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Sommes-nous prets a partager les donnees du dossier pharmacologique informatise des patients hospitalises? To compare clinical and economic outcomes in patients receiving traditional meropenem dosing (1 g Q8H) with alternative dosing (500 mg Q6H) before and after the implementation of an autosubstitution policy based on pharmacodynamic evidence of equivalence.
A retrospective chart review of patients prescribed meropenem 5 months prior to (September 2008 – February 2009) and 5 months after the implementation of the autosubstitution policy (February – July 2009) for P&T committee approved indications was conducted.
28 patients who received meropenem 1 g Q8H and 29 who patients received 500 mg Q6H met our inclusion criteria. The pharmacodynamically optimized alternative dosing regimen of meropenem revealed similar clinical outcomes with significant economic benefits compared to the traditional dosing in the 5 month pre and post implementation period of the autosubstitution policy. Antibiotic prophylaxis is uniformly recommended for all clean-contaminated, contaminated and dirty procedures. More than half the surgeries (53.8%, n=284) were not fully compliant with all aspects of the guideline.
Obtaining blood samples from children is an activity which impacts patients, families and caregivers daily. This study evaluated the extent of agreement between PGCs determined in samples obtained via ports using the push-pull method and FLPs in children with febrile neutropenia. Children with cancer with single or double-lumen ports who were receiving gentamicin participated in this prospective study. The push-pull method of blood sampling is a reliable and safe option for obtaining PGC results in children with ports. In adult patient with febrile neutropenia, there is no difference in efficacy between single and double gram negative coverage antibiotic regimens. To compare the effectiveness and safety of a double coverage gram negative antibiotic regimen to a single coverage gram negative antibiotic regimen in pediatric febrile neutropenia patients.
Retrospective review of patients who received piperacillin-tazobactam with or without gentamicin. A novel vancomycin dosing nomogram has been developed and successfully validated at two major Canadian teaching hospitals.
For meropenem, maintaining time above minimum inhibitory concentration (MIC) relative to dosing interval (%T>MIC) at ?40% may improve clinical outcome.
The use of multiple medications can increase the risk of adverse effects, drug interactions and non-compliance with drug therapy, all of which may result in less-than-optimal health outcomes.
To examine the number and types of drugs being used by seniors, and how utilization changes as seniors age. This study examined claims for 1,039,642 seniors on public drug programs in Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia and PEI from 2002 to 2008, representing over 80% of the senior population in those provinces in 2008. Findings suggest a high proportion of seniors may be at risk for drug interactions and other adverse events due to the number of medications they are taking.
Adherence to antiretroviral is important to mitigate resistance and adolescents are considered to be high-risk for poor adherence. To determine the feasibility of a large-scale and long-term adherence study using electronic monitoring in an adolescent HIV-positive population in Uganda and to compare accuracy of pill count (PC) and self report (SR) adherence determination with adherence determination using electronic medication vials (eCAPs). Fifteen patients were included: 40% were female, the mean age was 14, the mean baseline CD4 count was 244, and average treatment duration was 9 months prior to study entry. A large-scale adherence study in Uganda is feasible using a more robust electronic monitoring system. Published guidelines for traumatic brain injured (TBI) patients include routine phenytoin prophylaxis for post-traumatic seizures (PTS). The incidence of PTS, potential drug interactions, rates of adverse drug reactions (ADR), and actual phenytoin utilization following TBI at The Ottawa Hospital (TOH) was unknown, therefore this project aimed to characterize these aspects of TBI.
In TBI patients at TOH, current phenytoin dosing results in lower than intended LD and MD and when phenytoin levels are evaluated, the therapeutic range is maintained for the minority of patients.
Pharmacotherapeutic problems (PTPs) are common in older people and can result in significant morbidity and mortality. The objectives of this study are to describe: 1) The types of PTPs present in patients who present to the clinic, and 2) medication assessment activities of the pharmacist. PTPs are common in older people with cognitive impairment or dementia, can be readily identified and managed by a clinical pharmacist. The efficacy of natural products (NPs) is being evaluated using randomized controlled trials (RCTs) with increasing frequency, yet a search of the literature did not identify a widely accepted critical appraisal instrument developed specifically for use with NPs.
The objective of this project was to develop and evaluate a critical appraisal instrument sufficiently rigorous to be used in evaluating RCTs of conventional medicines with a section specific for use with single entity NPs, including herbs and natural sourced chemicals. A new instrument for the critical appraisal of RCTs of NPs was developed and tested that is distinct from other available assessment instruments in its systematic development and validation. The ADapting pharmacists’ skills and Approaches to maximize Patient’s drug Therapy effectiveness (ADAPT) blended e-learning and experiential program (being piloted across Canada) aims to help pharmacists integrate professional skills required for collaborative patient care into everyday practice. To describe the demographics of the ADAPT pilot cohort, their preparedness and motivation levels and reasons for participating.
The pilot cohort of ADAPT participants represents both new and experienced practitioners with varied backgrounds.
Opportunities to improve patient safety are hindered by wide-spread under-reporting of medication errors.
A comparative case study analysis of medication error reporting practices and beliefs at four community hospitals in Nova Scotia was completed using focus groups (with physicians, pharmacists, and nurses) and in-depth interviews (with risk managers). Careful analysis of the textual data identified themes related to incentives for, barriers to, and positive facilitators of medication error reporting. These results could be used by hospitals to encourage reporting of medication errors and ultimately make organizational changes leading to a reduction in the incidence of medication errors and an improvement in patient safety. Mental health disorders pose a significant burden to the Canadian health care system, both from an epidemiological and financial perspective. Medication incidents from the ISMP Canada database were collected from October 7, 2000 to July 29, 2009. A total of 88 incidents were included in the analysis; 82 had an outcome of harm, and 6 had an outcome of death.
The results of this analysis can provide insights into areas for system improvements for the use of psychotropic medications. At the Children’s Hospital of Eastern Ontario, medication related events represent the highest percentage of patient safety incidents (28%). To identify and prioritize potential failures in morphine prescribing, so that these parts of the morphine prescribing process in greatest need of change are acted upon. A failure mode effects analysis (FMEA) was used by the multidisciplinary team to diagram the process of prescribing morphine and to brainstorm potential failure modes and predict their effects should the failures occur in real-time. 70 failure modes were identified and prioritized these using severity, detectability and frequency as scores.

Can a Pharmacy Student-Pharmacist Model Be Used to Overcome Challenges and Sustain Admission Reconciliation? Although many hospitals have started implementing admission medication reconciliation, sustaining it for all patients organization-wide can be challenging. One pharmacy student coordinated the process in the 120-bed oncology hospital; other students provided support when needed. Main challenges identified and addressed through the process map evaluation and collaborative effort were: 1) difficulty in identifying patients requiring a BPMH 2) efficiently tracking completed BPMHs with a paper-based recording system and 3) competing pharmacist workload priorities limiting time for reconciliation.
A collaborative model was developed that optimally facilitated an effective process of students (conducting BPMHs) supporting pharmacists in achieving target patient admission reconciliation. Clinical outcomes of proportion of patients afebrile at 72 hours, time to defervescence and clinical failure rate were assessed. No significant differences in baseline demographics, indication for meropenem use, duration of therapy, and concomitant antibiotic use were observed between groups. The type, dosing and timing of antibiotic administration is critical to its efficacy in reducing surgical infections. Gynecology-oncology (Gyn-Onc) surgeries were the highest at 85.7% (n=18) and urological surgeries were lowest at 22% (n=9).
Non-compliance was a result of inappropriate antibiotic selection, antibiotic dose and (or) timing of antibiotic administration. In children with cancer, blood samples are routinely drawn from subcutaneous central venous catheters (ports) using the discard method, finger lancet punctures (FLPs) or venipunctures to determine the plasma gentamicin concentrations (PGCs) required to individualize gentamicin dosing. PGCs were determined in blood samples obtained via the port using the push-pull method and via FLP. Outcomes of these different antibiotic regimens have not been assessed in the pediatric population.
The single coverage group received additional gram negative antibiotics more frequently than the double coverage group. Paul’s Hospital nomogram development and 78 patients were used for Vancouver General Hospital’s nomogram development.
Monte Carlo Simulations (MCS) using pharmacokinetic parameters of healthy subjects showed that prolonged infusion (PI) (?3 hours) improved probability of target attainment (pTA) over short infusion (SI). Drug classes were defined using the World Health Organization’s Anatomical Therapeutic Chemical classifications. This illustrates the importance of medication management strategies for seniors, and the need for communication between health care providers regarding seniors’ drug regimens.
Adherence measurements produced by pill counts and self reporting methods appear to overestimate adherence measured electronically.
Data were collected for the first 7 days of admission (or until discharge if earlier) and included demographics, loading (LD) and maintenance (MD) phenytoin dosing parameters, phenytoin levels, seizure occurrence, potential drug interactions, concomitant medications with anti-seizure properties and documented adverse reactions secondary to phenytoin.
Charts of 20 patients who were assessed between July 28-Sept 28th, 2010 were reviewed for demographic data, diagnoses, medications, and care plans.
Such an instrument would aid pharmacists and other health care providers in evaluating the evidence from trials of NPs to determine the quality of the evidence and applicability of results to their patients. The instrument is being used by pharmacists as well as academics teaching students critical appraisal skills. Understanding the pilot participants helps with understanding other results of the program evaluation.
Study Design and Methods: The ADAPT evaluation is a multi-component, mixed-methods assessment. They recognize the need for change and are motivated to engage in ongoing education to seek skills to adapt to change and improve patient care.
Data from these reports can be used to improve processes, identify areas for progress, and prevent similar errors from occurring in other settings. Focus groups and interviews were audio taped, transcribed verbatim, and analyzed for thematic content using the template style of analysis. Incentives were thematized into three categories: patient protection, provider protection, and professional compliance.
Future research efforts should focus on evaluating the effectiveness of implementing various strategies suggested for improving medication error reporting. Given the prevalence and financial burden of treating mental disorders, it is imperative that there is a strong emphasis on safe medication practices when managing psychotropic medications. Incidents with an outcome of harm or death involving antipsychotics, antidepressants, antimaniac agents, sedatives and hypnotics were included. These incidents occur at different patient care settings including the hospital, community pharmacy and long term care. The potential contributing factors identified provide a solid foundation for the development of solutions to minimize the recurrence of similar incidents.
Following this, the team identified causes of failure modes and prioritized these using severity, detectability and frequency. Single point weaknesses are steps so critical that their failure would result in a system failure or adverse event.
We attempted a quality improvement initiative to 1) identify and address workflow challenges and 2) explore whether a collaborative model of pharmacy student supporting pharmacists conducting best possible medication histories (BPMH) could sustain a target of > 80% of all admitted patients receiving reconciliation. All students were trained and certified in performing medication histories and reconciliation. Overall, 470 patients were admitted to inpatient units over the course of 11 weeks of observation in 2010.
We believe a similar model can successfully aid other hospitals having challenges sustaining reconciliation, while providing students with the opportunity to actively learn and engage in essential direct patient care. Why we should love and hate, why vegetarianism and why not drug, alcohol etc.     PEACEFUL LIVING PROGRAM - in pyramid cottage -    For mental, spiritual, internal peace and nature living in pyramid cottage with lush green peaceful atmosphere, unrestrained daily routine, voluntary yoga, pranayam, meditation, cleansing acts, spiritual class, personal chintan-sadhana etc. A cost minimization analysis was completed to quantify any cost savings accrued through implementation of the policy. The purpose of this audit was to evaluate the compliance with the pre-, intra-, and post-operative recommendations for antibiotic prophylaxis at a tertiary care hospital.
Agreement between PGCs determined in port and FLP blood samples was assessed by the intraclass correlation coefficient (ICC), Bland-Altman analysis and comparison of simulated dose adjustments. Wilcoxon Rank-Sum Test was used to compare duration of fever and change in serum creatinine between the two treatment groups. Although statistically significant, the change in serum creatinine in the double gram negative coverage group compared to the single coverage group was not clinically significant. Expansion of the nomogram to include patients with impaired renal function in addition to prospective evaluation of the nomogram is underway. Although it may be appropriate for a patient to be taking a high number of medications, the additional risks should be considered.

The number of drugs was calculated as the number of unique drug classes a person claimed in a given year. The most commonly used drug classes were used to treat chronic conditions such as high cholesterol, high blood pressure, heart failure, and emphysema. The Memory Clinic at the Centre for Family Medicine Family Health Team is a novel, primary-care based, inter-professional clinic for patients with cognitive impairment that includes a clinical pharmacist as part of the team. Pharmacotherapeutic interventions were necessary for most (95%) patients and consisted of discontinuing anticholinergic drugs (10%), medications without an indication (30%), untreated conditions (20%), and undertreated conditions (45%). The new assessment instrument was assembled based on content of the two lists and the addition of a Review’s Conclusion section. This component captured demographic information, preparedness and motivation levels (analyzed with descriptive statistics). Participants regularly engage in ongoing education, many possessing additional certifications. Barriers were thematized into five categories: reporter burden, professional identity, information gap, organizational factors, and fear. By analyzing the incidents involving psychotropic medications, systems based contributing factors could be identified which can inform quality improvement initiatives. A quantitative analysis was conducted to provide an overview of various trends such as the severity of outcome.
A number of themes have been identified and were classified under the patient care setting where the incident occurred.
Due to the voluntary nature of the Safety Reporting System, the recorded number of 38 reported events is likely an underestimation. In order to identify challenges, process maps were developed outlining the steps in the medication reconciliation workflow. Differences in dose adjustments calculated using port and FLP PGCs were clinically insignificant in the majority (88.4%) of cases. Validation in a total of 80 test patients showed that the integrated nomogram had the highest predictive success in the St. 3-hydroxy-3-methyl-glutaryl-Coenzyme A reductase inhibitors were the most commonly used drug class among seniors aged 65 to 84, while single-ingredient angiotensin-converting enzyme inhibitors were the most commonly used class among those aged 85 and over. Person-pill-days (one day where adherence was measured for one medication in one person) was calculated for each patient and a weighted paired t-test was then used to compare the levels of adherence among all subjects for the three different adherence methods.
There is a paucity of literature regarding the types of PTPs that burden these patients and that may be identified and managed by a clinical pharmacist. Qualitative analysis of introductory posts included deductive and inductive methods to identify themes. Positive facilitators were thematized into three categories: reducing reporter burden, closing the communication gap, and educating for success. A qualitative analysis was conducted to identify recurrent themes and contributing factors. For example, in the hospital setting, the themes identified included “multiple medications”, “incorrect dose”, “incorrect patient”, “incorrect medication”, “change in order”, “transitions of care” and “dose omission”. Although not the sole contributing factor, prescribing practices contributed to a number of these incidents. Secondly those scored with severity 5, meaning a severe or catastrophic effect should a failure of the step occur (n = 12). Compliance with recommendations was defined as appropriate antibiotic selection, dose and timing at each stage of surgery (pre-, intra- and post-operative). The acceptable targets for the lower limit of the ICC and Bland-Altman limits of agreement were ? 0.80 and ±6%, respectively. Addition of gram negative coverage antibiotics occurred more frequently in the single coverage group. The most frequent were initiating medications (21%), a change in dose (13%), discontinuing medications or switching to alternative medications (12% each), provide patient education (12%), and enhance adherence (10%).
Participants indicated they would report medication errors more frequently if reporting were made easier and if educated about the reporting process and timely feedback. Incidents classified under these themes were further analyzed to identify potential contributing factors.
Finally, risk priority number (RPN) which is calculated based on frequency, detectability and severity (n = 5). Team performance was monitored daily, posted weekly and new process improvements were implemented weekly. Voluntary fast, meditation in pyramid cottage with swar vigyan practices unrestrained daily routine. The overall compliance with antibiotic prophylaxis at University Health Network was 46.2% (n=244). Differences in simulated dose adjustments calculated using either the port or FLP samples that differed by > 20% were considered to be clinically significant.
Mean percent increase in serum creatinine was 25% in the double coverage group and 10% in the single coverage group (p = 0.03).
93%, 67% and 23% of patients had a measured compliance of greater than 95% among SR, PC and eCAP methods, respectively. Examples of contributing factors identified included complicated instructions in orders, pre-pouring of medications and the lack of a systematic medication reconciliation process.
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