Medication safety

Why reducing prescribing errors?

Prescribing errors, resulting from inappropriately prescribed medication, can cause iatrogenic patient harm, prolonged hospitalization and hospital readmission^1-3. These events are associated with an increased risk of morbidity and mortality and increased healthcare costs. Recent estimations show that 5–7% of all hospital admissions in economically developed countries are medication related. Approximately 66% of these admissions are due to inappropriate prescribed medication. Associated worldwide costs are estimated at 42 billion USD each year^{1, 4} and are therefore a worldwide topic of awareness⁵. 
In the Netherlands, the HARM study showed that 2.4% of all hospital admissions and 5.6% of all acute admissions in Dutch hospitals were related to medication errors⁶. Almost half (46%) of these admissions were potentially preventable. One or more prescribing errors were detected in most (71%) of the preventable admissions. 

In response, over the past decades, several strategies aiming to reduce in-hospital PEs and related patient harm have been developed. These strategies include programmes with a focus on specific medications and their harmful adverse drug reactions (ADEs) (e.g. nonsteroidal anti‐inflammatory drugs and antiplatelet drugs causing gastrointestinal tract bleeding^{6, 7}, medication reconciliation⁸ and the implementation of computerized physician order entry (CPOE) systems, often in combination with clinical decision support systems (CDSS)). Nonetheless, ADEs still occur and numbers are not declining^{9, 10}. A recent report, commissioned by the Dutch government¹⁰, revealed a rise of 26% in (the absolute number of) medication‐related hospital admissions between 2008 and 2013. This is in line with international publications⁹, underscoring the need for more effective strategies.

How to reduce prescribing errors in the in-hospital setting?

In-hospital prescribers are challenged in prescribing due to the increasing complexity of hospital-admitted patients (e.g. multimorbidity, polypharmacy, multiple prescribers involved, older age); the demanding work environment; hard to find or conflicting protocols; a heavy workload, appropriately. To prevent and reduce medication-related harm, new strategies are urgently needed. In this new strategy, we hypothesize that a multidisciplinary team (‘Pharmacotherapy team’) including a clinician and a hospital pharmacist, working together with local stakeholders, e.g. (junior) prescribers, nurses, medical managers, can make a valuable contribution to reduce prescribing errors.

Planning

Since September 2015, this Pharmacotherapy team is operational in Amsterdam University Medical Centers – location VUmc, and nowadays it is operational in both locations.

Between mid 2015 and mid 2018 we developed a multifaceted strategy using Participatory Action Research (PAR). PAR is characterized by the involvement of relevant stakeholders in the analysis of complex problems and in leading the change process¹¹. Stakeholders are empowered to identify the problem’s root causes as well as opportunities to improve, develop and implement a tailored plan of improvement. This process should result in sustainable improvement as stakeholders place value on an intervention they partially created, the IKEA effect¹². This study was recently published and led to several hospital-wide interventions.

Hospital-wide interventions

Based on the results of the individual wards, hospital-wide interventions are developed including:

– Consultation of the Pharmacotherapy team, involving clinical pharmacologists, clinical pharmacist and medical doctors in daily clinical practice.
– eLearning covering important prescribing topics (e.g. pain/fluid management, anticoagulation) for junior doctors;
– ‘App-ification and optimization of hospital guidelines for drug prescribing.

Eversince, the Pharmacotherapy team is inbedded in daily in-hospital practice. Future research will focuss on in-dept research of facilitators and protective barriers to in-hospital prescribing errors and how to use this information in developing a more effective multifaceted strategy to sustainably reduce prescribing errors in the in-hospital setting.

Output
1. The Pharmacotherapy-team: A novel strategy to improve appropriate in-hospital prescribing using a participatory intervention action method
2. Medication review 2.0 (Dutch) 
3. Prescribing errors in post-COVID-19 patients: prevalence, severity and risk factors in patients visiting a post-COVID-19 outpatient clinic

References 
1. Assiri GA, Shebl NA, Mahmoud MA, Aloudah N, Grant E, Aljadhey H, et al. What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ open. 2018;8(5):e019101.
2. De Vries T, Henning RH, Hogerzeil HV, Fresle D, Policy M, Organization WH. Guide to good prescribing: a practical manual. Geneva: World Health Organization; 1994.
3. Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients. Drug safety. 2009;32(5):379-89.
4. Organization GWH. Medication Errors – Technical Series on Safer Primary Care2016. 32 p.
5. Organization WH. Medication errors: World Health Organization; 2016.
6. Leendertse AJ, Egberts AC, Stoker LJ, van den Bemt PM. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Archives of internal medicine. 2008;168(17):1890-6.
7.  Warlé-van Herwaarden MF, Kramers C, Sturkenboom MC, van den Bemt PM, De Smet PA. Targeting outpatient drug safety. Drug safety. 2012;35(3):245-59.
8. Pronovost P, Weast B, Schwarz M, Wyskiel RM, Prow D, Milanovich SN, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of critical care. 2003;18(4):201-5.
9. Veeren JC. Trends in emergency hospital admissions in England due to adverse drug reactions: 2008-2015.: Journal of Pharmaceutical Health Services Research; 2017.
10. Sturkenboom MC. EINDRAPPORT: VERVOLGONDERZOEK MEDICATIEVEILIGHEID (2017)2017.
11. Baum F, MacDougall C, Smith D. Participatory action research. Journal of epidemiology and community health. 2006;60(10):854.
12. Norton MI, Mochon D, Ariely D. The IKEA effect: When labor leads to love. Journal of consumer psychology. 2012;22(3):453-60.