Vol 7, Issue 4, 2014 ISSN - 0974-2441

Review Article

DRUG RELATED PROBLEMS: AN OVER VIEW OF VARIOUS CLASSIFICATION SYSTEMS

ADUSUMILLI PK, ADEPU R
Department of Pharmacy Practice, JSS College of Pharmacy, JSS University, Mysore-570 015,
Karnataka, India. Email: adepu63@gmail.com
Received: 23 April 2014, Revised and Accepted: 16 May 2014

ABSTRACT

Identification and resolving the drug related problems (DRPs) in the prescriptions is the core activity in pharmaceutical care. Suitable classification
of DRPs is a vital element in pharmaceutical care practice and research. Different DRP classification systems are published in the literature in various
international journals. About fourteen different classifications on DRPs were found published with a different focus. Some classifications were
hierarchical, categorized into main groups and subgroups. Various terminologies and definitions for DRPs, as well as guidelines for an optimal DRPs
classification, were given. In this review, an effort was made to give a general idea about definition and classifications of DRPs. This knowledge may
assist the pharmacy practitioner to identify, classify and resolve the DRP and useful for researchers.

Keywords: Drug-related problems, Pharmaceutical care.

INTRODUCTION performed using these categories on various patient populations.
However, these studies focused on one selected patient group or on
A rational, safe and cost effective drug treatment depends on competent
one or only a few categories of DRPs. Because of such differences in
diagnosing, prescribing, effective monitoring and evaluation of drug
methodology and the use of different definitions on the DRPs concept,
therapy, patient understanding and compliance in relation to the
the frequency and type of DRPs among various patient groups, were
prescribed medication. Clinical pharmacist initiatives may contribute
found to define. Knowledge on possible differences between the
significantly to each of these objectives assuring a safe and effective
guidelines and patient groups plays an important role in detecting and
medication use. Evidences have documented pharmacist’s role in
preventing the DRPs. The aim of this review is to identify the different
hospital settings in identifying and resolving clinically significant
classifications of DRPs and discusses their suitability for documenting
drug-related problems (DRPs). Pharmacists’ role is much appreciated
DRPs in pharmaceutical care [3].
in improving medication adherence behavior in patients through
suitably designed one to one-education strategies. Their efforts are also
DRP CLASSIFICATIONS PUBLISHED IN LITERATURE
recognized in reducing the incidence of preventable adverse events,
thereby improving cost effectiveness and decreasing the length of Various classifications were published in the literatures regarding
hospital stay. definition and classification of DRPs. The published literature on DRPs
was reviewed systematically, and the following classifications were
DRP is defined as an event that may potentially affect the health found suitable for review and interpret.
outcomes in the patients. DRPs can occur at all stages of the medication
usage process starting from prescribing to dispensing stage. Lack The ABC of DRPs
of follow-ups and reassessment of therapeutic outcomes may also In 2000, Meyboom et al. published a basic system for DRPs seen from
contribute to DRPs. Pharmaceutical care is a co-operative activity in a pharmacovigilance viewpoint. It is primarily for use in the WHO and
concert with other health care professionals and offered directly to the focuses on side effects and adverse reactions. Each category has its own
patient for improved quality use of medicines and achieving achieve definition, but a general definition for DRPs was not given [4].
the desired therapeutic outcomes. Pharmaceutical care identifies and a. Type A (drug actions) adverse effects
resolves actual or potential DRPs [1]. b. Type B (patient reactions) adverse effects
c. Type C (statistical) adverse effects.
DRPs pose a challenge to the clinician, and that may affect patient’s
clinical outcomes and may result in morbidity or mortality and
increased health care costs. Health care costs may become a burden to American Society of Hospital Pharmacists (ASHP) classification
the patient or may be to the government or to the third parties. Clinical 1996
Pharmacy is a discipline that promotes the quality use of medicines In 1993, the ASHP accepted a statement in which a crude classification
through evidence-based medicine and helps in identification and of DRPs was proposed, although it was not named as such. In 1996, in a
resolving DRPs. A clinical pharmacist through his/her clinical accuracy guideline for a standardized method for pharmaceutical care, the ASHP
checking may identify DRPs and come out with suitable solutions to published a more detailed classification. DRPs were then defined as
resolve the same. In overseas these services are provided in different “medication-therapy problems.”
settings like nursing homes and tertiary care hospitals [2]. Number of
DRPs identified and resolved is a criterion to gaze the competency of The statement of 1993 was reviewed again in 1998, and a medication-
the pharmacists. related problem was defined as “…an event or circumstance involving
medication therapy that actually or potentially interferes with an
Many authors have tried to define DRPs. Summating their opinions, optimum outcome for a specific patient.” In this classification, the DRPs
DRPs may be defined as “an event or circumstance involving drug were classified as follows [5]:
therapy that actually or potentially interferes with desired health i. Medication with no indication
outcomes.” Based on the published literature, DRPs may be subdivided ii. Condition for which no drug is prescribed
into various categories. To validate these classifications, studies were iii. Medication prescribed inappropriately for a particular condition

Repeat prescription no longer required • Patient uses medicines that he does not need. Drug xii. Indication vii. Based upon the definition. • Patient uses dose. iv. or duration inferior to the one needed.14]. Need for additional therapy iv. Correct direction xi. the DRPs were classified as follows: iii. published in 1999. Duplication Cipolle/Morley/Strand classification ix. Over dosage iii. understood i. can only be employed when the event has already been experienced by the Definition: An event or circumstance involving a patient’s drug patient [6. Monitoring issues for different causes. was based upon key elements identified or method of administration from the literature and clinical experience.” focuses on negative clinical outcomes rather than on health problems of the patient in general. Actual and potential drug–drug. Expense. Failure to receive the full benefit of prescribed therapy iv. in turn. dosage form. classification based upon her own needed findings on a random sample of 50 patients with one or more DRPs. Inappropriate dose.9]. pharmaceutical care need which is addressed by the pharmacist [13. Adherence problem. either do not accomplish therapy objectives or iii. Failure to receive drugs ii. The classification is in use in many With their seminal publication on pharmaceutical care. In the wording. vii. They have used the term “pharmaceutical care the latter system. Dosage is too low vii. The MAI has been used in v. Potential/suspected adverse reactions as negative clinical outcomes.. Definition: Any undesirable event experienced by the patient that involves or is suspected to involve drug therapy and that actually or In this classification. and i. this classification seems to As per Krska et al. Krska et al. Untreated indication i. Lack of understanding of the medication vi. including problems in the whole drug therapy chain. viii. Drug use without indication. Practical directions xii. experience or is likely to experience either a disease or symptom having This tool for assessing a medication is based upon taxonomy of an actual or suspected relationship with drug therapy. Dosage x. Dose is too high vii. “DRP. Hepler and community pharmacies in the US to evaluate pharmacists’ activities Strand also introduced several categories of DRPs. Effectiveness ix. Krska et al. system During a drug-use evaluation study. 8 . Like the Hanlon system. Drug–disease interaction viii. Drug–drug interaction xiii. developed a classification Granada consensus based upon the DRPs they encountered during a research project in In 1998. No indication • Patient does not use the medicines needed viii. and • Patient uses an agent that causes an adverse reaction. i. In drug-use evaluation.” Hanlon approach Hanlon et al. She appalled her classification as “clinical DRPs. does not seem to include potential DRPs and. Actual and potential adverse drug events of drug therapy is given [10. Indication drug–laboratory test interactions that are clinically significant ii. Wrong drug vi.11]. from the patient’s Hepler–Strand classification perspective. therefore. a clinical DRP is considered to exist when a patient of medication based on the medication appropriateness index (MAI). Prescribing of medication to which the patient is allergic their classification is included here. Failure of the patient to adhere to the regimen. 2014 iv. Adverse drug reaction viii. Education required v.7]. vi. or duration greater than the one Mackie adapted the Cipolle et al. a group of Spanish experts reached a consensus on the 332 patients. pharmaceutical care issue is an element of focus ultimately on the patient’s behavior. have developed a method for assessing the appropriateness As per Mackie. potential problems were excluded. Issue 4. Duration These authors used the term “drug-therapy problem” rather than x. schedule. route of administration.” This concept generally refers to a system approach. or may cause. Effectiveness x. used the resulting classification for her own research. Therapeutic duplication several studies. their classification is based upon definition and analysis of DRPs. in their daily provision of pharmaceutical care. interval. Improper drug selection In this classification. ix. Potential ineffective therapy produce undesirable effects. drug–disease. Potential drug–disease interaction iii. Vol 7. treatment that actually or potentially interferes with the achievement of an optimal outcome. Other. and the definition issue. Their definition problems and causes were not separated [12]. Unnecessary therapy v. Adusumilli and Adepu Asian J Pharm Clin Res. resulting from pharmacotherapy that ii. Problems are arising from the financial impact of therapy v. Drug interactions v. Interference with medical therapy by social or recreational drug use iii. the DRPs were classified as follows: potentially interferes with a desired patient outcome. which was further revised in 2002. As inappropriate medication is. Safety Mackie classification • Patient uses a dose. Discrepancy between doses prescribed and used • Patient uses an erroneously chosen. drug–nutrient. interval. Subtherapeutic dosage i. In this classification the DRPs were classified as follows: Definition: Drug Therapy Problems are health problems. vi. Inappropriate duration of therapy ii. a DRP. In this approach. iv. but no definition of appropriateness vii. potential problems were excluded [8. Adverse reactions iv. inappropriateness that. Inappropriate dosage regimen In this classification the DRPs were classified as follows: vi. xi. Untreated indications ii.

the DRPs were classified as follows: National Coordinating Council for Medication Error Reporting and i. Therapy failure desired health outcomes [18]. assessment. but each updated version is In this classification. solutions are classified separately. Question about drug use (dosage/advice/way of use) v. Contraindication Problem–intervention documentation (PI-Doc) ix. The medication is in control of the health care professional. but does not SHB-SEP classification provide clear intervention taxonomy. The subcategories indicate the causes of a DRP [19. Wrong dosage form iv. Monitoring error (includes contraindicated drugs) x. It is currently in use in projects conducted i. or consumer. Monitoring required modified format. the Westerlund system underwent minor on their drug therapy. Information request (general/disease/complaint/disorder) ix. This hierarchical system comprises separate codes for problems. 2014 As per this classification. Issue 4. Adverse effect 9 . ii. or consumer. xi.0) current definition upon which the classification is based is shown as a The original classification was created in 1999 by pharmacy practice DRP is a circumstance related to the patient’s use of a drug that actually researchers during a working conference of the PCNE in an effort or potentially prevents the patient from gaining the intended benefit of to develop a standardized classification system that is suitable the drug [22. Improper dose opinion) iv. Dosing problem iv. Inappropriate formulation/delivery since then been used in several pharmaceutical care studies. Drug duplication iii.23]. It has xiii. Appropriateness i. non-preventable DRPs are not categories comprise both a patient- and pharmacy-oriented perspective. Wrong patient ix. Worries about complications/adverse reactions vi. Admitted non-adherence classification was used in a study conducted in Denmark in a slightly xv. Evaluation without patient consultation. Obviously. vii. the DRPs were classified as follows: not sequentially numbered to facilitate differentiation from previous i. The system includes an intervention classification and a manual for its use. The system is still being revised regularly. While the for use in pharmacy software’s based on the medical Subjective/ definition seems promising. No indication apparent iii. Wrong route of administration vi. and comparable for international studies. Alterations in prescription (not based on medication-surveillance xi. Ineffective therapy emphasis on the user-friendliness in community pharmacy practice. Wrong drug iii. Drug–drug interaction As per PCNE classification system. however. Drug use/administration problem v. causes. Untreated indication iv. Contraindication involving drug therapy that actually or potentially interferes with v. Wrong strength/concentration ii. This system no longer exists due to its inability to support in the classification of DRPs [17]. Inappropriate dose/dosing schedule been implemented in most German pharmacy-software systems. Adverse reaction vi. the DRPs were classified as [15]: In this classification the DRPs were classified as follows: i. Unsuitable dosage preventable event that may cause or lead to inappropriate medication iv. Deteriorated drug error (dispensing drug that has expired) xv. Safety v. not to classify DRPs. ii. patient. Miscellaneous. Wrong time signal) xii. and amendments. Wrong technique (includes inappropriate crushing of tablets) v. Prior to incorporation into the nationwide Swedish community The PAS coding originally was developed to document patients’ questions pharmacy software in 2001. Unnecessary therapy ii. Advice on medical aids viii. Problems. Adusumilli and Adepu Asian J Pharm Clin Res. Evaluation as result of a consultation by invitation xiii. Effectiveness A hierarchical system for PI-Doc was developed in Germany with an x. Vol 7. Patient initiative doubts or insufficient understanding (also second iii. The Pharmaceutical Care Network Europe (PCNE) system (version 4. whereas the medication is in control of the health v. Inappropriate choice of therapy The classification was first used in a study published in 1995 and has xii. Wrong duration viii. NCC-MERP separates the problem from the causes. patient. Adverse reaction(s) ii. vi. Wrong rate (probably relating to administration) vii. Drug choice problem iii. The main problem in a non-ambulatory setting. Clinically significant drug interaction viii.20]. Uncertainty about aim of the drug in Sweden and the UK. included [16]. Dose omission i. Unsuitable drug choice Prevention (NCC-MERP) taxonomy of medication errors ii. Drug–drug interactions use or patient harm. Pharmacy team initiative administration x. Unsuitable use by the patient This hierarchical classification by the NCC-MERP defines DRP as iii. All DRP and intervention categories are clearly defined. Self-care advice vii. Other. xiv. The error section includes errors The Health Base Foundation developed this system in The Netherlands (potential DRPs) that do not become relevant for the patient. the S and O codes oriented and focuses especially on administration of parenteral drugs have been combined into one problem description. a DRP is an event or circumstance iv. Other. The xiv. vi. versions [21]. the classification seems mainly process Objective/Evaluation/Plan structure. In this classification. Westerlund system This system was developed as part of a PhD thesis and was first used in PAS coding system 1996. and interventions and In this classification the DRPs were classified as follows: is hierarchically structured. xvi. Other. Interactions vi. Adverse reactions care professional.

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