The WHO High 5s project: medication reconciliation in a German university hospital. A prospective observational cohort study.

BACKGROUND: Ensuring medication accuracy during transitions in care is one of the five highly prevalent patient safety problems focused on within the World Health Organization High 5s Project. Medication reconciliation is a standardized patient care process that can be used to address this problem. The aim of the current study is to implement medication reconciliation in a German university hospital. METHODS: The study was conducted at the Emergency Department of the University Hospital Aachen, Germany. All discrepancies between the Best Possible Medication History and the Admission Medication Order were documented and classified as documentation errors or medication errors. The type of error was also recorded. A negative binomial regression model was used to test several factors influencing the number of discrepancies. RESULTS: The medications of 105 patients were reconciled. The mean number of discrepancies per patient was 4.6± 3.6, with a total of 298 medication errors and 189 documentation errors. The most common type of medication error was the omission of a drug (n=208; 69.8 %). In the negative binomial regression analysis, the care status (p=0.0015) as well as the number of preadmission drugs (p=0.0007) were significantly associated with medication errors. DISCUSSION: A high number of discrepancies was detected and analysed. Patients admitted from nursing homes were less likely to have discrepancies in their medication reconciliation, perhaps because a structured documentation system for medications is already in place at nursing homes including error prone products (special dosage forms or food supplements). CONCLUSIONS: In this study, medication reconciliation was implemented at a German full-care university hospital. The actual number of discrepancies observed strongly indicates the need for medication reconciliation at hospital admission.

Medication safety in a German telemedicine centre: Implementation of a telepharmaceutical expert consultation in addition to existing tele-intensive care unit services.

Introduction: Tele-intensive care unit (tele-ICU) services offer the possibility to provide specialized medical care in remote areas and to improve patient outcomes. The aim of this study was to implement and evaluate an additional telepharmaceutical expert consultation as part of tele-ICU services. Methods: This is a prospective observational study conducted in the telemedicine centre of the University Hospital RWTH Aachen, Germany. Between March and July 2015, all tele-ICU patients of one internal and two remote ICUs received telepharmaceutical consultation. Number and type of drug related problems (DRPs) were identified in a comprehensive medication safety check. Implementation of DRPs was discussed interdisciplinarily by tele-ICU pharmacist, tele-ICU physician and remote ICU physician. Special focus was on drug­drug interactions (DDIs) and dosage adjustment in renal and liver failure. Results: A total of 210 DRPs in 103 patients were identified and discussed. On average, 2.0 (range 0­17) DRPs per patient were found. At least one DRP was found in 62% of patients. Antibacterials for systemic use were most involved in DRPs. A total of 1129 DDI-alerts were generated by ID PHARMA CHECK®. Fifty-six DDIs (5%) were discussed in tele-ICU rounds. The tele-ICU team discussed 28 cases of dosage adjustment in organ failure. Discussion: Telepharmaceutical consultation as part of tele-ICU services was successfully implemented and can improve medication safety. Telemedicine infrastructure provides the possibility to implement guidelines recommending pharmaceutical service in the ICU in remote hospitals not having access to clinical pharmacists. Thus, quality of care can be improved.

A Clinical Drug-Drug Interaction Study Assessing a Novel Drug Transporter Phenotyping Cocktail With Adefovir, Sitagliptin, Metformin, Pitavastatin, and Digoxin.

A new probe drug cocktail containing substrates of important drug transporters was tested for mutual interactions in a clinical trial. The cocktail consisted of (predominant transporter; primary phenotyping metric): 10 mg adefovir-dipivoxil (OAT1; renal clearance (CLR )), 100 mg sitagliptin (OAT3; CLR ), 500 mg metformin (several renal transporters; CLR ), 2 mg pitavastatin (OATP1B1; clearance/F), and 0.5 mg digoxin (intestinal P-gp, renal P-gp, and OATP4C1; peak plasma concentration (Cmax ) and CLR ). Using a randomized six-period, open change-over design, single oral doses were administrated either concomitantly or separately to 24 healthy male and female volunteers. Phenotyping metrics were evaluated by noncompartmental analysis and compared between periods by the standard average bioequivalence approach (boundaries for ratios 0.80-1.25). Primary metrics supported the absence of relevant interactions, whereas secondary metrics suggested that mainly adefovir was a victim of minor drug-drug interactions (DDIs). All drugs were well tolerated. This cocktail may be another useful tool to assess transporter-based DDIs in vivo.

Working together to enhance medication safety: working group 'medication safety' of the Aktionsbündnis Patientensicherheit e.V. / Gemeinsam für mehr Arzneimitteltherapiesicherheit Die AG AMTS im Aktionsbündnis Patientensicherheit e. V.

For 12 years, the 'Aktionsbündnis Patientensicherheit e.V. (APS)' has been developing tools for improving patient safety. Experts with different professional backgrounds are working alongside patients and self-help associations in different working groups to develop and publish problem-oriented best-practice recommendations. Since its foundation in 2005, APS has published more than 20 best-practice recommendations and is one of the most important institutions for patient safety in Germany. In this article, the aims and initiatives of one working group of the APS, i.e. the medication safety working group, are presented. The standardized concept for the development of best-practice recommendations is illustrated by the example of the recommendations for medication safety in hospitals.

Analysis of drug-related problems in three departments of a German University hospital.

BACKGROUND: During the last decades, pharmaceutical care services have been developed and implemented to optimize drug therapies and ensure medication safety. To investigate the need for pharmaceutical care services, drug-related problems can be measured. OBJECTIVE: Thus, the aim of this study was to analyse number, type and occurrence of drug-related problems in different clinical departments. SETTING: A pharmaceutical care service was established on general wards in Urology, Neurology and Gastroenterology at the University Hospital RWTH Aachen, Germany. METHOD: For each of a total of 306 patients, a pharmacist conducted an extended medication history, performed medication reconciliation, conducted medication safety checks and if drug-related problems were discovered, gave valid recommendations to the attending healthcare team. Drug-related problems were classified using the APS-Doc system. For statistical analyses, SAS(®) 9.1.3, SAS Institute, Cary NC, USA was applied. The project was approved by the local ethics committee. MAIN OUTCOME MEASURE: Type, occurrence and frequency of DRP in different medical departments. RESULTS: On average, 2.3 drug-related problems per patient were documented for all three departments. Drug-related problems were found in each category of the APS-Doc system. The most pronounced drug-related problems found were drug-drug interactions (34.6 %). 37 % of the identified drug-related problems occurred before hospital admission, 27 % during transitional care, and 36 % on the ward. Subgroup analysis revealed specific drug-related problem patterns for each clinical department. The number of drug-related problems was found to be associated with the number of drugs and age. CONCLUSION: Drug-related problems frequently occur in all investigated clinical departments. A holistic pharmaceutical care service could be an option to address this issue. In case of limited resources, individual drug-related problem patterns can be used as a basis for a tailored pharmaceutical care service. As number of drugs and age have been shown to be significant risk factors, it is crucial that the healthcare team including the pharmacist pays special attention to elderly patients and those with polymedication.

[Medication Reconciliation-theory and practice]. / Medication Reconciliation - Theorie und Praxis.

The World Health Organization initiated the project "High5s - Action on Patient Safety". The aim of the High5s project is to achieve a measurable, significant and sustained reduction in the occurrence of five serious patient safety problems within five years, in five countries. One of these patient safety issues is medication reconciliation - the process of assuring medication accuracy at transitions of care. In Germany, eleven hospitals are currently implementing medication reconciliation. Medication reconciliation represents the systematic comparison of the current patient's medication list with the medication list in hospital. For this purpose, Lead Technical Agencies of each participating country translated and adapted the standard operating procedure. This standard operating procedure describes the implementation and the procedure of the medication reconciliation process in detail. This process is divided into three parts. First, the best possible medication history is recorded. Second, based on those records, the responsible physician subsequently prescribes the medication. In the third step, the best possible medication history is compared with the medication orders at admission. During this process, it is likely that some discrepancies will occur. Such discrepancies are discussed with the responsible physician and clarified. A comprehensive acquisition of the best possible medication history is thus particularly important. It will be part of medical records throughout the patients' hospital stay. Thus it will be used as an additional source for comparison and adjustment of patients' medication in order to facilitate optimal drug treatment during the entire hospital stay. The practical implementation of medication reconciliation requires extensive change of the current prescription sheets or prescription software. Thus, this provides a great challenge for many hospitals. Nevertheless, in the Netherlands it has been shown that it is possible to prevent 90 % of unintentional discrepancies with medication reconciliation. A German hospital recently showed a reduction of discrepancies by about 77 %. The use of medication reconciliation to improve clinical endpoints is currently subject of further studies.