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Biomedical subjects

John Fanikos

Publications and source records attributed to John Fanikos.

15 recordsLinked to original sources
PubMed2006

How many hospital pharmacy medication dispensing errors go undetected?

BACKGROUND: Hospital pharmacies dispense large numbers of medication doses for hospitalized patients. A study was conducted at an academic tertiary care hospital to characterize the incidence and severity of medication dispensing errors in a hospital pharmacy. METHODS: Direct observation of dispensing processes was undertaken to determine presence of errors with review by a physician panel to determine severity. RESULTS: A total of 140,755 medication doses filled by pharmacy technicians were observed during a seven-month period, and 3.6% (5075) contalned errors. The hospital pharmacist detected only 79% of these errors during routine verification; thus, 0.75% of doses filled would have left the phannacy with undetected errors. Overall, 23.5% of undetected errors were potential adverse drug events (ADEs), of which 28% were serious and 0.8% were life threatening. The most common potential ADEs were incorrect medications (36%), incorrect strength (35%), and incorrect dosage form (21%). DISCUSSION: Given the volume of medications dispensed, even a low rate of drug distribution process translates into a large number of errors with potential to harm patients. Pharmacy distribution systems require further process redesign to achieve the highest possible level of safety and reliability.

Academic Medical Centers↗
PubMed2006

Risk factors for the assessment of patients with pulmonary embolism.

Pulmonary embolism (PE) occurs frequently among cancer patients, with a spectrum ranging from small, clinically insignificant thrombi to life-threatening massive PE. It is fatal in as many as 14% of cancer patients, primarily by producing right ventricular heart failure and cardiogenic shock. PE diagnosis is difficult because the signs and symptoms imitate other commonly occurring diseases. Clinicians must be able to integrate a wide array of diagnostic imaging tools and laboratory tests to ensure rapid assessment and diagnosis. Risk stratification with the use of cardiac biomarkers and imaging tests to evaluate right ventricular function will identify treatment options. Hemodynamically stable patients can be treated effectively with anticoagulation alone, whereas those with right ventricular dysfunction require an aggressive strategy with thrombolysis, surgical embolectomy, or a catheter-based intervention. When anticoagulation is contraindicated, a vena caval filter may be deployed. PE treatment must be customized to the individual and consider the existing thrombus burden, presence of underlying cardiopulmonary disease and right side heart dysfunction, and cancer status of the patient. Clinicians should focus on providing adequate thromboprophylaxis in hospitalized cancer patients to avoid PE treatment.

Humans↗
PubMed2005

Pattern of infliximab utilization in rheumatoid arthritis patients at an academic medical center.

OBJECTIVE: To investigate the pattern of use of infliximab with an emphasis on treatment escalation and the durability of infliximab use in the management of rheumatoid arthritis (RA) in an academic setting. METHODS: We conducted a retrospective review of pharmacy and medical records of 183 patients with RA who received at least 1 infliximab infusion at the infusion centers of the Brigham and Women's Hospital. Treatment escalation was defined as an increase in the dosage of infliximab to >3 mg/kg and/or a decrease in the dosing interval to <7 weeks between infusions. RESULTS: A total of 183 patients with RA received infliximab infusions for a mean +/- SD duration of 58.2 +/- 56.6 weeks. Infliximab was discontinued in 48% of the patients during the first year of therapy and in 67% of the patients overall. A total of 126 patients had a treatment escalation, including 25 patients with a dose increase, 35 patients with a decrease in the interval, and 66 patients with both. Infliximab treatment was associated with a decrease in corticosteroid and methotrexate doses. Patients who had a treatment escalation were more likely to continue infliximab infusions compared with patients without a treatment escalation (odds ratio 2.0, 95% confidence interval 1.0-4.1). CONCLUSION: The use of infliximab may be an effective treatment for RA; however, a substantial number of patients will discontinue its use. Treatment escalation is commonly used in the management of RA with infliximab and is associated with longer duration of infliximab use.

Antibodies, Monoclonal↗
PubMed2005

Predictors of major hemorrhage following fibrinolysis for acute pulmonary embolism.

One hundred four patients at Brigham and Women's Hospital who received alteplase for acute pulmonary embolism were evaluated. Major bleeding occurred in 20 patients (19.2%). The principal site of bleeding was unknown in 9 (45.0%), gastrointestinal in 6 (30.0%), retroperitoneal in 3 (15.0%), intracranial in 1 (5.0%), and splenic in 1 (5.0%). Independent predictors of major hemorrhage were the administration of catecholamines for systemic arterial hypotension (odds ratio [OR] 115, 95% confidence interval [CI] 9.4 to 1,410.9, p < 0.001), cancer (OR 16.0, 95% CI 3.2 to 80, p = 0.004), diabetes mellitus (OR 9.6, 95% CI 1.7 to 54, p = 0.010), and elevated international normalized ratio before fibrinolysis (OR 5.8, 95% CI 1.5 to 22, p = 0.012).

Diabetes Complications↗
PubMed2005

Major bleeding complications in a specialized anticoagulation service.

Major bleeding complications were investigated in 2,460 patients with 3,684 patient-years of warfarin exposure from 2000 to 2003. The most common indications for anticoagulation were atrial fibrillation (30%), venous thromboembolic disease (28%), and mechanical heart valve prosthesis (15%). Eleven patients had 12 nonfatal major bleeding complications, with no fatal bleeds during the study. The incidence of major bleeding complications was 0.12%/year; there were 0.32 bleeds/100 patient-years of coverage. Of the 12 bleeding events, 5 (42%) were intracranial hemorrhages. The average hospitalization cost per patient was dollar 15,988, and the average length of hospitalization was 6.0 days.

Adult↗
PubMed2004

International normalized ratio increase before warfarin-associated hemorrhage: brief and subtle.

OBJECTIVE: To determine the relationship between serial international normalized ratios (INRs) in patients who have been undergoing long-term anticoagulation and the onset of warfarin-associated bleeding complications. METHODS: The study cohort consisted of 2391 patients treated in the Anticoagulation Service at Brigham and Women's Hospital, Boston, Mass, from April 1999 through July 2003. For each patient with a bleeding event, we selected 2 controls who were matched for age, sex, indication for warfarin therapy, and duration of enrollment in our Anticoagulation Service. RESULTS: Warfarin-related hemorrhage occurred in 32 patients (1.3%). The mean +/- SD INRs at the time of the bleeding event or matched patient's event date (5.9 +/- 5.9 vs 2.3 +/- 0.7; P<.001) and the mean+/-SD last INRs before the bleeding event or matched patient's event date (3.0 +/- 1.2 vs 2.1 +/- 0.8; P<.001) were higher in the patients than in the controls. The last INRs before the bleeding event were obtained an average of 11.6 +/- 17.8 (mean +/- SD) days before the event in the patients and 18.3 +/- 28.0 (mean +/- SD) days before the matched date in the controls (P = .22). The mean second-to-last INRs were similar in both groups (2.8 +/- 2.1 vs 2.3 +/- 0.8; P = .11). When the INRs were plotted in relation to the time before the onset of bleeding, a marked increase in the patients' INRs was observed shortly before the bleeding began. CONCLUSIONS: Serial INRs are poor predictors of hemorrhagic events. There appears to be only a brief warning period during which a slightly elevated INR predicts an imminent bleeding event.

Adult↗
PubMed2004

Medication errors associated with anticoagulant therapy in the hospital.

Anticoagulation in hospitalized patients is frequently associated with medication errors. To determine the extent and severity of this problem, we reviewed consecutively reported, anticoagulation-related medication errors over a 3-year period. We identified 130 medication errors. There were 1.67 medication errors for every 1,000 patients treated with anticoagulants. These were most often associated with unfractionated heparin (66.2%), followed by warfarin (21.5%), low-molecular-weight heparin (9.2%), argatroban (1.5%), and lepirudin (1.5%). There were no deaths attributed to any anticoagulant medication errors, but 6.2% of patients required medical intervention and 1.5% needed prolonged hospitalization. Medication errors frequently occur with anticoagulant therapy in hospitalized patients.

Anticoagulants↗
PubMed2004

Time trends in warfarin-associated hemorrhage.

The annual incidence of warfarin-related bleeding at Brigham and Women's Hospital increased from 0.97/1,000 patient admissions in the first time period (January 1995 to October 1998) to 1.19/1,000 patient admissions in the second time period (November 1998 to August 2002) of this study. The proportion of patients with major and intracranial bleeding increased from 20.2% and 1.9%, respectively, in the first time period, to 33.3% and 7.8%, respectively, in the second.

Adult↗
PubMed2004

The effect of excessive anticoagulation on mortality and morbidity in hospitalized patients with anticoagulant-related major hemorrhage.

BACKGROUND: We aimed to determine the effect of excessive anticoagulation on morbidity and mortality in hospitalized patients with major anticoagulant-associated hemorrhage. METHODS: We prospectively identified 101 consecutive inpatients admitted to Brigham and Women's Hospital with major bleeding occurring during administration of warfarin sodium, unfractionated heparin (UFH), or low-molecular-weight heparin (LMWH). RESULTS: Fifty patients had excessive and 51 had nonexcessive anticoagulation. The overall mortality at 60 days was 26% (13/50) in the excessive group compared with 10% (5/51) in the nonexcessive group (P =.03). Excessive warfarin therapy was associated with an increased 60-day mortality (P =.049), in contrast to excessive anticoagulation with UFH or LMWH alone (P =.27) or UFH or LMWH as a "bridge" to warfarin therapy (P =.10). Multivariate regression identified excessive anticoagulation as an independent predictor of 60-day mortality (adjusted hazard ratio [HR], 4.17; 95% confidence interval [CI], 1.39-12.49; P =.01), along with intracranial hemorrhage (adjusted HR, 6.16; 95% CI, 1.75-21.67; P =.005) and active cancer (adjusted HR, 3.79; 95% CI, 1.13-12.70; P =.03). Excessive anticoagulation was also a significant predictor of the combined nonfatal end point of stroke, myocardial infarction, hypotension, critical anemia, and surgical or angiographic intervention at 30 days (HR, 2.17; 95% CI, 1.25-3.78; P =.006). CONCLUSION: In a cohort of patients with anticoagulation-associated hemorrhage, excessive anticoagulation contributed independently to increased morbidity and mortality.

Adult↗
PubMed2004

Cost analysis of "bridging therapy" with low-molecular-weight heparin versus unfractionated heparin during temporary interruption of chronic anticoagulation.

Patients on long-term anticoagulation who require interruption of therapy for surgery may receive "bridging therapy" with continuous-infusion unfractionated heparin or low-molecular-weight heparin (LMWH). We estimated the costs of bridging therapy with: (1) LMWH self-administered at home, (2) LMWH administered by a nurse to patients at home, and (3) continuous-infusion unfractionated heparin in the hospital. For surgeries requiring an overnight stay, bridging costs are estimated to be 672, 933, and 3,816 US dollars, respectively, for each of these strategies.

Ambulatory Care↗
PubMed2004

Comparison of efficacy, safety, and cost of low-molecular-weight heparin with continuous-infusion unfractionated heparin for initiation of anticoagulation after mechanical prosthetic valve implantation.

We compared the efficacy, safety, and impact on postoperative hospital length of stay and inpatient hospital costs of low-molecular-weight heparin with that of unfractionated heparin as a "bridge" to achieving therapeutic levels of anticoagulation with warfarin in patients with newly implanted prosthetic heart valves. The patients who received low-molecular-weight heparin had a shorter length of stay and decreased postoperative costs compared with the control subjects receiving unfractionated heparin.

Anticoagulants↗