5/3/2013

Drug Related Problems

Tommy Eriksson
Pharmacist, PhD, Professor in Clinical Pharmacy
Director MSc Pharmacy Program at Lund University,
Sweden

Relevance for focus on

Drug Related Problems (DRP)
If not properly selected and used medications can cause
problems with potential negative clinical consequences.
Clinical Pharmacy, Pharmaceutical Care and Medication
Therapy Management are all based on identifying, resolving
and preventing DRPs for the patient.
Pharmacists need basic skills for practice, development of
services, and research

5/3/2013

Teaching goals:
Highlight the importance of and methods to identify, solve
and prevent DRPs.
Present information available from medication
reconciliation, medication review, hospital charts and patient
interviews.
Present how the problems can be organised, prioritised,
and communicated for implementation by the patient and by
the health care team.
Help the participants to improve their own skills and
practice.

Learning objectives
After the workshop the participant should be able to:
Explain how DRPs can be used to document clinical
pharmacy services and research.
Discuss potential clinical consequences for DRPs.

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Outline of workshop, three parts

1. Presentation of background, definitions, classifications,
sources for information, and consequences of DRP as a
base for clinical pharmacy practice and research.
2. Semi-interactive assessment of importance of clinical
pharmacist recommendations.
Presentation of DRP from a clinical setting/publication
The audience asses importance and compare to actual
actions and expert group rating of importance
3. Presentation of how problems can be organised,
prioritised, and communicated for improvement by the
patient and the health care personal.
Experiences from the LIMM-model

Part 1
Presentation of background, definitions, classifications,
sources for information, and consequences of DRP as a
base for clinical pharmacy practice and research.

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Quality of care according to Donabedian

Best patient outcome to the lowest possible cost

Structure

Process

Outcome

How can pharmacist add value to this?

Practice & research!

Focus on problems related to medication

Pharmaceutical Care issues

Drug (Medication) Related Problems
Drug (Medication) Therapy Problems
Medicines Management Problems

Health care (structure, process)

Patient (outcome)
Base for practice and research

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Clinical pharmacy
Definition (European Society of Clinical Pharmacy)
"Clinical pharmacy is a health specialty, which describes the
activities and the services of the clinical pharmacist to develop
and promote the rational and appropriate use of medicinal
products and devices"

Includes:
Medication reviews
Educations
Ward stocks
Therapeutic Drug Monitoring etc.

Focus on activities of the professional (structure and

process)

Pharmaceutical care
Definition (Hepler & Strand. AJHP 1990; 47:533-43)
"The responsible provision of drug therapy for the purpose of
achieving definite outcomes that improve a patients quality of
life"

Involves three fundamental functions performed on

the behalf of the patients.
Identify potential and real DRPs
Solve real DRP
Prevent potential DRP

Focus on responsibility and patient benefit (outcome)

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Medicine Management
Definition (Keele University)
"Seeks to maximize health gain through the optimum use
of medicines. It encompasses all aspects of medicines
use, from the prescribing of medicines through the ways
in which medicines are taken or not taken by patients

Includes: (according to NHS)

Clinical Benefit and Cost efficiency in the use of drugs
Safe and Secured handling of drugs

Focus on patient and health-care quality (process)

Examples of Definition DRP

Cipolle et al.

PCNE.org

McGraw-Hill 2012

Version 6.2. Assessed 2012 Oct 19

An undesired patient
experience that involves
drug therapy and that
actually or potentially
interferes with the desired
patient outcome

An event or circumstance
involving drug therapy that
actually or potentially
interferes with desired
health outcomes.

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Classification; problems and causes for DRP

Cipolle et al.

PCNE

Need for additional

therapy
Unnecessary drug therapy
Wrong drug
Dosage too low
Adverse drug reaction
Dosage too high
Non-compliance

Problems

Treatment effectiveness
Adverse reactions
Treatment costs
Other

Causes

Drug selection
Drug form
Dose selection
Treatment duration
Drug use/administration
Logistics
Patient
Other

DRP- Classification systems

Van Mil et al. Ann Pharmacother 2004;38:859-67

5/3/2013

Optimal classification system,

According to Van Mil et al 2004

Based on clear definitions

One choice of coding only; in general & for each category.
Validated
Easy to use for research and clinical practice
Structured in a hierarchical manner
Clearly separate causes from problems
Have an intervention section
Focus on the process of pharmaceutical care and outcomes
of pharmacotherapy

Optimal classification system,

According to Van Mil et al 2004

No such system is available

Five of the identified systems are not based upon a
definition
Only 4 systems are hierarchically constructed
Some form of validation has been published for only 3
systems.
PCNE system (Version 4) comes closest
still some inconsistencies originated from its usability in
practice

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Relationship DRP, ME, ADR and ADE

Examples from publications

Sourses; identification of DRP

Patient/career
Prescribed
Dispenses
Consumed/compliance
Practical handling
Knowledge
Attitude

Health Care
Records

Diagnosis
Allergies/cave
Prescription
Dispensed
Notes
Tests; lab, ADL

Specific checklists
Symtom/problems

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Resources
Competent professionals, clinical pharmacists
Trained and experienced
Continnous education
Systematic approach
Team based, skills used optimal
Medication Reconciliation, Medication Review, patient
support (concordance)
Checklists and support
Documentation and Communication
Reporting
Responsibilities

Evidence; from process to outcomes

Outcomes
Process

Mortality

Morbidity Health
Care
contacts

Costs

DRP
Medication Errors
ADE ADR
Compliance
Appropriateness

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5/3/2013

Cochrane Effective Practice and

Organisation of Care Group, 150 reviews
Clinical pathways: effects on professional practice, patient outcomes,
length of stay and hospital costs
Discharge planning from hospital to home
Effect of outpatient pharmacists' non-dispensing roles on patient
outcomes and prescribing patterns
The effect of pharmacist-provided non-dispensing services on patient
outcomes, health service utilisation and costs in low- and middleincome countries
Hospital at home admission avoidance
Interventions for improving outcomes in patients with multi-morbidity
in primary care and community settings
Medication review in hospitalised patients to reduce morbidity and
mortality

Christensen M, Lundh A. Medication review in hospitalised

patients to reduce morbidity and mortality.
Cochrane Database of Systematic Reviews 2013, Febr 28

Authors conclusions
It is uncertain whether medication review reduces mortality
or hospital readmissions, but medication review seems to
reduce emergency department contacts.
However, the cost-effectiveness of this intervention is not
known and due to the uncertainty of the estimates of
mortality and readmissions and the short follow-up,
important treatment effects may have been overlooked.
Therefore, medication review should preferably be
undertaken in the context of clinical trials. High quality trials
with long follow-up are needed before medication review
should be implemented.

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Part 2. Semi-interactive session

Assessment of importance of clinical pharmacist
recommendations, 11 patient cases.
Based on patient DRP cases
Presentation of background and DRP
Ratings from the audience
Presentation of ratings from experts, and actions
performed by pharmacist and physician

Objective
To evaluate the quality of the clinical pharmacy
according to the LIMM-mode (Lund Integrated
Medicines Management) l, in terms of the
acceptance and clinical significance of the
recommendations made by clinical pharmacists.

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Methods

Classification
Type

Action taken by
pharmacist and physician

DRP
Assessment of
clinical relevance

Methods

DRP (Cipolle et al)

Recommendation by pharmacist
need for additional therapy
was;
drug therapy
Ranking according tounnecessary
Hatoum;
accepted and implemented,

wrong
drug
1. Adverse significance
accepted but not implemented
2. No significance dosage too low
(lack of time or
forgetfulness)
adverse
drug taken
reaction
Action
by
Classification
3. Somewhat significant
already implemented
by
the

dosage
too
high
pharmacist and physician
Type4. Significant
physician
5. Very significant non-compliance
not accepted.
6. Extremely significant
DRP

Assessment of
Accessed in clinical practice based
the LIMM-model in 2007
clinicalonrelevance
Random sample 132 of 800 patients
By two independent senior scientist physicians

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5/3/2013

Man 79 years

Id804

Diagnose

Myocardial infarction x 2, heart failure, diabetes, hiatus

hernia, claudiocatio intermittence, gout, Hip-replacement

Reason
Admission

Found on the floor in own home, layed there for a couple of

days, very weak

Description

Needs iv antibiotics.
GFR < 20 ml/min, recommendation cefuroxim 0,75 g x 1

Medication

Cefuroxim 0,75 g x 2 prescribed

Recommendation

Lower dose cefuroxim to 0,75 g x 1

Type DRP

High dose

Assessed
relevance

4,1.significant
Adverse significance , 2. No significance,

Action

Recommended + Accepted (lowered dose)

3. Somewhat significant, 4. Significant,

5. Very significant, 6. Extremely significant.

Woman 83 years

Id830

Diagnose

COPD?. Microscopic colitis (treated with budesonid extended

release tablets)

Reason
Admission

Cough, fever, Pneumonia suspected

Description

Doxycycline and Calcium tablet prescribed to be given

simultaneously. Complex-formation with decreased
absorption of doxycycline and risk of therapeutic failure

Medication

Doxycycline/calcium

Recommendation

Give medications separated by at least 2 hours

Type DRP

Wrong medication

Assessed
relevance

4,1.significant
Adverse significance , 2. No significance,

Action

5. Very significant,
Extremely(changed
significant.dose intervall)
Recommended
+ 6.
Accepted

3. Somewhat significant, 4. Significant,

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5/3/2013

Woman 85 years

Id557

Diagnose

Diabetes type 2, high blood pressure, kidney failure,

PCI/stent, and atrial fibrillation (1 y ago) (Ticlopedine)

Reason
Admission

Ticlopedine - toxic hepatitis

Description

Lactulose for encephalopathy 30 ml x 4 during one week.

Previously 30 ml x 2-3 for 2 weeks.
Problem loose stools and patient complaints about this

Medication

Lactulose

Recommendation

Lower dose to 30 ml x 2 + on demand

Type DRP

High dose

Assessed
relevance

3,
significant
1. somewhat
Adverse significance
, 2. No significance,

Action

Recommended, not accepted

3. Somewhat significant, 4. Significant,

5. Very significant, 6. Extremely significant.

Woman 85 years (2)

Id557

Diagnose

Diabetes type 2, high blood pressure, kidney failure,

PCI/stent, and atrial fibrillation (1y ago) (Ticlopedine)

Reason
Admission

Ticlopedine - toxic hepatitis

Description

Spironolaktone 100 mg 1x1; due to hypokalemia.

Kabiven (TPN-solution) prescribed. Interaction and risk of
hyperkalemia. S-Potassium 4.9 mmol/L

Medication

Kabiven/Spironolaktone

Recommendation

Delete spironolaktone temporarilly

Type DRP

Adverse drug reaction

Assessed
relevance

4,1.significant
Adverse significance , 2. No significance,

Action

3. Somewhat significant, 4. Significant,

5. Very significant,
Extremelybut
significant.
Recommended
+ 6.
accepted,
not performed

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Woman 50 years

Id 279

Diagnose

Asthma, epilepsy, movement handicapped and mentally

retarded due to traffic accident in the age of 10, impaired
cough reflex aspiration pnemonia x several, gastric
retention - atrophic gastritis? PEG (feeding tube)

Reason
Admission

Breathing problems, increased ep-seizure frequencies past 2

weeks, pneumonia?

Description

Cefuroxim inj prescribed after chest X-ray. CRP day 0;30

mg/L (no more values). Temp; 36.7 day 1, 36.1 day 2.
Cefuroxim 1.5 g x 3 prescribed on day 1

Medication

Cefuroxim injection

Recommendation

Change to oral antibiotics (recommended day 2)

Type DRP

Unnecessary drug therapy

Assessed
relevance

Adverse significance
1,1.adverse
significance, 2. No significance,

Action

Recommended+ Accepted (changed)

3. Somewhat significant, 4. Significant,

5. Very significant, 6. Extremely significant.

Man 70 years

Id 556

Diagnose

DVTx several, COPD, AF-warfarin, digoxin, Angina,

abstinence seizures, delirium (former alcoholic), lower back
pain.

Reason
Admission

syncope, falls (ortostatic)

Description

Tramadol 400 mg, and paracetamol 1500 daily without

enough effect

Medication

Tramadol

Recommendation

Add slow release morphine 10mgx2 and as needed and

delete tramadol

Type DRP

2, untreated indication

Assessed
relevance

4,1.significant
Adverse significance , 2. No significance,

Action

No

3. Somewhat significant, 4. Significant,

5. Very significant, 6. Extremely significant.

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Man 70 years (2)

Id 556

Diagnose

DVTx several, COPD, AF-warfarin, digoxin, angina,

abstinence seizures, delirium (former alcoholic), lower back
pain.

Reason
Admission

syncope, falls (ortostatic)

Description

Nitrazepam has long half-life, is potential inappropriate in

elderly, and un-suitable as sleeping medicine

Medication

Nitrazepam

Recommendation

Decrease nitrazepam slowly

Type DRP

3, wrong drug

Assessed
relevance

4,
1. significant
Adverse significance , 2. No significance,

Action

3. Somewhat significant, 4. Significant,

5. Very significant, 6. Extremely significant.
No

Man 70 years (3)

Id 556

Diagnose

DVTx several, COPD, AF-warfarin, digoxin, Angina,

abstinence seizures, delirium (former alcoholic), lower back
pain.

Reason
Admission

syncope, falls (ortostatic)

Description

Tavegyl prescribed continously without indication

Medication,

Tavegyl (clemastine)

Recommendation

Delete Tavegyl

Type DRP

2, unnessessary drug

Assessed
relevance

1. significant
Adverse significance , 2. No significance,
4,

Action

No

3. Somewhat significant, 4. Significant,

5. Very significant, 6. Extremely significant.

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5/3/2013

Woman 87 years

ID740

Diagnose

Renal failure (diabetic nephropathy), hypothyroidism,

diabetes type 2, AF-chronic (warfarin), CVI -91

Reason
Admission

Syncope / fall, increasing shortness of breath, swollen legs

Description

Admitted due to dizziness and fainting. Metoprolol can

cause these side effects and is newly prescribed (patient
associate the symptoms with the start of metoprolol)

Medication

Metoprolol SR tablet 25 mg

Type DRP

5, Adverse effect

Recommendation

Observe the connection and decide on further theraphy.

Assessed
Relevance

5,1.Very
significant
Adverse
significance , 2. No significance,

Action

Recommended + Accepted (deleted)

3. Somewhat significant, 4. Significant,

5. Very significant, 6. Extremely significant.

Woman 77 years

ID385

Diagnose

Ischemic heart disease, PCI-96, 97; hypertension; AF-chronic;

pacemaker; warfarin; Mb Meniere -92; trigeminal neuralgia
(Carbamazepine); restless legs syndrome, cholecystectomy, UTI x
several.

Reason
Admission

Dizziness, tiredness, swollen legs

Description

Interaction Carbamazepine warfarin (decreased warfarin effect) .

Carbamazepine dose decresed from 200 mg 2x2 to 1x2, risk of
increased effect of warfarin, INR=4,1.

Medication

Warfarin tabl 2,5 mg

Recommendation

Observe the problem, follow INR and consider decresing dose of

warfarin

Type DRP

5, adverse effect

Assessed
relevance

5,1.Very
significant
Adverse
significance , 2. No significance,
3. Somewhat significant, 4. Significant,
5. Very significant,
6. Extremely
significant.
Recommended+
Accepted
(information)

Action

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5/3/2013

Woman 77 years (2)

Diagnose

Ischemic heart disease, PCI-96, 97; hypertension; AF-chronic;

pacemaker; warfarin; Mb Meniere -92; trigeminal neuralgia
(Carbamazepine); restless legs syndrome, cholecystectomy, UTI x
several.

Reason
Admission

Dizziness, tiredness, swollen legs

Description

The patient is using nitroglycerin spray 1-2 as needed

according to interview. Not inserted in medication list in EHR

Medication

Nitroglycerine spray

Recommendation

Insert nitroglycerine spray in medication list in the EHR and

evaluate further need

Type DRP

1, need for additional therapy

Assessed
relevance

3,1.somewhat
significant
Adverse significance
, 2. No significance,

Action

5. Very significant,Accepted
6. Extremely
significant.
Recommended+
(Inserted)

3. Somewhat significant, 4. Significant,

Results
The clinical significance of 197 recommendations in 132
patients was assessed.
The physicians accepted and implemented 178 (90%) of the
clinical pharmacists recommendations.
Most of these recommendations, 170 (83%), were ranked 3
(somewhat significant) or higher.

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5/3/2013

Conclusion
This study provides further evidence of the quality of the
LIMM model and confirms that the inclusion of clinical
pharmacists in a multi-professional team can improve drug
therapy for inpatients.
The very high level of acceptance by the physicians of the
pharmacists recommendations further demonstrates the
effectiveness of the process.

Part 3
Presentation of how problems can be organised, prioritised,
and communicated for improvement by the patient and by
the health care team.
Experiences from the LIMM-model (Lund Integrated
Medicines Management)

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5/3/2013

Aim and objectives for development of the LIMM

(Lund Integrated Medicines Management) model
Develop and research a systematic model for improved
medication use during a patient hospital stay.

Analyse problems and limitations in the standard patient

medication care process
Develop a structured team-based model incl. clinical
pharmacy service
Study the process and outcomes (clinical, humanistic, and
economic)

LIMM developed at Lund University Hospital

City of Lund

Lund University

Founded y 990
Population 76.000

Founded y 1666 (1438)

47.000 students

21

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Hospital Care, a supportive process

How to identify, solve and prevent DRP in the

hospital process and further .?

At
Home

Admission

Hospital Care

Discharge

At
Home

Hospital Care, a (non-) supportive process

Low quality in documentation and communication

At
Home

Admission

Hospital Care

2 errors in
Changes of drugs without
medication list
documentation of reason
The LIMM-model
solves
all problems
Errors
not
9
DRPs/patient
not
corrected
identied

Discharge

At
home

2 errors in medication list

written100%
patient inform
at No
almost
"Discharge note" to late

22

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The LIMM-model

Admission

Medication
Reconciliation
Correct Medication list
Medication interview

Discharge

Hospital Care

Medication Care Plan

Symptom Assessment

Activities

Medication Review

Medication
Reconciliation
Discharge Information
incl. a Medication Report

A systematic approach to individualise and optimise drug treatment

Process for handling of DRP

Clinical relevance
Approriateness

DRP identified by
pharmacist

Recommendation
to physician/nurse

Solved by
pharmacist

Solved
by physician/nurse

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5/3/2013

Example of tools
LIMM Medication Interview (admission)
Part 1 is focused on a correct
patient medication list
Part 2 adds questions on the
patient problems with practical
handling, knowledge and
adherence
Part 3 adds questions for a
deepened assessment of
adherence and beliefs

Ester 80 years old

Found on the floor in her
apartment Friday afternoon
At hospital admission
Slightly confused
High blood sugar
Low blood preassure

Medication interview by a
pharmacist Monday morning
according to LIMM

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5/3/2013

LIMM Medication Interview

Namn Ester

Anamnes/Aktuell lkemedelslista
Apodos? X Nej Ja, version
Dos

Omeprazol tabl 20 mg

1x1

Ramipril tabl 10 mg

1x1

1x1

1x1

1x1

Seloken ZOC
Metoprolol
SRtabl
tabl50
50mg
mg

2x1

1x1

1x1

1x1

Simvastatin tabl 20 mg

1 tn

1 tn

1 tn

1 tn

Trombyl tabl 75 mg
Aspirin

1x1

1x1

1x1

1x1

Furix tabl 40
Furosemid
tabl
mg20 mg

1+1+0

1+1+0

1+1+0

1+1+0

Citalopram tabl 20 mg

1x1

10 mg
x1

10 mg
x1

10 mg
x1

Flunitrazepam tabl
tabl11mg
mg

1 tn

1 vb

1vb

1 vb

Metformin tabl 850 mg

1x1

1x1

1x1

1x1

Atenolol tabl 50 mg

1x1

1x1

1x1

1x1

Kommentar

Dat

LIMM Medication Interview

Avd 5

Sng 1:2

Namn Ester

PAT

LMF

Korrekt
Correct

Initial
(datum,
sign B
2008 -09-30

Fdelsenr XXXXXX

Apodos? X Nej Ja, version

Dos

Omeprazol tabl 20 mg

1x1

Ramipril tabl 10 mg

1x1

Stopped taking, no effect

1x1

1x1

tabl50
50mg
mg
Seloken ZOC
Metoprolol
SRtabl

2x1

Stopped taking no effect

1x1

Simvastatin tabl 20 mg

1 tn

Patient think it is sleeping pill

1 tn

Aspirin tabl 75 mg
Trombyl

1x1

Dont like it

Furix tabl 40
Furosemid
tabl
mg40 mg

1+1+0

Citalopram tabl 20 mg

1x1

Flunitrazepam tabl 1 mg

1 tn

Patient sometimes take two

Metformin tabl 850 mg

1x1

Do not take this, do not know

reason for use

Atenolol tabl 50 mg

1x1

UF

Dat

PAT

LMF

Uppfljn (dat
sign)

Om problem (x)
Ej problem (P)

Dosering*
Dose

Lkemedel,
beredningsform, styrka

Kommentar

Fljs

Sk ter lm sj lv

Korrekt lm lista

Patient sk ter lm sjlv? x Ja Nej

Ind

Focus Knowledge abd compliance

Anamnes/Aktuell l kemedelslista

Dat
IN

Om problem (x)
Ej problem ( P)

Dosering*
Dose

Lkemedel, beredningsform,
styrka

Medications

Uppfljn (dat
sign)
Sk ter lm sj lv

Korrekt lm lista

Patient skter lm sj lv? x Ja Nej

Dat
IN

Initial
(datum,
sign B
2008-09-30

Fdelsenr XXXXXX

Compliance

Sng 1:2

Knowledge

Avd 5

Focus correct medication list

Korrekt
Correct

Ind

Fljs

1x1

1x1

1x1

1 tn

1 tn

P
P

1x1

1x1

1x1

1+1+0

1+1+0

1+1+0

10 mg
x1

10 mg
x1

10 mg x1

1 vb

1vb

1 vb

1x1

1x1

1x1

1x1

1x1

1x1

UF

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LIMM Medication Interview studies

Descriptiv study at two Acute Medicine wards Lund
University Hospital 2007 (Hellstrm 2012a)
Performed by a trained clinical pharmacist using LIMMadmission forms
Review of medication list in EHR, >1 dose given to the patient
420 of 670 patients (63%) > 1 discrepancy in medication list, in
total 1136, mean 1.7 per patient.
Pharmacist recommended 813 corrections
760 (93%) recommendations were corrected/solved

59% of pharmacists recommendations were ranked at

least as somewhat significant (Bondesson 2012b)

Exemple of tools
LIMM Medication Review (continously)
Decreased physical/body functions
Liver, kidney, swallowing problems, GIprobes
Specific medications
TDM-drugs, toxic/ high ADR,
allergy/oversensitive, PIM (inappropriate in elderly)
Interactions
Drug-drug, food-drug, drug-food
Symptom cased by medications
Correct selection of medication
EBM, recommendations, Care-programs
Individualization and the big picture
Benefit-risk, polypharmacy, indication for
treatment, compliance

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LIMM Medication Review studies

Un-identified DRPs decreased from from 9 to1 with the

introduction of a clinical pharmacist (Bondesson 2012b)
62-81% of DRP identified by pharmacist were recommended to
physician for implementation (Bondesson 2012a, Bergkvist 2011)
The physicians accepted and implemented 90% of the clinical
pharmacists recommendations (Bondesson 2012a)
Most recommendations, 83%, were ranked 3 (somewhat
significant) or higher (Bondesson 2012a)
Medication appropriateness index (MAI) improves and ,inappropriate drugs decreased by 50-60% (Bergkvist 2009a, Hellstrm 2011)

Example of tools
LIMM Discharge Information
Written for the patient and includes ;
Short presentation of causes for
admission, what has been done
and planned
Medication Report of all
medication changes and the
reasons for it (what and why)
Medication List with information
on drug, dosing, effects and
special remarks;
Given to the patient at discharge
Sent to the GP and the community
care nurses on the day of discharge

Avd 8, V.O Akutsjukvrd

Universitetssjukhuset
221 85 Lund
046-172408
Discharge information
Discharge physician: Jan Oscarsson
Responsible physician: Lydia Holmdahl
Family doctor: Sven Svensson, VC Mosseby
Admitted: 2009-03-08 03-14

About your disease

You have been admitted to hospital due to fever and shortness of breath and treated at ward nr
8. X-ray of the lungs showed pneumonia. Fluid in the lungs is a sign of worsening heart
failure. You have been treated with antibiotics and diuretics during the hospital stay.
Plans and follow up
You will be admitted to the nursing home at for expanded care-planning. Your Family doctor
will contact you within 4-5 weeks for control of your heart and lungs.
Medication Report
Furosemide has been increased from 1 to 2 tablets due to increased heart failure
Spironolakton has been added due to low potassium levels and heart failure.
Doxycyline (antibiotics) added for another week
Importal substitutes Lactulose due to nausea
Tramadole has been deleted due to nausea and no further need
Digoxin dose has been decreased from 0.25 mg to 0.13 mg, blood level was to high.
Medication

Developed by experts and patients

19 121212-1212
Test Testsson
Testgatan 11
21748 Teststad

Effect

Tabl Furosemide 40mg diuretics

Tabl Spironolakton 25mg diuretics,
potassium sparing
Tabl digoxin
0.13mg for the heart
Tabl Stilnoct
5mg for sleeping
Tabl Doxycycline 100mg antibiotics
Dose powder Importal
against constipation
Tabl Paracetamol 500mg against pain

Morning

Lunch

1
1

Evening

Night Comment

1
1
1
1
1

As needed
To Mars 16

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LIMM Discharge Information studies

Comparativ studie before (179 patients) and after introduction (248
patients) at 7 wards, Lund University Hospital 2006 (Midlv 2008a+b)
Errors were non-documented discrepancies between medication list in
discharge information and actual Medication list in community care
Correct medication list improved from 34 to 68% (p<0.001) and
mean number of errors per patient decreased from 2.2 to 0.97 (p<0.001)
(Midlv 2008a)

Health care contacts within 3 months after discharge decreased from 8.9
to 4.4% (p=0.049) (Midlv 2008b)
Quality control and feedback by a pharmacist before patient discharge
further decreased error rates by;
45% (p=0.012) (Bergkvist 2009b)
35% (p=0.037) (Midlv 2012)

Description of outcome of identified DRPs

Bergkvist-Christensen et al. Int J Clin Pharm 2011; 33:10108.

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The number of identified, put forward and

adjusted DRPs in each DRP subgroup.

Bergkvist-Christensen et al. Int J Clin Pharm 2011; 33:10108.

Research: Methods
Design:
Descriptive studies to investigate problems
Comparative controlled studies to investigate improvements
Blinded evaluators for errors, consequences and clinical
significance
Study size based on power calculations
Analyses:
Descriptive and comparative statistics
Trend, regression and survival analysis
ITT and PP analysis
Probabilistic decision tree model

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Outcomes from the LIMM-model

Decreased drug related hospital revisits by >50%, from 12.0 to 5.6
(p=0.047) (Hellstrm 2011)
No effect on total hospital revisits (Hellstrm 2012b)
For each hour spent by a pharmacist physicians and nurses
saved; (Eriksson 2012)
1-2 h at hospital
-1 h in primary care
The total model generate savings of 390 and gained utility of
0.005 for each patient. The model is cost saving at a 98% chance
(Ghatnekar 2013).

Physicians/nurses very satisfied (process, pharmacist) (Bergkvist 2011,

Bondesson 2012)

Quality assurance in the LIMM-model

Structure
Professional competencies
Checklists, tools and
information material
Responsibilities in the team
Clinical Pharmacist

Process
Team approach
Communication and
information
Follow-up on quality
R&D

Outcome

Using the same structure and process (and prove it)

the LIMM-model can be implemented in similar settings
and the outcomes guaranteed

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Acceptance
4 PhD- and 30 Masters- thesis, 19 scientific publications
4 national quality and research awards
Best innovation in Swedish health care in 2009
LIMM-Discharge Information
Mandatory at Lund University Hospital 2005
National patient safety action plan 2008
Skne County Council incentives, pay for performance 2011
Amendment to National constitution 2012
The total LIMM-model
at wards in all 8 acute hospitals in Skne, 30 clinical
pharmacist employed
starting in Mid-Norway
5-year MSc Pharmacy program at Lund University focusing on
Clinical Pharmacy using LIMM-framework

Reason for success

Structure

Process

Outcome

Practice

Research

Implementation

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LIMM-Scientific publications
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

Midlv P, Bergkvist A, Bondesson , Eriksson T, Hglund P. Medication errors when transferring elderly patients between primary health care and hospital care.
Pharm World Sci 2005; 27(2): 116-20.
ErikssonT, Holmdahl L, Midlv P, Bondeson , Hglund P. Lkemedelsberttelse minskar fel vid utskrivning frn sjukhus. Lkartidningen 2005; 40: 2874-5
Midlv P, Holmdahl L, Eriksson T, Bergkvist A, Ljungberg B, Widner H, Nerbrand C, Hglund P. Medication report reduces number of medication errors when
elderly patients are discharged from hospital. Pharmacy World and Sciences 30, 92-8, 2008.
Midlv P, Deierborg E, Holmdahl L, Hglund P, Eriksson T. Clinical outcomes from the use of Medication Report when elderly patients are discharged from
hospital. Pharmacy World and Scences 30, 840-5, 2008.
Bergkvist A, Midlv P, Hglund P, Larsson L, Bondesson , Eriksson T. Improved quality in the hospital discharge summary reduces medication errorsLIMM:
Landskrona Integrated Medicines Management. European Journal of Clinical Pharmacology 2009;65:1037-46.
Bergkvist A, Midlv P, Hglund P, Larsson L, Eriksson T. A multi-intervention approach on drug therapy can lead to a more appropriate drug use in the elderly.LIMM-Landskrona Integrated Medicines Management. Journal of Evaluation in Clinical Practice 2009;15:660-7.
Bondesson , Hellstrm L, Eriksson T, Hglund P. A structured questionnaire to assess patient compliance and beliefs about medicines taking into account the
ordered categorical structure of data. Journal of Evaluation in Clinical Practice 2009;15:71323.
Eriksson T, Holmdahl L, Bondesson , Midlv P, Hglund P. Medicin och farmaci i samverkan fr bttre lkemedelsansvndning: LIMM-modellen. I vrden 22,
22-27, 2010.
Hellstrm, LM, Bondesson , Hglund P, Midlv P, Holmdahl L, Rickhag E, Eriksson T. Impact of the Lund Integrated Medicines Management (LIMM) model on
medication appropriateness and drug-related hospital revisits. Eur J Clin Pharmacol 2011;67:741-52.
Eriksson T, Hglund P, Holmdahl L, Bondesson . Experiences from the implementation of structured patient discharge information for safe medication
reconciliation at a Swedish university hospital. Eur J Hosp Pharm Sci. 2011;2:42-49.
Bergkvist-Christensen A, Bondesson , Hglund P Larsson L, Holmbjer L, Eriksson T. The process of identifying, solving and preventing Drug Related Problems
in the LIMM-study. Int J Clin Pharm 2011; 33:10101018.
Midlv P, Bahrani L, Seyfali M, Hglund P, Rickhag E, and Eriksson T. Medication Reconciliation Interventions reduce medication errors when elderly patients are
discharged from hospital. Int J Clin Pharm. 2012 Feb;34(1):113-9
Bondesson , Holmdahl L, Midlv P, Hglund P, Andersson, Eriksson T. Acceptance and importance of clinical pharmacists LIMM-based recomendations. Int J
Clin Pharm 2012;34:272276
Hellstrom L, Bondesson , Hglund P, Eriksson T. Prediction of medication history errors at admission to hospital, BMC Clinical Pharmacology 2012, 12:9. Online
Eriksson T, Holmdahl L, Midlv P, Hglund P, Bondesson . The hospital LIMM-based clinical pharmacy service improves the quality of the patient medication
process and saves time. Eur J Hosp Pharm 2012;19:4 375-377
Hellstrom L, Hglund P, Bondesson , Petersson G, Eriksson T. Clinical implementation of systematic medication reconciliation and review as part of the Lund
Integrated Medicines Management model impact on all-cause emergency department revisits. J Clin Pharm Therapeut 2012;37:86692, doi: 10.1111/jcpt.12001.
Bondesson , Eriksson T, Holmdahl L, Midlv P, Kragh A, Hglund P. In-hospital medication reviews reduce unidentified drug-related problems. Eur J Clin
Pharmacol (2013) 69:647-655. DOI 10.1007/s00228-012-1368-5
Ghatnekar O, Bondesson , Persson U, Eriksson T. Health economic evaluation of the Lund Integrated Medicines Management Model (LIMM) in elderly patients
admitted to hospital. BMJ Open 2013;3:1 e001563 doi:10.1136/bmjopen-2012-001563
Milos V, Rekman E, Bondesson , Eriksson T, Jakobsson U, Westerlund T, Midlv P. Improving the quality of pharmacotherapy in elderly primary care patients
through medication reviews- a randomized controlled study. Drugs and Aging Published on Line 2013 Febryary 14. DOI 10.1007/s40266-013-0057-0

Conclusion
The LIMM-model including Clinical Pharmacy Services
identifies, resolves and prevents drug related
problems.
improves the process of care
Improves important clinical, humanistic and
economic outcomes
Strong clinical and scientific base
Can be used as a framework for study the process of
DRP

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Learning objectives and final word

You can now:
* Explain how DRPs can be used to document clinical
pharmacy services and research.
* Discuss potential clinical consequences for DRPs.
Go home and do it!

Thanks
tommy.eriksson@med.lu.se

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