7 research outputs found
Rational and safe dosing of phenprocoumon during loading and maintenance phase
No full textPhenprocoumon is the second most commonly used oral anticoagulant worldwide
and the most common agent in many European countries including Switzerland.
Given its long half-life of about one week, an initial loading-dose is generally applied.
A high loading-dose is helpful to rapidly reach a therapeutic concentration but may be
associated with an increased risk of bleeding if the effect overshoots.
Phenprocoumon has a narrow therapeutic range, and individual dose requirements
are highly variable. In clinical practice the initial dose-finding process for
phenprocoumon is largely empiric and often delegated to inexperienced staff
members. Thus, both a prolonged loading phase and overshooting of anticoagulation
is commonly observed.
Question under study
The general aim of the thesis was to define one or more algorithms for the loading
phase of phenprocoumon-treatment. These algorithms should be easily applicable in
a clinical setting and help to improve the drug safety of phenprocoumon especially
during the initial dose-finding process.
Retrospective study
In a retrospective study, predictors of individual dosing needs for a target-INR of 2.0
to 3.0 in medical and orthopaedic inpatients were determined. Several significant
predictors of the loading dose could be identified. Using these predictors two simple
clinical algorithms for the initial dosing of phenprocoumon in medical and orthopedic
inpatients were developed. One algorithm contains clinical data and, additionally,
serum albumin; the second algorithm contains clinical data only.
Prospective study
The aim of the prospective, randomized interventional study was to validate the efficacy and
safety of the two previously proposed dosing algorithms for the initiation of oral
anticoagulation with phenprocoumon. Additionally, the predictive value of
pharmacogenetic markers was to be studied.
Both algorithms could be validated and were slightly optimized. They proved to be
very safe and effective in hospitalized patients with a high rate of comorbidity. The
algorithm using clinical data can be especially recommended due to its simplicity of
use
Prescribing errors in children
No full textPrescribing errors are a well-known safety concern in pediatric patients. The aim of this thesis was to
investigate factors related to patients, drugs, and the mode of prescription, that influenced the rate of
prescribing errors in a population of 1000 pediatric patients hospitalized on general medical and surgical
wards at the University Children's Hospital Zurich. The data were collected during two periods in 2018
and 2019. In total 5022 prescriptions were analyzed.
The prevalence of prescribing errors under different circumstances of prescribing (2299 pre-CPOE
prescriptions with semi-structured order forms or handwritten prescriptions versus 2723 post-CPOE
prescriptions as electronic prescriptions with limited clinical decision support (CDS)), was investigated
in different age groups and different types of drugs. Additionally, the types of errors that occurred and
the severity of harm potentially caused by these errors were revealed. Furthermore, associations of
errors withs specific drug types or patients were investigated, with a particular emphasis on unlicensed
drugs.
In the first study Prescribing errors in children – what is the influence of a computerized physician order
entry (CPOE)? the influence of the prescribing mode was investigated. The prescriptions of 500 patients
before (2018) and after (2019) introduction of a CPOE were analyzed and prescribing errors assessed.
It was found that the post-CPOE prescriptions overall contained significantly fewer prescribing errors
(25 errors / 100 prescriptions) than pre-CPOE prescriptions (78 errors / 100 prescriptions) (p < 0.001).
Errors that actually could have led to patient harm with a severity rated as “temporary harm possible” to
“death” (further referred to as potentially harmful errors: PHE), were also reduced from 18 errors / 100
prescriptions pre-CPOE to 11 errors / 100 prescriptions post-CPOE (p < 0.001). The errors that occurred
most frequently in the pre-CPOE period were errors due to missing information. These errors were of
minor severity and were strongly decreased post-CPOE, where dosing errors were the most frequent
type of error. A statistically significant increase in medication reconciliation errors was observed after
CPOE introduction due to remaining hybrid prescriptions in certain cases. Overall, the CPOE had a
positive impact on patient safety.
In Prescribing patterns in pediatric general wards and their association with prescribing errors, the
second study, a sub-analysis of the first study was conducted in which prescribing patterns in the post-
CPOE population were revealed. Newborns were excluded from the study due to small sample size,
leading to a remaining population of 489 patients with 2693 prescriptions. Drugs for the nervous system,
drugs for the alimentary system and anti-infective drugs were the most frequently prescribed drug
classes, with paracetamol, metamizole and ibuprofen being the most frequently prescribed active
substances. Patient characteristics like age and gender as well as drug use were associated with
prescribing errors. Children between 2 and 11 years experienced higher error rates than infants under
2 years of age: 12.2 potentially harmful errors (PHE) / 100 prescriptions, vs. 8.5 PHE / 100 prescriptions
(p = 0.026). A statistically significant difference was also found for female patients as compared to male
patients, with the female patients having higher rates of PHE than the male (25.6 errors or 12.1 PHE /
100 prescriptions vs. 24.7 errors or 9.3 PHE / 100 prescriptions) (p = 0.035 for PHE), even though there
was no difference in the overall error rates. This finding needs further investigation.
The third study, Use of unlicensed drugs in a Swiss Pediatric University Hospital and associated
prescribing error rates, another sub-analysis of the first study laid a focus on unlicensed drugs in the
population of 1000 patients (pre- and post-CPOE), which accounted for a proportion of 10.8% of all
prescriptions. 34% of patients were prescribed at least one unlicensed drug. Oral liquid forms were the
most frequently prescribed drug form in unlicensed drugs. In the post-CPOE population unlicensed
drugs were more prone to prescribing errors than licensed drugs (32 errors / 100 prescriptions vs.
24 errors / 100 prescriptions, p = 0.024). Particularly extemporaneously prepared drugs had high error
rates of 36.4 errors / 100 prescriptions. Therefore, licensed drugs are favorable in terms of medication
safety.
Overall, this thesis highlights various aspects of prescribing errors in children and illustrates, that
pediatric patients are still at a high risk of experiencing a prescribing error. Ongoing efforts are necessary
to improve medication safety. These include electronic solutions like CPOE and CDS, multifaceted
approaches on healthcare professional and organizational level as well as support from the
pharmaceutical industry by licensing more suitable formulations for pediatric patients
Randomised trial of a clinical dosing algorithm to start anticoagulation with phenprocoumon
No full textProspective validation of two algorithms for the initiation of phenprocoumon treatment
Use of unlicensed drugs in a Swiss Pediatric University Hospital and associated prescribing error rates – a retrospective observational study
No full textAIMS OF THE STUDY: Unlicensed drugs are frequently used in paediatric care. To what extent they are prescribed in hospital care in Switzerland is unclear. Because prescribing errors seem to occur more frequently with unlicensed drugs, we aimed to assess the prevalence of unlicensed drug prescriptions in two study periods (2018 and 2019) at the University Children’s Hospital Zurich, compare these periods and investigate whether unlicensed drugs were more prone to prescribing errors than licensed drugs.
METHODS: We conducted a sub-analysis of a retrospective single-centre observational study and analysed 5,022 prescriptions for a total of 1,000 patients from 2018 and 2019 in paediatric general wards. The rate of unlicensed drugs, consisting of imported or formula drugs, was investigated. The prescriptions from 2019 were further analysed on prescribing errors to see whether errors occurred more often in unlicensed or licensed drug use.
RESULTS: Of all prescriptions, 10.8% were unlicensed drugs, with around half each being imported and formula drugs. Among all patients, 34% were prescribed at least one unlicensed drug. Younger paediatric patients were prescribed more unlicensed drugs than older paediatric patients (newborns: 15.8% of prescriptions, infants: 13.4%, children: 10.6%, adolescents: 7.1%). Ibuprofen suppositories, midazolam oral solution and gentamicin i.v. solution were the most frequently prescribed imported drugs. Macrogol powder, lisinopril oral suspension and potassium chloride i.v. solution were the most frequently prescribed formula drugs. The most common drug forms in unlicensed use were oral liquid forms and i.v. solutions. Unlicensed drugs had a significantly higher rate of prescribing errors than licensed drugs (31.6 errors per 100 prescriptions [95% CI: 26.1–37.0] versus 24.3 errors per 100 prescriptions [95% CI: 22.3–26.2], p = 0.024). In particular, formula drugs carried a higher risk (36.4 errors per 100 prescriptions, p = 0.012).
CONCLUSIONS: Unlicensed drugs are frequently prescribed in this paediatric hospital setting in Switzerland. Around every tenth prescription is an unlicensed drug. Because unlicensed drugs showed a significantly higher rate of prescribing errors, licensed drugs are favourable in terms of medication safety and should be prescribed whenever possible. If no licensed drug is available, imported drugs should be favoured over formula drugs due to lower prescribing error rates. To increase medication safety in paediatrics in Switzerland, efforts are necessary to increase the number of suitable licensed drug formulations for paediatric patients, including developing new innovative drug formulations for children
Prescribing Patterns in Pediatric General Wards and Their Association with Prescribing Errors: A Retrospective Observational Study
No full textAbstract Purpose There are only limited data on drug utilization patterns in pediatric inpatients, especially on general wards. The aim of the study was to describe prescribing patterns and their associations with prescribing errors in a university children’s hospital in the German-speaking part of Switzerland. Method This was a subanalysis of a retrospective single-center observational study. Patient characteristics and drug use of 489 patients with 2693 drug prescriptions were associated with prescribing errors. Drugs were categorized by the Anatomic Therapeutic Chemical Classification System (ATC), patients were categorized by age group according to European Medicines Agency guidelines, and prescribing errors were analyzed by type [Pharmaceutical Care Network Europe (PCNE) classification] and severity of error [adapted National Coordinating Council for Medication Error Reporting (NCC MERP) index]. Results The most frequently prescribed ATC classes were nervous system (N) (42.6%), alimentary system (A) (15.6%), and anti-infective drugs (J) (10.7%). Eighty-two percent of patients were prescribed an analgesic. Most drugs were prescribed for oral (47%) or intravenous (32%) administration, but the rectal route was also frequent (10%). The most frequently prescribed drugs were paracetamol, metamizole, and ibuprofen. The high number of metamizole prescriptions (37% of patients were prescribed metamizole) is typical for German-speaking countries. Older pediatric patients were prescribed more drugs than younger patients. A statistically significant difference was found in the rate of potentially harmful errors across age groups and for gender; children between 2 and 11 years had a higher rate of potentially harmful errors than infants under 2 years (p = 0.029) and female patients had a higher rate of potentially harmful errors than male patients (p = 0.023). Recurring errors were encountered with certain drugs (nalbuphine, cefazolin). Conclusions Our study provides insight into prescribing patterns on pediatric general wards in a university children’s hospital in Switzerland and highlights some areas for future research. Especially, the higher risk for prescribing errors among female pediatric patients needs further investigation
Prescribing errors in children: what is the impact of a computerized physician order entry?
No full textPrescribing errors represent a safety risk for hospitalized patients, especially in pediatrics. Computerized physician order entry (CPOE) might reduce prescribing errors, although its effect has not yet been thoroughly studied on pediatric general wards. This study investigated the impact of a CPOE on prescribing errors in children on general wards at the University Children’s Hospital Zurich. We performed medication reviews on a total of 1000 patients before and after the implementation of a CPOE. The CPOE included limited clinical decision support (CDS) such as drug-drug interaction check and checks for duplicates. Prescribing errors, their type according to the PCNE classification, their severity (adapted NCC MERP index), as well as the interrater reliability (Cohen’s kappa), were analyzed. Potentially harmful errors were significantly reduced from 18 errors/100 prescriptions (95% CI: 17–20) to 11 errors/100 prescriptions (95% CI: 9–12) after CPOE implementation. A large number of errors with low potential for harm (e.g., “missing information”) was reduced after the introduction of the CPOE, and consequently, the overall severity of potential harm increased post-CPOE. Despite general error rate reduction, medication reconciliation problems (PCNE error 8), such as drugs prescribed on paper as well as electronically, significantly increased after the introduction of the CPOE. The most common pediatric prescribing errors, the dosing errors (PCNE errors 3), were not altered on a statistically significant level after the introduction of the CPOE. Interrater reliability showed moderate agreement (Κ = 0.48). Conclusion: Patient safety increased by reducing the rate of prescribing errors after CPOE implementation. The reason for the observed increase in medication reconciliation problems might be the hybrid system with remaining paper prescriptions for special medication. The lacking effect on dosing errors could be explained by the fact that a web application CDS covering dosing recommendations (PEDeDose) was already in use before the implementation of the CPOE. Further investigations should focus on eliminating hybrid systems, interventions to increase the usability of the CPOE, and full integration of CDS tools such as automated dose checks into the CPOE
