Potentially inappropriate medicine prescribing by nurse practitioners in New Zealand.

BACKGROUND AND PURPOSE: Nurse practitioners (NPs) in New Zealand (NZ) prescribe a broad range of medicines; little is known about their prescribing practice for older adults. Potentially inappropriate medicines (PIMs) can cause more harm than benefit. This study reports on the prescribing of PIMs to older adults (≥65 years) by NPs in NZ. METHODS: A subset analysis using data from NZ Ministry of Health pharmaceutical collection from 2013 to 2015 was completed. Data included NP registration number, medicines dispensed, patient age, sex, and NZ Deprivation level. Those <65 years were excluded. Beers 2015 criteria were used to identify the PIMs. RESULTS: There were 106 NPs that prescribed medicines to 12,410 patients aged ≥65 years. One third of the patients were prescribed ≥1 PIMss. Most (68.4%) were prescribed one PIM; 21.9% two PIMs; 7.1% three PIMs; and 2.6% were prescribed ≥4 PIMs. NPs prescribed an average of 14.9% PIMs. Primary care NPs were more likely to prescribe PIMs, compared to those with a scope of older adults and long-term conditions (p ≤ 0.001). The most common Beers 2015 PIMs prescribed were proton pump inhibitors, non-steroidal anti-inflammatory drugs, alpha blockers, hypnotics, tricyclic antidepressants, and benzodiazepines. IMPLICATIONS FOR PRACTICE: NPs prescribe lower rates of PIMs to older adults than other prescribers in NZ. However, prescribing practices can be improved and the findings indicate that a more specific educational focus on prescribing to older adults is required. The findings provide an important baseline internationally for NP PIM prescribing and can be used by NPs, and educationally to review and improve practices.

Reducing inappropriate psychotropic drug use in nursing home residents with dementia: protocol for participatory action research in a stepped-wedge cluster randomized trial.

BACKGROUND: Psychotropic drugs are often prescribed to treat neuropsychiatric symptoms in nursing home residents with dementia, despite having limited efficacy and considerable side effects. To reduce the inappropriate prescribing of these psychotropic drugs, various non-pharmacological, psychosocial, person-centered, or multidisciplinary interventions are advocated. However, existing multidisciplinary interventions have shown variable effects, with limited effectiveness often resulting from suboptimal implementation. We hypothesize that an effective intervention needs to fit the local situation of a nursing home and that support should be offered during implementation. METHODS: We will embed participatory action research within a stepped-wedge cluster randomized controlled trial to study the effects of a tailored intervention and implementation plan to reduce inappropriate psychotropic drug prescribing. Nursing homes will be provided with tailored information about the perceived problems of managing neuropsychiatric symptoms and we will offer coaching support throughout. Alongside the participatory action research, we will perform a process evaluation to examine the quality of the study, the intervention, and the implementation. Our aim is to recruit 600 residents from 16 nursing homes throughout the Netherlands, with measurements taken at baseline, 8 months, and 16 months. Nursing homes will be randomly allocated to an intervention or a deferred intervention group. During each intervention stage, we will provide information about inappropriate psychotropic drug prescribing, neuropsychiatric symptoms, and difficulties in managing neuropsychiatric symptoms through collaboration with each nursing home. After this, a tailored intervention and implementation plan will be written and implemented, guided by a coach. The primary outcome will be the reduction of inappropriate prescribing, as measured by the Appropriate Psychotropic drug use In Dementia index. Secondary outcomes will be the frequency of psychotropic drug use and neuropsychiatric symptoms, plus quality of life. A mixed methods design will be used for the process evaluation. Effects will be assessed using multilevel analyses. The project leader of the nursing home and the coach will complete questionnaires and in-depth interviews. DISCUSSION: We anticipate that the proposed tailored intervention with coaching will reduce inappropriate psychotropic drug prescribing for nursing home residents with neuropsychiatric symptoms. This study should also provide insights into the barriers to, and facilitators of, implementation. TRIAL REGISTRATION: NTR5872 , registered on July 2, 2016.

Integrating bedside nurses into antibiotic stewardship: A practical approach.

Nurses view patient safety as an essential component of their work and have reported a general interest in embracing an antibiotic steward role. However, antibiotic stewardship (AS) functions have not been formally integrated into nursing practice despite nurses' daily involvement in clinical activities that impact antibiotic decisions (e.g., obtaining specimens for cultures, blood drawing for therapeutic drug monitoring). Recommendations to expand AS programs to include bedside nurses are generating support at a national level, yet a practical guidance on how nurses can be involved in AS activities is lacking. In this review, we provide a framework identifying selected practices where nurses can improve antibiotic prescribing practices through appropriate obtainment of Clostridioides difficile tests, appropriate urine culturing practices, optimal antibiotic administration, accurate and detailed documentation of penicillin allergy histories and through the prompting of antibiotic time outs. We identify reported barriers to engagement of nurses in AS and offer potential solutions that include patient safety principles and quality improvement strategies that can be used to mitigate participation barriers. This review will assist AS leaders interested in advancing the contributions of nurses into their AS programs by discussing education, communication, improvement models, and workflow integration enhancements that strengthen systems to support nurses as valued partners in AS efforts.

''As-Needed'' Range Orders for Opioid Analgesics in the Management of Pain: A Consensus Statement of the American Society for Pain Management Nursing and the American Pain Society.

Effective pain management requires careful titration of analgesics and evaluation of individual patient's responses to treatment using valid and reliable pain and pain relief assessment tools, and evidence-based patient monitoring for adverse treatment effects. A registered nurse, competent in pain assessment and analgesic administration, can safely interpret and implement properly written ''as-needed'' or ''PRN'' range orders for analgesic medications. The American Society for Pain Management Nursing (ASPMN) and the American Pain Society (APS) support safe medication practices and the appropriate use of PRN range orders for opioid analgesics in the management of pain.

Diseño y validación de un cuestionario sobre competencia enfermera en la notificación de incidentes por medicamentos / Design and validation of a questionnaire on nursing competence in the notification of medication incidents

Objetivo: Diseñar y realizar una validación de aspecto y contenido de un cuestionario para medir la competencia notificadora de incidentes por medicamentos de los enfermeros hospitalarios. Método: Estudio descriptivo de validación de aspecto y contenido de un cuestionario. Se realizó una revisión de la literatura para la creación de ítems. Seis expertos valoraron la pertinencia de la inclusión de cada ítem en el cuestionario mediante el cálculo del índice de posición; se seleccionaron aquellos con índice de posición>0,70. El cuestionario fue pilotado por 59 enfermeros. Un grupo de expertos redujo la extensión del cuestionario pilotado mediante revisión, discusión y decisión por consenso de cada ítem. Resultados: Tras la revisión bibliográfica se elaboró una batería con 151 ítems agrupados en 3 dimensiones competenciales: actitudes, conocimientos y habilidades. El 52,9% (n=80) obtuvo un índice de posición>0,70. La tasa de respuesta en el estudio piloto fue del 40,65%. La mediana de tiempo para completar el cuestionario fue de 23:35 min. Tras la reducción por expertos, el cuestionario definitivo se conformó con 45 ítems agrupados en 32 preguntas. Conclusiones: El cuestionario NORMA diseñado para explorar la competencia en la notificación de incidentes por medicamentos por los profesionales de enfermería hospitalarios, presenta una adecuada validez de aspecto y contenido, además de fácil administración, lo que posibilita su implementación institucional (AU)

Aim: To design and perform a face and content validation of a questionnaire to measure the competence of hospital RN to report medication incidents. Methods: Content and face questionnaire validation descriptive study. A review of the literature was performed for the creation of ítems. A panel of six experts assessed the relevance of the inclusion of each ítem in the questionnaire by calculating the position index; ítems with position index >0.70 were selected. The questionnaire was piloted by 59 RN. Finally, a meeting was convened with experts, in order to reduce the length of the piloted questionnaire through review, discussion and decision by consensus on each item. Results: From the literature review, a battery of 151 ítems grouped into three elements of competence: attitudes, knowledge and skills was created. 52.9% (n=80) of the ítems received a position index > 0.70. The response rate in the pilot study was 40.65%. The median time to complete the questionnaire was 23:35minutes. After reduction by the experts, the final questionnaire comprised 45 ítems grouped into 32 questions. Conclusions: The NORMA questionnaire, designed to explore the competence of hospital RN to report medication incidents, has adequate face and content validity and is easy to administer, enabling its institutional implementation (AU)

Prescripción inapropiada de medicamentos en el paciente anciano y criterios para la mejora / Inappropriate drug therapy prescription in the elderly and criteria for improvement

No disponible

Adaptación española de los criterios Beers / Spanish adaptation of Beers criteria

Fundamento: Los Criterios de Beers, de procedencia estadounidense y actualizados en 2012, son una herramienta asesora en la prescripción en pacientes ancianos. Dadas las diferencias entre nuestro catálogo de medicamentos y el norteamericano, el objetivo del estudio fue obtener una adaptación española de dichos criterios. Material y método: La comparación de los Criterios de Beers con el catálogo español de medicamentos de 2012 permitió detectar los principios activos, presentes en los criterios, no comercializados en España. Además se buscaron medicamentos comercializados en España similares a los presentes en los criterios. Se asume que los medicamentos comercializados en Estados Unidos ya fueron evaluados en la elaboración de los Beers. Así, sobre los medicamentos similares, disponibles en España y no en Estados Unidos, se realizó una evaluación de acuerdo a 3 tipos de fuentes: los artículos presentados por la American Geriatrics Society para avalar la evidencia de los Beers; las fichas técnicas y prospectos; y los criterios europeos STOPP/START, NORGEP y PRISCUS. Resultados: De los 199 principios activos presentes en los criterios Beers, se detectaron 54 (27,0%) no comercializados en España. Además se incorporaron 50 principios activos. Entre el grupo de los "Criterios Directos" se detectaron 47 (34,3%) no disponibles y 40 posibles inclusiones, y en el grupo de los "Criterios Dependientes de Enfermedad" 33 (21,3%) y 48 respectivamente. Conclusiones: Se ha detectado una importante presencia de medicamentos no comercializados en España, así como un elevado número de principios activos no incluidos en la versión original. Este trabajo facilita una adaptación de los Criterios de Beers a los profesionales de nuestro entorno (AU)

Background: The Beers criteria, which were drawn up in the USA and updated in 2012, were developed to detect potentially inappropriate prescriptions in older adults. Since there are significant differences between the Spanish and North American drug catalogues, our aim was to produce a Spanish adaptation of the criteria. Patients and methods: A comparison of the drugs mentioned in the Beers list with the 2012 Spanish Drugs Catalogue identified those active substances that were on the list in the USA but not commercially available in Spain. We also searched for Spanish drugs that were similar to those listed in the criteria. If these drugs were available in the USA, it was assumed that they had been evaluated by the Beers authors. On the other hand, if similar active substances were not available in the USA, they were evaluated by reference to three information sources: articles reviewed by the American Geriatrics Society in support of the Beers criteria, the product characteristics and information leaflets, and the European STOPP/START, NORGEP and PRISCUS criteria. Results: Of the 199 active substances listed in the Beers criteria, 54 (27.0%) were not commercially available in Spain, but 50 new active substances could be included. These figures differed when "Direct Criteria" were considered: 47 (34.3%) active substances were not commercially available in Spain and 40 new ones could be included in the Beers list. As regards "Disease Dependent Criteria" the figures were 33 (21.3%) and 48, respectively. Conclusions: A great number of drugs on the Beers list were not commercially available in Spain, and we added many active substances not included in the original version. This study is thus an adaptation of the Beers Criteria to the Spanish health care scenario (AU)

Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting / Impacto de la reconciliación de medicación por el servicio de farmacia en los errores de medicación durante la transición en el hospital

Objective: To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting. Methods: This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients’ community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment. Results: During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04). Conclusion: Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved (AU)

Objetivo: Evaluar si un servicio de farmacia debería estar más involucrado en el proceso de reconciliación de la medicación para ayudar a reducir los errores de medicación que ocurren durante la transición de servicio en un hospital. Métodos: Este fue un estudio de cohorte prospectiva observacional en un hospital de 531 camas en Pensacola, FL desde 1 de junio a 31 de agosto de 2014. Se incluyó a los pacientes si tenían seguro de salud y estaban tomando 5 o más medicamentos. Los pacientes con fallo cardiaco congestivo fueron excluidos del estudio. Los estudiantes de farmacia recogieron y evaluaron las historais de medicación obtenidas de las farmacias comunitarias de los pacientes y realizaron entrevistas a los pacientes. Solo se contactaba a los médicos de atención primaria si era necesario. La información recogida era presentada al farmacéutico clínico, que hacía intervenciones si lo consideraba adecuado. Resultados: Durante los 3 meses de estudio, se revisaron 1045 medicaciones ambulatorias. De ellas, se descubrieron 290 discrepancias (27,8%; p=0,02). La discrepancia más común fue la optimización de dosis (45,5%). Las restantes discrepancias incluían: tratamiento añadido (27.6%), otras (15.2%), y tratamiento discontinuado (11.7%). Los farmacéuticos realizaron 143 intervenciones basadas en su juicio clínico (49.3%; p=0.04). Conclusión: La participación de l personal de farmacia durante el proceso de reconciliación de la medicación puede ser un componente esencial para reducir errores de medicación. Con la inclusión del servicio de farmacia durante el proceso de ingreso, se consiguió precisión, ahorro de costes y aumento de seguridad del paciente en todas las fases de la transición de servicio (AU)

Errores de prescripción como barrera para la Atención Farmacéutica en establecimientos de salud públicos: Experiencia Perú / Prescription errors as a barrier to pharmaceutical care in public health facilities: Experience Peru

Objetivos: Evaluar la calidad de llenado de las recetas médicas en los establecimientos públicos de salud del distrito de Independencia, departamento de Lima como barrera para brindar atención farmacéutica a los pacientes. Material y métodos: Estudio de diseño transversal, se emplearon recetas atendidas en las farmacias ambulatorias de todos los establecimientos de salud del distrito de Independencia (11). En el mes de noviembre 2013 se seleccionaron aleatoriamente, de cada uno de los 11 establecimientos, 384 recetas atendidas en el mes de octubre de 2013. Resultados: Se tomó de modo aleatorizado 384 recetas de cada uno de los 11 establecimientos de salud, haciendo un total de 4224 recetas. El 24% de recetas consignaban el dato del peso del paciente (IC: 22,76%-25,30%); el 34,2% mencionaba el diagnóstico (IC: 32,80%-35,62%); el 93,7% tenían descrito los medicamentos expresados en DCI (IC: 93,00-94,41%). Asimismo, solo el 11,3% consignaban la vía de administración (IC: 10,40%-12,28%) y el 41,4% señalaban la frecuencia (IC: 39,94%- 42,88%). La duración del tratamiento estuvo ausente en 32% de las recetas evaluadas (IC: 66,62%-69,41%) y solo el 5,7% tuvieron la fecha de vencimiento (IC: 5,00%-6,41%). Estos errores son barreras para la atención farmacéutica ya que dificulta la detección de problemas relacionados con medicamentos y asimismo limita la información que se pueda brindar al paciente sobre el uso de sus medicamentos. Conclusión: Se necesita de estrategias innovadoras para mejorar la prescripción de modo que no sea una barrera para poder detectar, resolver y prevenir la aparición de problemas relacionados a los medicamentos

Objectives: to evaluate the quality of prescriptions' filling in Independencia’s District public health facilities in the department of Lima as a barrier to provide pharmaceutical care to patients. Materials and methods: It was carried out a cross-sectional study with prescriptions from the outpatients pharmacies of all the Independencia’s District health facilities (11). During the month of November 2013, 384 prescriptions that have been assisted in October were randomly selected of each of the health facilities. Results: 384 prescriptions were randomly selected of each of the 11 health facilities which represented a whole of 4224 prescriptions. 24% of the prescriptions recorded the patient’s weight (IC: 22,76%-25,30%); 34,2% included the diagnosis (IC: 32,80%- 35,62%); 93,7% included drugs expressed in INN (IC: 93,00-94,41%). Furthermore, only 11,3 mentioned the route of administration (IC: 10,40%-12,28%) and 41,4 pointed out the frequency (IC: 39,94%-42,88%). The length of treatment was missing in 32% of the evaluated prescriptions (IC: 66,62%-69,41%) and only 5,7 included the expiration date (IC: 5,00%-6,41%). These errors are barriers for the pharmaceutical care due to the fact that they make difficult the detection of problems related to drugs; on the other hand, they limit the information that can be given to a patient about the use of his/her drugs. Conclusion: Innovative strategies are needed in order to improve prescriptions so that they are not a barrier any more for the detection, solution and prevention of problems related to drugs

Advancing safe drug use through interprofessional learning (IPL): a pilot study.

Interprofessional collaborative patient-centered care (IPCPC) improves healthcare quality and cost. Drug-related morbidity drives healthcare costs, thus requiring IPCPC approaches. The lack of educational preparedness for would-be IPCPC practitioners underlies the failure of historic IPCPC attempts, hence today's emphasis on pre-licensure interprofessional education (IPE). A pilot IPE class was conducted on rational drug use (RDU) through rational drug prescribing. Twenty fourth-year nursing students and 88 second-year medical students participated (8-10 medical per 2-3 nursing students) in small group activity in a lecture hall. A case study on rational drug choice and prescription writing processes from medical and nursing perspectives was used. Eighty of 108 (74%) students completed the post-activity questionnaire and were satisfied with the class, with a mean weighted score (mws) of 0.8. The learning outcomes (mws = 1.0) contributed more (P < 0.05) to students satisfaction than the organization/delivery (mws = 0.6). A majority (84-94%) agreed the class objectives were achieved and favored more classes. Interaction with other healthcare professionals and the crowded classroom were, respectively, the most- and least-liked aspects of the class. The study revealed students' appetite for IPE, highlights the challenges in developing IPE curricula, and could serve as impetus for schools developing IPE for RDU curricula.

An evaluation of the appropriateness and safety of nurse and midwife prescribing in Ireland.

AIM: To evaluate the clinical appropriateness and safety of nurse and midwife prescribing practice. BACKGROUND: The number of countries introducing nurse and midwife prescribing is increasing; however, concerns over patient safety remain. DESIGN: A multi-site documentation evaluation was conducted using purposeful and random sampling. The sample included 142 patients' records and 208 medications prescribed by 25 Registered Nurse Prescribers. METHODS: Data were extracted from patient and prescription records between March-May 2009. Two expert reviewers applied the modified Medication Appropriate Index tool (8 criteria) to each drug. The percentage of appropriate or inappropriate responses for each criterion was reported. Reviewer concordance was measured using the Cohen's kappa statistic (inter-rater reliability). RESULTS: Nurse or midwife prescribers from eight hospitals working in seventeen different areas of practice were included. The reviewers judged that 95-96% of medicines prescribed were indicated and effective for the diagnosed condition. Criteria relating to dosage, directions, drug-drugs or disease-condition interaction, and duplication of therapy were judged appropriate in 87-92% of prescriptions. Duration of therapy received the lowest value at 76%. Overall, reviewers indicated that between 69 (reviewer 2)-80% (reviewer 1) of prescribing decisions met all eight criteria. CONCLUSION: The majority of nurse and midwife prescribing decisions were deemed safe and clinically appropriate. However, risk of inappropriate prescribing with the potential for drug errors was detected. Continuing education and evaluation of prescribing practice, especially related to drug and condition interactions, is required to maximize appropriate and safe prescribing.

Challenges to nurse prescribers of a no-antibiotic prescribing strategy for managing self-limiting respiratory tract infections.

AIMS: To report a qualitative study of the experiences of nurse prescribers in managing patients with self-limiting respiratory tract infections. BACKGROUND: Patients frequently attend primary care with respiratory tract infections. Although a no-prescribing strategy is recommended for these consultations, general practitioners frequently prescribe antibiotics, citing non-clinical reasons such as patient pressure. Nurses increasingly manage people with respiratory tract infections, but research has not yet explored their experiences within such consultations. DESIGN: Semi-structured interviews and focus groups. METHODS: Fifteen semi-structured interviews and three focus groups (n=5, n=4, and n=12) with a purposive sample of nurse prescribers (n=34) and other non-medical prescribers (n=2) were conducted between November 2009-November 2010. A qualitative approach was used to develop conceptual categories from the dataset, and emerging themes were explored in subsequent interviews/focus groups. FINDINGS: Although participants reported experiencing numerous challenges within these consultations, they believed that they possessed some of the communication skills to deal effectively with patients without prescribing antibiotics. Participants reported that protocols supported their decision-making and welcomed the benefits of peer support in dealing with 'demanding' patients. However, the newness of nurses and other non-medical prescribers to the prescribing role meant that some were cautious in dealing with patients with respiratory tract infections. CONCLUSION: Training for nurses and other non-medical prescribers should focus on building their confidence and skills to manage people with respiratory tract infections without recourse to antibiotics. Further work should seek to explore which strategies are most effective in managing respiratory tract infections while maintaining patient satisfaction with care.

Responsabilidad por daños producidos por medicamentos / Responsability due to damages produces by drugs

Un medicamento, desde la fase de ensayos clínicos, hasta que es administrado a un paciente, pasa por diferentes situaciones de riesgo que conviene conocerlas para evitarlas en lo posible, y poderlas controlar. En la fase de ensayos clínicos, el riesgo es claro, los conocimientos del fármaco son muy limitados, por ello la normativa obliga a contratar una importante póliza de responsabilidad por posibles daños. En la fase de fabricación, son frecuentes los lotes defectuosos que escapan al control y suponen un riesgo. En la fase de comercialización (dispensación y administración) es donde se dan el mayor número de daños, puesto que al prescribir el medicamento ante la generalidad de pacientes (distinto del ensayo clínico donde el enfermo es elegido cuidadosamente), es cuando aparecen reacciones adversas desconocidas, etc. que generan responsabilidad para el laboratorio fabricante o comercializador. La ficha técnica de nuevos productos, que deben recibirla todos los sanitarios prescriptores, es la mejor guía para hacer un buen uso del medicamento, puesto que aparece la frecuencia y gravedad de reacciones adversas, las interacciones y cualquier acción que deba tenerse en cuenta. Finalmente, debemos tener en cuenta la farmacovigilancia, o sea, que el prescriptor, en el caso de cualquier sospecha de una reacción adversa o cualquier circunstancia, tiene la obligación de comunicarla a la Consejería, por cualquier medio, del posible evento será tenida en cuenta en el seguimiento del producto (AU)

A drug, from the phase of its clinical trial until the administration to a patient, goes through different situations of risk that we should know in order to avoid and control. In the clinical trial phase, the risk is clear, the familiarity with the drug is limited. This is why the rules oblige to hire a liability policy for possible future damages. In the manufacturing phase, there exists defective batches that escape from the control and involve a risk. In the marketing phase (dispensation and administration) is where there exists the highest number of damages, because when the drug is administred to different kind of patients (different from the clinical trial where the patient is chosen) is when there appears unknown adverse reactions, etc... that generate responsibility for the manufacturer or the marketer laboratory. The technical data sheet of the new product, that must be received by all the medical prescribers is the best guide in order to make a good use of the drug, because it shows the frequency and seriousness of the adverse reactions, the interactions and any other action that should be taken into account. Finally, we should take into account the pharmaco-surveillance, that is to say, the prescriber, under any question of an adverse reaction or any circumstance, has the obligation to inform to the Ministry, of any way, about the possible fact that is going to be taken into account (AU)