The impact of a pharmacist on post-take ward round prescribing and medication appropriateness.

Background Medication communication and prescribing on the post-take ward round following patient admission to hospital can be suboptimal leading to worse patient outcomes. Objective To evaluate the impact of clinical pharmacist participation on the post-take ward round on the appropriateness of medication prescribing, medication communication, and overall patient health care outcomes. Setting Tertiary referral teaching hospital, Brisbane, Australia. Method A pre-post intervention study was undertaken that compared the addition of a senior clinical pharmacist attending the post-take ward was compared to usual wardbase pharmacist service, with no pharmacist present of the post-take ward round. We assessed the proportion of patients with an improvement in medication appropriateness from admission to discharge, using the START/STOPP checklists. Medication communication was assessed by the mean number of brief and in-depth discussions, with health care outcomes measured by comparing length of stay and 28-day readmission rates. Main outcome measures: Medication appropriateness according to the START/STOPP list, number and type of discussions with team members and length of stay and readmission rate. Results Two hundred and sixty patients were recruited (130 pre- and 130-post-intervention), across 23 and 20 post-take ward rounds, respectively. Post-intervention, there was increase in the proportion of patients who had an improvement medication appropriateness (pre-intervention 25.4%, post-intervention 36.9%; p = 0.004), the number of in-depth discussions about patients' medication (1.9 ± 1.7 per patient pre-intervention, 2.7 ± 1.7 per patient post-, p < 0.001), and the number relating to high-risk medications (0.71 ± 1.1 per patient pre-intervention, to 1.2 ± 1.2 per patient post-, p < 0.05). Length of stay and 28-day mortality were unchanged. Conclusion Clinical pharmacist participation on the post-take ward round leads to improved medication-related communication and improved medication appropriateness but did not significantly improve health care outcomes.

The effect of pharmacists on ward rounds measured by the STOPP/START tool in a specialized geriatric unit.

WHAT IS KNOWN AND OBJECTIVE: The STOPP/START tool has been validated to assess elderly patients for potentially inappropriate prescribing. This study aimed to assess the effect of inclusion of a pharmacist on a physician-led ward round on potentially inappropriate prescribing in hospitalized elderly patients. METHODS: This was an observational study of prescribing for patients using the STOPP/START tool at three points during hospital stay; admission to hospital, on transfer to the specialized geriatric unit and on discharge from hospital. Data were collected over 4 months pre- and post-introduction of a pharmacist to a physician-led ward round. Demographic and clinical data, including total number of medications and STOPP/START criteria met, were collected. The mean number of STOPP/START criteria at each time-point was compared for pre- and post-introduction of a pharmacist using a Mann-Whitney U-test. The mean number of criteria for each time-point within each group was compared using a paired Student's t-test. RESULTS AND DISCUSSION: The demographic characteristics of the participants in the pre- and post-intervention groups were similar. The post-intervention group had numerically less STOPP/START criteria, mean 1·18 (1·37) compared to the pre-intervention group 1·50 (1·41), P = 0·07 at discharge. The pre-intervention group had no significant change in the criteria from admission 1·78 (1·57) to geriatric unit transfer 1·72 (1·54) (P = 0·37); however, there was a significant decrease from geriatric unit transfer 1·72 (1·54) to discharge 1·50 (1·41) (P = 0·02). The post-intervention group had a significant decrease from hospital admission 2·30 (1·91) to geriatric unit transfer 1·59 (1·60) (P < 0·01) and again to discharge 1·18 (1·37) (P < 0·01). WHAT IS NEW AND CONCLUSION: Pharmacist participation on the ward round in a specialized geriatric unit resulted in a numerical improvement in prescribing quality as measured by the STOPP/START tool.

Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing.

OBJECTIVES: Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework. DESIGN: Single centre, randomised controlled, two-arm trial. SETTING: Elective surgery PAC in a Brisbane-based tertiary hospital. PARTICIPANTS: 400 adults scheduled for elective surgery were randomised to intervention or control. INTERVENTION: A pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers. OUTCOME MEASURES: Primary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing. RESULTS: There were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29). CONCLUSIONS: Medication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups. TRIAL REGISTRATION: Registered with ANZCTR-ACTR Number ACTRN12609000426280.

Impact of a standard medication chart on prescribing errors: a before-and-after audit.

OBJECTIVES: (1) To develop and implement a standard medication chart, for recording prescribing (medication orders) and administration of medication in public hospitals in Queensland. (2) To assess the chart's impact on the frequency and type of prescribing errors, adverse drug reaction (ADR) documentation and safety of warfarin prescribing. (3) To use the chart to facilitate safe medication management training. DESIGN, SETTING AND PARTICIPANTS: The medication chart was developed through a process of incident analysis and work practice mapping by a multidisciplinary collaborative. Observational audits by nurse and pharmacist pairs, of all available prescriptions before and after introduction of the standard medication chart, were undertaken in five sites. RESULTS: Similar numbers of both patients (730 pre-implementation and 751 post-implementation; orders, 9772 before and 10 352 after) were observed. The prescribing error rate decreased from 20.0% of orders per patient before to 15.8% after (Mann-Whitney U test, p = 0.03). Previous ADRs were not documented for 19.5% of 185 patients before and 11.2% of 197 patients after (chi(2), p = 0.032). Prescribing errors involving selection of a drug to which a patient had had a previous ADR decreased from 11.3% of patients before to 4.6% after (chi(2), p = 0.021). International normalised ratios (INRs) >5 decreased from 1.9% of 14 405 INRs in the 12 months before to 1.45% of 15 090 INRs after (chi(2), p = 0.004). After minor modifications, the chart was introduced into all hospitals statewide, which enabled standardised medication training and safer rotation of staff. The chart also formed the basis for the National Inpatient Medication Chart. CONCLUSION: Introduction of a standard revised medication chart significantly reduced the frequency of prescribing errors, improved ADR documentation and decreased the potential risks associated with warfarin management. The standard chart has enabled uniform training in medicine management.

A feasibility study of sequential doublet chemotherapy comprising carboplatin-doxorubicin and carboplatin-paclitaxel for advanced endometrial adenocarcinoma and carcinosarcoma.

BACKGROUND: Platinum compounds, taxanes and anthracyclines provide the major effective drug classes in the treatment of advanced and recurrent endometrial cancer and carcinosarcoma. PATIENTS AND METHODS: A total of 52 women with advanced or recurrent endometrial cancer and carcinosarcoma were treated with four cycles of carboplatin area under the curve (AUC) 5 and doxorubicin (50 mg/m(2)) for four cycles before or after four cycles of carboplatin AUC5 and paclitaxel (175 mg/m(2)) with each cycle administered at 21-day intervals. RESULTS: Thirty-seven patients (71.2%) completed all planned treatment. Excluding six patients who did not complete treatment for non-drug-related causes, 80.4% completed all planned treatment. Three hundred and seventy-one treatment cycles were administered and 303 (81.7%) occurred on time. Common Toxicity Criteria grade 3/4 haematological toxic effects, particularly neutropenia and thrombocytopenia, were the predominant cause of treatment delays and dose reductions. A low incidence of grade 3 neurotoxicity and no cardiac toxicity were observed. The overall response rates for patients with evaluable disease were 82.1% and 66.7% for endometrial and carcinosarcoma, respectively. At a median follow-up of 21 months, the median progression-free survival for the endometrial adenocarcinoma and carcinosarcoma cohorts were 15.3 and 12.0 months, respectively. CONCLUSION: This regimen is generally well tolerated with encouraging efficacy.

Factors predictive of intravenous fluid administration errors in Australian surgical care wards.

BACKGROUND: Intravenous (IV) fluid administration is an integral component of clinical care. Errors in administration can cause detrimental patient outcomes and increase healthcare costs, although little is known about medication administration errors associated with continuous IV infusions. OBJECTIVES: (1) To ascertain the prevalence of medication administration errors for continuous IV infusions and identify the variables that caused them. (2) To quantify the probability of errors by fitting a logistic regression model to the data. METHODS: A prospective study was conducted on three surgical wards at a teaching hospital in Australia. All study participants received continuous infusions of IV fluids. Parenteral nutrition and non-electrolyte containing intermittent drug infusions (such as antibiotics) were excluded. Medication administration errors and contributing variables were documented using a direct observational approach. RESULTS: Six hundred and eighty seven observations were made, with 124 (18.0%) having at least one medication administration error. The most common error observed was wrong administration rate. The median deviation from the prescribed rate was -47 ml/h (interquartile range -75 to +33.8 ml/h). Errors were more likely to occur if an IV infusion control device was not used and as the duration of the infusion increased. CONCLUSIONS: Administration errors involving continuous IV infusions occur frequently. They could be reduced by more common use of IV infusion control devices and regular checking of administration rates.

Barriers to optimum management of heart failure by general practitioners.

BACKGROUND: Published research offers clear pointers to the management of heart failure; however, the evidence for implementation into practice is sub-optimal. AIM: To identify the salient barriers to adopting evidence-based management of heart failure in the community. METHOD: Structured interviews were used to elicit the views of a stratified sample of 100 general practitioners (GPs) about the diagnosis and treatment of heart failure. Responses to three heart failure case scenarios provided an indication of the degree to which GPs' knowledge of heart failure and trial results might be applied to diagnosis and treatment intentions. RESULTS: Participants were generally well aware of clinical trials that showed that prognosis could be improved by treatment, but trial results appeared to have little influence on treatment intentions in the three case scenarios. The major barriers to optimum management were the difficulties of differential diagnosis and the perceived properties of angiotensin-converting enzyme inhibitors (ACE-I) relative to diuretics. In the case scenarios, less than 30% reported that they would undertake basic investigations, such as chest X-ray or haemoglobin, or prescribe ACE-I. Over 70% perceived diuretics to be a useful diagnostic tool. The most frequent reasons for not prescribing ACE-I were the perceived inconvenience and risks of adverse effects (41%) and the view that most patients can be managed successfully on diuretics alone (27%). Over two-thirds of the sample were dissatisfied with the quality of information accompanying heart failure patients discharged from hospital. CONCLUSION: Facilitating evidence-based management of heart failure in the community requires further support for GPs in the form of additional training in the diagnosis of heart failure and the optimum use of both ACE-I and diuretics, and by improved communication between GPs and hospital doctors on a case-by-case basis.