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Background: Uppsala University Hospital Sweden is planning to implement a closed loop medication system, with the aim of reducing risk prescriptions from the point of drugs being prescribed to orders being produced and administered. With inspiration from Leuven, an advanced system for pharmaceutical validation; System Assisted Pharmaceutical VALidation (SAPVAL) is planned to be developed. Aim: The aim of the study was to obtain a deeper understanding of clinical rules as an important element for building the SAPVAL system. This study will review and further develop a first set of clinical rules and validate these on the intended study population.  Methods: A retrospective cross-sectional study was performed to validate the clinical rules on a study population of 500 patients who were discharged from Uppsala University Hospital between May to July 2020. The clinical rules were applied cross-sectionally based on patient data from the electronic health records. From the total generated alerts, 10 % was randomly selected for assessment of the clinical relevance. Results: The clinical rules generated 893 alerts in 500 patients, of which 84 % alerts still remained two days after the patient was admitted to the hospital or at discharge. From the randomly selected alerts, 26 % were deemed clinically relevant. Conclusions: The developed clinical rules generate a large number of alerts for risk prescriptions for inpatients at Uppsala University hospital. The majority of the alerts remained during the care period and approximately a quarter of them were considered to be clinically relevant to remedy.

Background: Drugs are an important part of treating diseases but can also come with its risks. To reduce the risks, a system assisted pharmaceutical validation (SAPVAL) is being developed at Uppsala University Hospital. This will include the generation of alerts regarding different risks, sent to a clinical pharmacist who assesses whether the alerts should be forwarded to a physician or not. One of the risks included is QT prolongation, a relatively uncommon condition which however can result in sudden cardiac death. Aim: The aim was to map the management and the consequences of QT-related risk prescriptions and to determine the clinical relevance of QT-related alerts. Method: A retrospective cross-sectional study was performed at Uppsala University Hospital. It included the review of patients´ electronic health records (EHR) and determination of risk periods. The clinical relevance of the alerts was assessed by a physician and a developed flowchart. Results: 65 patients (age=71 ± 15 years, 54% women), and their 85 QT-related alerts were included, with a median risk period of 145 days. Within the risk period, 46 patients had an ECG taken with 35% having one or more prolonged QTc ≥ 480 ms. The risk of QT prolongation had been noticed or mitigated for 23% of the 65 patients. 89% of the alerts were concluded to be clinically relevant. Conclusion: The management and documentation of QT-related risks could be improved. It is also important to further study QT-related risk factors to better assess which patients are at the highest risk.

Abstract [en] Title: Discrepancies in medication lists at hospital wards identified by medication reconciliation Authors: Anderberg M. Institute: Uppsala University, Uppsala, Sweden Background and objective: An accurate medication list is essential for a correct assessment of a patient´s condition at hospitals. Previous studies have shown that patients in emergency departments often are affected by discrepancies in medication lists at hospital admission. Less research has been done regarding discrepancies after transferring patients to medical wards. The aim of this study was to identify discrepancies in the electronic medical record in hospital wards for patients admitted via the emergency department. Design: Observational study. Medication reconciliation was performed by a pharmacist shortly after the arrival of patients from the emergency department. This included a patient interview and the investigation of the patient’s medical record. The discrepancies identified at the wards were classified as either omitted drug, wrong dose, additional drug, incorrect frequency or duplicate therapy. Descriptive statistics were used and the proportion of medication lists with at least one discrepancy was presented with 95 % confidence interval. Setting: Three medical wards at Capio S:t Görans Hospital in Stockholm.  Main outcome measures: The proportion of medication lists with at least one discrepancy. The mean value of discrepancies among all patients. Classification and categorization of discrepancies regarding type and ATC index.  Results: In total, 63 patients were included with a mean age of 63 years. At least one discrepancy was identified in 43 % (95 % CI 31-55) of the medication lists. 52 discrepancies were found in total generating a mean value of 0,83 ± 1,17 discrepancies per medication list. The two most common categories were Omitted drug(33%) and Wrong dose(33%). The most frequent drug class associated with medication discrepancies was Drugs for obstructive airway diseases.  Conclusion: 43 % of the patients had at least one discrepancy in the medication list. This indicates the importance of medication reconciliations at medical wards even though the medication list has been updated at the emergency department.

Impact on accuracy in elderly patients’ medication list, introducing pharmacy-led medical reconciliation at the Emergency department in a Swedish hospital. Background and objective: Discrepancies in patients‘ medication list is a well-known problem and contribute to preventable medication errors. Medication errors could increase morbidity and mortality and are cost-driving to the Health Care System. The primary objective was to investigate if a pharmacist-led medical reconciliation at the Emergency department could increase the accuracy in medication lists for patients at the age of 75 years and older, with five or more drugs in their initial medication list. The second objective was to categorize the discrepancies and the drugs causing them. Study design: Intervention study with retrospective control group. In the intervention group, patients received a medical reconciliation at the Emergency department. In conformity with the retrospective control group, the intervention group also received a medical reconciliation at the hospital ward. All medical reconciliations where pharmacy-led. Discrepancies identified at the medical reconciliation at the ward, were quantified and categorized. Drugs causing discrepancies were categorized by the ATC-index. Descriptive statistics, Chi2-tests and T-tests were performed.  Setting: The Emergency department at the hospital of Kristianstad, four wards at the larger emergency hospital in Kristianstad and two wards at the smaller local hospital in Hässleholm in Sweden Main outcome measures: Numbers of discrepancies in patients ‘medication list identified at medical reconciliation at hospital ward after having an initial medical reconciliation at the Emergency department (intervention) or not (control). Category of discrepancy and ATC-index of the substance causing the discrepancy. Results: In control group (n=65), 170 discrepancies were identified, on average 2,6 discrepancies/medication list. In intervention group (n=65), corresponding figures were 44 and 0,7 respectively. The difference between the groups was significant (p <0,0001).  The main category of discrepancy was “commission of a medication” in the control group and “route of administration” in the intervention group. Paracetamol was the most common drug to cause discrepancies in the control group, zopiklon and furosemid in intervention group. Conclusion: Pharmacy-led medical reconciliation at the Emergency department significantly reduced the number of discrepancies in patients´medication list.

Bakgrund: I Sverige förekommer epilepsi hos 1-2 % av alla hundar. De första anfallen visar sig oftast när hunden är mellan ett och sex år gammal. Det nuvarande förstahands­preparatet är fenobarbital, en substans som ökar tröskeln för elektrisk stimulering av motorcortex samt minskar monosynaptisk transmission som leder till minskad neuronal retbarhet. I februari 2013 registrerades ett nytt antiepileptikum med det verksamma äm­net imepitoin. Imepitoin är en partiell agonist som binder till bensodiazepinsätet på GABAA-receptorn. Det förstärker de GABAA-receptormedierade effekterna på neuro­nen samt har en svag kalciumblockerande verkan. Syfte: Arbetets syfte var att undersöka om imepitoin har förutsättningar att bli det nya förstahandspreparatet vid behandling av idiopatisk epilepsi. Vidare var syftet att under­söka i vilken utsträckning imepitoin fungerar som antiepileptikum samt vilken biverk­ningsprofil det har. Resultat: Behandling med imepitoin gav en sänkning av antalet epileptiska anfall per månad (MSF), liknande den som erhölls vid fenobarbitalbehandling. Imepitoin sänkte MSF både som monoterapi och i kombination med fenobarbital eller kaliumbromid. Biverkningsprofilen var överlag skonsammare för imepitoin jämfört med fenobarbital. Fenobarbital visade en leverpåverkan medan imepitoin påverkade kolesterolvärdet. Slutsats: Imepitoin har en antiepileptisk effekt, liknande den som fås vid behandling med fenobarbital. Behandling med imepitoin kan ske både som mono- samt kombina­tionsterapi. Den mildare biverkningsprofilen talar för användning av imepitoin. Samti­digt har fenobarbital använts under en längre tid så biverkningar vid långtids­användning är mer välkända än de vid imepitoinanvändning. / Background: In Sweden, approximately 1-2 % of all dogs suffer from epilepsy. The first seizures often occur when the dog is between one and six years old. In Sweden the first-line drug is phenobarbital, a substance which increases the threshold of electrical stimulation in the motor cortex. It also decreases synaptic transmission which leads to decreased neuronal excitability. In February 2013 a new antiepileptic drug was regis­tered with imepitoin as active substance. Imepitoin is a partial agonist which binds to the benzodiazepine binding site at the GABAA receptor and amplifies the effects medi­ated by GABAA receptors at the neurons. Additionally, imepitoin has a weak calcium channel blocking effect. Objective: The main aim of the study was to examine if imepitoin should be the first-line drug instead of phenobarbital when treating dogs diagnosed with idiopathic epi­lepsy. A further aim was to look into which effect imepitoin had in controlling the epilepsy and which adverse effects were experienced when dogs are treated with imepitoin. Results: Treatment with imepitoin resulted in a decrease in monthly seizure frequency (MSF), similar to the decrease seen upon treatment with phenobarbital. Imepitoin was decreasing MSF both when used as monotherapy and in combination with phenobarbital or potassium bromide. The adverse effects were in general less severe with imepitoin than with phenobarbital. Treatment with phenobarbital affected the liver while treatment with imepitoin affected the cholesterol levels. Conclusion: Imepitoin has a good antiepileptic effect, similar to that of phenobarbital. Treatment with imepitoin can be used both as monotherapy and in combination with other antiepileptic drugs. Less severe adverse effects makes imepitoin a possible choice for treating idiopathic epilepsy in dogs. On the other hand, phenobarbital has been used during a long period of time and adverse effects of long term use are therefore better known than for imepitoin.

Abstract Medicines are substances used to prevent, alleviate or cure diseases which is an important part of health care. The role of the pharmacist in the healthcare chain is important because they are the patients last contact with healthcare professionals. After this contact they must assume responsibility over their own treatment. The pharmacist's responsibility is to make sure that the patient has received essential information about their drugs and to check that the prescribed dose is correct. The increased digitalization of society brings an opportunity for the patients to increase participation and understanding of their drug treatment. Decision support systems are different methods used to obtain a basis for decision making. Pharmacists use these systems to check if prescriptions are correct, for example by ensuring that the right medication, in the correct dose, has been prescribed to the right patient at the right time. In Sweden there is a decision support system called elektroniskt expertstöd (EES). This system offers pharmacy customers further drug control in addition to other controls that are available through the pharmacy's other systems. The benefit of this system is that the pharmacist has better support in detecting incorrect doses, interactions, duplicate medications and if the drug is inappropriate for the patient's gender or age. When the system alerts, the pharmacist makes an assessment which may be discussed with the patient or the physician if needed. Purpose The purpose of this survey study was to investigate what the pharmacy customers knows about EES and the pharmacists use of the system. Method Before the study started, approval from the southeast ethic committee was obtained which said that there were no ethical barriers for the performance of the study. The surveys were handed out to anyone who would receive prescriptions at different pharmacies in Luleå, Grängesberg, Värnamo, Kalmar and Torsås. The common goal was to spend 20 hours of handing out surveys per student. The results were put together and analyzed in IBM SPSS Statistics with descriptive statistics.  Results and discussion The results show that most of the respondents did not know about EES and did not know if the pharmacists are using this support system. The results also show that most of the respondents had not given their consent to EES and did not know if EES could support the pharmacists work. More than half of the survey population answered “do not know” on a question asking if they wanted the pharmacist to use EES when dispensing drugs. Almost a quarter of the total population wanted the pharmacist to use EES and close to three quarters of the total population had no knowledge of the system. This could mean that the customers who have knowledge wants the system to be used. A reason for wanting the system to be used without having knowledge of it could be that customers trust it is beneficial for themselves and for the pharmacists. Building trust and showing care in each customer meeting is important to make the customer susceptible to information. Sufficient information can lead to better compliance in drug treatments. Before the pharmacist can use EES for the first time the customer must consent. Although it was a few years since the introduction of EES into pharmacies, some pharmacists find it difficult to connect customers to the system. It is a relatively new way of working with drug analysis at the pharmacies in Sweden. More practice in the system could provide increased use of it and help the pharmacists decision making.   Conclusion Only a small proportion of the pharmacy customers have knowledge of EES. But even so, one fourth of them wanted the system to be used to analyze their medication which is considered positive.

Abstract Background and Objective: An accurate medication history list is an integral part of the patient assessment at hospital admission. The objective of the study was to describe the frequency, type, and predictors of unintentional medication errors and to evaluate the quality of the clinical pharmacy services focusing on the acceptance of the recommendations made by the clinical pharmacist. Setting and methods: A descriptive study was conducted at two internal medicine wards at Baghdad Teaching Hospital in Iraq using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. The study pharmacist conducted medication interviews for patients shortly after hospital admission to obtain the most accurate pre-admission medication history list. This list was compared with the medication list in the patient’s medical chart. Intended addition, withdrawal of a drug, or changes to the dose/ dosage form in the patient’s medical list was considered as medication discrepancies. However, medication discrepancies were considered as medication errors based on no identified clinical reason. Results: A total of 114 patients were included in this study. Over two-thirds of the study patients (73.7%) experienced 215 medication errors identified by a clinical pharmacist conducting medication reconciliation. Most errors were omission (87.9%). Cardiovascular agents followed by NSAID were commonly in error (53%) and (10.2%) respectively. In a logistic regression model, age (odds ratio (OR), 1.055: 95% confidence interval (CI) 1.010 - 1.102), female gender (OR, 3.468: 95% CI 1.232- 9.761) and number of medications at admission (OR, 0.810: 95% CI 0.681-0.963) were predictors for medication history errors at admission. Conclusions: Medication errors at the time of hospital admission are common and undetected.  A structured approach like the LIMM-based medication reconciliation at Iraqi hospital is needed to detect these errors.

Abstract Elective urological patients’ medication usage at the time of admission Author: Nygren. J. Supervisor: Gillespie. U. Examiner: Nielsen. E. Department of Pharmaceutical Biosciences, division of pharmacokinetics and drug therapy. Faculty of pharmacy. Uppsala University, Sweden.   Background and Objective: Information about the patient’s current medication treatment before elective urologic surgery has been based upon a prefilled self-reported health declaration or a patient provided medication list. A new work procedure has recently been adopted where a pharmacist performs a medication reconciliation in order to increase the patient safety, receive deeper insight into the patients ongoing treatment and to reduce the physician’s workload. The objective of the study was to map out how well the patients could account for their medication usage at the time of admission and to identify discrepancies between the health declaration/patient’s medication list and the medication list after medication reconciliation. Design: The study population consisted of adult men and women scheduled for elective urological surgery.  A clinical pharmacist performed a medication reconciliation and stored appurtenant patient data and medication lists in anonymised forma. Data was then analysed by a student undertaking his degree project (MSc Clinical pharmacy). The population and discrepancies were divided into sub-groups and a t-test was performed to identify any statistical difference between selected sub-groups of the population. Setting: Urology department, Uppsala University Hospital Main outcome measures: The proportion of patients having at least one discrepancy were studied. Distribution of discrepancies per patient was compared between sub-groups; number of medications, age and county of residence. Results: At least one discrepancy (range 1-7) was observed in 51 (66%) out of the 77 patients included in the study. Patients using >5 medications at the time of admission had more discrepancies per patient than those using 0-5 medications (3.2 vs 1.0; p=5.6x10-6) and there was a trend towards Uppsala patients having more discrepancies per patient than those residing outside the region (2.4 vs 1.5; p=0.057). There was no significant difference observed between the age groups. Conclusion: The health declaration/medication list presented at the time of admission did not provide enough information to determine the patient’s complete medication usage.

Bakgrund: Användning av läkemedel ökar och därmed ökar också läkemedelsrelaterade problem. För att patienter ska kunna ha en säker läkemedelsbehandling krävs bland annat korrekt och fullständig läkemedelsinformation. I dagsläget finns det olika informationskällor som patienter använder för att hålla koll på sin läkemedelsbehandling men i många av dem förekommer avvikelser som gör att risken för felmedicinering eller överdosering ökar. Syfte: Syftet med det här arbetet var att undersöka prevalensen av avvikelser i läkemedelslista ”Mina sparade recept på apotek” (MSR), samt att se om vissa läkemedelsgrupper skulle förekomma oftare än andra bland avvikelserna. Även andra variabler, såsom informationskällor som patienter använder för att hålla reda på sin läkemedelsbehandling, avsaknad av receptbelagda läkemedel i MSR och användning av receptfria läkemedel mättes. Metod: Data for studien samlades in genom speciellt utformade läkemedelsintervjuer med patienter på ett öppenvårdsapotek i Sverige under veckorna 3–5 i början av 2021. Patienterna som inkluderades var vuxna patienter som hade åtminstone tre receptbelagda läkemedel i sin MSR och som hämtade ut läkemedel åt sig själva. Innan läkemedelsintervjuerna påbörjade erhölls också ett skriftligt samtycke från alla deltagare. Resultat: Nästan 70 procent av 69 intervjuade patienter hade minst en typ av avvikelse i MSR, därav dubbla och inaktuella recept var vanligaste. Bland avvikelserna var de vanligaste läkemedel för behandling av sjukdomar som rör nervsystemet, hjärta och kretslopp samt matsmältningsorgan och ämnesomsättning. En del av patienterna (35 procent) saknade receptbelagda läkemedel i sin MSR, medan 30 procent av dem uppgav att de använde receptfria läkemedel. Informationskällan som användes av de flesta patienterna för att hålla koll på deras läkemedelsbehandling var just MSR.  Slutsats: Avvikelser i MSR förekommer hos nästan 7 av 10 patienter och de läkemedelsgrupperna som var vanligare bland avvikelser är också läkemedelsgrupper som orsakar mest läkemedelsrelaterade problem. Dessa avvikelser måste åtgärdas eftersom de påverkar patienternas säkerhet och förhoppningsvis kommer implementering av den nya nationella läkemedelslistan (NLL) kunna förbättra situationen för både patienten och hälso- och sjukvårdspersonalen. / Background: The use of medicines has increased in the past few years, which has also led to increased amount of drug-related problems (DRP), such as drug-drug interactions and serious adverse effects which lead to hospitalization. In order to decrease the amount of DRP, the medication lists of individual patients need to be accurate and updated. The most used medication list among those available is the one that is printed out at a pharmacy “My stored prescriptions at pharmacy”.  It is also called “Prescription List” (PL). Even though a lot of patients use the PL, there are a lot of discrepancies in it, such as noncurrent and missing prescriptions, but also prescription duplicates. Aim: The aim of this study was to study the prevalence of discrepancies in the PL, such as noncurrent or duplicate prescriptions, wrong dosage or other unclarities, but also to see if there are some particular drug groups which are more common among the discrepancies. Secondary outcomes that were measured included the amount of missing prescriptions in the PL, as well as the usage of over-the-counter (OTC) medicines and primary information sources that patients use to keep track of their prescriptions. Methods: Data needed for the study was collected by interviewing patients at a local pharmacy. The interview was specially designed to answer to all the outcomes and the patient’s individual PL was also used to identify the discrepancies. In order to be included in the study patients needed to be at least 18 years old, have three or more prescriptions in the national prescription repository (NPR) and pick up their own medication, as well as provide a written consent to participate. Pharmacists that were dispensing patient’s prescriptions were also in charge of the recruitment of patients. Result: Out of the 103 patients that were informed about the study, 69 patients were included. Almost 70 percent of them had at least one type of discrepancy in the PL. The most common discrepancy was prescription duplicates (46 percent), followed by noncurrent prescriptions (44 percent). Drug groups which were common among the discrepancies were the drugs used to treat diseases in the nervous system, cardiovascular system and digestive system (including metabolism). Secondary outcomes showed that 35 percent of the patients had at least one missing prescription in the PL, but also that 30 percent of the patients used OTC medicines, the most common being paracetamol (acetaminophen). The most used information source was the PL with 32 percent of patients using it as their primary information source for their medication therapy. Conclusions: Prescription duplicates and noncurrent prescriptions are frequent in the PL and are a major source of medication errors for patients and health-care workers. Drug groups which where the most common among the discrepancies are also the ones responsible for half of the hospitalizations in Sweden. This implies that they could probably be prevented by improving the PL. The number of the missing prescriptions was quite low. The usage of OTC medicines showed that most of patients used painkillers. These are the drugs that Swedes often overuse and therefore, for future safety, monitoring of OTC sales should be implemented. Although it had 21 percent of inaccuracies, the PL was the most used information source for the patients, which gives the conclusion that the improvement of it is needed as soon as possible in order to prevent and decrease the frequency of DRP.