Letter to the Editor
When the drug utilization process can be improved
Cuando el proceso de utilización de los medicamentos es mejorable
Luis Angel Sánchez-Muñoz
Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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In the ENEAS study, conducted with 5624 patients from 24 hospitals, drugs were responsible for 37.4% of AEs (4% of patients included), ahead of nosocomial infection (25.3%) and procedure-related AEs (25%)<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. They were more common in medical services than in surgical services (53.8% vs. 22.2%) and were avoidable in 34.8%. In the APEAS study, carried out in 96,047 clinics of 48 health centres, drugs were the cause of 48% of AEs<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">As the editorial indicates, it is important to register any adverse drug reaction (ADR) in the Suspected Adverse Drug Reaction Reporting System of the Spanish Agency of Medicines and Medical Devices (AEMPS), in order to know their prevalence, identify risk factors and establish preventive measures<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. In addition, in our autonomous community we have a voluntary and anonymous system for reporting events without damage (SISNOT), with a system approach, which allows local department or centre analysis. Its usefulness lies in the fact that it allows learning from incidents without damage (they share the causal process with incidents with damage and are more common) and implementing local corrective measures, since most events are due to medication errors (wrong drug, route, dose, timing, patient) than to infrequent adverse reactions derived from the approved indication use of the drug.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Medication errors can occur at any stage of the medication utilization process (selection and management, prescription, validation, preparation and dispensing, administration, and follow-up). The impact of drug-related AEs on costs and morbidity and mortality, and the fact that one third of them are avoidable, makes it necessary to introduce improvements in this process.</p><p id="par0025" class="elsevierStylePara elsevierViewall">As doctors, we are responsible for the prescribing and patient follow-up phases.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Several measures have been proposed to reduce prescribing errors<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0035" class="elsevierStylePara elsevierViewall">Ensure patient's identity.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0040" class="elsevierStylePara elsevierViewall">Accessible patient and medicinal product information.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall">Obtain actual listing of patient's medication (discrepancies with electronic records).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">Assess drug indication, appropriateness (to patient, renal function, contraindications, interactions, duplicities, STOPP/START criteria, BEERS criteria, Choosing Wisely), adherence (Morisky-Green test) and achievement of therapeutic objectives.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">Revision and simplification of treatment.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Deprescribing.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Treatment reconciliation in care transitions.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Standardization of medical prescription: electronic prescription, protocols for high-risk medication; avoid abbreviations, verbal prescriptions and generic orders such as "all other medication as usual" or "continue usual treatment".</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">To improve the follow-up phase, it is proposed to monitor and record patient response, identify and report adverse reactions and medication errors, and re-evaluate drug selection, dosage, frequency and treatment duration<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>.</p><p id="par0080" class="elsevierStylePara elsevierViewall">A recent Cochrane review found that some of the proposed interventions have already shown evidence in reducing medication errors<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In summary, many drug-related AEs are preventable and depend on the prescribing and monitoring processes for a small number of drugs, so safe practices need to be put in place to reduce their frequency. The use of reporting systems is essential to learn about infrequent adverse reactions and to improve the drug utilization process.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0090" class="elsevierStylePara elsevierViewall">Unfunded paper.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reacciones adversas a medicamentos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.F. Sánchez Muñoz-Torrero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medcli.2022.05.001" "Revista" => array:6 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2022" "volumen" => "159" "paginaInicial" => "385" "paginaFinal" => "387" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/35760605" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Estudio Nacional sobre los Efectos Adversos ligados a la Hospitalización. ENEAS 2005. Secretaría General de Sanidad. Dirección General de la Agencia de Calidad del Sistema Nacional de Salud. Ministerio de Sanidad y Consumo; [Accessed 21 October 2022]. 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