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Theory can play an important role in providing the framework, and underpinning the design and implementation of interventions to improve medication adherence. Interventions that are grounded in a theory are relatively more effective in improving medication adherence than interventions which do not have a theoretical support. However, a large body of adherence research does not appear to be linked to any theory or model, which therefore may have resulted in interventions that are either ineffective or not sustainable. Interventions that are based on theory have mainly employed socio-behavioural models to explain, and design interventions to address, the complex phenomenon of adherence. Yet, the effectiveness of these interventions is inconclusive, supporting the argument that socio-behavioural models alone have limited applicability in explaining behaviour associated with medication-taking. An important reason for this limitation may be the complex and dynamic nature of adherence. There is a need to include a wide variety of factors in a model and examine adherence in the context of its three phases (initiation, implementation, and discontinuation). One possible way forward is to also examine medication-taking behaviour from an economic perspective, for example, by using a discrete choice experiment (DCE), which provides a different approach to understanding human behaviour about medication-taking and the complexities of decision-making in adhering to medication. DCEs can help in understanding how patients decide to initiate, continue or discontinue taking medication, factors that influence their decision, and the relative importance of those factors, which can assist researchers to prioritise interventions to improve medication adherence. Integration of multiple theories is needed to examine adherence from multiple perspectives and design interventions that are effective and sustainable. This commentary focusses on the pros and cons of some of the commonly used socio-behavioural models in adherence research and suggests a way forward by incorporating DCEs in adherence research.

AIMS AND OBJECTIVES: To explore the perceptions and experiences of surgical nurses before and after introducing the Medications and Oral Restrictions Policy (the Policy). BACKGROUND: The Policy was developed following extensive consultation, and evidence-based strategies were considered for its implementation. However, it is possible uptake did not meet expectations. DESIGN: Focus group interviews. METHODS: Three focus groups were conducted in November 2015 around 'what worked, what didn't and why, before and after hospital-wide implementation of the Policy.' Data were coded and analysed using an inductive-deductive thematic analysis approach. The COREQ checklist guided reporting. RESULTS: The three groups consisted of 16, 14 and six surgical nurses. Before the Policy, there was confusion, lack of clarity and guidance, and lack of experience and confidence in managing medications when patients had oral restrictions. After the Policy rollout, there was a sense of 'knowing what to do' because of improved clarity and decision support; but there were also problems with: not everyone knowing about the policy, particularly due to staff movement and turnover; and, individual interpretation of the policy including use of its signs outside of context, and decision-making processes. CONCLUSION: Exploration of nurses' perceptions of a medication-related policy change found that while the Policy provided clarity and decision support for some, it made little difference for others. Limited reach of the policy was an issue despite an effort to address this at the outset, as well as variations in interpretation of the policy and subsequent decision-making. RELEVANCE TO CLINICAL PRACTICE: How individuals interpret information and their understanding of the context behind the policy or guideline may affect implementation and should be considered alongside other barriers when implementing medication-related initiatives. Furthermore, implementation strategies that are independent of ongoing resources and/or key champions to sustain should be prioritised for all initiatives.

Rationale, aims, and objectives Investigation of several serious adverse events in our organization highlighted that medications were managed inappropriately when patients have oral intake restrictions. The aim of this work was to identify the barriers to optimal medication management when patients have restrictions on their oral intake. Method Data were feedback and comments obtained between 2011 and 2014 from a hospital-wide quality assurance project. Data had not been purposefully collected and were in response to a general request for feedback regarding managing oral medications when patients have oral intake restrictions. Data came from a range of clinical staff and from various forums associated with the quality assurance project, including 37 presentations, 34 group meetings, and over 50 one-on-one meetings, as well as emails and other sources. Data were analysed using the thematic analysis approach. Data were coded inductively, and the domains of the Theoretical Domains Framework were used to categorize the data. Subthemes and themes were then developed. Results Barriers could be broadly grouped into systems-level issues (organizational guidance and work environment) and the individual person-level issues (staff knowledge and beliefs). These barriers highlight the complexity of the medication management task. The lack of standardized guidance and consistent terminology regarding medication administration when patients have restrictions on oral intake, particularly when fasting or nil by mouth, were important systems factors, as were workflow issues and the "culture" of the environment in which staff practiced. Lack of knowledge about medication administration, social influences, and role interpretation were important individual person factors. Conclusion Systems- and individual person-level issues were significant contributors to inappropriate medication management when patients have oral intake restrictions. Many of the barriers may be addressed with systems approaches such as hospital-wide guidance that simplifies and standardize oral medication administration instructions, particularly regarding fasting and nil by mouth terminology.

Introduction In resource-limited settings, it is particularly important to explore the priorities for, as well as barriers to, development of health services. There has been limited development of medicines information (MI) services in Vietnam despite national guidelines. Objectives To explore the current status of MI services for healthcare professionals and patients in Vietnamese hospitals. Methods In 2018, all hospitals which were under the direct administration of the Ministry of Health and all 63 Provincial Health Bureaus were invited to participate (n = 1359). All national, provincial and district hospitals, as well as private hospitals and hospitals from other Ministries in Vietnam, were included. An online questionnaire about MI facilities, workforce, and activities was used. Results There were 560 eligible responses from pharmacists in hospitals. The most common MI service was pharmacovigilance (provided in 91% of hospitals), and the least common was providing MI for clinical case management (30%), nurse training (31%), and MI provision to patients (27%). Multivariate logistic regression analysis showed that the number of pharmacists and the geographical-economical area where hospitals were based had the strongest impact on the likelihood of offering more MI services in hospitals. While the type of hospital (traditional medicine vs. other hospitals) had some impact, hospital size, level, and specialization of hospital (general vs. specialized) did not have a significant impact on the provision of MI services. Conclusion The differences in workforce and location may contribute to differences in MI practices between hospitals. These findings are relevant for the implementation of a national MI strategy in Vietnam and other developing countries.

Background The role of pharmacists in medication reconciliation (MedRec) is highly acknowledged in many developed nations. However, the impact of this strategy has not been well researched in low-and-middle-income countries, including Ethiopia. Objective The aim of this study was to investigate the impact of pharmacist-led MedRec intervention on the incidence of unintentional medication discrepancies in Ethiopia. Setting Emergency department in a tertiary care teaching hospital in Ethiopia. Method A single centre, prospective, pre-post study was conducted on adults (aged 18 years or over) that had been hospitalized for at least 24 h and were taking at least 2 home medications on admission. The intervention involved assignment of a pharmacist to an emergency care team so as to take the best possible medication history and reconcile this list with the current medications in use. Main outcome measure Incidence and potential clinical severity of unintentional medication discrepancies. Results 123 patients were included (pre-intervention, 49; post-intervention, 74). The proportion of patients with at least one unintended discrepancy was reduced from 59 to 10.5% after the intervention (p

Background Research has shown that patients are most susceptible to medication-related problems (MRPs) when transitioning from hospital to home. Currently, the literature in this area focuses on interventions, which are mainly orientated around the perspective of the health-care professional and do not take into account patient perspectives and experiences. Objective To capture the experiences and perceptions of Australian patients regarding MRPs following discharge from hospital. Design A cross-sectional study was conducted using a questionnaire collecting quantitative and qualitative data. Thematic analysis was conducted of the qualitative data. Setting and participants Survey participants were recruited through The Digital Edge, an online market research company. Five hundred and six participants completed the survey. Results A total of 174 participants self-reported MRPs. Two concepts and seven subthemes emerged from the analysis. The first concept was types of MRPs and patient experiences. Three themes were identified: unwanted effects from medicines, confusion about medicines and unrecognized medicines. The second concept was patient engagement in medication management, of which four themes emerged: informing patients, patient engagement, communication amongst health-care professionals and conflicting advice. Discussion and conclusion This study provides an important insight into patients’ experiences and perceptions of MRPs following discharge from hospital. Future direction for practice and research should look into implementing patient-centred care at the time of hospital discharge to ensure the provision of clear and consistent information, and developing ways to support and empower patients to ensure a smooth transition post-discharge from hospital.

To explore anti-diabetic medication taking behaviour in Nepalese patients with type 2 diabetes and investigate the factors impacting medication taking in this population.Face-to-face interviews (n = 48) were conducted with Nepalese patients with type 2 diabetes in Sydney (Australia) and Kathmandu (Nepal). All interviews were audio-recorded, transcribed verbatim and thematically analysed. Participants' medication adherence was also assessed quantitatively using the summary of diabetes self-care activity (SDSCA) questionnaire.The medication taking behaviour of Nepalese participants aligned with the Stages of Change Model, with some notable patterns of behaviour. Most participants initiated and implemented anti-diabetic medications soon after obtaining their prescription. However, a few, delayed initiation and/or ceased medications after initiation to recommence later. Nonetheless, upon recommencement, participants persisted fairly well with their medications. The self-reported medication adherence was high (97.3%). Although some participants expressed adherence as a challenge at the start of therapy, medication taking on a day-to-day basis was not reported as difficult. Factors such as participants' reluctance towards using medications and preference for natural methods of treatment, together with inadequate understanding about diabetes and treatment resulted in the delay in initiating therapy, and contributed to cessation of therapy. On the other hand, ooccasional non-adherence in daily medication taking was mostly related to inconsistency in meal practices and forgetfulness. Encouragement from doctors and increased awareness about the disease and treatment facilitated medication adherence, including initiation of therapy.This study demonstrates that Nepalese patients are likely to delay or cease anti-diabetic medications until they fully accept and acknowledge the benefits and necessity of medications for effective diabetes management. Thus, educating patients about the need for medications, as well as implementing strategies to address patients' psychological resistance towards medications will be essential for effective medication management.

Objective The aim of this study was to investigate the consumer's perspectives and experiences regarding medication related problems (MRPs) following discharge from hospital. Design A cross-sectional study was conducted using an online 80-question survey. Setting Survey participants were recruited through an online market research company. Participants Five hundred and six participants completed the survey. Participants were included if they were aged 50 years or older, taking 5 or more prescription medicines, had been admitted to hospital with a minimum stay of 24 h, admitted to hospital within the last 4 months and discharged from hospital within the last 1 month. Main Outcome Measures The survey comprised questions measuring: health literacy, health status, medication safety (measured by reported MRPs), missed dose(s), role of health professionals, health services and cost, and socio-demographic status. Descriptive and univariate statistics and logistic regression analysis was performed to examine the predictors of experiencing MRPs. Results Four main risk factors of MRPs emerged as significant: health literacy ( P < 0.05), health status ( P < 0.05), consumer engagement ( P < 0.05) and cost of medicines ( P = 0.001). Participants reporting a lack of perceived control over their medicines (OR 6.3; 95% CI: 3.4–11.8) or those who played less of a role in follow-up discussions with their healthcare professionals (OR 7.6; 95% CI: 1.3–45.7) were more likely to experience a self-reported MRP. Conclusions This study provides insight into consumers' experiences and perceptions of self-reported MRPs following hospital discharge. Results highlight novel findings demonstrating the importance of consumer engagement in developing processes to ensure medication safety on patient discharge.

Background Hospital pharmacists play a central role in medication safety activities. However, in Ethiopia, this role has been launched recently and little is known regarding the current status of this extended service. Using the Theoretical Domains Framework (TDF), we aimed to identify the barriers and facilitators to hospital pharmacists’ engagement in medication safety activities across various public hospitals in the Amhara region of Ethiopia. Methods Eight focus group discussions, using an interview guide that was drawn upon the TDF, were conducted with 44 hospital pharmacists to explore their beliefs regarding their involvement in clinical services. Group discussions were audio-recorded, transcribed verbatim, and analysed using directed content analysis based on the TDF. Relevant domains were identified by applying relevance criteria to each of the domains in the TDF. Results Content analysis revealed six domains that influence hospital pharmacists’ engagement in medication safety activities. These domains included ‘Knowledge’, ‘Skills’, ‘Environmental context and resources’, ‘Motivations and goals’, ‘Social influences’ and ‘Social/professional role’. Most hospital pharmacists believed knowledge gap was an issue, as was the lack of training and supportive skills although some expressed as they were competent enough for their skills in identifying medication related problems. Most participants were very much enthusiastic for their extended roles and were positive towards the future of the profession; however, competing priorities along with the lack of remuneration and awareness (of other health care professionals) regarding the profession’s role were barriers to service delivery. There were also a number of resource constraints, such as staffing, infrastructure and government funding, and acceptance rate of pharmacist’s recommendation that were likely to influence the clinical practice of pharmacists. Conclusion Using the TDF, this study identified a wide range of barriers and facilitators to hospital pharmacists’ engagement in medication safety activities in resource-limited settings. There existed considerable interrelationships between domains that were perceived to influence hospital pharmacists’ behaviours, and this may assist in designing behaviour change interventions that target common behavioural domains. Electronic supplementary material The online version of this article (10.1186/s40545-018-0129-y) contains supplementary material, which is available to authorized users.

Background— This study explores health provider and patient attitudes toward the use of a cardiovascular polypill as a health service strategy to improve cardiovascular prevention. Methods and Results— In-depth, semistructured interviews (n=94) were conducted with health providers and patients from Australian general practice, Aboriginal community-controlled and government-run Indigenous Health Services participating in a pragmatic randomized controlled trial evaluating a polypill-based strategy for high-risk primary and secondary cardiovascular disease prevention. Interview topics included polypill strategy acceptability, factors affecting adherence, and trial implementation. Transcribed interview data were analyzed thematically and interpretively. Polypill patients commented frequently on cost-savings, ease, and convenience of a daily-dosing pill. Most providers considered a polypill strategy to facilitate improved patient medication use. Indigenous Health Services providers and indigenous patients thought the strategy acceptable and beneficial for indigenous patients given the high disease burden. Providers noted the inflexibility of the fixed dose regimen, with dosages sometimes inappropriate for patients with complex management considerations. Future polypill formulations with varied strengths and classes of medications may overcome this barrier. Many providers suggested the polypill strategy, in its current formulations, might be more suited to high-risk primary prevention patients. Conclusions— The polypill strategy was generally acceptable to patients and providers in cardiovascular prevention. Limitations to provider acceptability of this particular polypill were revealed, as was a perception it might be more suitable for high-risk primary prevention patients, though future combinations could facilitate its use in secondary prevention. Participants suggested a polypill-based strategy as particularly appropriate for lowering the high cardiovascular burden in indigenous populations. Clinical Trial Registration— URL: http://www.anzctr.org.au . ANZCTRN: 12608000583347.

usc Refereed/Peer-reviewed Background: Adherence to medications for chronic disease is sub-optimal. Current adherence-enhancing strategies do not seem to adequately address the fundamental need to sustain adherence or prevent non-adherence. Intentional non-adherence, involving active medication-taking decisions, is not well described within the Australian community setting. Understanding if, how and why non-adherent decisions are made may help develop strategies to sustain adherence in chronic disease. Objective: This study aimed to describe intentional non-adherent behavior in chronic disease within the Australian community setting and identify the factors that promote and prevent non-adherent decisions. Methods: In-depth, semi-structured interviews were conducted with 21 patients (12 rural, 9 metropolitan; New South Wales) prescribed medications for a diverse range of chronic conditions. Using the Theory of Planned Behavior as the theoretical framework, an iterative thematic framework analysis method was used to characterize the intentions and the decisions underlying non-adherent behavior. Data were indexed and charted within the thematic framework using Excel, and linked themes were combined, and associations and explanations drawn. Results: Although there was a strong intent to follow prescribers' recommendations, most patients described instances of intentionally non-adherent behavior. Trading between perceived treatment inefficacy, unfavorable side effects and unaffordable medication costs promoted non-adherent decisions; trusting prescriber–patient relationships, positive family values and lack of perceived control over treatment choice maintained adherent intentions. Intentional non-adherence was mostly temporary. Conclusions: Intentional medication non-adherence in chronic disease appears reversible and amenable to interventions that address treatment-related barriers such as medication affordability. Strategies that strengthen patient–prescriber relationships and empower patients as informed decision-makers may help maintain adherence intentions. Crucially, regular and sustained interventions that are refreshed to meet the changing needs of patients are needed to curb the temporal decline in adherence to chronic disease medications.

Background Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. Objective The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. Methods We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Results Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5–20.1%), while adverse drug events causing admission were reported in 2.8% (0.7–6.4%) of patients but it was reported that a median of 43.5% (20.0–47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0–0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8–72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5–50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge/training) and environmental factors, such as workplace distraction and high workload. Conclusion Medication errors in the African healthcare setting are relatively common, and the impact of adverse drug events is substantial but many are preventable. This review supports the design and implementation of preventative strategies targeting the most likely contributing factors. Electronic supplementary material The online version of this article (10.1007/s40801-017-0125-6) contains supplementary material, which is available to authorized users.

Background Internationally, patient safety is increasingly seen as a priority area, and improving patient safety highly depends on achieving a culture that supports and encourages health care staffs to report their errors or near misses without fear of punishment. In Ethiopia, however, patient safety culture is a relatively new focus, and little is known regarding the current status of patient safety culture in public hospitals. The purpose of the current study was thus, aimed to assess the views and perceptions of health care professionals about patient safety culture in public hospitals in Ethiopia. Methods A cross-sectional study, utilizing the ‘Hospital Survey on Patient Safety Culture (HSOPSC)’ questionnaire was carried out in 2016 in the Amhara region. A self-administered questionnaire was distributed to the 480 health care staffs, including physicians, nurses, pharmacists, and other clinical and non-clinical staffs. Data were summarized as percentages, means, and standard deviations. ANOVA and chi-square tests were employed to examine statistical differences between health care worker’s characteristics and patient safety predictors. We also computed internal consistency coefficients, correlation analysis, and exploratory factor analysis. Results A total of 410 questionnaires were returned (response rate, 85.4%). The overall patient safety score (46%) and most of the scores related to dimensions were lower than the benchmark scores. The positive response rate of two dimensions (‘Teamwork within units’ and ‘Organizational learning–continuous improvement’) received the highest score (each 72%), and the lowest score was attributed to ‘Staffing’ (26%). Approximately, two thirds of staffs reported at least one event in the past 1 year. Nurses reported better in the overall patient safety score compared with other health care professionals (P = 0.03). The internal consistency of the total survey was fairly satisfied (Cronbach’s α = 0.77). Conclusions There is a severe deficit of patient safety culture in Ethiopian public hospitals. Creating a positive patient safety culture by implementing actions that support all dimensions of safety culture is inevitable. Further research is needed to confirm the applicability of the translated version of the HSOPSC in the Ethiopian hospital settings.

Background Clinical pharmacy is key to the quality use of medicines. While there are different approaches in different countries, international perspectives may inform health service development. The Vietnamese Ministry of Health introduced a legal regulation of clinical pharmacy services in December 2012. Objective To describe the services, and to explore reported barriers and facilitators in implementing clinical pharmacy activities in Vietnamese hospitals after the introduction of Vietnamese Ministry of Health legal regulation. Setting Thirty-nine hospitals in Hanoi, Vietnam, including 22 provincial and 17 district hospitals. Method A mixed methods study was utilized. An online questionnaire was sent to the hospitals. In-depth interviews were conducted with pairs of nominated pharmacists at ten of these hospitals. The questionnaire focused on four areas: facilities, workforce, policies and clinical pharmacy activities. Main outcome measure Proportion of clinical pharmacy activities in hospitals. Themes in clinical pharmacy practice. Results 34/39 (87%) hospitals had established clinical pharmacy teams. Most activities were non-patient-specific (87%) while the preliminary patient-specific clinical pharmacy services were available in only 8/39 hospitals (21%). The most common non-patient-specific activities were providing medicines information (97%), reporting adverse drug reactions (97%), monitoring medication usage (97%). The patient specific activities varied widely between hospitals and were ad hoc. The main challenges reported were: lack of workforce and qualified clinical pharmacists. Conclusion While most hospitals had hospital-based pharmacy activities, the direct patient care was limited. Training, education and an expanded work forces are needed to improve clinical pharmacy services.

OBJECTIVE To evaluate the processes by which pharmaceuticals are added to the formularies of Australian paediatric hospitals. DESIGN Descriptive study of the processes and outcomes of all submissions to Australian paediatric hospital drug and therapeutics committees from 1 July 2010 to 31 December 2011. SETTING All eight tertiary paediatric hospitals in Australia. PARTICIPANTS Interviews with committee secretaries or delegates and document analysis. MAIN OUTCOME MEASURES Total number of formulary applications, stratified by therapeutic class, approval rates for each hospital and quality of supporting information. RESULTS One hundred and twenty applications were considered during the study period, with most applications approved (range, 67%-100%). Neurological agents were the most common therapeutic class considered. A conflict of interest was declared for 10 applications (8%). Forty-five (38%) were independently reviewed by a statewide medicines advisory committee or hospital pharmacist. Several committees approved identical applications during the period of review and with different outcomes. For applications submitted for new drugs or new indications (95 applications), supporting data included randomised controlled trials (37/95), case series (36/95), product information (34/95) and narrative reviews (29/95). Few applications (14/95) included a systematic review or meta-analysis. No application included an evaluation of the risk of bias of supporting studies. CONCLUSIONS There is limited high-quality evidence informing paediatric hospital-based drug approvals. Approval processes vary considerably among institutions with substantial duplication of effort and variable outcomes. Resources and training appear insufficient given the technical complexity of submissions. A national, standardised approach to hospital-based drug evaluation could reduce overlap and improve decision making.

The personally controlled electronic health record (PCHER) was designed to bring important information together to facilitate effective communication between clinicians and so improve patient care. This national cross-sectional survey of 405 healthcare providers and consumers found that they had relatively low awareness and knowledge about the PCEHR; that 62% of respondents believed that healthcare providers with access to the PCEHR would be able to provide better quality of care but only 50% of respondents would sign up to have a PCEHR.

Sujata Sapkota, Jo-anne E Brien, Parisa Aslani Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia Background: Perceptions and beliefs about treatment can influence patients’ adherence to treatment regimens. Perceptions, in turn, are often shaped by patients’ sociocultural context. Nepal and the Nepalese have unique sociocultural traditions and beliefs, and their perceptions of diabetes treatment remain largely unexplored. This study explored Nepalese participants’ perceptions of diabetes treatment, and whether perceptions differed between the Nepalese living in Australia and Nepal. Methods: Face-to-face qualitative interviews (n=48) were conducted with Nepalese participants with type 2 diabetes in Sydney and Kathmandu. All interviews were audio-recorded, transcribed verbatim, and thematically analyzed. Results: Perceptions of diabetes treatment were similar among Nepalese participants in Australia and Nepal. There was a general reluctance to start oral antidiabetic medications and an even greater reluctance to commence parenteral (insulin) therapy. Participants preferred to try lifestyle modifications and alternative treatments such as herbs and “traditional” medicines, particularly as a first step. Unwillingness to take medications was primarily associated with the belief that, once started, these medications needed to be taken for life, and perceptions of long-term harms caused by such medications. Even when commenced on medication, participants were averse to any type of therapy escalation, for example, moving to insulin therapy. Insulin was perceived as the “last option” available for diabetes treatment. Most participants, however, did not find medication taking challenging once they had commenced treatment. Conclusion: Antidiabetic medications were perceived to be harmful and unstoppable once initiated. These perceptions significantly impacted participants’ willingness to commence antidiabetic medications and therefore have the potential to adversely affect their medication-taking behavior. This study therefore highlights the need to explore the impact of these perceptions on participants’ medication-taking behavior, and the need to address patients’ views of “modern” (commonly prescribed) and “traditional” (natural) medications through information and education, to ensure increased understanding of how medications are used for diabetes management. Keywords: adherence, antidiabetic medications, qualitative study, Nepal, Australia

Background Medication reconciliation has been identified as an important intervention to minimize the incidence of unintentional medication discrepancies at transitions in care. However, there is a lack of evidence for the impact of information technology on the rate and incidence of medication discrepancies identified during care transitions. This systematic review was thus, aimed to evaluate the impact of electronic medication reconciliation interventions on the occurrence of medication discrepancies at hospital transitions. Methods Systematic literature searches were performed in MEDLINE, PubMed, CINHAL, and EMBASE from inception to November, 2015. We included published studies in English that evaluated the effect of information technology on the incidence and rate of medication discrepancies compared with usual care. Cochrane’s tools were used for assessment of the quality of included studies. We performed meta-analyses using random-effects models. Results Ten studies met our inclusion criteria; of which only one was a randomized controlled trial. Interventions were carried out at various hospital transitions (admission, 5; discharge, 2 and multiple transitions, 3 studies). Meta-analysis showed a significant reduction of 45 % in the proportion of medications with unintentional discrepancies after the use of electronic medication reconciliation (RR 0.55; 95 % CI 0.51 to 0.58). However, there was no significant reduction in either the proportion of patients with medication discrepancies or the mean number of discrepancies per patient. Drug omissions were the most common types of unintended discrepancies, and with an electronic tool a significant but heterogeneously distributed reduction of omission errors over the total number of medications reconciled have been observed (RR 0.20; 95 % CI 0.06 to 0.66). The clinical impact of unintended discrepancies was evaluated in five studies, and there was no potentially fatal error identified and most errors were minor in severity. Conclusion Medication reconciliation supported by an electronic tool was able to minimize the incidence of medications with unintended discrepancy, mainly drug omissions. But, this did not consistently reduce other process outcomes, although there was a lack of rigorous design to conform these results. Electronic supplementary material The online version of this article (doi:10.1186/s12911-016-0353-9) contains supplementary material, which is available to authorized users.

Consuming a healthy diet forms an important component of diabetes management; however, adhering to a healthy diet is challenging. Dietary behaviour is often guided by socio-cultural, environmental and emotional factors, and not necessarily by physical and nutritional needs. This study explored Nepalese patients' perceptions of the impact of diet, diet management requirement for diabetes and how Nepalese food culture in particular influenced diet management. Interviews were conducted with Nepalese participants with type 2 diabetes in Sydney and Kathmandu; and data was thematically analysed. Diet was recognized as a cause of, and a key treatment modality, in diabetes. Besides doctors, participants in Nepal received a large amount of dietary information from the community. Dietary changes formed a major component of lifestyle modifications adopted after diagnosis, and mostly consisted of removal of foods with added sugar and foods with high total sugar content from the diet, and a reduction in overall quantity of foods consumed. Perceived dietary restriction requirements created social and emotional discomfort to patients. Most participants perceived the Nepalese food culture as a barrier to effective diet management. Meals high in carbohydrates, limited food choices, and food preparation methods were identified as barriers, particularly in Nepal. In Australia, participants reported greater availability and easier access to appropriate food, and healthier cooking options. The socio-cultural aspects of food behaviour, mainly, food practices during social events were identified as significant barriers. Although diet was acknowledged as an important component of diabetes care, and most adopted changes in their diet post-diagnosis, effective and sustained changes were difficult to achieve. Future public health campaigns and education strategies should focus on improving diet knowledge, awareness of food options for diabetes, and effective dietary management.

Objectives Despite growing recognition of the importance of staff perceptions of safety culture to the quality of care provided to patients, there is limited published work describing the safety culture within hospital pharmacy practice. The aim of this study was to investigate the patient safety culture within the pharmacy service across a group of publically funded hospitals. Method An anonymous safety-culture assessment tool was made available to all pharmacy staff, measuring respondents9 level of agreement with 43 statements relating to seven principle safety ‘domains’. Responses were recorded using a five-point Likert scale and reported using percentage-positive agreement and Bayes factor (BF) analysis. Results Based on a response rate of 51% (n=99/195), pharmacy staff report a very strong positive safety culture profile for ‘Investigating and learning from incidents’ and ‘Perceptions of the causes of incidents/reporting’ (99.9%, BF>1000(decisive), for both). However, there was decisive evidence toward negative Likert responses for the domains ‘Staffing and management’ (99.9%, BF>1000 (decisive)) and ‘Team working’ (99.3%, BF=132 (decisive)). Significant differences also emerged in favour of smaller hospitals for ‘Teamwork’ (96.2%, BF=26 (very strong)), clinical pharmacists (n=51) versus technicians (n=21) for ‘Perceptions of the causes of incidents/reporting’, ‘Teamwork’ and ‘Commitment to patient safety and education’ (99.9%, BF>1000 (decisive), for all). Also for pharmacists affiliated with a professional association (n=54) compared with all staff without an affiliation (n=43) (99.9%, BF>1000 (decisive)). Conclusions Our findings identify important influences on the patient safety culture of hospital pharmacy, including the role of hospital type, pharmacy staff group and membership with professional-advocacy groups. A better understanding of the factors which drive these differences is necessary for pharmacy services to better embrace safety improvement initiatives.

Background and objective This study investigates health professionals’ reactions to patients’ perceptions of health issues – a little-researched topic vital to the reform of the care of chronic illness. Methods Focus groups were undertaken with doctors, nurses, allied health staff and pharmacists (n = 88) in two Australian urban regions. The focus groups explored responses to patient experiences of chronic illness (COPD, Diabetes, CHF) obtained in an earlier qualitative study. Content analysis was undertaken of the transcripts assisted by NVivo7 software. Results Health professionals and patients agreed on general themes: that competing demands in self-management, financial pressure and co-morbidity were problems for people with chronic illness. However where patients and carers focused on their personal challenges, health professionals often saw the patient experience as a series of failures relating to compliance or service fragmentation. Some saw this as a result of individual shortcomings. Most identified structural and attitudinal issues. All saw the prime solution as additional resources for their own activities. Fee for service providers (mainly doctors) sought increased remuneration; salaried professionals (mainly nurses and allied health professionals) sought to increase capacity within their professional group. Conclusions Professionals focus on their own resources and the behaviour of other professionals to improve management of chronic illness. They did not factor information from patient experience into their views about systems improvement. This inability to identify solutions beyond their professional sphere highlights the limitations of an over-reliance on the perspectives of health professionals. The views of patients and carers must find a stronger voice in health policy.

Background Healthcare reforms are needed to meet the predicted increase in the chronic disease burden. A multidisciplinary team approach has been extensively evaluated and shown to improve health outcomes. There is also support for including pharmacists in these teams. Pharmacists have valuable insight, from a medication perspective, to improve the management of patients with chronic illness. Aim To explore the perceptions of community pharmacists regarding the incentives, barriers and solutions in managing the medication regimens of patients with chronic illness. Method Semi-structured group discussions and individual interviews were conducted in October and November 2008 with community pharmacists working in Western Sydney and the Blue Mountains. Results Community pharmacists struggle to provide optimal care for patients with chronic illness. Identified reasons include poor communication with patients and health professionals, lack of care coordination and continuity of care. Many patients were thought to struggle financially when managing a chronic illness, which negatively influenced their adherence to medication regimens and recommendations on lifestyle changes. Better teamwork and communication, possibly through co-locating health professionals under one roof were suggested by pharmacists as possible solutions. Conclusion Pharmacists have a good understanding of patients' social circumstances but lack relevant clinical data. Community pharmacists are willing to take a greater role in the management of patients with chronic illness.

Aim To investigate the perceptions, concerns and attitudes of decision-makers regarding access to high cost medicines (HCMs) in public hospitals. Methods In-depth semi-structured interviews were conducted with 24 decisions-makers (executive directors of hospitals, area health service managers, directors of hospital pharmacy departments and senior medical doctors) in a Sydney Area Health Service. The interviews were digitally recorded and transcribed and analysed using a modified grounded theory approach. Results Decision-makers perceived health care system funding models as obstacles to equity of access to HCMs. They were concerned that there were inequities in decisions for individual patients according to public or private sector status. A major concern for respondents was the lack of consistency in decision-making about funding for HCMs. Respondents described that besides safety, efficacy, effectiveness and cost, ethical principles should be borne in mind when deciding whether a HCM should be available in a public hospital. Most wanted a consistent, transparent, accountable, evidence-based decision-making process. Conclusions The results of this study suggest that decision-makers were concerned about the equity of access to HCMs in public hospitals and wanted an explicit, systematic process to allocate resources to HCMs.

Aims: To evaluate the impact of the Pharmaceutical Benefits Advisory Committee (PBAC) decisions on access to medicines listed on the Pharmaceutical Benefits Scheme (PBS) for children. Methods: We analysed all public summary documents from PBAC meetings from July 2005 to November 2006 and compared these with the Therapeutic Goods Administration (TGA) recommendations for children for the same medicine. Main outcome measures stratified by age, the total number of medicines for specific indications (accepted and rejected) by therapeutic class; estimated cost to the PBS per annum for each medicine recommended for listing; comparison of TGA-approved product information and PBS listing for recommended medicines. Results: Of the 102 medicines for specific indications considered by the PBAC, 7% (7/102) of submissions were for new paediatric indications. Most submissions (60%, 61/102) did not specify age for the PBS recommendation and were for conditions which only affect adults. Listings which specifically included children were more likely to have a positive PBAC recommendation. Of the six recommended medicines for children, four were estimated to cost between $10–30 million per year. There was fair concordance between PBS- and TGA-approved product information for age (kappa 0.21) but in 46%, PBAC recommendations were for age-unrestricted listing compared with adults-only use in the TGA-approved product information. Conclusion: Access to new subsidised medicines for children in Australia lags behind adults because most applications to the PBAC for new medicines are for conditions which only affect adults. PBS processes facilitate access for children to new medicines by avoiding age restrictions.

Background:Continuity of care is important for the delivery of quality health care. Despite the abundance of research on this concept in the medical and nursing literature, there is a lack of consensus on its definition. As pharmacists have moved beyond their historical product-centered practice, a source of patient-centered research on continuity of care for practice application is required.Objective:To determine the scope of research in which pharmacists were directly involved in patients' continuity of care and to examine how the phrase continuity of care was defined and applied in practice.Methods:A working definition of continuity of care and a tool for relevance quality assessment of search articles were developed. MEDLINE, International Pharmaceutical Abstracts, EMBASE, and the Cochrane Collaboration evidence-based medicine reviews and bibliographies were searched (1996–March 2008). Reporting clarity was assessed by the Consolidated Standards of Reporting Trials checklist and outcomes were grouped by economic, clinical, and/or humanistic classification.Results:The search yielded 21 clinical and randomized controlled trials, including 11 pharmacist-only and 10 multidisciplinary studies. A broad range of research topics was identified and detailed analysis provided ready reference for considerations of research replication or practice application. Studies revealed a range of research aims, settings, subject characteristics, attrition rates and group sizes, interventions, measurement tools, outcomes, and definitions of continuity of care. Research focused on patients with depression (n = 4), cardiovascular disease {n = 4), diabetes (n = 2), and dyslipidemia (n = 1); specific drugs included non–tricyclic antidepressants, cardiovascular drugs, and benzodiazepines. From the proposed endpoints of economic cost (n = 6) and clinical (n = 14) and humanistic (n = 16) outcomes, 15 studies reported statistically significant results.Conclusions:Medication management at primary, secondary, and tertiary levels of care indicated an expanded role and collaboration of pharmacists in continuity of care. However, the exclusion of disadvantaged patients in 19 studies is at odds with continuity of care for these patients, who may have been the most in need for the same reason that they were excluded.

Background Hospitalised patients with diabetes often have poor glycaemic control. To improve the management of hospitalised patients with diabetes, a new insulin chart incorporating documentation of blood glucose levels was developed and introduced at St Vincent's Hospital, Sydney. Aim To evaluate the impact of a new insulin chart on the management of hospitalised patients with diabetes. Method A retrospective study comparing the management of three groups of hospitalised diabetic patients. The use of insulin and management of hypoglycaemic events before and after the introduction of the new insulin chart were compared. Clinical data were collected from medical records from April 2004 to April 2005. Chi-square tests were performed to analyse the data for significant differences. Results Post-implementation of the new insulin chart, patients seen by the endocrine team were more frequently ordered regular insulin (p < 0.017) than patients not managed by the endocrinologists. The number of omitted doses of regular insulin remained unchanged. Poor cross-referencing of the insulin and standard medication charts may have been a contributing factor. Post-implementation, significantly more hypoglycaemic events were treated according to the hospital's protocol (p < 0.001). Staff satisfaction with the new insulin chart was high except for some doctors' dissatisfaction with the chart when ordering regular insulin. Conclusion Introduction of the new insulin chart had a positive impact on the management of hypoglycaemic events. Other aspects of diabetes management, such as the number of patients on regular insulin and insulin dose omissions were suboptimal.

Objective: To investigate the quality of drug interaction decision support in selected prescribing and dispensing software systems, and to compare this information with that found in a range of reference sources. Design and setting: A comparative study, conducted between June 2006 and February 2007, of the support provided for making decisions about 20 major and 20 minor drug interactions in six prescribing and three dispensing software systems used in primary care in Australia. Five electronic reference sources were evaluated for comparison. Main outcome measures: Sensitivity, specificity and quality of information; for major interactions: whether information on clinical effects, timeframe and pharmacological mechanism was included, whether management advice was helpful, and succinctness. Results: Six of the nine software systems had a sensitivity rate 90%, detecting most of the major interactions. Only 3/9 systems had a specificity rate of 80%, with other systems providing inappropriate or unhelpful alerts for many minor interactions. Only 2/9 systems provided adequate information about clinical effects for more than half the major drug interactions, and 1/9 provided useful management advice for more than half of these. The reference sources had high sensitivity and in general provided more comprehensive clinical information than the software systems. Conclusions: Drug interaction decision support in commonly used prescribing and

Background General practitioners integrate an array of social and environmental factors into their prescribing decisions. In teaching hospitals, despite the involvement of multiple practitioners in making and acting on prescribing decisions, little is known about the influence of roles, relationships, professional subcultures and underlying beliefs, on prescribing practices. Aim To explore the social and cultural dynamics of prescribing in teaching hospitals. Method Consultants, registrars, junior doctors, nurses and pharmacists from 2 large Sydney teaching hospitals were sampled purposively and invited to participate in a qualitative study involving semi-structured interviews. The interview topics explored included: attitudes about prescribing, roles and responsibilities, communication of decisions, influences on prescribing and factors contributing to prescribing errors. Interviews were transcribed verbatim and the content analysed thematically. Results Participants included 8 consultants, 8 registrars, 9 junior doctors, 7 nurses and 11 pharmacists. 5 distinct sets of social and cultural influences on prescribing behaviours were identified. The dominant set of influences related to the structure of how prescribing took place and chief among these were the strong intra-professional relationships of medical teams. Other social and cultural influences related to how prescribing decisions were communicated, underlying assumptions within medical teams, knowledge acquisition and the hospital environment. Conclusion Prescribing in teaching hospitals is shaped by a complex web of social and cultural dynamics. An appreciation of these influences may be vital to the success of strategies to improve use of medicines in teaching hospitals.

Background Heart failure is a progressive disease with a high mortality rate and significant cost burden. Various roles have been proposed for pharmacists in the multidisciplinary outpatient care of heart failure patients. In 2002, an outpatient heart failure pharmacy service was established in the Heart Lung Clinic, St Vincent's Hospital, Sydney. Aim To describe the patients attending the Heart Lung Clinic on the days that the outpatient heart failure pharmacy service was available, including patients using the service; the pharmacy activities delivered to patients; and to measure patient satisfaction with the service. Method Data were collected prospectively over 4 weeks. Patient medical records were manually reviewed. Documented pharmacy activities were classified using the ICD-10-AM codes for pharmacy-specific activities. A self-administered patient satisfaction survey was used. Results Of the 46 patients included in the study (mean age 56 SD 16 years), 36 patients had heart failure as the primary diagnosis for referral. 11/36 patients had preserved left ventricular ejection fraction, 28 patients were prescribed angiotensin converting enzyme inhibitors, and 28 patients were prescribed beta-blockers. 17 patients used the outpatient heart failure pharmacy service. Medication order review, clinical review and medication counselling were the most frequently documented pharmacy activities. 15/16 patient satisfaction surveys were returned. Mean satisfaction score was 4.64 (maximum score = 5). Conclusion Data obtained were used to streamline the outpatient heart failure pharmacy service at the Heart Lung Clinic.

Health care providers (HCPs) are increasingly aware of pressures on funding for health care services, including high cost medicines (HCMs). Allocating resources to innovative and expensive medications is particularly challenging and the decision-making processes and criteria used to allocate resources to HCMs have not been widely described in the literature. This case study aimed to describe the operations of the first reported High Cost Drug Sub-Committee (HCD-SC) in a public hospital in Australia. In addition the study also evaluated the decision-making process using Daniel and Sabin's ethical framework of “accountability for reasonableness”. Some lessons emerged from the description of the operations of the HCD-SC. Decisions were not solely based on effectiveness and cost. Additional factors such as “clinical need” and the lack of an alternative treatment were involved in decisions about access to HCMs. Members of the HCD-SC also considered it was important to have consistency in the way decisions were being made. The findings from this study provide an evidence base for developing strategies to improve this hospital's decision-making process regarding access to HCMs.

Aim To explore the relationship pharmacy has with private hospitals and identify areas that can be targeted for improvement. Method Information about each hospital's characteristics, e.g. bed size, location, specialty services, were gathered and semi-structured, in-depth interviews were conducted with pharmacists servicing private hospitals. Information was gathered about the types of pharmaceutical services provided to the hospitals and the models of service provision. 82 private hospitals were identified in NSW during the study period. Data for 72 (88%) hospitals were gathered. 51 pharmacies were involved, demonstrating that some pharmacies serviced more than one hospital. 53 interviews were conducted, involving these 51 pharmacies across the state. Results The majority of pharmacies were off-site community pharmacies (80%). 10 hospitals (14%) had an on-site pharmacy and 6% of hospitals had a mixed pharmacy model. The range of pharmacy services provided to each hospital varied greatly. Overall, clinical services appeared to be underdeveloped with only a third of hospitals having pharmacists review drug charts or provide patient counselling; however, some pharmacists appeared to provide a comprehensive service. Conclusion This study provided insight into the relationships private hospitals have with pharmacy. It also identified areas within the private hospital sector that may need improvement with respect to pharmacy services. It provided background to research on the development, implementation and evaluation of professional pharmacy services for private hospital patients.

SummaryWhat is known and objective Medication reconciliation is recognized as an important tool for the prevention of medication discrepancies and subsequent patient harm at care transitions. However, there is inconclusive evidence as to the impact of medication reconciliation at hospital transitions overall, as well as pharmacy-led medication reconciliation services. This review sought to evaluate the impact of pharmacy-led medication reconciliation interventions on medication discrepancies at hospital transitions and to categorize these interventions as single transition interventions or multiple transitions interventions. Methods PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO databases, inclusive from inception to December 2014, were searched. Included studies were published studies in English that compared the effectiveness of pharmacy-led medication reconciliation interventions to usual care and that aimed to assess medication discrepancies at hospital transitions. ‘Usual care’ was defined as any care where targeted medication reconciliation was not undertaken as an intervention, or if an intervention was conducted, it was not provided by a pharmacist/pharmacy technician. Results and discussion Nineteen studies which involved a total of 15 525 adult patients were included. Eleven studies were randomized controlled trials. Overall, pharmacy-led medication reconciliation intervention usually revealed a trend towards reduction in medication discrepancies, compared with usual care. Seventeen studies involving 18 medication reconciliation interventions targeting the various transitions (admission, 9; discharge, 4; and multiple transitions, 5) were included in the meta-analysis. Compared with usual care, single medication reconciliation interventions at transitions in care (either admission or discharge) showed a significant reduction of 66% in patients with medication discrepancies (RR 0·34; 95% CI: 0·23–0·50) in favour of the intervention. There was no difference between groups for interventions targeting multiple transitions (RR 0·88; 95% CI: 0·77–1·02). Subgroup analyses confined to RCTs showed that there were no differences for target of transition (admission vs. discharge), type of intervention (multifaceted intervention vs. medication reconciliation) and setting (single centre vs. multicentre), nor pharmacists vs. pharmacy technicians (non-RCTs only). Importantly, medication discrepancies of higher clinical impact were more easily identified through pharmacy-led interventions than with usual care. What is new and conclusion Pharmacy-led medication reconciliation interventions were found to be an effective strategy to reduce medication discrepancies, and had a greater impact when conducted at either admission or discharge but were less effective during multiple transitions in care. Further studies that are designed to assess the impact of the involvement of pharmacy technicians in medication reconciliation are also needed.

Aim To identify Australian pharmacists' awareness of their international colleagues' prescribing practices and explore their views about the feasibility and utility of pharmacist prescribing privileges within the scope of their current practice. Method Members of the AusPharmList, Australian Association of Consultant Pharmacy and The Society of Hospital Pharmacists of Australia were invited by e-mail to participate in a community pharmacist, consultant pharmacist or hospital pharmacist electronic survey. These surveys were designed to elicit views concerning: dependent and independent prescribing; resource availability to support pharmacist prescribing; ability to justify prescribing decisions; and limitations of pharmacist prescribing. Results Of the 268 surveys completed (response rate 6.4%), 45% of respondents were aware of their international colleagues' prescribing activities. 74% agreed that pharmacists should be granted dependent prescribing authority, while 52% agreed that pharmacists should be granted independent prescribing authority. The majority (88%) indicated they could identify their own limitations and 86% believed they could justify their prescribing decisions as dependent prescribers. 73% believed they would benefit from prescribing authority in their daily scope of practice. Conclusion In 2004, awareness of international developments in pharmacist prescribing was not extensive among the respondents. However, many identified areas where they would benefit from dependent prescribing activities in their daily scope of practice.

ObjectiveTo identify appropriate methods to evaluate a specialist pharmacy service for heart failure patients in an ambulatory care setting.MethodAn extensive literature review was undertaken to identify the published data on evaluative studies of specialist pharmacy services, including those directed at heart failure patients in an ambulatory care model of service provision.Key findingsSix studies were identified evaluating outpatient pharmacy services for heart failure. The pharmacy services provided in these settings were not well defined. The impact of the pharmacist was compared to ‘usual care’, that is care delivered without a pharmacist, by either a prospective randomised controlled trial (RCT), or before and after studies. In most cases the service was delivered by one pharmacist at one site. Services were primarily targeted at patients and focused on medication and lifestyle education, adverse drug reaction monitoring, and compliance/adherence. In all studies, there was a trend for improvement in the outcomes measured. Different study endpoints were examined, including process indicators such as compliance and outcome measures such as morbidity (clinical), quality of life (humanistic), and hospital admissions (economic). The ideal evaluative study would be an adequately powered, prospective, randomised controlled trial, comparing the effect of the pharmacist service to usual care (without the specified pharmacy service). Appropriate study endpoints including process indicators and outcome measures are needed. Identification of specific components and the extent of the service that would provide the most benefit to selected patient groups would be of interest.ConclusionsSpecialist ambulatory care pharmacy services have not been well defined or evaluated in the literature. Limited randomised controlled data exist.

Background Drug and therapeutics committees (DTCs) are expected to make difficult decisions that may have an impact on the clinical and economic outcomes of drug use. There have been few studies investigating the barriers to DTC policy implementation, and little is known about ways to improve the process. Objectives The specific objectives of this qualitative study were to explore stakeholder opinions with respect to (1) the perceptions of barriers to Drug and Therapeutics Committee (DTC) policy implementation and (2) ways to improve DTC policy implementation. Methods Stakeholders of Australian DTCs participated in focus group discussions. Discussions were audiotaped and transcribed verbatim. Thematic content analysis was conducted. Results Six focus group discussions were conducted. A number of barriers were identified (lack of resources, lack of follow-up, lack of ownership, low DTC profile within the organization, and overreliance on pharmacy to implement policy). Participants were of the opinion that prioritizing decisions, optimizing pharmacy roles, provision of real-time information, and active procurement of organizational commitment were some of the ways to improve DTC policy implementation. Conclusions Although this study was conducted in an Australian setting, the challenges facing DTCs in other countries are likely to be similar. Ownership, social influence, and resources are important issues in the implementation of policy/guidelines for many DTCs, both in Australia and internationally. It is expected that these issues will have an impact on policy implementation. Therefore, the findings of this study may be widely applicable. This work reinforced the notion that the significance of DTCs lies beyond decision making alone. The time and expertise invested in decision making could be undermined, if DTC policies are not effectively implemented.

Objective The profession of pharmacy has the unique characteristic of having both professional and business orientations. There is today, in addition to this unique characteristic, a strong shift in pharmacy towards more involvement in patient-centred health care, and increased emphasis on the patient's best interests and autonomy, within a framework of what is known as ‘bioethics’. With this shift of professional focus comes a heightened level of responsibility due to increased expectations of the patient and greater involvement in healthcare and decision making at a personal level with the patient. There is therefore inherent in this increased involvement an increased propensity for ethical problems to arise. The aim of this study is to investigate the application of ethical theory in the practice of pharmacy in New South Wales (NSW), Australia. Method Semi-structured interviews were carried out with 25 practitioners. The content of transcribed interviews was qualitatively analysed for emerging themes. Themes were identified by the primary researcher and independently validated by the other investigators. Key findings The majority of pharmacists interviewed in NSW Australia practised within a theoretical framework of ‘best interests of the patient’. Pharmacists experienced dilemmas in practice involving a number of ethical principles. Pharmacists relied on common sense to circumvent such dilemmas and never referred to their professional code of ethics. There appeared to be a general lack of training, and a varying perception of difficulty with decision making, regarding ethical dilemmas encountered, depending on issues such as legal requirements, personal opinions or financial demands. Conclusion Findings of this study indicated primarily that pharmacists in Australia regard the ethical principle of ‘best interest’ of the patient as the fundamental framework within which they practice. Pharmacists experience ethical dilemmas in practice, predominantly in the community setting, relying on logical reasoning, practical skills and personal morals to manage the situation, rather than consulting with a code of ethics. Also of significance in this study was the finding that financial pressure had a strong negative impact on the decision making and application of ethical principles of younger pharmacists in practice.

An innovative reversed-phase high-performance liquid chromatographic method is validated for the simultaneous determination of rofecoxib and celecoxib in human plasma. The internal standard is 4-n-pentyl-phenyl-acetic acid. Good chromatographic separation is achieved using a Zorbax SB-CN (5 microm) analytical column operated at room temperature and mobile phase consisting of acetonitrile and water containing 0.1M potassium dihydrogen orthophosphate buffer adjusted to pH 2.4 with 85% orthophosphoric acid (42:58, v/v). UV detection is performed at 254 nm, and the flow rate is maintained at 1.0 mL/min. Plasma samples are extracted into an organic solvent (1-chlorobutane) and evaporated under an air flow. The calibration curve for rofecoxib is linear over the range of 10 to 500 microg/L, and the celecoxib calibration curve is linear over the range of 20 to 2000 microg/L. The lower limit of quantitation for rofecoxib and celecoxib is 10 and 20 microg/L, respectively, using 1.0 mL of human plasma. The validation data show that the assay is sensitive, accurate, specific, and reproducible for the determination of rofecoxib and celecoxib. This method is therefore appropriate for pharmacokinetic studies to quantitate these therapeutic agents in patients with arthritis conditions.

Aim: To evaluate the literature describing pharmacist prescribing activities and identify areas in need of further research. Method: Relevant literature was identified by searching Medline (1974 to February 2004), Embase (1980 to February 2004) and Pharmline (1980 to February 2004). Relevant studies were selected based on titles and abstracts. Results: 18 studies (17 USA, 1 UK) measured outcomes of drug therapy management by a dependent pharmacist prescriber compared to standard care. 19 studies described pharmacist interventions or recommendations on drug therapy that could be implemented with the approval of an independent prescriber. 52 papers described pharmacist-prescribing activities in practice but lacked an experimental design. Prescribing protocols used were presented in 14 papers. Evidence from these studies supports the role of dependent prescribing pharmacists through positive patient outcomes. Conclusion: Few studies employed adequate research designs to control threats to internal and external validity. Additional research is needed to assess clinical, humanistic and economic outcomes to establish the viability of pharmacist prescribers. J Pharm Pract Res 2004; 34: 300–4.

Aims: To determine the number of omitted medication doses for hospital inpatients, identify the reasons and assess their severity. Method: The study involved intensive drug chart surveillance over a period of 5 days in two wards that included a wide range of medical and surgical specialties of a metropolitan teaching hospital. Inpatients receiving regular or once-only medication for at least 5 days were monitored. A multidisciplinary committee assessed the severity of the omitted doses on a visual analogue scale of 0 to 10, where 0 is no potential harm to the patient and 10 is the potential for death. Results: Drug charts for 67 inpatients were audited. A total of 4887 doses were prescribed of which 369 (7 .6%) were recorded as dose omissions. In 273 of the 369 (74%) omitted doses, there were documented reasons for omission. 120 of the 369 doses omitted were scored for severity, with 86% (103/120) of these considered to have placed the patients at some risk of harm. No omitted doses were rated above 7 in severity. Conclusion: This study identified a substantial number of doses omitted, and a significant proportion of these were for no clear reason. The majority of the omitted doses were considered to have a potentially negative effect on the patient. Greater awareness of the extent of this problem has facilitated a collaborative effort, led by pharmacists, to improve the medication administration system.