The medical records of patients who underwent elective total joint arthroplasty between January and December 2005 were examined retrospectively. This time period was selected to obtain a representative sample of patients who received standard care immediately before the prehabilitation clinic became operational. The study was limited to those who had undergone elective (rather than emergency) arthroplasty to ensure that all patients included in the study had undergone preoperative assessment at a preadmission clinic.
The study population was identified from the regional Joint Replacement Registry, a database of all patients who undergo total joint arthroplasty in the region. A convenience sample of 150 cases was randomly selected from the list of all elective, single total joint arthroplasty procedures performed at the 3 sites in the health region in 2005. The number of cases from each site was proportional to the total number of procedures performed at the site. The random number generator in Microsoft Excel was used in the random selection process. Patients were included if review of the medical chart revealed that they had been taking more than one medication at home before the surgery. Patients were excluded if the records from the preadmission clinic were incomplete or the medical records were unavailable. canadian pharmacy viagra
The primary outcome was the proportion of patients with at least one drug-related problem arising from medication orders written before or immediately after the surgery. Secondary outcomes were the number and description of these problems according to patient age and the category, type, and severity of the problem.
The drug-related problems were grouped into 3 main categories: problems related to a home medication, problems related to a postoperative medication, and problems related to a potential indication for drug therapy. A problem was defined as being related to home medications if the patient had a postoperative prescription that was inconsistent with home medications. A problem was defined as being related to postoperative medications if the prescription for a postoperative medication (specifically antibiotics, analgesics, anticoagulants, or antiemetics) was potentially inappropriate. If a medication considered appropriate for a specific comorbid condition had not been prescribed (at home or in hospital) and the patient had no obvious contraindication to the drug, the problem was categorized as a potential indication for drug therapy.
The drug-related problems were then described according to the patients’ age and the type and severity of the problems. The number of patients with at least one drug-related problem and the number of drug-related problems per patient were determined for patients younger than 65 years of age and those 65 years of age or older. The prespecified types of drug-related problems were drug—allergy interactions, therapeutic duplication, nonformulary drug, incorrect formulation, inappropriate dose or strength, inappropriate route of administration, inappropriate frequency, illegible order, omission of a medication, contraindication, or incorrect drug. This method of characterization was chosen to reflect drug-related problems that a hospital pharmacist would be likely to encounter at the point of order entry for home and postoperative medications. The severity of each problem was evaluated according to a condensed version of the index categorization system of the National Coordinating Council for Medication Error Reporting and Prevention: no harm, monitoring required, or harmful. According to this categorization, a drug-related problem that was deemed to be harmful would, by definition, potentially cause the impairment of the physical, emotional, or psychological function or structure of the body. Examples of this type of problem would be inappropriate dosing of a potentially toxic medication or prescription of a medication to which the patient is allergic. A drug-related problem was considered to require monitoring if observation or recording of relevant physiological or psychological signs was needed. Examples of this type of problem would be prescription of a regular-release blood pressure medication in hospital for a patient who was taking a controlled-release formulation at home.
A licensed pharmacist (M.H.) reviewed all of the randomly selected medical charts to identify drug-related problems and to determine their category, type, and severity. A second pharmacist (C.R.) independently identified drug-related problems from a random selection of 15 charts (10.3% of the total) to validate the process for identifying problems. The second pharmacist also assessed a random sample of 10 charts (6.8% of the total) to validate the collection of data for each identified problem. Finally, all of the drug-related problems identified were reviewed by the second pharmacist (C.R.) for validation of the classification by category type and severity. Any discrepancies in the identification or classification of drug-related problems were resolved through discussion. The following sections of the chart were reviewed to identify drug-related problems: assessment forms from the preadmission clinic, which were completed by a preadmission nurse (containing a history of medications that the patient was taking before surgery); preoperative orders for postoperative administration of home medications; and orders for medications such as antibiotics and opioids to be administered perioperatively.
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The data were collated into a database created in Microsoft Excel. The mean number of drug-related problems per patient and the proportion of patients with at least one drug-related problem were calculated. Differences between age groups (those younger than 65 years of age and those 65 years of age or older) were compared with Student t tests and X2 tests performed in Microsoft Excel.
The study protocol was approved by the University of Manitoba health research ethics board and the research impact committee of each of the 3 study institutions. Inclusion of patients in the Joint Replacement Registry was voluntary, and all information collected for this study was stored and used in a manner that would protect patient confidentiality.