metabolites and toxic plasma levels is required. The effects of haemodialysis on BP and metabolites require further study. A dose of 150 mg bupropion every 3 days in patients receiving haemodialysis is more appropriate than the current manufacturer’s recommendation (in renal impaired patients) of 150 mg daily. A multi-dose study is required.

Avoiding Acyclovir Neurotoxicity in Patients with Chronic Renal Failure Undergoing Haemodialysis

Acute neurotoxicity following the administration of the recommended oral dose of acyclovir (800 mg twice daily) to dialysis-dependent patients is increasingly recognised. This suggests that the recommended dose is too high. Little is known of the pharmacokinetics of oral acyclovir in dialysis patients. We studied 7 patients with oliguric end stage renal failure receiving haemodialysis. Following haemodialysis, each patient received a single 800-mg tablet of acyclovir. Plasma acyclovir levels were monitored over the next 48 h as well as before and after the next routine dialysis. Peak plasma levels were achieved at 3 h (12.54 +/- 1.76 microM, range 8.5-17.5 microM) with the half-life calculated to be 20.2 +/- 4.6 h. Mean plasma level of 6.29 +/- 0.94 microM were within the quoted range to inhibit herpes zoster virus (4-8 microM) at 18 h. Haemodialysis (4-5 h) eliminated 51 +/- 11.5% of the acyclovir which remained at 48 h. Computer modelling of various dose modifications suggests that a loading dose of 400 mg and a maintenance dose of 200 mg twice daily is sufficient to maintain a mean plasma acyclovir level of 6.4 +/- 0.8 microM. A further loading dose (400 mg) after dialysis would raise the residual acyclovir concentration by 6.1 +/- 1.0 microM. Such a dose modification should prevent neurotoxicity, whilst the rapid elimination of acyclovir by a single haemodialysis treatment provides both a diagnostic and therapeutic tool when toxicity is suspected.