Health System

Medicare reform has produced an unexpected crop of beneficiaries. Hundreds of rural and small urban hospitals are eligible to join the 340B drug discount program thanks to the 2003 Medicare law. Savings depend on the details of each hospital's drug spend, but more than half of 340B participants reported saving more than 30% in a recent survey.

Of overall computer entry errors, 56% are caused by distractions, according to a U.S. Pharmacopoeia 2003 MEDMARX study. In addition, distractions were cited in 78% of computerized physician order entry (CPOE) errors in reports "that documented a contributing factor other than 'none,'" said John Santell, director of educational program initiatives for the U.S. Pharmacopoeia in Rockville, Md.

Imagine being awarded a cool $50,000. That's what pharmacists at OhioHealth, a not-for-profit healthcare organization, nabbed for designing a program that reduced by 51% the adverse drug event (ADE) rate for the eight hospitals in its network. This was the first Award for Excellence in Medication-Use Safety offered by ASHP's Research & Education Foundation and sponsored by the Cardinal Health Foundation.

When clinical pharmacists teamed up with hospitalists, patient stays were shorter and drug costs lower, according to a study conducted at Brookhaven Memorial Hospital Medical Center in East Patchogue, N.Y., and presented at the 2004 annual meeting of the Society of Hospital Medicine in New Orleans.

Virginia Mason Medical Center in Seattle didn't waste any time issuing a public apology when a 69-year-old patient died as a result of a preventable error. The tragedy occurred when the patient was injected with the antiseptic skin prep solution chlorhexidine instead of a contrast medium designed for radiological procedures. Both solutions were clear and available in the sterile field in unlabeled basins at the time of occurrence.

If you have a leaky pipe, you call a plumber, not an electrician. Similarly, if you are in a hospital and receiving prescription drugs, having a pharmacist—the drug expert—review your medication orders is the right thing to do. Certainly, the Joint Commission on Accreditation of HealthCare Organizations thinks so.

At the recent annual meeting of the American Society of Hematology held in San Diego, researchers reported improved results with certain types of leukemia. These outcomes were achieved by using higher drug dosages to treat early chronic myelogenous leukemia (CML), and equivalent results occurred with a more convenient subcutaneous, rather than intravenous, route for delivering a biologic for chronic lymphocytic leukemia (CLL).

A 70-year-old Caucasian man, N.B., presents to your emergency department with dyspnea, peripheral edema, and weight gain. He had a myocardial infarction five years ago and has progressive congestive heart failure (HF) (NYHA Class IV stage D). Currently, BP = 90/60, HR = 78, labs normal except BUN = 48, SrCr = 2 mg/dl, B-type natriuretic peptide = 1100 pg/ml. Physical assessment shows bilateral rales and warm and wet skin turgor. Current medications: furosemide 40 mg q.d., ramipril (Altace, Aventis) 2.5 mg q.d., carvedilol (Coreg, GlaxoSmithKline) 12.5 mg b.i.d., metolazone 2.5 mg p.r.n., weight gain (not taken last month). To treat his acutely decompensated HF and pulmonary edema, his physician prescribes furosemide 40 mg IV x 1. She asks whether to add nesiritide (Natrecor, Scios) or nitroglycerin (NTG) infusion.

Relief is finally at hand for patients with leukemia or lymphoma who must undergo extremely high dose chemotherapy and radiation to prep for bone marrow transplant. A new agent will reduce their chances of developing mucositis-severe ulceration of the oral mucosa caused by the cancer treatments themselves.

Relief is finally at hand for patients with leukemia or lymphoma who must undergo extremely high dose chemotherapy and radiation to prep for bone marrow transplant. A new agent will reduce their chances of developing mucositis-severe ulceration of the oral mucosa caused by the cancer treatments themselves.

Coming soon to a hospital near you: medication reconciliation. That's the directive from the Joint Commission on Accreditation of Healthcare Organizations, which made medication reconciliation one of a dozen National Patient Safety Goals for 2005. JCAHO surveyors started looking for evidence of compliance on Jan. 3.

Nearly five million Americans have heart failure (HF), and its incidence is rising dramatically among the elderly. Approximately 80%of patients hospitalized with HF are over the age of 65 years. Heart failure is the most prevalent Medicare diagnosis-related group (DRG), and more Medicare dollars are spent for its diagnosis and treatment than for any other medical condition. Accordingly, tremendous efforts are being initiated to identify and treat the factors that predict recurrent hospitalization.

True to form, ASHP took the high road on several issues during a press conference at its midyear meeting in Orlando last month.

The federal government is raising Medicare outpatient prospective payment system (OPPS) rates for 2005, but pharmacists are not cheering. Hospital pharmacy departments will see little, if any, of the increase.

Two Philadelphia-area hospitals recently received patient safety awards for medication administration improvements that ranged from the very simple to the very technical. The Delaware Valley Medication Safety Award was shared in November by Northeastern Hospital of the Temple Health System and the Albert Einstein Medical Center of Jefferson Health System. The two hospitals split a $5,000 cash prize.

According to the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System, medication errors are responsible for approximately 7,000 deaths annually. Said Raymond Muller, M.S., R.Ph., associate director of pharmacy services at Memorial Sloan-Kettering Cancer Center in New York City, "More people in the United States die from medical errors per year than die from motor vehicle accidents, breast cancer, or AIDS." Muller addressed a session at The Chemotherapy Foundation symposium, Innovative Cancer Therapy for Tomorrow, held recently in New York City. The symposium was sponsored by the Mount Sinai School of Medicine.

Disruptions in influenza vaccine supplies are creating headaches. Faced with one of the lowest stocks of flu vaccine on record, the Centers for Disease Control & Prevention has issued interim guidelines on flu vaccination, prophylaxis, and treatment. CDC recommends that HIV/AIDS patients and seven other high-risk groups be vaccinated against influenza. Patients at highest risk should receive chemoprophylaxis and antiviral treatment under certain circumstances.

Disruptions in influenza vaccine supplies are creating headaches. Faced with one of the lowest stocks of flu vaccine on record, the Centers for Disease Control & Prevention has issued interim guidelines on flu vaccination, prophylaxis, and treatment. CDC recommends that HIV/AIDS patients and seven other high-risk groups be vaccinated against influenza. Patients at highest risk should receive chemoprophylaxis and antiviral treatment under certain circumstances.

A 65-year-old man, D.G., who weighs 100 kg and smokes half a pack of cigarettes per day has been admitted to your hospital with pneumonia. His medical history is significant for gastroesophageal reflux disease (GERD) treated with pantoprazole (Protonix, Wyeth) 40 mg q.d. for several years. D.G. was treated empirically with ceftriaxone 1 gm q 24 h, and H. influenzae was cultured. His dismissal orders are cefaclor 500 mg t.i.d., dietitian referral, and smoking-cessation class. D.G.'s physician asks your opinion on continuing his proton pump inhibitor (PPI) to treat GERD given the newly documented risk of pneumonia (JAMA 2004;292:1955-1960).

Some help for battling the obesity epidemic may be arriving, according to continuing encouraging results for rimonabant (Acomplia, Sanofi-Aventis), not just in helping weight loss but also in improving metabolic risk factors. Other research at this year's American Heart Association 2004 Scientific Sessions, held recently in New Orleans, focused, as well, on metabolic effects of pharmacological agents.

Of the hundreds of posters at this year's Interscience Conference on Antimicrobial Agents and Chemotherapy, only seven featur-ing preclinical antibiotics research worldwide were selected as worthy of mention by the ICAAC program committee in its annual poster summary. Of these, only two were called "outstanding" by expert Steven J. Projan, Ph.D., Wyeth research, who warned in a press briefing, "Fewer and fewer important antibiotics are being developed." Here are the two he recommended for special attention by ICAAC attendees:

Get set for possible sticker shock when wholesale distribution contracts come up for renewal. Drug wholesalers are starting to charge drugmakers fees for distributing their products. Pharmacy providers-retail pharmacies, managed care organizations, and health systems-will see the change reflected in new contract prices.

The pharmaceutical industry has given a thumbs-up to NABP's voluntary plan to accredit wholesale drug distributors. Nevertheless, representatives from various drug companies gave NABP officials an earful at a seminar for pharmaceutical manufacturers in early November.

The Medicare Modernization Act (MMA) that established the system's first outpatient drug benefit gives pharmacists more questions than answers. The reason is clear: politics. "The entire process is driven by politics," said Dan Mendelson, president of the Health Strategies Consultancy, a Washington, D.C., health policy firm. "Medicare is a political act, and the changes you will see to it will be politically driven."

Since 2000, there have been several types of warnings about the drug Remicade (infliximab), a biological therapeutic product indicated for rheumatoid arthritis and Crohn's disease. Tuberculosis and other opportunistic infections have been reported in clinical research and elsewhere. The manufacturer has warned that patients should be given a TB skin test, and that treatment for any latent TB infection should be started before infliximab use.

A severe shortage of pharmacy directors and assistant directors could put a damper on progress made by pharmacists at a time when they are poised to take commanding ownership of medication and patient-safety leadership positions in hospitals.

A workforce shortage combined with federal government funding cutbacks may complicate the lives of an incoming generation of pharmacists. So claimed two of the profession's topsiders at an ASHP leadership conference, held recently in Chicago.

Gout was the subject of nearly 30 abstracts and the first plenary session in more than 20 years at the recent American College of Rheumatology (ACR) 2004 annual meeting held in San Antonio, Texas. The prevalence of gout, the most common form of arthritis in men older than 40, is increasing worldwide. Interest was strong also for a session on a new treatment for rheumatoid arthritis patients who respond inadequately to anti-TNF therapy.

Anesthesia awareness-the unexpected cognizance that occurs when anesthesia lightens during surgery-is the subject of a recent Sentinel Event Alert issued by the Joint Commission on Accreditation of Healthcare Organizations. Forty-eight percent of patients who experience awareness report auditory recollections, 48% report being unable to breathe, and 28% report pain-without being able to communicate this to the surgical team.

A 60-year-old Hispanic man, L.C., is being discharged from your hospital after an episode of gastrointestinal bleeding. Prior to admission he was switched to naproxen 500 mg b.i.d. for his osteoarthritis when rofecoxib (Vioxx, Merck) was taken off the market. Dismissal orders include ongoing medications: metformin 850 mg b.i.d., pravastatin 40 mg q.d., ramipril (Altace, Aventis) 10 mg q.d., now with the addition of lansoprazole (Prevacid, TAP) 30 mg q.d. L.C.'s physician is in a quandary about whether to prescribe a different COX-2 inhibitor or an NSAID. Previously, L.C. failed to obtain pain relief from acetaminophen or salsalate therapy. What do you recommend?