INTRODUCTION

It has been proposed that therapeutic drug monitoring is warranted when a drug exhibits a narrow therapeutic range, therapy is of sufficient duration, pharmacokinetic parameters have been correlated with clinical outcome, the pharmaco­dynamic response is not readily assessable, and/or the drug assay results provide more information than clinical judgement alone. For a drug that is suitable for therapeutic drug monitoring, measurement of the area under the concentration- time curve (AUC) is considered a good representation of overall exposure to the drug. For selected anti-infective agents, pharmacokinetic parameters such as AUC/MIC (drug exposure relative to the bacterial minimum inhibitory concentration) and peak/MIC (peak concentration relative to the bacterial minimum inhibitory concentration) have been correlated with outcomes in animal, in vitro, and a small number of human studies. In their review of pharmacokinetic and pharmacodynamic considerations for selecting agents for outpatient parenteral antimicrobial therapy, Slavik and Jewesson discussed several anti-infectives for which AUC/MIC may correlate with clinical efficacy. Such agents include, but are not limited to, fluoroquinolones (ciprofloxacin, levofloxacin, gatifloxacin) and quinupristin-dalfopristin.

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Practitioners should also be educated about the impor­tance of routinely collecting information for nonprescription products. Although a perception may exist that nonprescrip- tion medications are a relatively low priority in the context of a hospital admission, 7 (35%) of the patients in this study had an admission order discrepancy associated with a nonprescription medication, and 23% of these discrepancies were judged to have potential for a severe adverse outcome. Many of these discrepancies occurred because the patient was simply not asked about nonprescription medication use. Even if nonpre- scription medications are intentionally discontinued upon admission to hospital, information about their use is important. For example, it may give insight into possible drug interactions and adverse effects experienced on admission or even after discharge.

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Medication errors are a major source of in-hospital adverse events, and strategies to reduce these potentially avoidable errors are needed. Although the use of a province-wide prescription database is widely assumed to reduce hospital medication-ordering errors, this strategy had not previously been evaluated. In this pilot study, despite use of the PharmaNet database at the time admission orders were pre­pared, the proportion of patients with unintended medication discrepancies remained high, and a substantial proportion of the discrepancies were classified as having potential for moderate or severe patient discomfort or clinical deterioration. In a similar study in Ontario, where a provincial prescription database was not available, the proportion of patients with unintended discrepancies was similar (54% versus 60% in the current study), as was the level of potential harm associated with the discrepancies identified. Although the rate of omission errors in the current study was slightly lower than in the Ontario study (37% versus 46%), this benefit was offset by a higher rate of errors of commission (27% versus 0%).

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Inter-rater reliability in the judging of severity was fair to good34 (к = 0.56, 95% confidence interval 0.42-0.70). A substantial proportion of the medication discrepancies (43%) were rated as having potential for moderate or severe patient discomfort or deterioration (Table 3). Three (23%) of the 13 nonprescription drug discrepancies and 2 (12%) of the 17 prescription drug discrepancies were rated as having the potential for severe patient discomfort or deterioration (Table 4).

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To reach the intended sample size of 20 patients, a total of 33 patients were approached between September 2005 and January 2006 and asked to participate in the study. Of these, 2 who initially agreed to participate were discharged before their scheduled interview with the investigator; 2 additional patients were recruited to replace them, and the final sample size was 20 patients (Table 1), as planned. The study participants were mostly male and elderly, with 80% using 8 or more medications before admission. Eleven patients (55%) had prescription vials available for inspection during the interview.

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Patients admitted from the emergency department to a general internal medicine ward by 1 of 2 preselected medical teams were identified the morning after admission by means of a computerized admission roster. Patients were considered for inclusion if their medication history indicated use of at least 4 regular prescription medications before admission. Patients were excluded if they had been transferred from a long-term care or nursing facility or from another acute care facility (since PharmaNet consistently records only outpatient prescriptions), if they were discharged within 24 h after admission, or if they were unable to consent to participate in the study. Because PharmaNet records prescription filling histories only for pharmacies located in British Columbia, patients from outside the province were also excluded. The study investigator (K.K.) approached all other patients, seeking their enrolment in the study, until a total of 20 patients had been recruited. Those who agreed were asked to provide informed consent. Patients who were not available to the study investigator because of obligations pertaining to their care and/or time constraints were not approached.

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INTRODUCTION

Medication errors are thought to account for up to 20% of all adverse reactions experienced in the hospital setting. One common source of medication error occurs on admission, when the health care provider collects information about the patient’s medications before admission and then decides to con­tinue or discontinue these medications during the hospital stay. Adverse events can arise if there is an unintended discrepancy between the patient’s actual medication history and the medications ordered in the hospital. In 2005, Cornish and others2 reported that for 53.6% of study patients at a 1000- bed tertiary care hospital in Ontario, there were unintended discrepancies between orders written on admission to a general medicine ward and an interview-based medication history. Thirty-nine percent of these discrepancies were identified as having the potential to cause moderate or severe patient discomfort or clinical deterioration.

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