Characteristics of Pharmacists' Interventions Related to Proton-Pump Inhibitors in French Hospitals: An Observational Study.

Methods: The study was based on a retrospective analysis of pharmacist interventions for DRPs detected during the medication order review and documented into the French Act-IP© database over a 12-year period. DRPs and PIs were analyzed, and independent factors of physician acceptance were assessed via multiple logistic regression. Results: Out of the 620,620 PIs registered, 29,694 targeted a PPI (4.8%). PPI's DRPs were mostly related to the prescription of a "drug not available at the hospital" (26.1%) and a "drug use without indication" (18.3%); PIs were mostly "drug switch" (35.9%) and "drug discontinuation" (26.1%). In all, 18,919 PIs were accepted by physicians (63.7%). Acceptance was significantly associated with patient age: less accepted for the 18-75 years group (OR = 0.59, 95 CI [0.46-0.76]), and the >75 years group (OR = 0.57, 95 CI [0.44-0.73]) vs. <18 years group; for the type of DRP, "drug use without indication" was the less accepted (OR = 0.73, 95 CI [0.63-0.85]); for the type of PI, "dose adjustment" was the less accepted (OR = 0.32, 95 CI [0.23-0.45]). Conclusion: Pharmacists contribute to preventing DRPs associated with PPI prescriptions during the medication order review process. Moreover, they often detect PPIs used without indication and they propose drug discontinuation, which contributes to the PPI deprescribing process. PIs should be further developed in the future to reduce PPI overprescription.

[Education program for cardiac rehabilitation: Impact of the "Drugs" multidisciplinary workshop on the patients' knowledge in the short- and long-term]. / Éducation thérapeutique en réadaptation cardiaque : impact d'un atelier pluridisciplinaire « Médicaments ¼ sur les connaissances des patients à court et long terme.

OBJECTIVE: The aim of this study is to assess the impact of the "Drugs" workshop of a therapeutic education program for cardiac rehabilitation on the patients' knowledge in the short and long term. METHODS: This observational study includes patients who participated in the workshops from June 2016 to June 2017 (10 workshops). The scores obtained on the knowledge assessment survey submitted before (S1), after (S2) and at a distance (S3) from the workshops were compared (total scores and scores per question). The existence of a link between the patients' characteristics and the overall progression was assessed. RESULTS: The mean total S1 (4.46/10) and S2 (7.98/10) scores were statistically different (n=62; P<0.0001) as well as the S1 (4.46/10) and S3 (7.53/10) scores (n=46; P<0.0001). A significant difference was observed for five out of six questions (P<0,0001) in the first sequence and for four out of six in the second one (P<0,0001). Initially, the best progress was made in terms of actions to be taken if a dose of medication has been missed; the worst one was the role of platelet inhibitors. Among the patients, 93.5% had a higher distance score than initially obtained. None of the chosen patient characteristics had a significant influence on the progression. CONCLUSION: The workshop significantly improved patients' knowledge in the short and long term, regardless of their profile. This study identified areas for improvement for future workshops.

[Pharmaceutical record's use in drugs sales service: Analysis of five months of experimentation]. / Utilisation du dossier pharmaceutique en rétrocession : analyse de 5 mois d'expérimentation.

OBJECTIVE: The pharmaceutical record integrated in the health insurance card is now exploitable by hospital pharmacists. The aim of this study is to assess the impact of pharmaceutical record's use in hospital drugs sales service and the relevance of this tool to secure the ambulatory dispensing of drugs. METHOD: All patients admitted in hospital drugs sales service between June and October 2016 were included. With the patient's consent, pharmaceutical record was created and/or consulted and implemented. When it included the city pharmacy's treatment, a pharmaceutical analysis was carried out to research drug interaction with hospital drugs sales service's treatment. If a contraindicated or not recommended association was detected, a pharmaceutical intervention was sent to the general practitioner, by secured mail. Each stage was timed. RESULTS: For the 183 included patients, 40 pharmaceutical records have been created and 74 completed. For the 69 remaining patients, pharmaceutical record could not be used. At the end of these 5 months, 86 pharmaceutical records included city pharmacy's and hospital treatments. The pharmaceutical analysis performed have shown 24 drugs interactions related to hospital treatment; seven inappropriate associations were transmitted to the general practitioner. Five minutes were required for both the use and the analysis of pharmaceutical record. CONCLUSION: Now, the pharmaceutical record is systematically used in the hospital drugs sales service, and its content is systematically analyzed. It represents one of the tool improving communication between town-hospital networks, and helps secure the ambulatory drugs dispensation.

[Targeted pharmacist-led medication order review in hospital: Assessment of a selection method for drug prescriptions]. / Analyse pharmaceutique ciblée des prescriptions à l'hôpital : évaluation d'une méthode de sélection des ordonnances.

OBJECTIVES: The aim of this study was to assess a selection method for drug prescriptions developed at the hospital level that allows to target pharmacist-led medication order review for at-risk patients and drugs. METHODS: A one-month study has been conducted on all targeted medication orders in 19 care units. Selection criteria have been identified: biological criteria, alert medications and drug interactions. Pharmacists' interventions proposed during medication order review were listed and the possible links to the selection criteria were determined. RESULTS: A total of 1612 prescriptions were analysed and 236 pharmacists' interventions were performed (14.6 interventions per 100 prescriptions). Physicians' acceptance rate was 60.6%. The percentage of pharmacists' interventions linked to the selection criteria was 35.6%. The relevance of the biological criteria was identified, particularly the one identifying patients with creatinine clearance below 30ml/min. Six alert medications were also relevant selection criteria: dabigatran, morphine, gentamicin, methotrexate, potassium chloride and trimethoprim sulfamethoxazole. Drug interactions criteria was irrelevant. CONCLUSIONS: This study allowed a first assessment of the selection criteria used. A largest study seems necessary to continue the analysis of this selection method for prescriptions, especially the assessment of the alert medications list, in order to refine the prescriptions targeting.

[How to act when an alpha-blocker is associated with a potent inhibitor of CYP3A4]. / Conduite à tenir en cas d'association d'un alpha-bloquant et d'un inhibiteur puissant du cytochrome 3A4.

OBJECTIVE: Combination of alpha-blockers with potent CYP3A4 inhibitors is either contra-indicated or not recommended. We searched data supporting this classification and guiding prescribers when such an interaction occurs. METHODS: We analyzed reports published by the French agency for drug safety, reference books and performed search in databases of pharmacokinetics studies and case or case series related with these interactions. RESULTS: The classification of the potential severity of these interactions defined by the French agency for drug safety evolved over time. Our literature search did not identify any cases or case series reporting serious clinical consequences of such interactions and no pharmacoepidemiological studies on the association between alpha-blockers and inhibitors of CYP3A4. The content of the summaries of product characteristics indicate that the combination of ketoconazole with alfuzosin, silodosin and tamsulosin increases the area under the curve of the alpha-blocker 3 fold. CONCLUSION: Data demonstrating the clinical consequences of an association between alpha-blocker and a potent CYP3A4 inhibitor are lacking. The 3 fold increase of the area under the curve for alfuzosin, silodosin and tamsulosin associated with ketoconazole while the association with the two first is contra-indicated and is not recommended with the third raises questions. This lack of data leaves doctors and pharmacists in a situation of uncertainty on how to proceed when such an interaction occurs.

[Medication errors related to computerized physician order entry at the hospital: Record and analysis over a period of 4 years]. / Erreurs médicamenteuses induites par l'informatisation de la prescription à l'hôpital: recueil et analyse sur une période de 4 ans.

OBJECTIVES: Computerized physician order entry (CPOE) can generate medication errors. It is necessary to identify them and analyse their causes in order to secure the medication use system. METHODS: Errors were recorded during the pharmaceutical analysis of prescriptions over a period of 4 years on 425 beds. A code frame was provided. Errors were classified according to type, causes and time of detection. The most often drug implicated and the error correction rate were studied. Deep causes were determined and contributing factors were listed. RESULTS: Among 99,536 prescriptions analyzed, 2636 errors were detected (2.65 errors per 100 orders analyzed). The most common error was omission (31.49%). The most represented cause was redundancy requirement (11.34%). Antibacterials were most commonly involved (224 errors). Exactly 65.9% of the prescriptions were modified by physicians. Three root causes were identified: (1) configuration issues; (2) misuse; (3) design problem. Three types of contributing factors have also been detailed: economic, human and technical factors. CONCLUSIONS: Identifying root causes has targeted three types of improvement actions: (1) software settings; (2) training of users; (3) requests for improvements. Contributing factors have to be identified to control the generated risk. Some errors related to CPOE may lead to serious side effects for the patient. That is why it is necessary to identify these errors and analyze them in order to implement improvement actions and prevention to secure the prescription.

Trends in pharmacists' medication order review in French hospitals from 2006 to 2009: analysis of pharmacists' interventions from the Act-IP© website observatory.

WHAT IS KNOWN AND OBJECTIVES: The French Society of Clinical Pharmacy has developed a website, named Act-IP©, enabling hospital pharmacists to document and analyse pharmacists' interventions (PIs) proposed during medication order review when a drug-related problem is detected. This study analyses PIs documented in Act-IP© and assesses factors associated with physicians' acceptance of PIs. METHODS: PIs documented into Act-IP© over a 30-month period were analysed. Independent predictors of physicians' acceptance were assessed using multiple logistic regression. RESULTS AND DISCUSSION: A total of 34,522 PIs were registered by 201 pharmacists working in 59 hospitals. PIs were mostly related to 'dose adjustment' (25%), 'drug discontinuation' (20%) and 'drug switch' (19%). Of the 43,343 medications involved, 28% targeted drugs acting on the central nervous system, 17% anti-infective drugs and 16% cardiovascular drugs. Sixty-eight per cent of PIs were accepted by physicians (15% refusals and 17% non-assessable). Physicians' acceptance was significantly associated with 1/ drug group: antineoplastics and immunomodulators (OR = 2.29, CI 95[1.94-2.69]), anti-infectives (OR = 1.19, CI 95 [1.11-1.28]); 2/ type of intervention: drug switch (OR = 1.54, CI 95 [1.43-1.65]), drug discontinuation (OR = 1.38, CI 95 [1.29-1.48]), administration modality optimization (OR = 1.19, CI 95 [1.11-1.29]), addition of a new drug (OR = 1.12, CI 95 [1.00-1.24]); 3/ ward specialty: paediatrics (OR = 1.83, CI 95 [1.24-2.70]) and intensive care (OR = 1.34, CI 95 [1.10-1.64]); 4/ level of pharmacist integration in the ward: higher when the pharmacist is regularly in the ward compared with occasionally (OR = 0.74, CI 95 [0.70-0.79]) or never (OR = 0.68, CI 95 [0.60-0.75]) present. WHAT IS NEW AND CONCLUSION: This study highlights the role of routine pharmacist review of medication orders to prevent drug-related problems and gives new insights for a successful collaboration between physicians and pharmacists.

[Pharmacists' interventions conducted by hospital pharmacists on psychotropic drugs pharmacotherapy]. / Interventions pharmaceutiques émises par les pharmaciens sur les médicaments psychotropes.

INTRODUCTION: The French Society of Clinical Pharmacy (SFPC) through the special interest group "standardization and optimization of clinical pharmacy activities" stated that the study of pharmacists' interventions (PIs) conducted during prescription analysis was a priority. The SFPC developed an internet website named Act-IP(®) (http://www.sfpc.eu/fr/) where French speaking pharmacists were able to document PIs using a normalized codification. The objective of this study was to analyze medication-related problems linked to psychotropic drugs in hospital and to investigate PIs performed during prescription analysis. MATERIALS AND METHODS: This is a multicenter, retrospective, observational study using PIs involving psychotropic medications recorded between September 2006 and February 2009 on the Act-IP(®) website. RESULTS: Four thousand six hundred and twenty PIs recorded by 165 pharmacists in 57 hospitals were related to psychotropic drugs. Patients concerned by these drug-related problems were 64 years old on average. Seven categories of medication-related problems represented more than 69% of PIs (1.1-Non Conformity of the drug choice compared to the formulary; 4.1 Supratherapeutic dose; 5.3 Therapeutic redundancy; 6.2 Drug interaction (all levels of severity); 7.0 Adverse drug reaction; 8.3 Inappropriate drug form; 8.5 Inappropriate timing of administration). The PIs related to 9.2 Patient's non compliance, 2.0 Untreated indication and 3.2 Length of the treatment too short were infrequent (less than 1%). The most common type of intervention was the dose adjustment. Almost 45% of these PIs involved Zopiclone or Zolpidem prescription in elderly patients. Seven hundred and nine drug interactions were identified by pharmacists. The most common type of drug interaction considered the risk of cardiac arrhythmias due to antipsychotic medications. One hundred and thirty-three PIs concerned adverse drug reaction. The most frequent adverse drug reactions were a fall (36 PIs), hemorrhage/bleeding (32 PIs), drowsiness (12 PIs) and extrapyramidal syndrome (12 PIs). Antidepressant drugs were the greatest pharmacological class concerning adverse drug reaction. The overall acceptance rate was 57%. Eight hundred and seventy-four PIs (19%) were refused and 1111 (24%) were non-assessable. DISCUSSION: PIs avoids drug-related problems, such as the polyprescription of benzodiazepine or supratherapeutic dose. However, few PIs concern compliance to therapy or polyprescription of antipsychotic drugs. These two categories of medication-related problems are known to be an issue in mental health therapy. The lack of guidelines describing mental health pathology (such as the HAS guideline) is an obstacle for performing evidence-based PIs. The lack of information describing the context of the prescription is a limitation of this study. In order to improve their practice, pharmacists have to focus more on the context in which patients are evolving, and to take into account its entire situation based on Anglo-Saxon approaches. A second way is to identify clinical settings where PIs are useful and to describe PIs needed. Doctors and pharmacists should get together and talk about these clinical situations and PIs, because some may be misunderstood or disapproved by prescribers. This collaboration could take the form of a thesaurus combining clinical situation and PIs. CONCLUSION: It appears important for pharmacists to show their daily involvement in the quality of medical care. This feedback on medication problems encountered and PIs proposed should help prescribers to identify clinical situations at risk. Nevertheless, this study also suggests that progress is possible. Dialogue must allow pharmacists and physicians to delete misunderstandings about their practices.

Pharmacists' interventions on intravenous to oral conversion for potassium.

BACKGROUND: Guidelines recommend use of the oral route whenever possible to treat or prevent hypokalemia. Although a myriad of papers have been published regarding intravenous to oral (IV to PO) therapy conversion programs and about clinical pharmacy services provided in hospitals, little is known on the role of hospital pharmacists in promoting the oral route for potassium administration. OBJECTIVE: The aim of this work was to describe the frequency of interventions related to IV to PO potassium therapy conversions performed by hospital pharmacists. Setting French hospitals recording pharmacist's interventions on the website tool of the French Society of Clinical Pharmacy. METHODS: From the pharmacist's interventions (PI) dataset recorded we extracted all interventions related to potassium IV to PO conversion. We assessed the acceptance rate of these PI by prescribers. Additional free text information in the dataset was analysed. MAIN OUTCOME MEASURES: IV to PO potassium therapy conversions related to potassium chloride. RESULTS: From January 2007 to December 2010, 87 hospitals recorded 1,868 PIs concerning IV to PO therapy conversion. Among these, 16 (<1 %) concerned potassium chloride. They were recorded by four hospitals (4.6 %) with respectively 12, 2, 1 and 1 PIs. Six PIs were accepted by physicians and the prescriptions were modified. CONCLUSION: PIs to promote the administration of potassium by the oral route are extremely rare. Our results and scarce previously published data reveal that this field of practice remains almost unexplored. These findings highlight an important gap in the field of intravenous to oral therapy programs. This situation must be regarded as unsatisfactory and should lead to setting up more education and research programs.

Overdosed paracetamol (acetaminophen) prescriptions and subsequent pharmacist interventions in French hospitals.

INTRODUCTION: Little is known about the manner in which hospital pharmacists intervene for overdosed paracetamol prescriptions. The aim of this retrospective study was to describe the number and nature of pharmacists' interventions (PIs) for overdosed paracetamol adult prescriptions in hospitals. METHODS: We studied PIs that had been documented by pharmacists on the French Society of Clinical Pharmacy website tool between 2007 and 2010. We identified PIs that were related to paracetamol-containing prescriptions of one brand name only (type 1) particularly for patients with body weight ≤ 50 kg who were prescribed 4 g/day, and PIs that concerned the co-prescription of two paracetamol-containing products (type 2). RESULTS: Among 60 hospitals, seven did not report any paracetamol overdose-related PIs. Of the 53 hospitals that had at least one PI, 16 did not report any type 1 PIs. Bodyweight, liver disease, cirrhosis and chronic alcoholism were absent recorded criterion by most of the hospitals included in this study. DISCUSSION: Previously published studies have highlighted that the most frequent PIs are type 1, especially for patients whose body weight is ≤ 50 kg. We observed a broad variability in the number or type of PI that were related to overdosed paracetamol prescriptions compared with the total of all recorded types of PI. These data suggest that a significant number of hospital pharmacists are unaware of the risks that adult patients with low body weight are exposed to when receiving four grams paracetamol/day over several days. CONCLUSION: Pharmacist educational programs are needed.

[Opportunities for medication errors and pharmacist's interventions in the context of computerized prescription order entry: a review of data published by French hospital pharmacists]. / Opportunités d'erreurs médicamenteuses et interventions pharmaceutiques dans le cadre de la prescription informatisée : revue des données publiées par les pharmaciens hospitaliers français.

INTRODUCTION: Computerized prescription order entry (CPOE) is accelerating in France. CPOE has been shown to reduce the occurrence of some medication errors, but evidence of a beneficial effect on clinical outcomes remains limited. In some cases, new error types have arisen with its use. The aim of this study was to investigate the French data on the nature and frequency of medication errors opportunities generated by the computer use, which led pharmacists to alert prescribers. METHODS: We performed a search on PubMed and CAT-INIST databases completed by a manual one. RESULTS: Ten publications, 11 abstracts and three personal communications were analysed. As part of the analysis of computerized prescriptions, the rate of pharmaceutical interventions due to CPOE ranges from 5.9 to 35% depending on the study. Duplicate orders, unit errors, the use of free text, parameterization flaws and poor usability of software are probably the root of many prescribing errors. Errors generated by the tool can have serious potential consequences. DISCUSSION: Pharmacist's interventions due to CPOE are common. It is not known whether variability of the percentage of pharmacist's interventions is due to software used or to conditions by witch studies were carried out. With implementation of CPOE in hospital, pharmacists must acquire new knowledge and new skills in order to prevent prescription errors generated by these tools and its misuse. CONCLUSION: Studies are urgently needed in order to identify the safest tools and to discard the most dangerous.

[Designing a tool to describe drug interactions and adverse events for learning and clinical routine]. / Développement d'un outil d'aide à la description des interactions et des effets indésirables médicamenteux pour la formation et la routine clinique.

Pharmacists play an important role in prescription analysis. They are involved in therapeutic drug monitoring, particularly for drugs with a narrow therapeutic index, prevention and management of drug interactions, and may be called in to identify side effects and adverse events related to drug therapy. For the polymedicated patient, the medical file, the list of prescribed drugs and the history of their administration may be insufficient to adequately assign the responsibility of a given adverse effect to one or more drugs. Graphical representations can sometimes be useful to describe and clarify a sequence of events. In addition, as part of their academic course, students have many occasions to hear about "side effects" and "drug interactions". However, in the academic setting, there are few opportunities to observe the evolution and the consequences of these events. In the course of their hospital training, these students are required to perform patient follow-up for pharmacotherapeutic or educational purposes and to comment case reports to physicians. The aim of this paper is to present a tool facilitating the graphic display of drug interaction consequences and side effects. This tool can be a useful aid for causality assessment. It structures the students' training course and helps them better understand the commentaries pharmacists provide for physicians. Further development of this tool should contribute to the prevention of adverse drug events.