Simple prescribing errors and allergy documentation in medical hospital admissions in Australia and New Zealand.

This study aimed to quantify and compare the prevalence of simple prescribing errors made by clinicians in the first 24 hours of a general medical patient's hospital admission. Four public or private acute care hospitals across Australia and New Zealand each audited 200 patients' drug charts. Patient demographics, pharmacist review and pre-defined prescribing errors were recorded. At least one simple error was present on the medication charts of 672/715 patients, with a linear relationship between the number of medications prescribed and the number of errors (r = 0.571, p < 0.001). The four sites differed significantly in the prevalence of different types of simple prescribing errors. Pharmacists were more likely to review patients aged > or = 75 years (39.9% vs 26.0%; p < 0.001) and those with more than 10 drug prescriptions (39.4% vs 25.7%; p < 0.001). Patients reviewed by a pharmacist were less likely to have inadequate documentation of allergies (13.5% vs 29.4%, p < 0.001). Simple prescribing errors are common, although their nature differs from site to site. Clinical pharmacists target patients with the most complex health situations, and their involvement leads to improved documentation.

What does the future hold for general medicine?

General medicine is being challenged by increasing numbers of patients who are presenting with multiple comorbidities and a decline in numbers of suitably trained personnel to manage these patients. A resurgence in generalist care, with collaboration between generalists and specialists, is the key to successfully managing patients who present with acute medical conditions. Better funded collaborative training programs for general physicians, which promote a diversity of skills and address clinical demand in a proscriptive manner, are needed. Research aimed at designing acute services to match local clinical demand is also required.

Clinical deterioration in the condition of patients with acute medical illness in Australian hospitals: improving detection and response.

Medical Assessment Units (MAUs) provide an opportunity for multidisciplinary staff to manage recently admitted acutely unwell patients with complex medical illnesses. We propose concerted development of robust mechanisms for identifying and managing patients whose condition is unstable as they move through hospital departments. Track, trigger and response (TTR) systems (eg, medical emergency team calls and early warning scores) have been introduced to hospital practice, but evidence for their effectiveness is, so far, incomplete. The current variation in TTR systems within and between hospitals impairs intersite comparisons. A range of outcome measures, including risk of physiological deterioration, mortality and projected hospital length of stay, could be usefully investigated by future intersite collaborative research. More deliberate, systematic, evidence-based design of "response" in TTR systems may help in identifying patients who need early attention from skilled medical staff. We need more uniform TTR systems, more research on TTR systems and more multisite research; MAUs are ideally situated to address this important area.

Contrasts in acute medicine: a comparison of the British and Australian systems for managing emergency medical patients.

Increasing numbers of patients are presenting for unscheduled medical admission to hospitals worldwide, prompting clinical redesign of "front-door" emergency medical services. In the United Kingdom, there has been considerable investment in the establishment of acute medical units (AMUs) and the training of acute medicine physicians. Some centres in Australia have established similar medical assessment units. While these initiatives have undoubtedly met with some success, the evidence base for their overall benefit remains elusive. We describe key aspects of the recent establishment of acute medical services in Britain and discuss the relevance of these experiences to Australia. Successful models of care in acute medicine have often been shared with other centres. The adaptation of existing models of care to meet local demands is superior to simply adopting an existing model. Once the desired clinical functionality of a service is determined, informed decisions can be made on staffing requirements, skill mix, and the structure of any new clinical unit. The functionality of the acute medical service, rather than simply the physicality of an AMU, should drive service design.

Should thrombolysis have a greater role in the management of pulmonary embolism?

Pulmonary embolism (PE) continues to be associated with significant mortality despite advances in the diagnostic techniques available for its detection. Anticoagulation remains standard treatment in PE although there is a consensus view that 'step-up' to thrombolytic therapy in addition to anticoagulation is indicated in those patients who are systemically shocked at presentation--a group defined as having suffered 'massive pulmonary embolism'. Considerable research has been directed at attempting to identify further groups of patients with PE who are at high risk of morbidity and mortality--notably those who are labelled as having suffered 'sub-massive pulmonary embolism' where this is defined as the presence of right-heart strain in the absence of systemic shock. In particular, the potential benefit of extending thrombolytic therapy to include those patients with sub-massive PE has been the subject of much enquiry and debate. This review examines the evidence for thrombolytic therapy and explores the potential for risk stratification in PE.

What is the place of thrombolysis in acute stroke? A review of the literature and a current perspective.

The global burden of stroke, the undisputed success of intravenous thrombolysis in the management of myocardial infarction and subsequent evidence from animal models of cerebral infarction have all fuelled intense interest in the potential role for thrombolytic agents in the acute management of stroke in clinical practice. Before any clinical treatment is introduced universally its safety and efficacy must be demonstrated in the routine clinical environment and not just within the ideal conditions of controlled clinical trials. Similarly, the cost effectiveness of a new treatment modality is an essential consideration before its use is promulgated. This paper reviews the current scientific evidence for thrombolysis in stroke with reference to issues of safety, efficacy and cost effectiveness.

Intra-pericardial rupture of bacterial hepatic abscess: an unusual cause of 'cardiac' chest pain.

We report a rare case of bacterial pericarditis secondary to rupture of liver abscess into the pericardium. The patient presented with cardiac-sounding chest pain and with normal ECG, CXR and Troponin-I assay. The initial echocardiogram showed minimal pericardial fluid but, when he later developed overt clinical signs of cardiac tamponade, a CT scan of chest and abdomen revealed a pronounced pericardial effusion. It also revealed an abscess located in the left lobe of liver and this had apparently ruptured into the pericardial sac. Culture of the purulent pericardial aspirate grew Proteus and Enterococcus; these organisms have been reported only rarely as responsible for causing purulent pericarditis. The patient was treated initially by emergency ultrasound-guided pericardiocentesis; later he required thoracotomy and pericardiectomy in order to manage persistent re-accumulation of pus in the pericardium.