At our institution UC San Diego Health, formulary qualifiers such as indication expansions and restrictions based on provider specialty, patient location, or patient characteristics are input as free text into an online formulary platform. Inconsistency in formulary categories and their descriptions since the implementation of the electronic system have led to confusion and inconsistent formulary application amongst staff. We reviewed 880 unique medications with formulary qualifiers to standardize both categories and language. There were 537 items with inpatient restrictions (eg, restricted to service), 147 items with a restriction to outpatient use only, 94 items with a formulation restriction, 91 items with associated guidelines, and 11 items with formulary expansions. Formulary status descriptions were updated to be consistent and clear. A standardized and well-maintained formulary, via formulary reconciliation, can provide concise and informative insight to the formulary status for frontline healthcare staff.

OBJECTIVE: The main objective of this study was twofold: to investigate what kind of information patients with heart failure (HF) tell their doctors about their medication adherence at home, and how often such information is provided in consultations where medication reconciliation is recommended. To meet these objectives, we developed an analysis to recognise, define, and count (1) patient utterances including medication adherence disclosures in clinical interactions (MADICI), (2) MADICI including red-flags for non-adherence, and (3) MADICI initiated by patients without prompts from their doctor.
METHODS: Exploratory interaction-based observational cohort study. Inductive microanalysis of authentic patient-doctor consultations, audio-recorded at three time-points for each patient: (1) first ward visit in hospital, (2) discharge visit from hospital, and (3) follow-up visit with general practitioner (GP).
METHODS: Norway (2022-2023).
METHODS: 25 patients with HF (+65 years) and their attending doctors (23 hospital doctors, 25 GPs).
RESULTS: We recognised MADICI by two criteria: (1) they are about medication prescribed for use at home, AND (2) they involve patients\' action, experience, or stance regarding medications. Using these criteria, we identified 427 MADICIs in 25 patient trajectories: 143 (34%) at first ward visit (min-max=0-35, median=3), 57 (13%) at discharge visit (min-max=0-8, median=2), 227 (53%) at GP-visit (min-max=2-24, median=7). Of 427 MADICIs, 235 (55%) included red-flags for non-adherence. Bumetanide and atorvastatin were most frequently mentioned as problematic. Patients initiated 146 (34%) of 427 MADICIs. Of 235 \'red-flag MADICIs\', 101 (43%) were initiated by patients.
CONCLUSIONS: Self-managing older patients with HF disclosed information about their use of medications at home, often including red-flags for non-adherence. Patients who disclosed information that signals adherence problems tended to do so unprompted. Such disclosures generate opportunities for doctors to assess and support patients\' medication adherence at home.

OBJECTIVE: To assess antibiotics prescribing and use patterns for inpatients at Benjamin Mkapa Zonal Referral Hospital (BMH) using the WHO-Point Prevalence Survey (WHO-PPS).
METHODS: A cross-sectional survey.
METHODS: The Benjamin Mkapa Zonal Referral Hospital, Dodoma, Tanzania.
METHODS: Inpatient prescriptions, regardless of whether antibiotics were prescribed (n=286) on the day of PPS.
METHODS: Our study analysed the prevalence of antibiotic use at BMH for inpatients, the type of antibiotics used, the indications for use and the proportion of oral and parenteral antibiotics. We also assessed prescription-prescribed antibiotics after a positive antimicrobial susceptibility testing (AST) result.
RESULTS: A survey was conducted on 286 prescriptions, which revealed that 30.07% of them included antibiotics. On average, each prescription contained at least 1.6 antibiotics. All prescriptions that included antibiotics were written in generic names, and 77.91% (67/86) of them followed the Standard Treatment Guidelines. Of the prescriptions that included antibiotics, 58.14% (50/86) had a single antibiotic, 20.93% (18/86) had parenteral antibiotics and 79.07% (68/86) had oral antibiotics. Based on AWaRe\'s (Access, Watch and Reserve) categorisation of antibiotics, 50% (8/16) were in the Access group, 31.25% (5/16) were in the Watch group, 12.50% (2/16) were in the Reserve group and 6.25% (1/16) were not recommended antimicrobial combinations. Out of 86 prescriptions included antibiotics, only 4.65% showed positive culture growth. However, antibiotics were still prescribed in 29.07% of prescriptions where there was no growth of bacteria, and in 66.28% of prescriptions, antibiotics were prescribed empirically without any requesting of bacteria culture and AST.
CONCLUSIONS: BMH has reduced inpatient Antibiotic Use by half compared with the 2019 WHO-PPS. Adherence to National Treatment Guidelines is suboptimal. Clinicians should use AST results to guide antibiotic prescribing.

UNASSIGNED: There is currently no consensus on clinically effective interventions for polypharmacy among older inpatients.
UNASSIGNED: To evaluate the effect of multidisciplinary team-based medication optimization on survival, unscheduled hospital visits, and rehospitalization in older inpatients with polypharmacy.
UNASSIGNED: This open-label randomized clinical trial was conducted at 8 internal medicine inpatient wards within a community hospital in Japan. Participants included medical inpatients 65 years or older who were receiving 5 or more regular medications. Enrollment took place between May 21, 2019, and March 14, 2022. Statistical analysis was performed from September 2023 to May 2024.
UNASSIGNED: The participants were randomly assigned to receive either an intervention for medication optimization or usual care including medication reconciliation. The intervention consisted of a medication review using the STOPP (Screening Tool of Older Persons\' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria, followed by a medication optimization proposal for participants and their attending physicians developed by a multidisciplinary team. On discharge, the medication optimization summary was sent to patients\' primary care physicians and community pharmacists.
UNASSIGNED: The primary outcome was a composite of death, unscheduled hospital visits, and rehospitalization within 12 months. Secondary outcomes included the number of prescribed medications, falls, and adverse events.
UNASSIGNED: Between May 21, 2019, and March 14, 2022, 442 participants (mean [SD] age, 81.8 [7.1] years; 223 [50.5%] women) were randomly assigned to the intervention (n = 215) and usual care (n = 227). The intervention group had a significantly lower percentage of patients with 1 or more potentially inappropriate medications than the usual care group at discharge (26.2% vs 33.0%; adjusted odds ratio [OR], 0.56 [95% CI, 0.33-0.94]; P = .03), at 6 months (27.7% vs 37.5%; adjusted OR, 0.50 [95% CI, 0.29-0.86]; P = .01), and at 12 months (26.7% vs 37.4%; adjusted OR, 0.45 [95% CI, 0.25-0.80]; P = .007). The primary composite outcome occurred in 106 participants (49.3%) in the intervention group and 117 (51.5%) in the usual care group (stratified hazard ratio, 0.98 [95% CI, 0.75-1.27]). Adverse events were similar between each group (123 [57.2%] in the intervention group and 135 [59.5%] in the usual care group).
UNASSIGNED: In this randomized clinical trial of older inpatients with polypharmacy, the multidisciplinary deprescribing intervention did not reduce death, unscheduled hospital visits, or rehospitalization within 12 months. The intervention was effective in reducing the number of medications with no significant adverse effects on clinical outcomes, even among older inpatients with polypharmacy.
UNASSIGNED: UMIN Clinical Trials Registry: UMIN000035265.

Drug-related problems (DRPs) are critical medical issues during transition from hospital to home with high prevalence. The application of a variety of interventional strategies as part of the transitional care has been studied for preventing DRPs. However, it remains challenging for minimizing DRPs in patients, especially in older adults and those with high risk of medication discrepancies after hospital discharge. In this narrative review, we demonstrated that age, specific medications and polypharmacy, as well as some patient-related and system-related factors all contribute to a higher prevalence of transitional DPRs, most of which could be largely prevented by enhancing nurse-led multidisciplinary medication reconciliation. Nurses\' contributions during transitional period for preventing DRPs include information collection and evaluation, communication and education, enhancement of medication adherence, as well as coordination among healthcare professionals. We concluded that nurse-led strategies for medication management can be implemented to prevent or solve DRPs during the high-risk transitional period, and subsequently improve patients\' satisfaction and health-related outcomes, prevent the unnecessary loss and waste of medical expenditure and resources, and increase the efficiency of the multidisciplinary teamwork during transitional care.

UNASSIGNED: Medication discrepancies are a major safety concern for hospitalized patients and healthcare professionals. Medication Reconciliation (MR) is a widely used tool in different practice settings to ensure the proper use of medications.
UNASSIGNED: This study aimed to assess the effectiveness of the clinical pharmacists-led MR process in identifying, preventing, and resolving medication discrepancies among hospitalized patients.
UNASSIGNED: This was a prospective study with an observational and interventional part, conducted at the Internal Medicine Department of a tertiary Hospital in Sudan from January to September 2023. The enrolled patients were divided into two groups, the observation group, in which the routine MR process was performed by doctors (usual care), and the intervention group, in which clinical pharmacists led the MR process.
UNASSIGNED: Compared to the usual care, the clinical pharmacists were more efficient in identifying and preventing medication discrepancies (P=0.001). From a total of 1012 medications, clinical pharmacists\' interventions contributed to the detection of (39%) equivalent to 2.2 discrepancies per patient, resolving 325 (83%) and preventing (55%) clinically significant discrepancies. Dose discrepancy (43%) was the most common type of identified discrepancies. These interventions were accepted by (98%) of doctors and implemented in (86%) of the total cases. The main predictors of medication discrepancies (P ≤0.05) for patients were the length of hospital stay, patient-hospital transfer, high number of medication histories, and increased number of medications used during hospitalization.
UNASSIGNED: Through the implementation of the MR process, the clinical pharmacist\'s interventions substantially contributed to the detection and resolution of medication discrepancies among hospitalized patients. It is recommended that this intervention be disseminated in more hospitals in Sudan to encourage the implementation of appropriate practices.

UNASSIGNED: Patients who stay in the emergency department (ED) for prolonged periods of time require verification of home medications, a process known as medication reconciliation. The complex nature of medication reconciliation can lead to adverse events and staff dissatisfaction. A multidisciplinary team was formed to improve accuracy, timing, and staff satisfaction with the medication reconciliation process.
UNASSIGNED: Between November 2021-January 2022, stakeholders were surveyed to identify gaps in the medication reconciliation process. This project implemented education on role-specific tasks, as well as a \"Let\'s chat!\" huddle, bringing together the entire care team to perform medication reconciliation. We used real-time evaluations by frontline staff to evaluate effectiveness during plan- do-study-act cycles and obtain feedback. Following the implementation period, stakeholders completed the post-intervention survey between June-July 2022, using a 4-point Likert scale (0 = very dissatisfied to 3 = very satisfied). We calculated the change in staff satisfaction from pre-intervention to post-intervention. Differences in proportions and 95% confidence intervals are reported. This study adhered to the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) and followed the Lean Six Sigma rapid cycle process improvement (define-measure-analyze-improve-control).
UNASSIGNED: A total of 111 front-line ED staff (physicians, nurse practitioners, physician assistants, pharmacists, nurses) completed the pre-intervention survey (of 350 ED staff, corresponding to a 31.7% response rate), and 89 stakeholders completed the post-intervention survey (a 25.4% response rate). Subjective feedback from staff identifying causes of low satisfaction with the initial process included the following: complexity of process; unclear delineation of staff roles; time burden to completion; high patient volume; and lack of standardized communication of task completion. Overall satisfaction improved after the intervention. The greatest improvement was seen in the correct medication (difference 20.7%, confidence interval [CI] 6.3-33.9%, P < 0.01), correct dose (25.6%, CI 11.4-38.6%, P < 0.001) and time last taken (24.5%, CI 11.4-37.0%, P < 0.001).
UNASSIGNED: There is a steep learning curve to educate multidisciplinary staff on a new process and implement the associated changes. With goals to impact the safety of our patients and reduce negative outcomes, engagement and awareness of the team involved in the medication reconciliation process is critical to improve staff satisfaction.

BACKGROUND: Adherence to pharmacotherapy and use of the correct inhaler technique are important basic principles of asthma management. Video- or remote-direct observation of therapy (v-DOT) could be a feasible approach to facilitate monitoring and supervising therapy, supporting the delivery of standard care.
OBJECTIVE: To explore the utility and the feasibility of v-DOT to monitor inhaler technique and adherence to treatment in adults attending the asthma outpatient service in a tertiary hospital in Northern Ireland.
METHODS: The project evaluated use of the technology with 10 asthma patients. Patient and clinician feedback was obtained, in addition to measures of patient engagement and disease-specific clinical markers to assess the feasibility and utility of v-DOT technology in this group of patients.
RESULTS: The engagement rate with v-DOT for participating patients averaged 78% (actual video uploads vs expected video uploads) over a median 7 week usage period. Although 50% of patients reported a technical issue at some stage during the usage period, all patients and clinicians reported that the technology was easy to use and that they were satisfied with the outcomes. A range of positive impacts were observed, including optimised inhaler technique and an observed improvement in lung function. An increase in asthma control test scores aligned with clinical aims to promote adherence and alleviate symptoms.
CONCLUSIONS: The v-DOT technology was shown to be a feasible method of assessing inhaler technique and monitoring adherence in this small group of adult asthma patients. A range of positive impacts for participating patients and clinicians were observed. Not all patients invited to join the project agreed to participate or engage with using the technology, highlighting that in this setting, digital modes of delivering care provide only one of the approaches in the necessary \"tool kit\" for clinicians and patients.

OBJECTIVE: The aim of this study was to compare the validity of an integrated objective structured clinical examination (OSCE) station assessing both oral and written components with that of an OSCE station assessing 1 single skill (oral only), both targeted at assessing taking a best possible medication history.
METHODS: A convergent mixed-methods design that used the 4 inferences of Kane\'s validity framework (scoring, generalization, extrapolation, and implications) as a scaffold to integrate qualitative data (post-OSCE reflections) and quantitative data (assessment grades and categories of medication errors) was applied.
RESULTS: In 2022, 216 students completed the OSCE station with the oral component alone, while in 2023, 254 students completed the integrated (oral and written) OSCE station. Students in 2023 performed significantly better, with a median score of 88% vs 80% in 2022. There was a greater proportion of commission errors in the integrated assessment (20.4% vs 15.3%), but fewer omission errors (29.9% vs 31.8%) and patient profile errors (5.1% vs 69.4%). Student reflections revealed that conversations were rushed in the integrated assessment, with a greater focus on written formatting, but an appreciation for the authenticity and structured format of the integrated OSCE compared with the single-skill OSCE alone.
CONCLUSIONS: Students completing the integrated OSCE (with oral and written components) had fewer patient profile and medication omission errors than students who completed the oral-only OSCE. Considering Kane\'s validity framework, there was a stronger argument for the more authentic integrated OSCE in terms of the inferences of extrapolation and implications.

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