Online supplementary table S6.
Example of quality indicators classified according to causes of drug related problems classification system
Category
1. Drug selection
The (potential) cause of the
DRP is related to the
intentional selection of the
drug, generally by the health
care professional.
2. Drug form
3. Dose selection
Sub-category
Inappropriate drug due to
contraindication,
ineffectiveness, regimen
(regular rather than “when
required") or safer alternative
available
No indication for drug
Inappropriate combination of
drugs, or drugs and food, or
drugs and alcohol
Indication not treated/missing
therapy
More cost-effective drug
available
Synergistic/preventive drug
required and not given
Inappropriate or suboptimal
drug form
Drug dose too low
Drug dose too high
Dosage regimen not frequent
enough
Dosage regimen too frequent
Ex. Classified quality indicators
Numerator: Use of a long-acting benzodiazepine (e.g., diazepam, chlordiazepoxide, etc.)
Denominator: 1. Over 65 years of age, 2. History/diagnosis of depression1
Numerator: Number of patients older than 1 year diagnosed with acute upper respiratory infection
prescribed antibacterials for systemic use
Denominator: Number of patients older than 1 year diagnosed with acute upper respiratory infection2
Prescription of verapamil to a patient who is also receiving a beta-blocker3
Numerator: Acute myocardial infarction (AMI) patients who are prescribed aspirin at hospital discharge
Denominator: AMI patients alive at discharge4
Compared with alternative treatments in the same therapeutic class, which are just as safe and effective,
the drug prescribed is either one of the cheapest or a valid reason is given for using an alternative5
IF a person aged 65 or older has no history of anaphylactic hypersensitivity to eggs or to other
components of the influenza vaccine, THEN the patient should be offered an annual influenza
vaccination6
Numerator: Number of patients treated in an emergency department (ED) with intramuscular
epinephrine (or IV for cardiovascular collapse or intramuscular refractory)
Denominator: Total number of patients with anaphylaxis treated with epinephrine in ED by any route7
IF oral pharmacological therapy for osteoarthritis in an elder is changed from paracetamol
(acetaminophen) to a different oral agent, THEN there should be evidence that the patient has had a trial
of maximum dose of paracetamol suitable for age and co-morbid conditions8
Numerator: The number of patients who were dispensed a dose of a biguanide higher than the daily
recommended dose
Denominator: Patients 18 years and older who were dispensed one or more prescriptions for a biguanide
during the measurement year2
Numerator: Is receiving prn dosing only
Denominator: 1. Over 65 years of age, 2. Patient has chronic pain, 3. Is receiving an analgesic
medication (NSAID or opioid)9
(Asthma primary care) Number (or %) of beta2-agonist-free days in last 4 weeks10
(Continues)
1
Online supplementary table S6. (Continued)
Category Sub-category
3. Dose selection
(Continued)
4. Treatment duration
5. Drug use process
The (potential) cause of the
DRP can be related to the
way the patient selects or
uses the drug, or the way in
which it is administered. This
is generally due to low health
literacy, a misunderstanding,
misperception or an
idiosyncratic thought process
by the patient/carer/health
care professional, but may be
due to adequate information
not being provided, or
directions that cause the
patient to administer the drug
incorrectly
Deterioration/improvement of
disease state requiring dosage
adjustment
Dosage instructions unclear,
incomplete, or not understood
by patient/carer
Duration of treatment too
short
Duration of treatment too long
Inappropriate timing of
administration and/ or dosing
intervals by patient/carer/nurse
Drug
underused/underadministered
Drug
overused/overadministered
Drug not taken/administered at
all
Wrong drug selected, taken, or
administered
Drug abused
Patient, carer, or nurse unable
to use/does not use drug/form
as directed
Adequate information not
provided or not understood or
misunderstood or not followed
Ex. Classified quality indicators
Numerator: Number of patients with INR above 4 whose dosage has been adjusted or reviewed prior to
the next warfarin dose
Denominator: Number of patients with INR above 4 in sample11
IF a homebound patient is being treated for depression with antidepressants, THEN the antidepressants
should be prescribed at appropriate starting doses, and they should have an appropriate titration schedule
to a therapeutic dose, therapeutic blood level, or remission of symptoms by 12 weeks12
Numerator: Patients who were administrated at least four cycles of adjuvant chemotherapy
Denominator: Breast cancer patients who received adjuvant chemotherapy13
(Medication Use) IF a vulnerable elder receives prescription pharmacological treatment for back or neck
pain, THEN cyclobenzaprine, methocarbamol, carisoprodol, chlorzoxasone, orphenadine, tizanidine, or
metaxolone should not be prescribed for >1 week14
Numerator: Patients with AMI who received fibrinolytic therapy within 30 min after hospital arrival
Denominator: AMI patients ST-segment elevation or left bundle branch block on electrocardiogram
(ECG) and fibrinolytic therapy within 12 h after onset and age, 754
Numerator: The number of patients who met the Proportion of Days Covered (PDC) threshold of 80%
during the measurement year
Denominator: Patients 18 years and older who filled at least two prescriptions for a sulfonylurea or
sulfonylurea combination on two unique dates of service during the measurement period2
(Follow up of pharmacotherapy guidelines) Percentage of triptan users without overuse within all triptan
users15
No QI identified
No QI identified
No QI identified
Numerator: Patients who underwent a dysphagia screening process before taking any foods, fluids or
medication by mouth
Denominator: All patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial
hemorrhage who receive any foods, fluids or medication by mouth2
Numerator: Number of patients with an indication of adequate inhaler technique in the past six months
Denominator: Number of children with a verification of the technical inhaler16
(Continues)
2
Online supplementary table S6. (Continued)
Category Sub-category
5. Drug use process
(Continued)
6. Logistics
The (potential) cause of the
DRP can be related to the
logistics of the prescribing,
dispensing, manufacturing or
administering process
7. Monitoring
8. Unexpected or adverse
drug reactions or no
obvious cause of DRP
9. Other – A cause that
cannot be classified into one
of the 8 categories
Patient uses or stores drug
inappropriately
Prescribed drug not available
Drug order incorrect,
incomplete, poorly
legible/illegible or discrepant
(also known as transferring
Error in drug selection
Monitoring too frequent
No or too infrequent
monitoring
Inappropriate test ordered
Patient unable to attend/pay
for monitoring
An adverse drug reaction
occurred
No obvious cause of treatment
failure
Ex. Classified quality indicators
No QI identified
The availability of a nebuliser for administration of Salbutamol17
Numerator: Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist, or
registered nurse on or within 30 days of discharge
Denominator: Discharges for patients age 66 years and older as of December 31 of the measurement
year who had an acute or nonacute inpatient discharge on or between January 1 and December 1 of the
measurement year2
(Logistics) Number of dispensed expired medication that was reported by the patient and thus was
noticed after dispensing15
No QI identified
Numerator: Hemoglobin A1c level not measured at least every 6 months
Denominator: 1. Over 65 years of age, 2. Use of a long-acting antihyperglycemic agent (eg,
chlorpropamide)9
Numerator: Number of patients taking regular antipsychotic medicines who receive appropriate
monitoring for development of metabolic side effects
Denominator: Number of patients receiving regular antipsychotic medicines11
No QI identified
Numerator: Number of patients with severe opioid-related constipation or fecal impaction
Denominator: Number of all patients aged greater than or equal to 65 years receiving opioid treatment
for pain2
No QI identified
(Medication Use) ALL vulnerable elders should have an up-to-date medication list readily available in
the medical record, accessible by all healthcare providers, and including over-the-counter medications14
3
REFERENCES
1 Mackinnon NJ, Hepler CD. Preventable drug-related morbidity in older adults 1. Indicator
development. J Manag Care Pharm 2002;8:365-71.
2 Quality AfHRa. National Quality Measures Clearinghouse: U.S. Department of Health & Human
Services; 2017 [accessed 5 May 2017]. Available from:
https://www.qualitymeasures.ahrq.gov/.
3 Spencer R, Bell B, Avery AJ, et al. Identification of an updated set of prescribing-safety indicators
for GPs. Br J Gen Pract 2014;64:e181-e90.
4 Sun H, Liu M, Hou S. Quality indicators for acute myocardial infarction care in China. Int J Qual
Health Care 2011;23:365-74.
5 Cantrill JA, Sibbald B, Buetow S. Indicators of the appropriateness of long-term prescribing in
general practice in the United Kingdom: consensus development, face and content validity,
feasibility, and reliability. Qual Health Care 1998;7:130-5.
6 Steel N, Melzer D, Shekelle PG, et al. Developing quality indicators for older adults: transfer from
the USA to the UK is feasible. Qual Saf Health Care 2004;13:260-64.
7 Stang AS, Straus SE, Crotts J, et al. Quality indicators for high acuity pediatric conditions.
Pediatrics 2013;132:752-62.
8 Wierenga PC, Klopotowska JE, Smorenburg SM, et al. Quality Indicators for In-Hospital
Pharmaceutical Care of Dutch Elderly Patients. Drugs Aging 2011;28:295-304.
9 Robertson HA, MacKinnon NJ. Development of a list of consensus-approved clinical indicators of
preventable drug-related morbidity in older adults. Clin Ther 2002;24:1595-613.
10 Teresato, Guttmann A, Lougheed MD, et al. Evidence-based performance indicators of primary
care for asthma: A modified RAND Appropriateness Method. Int J Qual Health Care
2010;22:476-85.
11 Australian Commission on Safety and Quality in Health Care and NSW Therapeutic Advisory
Group Inc. National Quality Use of Medicines Indicators for Australian Hospitals Sydney:
ACSQHC; 2014 [accessed 5 May 2017]. Available from:
https://www.safetyandquality.gov.au/wp-
content/uploads/2014/11/SAQ127_National_QUM_Indicators_V14-FINAL-D14-39602.pdf.
12 Smith KL, Soriano TA, Boal J. Brief communication: National quality-of-care standards in home-
based primary care. Ann Intern Med 2007;146:188-92.
13 Bao H, Yang F, Wang X, et al. Developing a set of quality indicators for breast cancer care in
China. Int J Qual Health Care 2015;27:291-96.
14 Wenger NS, Roth CP, Shekelle P, et al. Introduction to the assessing care of vulnerable elders-3
quality indicator measurement set. J Am Geriatr Soc 2007;55:S247-52.
15 Teichert M, Schoenmakers T, Kylstra N, et al. Quality indicators for pharmaceutical care: a
comprehensive set with national scores for Dutch community pharmacies. Int J Clin Pharm
2016;38:870-79.
16 Ruiz-Canela-Caceres J, Aquino-Llinares N, Sanchez-Diaz JM, et al. Indicators for childhood
asthma in Spain, using the Rand method. Allergol Immunopathol (Madr) 2015;43:147-56.
17 Ntoburi S, Hutchings A, Sanderson C, et al. Development of paediatric quality of inpatient care
indicators for low income countries - a Delphi study. BMC Pediatr 2010;10.