Cost-outcome description of clinical pharmacist interventions in a university teaching hospital

Pattern of medication errors among inpatients in a resource-limited hospital setting

PURPOSE OF THE STUDY

There are limited studies on medication errors in South Asian and South East Asian regions. To bridge this gap, we assessed prescribing errors and selected medicine administration errors among inpatients, and the level of acknowledgement of prescribing errors by specialist physicians in a resource-limited hospital setting.

STUDY DESIGN

The study was conducted in two medical wards of a hospital in Sri Lanka. Prescribing errors were identified among medicines prescribed in the latest prescription of randomly selected inpatients. Medical notes, medication histories and clinic notes were information sources. Consistency of medicine administration according to prescribing instructions was assessed by matching prescriptions with medicine charts. The level of acknowledgement of prescribing errors by specialist physicians of study wards was assessed by questionnaire.

RESULTS

Prescriptions of 400 inpatients (2182 medicines) were analysed. There were 115 patients with at least one medication error. Among the 400 patients, 32.5% (n=130) were prescribing errors. The most frequent types of prescribing errors were 'wrong frequency' (10.3%, n=41), 'prescribing duplications' (10%, n=40), 'prescribing unacceptable medicine combinations' (6%, n=24) and 'medicine omissions' (4.3%, n=17). Medicine charts of 10 patients were inconsistent with prescribing instructions. Wrong medicine administration frequencies were common. The levels of acknowledgment of prescribing errors by the two specialist physicians were 75.5% and 90.9%, respectively.

CONCLUSIONS

Prescribing and medicine administration errors happen in resource-limited hospitals. Errors related to dosing regimen and failing to document medicines prescribed or administered to patients in their records were particularly high.

Pharmacist Intervention Program at Different Rent Levels of Geriatric Healthcare

As a pharmacy service giving pharmaceutical care at different levels of health care for elderly people, we needed a standardization procedure for recording and evaluating pharmacists' interventions. Our objective was to homogenize pharmacist interventions; to know physicians' acceptance of our recommendations, as well as the most prevalent drug related problems (DRP); and the impact of the pharmacists' interventions. To achieve this goal we conducted a one year prospective study at two levels of health care: 176 nursing homes (EAR) (8828 patients) and 2 long-term and subacute care hospitals (HSS) (268 beds). Pharmacists' interventions were recorded using the American Society of Health-System Pharmacists classification as the basis. Frequency of the different DRP and the level of response and acceptance on the part of physicians was determined. The Medication Appropriateness Index (MAI) was used to evaluate the impact of the interventions on the prescription quality. Patients' mean age was 84.2 (EAR) and 80.7 (HSS), and in both cases, polypharmacy ≥ 9 drugs was around 63-69%. There were 4073 interventions done in EAR and 2560 in HSS. Level of response: 44% (EAR), 79% (HSS); degree of acceptance of the recommendations: 84% (EAR), 72% (HSS). Most frequent DRP: inappropriate dose, length of therapy, omissions, and financial impact. Drugs for the nervous system are those with the most DRP. MAI values/medication improved from 4.4 to 2.7 (EAR) and 3.8 to 1.7 (HSS). A normalized way of managing pharmacists' interventions for different health care levels has been established. We are on the way to increasing collaborative work with physicians and we know which DRPs are most prevalent.

The effect of the TIM program (Transfer ICU Medication reconciliation) on medication transfer errors in two Dutch intensive care units: design of a prospective 8-month observational study with a before and after period

BACKGROUND

The transfer of patients to and from the Intensive Care Unit (ICU) is prone to medication errors. The aim of the present study is to determine whether the number of medication errors at ICU admission and discharge and the associated potential harm and costs are reduced by using the Transfer ICU and Medication reconciliation (TIM) program.

METHODS

This prospective 8-month observational study with a pre- and post-design will assess the effects of the TIM program compared with usual care in two Dutch hospitals. Patients will be included if they are using at least one drug before hospital admission and will stay in the ICU for at least 24 h. They are excluded if they are transferred to another hospital, admitted and discharged in the same weekend or unable to communicate in Dutch or English. In the TIM program, a clinical pharmacist reconciles patient's medication history within 24 h after ICU admission, resulting in a "best possible" medication history and presents it to the ICU doctor. At ICU discharge the clinical pharmacist reconciles the prescribed ICU medication and the medication history with the ICU doctor, resulting in an ICU discharge medication list with medication prescription recommendations for the general ward doctor. Primary outcome measures are the proportions of patients with one or more medication transfer errors 24 h after ICU admission and 24 h after ICU discharge. Secondary outcome measures are the proportion of patients with potential adverse drug events, the severity of potential adverse drug events and the associated costs. For the primary outcome relative risks and 95% confidence intervals will be calculated.

DISCUSSION

Strengths of this study are the tailor-made design of the TIM program and two participating hospitals. This study also has some limitations: A potential selection bias since this program is not performed during the weekends, collecting of potential rather than actual adverse drug events and finally a relatively short study period. Nevertheless, the findings of this study will provide valuable information on a crucial safety intervention in the ICU.

TRIAL REGISTRATION

Dutch trial register: NTR4159 , 5 September 2013.

Role of the pharmacist in reducing healthcare costs: current insights

Global healthcare expenditure is escalating at an unsustainable rate. Money spent on medicines and managing medication-related problems continues to grow. The high prevalence of medication errors and inappropriate prescribing is a major issue within healthcare systems, and can often contribute to adverse drug events, many of which are preventable. As a result, there is a huge opportunity for pharmacists to have a significant impact on reducing healthcare costs, as they have the expertise to detect, resolve, and prevent medication errors and medication-related problems. The development of clinical pharmacy practice in recent decades has resulted in an increased number of pharmacists working in clinically advanced roles worldwide. Pharmacist-provided services and clinical interventions have been shown to reduce the risk of potential adverse drug events and improve patient outcomes, and the majority of published studies show that these pharmacist activities are cost-effective or have a good cost:benefit ratio. This review demonstrates that pharmacists can contribute to substantial healthcare savings across a variety of settings. However, there is a paucity of evidence in the literature highlighting the specific aspects of pharmacists' work which are the most effective and cost-effective. Future high-quality economic evaluations with robust methodologies and study design are required to investigate what pharmacist services have significant clinical benefits to patients and substantiate the greatest cost savings for healthcare budgets.

Impact of pharmacist interventions on cost avoidance in an ambulatory cancer center

Objective

To provide a foundation to justify the presence of a full-time clinical pharmacist in the ambulatory cancer center in addition to an existing centralized pharmacist through cost avoidance calculation and patient and staff satisfaction surveys.

Methods

The prospective, pilot study took place in an ambulatory cancer center over four weeks in 2014. Cost avoidance values were assigned to interventions performed by a pharmacy resident, who was present in the ambulatory cancer center during clinic hours, along with a centralized oncology pharmacist routinely working with the cancer center. Anonymous patient and staff satisfaction surveys based on a 5-point Likert scale were distributed to assess the perceived benefit of a pharmacist located in the ambulatory cancer center.

Results

Data collection took place over approximately one month. After evaluation of 962 interventions from both pharmacists, the estimated cost avoidance was US$282,741 per pharmacist per year, yielding a net benefit of US$138,441. The most common interventions made by the resident included chemotherapy regimen review (n = 290, 69%) and patient counseling (n = 102, 24%), while the majority of the centralized pharmacist’s interventions was chemotherapy regimen review (n = 525, 97%). Results from the anonymous patient and staff surveys revealed an overall positive perception of the pharmacy resident while in the ambulatory cancer center.

Conclusion

A full-time clinical pharmacist in an ambulatory cancer center is both financially beneficial and positively perceived by patients and staff.

Evaluation of Clinical Pharmacists' Interventions in the Czech Republic

STUDY OBJECTIVES

To determine the frequency of interventions, categorized by type of intervention and therapeutic class, made by a team of four clinical pharmacists over a 1-year period, and to assess the potential economic impact of these interventions.

DESIGN

Prospective analysis.

SETTING

Large medical center in Prague, Czech Republic.

PATIENTS

A total of 9153 adults who were admitted to the general surgery, infectious diseases, oncology, orthopedics, and thoracic surgery and respiratory medicine services between January 1, 2014, and December 31, 2014.

INTERVENTION

Four clinical pharmacists reviewed patients' medication profiles, participated in medical and surgical rounds, and made drug therapy-related recommendations to physicians.

MEASUREMENTS AND MAIN RESULTS

Clinical pharmacists' interventions were categorized by therapeutic class and divided into eight types: introduction of a drug, discontinuation of a drug, dosage change, route of administration change, recommendation to continue therapy, recommendation to perform further evaluation (e.g., laboratory assessment), reintroduction of a missing medication, and therapeutic drug monitoring (request to measure a drug concentration and provide its interpretation). All interventions accepted by the attending physicians were recorded by using a software application. For the evaluation of the economic impact of the interventions, published statistical data were used from the Institute of Health Information and Statistics of the Czech Republic. During the 1-year period, the clinical pharmacists performed 1916 interventions. The most frequent intervention was drug discontinuation (27.9% of all interventions), and the drug category with the highest frequency of interventions was central nervous system drugs (25.1%). All interventions were accepted by the physicians. For the evaluation of potential economic impact, a select group of drugs was used, representing 14.4% of the interventions. The benefit:cost ratio was 3:1.

CONCLUSION

All interventions made by clinical pharmacists were accepted by the physicians. Drug discontinuation was the most frequent intervention. The analysis of potential economic savings showed the positive impact of these interventions, with a benefit:cost ratio of 3:1.

Effect of pharmacist intervention on physician prescribing in patients with chronic schizophrenia: a descriptive pre/post study

BACKGROUND

Although pharmacotherapy is one of the most important treatments for schizophrenia, the prominent levels of antipsychotic polypharmacy and high-dose regimens used in Japan are thought to be inconsistent with treatment regimens used in other countries. In this study, we evaluated the effect of pharmacist intervention on physician prescribing in patients with chronic schizophrenia.

METHODS

Participants comprised 52 inpatients at Sawa Hospital (Osaka, Japan), treated with at least one antipsychotic agent, who received pharmacist intervention for 1 year (2012). We compared the dose and the number of antipsychotics prescribed, and the rate of concurrent prescribing of anti-Parkinson, benzodiazepine and mood-stabilizer medication, pre- and post-pharmacist intervention. As an indicator of psychosis symptoms, the rate of seclusion room use was recorded. Additionally, we evaluated the impact of pharmacist intervention on medicine costs. Continuous variables were analyzed by Wilcoxon signed-rank sum tests, and categorical data were analyzed using Fisher's exact tests.

RESULTS

Compared with pre-intervention, the dose (982.6 mg pre vs. 857.6 mg post; p < 0.01) and the number of antipsychotics (2.0 pre vs. 2.0 post; p < 0.05) at 1 year were significantly lower post-intervention. The seclusion room use rate was not significantly different but tended to be lower post-intervention than pre-intervention (p < 0.1). The cost (in USD) for all medicines (10.33 pre vs. 8.76 post; p < 0.05), antipsychotics (8.04 pre vs. 6.48 post; p < 0.05), and psychotropics (9.24 pre vs. 7.68 post; p < 0.01) were significantly lower post-intervention than pre-intervention.

CONCLUSION

Pharmacist intervention has the potential to optimize medication prescribing and reduce medication costs in patients with chronic schizophrenia. It might be suggested that clinical practitioners as well as medical hospital administrators consider the pharmacists' ability to rationalize medication therapy in schizophrenia.