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Resume Objectifs Les conditionnements des medicaments utilises pour la supplementation electrolytique expriment la concentration en electrolyte element avec differentes unites. Ces differences constituent un facteur de risque d’erreur medicamenteuse. Cet article propose un outil d’aide a la prescription qui definit des equivalences de doses entre les specialites orales et injectables du phosphore, du calcium et du magnesium. Methode Les quantites en electrolyte element ont ete relevees a partir des informations contenues sur le conditionnement et les resumes des caracteristiques du produit. Seules les specialites du livret therapeutique de notre etablissement ont ete etudiees. Pour chaque element, le rendement de repletion a ete determine a partir des donnees de la litterature. Resultats Trois tableaux d’equivalence entre les formulations orales et injectables du phosphore, du calcium et du magnesium sont presentes. Un outil d’aide a la prescription est cree a partir de ces donnees. Conclusion L’utilisation de cet outil est un premier moyen d’attenuer les risques d’erreurs medicamenteuses. Il reste a determiner les conditions de sa diffusion et de son evaluation. Cette problematique souleve les questions de l’emploi de la seule unite millimole sur les conditionnements et pour la prescription, et celle de l’integration de ce type d’outil dans les logiciels de prescription et les systemes d’aide a la decision.

Proton pump inhibitors (PPI) are the most effective drugs in the treatment of acid-related gastrointestinal disorders. Yet, many studies reported potential adverse drug reactions associated with long-term use. In order to reduce the rates of inappropriate PPI prescriptions and to improve patient safety, a tool aimed at guiding pharmacists to analyze PPI prescriptions was designed. It results in a thesaurus of clinical situations designed to argue about the inappropriateness of some PPI prescriptions and to highlight the risk associated with them.Clinical situations in which PPIs are inappropriate were identified by four pharmacists in one gastroenterological, one surgery/liver transplantation, one internal medicine and one oncology units. A scientific literature search was performed for each clinical situation in order to corroborate the pharmacist interventions.The thesaurus comprises two parts, the first one is dedicated to 12 clinical situations in which a PPI is not required (acute pancreatitis, cholecystectomy etc.), while the second one focus on 22 situations in which PPIs are associated with specific adverse drug reactions (Clostridium difficile infection, vitamin deficiency etc.). Eighty-one articles were used to support the pharmacist interventions.This thesaurus is an analysis tool aimed at guiding pharmacists identify and argue about the inappropriateness of some PPI prescriptions in order to convince doctors to discontinue or not to initiate PPI prescriptions.

Background/Objective. Overprescribing proton-pump inhibitors (PPIs) has become the norm worldwide and represents a global health issue with tangible clinical and economic consequences. At national level, we do not know how pharmacists are contributing to this issue. Thus, the study focused on analyzing drug-related problems (DRPs) pertaining to PPI prescriptions, detected during the medication order review process in French hospitals, and associated pharmacist interventions (PIs). Methods. The study was based on a retrospective analysis of pharmacist interventions for DRPs detected during the medication order review and documented into the French Act-IP© database over a 12-year period. DRPs and PIs were analyzed, and independent factors of physician acceptance were assessed via multiple logistic regression. Results. Out of the 620,620 PIs registered, 29,694 targeted a PPI (4.8%). PPI’s DRPs were mostly related to the prescription of a “drug not available at the hospital” (26.1%) and a “drug use without indication” (18.3%); PIs were mostly “drug switch” (35.9%) and “drug discontinuation” (26.1%). In all, 18,919 PIs were accepted by physicians (63.7%). Acceptance was significantly associated with patient age: less accepted for the 18–75 years group (OR = 0.59, 95 CI [0.46–0.76]), and the >75 years group (OR = 0.57, 95 CI [0.44–0.73]) vs.

Report on the practices of prescribing continuous infusion of heparin sodium by syringe pump in our hospital and shed qualitative light on the protocols used in other French hospitals.We interviewed prescribers about the protocol they were using through the computerized provider order entry system. At the same time, we asked hospital pharmacists, particularly through a social network, whether in their hospital one or more protocols were used and which ones.In all, 81 prescribers responded to our request: 22 indicated prescribing the 25,000IU/50mL protocol, 7 the 20,000IU/48mL protocol, 2 the 25,000IU/48mL protocol and 14 indicated that they had no preference for one of them. Ten responded that they did not prescribe any protocols and 26 left the question unanswered. The responses of 42 pharmacists practicing in other establishments allowed us to identify 16 different protocols. Of these 42 establishments, 10 had at least two protocols.Several protocols for the administration by continuous infusion of heparin sodium with a syringe pump can coexist within a hospital. This diversity is confusing and puts patients and caregivers at risk of medication errors. Among all these protocols, it is not known whether some are riskier than others and research to clarify this unknown is warranted. Defining a national standard concentration of heparin and bringing to the market ready-to-administer solutions are measures to be promoted in order to reduce the risk of errors.

Highlights L’épidémie de SARS-CoV-2 a contraint les établissements hospitaliers à augmenter le nombre d’unités de soins critiques Les pharmacies hospitalières ont dû répondre dans des délais très courts aux besoins en médicaments et dispositifs médicaux. La présence de préparateurs affectés dans les unités de soins critiques à la gestion des produits pharmaceutiques en étroite collaboration avec les médecins et le personnel infirmier depuis plusieurs années a été un facteur déterminant dans la conduite des opérations. Le calcul quotidien des quantités notamment de curares consommées par patient a constitué un élément clé pour ajuster les commandes et les livraisons et préparer les changements de spécialités imposés par les ruptures d’approvisionnement. Cet épisode de crise légitime la question de l’extension de l’ouverture de la pharmacie d’un centre hospitalo-universitaire en équipe complète 365 jours par an., Le circuit du médicament hospitalier le plus sûr est la dispensation journalière individuelle nominative automatisée assurée par la pharmacie. Depuis plusieurs années nous essayons de convaincre les décideurs hospitaliers de l’implanter dans notre établissement. En attendant, pour pallier les risques d’erreurs médicamenteuses encourus par les patients et les soignants, nous avons constitué plusieurs équipes de travail au sein des unités de soins. Ces équipes sont constituées d’un pharmacien et d’un ou deux préparateurs en pharmacie hospitalière qui assurent notamment la gestion des armoires à pharmacie des unités de soins. La collaboration étroite avec médecins et personnel infirmier développée au fil des années a été un élément favorable déterminant lorsqu’il a fallu doter en médicaments et en dispositifs médicaux stériles (DMS) les nouvelles unités de soins critiques face à l’afflux de patients contaminés par le SARS-CoV2. Le suivi quotidien des médicaments consommés par patient, particulièrement les curares, et des DMS en rupture d’approvisionnement a été un élément clé de la gestion des stocks et des changements de principes actifs, de conditionnements et/ou de références de matériel. Les faits relatés donnent du poids au rapport Claris qui souligne les effets positifs en termes de qualité et de sécurité de prise en charge des patients du travail des PPH et pharmaciens dans les unités de soins. Ils soulignent par ailleurs les dangers auxquels sont exposés patients et soignants samedi, dimanche et jours fériés quand la pharmacie est fermée. Ils légitiment la question de l’extension de l’ouverture de la pharmacie en équipe complète 365 jours par an.

Information available on the packaging of drugs indicated for patients electrolytes replenishment differs from one manufacturer to another. They relate, for example, the unit chosen to express elemental electrolyte concentration. These differences constitute a risk factor for medication errors. This article proposes a clinical decision support tool which defines dose equivalences between the oral and injectable formulation galenic forms for medications providing phosphorus, calcium and magnesium and a calculated replenishment ratio.The amounts of elemental electrolyte were determined from the information contained on the packaging and the summaries of product characteristics. Only the specialties of our hospital drug formulary were studied. For each element, the replenishment ratio was determined from published data.Equivalence tables were created for the phosphorus, calcium and magnesium between oral and injectable formulation. A clinical decision support tool was developed from these data.The use of this tool is a first way to reduce the risk of medication errors. It remains to determine the conditions for its dissemination and evaluation. This issue raises the questions of the exclusive use of the millimole unit on packaging and for prescription, and that of the integration of this type of tool into prescription software and decision support systems.

OBJECTIVES: Clinical pharmacists’ interventions (PIs) are an important element in ensuring good pharmaceutical care. We aimed to develop and validate a comprehensive multidimensional tool for assessing the potential impact of PIs for daily practice of medication review. METHODS: Experts of the French Society of Clinical Pharmacy (SFPC) developed the CLinical, Economic and Organisational (CLEO) tool, consisting of three independent dimensions concerning clinical, economic and organisational impact. They were asked to analyse 30 scenarios of PIs, and re-rated 10 PIs with a washout of 1 month (internal validation). Then, seven external experts not involved in the development of the tool rated 60 scenarios collected when using the CLEO in daily practice. Inter- and intra-rater reliabilities were determined by calculation of the intra-class correlation (ICC(A,1)). Users’ satisfaction and acceptability of the tool were assessed on a 7-level Likert scale with a 17-item questionnaire. RESULTS: For internal reliability, the inter-rater reliability for the CLEO tool was good for clinical dimensions (ICC(A,1)=0.693), excellent for economic dimensions (ICC(A,1)=0.815) and fair for organisational dimensions (ICC(A,1)=0.421); and the intra-rater reliability was good for clinical dimensions (ICC(A,1)=0.822), excellent for economic dimensions (ICC(A,1)=0.918) and good for organisational dimensions (ICC(A,1)=0.738). For external reliability, the inter-rater reliability was good for clinical dimensions (ICC(A,1)=0.649), excellent for economic dimensions (ICC(A,1)=0.814) and fair for organisational dimensions (ICC(A,1)=0.500). CLEO was viewed as relevant (mean±SD 4.93±1.27), acceptable (4.81±1.78), practicable (5.56±1.45) and precise (5.38±1.47). CONCLUSIONS: CLEO is a comprehensive tool assessing clinical, economic and organisational impacts of PIs which has been developed, validated and was reliable and feasible for use in routine clinical practice.

Drug packaging contributes to the harm-benefit balance of a treatment. Poorly designed packaging can lead to drug misuse with serious consequences. We report a potassium double dose medication error concerning an oral solution. It was triggered by a packaging flaw related to the dosage indicated on the box, expressed for both potassium salt and elemental potassium. Standardizing the units used on packaging and for prescriptions, by using millimoles, could be a solution to avoid this type of medication error.

Resume Objectif L’informatisation des etablissements de sante francais fait l’objet d’obligations. L’objectif a ete d’analyser le contenu des echanges, operes au sein de reseaux sociaux, traitant des problemes rencontres avec les systemes d’information au sein des pharmacies hospitalieres. Methodes Les messages echanges via la liste de diffusion de l’Association pour le Digital et l’information en pharmacie ainsi que les resumes de communications presentes lors des congres syndicaux evoquant les systemes d’information ont ete analyses. Resultats De mars 2015 a juin 2016, 122 courriels emis par 80 pharmaciens concernaient les systemes d’information. Entre 2006 et 2016, 45 resumes ont traite de ce sujet. Les problemes rapportes dans ces 167 documents ont ete notamment « parametrage et/ou fonctionnalites » (n = 116), interfaces et complexite du systeme d’information (n = 52), relations avec le fournisseur et reactivite (n = 32), charge de travail (n = 32), ergonomie (n = 30), formation insuffisante des utilisateurs (n = 22). Ces problemes sont interdependants, entrainent des erreurs et contraignent, pour en attenuer les consequences, les professionnels a detourner une quantite importante d’heures de travail au detriment du soin et de la pharmacotechnie. Conclusion Les pharmaciens des etablissements de sante sont confrontes a de tres nombreux problemes d’insecurite et d’inefficience generes par les systemes d’information. Des recherches sont necessaires pour determiner leur cout, en preciser les effets deleteres sur les soins et identifier les systemes d’information les plus surs.

Potassium is used to treat or prevent hypokalemia and exhibits all the characteristics of an intravenous to oral therapy conversion program. Despite this, the intravenous route for potassium replacement seems frequently unjustified.To determine the impact of a conversion program on the use of intravenous and oral galenic forms in a university tertiary care hospital.Two promotion campaigns were conducted in 2006 and 2009. The following years this was completed by pharmacist interventions during prescription analysis and face-to-face discussions with physicians during ward rounds. The consumption of products containing potassium was obtained by analyzing the hospital's financial database.The proportion of the oral route increased from 18% in 2006 to 22% in 2011, and from 25% in 2012 to 44% in 2016; the increase was significantly greater in the second period (P0.0001). In 2016, in emergency, pulmonology, infectious diseases, and cardiology departments, the proportion of oral use ranged from 57% and 82%. The greatest progression from 2006 to 2016 was found for intensive care (4% vs. 12%) and visceral surgery departments (9% vs. 34%) that increased approximately four-fold, followed by the emergency department (28% vs. 57%) that increased approximately two-fold.Promoting the oral route for potassium replacement modifies prescriber habits and is followed by a notable increase in the proportion of potassium administered orally irrespective of department type.

Assessing the significance of pharmacist interventions (PIs) is essential to demonstrate the added value of pharmacists. Methods and tools for assessing the potential significance of PIs are diverse and their properties are questionable. We aimed to systematically review the tools available to assess the potential significance of PIs. We conducted a systematic search for English- or French-language publications from 1986 to 2013 in PubMed, PsycINFO, PASCAL, and CINAHL. Studies were screened by two independent reviewers based on inclusion/exclusion criteria and were abstracted for content, structure of tools, and validation process. Of 873 citations screened, 82 distinct tools were identified from 133 studies. While clinical aspects were often defined quite clearly, terminology regarding humanistic, economic, and process-related aspects of PIs was omitted, incomplete, or ambiguous in most tools. The probabilities of consequences of PIs/drug-related problems were evaluated in 20/82 tools. Few tools simultaneously measured economic, clinical, humanistic, and process-related variables. Structure of the tools varied from an implicit, mono-dimensional tool to an explicit, multi-dimensional algorithm. Validation processes were diverse in terms of quantification and number of raters, rating method, and psychometric parameters. Of 133 identified studies, there was limited evidence of validity (8/133, 6.0 %), inter-rater reliability (49/133, 36.8 %), and intra-rater reliability (2/133, 1.5 %). The majority of tools focused primarily on assessing clinical aspects and failed to detect comprehensive impacts. The heterogeneity of tools and assessment processes hindered our ability to synthesize the results of evaluations. Limited results for their validity and reliability cast doubt on the credibility of this methodology for justification of the value of PIs. Recommendations for development of tools with optimal theoretical, pragmatic, and psychometric properties are proposed.

SummaryWhat is known and objective The French Society of Clinical Pharmacy (SFPC) asked a group of experts to adapt the SFPC hospital pharmacists' interventions reporting tool for use in community pharmacy practice. This study aimed to develop and validate a tool for the routine reporting of pharmacists' interventions in French community settings. Methods Two groups of community pharmacists coded reports of 60 typical pharmacists' interventions. One group was “experts” (n = 4) who had participated in the development of the tool (internal validation) and the other were “external” community pharmacists (n = 6), naive to the tool (external validation). The Kappa coefficient was used to assess the inter-reliability of classification between participants. A 4-level Likert scale was used to evaluate ease of use and acceptability. Results and discussion The tool we developed for recording and classifying PIs has 19 items; 11 non-ordered categories describing drug-related problems; and 7 items describing interventions. Two tables of definitions were provided to help community pharmacists in the classification. The mean κ statistic was (i) 0.63 for experts and 0.73 for external community pharmacists in categorizing drug-related problems and (ii) 0.69 for experts and 0.75 for external community pharmacists in categorizing interventions. What is new and conclusion A specific tool for the documentation of pharmacists' interventions in community pharmacies is now available in French. Besides being useful to describe pharmacists' interventions in studies in community settings, it can be used to document the pharmaceutical patient record and to support the traceability process.

The development of information systems in French hospitals is mandatory. The aim of this work was to analyze the content of exchanges carried out within social networks, dealing with problems encountered with hospital pharmacies information systems.Messages exchanged via the mailing list of the Association pour le Digital et l'Information en Pharmacie and abstracts of communications presented at hospital pharmacists trade union congresses were analyzed. Those referring to information systems used in hospital pharmacies were selected.From March 2015 to June 2016, 122 e-mails sent by 80 pharmacists concerned information systems. From 2002 to 2016, 45 abstracts dealt with this topic. Problems most often addressed in these 167 documents were "parameterization and/or functionalities" (n=116), interfaces and complexity of the hospital information systems (n=52), relationship with health information technologies vendors and poor reactivity (n=32), additional workload (n=32), ergonomics (n=30), insufficient user training (n=22). These problems are interdependent, lead to errors and in order to mitigate their consequences, they compel pharmacy professionals to divert a significant amount of working hours to the detriment of pharmaceutical care and dispensing and preparing drugs.Hospital pharmacists are faced with many problems of insecurity and inefficiency generated by information systems. Researches are warranted to determine their cost, specify their deleterious effects on care and identify the safest information systems.

Over the past 25 years in various countries, researchers have developed tools for recording pharmacist's interventions (PIs) and observational databases aimed at the exhaustive collection of these interventions. The large amount of published data contrasts strikingly with the fact that little attention has been paid to defining the different types of PIs from a theoretical point of view. Whatever the paper we read on this topic, each PI is presented as necessary and appropriate. We suggest this customary approach is biased and that the reality is somewhat more subtle. In order to better reflect the real world, we propose a new approach to the classification of PIs that is based on whether they are present or absent in observational databases, and we explain how to identify the absent ones. Present and absent PIs can be subdivided in two additional categories: appropriate and inappropriate ones. This additional classification should encourage pharmacists to critically examine and evaluate their practice and subsequently improve their ability to identify drug related problems in clinical practice.

Resume La SFPC et son groupe « standardisation et valorisation des activites de pharmacie clinique » etudient les interventions pharmaceutiques (IP) emises lors de l’analyse des prescriptions. Cette etude explore les problemes medicamenteux et les IP relatifs aux medicaments psychotropes enregistres sur le site Act-IP ® entre septembre 2006 et fevrier 2009. Quatre mille six cent vingt IP emises dans 57 etablissements de sante concernent un medicament psychotrope. Sept problemes medicamenteux engendrent plus de 69 % des interventions (par ordre de frequence) : posologie supra-therapeutique, interaction medicamenteuse, plan de prise non optimale, effet indesirable, non conformite au livret therapeutique, redondance pharmacologique, mauvais choix de galenique. Les 2 types d’interventions les plus frequents sont l’adaptation de posologie et les arrets de traitement. Certaines problematiques ne sont pas identifiees ou ne trouvent pas un echo suffisamment favorable car le taux d’acceptation globale par les medecins est de 57 %. Ce retour d’information peut permettre aux medecins d’identifier des situations a risque. Pour evoluer, medecins et pharmaciens doivent se concerter et dialoguer. Ceci pourrait deboucher sur un thesaurus decrivant situations cliniques et IP base sur les recommandations et la vision pratique des prescripteurs.

Summary Objectives Over the past 10 years, the French Society of Clinical Pharmacy, through the working group “standardization and promotion of clinical pharmacy activities”, has made available a tool for documentation of pharmacy interventions performed during prescription analysis in hospitals. The aim of this article is to inventory the actions that followed, to highlight how hospital pharmacists appropriated this tool, and to discuss perspectives. Methods A bibliographic search was performed from PUBMED and French pharmaceutical journals. Results Published data shows that indeed hospital pharmacist practitioners seized on this tool. The most recent articles highlight changing practices: prescription analysis is included in a package incorporating medication reconciliation process, therapeutic monitoring in collaboration with other healthcare professionals, increased detection of adverse drug effects, outpatient counseling and communication between community pharmacists and hospital pharmacists. Discussion and conclusion To generalize these activities, given the era of resources decrease in the health care system, pharmacists should list the tasks entrusted to them that are not pharmaceutical in nature and reflect on how to get them relieved. The analysis of the content of the ACT-IP© database offers prospects for evaluation of professional practices but also to assess skills developed by students and residents during pharmacy practice experiences and internship. The adoption of these new practices by new future postgraduates requires effective coordination between undergraduate teaching programs and first year's practical application trainings. In order to improve efficiency, French pharmacists should also inventory information tools at their disposal and analyze their strengths and weaknesses.

Resume Objectifs En 2003, la Societe francaise de pharmacie clinique a mis a disposition des pharmaciens un outil de codification des interventions pharmaceutiques. L’objet de cet article est de dresser un bilan des actions menees par les pharmaciens hospitaliers sur les 10 annees qui ont suivi et de discuter des perspectives. Methodes Une veille documentaire portant sur les revues francaises completee par une consultation de PUBMED a permis d’identifier les travaux realises. Resultats Les publications montrent que les pharmaciens se sont empares de cet outil. Les plus recentes mettent en lumiere une evolution des pratiques : l’analyse des prescriptions se trouve integree dans un ensemble incorporant la conciliation medicamenteuse, le suivi therapeutique en collaboration avec les autres professionnels de sante, une detection accrue des effets indesirables medicamenteux, le conseil au patient sortant et la collaboration ville hopital. Discussion/conclusion Pour generaliser ces activites, compte tenu de la crise que traverse le systeme de sante, les pharmaciens devraient lister des missions qui leur sont confiees qui ne sont pas pharmaceutiques par essence et reflechir sur la maniere de s’en delester. L’analyse du contenu de la base ACT-IP offre des perspectives en matiere d’evaluation des pratiques professionnelles mais aussi de mesure des competences developpees au cours des stages professionnalisant. La generalisation de ces nouvelles pratiques suppose une reelle coordination entre enseignements theoriques et applications pratiques au cours de la formation initiale. Pour garantir leur efficience, les pharmaciens francais devraient proceder a l’inventaire des outils documentaires a leur disposition et a une analyse de leurs forces et leurs faiblesses.

Resume Objectif L’association des alpha-bloquants avec les inhibiteurs puissants du cytochrome (CYP) 3A4 est contre-indiquee ou deconseillee. Nous avons recherche les donnees qui justifient ce classement afin de definir une conduite a tenir. Methodes Nous avons analyse les documents produits par l’Agence nationale de securite du medicament (ANSM), consulte des ouvrages de references et interroge des bases bibliographiques. Resultats Les avis rendus par l’ANSM ont evolue au cours du temps. La recherche bibliographique n’a identifie aucun cas ou series de cas rapportant des consequences cliniques graves resultant d’une interaction de ce type et aucune etude epidemiologique sur l’association entre les alpha-bloquants et les inhibiteurs du CYP3A4. Le contenu des resumes caracteristiques produits des specialites commercialisees a l’etranger indique que l’association du ketoconazole avec alfuzosine, silodosine et tamsulosine entraine une augmentation de l’aire sous la courbe (ASC) de l’alpha-bloquant d’un facteur 3. Conclusion Les donnees attestant des consequences cliniques d’une association entre un alpha-bloquant et un inhibiteur puissant du CYP3A4 sont quasiment inexistantes. L’augmentation d’un facteur voisin de 3 de l’ASC aussi bien pour l’alfuzosine et la tamsulosine associee au ketoconazole alors que l’association avec la premiere est contre-indiquee et avec la seconde est deconseillee souleve question. Cette absence de donnees laisse medecins et pharmaciens en situation d’incertitude quant a la definition d’une conduite a tenir.

Resume Objectifs On ne dispose pas de publications faisant etat de la politique d’inscription au livret therapeutique du Mediator® dans les etablissements de sante francais et la maniere avec laquelle les pharmaciens sont intervenus sur cette specialite n’a jamais ete etudiee. Le contenu de la base ACT-IP de la Societe francaise de pharmacie clinique permet de connaitre la nature des interventions pharmaceutiques (IP) realisees en milieu hospitalier. Le but de cet article est de rapporter le nombre et la nature des IP concernant le Mediator® enregistrees dans cette base avant son retrait du marche. Methodes De 2007 a 2010, 337 pharmaciens exercant dans 87 hopitaux ont saisi au moins 10 interventions pharmaceutiques (IP), soit un total de 77 219 sur le site ACT-IP. Les IP relatives au Mediator® ont ete analysees. Resultats Quatorze pharmaciens (4 %) travaillant dans cinq hopitaux (6 %) ont enregistre un total de 45 IP avec 36 d’entre elles (80 %) realisees dans un seul centre. Pour 42 d’entre elles, le pharmacien a propose l’arret. A 23 reprises (55 %), le prescripteur a accepte. Discussion Considerant que le Mediator® a ete prescrit a plus de 300 000 patients en France chaque annee, l’analyse du contenu de la base ACT-IP de la SFPC met en evidence que les pharmaciens hospitaliers ont enregistre tres peu d’interventions sur cette specialite. Conclusion Ce constat souleve la question plus generale des interventions des pharmaciens hospitaliers vers les medicaments presentant un rapport benefice-risque defavorable et de leur enregistrement dans la base ACT-IP. D’autres etudes sont necessaires pour repondre a cette question.

Summary Introduction Little is known about the manner in which hospital pharmacists intervene for overdosed paracetamol prescriptions. The aim of this retrospective study was to describe the number and nature of pharmacists’ interventions (PIs) for overdosed paracetamol adult prescriptions in hospitals. Methods We studied PIs that had been documented by pharmacists on the French Society of Clinical Pharmacy website tool between 2007 and 2010. We identified PIs that were related to paracetamol-containing prescriptions of one brand name only (type 1) particularly for patients with body weight ≤ 50 kg who were prescribed 4 g/day, and PIs that concerned the co-prescription of two paracetamol-containing products (type 2). Results Among 60 hospitals, seven did not report any paracetamol overdose-related PIs. Of the 53 hospitals that had at least one PI, 16 did not report any type 1 PIs. Bodyweight, liver disease, cirrhosis and chronic alcoholism were absent recorded criterions by most of the hospitals included in this study. Discussion Previously published studies have highlighted that the most frequent PIs are type 1, especially for patients whose body weight is ≤ 50 kg. We observed a broad variability in the number or type of PI that were related to overdosed paracetamol prescriptions compared with the total of all recorded types of PI. These data suggest that a significant number of hospital pharmacists are unaware of the risks that adult patients with low body weight are exposed to when receiving four grams paracetamol/day over several days. Conclusion Pharmacist educational programs are needed.

Resume Introduction L’analyse d’ordonnance requiert l’emploi de sources documentaires fiables, regulierement mises a jour, elaborees a partir de procedures redactionnelles definies, et dont l’ergonomie rend rapide l’acces a l’information. L’objectif du travail etait de recenser les documents francophones accessibles tout ou en partie gratuitement aux pharmaciens via Internet, d’en discuter l’interet et les limites. Materiel et methode Entre juillet 2011 et juillet 2012, les documents utilisables au cours de l’analyse d’ordonnance ont ete recenses. Leurs sources Internet, leurs procedures redactionnelles, leurs conditions d’actualisation ont ete recherchees et leur facilite d’acces a ete analysee. Resultats Pres de 300 documents ont ete identifies. Seules 20 sources ont defini leurs procedures redactionnelles dont des organismes publics et prives ayant une activite commerciale. Pour les autres, en majorite, ces procedures ne sont pas definies et les conditions de mises a jour sont absentes. Pour un meme sujet, des discordances existent d’un document a l’autre. La rapidite d’acces est variable. Dans des domaines comme l’adaptation de posologie en cas d’insuffisance hepatique ou d’obesite, il n’existe pas de base de donnees. Discussion Ce constat souligne la preoccupation des professionnels a combler un vide du aux insuffisances des bases d’information existantes. Neanmoins, il invite a nous interroger sur le rapport cout-efficacite du temps consacre par ces professionnels a l’elaboration de documents de qualite inegale. Conclusion Une demarche collective coordonnee des pharmaciens dans le cadre de procedures redactionnelles validees devrait aboutir a la creation d’une base documentaire francophone couvrant l’ensemble des champs documentaires necessaires a l’analyse d’ordonnances.

Resume Les stages en milieu professionnels ont pour objectif d’amener les stagiaires a devenir des professionnels capables d’exercer de maniere autonome apres avoir acquis habiletes et competence. En France, il n’existe pas d’etudes sur les stages en milieu professionnel des etudiants en pharmacie. L’objectif de ce travail a ete d’interroger les etudiants sur les activites realisees et leur ressenti vis-a-vis des stages programmes tout au long des six annees d’etudes. Concernant le stage officinal d’initiation, 73 % des 8491 etudiants ayant complete le questionnaire ont juge sa duree trop longue par rapport a l’etat de leurs connaissances du moment et les objectifs ne sont pas toujours atteints. De meme, concernant les stages d’application des enseignements coordonnes, 62 % des etudiants (sur les 4011 reponses recues) indiquent ne pas avoir delivre d’ordonnances en rapport avec le theme du stage et 57 % d’entre eux se sont vus confier le rangement des commandes. Quant aux stages hospitaliers, 68 % des 1067 reponses indiquent que les etudiants n’etaient pas indispensables au bon fonctionnement de leur lieu de stage et 41 % n’ont pas fourni un travail en rapport avec leur niveau de connaissances. Les 853 reponses relatives au stage de sixieme annee officine indiquent que 88 % des etudiants ont ete satisfaits de leur stage mais que 30 % d’entre eux ne se sentaient pas capables de remplacer un pharmacien a la fin dudit stage. Les resultats de ce travail de grande ampleur sont une incitation forte a entreprendre des recherches sur le contenu et la pedagogie des stages professionnalisant.

International audience; Objectifs. Déterminer les outils documentaires utilisés par les pharmaciens hospitaliers pour la gestion des interactions médicamenteuses (IAM) et connaître le ressenti qu'ils éprouvent pour cette problématique dans le cadre de l'analyse des prescriptions médicamenteuses. Matériel et méthode. Un questionnaire a été diffusé aux adhérents de la Société française de pharmacie clinique (SFPC) et aux pharmaciens hospitaliers inscrits sur la liste de diffusion de l'Association pour le développement d'Internet en pharmacie hospitalière. Résultats. Deux cent quatre-vingt-onze pharmaciens ont répondu. La base de données Theriaque et le dictionnaire Vidal apparaissent comme les outils les plus répandus et les plus utilisés en première intention. Plus des trois quarts des participants se sentent a' l'aise ou très à l'aise pour citer les médicaments impliqués et décrire l'effet d'une IAM. Respectivement 76 %, 75 %, 59 %, 72 % et 57 % des répondeurs se sont déclarés peu ou pas à l'aise pour décrire le délai de survenue, son intensité, et en coter la gravité, préciser le niveau de preuves à partir des données de la littérature, et proposer la ou les mesures à mettre en oeuvre. Respectivement 68 %, 56 %, 30 % et 21% des participants pensent qu'ils pourraient être plus à l'aise dans le domaine des IAM au moyen de la formation continue, en procédant à un travail de lecture plus régulier, par l'acquisition d'un logiciel qui analyse automatiquement les IAM ou en acquérant un outil documentaire supplémentaire. Conclusion. La mise en place d'un programme de formation continue sur la gestion des IAM en routine clinique apparaît nécessaire.

Combination of alpha-blockers with potent CYP3A4 inhibitors is either contra-indicated or not recommended. We searched data supporting this classification and guiding prescribers when such an interaction occurs.We analyzed reports published by the French agency for drug safety, reference books and performed search in databases of pharmacokinetics studies and case or case series related with these interactions.The classification of the potential severity of these interactions defined by the French agency for drug safety evolved over time. Our literature search did not identify any cases or case series reporting serious clinical consequences of such interactions and no pharmacoepidemiological studies on the association between alpha-blockers and inhibitors of CYP3A4. The content of the summaries of product characteristics indicate that the combination of ketoconazole with alfuzosin, silodosin and tamsulosin increases the area under the curve of the alpha-blocker 3 fold.Data demonstrating the clinical consequences of an association between alpha-blocker and a potent CYP3A4 inhibitor are lacking. The 3 fold increase of the area under the curve for alfuzosin, silodosin and tamsulosin associated with ketoconazole while the association with the two first is contra-indicated and is not recommended with the third raises questions. This lack of data leaves doctors and pharmacists in a situation of uncertainty on how to proceed when such an interaction occurs.

Resume Introduction Le contenu de l’enseignement dispense au cours des etudes de pharmacie doit permettre l’utilisation pratique des connaissances acquises, dans un souci d’amelioration du soin medicamenteux. L’objectif de ce travail a ete de mettre en lumiere les lacunes que presentent les etudiants de la filiere officine debutant leur stage hospitalier de 5 e annee. Methode Quatorze etudiants en stage de 5 e annee accompli dans un CHU ont ete invites a mettre en lumiere ces lacunes au fur et a mesure de leur immersion dans le soin medicamenteux. Ils l’ont fait sous l’observation attentive des praticiens hospitaliers les encadrant. Ces praticiens se sont appuyes sur des referentiels metiers, des outils documentaires employes en routine clinique et des publications leur ayant servi a asseoir leurs pratiques de soins pharmaceutiques. Resultats Les insuffisances ou lacunes identifiees ont ete : la forme et le contenu de la communication avec d’autres professionnels de sante, la forme de la communication avec les patients, la faible appropriation des outils documentaires indispensables a une pratique clinique pertinente, la meconnaissance de la codification des interventions pharmaceutiques, les risques lies au conditionnement des medicaments et les avancees et dangers lies aux technologies de l’information. Discussion Ces lacunes constituent un handicap retardant le processus qui conduit a passer du stade d’etudiant au stade de professionnel de sante. Il revient aux praticiens hospitaliers la necessite de combler ces lacunes avant immersion totale en situation de soin. Conclusion Ces resultats invitent a reviser partiellement le contenu du programme d’enseignement dispense avant la 5 e annee.

Summary Introduction Paracetamol is the most commonly used analgesic and antipyretic. Reviews of hospital use of paracetamol are scarce. Little is known about the appropriateness of the dose of paracetamol prescribed for hospitalized adults. The aim of this study was to report on the nature and the frequency of the overdosed prescription of paracetamol observed in adult patients over a 4.5-year period in a teaching hospital. Methods Prescription analysis by pharmacists was performed once a week in six medical and three surgical departments and daily in a post-emergency unit. In cases of prescription error, the pharmacist notified the physician through an electronic alert when a computerized prescription order entry system was available or otherwise by face-to-face discussion. For each drug-related problem detected, the pharmacists recorded relevant details in a database. Results From October 2006 to April 2011, 44,404 prescriptions were reviewed and 480 alerts related to the overdosed prescription of paracetamol were made (1% of analyzed prescriptions). The extent of errors of dosage was within the intervals [90–120 mg/kg/d] and greater than 120 mg/kg/d for 87 and 11 patients respectively, who were prescribed a single non-combination paracetamol containing product. Sixty alerts concerned co-prescription of at least two paracetamol containing products with similar frequency for computerized (1.4/1000) or handwritten (1.2/1000) prescriptions. Discussion Prescriptions of paracetamol for hospitalized adults frequently exceed the recommended dosage. Conclusion These results highlight the need for increased awareness of unintentional paracetamol overdose and support the initiation of an educational program aimed at physicians and nurses.

Resume Le developpement de l’informatisation de la prescription a l’hopital est un facteur facilitant l’acces aux prescriptions pour l’ensemble des professionnels de sante, notamment les pharmaciens. Ces derniers vont donc accroitre leur travail d’analyse et de validation des ordonnances informatisees. Les avis accompagnant les interventions pharmaceutiques (IP) issues de ces analyses vont naturellement integrer le dossier patient. Leur nature et leur contenu seront alors la marque du travail de fond du pharmacien clinicien. Si l’impact clinique et economique des IP a fait l’objet de quelques travaux en France, en revanche, a notre connaissance, la formulation et le contenu de l’avis pharmaceutique qui accompagne l’IP n’ont jamais fait l’objet de publication. Le but de cet article est de proposer une structure type destinee a argumenter efficacement l’IP. Cette proposition est completee par une reflexion et des illustrations qui integrent le contexte dans lequel cette intervention est realisee.

Resume Introduction L’informatisation de la prescription se developpe en France. Elle contribue a reduire certaines erreurs medicamenteuses, mais les preuves d’un effet benefique sur les resultats cliniques restent limitees. Elle engendre aussi de nouveaux types d’erreurs. L’objectif de ce travail etait de rechercher les donnees francaises relatives a la nature et a la frequence des opportunites d’erreurs medicamenteuses generees par l’outil informatique et ayant conduit le pharmacien a intervenir aupres des prescripteurs. Materiels et methodes Nous avons effectue une recherche sur PubMed et CAT-INIST completee par une recherche manuelle. Resultats Dix publications, 11 abstracts et trois communications personnelles ont ete etudies. Dans le cadre de l’analyse des prescriptions informatisees, le taux d’interventions pharmaceutiques dues a l’informatique varie de 5,9 a 35 % selon les etudes. Les redondances de prescriptions, les erreurs d’unite, l’emploi du texte libre, les problemes de parametrage ainsi que l’ergonomie deficiente des logiciels sont a l’origine de nombreuses interventions pharmaceutiques. Certaines erreurs generees par l’outil informatique peuvent avoir des consequences potentielles severes. Discussion Les interventions pharmaceutiques dues a l’informatique sont frequentes. On ne sait pas si les variations des pourcentages d’interventions sont dues aux logiciels employes ou aux conditions de realisation des etudes. L’informatisation implique que les pharmaciens acquierent de nouveaux savoirs et de nouvelles competences afin de prevenir les erreurs de prescription generees par l’outil informatique. Conclusion Il est urgent de realiser des travaux destines a identifier les outils les plus surs et a ecarter les plus dangereux.

Background Clinical pharmacists can help prevent medication errors. However, data are scarce on their role in preventing medication prescription errors in the post-operative period, a high-risk period, as at least two prescribers can intervene, the surgeon and the anesthetist. We aimed to describe and quantify clinical pharmacist' intervention (PIs) during validation of drug prescriptions on a computerized physician order entry system in a post-surgical and post-transplantation ward. We illustrate these interventions, focusing on one clearly identified recurrent problem. Methods In a prospective study lasting 4 years, we recorded drug-related problems (DRPs) detected by pharmacists and whether the physician accepted the PI when prescription modification was suggested. Results Among 7005 orders, 1975 DRPs were detected. The frequency of PIs remained constant throughout the study period, with 921 PIs (47%) accepted, 383 (19%) refused and 671 (34%) not assessable. The most frequent DRP concerned improper administration mode (26%), drug interactions (21%) and overdosage (20%). These resulted in a change in the method of administration (25%), dose adjustment (24%) and drug discontinuation (23%) with 307 drugs being concerned by at least one PI. Paracetamol was involved in 26% of overdosage PIs. Erythromycin as prokinetic agent, presented a recurrent risk of potentially severe drug–drug interactions especially with other QT interval-prolonging drugs. Following an educational seminar targeting this problem, the rate of acceptation of PI concerning this DRP increased. Conclusion Pharmacists detected many prescription errors that may have clinical implications and could be the basis for educational measures.

In France, community pharmacy students performed a hospital pharmacy practice experience during the 5th year of the university curriculum. The purpose of a part of the content of the academic teaching program delivered before this practice experience is to prepare the students for their future hospital activities. It should enable them for the practical use of knowledge in order to improve pharmacotherapy, laboratory diagnosis and monitoring of patients' care. The aim of this study was to show if there are gaps in this program.Fourteen students performing their clerkship in a teaching hospital were invited to highlight these gaps when they were gradually immersed in the pharmaceutical care. They did so under the careful observation of hospital pharmacist preceptors. These practitioners referred to professional guidelines, documentary tools used in daily clinical practice and publications supporting their pharmaceutical care practices.Shortcomings and gaps identified were: how to communicate with other healthcare professionals and the content of verbal exchanges, how to conduct a patient-centered consultation, documentation tools required for relevant pharmacist' interventions, codification of pharmacist's interventions, risks related to drug packaging and benefit risk assessment of health information technologies.These gaps represent a handicap by delaying the process that led to move from student to healthcare professional. Hospital pharmacist preceptors have to fill in these gaps before engaging students in pharmaceutical care.These results invite to revise partly the content of the academic teaching program delivered before the 5th year hospital pharmacy practice experience.

Resume Propos L’analyse des prescriptions par un pharmacien a l’hopital est definie reglementairement en France depuis 1991. Pour diverses raisons, elle reste peu developpee et a fait l’objet de peu de travaux. Elle souffre d’un manque de visibilite aupres des autres professionnels de sante et des decideurs hospitaliers. L’objectif de cet article est de presenter les resultats d’un travail portant sur l’analyse d’un grand nombre de prescriptions faites dans un centre hospitalo-universitaire afin d’identifier les problemes medicamenteux les plus frequemment rencontres. Methodes Pendant un an, les problemes lies aux medicaments detectes au cours de l’analyse des prescriptions ont ete enregistres de maniere systematique et prospective. Resultats Les 70 849 prescriptions analysees ont donne lieu a 7073 interventions pharmaceutiques avec notamment : surdosages avec trois principes actifs (zopiclone, zolpidem et paracetamol) ont represente plus de 10 % de l’ensemble des interventions realisees ; optimisation des modalites d’administration avec alertes sur les comprimes a ne pas ecraser et promotion de l’usage de la voie orale (7,5 %) ; non-conformite aux referentiels et contre-indications (12,8 %) ; interactions medicamenteuses (11,6 %) avec une forte proportion d’inhibition de l’absorption digestive d’un medicament par un autre. Les problemes medicamenteux potentiellement lies a l’informatisation de la prescription (5,1 %) sont apparus comme un phenomene emergent. Conclusion Ces resultats doivent servir a l’evolution des politiques de prescription a l’hopital. Ils incitent a etre attentif lors du deploiement de l’informatisation de la prescription. Ils peuvent aussi inviter a revoir le contenu des programmes de formation initiale et continue des professionnels de sante.

Resume L’erythromycine est un antibiotique doue de proprietes prokinetiques. Ces proprietes sont utilisees en pratique clinique pour accelerer la vidange gastrique, notamment chez les patients presentant une gastroparesie. Cependant, parmi les nombreuses etudes realisees dans cette indication, rares sont celles bien conduites methodologiquement et evaluant des criteres cliniques. Leurs resultats sont parfois contradictoires. Le rapport benefice–risque de la prescription doit integrer la gestion des nombreuses interactions medicamenteuses que presente ce principe actif, ainsi que la prevention du risque cardiovasculaire, notamment la torsade de pointe et l’arret cardiaque. L’objet de cette mise au point est de presenter les donnees recemment publiees sur les risques pour eclairer la prescription. La prevention de ces risques necessite une communication efficace entre chirurgiens, anesthesistes et pharmaciens.

Pharmacists play an important role in prescription analysis. They are involved in therapeutic drug monitoring, particularly for drugs with a narrow therapeutic index, prevention and management of drug interactions, and may be called in to identify side effects and adverse events related to drug therapy. For the polymedicated patient, the medical file, the list of prescribed drugs and the history of their administration may be insufficient to adequately assign the responsibility of a given adverse effect to one or more drugs. Graphical representations can sometimes be useful to describe and clarify a sequence of events. In addition, as part of their academic course, students have many occasions to hear about "side effects" and "drug interactions". However, in the academic setting, there are few opportunities to observe the evolution and the consequences of these events. In the course of their hospital training, these students are required to perform patient follow-up for pharmacotherapeutic or educational purposes and to comment case reports to physicians. The aim of this paper is to present a tool facilitating the graphic display of drug interaction consequences and side effects. This tool can be a useful aid for causality assessment. It structures the students' training course and helps them better understand the commentaries pharmacists provide for physicians. Further development of this tool should contribute to the prevention of adverse drug events.

Errors linked to injectable potassium chloride (KCl) have been the cause of deaths which have occurred for many years. Following an accidental direct intravenous injection of KCl of no clinical consequence for the patient, we have analyzed the contributive factors, established an action plan to prevent this risk and finally assessed its impact. Among the causes leading to medication errors, we have identified those linked to the handling of the drugs by nurses, the team, the work conditions, the organization, the institutional context and finally to the drug itself. The risk reduction procedure involved a withdrawal of injectable KCI ampoules from wards, possible in 52% of the care units, a reorganization of storage for the others. The subsequent monitoring of floorstocks revealed that these measures were insufficient and that the risks prevailed due to the presence of KCI ampoules in drawers assigned to other ionic solutions. A study carried out among the medical and nursing personnel revealed that 61.2% of the doctors thought that the risk existed in their ward and 68% of the nurses considered themselves to be exposed to the risk of a medication error. The drug supply chain of our institution, as in numerous others, is not safe. Hospitals are not yet organized adequately to prevent the occurrence of such an error. The comparison with foreign organizations of drug dispensation allows us to think that the improvement and professionalization of the drug supply chain will both be assets in the prevention of such medication errors.

Resume Contexte La prescription de plus en plus frequente de chimiotherapie anticancereuse par voie orale, la recente observation d’erreurs medicamenteuses et la complexite des protocoles de traitement nous ont conduits a nous interroger sur les risques associes avec ces medicaments. Objectif Il s’agit de presenter cet article est de presenter les donnees de la litterature relatives a ces risques et de discuter des perspectives pour le pharmacien. Methode Une recherche bibliographique a ete realisee en interrogeant la base de donnees Medline, completee par l’analyse des references des articles selectionnes. Resultats Au 4 mai 2008, 51 articles ont ete analyses. Des travaux recents ont montre l’heterogeneite des pratiques concernant le circuit de ces specialites et les risques d’erreurs medicamenteuses qui en decoulent. Ces therapeutiques sont a l’origine de nombreuses interactions medicamenteuses (IAM). L’observance est un parametre nouveau a integrer, puisque le patient devient acteur de l’administration de sa chimiotherapie. Discussion–conclusion Des mesures calquees sur celles mises en place pour les chimiotherapies injectables sont a definir. La creation d’une base referencant les IAM, une etude des comportements des patients face a ces traitements et enfin l’evaluation de la perception par les medecins des risques associes a ces medicaments devraient permettre de securiser le circuit de ces chimiotherapies.

Resume La consultation pharmaceutique proposee aux patients transplantes hepatiques est l’une des composantes de l’education therapeutique. Le contenu de cette consultation a ete defini a partir des resultats des recherches conduites dans le domaine de la communication en sante. Ces travaux incitent a preciser au patient les objectifs de cette consultation, son deroulement, a solliciter son accord et a requerir sa participation dans l’elaboration du plan de traitement. L’etude et la prise en compte des representations du patient relatives a la transplantation, au traitement et au rejet de son greffon sont indispensables a l’elaboration d’un plan de communication efficace. La mise en œuvre de cette consultation suppose une formation initiale ou continue du pharmacien qui integre des connaissances en psychologie, sciences cognitives et communication en sante. Elle fait actuellement defaut tant dans la formation initiale que dans la formation continue. Elle devrait etre completee par une mise en pratique et un entrainement au cours des stages hospitaliers et officinaux.

The objective of the research was to evaluate the impact of a training program on pharmacy residents’ performance in the field of prescription analysis. A before-and-after study was conducted. The criteria for assessing the level of performance were the type and frequency of interventions. Before the training program, 279 pharmaceutical opinions were given (6.3% of 4458 prescriptions) versus 330 (12.1% of 2731 prescription) after the training program. Findings showed a significant improvement after the training in the fields of non-conformity to guidelines or contra-indication (0.3 vs. 0.9%), untreated indication (0.02 vs. 1.2%), overdosage (2.1 vs. 3.9%), drug interaction (2.2 vs. 3%) improper administration (1.1 vs. 2.1%) and failure to receive drug (0.07 vs. 0.5%). Insufficient analysis persisted for parenteral nutrition, drug interactions and physicochemical incompatibilities. Behaviour may have been a factor in this failure, as residents did not systematically refer to documentary tools. Methods to assess behaviour would be useful as a future research project.

In France, efforts to optimize prescribing of proton-pump inhibitors (PPIs) are rare. Various studies have shown that the prescription of these drugs is excessive. This has consequences regarding costs and iatrogenesis. The objective of this study was to describe the type of drug related problems (DRP) and pharmaceutical interventions reported by pharmacists practicing in a university hospital.Drug related problems and pharmaceutical interventions (PI) made, were recorded on a database. They were classified according to the grid code of the French Society of Clinical Pharmacy.Over a 3 years period, 132.890 prescriptions were analysed. 15.347 generated PI. Among them 701 (4.6%) concerned PPIs. Most frequently reported problems were: lack of indication or patients without a documented indication (24.4%), drug-drug interactions (22.4%) and inappropriate route or mode of administration (19.8%). Discontinuation has been proposed in 40.5% of cases, followed by substitution (22.0%) and dosage titration (17.3%). Physicians modified the prescription according to 51.3% of PI. The main PI, discontinuation therapy, is associated with over-prescription of this drug class. Nevertheless, the rate of DRP recorded (0.5%) is low compared to the high exposure of patients on PPIs and misuse (or overuse?) reported in the literature.PI made during the analysis of prescription contributes to rationalizing the use of PPIs. The action of the pharmacist must be strengthened through training of health professionals, and communication strategies to improve practices.

Summary What is known and objectives The French Society of Clinical Pharmacy has developed a website, named Act-IP©, enabling hospital pharmacists to document and analyse pharmacists' interventions (PIs) proposed during medication order review when a drug-related problem is detected. This study analyses PIs documented in Act-IP© and assesses factors associated with physicians' acceptance of PIs. Methods PIs documented into Act-IP© over a 30-month period were analysed. Independent predictors of physicians' acceptance were assessed using multiple logistic regression. Results and discussion A total of 34 522 PIs were registered by 201 pharmacists working in 59 hospitals. PIs were mostly related to ‘dose adjustment’ (25%), ‘drug discontinuation’ (20%) and ‘drug switch’ (19%). Of the 43 343 medications involved, 28% targeted drugs acting on the central nervous system, 17% anti-infective drugs and 16% cardiovascular drugs. Sixty-eight per cent of PIs were accepted by physicians (15% refusals and 17% non-assessable). Physicians' acceptance was significantly associated with 1/ drug group: antineoplastics and immunomodulators (OR = 2·29, CI 95[1·94–2·69]), anti-infectives (OR = 1·19, CI 95 [1·11–1·28]); 2/ type of intervention: drug switch (OR = 1·54, CI 95 [1·43–1·65]), drug discontinuation (OR = 1·38, CI 95 [1·29–1·48]), administration modality optimization (OR = 1·19, CI 95 [1·11–1·29]), addition of a new drug (OR = 1·12, CI 95 [1·00–1·24]); 3/ ward specialty: paediatrics (OR = 1·83, CI 95 [1·24–2·70]) and intensive care (OR = 1·34, CI 95 [1·10–1·64]); 4/ level of pharmacist integration in the ward: higher when the pharmacist is regularly in the ward compared with occasionally (OR = 0·74, CI 95 [0·70–0·79]) or never (OR = 0·68, CI 95 [0·60–0·75]) present. What is new and conclusion This study highlights the role of routine pharmacist review of medication orders to prevent drug-related problems and gives new insights for a successful collaboration between physicians and pharmacists.

The report published by the French Agency for the Medical Safety of Health Products in 2001 estimated the number of hospital admissions in France for hemorrhagic accidents caused by oral anticoagulants (OA) to be 17,000. For this reason, we have set up pharmaceutical counselling for hospitalized patients treated with OA. The object of this article is to describe this therapeutic education program and to present the level of knowledge that patients have of their OA treatment. Among 68 patients treated prior to their admission, 87% knew the name of the OA, 86% the role of this treatment, 80% the dosing schedule, 57% what to do if a dose had been forgotten, 34% the signs of overdose, 48% the signs of and risks associated with not following the treatment schedule, 94% the advantage of biological follow-up and 68% the principal combinations of drugs that should be avoided. Among 118 patients whose treatment was begun during hospitalization, the level of knowledge for each item were respectively: 41%, 61%, 38%, 37%, 19%, 23%, 34% and 24% at the time of counselling. Newly treated patients acquired their knowledge from contact with nurses. The least known items were the symptoms and risks associated with overdosing or underdosing. This knowledge is therefore fragmentary and does not guarantee the patients' safety, which justifies the proposition of this type of counselling to such hospitalized patients.

International audience; IntroductionThe medical care of patients generates questions among healthcare professionals. Some will necessitate an advanced research. The hospital pharmacist is at the interface between prescribers, caregivers and the medicines and is requested to answer these requests. Studies conducted in others countries showed that this question-answer activity represents a significant amount of time in daily work. In France, this topic was poorly explored. The objective of our work was to study the volume and the type of questions, the clinical situations, the time required, the medicines implicated and the sources of information used.Materials and methodsA prospective study was conducted in the pharmacy of a university hospital. All the requests answered by the pharmaceutical team, which needed a specific research, analysis and writing of an answer were collected.ResultsA hundred and one questions were analyzed, originating from doctors or medicals interns. Almost half concerned drug interactions, and among them, almost a fourth were not mentioned in the Summary of Product Characteristics of the medicines involved. A pharmaceutical advice was provided in 91,5% of the cases. Time dedicated to the research varied between less than 30 minutes and more than 8 hours.Discussion and conclusionThis study illustrates the question-answer activity of a hospital pharmacy, which is currently not taken into account as an indicator of pharmaceutical activity. A large part concerns analysis and management of drug interactions and requires a significant amount of pharmaceutical time.; IntroductionLa prise en charge médicamenteuse d’un patient génère des questions chez les professionnels de santé impliqués. Certaines vont nécessiter une recherche avancée. Le pharmacien hospitalier est situé à l’interface entre les prescripteurs, le personnel soignant et le médicament et est sollicité pour répondre à ces demandes. Des études menées à l’étranger, ont montré que cette activité question-réponse représente une part significative du travail quotidien. En France, ce sujet est peu exploré. L’objectif de notre travail a été de connaître cette activité : volume et nature des questions, situations cliniques, temps consacré, médicaments concernés, sources d’information utilisées.Matériels et méthodesUne étude prospective a été menée au sein de la pharmacie d’un centre hospitalo-universitaire. Toutes les demandes traitées par l’équipe pharmaceutique, ayant nécessité un travail de recherche, d’analyse et de rédaction d’une réponse ont été recensées.RésultatsCent-une questions ont été analysées, émanant pour plus des deux tiers de médecins ou d’internes en médecine. Près de la moitié concernait des analyses d’interactions médicamenteuses et presqu’un quart d’entre elles n’était pas mentionné dans le Résumé des Caractéristiques des spécialités concernées. Une conduite à tenir a été proposée dans 91,5% des cas. Le temps consacré à la recherche d’information variait de moins de 30 minutes à plus de 8 heures.Discussion et conclusionCette étude illustre l’activité question-réponse d’une Pharmacie à Usage Intérieur, actuellement absente des indicateurs d’activité pharmaceutique. Une grande partie porte sur l’analyse et la gestion des interactions médicamenteuses et nécessite un temps de travail conséquent.

We report a case of an extreme bradycardia in a cardiac patient, due to multiple drug–drug interactions. This case caused significant diagnostic problems and illustrates the interplay between pharmacokinetics and pharmacogenetics. A 51-year-old man with a history of hypertensive and ischaemic myocardiopathy (cardiac infarction 11 years ago), osteoarthritis and hypothyroidism, was treated daily with lacidipine 2 mg, ramipril 5 mg, levothyroxine 75 µg, rosuvastatin 20 mg, metoprolol 100 mg and acetylsalicylic acid 325 mg. The patient consulted after a possible exposure to HIV during unsafe sexual activity. The physician prescribed a post-exposure prophylaxis (PEP) containing tenofovir disoproxil fumarate 245 mg/emtricitabine 200 mg combination once daily plus lopinavir 400 mg/ritonavir 100 mg combination twice daily for 1 month. Forty-eight hours after starting PEP, the patient presented a vasovagal syncope with severe hypotension (blood pressure was 50/20 mmHg) and extreme bradycardia (20–25 beats min−1). An electrocardiogram showed complete atrioventricular block (AV). The patient recovered a regular sinus rhythm after treatment with isoprenaline. Results of all diagnostic tests, including cardiac enzymes, complete blood cell count, electrolytes and tomodensitometry were normal. Lopinavir/ritonavir, lacidipine, ramipril and metoprolol were discontinued. Raltegravir was prescribed on day 4. Lacidipine, ramipril were re-instated on day 7 and metoprolol on day 9. We suspected the involvement of multiple drug–drug interactions between ritonavir and metoprolol and/or lacidipine. Lopinavir, ritonavir, tenofovir and emtricitabine were quantified by high-performance liquid chromatography. The subject was genotyped for several allelic variants most commonly found in Caucasians. The genes CYP2D6, CYP3A4, CYP3A5 and ABCB1 were amplified to detect 26 single nucleotide polymorphisms on CYP2D6, the CYP3A5*3 alleles, the −392A>G variant on CYP3A4 and the variants 1236C>T on exon 12, 2677 G > T/A on exon 21, and 3435 C > T on exon 26 on ABCB1. CYP2D6 deletion and gene duplication were also assessed. Blood concentrations were analyzed approximately 12 h after the last dose of tenofovir/emtricitabine combination and 20 h after the last dose of lopinavir/ritonavir combination. Lopinavir, ritonavir, tenofovir and emtricitabine plasma concentrations were 8.40 mg l−1, 0.29 mg l−1, 0.059 mg l−1 and 0.12 mg l−1, respectively. The lopinavir plasma concentration was higher than usual (3 to 7 mg l−1); but the measurement was done only 3 days after treatment initiation while 2 weeks are required to see the maximal enzyme inducing effects of ritonavir. Tenofovir and emtricitabine plasma concentrations were in the normal range. The patient carried CYP2D6*4/*2 alleles. No duplication of the CYP2D6 gene was found. The patient was classified as an intermediate metabolizer of CYP2D6. He had no potential functional alteration of CYP3A as the CYP3A4*1B polymorphism was not found, and CYP3A5 was not expressed (*3/*3). The patient appeared to be a CYP3A normal metabolizer. He was homozygous for the haplotype 2677T, 1236T and 3435T on ABCB1. This haplotype TTT is associated with lower ABCB1 expression. The AV block and hypotension in this case is consistent with an overexposure to metoprolol and lacidipine. This overexposure may be due to multiple pharmacokinetic interactions with the protease inhibitors ritonavir and lopinavir and/or to genetic polymorphism. Metoprolol undergoes α-hydroxylation and O-demethylation by several CYPs (predominantly 2D6 but also 3A4) [1]. Ramipril is hydrolyzed by esterases to ramiprilat, which is glucuronoconjugated [2]. Lacidipine is oxidized to pyridine derivatives by CYP3A4 [3]. We have several reasons to conclude that the AV block and the hypotension in this case was primarily associated with co-administration of the lopinavir/ritonavir combination with metoprolol and lacidipine. First, the patient was asymptomatic while he started antiretroviral therapy. Second, discontinuation of lopinavir/ritonavir, lacidipine, ramipril and metoprolol, restored normal rhythm. Third, the re-introduction of lacidipine, ramipril and metoprolol without lopinavir/ritonavir induced no bradyarrythmia. So, the antiprotease combination might have induced a drug–drug interaction and consequently a disruption in the treatment. Ritonavir is a potent inhibitor of CYP3A4 and to a lesser extent, of CYP2D6. Ritonavir exerts a complex dose and time dependent inhibitory/induction effect on CYP3A and on the multidrug efflux P-glycoprotein (P-gp) [4]. It exerts a moderate dose-related inhibition of CYP2D6 [5]. Lopinavir is a substrate of CYP3A, P-gp and to a lesser extent CYP2D6 [6]. Metoprolol, a selective β1-adrenoceptor antagonist, undergoes significant first pass metabolism with approximately 85% of the dose converted mainly into an inactive metabolite via CYP2D6 in extensive metabolizers. Finally, lacidipine (a dihydropyridine calcium antagonist) is a CYP3A4 substrate. Because lacidipine is a P-gp inhibitor [7], it is also possibly a substrate of P-gp. Even though the ritonavir-metoprolol interaction has never been studied, a possible increase in the average plasma exposure to metoprolol is supported by theoretical considerations and several case reports [8–10]. One of these described a complete AV block with metoprolol after co-administration of paroxetine, another CYP2D6 inhibitor [5]. The in vitro Ki of ritonavir for CYP2D6 is 2.5 mg l−1[11], which is higher than the ritonavir concentration measured in plasma (0.3 mg l−1). Nevertheless, it has been shown that low-dose ritonavir (100 mg twice daily) increased desipramine (a substrate of CYP2D6) AUC by 1.26 [12]. Because the contribution of CYP2D6 to total clearance is similar for desipramine and metoprolol (fm = 0.85) [13], the same degree of interaction is expected. In addition, metoprolol is metabolized by CY3A4. Because the patient was an intermediate metabolizer for CYP2D6, the contribution of CYP3A4 to the total clearance of metoprolol was increased. The in vitro Ki of ritonavir for CYP3A4 is 0.05 mg l [11]. Hence inhibition of CYP3A4 by low dose ritonavir might have contributed to an increased metoprolol exposure. Co-administration of ritonavir with lacidipine, whose bioavailability is less than 50% [14], may increase exposure to lacidipine by inhibiting CYP3A4 and P-gp, resulting in hypotension. Although this interaction has only a theoretical basis, it is well described with other dihydropyridine calcium antagonists. The co-administration of nifedipine with ritonavir may significantly increase nifedipine exposure, resulting in toxicity [15]. Indinavir plus ritonavir increases the AUC of amlodipine [16]. A case of symptomatic orthostasis and heart block after starting antiretroviral therapy that included nelfinavir was reported in a man who was receiving extended release nifedipine [17]. From a pharmacogenetic point of view, the patient was an extensive metabolizer for CYP3A and low expressor of P-gp. The TTT haplotype found in this patient is associated with higher plasma concentrations of P-gp substrates leading to a potential increase of lacidipine bioavailability without an increase in its metabolism because of the CYP3A5 genotype [18]. This case raises several important points. Firstly, HIV PEP has a strong potential for drug–drug interactions in patients with comorbidities requiring long term medications. Secondly, as illustrated by our case report, these potential interactions have to be identified as they may lead to early near-fatal complications. Systematic pharmacogenetic analyses combined with pharmaceutical analysis of the prescriptions may help in understanding, forecasting and managing these interactions.

The medical care of patients generates questions among healthcare professionals. Some will necessitate an advanced research. The hospital pharmacist is at the interface between prescribers, caregivers and the medicines and is requested to answer these requests. Studies conducted in other countries showed that this question-answer activity represents a significant amount of time in daily work. In France, this topic was poorly explored. The objective of our work was to study the volume and the type of questions, the clinical situations, the time required, the medicines implicated and the sources of information used.A prospective study was conducted in the pharmacy of a university hospital. All the requests answered by the pharmaceutical team, which needed a specific research, analysis and writing of an answer were collected.A hundred and one questions were analyzed, originating from doctors or medicals interns. Almost half concerned drug interactions, and among them, almost a fourth were not mentioned in the Summary of Product Characteristics of the medicines involved. A pharmaceutical advice was provided in 91.5% of the cases. Time dedicated to the research varied between less than 30 minutes and more than 8 hours.This study illustrates the question-answer activity of a hospital pharmacy, which is currently not taken into account as an indicator of pharmaceutical activity. A large part concerns analysis and management of drug interactions and requires a significant amount of pharmaceutical time.

Background Guidelines recommend use of the oral route whenever possible to treat or prevent hypokalemia. Although a myriad of papers have been published regarding intravenous to oral (IV to PO) therapy conversion programs and about clinical pharmacy services provided in hospitals, little is known on the role of hospital pharmacists in promoting the oral route for potassium administration. Objective The aim of this work was to describe the frequency of interventions related to IV to PO potassium therapy conversions performed by hospital pharmacists. Setting French hospitals recording pharmacist’s interventions on the website tool of the French Society of Clinical Pharmacy. Methods From the pharmacist’s interventions (PI) dataset recorded we extracted all interventions related to potassium IV to PO conversion. We assessed the acceptance rate of these PI by prescribers. Additional free text information in the dataset was analysed. Main outcome measures IV to PO potassium therapy conversions related to potassium chloride. Results From January 2007 to December 2010, 87 hospitals recorded 1,868 PIs concerning IV to PO therapy conversion. Among these, 16 (