INTRODUCTION

Medication reconciliation is a formal process of obtaining a complete and accurate list of each patient’s current home medications and comparing the list with orders written at each transition of care. The Safer Healthcare Now! Campaign is a national program intended to improve the safe­ty of the Canadian health care system. The campaign consists of a variety of initiatives, one of which is preventing adverse drug events by means of medication reconciliation.

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In this study of patients treated in hospital for acute myocardial infarction, the prescribing rates at discharge for the 4 classes of medications were higher than established bench­mark values. One-third to one-half of the patients were already receiving one or more of the medications of interest at admission. This finding is clinically significant, as improvements in morbidity and mortality after acute myocardial infarction have been linked to the use of these classes of medications. The results indicate awareness on the part of the health care team of the importance of adhering to current standards of therapy. Another retrospective Canadian study published in 2005 reported rates of discharge prescribing for “ideal” patients after acute myocardial infarction of 85% for ASA, 78% for fi-blockers, 72% for ACE inhibitors, and 61% for statins, all lower than the rates reported here. The demographic characteristics of our sample were similar to those in the earlier study.

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Patient Characteristics

Medical records for a total of 346 patients were reviewed. The mean age (± SD) of patients was 65.3 ± 13.4 years, andalmost two-thirds (226 [65.3%]) were male (Table 2). Before admission, approximately half of the patients had dyslipidemia (181 [52.3%]) or hypertension (197 [56.9%]), and almost one-third (100 [28.9%]) had a history of acute myocardial infarction. Each medication of interest was prescribed to more than one-third of the patients at the time of admission. For the 100 patients with a history of acute myocardial infarction, the prescribing rates for the 4 medication classes at the time of admission were lower than the established benchmarks: 60.0% (60 patients) for ASA, 66.0% (66 patients) for fi-blockers, 57.0% (57 patients) for ACE inhibitors, and 50.0% (50 patients) for statins.

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This retrospective study involved patients discharged from 2 adult acute care sites of Eastern Health. At the time of the study, the 2 sites had a total of about 550 acute care beds, and each contained a coronary care unit. One of these sites housed the cardiac catheterization laboratory and the cardiac surgery program for the entire province. During the 2007/2008 fiscal year, a total of 526 coronary artery bypass graft procedures and 766 percutaneous coronary interventions were performed. Eastern Health is also affiliated with the province’s only university (Memorial University of Newfoundland), having particularly strong links to its medical and allied health professional schools.

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INTRODUCTION

Over the past 20 years, treatment of acute myocardial infarction has improved through more rapid recognition of symptoms, treatment with fibrin-specific thrombolytics and percutaneous coronary intervention, and clinical trials that have demonstrated reductions in morbidity and mortality with appropriate acute treatment and secondary prevention. Specifically, evidence now supports the use of acetylsalicylic acid (ASA), adrenergic fi-receptor antagonists (fi-blockers), angiotensin-converting enzyme inhibitors (ACE inhibitors), and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) for eligible patients who have experienced acute myocardial infarction. This information has led to the publication of guidelines outlining optimal treatments for patients with acute myocardial infarction.1,2 From these guidelines, processes of care have been developed to ensure that patients receive evidence-based care that will improve outcomes.

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Based on the fastest degradation rate observed, with 95% confidence, this study has demonstrated that solutions of norepinephrine, diluted in NS or D5W to a concentration of 64.5 mg/L and stored for 60 days with protection from light at 4°C and then at room temperature for an additional 24 h, will retain more than 95% of the initial concentration. Solutions that are not protected from light will retain only 90% of the initial concentration with storage for 39 days at 4°C. This storage period could include up to 24 h of storage at room temperature, without protected from light.

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Accelerated Degradation and Assay Validation

Degradation of norepinephrine with heat and base (pH 8.264) occurred relatively quickly, such that less than 1% of the initial norepinephrine concentration remained after 37 min. As the norepinephrine concentration decreased, degradation products eluted at 1.3, 1.7, 2.1, 2.5, 2.8, and 4.8 min. These degradation products were well separated from norepinephrine, which eluted at 5.5 min (Figure 1). Degradation appeared to occur in a first-order fashion, with a half-life of 5.5 min (r = 0.9969, n = 8). Degradation of norepinephrine with heat and acid (pH 1.977) occurred more slowly, such that about 80% of the initial norepinephrine concentration remained after 142 h. As a result of the chromatographic separation of these degradation products from norepinephrine, and the similarity of the UV spectrum (200-320 nm) between a fresh norepinephrine sample and norepinephrine in a degraded sample, it was concluded that this analytical method was stability-indicating.

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