No.
Case description of potentially preventable drug-related revisit
Results of preventability assessment: Readmission or ED visit ICD-10 diagnosis Main cause (other causes) Origin Could have been prevented by MR (explanation)?
1
87-year-old man with a.o.t. heart failure with midrange ejection fraction, chronic atrial fibrillation and orthostatism in medical history, admitted to hospital (index) because of dizziness, dyspnoea and chest pain. Unclear aetiology of symptoms (blood pressure 130/70, no abnormal cardiac biomarker test results, no changes compared with previous echocardiogram, chest radiograph normal). Ward physician suspected adverse drug effects due to complex pharmacotherapy and adjusted treatment: oral furosemide 20 mg once daily, metoprolol 25 mg once daily and simvastatin 20 mg once daily were stopped, enalapril was reduced from 10 mg to 5 mg once daily, felodipine 5 mg was started and an antacid was given during hospital stay. Patient symptoms decreased and the patient was discharged two days after pharmacotherapy adjustments. Referral for follow-up was sent to the GP. One and a half weeks later (before GP follow-up took place), the patient presented at the ED with dyspnoea and enalapril was increased to 7.5 mg once daily.
ED visit I509 Heart failure Insufficient or no follow-up (inappropriate treatment) Hospital Yes (ward pharmacist cautioned about a relatively large number of pharmacotherapeutic changes during hospital stay, but no clear action/follow-up was proposed)
2
75-year-old woman with a.o.t. diabetes mellitus type 1, hypertension, heart failure with preserved ejection fraction (diastolic heart failure), pulmonary hypertension and paroxysmal atrial fibrillation in medical history, admitted to hospital (index) because of dyspnoea due to newly diagnosed COPD stage 2. COPD exacerbation was treated with 5-day course of amoxicillin and prednisolone, and the patient was prescribed tiotropium and terbutaline inhalers upon discharge. Previous treatment with carvedilol (non-selective beta-blocker) 25 mg twice daily for heart failure was continued. Three days later, the patient was readmitted due to worsening dyspnoea. Patient had not been taking the inhalers, because no inhalation instruction had been provided. During readmission, the patient received inhaler training and carvedilol was replaced with bisoprolol (selective beta-blocker).
Readmission J441 COPD with acute exacerbation Non-compliance (inappropriate treatment) Hospital Yes (ward pharmacist tested patient’s inhalation technique and recommended prescribing specific inhalers during hospital stay, but there was a lack of medication reconciliation and inhaler instructions upon discharge)
3
88-year-old woman with a.o.t. diastolic heart failure and chronic atrial fibrillation, admitted to hospital (index) because of dyspnoea and lower back pain due to pneumonia and lung oedema and collapsed vertebra due to osteoporosis, respectively. During hospital stay, enalapril/hydrochlorothiazide 20/12.5 mg was replaced by losartan 50 mg once daily because of high age and dry cough (adverse drug effect of enalapril). Oral furosemide 40 mg once daily was started, but the patient developed hypokalaemia and received potassium supplementation during hospital stay. Previously prescribed bisoprolol 10 mg and felodipine 5 mg once daily were continued. Patient discharged to nursing home with referral to GP for follow-up. After two weeks, hospital readmission due to dyspnoea and tachycardia (heart rate 130–160 beats/minute) with normokalaemia. Bisoprolol dosage was increased to 15 mg once daily and felodipine was stopped. Furosemide was increased to 40 mg in the morning and at noon.
Readmission I489 Atrial fibrillation Inadequate treatment (insufficient or no follow-up, inappropriate treatment) Hospital Not applicable (no MR, control group)
4
69-year-old man with a.o.t. persistent atrial fibrillation in medical history, admitted to hospital (index) because of diarrhoea, vomiting and iron deficiency anaemia, probably due to gastrointestinal bleeding (no clear source of bleeding identified through gastroscopy and colonoscopy). Apixaban was temporarily paused and replaced with dalteparin awaiting capsule endoscopy. During 6-week post-discharge follow-up, the physician and patient discussed the potential restart of apixaban if haemoglobin levels are recovered and stabilised, followed by close monitoring of haemoglobin. Two weeks later, no identification of bleeding source through capsule endoscopy, although some parts of the endoscopy results were unclear. Follow-up visit planned by hospital, but did not take place (reason unclear) and no reminder to patient. Three months later, readmission with iron deficiency anaemia. Patient had switched back from dalteparin to apixaban on his own initiative, having misunderstood the physician as stating that apixaban could be restarted.
Readmission K922 Gastrointestinal haemorrhage Non-compliance (insufficient or no follow-up) Hospital Not applicable (no MR, control group)
5
69-year-old man with a.o.t. dysuria with haematuria due to suspected thickening of bladder wall and enlarged prostate in medical history, admitted to hospital (index) because of fever and weakness due to endocarditis. Decrease in renal function (eGFR from 58 to 31 ml/min/1.73 m2) during hospital stay, probably due to antibiotic treatment. Discharged to nursing home with antibiotic treatment adapted to renal function and follow-up by hospital. Ten months later, the patient presented to GP with sleep problems, nocturia, constipation and an ‘unpleasant feeling in the stomach’. GP prescribed mirtazapine 15 mg once daily in the evening and hyoscyamine sulphate (anticholinergic) 0.4 mg twice daily without any lab tests or notes regarding previous renal and urinary problems. Three days later, the patient presented at the ED with acute urinary retention for which he received a urinary catheter.
ED visit R33 Retention of urine Inappropriate treatment Primary care No (cause originated after MR)