The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure.

OBJECTIVE: Heart failure patients are regularly admitted to hospital and frequently use multiple medication. Besides intentional changes in pharmacotherapy, unintentional changes may occur during hospitalisation. The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure. SETTING: A general teaching hospital in Tilburg, the Netherlands. METHOD: An open randomized intervention study was performed comparing an intervention group, with a control group receiving regular care by doctors and nurses. The clinical pharmacist discharge service consisted of review of discharge medication, communicating prescribing errors with the cardiologist, giving patients information, preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication. Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured. MAIN OUTCOME MEASURE: The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined. RESULTS: Forty-four patients were included in the control group and 41 in the intervention group. Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39% in the intervention group (RR 0.57 (95% CI 0.37-0.88)). The percentage of medications with a discrepancy or prescription error in the control group was 14.6% and in the intervention group it was 6.1% (RR 0.42 (95% CI 0.27-0.66)). CONCLUSION: This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge.

Comparison of potential risk factors for medication errors with and without patient harm.

PURPOSE: To compare determinants for medication errors leading to patient harm with determinants for medication errors without patient harm. METHODS: A two-way case-control design was used to identify determinants for medication errors without harm (substudy 1) and determinants for medication errors causing harm (substudy 2). Data of patients admitted to five internal medicine wards of two Dutch hospitals during 5 months were collected prospectively by chart review. Medication errors were detected and classified by two pharmacists. Consensus between five pharmacists was reached on the causal relationship between medication errors and patient harm. Data analysis was performed by multivariate logistic regression. RESULTS: We included 7286 medication orders, of which 3315 without errors (controls), and 5622 medication errors without harm (cases substudy 1) and 102 medication errors causing harm (cases substudy 2) were identified. Hospital, ward and the therapeutic class anti-infectives were associated with both medication errors without harm (hospital odds ratio (OR) 1.40; 95% confidence interval (CI) 1.21-1.63), TweeSteden hospital (TSh) geriatrics OR 2.03; 95% CI 1.73-2.38, TSh general internal medicine OR 1.44; 95% CI 1.23-1.69 and anti-infectives OR 1.28; 95% CI 1.06-1.56) and medication errors with harm (hospital OR 4.91; 95% CI 3.02-7.79, TSh geriatrics OR 5.76; 95% CI 2.52-13.15, TSh general internal medicine OR 6.51; 95% CI 2.82-15.02 and anti-infectives OR 4.20; 95% CI 2.24-7.90). CONCLUSIONS: This study shows that organisational determinants (hospital, ward) are comparable for medication errors with and without harm. For conclusions on patient- and medication-related determinants studies with larger sample sizes are needed.

Medication reconciliation performed by pharmacy technicians at the time of preoperative screening.

BACKGROUND: Medication errors occur regularly in surgical patients, especially due to transfer problems at the time of hospital admission. A method for decreasing the error rate is medication reconciliation by hospital pharmacists as part of a preoperative clinic. The role of pharmacy technicians in this process has not been studied. OBJECTIVE: To study the use of pharmacy technicians in medication reconciliation by measuring the effect of early reconciliation in the preoperative clinic on medication and allergy discrepancies and on inadvertent continuation of antithrombotics. A secondary objective was to study the effect of community pharmacist follow-up on recommendations to discontinue antithrombotic therapy. METHODS: During the preintervention measurement period, patients received usual care by anesthesiologists, who recorded the medication and documented allergies of the patient. The intervention consisted of the addition of a pharmacy technician to the preoperative screening clinic to perform the same tasks as anesthesiologists as related to medication reconciliation. If necessary, the patient was advised on stopping the antithrombotic. On the day that the patient was supposed to stop the antithrombotic, that person's community pharmacist contacted the patient to determine whether this had been done. The main outcome measures were the proportions of patients with one or more medication discrepancy, one or more allergy discrepancy, and one or more antithrombotic error. RESULTS: In the preintervention period, 204 patients were evaluated; 93 were included in the postintervention analysis. The proportion of patients with one or more medication discrepancy (RR 0.29; 95% CI 0.12 to 0.71) was statistically significantly reduced in the postintervention group. The proportions of patients with one or more allergy discrepancy (RR 0.76; 95% CI 0.35 to 1.64) and one or more antithrombotic errors (RR 0.18; 95% CI 0.02 to 1.33) were reduced, but not significantly. Follow-up by the community pharmacist did not identify any patients who had not followed the preoperative clinic's advice on temporarily withholding their antithrombotics. CONCLUSIONS: The results of this study show that pharmacy technicians can be successfully assigned to a preoperative clinic, resulting in a statistically significant decrease in medication discrepancies.

Effect of low-intensity acenocoumarol on frequency and severity of migraine attacks.

OBJECTIVE: To investigate the effect of low-intensity acenocoumarol treatment (target INR 1.5 to 2.0) on the frequency and severity of migraine attacks. BACKGROUND: The positive effect of anticoagulation on migraine has been described in case reports and observational studies. METHODS: We conducted a randomized, open, crossover study in migraine patients. After a run-in period of 8 weeks, all patients received acenocoumarol or propranolol during a period of 12 weeks and, after a washout period of 2 weeks, propranolol or acenocoumarol during a second period of 12 weeks. RESULTS: Nineteen patients fulfilling the criteria were included. In 12 patients with complete data collection, only one good responder could be noted. In the other patients, treatment with low-intensity acenocoumarol did not show improvement of migraine symptoms compared with the run-in period. Treatment with propranolol showed a trend towards improvement compared with the run-in period. No serious adverse events were observed. CONCLUSIONS: Overall, low-intensity acenocoumarol treatment has no prophylactic effect in migraine patients.

Association between antidepressant drug use and hyponatraemia: a case-control study.

AIMS: To estimate the risk of, and risk factors for, hyponatraemia associated with the use of selective serotonin reuptake inhibitors (SSRIs) compared with the use of other antidepressant drugs. METHODS: A case-control study of psychiatric in- and out-patients on antidepressant drugs performed in the mid-southern part of The Netherlands over a 2 year period. Cases (n=29) were all using antidepressant drugs with a serum sodium concentration of < or = 130 mmol l(-1) while controls (n=78) were patients on antidepressants with a normal sodium concentration (136-144 mmol l(-1)). Information on blood sodium concentrations was obtained from clinical chemistry data while information on drug use was obtained from community and hospital pharmacy databases. Medical records were used to ascertain possible risk and confounding factors. Unconditional multivariate logistic regression was used to estimate odds ratios for hyponatraemia in patients on SSRIs compared with patients on other antidepressant drugs. RESULTS: SSRIs were associated with an increased risk of hyponatraemia (OR 3.3; 95% CI 1.3, 8.6) compared with other classes of antidepressant drugs. Stratified and interaction analyses revealed that elderly patients using diuretics concomitantly with SSRIs were at the highest risk of experiencing hyponatraemia (OR 13.5; 95% CI 1.8, 101). CONCLUSIONS: SSRIs are more frequently associated with hyponatraemia than other classes of antidepressant drugs. This adverse drug reaction was more common in older patients (> or = 65 years) and in those using diuretics.