En el número de abril de la revista British Journal of General
Practice publican una actualización de indicadores de seguridad para la
prescripción en Atención Primaria. Creo que es una lista que merece la
pena revisar y tener presente.
El artículo que describe el proceso de identificación está disponible a texto completo en http://bjgp.org/content/64/
Se puede acceder diréctamente a la lista en: http://bjgp.org/content/64/El artículo que describe el proceso de identificación está disponible a texto completo en http://bjgp.org/content/64/
Un saludo,
Ernesto Barrera
| Indicator | Risk of harm (1 = low, 2 = moderate, 3 = high, 4 = extreme) |
|---|---|
| A: Cardiovascular and respiratory disease | |
| 1. Aspirin or clopidogrel prescribed to people with previous peptic ulcer or gastrointestinal bleed without gastroprotectiona | 3 |
| 2. Prescription of aspirin at a dose >75mg daily for ≥1 month in a patient aged >65 years | 2 |
| 3. Prescription of digoxin at a dose >125 μg daily in a patient with renal impairment (for example, CKD 3 or worse) | 3 |
| 4. Prescription of digoxin at a dose of greater than 125 μg daily for a patient with heart failure who is in sinus rhythm | 3 |
| 5. Prescription of diltiazem or verapamil in a patient with heart failurea | 3 |
| 6. Prescription of a beta-blocker to a patient with asthma (excluding patients who also have a cardiac condition, where the benefits of beta-blockers may outweigh the risks)a | 3 |
| 7. Prescription of a long-acting beta-2 agonist inhaler to a patient with asthma who is not also prescribed an inhaled corticosteroid | 3 |
| B: Central nervous system (including analgesics) | |
| 8. Prescription of a benzodiazepine or Z drug for ≥21 days, in a patient aged >65 years, | 3 |
| who is not receiving benzodiazepines or Z drugs on a long-term basis | |
| 9. Initiation of prescription of benzodiazepine or Z drugs for ≥21 days in a patient aged >65 years with depression | 3 |
| 10. Antipsychotics prescribed for >6 weeks in the over 65s with dementia but not psychosisa | 3 |
| 11. Amitriptyline at dose >75mg prescribed to a patient with heart failure, arrhythmia, heart block. or postural hypotension | 3 |
| 12. Prescription of aspirin to a child aged ≤16 years | 2 |
| 13. Bupropion prescribed to a patient with epilepsy | 3 |
| C: Anti-infective agents | |
| 14. Prescription of mefloquine to a patient with a history of convulsionsa | 3 |
| D: Endocrine and metabolic | |
| 15. Glitazone prescribed to patient with heart failurea | 3 |
| 16. Metformin prescribed to a patient with renal impairment where the eGFR is ≤30ml/mina | 4 |
| 17. Oral prednisolone prescribed at a dose ≥7.5mg daily for more than 3 months to the over 65s without co-prescription of osteoporosis-preventing treatmentsa | 3 |
| 18. Modified-release potassium supplements prescribed to a patient with a history of peptic ulcer disease | 2 |
| E: Women’s health and urinary disorders | |
| 19. Prescription of a combined hormonal contraceptive to a woman with a history of venous or arterial thromboembolism | 3 |
| 20. Prescription of oral or transdermal oestrogens to a woman with a history of breast cancer | 3 |
| 21. Prescription of oral or transdermal oestrogen without a progestogen in a woman with an intact uterus | 3 |
| 22. Prescription of a combined hormonal contraceptive to a woman aged ≥35 years who is a current smoker | 3 |
| 23. Prescription of a combined hormonal contraceptive to a woman with a body mass index of ≥40a | 3 |
| F: Immunosuppression | |
| 24. Methotrexate prescriptions should state ‘weekly’ | 3 |
| 25. Methotrexate 2.5/10mg co-prescription | 3 |
| 26. Methotrexate prescribed without folic acid | 3 |
| G: Musculoskeletal | |
| 27. Concurrent use of two NSAIDS for more than 2 weeks (not including low-dose aspirin) | 3 |
| 28. Prescription of an NSAID, without co-prescription of an ulcer-healing drug, to a patient with a history of peptic ulcerationa | 4 |
| 29. Prescription of an NSAID in a patient with heart failurea | 3 |
| 30. Prescription of an NSAID in a patient with chronic renal failure with an eGFR <45a | 4 |
| 31. Allopurinol prescribed at a dose of >200mg/day to patients with renal impairment (eGFR <30 or CKDA)a | 3 |
| H: Hazardous co-prescriptions and allergy | |
| 32. Prescription of warfarin and aspirin in combination (without co-prescription of gastroprotection)a | 3 |
| 33. Concurrent use of warfarin and any antibiotic without monitoring the INR within 5 daysa,b | 4 |
| 34. Prescription of warfarin in combination with an oral NSAID | 3 |
| 35. Prescription of a phosphodiesterase type-5 inhibitor, for example sildenafil, to a patient who is also receiving a nitrate or nicorandila,c | 3 |
| 36. Co-prescription of lithium with thiazide diuretic | 3 |
| 37. Prescription of a potassium salt or potassium-sparing diuretic (excluding aldosterone antagonists) to a patient who is also receiving an ACE inhibitor or angiotensin II receptor antagonista | 3 |
| 38. Prescription of verapamil to a patient who is also receiving a beta-blocker | 3 |
| 39. Co-prescription of itraconazole with simvastatin, or with atorvastatin at a dose ≥80mga,c | 3 |
| 40. Co-prescription of trimethoprim with methotrexate for >7 daysa | 3 |
| 41. Prescription of clarithromycin or erythromycin to a patient who is also receiving simvastatin, with no evidence that the patient has been advised to stop the simvastatin while taking the antibiotica | 3 |
| 42. Prescription of a penicillin-containing preparation to a patient with a history of allergy to penicillin | 4 |
| I: Laboratory test monitoring | |
| 43. Patients aged >75 years on loop diuretics who have not had a U+E in the previous 15 monthsa | 3 |
| 44. Prescription of amiodarone without a record of liver function being measured in the previous 9 months | 3 |
| 45. Prescription of amiodarone without a record of thyroid function being measured within the previous 9 months | 3 |
| 46. Prescription of an ACE inhibitor or angiotensin II receptor antagonist without a record of renal function and electrolytes being measured prior to starting therapy | 3 |
| 47. Patients on an ACE inhibitor or angiotensin II receptor antagonist who have not had a U+E in the previous 15 monthsa | 3 |
| 48. Prescription of warfarin to a patient without a record of INR having been measured within the previous 12 weeks (excluding patients who self-monitor) | 4 |
| 49. Prescription of a statin without an ALT taken prior to starting treatment | 3 |
| 50. Prescription of a statin without an ALT taken prior to starting treatment and within 3 months of starting treatment | 3 |
| 51. Prescription of lithium without a record of a lithium level being measured within the previous 6 monthsa | 3 |
| 52. Metformin without yearly serum creatinine | 3 |
| 53. Use of a hypothyroid agent without monitoring relevant thyroid function tests within 2–4 months of initiation or dosage change and at least every 15 months thereafter | 3 |
| 54. Prescription of methotrexate without a record of a full blood count within the previous 3 months | 3 |
| 55. Prescription of methotrexate without a record of liver function having been measured within the previous 3 months | 3 |
| 56. Allopurinol without baseline urea, electrolytes, creatinine and eGFR | 2 |
-
↵a For 23 items (19 high risk and 4 extreme risk) 80% or more of the responders rated the indicator as high or extreme risk.
-
↵b Consensus reached for assessing the safety of prescribing of practices, but not individual GPs.
-
↵c Consensus
reached for assessing the safety of prescribing of individual GPs, but
not practices. ACE inhibitor = angiotensin-converting
enzyme inhibitor. ALT = alanine
transferase. CKD = chronic kidney disease. eGFR = estimated glomerular
filtration rate. INR
= International Normalised Ratio. NSAID =
non-steroidal anti-inflammatory drug. U+E = urea and electrolytes.
Amplío la información con la referencia a un articulo (en prensa) que respalda la inclusión de uno de los cuatro indicadores de riesgo extremo (el número 33): La no realización de un control de INR en los 5 primeros días de la prescripción de un antibiótico.
Lane MA, Zeringue A, McDonald JR. Serious Bleeding Events due to Warfarin and Antibiotic Co-prescription In a Cohort of Veterans. Am J Med. 2014 Mar 19;
http://pmid.us/24657899
Aún tratándose de un indicador de proceso, la realización de un INR en los 3-14 días de la co-prescripción warfarina-antibiótico se asocia una disminución del riesgo de sangrado:
"Patients who had INR performed 3-14 days of co-prescription were at a decrease risk of serious bleeding (HR 0.61, 95% CI 0.42-0.88)"
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