Hello, Matej,

This is a very good question and a very big one. In Taiwan nowadays, hospital-based practice is equipped with informatics-assisted alert system aiming proactively to prevent inappropriate prescriptions for a variety of medical conditions. For example, duplicate medicines like simultaneous prescription of two NSAIDs, or two calcium blockers, double ACEI will be easily blocked by the system. In patients with impaired renal function, their prescription or dosage of medication will be checked against their estimated CCr level. For the antineoplastic chemotherapeutic prescriptions, the doctor will be alerted about the patient's current CCr, bilirubin level and current neutrophil count. And sometimes, clinical staffs prescription will be checked against the insurance reimbursement criteria and preauthorization existence.

In Catalonia (Spain, yet) we are working with a computerised clinical record (called eCAP) which includes a prescription module with a automated system for detection and alerts of contraindications, incompatibilities and cautions. Moreover, there is an automated self-audit that weekly offers lists of patients with duplicities, polypharmacy, incompatibilities and

drug safety alerts. So, it is easy for the doctor detect and arrange these situations in his/her patients.

See information about eCAP in: https://ecapics.wordpress.com/

https://ecapics.wordpress.com/

In NIGERIA, this is an important problem but unfortunately, the mechanisms in place aren't yet effective in preventing/curtailing the problem.

Thanks Dr. Kamilu for real answer. You are right, in many countries worldwide, including many European countries, the situation is more or less the same. This is not good for our patients and also for us (future patients). This situation is very sad, although usually healthcare professionals are very loud about teamwork, however this is one of the most important result that there is no enough teamwork within the team next to the patients' beds. In many European hospitals we do not have appropriate risk assessment plans how to avoid serious harms to the patients in term of inappropriate prescribing (e. g. antipsychotic polypharmacy). In U.S. Medicare (payer) made great decision to support this practice and to show the hospitals that this is very important issue.

I think we should conduct those studies to give the patients right answers about these 'hidden' topics. After that the patients will have right to choose appropriate hospita, which has not so many inppropriate prescribing cases for example. Why I as payer of my insurance should be treated with several drug-drug combinations without EBM or even with supportive EBM?

According to the last data about 50 % patients with antibiotics are treated with inappropriate antibiotics or even they do not have indications for their use. About 1/2-1/3 antipsychotic polypharmacy is used without any reason. About 20-30 % of patients with heart failure (CHF) are not treated with the best EBM combinations. In each patients, who has been treated with at least 8 medications together, there is serious DDI inside. Why medication are not checked in each hospitals before administering? There are many interesting data to support assesement of inappropriate medications in each hospital. This plan would be very helpful for our patients and payers.

Dear Victor and Eric many thanks for your opinion according to this problem. You are right, these systems are very good, however these system cannot substitute weel-trained clinical pharmacist next to the patients' beds. For example, patient is treated with quetiapine SR, however absorption by food is limited. Another example is solifenacin and delirium-induced by drugs. In many multiple combinations you won't get any outcome that you can substitute solifenacin by darifenacin, which has smaller penetration in to the CNS and consequently different effects (General Hospital Psychiatry 35: 682.e3-682.e4, No. 6, Nov-Dec 2013.). Another example is nitrofurantoin and trazodone. There is no interaction made by LEXI, however small additional anticholinergic effect is additive to produce delirium in this case. Nitrofurantoin should be immediately switched to even amoxicillin with clavulanic acid (Wien Klin Wochenschr. 2014 Sep;126(17-18):549-52.). Another interesting case is additive pharmacological effect, which is often seen in real clinical practice. Excessive sweating was produced, when agomelatine added to the duloxetine therapy. In programs you won't get nothing important, however this is pharmacodynamic drug drug interaction (blockade of 5HT-2C lead to additional adrenergic stimulations which is summed up by duloxetine mechanism of action) (Wien Klin Wochenschr. 2015 Sep;127(17-18):703-706.).

There are many cases, where programs cannot substitute weel-teached clinical pharmacist. When we remove any drug from patient's pharmacotherapy then is very important which drug we add. This is another important topic, where cooperation is beneficial for patients and payers.

Without a pharmaceutical care done by clinical pharmacist, there is a big lack of treatment efficacy and patients' safety. With this cooperation established patients are much more better protected from inappropriate medications and drug-drug combinations. in addition, one thing is outcome from clinical trial, the second thing is often real clinical work (should be teamwork). However, both sides are important we cannot ignore the reasults from well-designed clinical trials, guidelines and meta-analysis. Patients should be protected first and there is no place for ignore teamwork, which is often 'only on the paper' in real clinical practice.

Dear Dr Stuhec, The use and overuse of medicines depends on prevailing regulations , laws and drug use practices in a particular country. For example a large number of FDCs are available in India and thus likelihood of duplication of one or more active ingredients is increased. In addition, different systems of medicines ayurveda, homeopathy, unani and modern medicines all make the difference. A large number of OTC preparations such as pain relievers, vitamins are taken by consumers and patients along with concurrent prescription drugs. So the problem is a big one and requires multi-pronged action. The focus should on the prescribers' behavioral change. Antibiotic overuse can be reduced by antibiotic steward programs in bigger hospitals

The irrational use of antibiotics is one the major concerns and for this the OTC dispensing of the antibiotics should be completely curtailed, i was told in some countries there is no need for a prescription and the patients can get the antibiotics freely from the pharmacy. Further to this the duration/course of the treatment  of the antibiotics is also not complied with , as the patient takes the antibiotics for few days and abruptly stop the medications. This practice results in the enormous increase of bacterial resistance and as well as morbidity and some times in hospital admission due to ADR.

most interesting is the assumption that "properly prescribed" meds do not lead to

adverse effects serious enough to require hospitaloization- you might first want to

examine these data

In Iran, there is no comprehensive and national wide systems to monitor this issue. It completely depends on the hospital where the patient is admitted to!!. Most Private and expensive hospitals have appropriate condition and well- experienced staffs and doctors that pay more attention to every details. In some hospitals, there are very consistent and comprehensive records of patient's history while I am not sure about the rest. Any way, there is no national wide network and system. I know that Switzerland, South Korea and New Zealand have  computerized clinical record, and they record details as a history for every patient.

In Indonesia, the situation is more or less the same with Mr. Naraye from Nigeria and Mr. Alimoradi from Iran. We do have regulations regarding pharmacist's duty in implementation of pharmaceutical care but we do not have a national/regional regulation to support informatics-assisted alert system. It only depends on the hospital will.

Dear Dr Gurudas Khilnani,

You wrotte: So the problem is a big one and requires multi-pronged action. I highly agree with You. This is the main sentence, which should pay attention among payers and patients and also all healt care proffesionals. This is very hard issue, especially prescribing trends are chenging very slowly, although new guidelines are available. The second issue is good teamwork, which should be establis within the hospitals. As I surveyor for international accreditation company i saw in some hospitals in Eastern Europe very bad situation (no risk assesement, no prevention strategy, no clinical pharmacists next to the patients' beds). I dont want to be treated in those hospitals. When i asked hospital leadership, where they have adverse events reports and how many complications with inappropriate prescribing they have, they answered: 'we are very good in treatment so we do not have etc ...'. This should not be happen in any hospital. The governments should protect the patients and conduct trials within the hospitals about this topic. Very important topic is for example antipsychotic polypharmacy, which should be documented in the patients' charts why was used and what was difference (outcome) between monotherapy and polypharmacy. Few hospitals had this systems within Eastern Europe. Why they do not establish this system? I ask myself why.

First reason is bad cooperation among different health care profesionals and high conviction. Second, the patients are not so careful on mistakes in the field of inappropriate prescribing (they thing automatically that they are well treated). Third, the hospital leadership think that they do not have resourses, which is ONLY partly true. Although there is a lack of resourses, the inappropriate prescribing and medical errors should be discussed within the team member (prescribers, clinical pharmacists, nurses, directors etc ..). There is no place for those errors! Fourthly, very bad communication among different specialities. In one hospital I asked hospital director if they have clinical pharmacist and he answered: 'Why we need it? Who will correct us?'. These answers are very stupid and not according to the EBM and Standards for Accreditation International (NIAHO, AACI, Canadian International etc ... ). After a survey was completed he had not the same opinion again (because many serious errors and inappropriate prescribing and drug administration were seen). I think the last issue is critical within many hospitals and systems how to improve better communication are lacking. There should be no place for aggresive communication if there are many EBM to support the use of one method (e.g. clinical pharmacy). Very important issue is to protect health care members, when they detect errors.

Regards,

Matej

It is right polypharmacy is very much in medical practice. 

as far as check and balance system - In India there is very less space for Clinical Pharmacy or bedside Clinical Pharmcology services. Some hospital in private sector(mostly corporate hospital) have some policy for bedside prescription audit. 

but most hospital do not use clinical pharmacy/Pharmacology services especially Medical Colleges, where most of the teaching for UG as well as PG is going on. 

this should be taken as matter of priority by hospital administrators- so that resources of hospital are less wasted and care of patient can be improved.

Unfortunately, this practice is not developed in my country. A study performed in the University Hospital of Montevideo showed that a high percentage of patients suffered from well-known adverse drug reactions due to the lack of assessment of pharmacotherapy at the bedside. So our reality is no far from yours. 

With the advent of pharmacy informatics and electronic health records system the patients and as well as the healthcare providers are at much comfort zone than before. This does not completely eradicate the inappropriate prescribing pattern of the physicians, having said that CPOE -computerized physician order entry would likely to considerably reduce the common medication errors and as well as poly pharmacy.

Interlinking of the patients medical records country wise will be a key issue and at the same time is a challenge to HIS.

Dear Dr Stuhec, 

     Thanks a lot for your interest in this issue concerning public health. Actually answer to the problem of curtailing inappropriate use is simple (Of course simple things are most difficult to follow!) that is

Doctors (Prescribers) should be miser in prescribing!

Users (patiients) should be wiser in subscribing !!(consent and drug-intake)

Every stakeholder ranging from the Government Agencies, the Doctors and Pharmaceutical companies play their various roles to the extent to which they can. I believe the Doctors have the biggest role, in my country and from my experience they play the role of informing the patient and regularly monitor the medications patients have access as well as ensuring there are no drug interactions when they prescribe.

more significant issue is how many patients admitted as  well as how many fatalities

from properly administered medications- e.g total number of fatalities with

"appropriate" administration- "appropriate" refers to FDA approval and 

guidelines-  consumers are advised to avoid new meds until they have been

on market for a number of years- transparency would be helpful for actual

FDA results- would help decisions for cosumers and Physicians, especially

because approval of new med does not require evidence that it works better

than existing meds for the condition it is prescribed 

'

Pharmacovigilance is the process and science of monitoring the safety of medicines and taking action to reduce the risks and increase the benefits of medicines. This is very important process after ADR (ADE) has already been occured. The strategies to prevent serious ADR (ADE) are also connected by inappropriate prescribing. Inappropriate prescribing may lead to ADR (ADE) or not. Many discrepancies on the patient's chart can lead to several harms or not. According to the some reports this number is very high (number of inappropriate prescribed medications). The best protective strategy is to include clinical pharmacists next to the patients' beds, where pharmacotherapy can be checked immediately after prescribing and constructive discussion should be established before drug dispensing and administering to the patients. In several countries, where this mechanism has not yet been established I am afraid of several medical errors as consequences of inappropriate prescribing (e.g. methotrexate is prescribed every day 20 mg instead weekly etc ... ). This is a part of pharmaceutical care within the hospitals, where should be established. Why has not been established in many European countries I really don't know ... Probably the patients and payers will tend to establish this system as soon in possible.

Concerted awareness by the medics to the citizens through various media is helping alot

The use of electronic health records can reduce, but not eliminate medication errors. Physicians can make mistakes during data entry, and pharmacists may not always catch them. In many cases, pharmacists recognize inappropriate prescribing and prevent these errors from affecting patient outcomes and unnecessary hospitalizations.     

I agree with you both. Dear Edward you are right.

'In many cases, pharmacists recognize inappropriate prescribing and prevent these errors from affecting patient outcomes and unnecessary hospitalizations.'

Congratulations for this sentence!

Your opinion is perfect for the patients. Next to this we need system, which will establish this cooperation before patients is treated with inappropriate medication. At this level we show to the patients if we are team-players or not. On the other side, to talk about teamwork and patients are treated with inappropriate medications is not very useful for patients. This concern is very important for patients' safety.

I am still waiting for the health professionals (M.D., Pharm.D., nurses ... ) from Central-Eastern Europe (e.g. Croatia, Serbia, Bosnia, Hungary, Croatia, Slovenia ... ) to make comments on this important issue for patients in these countries.

In Austria, health insurers make efforts to educate and monitor physicians regarding this very relevant issue. There are also databases and programs which issue alerts about inappropriate combinations. Unfortunately, these are often ignored, because of the number of irrelevant alerts, or where the combination is deemed necessary, and  the risk is considered acceptable. 

Thanks Anna. The situation in Austria with inappropriate prescribing is comparable with those in Slovenia few years ago (similar system former Habsburg health system we have with many similarities), before our system has established clinical pharmacy services within the hospitals and also in primary health settings. With the use of clinical pharmacy service this risk is reduced by 50 % more or less. How to establish this system in the systems where there is no clinical pharmacists next to the patients' beds is very difficult issue. However, this step should be supported by national insurance company and ministra of health and patients. This is the most important. These institutions should establish trials in 'high risk parts of Austria' where so many inappropriate prescribing exsists and conduct trials there. After positive results for patients have been seen a future for establishing is much more easy. For example now you pay (as payer) for bad service in some cases, which could be improved by addition of clinical pharmacists in to the system. Usually in normal life we do not pay (do not want) for a bad service or inappropriate, although in health service we pay the same bill for a bad service without any complaints. I ask often myself why.

Normally the specialist consults the Beer Criteria but it is real to the wealthy population. Unfortunately, the poor people uses the list of medicine that the free one medicine tha the government dispose and in most part of these conditions, they are not the best choice in the therapy.

Best Regards,

Patricia

Inappropriate treatment and even combinations are difficult to prevent in areas where very few doctors do practice...but in setting of a large hospital or medical colleges, the treatment plan is not decided by a single doctor, but by a list of doctors, starting from beginner to the seniors...hence, we suppose the patient gets proper treatment...and we also have meetings regarding the cases between inter-department doctors, where the discussion regarding the case occurs....along with the treatment....

i suppose this happens in every hospital where at-least few doctors are available for the same patient.

Thanx

Hi Matej,

In Ecuador where I am from, public-free health services cover the majority of people´s needs. For the most common diseases, we have standarised protocols/guidelines (tropical diseases, pregnancy problems, pediatric morbidity, tuberculosis, AIDS, etc.). There you have how to deal with specific diseases and which pharmacological and non-pharmacological approaches you should make (including dealing with antibiotic resistance). However, what I found problematic is when you deal with diseases that are not that common and you don´t have the right drugs to use. When I was in the clinical setting, antibiotics were always the problem (specially in rural areas), because sometimes you didn´t have the drugs that you were suppose to use according to the protocols. But at the moment, within the Public Ministry of Health, there is this area of normatization, which tries to correct, update and develop clinical guidellines and protocols based on evidence. Currently there is no control on how clinicians use the drugs provided by the government.

Cheers!  

Esteban Bonilla

MD MSc

Hello.

In the hospitals of Belarus is a Clinical Pharmacologist duties, which analyzes the consumption of medical products, audits medical records.

Sincerely, Zmicer

Yo sigo a los pacientes desde Atención Primara debido a que es allí donde trabajo , tenemos u programa de supervisión en pacientes ancianos polimedicados,pero e Hospital lo desconozco

In Ireland all medicines must be approved and licensed by the HPRA.Pharmacists are very careful in dispensing prescriptions for patients and all Pharmacy computers have built in interaction programmes.

Thank You very much for nice comments here. Dear Bernard, i highly agree with you. Clinical pharmacists are necessary in this process, otherwise many mistakes have not been seen. If many mistakes have not been seen there is a high risk of treatment failure, which can have life-threatening consequences.

General opinion (often written and heard):

- there are no inappropriate prescribing within the hospitals,

- prescribers know everything and do not need team-based support,

- there is no necessary to accept clinical pharmacists,

- patients do not know why are the medications,

- there are no adverse drug reactions, because we treated very well,

- all drugs are administered and dispensed according to the regulations,

- eminence-based prescribing is more important than evidence-based prescribing,

- guidelines are written in ideal conditions and should not be respected very well.

- the price for inappropriate prescribing is low.

However, the reality is totally different:

- Almost 10 % of patients are admitted to the hospitals, because of inappropriate medications.

- More than 50 % of elderly psychiatric patients are treated with at least one psychotropic drug, which is prescribed inappropriately.

- Almost every second antibiotic is written inappropriately.

- Almost every fifth prescribed medication is inappropriate.

- Almost 50 % of patients are treated with antipsychotic polypharmacy, which is used inappropriately.

- Inappropriate prescribing is one of the highest burden in medicine, with its annual cost more than 1 billion in USA.

- There are many errors in drug administering and dispensing (almost every fifth medication is administrating inappropriately).

- Almost every fifth medication is released on the admission to the hospitals.

- Well designed clinical trials and meta-analysis should be respected. Their evidence level is much higher than opinions of individuals. EBM should be always first. EBM supports an inclusion of clinical pharmacists and this should be respected.

- The inclusion of clinical pharmacists next to the patients' beds can reduce overall inappropriate prescribing by 50 %, ADR by 50 % and total cost five times more than is salary for clinical pharmacists (1 $ for 5 $).

Are given reasons and not enough support to employ clinical pharmacists next to the patients' beds and establish this service within your country? Is not a common goal to reduce those mistakes?

Many hospitals within Europe don't have their own data. Why they do not have? Because they think that they are perfect. But unfortunately ... They just think ...

Regards!

how can anyone determine what is appropriate in the U.S.- is there a way to

determine how many meds are prescribed off-label- those that are appropriate-

to secure FDA approval, a medication must provide research results that meet

FDA criteria and approval by a review panel- once approved for specific conditions

companies are not allowed to advertise benefits for other conditions- however,

once approved,, Physicians can legally prescribe that medication off-label- I

understand that off-label means the basis is not  one of relevant approved research-

is this accurate? -  are all off-label prescriptions considered  inappropriate and

what percent of prescriptions  are off-label? 

In Portugal, there is no nationwide initiative to prevent this. However, many pharmacies are quite active in detecting interactions (supported by the software, which grades them according to the severity). The software does not address potentially inappropriate medicines, so pharmacies trying to detect these are isolated cases of motivated pharmacies that sometimes join initiatives of various faculties. We do have a nationally validated tool (Beers), so I guess the next step missing in our country is to include it in the software to help pharmacists to be able to implement detection of PIMs in a sustainable manner. There have been studies done in Portugal in nursing homes but, to my knowledge, not in hospitals.

I work in a Group that manages long term and subacute care institutions for old people, then this is a usual and important problem. Our approach is from the Pharmacy Service. Pharmacists review the medication at the time of admission and when the physicians make new prescriptions. When we detect inappropriate medications, we try to communicate with the physicians and recommend them alternative medications. This is not always easy, because they are busy and sometimes they do not answer our recommendations or are not accepted for different causes. In order to be more effective, we have narrowed the number of medications to alert the physicians and give them feed-back about our finding when we meet to talk about medication problems. We this little strategies it seems that we are improving the rate of prescription of inappropriate medications.

Thanks for these nice answers. As I see the situations are much different along different countries. In many countries worldwide there are still no mechanisms, which would protect patients by inappropriate prescribing/prescriptions. Dear Conxita I see that your Catalan approach is good, although not ideal/suitable for our patients. We should establish the mechanisms that would produce possible feedback from prescribers and the reason why suggestions were not accepted by prescribers. This way is very hard in some settings, because opinion about its necessarity should be changed (prescribers' beliefs are very different from pharmacists). This way and kind of teamwoork should be built from first years within faculties of medicine and pharmacy. They should have an awareness that we share the same patients and same time. The most dangerous for the patients is the awareness that we do not need any help and we do not make mistakes. This can be even fatal for our patients as many cases demonstrate clearly. Prescribers and pharmacists (where they do not have prescribing rights) should establish the mechanisms how they can prevent inappropriate prescribing/prescriptions. As I surveyor in Eastern European hospitals i have seen many directors and M.D.s without any plan about inappropriate prescribing within the hospitals. I think this indicator should be available for patients along the Europe. 

Hello to everybody!

I am still waiting for more opinions from Eastern European countries and Central European why this system is not established? Are medical errors reported to the hospital committee for medications/quality assessment? Are quality indicators established and respected within your hospital? How the pharmacotherapy from your colleagues has been changed, if a serious inappropriate prescribing is recognized?

Are reporters of these errors involved in serious mobing or they are awarded by hospital leadership?

I think it is the most important issue for new leaders, how to prevent patients from being treated with inappropriate medications and protect workers who report medical errors within the hospitals. In many European countries it has not been done and therefore are patients not so protected as they should be. If the hospitals have not established this policies within their systems I would not go as pacient to these hospitals. We are in the hospitals because of our patients and they should be protected first.

Regards,

Matej Stuhec, Pharm.D., Ph.D.

Clinical pharmacist consultant

Dear Matej, I can recommend some personal contacts with colleagues from countries you say are lacking. Please try [email protected], [email protected] and [email protected].

Regards,

Tx Filipa for the contact, which are given above! However, i expect open discussion among M.D., Pharm.D. and patients. The solutions should be given to the patients. They should not be treated with inappropriate medication!

Dear professors Stuhec,

You have set a very curious question, for which I thank you!

I can say as a clinical pharmacologist at least for the Federation of Bosnia and Herzegovina that there is no developed adequate health system to monitor and thus prevent polypharmacy in daily practice!

More is given and relies on the expertise and knowledge of Medicus in prescribing drugs, but in an organized tracking system, which is not good! I think the ministry in charge need to introduce monitoring of prescription drugs, their control and analysis to inject prevention to avoid polypharmacy and possible malpraktice!

 Dear  dr.Stuhec,

I'm interested in that Slovenia resolve this issue, because I think as a leader of the progress of the countries of former Yugoslavia and I had a very good and fruitful contact and good cooperation with excellent pharmacologists from Ljubljana (example prof.dr.Metka Budihna, of which I have a lot of good things learned) with other my dear colleagues!

Best Regards

Jasenko Karamehic

Dear dr. Karamehic,

sorry for a short delay, because i was very busy with article publishing. Anyway, i am glad that you are interested in this important topic. It is a pity, because ex-yugoslavian countries didn't invest more resources in to this important topic, which is the one of the most important in patients' view. These resourses are not only finance but also collaboratice care practice within Mstudy/Phstudy. When this system should be applied in real clinical practice is much harder, because many healthcare professionals do not need or even worst think that they do not need to be within a team care.

1) Primary care

In this point of view, especially clinical pharmacy make very huge step up in the last decade in Slovenia, especially with adding clinical pharmacist as care provider in primary comunity health setting, where each slovenian primary health setting (slo zdravstveni dom/cro dom zdravlja) has own office of clinical pharmacist and each GP can send patient to the clinical pharmacist. This system has been established in the last 5 years. We are absolutely first in this part of Europe. How this collaborative care practice is important, I have already discussed in many different topics on ResearchGate.

To put clinical pharmacist in to the healthcare team is the most effective approach to minimize medical errors. There are no more effective system strategy according to the HTA systems and well-designed trials.

2) Hospitals

There are many discussion in this part of Europe if clinical pharmacist is a appropriate and equal member within daily rounding on wards (slo/cro vizite). Network for Excellence in Health Innovation (HIHE), which covers more than 100 U.S. hospitals analysed that to put clinical pharmacist on the ward and rounding is the most effective approach to minimize medical errors.

Patients who received pharmacist follow-up calls were 88 percent less likely

to have a preventable medication error resulting in an ED visit or hospitalization. Including a pharmacist on routine medical rounds led to a 78 percent reduction in medication errors. Adding a pharmacist to a physician rounds team in an intensive care  unit led to annual savings of $270,000.

About clinical pharmacologist, we also have just some of them, we have a specialization from clinical pharmacy in Slovenia to deal with these problems and now the new law (adopted in 2017) includes also clinical pharmacist as indispensible part of the healtcare team member within the ward.

How clinical pharmacists could deal with patients with mood disorder please follow our paper.

Regards to Sarajevo,

Matej

http://www.nehi.net/bendthecurve/sup/documents/Medication_Errors_%20Brief.pdf

Article Comment on: An Open Trial of Lurasidone as an Acute and Main...

Dear dr.Stuhec,

Thank you for this comprehensive response that heard with great pleasure to read and then you'll volunteer my impressions

Thanks for the compliments to Sarajevo and also from the heart to welcome Ljubljana and the whole me to "dear Deželu"!

Dear dr. Karamehic,

I am glad to hear these news that you are interesting in clinical pharmacy. If you will need any additional info do not to hesitate to contact me via message. I am sure that this collaborative approach is the key step to get outcomes more optimistic and of course better. This goal should be implemented in daily clinical practice. But i know that is not easy to change it "during the night". Appropriate strategies to report and re-correct medical errors should be also established to protect patients from being treated by inappropriate medications. Regard!

Matej

Dear dr.Stuhec,

Thank you for your response and offer to cooperate in this for me stem the interesting areas! I see that you are very active and that you are well aware in this area and have a very good experience and knowledge in this field!

Very happy to accept, your proposal for cooperation with you and I want it to be mutually beneficial, and to exchange and discuss this issue, which is extremely important with any aspect of society but unfortunately in our country and in the world is not as sufficient developed as it should be!

Best Wishes

Jasenko Karamehic

ADL are readily available for adults, paediatrics and primary health care. Second, therapeutic comitees are periodically reviewing therapeutic practices and updating information related to drug use and misuse at the hospital, district, provincial and national levels. Members of therapeutics comitees include pharmacists, doctors, nurses, managers, etc. Third, à program of continuous development exist and every practitioner is required to update his knowledge in his field of practice. There is a minimum of CME point every practitioner must earn through these programs. Failure to do so may result in medical council taking action against these practitioners. Fourth, pharmacists still have oversight over prescription on hands, prior to dispensing the prescribed medicines.