Dear Mr. Stuhek,

I agree with you entirely. It is not posssible to underestimate the significance of this global problem

I suppose the enclosed paper will be interesting to you.

Thanks marianne for your answer. In real clinical practice I see many problems and gaps. For example how can Boeing and Airbus etc so optimize their process that they have not almost any accident. We should copy their quality and teamwork within the healthcare systems.Teamwork is often only written 'on the paper' and adverse drug events and mistakes are used for fight among the professionals (healthcare), which is again a big mistake for our patient.We should build a culture of a collaborative care within which each colleague will report the mistake of the best friend. When this system will be built the patients can be satisfied. In each hospital risk assesement should be done within this field by independent source of professionals and after appropriate system should be built. This is the way to do ... with support of evidence-based-medicine/science. As a surveyor in some E.U. hospitals I see many problems with this field and managers and medical directors even do not have their plans how to deal with errors, report and plan to solve and to communicate with a patient. Within each hospitals reports should be supporters by managers and patients and medical directors. 10-20 % or even more within their wages should be established to promote reporting of adverse events. Do not forget that cost for inappropriate treatment in U.S. is very huge and in E.U. there is no difference. Why we do not solve this problem with system adoption?

Regards,

Matej

Dr. Stuhec,  I would refer you to 2 books on the subject written for laypeople but entirely relevant to your question:  The Checklist Manifesto by Atul Gawande MD and Why Hospitals Should Fly by John Nance (an airline pilot who had a family member with fatal outcome in a hospital).  In the US, we have a number of organizations in charge of documenting medication errors, adverse effects, etc.  I would suggest looking into organizations such as the Institute for Healthcare Improvement (IHI), Institute for Safe Medication Practices (ISMP), the Joint Commission Accreditation Hospital Organization (JCAHO)

Hi.

It is very interesting topic and a huge one at same time. However, it is good that is open. 

I have to agree with all previously said, particularly that there is no clinical pharmacist next to the patients' beds. Also, there is not well enough defined and established collaboration between different healthcare professionals. Still, sometimes is difficult to make a difference between pathological state worsening and adverse effect. Clinical pharmacist will be probably more adverse effect focused than physicians, oppositely physicians would be more disease focused. On the other hand it is always hard to accept a ,,policeman'' at the hospital, even it is not actually policeman, rather team co-worker. At the first glance it is difficult to accept, so we need systemic approach and go back to medical and pharmacy schools and try to implement collaboration on that level. Medical errors or pharmacist errors (why not!) are also very expensive. So the government or some regulatory agencies should also be the stakeholders. What about errors noticed by the pharmacist at the community pharmacy? Do they have ability to report medical error?Or even to respond?

Sincerely,

Nikola

In many European countries more and more errors are reported and many hospitals have lost their income because of medical errors done by healthcare professionals.

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.

- About 50 % patients who need antidepressants and statins are treated inappropriately (not reach treatment goals).

- 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 missed (forgotten) 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 ...

About community pharmacists... In many European countries they do not report errors to often or even they are not included in the treatment in a collaborative way. Their position is often underestimated, however they should make next step towards clinical outcomes more intensively. They should report the errors!

How to improve real system now it is not an easy job. First of all we should accept a collaborative care model, where there are clinical pharmacist and physicians next to the patients' beds together to improve clinical outcomes. This should be done in a collaboration between medical and pharmacy schools with a support by the government. It is also not easy. I remember I have one talk about clinical pharmacy in Zagreb and the audience was very opposite towards clinical pharmacy next to the patients' beds. However, after some data has been shown to them, the situation was completely different. What is really very important (must to do) within the hospitals is to write and RESPECT the protocol in which is shown what is the treatment goal of each specialist and how would be measured. And after appropriate risk assesement is done then each speciality do their job and after meetings (e.g. clinical rounds) they discuss if their treatment goal has been done. This should be included in the patients' papers and charts. For example, if there is patient with MDD (diagnosed with MDD with DSM-5 or ICD-10) clinical pharmacist should be included in the appropriate drug selection, measuring of treatment response (e.g. remission and response) and possible re-evaluation. On the chart there should be clear evidence (with EBM supported) why this or that drug was titrated or switched or combined (this is very critical in the use of antipsychotic polypharmacy, where often there is no data why clozapine was not used before APP or why antipsychotic was added after only few days of monotherapy). Before the treatment all specialists should discussed with the patients about appropriate treatment plan and what is the treatment goal. In this model there is clear that physicians should cooperate very intensively with other healthcare professionals.

Regards!

Hi Mr. Stuhec,

Pharmaceutical industries still dominate most decisions around the world. But we can reflect on what our function before all this.

Regards,

 Hello , Mr.Stuhec,

The question is in place, however, to it is both easy and difficult to answer ...!

The first was too strong influence of pharmaceutical lobbies on prescriptions for medicine, which can often lead to polypharmacy!

The state and its bodies dealing with health and patient safety is often under the influence of pharmaceutical companies, many do not regulate in this field

Third, the state must impose stricter system of checks, which she is not willing to very often and to do so at the level of the profession Medicus or hospital does not have the will because they are afraid that it will increase the number of medical errors -malpraktice or judicial proceedings against them

Fourthly, the patients nor their associations do not have enough strength nor the courage to do so, except for individual cases where it apparently happened ... etc....etc...