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Background: The provision of information by pharmacy staff is a key factor to ensure patients’ understanding and quality use of medications, including antibiotics. However, little is known regarding the transmission of information between pharmacy staff and patients in Indonesia. Objective: This study aimed to identify information on antibiotics provided by pharmacy staff and recalled by patients in an Indonesian outpatient setting. Methods: The study was conducted in a hospital outpatient clinic in Malang, Indonesia, in 2019. A checklist was used to obtain the data on information provided by pharmacy staff, while interviews were conducted to determine information recalled by patients (only presenting patients were included); a total of 15 information items - i.e. 14 essential and one secondary - were observed. Descriptive analysis was used to summarise data on the checklists (‘given’ versus ‘not given’) as well as responses from the interviews (‘recalled’ versus ‘missed’). Results: Eleven pharmacy staff (two pharmacists and nine pharmacy technicians) were involved in providing information for patients obtaining oral antibiotics during the study period. Of 14 essential information items, only about half was given by pharmacy staff, with pharmacists significantly providing on average more information items than pharmacy technicians (7.96 versus 7.67 respectively; p90%) included “antibiotic identification”, “indication”, administration directions (i.e. “dosage”, “frequency”, “hour of administration”, “administration before/after meal”, “route of administration”), and “duration of use”. A total of 230 patients consented to the study, giving 79.9% response rate. The average number of information items recalled by patients was 7.09 (SD 1.45). Almost all patients could recall information on administration directions [i.e. “route of administration” (97.0%), “frequency” (95.2%), “dosage” (92.6%), “hour of administration” (85.7%), “administration before/after meal” (89.1%)] and “duration of use” (90.9%). Fewer patients were able to recall “antibiotic identification” (76.5%) and “indication” (77.0%). Conclusions: Pharmacy staff provided antibiotic information in a limited fashion, while patients showed adequate ability to recall the information given to them. Further study is needed to better understand the effective process of information transmission between pharmacy staff and patients, especially if more information was provided, to better optimise the use of antibiotics in outpatient settings in Indonesia.

Background: Hospital readmissions are considered as the primary indicator of insufficient quality of care and are responsible of increasing annual medical costs by billions of dollars. Different factors tend to reduce readmissions, particularly instructions at discharge. Objectives: Our study objective was to evaluate discharge instructions given to hospitalized Lebanese patients and associated factors. Methods: Two hundred patients, aged between 21 and 79 years and admitted to the emergency department, were recruited from a Lebanese university hospital. Discharge instructions were evaluated by a face-to-face interview to fill a questionnaire with the patients immediately after their final contact with the physician or nurse in charge. We mainly focused on medications instructions and created two scores related to “instructions given” and “instructions appropriate” to later conduct bivariate analysis. Results: We found that discharge instructions were not completely given to all our study population. The degree of appropriateness fluctuated between 25% and 100%. The instructor in charge of giving discharge instructions had its significant influence on medication instructions given (p=0.014). In addition, the instructor and his experience influenced the degree of “appropriate instructions”. In fact, our study showed that despite being capable of giving good medication advice, nurses’ instructions were significantly less effective in comparison with physicians, fellows and residents. However, nurses gave 52% of the instructions, which questions the quality of those instructions. Conclusions: In conclusion, our observational study showed that in a Lebanese university hospital, patients’ understanding of discharge instructions is poor. Careful attention should be drawn to other hospitals as well and interventions should be considered to improve instructions quality and limit later complications and readmissions. The intervention of clinical pharmacists and their medication-related advice might be crucial in order to improve instructions’ quality.

Background: Based on a retrospective study performed at our institution, 38% of inpatients living with human immunodeficiency virus (HIV) were found to have a medication error involving their anti-retroviral (ARV) and/or opportunistic infection (OI) prophylaxis medications. Objective: To determine the impact of a dedicated HIV-trained clinical pharmacist on the ARV and OI prophylaxis medication error rates at our institution. Methods: A prospective quality improvement project was conducted over a six month period to assess the impact of a dedicated HIV-trained clinical pharmacist on the ARV and OI prophylaxis medication error rates. IRB approval received. Results: There were 144 patients included in this analysis, who experienced a combined 76 medication errors. Compared to historical control study conducted at our institution, the percent of patients who experienced a medication error remained stable (38% vs. 39%, respectively) and the error rate per patient was similar (1.44 vs. 1.36, p=NS). The percent of medication errors that were corrected prior to discharge increased from 24% to 70% and the median time to error correction decreased from 42 hours to 11.5 hours (p

Objective: The objectives of this study were to evaluate the current practice of postoperative fluid prescribing and assess the effectiveness of pharmacist-led intervention in the implementation of the National Institute of Health and Care Excellence (NICE) fluid therapy guideline in an Iraqi hospital. Methods: The prospective interventional study was conducted at AL-Hilla Teaching Hospital, Babylon, Iraq between November 2017 and July 2018. The study included two phases: The pre-intervention phase with 84 patients and the post-intervention phase with 112 patients. A pharmacist provided training and educational sessions for the hospital physicians and pharmacists about the NICE guideline of fluid therapy. The researcher calculated the amount of given post-operative fluids and compared to the NICE guideline and also measured the patients’ body weight, serum Na, K and creatinine pre-and post-operatively. Results: The pre-intervention phase showed no correlation between the amounts of prescribed fluids and body weight which caused increases in patients’ body weight. In pre-intervention phase, 6% of patients experienced hyponatremia, 19% had hypernatremia and 7.1% had hypokalemia. In the post-intervention phase, abnormal level of electrolytes and patient weight gain decreased significantly. Additionally, the intervention led to a strong correlation between body weight and amount of prescribed fluids in addition to lowering the incidence of electrolyte disturbances. Conclusions: A high proportion of patients in the pre-intervention phase experienced fluid overload, weight gain and electrolyte disturbances when fluid therapy was not prescribed in accordance with the NICE guidelines. The pharmacist-led intervention increased the surgeon awareness of the proper use of the NICE guideline which decreased the incidence of fluid-related complications and the inconsistency of fluid prescribing. Pharmacists can play a critical role to enhance post-operative fluid prescribing and minimize fluid-induced complications.

Background: Patients requiring medications during discharge are at risk of discharge medication errors that potentially cause readmission due to medication-related events. Objective: The objective of this study was to develop interventions to reduce percentage of patients with one or more medication errors during discharge. Methods: A pharmacist-led quality improvement (QI) program over 6 months was conducted in medical wards at a tertiary public hospital. Percentage of patients discharge with one or more medication errors was reviewed in the pre-intervention and four main improvements were developed: increase the ratio of pharmacist to patient, prioritize discharge prescription order within office hours, complete discharge medication reconciliation by ward pharmacist, set up a Centralized Discharge Medication Pre-packing Unit. Percentage of patients with one or more medication errors in both pre- and post-intervention phase were monitored using process control chart. Results: With the implementation of the QI program, the percentage of patients with one or more medication errors during discharge that were corrected by pharmacists significantly increased from 77.6% to 95.9% (p

© 2019, Grupo de Investigacion en Atencion Farmaceutica. All rights reserved. Background: Drug utilisation studies from paediatric hospitals that do not have access to patient level data on medication use are limited by a lack of standardised units of measures that reflect the varying daily dosage requirements among patients. The World Health Organization’s defined daily dose is frequently used in adult hospitals for benchmarking and longitudinal analysis but is not endorsed for use in paediatric populations. Objective: Explore agreement between standard adult-based defined daily doses (DDD) and paediatric estimates of daily injectable antibiotic use in a Paediatric Intensive Care Unit that does not have access to individual patient-level data. Methods: Hospital pharmacy antibiotic use reports and age-specific occupied bed-day data from 1 January 2010 to 31 May 2016 were extracted. Paediatric reference dosages and frequencies for antibiotics were defined and applied to three paediatric units of measure. Measures were applied to extracted data, agreement between antibiotic use measured in the adult DDD and each of the paediatric measures was assessed visually via Bland-Altman plots and linear regression for each antibiotic. Results: Thirty one different antibiotics were used throughout the study period. Despite varying daily dosages in grams, the daily use of vials was unchanged from birth to 18 years for thirteen antibiotics. Agreement between DDD and vial-based measures was closer than the total recommended daily dose that did not account for wastage during preparation and administration. Vial-based measures were unaffected by vial size changes due to drug shortage. Conclusions: Agreement between the DDD and vial-based measures of use supports the use of DDD for select antibiotics that may be targeted by antimicrobial stewardship programs. Vial based measures should be further explored in hospitals with single vial policies; detailed understanding of hospital practice is needed before inter-hospital comparisons are made.

Background: Benzodiazepine and z-hypnotic prescribing has slowly decreased over the past 20 years, however long-term chronic prescribing still occurs and is at odds with prescribing guidance. Objectives: To identify the pattern of benzodiazepine and z-hypnotic prescribing in psychiatric inpatients at discharge and 12 months post-discharge. Methods: Retrospective observational longitudinal cohort study of patients admitted to two adult psychiatric wards between June and November 2012 (inclusive) who were discharged with a prescription for a benzodiazepine or z-hypnotic drug. Routinely collected prescription data available from NHS Scotland Prescribing Information System was used to identify and follow community prescribing of benzodiazepine and z-hypnotics for a 12 month period post-discharge. Data were entered in Excel® and further analysed using SPSS 23. Ethical approval was not required for this service evaluation however Caldicott Guardian approval was sought and granted. Results: Eighty patients were admitted during the study period however only those patients with a single admission were included for analysis (n=74). Thirty per cent (22/74) of patients were prescribed a benzodiazepine or z-hypnotics at discharge; 14 of whom received ‘long-term’ benzodiazepine and z-hypnotics i.e. continued use over the 12 month period. Seven patients received a combination of anxiolytics and hypnotics (e.g., diazepam plus temazepam or zopiclone). Long-term use was associated with a non-significant increase in median benzodiazepine or z-hypnotic dose, expressed as diazepam equivalents. Conclusions: One in three patients were prescribed a benzodiazepine or z-hypnotics at discharge with 1 in 5 receiving continuous long-term treatment (prescriptions) for 12 months post-discharge. As chronic long-term B-Z prescribing and use still remains an issue, future strategies using routine patient-level prescribing data may support prescribers to review and minimise inappropriate long-term prescribing.

Background: There is a dearth of literature on perceptions of preparedness to practise, which explores the extent to which educational institutions prepare their students to fulfil their professional role. Objective: The aim of this study was to explore perceptions of preparedness to practise among Saudi Arabian pharmacy graduates working in hospital. Method: Face-to-face, semi-structured interviews were conducted with ten hospital pharmacists based in four hospitals in the Eastern Province of Saudi Arabia who had qualified within the last five years from a Saudi Arabian School of Pharmacy. Interviews focused on expectations of hospital practise, perceptions of preparedness and challenges encountered, and reflections on how to better prepare students. Interviews were audio-recorded, transcribed and analysed thematically by two independent researchers using the Framework Approach. Results: Five key themes were identified: expectations versus reality of practise; issues relating to university course; practice related training; adapting to the work environment; and proposed improvements to undergraduate education. Participants were generally disappointed to find practise was not as expected. University training was largely didactic, with skills such as critical thinking not being sufficiently developed. Where practice related training was provided, it was variable in length and content. Cultural issues, most notably working in a mixed sex environment, were also considered to impact preparedness. Suggested improvements included greater focus on skills development and structured training placements. Conclusions: Participants experiences in university, and experiential placements varied greatly and were perceived to impact greatly on preparedness to practise. Further multiple perspective exploration of perceptions of preparedness to practise is warranted.

Background: Currently, clinical pharmacists have in-depth therapeutic knowledge and scientific skills to act as drug therapy experts in healthcare settings. Objective: The aim of this study was to assess the opportunities and challenges of clinical pharmacy services from the health practitioners’ perspective in University of Gondar (UOG) hospital Ethiopia. Methods: A qualitative study was performed using face-to-face in-depth interviews with health practitioners who were directly involved in clinical pharmacy services (clinical pharmacists, physicians, and nurses) in UOG hospital. Results: A total of 15 health professionals from various specialties were interviewed to express their views towards clinical pharmacists’ competencies and identified challenges and opportunities regarding their clinical services. Based on interviewees report, the opportunities for clinical pharmacists includes acceptance of their clinical services among health specialties, new government policy and high patient load in hospital. However, inadequacy of service promotions, lack of continuity of clinical pharmacy services in wards, poor drug information services, lack of commitment, lack of confidence among clinical pharmacists, conflict of interest due to unclear scope of practice, and absence of cooperation with health workers were some of the challenges identified by the interviewees. Conclusion: We identified health professionals working in UOG hospital are receptive towards clinical pharmacy services, but identified some of the potential challenges that needed to be focused to strengthen and promote clinical pharmacy services. Further, the opportunities at hand also need to be utilized astutely to boost the services.

Background: Drug and Therapeutics Committees (DTCs) were founded about a century ago as a guide for dealing with drugs in hospitals. Since then, it has shown a vital role in rational drug use in terms of regulatory and educational activities. Objective: To describe structures, functions, and activities of hospital DTCs. Methods: A questionnaire was developed based on previous studies. Questions consisted of information on respondents’ demographics; structures, functions, and activities of DTCs; drug selection process and resources used, and factors and criteria used in drug selection. Results: The overall response rate was 95%. DTCs were mainly present in most large hospitals (45%). All DTCs had hospital pharmacists in their structure and most of them (66%) met monthly. The main responsibilities of DTCs were related to general prescribing policies. The number, frequency, and severity of adverse drug reactions were the most reported criteria for the drug selection process. Legal implications for practical, economic, and organizational factors were the most important factors that were reported for drug selection. Conclusions: DTCs are mainly present in most large hospitals. The main responsibilities of the DTC in Jordanian hospitals are general prescribing policies, drug selection, hospital formulary editing, and reporting of ADR to external authorities.

Background: Inappropriate use of antimicrobial agents is one of the most important factors in inducing resistance and prolonged hospitalization as well as increase in patient mortality rate. Objective: The aim of this study was to evaluate aminoglycosides (AGs) usage pattern at intensive care units (ICUs) of Nemazee hospital Shiraz, Iran. Methods: In this cross-sectional study, the usage pattern of AGs was evaluated during 32 months. Guidelines for AGs usage were approved by the drug and therapeutic committee of the hospital, and criteria were developed to assess 11 parameters involving AGs therapy, such as proper indication for the use of the drug, dosage and duration of therapy. Clinical parameters, such as microbial culture and sensitivity, serum creatinine (SCr) and creatinine clearance, and white blood cell count were evaluated. Results: Ninety-five patients were recruited, 50 male and 45 females. In most patients (64%) the origin of infection was hospital and only in 36% of them, community was the source. Ventilator associated pneumonia (27%), central nervous system (25%) and urinary tract infection (10%) were the most important indications for AGs prescription. Scores of AGs usage at Nemazee hospital was calculated as 5.9 out of 11, which meant that in only 54% of cases AGs prescription was based on guideline proposed by the Department of Clinical Pharmacy of Nemazee Hospital. Conclusions: Non-adherence to the guidelines occurred frequently in the ICUs of Nemazee hospital. Prescription of loading dose, and AGs level measurement were not done and evaluating microbiological data was often neglected. Incorporating pharmacists in the health care team and holding training programs for physicians and nurses with the goal of raising awareness about the proposed guideline.

Background: Pharmacist involvement has been shown to improve various aspects of patient care. Patients undergoing knee and hip replacement surgery generally experience post-operative pain and discomfort. Pain control can impact patient satisfaction, as reported by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Objective: The current pilot study aims to measure the potential impact that incorporating pharmacists into preoperative patient education programs has on the response to select HCAHPS questions. Methods: Patient responses to two select HCAHPS questions related to pain were recorded for a year prior to pharmacist involvement in a comprehensive preoperative patient education program (2012) and a year after pharmacists became actively involved (2013). Results: In all reporting surgical patients, there was a modest 3.68% improvement in mean scores reflecting patient’s feelings that hospital staff did “everything they could” to attend to their pain (mean2012=3.66, SD=0.63 versus mean2013=3.80, SD=0.43, p=0.018, Mann-Whitney U test). There was a non-significant 2.98% improvement in scores reflecting the level that pain was “well controlled” (mean2012=3.54, SD=0.651 versus mean2013=3.65, SD=0.554, p=0.069, Mann-Whitney U test) in surgical patients. Conclusion: The results suggest comprehensive pharmacist involvement in patient education prior to joint replacement surgery may impact HCAHPS scores related to pain control. While the observed potential improvements were modest, the current results justify larger, multi-institution prospective studies to better elucidate the impact pharmacists can have on pain management in patients undergoing joint replacement.

Objectives: To evaluate the impact of a pharmacy-technician centered medication reconciliation (PTMR) program by identifying and quantifying medication discrepancies and outcomes of pharmacist medication reconciliation recommendations. Methods: A retrospective chart review was performed on two-hundred patients admitted to the internal medicine teaching services at Cooper University Hospital in Camden, NJ. Patients were selected using a stratified systematic sample approach and were included if they received a pharmacy technician medication history and a pharmacist medication reconciliation at any point during their hospital admission. Pharmacist identified medication discrepancies were analyzed using descriptive statistics, bivariate analyses. Potential risk factors were identified using multivariate analyses, such as logistic regression and CART. The priority level of significance was set at 0.05. Results: Three-hundred and sixty-five medication discrepancies were identified out of the 200 included patients. The four most common discrepancies were omission (64.7%), non-formulary omission (16.2%), dose discrepancy (10.1%), and frequency discrepancy (4.1%). Twenty-two percent of pharmacist recommendations were implemented by the prescriber within 72 hours. Conclusion: A PTMR program with dedicated pharmacy technicians and pharmacists identifies many medication discrepancies at admission and provides opportunities for pharmacist reconciliation recommendations.

Background: Early intravenous to oral (IV-PO) antibiotics switch, which is one of the important elements in antimicrobial stewardship (AMS) is not well implemented in Malaysian district hospitals. A systematic interventional strategy is required to facilitate IV-PO antibiotic switch. Objective: This study aimed to evaluate the impact of printed AMS recommendations on early IV-PO antibiotics switch practice in district hospitals. Methods: This study was an interventional study conducted in medical wards of eight Sarawak district hospitals from May to August 2015. In pre-intervention phase, pharmacists performed the conventional practice of reviewing medication charts and verbally informed the prescribers on eligible IV-PO switches. In post-intervention phase, pharmacists attached printed checklist which contained IV-PO switch criteria to patients’ medical notes on the day patients were eligible for the switch. Stickers of IV-PO switch were applied to the antibiotic prescription to serve as reminders. Results: 79 and 77 courses of antibiotics were studied in the pre-intervention phase and post-intervention phase respectively. Timeliness of switch was improved by 1.63 days in the post-intervention phase (95%CI 1.26:2.00 days, p

Objective: To assess adherence to current national guidelines for appropriate albumin use at an academic medical center. Methods: This retrospective chart review of 150 randomly selected patients prescribed and administered at least one dose of albumin was conducted in an urban academic medical center to evaluate the adherence of albumin orders to current national guidelines. Inclusion criteria consisted of discharged patients at least 18-years-old admitted to the intensive care unit or medical/surgical unit from September 1, 2015 to August 31, 2016. The primary outcome was the number of patients who inappropriately received albumin based on national guidelines and FDA approved indications. Secondary outcomes included the number of patients who received the incorrect concentration or dose of albumin based on indication, as well as the cost associated with inappropriate albumin prescribing. Descriptive statistics were used to report outcomes. Results: There were 68 instances (45%) where albumin was prescribed inappropriately according to guideline recommendations. Of the 82 instances where albumin was used appropriately, 18 patients received an incorrect dose (22%), and 6 received the inappropriate concentration of albumin (7%). The cost for the 150 patients included in the study associated with inappropriate albumin prescribing was approximately $13,000. Conclusions: This study identified areas for pharmacist intervention to ensure appropriate albumin utilization, as well as proper dosing for the most frequently incorrectly dosed indications, including hepato-renal syndrome, spontaneous bacterial peritonitis, and paracentesis. This study also identified an unexpected indication with significant inappropriate albumin utilization, perioperative hypotension, which is an area for further intervention to monitor and decrease use.

Objective: To identify and describe actual or potential medication errors related to drug information inquiries made by staff members of a teaching hospital to a Drug Information Centre from January 2012 to December 2013. Methods: Data were collected from the records of inquiries made by health care professionals to the Drug Information Centre throughout this period. Results: During the study period, the Drug Information Centre received 3,500 inquiries. Of these, 114 inquiries had medication errors. Most errors were related to prescribing, preparation, and administration and were classified according to severity as category B (57%) (potential errors) and categories C (26.3%) and D (15.8%) (actual errors that did not result in harm to the patient). Error causes included overdose (13.2%), wrong route of administration (11.4%), inadequate drug storage (11.4%), and wrong dosage form (8.8%). The drugs most frequently involved in errors were vitamin K (4.4%), vancomycin (3.5%), and meropenem (3.5%). Conclusion: In this study, it was not possible to measure the reduction in error rate involving medication use because of the lack of previous data on this process in the institution. However, our findings indicate that the Drug Information Centre may be used as a strategy to seek improvements in processes involving medication use. Objetivo: Identificar uy describir los errores de medicación potenciales y reales relacionados con consultas de información sobre medicamentos realizadas por personal sanitario de un hospital universitario a un centro de información sobre medicamentos entre enero 2012 y diciembre 2013. Métodos: Se recogieron los datos de las fichas de consultas realizadas por el personal sanitario al centro de información de medicamentos durante este periodo. Resultados: Durante el periodo de estudio el centro de información de medicamentos recibió 3.500 consultas. De esas, 114 consultas tenían errores de medicación. La mayoría de los errores estaban relacionados con prescripción, preparación y administración, y se clasificaron de acuerdo a su gravedad como categoría B (57%) (errores potenciales) y categorías C (26,3%) y D (15,8%) (errores reales que o produjeron daño en el paciente). Las causas de ero incluían sobredosis (13,2%), via de administración equivocada (11,4%), almacenamiento inadecuado del medicamento (11,4%), y forma farmacéutica equivocada (8,8%). Los medicamentos más involucrados en los errores eran la vitamina K (4,4%), vancomicina (3,5%), y meropenem (3,5%). Conclusión: En este estudio no fue posible medir la reducción de la tasa de errores relativos al uso de medicamentos por la falta de datos previos sobre este proceso en la institución. Sin embargo, nuestros hallazgos indican que el centro de información de medicamentos puede ser utilizado como una estrategia para buscar mejoras en el proceso de uso de medicamentos.

Background: Vancomycin is used primarily for Gram-positive infections. Recommended dosage regimens and targeted therapeutic levels vary between institutions. Objectives: This study aims to describe therapeutic levels according to initial vancomycin doses and patient’s age. A secondary objective was to evaluate appropriateness of vancomycin use in our hospital. Methods: A retrospective chart review was conducted at the Children’s Hospital of Eastern Ontario. Patients included in this study were classified by age (neonates, infants, children and adolescents) and categorized into those who received vancomycin ≤5 and >5 days. Initial vancomycin dosing regimens and corresponding initial trough levels obtained were evaluated. Initial trough levels drawn in relation to the third, fourth, or fifth doses corresponding to the first course of therapy were analyzed. Acceptable trough levels ranged from 5-20 mg/L. Results: One-hundred-and-sixty-four patients who received intravenous vancomycin in 2013 were included. Of the 229 courses of vancomycin, 190 (83%) were used 5 days or less (mean 4.9 days). Sixteen infants (88.9%) and 21 adolescents (100%), who received vancomycin empiric dosing of 60 mg/kg/day, had initial trough levels >5mg/L. However, in the children’s group 20 (37.7%) did not reach levels >5 mg/L. None of vancomycin minimum inhibitory concentration (MIC) values were >1mg/L for the four patients who had infections due to methicillin-resistant Staphylococcus aureus strains. Conclusions: In our institution, initial empiric vancomycin dosing of 60 mg/kg/day resulted in levels ≥5mg/L in most infants and adolescents. It remains unclear why some children aged 1-12 years did not achieve these levels.