OBJECTIVE: Drug incompatibility, a significant subset of medication errors, threaten patient safety during the medication administration phase. Despite the undeniably high prevalence of drug incompatibility, it is currently poorly understood because previous studies are focused predominantly on intensive care unit (ICU) settings. To enhance patient safety, it is crucial to expand our understanding of this issue from a comprehensive viewpoint. This study aims to investigate the prevalence and mechanism of drug incompatibility by analysing hospital-wide prescription and administration data.
METHODS: This retrospective cross-sectional study, conducted at a tertiary academic hospital, included data extracted from the clinical data warehouse of the study institution on patients admitted between January 1, 2021, and May 31, 2021. Potential contacts in drug pairs (PCs) were identified using the study site clinical workflow. Drug incompatibility for each PC was determined by using a commercial drug incompatibility database, the Trissel\'s™ 2 Clinical Pharmaceutics Database (Trissel\'s 2 database). Drivers of drug incompatibility were identified, based on a descriptive analysis, after which, multivariate logistic regression was conducted to assess the risk factors for experiencing one or more drug incompatibilities during admission.
RESULTS: Among 30,359 patients (representing 40,061 hospitalisations), 24,270 patients (32,912 hospitalisations) with 764,501 drug prescriptions (1,001,685 IV administrations) were analysed, after checking for eligibility. Based on the rule for determining PCs, 5,813,794 cases of PCs were identified. Among these, 25,108 (0.4 %) cases were incompatible PCs: 391 (1.6 %) PCs occurred during the prescription process and 24,717 (98.4 %) PCs during the administration process. By classifying these results, we identified the following drivers contributing to drug incompatibility: incorrect order factor; incorrect administration factor; and lack of related research. In multivariate analysis, the risk of encountering incompatible PCs was higher for patients who were male, older, with longer lengths of stay, with higher comorbidity, and admitted to medical ICUs.
CONCLUSIONS: We comprehensively described the current state of drug incompatibility by analysing hospital-wide drug prescription and administration data. The results showed that drug incompatibility frequently occurs in clinical settings.

BACKGROUND: Health care professionals receive little training on the digital technologies that their patients rely on. Consequently, practitioners may face significant barriers when providing care to patients experiencing digitally mediated harms (eg, medical device failures and cybersecurity exploits). Here, we explore the impact of technological failures in clinical terms.
OBJECTIVE: Our study explored the key challenges faced by frontline health care workers during digital events, identified gaps in clinical training and guidance, and proposes a set of recommendations for improving digital clinical practice.
METHODS: A qualitative study involving a 1-day workshop of 52 participants, internationally attended, with multistakeholder participation. Participants engaged in table-top exercises and group discussions focused on medical scenarios complicated by technology (eg, malfunctioning ventilators and malicious hacks on health care apps). Extensive notes from 5 scribes were retrospectively analyzed and a thematic analysis was performed to extract and synthesize data.
RESULTS: Clinicians reported novel forms of harm related to technology (eg, geofencing in domestic violence and errors related to interconnected fetal monitoring systems) and barriers impeding adverse event reporting (eg, time constraints and postmortem device disposal). Challenges to providing effective patient care included a lack of clinical suspicion of device failures, unfamiliarity with equipment, and an absence of digitally tailored clinical protocols. Participants agreed that cyberattacks should be classified as major incidents, with the repurposing of existing crisis resources. Treatment of patients was determined by the role technology played in clinical management, such that those reliant on potentially compromised laboratory or radiological facilities were prioritized.
CONCLUSIONS: Here, we have framed digital events through a clinical lens, described in terms of their end-point impact on the patient. In doing so, we have developed a series of recommendations for ensuring responses to digital events are tailored to clinical needs and center patient care.

The treatment of painful KOA in adult patients with ITP has not been well studied yet. We conducted a prospective, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of intra-articular allogeneic PRP injections on symptoms and joint structure in patients with KOA and ITP. 80 participants were randomly allocated in a 1:1 ratio to allogeneic PRP group or saline group. The primary outcome was the WOMAC total score at 12 months post-injection. The number of patients in each group who achieved MCID of primary outcome showed a statistically significant difference only at 3-month (27/39 vs. 5/39, p = 0.001) and 6-month (15/39 vs. 3/38, p = 0.032). The difference in WOMAC total score exceeded the MCID only at 3 month (mean difference of -15.1 [95% CI -20.7 to -9.5], p < 0.001). Results suggest that allogeneic PRP was superior to placebo only with respect to symptoms at 3-month of follow-up.

OBJECTIVE: Drug shortages are of increasing concern to worldwide public health. The consequences of drug shortages for patient safety have been little studied, especially from a pharmacovigilance point of view. In this context, the network of French pharmacovigilance centres conducted the CIRUPT study (Conséquences Iatrogènes des RUPTures de stock/iatrogenic consequences of drug shortages) based on a prospective campaign of adverse effects occurring in the context of drug shortage notifications.
METHODS: All notifications involving a shortage drug submitted to the French pharmacovigilance centres between 1 January 2020 and 30 June 2021 were collected and registered in the French national pharmacovigilance database with the standardised high level term \'product supply and availability issues\' and with predefined keywords in the narrative section.
RESULTS: 224 cases were included, involving mainly adverse drug reactions (ADRs) (n=131/224, 59%) and medication errors (n=51/224, 23%); 29% of the cases were serious. The most represented classes of shortage drugs were: vaccines (n=78/224, 35%); drugs for acid-related disorders (H2-receptor antagonists) (n=27/224, 12%); antineoplastic agents (n=17/224, 8%); and antiepileptics (n=15/224, 7%). In 82% of cases, the involved shortage drug was the subject of information delivered to health professionals by the National Agency for the Safety of Medicines and Health Products. Drug shortages were associated with an ADR related to replacement drugs in 59% (n=131/224) of the cases, drug inefficacy in 18% (n=41/224), and/or an aggravation of the underlying disease in 11% (n=25/224).
CONCLUSIONS: From a pharmacovigilance point of view, a large diversity of anatomical therapeutic classes is involved and the risk related to drug shortages is not limited to drugs registered on \'major therapeutic interest or essential drug\' lists. Information from health agencies is not sufficient to avoid the risks, and further strategies should be developed.

UNASSIGNED: The utility of a clinical decision support system using a machine learning (ML) model for simultaneous cardiac and pulmonary auscultation is unknown.
UNASSIGNED: This study aimed to develop and evaluate an ML system\'s utility for cardiopulmonary auscultation.
UNASSIGNED: First, we developed an ML system for cardiopulmonary auscultation, using cardiopulmonary sound files from our previous study. The technique involved pre-processing, feature extraction, and classification through several neural network layers. After integration, the output class was categorized as \"normal,\" \"abnormal,\" or \"undetermined.\" Second, we evaluated the ML system with 24 junior residents in an open-label randomized controlled trial at a university hospital. Participants were randomly assigned to the ML system group (intervention) or conventional auscultation group (control). During training, participants listened to four cardiac and four pulmonary sounds, all of which were correctly classified. Then, participants classified a series of 16 simultaneous cardiopulmonary sounds. The control group auscultated the sounds using noise-cancelling headphones, while the intervention group did so by watching recommendations from the ML system.
UNASSIGNED: The total scores for correctly identified normal or abnormal cardiopulmonary sounds in the intervention group were significantly higher than those in the control group (366/384 [95.3%] vs. 343/384 [89.3%], P = 0.003). The cardiac test score in the intervention group was better (111/192 [57.8%] vs. 90/192 [46.9%], P = 0.04); there was no significant difference in pulmonary auscultation.
UNASSIGNED: The ML-based system improved the accuracy of cardiopulmonary auscultation for junior residents. This result suggests that the system can assist early-career physicians in accurate screening.

BACKGROUND: ChatGPT, an artificial intelligence (AI) based on large-scale language models, has sparked interest in the field of health care. Nonetheless, the capabilities of AI in text comprehension and generation are constrained by the quality and volume of available training data for a specific language, and the performance of AI across different languages requires further investigation. While AI harbors substantial potential in medicine, it is imperative to tackle challenges such as the formulation of clinical care standards; facilitating cultural transitions in medical education and practice; and managing ethical issues including data privacy, consent, and bias.
OBJECTIVE: The study aimed to evaluate ChatGPT\'s performance in processing Chinese Postgraduate Examination for Clinical Medicine questions, assess its clinical reasoning ability, investigate potential limitations with the Chinese language, and explore its potential as a valuable tool for medical professionals in the Chinese context.
METHODS: A data set of Chinese Postgraduate Examination for Clinical Medicine questions was used to assess the effectiveness of ChatGPT\'s (version 3.5) medical knowledge in the Chinese language, which has a data set of 165 medical questions that were divided into three categories: (1) common questions (n=90) assessing basic medical knowledge, (2) case analysis questions (n=45) focusing on clinical decision-making through patient case evaluations, and (3) multichoice questions (n=30) requiring the selection of multiple correct answers. First of all, we assessed whether ChatGPT could meet the stringent cutoff score defined by the government agency, which requires a performance within the top 20% of candidates. Additionally, in our evaluation of ChatGPT\'s performance on both original and encoded medical questions, 3 primary indicators were used: accuracy, concordance (which validates the answer), and the frequency of insights.
RESULTS: Our evaluation revealed that ChatGPT scored 153.5 out of 300 for original questions in Chinese, which signifies the minimum score set to ensure that at least 20% more candidates pass than the enrollment quota. However, ChatGPT had low accuracy in answering open-ended medical questions, with only 31.5% total accuracy. The accuracy for common questions, multichoice questions, and case analysis questions was 42%, 37%, and 17%, respectively. ChatGPT achieved a 90% concordance across all questions. Among correct responses, the concordance was 100%, significantly exceeding that of incorrect responses (n=57, 50%; P<.001). ChatGPT provided innovative insights for 80% (n=132) of all questions, with an average of 2.95 insights per accurate response.
CONCLUSIONS: Although ChatGPT surpassed the passing threshold for the Chinese Postgraduate Examination for Clinical Medicine, its performance in answering open-ended medical questions was suboptimal. Nonetheless, ChatGPT exhibited high internal concordance and the ability to generate multiple insights in the Chinese language. Future research should investigate the language-based discrepancies in ChatGPT\'s performance within the health care context.

OBJECTIVE: The Access, Watch and Reserve (AWaRe) list of antibiotics was developed by the WHO to support antibiotic stewardship programmes (ASP). The Access group incorporates first-line options, while Watch antibiotics have higher resistance potential or toxicity, and Reserve drugs should be used only for complex infections. ASP implementation has been challenged during the COVID-19 pandemic. There is a knowledge gap regarding in-hospital prescribing patterns of antibiotics nationally during the COVID-19 pandemic, and on the characteristics of hospitalised patients prescribed antibiotics during this time. We aimed to evaluate quality of antibiotic use according to AWaRe classification in Scottish hospitals, including assessing the impact of COVID-19 on trends.
METHODS: Cross-sectional study of antibiotics prescribed to hospitalised patients from 1 January 2019 to 30 June 2022 in a selection of Scottish hospitals, covering approximately 60% (3.6 million people) of the Scottish population. Data were obtained from the Hospital Electronic Prescribing and Medicines Administration system. Prescribing trends were explored over time, by age and by sex.
RESULTS: Overall, a total 1 353 003 prescriptions were identified. An increase in Access antibiotics was found from 55.3% (31 901/57 708) to 62.3% (106 449/170 995) over the study period, alongside a decrease in Watch antibiotics from 42.9% (24 772/57 708) to 35.4% (60 632/170 995). Reserve antibiotic use was limited throughout, with minor changes over time. Changes in prescribing were most pronounced in the older age group (>65 years): proportions of Access antibiotics increased from 56.4% (19 353/34 337) to 65.8% (64 387/97 815, p<0.05), while Watch antibiotics decreased from 41.9% (14 376/34 337) to 32.3% (31 568/97 815, p<0.05) between Q1 2019 and Q2 2022. Differences between males and females were insignificant.
CONCLUSIONS: Findings showed encouraging trends in Access and Watch use among hospitalised patients, in line with Scottish national standards. There was no noteworthy effect of COVID-19 on prescribing trends despite reports indicating stewardship programmes being negatively impacted by the pandemic.

BACKGROUND: We aimed to identify patients at low risk of bloodstream infection (BSI) in the ED.
METHODS: We derived and validated a prediction model to rule out BSI in the ED without the need for laboratory testing by determining variables associated with a positive blood culture (BC) and assigned points according to regression coefficients. This retrospective study included adult patients suspected of having BSI (defined by at least one BC collection) from two European ED between 1 January 2017 and 31 December 2019. The primary end point was the BSI rate in the validation cohort for patients with a negative Bacteremia Rule Out Criteria (BAROC) score. The effect of adding laboratory variables to the model was evaluated as a second step in a two-step diagnostic strategy.
RESULTS: We analysed 2580 patients with a mean age of 64 years±21, of whom 46.1% were women. The derived BAROC score comprises 12 categorical clinical variables. In the validation cohort, it safely ruled out BSI without BCs in 9% (58/648) of patients with a sensitivity of 100% (95% CI 95% to 100%), a specificity of 10% (95% CI 8% to 13%) and a negative predictive value of 100% (95% CI 94% to 100%). Adding laboratory variables (creatinine ≥177 µmol/L (2.0 mg/dL), platelet count ≤150 000/mm3 and neutrophil count ≥12 000/mm3) to the model, ruled out BSI in 10.2% (58/570) of remaining patients who had been positive on the BAROC score. The BAROC score with laboratory results had a sensitivity of 100% (95% CI 94% to 100%), specificity of 11% (95% CI 9% to 14%) and negative predictive value of 100% (95% CI 94 to 100%). In the validation cohort, there was no evidence of a difference in discrimination between the area under the receiver operating characteristic for BAROC score with versus without laboratory testing (p=0.6).
CONCLUSIONS: The BAROC score safely identified patients at low risk of BSI and may reduce BC collection in the ED without the need for laboratory testing.

BACKGROUND: Lack of child-friendly dosage forms and strengths often leads to manipulation of medicines at hospital units or by caregivers in the home setting. One alternative to manipulating dosage forms is the use of extemporaneous preparations. In Sweden, these are produced according to good manufacturing practice by a few extemporaneous pharmacies.
OBJECTIVE: To compare frequencies of patients administered extemporaneous preparations in two separate years, 10 years apart.
METHODS: This registry-based study describes and compares the frequency of extemporaneous oral preparations administered to paediatric patients in 2009 and 2019 at a Swedish university hospital.The study included 117 023 oral administrations (to 4905 patients) and 128 638 oral administrations (to 4718 patients) from 2009 and 2019, respectively.
RESULTS: The frequency of inpatients administered one or more extemporaneous preparations increased from 22% in 2009 to 40% in 2019 (p<0.0001). The increase was observed in all age groups. The use of some active pharmaceutical ingredients increased (eg, captopril, clonidine, hydrocortisone, melatonin and propranolol), and some active pharmaceutical ingredients decreased between the study years (eg, midazolam and sildenafil).
CONCLUSIONS: The introduction of new authorised products has decreased the need for manipulation or extemporaneous preparations in some therapeutic groups. There remains, however, a pronounced lack of commercially available child-friendly dosage forms and suitable strengths enabling safe administration of medicines to children, indicated by the large percentage of patients receiving at least one extemporaneous preparation.

We aim to assess the data of patients with hypertension in Kanagawa Prefecture, Japan, collected in 2021 that were provided by the Japan Medical Association Database of Clinical Medicine. Data collected in 2011 and 2014 by the Kanagawa Physicians Association were used for comparative analysis. The target blood pressure (BP) achievement rates for patients whose target office and home BP were <140/90 mmHg and <135/85 mmHg, respectively, were 72.5% and 75.8% in 2011, 66.0% and 68.5% in 2014, and 46.7% and 83.3% in 2021, respectively. The target office BP achievement rate in 2021 was significantly lower than those in 2011 and 2014 (p ≤ 0.009). In contrast, there was no significant difference and improvement of the achievement rates for patients whose target office and home BP were <130/80 mmHg and <125/75 mmHg, respectively, among the three surveys. After the Japanese Society of Hypertension 2019 Guidelines were released, the achievement rates for patients whose target BP was tightened were significantly lower than those for patients with unchanged target BP (office/home, p < 0.001/0.04). The proportion of the patients who achieved their office and home target BP using more than three drugs was 38.5% and 20.0%, respectively. In the present analysis, we unveiled the current problems encountered in the clinical management of hypertension in Japan. In particular, efforts should be focused on the management of patients that require strict BP control.