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Clinical Interventions in Aging

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Evaluation of pharmacist interventions and commonly used medications in the geriatric ward of a teaching hospital in Turkey: a retrospective study

Elif Ertuna, Mehmet Zuhuri Arun, Seval Ay, Fatma Özge Kayhan Koçak, Bahattin Gökdemir & Gül İspirli

To cite this article: Elif Ertuna, Mehmet Zuhuri Arun, Seval Ay, Fatma Özge Kayhan Koçak, Bahattin Gökdemir & Gül İspirli (2019) Evaluation of pharmacist interventions and commonly used medications in the geriatric ward of a teaching hospital in Turkey: a retrospective study, Clinical Interventions in Aging, , 587-600, DOI: 10.2147/CIA.S201039

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Clinical Interventions in Aging 2019:14 587–600

Clinical Interventions in Aging

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evaluation of pharmacist interventions and commonly used medications in the geriatric ward of a teaching hospital in Turkey: a retrospective study

elif ertuna1

Mehmet Zuhuri Arun1

seval Ay2

Fatma Özge Kayhan Koçak2

Bahattin gökdemir2

gül İ spirli2

1Department of Clinical Pharmacy, Faculty of Pharmacy, ege University, Izmir, Turkey; 2Department of Internal Medicine, Division of geriatrics, Faculty of Medicine, ege University, Izmir, Turkey

Purpose: Aging increases the prevalence of diseases. The elderly population is consequently

often exposed to complex medication regimens. Increased drug use is one of the main reasons

for drug-related problems (DRPs). The primary objective of this study was to define and classify

DRPs, pharmacist interventions, and frequently prescribed medications in relation to possible

DRPs in patients admitted to the geriatric ward of a teaching hospital in Turkey.

Patients and methods: Pharmacist medication review reports for 200 orders of 91 patients

(mean age: 80.33±0.46) were analyzed retrospectively.

Results: A total of 1,632 medications were assessed and 329 interventions were proposed for

possible DRPs in 156 orders. A total of 87.5% of the patients used five or more drugs (mean:

8.17±0.23). The number of DRPs per order was higher when polypharmacy was present

(1.04±0.15 vs 1.66±0.11, P,0.05). In 71.31% of the cases, adverse drug events were recog-

nized as the problem. The principal cause of possible DRPs was determined as drug interactions

(40.12%). Only 22 potentially inappropriate medications were prescribed. The most common

interventions included monitoring drug therapy (31.0%), stopping the drug (20.06%), and chang-

ing dosage (13.98%). The acceptance rate of pharmacist interventions by treating geriatrician

was 85.41%. The most frequently prescribed drugs were for the nervous system, alimentary

tract and metabolism, and cardiovascular system (n=358, 314, and 304, respectively). The

pharmaceutical forms of 23 drugs were deemed inappropriate by pharmacists.

Conclusion: Clinical pharmacy services are still not properly implemented in Turkey. The

study highlights ways in which clinical pharmacy services can be instrumental in a geriatric

ward. The high acceptance rates of pharmacist recommendations concerning a wide variety of

DRPs and different classes of drugs indicate that advanced collaboration among geriatricians

and pharmacists is possible in interdisciplinary geriatric assessment teams in Turkey.

Keywords: pharmaceutical care, clinical pharmacy, elderly, medication review, polypharmacy,

potentially inappropriate medication

Introduction According to the United Nations’ World Population Prospects report, population

aging is occurring throughout the world and the number of older persons in the world

is projected to be 2.1 billion in 2050. In Turkey, life expectancy at birth is estimated

to be 82.5 and 89.1 years by the end of 2050 and 2100, respectively.1 With aging,

the prevalence of diseases and geriatric syndromes increases; as a consequence, the

elderly population is more frequently exposed to complex medication regimens and

Correspondence: elif ertuna Department of Clinical Pharmacy, Faculty of Pharmacy, ege University, 35040 Bornova, Izmir, Turkey Tel +90 532 672 5988 Fax +90 232 388 5258 email [email protected]

Journal name: Clinical Interventions in Aging Article Designation: Original Research Year: 2019 Volume: 14 Running head verso: Ertuna et al Running head recto: Ertuna et al DOI: 201039

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increased drug use.2–5 Polypharmacy increases the risk of

drug-related problems (DRPs), potentially inappropriate use

of medications (PIMs), and hospitalizations, all of which are

common among elderly people.2,3,6,7

A DRP is defined as “an event or circumstance involv-

ing drug therapy that actually or potentially interferes with

desired health outcomes”.8 In addition to clinical impact,

DRPs also increase health expenditure, which causes eco-

nomic burden.9,10 Several studies have found that pharmacists

provide added value in resolving and preventing DRPs in

settings such as outpatient clinics, acute care in inpatients,

nursing homes, and palliative care.5,11–18 Studies from inpa-

tient settings have also shown that including a pharmacist

as a member of the interdisciplinary health care team may

improve outcomes and decrease drug-related readmissions

and mortality in geriatric patients.2,17,19–21 As team members,

pharmacists offer an additional perspective in the application

of medication reviews, resulting in an increase in detec-

tion of DRPs and a reduction of polypharmacy in elderly

inpatients.21

Pharmaceutical care, described as the pharmacist’s

contribution to the care of individuals in order to optimize

medicines use and improve health outcomes, is the founda-

tion of clinical pharmacy. In the past decade, changes in

pharmacy undergraduate education and new legislations in

the Turkish health care system have indicated increasing

recognition of the pharmaceutical care practice. However,

the provision of clinical pharmacy services is still a fairly

new concept. Therefore, the need to establish basic standard

operating procedures for ward-based pharmacy services and

improving efficiently delivered quality of care has emerged.

The primary objective of this study was to define and clas-

sify the DRPs and pharmacist interventions in the geriatric

ward of a teaching hospital in Turkey. The paper’s secondary

objective was to determine frequently prescribed medications

and pharmaceutical forms in relation to possible DRPs in the

study population.

Patients and methods settings and data collection The study was conducted between December 2017 and

July 2018 in the acute geriatric ward (10 beds) of a

government-run 1,800-bed tertiary university hospital in

Turkey. Patients aged 65 or over admitted to the outpatient

geriatric clinic or emergency department of the same hospital

with typical acute geriatric problems were hospitalized.

Referrals from other smaller district hospitals (primary or

secondary care) were also accepted. Patients were cared for

by an interdisciplinary team of geriatricians, nurses, and dieti-

cians. Medical care and discharge planning were provided.

Two licensed pharmacists working at the Department

of Clinical Pharmacy, Faculty of Pharmacy at the Ege

University began to participate in the weekly interdisciplinary

geriatric rounds in December 2017, and a medication review

service is provided routinely once a week thereafter. Phar-

macists reviewed medication orders, medication history,

and/or clinical data (such as vitals and biochemical markers)

in the medication review process to detect possible DRPs

and prepare a report of possible DRPs and interventions for

each order 1 day before weekly interdisciplinary rounds.

The reports were discussed and reviewed with a geriatrician

during the weekly interdisciplinary rounds. The acceptance

status of the proposals was then noted by pharmacists.

In the medication review process, the latest medication

orders of patients were evaluated for DRPs by software-

based, guideline-based, or knowledge-based approach by

the pharmacist. Drug–drug, food–drug, and disease–drug

interactions and intravenous incompatibilities were analyzed

with RxMediaPharma® Interactive Drug Database.22 PIM or

potentially inadequate medication use in geriatric patients

was determined using Beers criteria,23 Screening Tool of

Older Persons’ potentially inappropriate Prescriptions

(STOPP) criteria, and Screening Tool to Alert doctors to

the Right Treatment (START) criteria.24 The latest clinical

practice guidelines for specific diseases were used to support

clinical decisions when necessary.

Data analysis The pharmacist reports for 200 medication orders of

91 patients were examined retrospectively. Problem type,

cause of problem, proposed intervention, and acceptance

status for the proposed interventions were classified accord-

ing to Pharmaceutical Care Network Europe’s (PCNE)

definitions and DRP classifications (the PCNE Classifica-

tion V 8.02).8 As using standard terms would facilitate the

comparison of the results of studies, PCNE recommends the

utilization of standard pharmaceutical care terms in European

countries.8,25,26 Detailed classification of data is shown in

Table S1 with subcategories and frequencies. One DRP may

have more than one cause and may lead to the proposition

of more than one intervention.

Definitions A problem is defined as “the expected or unexpected event

or circumstance that is, or might be wrong, in therapy

with drugs”.8 As per definition, both manifest and possible

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problems are included in this study. Problems of a tech-

nical nature (logistic, computer error, etc.) are specified

accordingly.

The cause is defined as “the action (or lack of action) that

leads up to the occurrence of a potential or real problem”.8

The intervention is the proposed measures to be taken

to overcome the cause of the problem by the pharmacist to

prevent or solve a problem. The proposed course of action

is deemed to improve and/or maintain patients’ health and

well-being.

Acceptance is defined as the acceptance status of the

pharmacist intervention proposals evaluated by physicians.

statistical analysis The normality of the data was analyzed using the

Kolmogorov–Smirnov test. Continuous data were described

by mean ± standard error of mean. Categorical data were

described in terms of frequencies. Correlation between the

number of DRPs and total medications per order was assessed

using Pearson’s correlation test. The number of DRPs in

orders according to age and gender and the absence or pres-

ence of renal impairment and polypharmacy were analyzed

using Student’s t-test. Data were analyzed using SPSS ver-

sion 25.0 (IBM SPSS Statistics for Windows, Version 25.0;

IBM Corp., Armonk, NY, USA). A P-value #0.05 was

considered significant.

ethical considerations This study was approved by the Ethics Committee for

Clinical Research of Faculty of Medicine at Ege University

(Date: October 2, 2018; No: 18-10/4). All patients or their

substitute decision maker gave written informed consent for

their participation.

Results The pharmacists’ reports for 200 medication orders of 91

patients were analyzed. A total of 55 of these patients were

admitted to the hospital for two to six consecutive weeks,

and seven patients were readmitted two to three times within

6 months after discharge. Characteristics of the patients are

presented in Table 1.

Pharmacists detected 329 possible DRPs in 156 orders

and no problem was detected in 44 orders. The PCNE cat-

egories of possible DRPs and their frequencies are shown

in Figure 1. The number of medications and DRPs per order

was not different across different age groups, genders, or

in the absence or presence of renal impairment (Table 1).

There was a significant weak positive correlation between

the number of total drugs used and the number of DRPs

per order (P,0.05, r=0.2819; Pearson’s correlation test).

Polypharmacy, described as using five or more drugs, was

present in 175 (87.5%) orders. The number of DRPs was

higher when polypharmacy was present (P,0.05; Table 1).

One DRP may have had more than one cause that led to

the recommendation of more than one intervention. A com-

plete list of combinations of causes and interventions for

each DRP is presented in Table S1. In brief, most causes

of possible DRPs were drug interactions (including IV

incompatibilities), inadequate monitoring, and a high drug

dose (Table 2).

A total of 329 interventions were proposed and/or dis-

cussed by pharmacists – 282 (85.71%) of these interventions

were proposed to the prescribers, and on 47 (14.28%) occa-

sions, the prescriber was only informed, or the intervention

was discussed with the prescriber. The most frequently

recommended intervention was monitoring, which was fol-

lowed by stopping the drug and changing dosage or instruc-

tions for use (Figure 2). A full list of PCNE categories of

the interventions is presented in Table S1. The acceptance

rate of pharmacist interventions was 85.41% (n=281). Inter-

vention was accepted and fully implemented in 223 cases

(67.78%), partially implemented in 40 cases (12.16%),

Table 1 Characteristics of patients, number of medications, and DrPs

Medication (mean ± SEM)

DRP (mean ± SEM)

Patient’s age (n=200; 80.33±0.46)

8.17±0.23 1.58±0.098

65–79 years (n=78) 7.95±0.33 1.59±0.15

$80 years (n=122) 8.32±0.31 1.58±0.13

Patient’s gender

Male (n=69) 7.65±0.35 1.41±0.14

Female (n=131) 8.45±0.29 1.68±0.13

renal function

egFr .60 ml/min/1.73 m2 (n=84)

8.45±0.36 1.42±0.13

egFr #60 ml/min/1.73 m2 (n=83)

8.13±0.36 1.76±0.17

Unknowna (n=33) 7.58±0.44 1.58±0.23

number of medication per order

0–4 (n=25) 3.40±0.20 1.04±0.15

$5 (n=175) 8.86±0.21 1.66±0.11b

Notes: aUnknown at the time of medication review due to new admission of the patient and/or biochemistry results being incomplete at the time of interdisciplinary round. bP#0.05; student’s t-test (number of medications per order; 0–4 vs $5). Abbreviations: DrPs, drug-related problems; egFr, estimated glomerular filtration rate; SEM, standard error of mean.

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not implemented in 12 cases (3.65%), and implementation

status was not known in 6 cases (1.82%). Only 38 (11.55%)

of the proposed interventions were rejected by the physician

due to being not feasible (n=19, 5.78%), unknown reasons

(n=1, 0.3%), and other reasons (n=18, 5.47%), such as the

patient being closely monitored, prior recommendations of

another specialist (psychiatry/infectious disease/cardiology),

or patient record error in hospital information system leading

to misinformation but patient receiving the correct drug form/

dosage. The acceptance status of ten intervention proposals

(3.04%) was unknown due to the physician not making the

decision during rounds and referring the patient to other

physicians for further consultations. In one case, written

information was provided only to the physician. On account

of this study being performed in a teaching hospital, medical

students also participated in the routine rounds. Pharmacist

intervention proposals led to educational discussions on six

different cases and were noted as separate interventions.

Detailed acceptance rates with respect to intervention cat-

egory are presented in Figure 2.

During this study, 1,632 medications were ordered.

Medications were coded following the WHO–Anatomical

Therapeutic Chemical (WHO–ATC) classification. ATC

groups of the most ordered drugs were N (nervous system,

358), A (alimentary tract and metabolism, 314), C (cardio-

vascular system, 304), B (blood and blood-forming organs,

197), and J (anti-infectives for systemic use, 151) (Table 3).

The number of possible DRPs for each prescribed drug in

the geriatric ward was analyzed, and the ten medications

with overall highest DRP counts and the medications with

the highest DRP counts in each ATC class were determined

(Table 3).

Pantoprazole, enteral nutrition products, enoxaparin, furo-

semide, metoprolol, sertraline, quetiapine, insulin glargine,

Figure 1 PCne categories of possible drug-related problems and their frequencies. Abbreviations: PCne, Pharmaceutical Care network europe; DrPs, drug-related problems.

No problem

Not suitable strength

Wrong administration route Ty

pe o

f p os

si bl

e D

R P

Unnecessary drug treatment

Untreated symptom/indication

Effect not optimal

Adverse drug event possible

0 20 40 60

Percentage of possible DRPs (%) 80

Total counts

44

2

2

20

21

44

266

Table 2 PCne categories of most encountered causes of possible DrPs and their frequencies

PCNE code PCNE category Total counts (n, %)

C 1.4 Inappropriate combination of drugs or drugs and herbal medication (includes intravenous incompatibility) 132 (40.12%)

C 8.1 no or inappropriate outcome monitoring 47 (14.29%)

C 3.2 Drug dose too high 41 (12.46%)

C 1.2 Inappropriate drug (within guidelines but otherwise contraindicated) 30 (9.12%)

C 8.2.1 Patient education required 28 (8.51%)

C 6.6 Drug administered via wrong route 27 (8.21%)

C 1.6 no drug treatment in spite of existing indication 23 (6.99%)

C 2.1 Inappropriate drug form (for this patient) 23 (6.99%)

C 1.1 Inappropriate drug according to guidelines/formulary 22 (6.69%)

Abbreviations: PCne, Pharmaceutical Care network europe; DrPs, drug-related problems.

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Figure 2 PCne categories of interventions proposed by the pharmacist and their acceptance rates. Abbreviation: PCne, Pharmaceutical Care network europe.

Table 3 Total number of ordered medications, most frequently ordered medications, and medications with the highest number of possible DrPs in each ATC class

ATC class Number of ordered medications

Most frequently ordered medication (n, % in related ATC group)

Medications with highest DRP (possible) counts (n, % in related ATC group)

A 314 Pantoprazole (107, 34.08%) Pantoprazole (19, 6.05%)

B 197 enoxaparin (60, 30.46%) Enoxaparin (15, 4.93%)

C 304 Furosemide (57, 18.75%) Furosemide (15, 7.61%) Metoprolol (12, 6.09%)

D 34 silver sulfadiazine (10, 29.41%) –

g 44 Tamsulosin (19, 43.18%) silodosin (3, 6.82%)

h 53 levothyroxine (20, 37.74%) Methylprednisolone (13, 24.53%)

J 151 Ceftriaxone (26, 17.22%) Ciprofloxacin (11, 7.28%)

l 10 Methotrexate (2, 20.00%) Mycophenolate (3, 30.00%)

M 11 Allopurinol (3, 27.27%) Allopurinol (2, 18.18%) Colchicine (2, 18.18%)

n 358 sertraline (45, 12.57%) Quetiapine (41, 11.45%) Donepezil (27, 7.54%) Sertraline (19, 5.31%) Escitalopram (12, 3.35%)

P 2 Metronidazole (2, 100.00%) Metronidazole (1, 50.00%)

r 65 salbutamol + Ipratropium (26, 40.00%) Salbutamol + Ipratropium (11, 16.92%)

s 11 Brimonidine + Timolol (4, 36.36%) –

V 78 enteral nutrition (61, 78.21%) enteral nutrition (6, 7.69%)

Total 1,632

Note: Boldface medications are the 10 medications with overall highest possible DrP counts. Abbreviations: DrPs, drug-related problems; ATC, Anatomical Therapeutic Chemical.

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acetylsalicylic acid (ASA), and parenteral nutrition were the

most frequently prescribed medications in 200 orders among

elderly patients (Figure 3). Possible drug–drug, drug–herbal

medication, food–drug interactions, and intravenous incom-

patibilities related to these medications were represented as

a percentage of possible clinically significant interactions

encountered per total number of times prescribed (Figure 3).

Only 22 PIMs, according to the Beers criteria, STOPP/

START criteria, or latest clinical practice guidelines were

prescribed during the study period. PIMs ordered on more

than one occasion were ipratropium, lorazepam, haloperidol,

ASA, and dimenhydrinate (prescribed 3, 2, 2, 2, and 2 times,

respectively). Adverse events were deemed possible in

20 of these cases, 10 of which were due to inappropriate

combinations of drugs and excessively high dosages.

On two occasions, medication was regarded unnecessary

by the pharmacist. Intervention proposals to stop or change

drugs, monitor effects, or educate patients were accepted in

19 (86.36%) occasions (Table S1).

The appropriateness of the drug formulation for each

patient was also evaluated and coded following NFC

(EphMRA [The European Pharmaceutical Market Research

Association] New Form Code) classification. Only 23 drug

formulations were interpreted as inappropriate by phar-

macists. For the most part, swallowing difficulties among

patients or crushing or splitting of oral solid ordinary film-

coated tablets (ABC, n=15), oral solid retard film-coated

tablets (BBC, n=3), oral solid ordinary enteric-coated tablets

(ABD, n=2), and oral solid retard tablets (BAA, n=2) caused

the problem. Finally, as intramuscular injection is not a favor-

able route of administration in the elderly, prescription of a

parenteral ordinary IM ampoule (FMD) instead of an oral

pharmaceutical form led to intervention in one order. How-

ever, on 14 of these occasions, suitable drug formulation was

not available in the hospital pharmacy, and three occasions

resulted from an error in the hospital information system, and

the patient was administered the correct form of the drug.

Discussion This study found that pharmacists contribute to health care

provisions, as members of interdisciplinary geriatric teams

in Turkey, by proposing a large number of accepted inter-

ventions to a wide variety of DRPs, different classes, and

pharmaceutical forms of drugs.

Aging is associated with an increase in medication use

parallel to the increase in chronic diseases and geriatric

syndromes.3,7,27 Based on this paper’s findings, patients’

orders consisted of an average of 8.17 medications. This

paper supports previous studies reporting an average of

7.2–9 medications taken by patients daily.17,19,28,29 A slightly

high number (mean 11.4 drugs) was reported in a study in

Belgium.20

While pharmacotherapy contributes to a patient’s general

state of well-being, all medications also have a risk of adverse

or unwanted effects. Although the number of prescribed

drugs or possible DRPs was not different in patients with

renal impairment, pharmacists must focus on drug doses as

both aging and poor renal functions may alter drug metabo-

lism leading to untoward consequences and interactions.

The number of DRPs was not different in older patients

(65–79 years vs $80 years) in our study, which matches the

previous findings that age does not have a direct effect on

Figure 3 Most frequently ordered medications and possible interaction or incompatibility risk in function of their prescription frequency. (numbers above each bar represent total counts.)

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adverse drug events (ADEs).30 It is widely accepted that the

higher the number of drugs, the higher the number of DRPs,

and polypharmacy is a known risk factor in the development

of DRPs.2,3,6,7 In accordance, this study found a positive

correlation between the number of medications and DRPs.

Polypharmacy was present in most of the orders (87.5%), and

the DRP count was higher in the presence of polypharmacy.

DRPs have a significant impact on health, and ADEs

are an important component of DRPs. It is estimated that,

one in every ten elderly patients experience ADEs during

or leading to their hospital stay.31 In our study, in 71% of

the cases, ADE possibility was recognized as a problem.

The main cause of this possible problem was determined

as drug interactions (44.4%). This study’s results indicate

that geriatric patients’ orders must be reviewed by focus-

ing on drug interactions. Regardless of the problem type,

drug interactions were also the leading cause of problems

(40.1%) in all DRPs. Clinically significant interactions were

the main factor in pharmacist interventions in a geriatric day

unit and orthogeriatric wards in another study with rela-

tive compatibility to our results (21.1% and 30.4% of the

interventions, respectively).2 In another study conducted in

Turkey, inappropriate combination of drugs was accounted

as the reason for 29.5% of the overall DRPs in the general

internal medicine ward.11

A total of 329 interventions were recommended by the

pharmacist, and 85.4% of these interventions were accepted

by the treating physician in this study. Comparable accep-

tance rates were reported in a study focused on the imple-

mentation of ward-based pharmacy services in Belgium.17

The high acceptance rates indicate that, although clinical

pharmacy is a new concept in Turkey, the physicians in the

geriatric ward of the hospital is open to collaboration with

pharmacists. The most common interventions were moni-

toring drug therapy (monitoring ECG, serum electrolytes,

bleeding risk, vitals, anticholinergic side effects; 31%),

stopping drug use (20.1%), and changing dosage (14%) or

instructions for use (13.4%) in this study. Interestingly, the

most common interventions were cessation or dose alteration

of drugs in three studies, where an average of 9.6–11.5 medi-

cations was used,15,20,32 and monitoring drug therapy was the

second most prevalent intervention in one of them.15 Taken

these results into account, it may be assumed that, when the

number of drugs used by patients increases, pharmacists’ and

geriatricians’ efforts to simplify patients’ therapy outweigh

the need for monitoring.

According to the ATC classification system, drugs

affecting the nervous system (N), alimentary tract and

metabolism (A), cardiovascular system (C), and blood and

blood-forming organs (B) were the most frequently ordered

drugs. In a study from Brazil, N-, A-, and C-class drugs were

mostly prescribed for patients above 60 years.33 Likewise,

Recoche et al34 and Somers et al20 reported that C-, N-,

A-, and B-class drugs were the most frequently prescribed

drugs for frail elderly inpatients. Pantoprazole was the most

frequently ordered medication in this study (53.5% of total

orders). The reason for this high rate may be due to concurrent

enoxaparin, ASA, or sertraline use (30%, 16%, and 22.5% of

total orders) and the presence of conditions that can increase

the risk of bleeding. Accordingly, monitoring bleeding risk

was proposed by the pharmacist as an intervention when the

medications were prescribed.

Delirium incidences increase in patients over 65 years,

and in selected patients, haloperidol or second-generation

antipsychotics can be used to reduce agitation and

hyperactivity.35,36 In this study, quetiapine was ranked first

among medications with the highest possible DRP count

among nervous system drugs and was also found to almost

always (97.5%) cause possible drug interactions when

prescribed. As polypharmacy is a factor known to increase

mortality in patients with delirium,36 pharmacists should

control quetiapine orders for interactions and other DRPs.

Depression is common in older individuals and selective

serotonin reuptake inhibitors (SSRIs) are prescribed as

first-line treatment, though drug interactions are common

in patients with polypharmacy.37 Consistent with this find-

ing, sertraline was the overall sixth most prescribed drug in

this study. This drug was also among medications with the

highest possible DRP count and deemed to cause possible

drug interaction 31% of the times that it was prescribed. This

paper recommends that particular attention be paid to the

prescription of SSRIs in elderly patients when polypharmacy

is present. The most noted interaction with either quetiapine

or sertraline was the possibility of QTc prolongation in this

study. The categories of intervention recommendations

(monitoring serum electrolytes and ECG, or stopping or

reducing the dosage of the drug) were similar to those of

another study investigating drug-induced QT prolongation.38

Therefore, this paper suggests that pharmacists perform a

thorough medication review and recommends monitoring

ECG in patients using drugs with known risk of QT interval

prolongation taking additional risk factors such as advanced

age, gender, and electrolyte derangements into consideration

in elderly population.38

Potentially inappropriate prescribing is highly preva-

lent among geriatric patients.3 Di Giorgio et al39 reported

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that 49% and 27% of the geriatric patients had at least one

PIM during hospitalization period according to Beers and

STOPP criteria, respectively. In a study from Turkey, PIMs

were found in 19.5% of elderly patients admitted to internal

medicine ward.19 Conversely, only 22 PIMs were present

in 21 orders (10.5%) in this study. The reason for this low

prevalence may be due to patients’ treatment being under-

taken by geriatric specialists. Indeed, a study reported that

patients discharged from geriatric wards were found to have

lower prevalence of PIMs compared to those discharged

from an internal medicine ward.28 The acceptance rates of

intervention recommendations for resolving PIMs (patient

counseling, dosage change, monitoring therapy, and stop-

ping drug) were high (86.36%) in this study. Pharmacists in

Turkey should ensure that their knowledge is up-to-date and

follow current guidelines to ensure that they make accurate

and valid contributions to geriatric patient care as members

of the interdisciplinary team.

Swallowing difficulties have particular importance in

clinical pharmacy practice as oral solid pharmaceutical forms

are usually needed to be split or crushed. As a result, the

pharmacokinetics and stability of these drugs may alter

causing ADEs or undertreatment. The need for giving the

drugs via nasogastric tube is further complicated, as drugs

can cause clogging of the feeding tube or drug-enteral nutri-

tion interactions.40 According to this study’s results, only 23

drug formulations’ pharmaceutical form was deemed inap-

propriate by pharmacists. Swallowing difficulties and the need

for dosage reduction resulted in crushing or splitting of oral

solid ordinary/retard film-/enteric-coated tablets and oral solid

retard tablets in 22 cases. Recommended pharmaceutical form

change could not be accepted in 14 of these cases because the

suitable form was not available in the hospital formulary. This

paper suggests that hospital pharmacists’ awareness of this

geriatric syndrome should be extended in Turkey. Consider-

ing the needs of special populations, more than one choice

of pharmaceutical form (oral liquid, oral immediate release,

or patch formulations) for each highly prescribed active

ingredient should be made available to hospital pharmacies.

Finally, making comparisons with other studies was dif-

ficult, mainly because most of the previous studies did not

report DRPs, their causes, or recommended intervention

categories in accordance with standardized classification

systems. This study supports the use of the PCNE classifica-

tion systems for documenting clinical pharmacy activities,

both for standard record keeping and facilitating scientific

data sharing and comparison across Turkey and Europe.

Limitations In this study, pharmacist interventions were evaluated retro-

spectively. The pharmacists assessed and defined the DRPs

prior to ward rounds. Therefore, DRPs were not classified

as possible or actual (manifest) problems. Although the

acceptance status of the recommended interventions was

recorded, the outcomes were not determined with follow-up

evaluations due to time and resource restrictions. As par-

ticipation of pharmacists in geriatric assessment teams is a

fairly new practice in Turkey, this study was conducted in

one hospital. This setting resulted in a relatively small sample

size and may be considered another limitation of the study.

Based on this study’s findings, it may be more beneficial to

reassess frequently encountered DRPs and associated drugs

in subgroups of patients with the outcome analysis of phar-

macist interventions.

Conclusion The present study highlights the ways in which clinical

pharmacy services can be instrumental in a geriatric ward.

Pharmacists must be vigilant about ADEs and drug interac-

tions as these issues are the most frequently encountered

problems and the most common causes of problems,

respectively. This study found that pharmacists may

need to suggest monitoring drug therapy, stopping drugs,

and changing dosages or instructions for use frequently.

Raising awareness of the lack of available pharmaceutical

form choices for highly prescribed medications in hospital

formularies can reduce the problems associated with

splitting or crushing of oral solid pharmaceutical forms.

Polypharmacy, alterations in pharmacokinetics and phar-

macodynamics of drugs, is largely unavoidable in many

geriatric inpatients. The participation of pharmacists in

geriatric assessment teams can assist geriatric specialists

in rational therapeutic decision-making and improving care

quality. The findings of this study suggest that advanced

collaboration among geriatricians and pharmacists as

well as other health care professionals is possible and

preferable in an interdisciplinary geriatric team in Turkey.

Pharmacists’ recommendations on a wide variety of DRPs

and different classes and pharmaceutical forms of drugs

have been accepted by physicians. The results may also

be used to extrapolate and construct a feasible standard

operating model that defines both the role of the pharmacist

and the pharmacist’s relationship with other health care

professionals, leading to the effective use of resources in

the Turkish health care system.

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Acknowledgments The authors would like to thank Prof Fehmi Akçiçek, MD

(Head of the Department), for permitting them to conduct this

study in the Division of Geriatrics, Department of Internal

Medicine, Faculty of Medicine, Ege University, Izmir,

Turkey. The authors would also like to thank Prof Fulden

Saraç, MD, and Assoc Prof Sevnaz Şahin, MD, for their kind

help and encouragement.

Disclosure The authors report no conflicts of interest in this work.

References 1. United Nations World Population Prospects. The 2017 revision. Key

findings and advance tables. 2017. Available from: https://esa.un.org/ unpd/wpp/publications/files/wpp2017_keyfindings.pdf. Accessed January 5, 2019.

2. Cortejoso L, Dietz RA, Hofmann G, Gosch M, Sattler A. Impact of pharmacist interventions in older patients: a prospective study in a tertiary hospital in Germany. Clin Interv Aging. 2016;11:1343–1350. doi:10.2147/CIA.S109048

3. Gallagher P, Barry P, O’Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther. 2007;32(2):113–121. doi:10.1111/j. 1365-2710.2007.00793.x

4. Mangin D, Bahat G, Golomb BA, et al. International Group for Reduc- ing Inappropriate Medication Use & Polypharmacy (IGRIMUP): position statement and 10 recommendations for action. Drugs Aging. 2018;35(7):575–587. doi:10.1007/s40266-018-0554-2

5. Shim YW, Chua SS, Wong HC, Alwi S. Collaborative intervention between pharmacists and physicians on elderly patients: a randomized controlled trial. Ther Clin Risk Manag. 2018;14:1115–1125. doi:10.2147/ TCRM.S146218

6. Brahma DK, Wahlang JB, Marak MD, Ch Sangma M. Adverse drug reactions in the elderly. J Pharmacol Pharmacother. 2013;4(2):91–94. doi:10.4103/0976-500X.110872

7. Suggett E, Marriott J. Risk factors associated with the requirement for pharmaceutical intervention in the hospital setting: a systematic review of the literature. Drugs Real World Outcomes. 2016;3(3): 241–263. doi:10.1007/s40801-016-0083-4

8. Pharmaceutical Care Network Europe Foundation. The PCNE clas- sification V 8.02, 2018. Available from: https://www.ismp.org/sites/ default/files/attachments/2018-10/highAlert2018new-Oct2018-v1.pdf. Accessed January 5, 2019.

9. Gammie T, Vogler S, Babar ZU. Economic evaluation of hospital and community pharmacy services. Ann Pharmacother. 2017;51(1):54–65. doi:10.1177/1060028016667741

10. Westerlund T, Marklund B. Assessment of the clinical and economic outcomes of pharmacy interventions in drug-related problems. J Clin Pharm Ther. 2009;34(3):319–327. doi:10.1111/j.1365-2710.2008.01017.x

11. Abunahlah N, Elawaisi A, Velibeyoglu FM, Sancar M. Drug related problems identified by clinical pharmacist at the Internal Medicine Ward in Turkey. Int J Clin Pharm. 2018;40(2):360–367. doi:10.1007/ s11096-017-0585-5

12. Apikoglu-Rabus S, Yesilyaprak G, Izzettin FV. Drug-related problems and pharmacist interventions in a cohort of patients with asthma and chronic obstructive pulmonary disease. Respir Med. 2016;120:109–115. doi:10.1016/j.rmed.2016.10.006

13. Bosnak AS, Birand N, Diker O, Abdi A, Basgut B. The role of the pharmacist in the multidisciplinary approach to the prevention and resolution of drug-related problems in cancer chemotherapy. J Oncol Pharm Pract. 2018. doi:10.1177/1078155218786048

14. Demirkan K, Bayraktar-Ekincioglu A, Gulhan-Halil M, Abbasoglu O. Assessment of drug administration via feeding tube and the knowledge of health-care professionals in a university hospital. Eur J Clin Nutr. 2017;71(2):164–168. doi:10.1038/ejcn.2016.147

15. Halvorsen KH, Ruths S, Granas AG, Viktil KK. Multidisciplinary intervention to identify and resolve drug-related problems in Norwe- gian nursing homes. Scand J Prim Health Care. 2010;28(2):82–88. doi:10.3109/02813431003765455

16. Korcegez EI, Sancar M, Demirkan K. Effect of a pharmacist-led pro- gram on improving outcomes in patients with type 2 diabetes mellitus from northern cyprus: a randomized controlled trial. J Manag Care Spec Pharm. 2017;23(5):573–582. doi:10.18553/jmcp.2017.23.5.573

17. Spinewine A, Dhillon S, Mallet L, Tulkens PM, Wilmotte L, Swine C. Implementation of ward-based clinical pharmacy services in Belgium– description of the impact on a geriatric unit. Ann Pharmacother. 2006; 40(4):720–728. doi:10.1345/aph.1G515

18. Wilson S, Wahler R, Brown J, Doloresco F, Monte SV. Impact of pharma- cist intervention on clinical outcomes in the palliative care setting. Am J Hosp Palliat Care. 2011;28(5):316–320. doi:10.1177/1049909110391080

19. Selcuk A, Sancar M, Okuyan B, Demirtunc R, Izzettin FV. The potential role of clinical pharmacists in elderly patients during hospital admission. Pharmazie. 2015;70(8):559–562.

20. Somers A, Robays H, De Paepe P, Van Maele G, Perehudoff K, Petrovic M. Evaluation of clinical pharmacist recommendations in the geriatric ward of a Belgian university hospital. Clin Interv Aging. 2013; 8:703–709. doi:10.2147/CIA.S42162

21. Van der Linden L, Hias J, Dreessen L, et al. Medication review versus usual care to improve drug therapies in older inpatients not admitted to geriatric wards: a quasi-experimental study (RASP-IGCT). BMC Geriatr. 2018;18(1):155. doi:10.1186/s12877-018-0843-y

22. LA U, Arun M, Ege M, et al. Media Pharma İnteraktif İlaç Bilgi Kaynağı 2018. In: Ustunes L, editor GEMAŞ Genel Mühendislik Mekanik Sanayi ve Ticaret A.Ş. İzmir, Turkey; 2018.

23. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for poten- tially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–2246. doi:10.1111/jgs.13702

24. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2): 213–218. doi:10.1093/ageing/afu145

25. Allemann SS, van Mil JW, Botermann L, Berger K, Griese N, Hersberger KE. Pharmaceutical care: the PCNE definition 2013. Int J Clin Pharm. 2014;36(3):544–555. doi:10.1007/s11096-014-9933-x

26. van Mil JW, Westerlund LO, Hersberger KE, Schaefer MA. Drug- related problem classification systems. Ann Pharmacother. 2004;38(5): 859–867. doi:10.1345/aph.1D182

27. Baijens LW, Clave P, Cras P, et al. European Society for Swallowing Disorders – European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome. Clin Interv Aging. 2016;11:1403–1428. doi:10.2147/CIA.S107750

28. Bo M, Gibello M, Brunetti E, et al. Prevalence and predictors of inap- propriate prescribing according to the screening tool of older people’s prescriptions and screening tool to alert to right treatment version 2 criteria in older patients discharged from geriatric and internal medicine wards: a prospective observational multicenter study. Geriatr Gerontol Int. 2019;19(1):5–11.

29. Piau A, Huet Y, Gallini A, Andre L, Vellas B, Nourhashemi F. Opti- mization of drug therapy in elderly individuals admitted to a geriatric unit. Clin Interv Aging. 2017;12:1691–1696. doi:10.2147/CIA.S132309

30. Gurwitz JH, Avorn J. The ambiguous relation between aging and adverse drug reactions. Ann Intern Med. 1991;114(11):956–966.

31. Alhawassi TM, Krass I, Bajorek BV, Pont LG. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging. 2014;9:2079–2086. doi:10.2147/CIA.S71178

Clinical Interventions in Aging 2019:14submit your manuscript | www.dovepress.com

Dovepress

Dovepress

596

ertuna et al

32. Poudel A, Peel NM, Mitchell CA, Gray LC, Nissen LM, Hubbard RE. Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities. Clin Interv Aging. 2015;10: 1043–1051. doi:10.2147/CIA.S84402

33. Castilho ECD, Reis AMM, Borges TL, Siqueira LDC, Miasso AI. Potential drug-drug interactions and polypharmacy in institutionalized elderly patients in a public hospital in Brazil. J Psychiatr Ment Health Nurs. 2018;25(1):3–13.

34. Recoche I, Lebaudy C, Cool C, et al. Potentially inappropriate pre- scribing in a population of frail elderly people. Int J Clin Pharm. 2017;39(1):113–119. doi:10.1007/s11096-016-0406-2

35. Kukreja D, Gunther U, Popp J. Delirium in the elderly: current prob- lems with increasing geriatric age. Indian J Med Res. 2015;142(6): 655–662. doi:10.4103/0971-5916.174546

36. Tosun Tasar P, Sahin S, Akcam NO, et al. Delirium is associated with increased mortality in the geriatric population. Int J Psychiatry Clin Pract. 2018;22(3):200–205. doi:10.1080/13651501.2017.1406955

37. Kok RM, Reynolds CF 3rd. Management of depression in older adults: A Review. JAMA. 2017;317(20):2114–2122. doi:10.1001/jama. 2017.5706

38. Buss VH, Lee K, Naunton M, Peterson GM, Kosari S. Identification of patients at-risk of QT interval prolongation during medication reviews: a missed opportunity? J Clin Med. 2018;7:12. doi:10.3390/jcm7120533

39. Di Giorgio C, Provenzani A, Polidori P. Potentially inappropriate drug prescribing in elderly hospitalized patients: an analysis and comparison of explicit criteria. Int J Clin Pharm. 2016;38(2):462–468. doi:10.1007/ s11096-016-0284-7

40. Boullata JI, Carrera AL, Harvey L, et al. ASPEN safe practices for enteral nutrition therapy [formula: see text]. JPEN J Parenter Enteral Nutr. 2017;41(1):15–103. doi:10.1177/0148607116673053

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Supplementary material

Table S1 Types and causes of problems, proposed interventions, and acceptance status for proposed interventions

Cause Intervention Acceptance

Problem: none (n=44)

Problem: effect of drug treatment not optimal (n=20)

Inappropriate combination of drugs* (n=6) Drug changed (n=1) Fully accepted (n=1)

Dosage changed (n=1) Accepted; implementation unknown (n=1)

Monitoring required (n=4) Fully accepted (n=2)

not accepted: not feasible (n=1)

not accepted: other (n=1)

Inappropriate combination of drugs* + inappropriate timing of administration and/or dosing intervals (n=2)

Instructions for use changed (n=2) Fully accepted (n=1)

Partially accepted (n=1)

Inappropriate combination of drugs* + patient education required (n=5)

Patient (drug) counseling (n=1) Fully accepted (n=1)

Patient (drug) counseling + instructions for use changed (n=3)

Fully accepted (n=3)

spoken to family member/caregiver (n=1) Fully accepted (n=1)

Inappropriate drug form (n=1) Drug changed (n=1) Fully accepted (n=1)

Drug dose too low (n=1) Dosage changed (n=1) Fully accepted (n=1)

Drug dose too low + patient education required (n=1) Patient (drug) counseling (n=1) Fully accepted (n=1)

Dosage regimen not frequent enough (n=1) educational discussion started during routine rounds (n=1)

Fully accepted (n=1)

Wrong drug administered (n=1) Drug changed (n=1) Partially accepted (n=1)

Patient stores drug inappropriately + patient education required (n=1)

Patient (drug) counseling (n=1) Fully accepted (n=1)

Addition of new drug might be needed due to microbial resistance (n=1)

new drug started (n=1) Fully accepted (n=1)

Problem: effect of drug treatment not optimal + adverse drug event (possibly) occurring (n=24)

Inappropriate combination of drugs* (n=2) Monitoring required (n=1) Partially accepted (n=1)

Drug stopped (n=1) Partially accepted (n=1)

Drug administered via wrong route (n=22) Instructions for use changed (n=22) Fully accepted (n=22)

Problem: untreated symptoms or indication (n=20)

no drug treatment in spite of existing indication (n=20) new drug started (n=20) Fully accepted (n=9)

Partially accepted (n=2)

not accepted: not feasible (n=5)

not accepted: other (n=4)

Problem: untreated symptoms or indication + adverse drug event (possibly) occurring (n=1)

Inappropriate combination of drugs* + no drug treatment in spite of existing indication (n=1)

new drug started (n=1) Partially accepted (n=1)

Problem: adverse drug event (possibly) occurring (n=240)

Inappropriate drug according to guidelines/formulary (n=10) Drug stopped (n=10) Fully accepted (n=4)

Partially accepted (n=2)

Accepted; not implemented (n=1)

not accepted: other (n=2)

Acceptance status unknown (n=1)

(Continued)

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Table S1 (Continued)

Cause Intervention Acceptance

Inappropriate drug according to guidelines/ formulary + inappropriate combination of drugs (n=5)

Drug stopped (n=2) Partially accepted (n=2)

Drug stopped + monitoring required (n=2)

Fully accepted (n=1)

Partially accepted (n=1)

Monitoring required (n=1) Fully accepted (n=1)

Inappropriate drug according to guidelines/formulary + drug dose too high (n=5)

Dosage changed (n=2) Partially accepted (n=2)

Drug stopped (n=2) Fully accepted (n=1)

Partially accepted (n=1)

Monitoring required (n=1) Fully accepted (n=1)

Inappropriate drug (within guidelines but otherwise contraindicated) (n=23)

Drug changed (n=2) Fully accepted (n=1)

Acceptance status unknown (n=1)

Dosage changed (n=6) Fully accepted (n=2)

not accepted: not feasible (n=4)

Instructions for use changed (n=2) Fully accepted (n=2)

Drug stopped (n=10) Fully accepted (n=4)

Partially accepted (n=2)

not accepted: not feasible (n=2)

not accepted: other (n=1)

Acceptance status unknown (n=1)

Monitoring required (n=3) Fully accepted (n=3)

Inappropriate drug (within guidelines but otherwise contraindicated) + drug dose too high (n=4)

Dosage changed (n=3) Fully accepted (n=3)

Drug stopped (n=1) Partially accepted (n=1)

Inappropriate drug (within guidelines but otherwise contraindicated) + drug dose too high + no or inappropriate outcome monitoring (n=1)

Dosage changed + monitoring required (n=1)

Fully accepted (n=1)

Inappropriate drug (within guidelines but otherwise contraindicated) + dosage regimen too frequent (n=1)

Drug stopped (n=1) Fully accepted (n=1)

Inappropriate drug (within guidelines but otherwise contraindicated) + no or inappropriate outcome monitoring (n=1)

Monitoring required (n=1) Fully accepted (n=1)

Inappropriate combination of drugs* (n=67) Written information provided only (n=1) Fully accepted (n=1)

Drug changed (n=4) Fully accepted (n=1)

Partially accepted (n=1)

not accepted: not feasible (n=1)

Acceptance status unknown (n=1)

Drug changed + monitoring required (n=2)

Partially accepted (n=1)

not accepted: not feasible (n=1)

Dosage changed (n=3) Fully accepted (n=2)

not accepted: other (n=1)

Instructions for use changed (n=2) Fully accepted (n=1)

not accepted: not feasible (n=1)

Drug stopped (n=11) Fully accepted (n=3)

Partially accepted (n=5)

not accepted: not feasible (n=1)

not accepted: other (n=2)

Monitoring required (n=44) Fully accepted (n=42)

not accepted: other (n=1)

not accepted: unknown reason (n=1)

(Continued)

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Table S1 (Continued)

Cause Intervention Acceptance

Inappropriate combination of drugs* + too many drugs prescribed for indication (n=1)

Drug stopped + monitoring required (n=1)

Partially accepted (n=1)

Inappropriate combination of drugs* + too many drugs prescribed for indication + no or inappropriate outcome monitoring (n=2)

Drug stopped + monitoring required (n=1)

Partially accepted (n=1)

Monitoring required (n=1) Fully accepted (n=1)

Inappropriate combination of drugs* + drug dose too high (n=1) Dosage changed (n=1) Fully accepted (n=1)

Inappropriate combination of drugs* + no or inappropriate outcome monitoring (n=27)

Drug changed + monitoring required (n=1)

Fully accepted (n=1)

Drug stopped + monitoring required (n=5)

Fully accepted (n=2)

Partially accepted (n=3)

Monitoring required (n=21) Fully accepted (n=21)

Inappropriate combination of drugs* + patient education required (n=11)

Patient (drug) counseling (n=6) Fully accepted (n=4)

Accepted; implementation unknown (n=1)

Acceptance status unknown (n=1)

spoken to family member/caregiver (n=5) Fully accepted (n=5)

Inappropriate duplication of therapeutic group or active ingredient (n=1)

Drug stopped (n=1) not accepted: not feasible (n=1)

Inappropriate duplication of therapeutic group or active ingredient + too many drugs prescribed for indication (n=1)

Drug stopped (n=1) Partially accepted (n=1)

Inappropriate duplication of therapeutic group or active ingredient + drug dose too high (n=1)

Drug stopped (n=1) Fully accepted (n=1)

no drug treatment in spite of existing indication (n=2) new drug started (n=2) Fully accepted (n=1)

not accepted: not feasible (n=1)

Inappropriate drug form (n=19) Drug changed (n=2) Fully accepted (n=1)

not accepted: other (n=1)

Formulation changed (n=13) Fully accepted (n=1)

Partially accepted (n=1)

Accepted; not implemented (n=7)

Accepted; implementation unknown (n=3)

Acceptance status unknown (n=1)

Instructions for use changed (n=4) Fully accepted (n=2)

not accepted: not feasible (n=1)

Acceptance status unknown (n=1)

Inappropriate drug form + prescribed drug not available (n=1) Instructions for use changed (n=1) Accepted; not implemented (n=1)

Drug dose too low (n=2) Dosage changed (n=1) Fully accepted (n=1)

Dosage changed + new drug started (n=1)

Acceptance status unknown (n=1)

Drug dose too high (n=26) Dosage changed (n=22) Fully accepted (n=14)

Partially accepted (n=6)

not accepted: other (n=1)

Acceptance status unknown (n=1)

Instructions for use changed (n=1) Fully accepted (n=1)

new drug started (n=1) Fully accepted (n=1)

Monitoring required (n=2) Fully accepted (n=2)

Drug dose too high + no or inappropriate outcome monitoring (n=1)

Drug stopped + monitoring required (n=1)

Fully accepted (n=1)

(Continued)

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Table S1 (Continued)

Cause Intervention Acceptance

Dosage regimen too frequent (n=3) Dosage changed (n=2) not accepted: other (n=2)

Instructions for use changed (n=1) Fully accepted (n=1)

Dose timing instructions wrong, unclear or missing + no or inappropriate outcome monitoring (n=1)

Monitoring required (n=1) Partially accepted (n=1)

Drug administered via wrong route (n=3) Instructions for use changed (n=3) Fully accepted (n=2)

Acceptance status unknown (n=1)

Patient uses/takes less drug than prescribed or does not take the drug at all + patient education required (n=2)

Patient (drug) counseling (n=1) Fully accepted (n=1)

spoken to family member/caregiver (n=1) Fully accepted (n=1)

Patient takes food that interacts + patient unable to use drug/ form as directed + patient education required (n=1)

Patient (drug) counseling (n=1) Fully accepted (n=1)

no or inappropriate outcome monitoring (n=11) Drug changed (n=1) Partially accepted (n=1)

educational discussion started during routine rounds (n=5)

Fully accepted (n=5)

Monitoring required (n=5) Fully accepted (n=5)

no or inappropriate outcome monitoring + patient education required (n=2)

Patient (drug) counseling (n=1) Fully accepted (n=1)

Patient (drug) counseling + monitoring required (n=1)

Fully accepted (n=1)

Patient education required (n=4) Patient (drug) counseling (n=4) Fully accepted (n=4)

Problem: adverse drug event (possibly) occurring + unnecessary drug-treatment (n=1)

Inappropriate combination of drugs* (n=1) Drug stopped (n=1) Fully accepted (n=1)

Problem: unnecessary drug treatment (n=19)

Inappropriate drug according to guidelines/ formulary + inappropriate combination of drugs* (n=1)

Drug stopped (n=1) Fully accepted (n=1)

Inappropriate drug according to guidelines/formulary + patient education required (n=1)

Patient (drug) counseling + drug stopped (n=1)

Fully accepted (n=1)

no indication for drug (n=3) Drug stopped (n=3) Fully accepted (n=3)

Inappropriate duplication of therapeutic group or active ingredient (n=6)

Instructions for use changed (n=1) not accepted: other (n=1)

Drug stopped (n=5) Fully accepted (n=3)

Accepted; implementation unknown (n=1)

not accepted: other (n=1)

Too many drugs prescribed for indication (n=4) Drug stopped (n=4) Fully accepted (n=4)

Drug dose too high (n=2) Dosage changed (n=2) Fully accepted (n=2)

Duration of treatment too long (n=2) Monitoring required (n=2) Fully accepted (n=2)

Problem: more suitable drug strength is available (n=2)

Inappropriate drug form (n=2) Formulation changed (n=2) Accepted; not implemented (n=2)

Problem: wrong administration route (n=2)

Drug administered via wrong route (n=2) Instructions for use changed (n=2) Fully accepted (n=2)

Note: *Includes intravenous incompatibility.