Too frequent low-dose methotrexate prescriptions: multicentre quality control and quality assurance with pre- and post-analysis.

INTRODUCTION: Methotrexate is used to treat many medical conditions with medication schedules that differ widely in dosage and frequency. The high potential of erroneous too frequent low-dose methotrexate prescriptions leading to severe adverse reactions is well known; however, documentation is mainly limited to case reports. We reviewed all methotrexate prescriptions in a secondary and a tertiary care hospital to analyse the incidence of too frequent low-dose methotrexate prescriptions, and assessed the quality assurance concepts implemented. METHODS: All nononcological low-dose methotrexate prescriptions issued for inpatients within 55 months were analysed to identify too frequent prescriptions potentially leading to harmful overdosing. Subsequently, clinical pharmacologists reviewed all new methotrexate prescriptions with resulting interventions at the physician level in the tertiary care hospital. The impact of an interruptive alert displayed at methotrexate order entry was assessed in the secondary care hospital. RESULTS: The incidence of too frequent prescriptions at the tertiary hospital was 1.6% (five medication errors and nine near misses in 888 inpatients). After introducing checks by pharmacologists, two prescription errors were intercepted during the 8 month quality assurance period. At the secondary care hospital the incidence dropped from 2.5% (2/79, 20 months) to 0.8% (1/123, 35 months) after the alert was implemented. CONCLUSIONS: The incidences of erroneous too frequent low-dose methotrexate prescriptions observed at both hospitals were considered too high due to the high potential for increased morbidity, mortality and costs. Therefore, quality assurance measures were implemented and the preliminary data show a positive impact on patient safety for both approaches.

Frequency and nature of drug-drug interactions in a Swiss primary and secondary acute care hospital.

QUESTIONS UNDER STUDY: Drug-drug interactions (DDI) are considered a risk factor in medication safety and computerised alerting tools are increasingly promoted and implemented in order to detect and minimise DDI. As only little is known about the frequency and nature of DDI in hospitalised patients in Switzerland as well as about the usefulness of current alerting systems, this analysis based on a computerised medication record in a typical regional hospital setting was performed. METHODS: All inpatients with at least one drug prescription between 2006 and 2010 were included. A total of 1,654,987 prescriptions were analysed with regard to the maximal seriousness level of DDI between each added prescription versus the existing prescription and with regard to all underlying DDI. RESULTS: On average, each inpatient received 16 different drugs including on-demand prescriptions and encountered 5 DDI. A total of 27% of all prescriptions caused DDI. Within the last 12 months, 5% of all DDI were classified in category 1 (contraindicated), 3% in category 2, 53% in category 3, 8% in category 4 and 31% in category 5. The vast majority of DDI were caused by a very limited number of drugs. DISCUSSION: Drug-drug interactions were very frequent and were very stable over the years studied, involving on average 27% of all prescriptions and 44% in internal medicine. Only a very limited amount of drugs were responsible for the vast majority of DDI, especially when the most severe categories of DDI were considered. Most of the severe DDI alerts could be automatically handled, if for example laboratory values could be taken into account. The DDI database should ideally be supplemented by information enabling more sophisticated computerised support in order to deliver more reasonable results from DDI checks.

Prescribing practice in a Swiss primary and secondary acute care hospital.

QUESTIONS UNDER STUDY: Little is known about the prescribing behaviour of physicians in hospitals. This analysis, using data based on Computerised Physician Order Entry (CPOE), was performed to evaluate prescription patterns, to analyse possible over-prescribing of drugs and to assess the compliance with therapy-guidelines. METHODS: Within a 12 month period, 68,133 prescriptions in three departments were analysed with respect to drug class, duration of therapy, dosage, administration route, patient's age, patient's length of stay and number of prescriptions per patient. RESULTS: On average, each patient received 12 drugs. A steady increase in the number of prescribed drugs can be seen between the age of 20 and 85. The median duration of intravenously administered antibiotics was 4.0 days, the median duration of antibiotic therapy was 9.5 days. DISCUSSION: On average, patients were taking 5 drugs on a regular basis on admission to hospital. This number was doubled during the hospital stay where patients were prescribed 12 drugs on average. On discharge 6 drugs were prescribed and thus a reasonable reduction was made. Surgical and Internal Medicine wards were using very similar drug classes. Concerning the use of low molecular-weight heparin, guidelines were widely adhered to whereas proton-pump-inhibitors were prescribed too often and the duration of intravenous antibiotic therapy tended to be too long.