Objectives: To evaluate whether pharmacists completing the medication management plan in the medical discharge summary reduced the rate of medication errors in these summaries. Design: Unblinded, cluster randomised, controlled investigation of medication management plans for patients discharged after an inpatient stay in a general medical unit. Setting: The Alfred Hospital, an adult major referral hospital in metropolitan Melbourne, with an annual emergency department attendance of about 60000 patients. Participants: The evaluation included patients' discharge summaries for the period 16 March 2015 – 27 July 2015. Interventions: Patients randomised to the intervention arm received medication management plans completed by a pharmacist (intervention); those in the control arm received standard medical discharge summaries (control). Main outcome measures: The primary outcome variable was a discharge summary including a medication error identified by an independent assessor. Results: At least one medication error was identified in the summaries of 265 of 431 patients (61.5%) in the control arm, compared with 60 of 401 patients (15%) in the intervention arm (P<0.01). The absolute risk reduction was 46.5% (95% CI, 40.7–52.3%); the number needed to treat (NNT) to avoid one error was 2.2 (95% CI, 1.9–2.5). The absolute risk reduction for a high or extreme risk error was 9.6% (95% CI, 6.4–12.8%), with an NNT of 10.4 (95% CI, 7.8–15.5). Conclusions: Pharmacists completing medication management plans in the discharge summary significantly reduced the rate of medication errors (including errors of high and extreme risk) in medication summaries for general medical patients. Australia New Zealand Clinical Trials Registry number: ACTRN12616001034426.

Partnering between medical staff and pharmacists to jointly chart initial medications on admission significantly reduced inpatient medication errors (including errors of high and extreme risk) among general medical and emergency short-stay patients with complex medication regimens or polypharmacy.

Aims To undertake a multicentre evaluation of translation of a partnered pharmacist medication charting (PPMC) model in patients admitted to general medical units in public hospitals in the state of Victoria, Australia. Methods Unblinded, prospective cohort study comparing patients before and after the intervention. Conducted in seven public hospitals in Victoria, Australia from 20 June 2016 to 30 June 2017. Patients admitted to general medical units were included in the study. Medication charting by pharmacists using a partnered pharmacist model was compared to traditional medication charting. The primary outcome variable was the length of inpatient hospital stay. Secondary outcome measures were medication errors detected within 24 h of the patients' admission, identified by an independent pharmacist assessor. Results A total of 8648 patients were included in the study. Patients who had PPMC had reduced median length of inpatient hospital stay from 4.7 (interquartile range 2.8–8.2) days to 4.2 (interquartile range 2.3–7.5) days (P < 0.001). PPMC was associated with a reduction in the proportion of patients with at least 1 medication error from 66% to 3.6% with a number needed to treat to prevent 1 error of 1.6 (95% confidence interval: 1.57–1.64). Conclusion Expansion of the partnered pharmacist charting model across multiple organisations was effective and feasible and is recommended for adoption by health services.

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Aim Iron polymaltose infusions are increasingly prescribed in the management of iron deficiency but the efficacy of premedication to prevent complications of infusion remains uncertain. In order to simplify our infusion protocol, we retrospectively reviewed our experience of patients receiving iron polymaltose infusion to assess its safety profile, identify risk factors for adverse reactions and evaluate the efficacy of premedication in preventing adverse reactions. Methods We conducted a retrospective re view of 300 patients who received iron infusions at Alfred Health (including The Alfred, Caulfield Hospital and Sandringham Hospital) between April 2010 and April 2011. Patients were identified via pharmacy dispensing records during the study period regardless of inpatient or day procedure admission status. Data collected from scanned medical records included: gender, body weight, iron dose, compliance to current guideline, units of blood received, serum iron levels, haemoglobin levels, premedications given/charted, duration of infusion, and any adverse effects that occurred. Results From April 2010 to April 2011, 300 patients who received an iron infusion were reviewed. Mean age was 64 years (range: 19–100), with balanced sex distribution (male:female = 148:152). The existing protocol was followed in 90.3% of the patients; however, premedications (cetirizine and hydrocortisone) were given to only 76.25% patients. Only three (1%) patients developed anaphylaxis, but other side effects included headache (1.4%), rash (1%), chest pain (1%) and fever (0.3%). All three patients who developed anaphylaxis had received premedication. Most side effects occurred within 30–60 min of commencing the infusion, with a mean infusion rate of 117 mL/h. Conclusion Iron polymaltose infusions are generally well tolerated and serious adverse reactions are rare. As a result of this audit, we have modified our guidelines to minimise the use of premedications and to rationalise the monitoring of patients receiving iron infusions. Further research to identify specific risk factors for adverse reactions may allow more targeted use of premedications to prevent specific side effects. Reducing the use of premedication and focusing attention to potential side effects during the 60 min after commencement of infusion could improve efficiency, reduce cost and minimise the inconvenience associated with iron infusions.

Objective To evaluate the need for and the feasibility of a pharmacist‐led physician‐supported deprescribing model. Methods All patients aged ≥65 years, with polypharmacy, admitted to the acute general medical unit (GMU) of an Australian tertiary hospital over a 6‐week period were prospectively evaluated for deprescribing by team pharmacists. Clinical decision‐making was supported by physicians. Results One hundred and twenty‐nine patients met inclusion criteria, and 58 (45%) were identified for deprescribing. Ninety‐two (7.2%) deprescribing instances were identified of 1277 medications prescribed. Of these, 46 (50%) were successfully deprescribed during inpatient admission in 35 (60%) patients. The most prevalent rationale for deprescribing was “harm outweighing benefits.” Outpatient deprescribing was planned in 16 (17%) of instances, and 39 (42%) would require outpatient follow‐up to ensure adherence to recommendations and safety. No predictors for deprescribing were identified on univariate analyses. Conclusions A pharmacist‐led physician‐supported deprescribing model is feasible in GMU patients who have polypharmacy.

No abstract

Background Proton pump inhibitors (PPI) are extensively prescribed internationally and in Australia. However, minimal information is available on the appropriateness of PPI use in the general medical population. Aim This study determined the proportion of general medical unit (GMU) inpatients taking a PPI on admission and evaluated the appropriateness of these PPI prescriptions. Methods A single‐centre prospective observational study was conducted from 6 June to 11 July 2016. Consecutive patients were screened, and those taking a PPI prior to admission were included, whereas those not taking a PPI formed the control cohort. Appropriateness of PPI use was evaluated by: (1) reviewing for concordance with the Australian Therapeutic Guidelines and National Prescribing Service Guidelines on PPI use in gastro‐oesophageal reflux disease; (2) assessment of indication, dose and treatment duration by an expert panel consisting of two general physicians and one senior pharmacist. Results Among 440 consecutive GMU patients, 198 (45.0%) were taking a PPI on admission. Of these, 66.2% had an inappropriate indication, dose or treatment duration. The largest category of inappropriate PPI use was excessive treatment duration (43.4%). In terms of comorbid conditions, PPI users had a higher prevalence of osteoporosis and/or history of fracture (42.9% vs 27.2%; p < 0.001) and hypomagnesaemia (10.6% vs 3.4%; p = 0.003). Conclusion Inappropriate PPI use is highly prevalent among GMU inpatients. Given the potential for adverse effects, unnecessary health expenditure and pill burden, strategies should be developed to aid clinicians to consistently consider the utility of continuing long‐term PPI prescriptions in each patient's situation.