Total Parenteral Nutrition Management Based on Intravenous Drug Compounding Service

Total parenteral nutrition treatment is complex and has serious and detrimental complications, including catheter-related blood stream infections, fluid and electrolyte imbalance, hyperglycemia and hypercalcemia. This research examines how Intravenous Drug Compounding Service (IDCS) figures in total parenteral nutrition prescriptions reviewed by pharmacists, strengthens hospital clinical care and improves patients’ health. For this study, a total of 56164 nutritional prescriptions or medical orders from a hospital in Guangdong from 2016 to 2020 were randomly selected. According to whether IDCS was administered, the patients were divided into two experimental groups: the intervention group and the control group. The types and numbers of irrational prescriptions in the two groups were analyzed and compared, and further analysis of the role of IDCS in improving the level of nutritional prescriptions was performed. The results showed that the rate of irrational prescriptions in the intervention group from 2016 to 2020 was significantly lower than that in the control group, and the difference was statistically significant (P<0.01). The total irrational prescription rate in the intervention group was 32.53‱ on average, which was significantly lower than the 156‱ in the control group. The difference was statistically significant (P<0.01). After the administration of IDCS, the incidence rates of both total prescription errors and formulation errors were significantly lower than the incidence rate of irrational prescriptions without pharmacists’ intervention. The study confirms the importance and necessity of IDCS, so that patients can receive more efficient nutrition and health management services.

Use and impact of technology-assisted workflow (TAWF) systems for drug compounding in pharmacy practice: a scoping literature review

Objectives The aim of this study was to review studies describing the use and the impact of technology-assisted workflow (TAWF) systems for drug compounding in hospital pharmacy. Content This is a scoping literature review. A search was conducted on studies describing or evaluating the use of TAWF published from January 1st, 2015 to July 31st, 2021. Two databases were searched (PubMed and Embase), followed by a search on Google Scholar. Summary 218 articles were screened and 17 were identified as meeting the inclusion criteria. TAWFs all included preparation assistance software (17/17), barcode reader (17/17), photo or video taking (17/17), and some included gravimetric systems (8/17), and the use of robots (2/17). A majority of the studies included used technology for parenteral preparations (15/17, one for oral preparations only (1/17), and one used technology for both types of preparations (1/17). Most of the articles selected presented drugs prepared for adults (10/17), the others presented drugs intended for children (4/17) or for a mix of adults and children (3/17). Four parameters were evaluated: error detection rate (n=15), preparation and validation time (n=7), and costs generated or saved (n=7). Ten studies evaluated the pre-post impact of implantation of a TAWF (10/17). Outlook Given the heterogeneity of the data available, the use of TAWF was associated with an increased ability to detect preparation errors, a reduction in preparation time and costs, and increased satisfaction of pharmacy technicians and pharmacists. However, better quality studies are needed to confirm the positive impacts studied.

Mistakes of healthcare workers during antineoplastic infusions: how can we prevent them?

Background. 39 years old Betsy Lehman, which in 1994 took part in a clinical study, died because of the excessive infusion of cyclophosphamide (4 times higher dose). The mistake was revealed only in 10 weeks after the patient’s death. Now there is a Betsy Lehman Center of Patient Safety and Decrease of Medical Errors. According to the definition, medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to the harm of the patient. In turn, wrong usage of the drug is an intentional misuse not in accordance with the instruction for medical usage (including, with some illegal aims). According to the statistics, only in USA medical errors harm 44,000-98,000 patients annually and cause the death of 7,000 patients. Objective. To define the main concepts of medical errors and methods of their avoidance. Materials and methods. Analysis of literature data on this topic. Results and discussion. Categories of medical mistakes include the mistakes of prescribing, of dispensing, of preparation, of administration and of monitoring. Retrospective analysis of the correctness of drug administration had revealed that the risk factors of mistakes included patient’s age <15 y. o. or >64 y. o., and a big quantity of administered drugs. Nurses with different professional experience equally often made mistakes; mistakes were more often during night shifts. Medical mistakes in oncology have some peculiarities. Namely, in oncology the drug dose often depends on the body surface and other factors; exceeded dose is accompanied by the high toxicity, and the insufficient dose – by the severe decrease of treatment effectiveness; anticancer treatment is accompanied by the administration of the big amount of additional drugs (antiemetics, hemopoesis stimulators, glucocorticoids, etc.). Analysis of chemotherapy of 1311 adult patients, which underwent the treatment in the university clinics of Valencia (Spain), revealed the mistakes in 17.2 % of cases. Mistakes in drug prescription were the most often (75.7 %). Similar French study revealed the mistakes in 5.2 % of cases, the majority of them (91 %) were also the mistakes in prescription (wrong choice of treatment regimen, incomplete prescriptions, inadequate doses). Such mistakes have not only medical, but also the social and economic consequences, including the increase of treatment cost. Meta-analysis of R. Ashokkumar et al. (2018) revealed that the frequency of medical errors in oncology, according to the different studies, was about 0.004-41.6 %. There is one more problem: because of the fear of punishment healthcare workers hide their errors, that’s why the small amount of errors may not be the real favorable parameter, but just a result of incomplete notification. Factors of medical mistakes appearance are divided into 3 groups: due to healthcare workers (training level, knowledge, physical and emotional condition), due to clinics administration (presence of treatment standards, communication quality, registration and analysis of error cases) and social (staff workload, time limitations, workplace organization, payment). With the aim of prevention of medical errors in oncology we must implement the treatment standards and local protocols, control technics of preparation and administration of anticancer drugs, widen the network of clinical pharmacists, use external drug compounding, thoroughly manage the medical documents, introduce electronic control systems and improve the communication between medical workers. Talking about legal aspects, concept of medical error does not have any legal consolidation. Literature includes about 70 its definitions. In case of a complaint of patient or his/her relatives healthcare workers will be asked such questions: whether the diagnostics of the patient was complete, whether the diagnosis was correct and timely made, what are the causes of the unfavorable outcomes, is there any direct causative link between healthcare workers’ actions and these outcomes, whether there was any standards’ violations. In general, vague criteria of standardization of medical care decrease the level of legal protection of both patients and healthcare workers. Conclusions. 1. Medical errors are quite often, but their exact incidence can’t be established. 2. Medical errors in oncology have some peculiarities because of the peculiarities of tumor treatment. 3. With the aim of prevention of medical errors in oncology we must implement the treatment standards and local protocols, control technics of preparation and administration of anticancer drugs, widen the network of clinical pharmacists, use external drug compounding, thoroughly manage the medical documents, introduce electronic control systems and improve the communication.

Oncology of the beginning of XXI century: elements of individualized cancer treatment

Background. Early chemotherapy (ChT) was extremely toxic and dangerous. The paradigm has changed in the late ХХ century and the beginning of ХХІ century, when the first target drug imatinib was created and the scientists managed to decode a human genome. The main achievements of the postgenome era of cancer treatment include the molecular neoplasm classifications and the revealing of intertumoral heterogeneity. It was proven that the patients’ survival depends not only on the TNM stage, but also on the molecular subtype of the tumor. Objective. To reveal the backgrounds of personalized cancer treatment. Materials and methods. Analysis of the literature data on this topic. Results and discussion. Targeted cancer treatment needs thorough diagnostics with the estimation of all tumor characteristic. According to their clinical value, modern oncomarkers can be divided into prognostic, surrogate and pharmacodynamical and can be assessed in tissues, blood, urine and other biological liquids or exhaled air. Analysis of cancer tissues now includes the assessment of genome, transcriptome, proteome, metabolome, lipidome, epigenome, microbiome, etc. Technologies of DNA sequencing are also developing: new generation methods allow to read billions of short DNA molecules simultaneously. According to the experts’ prognosis, in 2025 the complete genome sequencing will cost only 400 USD. New generation sequencing (NGS) has such possibilities as a complete metagenome sequencing, RNA sequencing, analysis of DNA-protein interactions, bisulfite sequencing and its modifications, target sequencing (exome, mitochondrial, amplicon sequencing). Advantages of NGS include high sensitivity and specificity, possibility of multiplexing, wide spectrum and high speed of mutations assessment, whereas its disadvantages include the need in an expensive equipment and high-quality calculations. Modern individual genome therapy of cancer can also be called personalized medicine, prognostic medicine, integrative medicine, pharmacogenomics medicine. In general, it meets the principles of Leroy Hood. According to his 4Р rule, the healthcare must be Рredictive, Preventive, Personalized and Participatory. Nowadays there is a new trend in the oncological science, which anticipates creating of the avatars of human tumors in genetically modified mice or Zebrafish (Danio rerio). It allows to cultivate tumor cells, taken from an individual patient, in a new organism, and to study their reaction to the various kinds of treatment. Personalization of treatment also cover the drug compounding, that is, creation of an individual pharmacological product taking into account the individual characteristics of each patients. Domestic compounding center “Khemoteka” provides personification of patients’ treatment and excludes the possible causes of the decrease of cytostatic dose during ChT. The prescription is made online, and individually created ready-to-use drug is delivered to the hospital. Conclusions. 1. Accurate classification and the exact assessment of molecular and genetic characteristics of tumor is a background of the optimal treatment of cancer. 2. NGS allows to reveal a wide spectrum of mutations very fast. 3. Drug compounding is an important part of personalized cancer therapy.

Biopolymer Substrates in Buccal Drug Delivery: Current Status and Future Trend

Background: This paper provides a critical review of biopolymer-based substrates, especially the cellulose derivatives, for their application in buccal drug delivery. Drug delivery to the buccal mucous has the benefits of immobile muscle, abundant vascularization and rapid recovery, but not all the drugs can be administered through the buccal mucosa (e.g., macromolecular drugs), due to the low bioavailability caused by their large molecular size. This shortfall inspired the rapid development of drug-compounding technologies and the corresponding usage of biopolymer substrates. Methods: Cellulose derivatives have been extensively developed for drug manufacturing to facilitate its delivery. We engaged in structured research of cellulose-based drug compounding technologies. We summarized the characteristic cellulose derivatives which have been used as the biocompatible substrates in buccal delivery systems. The discussion of potential use of the rapidly-developed nanocellulose (NC) is also notable in this paper. Results: Seventy-eight papers were referenced in this perspective paper with the majority (sixty-five) published later than 2010. Forty-seven papers defined the buccal drug delivery systems and their substrates. Fifteen papers outlined the properties and applications of cellulose derivatives. Nanocellulose was introduced as a leading edge of nanomaterial with sixteen papers highlighted its adaptability in drug compounding for buccal delivery. Conclusion: The findings of this perspective paper proposed the potential use of cellulose derivatives, the typical kind of biopolymers, in the buccal drug delivery system for promoting the bioavailability of macromolecular drugs. Nanocellulose (NC) in particular was proposed as an innovative bio-binder/carrier for the controlled-release of drugs in buccal system.