bluuebunny/crossref_metadata_2025 huggingface dataset:
Factors Influencing Concomitant Use of Complementary and Alternative Medicines with Warfarin
Authors: Hasan Shahzad S , Feng Siow R , Ahmadi Keivan , Ahmad Kamarunnesa M , Chong David WK , Anwar Mudassir , Badarudin Nurul Z
Published: April 2015

Aim

To investigate factors influencing complementary and alternative medicines (CAM) use among patients on warfarin.

Method

Cross‐sectional study of randomly selected patients at a hospital‐based anticoagulation clinic in Malaysia. A 38‐item validated data collection form was used to interview patients and investigate the reasons, perceived efficacy and adverse drug events experienced. Data were also collected on potential drug interactions and the international normalised ratio (INR).

Results

Of the 138 randomly selected patients, 76 (55%) reported using CAM – 46 (61%) used biologically based practices such as herbal products, vitamins and supplements. Monthly household income (p = 0.05, rs = 0.13) and family history of CAM use (p = 0.001, rs = 0.32) were significantly associated and positively correlated with CAM use. 19 patients reported adverse events with warfarin use while none reported adverse events with CAM use. 19 and 58 patients, respectively, were identified as being at risk of potential interactions between warfarin‐CAM and warfarin‐conventional medicines. No significant difference in the mean INR was found between CAM and non‐CAM users.

Conclusion

A large number of patients attending the anticoagulation clinic reported using CAM. Socioeconomic factors such as monthly household income, education level and family history of CAM use were significantly related with CAM use. Routine medication interviews should include questions about concomitant CAM use.
Review of Instruments used in Clinical Practice to Assess Patients' Ability to Manage Medications
Authors: Elliott Rohan A , Marriott Jennifer L
Published: April 2015

Background

Managing medications can be challenging, especially in the presence of cognitive and physical impairments that are common in older age.

Aim

To identify instruments used in clinical practice to assess patients' ability to manage medications; to determine whether they have been tested for reliability and validity; and to compare unvalidated and validated instruments.

Method

A sample of health professionals involved in geriatric practice or research in Australia, the UK and USA were asked to provide copies of medication management assessment instruments that they had developed or used. A literature search was conducted to identify published instruments. The instruments were then categorised into 2 groups based on whether or not they had been tested for reliability and validity. The medication management skills assessed by each instrument were also categorised.

Results

Of the 69 (33 published, 36 unpublished) instruments located, 44 (26 unvalidated, 18 validated) instruments met the inclusion criteria and were reviewed. None of the instruments used in clinical practice had been validated. Skills assessed, and methods for assessment, were highly variable. Skills most commonly assessed were: ability to open at least one type of medication packaging (96%), ability to read a standard medication label without interpreting meaning (75%), ability to remove medication from at least one type of packaging (73%), and ability to either comprehend and explain medication instructions or demonstrate setting out a medication regimen (52%). Most validated instruments used a standardised, simulated medication regimen, whereas unvalidated instruments mostly used patients' own medications with inadequate detail or instructions to enable standardised administration.

Conclusion

Numerous instruments have been developed to assess patients' ability to manage medications. Instruments used in clinical practice have not been validated and are generally not standardised, leading to potential for poor reliability.
Optimisation of Digoxin Maintenance Dose in Toxicity
Authors: Bhindi Arun K
Published: April 2015

Background

Digoxin pharmacokinetics can be altered by disease states, age‐related decline in renal function, decreased skeletal muscle mass and drug interactions.

Aim

To report a case of digoxin toxicity in a patient with advanced congestive heart failure in atrial fibrillation and worsening renal failure; and to describe the application of pharmacokinetic principles in the optimisation of digoxin dosing.

Clinical details

A 59‐year‐old Caucasian male presented with a week long history of abdominal pain, increased dyspnoea and lethargy. His medical history included heart failure, atrial fibrillation, hypertension, ischaemic heart disease, type 2 diabetes, acute on chronic renal failure, dyslipidaemia, anaemia and morbid obesity. His serum biochemistry revealed hyperkalaemia of 6.9 mmol/L, elevated creatinine of 407 μmol/L (prior baseline 247 μmol/L) and a trough serum digoxin concentration of 3.4 nmol/L at steady state on an oral maintenance digoxin dose of 125 microgram daily. His calcium and magnesium levels were in the normal range.

Outcomes

Hyperkalaemia was corrected and the potassium‐sparing medications, spironolactone and perindopril, were withheld. Digoxin was withheld until digoxin's serum concentration returned to the therapeutic range. A reduced maintenance dose of digoxin 62.5 microgram on alternate days was calculated and recommended by the clinical pharmacist. At discharge, the patient felt significantly better and was able to engage with activities of daily living. Perindopril and spironolactone were recommenced once the potassium had returned to normal levels. The patient was unaware of signs and symptoms of digoxin toxicity and the clinical pharmacist provided counselling prior to discharge. The patient's local doctor was requested to closely monitor his renal function and potassium levels and to check his trough serum digoxin concentration if toxicity was suspected.

Conclusion

Pharmacists and clinicians need to understand digoxin's pharmacokinetics in various clinical settings to be able to make appropriate dose adjustments.
Impact of Hospitalisation on the Complexity of Older Patients' Medication Regimens and Potential for Regimen Simplification
Authors: Elliott Rohan A , O'Callaghan Christopher J
Published: April 2015

Aim

To investigate the impact of hospitalisation on the complexity of older patients' medication regimens; and to determine whether discharge medication regimens could be simplified.

Method

Medication Regimen Complexity Index (MRCI) scores were calculated on admission and discharge for 186 consecutive patients (mean age 80 years) discharged from 2 acute general medicine and 2 subacute aged care wards. A random sample of 40 discharge medication regimens were retrospectively simplified by clinical pharmacists and proposed changes reviewed by a clinical pharmacologist to determine feasibility of the changes and likelihood of equivalent therapeutic outcomes.

Results

On average, 1.2 regularly scheduled long‐term medications/patient were ceased in hospital and 2.5 added. 0.6 regularly scheduled short‐term (defined duration) medications were commenced. MRCI scores increased by 22% (18 to 22; p < 0.0001) for regularly scheduled long‐term medications and 32% (21 to 27; p < 0.0001) for all medications. In multivariate analysis, using fewer medications prior to admission and being discharged from a subacute aged care ward were associated with increased regimen complexity. For the 40 discharge medication regimens reviewed, 90 simplifications to regularly scheduled long‐term medications were proposed, and 84 (93%) were rated by the clinical pharmacologist as feasible and likely to have the same or similar therapeutic outcomes to the complex regimens. These changes, if implemented, could have reduced medication regimen complexity at discharge by an average of 14%.

Conclusion

Hospitalisation resulted in multiple medication changes and increased regimen complexity. Most medication regimens had the potential to be simplified.
Feasibility and Timeliness of Alternatives to Post‐Discharge Home Medicines Reviews for High‐Risk Patients
Authors: Angley Manya , Ponniah Anne P , Spurling Lisa K , Sheridan Louise , Colley Des , Nooney Vivek B , Bong Xin Jou , Padhye Vaishali , Shakib Sepehr
Published: April 2015

Background

The period 7 to 10 days following hospital discharge is associated with a significant risk of medication misadventure, especially in high‐risk patients.

Aim

To investigate whether post‐discharge hospital‐initiated medication review (HIMR) pathways are more timely than the post‐discharge home medicines review (HMR) pathway.

Method

An implementation study conducted over 9 months in 2008/2009 of patients from 3 South Australian hospitals. A risk stratification instrument was used to identify patients at “high” risk of medication misadventure. Feasibility was assessed and time to conduct the post‐discharge medication reviews was determined for the HMR and HIMR pathways.

Results

Of the 97 consenting patients, 92 were stratified as “high” risk. HIMR were organised for 59 patients − 52 patients completed the HIMR process. Of the 22 HMRs organised via the patient's general practitioner, 18 patients completed the HMR process. The time from request to conducting the HIMR and HMR were statistically significantly different – HIMR and HMR took 6.5 ± 4.7 days and 11 ± 7.4 days, respectively (p = 0.02).

Conclusion

This study has demonstrated the feasability of alternative pathways to post‐discharge medication reviews. The HIMRs were conducted sooner than HMRs organised via existing community processes. If post‐discharge medication reviews are organised via the HIMR pathway, there is potential to reduce medication misadventure in high risk patients in a more timely manner than when post‐discharge HMRs are organised.
Snapshot of Barriers to and Indicators for Antimicrobial Stewardship in Australian Hospitals
Authors: Chen Alex WJ , Khumra Sharmila , Eaton Vaughn , Kong David CM
Published: April 2015

Background

Effective antimicrobial stewardship programs are vital in an environment of emerging resistance to existing antimicrobials and the limited availability of new antimicrobials. There are institutional barriers to successful implementation of these programs. Key performance indicators (KPI) are useful for determining the success of antimicrobial stewardship programs and for benchmarking purposes.

Aim

To identify barriers to implementation of antimicrobial stewardship programs, KPI used to measure program outcomes and the perceived usefulness of these KPI in Australian hospitals.

Method

Australian Directors of Pharmacy in private and public hospitals or their nominees (n = 281) were surveyed by mail to identify barriers to, and KPI used for antimicrobial stewardship programs at their hospitals. Hospital pharmacists, infectious diseases clinicians and infection control nurses were interviewed until saturation of themes was reached.

Results

Response rate for the postal survey was 29% (n = 80). Main barriers to implementing antimicrobial stewardship programs encountered by respondents included: lack of education and training related to antimicrobial usage; prescribing culture at the hospital which was resistant to change; lack of resources to conduct stewardship activities; and lack of feedback to doctors, nurses and pharmacists on institutional antimicrobial use. Only 14 respondents used KPI to measure program outcomes. The KPI used between institutions were variable.

Conclusion

Australian hospitals encounter many barriers to implementing antimicrobial stewardship programs. There were no standard national KPI to measure program outcomes. Most participants agreed that the KPI at their hospitals were useful.
Drug Interactions Between Anti‐Epileptics and Chemotherapeutic Drugs: Value of a Pre‐Treatment Pharmaceutical Review
Authors: Mellor James D , Jayasinghe Charini
Published: April 2015

Background

Many cancer patients take medications for preexisting comorbidities that are unrelated to their malignancy. Eliciting an accurate medication history prior to cancer chemotherapy is important to ensure that any drug‐drug interactions are detected, assessed and avoided.

Aim

To report a potential case of an interaction between antiepileptics and chemotherapeutic drugs.

Clinical details

A 24‐year‐old female with rapidly progressing metastatic rhabdomyosarcoma of the right maxillary sinus was treated with the Children's Oncology Group ARST0431 protocol for high‐risk rhabdomyosarcoma. This intensive regimen combines radiation therapy with 7 chemotherapeutic drugs: vincristine, irinotecan, cyclophosphamide, ifosfamide, doxorubicin, etoposide and actinomycin‐D. During routine pre‐treatment medication reconciliation, the pharmacist identified that the patient was also taking carbamazepine, a potent inducer of cytochrome P450 (CYP) enzymes, for left‐sided focal epilepsy.

Outcome

There was potential for clinically relevant drug interactions because CYP enzymes were responsible for metabolising some of the chemotherapy drugs planned for her treatment. The pharmacist's intervention resulted in carbamazepine switched to levetiracetam, a non‐enzyme inducing antiepileptic, and avoiding the potential interaction.

Conclusion

This case highlights the value of clinical pharmacists undertaking medication reconciliation prior to the start of cancer chemotherapy.
Possible Metformin‐Induced Otorrhoea: A Rare Case
Authors: Maarup Norlela , Palaian Subish , Ibrahim Mohamed Izham M , Khanal Saval , Alshakka Mohammed
Published: April 2015

Background

Ear problems attributed to metformin use are not documented in the literature.

Aim

To report a possible case of otorrhoea from metformin therapy.

Clinical details

A 50‐year‐old male developed an ear discharge during metformin therapy.

Outcomes

His ear discharge reappeared when metformin was reintroduced and disappeared when it was discontinued, suggesting a possible association between metformin and otorrhoea. The causality assessment revealed a “probable” (Naranjo algorithm score 8) association and the severity was ‘moderate’ (Level 3).

Conclusion

First case of possible otorrhoea from metformin therapy to be reported in the literature.
Peptic Ulcer Disease in Older People
Authors: Lockrey Gregory , Lim Lucy
Published: April 2015

Peptic ulcer disease is a common disorder that affects millions of people worldwide. Peptic ulcer disease has a major impact on quality of life and on the utilisation of the health system when complications occur. Understanding the causative roles of Helicobacter pylori and non‐steroidal anti‐inflammatory drugs has led to changes in management of the disease. Comorbidities in older people add further complexity to treatment. This article summarises the clinical aspects of peptic ulcer disease and outlines principles which enable effective treatment.
Restricted Antimicrobial Use at Transitions of Care at an Australian Hospital
Authors: Lee Yi JF , Levy Russell , Bajorek Beata V
Published: April 2015

Background

The emergence of antimicrobial resistance reinforces the need for antimicrobial stewardship to promote the appropriate and judicious use of antimicrobials.

Aim

To quantify restricted antimicrobial use among intensive care unit (ICU) discharges to general wards, and to review appropriateness of antimicrobial use.

Method

A prospective clinical audit was conducted over a 2‐week period. Medical records for ICU discharges were reviewed, with relevant data extracted (patient characteristics, antimicrobial therapy prescribed, treatment instructions). Appropriateness of restricted antimicrobials used was gauged in accordance with hospital policies and the Therapeutic Guidelines: Antibiotic.

Results

98 patients were discharged from the ICU – 74 (76%) discharged to general wards were on antimicrobials, 15 discharged to general wards were not on antimicrobials and 9 discharged out of the hospital. Of these 74 patients, 31 (42%) were prescribed a total of 57 restricted antimicrobials; only 11 of these 31 (36%) patients had documented approval (from microbiology/infectious diseases teams) for use of restricted antimicrobials. 46 restricted antimicrobials (n = 57; 81%) were deemed clinically appropriate and the remaining 11 were prescribed outside guideline‐recommended indications.

Conclusion

While most restricted antimicrobials were prescribed according to national guidelines, in only one‐third of patients were the restricted antimicrobials ‘approved’ for use according to hospital policies. Better clinical documentation on treatment plans and review processes for restricted antimicrobial use is needed during the transition from ICU to general wards.
Prescriber Feedback to Improve Quality Use of Medicines among Older People: the Veterans' MATES Program
Authors: Bell J Simon , Kalisch Lisa M , Ramsay Emmae N , Pratt Nicole L , Barratt John D , LeBlanc Tammy , Roughead Elizabeth E , Gilbert Andrew L
Published: April 2015

Since 2004, the Department of Veterans' Affairs (DVA) has funded the Veterans' Medicines Advice and Therapeutics Education Services (MATES) program. The main intervention of the program is quarterly targeted patient‐specific prescriber feedback. The feedback comprises a list of relevant medications dispensed to each patient and notes about potential medication‐related problems specific to the intervention. Supportive educational material is provided to assist general practitioners (GPs) resolve these medication‐related problems. Veterans identified in the GP mailing are sent an educational brochure highlighting medication issues and encouraging them to speak with their doctor. To enable pharmacists to support this practice change, educational material is also provided to all pharmacies and accredited pharmacists. The most recent of the 28 interventions implemented to date have addressed osteoporosis, opioid‐induced constipation and urinary incontinence. Overall, program materials have been mailed to 249 454 veterans, 34 527 GPs and around 8000 pharmacies and accredited pharmacists. Evaluation has demonstrated a doubling of home medicines review (HMR) rates in the veteran population. Analyses of the DVA data have reported a 45% reduction in hospitalisation for heart failure following HMR among veterans with heart failure (adjusted hazard ratio [HR] 0.6; 95% confidence interval [CI] 0.4–0.8), and a 79% reduction in hospitalisation for haemorrhage (HR 0.2; 95%CI 0.05–0.9) 2 to 6 months after an HMR in veterans dispensed warfarin. Veterans' MATES has resulted in clinically significant improvements in medication and health service use.
Medication Prescribing, Surveillance and Safety in Australasian Emergency Departments
Authors: Marmor Gerrard O , Braitberg George , Nicolas Caroline M
Published: April 2015

Background

The prescribing practices of the Fellows of the Australasian College of Emergency Medicine (FACEM) in Australasian emergency departments (EDs) are unknown.

Aim

To describe the FACEM's prescribing practices in relation to charting and monitoring medications in the ED; and to investigate the differences in the prescribing practices between the users and non‐users of the National Inpatient Medication Chart (NIMC) in EDs.

Method

Analysis of a multimodal survey sent to FACEM across Australasia.

Results

Responses were received from 122 (n = 940) FACEM (13% response rate). 91% of FACEM considered medication safety to be a quality issue. Most FACEM (56%) prescribed on 2 to 3 different documents in the ED and only 39 (32%) prescribed on 1 document. Time pressure was the main barrier to safe prescribing in the ED. Prescribing guidelines for analgesics and antibiotics were often in situ but times to administration were not monitored. 65% of FACEM who used the NIMC tended to prescribe on only 1 document and came from larger EDs that employed an ED pharmacist. Strategies cited to decrease the rate of prescribing errors included educational interventions, ED pharmacists and use of the NIMC.

Conclusion

There are a wide range of prescribing and medication safety practices and a lack of conformity among Australian emergency physicians. Despite the introduction of the NIMC, most FACEM prescribed on multiple documents in the ED. The differences between users and non‐users of the NIMC identified may aid future initiatives to increase its use.
Managing Patients on Antiplatelet Drugs Requiring Emergency Non‐Cardiac Surgery
Authors: Seleem Mostafa , Ratnapala Dinesh N , Stride Peter JO , Wood Peter , Lambrianides Andreas L , Gupta Shravani
Published: April 2015

Background

The antiplatelet drugs, aspirin and clopidogrel, are widely prescribed for cardiovascular and neurovascular diseases. It is recommended that these drugs should be ceased 5 days prior to elective surgery. If patients on these drugs require emergency non‐cardiac surgery, the peri‐operative risk of haemorrhage and thrombosis causes management dilemmas. Current guidelines are limited to the management of patients with coronary stents who are on antiplatelet drugs and require elective surgery. There is no universal evidence‐based consensus, for the indications, method, timing or endpoints of treatment to reverse the antiplatelet action of clopidogrel in patients requiring emergency non‐cardiac surgery.

Aim

To report two cases where emergency abdominal surgery was required in patients on concomitant clopidogrel and aspirin.

Clinical details and outcome

Two patients who were on concomitant aspirin and clopidogrel required urgent abdominal surgery. The two cases were managed differently. In the first case, no pre‐operative platelets or fresh frozen plasma were administered and surgery was complicated by major bleeding. The second patient received pre‐operative platelet transfusion and encountered no significant bleeding or thrombotic complications.

Conclusion

There is an urgent need for the development of guidelines to manage patients receiving antiplatelet drugs requiring emergency non‐cardiac surgery.
Deprescribing in the Last Year of Life
Authors: Hardy James E , Hilmer Sarah N
Published: April 2015

Polypharmacy and adverse drug reactions are common with ageing. Deprescribing or ceasing unnecessary or harmful medications is an important component of aged care practice, especially in the final year of life. Changes in pharmacokinetics and pharmacodynamics with ageing can affect decisions about deprescribing. Similarly, the balance between risk and benefit for medications is often altered in patients in their final year of life and needs to be taken into account. There is evidence for medicines that can be safely ceased abruptly and medicines that need to be weaned. An individualised approach is required to assess prognosis, trajectory of decline and therapeutic goals for each patient. An algorithm is provided in this review to guide safe, rational deprescribing for patients who are believed to be in their last year of life.
External Surface Contamination of Cytotoxic Admixtures: Caveat Emptor
Authors: Siderov Jim , Kirsa Sue , McLauchlan Robert
Published: April 2015

Background

Published studies suggest that cytotoxic contamination in the workplace may originate from the external surface of commercially available vials. No published studies were found describing the testing of surface contamination of cytotoxic products purchased from commercial compounders.

Aim

To determine if cytotoxic admixtures purchased from a commercial compounder would test positive for surface contamination with cyclophosphamide.

Method

Surface wipe sampling was performed to detect cyclophosphamide surface contamination on products sourced from a commercial compounder. Surface wipe sampling was performed using previously published methods.

Results

Surface contamination was detected on all of the samples taken.

Conclusion

Cytotoxic products purchased from commercial compounders may have external surface cytotoxic contamination. Safe handling procedures should be instituted for these products.
Non‐Therapeutic Medication Omissions: Incidence and Predictors at an Australian Hospital
Authors: Latimer Sharon L , Chaboyer Wendy , Hall Tony
Published: April 2015

Background

The inconsistent definition of non‐therapeutic medication omissions, under‐reporting, and a poor understanding of their associated factors hamper efforts to improve medication administration practices.

Aim

To examine the incidence of non‐therapeutic medication omissions among acutely ill medical and surgical adult patients; and to identify the patient‐, drug‐ and system‐related predictors of these omissions.

Method

A medication chart audit of 288 acutely ill adult medical and surgical patients admitted to 4 target wards (2 surgical and 2 medical) at an Australian hospital. Patients admitted to these wards from December 2008 to November 2009, with at least one regularly prescribed medication, were eligible. The sample was stratified according to gender, season and ward. A medication chart audit identified medication omissions, and data were collected on gender, age, length of stay, comorbidities, medication history and clinical pharmacy review.

Results

Of the 288 medication charts audited, 220 (75%) had one or more medication omissions. Of the 15 020 medication administration episodes, there were 1687 omissions, resulting in an omission rate per medication administration episode of 11%. Analgesics and aperients were the most frequently omitted medications, with failure to sign the medication record and patient refusal, the main reasons for omission. Female gender (p < 0.001) and the number of medication administration episodes (p < 0.001) were statistically significant predictors of non‐therapeutic medication omissions.

Conclusion

The high incidence of medication omissions suggests there is need for an agreed definition of medication omission and its inclusion as a reportable incident. Increasing medication reconciliation via implementation of the Medication Management Plan may also reduce the opportunity for error.
Smart Infusion Pumps Reduce Intravenous Medication Administration Errors at an Australian Teaching Hospital
Authors: Pang Rebecca KY , Kong David CM , de Clifford Jan‐Marie , Lam Skip S , Leung Benjamin K
Published: April 2015

Background

Serious and life‐threatening adverse drug events are often attributed to intravenous medication administration errors. Although smart infusion pumps are increasingly being adopted by hospitals to prevent such errors, data are lacking on their effectiveness in clinical practice.

Aim

To measure and characterise intravenous medication administration errors and their clinical significance before and after the implementation of smart infusion pumps.

Method

In the pre‐intervention period, an independent observer over 41 working days recorded the prescribing and administration details of infusions administered via the IMED Gemini Volumetric Infusion Pumps. 20 months after the introduction of the smart pumps – Alaris GP Volumetric Pump with Guardrails software – a repeat audit was conducted over 27 working days. Only infusions containing drugs that were to be incorporated into Guardrails (the medication–error–prevention software of the Alaris GP pump) were evaluated. The clinical significance of the identified errors was evaluated by 2 independent assessors (pharmacist and doctor) and rated as ‘low’, ‘moderate’, ‘high’ or ‘extreme’.

Results

In the pre‐intervention period, 76 infusions (n = 432, 18%) had one or more errors compared to 25 infusions (n = 266, 9.4%) following the introduction of the smart pumps. Of the 165 infusions administered using Guardrails, only 6 infusions with errors (3.6%) were identified. When drugs were infused with the Alaris GP pumps without Guardrails, the number of errors post‐intervention when compared with errors in the pre‐intervention period were not statistically significant (p = 0.8). When Alaris GP pumps with Guardrails were used there were no errors of ‘extreme’ clinical significance and only 1 error of ‘high’ clinical significance compared to the pre‐intervention period where 1 ‘extreme’ and 30 errors with ‘high’ clinical significance were identified.

Conclusion

Alaris GP pumps with Guardrails resulted in significant reductions in the number and clinical significance of intravenous medication administration errors.
Successful Implementation of a Pharmacist Anticoagulant Dosing Service in Ambulatory Care
Authors: Dooley Michael J , McGuiness Josephine V , Choo Shin , Ngo‐Thai Lam‐Lan , Tong Erica , Neave Katrina , Poole Susan , Street Alison
Published: April 2015

Aim

To assess the effectiveness of a pharmacist anticoagulant dosing service in an ambulatory care program at an Australian hospital.

Method

A pre‐ and post‐intervention study method was used. The pre‐intervention group consisted of patients admitted for anticoagulation to the Hospital‐in‐the‐Home program from September 2009 to January 2010, where warfarin was managed by doctors from the treating unit. The post‐intervention group consisted of patients enrolled in the pharmacist dosing service from February 2010 to October 2010. Eligibility criteria for enrolment in the pharmacy dosing service included: admission to the Hospital‐in‐the‐Home program for anticoagulation; warfarin dosing initiated in line with the existing hospital anticoagulation guidelines (modified to accommodate a pharmacist dosing service); medical unit consent for patient inclusion; and patients able to undergo daily INR blood tests.

Results

The mean number of days for a patient to achieve 2 consecutive therapeutic international normalised ratios was 8.8 days for the pharmacist dosing service (n = 35) and 11.8 days for the pre‐intervention group (n = 53) (p = 0.002). There was no difference in the mean number of international normalised ratios measured between the two groups.

Conclusion

A pharmacist anticoagulant dosing service effectively managed warfarin dosing in patients admitted to an ambulatory care program.
Impact of a Surgical Preadmission Clinic Pharmacist on the Quality of Medication Management from Preadmission to Discharge: a Randomised Controlled Study
Authors: George Lewis JW , Senturk‐Raif Reyhan , Hodgkinson Marisa R , Emmerton Maggie , Larmour Ian
Published: April 2015

Background

Studies evaluating the impact of surgical preadmission clinic (PAC) pharmacists have reported significant improvements in medication management. However, despite the increased uptake of pharmacy services in this area, randomised controlled studies are limited.

Aim

To investigate the impact of a surgical PAC pharmacist on the quality of medication management from preadmission to discharge.

Method

A prospective, randomised, controlled design was used to assign patients to either the intervention or control groups. The intervention group received standard PAC care plus assessment by a PAC pharmacist. The control group received standard PAC care only. Both groups also received standard inpatient care, and were followed from PAC to discharge, and data collected on pharmacist interventions, medication reconciliation and medication history documentation.

Results

171 patients were randomised to the intervention group and 184 to the control group. The intervention group had significantly more regular and as required prescription medicines, and complementary and alternative medicines documented per patient than the control group; and significantly more pharmacist interventions (31%) than the control group. The PAC pharmacist made 27% of interventions in the intervention group. Medication reconciliation at admission was 81% for the intervention group and 75% for the control group. Medication reconciliation for both groups was 90% at discharge.

Conclusion

A surgical PAC pharmacist had a positive impact on medication management through improved quality of medication histories and documentation, interventions and medication reconciliation.
Dexamethasone Use in Inpatient Palliative Care
Authors: Kiani Mona , Yip Anna YM , Tuffin Penelope HR , Roberts Malcolm , Clifford Rhonda M
Published: April 2015

Aim

To describe the prescribing patterns of dexamethasone in a cohort of palliative care inpatients.

Method

Data were collected from a consecutive sample of patients admitted to 2 palliative care units over an 8 week period. Data on dexamethasone use was also collected, i.e. indication for use, dosages, concurrent medications, adverse effects, blood glucose levels and reasons for changes in dose.

Results

359 patients were admitted during the recruitment period and 185 (52%) were prescribed dexamethasone. 37 (20%) patients were prescribed dexamethasone for specific indications, such as cerebral disease, spinal cord compression and bowel obstruction. The majority of dexamethasone was prescribed for non‐specific indications: poor appetite, nausea, and poor wellbeing. A range of doses was prescribed for each indication and during their inpatient stay most patients (65%) had their dose reduced. Adverse effects were commonly reported; 117 (63%) patients experienced adverse effects attributable to dexamethasone.

Conclusion

Dexamethasone use is widespread in palliative care for a myriad of indications.
Systemic Absorption from Oral Vancomycin: Check the Dose!
Authors: Coutsouvelis John , Witney Kate A , Corallo Carmela E , Spelman Denis
Published: April 2015

Background

Oral vancomycin is increasingly being used to treat Clostridium difficile infection. The extent of systemic absorption of oral vancomycin is unpredictable and usually minimal. However, in the presence of factors, such as renal impairment, or if high doses are used for prolonged periods, systemic absorption may occur, resulting in therapeutic levels of vancomycin.

Aim

To describe a case of systemic absorption of oral vancomycin.

Clinical details

A 69 year‐old female with neutropenia and severe diarrhoea was admitted to the intensive care unit after an episode of hypotension due to hypovolaemia and septic shock. Fecal cultures were positive for C. difficile infection and she was started on oral vancomycin 500 mg 6‐hourly. Serum creatinine at this time was 161 micromol/L. The clinical pharmacist identified the high dose of oral vancomycin being used and the potential problem with its absorption and recommended monitoring levels. After 7 days of treatment at this dose, the last 6 with normal creatinine, a spot level indicated a systemic vancomycin level of 5 mg/L.

Outcome

On the return of a negative C. difficile culture, oral vancomycin was ceased after 9 days of treatment.

Conclusion

The literature does not support oral vancomycin doses above 125 mg 6‐hourly for the initial treatment of C. difficile‐associated diarrhoea.
Hospital Pharmacist‐Led Lipid Clinic for Surgical Patients with Peripheral Vascular Disease at a Regional Australian Hospital
Authors: Weeks Greg R , Fyfe Rachel , Amerena John , George Johnson
Published: April 2015

Aim

To report patient and pharmacist experiences with a pharmacist‐led lipid clinic for surgical patients with PVD.

Method

A pharmacist completed a non‐medical prescribing course and tutelage under a cardiologist to enhance consultation and lipid management skills. Eligible patients were randomised into control or intervention groups. The intervention group was reviewed by the pharmacist during four 6‐weekly visits, and given lifestyle advice, lipid levels measured, and (if required) statins were initiated or adjusted. The control group was given dietary advice, a booklet on cholesterol management and lipid levels measured at baseline and 6 months. The intervention group completed a questionnaire on their experiences. The pharmacist's reflections on their role were also recorded.

Results

Of the 8 intervention group patients who completed the study, 5 reduced their low‐density lipoprotein (LDL) levels below 2 mmol/L, 2 reduced their LDL to 2 and 2.1 mmol/L, and 1 maintained their LDL at 2 mmol/L (mean 1.8, range 1.3–2.1). The entire control group (n = 6) had elevated LDL levels (mean 2.9 mmol/L, range 2.3–3.9). Statins were initiated or adjusted in 4 intervention group patients. Participants were highly satisfied with their pharmacist consultations. The pharmacist was positive about the training, self confidence and ability to answer questions, and less positive about the clinic setting, usefulness of the algorithm and point‐of‐care cholesterol testing.

Conclusion

A suitably trained hospital pharmacist can undertake extended roles with a prescribing element. However, the patient group and setting require careful consideration.
Lifelong Learning: Views of Australian Pharmacy Interns
Authors: Stupans Ieva
Published: April 2015

Background

Lifelong learning is critical for the professional practice of pharmacists. Lifelong learning can be described as a philosophy recognising that learning occurs throughout one's life. Pharmacists' concept of lifelong learning has not been investigated, with most literature focused only on one aspect of lifelong learning – continuing professional development.

Aim

To explore pharmacy interns' understanding of lifelong learning.

Method

Thematic analysis of interviews with interns from an Australian university was undertaken

Results

There were 2 major findings. The very narrow definition of lifelong learning adopted by the interns, i.e. it was viewed as continuing professional development and the need to keep up‐to‐date. The intern period was described as a period of intense learning.

Conclusion

Pharmacy interns appear to be focused on continuing professional development rather than lifelong learning. This may reflect disciplinary contextualisation of university graduate attributes or the focus of activity during the intern period.
Prevalence of Potentially Harmful Drug Interactions in Older People in Australian Aged‐Care Facilities
Authors: Dolton Michael J , Pont Lisa , Stevens Gerard , McLachlan Andrew J
Published: April 2015

Background

Older people living in aged‐care facilities are prescribed more medications than those living in their own homes. Thus, increasing their risk of potentially harmful drug interactions. Few studies have investigated potential drug interactions in residents of aged‐care facilities.

Aim

To determine the prevalence of potentially harmful drug interactions in long‐term residents of aged‐care facilities.

Method

Potentially harmful drug interactions were investigated using dispensing data from residents of 26 aged‐care facilities who received one or more medications from July 2008 to June 2010. Drug interactions analysed were chosen based on their inclusion at the highest severity rating in at least 3 of 4 international drug information resources. Data were compared to findings from a cohort of Australian veterans.

Results

Potentially harmful drug interactions were identified for 6.1% of the 3876 residents included in the study. A substantially higher incidence than previously reported in Australian veterans (1.5%) and certain overseas populations. Interactions involving warfarin, amiodarone, verapamil, lithium and methotrexate had the highest prevalence in aged‐care residents, and generally a higher prevalence than in the Australian veteran population.

Conclusion

Potentially harmful drug interactions were more prevalent in aged‐care residents than in an Australian veteran population.
Adherence to Prophylaxis Guidelines for Symptomatic Venous Thromboembolism at a Darwin Hospital
Authors: De Zylva Joseph B , Naunton Mark , Szabo Ferenc , Dettwiller Pascale
Published: April 2015

Aim

To investigate adherence to venous thromboembolism (VTE) prophylaxis guidelines in patients who developed VTE within 90 days of hospital discharge.

Method

Inpatients diagnosed with VTE (January 2007 to December 2009) were identified retrospectively from the medical records coding department. Patients were ineligible if they were outpatients, admitted to another hospital in the 3 months prior to the diagnosis of VTE, or if the diagnosis was not confirmed via a Doppler ultrasound or computed tomography pulmonary angiogram scan. A single cycle audit measured adherence to the guidelines by comparing prophylaxis delivered to eligible patients prior to the diagnosis of VTE to the prophylaxis recommended by the hospital guidelines.

Results

59 medical and surgical patients were eligible (median age 62 years; interquartile range 23 to 84) and 59% (n = 35) were male. Adherence to VTE prophylaxis guidelines was investigated for 59 patients who developed VTE associated with their current indexed admission (n = 32) or within 90 days of discharge (n = 27). Adherence to VTE prophylaxis for high‐risk patients who developed VTE was: 50% for pharmacological prophylaxis and 57% for mechanical prophylaxis in surgical patients, and 63% for pharmacological prophylaxis and 26% for mechanical prophylaxis in medical patients.

Conclusion

Nearly half of the patients had not received appropriate VTE prophylaxis prior to developing VTE.
Two National Surveys of Hospital Pharmacy Technician Activities to Support the Review of National Qualifications
Authors: O'Leary Karen M
Published: April 2015

Aim

To explore if the 2006 Certificates III and IV in Hospital/Health Services Pharmacy Support qualifications meet workplace requirements and to make recommendations on the changes needed so that the qualifications meet workplace requirements.

Method

2 national web‐based surveys were undertaken of Australian hospital pharmacy technicians/assistants (HPT) and hospital pharmacy managers.

Results

Distribution activities are the core business of the majority of HPT. A minority undertake extemporaneous compounding or support clinical pharmacy activities, which are considered advanced practice activities and covered in the Certificate IV qualification. Most of the 10 management activities undertaken by HPT are not supported by the current qualifications. The number of HPT performing these activities highlights a gap in the current qualifications.

Conclusion

The day‐to‐day activities undertaken by HPT validates the need for, the content of and competencies obtained via the Certificates III and IV in Hospital/Health Services Pharmacy Support. There is room to improve the content and relevance of both qualifications.
Medication Safety Series
Authors: Thornton Penny
Published: April 2015

This series brings you up‐to‐date information about medication safety issues and strategies to prevent medication errors. It draws on Australian incidents and US experience, including (with permission) material from ISMP Medication Safety Alert! a bulletin published by the US Institute for Safe Medication Practices . This series is coordinated via the Committee of Specialty Practice in Medication Safety (Chair, Rosemary Burke, Director of Pharmacy, Concord Hospital, NSW). Australian incidents are collated and editorial recommendations made by Penny Thornton (Medication Safety Consultant, QuAMS Pty Ltd. Send incident reports to ).
Drug Treatments in Development for Alzheimer's Disease
Authors: Woodward Michael C
Published: April 2015

New therapies are needed to combat the symptoms and underlying disease processes in the dementias. A rapid increase in our understanding of the risk factors for dementia and the underlying pathologies has not been matched with new effective therapies. In this review, potential new symptomatic and disease‐modifying therapies will be described. Most are directed at modifying the amyloid cascade that seems to be the primary pathogenic feature of Alzheimer's disease, other targets include tau pathology, inflammation, neurogenesis and oxidative stress. Some of these therapies may be beneficial for other dementias. It is sobering that in 2012 we only have 4 drugs that are modestly effective for the features of one dementia.
Adverse Drug Reactions during Hospital Stay: Evaluation of a Model for Informing Patients
Authors: Graudins Linda V , Hopper Ingrid , Treseder Rowena J , Lord Julie AV , Dooley Michael J
Published: April 2015

Background

Informing patients about their adverse drug reactions (ADRs) and involving them in their medication management should decrease repeat ADRs. An innovative model for informing patients about their ADRs has been in place at an Australian health network. The health network's ADR Review Committee reviews the ADR reports, assigns causality and makes recommendations. Patients are sent a letter about their ADR along with an alert card.

Aim

To evaluate the existing ADR model.

Method

Over a 6‐month period, patients who had an ADR report reviewed by the ADR Review Committee were contacted by telephone within 4 weeks of the review and asked questions about the ADR information sent to them. Patients' discharge summaries were concurrently reviewed for ADR information. Feedback about the model was also sought from the hospital's consumer groups.

Results

Of the 89 ADR reports reviewed, 76 patients were eligible, and 55 (72%) patients consented to participate in the survey. 50 (91%) patients recalled the name of the causative drug, 53 (96%) recalled the reaction, 48 (87%) recalled the ADR Review Committee's recommendation, 28 (50%) had an alert card in their wallet, and 29 (52%) had shown or were intending to show the letter to their doctor, but only 3 to their pharmacist. 95% of respondents would recommend this model to other hospitals. 35 (63%) patients wanted the letter sent directly to their doctor. Of the 54 discharge summaries reviewed, the ADR was documented in 43 (80%), details of the reaction in 43 (80%) and specific management advice in 10 (19%). Feedback from the hospital's consumer groups (n = 15) was positive and informed improvements to the model.

Conclusion

The ADR model was well received by patients, who retained the information sent. Patient feedback was used to improve the format and content of the ADR information sent. This model could be adapted by other acute and ambulatory settings to facilitate communication between health professionals and patients to avoid repeat ADRs.
Preparation Method and Stability of a Temozolomide Suspension: A Pilot Study
Authors: Ambados Fotios , Crea Joe , Chin May , Lee Su‐Gil
Published: April 2015

Aim

To investigate a compounding process for temozolomide 10 mg/mL suspension from capsules without using a mortar and pestle; and the stability of the suspension under refrigeration (2 to 8 °C) and at room temperature (22 to 23 °C).

Method

Temozolomide 10 mg/mL suspension was prepared using a modified formulation and method to contain the product in the final container and limit operator exposure to cytotoxic powder or residue. Decontamination was undertaken of work and finished product surfaces. Samples were stored at room temperature and under refrigeration. Both samples were protected from light and stored in identical polypropylene containers. High‐pressure liquid chromatography was used to assay the potency of the suspension.

Results

The sample refrigerated and protected from light exhibited little or no chemical degradation for 22 days. At room temperature, the concentration fell below the acceptable concentration after 8 days. An acceptable product was produced which re‐suspended evenly when shaken.

Conclusion

Preliminary results indicate that temozolomide 10 mg/mL suspension prepared via this method, refrigerated, protected from light and stored in polypropylene containers may be stable for up to 22 days.