PHASE 1: IDENTIFICATION OF DRUG - RELATED PROBLEMS
3.4 DATA PRESENTATION, ANALYSIS AND INTERPRETATION
3.4.6 ANALYSIS OF PRESCRIPTION INTERVENTIONS
The data on the PIP was analysed as for the patient profile. However, the actual prescription interventions were further classified into categories, types and significance, which will be discussed next.
Drug reloted problems among geriatric out-patients at a public sector hospital: An intervention study
3.4.6.1 DRPs warranting prescription interventions
In analysing the intervention data to present the results in the most meaningful way, several classification systems were investigated. Those that were potentially useful were modified to form a comprehensive categorization system. The classification in Table 3.4.7 was found useful, as it best illustrated the professional expertise from which the patients benefited. Pharmacist recommendations (or pharmacist-initiated interventions) and prescribing errors, were used as the basis for the analysis.
Drug reloted problems among geriatric out-patients at a public sector hospital: An intervention study
Table 3.4 DRPs warranting prescription interventions DRPs WARRANTING PRESCRIPTION INTERVENTIONS 1. PRESCRIPTION INFORMATION OMISSION
•
Drug omitted / not specified•
No strength specified where multiple strengths available•
Dose or dosage regimen is not specified•
Dosage form not specified / unavailable•
Quantity to dispense/ duration of therapy not specified•
Vague / Incomplete directions for use•
Prescription order is illegible•
Violates legal requirements -Unsigned by prescriber - Undated2. PRESCRIBING ERROR
•
Inappropriate / incorrect drug or medical indication•
Inappropriate dose /dosage regimen/strength - extra or wrong dose- subtherapeutic dose - potentially toxic dose
•
Inappropriate dosage form / route of administration•
Inappropriate quantity / duration of therapy•
Inappropriate dosage interval•
Incorrect patient name on prescription•
Policy infraction - non-coded item -Item restricted to specialist use-Item restricted to certain specialists only - > five items on prescription
•
Drug is out of stock•
Less costly medicine available•
Other3. DRUG INTERACTIONS
•
Drug-drug•
Drug - OTe drug•
Drug - disease•
Drug-food•
Drug - allergy / sensitivity•
Drug-age•
Drug - lifestyle•
Other4. DRUG THERAPY MONITORING
•
Allergy / sensitivity / contra-indication•
Side effects / toxicity / suspected adverse reaction•
Duplication of drug therapy•
Overutilization - overuse of drug•
Underutilization - underuse of drug•
Patient concern / question(Rupp, 1991 Pg.76).
Drug related problems among geriatric out-patienJs at a public sector hospital: An intervention study
3.4.6.2 Significance of documented interventions
The researcher subjectively categorized the significance of each intervention into one of five categories from intervention is "not significant" to intervention is
"potentially life-saving." (Eadon, 1992).
Interventions classified as significant but not improving patient care included clarification (rather than correction) of drug strength, quantity and dosage form.
Examples of "significant" improvement in patient care were correction of doses and instructions where an error was evident, duplication of therapy and compliance problems, while "very significant" interventions were predominantly major dose corrections, which in the pharmacist's opinion would have caused serious harm to the patient.
Table 3.5 Subjective significance of documented interventions
Subjective significance of documented interventions Intervention is of no significance to patient care e.g. undated Rx
Intervention is of low significance but does not result in an improvement in patient care - infonnational only
Intervention is significant and results in an improvement in patient care (benefit could affect patient quality oflife)
Intervention is very significant and prevents major organ damage or an adverse reaction of similar importance (averted potential major trauma / dysfunction)
Intervention is extremely significant - potentially lifesaving
3.4.6.3 Categories of prescription interventions
According to Eadon (1992) prescription interventions may be classified into the following categories based on the pharmacist's knowledge in specific areas:
(A) Clinical pharmacy: recommendations based on drugs, doses and factors specific to individual patients.
- Pharmacokinetic: Dose or frequency
Dose changed based on renal function Dose changed based on hepatic function Drug assays
Drug related problems among geriatric out-patients at a public sector hospital: An intervention study
- Drug interactions
_ Inadvisable choice of drug: Hypersensitivity or intolerance
Patient factors or medical conditions (e.g. B-blockers in asthma)
Recommendations to cease due to adverse effects
(B) Pharmaceutical: (i.e. Product-orientated advice)
Advice to alter drugs or dose due to product knowledge (e.g. temazepam 5-10mg). Also advice to obtain approval to use restricted drugs or other advice related to hospital policy or legal matters. These interventions include knowledge of drug names, dose fonns, standard dosages and dose intervals frequently allows the clinical pharmacist to identify any simple errors, which occur in prescribing. The following are example of product-orientated interventions.
• Drug name errors
• Transcription errors
• Omissions
• Duplications
• Pharmacological duplications
• Legal problems (unsigned prescriptions)
• Non-compliance with hospital policy ( e.g. coding)
• Allergy documentation incomplete
• Incorrect doses
Pharmacological duplications included orders for two drugs in the same pharmacological class or having very similar phannacological activity.
(C) Therapeutic: Advice to initiate a drug or change therapy based on the pharmacist's observation of medication charts, notes, results of tests or discussions with the patient, the patient's condition and alternative therapeutic avenues (e.g.
suggesting a more appropriate antibiotic). Common therapeutic consultation interventions consisted of advising the physician about a drug for symptom control such as ordering pain relief or alternative analgesics.
Drug related problems among geriatric out-patien1s at a public sector hospital: An intervention study 105
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(D) Cost minimisation: These interventions included advice to cease unnecessary drugs or change a route or drug to a cheaper alternative. These were interventions, in which the impact was largely on reducing potential expenditure, although therapeutic benefits may also be achieved. Discontinuation of drug therapy that was inappropriate or no longer required constituted the largest category of interventions (Bebee, 1990).
(E) Other relevant recommendations of the pharmacist:
The following are some recommendations or suggestion from pharmacists from other published studies on DRPs.
• Discontinue a drug
• Order blood test
• Increase, decrease or withhold a dose
• Increase or decrease dose intervals
• Change scheduling of medications or advice on dosage scheduling
• Initiate a drug
• Change dosage form
• Change drug or dose where pharmacist has identified drug interactions
• Discontinue order for serum drug concentrations
• Change drugs within a pharmacological class
3.4.6.4 Types of Prescription Interventions
In analysing the intervention data to present the results in the most meaningful way, several classification systems were investigated. Those that were potentially useful were modified to form a comprehensive categorization system. The categorisation was found useful, as it best illustrated the professional expertise from which the patients benefited. Pharmacist recommendations (or pharmacist-initiated interventions) and prescribing errors, were used as the basis for the analysis.
Two major types for the analysis of the pharmacist interventions were used:
1. Pharmacist-initiated interventions 2. Prescribing errors
Drug reloted probkms among geriatric out-patients at a public sector hospital: An intervention study 106
Pharmacist-initiated interventions were suggested by the pharmacist to improve the monitoring and appropriateness of the patient's drug therapy, such as a request to discontinue a drug and· advice on dosage scheduling. Prescribing errors (errors of commission) included wrong drug; doses outside the recommended range and failure to indicate required drug the strength.
3.4.6.5 Preventability of DRPs
Many DRPs should be avoidable due to their predictability, and it is reported in previous studies that around half are preventable. The DRPs identified were categorised into therapeutic groups responsible, or other specific problems, and the circumstances surrounding the problem examined. Health care professional's responsible examined aspects of management of the patient's drug therapy in the community to assess the preventablity of the identified DRPs for the patient's drug therapy. This included the possibility of the pharmacist's contribution in the prevention ofDRPs identified in the elderly patients, rather than concentrating mainly on the role of the prescriber. The assessment was based on previously documented criteria for preventability, which were further expanded and categorised in relation to each specific drug group or problem category identified in the present study.
The categorisation of DRPs identified is illustrated using the therapeutic group non- steriodal anti-inflammatory drugs (NSAIDs) as an example. Similar categorisation was used for other drug groups (Cunningham, 1997). The assessment was based on previously documented criteria for preventability (Hallas, 1990).
(A) Definitely preventable: the DRP was due to a drug treatment inconsistent with present-day knowledge of accepted medical practice or was clearly unrealistic, considering the known circumstances. (No valid indication for prescription, prescription to patients with a past history of ADRs to NSAIDs, more than one NSAID prescribed concurrently, unreasonable dose for an elderly patient, NSAID inappropriate due to a contra-indication, unsuitable choice of NSAID for an elderly patient, NSAID prescribed to patient with past history of peptic Ulcer). If it was considered that the patient had received sub-standard care, the DRP was categorised as preventable.
Drug reiJlted prob1ems among geriatric out-patients at a public sector hospital: An intervention study
(B) Possibly preventable: the prescription was not erroneous, but the DRP could have been avoided by appropriate measures taken by the prescribing physician or pharmacist over and above the obligatory requirements. (If any of the following possible solutions could have been applied- Co-prescription of an H2- receptor antagonist or Misoprostol to those patients at high risk of side effects ofNSAIDs, counseling of patients by the prescriber and pharmacist on possible side effects of therapy and action to be taken should they occur, Patient Medication Records (PMRs) with information held on aTC medicines and disease states as well as prescribed medication.)
(C) Not preventable: the DRP could not have been avoided by any reasonable means or was an unpredictable event in the course of treatment fully in accordance with accepted medical or pharmaceutical practice e.g. the patient was using the drug for an inappropriate indication which could not have been known by the prescriber or pharmacist by reasonable means.
Drug reloted problems among geriatric out-patients at a public sector hospital: An intervention study