Drug-Related Problems in Patients Undergoing Elective Total Joint Arthroplasty: RESULTS

Prevalence of Drug-Related Problems

Of the 150 patients in the convenience sample, charts could not be obtained for 4 (2.7%). The mean age of the 146 patients for whom charts were reviewed was 68.5 years, and 84 (57.5%) were women (Table 1). Of these 146 patients, 116 (79.5%) had at least one drug-related problem, and a total of 275 such problems were identified (Table 2), for an overall mean of 1.88 drug-related problems per patient. Most of the drug-related problems were related to home medications.

Drug-Related Problems According to Patient’s Age

Among patients at least 65 years of age (n = 100) and younger than 65 years of age (n = 46), the proportions who experienced at least one drug-related problem of any type were similar (81% [81/100] versus 76% [35/46], p = 0.64). There was no statistically significant difference in the mean number of drug-related problems per patient between the 2 age groups (2.03 versus 1.56, p = 0.09). However, more of the older patients experienced at least one problem related to home medications (67% [67/100] versus 46% [21/46], p = 0.02). Similar proportions of patients in each age group experienced 2). Only 30 (20.5%) of the patients had no drug-related problems, whereas 48 (32.9%) had a single drug-related problem, 25 (17.1%) had 2 problems, and 16 (11.0%) had 3 problems. Twenty-seven patients (18.5%) had 4 or more drug-related problems. canadian discount drugs

Table 1. Baseline Characteristics 146 of Patients Admitted for Elective Total Joint Arthroplasty

Characteristic

No. (%) of Patients*

Age, years, mean (range)

68.5

(31-91)

Sex

Male

62

(42.5)

Female

84

(57.5)

Chronic medical conditions


Coronary artery disease


24


(16.4)


Congestive heart failure


12


(8.2)


Diabetes mellitus


35


(24.0)


Chronic obstructive pulmonary disease


6


(4.1)

Type of surgery


Hip


60


(41.1)


Knee


86


(59.0)

No. of home medications,

mean (range)


6.2


(0-16)

The most common type of problem related to home medications was omission of a medication (32.8% [59/180]), followed by illegible orders (16.7% [30/180]) (Tables 3 and 4). The most common type of problem related to postoperative medications was inappropriate frequency (45% [17/38]), followed by drug-allergy interaction (37% [14/38]). A total of 57 problems were related to potential indications for drug therapy; this category included patients with a diagnosis of congestive heart failure or diabetes mellitus (and no obvious contraindications) for whom angiotensin-converting enzyme inhibitor had not been prescribed.  erectalis

Table 2. Prevalence of Drug-Related Problems (DRPs) by Category

Category of DRP

No.
(%)
of Patients with
1
or More
DRPs

(n
= 146)

No. (%) of DRPs


All


116 (79.5)


275 (100)


Home medication


88 (60.3)


180 (65.5)


Postoperative medication


34 (23.3)


38 (13.8)


Potential indication


37 (25.3)


57 (20.7)

Severity of Drug-Related Problems

Of the 275 drug-related problems identified in this study, 147 (53.5%) were deemed potentially harmful, 78 (28.4%) were deemed to require monitoring, and 50 (18.2%) were not considered harmful, according to the index categorization system of the National Coordinating Council for Medication Error Reporting and Prevention.

Table 3. Examples of Drug-Related Problems by Category and Type

DRP Category and Type

Example

Home medication

Therapeutic duplication

Prescriptions for both losartan and candesartan

Incorrect formulation

Prescription for nifedipine regular release when XL (extended release)
formulation was intended

Inappropriate dose or strength

Prescription for metoprolol
5 mg
when dose at home was

50 mg

Inappropriate route

Prescription for brimonidine eyedrops to be administered to both eyes
when home prescription

was for left eye only

Inappropriate frequency

Prescription for metoprolol regular release to be given once daily
instead of twice daily

Omission of medication

Patient was taking ramipril at home but had no prescription for this
drug while in hospital

Incorrect drug

Patient was taking formoterol at home but had a prescription for
salmeterol in hospital

Contraindication

Prescriptions for ramipril and spironolactone with high potassium
obtained during preadmission

clinic, with no serum electrolytes ordered on hospital admission

Other

Allergy assessment required (morphine allergy recorded in chart as
“nausea and vomiting”)

Postoperative medication

Drug-allergy interaction

Prescription for morphine for a patient with documented allergy to
codeine

Therapeutic duplication

Prescription for both warfarin
5 mg
daily and warfarin

7.5 mg daily

Inappropriate dose or strength

Lorazepam 5 to 10 mg prescribed instead of intended dose of 0.5 to 1 mg

Inappropriate frequency

Prescription for lorazepam “as needed”, with no dosing frequency
specified

Omission of medication

Order for preoperative antibiotic missing

Order for postoperative thromboprophylaxis missing

Contraindication

Celecoxib prescribed for patient with recent history of bleeding ulcer

Potential indication

Patient with myocardial infarction but no prescription for B-blocker

for drug therapy

Patient with diagnosis of diabetes mellitus but no prescription for
angiotensin-converting

enzyme inhibitor

Patient with diagnosis of coronary artery disease but no prescription
for statin

Of the 180 problems related to home medications, 78 (43.3%) were deemed potentially harmful, 54 (30.0%) were deemed to require monitoring, and 48 (26.7%) were not considered harmful. An example of a potentially harmful problem related to home medications was an incorrect dose of methotrexate ordered in hospital (i.e., different from the home dose). An example of a problem classified as requiring monitoring was an order for diltiazem regular-release in hospital for a patient who had been taking diltiazem sustained- release at home. Viagra Professional

Of the 38 postoperative drug-related problems, 32 (84%) were deemed potentially harmful and 4 (11%) were deemed to require monitoring, with only 2 (5%) considered not harmful. The potentially harmful problems related to postoperative medications included an order for lorazepam “as needed” with no maximum dose or frequency and an order for morphine for a patient with a documented codeine allergy. A postoperative drug-related problem that was deemed to require monitoring was an inappropriate dosing schedule for oxycodone controlled-release (4 times per day, instead of the appropriate twice-daily schedule).

Table 4. Number of Drug-Related Problems (DRPs) by Type and Category

DRP Category; No. (%) of DRPs

Type of Drug-Related Problem

Home Medications

Postoperative Medications

Potential Indication

(n= 180)

(n= 38)

(n= 57)

Drug-allergy interaction

0

14 (37)

0

Therapeutic duplication

4 (2.2)

2 (5)

0

Nonformulary drug

10 (5.6)

0

0

Incorrect formulation

6 (3.3)

0

0

Inappropriate dose or strength

24 (13.3)

1 (3)

0

Inappropriate route of administration

1 (0.6)

0

0

Inappropriate frequency

22 (12.2)

17 (45)

0

Illegible order

30 (16.7)

1 (3)

0

Omission of medication

59 (32.8)

2 (5)

0

Contraindication

11 (6.1)

1 (3)

0

Incorrect drug

3 (1.7)

0

0

Other

10 (5.6)

0

57 (100)*

Of the 57 potential indications for drug therapy identified in this study, 37 (65%) were deemed potentially harmful and 20 (35%) were deemed to require monitoring. One example of a potentially harmful problem of this type was lack of prescrip­tion for a fi-blocker for a patient with previous ischemic heart disease (and no obvious contraindications). One example of a problem of this type that was deemed to require monitoring was lack of prescription for a statin for a patient over 65 years of age with a diagnosis of diabetes mellitus.
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Category: Drugs

Tags: drug-related problems, total joint arthroplasty

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