eLetters

15 e-Letters

  • Re: Incidence and prevalence of intravenous medication errors in the United Kingdom: A Systematic Review; Refined Data

    We thank Dr Jones and Professor Franklin’s insightful and constructive response to our systematic review of the incidence and prevalence of intravenous medication errors in the UK. We appreciate and are grateful for their consideration and the opportunity to respond to their observation.

    They are absolutely right to suggest that this is an example of both the limitations of our systematic review methodology, and the importance of grey literature accessing wider datasets as part of these reviews. Our protocol allowed us to contact authors of papers for more detailed data, however did not provide for occasions where authors were not contactable, and did not include grey literature. Two independent data extractors flagged that the data in the original publication [1] was ambiguous. When it was clear that further data was not accessible through direct contact with the author a consensus decision was taken to present only the data that we could reliably associate with IV medication errors from the paper and acknowledge this limitation.

    As the correspondents rightly suggest, by supplanting the thesis data into the analysis, we identify 1773 intravenous doses, and 789 errors, resulting in a weighted prevalence estimate of 451/1000 administrations (95% CI 420–482), however the limitations related to the definition and operationalisation of errors, and how they affect estimates still hold, particularly around the impact of including “wrong time” errors into the...

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  • Re: "Incidence and prevalence of intravenous medication errors in the UK: a systematic review”: refined data

    We read this article with great interest. Given differences among countries in preparation and administration practices for intravenous medicines, it is an important contribution to the literature.

    Sutherland et al. state that their calculation of the incidence of intravenous medication errors may be an underestimate (1), as they were not able to clearly differentiate intravenous from non-intravenous administrations in the study by Ghaleb et al. (2) We are writing to highlight refined data related to the Ghaleb et al. study, which will be useful to readers interested in interpreting the review’s findings.

    Specifically, Table 2 of the review reports that in the Ghaleb et al. study, 85 infusions (5.5%) of a total of 1,554 contained at least one error. However, the Ghaleb et al. study reports data relating to all routes of administration, and not just the intravenous route (2). The total of 1,554 observed doses therefore includes both intravenous and other routes of administration, with the number of intravenous doses not reported in the published paper. Consequently, the incidence of intravenous medication errors reported Table 2 for the Ghaleb et al. study is artificially low. This is likely to considerably influence the systematic review’s pooled estimate of the incidence of intravenous medication errors, (1) as Ghaleb et al. (2) contributes 60% of the observations included in this calculation.

    The PhD thesis on which the paper by Ghaleb et al. is bas...

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  • Response to Van den Eynde and Gillman's letter

    I) We agree with Dr. Van den Eynde that since tedizolid is a more potent inhibitor than linezolid, it is administered at lower doses. Thus, the MAO inhibition would be lower. This is probably the reason why there have been no reports regarding serotoninergic toxicity. However, the possibility of MAO inhibition cannot be ruled out, especially when tedizolid is administered together with serotoninergic drugs. We would like to emphasize that the spontaneous reporting of suspected adverse reactions is useful to identify potential signals that suggest a causal association between a medicinal product and a previously unknown reaction. Whether this suspected adverse reaction is a signal, it should be confirmed by further reports.

    II) In our article we do not affirm that it is a serotonin syndrome or a serotonin toxicity, since, in fact, we do not have enough clinical information to confirm it. We only discuss the possibility that the hypertensive crisis could be related to the co-administration of tedizolid and other serotoninergic drugs. Our position is well defined in the following paragraph of the article: “The causality of hypertension as an adverse drug reaction due to the co-administration of tedizolid and other serotonergic treatments was evaluated using the algorithm of Naranjo et al, obtaining a final score of 3. According to this value, the relationship between tedizolid and the hypertensive crisis should be classified as possible, as we were not able to rule ou...

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  • A critical appraisal

    We note, upon critical appraisal of this case report, two shortcomings:
    (I) the authors provide a one-sided and inaccurate extrapolation to clinical practice from the literature data on tedizolid;
    (II) the authors do not adhere to well-established ‘diagnostic decision rules for serotonin toxicity’: the Hunter criteria.<1>
    I. In gauging the MAO-inhibiting potential of both antibiotics, de Castro Julve et al. rightly note that ‘tedizolid appears to be a more potent inhibitor in vitro of MAO-A than linezolid’ <2>– but neglect to mention (a) that tedizolid is also four to sixteen (or – depending on the source – ‘two to eight’)<3> times more potent than linezolid at treating most gram-positive infections;<4> and (b) that tedizolid is therefore administered at a lower dose than is linezolid (200mg/day vs. 600mg/12 hours).<3> This likely leads, in practice, to less tedizolid-induced (vs. linezolid-induced) MAO-inhibition<3>, as evidenced by the clinically insignificant potentiation of the tyramine pressor response (TYR30)<2>, and to less potential for serotonergic drug interactions<5>, as further evidenced by the fact that no changes in the murine head twitch response occur, even at plasma tedizolid concentrations which exceed – ‘by up to ~25-fold’ – the Cmax observed in humans at the clinical dose of 200mg/day.<3>
    II. The detection in their patient of a hypertensive crisis ‘suspected to be an adverse r...

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  • Correction to 2012 legal change

    The section in this paper which says pharmacists could prescribe controlled drugs from 2012 with the exception of schedule 1 and 2 CDs for drug misuse is misleading. Schedule 1 cannot be prescribed by anyone without out a licence to do so (this includes doctors) and schedule 1 contains substances of no medicinal use. Schedule 2 CDs can be prescribed by pharmacists for drug misuse, the only exception is diamorphine (and technically cocaine and dipipanone although these are not used). Diamorphine is prescribed as an injectable by prescribers on the Dept of Health approved list to do so and this list is restricted to medical doctors. Other schedule 2 drugs for addiction such as methadone and morphine (unlicensed) can be prescribed by pharmacist prescribers.

  • Some issues with dose administration aids/monitored dosage systems

    Monitored dosage systems (or dose administration aids) are widely used but it is important to reduce their inappropriate use by ensuring they are only issued on a case-by-case basis to address specific practical problems of medicines adherence. It should be assumed that patients can manage their medicines unless indicated otherwise. NICE guidance (1) states monitored dosage systems should be considered as an option to improve adherence on a case-by-case basis, and only if there is a specific need to overcome practical problems. This should follow a discussion with the patient to explore possible reasons for nonadherence and the options available to improve adherence, if that is their wish.
    • The inappropriate use of monitored dosage systems can make patients and carers less familiar with their medicines. Health literacy including awareness of medicines should be promoted.
    • Transferring medicines to monitored dosage systems carries the risk of human error. The stability of many medicines cannot be guaranteed outside their original packaging.
    • Patients who may benefit from monitored dosage systems include patients who have less ability to read or understand the instructions on standard medicines packaging, but who have the dexterity to use the devices and who wish to adhere to their medicines regimen.
    • Pharmacists should check compliance issues and provide a monitored dosage system only if compliance cannot be addressed by other methods a...

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  • Time to early reduction and immobilization or pain relief for extremity fracture
    Tze Hong Wong

    Comment 1: In case of stable patient, the priority of management for extremity fracture in emergency department would be early reduction with immobilization, pain relief is not the primary concern, on the other hand, early pain relief might put the patient in a risk of delayed reduction trial . As we know neurovascular compromise around fracture site is critical for fracture management, and so, instead of decreasing time...

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  • Government intervention in pricing has great impact on cost and therefore on value.

    Reading the editorial – “Value or cost: looking for the wider perspective”,the one thing that struck us the most was,when pharmacists determine value,one of the most important variables that they take into account is the monetary cost of the intervention,say antibiotics.This raised several questions in our minds.What if the antibiotics on the hospital formulary were priced at a point that their use in certain situations seemed unjustified to pharmacists,but would seem perfectly justified at lower price points?What if generics,available at a fraction of the price of the branded variety,were used in place of the brands?It seems to us that they would most certainly impact the way that “value” is calculated for that particular scenario.What if the pharmacist knew a perfectly good enough generic,but hospital policy allowed procurement,and hence prescribing of,only a more expensive brand?
    When hospital pharmacists try to assess the value of a new health technology,we feel that they would be well served if they took a long,hard look at the evidence.Sometimes claims might not be very genuine.And this could place heavy costs on the patients.A very contemporary example would be the pricing of cardiac stents. Cardiac stents are sold at a 300 to 400 percent mark up to Indian patients.A stent that costs Rs.20,000(Euro 284) if bought from a vendor would miraculously cost Rs.160,000(Euro 2273)at the hospital pharmacy,all other charges being separate.1The patient is not given the o...

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  • Deprescribing in the population with intellectual disabilities

    The population with intellectual disabilities are vulnerable in the prescribing and the deprescribing process.

    In the population with intellectual disabilities compared to the general population, the multi-morbidity burden is greater, occurs at much earlier age, and the profile of health conditions differs [1].
    People with intellectual disabilities use multiple medications and may have been taking them for many years. Extreme care in required when de- prescribing many medications in this population group. The principles of good de-prescribing during medication review in the population with intellectual disabilities, based on the British Pharmacological Society’s Principles for Good Prescribing 2010, provide a template for quality de-prescribing in this vulnerable population group.

    Principles of Good De-prescribing during Medication Review in the Population with Intellectual Disabilities and Behaviour Disorders. Based on the British Pharmacological Society’s Principles for Good Prescribing 2010
    1. Be clear about the reasons for de-prescribing.
    2. Take into account the patient with intellectual disabilities and behaviour disorders medication history before de-prescribing.
    3. Take into account other factors that might alter the benefits and risks of de-prescribing treatment in the patient with intellectual disability and behaviour disorders.
    4. Take into account the patient’s/carer’s/families/advocates ideas, concerns, and expec...

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  • Deprescribing in the population with learning/intellectual disabilities
    Bernadette Flood

    Vulnerable populations are vulnerable because they are susceptible to harm in health care environments. It is important that the healthcare issues specific to the population with learning/intellectual disabilities are considered when prescribing and deprescribing.

    Deprescribing tools must be validated in the population with learning/intellectual disabilities to ensure safety and quality care. People with learn...

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