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Sistem produktne odgovornosti v zdravstvu

Članek obravnava problematiko odgovornosti za škodo, ki nastane kot posledica napake izdelka in povzroči smrt, telesno poškodbo ali okvari bolnikovo zdravje. Hiter razvoj znanosti je tudi v medicini omogočil razvoj novih izdelkov in tehnologij, ki vzbujajo pri bolnikih velika pričakovanja po bolj učinkovitem zdravljenju. Vendar pa nove tehnologije s seboj prinašajo tudi tveganje za nastanek poškodb zaradi morebitnih napak. Standardi kakovosti in varnosti izdelkom slabe kakovosti sicer preprečujejo dostop na trg, vendar pa t. i. varnostne norme ne morejo preprečiti napak in nevarnosti, ki jih zaradi omejenosti znanja ne moremo predvideti. Zato do poškodb in z njimi povezanih stroškov kljub vsemu prihaja. V prispevku natančno opredeljujemo, kdo naj nosi nepredvidljive stroške: bolnišnica, proizvajalec, bolnik ali preko socializacije tveganja družba kot celota. Gre za zapleten sistem ekonomske razporeditve tveganja poškodb, ki skuša uravnovesiti željo po učinkovitosti ob upoštevanju nepredvidljivih nevarnosti izdelka. Opredeljujemo pojme, ki so ključni za razumevanje problematike: proizvajalec, potrošnik, bolnik, izdelek in napaka. Največ pozornosti namenjamo sistemu odgovornosti za škodo, ki ga uvaja Direktiva Sveta Evropske Unije 85/374 o odgovornosti za brezhibnost izdelka. Direktiva uvaja sistem, ki ob sprejemu pravil v nacionalno zakonodajo dopušča pravnopolitične prilagoditve. V prispevku analiziramo sistem razporeditve škode in ga skušamo orisati s ključnimi primeri iz prakse sodišč Evropske unije.

Comprehensive medication history: the need for the implementation of medication reconciliation processes

Introduction: Providing comprehensive medication history (CMH) upon hospital admission is of outmost importance for proper patient evaluation and prescription of drug treatment. The aim of this study was to evaluate the implementation of medication reconciliation in clinical practice.

Methods: Patients admitted to a teaching hospital in Slovenia were randomly selected and included in the study. For each patient a CMH was obtained by a research pharmacist using various sources of information. Next, the medication history in the hospital medical record was reviewed. The prescribed drugs were assessed for completeness of information, and possible discrepancies between both medication histories were recorded and classified.

Results: Overall, 108 patients with a median age of 73 years were included in the study. The research pharmacist recorded the use of 651 medicaments, with all relevant details being available for 94.9% of these drugs. Of the 464 medicines listed in the hospital medical record, only 42.0% were considered complete. A comparison of the medication history and the medical record with the CMH revealed at least one discrepancy in 72.4% of the drugs listed. The majority of the identified discrepancies were often present both in the medication order on the drug chart (76.2%) and in the discharge letter (69.9%). Most medication discrepancies were due to drug omissions (20.9%) and commissions (6.5%).

Conclusion: The high rate of discrepancies between the recorded drug history and CMH reported in our study stresses the need for the implementation of medication reconciliation. The participation of pharmacists in the reconciliation process, described in this study, resulted in more complete and accurate drug histories acquired.

References Robida A. Nacionalne usmeritve za razvoj kakovosti in varnosti v zdravstvu ter uvajanje izboljševanja kakovosti v bolnišnice. Sporočila 2006; 16: 5-7. Kersnik J. Bolnik v slovenskem zdravstvu : monografija o zadovoljstvu bolnikov in organizaciji pritožnega sistema, (Zbirka PiP). Ljubljana: Združenje zdravnikov družinske medicine SZD, 2003. Tomšič B, Grahek Cujnik A, Lešnik Hren J. Sistem vodenja kakovosti v zdravstvenih domovih. In: Žargi D, et al. editors. Kakovost - različni pristopi, skupen cilj. Ljubljana: Slovensko združenje za kakovost, 2004: 166

Patients' adherence to treatment of diabetes mellitus

Objectives: Diabetes is a chronic disease where patient's ability for self management is very important. Patients are every day taking decisions how to integrate treatment recommendations into their lives without impacting the quality of life. The aim of this study was to explore participants' perceived barriers to adherence to treatment.

Methods: A qualitative study with five focus groups of patients with Type 2 diabetes and one group of experts on diabetes mellitus was performed in the central area of Slovenia. The transcribed text was independently analysed by principles of grounded theory with codes merging into themes and categories.

Results: Time changes patients' attitudes toward disease. Good education about the disease and their own experience with the disease help patients to adapt to different life situations and to regain control in their life. Family and friends are not always supportive to diabetes treatment. Some patients deny having disease in social encounters because they feel stigmatised. Diabetes also challenges patient's working ability and financial welfare. Patients also emphasise that mutual trust with physician and his true interest in patients' problems is very important for good results of medical care. They refuse universal advice and expect that the doctor helps them to develop self-management skills and coping with the disease. Additional prerequisites for good self management are also adequate organisation of life and adequate personal characteristics of the patients.

Discussion: This study offers additional insights into patients' views of the barriers to adherence. Patients feel empowered for occasional departure from recommended treatment in some social and life situations. Better medical care could be the result of good balance between social expectations of the patients, treatment and working demands on one side and individualised support of the physician with patients' own capacity to rearrange life on the other side.

Analiza Neprimernega Predpisovanja Zdravil Starostnikom v Sloveniji na Podlagi Beersovih in Larochevih Meril

Namen: Zaradi velikega števila starostnikov, kijemljejo zdravila, je bil cilj analize ugotoviti razširjenost neprimernega predpisovanja zdravil v letu 2006 med starostniki v Sloveniji. Za analizo neprimernega predpisovanja smo izbrali merila Beers 2002 in merila Laroche 2007 in Skupna merila neprimernega predpisovanja.

Metode: Analiza je bila opravljena na anonimizirani zbirki podatkov Zavoda za zdravstveno zavarovanje Slovenije o izdaji ambulantno predpisanih zdravil v letu 2006. Analizo z merili Beers 2002 smo opravili na vzorcu starostnikov, starih 65 let in več, analizo z merili Laroche 2007 in s Skupnimi merili pa na vzorcu starostnikov, starih 75 let in več.

Rezultati: Po merilih Beers 2002 je 22,41 % starostnikov prejelo vsaj eno neprimerno učinkovino, po merilih Laroche 2007 25,72 %, po Skupnih merilih pa 35,95 %. Glede na objavljene raziskave so deleži dokaj visoki. Delež receptov z neprimerno predpisanimi zdravili (glede na vse recepte) je v primeru analize z merili Beers 2002 znašal 3,43 %, v primeru z merili Laroche 2007 4,01 % in na podlagi Skupnih meril 6,03 %. Deleži so višji kot na Hrvaškem, predvsem zaradi večjega števila zdravil, ki jih uporabljamo v Sloveniji. Ugotovili smo tudi, da se verjetnost, da bolnik prejme neprimerno zdravilo, povečuje s številom predpisanih zdravil.

Zaključek: Kljub ugotovljenemu dokaj visokemu deležu neprimernega predpisovanja so mnenja v objavljeni literaturi glede vpliva na zdravstveno stanje starostnikov deljena. Pomembno je poudariti, da naj bi merila bila pomoč zdravnikom pri izbiri zdravljenja in ne kot zapoved. Prav tako so namenjeni uporabi v farmakoloških in epidemioloških študijah. Predlagani so načini, kako zmanjšati delež neprimernega predpisovanja zdravil.

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.1146/annurev.publhealth.25.050503.153958 16. Adang EM, Borm GF. Is there an association between economic performance and public satisfaction in health care? The European Journal of Health Economics, 2007; 8: 279–285. https://doi.org/10.1007/s10198-007-0045-6 17. Grol R, Wensing M, Mainz J, et al. Patients’ priorities with respect to general practice care: an international comparison. European Task Force on Patient Evaluations of General Practice (EUROPEP). Family practice. 1999; 16(1): 4–11. 18. Kersnik J. Bolnik v slovenskem zdravstvu. Monografija o zadovoljstvu bolnikov