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ABSTRACT. Objective. To determine if combining standard drug concentrations with "smart-pump" technology reduces reported medication-infusion errors. Design. Preintervention and postintervention comparison of reported medication errors related to infusion therapies during the calendar years 2002 and 2003.Setting. A 242-bed university-affiliated tertiary pediatric hospital.Intervention. Change in continuous-medication-infusion process, comprising the adoption of (1) standard drug concentrations, (2) "smart" syringe pumps, and (3) human-engineered medication labels. Main Outcome Measures. Comparison of reported continuous-medication-infusion errors before and after the intervention.Results. The number of reported errors dropped by 73% for an absolute risk reduction of 3.1 to 0.8 per 1000 doses. Preparation errors that occurred in the pharmacy decreased from 0.66 to 0.16 per 1000 doses; the number of 10-fold errors in dosage decreased from 0.41 to 0.08 per 1000 doses.Conclusions. The use of standard drug concentrations, smart syringe pumps, and user-friendly labels reduces reported errors associated with continuous medication infusions. Standard drug concentrations can be chosen to allow most neonates to receive needed medications without concerns related to excess fluid administration. M edication errors are a major source of potential and actual harm in pediatric patients. [1][2][3] Pediatric patients are at greater risk for medication error than adult patients because of the need for weight-based dosing and individualized dose calculation for most medications. Effective communication about symptoms and elicitation of pertinent clinical findings is often difficult in children. 2,4 Medical complexity and the need for multiple medications places hospitalized children at an even greater risk; nowhere is this more evident than in intensive care units. [2][3][4][5] Continuous medication infusions are a category of medications delivered to hospitalized patients that often include "high-alert" medications. As defined by the Institute of Safe Medication Practice, highalert medications are drugs that bear a heightened risk of causing significant patient harm when used in error and may lead to devastating complications for patients. 6 The process of ordering, preparing, and administering continuous medication infusions offers several opportunities for error. 4,[7][8][9] Providing the correct weight-adjusted dose (at an acceptable rate, concentration, and volume) usually requires a multivariable calculation; moreover, a new calculation must be performed whenever the dose is changed. The need for individualized concentrations makes drip preparation a high-frequency and time-consuming task for the pharmacy. The appropriate information must be entered correctly into the pump initially and when changes are made.Several common practices influence the likelihood of continuous-medication-infusion errors. The "rule of 6" is a calculation aid that was developed originally to facilitate rapid dose calculation and drip preparation in ...

Influencing the various PPARs results in improved glucose, lipid, and weight management, with effects dependent on full or partial agonist activity at single or multiple receptors. Although the dual PPAR compounds have been associated with unacceptable toxicities, new PPAR agonist medications continue to be developed and investigated to discover a safe drug with benefits in multiple disease states.

Due to the complex nature of endogenous and exogenous hormone concentration, formation, and metabolism and assay complexity, the pharmacokinetics of estrogen are difficult to study. Oral estrogens have minimal systemic bioavailability (2% to 10%) due to gut and liver (first-pass) metabolism. High concentrations of estrone are achieved with oral administration, whereas higher concentrations of estradiol are generally achieved after percutaneous absorption. Although vaginal products (such as gel, rings, etc.) are administered locally, they achieve high serum concentrations. Estradiol and estrone concentrations and estradiol-to-estrone ratios vary with different estrogen therapies. Approximately 95% to 98% of estradiol is bound loosely to albumin or tightly to sex hormone binding globulin, the major binding protein. The terminal half lives for the different estrogen compounds (after oral or intravenous administration) vary from 1-12 hours. Some conversion rates have been calculated between estrogen and its metabolites. Smoking decreases achievable estrogen concentrations, and has a greater effect on oral products. Oral contraceptives have been found to decrease antipyrine clearance. In the one study evaluating conjugated estrogens, antipyrine clearance was not altered. Oral contraceptives have a variable effect on the elimination of medications. Acetaminophen clearance is increased, whereas clearance of some benzodiazepines, caffeine,and prednisolone is decreased. Phenytoin increases the metabolism of conjugated estrogens. The various estrogen products may produce different clinical effects based on composition. The metabolites (minor components) of conjugated estrogens have been found to have significant effects on lipid concentrations, uterine weight, liver generated compounds, and bone resorption. Because transdermal products bypass the first-pass effect, delayed or decreased effects on lipid profiles and liver generated compounds have been observed.

Fifteen percent of premenopausal women, 10-40% of postmenopausal women, and 10-25% of women receiving systemic hormone therapy experience urogenital atrophy. The most common symptoms are dryness, burning, pruritus, irritation, and dyspareunia. Estrogen loss, drugs, and chemical sensitivities are causes. Estrogen or hormone replacement therapy (ERT-HRT) is the treatment of choice in postmenopausal women. Dosages prescribed for menopause symptoms or to prevent osteoporosis (and, potentially, other conditions) can restore the vagina to premenopausal physiology and relieve symptoms. Concomitant progestins are necessary for women with an intact uterus to minimize or eliminate estrogen-induced endometrial cancer. Low-dosage oral and vaginal ERT can relieve urogenital atrophy but might not produce systemic effects. Progestins are not necessary with vaginal rings and vaginal tablets. If ERT is given only to treat urogenital atrophy, estrogen creams 1 or 2 times/week may prevent recurrence after symptoms are resolved. Progestins are not required for occasional estrogen cream use. Vaginal moisturizers provide longer relief by changing the fluid content of endothelium and lowering vaginal pH. Vaginal lubricants provide short-term relief. Women with contraindications to ERT-HRT could use lubricants for intercourse-related dryness or moisturizers for more continuous relief. The lay press promotes agrimony, black cohosh, chaste tree, dong quai, witch hazel, and phytoestrogens for vaginal dryness and dyspareunia; however, no evidence exists to support these specific claims. Pharmacists should be actively involved in identifying, preventing, and treating urogenital atrophy.