Introduction: Febrile neutropenia (FN) is a frequent complication of chemotherapy use in cancer patients. There is evidence to suggest that the time to antibiotic administration is associated with increase survival and effective clinical outcome. The Australian consensus guidelines for the management of FN in adult cancer patients recommends treatment within 30 minutes to patients with features of systemic compromise. A study performed at The Alfred Hospital in 2010 revealed a median time of 145 minutes to first antibiotic administration. A new guideline was therefore developed and education was implemented. This study was conducted to evaluate the intervention. Aim: To determine time to first antibiotic prescribing and administration for patients with suspected FN presenting to the Alfred Emergency and Trauma centre. Materials and Methods: The electronic medical record of 112 episodes of suspected FN presenting between March and August 2012 were reviewed.  Data were retrospective collected according to a FN data spreadsheet. An observational study were also performed at  The Alfred Emergency and Trauma centre during October and November 2012 to determine time to first antimicrobial prescribing, because this data could not be collected from the electronic medical record. Results: The median time from presentation to antibiotic prescribing was 68 minutes. The median time from presentation to antibiotic administration was 121 minutes. Conclusions: The implementation of the new guidelines has reduced the time with 16.6%, but the target first antibiotic administration within 30 minutes has not been reached.

Background: Defined daily dose (DDD) is a unit that gives an estimate of drug utilization. The DDDs that are developed today are only based on adult’s drug use. That means that the DDDs for adults may not necessarily apply to children. 

Aim: To calculate recommended daily dose for boys and girls in different ages and compare it with DDD for adults for paracetamol, phenoxymethylpenicillin, desloratadine and melatonin.  

Methods: This descriptive cross-sectional study was conducted September-October 2021. Boys and girls in ages 1, 5, 12 and 16 years were included. Data was retrieved from FASS.se, tillväxtkurvor.se and WHO Collaborating Centre for Drug Statistics Methodology. 

Results: The children’s daily doses are lower than DDD for adults for paracetamol for all ages, phenoxymethylpenicillin for ages 1, 5 and 12 and desloratadine for ages 1 and 5. The daily doses of phenoxymethylpenicillin aged 16 are higher than DDD for adults. Daily doses for melatonin and desloratadine age 12 and 16 were the same as DDD for adults. Paracetamol and phenoxymethylpenicillin have variations in the daily doses for the children. Girls in all ages except from 12 years and the youngest children had lowers doses. Desloratadine ages 1 and 5 had the same dose and ages 12 and 16 had the same dose. For melatonin the children received the same doses. 

Conclusion: The calculated recommended daily doses for children are to some extent in line with WHO DDDs. In order to use WHO DDDs in children, it is important to have knowledge of which drugs and ages they can be applied for.  

Background: Medications are used to treat, cure, or relieve symptoms of diseases, but there is a risk with the use of medications. Drug-related-problems are known to increase morbidity and mortality. Incorrect medical list and discrepancies in these lists can lead to drug-related problems as side effects, hospitalization, non-compliance, drug interactions and overtreated or undertreated patients. Discrepancies can be for example: more prescriptions than necessary, outdated prescriptions, i.e., medicines that will not be used, prescriptions with incorrect dosing and missing prescriptions i.e., medicines used by patients that cannot be seen in the medication list.

Purpose:  The aim of this study was to investigate discrepancies in the Swedish prescription list "My saved prescriptions at the pharmacy". The secondary aim was to investigate how common it is to use this prescription list or the dosage label on the medicine packaging to know which medicines to use and which dosage.

Methods: The data collection was performed by four pharmacy students at seven pharmacies in Sweden over a period of three weeks during Jan-Feb. 2021 where the prescription list was investigated together with patients to identify any discrepancies. The study included patients who was over 18 years old, spoke Swedish, had three or more prescribed drugs, and agreed to participate. 

Results A total of 215 patients were interviewed, where 61% had one or more discrepancies in their medication list. A total of 1717 prescriptions were analyzed, of which 10% were double prescriptions (n = 167), 8% outdated prescriptions (n = 141) and 3% prescriptions with the wrong dosage (n = 42). When analyzing the primary sources of information used by patients to know which medicine to use, the printout of the list "my saved prescriptions at the pharmacy” dominated (n = 72).  Most used information source to know drug dosage was the dosage label on the medicine packaging (n = 112).

Conclusions: It is important to have an updated and correct information in the medication list, to prevent drug-related-problems caused by discrepancies. It becomes even more important when we see that the medication list "My saved prescriptions at the pharmacy" and dosage label (containing the same information in the medication list), are the most used primary sources by patients to know which drug to use and in what dosage. Finally, results show a relationship between the number of prescribed drugs and the number of discrepancies that occur, and therefore we see more discrepancies in elderly patients who are usually ill and are being treated for several diseases. 

There are opportunities for further research to study e.g., which drug-related-problems are caused by discrepancies in the medication list as well as the degree of danger in these problems. 

The word communication originates from the Latin word communicare that means to do something in common. When human beings communicate with each other, we share thoughts, emotions, values and actions. The foundation in communication is found within the interpersonal communication, which is the act of communication between two persons. All types of communications include of verbal and nonverbal acts of communication.

The verbal communication consists of words either in speech or writing, the nonverbal act implies gestures, frequency of the tone and facial expressions.

Within the pharmaceutical profession, good communication between the pharmacist and the customer is important and can affect the customer’s health and quality of life in both direct as well as indirect ways. In recent years, the pharmacist's role in the pharmacy has drastically changed. Nowadays the care of the customer has gained more significance than before. To improve customer health and quality of life it is important that the pharmacist acts to promote a good relationship with the customer and the foundation for this relationship should be built on good terms of communication.

The purpose of this study was to study how common it is with communication errors between pharmacist and customer, and to demonstrate probable underlying causes. Secondary questions were, how is the drug advice the pharmacist provides affected by communication errors?

Collection of data for the study was done with structured observation charts, where the customer and pharmacist were strictly observed. A total of 316 meetings were observed and the data collected referred to prescriptions. In more than one-third of the observed meetings, there were communication errors between the pharmacist and the customer. Communication errors that arose concerned lack of eye contact, language barriers, choice of questions, background noise from colleagues and customers and discussions from generic exchanges. To reduce future communication errors, the pharmacist's actions should be strengthened, such as eye contact, clear follow-up questions and improved feedback.

Bakgrund: Demens orsakas av hjärnskador som främst drabbar äldre. Antalet dementa personer i Sverige uppgår idag till ca. 150 000 och beräknas fördubblas de kommande 30 åren i och med den allt äldre befolkningen. De äldre har ofta flera diagnoser. Detta samt åldersrelaterade förändringar i fysiologiska funktioner leder till stor läkemedelsanvändning, vilket i sin tur ger upphov till läkemedelsrelaterade problem (LRP) i form av exempelvis biverkningar, interaktioner, avsaknad av indikation, indikation utan behandling, olämplig läkemedelsbehandling eller doseringsfel. LRP kan upptäckas, åtgärdas, minskas eller förebyggas med hjälp av läkemedelsgenomgång.

Syfte: Syftet med detta arbete var att genomföra läkemedelsgenomgång för äldre patienter med demenssjukdom och med minst fem eller fler ordinerade läkemedel för att analysera förekomsten av LRP bland patienterna.

Metod: Läkemedelsgenomgång för 20 patienter utfördes i ett särskilt demensboende genom avidentifierade patientdata i form av läkemedelslista, senaste labprover samt diagnoslista. Även frågeställningar baserade på en lathund för läkemedelsgenomgång besvarades. Aktuella frågeställningar var att rätt och uppdaterad läkemedelslista fanns i journalen, läkemedelsinteraktioner, olämpliga läkemedel för äldre, dosering anpassad till njur-, och leverfunktion, laboratorievärden, diagnos utan aktuell/rimlig behandling, läkemedel utan aktuell/rimlig indikation samt biverkningar. Även användningen av icke-farmakologisk behandling kontrollerades.

Resultat: Studien visade att samtliga patienter hade korrekt och uppdaterad läkemedelslista registrerad i journalen. 55% av patienterna hade minst en läkemedelsinteraktion. 10% hade olämpliga läkemedel för äldre. 20% hade ett eller fler feldoserade läkemedel. 25% behövde åtgärder i form av komplettering av blodprover eller insättning av läkemedel efter utvärdering av labvärden i samband med existerande diagnos. 50% hade minst en diagnos registrerad, men saknade aktuell läkemedelsbehandling och 10% tog läkemedel utan att det fanns aktuell eller rimlig indikation registrerad i deras journal.Slutsats: Projektet tyder på att flera olika LRP upptäcktes bland dementa patienter i boendet där de vanligast förekommande är läkemedelsinteraktioner samt registrerad diagnos utan aktuellt läkemedel. Åtgärder utfördes i form av dosjustering av läkemedel, insättning av läkemedel, borttagning av olämpligt läkemedel, kontroll av diagnos som saknade behandling samt att ytterligare blodprover beställdes för en del patienter. Detta indikerar att läkemedelsgenomgång är en viktig procedur och därmed bör tillämpas på alla äldre patienter som använder sig av flera läkemedel för att upptäcka och åtgärda LRP. Målet med detta är i sin tur att förbättra livskvaliteten, välmåendet samt patientsäkerheten för äldre dementa patienter.

Background: High blood pressure (BP) or hypertension is defined as a systolic and diastolic pressure over 140/90 mmHg. High blood pressure increases the risk for premature death, and previous research has shown that many patients do not reach targets and that there are differences between primary healthcare centers in the proportion of patient reaching targets. The reasons for these variations, however, are unknown. Aim: To investigate variations in blood pressure target achievement between primary care centers in Stockholm county and how different factors such as practice size, ownership, socioeconomic and antihypertensive drug treatment can influence this diversity. Method(s): This study was designed as a cross-sectional register study with a descriptive quantitative perspective. Data was collected from three sources: National Primary Care Quality register, Care Need Index for healthcare in Stockholm region and Stockholm County Council data warehouse VAL. The study included 179 out of all 227 primary care centers in the region. The proportion of all patients with hypertension reaching targets was assessed each year during 2019-2021, and correlations studied for potential predictors. Results: there was a variation between primary care centers in target blood pressure fulfillment, ranging from 22-66% during 2021, 23-63% during 2020 and 33-66% during 2019, respectively. There was no overall difference between public and private centers in the proportion of patients reaching targets, but a larger practice variation among private centers. No correlation was found between the other studied factors and target blood pressure fulfillment during 2021. Conclusion: There was a variation between primary care centers in the proportion of patients reaching blood pressure targets. Different practices may change ranking between years and other factors than practice size, ownership and socioeconomic appears to explain the variation.

The clinical support system Electronic Expert Support (EES) is available at all pharmacies in Sweden to examine electronic prescriptions when dispensing to prevent drug-related problems (DRPs). DRPs are common, and result in patient suffering and substantial costs for society. The aim of this research was to study the use of EES for the pediatric population (ages 0-12 years), by describing what types of alerts are generated for potential DRPs, how they are handled, and how the use of EES has changed over time. Data on the number and categories of EES analyses, alerts, and resolved alerts were provided by the Swedish eHealth Agency. The study shows that the use of EES has increased. The most common type of alert for a potential DRP among pediatric patients was regarding high doses in children (30.3% of all alerts generated). The most common type of alert for a potential DRP that was resolved among pediatrics was therapy duplication (4.6% of the alerts were resolved). The most common reason for closing an alert was dialogue with patient for verification of the treatment (66.3% of all closed alerts). Knowledge of which type of alerts are the most common may contribute to increased prescriber awareness of important potential DRPs.

Background: Artemisinin resistance in Plasmodium falciparum manifests as slow parasite clearance but this measure is also influenced by host immunity, initial parasite biomass and partner drug efficacy. This study collated data from clinical trials of artemisinin derivatives in falciparum malaria with frequent parasite counts to provide reference parasite clearance estimates stratified by location, treatment and time, to examine host factors affecting parasite clearance, and to assess the relationships between parasite clearance and risk of recrudescence during follow-up. Methods: Data from 24 studies, conducted from 1996 to 2013, with frequent parasite counts were pooled. Parasite clearance half-life (PC1/2) was estimated using the WWARN Parasite Clearance Estimator. Random effects regression models accounting for study and site heterogeneity were used to explore factors affecting PC1/2 and risk of recrudescence within areas with reported delayed parasite clearance (western Cambodia, western Thailand after 2000, southern Vietnam, southern Myanmar) and in all other areas where parasite populations are artemisinin sensitive. Results: PC1/2 was estimated in 6975 patients, 3288 of whom also had treatment outcomes evaluate d during 28-63 days follow-up, with 93 (2.8 %) PCR-confirmed recrudescences. In areas with artemisinin-sensitive parasites, the median PC1/2 following three-day artesunate treatment (4 mg/kg/day) ranged from 1.8 to 3.0 h and the proportion of patients with PC1/2 > 5 h from 0 to 10 %. Artesunate doses of 4 mg/kg/day decreased PC1/2 by 8.1 % (95 % CI 3.2-12.6) compared to 2 mg/kg/day, except in populations with delayed parasite clearance. PC1/2 was longer in children and in patients with fever or anaemia at enrolment. Long PC1/2 (HR = 2.91, 95 % CI 1.95-4.34 for twofold increase, p < 0.001) and high initial parasitaemia (HR = 2.23, 95 % CI 1.44-3.45 for tenfold increase, p < 0.001) were associated independently with an increased risk of recrudescence. In western Cambodia, the region with the highest prevalence of artemisinin resistance, there was no evidence for increasing PC1/2 since 2007. Conclusions: Several factors affect PC1/2. As substantial heterogeneity in parasite clearance exists between locations, early detection of artemisinin resistance requires reference PC1/2 data. Studies with frequent parasite count measurements to characterize PC1/2 should be encouraged. In western Cambodia, where PC1/2 values are longest, there is no evidence for recent emergence of higher levels of artemisinin resistance.

Abstract

Background and Objective: An accurate medication history list is an integral part of the patient assessment at hospital admission. The objective of the study was to describe the frequency, type, and predictors of unintentional medication errors and to evaluate the quality of the clinical pharmacy services focusing on the acceptance of the recommendations made by the clinical pharmacist.

Setting and methods: A descriptive study was conducted at two internal medicine wards at Baghdad Teaching Hospital in Iraq using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. The study pharmacist conducted medication interviews for patients shortly after hospital admission to obtain the most accurate pre-admission medication history list. This list was compared with the medication list in the patient’s medical chart. Intended addition, withdrawal of a drug, or changes to the dose/ dosage form in the patient’s medical list was considered as medication discrepancies. However, medication discrepancies were considered as medication errors based on no identified clinical reason.

Results: A total of 114 patients were included in this study. Over two-thirds of the study patients (73.7%) experienced 215 medication errors identified by a clinical pharmacist conducting medication reconciliation. Most errors were omission (87.9%). Cardiovascular agents followed by NSAID were commonly in error (53%) and (10.2%) respectively. In a logistic regression model, age (odds ratio (OR), 1.055: 95% confidence interval (CI) 1.010 - 1.102), female gender (OR, 3.468: 95% CI 1.232- 9.761) and number of medications at admission (OR, 0.810: 95% CI 0.681-0.963) were predictors for medication history errors at admission.

Conclusions: Medication errors at the time of hospital admission are common and undetected.  A structured approach like the LIMM-based medication reconciliation at Iraqi hospital is needed to detect these errors.

OBJECTIVE: To explore communication about medication management during annual consultations in primary care.

DESIGN: passive participant observations of primary care consultations.

SETTING: Two primary care centres in southern Sweden.

PARTICIPANTS: Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis.

RESULTS: Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further.

CONCLUSION: Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.

Automated phase-contrast video microscopy now makes it feasible to monitor a high-throughput (HT) screening experiment in a 384-well microtiter plate format by collecting one time-lapse video per well. Being a very cost-effective and label-free monitoring method, its potential as an alternative to cell viability assays was evaluated. Three simple morphology feature extraction and comparison algorithms were developed and implemented for analysis of differentially time-evolving morphologies (DTEMs) monitored in phase-contrast microscopy videos. The most promising layout, pixel histogram hierarchy comparison (PHHC), was able to detect several compounds that did not induce any significant change in cell viability, but made the cell population appear as spheroidal cell aggregates. According to recent reports, all these compounds seem to be involved in inhibition of platelet-derived growth factor receptor (PDGFR) signaling. Thus, automated quantification of DTEM (AQDTEM) holds strong promise as an alternative or complement to viability assays in HT in vitro screening of chemical compounds.

Introduction The role of global health and sustainable development in medical education is often debated. However, research regarding medical doctors' views on the application of their global health knowledge in the clinical setting remains scarce. This study aimed to explore junior doctors' perceptions of global health and sustainable development, the education they have received on these issues and the relevance of this knowledge in their current and future work.Methods This was a qualitative study based on individual interviews conducted between May and June 2022. 16 junior doctors, in mandatory clinical training after completing medical school, were purposively sampled from five Swedish hospitals. Transcripts were analysed using qualitative content analysis.Results Three themes were identified. The first theme (1) 'medical doctors have a role in the transition to a sustainable society', shows that sustainable development is increasingly perceived as relevant for junior doctors' clinical work. The second theme (2) 'global health and sustainable development teaching is inconsistent and somewhat outdated', highlights that there is an assumption that global health and sustainable development can be self-taught. A discrepancy between what is being taught in medical school and the clinical reality is also recognised. This causes challenges in applying global health interest and knowledge in the clinical setting, which is described in the third theme (3) 'application of global health and sustainable development is difficult'. This theme also highlights opportunities for continued engagement, with the perceived benefit of becoming a more versatile doctor.Conclusion This study emphasises the need for conceptual clarity regarding global health in medical education and raises the need for clarification regarding the level of responsibility for integrating sustainable practices in Swedish healthcare settings.

PPIs (Proton-pump inhibitors) offers the best treatment for acid related diseases. The predominant indications for PPI prescription are:

• GERD
• eradication of H. pylori-infection in combination with antibiotics
• H. pylori-negative peptic ulcer 
• healing of and prophylaxis against NSAID/COXIB--induced gastroduodenal lesions 
• acid hypersecretory states such as Zollinger-Ellisons syndrome.

The market for PPIs continues to expand in most countries. A significant over- and misuse of PPIs prevails in hospital care as well as in general practice. The predominant reasons for and mechanisms behind the over- and misuse of PPIs are well recognised. The most important consequences of this overprescription of PPIs are increasing medical costs and risk for long-term adverse side effects. Continued education and dedicated information are key factors to guide physicians, medical personnel and patients to adopt to generally accepted principles for and balanced use of PPIs.

Introduktion: Läkemedel har en stor roll i vårt liv och användning av läkemedel påverkar vår miljö. De största utsläppen av läkemedel sker efter användningen och utsöndras i urinen. Slutligen hamnar de i avloppet och vattendrag och därefter når de oss och fiskar genom vattnet. Det finns få studier om hur läkemedelsanvändningen ser ut i relation till miljörisk.

Syfte: Syftet med denna tvärsnittsstudie var att undersöka data kring förbrukningen av NSAID och Paracetamol i relation till miljörisk.

Metod: Studien genomfördes genom datainsamling från Socialstyrelsens statistikdatabas för smärtstillande läkemedel och E-hälsomyndigheten statistikverktyg Concise för perioden 2010–2020. Förbrukningen av paracetamol (N02BE01) och NSAID (M01A) analyserades i kg som sålts på recept, receptfritt, till sjukhus och på öppenvård-rekvisition och bedömdes i förhållande till klassifikation av miljörisk.

Resultat: De mest använda läkemedlen var paracetamol, ibuprofen, naproxen och diklofenak. Paracetamol och ibuprofen har låg miljöfara och försumbar miljörisk. Naproxen har medium miljöfara och låg miljörisk. Miljöfara för diklofenak finns ej publicerat på regions Stockholms databas för läkemedelsmiljöpåverkan, men risken anses vara hög jämfört med andra NSAID. En stor andel av försäljningen av paracetamol, naproxen och diklofenak expedierades via recept. Förbrukningen av paracetamol, ibuprofen och naproxen har ökat medan konsumtionen av diklofenak har minskat med 71% under 2010–2020. Slutsats: Av de fyra mest använda smärtstillande läkemedel som inte är opioder, är naproxen och diklofenak skadliga för miljön eftersom de har högt respektive medium miljöfara. Det bästa alternativet är paracetamol och ibuprofen ur ett miljöperspektiv.

Background and objective: Holistic patient care is dependent upon the accurate and reliable flow of information between care settings and healthcare professionals (HCP). Inaccurate medical records may increase the risk of patient harm as HCPs risk continuing to prescribe a medication that has been discontinued or re-prescribing a medication that has previously been discontinued. The aim of this project was to analyse the HCPs documentation of medical changes in the patients’ medical records and evaluate the extent of adherence to a predefined criteria within the regions guidelines at six general practices (GP) across Jönköping County.

Study design: A retrospective observational study, reviewing 240 medical records between June-December 2019.

Main outcome measures: The number and the type of medication changes registered, and the extent to which the documentations adhered to regional guidelines concerning the criteria of the information that ought to be included in a documentation upon a registration of a medical change.

Results: There was an average of 63 (95% CI:53.4 – 73.2) medical changes identified across the six GPs. None of the documentations completely adhered to all points in the guideline. Follow-up plans was found to be the most omitted data point having only been mentioned in 2% of the medical changes. The name of the prescribed medication was mentioned on 378 occasions however, it was only accompanied with dosage form on 44% of occasions. In 9% of the medical records that were analysed it was not found to include any medical changes at all, instead it was either filled in with a “0” or the HCPs had for instance confirmed that the patients’ prescriptions had been renewed.

Conclusions: Despite the clear guidance regarding the content of documentation for a medical change, no documentation followed the guidelines fully. Adherence to the guidelines may be enhanced by being easier to access for HCPs. As there were documents that were not classed as medical changes identified, the information regarding what is acceptable to be included in that section needs to be made clearer to the HCPs. The findings from this study can be further developed and used as a reference for future studies on this subject.

En kartläggning av läkemedelsanvändning och köpbeteende vid köp av receptfria NSAID på apotek

Mervan Akay

Handledare: Pia Frisk, Hälso- och sjukvårdsförvaltningen SLL Institutionen för farmaceutisk biovetenskap, avdelningen för farmakokinetik och läkemedelsterapi Examinator: Margareta Hammarlund-UdenaesFördjupningsprojekt i farmakoterapi D, 30 hp

Introduktion: NSAID är en av de mest förskrivna läkemedelsgrupperna över hela världen. Efter omregleringen av apoteksmarknaden har tillgängligheten av NSAID-preparat ökat. Syfte: Att kartlägga läkemedelsanvändningen och köpbeteendet avseende receptfria läkemedel med diklofenak, ibuprofen, naproxen och acetylsalicylsyra, hos kunder som köper dessa läkemedel på öppenvårdsapotek. Detta med anledning av att det finns begränsad information om användningen av dessa receptfria substanser. Material och metoder: En prospektiv tvärsnittsstudie som omfattade fyra apotek i Stockholm-Uppsala regionen under tidsperioden 2014-09-15 till 2014-10-21. Data samlades in med hjälp av en enkät som delades ut av en observatör till individer som köpt ett preparat med diklofenak, ibuprofen, naproxen eller acetylsalicylsyra. Resultat: Det var fler kvinnor (148 stycken, 64,1 %) än män som köpte ett receptfritt NSAID-preparat. Den vanligaste åldersgruppen som köpte receptfritt NSAID var 40-49 år (20,8 %) medan det var 11,7 % som tillhörde åldersgruppen 70+. Den mest använda substansen bland NSAID var ibuprofen (46,3 %). De två vanligaste användningsområden för bägge könen var huvudvärk (43,1 %) och muskelvärk (30,4 %). Av samtliga deltagare var det 14 stycken (6,7 %) som kombinerade det köpta läkemedlet med ett annat receptfritt NSAID. Konklusion: Det var fler kvinnor än män som köpte receptfritt NSAID på apotek. Drygt 12 % av deltagarna, som var 70 år och äldre använde sig utav NSAID vilket är en olämplig läkemedelsklass för äldre personer.    

Background Medication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient’s medication use at home.

Aim In preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients and data collection to reduce medication discrepancies at discharge and improve medication adherence and (2) to explore the outcomes of the interventions.

Method Participants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed.

Results Of 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores.

Conclusion Based on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs.

BackgroundMedication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient's medication use at home.AimIn preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients, and data collection to reduce medication discrepancies at discharge and improve medication adherence, and (2) to explore the outcomes of the interventions.MethodParticipants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed.ResultsOf 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores.ConclusionBased on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs.

Abstrakt

Inledning

Övervätskning har under senare tid väckt ett stort intresse då de kan leda till ödem och organdysfunktion. Patienter som vårdas på intensivvårdsavdelningar (IVA) administreras ofta intravenöst med vätskor i form av läkemedel och näring. Genom att ge mer koncentrerad administrering av läkemedel kan problem med övervätskning hanteras. På begäran av IVA i Västmanlands sjukhus begränsades fem läkemedelssubstanser där syftet för arbetet skulle studeras och besvaras. Syftet med denna studie var att undersöka om man på ett säkert sätt kan administrera de intravenösa läkemedelssubstanserna trimetoprim/sulfametoxazol, remifentanil, dexmedetomidin, erytromycin samt aciclovir i högre koncentrationän gängse praxis på en intensivvårdsavdelning.

Metod

Studien utfördes under perioden januari – maj 2020 på enheten för sjukvårdsfarmaci på Västmanlands sjukhus i Västerås. Metoden som användes för detta arbete var en litteratursökning i databaserna Pubmed och Cinahl. För att komplettera sökningen användes databaserna Eped, Micromedex samt UKCPAs handbok Minimum infusion volumes for fluid restricted critically ill patients.

Resultat

Totalt erhölls elva artiklar som inkluderades i studien. Trimetoprim/sulfametoxazol, remifentanil, erytromycin samt aciclovir kunde administreras i högre koncentration på ett säkert sätt än gängse praxis på IVA i Västmanlands sjukhus. Ingen artikel visade att dexmedetomidin kan administreras intravenöst i högre koncentration medan en studie visade att den kan administreras subkutant i högre koncentration.

Slutsats

Det fanns sparsamt med information inom detta område i dagsläget. Stabilitetsstudier var av hög kvalité, men kliniska studier saknas. Fyra av fem läkemedel kan antas  administreras i högre koncentration än vad IVA i Västmanlands sjukhus använder sig av idag. Som vidare forskning kan man göra studier på dexmedetomidin intravenöst eftersom den går att administreras subkutant i en högre koncentration. I framtiden krävs mer forskning inom detta område för att komma fram till fler resultat samt styrka resultaten av de studier som finns idag.

Background 

Medication errors frequently occur when patients are transferred between health care settings. The main objective of this study was to investigate the frequency, type and severity of prescribing and transcribing errors for drugs dispensed in multidose plastic packs when patients are discharged from the hospital. The secondary objective was to correct identified errors and suggest measures to promote safe prescribing.

Methods 

The drugs on the patients' multidose drug dispensing (MDD) order sheets and the medication administration records were reconciled prior to the MDD orders being sent to the pharmacy for dispensing. Discrepancies were recorded and the prescribing physician was notified and given the opportunity to change the order. Discrepancies categorized as unintentional and related to the discharge process were subject to further analysis.

Results 

Seventy-two (25%) of the 290 reviewed MDD orders had at least one discharge error. In total, 120 discharge errors were identified, of which 49 (41%) were assessed as being of moderate and three (3%) of major severity. Orders with a higher number of medications and orders from the orthopaedic wards had a significantly higher error rate.

Conclusion 

The main purpose of the MDD system is to increase patient safety by reducing medication errors. However, this study shows that prescribing and transcribing errors frequently occur when patients are hospitalized. Because the population enrolled in the MDD system is an elderly, physically vulnerable group with a high number of prescribed drugs, preventive measures to ensure safe prescribing of MDD drugs are warranted.

Background and Objective: Medication reviews are important to identify drug related problems (DRP). Due to time limit it is unusual that all patients obtain a medication review. Priority of patients for medication reviews may be facilitated by using a DRP risk score that correlates to a patient’s risk for DRP. The objective of this study is to explore applicability of a specific Spanish risk score system in patients admitted to internal medicine or orthopedic wards in Skåne.

Design and Setting: This is a cross-sectional study with collected data during 6 weeks from department of Medicine and department of Orthopaedics in Malmö, Lund and Ystad. Data was collected from patient’s medical journals and used to apply DRP risk score. Medication reviews conducted by clinical pharmacists were used to register identified DRP. Patients were divided into two groups, Medicine Department and Orthopaedics Department. Linear regression was performed on each group separately. 

Main outcome measures: Correlation coefficient of DRP risk score and actual identified DRP. Area under ROC curve.  

Results: Correlation coefficient of DRP risk score and actual identified DRP was 0,85 (p-value < 0,01) for patients admitted to a medical ward and 0,59 (p-value < 0,05) for orthopaedic ward. Area under the ROC curve was estimated to 0,72 (CI 95%: 0,70-0,74) for Medicine Department and 0,61 (CI 95%: 0,59-0,63) for Orthopaedics Department.

Conclusion: There is a good capacity for the DRP risk score to identify patients with actual DRP at medicine department. For a 50% probability of at least one DRP for a patient a risk score of 6 points or more can be used. Acceptance of the risk taking of deprioritization of patients for medication reviews should be taken into consideration before using the risk score in clinical practice. The results for the orthoapedics department do not show certainty of correlation for the DRP risk score and actual DRP.  

Uppföljning & utvärdering av farmaceuter som jobbar på pediatrisk vårdavdelning

Introduktion

År 2014 inledde barnläkemedelsgruppen på Astrid Lindgrens barnsjukhus (ALB) implementering av en funktion för vårdenhetsfarmaceut (VEF). Projektet resulterade i anställande av två apotekare som placerades på Barnonkologen respektive Neonatalverksamheten. Därefter har antalet VEF ökat.

Syfte

Deskriptiv uppföljningsstudie för att erhålla vetskap om hur projektet från 2014 fallit ut. Hur ser det ut idag sedan införandet av permanenta farmaceuttjänster inom pediatriska vårdavdelningar? Framförallt på Barnonkologen respektive Neonatalverksamhet, men även övriga vårdavdelningar.

Material och metod

En tidsstudie utfördes på de sju avdelningar på ALB som har VEF för att studera tiden för olika aktiviteter i läkemedelsrummet under givna tidpunkter. En enkätstudie genomfördes med syfte att följa upp hur sjuksköterskor upplevde läkemedelsarbetet med VEF på avdelningen. På de avdelningar med journalsystemet TakeCare utfördes läkemedelsförrådsstudie för kassationsberäkning av ett bestämt antal läkemedel. Vårdproduktionsstudie genomfördes för att ta reda på antalet läkemedelsdoser som enheterna exponeras för, därav läkemedelsbelastningen. Slutligen studerades databas för barnläkemedel (ePed) för att se hur stor andel av beställningarna på enheterna som har läkemedelsinstruktioner.

Resultat

För farmaceuter var mediantiden för faktiskt iordningställandetid (ställtid ej inkluderad) 53 min och för övrig aktivitet (ex; rådgivning, annat läkemedelsarbete) 47 min under tidsperiod om fyra timmar i läkemedelsrummet. Enkätstudien visade stor uppskattning bland sjuksköterskor och att VEF bidrar med mycket mer än bara iordningställande. Jämfört med 2014 fanns ökad positiv inställning på Neo Solna, dock utan signifikant skillnad. Läkemedelsförrådsstudien visade att en betydande kassation förekommer på barnavdelningar, därav ett viktigt mått vid framtida uppföljningar. Läkemedelsbelastningen på enheterna var likvärdig 2014 och kring 80% av beställningarna på enheterna har läkemedelsinstruktioner i ePed.

Slutsats

Farmaceuter uppfyller en avlastande och kvalitetshöjande funktion på ALB, samt fungerar som stöd vid läkemedelsrelaterade frågor. Farmaceuterna är mycket uppskattade bland sjuksköterskor, dels för iordningställande hjälpen (ca två timmar under arbetsdag om åtta timmar, ställtid ej inkluderad) men även för att de bidrar med annan nödvändig kompetens. Det finns gott om läkemedelsjobb samt annat typ av arbete för farmaceuter på ALB.

The aim of this study was to identify structure and language elements affecting the quality of responses from Scandinavian drug information centres (DICs). Six different fictitious drug-related queries were sent to each of seven Scandinavian DICs. The centres were blinded for which queries were part of the study. The responses were assessed qualitatively by six clinical pharmacologists (internal experts) and six general practitioners (GPs, external experts). In addition, linguistic aspects of the responses were evaluated by a plain language expert. The quality of responses was generally judged as satisfactory to good. Presenting specific advice and conclusions were considered to improve the quality of the responses. However, small nuances in language formulations could affect the individual judgments of the experts, e.g. on whether or not advice was given. Some experts preferred the use of primary sources to the use of secondary and tertiary sources. Both internal and external experts criticised the use of abbreviations, professional terminology and study findings that was left unexplained. The plain language expert emphasised the importance of defining and explaining pharmacological terms to ensure that enquirers understand the response as intended. In addition, more use of active voice and less compressed text structure would be desirable. This evaluation of responses to DIC queries may give some indications on how to improve written responses on drug-related queries with respect to language and text structure. Giving specific advice and precise conclusions and avoiding too compressed language and non-standard abbreviations may aid to reach this goal.

Abstract [en]

Title: Discrepancies in medication lists at hospital wards identified by medication reconciliation

Authors: Anderberg M.

Institute: Uppsala University, Uppsala, Sweden

Background and objective: An accurate medication list is essential for a correct assessment of a patient´s condition at hospitals. Previous studies have shown that patients in emergency departments often are affected by discrepancies in medication lists at hospital admission. Less research has been done regarding discrepancies after transferring patients to medical wards. The aim of this study was to identify discrepancies in the electronic medical record in hospital wards for patients admitted via the emergency department.

Design: Observational study. Medication reconciliation was performed by a pharmacist shortly after the arrival of patients from the emergency department. This included a patient interview and the investigation of the patient’s medical record. The discrepancies identified at the wards were classified as either omitted drug, wrong dose, additional drug, incorrect frequency or duplicate therapy. Descriptive statistics were used and the proportion of medication lists with at least one discrepancy was presented with 95 % confidence interval.

Setting: Three medical wards at Capio S:t Görans Hospital in Stockholm. 

Main outcome measures: The proportion of medication lists with at least one discrepancy. The mean value of discrepancies among all patients. Classification and categorization of discrepancies regarding type and ATC index. 

Results: In total, 63 patients were included with a mean age of 63 years. At least one discrepancy was identified in 43 % (95 % CI 31-55) of the medication lists. 52 discrepancies were found in total generating a mean value of 0,83 ± 1,17 discrepancies per medication list. The two most common categories were Omitted drug(33%) and Wrong dose(33%). The most frequent drug class associated with medication discrepancies was Drugs for obstructive airway diseases. 

Conclusion: 43 % of the patients had at least one discrepancy in the medication list. This indicates the importance of medication reconciliations at medical wards even though the medication list has been updated at the emergency department. 

Aim: In order to deliver high quality pharmacy services, it is essential to evaluate patients’ satisfaction with the services. However, no study has yet assessed patient satisfaction with the Long-Term Conditions (LTC) service in New Zealand. Therefore, the aim of this study is twofold. Firstly, to identify questionnaires that are used to assess patient satisfaction with community pharmacy services. Secondly, to adapt a questionnaire that can be used to measure patient satisfaction with the LTC service in New Zealand.

Methods: A literature review was conducted to identify questionnaires that had been used to measure patient satisfaction with community pharmacy services. The utilised databases were EMBASE, Medline, International Pharmaceutical Abstracts, and PsychInfo. Retrieved articles were evaluated against pre-determined inclusion and exclusion criteria. Upon completion of the review, a questionnaire was selected and modified before being pilot tested on six LTC patients from a community pharmacy in Auckland, New Zealand.

Results: The database search yielded 13 articles that were eligible for the final review. In these articles, six different questionnaires for measuring patient satisfaction were identified. The questionnaire that was selected for adaptation had eight items removed, four modified, and 13 added from other sources. The final version consisted of 20 items. Overall, the questionnaire proved to be comprehensible and convenient to use during the piloting phase. However, the patients had a tendency to misunderstand two of the negative statements.

Conclusions: Selecting and utilising an appropriate tool for measuring patient satisfaction could help to enhance the quality of pharmacy services, leading to improved patient care. This study has identified and adapted a questionnaire for measuring patient satisfaction with the LTC service in New Zealand. Based on the findings of the pilot study, alterations must be made to the questionnaire before it is psychometrically analysed in a larger sample. The final goal is then to apply it in a nation-wide survey in New Zealand.

Objective Antimicrobial resistance is a growing worldwide problem and is considered to be one of the biggest threats to global health by the World Health Organization. Insights into the determinants of antibiotic prescribing may be gained by comparing the antibiotic usage patterns of Australia and Sweden. Design Publicly available data on dispensed use of antibiotics in Australia and Sweden between 2006 and 2018. Medicine use was measured using defined daily dose per 1,000 inhabitants per day (DDD/1000/day) and the number of dispensed prescriptions per 1000 inhabitants (prescriptions/1000). Results The use of antibiotics increased over the study period in Australia by 1.8% and decreased in Sweden by 26.3%. Use was consistently higher in Australia, double that of Sweden in 2018. Penicillin with extended spectrum was the most used class of antibiotics in Australia followed by penicillin with beta lactamase inhibitors. In Sweden, the most used class was beta lactamase-sensitive penicillin and the least used class was penicillin with beta lactamase inhibitors. Conclusion Antibiotic use in Australia is higher than in Sweden, with a higher proportion of broad-spectrum penicillin, including combinations with beta lactamase inhibitors, and cephalosporins. Factors that may contribute to these differences in antibiotic use include differences in guidelines, the duration of national antimicrobial stewardship programs, and differences in funding mechanisms.

Introduction:  Patient non-adherence is a well-known issue that causes problems on many levels, and many interventions regarding improving adherence have been evaluated. Pharmacists and doctors are in good positions to influence and support patient adherence, which makes them suitable intervention targets. However, to date, no one has specifically reviewed interventions with a defined role of pharmacists and/or doctors. Aim:  To evaluate the role of pharmacists and doctors in the delivery of patient adherence support.  Materials and Methods:  A systematic review was carried out. An electronic search was performed in MEDLINE, EMBASE, International Pharmaceutical Abstracts, PsycINFO and CINAHL for papers including randomised controlled trials of interventions to improve adherence, where pharmacists and/or doctors had a defined role in terms of delivery. The retrieved papers were screened to decide whether to include or exclude. The results of the included papers were then summarized, discussed and evaluated in line with the objectives. Results:  A total of 103 papers met the inclusion criteria and was included in the review. Only 14 of the interventions (14%) were delivered by doctors, and the rest by different kinds of pharmacists. The overall effectiveness was very good in most studies. Sixty-eight of the 103 papers resulted in enhanced medication adherence. However, 35 interventions failed to show improvement in adherence. Conclusions:  This review shows that pharmacists and doctors have a good potential to influence patients’ adherence. However, it also shows that more research is needed to get control over this growing global issue.  

Introduction: Carers, unpaid relatives or friends, are recognized as providing important assistance to older people with their medicines. These activities have been associated with medication-related problems and carer stress.  Aim: This project is aimed to characterize and evaluate pharmaceutical interventions to support carers of older people and inform of ways for future developments. Materials and Methods: A systematic review was conducted together with a descriptive cross-sectional study, where interviews were done with eleven purposely selected pharmacists and eight carers in London. The electronic databases: Cochrane Library, Embase, International Pharmaceutical Abstract, PubMed and Web of Knowledge were searched systematically for studies from 1990 to 2012 regarding pharmaceutical interventions to support carers of older people. Results: Based on the systematic review, twenty-two interventions were identified, of which twenty were evaluated. The most common interventions were services provided to assist in medication administration and education or skills training programs. Some evidence supported education and drug formulations. Field-work revealed that diverse needs could arise and all participants had comments about the subject. Views added from concerned stakeholders included improvements of currently available services and changes on systemic levels. Conclusions: The evidence supporting pharmaceutical interventions for carers of older people is low and it was not considered credible to recommend any details regarding duration, format or provider of the interventions. Field-work reflected that services are needed but that standards are lacking. Future work including other study populations, settings, locations and evaluations is thus required to establish the evidence, regarding interventions that are likely to be effective, and standardize the support. 

AIM: Studies on frequencies of manipulated medicines in paediatric care are common, but there is little knowledge of experiences of pharmacists and registered nurses in this area. The aim of this study was to explore registered nurses' and pharmacists' reasoning in the manipulation of medicines to paediatric inpatients.

METHODS: Semistructured interviews with twelve registered nurses and seven pharmacists were performed at a Swedish paediatric university hospital. The interviews were transcribed verbatim and analysed using content analysis.

RESULTS: Four major categories emerged from the analysis of the interviews: medicines management, knowledge, consulting others and organisation. Medicines management involved the process of drug handling, which is prescribing, reconstitution or manipulation and administration. Knowledge concerned both the knowledge base and how healthcare personnel seek information. Consulting others involved colleagues, registered nurses and pharmacists, between registered nurses, pharmacists and physicians and between registered nurses, pharmacists and caregivers. Organisation covered documentation, time and working environment.

CONCLUSION: Both pharmacists and registered nurses stated that manipulation of medicines to paediatric patients was often necessary but felt unsafe due to lack of supporting guidelines. Pharmacists were natural members of the ward team, contributing with specific knowledge about medicines and formulations.

Aim: Studies on frequencies of manipulated medicines in paediatric care are common, but there is little knowledge of experiences of pharmacists and registered nurses in this area. The aim of this study was to explore registered nurses' and pharmacists' reasoning in the manipulation of medicines to paediatric inpatients.

Methods: Semistructured interviews with twelve registered nurses and seven pharmacists were performed at a Swedish paediatric university hospital. The interviews were transcribed verbatim and analysed using content analysis.

Results: Four major categories emerged from the analysis of the interviews: medicines management, knowledge, consulting others and organisation. Medicines management involved the process of drug handling, which is prescribing, reconstitution or manipulation and administration. Knowledge concerned both the knowledge base and how healthcare personnel seek information. Consulting others involved colleagues, registered nurses and pharmacists, between registered nurses, pharmacists and physicians and between registered nurses, pharmacists and caregivers. Organisation covered documentation, time and working environment.

Conclusion: Both pharmacists and registered nurses stated that manipulation of medicines to paediatric patients was often necessary but felt unsafe due to lack of supporting guidelines. Pharmacists were natural members of the ward team, contributing with specific knowledge about medicines and formulations.

Background: Uncertainty is inevitable in clinical practice in primary care and tolerance for uncertainty and concern for bad outcomes has been shown to vary between physicians. Uncertainty is a factor for inappropriate antibiotic prescribing. Evidence-based guidelines as well as near-patient tests are suggested tools to decrease uncertainty in the management of patients with respiratory tract infections. The aim of this paper was to describe strategies for coping with uncertainty in patients with pharyngotonsillitis in relation to guidelines. Methods: An interview study was conducted among a strategic sample of 25 general practitioners (GPs). Results: All GPs mentioned potential dangerous differential diagnoses and complications. Four strategies for coping with uncertainty were identified, one of which was compliant with guidelines, "Adherence to guidelines", and three were idiosyncratic: "Clinical picture and C-reactive protein (CRP)", "Expanded control", and "Unstructured". The residual uncertainty differed for the different strategies: in the strategy "Adherence to guidelines" and " Clinical picture and CRP" uncertainty was avoided, based either on adherence to guidelines or on the clinical picture and near-patient CRP; in the strategy " Expanded control" uncertainty was balanced based on expanded control; and in the strategy "Unstructured" uncertainty prevailed in spite of redundant examination and anamnesis. Conclusion: The majority of the GPs avoided uncertainty and deemed they had no problems. Their strategies either adhered to guidelines or comprised excessive use of tests. Thus use of guidelines as well as use of more near-patient tests seemed associated to reduced uncertainty, although the later strategy at the expense of compliance to guidelines. A few GPs did not manage to cope with uncertainty or had to put in excessive work to control uncertainty.

OBJECTIVE: To assess antiretroviral therapy (ART) adherence among people with HIV (PWH) in Canada and identify baseline characteristics associated with suboptimal adherence (<95%). DESIGN: Retrospective observational study using data from the National Prescription Drug Utilization Information System and Régie de l'assurance maladie Quebec (RAMQ) Public Prescription Drug Insurance Plan. METHODS: This analysis included PWH aged 18 years or older who initiated an ART regimen and were followed for at least 12 months (2010-2020). Patient characteristics were summarized using medical/pharmacy claims data from seven provinces (Alberta, Manitoba, New Brunswick, Newfoundland and Labrador, Ontario, Saskatchewan, and Quebec). ART regimen at index date (first dispensing of a regimen including a core agent) was defined as a single-tablet or multitablet regimen (MTR). Adherence was calculated using a Proportion of Days Covered approach, based on ART dispensing, recorded between April 2010 and the last available date. Multivariate linear regression analysis was used to determine correlations between suboptimal adherence and baseline characteristics. RESULTS: We identified 19 322 eligible PWH, 44.7% of whom had suboptimal adherence (<95%). Among 12 594 PWH with evaluable baseline data, 10 673 (84.8%) were ART-naive, 74.2% were men, mean age was 42.9 years, and 54.1% received a MTR as their ART. Based on multivariate regression analysis, suboptimal adherence was significantly associated with multitablet ART ( P  < 0.001) and younger age ( P  < 0.001) but not sex. CONCLUSION: Almost half of adult PWH in Canada had suboptimal adherence to ART. Better understanding of factors influencing adherence may help address gaps in current care practices that may impact adherence.

Purpose: Telotristat ethyl, an oral tryptophan hydroxylase inhibitor, is intended to treat carcinoid syndrome by reducing serotonin production. Telotristat ethyl was evaluated in FELESTAR, a Phase HI study for patients who had carcinoid syndrome with at least 4 bowel movements (BMs) per day and who were receiving somatostatin analogue therapy. This interview sub study was conducted to provide insight into the patient experience in ILLESTAR and to help understand whether reductions in BM frequency (the primary end point) and other symptoms were clinically meaningful. Methods: Participating sites were asked to invite (before randomization) all eligible patients to telephone interviews scheduled at the end of the double-blind treatment period. Patients and interviewers were blinded to treatment. Findings: All 35 interviewed participants reported diarrhea and/or excessive BMs at baseline. Patients reported that these symptoms negatively affected emotional, social, physical, and occupational well-being. Prespecified criteria for treatment response (achieving >= 30% reduction in BM frequency for at least 50% of the days) were met by 8 of 26 patients taking telotristat ethyl and 1 of 9 patients taking placebo. All 8 patients taking telotristat ethyl described clinically meaningful reductions in BM frequency and were very satisfied with the ability of the study drug to control their carcinoidsyndrome symptoms. Overall, reports of being very satisfied were observed in 12 patients taking telotristat ethyl and 0 taking placebo. Implications: Patient interviews revealed that I ELESTAR patients, at baseline, were significantly affected by their high BM frequency. Patient reports of their clinical trial experience supported the significance of the primary end point and clinical responder analysis in TELESTAR, helping identify and understand clinically meaningful change produced by telotristat ethyl. (C) 2017 The Authors. Published by Elsevier HS Journals, Inc.

Background: Individual differences in drug response are large and difficult to predict in a real-world setting. Some of these differences can be explained by the patient’s genes. Prescription guided by so called pharmacogenetic information alleviates the traditional “trial and error” approach, making drug treatment more safe, efficient and cost-effective. The major goal of this research is to investigate the potential need and benefit of pharmacogenetic testing in a vulnerable group at the hospital; the elderly with polypharmacy.  

Aim: The main aim of this study was to determine the prevalence of elderly hospitalised patients with polypharmacy, who are expected to benefit from pharmacogenetic testing. The secondary aim was to prepare a study protocol for a pilot study where pharmacogenetic data is included in the medication reviews performed by clinical pharmacists.

Methods: Three-hundred anonymized medications lists from elderly hospitalized patients were examined to determine the occurrence and types of medications involved with pharmacogenetics. A list of gene-drug interactions and recommendations, adapted to Swedish conditions, was compiled by using existing guidelines, and later applied to the medication lists. The findings were used in the design of a pilot study. 

Results: Eighty-five percent of the patients had at least one medication with a pre-defined actionable gene–drug interaction. Most of the medications (56%) affected the nervous system, while the most reoccurring medications were metoprolol, omeprazole and atorvastatin, affecting the cardiovascular system and the alimentary tract and metabolism. 

Conclusions: We can expect elderly hospitalised polypharmacy patients to benefit from pharmacogenetic testing, due to the high prevalence (85%) of patients having at least one medication involved with pharmacogenetics. A future prospective pharmacogenetic intervention study is therefore planned.

Introduktion: Benzodiazepiner (BzD) och benzodiazepinliknande preparat (BzDLP) kan leda till beroende vid långtidsanvändning. En prövning för utsättning bör därför övervägas efter 4 veckors användning och utsättningen bör ske med utfasning vid långtidsanvändning. Tidigare studier är otillräckligt för att dra säkra slutsatser om BzD/BzDLPs inverkan på fall-frakturhändelser. Socialstyrelsen har sammanställt de substanser som inte är lämplig för användning av äldre personer om det inte finns särskilda skäl. Syftet med denna studie var att analysera läkemedelsbehandling hos äldre avseende följande områden: 1. Behandlingsfrekvens och behandlingslängd, samt utsättningsmetoden av BzD/BzDLP. 2. BzD/BzDLPs inverkan på fall-frakturhändelser. 3. Behandlingsfrekvens av Socialstyrelsens icke-rekommenderade preparat hos personer som är 75 år och äldre. Material och metoder: Journalerna för 84 patienter som behandlades på en geriatrisk avdelning i Uppsala län granskades under en 2 månaders period. Resultat: Behandlingsandel av BzD/BzDLP hos de undersökta patienterna var 80 procent och 70 procent av användningen skedde minst 5 veckor eller mer. Att byta ut preparatet med ett annat preparat, eller ändra stående ordination till vid behovsordination var den vanligaste utsättningsformen. BzD/BzDLP användningen var 49 procent vid fall-frakturhändelser i denna studie och Socialstyrelsens icke-rekommenderade läkemedelsbehandling förekom hos 14 procent av de icke-palliativa patienterna. Konklusion: Användning av BzD/BzDLP var högre hos deltagarna i studien, jämfört med användningen i riket. En större del av behandlingslängden var högre än Socialstyrelsens rekommendationer och utfasning vid utsättningen förekom inte. Inget samband mellan BzD/BzDLP och fall-frakturhändelser kunde ses i materialet. Den icke-rekommenderade läkemedelsanvändning var lägre hos deltagarna i studien jämfört med i riket.

Background: Electronic transmitted prescriptions (ETPs) became common after 1995 in Sweden; however, it is accompanied by a substantial increase in the number of prescriptions not picked up at pharmacies.

Objective: To investigate the ‘‘no pick-up’’ rates of ETPs at pharmacies across type of drug and patient age and gender and the reasons patients’ report for no pick-up.

Methods: A cross-sectional study examining no pick-up of ETPs transmitted during 3 months in 2002, and a mail survey of patients to determine the reasons for failure to pick-up in the county of Sormland, Sweden, with a population of 261,000, and 21 pharmacies. Chi-square tests were used for calculations of frequency differences among groups.

Results: The overall no pick-up rate of ETPs was 2.5%; men had consistently higher rates than women. The highest rates were seen for adolescents and young adults. Rates were higher than average for antibiotics. About 60% of the answers indicated that prescriptions not picked up were duplicate prescriptions or not needed. ‘‘Unintentional nonadherence’’ was reported by one-fifth of patients.

Conclusions: No pick-up rate in general was low (2.5%), but there were differences across patient age and sex, the rates being higher among adolescents and young adults. Duplicate prescriptions may explain a significant share of the abandoned prescriptions.

Background. There is high evidence for secondary prevention of fractures, including hip fracture, with alendronate treatment, but alendronate's efficacy to prevent hip fractures in the oldest-old (80 years old), the population with the highest fracture risk, has not been studied. Objective. To investigate whether alendronate treatment amongst the oldest-old with prior fracture was related to decreased hip fracture rate and sustained safety. Methods. Using a national database of men and women undergoing a fall risk assessment at a Swedish healthcare facility, we identified 90 795 patients who were 80 years or older and had a prior fracture. Propensity score matching (four to one) was then used to identify 7844 controls to 1961 alendronate-treated patients. The risk of incident hip fracture was investigated with Cox models and the interaction between age and treatment was investigated using an interaction term. Results. The case and control groups were well balanced in regard to age, sex, anthropometrics and comorbidity. Alendronate treatment was associated with a decreased risk of hip fracture in crude (hazard ratio (HR) 0.62 (0.49-0.79), P < 0.001) and multivariable models (HR 0.66 (0.51-0.86), P < 0.01). Alendronate was related to reduced mortality risk (HR 0.88 (0.82-0.95) but increased risk of mild upper gastrointestinal symptoms (UGI) (HR 1.58 (1.12-2.24). The alendronate association did not change with age for hip fractures or mild UGI. Conclusion. In old patients with prior fracture, alendronate treatment reduces the risk of hip fracture with sustained safety, indicating that this treatment should be considered in these high-risk patients.

Background: It is common for medicine formulations such as oral tablets to need to be manipulated, i.e., crushed or divided. This is often seen in dysphagia patients where diseases such as stroke or dementia affect the swallowing reflex. The Handbook of Healthcare is a website which contains regulations for how medicines are to be handled which are used by healthcare workers in Sweden. The regulation is based on the Swedish Health and Medical Service Act and Social Services Act. 

Aim: The aim of this study is to map how oral tablets and capsules that cannot be given as a whole or divided dose are manipulated and handled at different activities in Vastmanland. 

Method: An observational study was performed for six weeks in a hospital ward and two nursing homes where handling and preparation of medicines were observed. The study was conducted between 1 Oct-12 Nov 2020. Study population were nurses, and delegated staff. The data collection was carried out using a checklist by consistently following the manual. The data collection from the checklists was transferred to an excel file. Frequencies were calculated for each question and study places. The results were presented in tables and pie charts. 

Results: A total of 185 observations were observed for the study sites. There were 96 observation for hospital ward 1, 72 observation for nursing home 1 and 27 observation for nursing home 2. Approximately 50% of the 185 observations at the study sites were medicine manipulations. The tools were cleaned in 42% of cases for hospital ward 1, 100% for nursing home 2, and never for nursing home 1. Almost all observations showed that the tablets were crushed simultaneously for each patient. 

Conclusion: The study shows a variation between the activities in how to handle oral medicines, where crushing tablets was the most common manipulation. To achieve a manipulation, different tools were used on the study places. What also differs between the study places was how the tools were cleaned and if it was cleaned, which did not occur in all study places. The handling of medicines was observed in different environments for the study site. 

The manipulation of oral tablets and capsules on a hospital ward and two nursing homes in Västmanland: an observational study.

Background: It is common for medicine formulations such as oral tablets to need to be manipulated, i.e., crushed or divided. This is often seen in dysphagia patients where diseases such as stroke or dementia affect the swallowing reflex. The Handbook of Healthcare is a website which contains regulations for how medicines are to be handled which are used by healthcare workers in Sweden. The regulation is based on the Swedish Health and Medical Service Act and Social Services Act.

Aim: The aim of this study is to map how oral tablets and capsules that cannot be given as a whole or divided dose are manipulated and handled at different activities in Vastmanland.

Method: An observational study was performed for six weeks in a hospital ward and two nursing homes where handling and preparation of medicines were observed. The study was conducted between 1 Oct-12 Nov 2020. Study population were nurses, and delegated staff. The data collection was carried out using a checklist by consistently following the manual. The data collection from the checklists was transferred to an excel file. Frequencies were calculated for each question and study places. The results were presented in tables and pie charts.

Results: A total of 185 observations were observed for the study sites. There were 96 observation for hospital ward 1, 72 observation for nursing home 1 and 27 observation for nursing home 2. Approximately 50% of the 185 observations at the study sites were medicine manipulations. The tools were cleaned in 42% of cases for hospital ward 1, 100% for nursing home 2, and never for nursing home 1. Almost all observations showed that the tablets were crushed simultaneously for each patient.

Conclusion: The study shows a variation between the activities in how to handle oral medicines, where crushing tablets was the most common manipulation. To achieve a manipulation, different tools were used on the study places. What also differs between the study places was how the

tools were cleaned and if it was cleaned, which did not occur in all study places. The handling of medicines was observed in different environments for the study site.

What was done?: Final year undergraduate pharmacy students, specialising clinical pharmacy,were given the opportunity to spend two weeks of their six months pharmacypractice to participate in an interprofessional training ward placement(ITWP) together with medical, nursing and physiotherapy students. During thistwo-week clinical placement, the students were collaboratively responsiblefor managing the care of geriatric inpatients while under supervision oflicensed practitioners.

Why was it done?: ITWP for health care students is established at various teaching hospitals.However, to our knowledge, no such program in Scandinavia has includedpharmacy students. Clinical pharmacy is a growing profession in Sweden andother health care students will in the future work alongside with clinicalpharmacists. Therefore we set out to add pharmacy students to the ITWP team,believing that it would be a valuable experience for them to collaborate andshare knowledge with students from other health care professions. Equallyimportant, it is a way to promote the pharmacist’s competence andcontribution to the multiprofessional health care team, prior to graduation.

How was it done?: A working group was formed consisting of teachers from the faculty ofpharmacy, a student representative and a working clinical pharmacist. Thegroup developed the initiative, including among other things, prerequisites,an evaluation plan, a workflow tool for clinical rounds and suggested tasksfor pharmacy students during the placement.

What has been achieved?: The program has been running for three semesters and 6–8 pharmacy studentshave participated in the ITWP each semester. The initiative has beenevaluated using surveys. Participating pharmacy students expressed gainingnew knowledge and better insight into nursing care and the roles of the otherprofessions. Nursing students appreciated the support in medicationmanagement and medical students found the pharmacy students to be valuablediscussion partners that could challenge their drug-related decisions. Tutorsexpressed that the pharmacy students brought a beneficial dynamic to the ITWPteam.

What next?: The opportunity for students from different professions to work together witha common objective in a real-life setting gives them valuable insight in eachother’s professional roles early in their careers. This good practiceinitiative could be used in other interprofessional training ward placementswishing to involve pharmacy students.

Background: During the 1980s, manual repackaging of multi-dose medications from pharmacies in Sweden was successively substituted with automated multi-dose drug dispensing (MDD). There are few studies evaluating the consequences of automated MDD with regard to patient safety, and those that investigate this issue are not very extensive.

Objectives: To investigate Swedish health care professionals’ perceived experience of automated MDD and its effects on patient adherence and patient safety.

Methods: Three questionnaire forms, one for physicians, nurses, and assistant nurses/nursing assistants, were developed based on reviews of the literature and pilot testing of the questions in the intended target groups. The target groups were health professionals prescribing or administrating MDD to patients. A sample (every sixth municipality) was drawn from the sampling frame of Swedish municipalities, resulting in 40 municipalities, about 14% of all municipalities in Sweden. Email addresses of general practitioners were obtained from county councils, while the municipalities assisted in getting contact details for nurses, assistant nurses and nursing assistants. A total of 915 questionnaires were distributed electronically to physicians, 515 to nurses, and 4,118 to assistant nurses/nursing assistants. The data were collected in September and October 2012.

Results: The response rate among physicians, nurses and assistant nurses/nursing assistants was 31%, 43% and 23%, respectively. The professionals reported that automated MDD reduces duplication of medication, contributes to correct dosages, helps patients take their medication at the right time, and reduces confusion among patients. Fifteen per cent of the physicians and about onethird of the nurses and assistant nurses/nursing assistants reported that generic substitution makes it more difficult for the patient to identify the various medicines available in the sachets. The physicians did, however, note that prescribing medicine to patients with automated MDD is complicated and can be a risk for patient safety. Both physicians and nurses requested more information on and training in automated MDD. They also asked for more medication reviews.

Conclusions: The professionals generally had a positive attitude to automated MDD with regard to improved medication adherence, but said they believed that the electronic prescribing system posed a safety risk for patients.

BACKGROUND: Previous work has examined the impact of technology on information sharing and communication between doctors and patients in general practice consultations, but very few studies have explored this in hospital settings.

AIMS: To assess if, and how, senior clinicians use an iPad to share information (e.g. patient test results) with patients during ward rounds and to explore patients' and doctors' experiences of information sharing events.

METHODS: Ten senior doctors were shadowed on ward rounds on general wards during interactions with 525 patients over 77.3 h, seven senior doctors were interviewed and 180 patients completed a short survey.

RESULTS: Doctors reported that information sharing with patients is critical to the delivery of high-quality healthcare, but were not seen to use the iPad to share information with patients on ward rounds. Patients did not think the iPad had impacted on their engagement with doctors on rounds. Ward rounds were observed to follow set routines and patient interactions were brief.

CONCLUSIONS: Although the iPad potentially creates new opportunities for information sharing and patient engagement, the ward round may not present the most appropriate context for this to be done.

As hospitals transition from paper to electronic medication charts, an opportunity exists to 'nudge' prescribers to document medication indications by making this data-entry field mandatory. The aim of this study was to explore hospital doctors' perceptions of mandatory documentation of indications in an electronic medication management (EMM) system. Ten junior doctors took part in brief semi-structured interviews. Participants identified improved communication among staff as a key benefit of indication documentation. Recording indications was also seen to act as a prompt for medication review. Despite these benefits, indication documentation for all medications would be challenging to implement in practice. Users of the EMM system (i.e. junior doctors) explained that they are time poor and are often tasked with transcribing medication orders into the electronic system with limited knowledge of why medications are being prescribed. Determining the indication for use would require additional time and effort, and prescribers reported a high risk of working around the system if indication documentation was made mandatory.

OBJECTIVE: To determine the impact of the introduction of new pre-written orders for antimicrobials in a computerized provider order entry (CPOE) system on 1) accuracy of documented indications for antimicrobials in the CPOE system, 2) appropriateness of antimicrobial prescribing, and 3) compliance with the hospital's antimicrobial policy. Prescriber opinions of the new decision support were also explored to determine why the redesign was effective or ineffective in altering prescribing practices.

METHODS: The study comprised two parts: a controlled pre-post study and qualitative interviews. The intervention involved the redesign of pre-written orders for half the antimicrobials so that approved indications were incorporated into pre-written orders. 555 antimicrobials prescribed before (September - October, 2013) and 534 antimicrobials prescribed after (March - April, 2015) the intervention on all general wards of a hospital were audited by study pharmacists. Eleven prescribers participated in semi-structured interviews.

RESULTS: Redesign of computerized decision support did not result in more appropriate or compliant antimicrobial prescribing, nor did it improve accuracy of indication documentation in the CPOE system (Intervention antimicrobials: appropriateness 49% vs. 50%; compliance 44% vs. 42%; accuracy 58% vs. 38%; all p>0.05). Via our interviews with prescribers we identified five main reasons for this, primarily that indications entered into the CPOE system were not monitored or followed-up, and that the antimicrobial approval process did not align well with prescriber workflow.

CONCLUSION: Redesign of pre-written orders to incorporate appropriate indications did not improve antimicrobial prescribing. Workarounds are likely when compliance with hospital policy creates additional work for prescribers or when system usability is poor. Implementation of IT, in the absence of support or follow-up, is unlikely to achieve all anticipated benefits.

OBJECTIVE: To review evidence of the effectiveness of information technology (IT) interventions to improve antimicrobial prescribing in hospitals.

METHOD: MEDLINE (1950-March 2015), EMBASE (1947-March 2015) and PubMED (1966-March 2015) were searched for studies where an IT intervention involving any device (e.g. computer, mobile phone) was evaluated in practice. All papers were assessed for quality using a 10-point rating scale.

RESULTS: We identified 45 articles that evaluated an IT intervention to improve antimicrobial prescribing in hospitals. IT interventions took four main forms: (1) stand-alone computerized decision support systems (CDSSs), (2) decision support embedded within a hospital's electronic medical record (EMR) or computerized provider order entry (CPOE) system, (3) computerized antimicrobial approval systems (cAAS), and (4) surveillance systems (SSs). Results reported allowed us to perform meta-analyses for three outcome measures: appropriate use of antimicrobials, patient mortality and hospital length of stay (LOS). IT interventions increased appropriate use of antimicrobials (pooled RR: 1.49, 95%CI: 1.07-2.08); however no evidence of an effect was found when analysis included only studies with a quality score of five or above on the 10-point quality scale (pooled RR: 1.53, 95%CI: 0.96-2.44). There was little evidence of an effect of IT interventions on patient mortality or LOS. The range of study designs and outcome measures prevented meaningful comparisons between different IT intervention types to be made.

CONCLUSION: IT interventions can improve the appropriateness of antimicrobial prescribing. However, high quality, systematic multi-site comparative studies are critically needed to assist organizations in making informed decisions about the most effective IT interventions.

Background

3D printing is a promising new technology for medicines' production. It employs additive manufacturing techniques, and is ideal for producing personalized medicines (e.g., patient-tailored dose, dosage form, drug release kinetics).

Objective

To investigate how 3D printing technologies can be implemented in a European pharmaceutical system, by suggesting different scenarios and assessing aspects that could affect its implementation.

Method

Qualitative, semi-structured interviews were conducted with key stakeholders (e.g., from ministry, authorities, research organizations, pharmacies) in the Netherlands to elicit perspectives on 3D printing of personalized medicines. The Netherlands were chosen since it has a strong tradition in compounding. Five general scenarios were investigated: placing the 3D printers in industry, community pharmacies, hospital pharmacies, compounding facilities, and in patients' homes. Content analysis was used, building on verbatim transcripts.

Results

Fifteen stakeholders were interviewed. Regulatory, economic, ethical and organizational challenges were identified to varying degrees in the different scenarios. The industry and home scenarios were associated with the most challenges, hospital pharmacies and compounding facilities with the least. Other important aspects identified were the role of community pharmacies, and who should design the tablets to be printed.

Conclusion

All potential scenarios for 3D printing of personalized medicines include challenges. These should be taken into account when pursuing the use of 3D printing of medicine.