Patient safety has become a key component of quality of care, progressively relevant in recent years for patients and their families, as well as healthcare professionals aiming to deliver safe and efficient healthcare. Medication error and adverse drug events cost billions of dollars and are detrimental to the provider-patient relationship. 1,2 On average, hospitalised patients are subject to at least one medication error per day. More than 40% of medication errors are believed to result from inadequate reconciliation in handoffs during admission. 3 A multitude of factors-such as patients' lack of knowledge of their medications, physician and nurse workflows, and lack of integration of patient health records across the continuum of care-all contribute to a lack of a complete medication reconciliation which, in turn, creates the potential for error. One of the main reasons for medication error is patient transfer from one place to another to receive
Vancomycin has a complex pharmacokinetic profile and carries potential risks for nephrotoxicity and ototoxicity. The pharmacokinetic profile in elderly patients significantly differs from that of younger patients. It is common practice in many institutions for pharmacists to intentionally round serum creatinine levels to 1 mg/dl in elderly patients with levels <1 mg/dl to avoid overestimating clearance and toxicities. This can potentially lead to underestimation of creatinine clearance, and subsequently lead to vancomycin under dosing. The aim of this study was to evaluate vancomycin target trough attainment and the time to trough attainment with vancomycin dosing per pharmacy in elderly patients. Methods In this retrospective study, patients 75 years and older who received vancomycin at our institution were evaluated. Subjects were included in the study if they were at least 75 years of age, received intravenous vancomycin therapy, and had a vancomycin trough drawn after the third dose. The study patients were divided into three serum creatinine groups; <0.8 mg/dl (LSCr), 0.8–0.9 mg/dl (MSCr), and ≥1 mg/dl (HSCr). Patients were excluded from the study if they did not meet inclusion criteria, had no trough levels drawn, or were <75 years of age. Results Two hundred and four patients 75 years or older were included in the study. The target trough attainment was highest in the HSCr group (n = 37, 80%), which was significantly higher than the LSCr (n=21, 31%; p<0.0001) and MSCr (n=42, 46%; p<0.0001) groups. The time to target trough goals (days, mean ± SD) differed between the three groups, with the LSCr group taking the longest duration: LSCr: 5.14 ± 2.5; MSCr: 3.74 ± 1.1; HSCr: 3.78 ± 1.6, p=0.005. Conclusion Adjustments need to be done to improve vancomycin dosing per pharmacy in patients 75 years of age and older. This study shows that LSCr patients (<0.8 mg/dl) had the lowest rates of target trough level attainment. Intentionally rounding serum creatinine to 1 mg/dl if values are less when estimating renal function in this older patient population may not be predictive of true renal function and can decrease the likelihood of target attainment or increase time to target attainment.
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