Pharmacist-assisted electronic prescribing at the time of admission to an inpatient orthopaedic unit and its impact on medication errors: a pre- and postintervention study

Cost-effectiveness of preoperative pharmaceutical care consultations: a 5-year analysis

OBJECTIVES

Preoperative medication errors can be prevented by screening patients through a preoperative pharmaceutical care consultation. The aim of this study was to analyse the cost-effectiveness of implementing such a consultation and to determine which patients would benefit most.

METHODS

A retrospective study was conducted that included all patients who underwent a preoperative pharmacy consultation between 2016 and 2020. During this consultation, two part-time pharmacists reviewed patients' appropriate preoperative chronic medication management. All prevented errors were collected and classified by therapeutic group and type of error. A team of pharmacists and anaesthetists assigned to each prevented medication error a probability of causing an adverse event 'p', following the methodology of Nesbit et al by establishing five different 'p' values: 0, 0.01, 0.1, 0.4, and 0.6. 'p' = 1 was not considered. The cost of an adverse event was determined to be between €4124 and €6946 according to current literature, and a sensitivity analysis was performed by increasing the interval by 20% above and below. The cost of employing two part-time specialist pharmacists was estimated to be €59 142. Savings per medication error prevented were calculated as (€4124 OR €6946) × 'p'. Total savings were the sum of all costs associated with prevented medication errors. Patients on chronic medications who were in therapeutic groups with a 0.6 probability of an adverse event or who were in therapeutic groups responsible for 50% of the prevented adverse events were considered prioritisable.

RESULTS

3105 patients attended the consultation and 1179 medication errors were prevented, corresponding to 300 adverse events. 42.2% of the errors had a 'p' of 0.4. The costs avoided by this consultation ranged from €1 237 200 to €2 083 800, while the cost of its implementation was €295 710. The cost-effectiveness ratio was between €4.2 and €7.0 saved per euro invested. In the sensitivity analysis, the ratios ranged from €3.3 to €8.5 per euro invested. Fifteen different therapeutic groups accounted for 90% of the medication errors prevented. The therapeutic groups 'Agents acting on the renin-angiotensin system', 'Antidiabetics, non-insulin (excluding SGLT2)' and 'Antithrombotics: low molecular weight heparins' were responsible for 56% of the prevented adverse events. The therapeutic groups 'Antidiabetics: rapid-acting insulin' and 'Antithrombotic agents: vitamin K antagonists, low-molecular-weight heparins, or direct oral anticoagulants' had a 'p' of 0.6. Therefore, patients in six therapeutic groups should be prioritised for preoperative pharmacy counselling.

CONCLUSIONS

The implementation of preoperative pharmaceutical care consultations in Spain has proven to be cost-effective. Incorporating the probability of a medication error causing an adverse event allowed the prioritisation of patients for these consultations. Patients taking anticoagulants, oral antidiabetics, rapid-acting insulins, and agents acting on the renin-angiotensin system benefited the most. This study could serve as a basis for implementing such consultations in other hospitals, as they are effective in reducing the cost of medication errors in surgical patients.

Partnered pharmacist medication charting and prescribing in Australian hospitals

Medication charting and prescribing errors commonly occur at hospital admission and discharge. Pharmacist medication reconciliation, after medicines are ordered by a medical officer, can identify and resolve errors, but this often occurs after the errors have reached the patient. Partnered pharmacist medication charting and prescribing are interprofessional, collaborative models that are designed to prevent medication errors before they occur, by involving pharmacists directly in charting and prescribing processes. In the partnered charting model, a pharmacist and medical officer discuss the patient's current medical and medication-related problems and agree on a medication management plan. Agreed medicines are then charted by the pharmacist on the inpatient medication chart. A similar collaborative model can be used at other points in the patient journey, including at discharge. Studies conducted at multiple Australian health services, including rural and regional hospitals, have shown that partnered charting on admission, and partnered prescribing at discharge, significantly reduces the number of medication errors and shortens patients' length of stay in hospital. Junior medical officers report benefiting from enhanced interprofessional learning and reduced workload. Partnered pharmacist medication charting and prescribing models have the best prospect of success in environments with a strong culture of interprofessional collaboration and clinical governance, and a sufficiently resourced clinical pharmacist workforce.

Economic impact of a clinical pharmacist in the orthopaedic sector: a review of the literature

OBJECTIVES

This review of the literature aimed to evaluate the economic impact of a clinical pharmacist in the orthopaedic sector.

METHODS

The review followed the PRISMA recommendations. A bibliographic search was conducted on 23 June 2023 using PubMed, Cochrane Library and Web of Science. All articles in French or English with economic data on clinical pharmacy activities in orthopaedics were included. Articles not mentioning the term 'orthopaedics' and those published prior to 1990 were excluded. Data from the studies were compiled in an Excel table. A bias analysis using the ROBINS-I Cochrane tool was performed. The methodology of the studies was compared and weighted using the CHEERS and STROBE checklists.

RESULTS

Among 529 articles initially identified, 10 were included in the review. The cost-benefit ratio of a clinical pharmacist in orthopaedics ranged from 0.47:1 to 28:1. The maximum savings reached US$73 410 /year in the American study and €1 42 356 /year in the French study. For three studies, the cost of a clinical pharmacist was not evaluated. Eight studies showed a positive economic impact. The Dutch study showed a balance and the Danish study showed a negative economic impact of €3442/month.

CONCLUSIONS

This literature review has shown an economic benefit of a clinical pharmacist in the orthopaedic sector despite several biases and methodological limitations. The two studies that did not confirm this benefit only evaluated a limited number of expected benefits. Nevertheless, the economic impact of the clinical pharmacist in the orthopaedic sector seems positive and undervalued.

Impact of preoperative pharmaceutical care consultation on medication errors in surgical patients: a comprehensive analysis

OBJECTIVE

Assessing the impact of introducing preoperative pharmaceutical care consultations by analyzing the severity of prevented medication errors (MEs) and their potential effects on the surgical process.

METHODS

Preoperative pharmaceutical care consultation was implemented in our hospital to assess the preoperative medication management of surgical patients between the pre-anesthesia consultation and the day of surgery. Pharmacists evaluated the appropriateness of medication management based on a consensus multidisciplinary institutional protocol. All errors identified between 2016 and 2020 were analyzed, and their severity and potential impact on surgery were standardized. A list of therapeutic groups was created to prioritize patients for consultations.

RESULTS

During the study period, 3,105 patients attended the consultations and 1,179 MEs were prevented. According to severity, 30.6% of MEs were classified as category E and 26.2% as D. The Number Needed to Treat to prevent a category E or higher ME (indicating potential harm to patients) was 5 patients. About 14.84% of MEs belonged to the prioritized drug groups. One hundred and thirteen errors would have resulted in a surgery delay of more than 24 h, and 175 errors were classified as G-H (irreversible damage).

CONCLUSIONS

This study highlights the effectiveness of pharmaceutical care consultations in preventing MEs and improving surgical outcomes.

Impact of clinical pharmacist services on anticoagulation management of total joint arthroplasty: A retrospective observational study

WHAT IS KNOWN AND OBJECTIVE

Even if total joint arthroplasty (TJA) patients have received conventional antithrombotic therapy, the incidence of thrombosis remains high. Clinical pharmacists have been involved in the multidisciplinary team of orthopaedics, but their roles and functions are not yet defined. The objective of this study was to assess the impact of clinical pharmacist services on the use of anticoagulant drugs, the rationality of medication and the incidence of thrombosis in patients with TJA.

METHODS

This retrospective, observational cohort study was conducted for patients undergoing TJA procedures. Study variables were collected for a baseline period of 1 January 2016 to 30 June 2017 and an intervention period of 1 January 2018 to 30 June 2019, allowing for a 6-month run-in period. For demographic characteristics, the use of anticoagulant drugs and the incidence of thrombosis between the baseline and intervention periods, the data were statistically analysed.

RESULTS AND DISCUSSION

During the 36-month study timeframe, a total of 591 TJA procedures were performed. A total of 577 participants were included in the study (240 in the baseline group and 377 in the intervention group). After clinical pharmacist participation, the prevention rate of anticoagulant drugs (p < 0.05), the proportion of oral anticoagulants (p = 0.000) and the course of preventive treatment (p = 0.004) increased significantly. The time of administration was shortened from after 24 h to within 24 h post-surgery (p = 0.000). Although the incidence of symptomatic DVT reduced in the intervention period, there was no statistical difference in either the hospital, 1-month follow-up, or 3-month follow-up after surgery (all p > 0.05).

WHAT IS NEW AND CONCLUSION

Within the limitations of a retrospective study, clinical pharmacist intervention was associated with improvements in anticoagulation management of TJA procedures, likely conferring beneficial effects.

A randomised trial of pharmacist-led discharge prescribing in an Australian geriatric evaluation and management service

Background Prescribing discharge medications is a potential "next step" for pharmacists in Australian hospitals, however, safety must be demonstrated via a randomised controlled study. Objective To determine if a collaborative, pharmacist led discharge prescribing model results in less patients with medication errors than conventional prescribing for both handwritten and digital prescriptions. Setting Geriatric Medical ward in a quaternary hospital, Australia Methods A prospective, single-blinded randomised controlled study of patients randomised to conventional (control) or a pharmacist-led prescribing (intervention) arms at discharge from hospital. This study had 2 phases; (1) handwritten prescribing and (2) digital prescribing. In addition, the two prescribing methods were compared. Main outcome measures The primary outcome was the percentage of patients with a medication error on their discharge prescription. Results In phase 1, 45 patients were recruited; 21 (control) and 24 (intervention). 95% of control patients and 29% in the intervention arm had at least one medication error, p < 0.0002, relative risk (RR) 0.31, confidence interval (CI) 0.16-0.58. The number of items with at least 1 error reduced from 69 to 4%; p < 0.0001, RR 0.06, CI 0.03-0.11 and fewer items had at least 1 clinically significant error (11% vs 2%, p = 0.0004, RR 0.15, CI 0.04-0.30). In phase 2, 39 patients were recruited; 18 (control) and 21 (intervention). 100% of control patients and 62% in the intervention arm had at least one medication error (p = 0.005, RR 0.62, CI 0.44-0.87). Items with at least 1 error decreased from 21 to 7% (p < 0.0001, RR 0.34, CI 0.44-0.56), there were fewer items with at least 1 clinically significant error (13% vs 5%, p < 0.003, RR 0.4, CI 0.22-0.72). There was no significant change in the primary outcome between handwritten and digital (60% vs 79%, p < 0.055). Conclusion In a geriatric setting, pharmacist-led partnered discharge prescribing results in significantly less patients with medication errors than the conventional method for both handwritten and digital methods.

Clinical Pharmacist Service Associated With Improved Outcomes and Cost Savings in Total Joint Arthroplasty

BACKGROUND

Institutions providing total joint arthroplasty (TJA) procedures are subject to substantial outcomes reporting, including those influencing payment for services. Although clinical pharmacists are well-poised to add value, a comprehensive approach to optimizing pharmacotherapy across the care continuum for TJA patients has not been described.

METHODS

This prospective, interventional, sequential cohort study was approved by our Institutional Review Board. The objective was to assess the impact of an Orthopedic Clinical Pharmacist service on institutional TJA complication rates and costs. Outcomes were compared for a Baseline period of July 2015 to February 2016 and a Post-implementation period of September 2016 to February 2017, allowing for a 6-month run-in period. Additionally, we pursued a post-discharge, RN-administered patient survey and an exploratory economic assessment.

RESULTS

A total of 1715 TJA procedures were performed at the institution during the 20-month study timeframe. Postoperative readmission rate (1.3% vs 4.8%, P = .002) and complication rate (1.8% vs 3.4%, P = .760) were lower in the Post-implementation period. Postoperative VTE rate decreased to zero in the Post-implementation period (0.0% vs 0.6%, P = .13) and average hospital length of stay was unchanged (2.8 vs 2.9 days). Patient self-rated understanding of discharge medications was improved and satisfaction with pharmacist interaction was very high. The service conferred an estimated $73,410 net annual cost savings to the institution.

CONCLUSION

Integration of a clinical pharmacist service for TJA patients was associated with clinically meaningful improvements in institutional outcomes, likely conferring substantial cost-benefit.

Impact of pharmaceutical care in the orthopaedic department

WHAT IS KNOWN AND OBJECTIVE

In the mid-1960s, clinical pharmacy developed in the USA, and as the demand for pharmaceutical services continued to grow, their impact began to be taken seriously. However, the participation of clinical pharmacists as members of the multidisciplinary team in the orthopaedic department is still in its infancy, although its role in orthopaedics has not been defined. The object of this study was to identify and discuss the impact of pharmaceutical care in the orthopaedic department.

METHODS

A literature search was conducted on MEDLINE, PubMed, Web of Science, the Cochrane Library and CNKI (China National Knowledge Infrastructure) for papers published between 1998 and 2019, using the keywords pharmacy, pharmacist, and medication or drug combined with orthopaedic. Other available resources were also used to identify relevant articles.

RESULTS AND DISCUSSION

Based on the available evidence in 74 articles, it was found that clinical pharmacists play an important role in all aspects of rational use of medications, medication review and reconciliation, monitoring adverse drug events, risk assessment, and medication education and counselling. In addition, clinical pharmacy services were developed to minimize medication errors, adverse drug events and medical costs, but clinical pharmacy is still in its early stages in orthopaedics.

WHAT IS NEW AND CONCLUSION

A multidisciplinary approach should be adopted in the orthopaedic department, as pharmacist interventions can be vital for promoting the safety, effectiveness and cost-effectiveness of pharmacotherapy. Although pharmacists' contributions to orthopaedics are not yet fully recognized, pharmaceutical services can undoubtedly contribute to both clinical and societal outcomes.