This study provides evidence for pharmacists eliciting medication histories to prepare medication charts at the earliest possible opportunity following a patient's presentation to the Emergency Department.

No abstract

Background Patients with cancer are managed across the whole healthcare spectrum. This complex system of interdependencies has high potential for errors to occur. This is a focus area for pharmacists, who possess the skillset to optimise cancer care across the health care system, identifying errors and other medication‐related problems (MRP). Aim The aim of this study was to identify and describe the impact of the pharmacist’s contribution in reducing cancer therapy‐related errors. Methods A search of English‐language publications in Embase, Medline and CINAHL was conducted. Databases were searched from 1 January 2010 until 29 September 2020 to identify all quantitative studies of a descriptive, observational or experimental design. Articles describing pharmacist‐led interventions in adults receiving one or more cancer therapies including oral chemotherapy, intravenous chemotherapy or immunotherapy compared to no intervention, usual care or a service delivered by another healthcare professional were included. Researchers screened articles to identify eligible studies, and then data were extracted using a standardised data collection sheet. Quality assessment was undertaken using the modified Cochrane and the Newcastle Ottawa risk of bias tools. Data were reported as number or percentage. Results Of 2292 papers identified, nine studies were eligible for inclusion in this review. Pharmacist interventions consistently showed an increased identification of medication errors and medication‐related problems. Pharmacist contributions in many of the included studies comprised medication reviews and monitoring, laboratory monitoring, adverse drug reaction and drug–drug interaction management, adherence monitoring and medication counselling. All studies showed pharmacist intervention in cancer care resulted in fewer errors compared to control arms. Error minimisation was described for parenteral and oral cancer therapies and also for supportive medications such as antiemetics. Conclusion Pharmacists reduce errors and potential patient harm in practice settings where cancer patients are treated. Pharmacists are an integral component of cancer care teams.

The nephrotoxicity of vancomycin was thought to be largely due to impurities in older formulations but recent evidence suggests that even with modern, purified formulations, vancomycin is nephrotoxic, especially at high doses. Recent recommendations advise using actual body weight for obese patients as the basis for dose size and because MICs for important pathogens are increasing, larger doses are frequently recommended nowadays. Therapeutic drug monitoring is important for ensuring appropriateness of dosing and limiting nephrotoxicity but the most recent recommendations advise monitoring should not be performed until steady-state has been achieved.In late 2009, a 54 year old, morbidly obese patient (approximately 150 kg) was referred to our Hospital because of increasing tiredness, abdominal cramps, ulcerated leg and per rectum bleeding. She had been discharged just 9 days earlier following an admission for pneumonia at which time she had been also been diagnosed with atrial fibrillation and an ischaemic finger for which enoxaparin and warfarin were started. Warfarin was withheld because the INR was 3.4 and haemoglobin concentration had fallen from 143 g l -1 to 103 g l -1 over the preceding 9 days. The provisional diagnosis was a retroperitoneal bleed for which a CT scan (using 100 ml of nonionic, low osmolar, Iopromide contrast) was ordered. This revealed a rectus sheath haematoma. She was taking many drugs including paracetamol/doxylamine/codeine, warfarin, verapamil, digoxin, hydroxychloroquine, prednisolone, nitrazepam, oxazepam, furosemide and nystatin.At presentation, serum creatinine was 65 mmol l -1 , temperature 38°C and CRP was 200 mg l -1 . Vancomycin was prescribed because of a history of MRSA. According to Hospital protocol (15 mg kg -1 actual body weight twice daily), 2 g twice daily was ordered and the plan was to administer for 7 days. At that time, the hospital protocol advised not to monitor if treatment was planned for <7 days. However one sample was taken 11 h after the first dose and was reported at 14.2 mg l -1 .The temperature did not settle and vancomycin (as the sole antibiotic) was continued for a total of 17 doses over 10 days (three doses were omitted due to failure of i.v. access). The serum creatinine concentration increased (by >50% over baseline) on days 9 (121 mmol l -1 ) and 10 (173 mmol l -1 ) at which time vancomycin was stopped. Serum creatinine peaked on day 15 (252 mmol l -1 ) (Figure 1) then slowly fell though it did not reach baseline, pre-admission concentrations even 6 months later. Serum vancomycin concentrations were checked 27 h after the last dose (54.8 mg l -1 ), 24 h later (46.2 mg l -1 ) and a further 48 h later (29.6 mg l -1 ). Vancomycin is primarily renally cleared and the relationship between creatinine clearance (CLcr) and vancomycin clearance is so good, it has been suggested monitoring is not needed because dose can be calculated from CLcr [1]. A recent wide-ranging US review [2] advises trough monitoring be performed at 'steady-state' (generally four d...