Clinical pharmacist evaluation of medication inappropriateness in the emergency department of a teaching hospital in Malta
Appropriate prescribing remains an important priority in all medical areas of practice.
Objective: The objective of this study was to apply a Medication Appropriateness Index (MAI) to identify issues of inappropriate prescribing amongst patients admitted from the Emergency Department (ED).
Method: This study was carried out at Malta’s general hospital on 125 patients following a two-week pilot period on 10 patients. Patients aged 18 years and over and on medication therapy were included. Medication treatment for inappropriateness was assessed by using the MAI. Under-prescribing was also screened for.
Results: Treatment charts of 125 patients, including 697 medications, were assessed using a MAI. Overall, 115 (92%) patients had one or more medications with one or more MAI criteria rated as inappropriate, giving a total of 384 (55.1%) medications prescribed inappropriately. The mean SD MAI score per drug was 1.78 (SD=2.19). The most common medication classes with appropriateness problems were biguanides (100%), anti-arrhythmics (100%) and anti-platelets (96.8%). The most common problems involved incorrect directions (26%) and incorrect dosages (18.5%). There were 36 omitted medications with untreated indications.
Conclusion: There is considerable inappropriate prescribing which could have significant negative effects regarding patient care.
2. Schwartzberg E, Rubinovich S, Hassin D, Haspel J, Ben-Moshe A, Oren M, Shani S. Developing and implementing a model for changing physicians’ prescribing habits – the role of clinical pharmacy in leading the change. J Clin Pharm Ther. 2006;31(2):179-185.
3. Weant KA, Armitstead JA, Ladha AM, Sasaki-Adams D, Hadar EJ, Ewend MG. Cost effectiveness of a clinical pharmacist on a neurosurgical team. Neurosurgery. 2009;65(5):946-950.
4. MacLaren R, Bond CA. Effects of pharmacist participation in intensive care units on clinical and economic outcomes of critically ill patients with thromboembolic or infarction-related events. Pharmacotherapy 2009;29(7):761-768.
5. Devine EB, Hoang S, Fisk AW, Wilson-Norton JL, Lawless NM, Louie C. Strategies to optimize medication use in the physician group practice: The role of the clinical pharmacist. J Am Pharm Assoc. 2009;49(2):181-191.
6. Bond CA, Raehl CL, Patry R. Evidence-based core clinical pharmacy services in United States hospitals in 2020: services and staffing. Pharmacotherapy. 2004;24(4):427-440.
7. Cobaugh D, Schneider S. Medication use in the emergency department: Why are we placing patients at risk? Am J Health Syst Pharm. 2005;62(17):1832-1833.
8. Hanlon J, Schmader K, Samsa G, Weinberger M, Uttech KM, Lewis IK, Cohen HJ, Feussner JR. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045-1051.
9. Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, Lewis IK, Landsman PB, Cohen HJ. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol. 1994;47(8):891-896.
10. Chrischilles EA, Carter BL, Lund BC, Rubenstein LM, Chen-Hardee SS, Voelker MD, Park TR, Kuehl AK. Evaluation of the Iowa Medicaid Pharmaceutical case management program. J Am Pharm Assoc. 2004;44(3):337-349.
11. Pallant J. SPSS survival manual: a step by step guide to data analysis using SPSS. 4th edition. England. Open University Press: 2010, pp. 100
12. Hanlon JT, Artz MB, Pieper CF, Linblad CI, Sloane RJ, Ruby CM, Schmader KE. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother. 2004;38(1):9-14.
13. British Medical Association and the Royal Pharmaceutical Society of Great Britain. British National Formulary. Number 49. Great Britain: The Pharmaceutical Press: 2005.
14. Barber N, Bradley C, Barry C, Stevenson F, Britten N, Jenkins L. Measuring the appropriateness of prescribing in primary care: are current measures complete? J Clin Pharm Ther. 2005;30(6):533-539.
15. Schmader KE, Hanlon JT, Landsman PB, Samsa GP, Lewis IK, Weinberger M. Inappropriate prescribing and health outcomes in elderly veterans outpatients. Ann Pharmacother. 1997;31(5):529-533.
16. Hamilton JH, Gallagher PF, O’Mahony D. Inappropriate prescribing and adverse drug events in older people. BMC Geriatr. 2009 Jan 28;9:5
17. Bregnhoj L, Thirstrup S, Kristensen MB, Bierrum L, Sonne J. Prevalence of inappropriate prescribing in primary care. Pharm World Sci. 2007;29(3):109-115.
18. Jackson PR, Yeo WW, Bax NDS, Ramsay LE. Essentials of clinical pharmacology and therapeutics – 1. Prescribing. Student BMJ. 1995;3:13-16.
19. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-2120.
20. Perri M, Menon AM, Deshpande AD, Shinde SB, Jiang R, Cooper JW, Cook L, Griffin SC, Lorys A. Adverse Outcomes Associated with Inappropriate Drug Use in Nursing Homes. Ann Pharmacother. 2005;39(3):405-411.
21. Lindley C, Tully M, Paramsothy V, Tallis RC. Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Ageing. 1992;21(4):294-300.
22. Schmader K, Hanlon JT, Weinberger M, Landsman PB, Samsa GP, Lewis I, Uttech K, Cohen HJ, Feussner JR. Appropriateness of medication prescribing in ambulatory elderly patients. J Am Geriatr Soc. 1994;42(12):1241-1247.
23. Phillips J, Beam S, Brinker A. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. 2001;58(22):2130.
24. Stuijt CC, Franssen EJ, Egberts AC, Hudson SA. Appropriateness of prescribing among elderly patients in a Dutch residential home: observational study of outcomes after a pharmacist-led medication review. Drugs Aging. 2008;25(11):947-954.
25. Spinewine A, Swine C, Dhillon S, Franklin BD, Tulkens PM, Wilmotte L, Lorant V. Appropriateness of use of medicines in elderly inpatients: qualitative study. BMJ. 2005;331(7522):935-939.
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