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      Use of a generic protocol in documentation of prescription errors in Estonia, Norway and Sweden

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          Abstract

          Pharmacists have an important role in detecting, preventing, and solving prescription problems, which if left unresolved, may pose a risk of harming the patient.

          Objective

          The objectives of this study were to evaluate the feasibility of a generic study instrument for documentation of prescription problems requiring contact with prescriber before dispensing. The study was organized: 1) by countries: Estonia, Norway and Sweden; 2) by type of prescriptions: handwritten prescriptions, printouts of prescriptions in the electronic medical record and electronically transmitted prescriptions to pharmacies; and 3) by recording method - self-completion by pharmacists and independent observers.

          Methods

          Observational study with independent observers at community pharmacies in Estonia (n=4) and Sweden (n=7) and self-completed protocols in Norway (n=9).

          Results

          Pharmacists’'in Estonia contacted the prescriber for 1.47% of the prescriptions, about 3 times as often as in Norway (0.45%) and Sweden (0.38%). Handwritten prescriptions dominated among the problem prescriptions in Estonia (73.2%), printouts of prescriptions in the electronic medical record (89.1%) in Norway and electronically transmitted prescriptions to pharmacies (55.9%) in Sweden. More administrative errors were identified on handwritten prescriptions and printouts of prescriptions in the electronic medical record in Estonia and in Norway compared with electronically transmitted prescriptions to pharmacies in Sweden (p<0.05 for prescription types and p<0.01 for countries). However, clinically important errors and delivery problems appeared equally often on the different types of prescriptions. In all three countries, only few cases of drug interactions and adverse drug reactions were identified.

          Conclusions

          Despite the different patterns of prescription problems in three countries, the instrument was feasible and can be regarded appropriate to document and classify prescription problems necessitating contact with prescriber before dispensing, irrespective of the type of prescription or recording method.

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          Most cited references 29

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          Role of computerized physician order entry systems in facilitating medication errors.

          Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. To identify and quantify the role of CPOE in facilitating prescription error risks. We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders. Examples of medication errors caused or exacerbated by the CPOE system. We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.
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            What is a prescribing error?

            To develop a practitioner led definition of a prescribing error for use in quantitative studies of their incidence. Two stage Delphi technique. A panel of 34 UK judges, which included physicians, surgeons, pharmacists, nurses and risk managers. The extent to which judges agreed with a general definition of a prescribing error, and the extent to which they agreed that each of 42 scenarios represented a prescribing error. Responses were obtained from 30 (88%) of 34 judges in the first Delphi round, and from 26 (87%) of 30 in the second round. The general definition of a prescribing error was accepted. The panel reached consensus that 24 of the 42 scenarios should be included as prescribing errors and that five should be excluded. In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not. Health care professionals are in broad agreement about the types of events that should be included and excluded as prescribing errors. A general definition of a prescribing error has been developed, together with more detailed guidance regarding the types of events that should be included. This definition allows the comparison of prescribing error rates among different prescribing systems and different hospitals, and is suitable for use in both research and clinical governance initiatives.
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              The relationship between number of drugs and potential drug-drug interactions in the elderly: a study of over 600,000 elderly patients from the Swedish Prescribed Drug Register.

              Drug-drug interactions (DDIs) are of great concern, as they are known to be related to adverse drug reactions and hospitalisations. In addition, many DDIs are regarded as predictable and avoidable; therefore, they may be considered as targets for education and interventions. To analyse the relationship between number of dispensed drugs and the probability of potential DDIs among the elderly by using the new Swedish Prescribed Drug Register. We analysed data on age, sex and dispensed drugs for people aged > or = 75 years who were registered in the Swedish Prescribed Drug Register from October to December 2005, and constructed a list of current prescriptions for every individual on the arbitrarily chosen date of 31 December 2005. Thereafter, we included those who had at least two dispensed drugs to capture the elderly population at risk of being exposed to DDIs (n = 630 743). The main outcome measures were potentially clinically relevant DDIs (type C), which may require dose adjustment, and potentially serious DDIs (type D), which should be avoided. The prevalence of type C potential DDIs was 26% and of type D potential DDIs 5% in the study population. There was a strong association between number of dispensed drugs and the probability of type C potential DDIs and an even stronger association for type D potential DDIs, after adjustment for age and sex. In addition, the probability of type D potential DDIs decreased with increasing age, and women had a lower probability of type D potential DDIs than men. There seems to be a strong relationship between number of dispensed drugs and potential DDIs, especially for potentially serious DDIs, which has implications for the importance of trying to minimise the number of drugs prescribed in the elderly. Our findings that the probability of potentially serious DDIs decreases with increasing age among the elderly and that elderly women have a lower probability of potentially serious DDIs than elderly men need to be verified and investigated by further research.
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                Author and article information

                Affiliations
                Department of Pharmacy, University of Tartu . Tartu (Estonia).
                Centre for Pharmacy, University of Bergen . Bergen (Norway).
                Department of Rational Use of Medications, Medical Products Agency, Uppsala, Sweden; Linnæus University . Kalmar (Sweden).
                Contributors
                Department of Pharmacy, University of Tartu . Tartu (Estonia).
                Centre for Pharmacy, University of Bergen . Bergen (Norway).
                Department of Rational Use of Medications, Medical Products Agency, Uppsala, Sweden; Linnæus University . Kalmar (Sweden).
                Journal
                Pharm Pract (Granada)
                Pharm Pract (Granada)
                Pharm Pract
                Pharmacy Practice
                Centro de Investigaciones y Publicaciones Farmaceuticas
                1885-642X
                1886-3655
                Apr-Jun 2012
                30 June 2012
                : 10
                : 2
                : 72-77
                PhP-414
                3780480
                24155820
                Copyright © 2012, CIPF

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Original Research

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