bluuebunny/crossref_metadata_2025 huggingface dataset:
Vitamin B12 Deficiency in the Elderly using Metformin Long Term: Prevalence and Relationship to Putative Risk Factors
Authors: Sorich Wassana , Stranks Steve N , Kowalski Stefan R , Kuruvila Manoj T , Sorich Michael J
Published: April 2015

Aim

To determine the prevalence of vitamin B12 deficiency in elderly patients using metformin long term and to assess putative risk factors for reduced vitamin B12 concentrations.

Method

Patients using metformin for more than 2 years admitted to or reviewed in the Repatriation General Hospital from June to December 2006 were enrolled in this cross‐sectional study. The prevalence of vitamin B12 deficiency and the association between vitamin B12 deficiency and putative risk factors were determined.

Results

60 patients were recruited. Of the 53 patients not taking vitamin B12 supplements, 8 (15%; 95%CI 7.2–28.1) were vitamin B12 deficient (83–148 pmol/L). 7 patients taking vitamin B12 supplements had statistically significantly higher serum vitamin B12 concentrations and decreased B12 deficiency. Daily metformin dose was associated with a statistically significant negative correlation with vitamin B12 concentration and was statistically higher in vitamin B12‐deficient patients. Duration of metformin therapy, age and use of proton pump inhibitors or calcium supplements were not statistically significantly associated with vitamin B12 concentration or deficiency.

Conclusion

Elderly patients taking metformin should be monitored for vitamin B12 status, especially those on high doses of metformin. Vitamin B12, but not calcium, supplements should be considered to prevent or correct deficiency.
Successful Integration of a Clinical Pharmacist into a Disease Management Unit
Authors: Stell Robyn , Bonollo Marco , Fiddes Kaylene , Dooley Michael J
Published: April 2015

Aim

To evaluate the impact of integrating a clinical pharmacist into a disease management unit to provide a clinical pharmacy review service for patients in the outpatient clinic and at home.

Method

This pilot study consisted of two phases—service planning, and implementation and evaluation. The service planning phase involved multidisciplinary consultation on the clinical pharmacist role. After completion of the service planning phase and service implementation, the service was evaluated for a 4‐month period through quantification of accuracy of the medication list on attendance at the outpatient clinic, number and type of medication problems identified by the pharmacist and number and type of interventions undertaken by the pharmacist.

Results

The clinical pharmacy review service was implemented in October 2005 and evaluation of the service continued until January 2006. 122 patients were seen by the pharmacist in the 4‐month period. The accuracy of the medication list increased from 12 to 24% pre‐implementation to 91 to 94% postimplementation. Of the patients interviewed by the pharmacist, 49% of the outpatient clinic patients and 83% of the home visit patients were identified as having medication‐related problems. 66 medication‐related problems were identified by the pharmacist at the home visits and 47 in the unit's outpatient clinic.

Conclusion

The success of the pilot resulted in the implementation and evaluation of the impact of integrating a clinical pharmacist to a disease management unit. The demonstrated positive outcomes have resulted in the ongoing provision of the clinical pharmacy review service with expansion to other clinics.
Biological Drugs and the Coming of Biosimilars
Authors: Power David A , Ford David
Published: April 2015

Protein‐based therapies or ‘biological drugs' were developed using gene manipulation techniques and have been very successful in providing significant benefits in many clinical areas. They have also generated substantial profits for their innovators. Many of these drugs are now coming off patent and other manufacturers have expressed an interest in marketing similar proteins, competing on price in a manner similar to generic chemical drugs. In the case of biological drugs, however, there are significant problems in producing a drug with identical properties to the existing therapy. This problem has been acknowledged by the European Medicines Agency and they have developed a strategy to bring these ‘biosimilar' drugs to market. The entry of these biosimilars into the market is likely to produce problems, as the substitution of one biosimilar product for another is unlikely to be acceptable as they are not identical. The profusion of biosimilars for the more profitable biological drugs, such as erythropoietin, is also likely to provoke confusion in drug identification, as the World Health Organization seems unlikely to distinguish biosimilars produced by different manufacturers with distinct International Nonproprietary Names. These issues require identification by pharmacists, especially those in hospital practice, as they will be required to track and dispense these imminent different biosimilars.
Renal Effects of High‐Dose Tobramycin and Vancomycin Impregnated Bone Cement
Authors: Campbell David G , Nyfort‐Hansen Karin
Published: April 2015

Background

Bone cement impregnated with high doses of aminoglycosides is used to treat infection associated with joint arthroplasty.

Aim

To examine serum tobramycin and creatinine concentrations in patients who received high‐dose tobramycin and vancomycin impregnated bone cement during revision joint arthroplasty.

Method

This was a prospective cohort case series of 10 patients aged 58 to 82 years undergoing revision joint arthroplasty with high‐dose tobramycin and vancomycin impregnated bone cement. Serum tobramycin and creatinine concentrations were monitored post surgery.

Results

Sterile tobramycin 3.6 g and vancomycin 1.0 g powder was mixed into each 40 g of Palacos bone cement, resulting in total maximum doses of tobramycin 7.2 g and vancomycin 2.0 g. At the time of hospital discharge renal function was unchanged in 9 patients. A 75‐year‐old male patient with preexisting renal impairment developed significant and persistent worsening of his renal function.

Conclusion

Bone cement impregnated with high doses of aminoglycosides should be used with caution in patients with a history of renal impairment.
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 (Pharmacy Services Manager, The Children's Hospital, NSW; e‐mail: pennyt2@chw.edu.au).
Inter‐Regional Collaboration for Errors and Near Misses with Unfractionated Heparin
Authors: Loe Elizabeth A , Parsotam Nirasha , Blumgart Anne F , Jansen Lenore J
Published: April 2015

Background

Unfractionated heparin is a high‐risk medication, as serious adverse events may result from errors of use. Different practices and protocols for unfractionated heparin are used at the three district health boards in Auckland. Concern about the inadequacies of heparin use prompted a collaborative evaluation of adherence to unfractionated heparin protocols and to aid the formulation of solutions for process improvement.

Aim

To evaluate the three district health boards' compliance with unfractionated heparin protocols, and to identify issues with prescribing and administration and the occurrence of adverse events.

Method

A retrospective audit of all patients started on unfractionated heparin at the three district health boards was undertaken from March to June 2005. An audit tool was developed to evaluate compliance with 6 criteria of prescribing and administration common to each hospital protocol and data were collected on indication and occurrence of adverse events.

Results

61 patients were audited. 51% had a baseline activated partial thromboplastin time (aPTT) measured, 39% had an aPTT measured at 6 hours, 80% received a heparin loading dose (90% as per protocol), 85% received maintenance infusion dose and rate as per protocol and 35% had failed to reach target aPTT at 72 hours. None of the 6 criteria achieved 100% compliance.

Conclusion

Compliance with the specified protocols was low. Systems changes have been identified that can improve the safety and effectiveness of unfractionated heparin use.
Stability of Venlafaxine Hydrochloride Liquid Formulations Suitable for Administration via Enteral Feeding Tubes
Authors: Rosa Nicholas F De , Sharley Nicholas A
Published: April 2015

Background

Venlafaxine hydrochloride tablets have been discontinued and the extended‐release capsules are the only formulation available in Australia. The extended‐release capsule releases venlafaxine from pellets within the capsule. These pellets cannot be flushed through a syringe or enteral feeding tube as they adhere to the plastic.

Aim

To develop a liquid formulation of venlafaxine hydrochloride suitable for enteral feeding and to determine an evidence‐based shelf‐life for the formulation.

Method

High performance liquid chromatography was used for the analytical procedure. Venlafaxine hydrochloride was subjected to forced degradation at elevated temperatures under acidic, basic and oxidative conditions. Degradation products and formulation excipients were analysed with high performance liquid chromatography to verify the presence of any interfering peaks. Two venlafaxine liquid formulations were prepared in triplicate using Efexor‐XR capsules. Each sample, a blank, and a quality control sample were analysed in duplicate on each study day. Four calibration standards were used and sample venlafaxine hydrochloride concentrations were calculated from the linear regression equation derived from the calibration set.

Results

The chromatogram exhibited appropriate separation of the respective peaks for venlafaxine, degradation product, and formulation excipients, and can be considered stability indicating. All samples retained above 94% of the original venlafaxine content throughout the 30‐day study period.

Conclusion

Venlafaxine hydrochloride liquid formulations can be prepared from Efexor‐XR capsules that is stable for 30 days when stored at room temperature.
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 (Pharmacy Services Manager, The Children's Hospital, NSW; ).
Assessing Flucloxacillin Contamination and Decontamination—A Laboratory Study
Authors: Lee Su‐Gil , Jankewicz Ganyk J , Lee Nae‐Woo
Published: April 2015

Background

Flucloxacillin is a widely used antibiotic but data are lacking on the risks associated with occupational exposure.

Aim

To evaluate flucloxacillin stability; to identify an effective decontamination reagent for flucloxacillin; and to identify glove material that will prevent flucloxacillin permeation.

Method

Decontamination reagents used for flucloxacillin wipe sampling and degradation/stability tests included: isopropanol 50% and 70%, ethanol 60% and 100%, benzalkonium chloride 0.1% (Pine O Cleen), sodium hypochlorite 0.5% (Chloroclens), sodium hydroxide 0.03M and distilled water. Short‐term (0 to 90 minutes) and daily degradation (0 to 6 days) of flucloxacillin in these media and flucloxacillin recovery from surface wipe sampling was investigated using high pressure liquid chromatography with ultraviolet detection. Flucloxacillin permeation was tested using disposable, powder‐free latex and nitrile gloves in a disposable test cell to which solution was applied on one side of the glove material and wiped from the other side after 3 hours.

Results

This analytical method for assessing flucloxacillin contamination has a limit of detection of 0.1 μg/mL. Distilled water was the most suitable solvent as degradation of flucloxacillin was minimal. Sodium hypochlorite 0.5%, followed by sodium hydroxide 0.03M and benzalkonium chloride 0.1%, were the most effective decontamination reagents. No permeation of flucloxacillin was detected through the latex or nitrile gloves after a 3 hour period.

Conclusion

A method for assessing occupational exposure to flucloxacillin is described in this paper. Sodium hypochlorite 0.5% was the most effective decontamination reagent for flucloxacillin. Both the latex and nitrile gloves prevented flucloxacillin permeation for up to 3 hours.
Assessment of Risk Associated with Medication‐Related Problems in Elderly Outpatients
Authors: Elliott Rohan A , Woodward Michael C
Published: April 2015

Background

The Society of Hospital Pharmacists of Australia's (SHPA) Standards of Practice for Clinical Pharmacy provide a risk‐classification system for interventions made by pharmacists in hospital inpatients. These standards are based on Australian standards for risk management, where risk is based on an estimate of the likelihood and consequences of an adverse outcome from a medication‐related problem, if no intervention was made.

Aim

To adapt and validate the SHPA risk‐classification system for use in geriatric ambulatory care and to explore differences in classifications of risk made by pharmacists and geriatricians.

Method

The SHPA risk‐classification system was modified, piloted and reviewed by experts to assess face validity. 113 medication‐related problems identified by an outpatient clinical pharmacist in aged care were independently classified by a senior clinical pharmacist, a geriatrician and the outpatient clinical pharmacist. When there was disagreement, the case was discussed and consensus reached. A random sample of 30 medication‐related problems, stratified by consensus risk classification was classified by a second geriatrician.

Results

Face validity of the adapted risk‐classification system was established. Agreement between pharmacists on medication‐related problem risk was moderate and agreement between pharmacists and geriatricians was fair. Risk of adverse outcomes was rated lower by geriatricians than pharmacists. Consensus was easily reached through case discussion.

Conclusion

A system for classifying risk associated with pharmacist‐identified medication‐related problems in geriatric ambulatory care was developed. Differences were identified between pharmacists and geriatricians in the way medication‐related risks are perceived. Classification of pharmacist‐identified medication‐related problems/interventions may need to be based on consensus between at least one doctor and pharmacist.
Impact of Nurse Education on the Incidence of Omitted Medication Doses in Hospital Inpatients
Authors: O'Shea Timothy J , Spalding Ann R , Carter Fiona A
Published: April 2015

Background

A significant number of medication doses are omitted in hospitals because of the inability of nurses to source the medication and their lack of awareness of the significance of omitting medication doses.

Aim

To investigate the impact of nurse education on the incidence of omitted medication doses in hospital inpatients.

Method

A prospective study at a 174‐bed hospital comparing the incidence of omitted medication doses before and after the introduction of a nurse education program (education sessions, ward posters, questionnaires). Omitted medication doses were categorised as ‘drug not available’, ‘chart not signed’, ‘withheld’, ‘refused by patient’ or ‘nil orally’.

Results

Audits of over 40 000 medication administration records were undertaken – 20 154 medication doses were reviewed for 99 patients pre‐intervention and 24 337 medication doses were reviewed post‐intervention. 4.2% of medication doses were not administered as prescribed pre‐intervention compared to 2.9% post‐intervention (p < 0.001).

Conclusion

The interventions highlighting the importance of not omitting doses and the availability of information on how to obtain medications were effective in reducing the number of omission errors.
Rapidly Progressive Severe Amiodarone‐Induced Hypothyroidism in an Elderly Female
Authors: Ghiculescu Razvan A , Martin Jennifer
Published: April 2015

Background

Amiodarone‐induced hyperthyroidism has been extensively reported in the Australian and international literature. However, amiodarone‐induced hypothyroidism, although much less common, is also seen in clinical practice.

Aim

To describe a case of rapidly progressive severe amiodarone‐induced hypothyroidism complicated by myxoedema, cognitive decline and peripheral neuropathy in an elderly female.

Clinical Details

An elderly female presented with a 3 to 6 month history of fatigue, cold intolerance and constipation. Her medical history was significant for type 2 diabetes, ischaemic heart disease and moderate mitral regurgitation complicated by severe left atrial dilatation and chronic atrial fibrillation.

Outcomes

Her amiodarone was stopped and thyroxine commenced at 25 microgram daily. One week after admission her energy levels had improved to the point where she could safely manage at home. 6 months after amiodarone cessation she was euthyroid on thyroxine replacement and remained in rate controlled atrial fibrillation.

Conclusion

Prescribers are reminded of the risk of serious thyroid morbidity associated with amiodarone use. Current recommendations include evaluation of risk against benefit with prolonged amiodarone therapy and periodic screening for early toxicity.
Pharmacological Treatment of Frailty in the Elderly
Authors: Campbell Stephen , Szoeke Cassandra
Published: April 2015

The geriatric frailty syndrome can be characterised by a loss of physiological reserve in a variety of organ systems and an independent association with disability and mortality. The high cost of this condition in terms of decreased quality of life and an increased need for medical and personal care makes it an important focus for the development of effective pharmacological treatments. Several of these treatments have been trialled and have focused on the decreased levels of catabolic hormones seen in advancing age. Despite some improvement in muscle and tissue bulk, most of these treatments have failed to improve physical function in the elderly. In this review we examine the evidence for the pharmacological treatment of frailty in the elderly and provide recommendations for its management.
Pharmaceutical Reforms: Clinical Pharmacy Ward Service versus a Medical Team Model
Authors: Poh Eng Whui , Nigro Olimpia , Avent Minyon L , Doecke Christopher J
Published: April 2015

Background

The Australian Pharmaceutical Advisory Council's (APAC) Guiding principles to achieve continuity in medication management were developed to advocate the continuum of pharmaceutical care for hospital inpatients. As part of the Australian Health Care Agreements, pharmaceutical reforms that include implementation of the APAC guidelines are underway. Clinical pharmacy services at the Royal Adelaide Hospital do not fully comply with the APAC guidelines.

Aim

To assess whether key APAC guiding principles are achievable on a medical ward with one full‐time equivalent clinical pharmacist.

Method

Two clinical ward pharmacy models were investigated. A clinical pharmacy ward service was compared to a medical team model. Patients admitted to a general medical ward were included in the two phases of the study. In Phase A (4 weeks), the clinical pharmacist serviced a 30‐bed medical ward and in Phase B (4 weeks) the same clinical pharmacist serviced the same 30‐bed medical ward and also provided an extended hours service in the emergency department. During both phases all patients received a medication history interview, ongoing clinical review and discharge medication counselling.

Results

246 patients were admitted to the general medical ward during the study period – 138 in Phase A and 108 in Phase B. 109 (79%) patients were reviewed in Phase A and 83 (77%) patients in Phase B. As a result of the medication history interviews, incorrectly charted medications were amended in 48 (7%) interventions in Phase A and 20 (6%) interventions in Phase B. 207 interventions (Phase A: 129; Phase B: 78) were documented during clinical reviews. Discharge medication counselling was provided to 30 (60%) patients in Phase A and 27 (49%) patients in Phase B.

Conclusion

The key APAC guiding principles were partly achievable using the two models investigated. For either model, an increase in staffing resources would be necessary to comply with the APAC guidelines.
Paclitaxel Exposure and its Effective Decontamination
Authors: Lee Su‐Gil , Ambados Fotios , TkaczukPhD Michael , Jankewicz Ganyk
Published: April 2015

Background

Apart from generic guidelines for the safe handling of cytotoxic drugs in pharmacy departments, there is no specific published literature pertaining to cleaning procedures and inadvertent exposure to paclitaxel.

Aim

To examine occupational exposure to paclitaxel; to identify an effective decontamination reagent; and to determine suitable glove type for skin protection.

Method

8 decontamination reagents were tested for paclitaxel degradation. Air sampling filters, Ghost Wipes and cotton wipes were tested under different storage conditions (room temperature, ≤ 4 °C) for 3 days. Disposable latex and nitrile gloves were tested for paclitaxel permeation using a one‐inch ASTM standard test cell. Environmental (airborne and surface) monitoring was carried out in the cytotoxic compounding and work areas. High performance liquid chromatography and photo‐ionisation detector were used for sample analysis and glove permeation tests, respectively.

Results

Isopropanol 50% and ethanol 60% demonstrated the least degradation (< 2%) of paclitaxel in 80 minutes. Sodium hypochlorite 0.5% w/v showed the greatest degradation (> 99%) of paclitaxel in 20 minutes. Sample wipes should be stored at ≤ 4 °C until analysis. Paclitaxel and sodium hypochlorite 0.5% w/v did not permeate through the latex and nitrile gloves after 4 hours of continuous exposure. No paclitaxel was detected in airborne and surface wipe samples.

Conclusion

No detectable paclitaxel was measured within the cytotoxic compounding area. Sodium hypochlorite 0.5% w/v is a suitable decontamination reagent for paclitaxel surface contamination. Wearing either latex or nitrile gloves can prevent contamination when handling paclitaxel.
Pre‐Admission and Post‐Hospital Management of Heart Failure in Patients not Enrolled in Specialist Programs
Authors: Borgstedt Johanna , Clark Robyn A , Morran Jennifer L , Colley Desmond , Shakib Sepehr
Published: April 2015

Aim

To review the management of heart failure in patients not enrolled in specialist multidisciplinary programs.

Method

A prospective clinical audit of patients admitted to hospital with either a current or past diagnosis of heart failure and not enrolled in a specialist heart failure program or under the direct care of the cardiology unit.

Results

81 eligible patients were enrolled (1 August to 1 October 2008). The median age was 81 ± 9.4 years and 48% were male. Most patients (63%) were in New York Heart Association Class II or Class III heart failure. On discharge, 59% of patients were prescribed angiotensin converting enzyme inhibitors and 43% were prescribed beta‐blockers. During hospitalisation, 8.6% of patients with a past diagnosis of heart failure were started on an angiotensin converting enzyme inhibitor and 4.9% on a beta‐blocker. There was evidence of suboptimal dosage on admission and discharge for angiotensin converting enzyme inhibitors (19% and 7.4%) and beta‐blockers (29% and 17%). The results compared well with international reports regarding the under‐treatment of heart failure.

Conclusion

The demonstrated practice gap provides excellent opportunities for the involvement of pharmacists to improve the continuation of care for heart failure patients discharged from hospital in the areas of medication management review, dose titration and monitoring.
Professional Transgressions by Australian Pharmacists
Authors: Penm Jonathan , Chaar Betty B
Published: April 2015

Background

Investigating professional transgressions by pharmacists will aid to minimise their occurrence and ensure that the public's trust and well‐being are not compromised

Aim

To compare the definition of professional transgression in all Australian pharmacy acts; to identify the characteristics of pharmacists most likely to transgress; to identify the most prevalent transgressions; and to identify the justification provided by pharmacists for committing transgression.

Method

Definitions of professional transgression, commonly referred to as ‘professional misconduct’, were identified from all Australian pharmacy acts and then compared. Disciplinary hearings brought before the pharmacy regulatory bodies were collected and the demographic data of the pharmacists involved, transgressions committed and the justifications provided for committing them were identified and analysed.

Results

Professional transgression was defined differently in each state using a combination of terms, such as a lack of skill, experience, knowledge, care and judgement. Cases from 1990 to 2002 were analysed with 195 cases adjudged guilty. Of those cases that provided adequate detail, the majority of pharmacists found guilty were male (89%), worked in community pharmacy (97%) and were proprietors (64%). The most common misconduct was inappropriate supply of medications. Reasons cited for professional misconduct included human error, lack of knowledge, management skills, personal issues and intentional transgression.

Conclusion

Australian pharmacy acts require a unified definition of professional transgression to ensure pharmacists are treated equally. Adopting a systems approach may prevent unintentional transgressions from occurring in the future.
Myalgia in Patients on High‐Dose and Low‐to‐Moderate Dose Statin Therapy
Authors: Gujral Gina R , Cottrell W Neil , Barras Michael
Published: April 2015

Background

Statin use has been associated with muscle toxicity and clinically significant muscle symptoms.

Aim

To investigate if high‐dose statin users have a greater incidence of myalgia than low‐to‐moderate dose statin users.

Method

A questionnaire‐based interview of participants at a hospital and community pharmacy in Brisbane. Data were gathered on the history of statin use, presence of myalgia, analgesic use and self‐reported adherence. Participants were excluded if they had a chronic degenerative musculoskeletal condition, such as rheumatoid arthritis or osteoarthritis.

Results

192 participants were included in the study – 65 (34%) in the low‐to‐moderate dose group and 127 (66%) in the high‐dose group. Excluding participants with a pre‐existing painful condition (n = 72), myalgia was reported by 24 (37%) patients in the low‐to‐moderate dose group and 42 (33%) in the high‐dose group (p = 0.22). 8 (12%) patients in the low‐to‐moderate dose group used analgesics compared to 24 (19%) in the high‐dose group (p = 0.34). Adherence in both groups was the same when assessed using the Morisky scale.

Conclusion

There was no significant difference in myalgia between the high and low‐to‐moderate dose statin groups. The incidence of myalgia in statin users was higher than reported in previous studies.
Unplanned Medication‐Related Hospital Readmission following Transfer to a Residential Care Facility
Authors: Elliott Rohan A , Taylor Simone , Harvey Penelope A , Tran Tim , Belfrage Mary K
Published: April 2015

Background

Anecdotal evidence suggests that current medication arrangements following discharge from hospital to residential care facilities sometimes lead to medication delays and errors, which may result in adverse outcomes.

Aim

To describe a case where delays in initiating a revised antiepileptic medication regimen may have contributed to adverse clinical outcomes for a patient requiring unplanned hospital readmission.

Clinical details

A 41‐year‐old man was admitted to hospital from a residential care facility with seizures and hyponatraemia. Multiple changes were made to the patient's antiepileptic medication regimen and he was discharged on Day 11 (a Sunday). Following discussion with the residential care facility and their designated community pharmacy, it was agreed that the community pharmacy would dispense his medications and pack them into a dose administration aid, and the residential care facility would organise for a new medication chart to be written by a general practitioner. The hospital doctor prepared a discharge summary and a copy of the discharge prescription was faxed to the community pharmacy. The patient was discharged from hospital with no medications. 3 days later he was readmitted to hospital with seizures, falls and a subdural haemorrhage. On review, the revised antiepileptic regimen had not been implemented at the residential care facility. The patient spent a further 11 days in hospital before returning to the residential care facility.

Conclusion

Transferring patients from hospital to residential care poses challenges to continuity of care. Improved discharge planning processes to ensure continuity of medication administration on discharge to a residential care facility are urgently needed.
Tissue Distribution of Beta‐Lactam Antibiotics: Continuous versus Bolus Dosing
Authors: Roberts Jason A , Lipman Jeffrey
Published: April 2015

Background

In vitro studies suggest that administering beta‐lactam antibiotics by continuous infusion may maximise efficacy. Several pharmacokinetic studies have compared the distribution of beta‐lactam antibiotics administered by continuous and bolus dosing in plasma and tissues. Knowledge of pharmacokinetic exposure to tissues is essential, as tissue sites are most commonly the ‘target site’ for antibiotic therapy.

Aim

To identify published studies that measure the serum and tissue concentrations of beta‐lactam antibiotics administered by continuous and bolus dosing. Data sources: A number of studies in animals, healthy volunteers and hospitalised patients were identified.

Results

More prospective clinical trials are required to validate that the continuous infusion of beta‐lactam antibiotics attain better tissue distribution at the target site.

Conclusion

Beta‐lactam antibiotics administered by continuous infusion maintain higher concentrations in serum and tissue. There is also compelling evidence that tissue distribution of antibiotics is impaired with increased sickness severity, therefore, larger doses of beta‐lactam antibiotics may be required in severely sick patients to optimise antibiotic exposure at the target site.
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 (Principal Advisor, Medication Safety, NSW Health; ).
Abnormal Renal Function and Electrolyte Disturbances in Older People
Authors: Hsieh Michael , Power David A
Published: April 2015

The decline in renal and cardiac function with advancing age predisposes older people to abnormalities in renal function and electrolyte disturbances. The widespread availability of the estimated glomerular filtration rate has highlighted the high incidence of chronic kidney disease in the elderly, which is supported by data demonstrating that the elderly are the largest cohort undergoing kidney dialysis in the general population. Older people are also susceptible to electrolyte disturbances, especially if they have concomitant diseases, such as heart failure, and are receiving diuretics and blockers of the renin‐angiotensin system. Management of these patients requires skill, as well as realistic objectives. In this article we discuss some of the issues pertaining to renal and electrolyte abnormalities experienced by older people.
DrugScan Series
Authors: Eaton Vaughn
Published: April 2015

DrugScan is a review of the international literature on therapeutics. Leading pharmacy practitioners scan the literature and present information on major clinical trials, important pharmacoepidemiology studies, and pharmacoeconomic research in a succinct format. Interested readers are encouraged to explore the original publications in greater detail.
Clopidogrel Prescribing and Concordance with the Pharmaceutical Benefits Scheme in Hospital Patients
Authors: Luinstra Marianne , Naunton Mark , Peterson Gregory M , Bereznicki Luke R
Published: April 2015

Background

Clopidogrel is used for the secondary prevention of cerebrovascular and cardiovascular events. Clopidogrel has a similar safety profile to low‐dose aspirin but is considerably more expensive. Clopidogrel is subsidised for restricted indications via the Pharmaceutical Benefits Scheme (PBS).

Aim

To examine clopidogrel prescribing in hospital; and to identify patients discharged on clopidogrel according to PBS criteria.

Method

Cross‐sectional evaluation of patients started on clopidogrel (July 2006 to June 2007) at the Royal Darwin and Royal Hobart Hospitals. Clopidogrel prescribing was examined and the indication for discharge on clopidogrel was documented. The primary outcome was concordance between clopidogrel use and PBS criteria.

Results

Data were collected for 385 patients. 54% of patients from the Royal Darwin Hospital and 39% of patients from the Royal Hobart Hospital discharged on clopidogrel met PBS criteria. The main reason for noncompliance with the PBS was absence of a history of cardiovascular or cerebrovascular events while on low‐dose aspirin and an absence of contraindications to aspirin at the time of clopidogrel prescribing.

Conclusion

Although clopidogrel prescribing at the hospitals was often not in accordance with PBS criteria, in most cases prescribing was based on the available evidence.
Individualised Foreign Language Medication Lists for Non‐English Speaking Hospital Patients
Authors: Larizza Maria A , Wilson Rita , Dooley Michael J
Published: April 2015

Background

Language barriers can significantly impact on medication adherence and health outcomes.

Aim

To assess the impact on medication adherence of individualised foreign language medication lists for non‐English speaking hospital patients.

Method

Patients using foreign language medication lists at The Alfred hospital were invited to participate in the study (June to September 2007). A quantitative questionnaire incorporating modified validated assessment tools was used to collect data on patient demographics, motivations and perceptions. Data were also collected on the impact of the foreign language medication list and the patient's cultural environment on medication adherence. These factors were assessed for association with self‐reported medication adherence and estimated using the Morisky score.

Results

Two‐thirds (n = 43) of respondents reported moderate to high medication adherent behaviour. Factors with a positive influence on medication adherence were female gender (Wilcoxon rank sum test = 2.7; p = 0.007), patients' understanding of their medications (Spearman's rho = +0.36; p = 0.02) and services provided by the hospital (p = 0.04). Factors with a negative influence on medication adherence were patients' dissatisfaction with medication counselling undertaken by pharmacists using a foreign language medication list without a translator (Spearman's rho = −0.35; p = 0.02).

Conclusion

The availability of translators working alongside pharmacists using foreign language medication lists could improve medication adherence.
Implementation and Acceptance of a Pharmacist‐Initiated E‐Script Transcription Service for Discharge Prescriptions
Authors: deClifford Jan‐Marie , Lam Skip S , Leung Benjamin K
Published: April 2015

Aim

To describe the implementation of pharmacist‐initiated e‐script transcription service (PETS) in a teaching hospital; to validate the service through process indicators; and to explore the views of stakeholders.

Method

Following an initial trial, PETS was implemented in 7 medical and surgical units at Frankston Hospital. Data were collected on activities and discharge prescription errors. Stakeholders' satisfaction was measured using a Likert scale based survey and group interviews. Transcripts of group interviews were analysed by informal word‐based techniques, noting words or synonyms used repeatedly to discover themes.

Results

During the implementation phase (8 to 29 February 2008), a daily average of 15 prescriptions (112 items) were prepared by the PETS pharmacist, i.e 30 to 60% of weekday discharge prescriptions. The discharge prescription error/amendment rate was 0.06 per patient. 163 respondents (92%) were satisfied or very satisfied with PETS. As a result of 3 group interviews of 10 doctors, 10 nurses and 10 pharmacists, several areas for enhancement were identified and implemented.

Conclusion

PETS has transitioned from trial to mainstream service, facilitating the discharge process and improving continuity of care.
Effect of Nebulised Acetylcysteine on Sputum Quality and Diagnostic Yield
Authors: Taylor David McD , Taylor Simone , Ho Jiong , Cabalag Miguel , Hijazi Ramzi , Howden Benjamin P , Charles Patrick GP
Published: April 2015

Background

Acetylcysteine acts as a mucolytic by cleaving disulfide bonds in mucoprotein and decreasing sputum viscosity. Mucolysis should lead to easier expectoration and improved sputum sample quality for microbiological analysis.

Aim

To compare an effect size for the efficacy of nebulised acetylcysteine and sodium chloride 0.9% in the procurement of good quality sputum samples.

Method

A double‐blind, randomised, placebo‐controlled pilot study in the emergency department. Adults with probable lower respiratory tract infection requiring sputum sampling were enrolled. Patients were randomised to receive acetylcysteine 1 g or sodium chloride 0.9% (placebo) via nebuliser. Patients, emergency department and microbiology staff were blinded to the treatment allocation. The study endpoints were good quality sputum samples (< 10 squamous cells per high‐powered field and < 10 squamous cells plus > 25 polymorphs per high‐powered field), sputum samples where a predominant pathogen was isolated and adverse effects of acetylcysteine and sodium chloride 0.9%.

Results

28 patients were randomised to the acetylcysteine (n = 14) and sodium chloride 0.9% (n = 14) groups. Four (29%) patients in each group produced good quality sputum samples based on squamous cells alone. 2 (14%) and 3 (21%) patients in the acetylcysteine and sodium chloride 0.9% groups, respectively, produced good quality samples based on squamous cells and polymorph counts. Predominant pathogens were isolated in 2 (14%) patients in each group. 2 (14%) and 5 (36%) patients in the acetylcysteine and sodium chloride 0.9% groups, respectively, reported bronchospasm and/or coughing.

Conclusion

There was no detectable trend towards acetylcysteine improving sputum sample quality. A large scale trial is not warranted.
Insulin e‐Learning Module an Effective Means of Education Delivery to Hospital Health Professionals?
Authors: Ho Lisa , To The‐Phung , MacIsaac Richard
Published: April 2015

Background

Insulin is a high‐risk medication that is available in a range of products with potential for harm if administration errors occur. Anecdotally, insulin product knowledge among hospital health professionals is poor.

Aim

To develop and evaluate an insulin e‐learning module to improve the knowledge of hospital health professionals of insulin products and their appropriate use.

Method

An Internet‐based module was developed using Microsoft ASP.NET. Participants (doctors, nurses, pharmacists) undertook an initial knowledge test (pre‐test) on insulin products. After viewing an educational slide show, participants then undertook another evaluation (post‐test). Both tests contained 12 identical multiple choice questions. To pass the module successfully participants were required to score full marks on the post‐test. On completion, participants were asked to complete a brief survey on the usefulness of the module. The module was evaluated by comparing test scores and reviewing the responses to the survey. Knowledge retention was assessed by inviting participants who had passed to repeat the test after 3 months.

Results

324 participants undertook the pre‐test (7.4% doctors, 79% nurses, 7.1% pharmacists). 13 (4%) participants scored full marks on the pre‐test and did not proceed to the slide show. 200 (85%) of the 235 participants who viewed the slide show and undertook the post‐test, scored full marks. At 3 months, only 44 of the 213 participants who scored full marks in the pre‐test and post‐test agreed to the re‐test with 10 (23%) participants achieving full marks.

Conclusion

The e‐learning module was effective in delivering information on insulin products to hospital health professionals. Incorporating this e‐learning module into a mandatory formal education session with a revision strategy might improve participation and knowledge retention rates.
Cytochrome P450 Part 3: Impact of Drug‐Drug Interactions
Authors: Ward Michael B , Sorich Michael J , Evans Allan M , McKinnon Ross A
Published: April 2015

The role of individual hepatic cytochrome P450 (CYP) enzymes in drug metabolism and the factors that modulate CYP activity are becoming increasingly well understood. These advances have resulted in a better understanding of drug‐drug and drug‐ food interactions and an enhanced capacity to predict drug interactions that may occur with new drugs. This final article in the series describes the issues and principles that are important in identifying and assessing drug interactions that involve CYP enzymes.
Stability of Intravenous Flucloxacillin Solutions used for Hospital‐in‐the‐Home
Authors: To The‐Phung , Ching Michael S , Ellis Andrew G , Williams Louise , Garrett M Kent
Published: April 2015

Background

Despite the uncertainty regarding flucloxacillin's stability, flucloxacillin solutions are routinely used as 24‐hour ambulatory infusions for hospital‐in‐the‐home patients.

Aim

To determine the stability of flucloxacillin solutions in a simulated hospital‐in‐the‐home environment and to assess whether flucloxacillin loss can be minimised via pH control.

Method

Samples of flucloxacillin 5% and 12% solutions were prepared with either sodium chloride 0.9% or water for injection and with or without 5 mL phosphate buffer (0.384 M; pH 7). Flucloxacillin 5% solutions were tested in elastomeric infusion devices and the 12% solutions in polyvinyl chloride bags. All of the solutions were refrigerated for 6 days and then half of them were incubated at 37 °C for 24 hours. The remainder of the refrigerated solutions acted as controls. Incubated solutions were sampled for pH and high performance liquid chromatography analysis on Day 0, and Day 6 at 0, 12, 18 and 24 hours. Controls were sampled on Days 0, 6 and 14. Acceptable shelf life was ± 7.5% of initial flucloxacillin content.

Results

Refrigerated buffered controls remained stable for 14 days while the unbuffered controls were stable for 6 days. All of the buffered solutions were stable at 37 °C after 24 hours, except for flucloxacillin 12% in water for injection. Incubated unbuffered flucloxacillin 5% in water for injection lost approximately 27% flucloxacillin and all of the other incubated unbuffered solutions lost up to 60%. Incubated unbuffered solutions displayed significant yellowing and cloudiness. The pH of all solutions fell by approximately 1 unit, except for refrigerated buffered controls (fell by 0.5 units).

Conclusion

Unbuffered flucloxacillin 5% and 12% solutions lost up to 60% of flucloxacillin content when stored at 37 °C for 24 hours. Adjusting pH with phosphate buffer kept the incubated solutions stable for at least 24 hours (except flucloxacillin 12% in water for injection).
Electronic Medication Management Systems' Influence on Hospital Pharmacists' Work Patterns
Authors: Lo Connie , Burke Rosemary , Westbrook Johanna I
Published: April 2015

Background

Implementation of electronic medication management systems (eMMS) are advocated to reduce medication errors, improve patient safety and impact on hospital pharmacists' work patterns.

Aims

To quantify hospital pharmacists' distribution of their time and to identify differences in work patterns on wards with and without eMMS.

Method

An observational time and motion study was conducted at a major Sydney teaching hospital. 8 pharmacists (3 on wards with eMMS, 5 on wards without eMMS) were observed on their wards for 37 hours. Distribution of tasks across work categories, mean task times, tasks performed with others and tasks using information tools, were calculated and compared between wards with and without eMMS.

Results

Medication chart review was the most frequently performed task on both ward types. Pharmacists on eMMS wards had lower rates of interruptions (1/19.2 min vs 1/13.7 min) and multi‐tasking (2.4% vs 8.7%) than non‐eMMS wards. On eMMS wards, review activities were more frequent and faster, fewer ‘in‐transit’ tasks occurred and more work was completed alone compared to non‐eMMS wards. Patient care tasks took longer but occurred less often on eMMS wards. Pharmacists on eMMS wards spent more time clarifying medication orders but did it less often than pharmacists on non‐eMMS wards.

Conclusion

Pharmacists' work patterns in terms of task frequency, duration and location was different on the two ward types. Differences may be attributable to eMMS allowing easy and speedy access to information for reviews; shift away from the bedside to a computer terminal reducing tasks in‐transit, interruptions and contact with patients and others; and improved clarity of medication orders reducing queries.