Pharmacist- Versus Physician-Initiated Admission Medication Reconciliation: Impact on Adverse Drug Events

[Ward-based clinical pharmacists in intensive care medicine: an economic evaluation]

BACKGROUND

The positive impact of pharmaceutical care in improving medication safety is considered proven. Little is known about the economic benefit of clinical pharmaceutical services in Germany.

OBJECTIVE

In 2020, a pilot project was started at the Ernst von Bergmann Hospital to introduce ward-based clinical pharmacists in intensive care medicine, also in order to determine the economic benefit of the medication management offered.

METHODS

By a team of experienced intensive care physicians and clinical pharmacists on the basis of a consensus principle, each pharmaceutical intervention (PI) was assigned a probability score (Nesbit probability score) with which an adverse drug event (ADE) would have occurred. Assuming that each ADE results in an increased length of stay, the costs of intensive care treatment/day were used as potential savings. The model thereby combines the findings of two international publications to enable an economic analysis of pharmaceutical services.

RESULTS

During the study period, 177 pharmaceutical interventions were evaluated and corresponding probability scores for the occurrence of ADE were determined. From this, annual savings of € 80,000 through avoided costs were calculated.

CONCLUSION

In this project, the economic benefit of pharmaceutical services in intensive care medicine was proven. Ward-based clinical pharmacists are now an integral part of the intensive care treatment team at the Ernst von Bergmann Hospital.

Involvement of Pharmacists in the Emergency Department to Correct Errors in the Medication History and the Impact on Adverse Drug Event Detection

(1) Incomplete or wrong medication histories can lead to missed diagnoses of Adverse Drug Effects (ADEs). We aimed to evaluate pharmacist-identified ED errors in the medication histories obtained by physicians, and their consequences for ADE detection. (2) This prospective monocentric study was carried out in an ED of a university hospital. We included adult patients presenting with an ADE detected in the ED. The best possible medication histories collected by pharmacists were used to identify errors in the medication histories obtained by physicians. We described these errors, and identified those related to medications involved in ADEs. We also identified the ADEs that could not have been detected without the pharmacists' interventions. (3) Of 735 patients presenting with an ADE, 93.1% had at least one error on the medication list obtained by physicians. Of the 1047 medications involved in ADEs, 51.3% were associated with an error in the medication history. In total, 23.1% of the medications involved in ADEs were missing in the physicians' medication histories and were corrected by the pharmacists. (4) Medication histories obtained by ED physicians were often incomplete, and half the medications involved in ADEs were not identified, or were incorrectly characterized in the physicians' medication histories.

Adverse Drug Events Detected by Clinical Pharmacists in an Emergency Department: A Prospective Monocentric Observational Study

OBJECTIVES

Adverse drug events (ADEs) are a major public health issue in hospitals. They are difficult to detect because of incomplete or unavailable medication history. In this study, we aimed to assess the rate and characteristics of ADEs identified by pharmacists in an emergency department (ED) to identify factors associated with ADEs.

METHODS

In this prospective observational study, we included consecutive adult patients presenting to the ED of a French 2600-bed tertiary care university hospital from November 2011 to April 2015. Clinical pharmacists conducted structured interviews and collected the medication history to detect ADEs (i.e., injuries resulting directly or indirectly from adverse drug reactions and noncompliance to medication prescriptions). Unsure ADE cases were reviewed by an expert committee. Relations between patient characteristics, type of ED visit, and ADE risk were analyzed using logistic regression.

RESULTS

Among the 8275 included patients, 1299 (15.7%) presented to the ED with an ADE. The major ADE symptoms were bleeding, endocrine problems, and neurologic disorders. Moreover, ADEs led to the ED visit, hospitalization, and death in 87%, 49.3%, and 2.2% of cases, respectively. Adverse drug event risk was independently associated with male sex, ED visit for neurological symptoms, visit to the ED critical care unit, or ED short stay hospitalization unit, use of blood, anti-infective, antineoplastic, and immunomodulating drugs.

CONCLUSIONS

This study improves the knowledge about ADE characteristics and on the patients at risk of ADE. This could help ED teams to better identify and manage ADEs and to improve treatment quality and safety.

Medication Errors at Hospital Admission and Discharge: Risk Factors and Impact of Medication Reconciliation Process to Improve Healthcare

OBJECTIVE

First, the aim of the study was to assess the prevalence, characteristics, and severity of unintended medication discrepancies (UMDs) and medication errors (MEs) at admission and discharge of hospitalization. Second, the aim of the study was to identify clinical and hospitalization factors associated with risk of UMDs as well as characteristics of the medication reconciliation process associated with UMDs detection.

METHODS

This prospective observational study included all adult patients admitted from 2013 to 2015 in the Endocrinology-Diabetology-Nutrition Department of Montpellier Hospital, France. Clinical pharmacists conducted medication reconciliation by collecting the best possible medication history from different sources and comparing it with admission and discharge prescriptions to identify discrepancies. Unintended medication discrepancies corrected by the physician were considered as MEs. Risk factors of UMDs were identified with logistic regression.

RESULTS

Of 904 patients included, 266 (29.4%) had at least one UMD, at admission or at discharge. In total, 378 (98.2%) of 385 UMDs were considered to be MEs. Most MEs were omissions (59.3%). Medication errors were serious or very serious in 36% of patients and had potentially moderate severity in almost 40% of patients. The risk of UMDs increased constantly with the number of treatments (P < 0.001). Thyroid (adjusted odds ratio [OR] = 1.79, 95% CI = 1.12-2.86) and infectious diseases (adjusted OR = 1.80, 95% CI = 1.17-2.78) were associated with UMDs risk at admission. The best type of source for the detection of UMDs was the general practitioner or nurse (OR = 2.64, 95% CI = 1.51-4.63).

CONCLUSIONS

Unintended medication discrepancies are frequent at hospital and depend on intrinsic clinical parameters but also on practice of medication reconciliation process, such as number and type of sources used.

Development and validation of a score to assess risk of medication errors detected during medication reconciliation process at admission in internal medicine unit: SCOREM study

BACKGROUND

Medication errors (ME) can be reduced through preventive strategies such as medication reconciliation. Such strategies are often limited by human resources and need targeting high risk patients.

AIMS

To develop a score to identify patients at risk of ME detected during medication reconciliation in a specific population from internal medicine unit.

METHODS

Prospective observational study conducted in an internal medicine unit of a French University Hospital from 2012 to 2016. Adult hospitalised patients were eligible for inclusion. Medication reconciliation was conducted by a pharmacist and consisted in comparing medication history with admission prescription to identify MEs. Risk factors of MEs were analysed using multivariate stepwise logistic regression model. A risk score was constructed using the split-sample approach. The split was done at random (using a fixed seed) to define a development data set (N = 1256) and a validation sample (N = 628). A regression coefficient-base scoring system was used adopting the beta-Sullivan approach (Sullivan's scoring).

RESULTS

Pharmacists detected 740 MEs in 368/1884 (19.5%) patients related to medication reconciliation. Female gender, number of treatments >7, admission from emergency department and during night or weekend were significantly associated with a higher risk of MEs. Risk score was constructed by attributing 1 or 2 points to these variables. Patients with a score ≥3 (OR [95% CI] 3.10 [1.15-8.37]) out of 5 (OR [95% CI] 8.11 [2.89-22.78]) were considered at high risk of MEs.

CONCLUSIONS

Risk factors identified in our study may help prioritising patients admitted in internal medicine units who may benefit the most from medication reconciliation (ClinicalTrials.gov number NCT03422484).

[How complete is the Germany-wide standardised medication list ("Bundeseinheitlicher Medikationsplan")? An analysis at hospital admission.]

Einleitung  Bei stationärer Aufnahme scheint die Aktualität und Vollständigkeit des Bundeseinheitlichen Medikationsplans häufig nicht gegeben. Ebenso ist unklar, welche Charakteristiken der Pläne die Wahrscheinlichkeit für Diskrepanzen erhöhen.

Methoden  Retrospektiv wurden deshalb 100 Pläne, die zur Arzneimittelanamnese elektiver Patienten einer chirurgischen Klinik mitgebracht wurden, geprüft, ob und welche Abweichungen bestanden. Die Abweichungen wurden 7 Kategorien zugeordnet: Arzneimittel, das in der Anamnese erfasst wurde, fehlt auf dem Plan, Arzneimittel auf dem Plan wird nicht mehr eingenommen, Stärke oder Dosierung fehlt auf dem Plan bzw. ist falsch oder die Darreichungsform ist falsch dokumentiert. Hinweise zur Arzneimitteltherapiesicherheit, involvierte Arzneimittel und -formen wurden ebenfalls erfasst. Mithilfe multivariater Analysen wurde der Einfluss der Aktualität, der Anzahl der Arzneimittel und der ausstellenden Facharztdisziplin der Pläne auf die Art und Anzahl an Diskrepanzen untersucht.

Ergebnisse  Zur Arzneimittelanamnese wiesen 78 % (78/100) der Pläne Abweichungen auf. Insgesamt wurden 226 Abweichungen (2,3 ± 0,6 Abweichungen/Anamnese) dokumentiert. Am häufigsten fehlte ein Arzneimittel auf dem Plan (n = 103). Von allen Hinweisen und Empfehlungen betrafen 64 % (83/177) das perioperative Management von Antithrombotika (n = 55) und Antidiabetika (n = 28). In der multivariaten Analyse stieg nur das Risiko für fehlerhafte Angaben bei Stärke und Dosierung mit dem Alter der Pläne signifikant (p = 0,047) und war um mehr als das 2-fache erhöht, wenn der Plan älter als einen Monat war.

Diskussion  Die Aktualität, Vollständigkeit und Aspekte der Arzneimitteltherapiesicherheit des Bundeseinheitlichen Medikationsplans sollten umfassend und gezielt im Anamnesegespräch validiert werden. In der Praxis sollten Pläne, die älter als 1 Monat sind, besonders kritisch hinsichtlich Angaben zu Stärke und Dosierung geprüft und der Plan entsprechend regelmäßig aktualisiert werden.

Medication Reconciliation: The Foundation of Medication Safety for Patients Requiring Dialysis

Medication-related problems are a leading cause of morbidity and mortality. Patients requiring dialysis are at heightened risk for adverse drug reactions because of the prevalence of polypharmacy, multiple chronic conditions, and altered (but not well understood) medication pharmacokinetics and pharmacodynamics inherent to kidney failure. To minimize preventable medication-related problems, health care providers need to prioritize medication safety for this population. The cornerstone of medication safety is medication reconciliation. We present a case highlighting adverse outcomes when medication reconciliation is insufficient at care transitions. We review available literature on the prevalence of medication discrepancies worldwide. We also explain effective medication reconciliation and the practical considerations for implementation of effective medication reconciliation in dialysis units. In light of the addition of medication reconciliation requirements to the Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program, this review also provides guidance to dialysis unit leadership for improving current medication reconciliation practices. Prioritization of medication reconciliation has the potential to positively affect rates of medication-related problems, as well as medication adherence, health care costs, and quality of life.

Clinical and economic impact of medication reconciliation in cancer patients: a systematic review

PURPOSE

Medication reconciliation can reduce drug-related iatrogenesis by facilitating exhaustive information transmission at care transition points. Given the vulnerability of cancer patients to adverse drug events, medication reconciliation could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on medication reconciliation in cancer patients.

METHODS

A comprehensive search was performed in the PubMed/Medline, Scopus, and Web of Science databases, associating the keywords "medication reconciliation" and "cancer" or "oncology."

RESULTS

Fourteen studies met the selection criteria. Various medication reconciliation practices were reported: performed at admission or discharge, for hospitalized or ambulatory patients treated with oral or parenteral anticancer drugs. In one randomized controlled trial, medication reconciliation decreased clinically significant medication errors by 26%. Although most studies were non-comparative, they highlighted that medication reconciliation led to identification of discrepancies and other drug-related problems in up to 88% and 94.7% of patients, respectively. The impact on post-discharge healthcare utilization remains under-evaluated and mostly inconclusive, despite a trend toward reduction. No comparative economic evaluations were available but one study estimated the benefit:cost ratio of medication reconciliation to be 2.31:1, suggesting its benefits largely outweigh its costs. Several studies also underlined the extended pharmacist time required for the intervention, highlighting the need for further cost analysis.

CONCLUSION

Medication reconciliation can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Adverse Drug Events in Older Adults: Review of Adjudication Methods in Deprescribing Studies

OBJECTIVES

Polypharmacy is common in older adults and associated with adverse drug events (ADEs). Several methods have been described in studies to help correlate ADE causation. We performed a narrative review to identify methods for ADE adjudication. We compared their strengths and limitations to assess their applicability to deprescribing studies (of which clinical trials are a subset) and to encourage the use of a standardized method in future studies.

DESIGN

We performed a review of original articles (1946-2019) using the Medline (Ovid) and Cochrane databases. We also conducted a manual reference search of review articles. Abstracts were screened for relevance.

MEASUREMENTS

Adjudication methods were compared for advantages and limitations including validity, ease of use, and applicability to clinical trials with deprescribing as the primary intervention.

RESULTS

The search yielded 1881 articles of which 175 articles were included for full-text review. Following in-depth review, 135 were excluded: 79 had no ADE outcome data, 35 were not specific to older adults, 9 were not relevant, 6 were review articles, 5 contained duplicate data, and 1 was not written in French or English. Forty articles remained for analysis, from which we identified 10 unique ADE adjudication methods. No method was developed originally for use in a deprescribing setting.

CONCLUSION

A standard method to identify ADEs is important to capture the outcome reliably in deprescribing studies. All methods we identified had limitations in terms of capturing adverse events from the withdrawal of medications. Future work should focus on refining adjudication methods for capturing ADEs related not only to medication continuation and new drug starts but also to deprescribing and drug discontinuation. J Am Geriatr Soc 68:1594-1602, 2020.

Analysis of clinical pharmacist interventions in the neurology unit of a Brazilian tertiary teaching hospital

It is estimated that around five to 10.0% of hospital admissions occur due to clinical conditions resulting from pharmacotherapy. Clinical pharmacist's activity can enhance drug therapy's effectiveness and safety through pharmacotherapy interventions (PIs), thus minimizing drug-related problems (DRPs) and optimizing the allocation of financial resources associated with health care. This study aimed to estimate the DRPs prevalence, evaluate PI which were performed by clinical pharmacists in the Neurology Unit of a Brazilian tertiary teaching hospital and to identify factors associated with the occurrence of PI-related DRP. A single-arm trial included adults admitted in the referred Unit from 2012 July to 2015 June. Patients were evaluated during their hospitalization period and PIs were performed based on trigger DRPs that were detected in medication reconciliation (admission or discharge) or during inpatient follow-up. Student's t-test, Chi-square test, Pearson and Multiple logistic regression models to analise the association among age, number of drugs, hospitalization period, and number of diagnoses with occurrence of DRPs. Analyses level of significance was 5%. In total 409 inpatients were followed up [51.1% male, mean age of 49.1 (SD 16.5)]. Patients received, on average, 11.9 (SD 5.8) drugs, ranging from two to 38 drugs per patient, and 54.3% of the sample presented at least one DRP whose most frequent description was "untreated condition". From all 516 performed PIs that resulted from DRPs, 82.8% were accepted and the majority referred to "drug introduction" (27.5%). Multiple logistic regression showed that age, length of hospital stay, number of drugs used, diagnosis of epilepsy, multiple sclerosis and myasthenia gravis would be clinical variables associated with DRP (p < 0,05). Monitoring the use of drugs allowed the clinical pharmacist to detect DRPs and to suggest interventions that promote rational pharmacotherapy.

Accuracy of best possible medication history documentation by pharmacists at an Australian tertiary referral metropolitan hospital

Aim

To determine the quality of best possible medication history (BPMH) taking activities undertaken by pharmacists. To identify factors which impact upon erroneous documentation. To assess risks associated with erroneous documentation of BPMH by pharmacists.

Method

A clinical pharmacist randomly selected patients across a tertiary referral, metropolitan hospital over an 9-day period and documented comparator medication histories (CMHs) using a structured interview. BPMH documented by pharmacists as part of routine care and CMH were compared, and erroneous documentation was classified according to previous definitions in the literature. Erroneous documentation was risk stratified.

Results

99 BPMH and CMH were compared. There were 14 medication omissions which occurred across 10 patients and 14 discrepancies across 12 patients. There was no association identified between erroneous documentation and pharmacist seniority/experience (p=0.25), where BPMH taken (p=0.7), day of week BPMH documented (p=0.45) or time since admission to when BPMH was documented (p=1). Patient age did not impact erroneous documentation rates (p=0.22). There was an association between the number of sources used to confirm a medication history and erroneous documentation incidence (p=0.035). The number of medications increased the rate of documentation error. While 85.19% (n=115) of erroneous documentation were deemed unlikely to cause patient discomfort or clinical deterioration, 1.48% (n=2) had the potential to result in severe discomfort or clinical deterioration.

Conclusion

Six out of seven BPMH documented by pharmacists as part of usual clinical practice are accurate. Major influences on accuracy include the number of medications and sources used. There is a low possibility that erroneous documentation by pharmacists will cause harm.

Predictive factors for clinically significant pharmacist interventions at hospital admission

Pharmaceutical care activities at hospital admission have a significant impact on patient safety. The objective of this study was to identify predictive factors for clinically significant pharmacist interventions (PIs) performed during medication reconciliation and medication review at patient hospital admission.A 4-week prospective study was conducted in 4 medicine wards. At hospital admission, medication reconciliation and medication review were conducted and PIs were performed by the pharmaceutical team. The clinical impact of PIs was determined using the clinical economic and organizational (CLEO) tool. Clinical characteristics, laboratory results, and medication data for each patient were collected and analyzed as potential predictive factors of clinically significant PIs. Univariate and multivariate binary logistic regression were subsequently used to identify independent predictive factors for clinically relevant PIs.Among 265 patients admitted, 150 patients were included. Among 170 PIs performed at hospital admission, 71 were related to unintentional discrepancies (41.8%) during medication reconciliation, and 99 were related to drug-related problems (DRPs) (58.8%) during medication review. Overall, 115 PIs (67.7%) were considered to have a clinical impact. By multivariate analysis, number of medications ≥5 (P = .01) based on the best possible medication history, and Charlson comorbidity index score ≥2 (P < .01) were found to be independent predictive factors of clinically significant PIs at hospital admission.Identifying predictive factors of clinically significant PIs is valuable to optimize clinical pharmacist practices at hospital admission during both medication reconciliation and medication review. These 2 steps of the pharmaceutical care process improve medication safety at hospital admission.

Impact of collaborative pharmaceutical care on in-patients' medication safety: study protocol for a stepped wedge cluster randomized trial (MEDREV study)

Background

Clinical pharmaceutical care has long played an important role in the improvement of healthcare safety. Pharmaceutical care is a collaborative care approach, implicating all the actors of the medication circuit in order to prevent and correct drug-related problems that can lead to adverse drug events. The collaborative pharmaceutical care performed during patients’ hospitalization requires two mutually reinforcing activities: medication reconciliation and medication review. Until now, the impact of the association of these two activities has not been clearly studied.

Methods

This is a multicentric stepped wedge randomized study involving six care units from six French University Hospitals (each unit corresponding to a cluster) over seven consecutive 14-day periods. Each hospital unit will start with a control period and switch to an experimental period after a randomized number of 14-day periods. Patients aged at least 65 years hospitalized in one of the participating care units and having given their consent to be called for a 30-day and 90-day follow-up can be enrolled. For each 14-day period, 15 patients will be recruited in each care unit to obtain a total of 630 patients enrolled in all centers. Patients with a hospital stay of more than 21 days will be excluded. During the control period, there will be no clinical pharmacist in the care unit, whereas during the experimental period a clinical pharmacist will perform medication reconciliation and review with the healthcare team. The primary outcome will assess the impact of collaborative pharmaceutical care on preventable medication error rate. The secondary outcomes will evaluate the clinical impact of the strategy, the acceptance rate of pharmaceutical interventions, the induced and avoided costs of the strategy (cost-consequence analysis), and the healthcare team’s satisfaction.

Discussion

This study will assess the impact of collaborative pharmaceutical care associating medication reconciliation and review at patient admission to hospital in terms of preventable medication error rate and costs. This activity will prevent and correct medication errors arising earlier in the hospitalization.

Trial registration

ClinicalTrials.gov, NCT02598115. Registered on 4 November 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2412-7) contains supplementary material, which is available to authorized users.

Consequence of delegating medication-related tasks from physician to clinical pharmacist in an acute admission unit: an analytical study

OBJECTIVES

Studies have shown that medication histories obtained by clinical pharmacists (CPs) are more complete, and that medication reviews by CPs reduce healthcare costs, drug-related readmissions and emergency readmissions. The aim of this study was to identify the consequences of delegating medication-related tasks from physicians to CPs.

METHODS

An analytical study based on data from a prospective cluster randomised trial was performed. The intervention consisted of CPs obtaining medication history, performing medication reconciliation and medication review. The physician had to approve the prescriptions and assess changes proposed by the CP. The primary outcome measure was a comparison of changes in the Electronic Medication Module (EMM) and changes proposed by CPs.

RESULTS

232 and 216 patients were included on control days (n=63) and intervention days (n=63). In total, 1018 changes were made in the control group (by physicians). In the intervention group 2123 changes were made, 1808 by CPs and 315 by physicians. In particular, the number of substitutions, registration of drugs and change of instructions for use (eg, administration times) differed between physicians and pharmacists. CPs made 341 written proposals in the intervention group and, of these, 22.9% (95% CI 18.7% to 27.8%) and 50.9% (95% CI 45.5% to 56.2%) were accepted by a physician at discharge from the acute admission unit (AAU) and hospital, respectively.

CONCLUSIONS

CPs updated the EMM more thoroughly than physicians, especially entering new prescriptions, substitutions and changing instructions for use. Half of the written proposals were accepted. The extent to which patients benefit from a CP intervention is unknown.

Clinical Outcomes Used in Clinical Pharmacy Intervention Studies in Secondary Care

The objective was to investigate type, frequency and result of clinical outcomes used in studies to assess the effect of clinical pharmacy interventions in inpatient care. The literature search using Pubmed.gov was performed for the period up to 2013 using the search phrases: “Intervention(s)” and “pharmacist(s)” and “controlled” and “outcome(s)” or “effect(s)”. Primary research studies in English of controlled, clinical pharmacy intervention studies, including outcome evaluation, were selected. Titles, abstracts and full-text papers were assessed individually by two reviewers, and inclusion was determined by consensus. In total, 37 publications were included in the review. The publications presented similar intervention elements but differed in study design. A large variety of outcome measures (135) had been used to evaluate the effect of the interventions; most frequently clinical measures/assessments by physician and health care service use. No apparent pattern was established among primary outcome measures with significant effect in favour of the intervention, but positive effect was most frequently related to studies that included power calculations and sufficient inclusion of patients (73% vs. 25%). This review emphasizes the importance of considering the relevance of outcomes selected to assess clinical pharmacy interventions and the importance of conducting a proper power calculation.

A Time and Motion Study of Pharmacists and Pharmacy Technicians Obtaining Admission Medication Histories

Pharmacists' admission medication histories (AMHs) are known to reduce adverse drug events (ADEs). Pharmacist-supervised pharmacy technicians (PSPTs) have also been used in this role. Nonetheless, few studies estimate the costs of utilizing PSPTs to obtain AMHs. We used time and motion methodology to study the time and cost required for pharmacists and PSPTs to obtain AMHs for patients at high risk for ADEs. Pharmacists and PSPTs required 58.5 (95% confidence interval [CI], 46.9-70.1) and 79.4 (95% CI, 59.1-99.8) minutes per patient, respectively (P = 0.14). PSPT-obtained AMHs also required 26.0 (95% CI, 14.9-37.1) minutes of pharmacist supervision per patient. Based on 2015 US Bureau of Labor Statistics wage data, we estimated the cost of having pharmacists and PSPTs obtain AMHs to be $55.91 (95% CI, 44.9-67.0) and $45.00 (95% CI, 29.7-60.4), respectively, which included pharmacist supervisory cost, per patient (P = 0.32). Thus, we found no statistically significant difference in time or cost between the two provider types. Journal of Hospital Medicine 2017;12:180-183.

Patients with diabetes are at high risk of serious medication errors at hospital: Interest of clinical pharmacist intervention to improve healthcare

BACKGROUND

Medication errors (ME) are major public health issues in hospitals because of their consequences on patients' morbi-mortality. This study aims to evaluate the prevalence of ME at admission and discharge of hospitalization in diabetic and non-diabetic patients, and determine their potential clinical impact.

METHOD

This prospective observational study was conducted at the Endocrinology-Diabetology-Nutrition Department. All adult patients admitted were eligible. A total of 904 patients were included, of which 671 (74.2%) with diabetes mellitus. Clinical pharmacists conducted medication reconciliation: they collected the Best Possible Medication History and then compared it with admission and discharge prescriptions to identify medication discrepancies. ME were defined as unintended medication discrepancies if corrected by the physician.

RESULTS

Clinical pharmacists allowed correcting ME in 176/904 (19.5%) patients at admission and in 86/865 (9.9%) patients at discharge. More than half of ME were omissions. Diabetic patients were more affected by ME than non-diabetic patients, both at admission (22.1% vs 12.0%, p<0.001) and at discharge (11.4% vs 5.7%, p=0.01). The diabetic group also had more potentially severe and very severe ME. Diabetic patients had on average twice more medications than non-diabetic patients (8.7±4.5 vs 4.4±3.4, p<0.001). The polypharmacy associated with diabetes, but not diabetes mellitus itself, was identified as a risk factor of ME.

CONCLUSIONS

The intervention of clinical pharmacists allowed correcting 378 ME in 25.8% of the cohort before they caused harm. Clinicians, pharmacists and other health care providers should therefore work together to improve patients' safety, in particular in high-risk patients such as diabetic patients.

Medication Errors Despite Using Electronic Health Records: The Value of a Clinical Pharmacist Service in Reducing Discharge-Related Medication Errors

BACKGROUND

Medication errors continue to exist despite the use of electronic health records and electronic prescribing; patient-centered medication reconciliation is important to decrease errors.

OBJECTIVE

To identify whether a team-based approach with a pharmacist performing medication management and discharge medication reconciliation will reduce discharge-related medication errors in an academic tertiary care hospital already using an electronic health record and computerized physician order entry.

DESIGN

Prospective nonrandomized controlled trial.

PATIENTS

All patients were admitted to 2 of the 6 medicine teams from August 1, 2012, through October 31, 2012.

INTERVENTION

On the intervention team, a pharmacist assisted with medication management, medication reconciliation, and medication education upon discharge. Although the physicians on the control team had access to a pharmacist, they rarely collaborated with the pharmacist. The numbers of discharge-related medication discrepancies on the intervention and control teams were compared.

RESULTS

Collaboration with a pharmacist reduced discharge-related medication errors. The percentage of patients without medication errors within 72 hours of discharge was 93.8% on the intervention team compared with 40.2% on the control team (P < .0001).

CONCLUSION

Pharmacist's involvement in the patient care team improved patient safety by decreasing discharge medication errors caused by using electronic health records and computerized physician order entry.

Clinical pharmacist-led program on medication reconciliation implementation at hospital admission: experience of a single university hospital in Croatia

Aim

To evaluate the clinical pharmacist-led medication reconciliation process in clinical practice by quantifying and analyzing unintentional medication discrepancies at hospital admission.

Methods

An observational prospective study was conducted at the Clinical Department of Internal Medicine, University Hospital Dubrava, during a 1-year period (October 2014 – September 2015) as a part of the implementation of Safe Clinical Practice, Medication Reconciliation of the European Network for Patient Safety and Quality of Care Joint Action (PASQ JA) project. Patients older than 18 years taking at least one regular prescription medication were eligible for inclusion. Discrepancies between pharmacists' Best Possible Medication History (BPMH) and physicians' admission orders were detected and communicated directly to the physicians to clarify whether the observed changes in therapy were intentional or unintentional. All discrepancies were discussed by an expert panel and classified according to their potential to cause harm.

Results

In 411 patients included in the study, 1200 medication discrepancies were identified, with 202 (16.8%) being unintentional. One or more unintentional medication discrepancy was found in 148 (35%) patients. The most frequent type of unintentional medication discrepancy was drug omission (63.9%) followed by an incorrect dose (24.2%). More than half (59.9%) of the identified unintentional medication discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration in the patient.

Conclusion

Around 60% of medication errors were assessed as having the potential to threaten the patient safety. Clinical pharmacist-led medication reconciliation was shown to be an important tool in detecting medication discrepancies and preventing adverse patient outcomes. This standardized medication reconciliation process may be widely applicable to other health care organizations and clinical settings.

Pharmacist independent prescribing in secondary care: opportunities and challenges

In recent years a number of countries have extended prescribing rights to pharmacists in a variety of formats. The latter includes independent prescribing, which is a developing area of practice for pharmacists in secondary care. Potential opportunities presented by wide scale implementation of pharmacist prescribing in secondary care include improved prescribing safety, more efficient pharmacist medication reviews, increased scope of practice with greater pharmacist integration into acute patient care pathways and enhanced professional or job satisfaction. However, notable challenges remain and these need to be acknowledged and addressed if a pharmacist prescribing is to develop sufficiently within developing healthcare systems. These barriers can be broadly categorised as lack of support (financial and time resources), medical staff acceptance and the pharmacy profession itself (adoption, implementation strategy, research resources, second pharmacist clinical check). Larger multicentre studies that investigate the contribution of hospital-based pharmacist prescribers to medicines optimisation and patient-related outcomes are still needed. Furthermore, a strategic approach from the pharmacy profession and leadership is required to ensure that pharmacist prescribers are fully integrated into future healthcare service and workforce strategies.

Promoting Patient Safety with Human Factors Methods

Medication management is a complex and mentally demanding endeavor performed by multiple individuals in diverse settings and at variable points in time. Achieving the goal of safe care delivery with optimized patient outcomes requires ongoing communication, coordination, and interaction between an array of technologies and roles across the health care continuum. Human factors principles and methods have the potential to substantially improve patient safety throughout this high-risk cycle. The purpose of this interactive discussion panel is to explore the medication management process from a sociotechnical perspective to identify specific challenges and vulnerabilities, and recommend strategies that leverage human factors processes and design principles to efficiently and effectively address safety critical issues.

Function-specific Design Principles for the Electronic Health Record

This practice-oriented paper provides a collection of design principles that are specific to certain functions within the electronic health record (EHR). Design principles for EHRs tend to be broad rules of thumb rather than specific and actionable because the relevant literature is organized by specific EHR functions. That is, a good amount of research has been conducted on specific functions, rather than EHRs as a whole. Based on the relevant literature, we provide design principles with underlying rationale for progress notes, problem list, consults, clinical reminders, clinical decision support, medication list, medication alerts, and medication reconciliation. This paper is meant to offer a collection of practical guidelines for designers, grounded in the academic literature, that are more actionable than broad usability heuristics. Future work should include refinement of these principles through systematic literature review and the inclusion of additional EHR functions.

The pharmacist and the EHR

The adoption of electronic health records (EHRs) across the United States has impacted the methods by which health care professionals care for their patients. It is not always recognized, however, that pharmacists also actively use advanced functionality within the EHR. As critical members of the health care team, pharmacists utilize many different features of the EHR. The literature focuses on 3 main roles: documentation, medication reconciliation, and patient evaluation and monitoring. As health information technology proliferates, it is imperative that pharmacists' workflow and information needs are met within the EHR to optimize medication therapy quality, team communication, and patient outcomes.

Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis

OBJECTIVES

Pharmacists play a role in providing medication reconciliation. However, data on effectiveness on patients' clinical outcomes appear inconclusive. Thus, the aim of this study was to systematically investigate the effect of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO from inception to December 2014. Included studies were all published studies in English that compared the effectiveness of pharmacist-led medication reconciliation interventions to usual care, aimed at improving medication reconciliation programmes. Meta-analysis was carried out using a random effects model, and subgroup analysis was conducted to determine the sources of heterogeneity.

RESULTS

17 studies involving 21,342 adult patients were included. Eight studies were randomised controlled trials (RCTs). Most studies targeted multiple transitions and compared comprehensive medication reconciliation programmes including telephone follow-up/home visit, patient counselling or both, during the first 30 days of follow-up. The pooled relative risks showed a more substantial reduction of 67%, 28% and 19% in adverse drug event-related hospital revisits (RR 0.33; 95% CI 0.20 to 0.53), emergency department (ED) visits (RR 0.72; 95% CI 0.57 to 0.92) and hospital readmissions (RR 0.81; 95% CI 0.70 to 0.95) in the intervention group than in the usual care group, respectively. The pooled data on mortality (RR 1.05; 95% CI 0.95 to 1.16) and composite readmission and/or ED visit (RR 0.95; 95% CI 0.90 to 1.00) did not differ among the groups. There was significant heterogeneity in the results related to readmissions and ED visits, however. Subgroup analyses based on study design and outcome timing did not show statistically significant results.

CONCLUSION

Pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. This review supports the implementation of pharmacist-led medication reconciliation programmes that include some component aimed at improving medication safety.

[Management of outpatient medications in care units: An audit of clinical practices]

OBJECTIVES

To assess the outpatient medication management in care units two years after the release of an institutional procedure. To assess the patients' satisfaction with their treatment and with the information transmitted by healthcare professionals.

METHODS

An audit of clinical practices was conducted in 23 units of our universitary hospital - general, surgery, emergency departments. Questionnaires were developed and validated by an institutional working group and were composed of three themes: management of the outpatient medication at the admission, awareness of tools and information transmission. Two physicians (a senior and a resident), a registered nurse, a head nurse and a patient were interviewed.

RESULTS

Eighty-one medical and paramedical team members and 21 patients were interviewed for the study. According to statements collected, the procedure was unknown by 100% of the interviewed surgeons and 69% of the interviewed physicians. The practices being used by the medical units were more in line with recommendations than the surgery units. Among the patients interviewed, 19 (86%) were satisfied with the information they received during their hospitalization and 4 (19%) managed their own medication treatment with the help of a nurse in only 36% of the cases according to their statements.

CONCLUSIONS

The management of outpatient medications during hospitalization is representative of the difficulties to master the continuity of pharmaceutical care at the various transition points. Coordination and cooperation between the different healthcare professionals and patients are the major key success to ensure an optimized healthcare procedure.

Mentoring and supervising clinical pharmacist students at patients' bedside: which benefits?

RATIONALE, AIMS AND OBJECTIVES

 Hospital clinical pharmacists are involved in teaching students during professional internship. Organization between the unit care and the pharmacy place is complicated. This study evaluated the effectiveness of two pharmaceutical teams: an experienced pharmacist in the pharmacy place, reachable by phone (team 1) or an experienced pharmacist in the ward, near patients and students (team 2).

METHODS

Pharmaceutical interventions were collected during two successive time periods, each of 6 months in a 15-bed unit (neurology). During the first time period, prescriptions were analyzed by the student (resident) in the ward and experienced pharmacist in the pharmacy place. During the second time period, prescriptions were analyzed by both experienced pharmacist and the resident in the ward. We compared the number, the type, the approval of pharmaceutical interventions and the medication reconciliation activities. Proportions were compared by a chisquared test (or Fisher exact test) as well as the quantitative value was calculated by a Student test.

RESULTS

'Mentoring and supervising' students in the ward increased significantly the number of pharmaceutical interventions (PI; 104 interventions for 1408 analyzed prescriptions (7.4%) by the students in the ward and 317 interventions for 1391 (22.8%) by both the experienced pharmacist and the students in the ward (P = 0.002). Furthermore, specific interventions from medication reconciliation were significantly increased by the presence of experienced pharmacist in the ward (0.96% vs. 8.83% P = 0.018).

CONCLUSION

Effectiveness of clinical pharmacists can be improved by the presence of experienced pharmacist at patients' bedside, near students.

Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting

Objective:

To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting.

Methods:

This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients’ community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment.

Results:

During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04).

Conclusion:

Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved.

Pharmacist independent prescribing in critical care: results of a national questionnaire to establish the 2014 UK position

OBJECTIVES

Clinical pharmacist practice is well established in the safe and effective use of medicines in the critically ill patient. In the UK, independent pharmacist prescribers are generally recognised as a valuable and desirable resource. However, currently, there are only anecdotal reports of pharmacist-independent prescribing in critical care. The aim of this questionnaire was to determine the current and proposed future independent prescribing practice of UK clinical pharmacists working in adult critical care.

METHODS

The questionnaire was distributed electronically to UK Clinical Pharmacy Association members (closed August 2014).

KEY FINDINGS

There were 134 responses to the questionnaire (response rate at least 33%). Over a third of critical care pharmacists were practising independent prescribers in the specialty, and 70% intended to be prescribers within the next 3 years. Pharmacists with ≥5 years critical care experience (P < 0.001) or worked in a team (P = 0.005) were more likely to be practising independent prescribers. Pharmacists reported significant positives to the use of independent prescribing in critical care both in patient care and job satisfaction. Independently, prescribing was routine in: dose adjustment for multi-organ failure, change in route or formulation, correction prescribing errors, therapeutic drug monitoring and chronic medication. The majority of pharmacist prescribers reported they spent ≤5% of their clinical time prescribing and accounted for ≤5% of new prescriptions in critical care patients.

CONCLUSIONS

Most critical care pharmacists intend to be practising as independent prescribers within the next 3 years. The extent and scope of critical care pharmacist prescribing appear to be of relatively low volume and within niche prescribing areas.

Pharmacist's review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

PURPOSE

The purpose was to describe clinical pharmacist interventions across a range of critical care units (CCUs) throughout the United Kingdom, to identify CCU medication error rate and prescription optimization, and to identify the type and impact of each intervention in the prevention of harm and improvement of patient therapy.

MATERIALS AND METHODS

A prospective observational study was undertaken in 21 UK CCUs from November 5 to 18, 2012. A data collection web portal was designed where the specialist critical care pharmacist reported all interventions at their site. Each intervention was classified as medication error, optimization, or consult. In addition, a clinical impact scale was used to code the interventions. Interventions were scored as low impact, moderate impact, high impact, and life saving. The final coding was moderated by blinded independent multidisciplinary trialists.

RESULTS

A total of 20517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. This resulted in an overall intervention rate of 16.1%: 6.8% were classified as medication errors, 8.3% optimizations, and 1.0% consults. The interventions were classified as low impact (34.0%), moderate impact (46.7%), and high impact (19.3%); and 1 case was life saving. Almost three quarters of interventions were to optimize the effectiveness of and improve safety of pharmacotherapy.

CONCLUSIONS

This observational study demonstrated that both medication error resolution and pharmacist-led optimization rates were substantial. Almost 1 in 6 prescriptions required an intervention from the clinical pharmacist. The error rate was slightly lower than an earlier UK prescribing error study (EQUIP). Two thirds of the interventions were of moderate to high impact.

Accuracy of Electronic Medical Record Medication Reconciliation in Emergency Department Patients

BACKGROUND

Medication history discrepancies have the potential to cause significant adverse clinical effects for patients. More than 40% of medication errors can be traced to inadequate reconciliation.

OBJECTIVE

The objective of this study was to determine the accuracy of electronic medical record (EMR)-reconciled medication lists obtained in an academic emergency department (ED).

METHODS

Comprehensive research medication ingestion histories for the 48 h preceding ED visit were performed and compared to reconciled EMR medication lists in a convenience sample of ED patients. The reconciled EMR list of prescription, nonprescription, vitamins, herbals, and supplement medications were compared against a structured research medication history tool. We measured the accuracy of the reconciled EMR list vs. the research history for all classes of medications as the primary outcome.

RESULTS

Five hundred and two subjects were enrolled. The overall accuracy of EMR-recorded ingestion histories in the preceding 48 h was poor. The EMR was accurate in only 21.9% of cases. Neither age ≥ 65 years (odds ratio [OR] = 1.3; 95% confidence interval [CI] 0.6-2.6) nor sex (female vs. male: OR = 1.5; 95% CI 0.9-2.5) were predictors of accurate EMR history. In the inaccurate EMRs, prescription lists were more likely to include medications that the subject did not report using (78.9%), while the EMR was more likely not to capture nonprescriptions (76.1%), vitamins (73.0%), supplements (67.3%), and herbals (89.1%) that the subject reported using.

CONCLUSIONS

Medication ingestion histories procured through triage EMR reconciliation are often inaccurate, and additional strategies are needed to obtain an accurate list.

Impact of admission medication reconciliation performed by clinical pharmacists on medication safety

BACKGROUND

Many activities contribute to reduce drug-related problems. Among them, the medication reconciliation (MR) is used to compare the best possible medication history (BPMH) and the current admission medication order (AMO) to identify and solve unintended medication discrepancies (UMD). This study aims to assess the impact of the implementation of admission MR by clinical pharmacists on UMD.

METHOD

This prospective study was carried out in two units of general medicine and infectious and tropical diseases in a 1844-bed French hospital. A retroactive MR performed in an observational period was compared to a proactive MR realized in an interventional period. We used a logistic regression to identify risk factors of UMD.

RESULTS

During both periods, 394 patients were enrolled and 2,725 medications were analyzed in the BPMH. Proactive MR reduced the percentage of patients with at least one UMD compared with retroactive process (respectively 2.1% vs. 45.8%, p<0.001). Patients with at least one UMD during both periods were older compared to patients without UMD (79 vs. 72, p<0.005) and had more medications at admission (7 vs. 6, p<0.0001). UMD occur 38 times more often when there is no clinical pharmacist intervention. Among the 226 UMD detected in both periods, 42% would have required monitoring or intervention to preclude harm, and 10% had potential harm to the patient and 2% were life threatening.

CONCLUSION

Proactive MR performed by clinical pharmacists is an acute process of detection and correction of UMD, but it requires a lot of human resources.

The accuracy of self-reported drug ingestion histories in emergency department patients

Inaccuracies in self-reports may lead to duplication of therapy, failure to appreciate non-compliance leading to exacerbation of chronic medical conditions, or inaccurate research conclusions. Our objective is to determine the accuracy of self-reported drug ingestion histories in patients presenting to an urban academic emergency department (ED). We conducted a prospective cohort study in ED patients presenting for pain or nausea. We obtained a structured drug ingestion history including all prescription drugs, over-the-counter medication (OTC) drugs, and illicit drugs for the 48 hours prior to ED presentation. We obtained urine comprehensive drug screens (CDS) and determined self-report/CDS concordance. Fifty-five patients were enrolled. Self-reported drug ingestion histories were poor in these patients; only 17 (30.9%) of histories were concordant with the CDS. For the individual drug classes, prescription drug-CDS was concordant in 32 (58.2%), OTC-CDS was concordant in 33 (60%), and illicit drug-CDS was concordant in 45 (81.8%) of subjects. No demographic factors predicted an accurate self-reported drug history. Sixteen patients had drugs detected by CDS that were unreported by history. Nine of these 16 included an unreported opioid. In conclusion, self-reported drug ingestion histories are often inaccurate and resources are needed to confirm compliance and ensure unreported drugs are not overlooked.

Effectiveness of pharmacist dosing adjustment for critically ill patients receiving continuous renal replacement therapy: a comparative study

Background

The impact of continuous renal replacement therapy (CRRT) on drug removal is complicated; pharmacist dosing adjustment for these patients may be advantageous. This study aims to describe the development and implementation of pharmacist dosing adjustment for critically ill patients receiving CRRT and to examine the effectiveness of pharmacist interventions.

Methods

A comparative study was conducted in an intensive care unit (ICU) of a university-affiliated hospital. Patients receiving CRRT in the intervention group received specialized pharmacy dosing service from pharmacists, whereas patients in the no-intervention group received routine medical care without pharmacist involvement. The two phases were compared to evaluate the outcome of pharmacist dosing adjustment.

Results

The pharmacist carried out 233 dosing adjustment recommendations for patients receiving CRRT, and 212 (90.98%) of the recommendations were well accepted by the physicians. Changes in CRRT-related variables (n=144, 61.81%) were the most common risk factors for dosing errors, whereas antibiotics (n=168, 72.10%) were the medications most commonly associated with dosing errors. Pharmacist dosing adjustment resulted in a US$2,345.98 ICU cost savings per critically ill patient receiving CRRT. Suspected adverse drug events in the intervention group were significantly lower than those in the preintervention group (35 in 27 patients versus [vs] 18 in eleven patients, P<0.001). However, there was no significant difference between length of ICU stay and mortality after pharmacist dosing adjustment, which was 8.93 days vs 7.68 days (P=0.26) and 30.10% vs 27.36% (P=0.39), respectively.

Conclusion

Pharmacist dosing adjustment for patients receiving CRRT was well accepted by physicians, and was related with lower adverse drug event rates and ICU cost savings. These results may support the development of strategies to include a pharmacist in the multidisciplinary ICU team.

Impact of students pharmacists on the medication reconciliation process in high-risk hospitalized general medicine patients

OBJECTIVE" To compare the accuracy of medication lists obtained by student pharmacists, nurses, and physicians, and quantify the number of discrepancies identified as part of the medication reconciliation process.

METHODS

Between May and July 2012, patients admitted to an internal medicine team at a 350-bed tertiary academic medical center were assessed for inclusion in the study. Physicians and/or nurses conducted medication reviews for these patients at the time of admission, while student pharmacists conducted medication reconciliation.

RESULTS

Eighty-six patients were assessed, and 52 met all inclusion criteria. A total of 268 discrepancies were identified as part of the medication reconciliation performed by the student pharmacists, approximating 5 discrepancies per patient (range 0-13). Student pharmacists identified 532 preadmission medications, significantly more than did nurses (355) or physicians (368), p=0.006.

CONCLUSION

Student pharmacists, with appropriate oversight, can be used in several tasks that previously may have been designated to pharmacists only, such as medication reconciliation.

[Role of clinical pharmacist in the therapeutical optimization in geriatric outpatient hospital]

SETTING

Cares in outpatient hospital for elderly patients is a period of interest for multidisciplinary reassessment and pharmaceutical care of the prescription. The objective is to present the implementation of the pharmaceutical care activity at the outpatient hospital.

METHODS

Between August and October 2011, elderly patients hospitalized in the outpatient hospital for a brief appraisal had a pharmaceutical care. The clinician introduced pharmaceutical reviews in the synthesis letter for general practitioner. An analysis of the activity was carried out over 3 months.

RESULTS

A pharmaceutical care had been realized for 67 patients, mean age of 81.7 years. Among medical related problems identified, 39.6% were for potentially unnecessary medication. A stop was proposed for 44% of pharmaceutical interventions. A total of 91 pharmaceutical interventions and 13 recommendations were made and 34% of patients had potentially inappropriate medication.

CONCLUSION

According to the objective to reduce the therapeutics contributing to the iatrogenesis, this approach allowed us to undertake a multidisciplinary collaboration oriented toward the relay between hospital and city cares.

Impact of pharmacist antimicrobial dosing adjustments in septic patients on continuous renal replacement therapy in an intensive care unit

BACKGROUND

Correct dosing of antimicrobial drugs in septic patients receiving continuous renal replacement therapy (CRRT) is complex. This study aimed to evaluate the effects of dosing adjustments performed by pharmacists on the length of intensive care unit (ICU) stay, ICU cost, and antimicrobial adverse drug events (ADEs).

METHODS

A single-center, 2-phase (pre-/post-intervention) study was performed in an ICU of a university-affiliated hospital. Septic patients receiving CRRT in the post-intervention phase received a specialized antimicrobial dosing service from critical care pharmacists, whereas patients in the pre-intervention phase received routine medical care without involving pharmacists. The 2 phases were compared to evaluate the outcomes of pharmacist interventions.

RESULTS

Pharmacists made 183 antimicrobial dosing adjustment recommendations for septic patients receiving CRRT. Changes in CRRT-related variables (116, 63.4%) were the most common risk factors for dosing errors, and β-lactams (101, 55.2%) were the antimicrobials most commonly associated with dosing errors. Dosing adjustments were related to a reduced length of ICU stay from 10.7 ± 11.1 days to 7.7 ± 8.3 days (p = 0.037) in the intervention group, and to cost savings of $3525 (13,463 ± 12,045 vs. 9938 ± 8811, p = 0.038) per septic patient receiving CRRT in the ICU. Suspected antimicrobial adverse drug events in the intervention group were significantly fewer than in the pre-intervention group (19 events vs. 8 events, p = 0.048).

CONCLUSIONS

The involvement of pharmacists in antimicrobial dosing adjustments in septic patients receiving CRRT is associated with a reduced length of ICU stay, lower ICU costs, and fewer ADEs. Hospitals may consider employing clinical pharmacists in ICUs.