In many countries, payers conduct audits of doctors' prescribing behaviour. They will contact a doctor if his prescribing pattern is grossly inappropriate. Such institutions may also have programs to improve prescribing and reduce inappropriate polypharmacy.

See attached paper, most of my additional literature is in German, but there is more in English, if you search for "polypharmacy".

Tx Anna. However it is easy to say hard to do, especially in inpatients within psychiatric hospitals and neurologic clinics. I think patients and payers are the best choices to change this behaviour. We have in Slovenia clinical pharmacists specialists, however daily work is not very easy often, because to make compromise is sometimes very difficult.  How you solve this problem in Austria within the hospitals? You also have clinical pharmacists or/and pharmacologists next to the patient's bed? How you reduce medical errors, polypharmacy, inappropriate prescribing etc .. within the hospitals?

Next to this in outpatients medication management We have also clinical pharmacists' settings in primary health centres in some Slovenian primary community health centres. We have very good results in 2 years the polypharmacy was reduced for 8-10 %.

Matej, you are correct, it is hard to do. We have very few clinical pharmacists. A few hospitals are piloting "polypharmacy boards" which review patients' medication if someone flags the patient's medical history and therapy as particularly complicated, somewhat like "tumor boards". Actually, we consluted with experts from slovenia on this issue during a project...

Hi Anna, you are right. Within the hospitals is very hard because of our system, which is similar as this in Austria (Slovenian was also more than 500 years under Habsburg Empire and Vienna). I think patients and payers should move forward and we should publish our research from this topic. At the moment there is still opinion, which is often accepted, that we do not need clinical pharmacists or/and pharmacologists, but the new studies and evidence suggest that a collaborative care is better than care alone only. This opinion should be covered by national institutions, such as health insurance companies etc ...

However, my work is psychiatric clinical pharmacist, next to my UNI work and I have published many papers from coolaboration care and also in 'Your Austrian Paper Wienerklinische Wochenschrift. In this article below You will see that there is a great benefit from a coolaboration care. However as I have many supporters in my country I also have many people in opposition (workers in health system), who work alone although we have great evidence for a coolaborative care within the hospitals (nursers, practitioners). Even some of them they do not like my work, name etc ... 

In this paper, which is attached, a translator from english to german from WKW translated word 'clinical pharmacist' to 'clinical pharmacologist in german abstract'. I didn't make any letter but however this means that there are no almost clinical pharmacist in Austria. However, WKW published many my papers, where a collaborative care was presented, which is very interesting.

If we say polypharmacy is important it is (especially psychiatric polypharmacy is scarce). You are right. It is a good start to do a coolaborative care. Next step (step forward) is dealing with patients next to the patients' beds in improving patients outcomes.

If You consulted Slovenian people from this project in primary heath system is very good. This is good start and You should start from zero point and measure the results often. After articles will be published it will be easier to present these results among health system workers.

http://www.ncbi.nlm.nih.gov/pubmed/25576334

http://www.ncbi.nlm.nih.gov/pubmed/?term=stuhec+matej

Hi Matej

The literature shows that the error rate in medication administration is about 10% (not counting errors in timing). That means about 500 errors each day for a hospital with 600 beds. The reporting rates run at 200 per year which is a tiny percentage. I have come to appreciate that it is better to concentrate on those errors that are reported than to expend energy on increasing the reporting rate. Much can be learned from each error and implementing a change to prevent the error will also prevent many of the other unreported ones. In my own hospital there is a committee dedicated to analysis of error reports and making corrective suggestions. There are two doctors, two nurses and two pharmacists. Each brings their own experience and perspective to the discussions. This could be extended to the problem of inappropriate prescribing. Multidisciplinary groups are ideal and it should be implemented through each discipline with reports back to the committee. An essential part of this kind of activity is to have the full support of the management.

Regards

In the UK (NHS) there is a tight system where the service picks up errors ; the pharmacists always scrutinise all prescriptions. Any error is counted as an incident and investigated asap. The outcome is published within the service (no individuals named) and guidelines   and if appropriate  changes  in procedures/policies are made

Organizational systems for ordering, dispensing, and administering medications should be designed to minimize error. Medication errors may involve process breakdowns in more than one aspect of a system. Organizational policies and procedures should be established to prevent medication errors. Development of the policies and procedures should involve multiple departments, including pharmacy, medicine, nursing, risk management, legal counsel, and organizational administration.

Prescribing is an early point at which medication errors can arise. It has been estimated that 1% of hospitalized patients suffer adverse events as the result of medical mismanagement and that drug related complications are the most common type of adverse event. Written drug or prescription orders (including signatures) should be legible. Prescribers with poor handwriting should print or type medication or prescription orders if direct order entry capabilities for computerized systems are unavailable. A handwritten order should be

completely readable (not merely recognizable through familiarity). An illegible handwritten order should be regarded as a potential error. If it leads to an error of occurrence (that is, the error actually reaches the patient), it should be regarded as a prescribing error.

The pharmacist is expected to play a pivotal role in preventing medication misuse. The value of pharmacists’ interventions to prevent medication errors that would have resulted from inappropriate prescribing has been documented. Ideally, the pharmacist should collaborate with the prescriber in developing,

implementing, and monitoring a therapeutic plan to produce defined therapeutic outcomes for the patient. It is also vital that the pharmacist devote careful attention to dispensing processes to ensure that errors are not introduced at that point in the medication process.

By virtue of their direct patient-care activities and administration of medications to

patients, nurses—perhaps more than any other health-care providers—are in an excellent position to detect and report medication errors. Nurses often serve as the final point in the checks-and-balances triad (physicians and other prescribers, pharmacists, and nurses) for the medication use process; thus, they play an important role in risk reduction.

Patients (or their authorized caregivers or designees) have the right to know about all aspects of their care, including drug therapy. When patient status allows, health-care providers should encourage patients to take an active role in their drug use by questioning and learning about their treatment regimens. Generally, if patients are more knowledgeable, anxieties about the uncertainty of treatments can be alleviated and errors in treatment may be prevented.

Poor designs with respect to drug product packaging and labeling, as well as selection of inappropriate or confusing nomenclature, have been identified as factors that contribute to serious medication errors by practitioners. Pharmaceutical manufacturers and approval agencies should be responsive to efforts of practitioners to minimize errors.

Monitoring Medication Errors. Ongoing quality improvement programs for monitoring medication errors are needed. The difficulty in detecting errors has long been recognized as one of the barriers to studying the problem effectively. Medication errors should be identified and documented and their causes studied in order to develop systems that minimize recurrence. Monitoring programs for medication errors should consider the following risk factors

1. Work shift (higher error rates typically occur during the day shift).

2. Inexperienced and inadequately trained staff.

3. Medical service (e.g., special needs for certain patient populations, including geriatrics, pediatrics, and oncology).

4. Increased number or quantity of medications per patient.

5. Environmental factors (lighting, noise, and frequent interruptions).

6. Staff workload and fatigue.

7. Poor communication among health-care providers.

8. Dosage form (e.g., injectable drugs are associated with more serious errors).

9. Type of distribution system (unit dose distribution is preferred; floor stock should be minimized).

10. Improper drug storage.

11. Extent of measurements or calculations required.

12. Confusing drug product nomenclature, packaging, or labeling.

13. Drug category (e.g., antimicrobials).

14. Poor handwriting.

15. Verbal (orally communicated) orders.

16. Lack of effective policies and procedures.

17. Poorly functioning oversight committees.

Managing Medication Errors. Medication errors result from problematic processes, but the outcomes of medication errors could range from minimal (or no) patient risk to life-threatening risk. Classification of the potential seriousness and clinical significance of detected medication errors should be based on predefined criteria established by the P&T committee (or its equivalent). The error classification should be based on the original order, standard medication dispensing and administration procedures, dosage forms available, acceptable deviation ranges, potential for adverse consequences and patient harm, and other factors

There are various reasons that the errors go unnoticed, with the advent of the electronic prescribing with the structured orientation to the prescribers/physicians/clinicians before the implementation of the pharmacy informatics stage these medication errors can be minimized to the larger extent., having said that the pharmacy has a very active role to play in minimizing the medication errors in the hospital set-up, often the physicians with varying background of medical education are bound to  have less clarity with the medications,dosage,frequency,contraindications,interactions and so on and so forth. I strongly suggest for the implementation of the robust medication management policies and procedures in the health care settings and with the strong and proactive vision from the   governance.leadership and directions. I agree to an extent the pharmacy has invariably short staffed and does not get the ready  funding for their projects, but we as the custodian of the medication usage and management should involve all the stakeholders to comply with the policy and advocate for the safe medication use. Simply convening the meetings and minuting will not reduce the medication errors but a strong commitment and adopting the policies and procedure in strict sense will help the patient community to a larger extent.