Browsing by discipline "Socialfarmaci"

Background: Medication errors are the most important individual factor that jeopardizes patient safety in human care. The patient's medication process is a chain of successive operations which involves different health care providers and the medicine user. All the stages of the medication process are susceptible to the medication errors. Medication errors are approached from the system's point of view by James Reason`s (1990) theory of Human Error. Instead of blaming individuals the theory concentrates on developing operations models which enable identification of medication errors in the organizations. The development of medication safety culture in the human medication has led to systems which tolerate human mistakes and prevent errors. The increasing number of animals and pets and their changing status in the society have raised discussion about the medication safety in veterinary care. Little research has been conducted in this field. Objective: The objective of the study was to identify the most typical veterinary medication errors and their root causes. The medication management processes of veterinary care can be developed safer by becoming aware of the root causes of medication errors. Study design and data: All the cases investigated by the Assessment Board for Damages in Veterinary Practice in 2002-2013 considering medication errors (n=79) were analysed with the help of the structured data collection sheet by using descriptive statistics. The most typical cases were studied more in detail by using simplified Root Cause Analysis (RCA). Results: The medication errors found were related to the care of dogs (n=34), horses (n=26), bovines (n=10), cats (n=7) and pigs (n=2). The most general therapeutic groups that had caused medication errors were antibacterials for systemic use (17% of all the medicines related to the medication errors), NSAIDs and antirheumatic drugs (12%), neuroleptics and tranquillizers (12%), and analgesics (12%). Of the drugs, 39% were high alert medicines. Of the errors, 36% were related to the off label use (usage deviating from the summary of product characteristics, SPC). The error types which appeared most commonly in the cases were wrong route of administration (18% of all the medication errors), wrong dose (16%) and untreated diagnosed conditions left without the medicine by the veterinarian (15%). Because of the character of the data the majority of the medication errors occurred in the beginning of the medication process. It was estimated that 81% of the medication errors would have been preventable. Some of the root causes found were the lack of the commitment to the established care practice, environmental factors, communication problems, availability of tools, hurry and factors related to management, information and staff. Conclusion: The material of Assessment Board for Damages in Veterinary Practice gives valuable information about the veterinary medication errors. It is possible to influence the root causes of veterinary medication errors by paying attention to the management related factors and communication in veterinary care and improving access to therapeutic guidelines and electronic databases, and by expanding the electronic prescribing to veterinary care. The highest priority is to get Pharmaca Fennica Veterinaria to an electronic form.

According to international studies, medication records are often incomplete in hospitals' patient information system. Medication reconciliation is an effective method to prevent medication errors and improve medication safety. A medication review is a useful tool in the assessment of drug-related problems (DRPs). DRPs can cause severe patient harm and even cause death. Approximately one third of Finnish people are diagnosed with cancer during their lifetime. About 16 000 patients receive cancer treatments in the Helsinki University Central Hospital Cancer Centre (HUCHCC). There are no clinical pharmacy services in the division of the solid tumors of HUCHCC. Internationally clinical pharmacy services in oncology are patient oriented and often include medication reconciliations and reviews. The clinical pharmacy services have increased patient safety also in the oncological specialty. The aim of this study was to find out the accuracy of the medication charts and identify the DRPs among 70-80-year-old patients with 6 or more medicines in uro-oncological outpatient clinic of HUCHCC. Accuracy of the medication charts was assessed by pharmacist-led medication reconciliation with patient interview. Information concerning patient's medication was also searched from the national electronical prescription centre and from the records of previous hospital visits. DRPs, such as drug-drug interactions, adverse drug reactions and overlapping medications, were identified with the pharmacist-led medication review. Special attention was paid to renal insuffiency, high-alert medications and potentially inappropriate medication for patients over 75 years old. Pharmacist discussed the DRPs with the oncology specialist. The theoretical framework of this study was the theory of human error, where patient safety hazards can be prevented by using safety defences such as medication reconciliation and medication review. Altogether 30 patients with urological cancer were included in this study. On average, they were 74.3 years old and used 12.4 medications. On average, there were 6.8 discrepancies per patient in the hospital medication chart. Only one patient had the accurate medication chart. The discrepancies were most commonly related to paracetamol (n = 10), vitamin-D (n = 9) and the combination of calcium and vitamin-D (n = 8). The most common discrepancies of high-alert medications were related to enoxaparin (n=6) and oxycodone (n=6). Of the potentially inappropriate medications for over 75 years old, the most common discrepancies were related magnesium (n=8) and metoclopramide (n=5). In the medication review process, 4 acute and 44 non-acute DRPs were identified with 22 patients (2,2 per patient). 60 % of these were regarded clinically relevant and lead to actions by the oncology specialist. Reconsidering the need or efficacy of the medication was recommended 19 times and inappropriate dose or medication with renal insufficiency were identified six times in medication reviews. DRPs were usually related to non-oncological medications such as pantoprazol (n=8), the combination of calcium and vitamin-D (n=4) ja bisoprolol (n=3). The medication reconciliation process should be developed in the urology-oncology outpatient clinic. Multiprofessional medication review can be used to detect and resolve DRPs of patients with urological cancer. The results of this study can be exploited when clinical pharmacy services will be created and developed in HUCHCC.

In hospital care many medicines should be usually prepared before they are administered to patients. In Finland Finnish Medicines Agency (Fimea) gives regulatory requirements and instructions for preparation of medicines in hospital pharmacies and action in hospital pharmacies is strictly controlled regularly by Fimea. According to Fimea's instructions hospital pharmacies should also ensure that medicines are prepared properly before they are administered to the patients in hospital wards. Preparing of medicines in hospital wards should be done in accordance with instructions given from the hospital pharmacy. Medicines should be prepared by using aseptic technique in order to protect patient safety. Aim of this study was to develop an assessment tool which can be used to assess the quality of ward- prepared medicines. The assessment tool should be suitable for self-assessment and external audit. Aim of the assessment tool is to ensure the safety of preparation of medicines in the wards and at the end improve patient safety. For the assessment tool ISMP Guidelines for safe preparation of sterile compounds were translated to Finnish. The assessment tool was then developed from the translated ISMP-guideline and other literature. The assessment tool was validated by using two-rounded Delphi-method. Delphi-method is a consensus method in which selected experts evaluate the data. At the first Delphi-round suitability and feasibility of the tool were evaluated and new items were created based on the consensus of experts. At the second round the feasibility of the tool items, which were developed by the first round, were evaluated once again. A total of 19 experts were participated to the Delphi-rounds. After the Delphi-rounds the developed assessment tool contained 64 items for safe preparing of medicines in hospital wards. The developed assessment tool reviews the entire process of preparing medicines and it can be used to identify which items are not followed in preparing of medicines before administering to patients in hospital wards. The developed assessment tool for safe preparation of medicines in hospital wards can be used widely in Finnish hospitals in order to ensure the quality of preparing medicines and detect the deficiencies and errors in preparation processes. By detecting deficiencies and errors in preparing medicines, they can be corrected and processes can be modified appropriate. In this way patient safety can be improved.

Breast cancer is the most common cancer among women, about 25 % of all cancers in women. 15 - 20 % of them are HER2 positive. HER2 is a transmembrane protein receptor with tyrosine kinase activity. When the overexpressed receptor is activated it turns on a cascade which results to activation of genes coding for for the growth of the cancer cells. Drugs against HER2 protein have significantly improved the survival of patients with HER2 positive breast cancer. In this systematic review the epidemiology, diagnostics and the principles of treatment is reviewed with focus on the treatment of HER2 positive breast cancer and anti-HER2 medications. Endpoints of clinical trials and handling the data are also reviewed. The aim of this study is to collect data of lapatinib, pertuzumab and trastuzumab emtansine in randomized clinical trials studying progression free survival, overall survival and adverse effects of patients with metastatic HER2 positive breast cancer. As a result of the literature search 22 whole text articles were found. There were 14 of randomized clinical trials, 2 of previous systematic reviews and 6 of meta-analysis. The facts and results of the selected studies were collected in tables. The quality of the studies was evaluated with CONSORT and PRISMA guidance. Lapaninib is used mainly for treatment of patients with resistanse to trastuzumab. Lapatinib improves the progression free survival and overall survival but the effect has not been as goog as expected. Lapatinib is better than chemotherapy but worse than trastuzumab in the treatment of metastatic HER2 positive breast cancer. Combinaition therapy is better than none of these alone. Lapatinib is a small molecule tyrosine kinase inhibitor. Pertuzumab and trastuzumab emtansine are monoclonal antibodies targeting HER2 receptor. In trastuzumab emtansine there is also a cytotoxic drug which is delivered into the cancer cell. Pertuzumab is effective in the treatment of metastatic HER2 positive breast cancer and it improves the survival also after treatment with trastuzumab. Pertuzumab is now approved also as neoadjuvant. Promising results has been published with trastuzmab emtansine in the treatment of heavily medicated patients with progressive disease. Adverse effects were abundant but usually manageable and reversible. The quality of the studies was mainly good. Some limitations were noticed, especially in reporting methods. Cancer therapy with targeted medication improves the effect of the treatment and decrease systemic adverse effects. It seems that the use of lapatinib is going to be mostly complementary when more promising pertuzumab and trastuzumab emtansine turned up to be more effective in the treatment of metastatic HER2 positive breast cancer. In the future there should be more clinical experience with the use of lapatinib, pertuzumab and trastuzumab emtansine. That would guarantee a cancer patient the most effective treatment, hopefully at the early stage of cancer.

Population is aging. Within aging the morbidity and the use of medicines increase. Polypharmacy and the physiologic changes related to the ageing expose to medication-related problems. This has to be taken into consideration when planning the care of the elderly. Multiprofessional cooperation is seen as a solution to optimize the medicines' use among the aged people. Finnish Medicines Agency (Fimea) has started a network with local multiprofessional health care teams. The aim of the network is to make a national guideline for multiprofessional cooperation and optimizing the medicines' use among the aged people. The objective of the study was to clarify multiprofessional working models to optimize the medicines' use that had been carried out or planned by the teams belonging to the network. The models can work as examples when creating standardized practices to multiprofessional cooperation in Finland. Factors that promote or prevent multiprofessional cooperation and the problems of optimizing the medicines' use were clarified as were the possible solutions to solve them. Factors to strengthen cooperation and its effects were clarified on the basis of experience of the multiprofessional teams. As a material of the study were the interviews (n=15) of health care professionals (n=55) invited to Fimea's multiprofessional network. Fimea had collected the material that consists of group discussions (n=10), pair interviews (n=3) and individual interviews (n=2). The interviews that had been recorded were transcribed and analyzed by using a combine of inductive and deductive content analysis. A theoretical framework in the study was multiprofessional teamwork and networking. According to the interviews, multiprofessional cooperation in optimizing the medicines' use among the aged has been carried out in Finland in both public and private health care. The interviewees think that the most important way to optimize the medicines' use is clear division of tasks and responsibilities. Adding more pharmacists to all over the public health services and fostering the role of the community pharmacies as a part of the health care are seen as solutions. Multiprofessional meetings and education can break barriers between different professionals. The most common problems are the challenges related to economic limitations and to the busy work. There are problems in IT systems and information transfer. At the individual level, the most common problems seem to be in communication and the attitudes. The interviewees' experience is that successful multiprofessional cooperation increases medication safety and improves patients' state. The work of all the professions is faciliatated and burden of the public health service decreases. Lighter medication reviews could be used to find the patients who benefit from the comprehensive medication review. Information transfer and the currency of patients' medication should be secured with functioning IT systems. The results of the study can be utilised when developing multiprofessional practices to optimize the medicines' use. More study is needed to show the profitability of medical reviews, dose dispensing and other services.

In Finland first pharmacists started to work on wards in 1980s and 1990s. Ward pharmacy increased mainly in consequence of the lack of nurses. Common tasks were taking care of drug logistics (stock control), dispensing drugs to patient specific doses, preparing and diluting intravenous drugs and providing drug information to ward personnel. During the 2000s, ward pharmacy services have been increasing a lot. New tasks are, e.g., reviewing medications and prescriptions, medication counselling, and taking part in medical rounds. However, the tasks are still rather logistics compared to the United States and the United Kingdom where a pharmacist has an established role in a multiprofessional team. Internationally it has been proved that it is possible to achieve decreased and enhanced quality of care and patient safety with hospital clinical pharmacy services. The aim of this study was to explore the extent and benefits of ward pharmacy services in Finland. An online survey was conducted by sending the invitations to the chiefs of hospital pharmacies (n = 24) and medical dispensaries (n = 94) by using the e-mail register of the University of Helsinki and Satefa (Finnish Association of hospital and health centre pharmacists). Before compiling the questionnaire six theme interviews were conducted to set up the questionnaire. The survey respondents were asked to submit information about development projects and research reports if they had explored the benefits of ward pharmacy services. The response rate was 60 % (n/N = 72/118). A half of the respondents (n = 36) reported having ward pharmacy services in their units. Benefits were explored in 12 units and nine project reports were received. Altogether 157 pharmacists were working in 242 wards at the time of the survey in spring 2011. Most common tasks were providing drug information to ward personnel, drug logistics and dispensing drugs to patient specific doses. Patient oriented tasks were increased, including prescription and medication reviews, taking part on medical rounds and medication counselling gave patient information were reported. The most reported benefits on ward pharmacy services were increased multiprofessional collaboration, saved working time of nurses and physicians, decreased drug costs and decreased number of medication errors and/or enhanced reporting habits and developed functions on wards. Respondents also believed that ward pharmacy services can have positive impact on length of stay, readmission and hospitalisations and mortality during hospitalization, but these benefits were not demonstrated by studies. In the future it would be important to develop the Finnish ward pharmacy services by following the international example and the principles of pharmaceutical care. The help of automation technology and pharmacy technicians should be exploited more in drug logistics. The economical and patient related outcomes of new clinical and patient oriented services should be proved in Finland and the results of the researches and projects made in hospital and health centres should be published more.

Smoking poses a significant threat to public health. Major public health benefits could be attained if we could increase the incidence of smoking cessation on the national level. However, smoking cessation is often difficult, therefore different medical means have been devised to make it easier for people to quit. One of these medical means is nicotine replacement therapy(NRT). Since NRT entered the market it has been contested which kind of role counselling should have when people purchase NRT. NRT was deregulated In Finland in 2006. Prior to this thesis there has not been carried out studies that would have tried to investigate where the retailer shops are located after deregulation. The aim of this thesis is to investigate how the deregulation affected to the distribution of NRT sales in different NRT-outlets and pharmacies in 2006-2015. It is also aim to investigate if the new outlets have tangibly increased the coverage of NRT-outlets network in diverse municipalities, e.g.in more sparsely populated rural municipalities. Finnish Medical Agency‘s (FIMEA) data about NRT-outlets between the years of 2006-2015 was used as source data for this thesis. This data was analysed by comparing the number of NRToutlets and pharmacies in diverse municipalities. The municipalities have been classified regarding the area and population of diverse municipalities, among other parameters. The PDF sheet of FIMEA’s NRT-outlet data was converted into an Excel file, and using that as a basis different diagrams were made. The number of NRT-outlets grew steadily until during the year 2011 there was a slightly bigger increase in the number of NRT-outlets as NRT became available in restaurants too. Afterwards the growth of NRT-outlets diminished. It can be seen from the results that NRT-outlets, more than pharmacies, are concentrated to the crowded municipalities. On the other hand, there has hardly been an increase in the coverage of NRT-outlet network in more sparsely populated rural municipalities since deregulation took place. However, many of the municipalities that have a pharmacy and one or a few other NRT-outlets are located in Southern Finland surrounding bigger city municipalities or in Central Finland.

Many mental disorders, such as anxiety, mood and substance use disorders, become prevalent in adolescence and continue into young adulthood. Anxiety disorders are among the most common mental disorders in adolescents and approximately 6-13 % of adolescents and young adults suffer from them. Benzodiazepines have been used for the treatment of anxiety and sleep disorders for several years but they are not recommended for young patients due to risk of dependence and abuse. Nevertheless, benzodiazepines are also prescribed to treat mental disorders in children and adolescents under 18 -years of age. There is limited population-based evidence on the use of benzodiazepines among children and adolescents. The aim of this study was to investigate the use of benzodiazepines and benzodiazepine related drugs as anxiolytics and hypnotics in the Finnish population aged 0-25 years during 2006-2014. Data of this study were obtained from the Prescription Register of the Social Insurance Institution of Finland covering reimbursed drug purchases of benzodiazepines (N03AE, N05BA, N05CD, N06CA01) and benzodiazepine related drugs (N05CF) dispensed to 0-25 year olds. Purchases of orally administered dosage forms were included in this study. The majority (97 %) of anxiolytic and hypnotic users in the group of 0-25 year olds were 16-25-year-old adolescents and young adults. Use of anxiolytics and hypnotics among 16-25-year-olds decreased from the prevalence 19.9 / 1 000 to 15.9 / 1 000 inhabitants during the years 2006-2014. There were also decrease in incidence and prevalence of long-term use. The prevalence of long-term use among young adults decreased from 5.5 / 1 000 in 2006 to 3.3 / 1 000 young adults in 2014. The majority of anxiolytic and hypnotic users were females but long-term use was more common in males than in females. There was a decrease in use of almost every studied drug. Oxazepam was the only drug with increased number of users during the study period. Use of benzodiazepines as anxiolytics and hypnotics has decreased among adolescents and young adults since 2008 in Finland. Furthermore, long-term use of these drugs has decreased among young adults. Results indicate that rational drug therapy has been paid more attention in recent years which was reflected in decreased use of benzodiazepines.

Inappropriate polypharmacy refers to a situation where more than appropriate amount of medicines are used by a patient. Aged people with multiple morbidities and medications use a lot of health care services and are thus especially vulnerable to iatrogenesis, the health hazards resulting from the acts of a health care system. As a part of normal ageing, geriatric syndromes (e.g. falls, delirium and urinary incontinence) are clinical conditions and symptoms crossing several organ systems and they cannot be connected to a certain individual disease. Geriatric syndromes complicate recognition of adverse drug reactions on aged. This increases the risk of prescribing cascade, where medicines are prescribed to treat adverse drug reactions caused by another medicine. In this master´s thesis the root causes for inappropriate polypharmacy and drug-related problems (DRP) with home-dwelling aged were researched retrospectively from the viewpoint of risk management. Research method was based on root cause analysis (RCA) that was simplified suitable for this research. Research material was based on an intervention research conducted in 2015– 2017 on home-dwelling aged receiving regular home care from the City of Lohja, Finland. In the intervention research, a coordinated community-based medication management model for home-dwelling aged in primary care was developed to identify homedwelling aged with clinically significant drug-related problems. As research material, there were five (n=5) patient cases used who received comprehensive medication review (CMR) in the intervention research to solve their drug-related problems. The research material composed of individual patient interviews conducted at patients’ homes as a part of their CMR visits. Also, the nurses (n=3) of home care and physicians (n=2) from local health centres having participated in the treatment of the home-dwelling aged in question, were interviewed individually. Markings made in the patient records were utilized as well as research material. The interviews of the nurses and physicians were recorded, transcribed and analysed with inductive content analysis considering principles of root cause analysis. According to the nurses and physicians, central clinically significant medication-related problems with home-dwelling aged are various prescribing care parties, multiple medications, the increased use of over-the-counter (OTC) medicines and natural products, the uncertainty of health care professionals of the medication of a home-dwelling aged as well as the occurrence and medication of pain and sleeping disorders with aged. Other essential problems related to the health care system are various attending physicians, obscurely recorded medication data in patient record system, the use of benzodiazepines and other psychopharmaceuticals and ignored renal function in medicine dose adjustment. Problems related to home-dwelling aged are attachment for medicines, resistance to change and desire to take care of their own medication. In addition, memory disorders and vertigo were mentioned as problems related to the medication of aged. Seven root causes for inappropriate polypharmacy and drug-related problems were observed: lack of health care resources, segmented treatment between various health care parties, varying skills and knowledge of health care professionals, ambiguous division of responsibilities between health care professionals, challenges in communication between different care parties, the heterogeneity of patient record systems and problems related to their use as well as the knowledge, opinions and personal situation of a home-dwelling aged. Based on the research, the medication of home-dwelling aged should be improved by striving for centralizing care in one physician either on private or public health care. Among home care nursing personnel there is a need for additional training on medications and pharmacists should participate in regular medication reviews for home-dwelling aged. Patient record systems and data transmission between them should be improved and medication data should be recorded more precisely. Cooperation and communication between home care and health centre should be developed and the division of responsibilities should be clarified. Participation of the home-dwelling aged and their relatives in the care should be promoted. Furthermore, geriatric expertise should be utilized better in the care of the home-dwelling aged.

Individually tailored smoking cessation, SC, service provided by community pharmacies is a chargeable special service for customers motivated to quit smoking. The service is based on the PAS service model developed in Great Britain and it has been provided by Finnish community pharmacies since 2006. It includes 4-6 meetings with a specially trained pharmacist, who provides counselling, support, SC plan and follow-up. In this pilot study, the service was investigated from customers' viewpoint, assessing their SC outcomes and experiences. The pilot study was a cooperation project of Division of Social Pharmacy and Association of Finnish Pharmacies. It was a part of a larger SC project co-ordinated by Pulmonary Association Heli and financed by Ministry of Social Affairs and Health. This pilot study assessed the feasibility of the service from customer's viewpoint. It assessed weather the service could increase customers' ability to stay abstinent in different phases of the service. Customers' experiences in relation to SC service and SC itself were also assessed. 14 voluntary pharmacies in different geographical locations in Finland participated in this intervention study and they recruited altogether 36 customers. Before customer recruitment pharmacies received education and introduction of the SC service provided by the Association of Finnish Pharmacies. As part of study protocol, the pharmacies informed local healthcare professionals about the pilot study and asked them to send suitable customers to the service. Pharmacies were paid an expert reward for each customer and they were able to provide SC service to the customers either free or with a low charge. Customers' smoking status and experiences about SC service were assessed with two enquiry forms, which they had filled at the beginning of the service and after three months they had started the service. Their background information was collected with specific background forms during the first meeting and their progress in SC service was investigated by service progress forms. 20 of the 28 customers who returned the first enquiry form and 13 of the 17 customers who returned the second enquiry form were abstinent (55,6 % and 36,1 % of all customers, respectively). All the quitters used some pharmaceutical treatment. Customers who quitted assessed their ability to stay abstinent higher than those who were unable to quit, at the outset and during the service. The customers considered service useful and support of the pharmacist was found important. The customers also considered it significant for pharmacies to provide the SC service. Approximately 32 % of the customers who returned the first enquiry form and 41 % who returned the second enquiry form would pay for the service. They would pay 45 € on average (10-100 €). Multidisciplinary service model was not working as expected, since only a small number of customers were recruited by other healthcare professionals. As a result some of the pharmacies recruited customers also from the pharmacy counter without any contact to other healthcare. 36 % of the 36 customers were abstinent at three months. The control group, planned for the pilot study, failed in recruitment and thus we can only compare our findings to other international studies of the SC service, which have provided similar results. Individually tailored SC service provided by pharmacies is suitable SC support for motivated customers. Customers considered service important and useful, but poor willingness to pay creates challenges for pharmacies to provide this kind of service.