Intravenous medication administrations have a high incidence of error but there is limited evidence of associated factors or error severity.
To measure the frequency, type and severity of intravenous ...administration errors in hospitals and the associations between errors, procedural failures and nurse experience.
Prospective observational study of 107 nurses preparing and administering 568 intravenous medications on six wards across two teaching hospitals. Procedural failures (eg, checking patient identification) and clinical intravenous errors (eg, wrong intravenous administration rate) were identified and categorised by severity.
Of 568 intravenous administrations, 69.7% (n = 396; 95% CI 65.9 to 73.5) had at least one clinical error and 25.5% (95% CI 21.2 to 29.8) of these were serious. Four error types (wrong intravenous rate, mixture, volume, and drug incompatibility) accounted for 91.7% of errors. Wrong rate was the most frequent and accounted for 95 of 101 serious errors. Error rates and severity decreased with clinical experience. Each year of experience, up to 6 years, reduced the risk of error by 10.9% and serious error by 18.5%. Administration by bolus was associated with a 312% increased risk of error. Patient identification was only checked in 47.9% of administrations but was associated with a 56% reduction in intravenous error risk.
Intravenous administrations have a higher risk and severity of error than other medication administrations. A significant proportion of errors suggest skill and knowledge deficiencies, with errors and severity reducing as clinical experience increases. A proportion of errors are also associated with routine violations which are likely to be learnt workplace behaviours. Both areas suggest specific targets for intervention.
The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, ...healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a 3‐year cycle. The AGS Beers Criteria® is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions. For the 2019 update, an interdisciplinary expert panel reviewed the evidence published since the last update (2015) to determine if new criteria should be added or if existing criteria should be removed or undergo changes to their recommendation, rationale, level of evidence, or strength of recommendation. J Am Geriatr Soc 67:674–694, 2019.
See related editorial by Steinman et al. in this issue.
Objective The objective of the study was to provide information on overall medication use throughout pregnancy, with particular focus on the first trimester and specific prescription medications. ...Study Design The study design included the Slone Epidemiology Center Birth Defects Study, 1976-2008, and the National Birth Defects Prevention Study, 1997-2003, which together interviewed more than 30,000 women about their antenatal medication use. Results Over the last 3 decades, first-trimester use of prescription medication increased by more than 60%, and the use of 4 or more medications more than tripled. By 2008, approximately 50% of women reported taking at least 1 medication. Use of some specific medications markedly decreased or increased. Prescription medication use increased with maternal age and education, was highest for non-Hispanic whites, and varied by state. Conclusion These data reflect the widespread and growing use of medications by pregnant women and reinforce the need to study their respective fetal risks and safety.
Abstract
Objective
The High-Alert Medication Stratification Tool‒Revised (HAMST-R) was originally designed to standardize the identification of high-alert medications (HAMs) according to safety risk. ...The primary objective of this multisite study was to assess interrater reliability of the HAMST-R PRO, a version of the tool designed to prospectively evaluate safety risk of medications during evaluation for formulary addition.
Methods
HAMST-R was designed as an objective tool to evaluate HAMs at a single site during the HAMST-R phase I study. Phase II of the study demonstrated the validity of the tool in a multisite, national study. In this third study, 11 medication safety experts from 8 health systems across the United States and 1 in Canada facilitated evaluation of medications prospectively with the HAMST-R PRO during the formulary review process for 27 medications. At each site, at least 5 individuals were asked to review each medication. Interrater reliability was evaluated using Kendall’s coefficient of concordance. Ease of use was determined by participant interviews.
Results
Overall interrater reliability for HAMST-R PRO was found to be 0.76 (P < 0.001) across all sites, indicating substantial agreement between users. Interrater reliability among individual sites ranged from 0.52 to 0.82 (P < 0.05 for all sites).
Conclusion
Interrater reliability of HAMST-R PRO is substantial, indicating consistency and agreement among pharmacists utilizing this tool to evaluate safety risk of medications before their addition to a health-system formulary. This information can be used to identify potential interventions for each step of the medication-use process that institutions may implement to decrease a medication’s potential safety risk.
The management of cancer is predicated on the availability and affordability of anticancer therapies, which may be either curative or noncurative.
The primary aims of the study were to evaluate (i) ...the formulary availability of licensed antineoplastic medicines across Europe; (ii) patient out-of-pocket costs for the medications and (iii) the actual availability of the medication for a patient with a valid prescription.
The survey tool was based on the previous ESMO studies that addressed the availability and accessibility of opioids for the management of cancer pain. A total of 185 field reporters from 49 countries were invited to participate. The preliminary set of data was posted on the ESMO website for open peer-review, and amendments have been incorporated into the final report.
There are substantial differences in the formulary availability, out-of-pocket costs and actual availability for many anticancer medicines. The most profound lack of availability is in countries with lower levels of economic development, particularly in Eastern Europe, and these are largely related to the cost of targeted agents approved in the last 10 years. Discrepancies are less profound among medications on the WHO model essential medicines list (EML) for cancer and in curative settings. However, medicine shortages also affect WHO EML medicines, with relevant therapeutic implications for many patients.
The cost and affordability of anticancer treatments with recent market approval is the major factor contributing to inequity of access to anticancer medications. This is especially true with regards to new medications used in the management of EGFR- or ALK-mutated non-small-cell lung cancer, metastatic melanoma, metastatic renal cell cancer, RAS/RAF wild-type metastatic colorectal cancer, HER2 overexpressed breast cancer and castration-resistant metastatic prostate cancer.
COPD medications reduce exacerbations and improve quality of life. Despite this, some individuals do not receive medications recommended by practice guidelines.
How common is nonreceipt of ...recommended medications among people with COPD, and what factors are associated with nonreceipt?
This population cohort study was conducted in Ontario, Canada, a province with universal health care insurance and medication coverage for those aged ≥ 65 years. Health administrative data were used to identify people aged ≥ 66 years with physician-diagnosed COPD as of 2018 and group them into cohorts of lower or higher risk for future COPD exacerbations. Proportions of patients in each group who did not receive medications recommended by COPD guidelines were determined. Generalized estimating equation modeling was used to determine associations between patient and physician factors and nonreceipt of recommended medications.
About 54% and 88% of people with COPD received sufficient recommended medications in the low and high risk of exacerbation groups, respectively. Longer duration of COPD, higher comorbidity, dementia, and older physician age were associated with nonreceipt of recommended medications in both groups. People who had a co-diagnosis of asthma, who received care by a pulmonologist and who received spirometry were more likely to receive recommended medication.
COPD medications seem underused by the COPD population, and various factors are associated with suboptimal receipt. Targeting these factors would help improve the care and health of people with COPD.
Purpose
To elucidate the status of medication use among pregnant women in Japan, by means of a multigenerational genome and birth cohort study: the Tohoku Medical Megabank Project Birth and ...Three-Generation Cohort Study (TMM BirThree Cohort Study).
Methods
Questionnaires were distributed to pregnant women participating in the TMM BirThree Cohort Study (from July 2013 to March 2017) around 12 weeks (early pregnancy) and 26 weeks (middle pregnancy). We analysed medication use over three periods: (1) 12 months prior to pregnancy diagnosis, (2) the period between pregnancy diagnosis and around week 12 of pregnancy, and (3) post around week 12 of pregnancy.
Results
In total, 19,297 women were included in the analysis. The proportion of pregnant women using medications was 49.0% prior to pregnancy diagnosis, 52.1% from diagnosis to week 12, and 58.4% post week 12 of pregnancy. The most frequently prescribed medications were loxoprofen sodium hydrate (5.5%) prior to pregnancy diagnosis, magnesium oxide (5.9%) from diagnosis to week 12, and ritodrine hydrochloride (10.5%) post week 12 of pregnancy. The number of women who used suspected teratogenic medications during early pregnancy was 96 prior to pregnancy diagnosis, 48 from diagnosis to week 12, and 54 post week 12 of pregnancy.
Conclusion
We found that ~ 50% of the pregnant women used medications before and during pregnancy and some took potential teratogenic medications during pregnancy. In birth genomic cohort study, it is expected that investigations into the safety and effectiveness of medications used during pregnancy will advance.
Anti-IL-5 therapies for asthma Farne, Hugo A; Wilson, Amanda; Milan, Stephen ...
Cochrane database of systematic reviews,
07/2022, Volume:
7
Journal Article
Peer reviewed
Open access
This is the second update of previously published reviews in the Cochrane Library (2015, first update 2017). Interleukin-5 (IL-5) is the main cytokine involved in the proliferation, maturation, ...activation and survival of eosinophils, which cause airway inflammation and are a classic feature of asthma. Studies of monoclonal antibodies targeting IL-5 or its receptor (IL-5R) suggest they reduce asthma exacerbations, improve health-related quality of life (HRQoL) and lung function in appropriately selected patients, justifying their inclusion in the latest guidelines.
To compare the effects of therapies targeting IL-5 signalling (anti-IL-5 or anti-IL-5Rα) with placebo on exacerbations, health-related quality-of-life (HRQoL) measures and lung function in adults and children with chronic asthma, and specifically in those with eosinophilic asthma refractory to existing treatments.
We searched CENTRAL, MEDLINE, Embase, and two trials registers, manufacturers' websites, and reference lists of included studies. The most recent search was 7 February 2022.
We included randomised controlled trials comparing mepolizumab, reslizumab and benralizumab versus placebo in adults and children with asthma.
Two review authors independently extracted data and analysed outcomes using a random-effects model. We used standard methods expected by Cochrane.
Seventeen studies on about 7600 participants met the inclusion criteria. Six used mepolizumab, five used reslizumab, and six used benralizumab. One study using benralizumab was terminated early due to sponsor decision and contributed no data. The studies were predominantly on people with severe eosinophilic asthma, which was similarly but variably defined. One was in children aged 6 to 17 years; nine others included children over 12 years but did not report results by age group separately. We deemed the overall risk of bias to be low, with all studies contributing data of robust methodology. We considered the certainty of the evidence for all comparisons to be high overall using the GRADE scheme, except for intravenous (IV) mepolizumab and subcutaneous (SC) reslizumab because these are not currently licensed delivery routes. The anti-IL-5 treatments assessed reduced rates of 'clinically significant' asthma exacerbation (defined by treatment with systemic corticosteroids for three days or more) by approximately half in participants with severe eosinophilic asthma on standard care (at least medium-dose inhaled corticosteroids (ICS)) with poorly controlled disease (either two or more exacerbations in the preceding year or Asthma Control Questionnaire (ACQ) score of 1.5 or more), except for reslizumab SC. The rate ratios for these effects were 0.45 (95% confidence interval (CI) 0.36 to 0.55; high-certainty evidence) for mepolizumab SC, 0.53 (95% CI 0.44 to 0.64; moderate-certainty evidence) for mepolizumab IV, 0.43 (95% CI 0.33 to 0.55; high-certainty evidence) for reslizumab IV, and 0.59 (95% CI 0.52 to 0.66; high-certainty evidence) for benralizumab SC. Non-eosinophilic participants treated with benralizumab also showed a significant reduction in exacerbation rates, an effect not seen with reslizumab IV, albeit in only one study. No data were available for non-eosinophilic participants treated with mepolizumab. There were improvements in validated HRQoL scores with all anti-IL-5 agents in severe eosinophilic asthma. This met the minimum clinically important difference (MCID) for the broader St. George's Respiratory Questionnaire (SGRQ; 4-point change) for benralizumab only, but the improvement in the ACQ and Asthma Quality of Life Questionnaire (AQLQ), which focus on asthma symptoms, fell short of the MCID (0.5 point change for both ACQ and AQLQ) for all of the interventions. The evidence for an improvement in HRQoL scores in non-eosinophilic participants treated with benralizumab and reslizumab was weak, but the tests for subgroup difference were negative. All anti-IL-5 treatments produced small improvements in mean pre-bronchodilator forced expiratory flow in one second (FEV
) of between 0.08 L and 0.15 L in eosinophilic participants, which may not be sufficient to be detected by patients. There were no excess serious adverse events with any anti-IL-5 treatment; in fact, there was a reduction in such events with benralizumab, likely arising from fewer asthma-related hospital admissions. There was no difference compared to placebo in adverse events leading to discontinuation with mepolizumab or reslizumab, but significantly more discontinued benralizumab than placebo, although the absolute numbers were small (42/2026 (2.1%) benralizumab versus 11/1227 (0.9%) placebo). The implications for efficacy or adverse events are unclear.
Overall this analysis supports the use of anti-IL-5 treatments as an adjunct to standard care in people with severe eosinophilic asthma and poor symptom control. These treatments roughly halve the rate of asthma exacerbations in this population. There is limited evidence for improved HRQoL scores and lung function, which may not meet clinically detectable levels. The studies did not report safety concerns for mepolizumab or reslizumab, or any excess serious adverse events with benralizumab, although there remains a question over adverse events significant enough to prompt discontinuation. Further research is needed on biomarkers for assessing treatment response, optimal duration and long-term effects of treatment, risk of relapse on withdrawal, non-eosinophilic patients, children (particularly under 12 years), comparing anti-IL-5 treatments to each other and, in patients meeting relevant eligibility criteria, to other biological (monoclonal antibody) therapies. For benralizumab, future studies should closely monitor rates of adverse events prompting discontinuation.
The National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) use the American Geriatrics Society (AGS) Beers Criteria to designate the quality measure Use of High‐Risk ...Medications in the Elderly (HRM). The Centers for Medicare and Medicaid Services (CMS) use the HRM measure to monitor and evaluate the quality of care provided to Medicare beneficiaries. NCQA additionally uses the AGS Beers Criteria to designate the quality measure Potentially Harmful Drug–Disease Interactions in the Elderly. Medications included in these measures may be harmful to elderly adults and negatively affect a healthcare plan's quality ratings. Prescribers, pharmacists, patients, and healthcare plans may benefit from evidence‐based alternative medication treatments to avoid these problems. Therefore the goal of this work was to develop a list of alternative medications to those included in the two measures. The authors conducted a comprehensive literature review from 2000 to 2015 and a search of their personal files. From the evidence, they prepared a list of drug‐therapy alternatives with supporting references. A reference list of nonpharmacological approaches was also provided when appropriate. NCQA, PQA, the 2015 AGS Beers Criteria panel, and the Executive Committee of the AGS reviewed the drug therapy alternatives and nonpharmacological approaches. Recommendations by these groups were incorporated into the final list of alternatives. The final product of drug‐therapy alternatives to medications included in the two quality measures and some nonpharmacological resources will be useful to health professionals, consumers, payers, and health systems that care for older adults.
•Free text medication name entry include misspellings and can lead to medical errors.•Two user-friendly methods efficiently support medication spelling corrections.•Fuzzy string searches for ...retrospective use, require moderate programming skills.•Spell checkers for retrospective or prospective use only exist for some languages.
To identify and support correction of misspelled medication names recorded as free text, we compared the relative effectiveness of two user-friendly methods, used without reliance on clinical knowledge.
Leveraging the SAS® COMPGED function, fuzzy string search programs examined 1.8 million medication records from 183,600 World Trade Center General Responder Cohort monitoring visits conducted in New York and New Jersey between 7/16/2002 and 3/31/2021, producing replicable generalized edit distance scores between the reported and correct spelling. Scores < 120 were selected as optimal and compared to Stedman’s 2020 Plus Medical/Pharmaceutical Spell Checker first suggested word, used as the comparative standard because it employs both spelling and phonetic similarities to suggest matching words. We coded each methods’ results as identifying or not identifying the medications within each visit.
Most types of medications (94.4 % anxiety, 98.4 % asthma and 94.6 % ulcer/gastroesophageal reflux disease) were correctly spelled. Cross tabulations assessed the agreement (anxiety 99.9 %, asthma 99.6 % and 98.4 % ulcer/ gastroesophageal reflux disease), false positive (respectively 0.02 %, 0.03 % and 2.0 %) and false negative (respectively 1.9 %, 0.5 % and 1.0 %) values. Scores < 120 occasionally correctly identified medications missed by the spell checker. We observed no difference in medication misspellings across socio-economically and culturally diverse patient characteristics.
Both methods efficiently identified most misspelled medications, greatly minimizing the review and rectification needed. The fuzzy method is more universally applicable for condition-specific medications identification, but requires more programming skills. The spell checker is inexpensive, but benefits from modest programming skills and is only available in some languages.
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