Clinical risk management in community pharmacy

In this thesis, several studies are presented providing information about frequency, nature and determinants of drug therapy related problems as they occur in daily pharmaceutical practice, including unavailability, drug-drug interactions and heavy use of psychotropic medicines. These studies especially focused on the pharmacist and his contribution and quality to the 'solution' of these problems. - In 2001 Dutch community pharmacies still compound more than 13,000 medicines per day (2.3% of all prescriptions), mainly consisting of dermatological preparations. At least 1.2 compounded prescriptions per pharmacy per day (about 10%) have a specific pharmaceutical care reason according to the pharmacists, such as intolerance, contra-indication, inconvenience to use and special dose needed. Thereby, compounding remains an important though 'niche' activity of community pharmacy. - Dutch community pharmacies modified 2.8 prescriptions for “prescription only medicines” per pharmacy per working day, which could potentially have had clinical consequences if not altered. These interventions concerned an array of drug therapy related problems, but especially wrong doses. A multidisciplinary panel of reviewers unanimously rated almost 60% of these interventions as clinically relevant. By extrapolating these data, we estimated a daily occurrence of approximately 2,700 clinically relevant interventions leading to a prescription modification in all Dutch pharmacies. - A high frequency of drug-drug interaction alerts was found: 6% of all prescriptions generated such an alert. Most concerned recurrent alerts. External action by pharmacists, mostly concerning a communication with the patient, took place in about 27%. A first alert was the main determinant for external action. The abundance of apparently non-relevant alerts, which implies the risk of overriding these, needs further study and policy making. - In the latter study, we also found some indicators that the management of drug-drug interaction alerts by pharmacies can be improved. In another study in this thesis, an overall adherence of approximately 70% to a national guideline was revealed concerning the management of drug-drug interaction alerts. The degree of adherence varied with the nature of the drug-drug interaction, patient characteristics and the nature of the advised management actions in the guideline. Further research into underlying reasons for non-adherence is warranted to guide efforts to improve this situation. - In a selection of Dutch pharmacies at least one documented disease and/or intolerability was found in the electronic patient record of almost 60% of the patients. For some diseases, such as diabetes and hypothyroidism, the documentation was quite accurate, but for others the quality required further improvement, especially heart failure. - Community pharmacies are confronted with a modest, but clinically relevant level of heavy use of psychotropic drugs, especially of hypnotics and anxiolytics. Part of the problem will not be discovered because of pharmacy shopping behaviour of patients using these drugs. - Although pharmacy shopping behaviour in the Netherlands is (still) limited, unintentional shopping behaviour, for instance because of required medical treatment outside office hours, could lead to unnoticed but potentially harmful drug-drug interactions. Linking pharmacy computer systems, preferably nation-wide, will hopefully prevent intentional and unintentional problems related to pharmacy shopping behaviour