Medication-related visits to the emergency department: a prospective study.

OBJECTIVE: To assess the prevalence, preventability, category, and severity of drug-related problems; medications involved; common causes of preventable medication-related visits (MRVs); and cost of MRVs. METHODS: In this prospective, observational study of emergency department visits, patients were identified as having MRVs by use of a questionnaire. The patients or their representatives were interviewed to assess whether the emergency department visit was caused by a medication-related problem. Patient selection was consecutive. A blinded panel of pharmacists and one physician was used to assess study objectives. RESULTS: Of the 253 patients interviewed, 71 patients (28.1%) presenting to the emergency department had a medication-related reason for their visits. Of the 71 MRVs, 50 (70.4%) were judged to be preventable and 21 (29.6%) nonpreventable. The data showed that MRVs are most often caused by an adverse drug reaction, followed by overprescribing of the correct medication. The severity of MRVs was most often classified as moderate. The most common medications involved were cardiovascular agents. The preventable MRVs were mostly due to noncompliance issues, inappropriate prescribing, inappropriate monitoring, and lack of patient education. The average cost to the institution was approximately $1444 per preventable MRV. CONCLUSIONS: In our study, the prevalence of MRVs was higher than in previous studies due to the prospective nature of the study and the assistance of drug experts in identifying and classifying the incidents. Areas identified for improvement included compliance issues with patients, education of healthcare workers regarding prescribing and monitoring of medications, and patient education.

Framework for continuous quality improvement in the provision of pharmaceutical care.

Implementation of the continuous quality improvement (CQI) process by health-care organizations is described. CQI involves a chain of events: Improvement in quality leads to decreased costs because of less rework, fewer mistakes, fewer delays, and better use of people and materials; productivity improves; better quality and lower price facilitate capturing the market, staying in business, and providing more jobs. The implementation of CQI within an organization involves the development, standardization, and deployment of standard methods and the use of daily management, cross-functional management, policy management, departmental management, and quality control circles to maintain, improve, or innovate standard methods. An organization's standard methods, key indicators (indicators for measuring performance of the organization's key functions), and standards emanate from its vision and mission statements and midterm and short-term strategic plans. In a quality control audit, an agreed-upon method, as monitored through a key indicator, is used to measure a result against an established standard; when a problem is detected, a quality control diagnosis is conducted and the method is changed if necessary. Use of this process requires the creation of standard methods for all important aspects of the organization's services, including operations, clinical services, and training of personnel. Health-care managers can use the principles of CQI in assessing the quality of care provided.

A mid-sized hospital's experience in indicator data collection.

A hospital pharmacy department's experience in selection and use of indicators for measuring quality of care is described. At a 410-bed community teaching hospital, indicators were selected that would use data the department was already collecting. For the first indicator, "Patients on total parenteral nutrition (TPN) experiencing acid-base disorders," the goal was for no more than 20% of patients on TPN to have blood pH values outside the normal range, but 35% of patients were found to be outside the range. The standard TPN formula was examined and changed, after which only 16% of patients had pH values outside the normal range. For the second indicator, "Patients on TPN having negative nitrogen balance results," and the next two indicators, based on data available from the department's pharmacokinetics service, a similar process was followed. The department next examined incident reports and adverse drug reaction reports, categorized the drug-related problems represented, and established the indicator, "Patients on [nursing unit X] experiencing category 4 drug-related errors." Problems with indicator use included determining how an indicator relates to the quality of care and knowing how to analyze the data once they are collected. To maintain stature within their institutions by helping with the overall quality improvement effort, pharmacy departments need to expeditiously institute the use of indicators.

Cefamandole pharmacokinetics during standard and pulsatile cardiopulmonary bypass.

The pharmacokinetics of cefamandole during standard or pulsatile cardiopulmonary bypass were studied in 13 adult cardiac surgery patients. All patients received 20 mg/kg of cefamandole intravenously at midnight before surgery, 6 AM on the morning of surgery and just prior to the initiation of cardiopulmonary bypass (CPB) surgery. Serum, skeletal muscle, and fat samples were taken at the beginning of CPB and at 30-minute intervals thereafter and assayed for cefamandole concentration. The average elimination rate constant and elimination half-life for cefamandole in patients undergoing standard CPB were 0.73 +/- 0.09 hour-1 and 0.94 +/- 0.11 hour, respectively. In contrast patients undergoing pulsatile CPB had significantly slower elimination rate constants (0.50 +/- 0.1 hour-1 and 1.4 +/- 0.28 hours, respectively; P less than or equal to .05). Area under the curve (AUC) values for cefamandole in fat and muscle tissue were higher in patients undergoing pulsatile CPB, but the differences were not statistically significant. Prolonged elimination from the serum, skeletal muscle, and adipose tissue, as compared with normal subjects, is seen with both pulsatile and standard CPB but is greater for the pulsatile method. Intraoperative dosing of cefamandole is required to maintain adequate serum and tissue levels for operations lasting longer than 4 or 6 hours in which standard or pulsatile CPB, respectively, are used.

Acute adrenal insufficiency mimicking septic shock: a case report.

Acute adrenal insufficiency is an unusual problem that may mimic overwhelming sepsis. Elevated cardiac output and low systemic vascular resistance in a patient with known risk factors should alert clinicians to the possibility of that condition.

Collaborative clinical pharmacokinetics service in a community hospital.

A clinical pharmacokinetics service (CPS) operated through the collaborative efforts of the pharmacy and laboratory in a community hospital is described. Pharmacokinetic interpretations of aminoglycoside, vancomycin, chloramphenicol, digoxin, and theophylline concentrations are provided routinely by the CPS; other drug assays are interpreted upon physician request. The CPS is operated by two pharmacokinetics pharmacists and a clinical pharmacy coordinator during the week; pharmacy residents and staff pharmacists in decentralized areas assist on the weekends. Pharmacists assign sampling times to all assay requests unless otherwise specified by the physician. Pharmacy, nursing, laboratory, and medical staffs are involved in an ongoing quality-assurance monitoring program. During a recent one-year period, more than 100 pharmacokinetic consultations each were provided monthly for theophylline, digoxin, and antibiotic assays. Through the cooperation of the pharmacy and laboratory departments, the clinical pharmacokinetics service in this community hospital provides a valuable service to patients and serves as an educational forum for pharmacy and medical staffs.