Coverage of hospitalized patients with documented VTE risk assessment gradually increased after the CDSS implementation, but remained at a low level (19% of eligible patients). Partly it may be attributed to the lack of CDSS integration in electronic health record or computerized physician order entry systems that would facilitate routine documentation of VTE and bleeding risks. However, the introduction of CDSS has allowed reducing significantly the rate of hospital-acquired VTE. This can be explained by drawing doctor's attention to the VTE problem and by training effect of CDSS. After receiving appropriate recommendations doctors adhere to them, on average, in 85.4% of cases, although for LMWH pharmacoprophylaxis this level was lower (74.6%). Development of hospital-acquired VTE in most cases (74%) was accompanied by non-compliance with CPGs recommendations, emphasizing the importance of additional measures for better adherence to evidence-based clinical practices.

Введение. Антикоагулянты (АК) являются лекарственными средствами (ЛС) высокого риска причинения вреда пациенту. Безопасность применения АК во многом зависит от соблюдения врачами клинических руководств и инструкций по медицинскому применению ЛС. Цель. Проанализировать выполнение врачами стационара клинических рекомендаций и инструкций по медицинскому применению АК у пациентов с фибрилляцией предсердий (ФП) и тромбозом глубоких вен (ТГВ). Материал и методы. В ретроспективное когортное исследование включено 100 пациентов с ФП или ТГВ, пролеченных в 2016-2017 гг. в многопрофильном стационаре г. Москвы. С помощью системы поддержки принятия решения (СППР) лекарственные назначения в историях болезни сопоставлялись с клиническими руководствами и инструкциями по медицинскому применению АК для выявления отклонений от рекомендаций по назначению АК (соблюдение показаний/противопоказаний и режима дозирования АК). Результаты. Из 50 пациентов с ФП антикоагулянтная терапия в стационаре была назначена 43 (86%) пациентам, включая 20 (46,5%) назначений прямых оральных антикоагулянтов (ПОАК), 17 (39,5%) варфарина и 6 (14%)-низкомолекулярных гепаринов (НМГ). Для пациентов с ТГВ структура назначений АК в качестве основной терапии составила: 39,5% ПОАК, 33,5% НМГ и 27% варфарин. Уровень приверженности врачей рекомендациям по назначению АК пациентам с ФП и ТГВ (соблюдение показаний и противопоказаний) был равен 88%. При несоблюдении рекомендаций по назначению АК частота нежелательных лекарственных событий была статистически значимо выше, чем при соблюдении рекомендаций (34% против 11%, соответственно; отношение шансов (ОШ) 3,9; 95% доверительный интервал (ДИ) 0,9-15,3; p=0,045). Врачи соблюдали рекомендации по режиму дозирования АК в 63,5% случаях. При несоблюдении рекомендаций по дозированию АК прямые затраты в стационаре на терапию АК были статистически значимо выше, чем при соблюдении: 4,04 тыс руб (интерквартильный размах, interquartile range, IQR=7,501 тыс руб) против 1,13 тыс руб (IQR=5,911 тыс руб), соответственно; p=0,02. Заключение. Несоблюдение клинических рекомендаций и инструкций по медицинскому применению АК может повышать риск развития нежелательных лекарственных событий и увеличивать стоимость антикоагулянтной терапии. СППР является перспективным инструментом как для клинического аудита антикоагулянтной терапии, так и для повышения приверженности врачей клиническим рекомендациям при назначении АК пациентам с ФП и ТГВ. Ключевые слова: антикоагулянты, фибрилляция предсердий, тромбоз глубоких вен, нежелательные лекарственные события, приверженность клиническим рекомендациям.

Background. Failure of continuity at care transitions results in 50% of all medication errors and up to 20% of adverse drug events (ADEs). In surgical patients medication errors occur more often than in medical patients due to perioperative corrections of medications and greater number of in-hospital transitions. The frequency of ADE in surgical patients varies from 2.3 to 27.7%. Aims to determine the prevalence and structure of unintentional discrepancies (UDs) in medications at admission to and discharge from surgery departments, report their potential clinical impact and analyse possible risk factors. Methods. Retrospective observational study was conducted in a general hospital in Russia. The study included patients hospitalized for elective surgery in Surgical Departments from January to June 2019. The pre-admission Best Possible Medication History (BPMH) for every patient was obtained. The BPMHs were compared with admission medication orders and hospital discharge prescriptions to identify UDs. Detected UDs were analysed for potential ADE with severity evaluation. Results. 206 patients were included, 55.83% were female, mean age 63.85 (9.38), median of chronic medications was 3 drugs. At least one UD was detected in 70.87% of patients at admission and in 92.72% at discharge, respectively, with averages of 1.30 and 2.81 discrepancies per patient. Cardiovascular drugs were the most frequent class involved at both admission (72.2%) and discharge (68.05%) in UDs. The most often UDs at both admission (51.68%) and discharge (94.65%) were omissions, incorrect dose (22.47% and 2.25%), and additional medications (11.6% and 1.55%). UDs had the potential to cause significant ADEs in 81.27%, serious ADEs in 18.35% of cases. Only 0.37% of UDs could contribute to life-threatening ADEs. The relative risk of discrepancies in patients of 60 years and older was 1.292-fold higher; three and more chronic medications increase risk 1.565-fold; diabetic or thyroid medications increase risk 1.932-fold. Conclusions. We reported on the first study of medication discrepancies conducted in Russian hospital. Estimated frequency, structure and risk factors of UDs in medications at admission to and discharge from surgery departments are similar to those from other countries. To decrease UDs in medications, implementation of medication reconciliation is needed.

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Surgical care is associated with a high risk of complications. In 2014 the updated joint ESC/ESA guidelines on preoperative assessment and perioperative management of patients were published to improve patient safety in non-cardiac surgery. The increase in the adherence to clinical guidelines promotes the improving of the healthcare quality and safety improvement.Aim. To study physicians' level of adherence to ESC/ESA clinical guidelines for preoperative assessment and perioperative management of patients.Material and methods. A retrospective observational study included 102 patients admitted to Moscow general hospital from 01.03.2019 to 30.06.2018 for elective surgery. All of them underwent preoperative examination in outpatient department of the hospital and had at least one concomitant disease requiring drug therapy. The medical records data on the preoperative examination and perioperative treatment with beta-blockers, HMG CoA reductase inhibitors and angiotensin-converting-enzyme (ACE) inhibitors/ angiotensin receptor blockers (ARBs) were analyzed for compliance with the ESC/ESA guidelines.Results. A standardized cardiac risks assessment was not documented in the results of preoperative examination. Electrocardiography (ECG), echocardiography and non-invasive stress tests were performed according to clinical guidelines in 100%, 77.8% and 25% of cases, respectively. Unnecessary ECG and echocardiography were prescribed in 50.5% and 72% of cases, respectively. Appropriate correction of ACE inhibitors/ARBs therapy was performed in 66.7% patients with congestive heart failure and only in 2.7% with arterial hypertension. In 19 patients with ischemic cardiac disease, 13 (84.2%) patients received HMG CoA reductase inhibitors and 16 (68.4%) ones received beta-blockers during hospitalization. Inappropriate omission of statins, beta-blockers and ACE inhibitors (ARBs) during hospitalization was registered in 22.2%, 11% and 4.9% patients, respectively.Conclusion. The number of inappropriate ECGs and echocardiographies, as well as incorrect treatment with beta-blockers, HMG CoA reductase inhibitors and ACE inhibitors (ARBs) in perioperative period evidence that the adherence of physicians to the clinical guidelines on preoperative assessment and perioperative management of patients remains low.It is reasonably to develop risk-based interdisciplinary protocols for preoperative examination, algorithms for interdisciplinary communication and interaction between specialists and the healthcare levels, as well as physicians' education for better adherence to clinical guidelines.