We previously reported on the development and clinical efficacy of 2 % aspirin ointment (AO) for the topical pain relief of postherpetic neuralgia (PHN). Although 2 %AO has been used clinically in our hospital with high efficacy, the stability of aspirin in the ointment and the acceptability of the ointment to patients were inadequate. Therefore, to improve these points, we changed the active ingredient to ethenzamide and also adopted a wax-based ointment. Three different concentrations (1 %, 2 % and 5 %) of ethenzamide ointment (EO) were then prepared using transdermal absorption enhancers. The antinociceptive effect was tested by the Randall-Selitto method in a rat model of hyperalgesia with the ointment applied topically. Both 2 %EO and 5 %EO were found to be as effective as 2 %AO in a rat model of hyperalgesia, and 5 %EO was chosen for further study because it tended to have a longer duration of efficacy in a preliminary clinical study. A high stability of ethenzamide at room temperature for more than 56days was confirmed using high performance liquid chromatography while the stability of aspirin in the ointment was not good enough. The clinical efficacy was tested in 4 outpatients with PHN by dispensing either 2 %AO or 5 %EO weekly in a single-blind crossover study. 5 % EO was thus found to have a quick effect on pain relief and the efficacy was similar to that of 2 %AO. The acceptability of 5 %EO to patients was also better than that of 2 %AO in terms of stickiness. After the trial, the patients were treated with 5 %EO continuously for up to 8 months. This is the first demonstration of the efficacy of ethenzamide as a pain relief medication for patients with postherpetic neuralgia, and 5 %EO is thus considered to be a clinically useful analgesic for postherpetic neuralgia.
The system of intravenous injections (i.v.) being mixed by pharmacists is necessary to prevent contamination and dispensing errors. Such a system was started at the Municipal Ikeda Hospital on April 2000. The dispensing of injections consists of five steps, including the labeling, dispensing, setting and mixing, and the application of check systems. Dispensing errors that induced serious medical complications were examined over a 4-month period (2000.10. 1-2001. 1.31). In addition, resource management during dispensing errors were researched, and countermeasures against dispensing errors were developed. Dispensing errors involving i.v. mixing, which were identified after the preparation had been taken to the ward by nurses, were also surveyed for a 4-month period (2001. 6. 1-9.30). There were 9, 611 i.v. mixing by pharmacists in a 4-month period (2000.10. 1-2001. 1.31). There were 214 dispensing errors (2.23%) during those 4 months, those discovered in the final check comprised 0.28% (27cases), while those involving i.v. mixing taken to the ward by nurses was 0.04% (4 cases). The percentage of serious dispensing errors was 0.01 % (1 case). Fortunately, these mixed i.v. preparations were not administered to patients. In the second survey, there were 10, 478 i.v. mixings by pharmacists in a 4-month period (2001. 6. 1-9.30). There was only 1 case (0.01 %) of a dispensing error involving i.v. mixing identified after being taken to the ward by nurses. There were no cases involving serious dispensing errors. These erroneous instances of i.v. mixing were not administered to patients. When these two surveys are compared, no significant difference was observed, but the number of errors decreased after the establishment of countermeasures to reduce dispensing errors. As a result, it became clear that dispensing errors could occur at any step, but they were preventable by both making several checks and by developing countermeasures against dispensing errors at each step.
Medication errors frequently occur, and pharmacists must establish systems to prevent errors. Especially, the development of novel systems to facilitate the optimal usage of anticancer agents is recognized as an urgent issue, because these agents show severe side effects in comparison to other drugs. As a result, we prepared review sheets for prescriptions containing anticancer injectable drugs (check sheet) according to protocols of chemotherapy designed by our oncology surgery unit. In addition, explanation leaflets for injectable drugs were also prepared to provide drug information for patients. Using these check sheets, we found 3 out of 40 prescriptions which needed to be corrected before usage. Patients and doctors were asked to evaluate the explanation leaflets of anticancer agents, and good responses were obtained. Furnishing drug information on explanation leaflets could thus help improve patient's understanding of adverse reactions of anticancer agents and also help to detect adverse reactions in the early stages. In summary, we developed a new system to increase the optimal usage of anticancer agents, which allows for improved drug information regarding chemotherapeutic drug. This new system is expected to help reduce medical errors and facilitate the patient awareness regarding drug usage.
Taxoid antineoplastics, TAXOL® and TAXOTERE®, are similar brand names which are easy to confuse, when physicians prescribe them. This problem has become to be serious since 1999 when the applicable diseases and the daily doses for both drugs overlapped each other. We surveyed their applications and daily dose from 1998-2000 to assess the risk of medical errors in managing both drugs. A difference was observed in the daily doses between TAXOL® and TAXOTERE® in 1998. Their daily doses, however, overlapped at 20-80 mg/m2 in 2000, especially in patients with breast cancer. This might be one reason for current medical errors due to similar daily doses in addition to the similar brand name. We have started to use individual sheets to manage both taxoid antineoplastics since August 2000 to avoid medical errors. Our approach for managing taxoid antineoplastics was found to be useful for reducing the risk of medical errors owing to the similar brand name of these two drugs.
We examined the compatibility of a commercialized potassium canrenoate preparation (Soldactone®) with 124 other kinds of currently prescribed injectable preparations as counter substances based upon the physicochemical parameters : actually, the appearance, pH, and the concentration of canrenoate were used as markers after mixing for 24 hours with other injectable preparations, since appearances can be deceptive. In order to estimate the remaining content of canrenoate after mixing, the concentrations of canrenoate were determined by UV absorption at the wavelength of 293 nm, using a spectrophotometer and reversed phase high-performance liquid chromatography (HPLC). As the results, no change was detected in 53 of the 124 counter preparations in the mixture and the content of canrenoate was above 90%. Sixteen total parenteral nutrition solutions, 5 amino acid solutions and 17 antibiotics dissolved in saline were incompatible with canrenoate. We also examined the compatibility of canrenoate, which was directly added to furosemide (20mg and 100 mg) and 5 % of glucose preparations. In the case of a furosemide injection (20mg), the appearance, pH and turbidity did not change, while the concentration of canrenoate decreased to less than 90% of the control. On the other hand, a glucose preparation (5 %) did not show any incompatibility with the counter preparations. Therefore, the canrenoate preparations can be dissolved into 5 % glucose solution, prior to the clinical application.
We examined antibiotic use on an individual patient basis and investigated outstanding cases in detail to produce a guide for the activity of the Infection Control Committee of Kouseiren Chu-nou Hospital. The prescription data for 14 frequently used antibiotic injections were collected by utilizing a computer database of hospital inpatients between March 1st and June 30th, 2001. Although the overall antibiotic usage seemed appropriate, some inappropriate usages were uncovered by investigations on an individual-patient basis, including a prolonged administration. Vancomycin (VCM) was prescribed to some methicillin-resistant Staphylococcus aureus-negative patients. VCM was prescribed more than 14 days consecutively to 34. 4 % patients. All of these were considered to be inappropriate in regard to the usage specified for insurance. Therapeutic drug monitoring (TDM) was not carried out in all the patients administered VCM. Cefazopran was prescribed to many patients with respiratory infections. In addition, cefazopran was used as a first line medicine for empiric therapy in the treatment of pneumonia of the aged with chronic respiratory diseases. In conclusion, we found antibiotic usage problems in our hospital. According to the results in this study, we made new guidelines for pharmacists to monitor antibiotic usage by inpatients. We also suggest that the coordination of infection control nurses with pharmacists remains an important next step in improving the appropriate use of antibiotics in our hospital.
The purpose of this study was to evaluate the preparation and inhalation techniques for the administration of Flutide®. The population of this study comprised of three groups, one group of patients who had commenced using Flutide®, one group who had been on steroid inhalation therapy using a metered-dose inhaler (MDI) and one group who had never been on steroid inhalation therapy. We provided instructions in and assessed the in-halation techniques at the patient's first visit and reassessed the same action at second visit. A questionnaire was also provided. Regarding preparation, elderly patients at their first visit were suggested to have slight difficulties in removing the tray of the Diskhaler® and in rotating the Rotadisk® to place the next blister ready for use. At their second visit, however, most patients could perform these tasks without any significant problems. As for the inhalation technique, most patients, regardless of age, had difficulties in inhaling quickly from the Diskhaler®. It was found that the action was difficult not only for the elderly, but also for younger patients. We found a notable tendency for patients who had never been on inhalation therapy to be confused regarding how to inhale quickly from the Diskhaler®. At the second visit, almost all patients could perform this procedure without mistakes, but we thought it advisable to repeat both practice and instructions. Furthermore, the results of the questionnaire showed that 72 % of the patients found Flutide® easier to use than MDI, while 78% of them wanted to continuously use the Flutide®. These results indicated that Flutide® was a satisfactory device for patients, although some patients might have to repeat training for certain steps of the procedure. The overall results of our study indicate that patients expressed a high level of satisfaction with this device.
In Japan, there are no suitable training materials for community and hospital pharmacists to increase a common understanding for pharmaceutical care on several diseases. We therefore developed to following training materials consisting of 8 components, 1. Charts of case studies, 2. Items of pharmaceutical managements, 3. Items of pharmaceutical services, 4. Sheets for recording of medical history, 5. Sheets for drug information of patients, 6. Sheets for contents of pharmaceutical services, 7. Confirmation sheets for essential drugs and 8. Check sheets for essential drugs on 6 diseases, such as deep-vein thrombosis, myocardial infarction, hypertension, non-insulin-dependent diabetes, bronchial asthma and gastric ulcer. In the present study, to evaluate the usefulness of this system, a questionnaire regarding the benefit of “1. Charts of case studies” on community and hospital pharmacists selected randomly was conducted and analyzed. Community pharmacists recognized the style of these charts to be highly advantageous, while hospital pharmacists were interested in explanations for medical treatments. Furthermore, almost all pharmacists answered the usefulness of case studies for understanding pharmacotherapy. These findings showed the usefulness of using the “1. Charts of case studies” for the initial training of clinical works as a pharmacist.
Some Japanese herbal medicines (Kampo medicines) have been shown to inhibit the activity of aminopyrine N-demethylase in rat liver microsomes. Namely, Sho-seiryu-to and Keishi-kajutubu-to inhibited not only aminopyrine N-demethylation but also erythromycin N-demethylation, 7-ethoxycoumarin 0-deethylation, 4-nitrophenol 7-hydroxylation, desipramine 2-hydroxylation and coumarin 7-hydroxylation in rat liver microsomes to varying extents. Cinnamon Bark, Schisandra Fruit and Ephedra Herb, which are crude medicine ingredients contained in Sho-seiryu-to, showed a higher potential to inhibit erythromycin N-demethylation than Sho-seiryuto and other components such as Pinellia Tuber, Glycyrrhiza, Asiasarum Root and Peony Root at the same concentrations. From these results, some Kampo medicines are thought to have an inhibitory effect on cytochrome P450 in rat liver microsomes, and that the inhibitory effect of Sho-seiryu-to on erythromycin N-demethylation may be, at least in part, associated with the ingredient (s) of Cinnamon Bark, Schisandra Fruit and/or Ephedra Herb.
Many patients have anxiety regarding drug use during pregnancy because they fear their child will be born with congenital anomalies. Anxiety is heightened because the mother frequently feels guilt, believing she may have damaged her baby through some action of her own. Since March 1995, counseling a pregnant woman about possible effects of a drug was started at clinical department of obstetrics and gynecology by a pharmacist. In order to further study the development of medication counseling, we searched and analyzed 143 patients. 74 patients had therapeutic exposure during pregnancy and 69 had inadvertent exposure during pregnancy. An analysis of our data was made on the basis of the age, the type of disorder, the number of doses, the route of administration, the timing of the exposure, and outcome. A pregnant woman takes an average of 4.4 medications and takes up to 22 medications during pregnancy. 24 of 74 (32.4%) women asked our advice before conception. Only 1 of 144 (0.9%) cases showed a major birth defect (cardiovascular defect). These findings suggest that all counseling regarding drug or medication use during pregnancy should occur before conception. Our role of teratogen counseling is ultimately to provide the patient with as much information as possible and encourage her to make her own decisions regarding whether or not to continue the pregnancy.
Kanagawa Society of Hospital Pharmacists published in Oct. 2000 the booklet “Hospital Pharmacists' Story in Cartoon Style : Part 2-Obstetrics and Pediatrics Version” to enable the general public to obtain accurate knowledge of pharmaceutical products and to improve their understanding of the pharmacists' work in hospitals. In Feb. 2001 the booklet was mentioned in a national newspaper, and as a result many requests were made to the Kanagawa Society of Hospital Pharmacists for the booklet. Subsequently, we conducted research on the public's evaluation of this booklet by using a questionnaire (printed on a postcard) attached therein. The number of booklets sent out between Feb. 1 st and Mar. 31st in 2001 totaled 11, 019. One thousand seven hundred twenty-eight individuals responded to the questionnaires, and the response rate was 15.7%.Ninety-nine point two percent of the respondents said, “The booklet helped me understand (or understand very well) that pharmacists working in hospitals have a responsibility to carefully manage drug treatment.” Furthermore, 98.4% of them said, “The explanation of drugs at the end of the booklet was useful (or very useful).” The questionnaire revealed that a copy of the booklet had been read (or would be read) by an average of 3.8 persons. Consequently, it could be estimated that a total of over 40, 000 persons had read the booklet. We believe that the publication of this booklet has been effective in enabling the general public to obtain accurate knowledge of pharmaceutical products and also for improving their understanding of the pharmacists' work in hospitals. However, such an activity cannot be conducted thoroughly by a single body, therefore, we would like to engage in more far-reaching educational activities in the future by cooperating with other organizations.
We developed a computer ordering system for TDM in August 1998. This is a constituent of the total computer systems in our hospital, and comprises of two parts of practice, one part for the physician's ordering TDM and the role of pharmacist's in TDM. The system for pharmacists has predominantly five functions, including the check of objects to be examined, an acceptance of the objects, input of examined results, reference to the patient's TDM history, and dosage planning to be offered to physicians. Most of the 28 pharmacists contacted by questionnaire in our hospital pharmacy considered this system to be useful for improving the performance of TDM treatments, but found some incomplete information on patients, which was attributable to physician's incorrect ordering procedure in the database for dosage planning. This was due to the fact that physicians can easily input an order without accurate or the latest patient information. Therefore, the present ordering system for TDM was shown to still need improvement.
We developed a clinical pathway (CP) for cataract surgery patients, and the CP involved pharmaceutical consultation by pharmacists. 1) Prior to the start of the CP, the ophthalmologists conferred with the pharmacists and a conference determined the use one kind of oral antibiotics and four kinds of ophthalmic solutions as medicines. 2) Pharmacist gathered all of the patients who had similar operating days and explained the method of applying the ophthalmic solutions, the effects of the medicines, and so on by using illustrated instructions. After the group guidance, the pharmacist performed pharmaceutical consultations for individual patients. 3) A comment space about the pharmaceutical consultation was included in the table of the CP in order to exchange information with other medical staff members. 4) We studied the merits of the pharmacist in this CP by questionnaire. All patients (n=20) replied that they could receive detailed explanations about the medicines. All doctors (n=4) and four of nurses (n=5) replied that their explanation time about the medicines decreased and they could devote themselves to other medical services. There was a significant advantage when a pharmacist could efficiently perform the pharmaceutical consultation because the kind of medicines and the consultation schedule were fixed in this CP. We think that the medical staff can better concentrate on their specialty and more efficiently provide high-quality medical services for patients when the pharmacist's participate in the CP.
This study aimed to evaluate the role of the pharmacist as a member of the liver transplant team in controlling tacrolimus concentrations and the incidence of convulsions as a side effect. Interventions of the pharmacist in the liver transplant team include the indications of dose setting, the checking of drug interactions, the monitoring of adverse effects and the instruction for patient compliance. Fifty-two patients who underwent a living-related liver transplantation were enrolled. The total number of 691 whole blood samples were collected during 2 weeks after liver transplantation and then were analyzed by microparticle enzyme immunoassay (MEIA) for tacrolimus trough concentrations. The standard deviation of tacrolimus trough level was 5.9 before pharmacist participation, while it decreased markedly to 3.7 after pharmacist participation. In addition, the variance significantly decreased. Five of 25 patients treated with tacrolimus before pharmacist participation encountered convulsions, however, none of the 27 patients showed any signs of convulsion after pharmacist participation. There was no significant difference in the rejection before (32 %) or after (26 %) pharmacist participation. We conclude that pharmacotherapy in the liver transplant team improved after pharmacist participation.
A heparin lock is technique performed in order to prevent blood coagulation in the needle detained in the vessel, or a catheter. In Japan, when we perform a heparin lock, a heparin injection is diluted with physiological salt solution before use. We need to use prefilled syringes with diluted heparin. We received a sample of this product. We investigated the user-friendliness of the product. From our results, the prefilled syringe with the diluted heparin was found to be useful. Furthermore, when we use the prefilled syringe with diluted heparin, patient safety is increased.