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Background: Hospital medication errors are frequent and may result in adverse events. Data on non-prescription of regular medications to emergency department short stay unit patients is lacking. In response to local reports of regular medication omissions, a multi-disciplinary team was tasked to introduce corrective emergency department (ED) process changes, but with no additional financing or resources. Aim: To reduce the rate of non-prescription of regular medications for patients admitted to the ED Short Stay Unit (SSU), through process change within existing resource constraints. Methods: A pre- and post-intervention observational study compared regular medication omission rates for patients admitted to the ED SSU. Included patients were those who usually took regular home medications at 08:00 or 20:00. Omissions were classified as clinically significant medications (CSMs) or non-clinically significant medications (non-CSMs). The intervention included reinforcement that the initially treating acute ED doctor was responsible for prescription completion, formal checking of prescription presence at SSU handover rounds, double-checking of prescription completeness by the overnight SSU lead nurse and junior doctor, and ED pharmacist medication reconciliation for those still identified as having regular medication non-prescription at 07:30. Results: For the 110 and 106 patients in the pre- and post-intervention periods, there was a non-significant reduction in the CSM omission rate of -11% (95% CI: -23 to 2), from 41% (95% CI: 32-50) to 30% (95% CI: 21-39). Conclusion: Non-prescription of regular CSMs for SSU patients was not significantly reduced by institution of work practice changes within existing resource constraints.

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PURPOSE: To determine the prevalence of fast global and central visual field (VF) progression in individuals with glaucoma under routine care. DESIGN: Observational study. PARTICIPANTS: Six hundred ninety-three eyes of 461 individuals with glaucoma followed up over a median of 4.5 years. METHODS: This study included (1) patients at a private ophthalmology clinic in Melbourne, Australia, and (2) individuals in 2 prospective longitudinal observational studies across 3 sites in the United States. All individuals had a diagnosis of glaucoma and were under routine care, and had performed 5 or more reliable 24-2 VF tests over a 1- to 5-year period. Ordinary least squares regression analyses were used to calculate the rate of global mean deviation (MD) change over time and the rate of the mean total deviation values of the 12 test locations within the central 10° region (MTD10) for each eye. MAIN OUTCOME MEASURES: Prevalence of progression based on the rate of MD and the MTD10 change across various fixed cutoffs and cutoffs based on the estimated normal distribution (from the positive slopes). RESULTS: Based on the MD and the MTD10, 12.5% and 11.7% of the eyes, respectively, exhibited a rate of change that was less than -1.0 dB/year (being a rate that typically is defined as "fast progression" for MD values), and 29.0% of the eyes showed a change of less than -0.5 dB/year on MTD10. Furthermore, 12.7% and 9.1% of the eyes exhibited a rate of change that exceeded the 1% cutoff of the estimated normal distribution MD and the MTD10 values, respectively. CONCLUSIONS: This study found that approximately 1 in 8 eyes with glaucoma receiving routine care showed fast progression based on global MD values (< -1.0 dB/year) and that nearly 1 in 3 eyes showed a < -0.5 dB/year decline centrally. These findings highlight the clinical importance of assessing progressive central VF loss and reinforce the need for new therapies to prevent functional disability in a notable proportion of individuals who continue to exhibit fast progression. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

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BACKGROUND AND OBJECTIVE: There is evidence that opioid initiation post-surgery is contributing to the problem of chronic misuse and/or abuse of over the counter medications in the community, and that orthopedic patients may be particularly at risk. The aim of the systematic review with meta-analysis was to identify research that examined opioid use at 3, 6, and 12 months post-operatively by previously opioid naïve orthopedic surgery patients. Design, databases, and data treatment: A searched review with meta-analysis was undertaken. Eight databases were search. Meta-analyses conducted at all three time points (3 months, 6 months, and 12 months). RESULTS: The search yielded 779 records, and after screening, 13 papers were included in meta-analysis. Results provide strong evidence that post-operative opioid use amongst the opioid naïve is a real effect (7 percent at 3 months, 4 percent at 6 months, and 2 percent at 12 months). A Z-test for overall effect revealed strong evidence that this proportion was nonzero for opioid use at 3, 6, and 12 months (p < 0.001 for all time points). A small but significant proportion of opioid naïve patients who are prescribed opioids remain on these medications up to 12 months post-operatively. CONCLUSIONS: The nature of the studies included in the meta-analysis were varied, hence subanalyses regarding surgery type, characteristics of the patient group or other potential factors that might influence the progression to longer term opioid use after these surgeries could not be explored. Given this, further research in this area should explore such specific orthopedic subgroups.

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BACKGROUND: This study aimed to investigate the effects of an intervention focusing on better opioid prescription practice in a tertiary metropolitan hospital orthopaedic unit. METHODS: Following a previous audit of opioid prescribing in the orthopaedics unit, an intervention comprising the (i) Expert Advisory Group oversight of opioid prescribing, (ii) development of a prescription opioid guideline for various hospital contexts and (iii) a series of education sessions was undertaken to improve opioid prescription practice. A re-audit was subsequently carried out to determine whether the intervention had had an impact on the previously audited orthopaedic unit. RESULTS: Each audit period was 6 months. There were 281 orthopaedic patients in the original audit (1 January 2017-30 June 2017) and 289 in the re-audit (1 March 2018-31 August 2018). In both audits, a high proportion of patients were discharged to the community on opioids, 82.2% (n = 231) pre-intervention and 79.6% (n = 230) post-intervention. Statistically significant differences in opioid prescribing were found between audits, including: a reduction in the number of patients discharged on combination opioids from 71.4% to 45.7% (P < 0.001), a reduction in the provision of full pharmaceutical quantities of opioid on discharge from 29.4% to 6.1% (P < 0.001) and an increase in opioid weaning plans included in discharge summaries from 6.9% to 87.4% (P < 0.001). CONCLUSION: Raised awareness across the organization and education for staff more than halved the post-operative opioid prescription levels. This highlights the capacity for change in hospitals and the ability to work towards safer prescribing of post-operative opioid therapy.

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Cannabis is the most commonly used illicit substance worldwide and the prevalence of users continues to increase. Over the last 2 decades, the world has seen significant changes regarding cannabis for recreational use as well as application in its use as a therapeutic medicine. This is likely to have influenced the decreasing perception of risks associated with the use of cannabis. Cannabis, however, is not benign and, depending on the pattern of its use, can incur a range of harmful effects, which have implications when prescribing medicinal cannabinoids for individuals. Based on research evidence from recreational use of cannabis as well as the emerging data from trials of medicinal cannabis, we propose some clinical domains that will need specific considerations when prescribing medicinal cannabis.

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