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Background Adherence to injectable disease-modifying drugs becomes an imperative to achieve a reduction in the number of relapses and delay disease symptoms in relapsing-remitting multiple sclerosis patients. From our service, we estimate patient adherence by an indirect method, in order to focus our work on patients with adherence problems. Purpose To find out the relationship between the indirectly-calculated adherence from the Pharmacy service, with the real one measured by a self-injection device (Rebismart) in Multiple Sclerosis patients with ongoing Rebif treatment. Materials and methods A personal interview was performed with all the 31 patients currently in treatment with Rebif (all doses) in our Hospital. Sex, age, time on treatment with injectable disease-modifying drugs and time on treatment with Rebif were recorded. Indirect adherence was calculated as units dispensed/units needed x 100, and direct adherence was obtained by reading the Rebismart auto-injector device. The two values were compared using Student’s t test for paired samples, and differences were measured by the intraclass correlation coefficient. Results An intraclass correlation coefficient of 0.75 was obtained, which means that indirect method may be suitable to estimate adherence in our patients cohort. However, the use of this electronic device allowed us to detect some very low-adherence cases, which had not been suspected in the interview. In one case 31.270 € was wasted in two years (the medicine was delivered but the patient never took it). Conclusions In our cohort of patients, indirectly measured adherence correlates well with the directly measured adherence. Thus, we can use this way of measuring the patient’s adherence in order to focus pharmacist effort on those cases that really need it. However, we cannot forget that low-adherence cases can be underestimated. No conflict of interest.

Background A recently introduced computerised physician order entry system (CPOES) in hospital and a primary care electronic record system help prescribing and provide information about patients' medicines. These tools should improve the reconciliation process and diminish potential errors associated with chronic medication. Purpose The aim of this study is to describe and analyse the discrepancies between chronic medication recorded on the electronic health record system and the prescription of this medication upon admission to hospital. Materials and methods From March through May 2011, information was collected about patients admitted older than 60 years with chronically-prescribed medication and an updated preadmission treatment file. The pharmacist compared the computerised prescriptions with the current chronic medication listed by the prescription program (e-Osabide). Chronic medication data were verified with the patient primary care electronic record system (GlobalClinic). If discrepancies were found the admission reports were checked to decide if they were justified. Unjustified discrepancies were reported and classified as reconciliation errors. Results Chronic treatment of 88 patients was analysed (average age: 73.3 years. 48 women, 40 men). 33 patients were admitted as emergencies (E), 26 to surgical wards (S) and 29 to medical wards (NS). The average number of chronically-prescribed medicines per patient prescribed at admission were 7.3 and 5.4, respectively. 32 unjustified discrepancies were found (26.1% of patients, 0.36 per patient). Classified by route of admission: E, 24.2% of patients (0.42/patient); S, 30.8% (0.38); NS, 24.1% (0.28). By reconciliation errors: dose/frequency incorrect (21), omission (6), added medicine (5). The acceptance of interventions made was 56.3% (18/32). Conclusions The integration of CPOES and the electronic healthcare record system makes the reconciliation process easier and reduces prescription errors. With recently introduced CPOES incomplete prescriptions are no longer a problem. However, preventable prescription errors associated with reconciliation occur due to not using the tools now available.

BackgroundLinezolid is an antibiotic used for the treatment of serious infections caused by gram positive bacteria. Although first approved for skin infections, its use includes empiric treatment of infections usually caused by linezolid sensitive bacteria.PurposeTo describe, analyse and optimise the use of linezolid in a university hospital. To study new susceptible optimisation points.Material and methodsThis was a retrospective observational study (February–March 2016). Patient demographics and treatment related data were obtained from electronic clinical records. All linezolid prescriptions were reviewed, carrying out and registering pharmacy interventions. The results were compared with evidence observed in published guidelines and the literature.Results53 patients treated with linezolid were found (66 years (30–95)), 60% were men. Average treatment duration was 10.4 days (median 8 days, treatments longer than 90 days excluded). Indications were: 30% skin infections, 22.6% peritonitis, 18.8% pneumonia, 7.5% prosthesis infections and 7.5% meningitis. 51% of cases were unlabelled indications. 26.4% were empiric treatments (<5 days), and 28.3% longer than 14 days (labelled treatment duration). Infectious diseases (32%) and critical care units (34%) were the most prescriber services. Microbiological samples were obtained in 90.6% of patients (39.5% Staphylococcus spp, 18.7% Enterococcus spp). Only gram negative bacteria were isolated in 6 patients (3 following treatment). 3 patients treated for more than 7 days had no samples. Adverse drug reactions did not lead to drug withdrawal in any patient. 7 patients (13%) developed thrombocytopenia (average 15.7 days of linezolid (5–35)), 2 anaemia and 1 liver enzyme elevations. 15 drug interactions were detected and followed clinically.ConclusionMost uses of linezolid in our hospital were according to the hospital protocols and were highly supported by bibliography and clinical evidence, although they were not authorised by the drug data file or FDA. The issues identified for future pharmacy interventions were intravenous to oral switch (although not registered, it was considered too long), and treatment de-escalation (microorganisms sensitive to other drugs were isolated without antibiotic change). Pharmacists have contributed in a multidisciplinary team to optimise linezolid use, especially in the detection of drug interactions, drug adverse effects and validation of prescriptions of linezolid, in each case considering infection and causal microorganism.No conflict of interest