A refined management system focusing on medication dispensing errors: A 14-year retrospective study of a hospital outpatient pharmacy

Objectives

This study aimed to evaluate the efficiency of a 14-year refined management system for the reduction of dispensing errors in a large-scale hospital outpatient pharmacy and to determine the effects of person-related and environment-related factors on the occurrence of dispensing errors.

Methods

A retrospective study was performed. Data on dispensing errors, inventory and account management from 2008 to 2021 were collected from the electronic system and evaluated using the direct observation method and the Plan-Do-Check-Act (PDCA) cycle.

Results

The consistency of the inventory and accounts increased substantially (from 86.93 % to 99.75 %) with the implementation of the refined management program. From 2008 to 2021, the total number of dispensing errors was reduced by approximately 96.1 %. The number of dispensing errors in quantity and name was reduced by approximately 98.2 % and 95.07 %, respectively. A remarkable reduction in the error rate was achieved (from 0.014 % to 0.00002 %), and the rate of dispensing errors was significantly reduced (0.019 % vs. 0.0003 %, p < 0.001). Across all medication dispensing errors, human-related errors decreased substantially (208 vs. 7, p < 0.05), as did non-human-related errors also (202 vs. 9, p < 0.05). There was a correlation between the occurrence of errors and pharmacists' sex (females generally made fewer errors than males), age (more errors were made by those aged 31-40 years), and working years (more errors were made by those with more than 11 years of work experience) from 2016 to 2021. The technicians improved during this procedure.

Conclusions

Refined management using the PDCA cycle was helpful in preventing dispensing errors and improving medication safety for patients.

Developing an In-House Comprehensive Medication Review Training Program for Clinical Pharmacists in a Finnish Hospital Pharmacy

Long-term continuing education programs have been a key factor in shifting toward more patient-centered clinical pharmacy services. This narrative review aims to describe the development of Helsinki University Hospital (HUS) Pharmacy's in-house Comprehensive Medication Review Training Program (CMRTP) and how it has impacted clinical pharmacy services in HUS. The CMRTP was developed during the years 2017-2020. The program focuses on developing the special skills and competencies needed in comprehensive medication reviews (CMRs), including interprofessional collaboration and pharmacotherapeutic knowledge. The program consists of two modules: (I) Pharmacist-Led Medication Reconciliation, and (II) CMR. The CMRTP includes teaching sessions, self-learning assignments, medication reconciliations, medication review cases, CMRs, a written final report, and a self-assessment of competence development. The one-year-long program is coordinated by a clinical teacher. The program is continuously developed based on the latest guidelines in evidence-based medicine and international benchmarking in cooperation with the University of Helsinki. With the CMRTP, we have adopted a more patient-centered role for our clinical pharmacists and remarkably expanded the services. This program may be benchmarked in other countries where the local education system does not cover clinical pharmacy competence well enough and in hospitals where the clinical pharmacy services are not yet very patient-oriented.

Impact of Piperacillin-Tazobactam Dosing in Septic Shock Patients Using Real-World Evidence: An Observational, Retrospective Cohort Study

BACKGROUND

Sepsis and septic shock are associated with significant morbidity and mortality. Rapid initiation of appropriate antibiotic therapy is essential, as inadequate therapy early during septic shock has been shown to increase the risk of mortality. However, despite the importance of appropriate antibiotic initiation, in clinical practice, concerns for renal dysfunction frequently lead to antibiotic dose reduction, with scant evidence on the impact of this practice in septic shock patients.

OBJECTIVE

The purpose if this article is to investigate the rate and impact of piperacillin-tazobactam dose adjustment in early phase septic shock patients using real-world electronic health record (EHR) data.

METHODS

A multicenter, observational, retrospective cohort study was conducted of septic shock patients who received at least 48 hours of piperacillin-tazobactam therapy and concomitant receipt of norepinephrine. Subjects were stratified into 2 groups according to their cumulative 48-hour piperacillin-tazobactam dose: low piperacillin-tazobactam dosing (LOW; <27 g) group and normal piperacillin-tazobactam dosing (NORM; ≥27 g) group. To account for potential confounding variables, propensity score matching was used. The primary study outcome was 28-day norepinephrine-free days (NFD).

RESULTS

In all, 1279 patients met study criteria. After propensity score matching (n = 608), the NORM group had more median NFD (23.9 days [interquartile range, IQR: 0-27] vs 13.6 days [IQR: 0-27], P = 0.021). The NORM group also had lower rates of in-hospital mortality/hospice disposition (25.9% [n = 79] vs 35.5% [n = 108]), P = 0.014). Other secondary outcomes were similar between the treatment groups.

CONCLUSIONS AND RELEVANCE

In the propensity score-matched cohort, the NORM group had significantly more 28-day NFD. Piperacillin-tazobactam dose reduction in early phase septic shock is associated with worsened clinical outcomes. Clinicians should be vigilant to avoid piperacillin-tazobactam dose reduction in early phase septic shock.

The Development, Implementation, and Evaluation of a Pharmacist-Managed Therapeutic Drug Monitoring (TDM) Service for Vancomycin-A Pilot Study

BACKGROUND

In recent years, pharmacists in Australia have been able to expand their scope to include the provision of a range of services. Although evidence has demonstrated the benefits of pharmacist-managed TDM services, recent studies have shown that these services are not prominent within Australia and that the current TDM workflow may not be optimal.

METHODS

An interventional pilot study was conducted of a pharmacist-managed TDM program for vancomycin at a tertiary hospital in Australia.

RESULTS

In total, 15 pharmacists participated in the program. They performed 50.5% of the medication-related pathology over the intervention period. Pharmacist involvement in the TDM process was more likely to lead to appropriate TDM sample collection (OR 87.1; 95% CI = 11.5, 661.1) and to an appropriate dose adjustment (OR 19.1; 95% CI = 1.7, 213.5). Pharmacists demonstrated increased confidence after the education and credentialling package was provided.

CONCLUSIONS

This study demonstrated that a credentialling package for pharmacists can improve knowledge, skills, and confidence around the provision of pharmacist-managed TDM services for vancomycin. This may lead to the evolution of different roles and workflows enabling pharmacists to contribute more efficiently to improving medication safety and use.

Practical approaches to improve vancomycin-related patient outcomes in pediatrics- an alternative strategy when AUC/MIC is not feasible

BACKGROUND

Anecdotal experience and studies have shown that most pediatric patients fail to reach target therapeutic vancomycin trough levels (VTLs) and required higher total daily doses (TDD). This retrospective study aims to evaluate the frequency of hospitalized children who achieved target VTLs with a vancomycin (VNCO) dosing regimen of 40-60 mg/kg/d q6h and to assess the VNCO-TDD required to attain the target and their effects on clinical outcomes in pediatric patients.

METHODS

After ethical approval, patients of 3 month-12 years were evaluated in this chart review study who received ≥ 3 intravenous-VNCO doses and appropriately drawn blood samples of VTLs between October 2019 to June 2020. Data were retrieved for demographic and clinical characteristics, culture reports, VNCO-regimen, subsequent steady-state VTLs, concomitant nephrotoxic medications, and serum creatinine. Clinical pharmacists made interventions in VNCO therapy and higher VNCO-TDD were used. Safety of higher vs standard daily doses and their clinical impact on duration of therapy, hospital stay, and survival were evaluated.

RESULTS

A total of 89 (39.1%) patients achieved target VTLs (SD-group). The smallest proportion (18.2%) of 2-6 years patients achieved target VTLs and reported the lowest mean value of 10.1 ± 0.2 mg/L which was a significant difference (p < 0.05) from all subgroups. Subtherapeutic VTLs were observed in 139 (60.9%) cases (HD-group), who received higher VNCO-TDD of 72 ± 8.9 mg/kg/d q6h to achieve the targets. Duration of therapy in culture-proven septic patients was significantly (p = 0.025) longer in SD-group [18.4 ± 12.2 days] than HD-group [15.1 ± 8.9 days]. Nephrotoxicity and electrolyte imbalance were comparable in groups. Length of hospital stay was significantly (p = 0.011) longer [median 22 (range 8-55) days] in SD-group compared to HD-group [median 16 (range 8-37) days]. Number of patients survived in HD-group were significantly (p = 0.008) higher than SD-group [129 (92.8%) vs 75 (84.3%)].

CONCLUSION

Initial Vancomycin doses of 72 ± 8.9 mg/kg/day q6h are required to achieve therapeutic target in 3 months to 12 years patients. High doses are not associated with higher nephrotoxicity than reported with low doses. In addition, efficient pharmacist intervention for the use of higher VNCO-TDD may improve clinical outcomes in terms of duration of therapy, hospital stay, and survival.

Pharmacist-directed vancomycin therapeutic drug monitoring in pediatric patients: a collaborative-practice model

Background

Therapeutic drug monitoring (TDM) of Vancomycin (VCM) is required to prevent inappropriate dosage-associated bacterial resistance, therapeutic failure, and toxicities in pediatrics. Anecdotal experience and studies show that many healthcare institutions confront barriers while implementing TDM services, this study aimed to assess a pharmacist-directed VCM–TDM service for optimizing patient care in our institution.

Materials and methods

Patients aged 1 month–18 years who received intravenous VCM were included in this quasi-experimental study. The pre-implementation phase (March–June 2018) consisted of retrospective assessment of pediatric patients, the interventional phase (July 2018 to February 2020) included educational programs and the post-implementation phase (March–June 2020) evaluated the participants based on pharmacist-directed VCM–TDM services as a collaborative-practice model including clinical and inpatient pharmacists to provide 24/7 TDM services. Outcomes of the study included the mean difference in the number of optimal (i) prescribed initial VCM doses (primary) (ii) dosage adjustments and (iii) VCM-sampling time (secondary). After ethical approval, data were collected retrospectively.

Results

A hundred patients were there in each phase. The number of cases who were correctly prescribed initial VCM doses was significantly higher in the post-implementation phase, mean difference of 0.22, [95% CI (0.142–0.0.358), p < 0.0001]. Patients who had correct dosage adjustments in the post-implementation phase also had higher statistical significance, mean difference of 0.29, [95% CI (0.152–0.423), p < 0.05]. More correct practices of VCM-levels timing were observed in the post-implementation phase, mean difference of 0.15, [95% CI (− 0.053–0.264), p = 0.079].

Conclusion

This study showed the significant role of pharmacist-directed TDM services to optimize the correct prescribing of initial VCM doses and dose adjustments.

Self-reported clinical pharmacy service provision in Austria: an analysis of both the community and hospital pharmacy sector-a national study

Background With expansion of more advanced clinical roles for pharmacists we need to be mindful that the extent to which clinical pharmacy services are implemented varies from one country to another. To date no comprehensive assessment of number and types of services provided by either community or hospital pharmacies in Austria exists. Objective To analyse and describe the number and types of clinical pharmacy services provided in both community and hospital pharmacies, as well as the level of clinical pharmacy education of pharmacists across Austria. Setting Austrian community and hospital pharmacies. Method An electronic questionnaire to determine number and types of clinical pharmacy services provided was send to all chief pharmacists at all community (n = 1365) and hospital pharmacies (n = 40) across Austria. Besides current and future services provision, education and training provision were also assessed. Main outcome measure Extent of and attitude towards CPS in Austria. Results Response rates to the surveys were 19.1% (n = 261/1365) in community and 92.5% (n = 37/40) in hospital pharmacies. 59.0% and 89.2% of community and hospital pharmacies, respectively, indicated that the provision of clinical pharmacy services in Austria has increased substantially over the past 10 years. Fifty-one percent of community pharmacies reported to provide a medication review service, while 97.3% of hospitals provide a range of services. Only 18.0% of community pharmacies offer services other than medication review services at dispensing. Binary regressions show that provision of already established medication management is a predictor for the willingness of community pharmacists to extend the range of CPS (p < 0.01), while completed training in the area of clinical pharmacy is not (p > 0.05). More hospital than community pharmacists have postgraduate education in clinical pharmacy (17.4% vs 6.5%). A desire to complete postgraduate education was shown by 28.3% of community and 14.7% of hospital pharmacists. Lack of time, inadequate remuneration, lack of resources and poor relationship between pharmacists and physicians were highlighted as barriers. Conclusion Both community and hospital pharmacists show strong willingness to expand their service provision and will need continued support, such as improved legislative structures, more supportive resources and practice focused training opportunities, to further these services.

GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data

OBJECTIVES

We aimed to describe a new multidisciplinary team fall prevention intervention for older adults who seek care in the emergency department (ED) after having a fall, assess its feasibility and acceptability, and review lessons learned during its initiation.

DESIGN

Single-blind randomized controlled pilot study.

SETTING

Two urban academic EDs PARTICIPANTS: Adults 65 years old or older (n = 110) who presented to the ED within 7 days of a fall.

INTERVENTION

Participants were randomized to a usual care (UC) and an intervention (INT) arm. Participants in the INT arm received a brief medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist (PT). INT participants received referrals to outpatient services (eg, home safety evaluation, outpatient PT).

MEASUREMENTS

We used participant, caregiver, and clinician surveys, as well as electronic health record review, to assess the feasibility and acceptability of the intervention.

RESULTS

Of the 110 participants, the median participant age was 81 years old, 67% were female, 94% were white, and 16.3% had cognitive impairment. Of the 55 in the INT arm, all but one participant received the pharmacy consult (98.2%); the PT consult was delivered to 83.6%. Median consult time was 20 minutes for pharmacy and 20 minutes for PT. ED length of stay was not increased in the INT arm: UC 5.25 hours vs INT 5.0 hours (P < .94). After receiving the Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), 100% of participants and 97.6% of clinicians recommended the pharmacy consult, and 95% of participants and 95.8% of clinicians recommended the PT consult.

CONCLUSION

These findings support the feasibility and acceptability of the GAPcare model in the ED. A future larger randomized controlled trial is planned to determine whether GAPcare can reduce recurrent falls and healthcare visits in older adults. J Am Geriatr Soc 68:198-206, 2019.

The Impact of a Training Program on Clinical Pharmacists on Pharmacy Clinical Services in a Tertiary Hospital in Hunan China

Background

Prior to 2015, clinical consultation was the only clinical service provided by clinical pharmacists in Changsha Second Hospital. Between 2015 and 2017, a train-the-trainer program was implemented to train clinical pharmacists to provide pharmaceutical care and to conduct clinical research. The objective of the study is to examine the impact on the clinical services provided by pharmacists after the implementation of the train-the-trainer program.

Patients and methods

Between 2004 and 2014, all completed clinical consultation activities were tallied and summarized. The results from the tallied consultation activities were used as a baseline for clinical activities provided by pharmacists prior to the training. A structured training program was implemented between 2015 and 2017 to train clinical pharmacists to provide pharmaceutical care. After the implementation of the training program was completed, all clinical activities provided by pharmacists between January 2017 and December 2017 were documented in the clinical workload form. The clinical activities completed by each pharmacist were tallied and summarized.

Results

Between 2004 and 2014, a total of 6569 (average 657 per year) pharmacy consultations were requested and completed from a total of 44 departments. In 2017, a total of 15,078 hrs of clinical activities were logged. The pharmacists completed 3481 consultations in 2017 (an increase of 430%), averaging 316 consultations for each pharmacist and 271.8 hr per pharmacist. Over 2000 hrs (of the 15,078 hrs) were spent on direct patient care by the pharmacists.

Conclusion

This study shows that there was a 430% increase in clinical pharmacy consultation services provided by the clinical pharmacists after the implementation of the training program. This is directly related to the number of well-trained pharmacists available. After the implementation of the train-the-trainer program, the range of services as well as the number of clinical services and clinical hours spent on providing pharmaceutical care have significantly increased.

Implementation of clinical pharmacist recommendations and services at a University Hospital in Yemen

Background Studies have revealed that the inclusion of a clinical pharmacist as a member in multidisciplinary medical team has been associated with improved medication use, reduced adverse drug reaction, reduced cost of treatment, and improved health outcomes. Objective The objectives of this study were to evaluate the implementation of clinical pharmacy recommendations and services, the acceptance rate by the physicians, and the anticipated outcomes of the recommendations at a hospital in Yemen. Methods Different units of the University of Science and Technology Hospital, Sana'a were included in this study. All the recommendations and services provided by the clinical pharmacist during daily activities were documented between June 2013 and November 2015. The provided recommendations were classified based on the type, acceptance rate, and the anticipated outcomes. Main outcome measure Type and quality of clinical pharmacists' recommendations, anticipated impact of the recommendations on health outcomes, and their acceptance rate. Results Throughout the study period, a total of 957 patients in different hospital units were visited and provided with a total of 3307 interventions and services. The most frequent types of clinical pharmacist's interventions were drug discontinuation (23.6%, n = 782), inappropriate dose interval or time (n = 735, 22.2%), and add medication (18.9%, n = 626). Overall, 61.8% (n = 2044) of the provided recommendations were accepted by the physicians. The most anticipated outcomes were improved the effectiveness of therapy (45.1%, n = 1909), avoid adverse drug reactions (29%, n = 1228), and decrease the cost of medications (18.8%, n = 797). Conclusion Clinical pharmacist's recommendations resulted in improving drug therapy and decreasing adverse effects for inpatients at the University of Science and Technology Hospital. This suggests that the implementation of clinical pharmacy services is essential and has a positive outcome on patient care.

Strategies for improving medication safety in hospitals: Evolution of clinical pharmacy services

BACKGROUND

Medication safety risks are the most important preventable factors jeopardizing patient safety. To manage these risks, extending pharmacists' involvement in patient care and patient safety work has been systematically addressed in patient safety initiatives since the early 2000s.

OBJECTIVE

To explore the extent and range of clinical pharmacy services in Finnish hospitals to promote medication safety: 1) in 2011, when the first National Patient Safety Strategy, the new Health Care Act and the Medicines Policy 2020 had been recently enacted; and 2) five years later in 2016.

METHODS

The study was conducted in 2011 and 2016 as a national online survey targeted to hospital pharmacies (n = 24) and medical dispensaries (n = 131 in 2011; n = 28 in 2016). The questions were analyzed using descriptive statistics and qualitative content analysis.

RESULTS

Overall response rate was 60% in 2011 and 52% in 2016. Clinical pharmacy services were provided by 51% of the responding units in 2011, whereas by 85% in 2016. The reported number of clinical pharmacists had increased during the five years. The most notable increase in reported tasks occurred in conducting medication reconciliations (+63% increase in the number of providing units). By 2016 pharmacists had extended their tasks particularly towards system-based medication safety work: e.g. developing instructions for medication-use (91% of the responding units), creating and updating medication safety plans (87%) and using medication error reports in developing the process of medication use safer (78%). Pharmacists' participation in long-term continuing education became more common in 2016, which was perceived as helpful in extending their responsibilities to improve medication safety.

CONCLUSION

Pharmacists' involvement in patient care and system-based medication safety work was reported to become more common in Finnish hospitals during 2011-2016. This development is in line with patient safety policy initiatives and its impact on patient care outcomes should be followed up.

Evaluation of a medication error monitoring system to reduce the incidence of medication errors in a clinical setting

BACKGROUND

Medication errors have significant health and economic consequences. Monitoring medication errors by implementing monitoring systems proved in the USA and European countries since 1990s to be an effective method for error detection, leading to improved safety at all levels of health care. Currently, China does not have a universal medication error monitoring system.

OBJECTIVE

To evaluate the effectiveness of the Medication Error Monitoring System for the reduction of medication errors in Xiamen Maternity and Child Care Hospital.

METHODS

Between January-June 2014, the Medication Error Monitoring System developed by Xiamen Maternity and Child Care Hospital was employed to monitor medication errors through error reporting by physicians and pharmacists. The errors collected by this system were then thoroughly assessed and addressed by specific improvements including more frequent training, introducing computerised prescribing systems and a bar-coding medicine dispensing system. Data collected from January-June 2015, was then compared with the data collected in 2014 to determine whether medication errors had been reduced.

RESULTS

Between 2014 and 2015, the total medication errors in prescribing and dispensing were reduced by approximately 27%. Compared with 2014, there was a marked reduction in the number of errors due to misdiagnoses and inappropriate usage/dosage in 2015, while the number of data entry errors increased and became the most common cause of medication error. The success rate of pharmacy interventions increased from 95.25% to 96.88%, albeit modest. However, across all medication errors in the stage of prescribing and dispensing, non-human-related errors significantly decreased from 44.25% in 2014 to 37.94% in 2015 with apvalue of 0.021.

CONCLUSION

The Medication Error Monitoring System is effective at monitoring medication error data, leading to a reduction in reported medication errors. Better training for hospital staff including doctors and pharmacists will be critical to reduce human-related medication errors in the hospital.

Bridging the Gap between Theory and Practice; the Active Role of Inpatient Pharmacists in Therapeutic Drug Monitoring

Many hospitals face barriers in the implementation of TDM services, this study aimed to evaluate a pharmacist-led TDM service to optimize patients' outcomes. Adult patients who were administered vancomycin, gentamicin, or amikacin were included. The pre-phase included a retrospective assessment of patients and the intervention phase consisted of an educational program. The post-phase assessed patients based on TDM services provided by inpatient pharmacists on a 24-h, 7-day basis for 3 months. The primary outcome was to assess the mean difference in proportion of correct initial doses of prescribing orders. Secondary outcomes included assessing the mean differences in proportions of correct dose adjustments and correct drug sampling time. Seventy-five patients in each phase were eligible. Patients who received optimal initial dosing in the post-phase showed a higher statistical significance, mean difference of 0.31, [95% CI (0.181⁻0.4438), p < 0.0001]. Patients in the post-phase received more optimal dose adjustments, mean difference of 0.1, [95% CI (-0.560⁻0.260), p = 0.2113]. Drug levels were ordered more correctly in the post-phase, mean difference of 0.03, [95% CI (-0.129⁻0.189), p = 0.7110]. This study demonstrated the important role of TDM services led by pharmacists in optimizing the initial dosing for these antibiotics.

Significantly Lower Rates of Kidney Transplantation among Candidates Listed with the Veterans Administration: A National and Local Comparison

BACKGROUND

The process for evaluating kidney transplant candidates and applicable centers is distinct for patients with Veterans Administration (VA) coverage. We compared transplant rates between candidates on the kidney waiting list with VA coverage and those with other primary insurance.

METHODS

Using the Scientific Registry of Transplant Recipients database, we obtained data for all adult patients in the United States listed for a primary solitary kidney transplant between January 2004 and August 2016. Of 302,457 patients analyzed, 3663 had VA primary insurance coverage.

RESULTS

VA patients had a much greater median distance to their transplant center than those with other insurance had (282 versus 22 miles). In an adjusted Cox model, compared with private pay and Medicare patients, VA patients had a hazard ratio (95% confidence interval) for time to transplant of 0.72 (0.68 to 0.76) and 0.85 (0.81 to 0.90), respectively, and lower rates for living and deceased donor transplants. In a model comparing VA transplant rates with rates from four local non-VA competing centers in the same donor service areas, lower transplant rates for VA patients than for privately insured patients persisted (hazard ratio, 0.72; 95% confidence interval, 0.65 to 0.79) despite similar adjusted mortality rates. Transplant rates for VA patients were similar to those of Medicare patients locally, although Medicare patients were more likely to die or be delisted after waitlist placement.

CONCLUSIONS

After successful listing, VA kidney transplant candidates appear to have persistent barriers to transplant. Further contemporary analyses are needed to account for variables that contribute to such differential transplant rates.

Hospital clinical pharmacy services in Vietnam

Background Clinical pharmacy is key to the quality use of medicines. While there are different approaches in different countries, international perspectives may inform health service development. The Vietnamese Ministry of Health introduced a legal regulation of clinical pharmacy services in December 2012. Objective To describe the services, and to explore reported barriers and facilitators in implementing clinical pharmacy activities in Vietnamese hospitals after the introduction of Vietnamese Ministry of Health legal regulation. Setting Thirty-nine hospitals in Hanoi, Vietnam, including 22 provincial and 17 district hospitals. Method A mixed methods study was utilized. An online questionnaire was sent to the hospitals. In-depth interviews were conducted with pairs of nominated pharmacists at ten of these hospitals. The questionnaire focused on four areas: facilities, workforce, policies and clinical pharmacy activities. Main outcome measure Proportion of clinical pharmacy activities in hospitals. Themes in clinical pharmacy practice. Results 34/39 (87%) hospitals had established clinical pharmacy teams. Most activities were non-patient-specific (87%) while the preliminary patient-specific clinical pharmacy services were available in only 8/39 hospitals (21%). The most common non-patient-specific activities were providing medicines information (97%), reporting adverse drug reactions (97%), monitoring medication usage (97%). The patient specific activities varied widely between hospitals and were ad hoc. The main challenges reported were: lack of workforce and qualified clinical pharmacists. Conclusion While most hospitals had hospital-based pharmacy activities, the direct patient care was limited. Training, education and an expanded work forces are needed to improve clinical pharmacy services.

Effects of multidisciplinary teams and an integrated follow-up electronic system on clinical pharmacist interventions in a cancer hospital

Background The aim of drug therapy is to attain distinct therapeutic effects that not only improve patient's quality of life but also reduce the inherent risks associated with the therapeutic use of drugs. Pharmacists play a key role in reducing these risks by developing appropriate interventions. Whether to accept or reject the intervention made by the pharmacist is a relevant consultant's decision. Objective To evaluate the impact of electronic prompts and follow-up of rejected pharmacy interventions by clinical pharmacists in an in-patient setting. Setting Shaukat Khanum Cancer Hospital & Research Center, Lahore, Pakistan. Method The study was conducted in two phases. Data for 3 months were collected for each phase of the study. Systematic and quantifiable consensus validity was developed for rejected interventions in phase 1, based on patient outcome analyses. Severity rating was assigned to assess the significance of interventions. Electronic prompts for follow-on interventions in phase 2 were then developed and implemented, including daily review via a multidisciplinary team (MDT) approach. Main outcome measure Validity of rejected interventions, acceptance of follow-on interventions before and after re-engineering the pharmacy processes, rejection rate and severity rating of follow-on interventions. Result Of a total of 2649 and 3064 interventions that were implemented during phase 1 and phase 2, 238 (9%) and 307 (10%) were rejected, respectively. Additionally, 133 (56%) were inappropriate rejections during phase 1. The estimated reliability between pharmacists regarding rejected interventions was 0.74 (95% CI of 0.69, 0.79, p 0.000). Prospective data were analysed after implementing electronic alerts and an MDT approach. The acceptance rate of follow-on interventions in phase 2 was 60% (184). Conclusion Electronic prompts for follow-on interventions together with an MDT approach enhance the optimization of pharmacotherapy, increase drug rationality and improve patient care.

Comparing VA and Non-VA Quality of Care: A Systematic Review

BACKGROUND

The Veterans Affairs (VA) health care system aims to provide high-quality medical care to veterans in the USA, but the quality of VA care has recently drawn the concern of Congress. The objective of this study was to systematically review published evidence examining the quality of care provided at VA health care facilities compared to quality of care in other facilities and systems.

METHODS

Building on the search strategy and results of a prior systematic review, we searched MEDLINE (from January 1, 2005, to January 1, 2015) to identify relevant articles on the quality of care at VA facilities compared to non-VA facilities. Articles from the prior systematic review published from 2005 and onward were also included and re-abstracted. Studies were classified, analyzed, and summarized by the Institute of Medicine's quality dimensions.

RESULTS

Sixty-nine articles were identified (including 31 articles from the prior systematic review and 38 new articles) that address one or more Institute of Medicine quality dimensions: safety (34 articles), effectiveness (24 articles), efficiency (9 articles), patient-centeredness (5 articles), equity (4 articles), and timeliness (1 article). Studies of safety and effectiveness indicated generally better or equal performance, with some exceptions. Too few articles related to timeliness, equity, efficiency, and patient-centeredness were found from which to reliably draw conclusions about VA care related to these dimensions.

DISCUSSION

The VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care. Additional studies of quality of care in the VA are needed on all aspects of quality, but particularly with regard to timeliness, equity, efficiency, and patient-centeredness.

A Canadian Survey of Pharmacist Participation during Cardiopulmonary Resuscitation

BACKGROUND

The participation of pharmacists on cardiopulmonary resuscitation (CPR) teams has been associated with improvements in patient outcomes secondary to lower rates of adverse drug events and higher rates of compliance with guidelines for advanced cardiac life support (ACLS). The degree to which Canadian pharmacists participate on CPR teams and the services they provide have not previously been assessed.

OBJECTIVES

To measure the frequency of pharmacists' involvement on CPR teams in Canadian health care delivery organizations, to characterize the services provided by these pharmacists, to identify positive predictors of participation, and, for health care delivery organizations without pharmacists on CPR teams, to determine the reasons for the lack of involvement.

METHODS

An electronic survey was distributed to key informants in Canadian health care delivery organizations. The survey consisted of questions about characteristics of the health care delivery organizations, pharmacists' participation and role on the CPR team, training, and barriers to implementation. The primary outcome was the percentage of health care delivery organizations with pharmacists participating on CPR teams in at least one centre within the organization. The secondary outcomes were pharmacists' activities, training, and reasons for not participating on CPR teams.

RESULTS

Forty-three of 99 key informants responded to the survey. Twenty-nine respondents (67%) indicated that their organization had a CPR team, and 10 (23%) indicated participation by pharmacists on a CPR team. Roles reported to be performed by pharmacists during CPR events were provision of drug information, preparation and administration of medications, record-keeping, and chest compressions. Training for these pharmacists was variable: ACLS training for 4 (40%) of the 10 organizations with pharmacist participation, in-house training for 3 (30%), and no training for 2 (20%); one respondent (10%) did not report the level of training. Reasons for not having pharmacists on CPR teams included inconsistent coverage, lack of training, and staff shortages.

CONCLUSIONS

This study characterized current pharmacist participation on CPR teams in Canadian health care delivery organizations. As evidence arises showing the impact of this practice on patient outcomes, pharmacist participation on CPR teams may become more common.

Incidence and treatment costs attributable to medication errors in hospitalized patients

BACKGROUND

A significant financial burden arises from medication errors that cause direct injury and those without patient harm that represent waste and inefficiency.

OBJECTIVE

To estimate the incidence, types, and causes of medication errors as well as their attributable costs in a hospital setting.

METHODS

For a retrospective case-control study, data were collected for 57,554 patients admitted to two New Jersey (U.S. State) hospitals during 2005-2006 as well as hospital-specific voluntary error reports from these two hospitals for the same period. Medication errors were classified into categories of stage, error type, and proximal cause, and the incidence was estimated. The costs attributable to medication errors were calculated using both the recycled prediction method, and the Blinder-Oaxaca decomposition method after propensity score matching.

RESULTS

Medication errors occurred at a rate of 0.8 per 100 admissions, or 1.6 per 1000 patient days. Most errors occurred at the administration stage of the medication use process. The most frequent types of errors were wrong time, wrong medication, wrong dose, and omission errors. Treatment costs attributable to medication errors were in the range of $8,439 using the Blinder-Oaxaca decomposition method and $8,898 using the recycled prediction method.

CONCLUSIONS

Medication errors are associated with significant additional costs, even without patient harm. Considering the substantial costs associated with adverse drug events, the elimination of medication errors should be further emphasized and promoted, and guidelines should be developed to facilitate this goal.

Outcomes of expanded use of clinical pharmacist practitioners in addition to team-based care in a community health system intensive care unit

PURPOSE

Clinical and cost benefits achieved through expanded use of state-licensed clinical pharmacist practitioners (CPPs) with prescribing authority on a critical care team are reported.

METHODS

A retrospective pre-post analysis was conducted to evaluate patient care outcomes and cost savings during one-year periods before and after the number of CPPs on a North Carolina community health system's neurotrauma intensive care unit (NTICU) team was increased from one to three. Outcomes assessed included the number and types of medication management encounters, estimated cost savings, and the rate of preventable adverse drug events (ADEs) with expanded use of CPPs.

RESULTS

During the two-year study period, CPPs conducted 13,386 documented medication encounters involving 2,198 patients; associated cost savings totaled an estimated $2,118,426. During the 12 months after CPP involvement on the NTICU team was increased, there was a 182% increase in encounters for therapeutic optimization (p = 0.01), with an associated 29% increase in cost savings and an improved return on investment. The CPP service expansion was also associated with a reduction in preventable ADEs, including a 75% reduction in prescribing-related ADEs (risk ratio [RR], 0.25; 95% confidence interval [CI], 0.05-1.2; p = 0.09) and a 37% reduction in higher-severity ADEs (RR, 0.63; 95% CI, 0.25-1.57; p = 0.36).

CONCLUSION

With expanded CPP involvement on the NTICU team, there was a substantial increase in therapeutic optimization interventions and a clinically notable reduction in preventable ADEs, as well as an estimated 30% increase in associated cost savings.

Enhanced clinical pharmacy service targeting tools: risk-predictive algorithms

RATIONALE, AIMS AND OBJECTIVES

This study aimed to determine the value of using a mix of clinical pharmacy data and routine hospital admission spell data in the development of predictive algorithms. Exploration of risk factors in hospitalized patients, together with the targeting strategies devised, will enable the prioritization of clinical pharmacy services to optimize patient outcomes.

METHODS

Predictive algorithms were developed using a number of detailed steps using a 75% sample of integrated medicines management (IMM) patients, and validated using the remaining 25%. IMM patients receive targeted clinical pharmacy input throughout their hospital stay. The algorithms were applied to the validation sample, and predicted risk probability was generated for each patient from the coefficients. Risk threshold for the algorithms were determined by identifying the cut-off points of risk scores at which the algorithm would have the highest discriminative performance. Clinical pharmacy staffing levels were obtained from the pharmacy department staffing database.

RESULTS

Numbers of previous emergency admissions and admission medicines together with age-adjusted co-morbidity and diuretic receipt formed a 12-month post-discharge and/or readmission risk algorithm. Age-adjusted co-morbidity proved to be the best index to predict mortality. Increased numbers of clinical pharmacy staff at ward level was correlated with a reduction in risk-adjusted mortality index (RAMI).

CONCLUSIONS

Algorithms created were valid in predicting risk of in-hospital and post-discharge mortality and risk of hospital readmission 3, 6 and 12 months post-discharge. The provision of ward-based clinical pharmacy services is a key component to reducing RAMI and enabling the full benefits of pharmacy input to patient care to be realized.

Comparison of practice patterns between inpatient cardiology pharmacists with and without added qualifications in cardiology

BACKGROUND

There is a paucity of data comparing practice patterns between board-certified specialists with added qualifications in cardiology (AQCV) and cardiovascular pharmacists without these credentials.

PURPOSE

The purpose is to characterize differences in practice between inpatient pharmacists with and without AQCV.

METHODS

We conducted a multicenter, retrospective, cross-sectional, case-controlled survey. An AQCV pharmacist list was extracted from the Board of Pharmacy Specialties Web site. Hospitals with AQCV pharmacists comprised the case group. Hospitals were excluded if the AQCV pharmacists did not provide direct patient care, practiced in the outpatient setting, or were in a Veterans Affairs hospital. Each case hospital was matched to hospitals without an AQCV pharmacist in a 1:3 ratio (case:control) by region, cardiovascular discharges, and teaching hospital status. Institutions completed a survey characterizing their pharmacy services.

RESULTS

Fifty-six hospitals completed the survey (21 AQCV, 35 non-AQCV). More AQCV pharmacists participated on rounds (100% vs 82.9%, P = .04) and devoted more time performing administrative tasks (20.5% ± 15.3% vs 11.1% ± 8.1%, P = .001) than non-AQCV pharmacists. Conversely, AQCV pharmacists spent less time providing clinical care (52.4% ± 14.5% vs 66.2% ± 19.8%, P = .007), were less involved with drug protocol management (71.4% vs 91.4%, P = .05), and performed less order verification than non-AQCV pharmacists.

CONCLUSIONS

Practice patterns differ between inpatient pharmacists with and without AQCV. Further research is needed to determine whether AQCV credentialing improves patient outcomes and to delineate what specific tasks performed by inpatient cardiology pharmacists may improve patient outcomes.

Comparison of practice patterns between inpatient cardiology pharmacists with and without added qualifications in cardiology

BACKGROUND

There is a paucity of data comparing practice patterns between board-certified specialists with added qualifications in cardiology (AQCV) and cardiovascular pharmacists without these credentials.

PURPOSE

The purpose is to characterize differences in practice between inpatient pharmacists with and without AQCV.

METHODS

We conducted a multicenter, retrospective, cross-sectional, case-controlled survey. An AQCV pharmacist list was extracted from the Board of Pharmacy Specialties Web site. Hospitals with AQCV pharmacists comprised the case group. Hospitals were excluded if the AQCV pharmacists did not provide direct patient care, practiced in the outpatient setting, or were in a Veterans Affairs hospital. Each case hospital was matched to hospitals without an AQCV pharmacist in a 1:3 ratio (case:control) by region, cardiovascular discharges, and teaching hospital status. Institutions completed a survey characterizing their pharmacy services.

RESULTS

Fifty-six hospitals completed the survey (21 AQCV, 35 non-AQCV). More AQCV pharmacists participated on rounds (100% vs 82.9%, P = .04) and devoted more time performing administrative tasks (20.5% ± 15.3% vs 11.1% ± 8.1%, P = .001) than non-AQCV pharmacists. Conversely, AQCV pharmacists spent less time providing clinical care (52.4% ± 14.5% vs 66.2% ± 19.8%, P = .007), were less involved with drug protocol management (71.4% vs 91.4%, P = .05), and performed less order verification than non-AQCV pharmacists.

CONCLUSIONS

Practice patterns differ between inpatient pharmacists with and without AQCV. Further research is needed to determine whether AQCV credentialing improves patient outcomes and to delineate what specific tasks performed by inpatient cardiology pharmacists may improve patient outcomes.

Development and implementation of a pharmacist-managed, neonatal and pediatric, opioid-weaning protocol

OBJECTIVES

To compare the length of wean and abstinence severity in neonatal and pediatric patients with neonatal abstinence syndrome or iatrogenic opioid dependence treated with a pharmacist-managed, methadone-based protocol compared with physician-managed patients treated with either methadone or dilute tincture of opium (DTO).

METHODS

This was a prospective, single-centered, interventional evaluation of 54 pharmacist-managed patients versus 53 retrospective, physician-managed patients. Wean duration and severity of neonatal abstinence syndrome were compared between groups using the Student t test.

RESULTS

Significantly shorter wean duration in in utero-exposed pharmacist-managed patients compared with patients on physician-managed DTO (11.7 days vs 24.2 days, p < 0.001), but not compared with patients on physician-managed methadone (11.7 days vs 47 days, p = 0.101). No statistically significant difference was seen in wean duration in iatrogenic-exposed pharmacist-managed patients compared with patients on either physician-managed DTO or methadone (8.69 days vs 14 days, p = 0.096) and (8.69 days vs 9.82 days, p = 0.34), respectively. There were significantly fewer abstinence scores >12 in pharmacist-managed patients versus physician-managed DTO, but not physician-managed methadone (2.05 vs 17.3, p = 0.008 and 2.05 vs 74.3, p = 0.119, respectively). Significantly fewer abstinence scores ≥8 × 3 consecutively were seen in pharmacist-managed patients compared with patients on either physician-managed DTO or methadone (2.89 vs 11.9, p = 0.01 and 2.89 vs 24, p < 0.001, respectively).

CONCLUSIONS

Use of a pharmacist-managed, methadone-based weaning protocol standardizes patient care and has the potential to decrease abstinence severity and shorten duration of wean versus physician-managed patients exposed to opioids in utero. Additionally, a methadone wean of 10% to 20% per day was well tolerated in both neonatal and pediatric patients.

The impact of clinical pharmacy services in China on the quality use of medicines: a systematic review in context of China's current healthcare reform

INTRODUCTION

Recently, China initiated an ambitious healthcare reform aiming to provide affordable and equitable basic health care to all by 2020. To meet these goals, new policies issued by China's Ministry of Health mandate clinical pharmacy services be integrated into China's hospitals. This review aims to highlight the impact of clinical pharmacy services on the quality use of medicines in hospitals in China.

METHODS

Both English and Chinese databases were used. For the English databases, Web of Science, Medline, International Pharmaceutical Abstracts and Embase were searched using the following keywords ('pharmacists' OR 'pharmacy' OR 'pharmaceutical services/pharmaceutical care') AND ('China'). For the Chinese database, Chinese Biomedical Literature Database on disc was searched using the following keywords ('clinical pharmacist' OR 'clinical pharmacy' OR 'pharmaceutical care' OR 'pharmaceutical services'). Articles were then retrieved from WanFang database and China Knowledge Resource Integrated Database.

RESULTS

A total of 75 published papers were included in this review. The majority of studies were conducted in the inpatient setting (68%), which included clinical pharmacy interventions such as educating doctors and patients, evaluating and monitoring the implementation of hospital policies and/or reviewing medications on the ward. In the outpatient setting, the majority of studies conducted involved educating patients. Clinical pharmacy services frequently focused on antimicrobials (44%). More than half of these studies employed an administrative intervention alongside the clinical pharmacy service.

CONCLUSION

Clinical pharmacy services in China, with its unique healthcare system and cultural nuances, appear to positively influence patient care and the appropriate use of medications. From the published literature, it is expected that clinical pharmacy services can make a strong contribution to China's healthcare reform with further governmental and educational support.

Safety and efficacy of dexmedetomidine in children with heart failure

This retrospective observational study aimed to evaluate the safety and efficacy of dexmedetomidine (DEX) for children with heart failure. The study was conducted in the cardiovascular intensive care unit (CVICU) of a single, tertiary care, academic children's hospital. A retrospective review of the charts for all children (up to 18 years of age) with signs and symptoms consistent with congestive heart failure who received DEX in our CVICU between April 2006 and April 2011 was performed. The patients were divided into two groups for study purposes: the DEX group of 21 patients, who received a DEX infusion together with other conventional sedation agents, and the control group of 23 patients, who received conventional sedation agents without the use of DEX. To evaluate the safety of DEX, physiologic data were collected including heart rate, mean arterial pressure (MAP), and inotrope score. To assess the efficacy of DEX, the amount and duration of concomitant sedation and analgesic infusions in both the DEX and control groups were examined. The numbers of rescue boluses for each category before the initiation of sedative infusion and during the sedative infusion also were examined. The baseline characteristics of the patients in the two groups were similar. There was no effect of DEX infusion on heart rate, MAP, or inotrope score at the termination of infusion. The daily amount of midazolam administered was significantly less during the last 24 h of DEX infusion in the DEX group than in the control group (p = 0.04). The daily amount of morphine infusion did not differ between the DEX and control groups during any period. The numbers of sedation and analgesic rescue boluses were lower in DEX group throughout the infusion. No other significant side effects were noted. Two patients in the DEX group had a 50 % or greater drop in MAP compared with baseline in the first 3 h after initiation of DEX infusion, whereas one patient had a 50 % or greater drop in heart rate compared with baseline in the first 3 h after initiation of DEX infusion. Administration of DEX for children with heart failure appears to be safe but should be used cautiously. Furthermore, DEX use is associated with a decreased opiate and benzodiazepine requirement for children with heart failure.

Receipt of high risk medications among elderly enrollees in Medicare Advantage plans

BACKGROUND

Since 2005, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage (MA) plans to report prescribing rates of high risk medications (HRM).

OBJECTIVE

To determine predictors of receipt of HRMs, as defined by the National Committee for Quality Assurance's "Drugs to Avoid in the Elderly" quality indicator, in a national sample of MA enrollees.

DESIGN AND PARTICIPANTS

Retrospective analysis of Healthcare Effectiveness Data and Information Set (HEDIS) data for 6,204,824 enrollees, aged 65 years or older, enrolled in 415 MA plans in 2009. To identify predictors of HRM use, we fit generalized linear models and modeled outcomes on the risk-difference scale.

MAIN OUTCOME MEASURES

Receipt or non-receipt of one or two HRMs.

KEY RESULTS

Approximately 21 % of MA enrollees received at least one HRM and 4.8 % received at least two. In fully adjusted models, females had a 10.6 (95 % CI: 10.0-11.2) higher percentage point rate of receipt than males, and residence in any of the Southern United States divisions was associated with a greater than 10 percentage point higher rate, as compared with the reference New England division. Higher rates were also observed among enrollees with low personal income (6.5 percentage points, 95 % CI: 5.5-7.5), relative to those without low income and those residing in areas in the lowest quintile of socioeconomic status (2.7 points, 95 % CI: 1.9-3.4) relative to persons residing in the highest quintile. Enrollees ≥ 85 years old, black enrollees, and other minority groups were less likely to receive these medications. Over 38 % of MA enrollees residing in the hospital referral region of Albany, Georgia received at least one HRM, a rate four times higher than the referral region with the lowest rate (Mason City, Iowa).

CONCLUSIONS

Use of HRMs among MA enrollees varies widely by geographic region. Persons living in the Southern region of the U.S., whites, women, and persons of low personal income and socioeconomic status are more likely to receive HRMs.

Implementation of clinical pharmacy services at a university hospital in Jordan

OBJECTIVE

Clinical pharmacy services are still in the early stages of implementation in the Middle East. This study assessed the implementation of clinical pharmacy services at a major university hospital.

METHODS

All recommendations and services provided by clinical pharmacists were recorded for a period of 7 months.

KEY FINDINGS

During the study period a total of 3026 patients were followed up and 10,783 recommendations and services were provided. The physicians' rate of acceptance of clinical pharmacists' recommendations was 69.4%.

CONCLUSION

The implementation of clinical pharmacy services in this setting was successful and should positively impact patient care.

Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network

OBJECTIVE

Hospital incident reporting is widely used but has had limited effectiveness for improving patient safety nationally. We describe the process of establishing a multi-institutional safety event reporting system.

METHODS

A descriptive study in The Pediatric Emergency Care Applied Research Network of 22 hospital emergency departments was performed. An extensive legal analysis addressed investigators' concerns about sharing confidential incident reports (IRs): (1) the ability to identify sites and (2) potential loss of peer review statute protection. Of the 22 Pediatric Emergency Care Applied Research Network sites, 19 received institutional approval to submit deidentified IRs to the data center. Incident reports were randomly assigned to independent review; discordance was resolved by consensus. Incident reports were categorized by type, subtype, severity, staff involved, and contributing factors.

RESULTS

A total of 3,106 IRs were submitted by 18 sites in the first year. Reporting rates ranged more than 50-fold from 0.12 to 6.13 per 1000 patients. Data were sufficient to determine type of error (90% of IRs), severity (79%), staff involved (82%), and contributing factors (82%). However, contributing factors were clearly identified in only 44% of IRs and required extrapolation by investigators in 38%. The most common incidents were related to laboratory specimens (25.5%), medication administration (19.3%), and process variance, such as delays in care (14.4%).

CONCLUSIONS

Incident reporting provides qualitative data concerning safety events. Perceived legal barriers to sharing confidential data can be addressed. Large variability in reporting rates and low rates of providing contributing factors suggest a need for standardization and improvement of safety event reporting.

Integrated medicines management - can routine implementation improve quality?

RATIONALE, AIMS AND OBJECTIVES

Previous service development work in the area of integrated medicines management (IMM) has demonstrated clear quality improvements in a targeted group of patients within a hospital in Northern Ireland. In order to determine whether this programme could be transferable to routine practice and thereby assess its generalizability, research has been carried out to quantify the health care benefits of incorporating the concept of IMM as routine clinical practice.

METHOD

The IMM programme of care was delivered to all eligible patients (subject to inclusion criteria) across two hospital sites in Northern Ireland during normal pharmacy opening hours. All patients were followed up for a period of 12 months from their time of hospital admission. All patient data were collected using the custom-designed Electronic Pharmacist Intervention Clinical System at each stage of their hospital journey, that is, admission, inpatient stay and discharge.

RESULTS

Patients who received the IMM service benefited from a reduced length of hospital stay on their reference admission (1.42 days; P = 0.020) as well as a reduced length of stay during the first rehospitalization (5.86 days; P = 0.013). There was also a trend of a reduced number of readmissions and a longer time to readmission during the 12-month follow-up period. Potential significant opportunity cost savings were demonstrated as well as a significant improvement in medication appropriateness (discharge vs. reference admission).

CONCLUSIONS

The IMM programme of care has proven to be transferable to routine hospital care within two hospitals in Northern Ireland. It is anticipated that this current research will further inform the development of IMM as routine clinical practice across Northern Ireland and beyond.

Development of clinical pharmacy productivity metrics

PURPOSE

The development of an automated tool to quantify decentralized clinical pharmacists' productivity at a large metropolitan hospital is described.

SUMMARY

From 2008 to 2010, pharmacy administration, clinical pharmacy, and information technology (IT) staff at Regions Hospital in St. Paul, Minnesota, developed a tool to identify, abstract, and report measures of clinical pharmacy productivity. The primary goal was to create automated metrics to accurately and comprehensively collect relevant clinical data without adding to the clinical pharmacy or administrative staff workload. Electronically captured measurable clinical activities were identified by staff, and methods to extract these data from the electronic medical record (EMR) were developed by IT staff using existing EMR variables. These activities included verification of orders, entry of oral orders, discontinuation of orders, patient profile review, preparation of progress notes, reporting of unexpected medication events, and responses to emergency resuscitation codes. Decentralized pharmacists were asked to weigh each activity relative to other activities on the basis of the average time and cognitive skill required to complete a specific intervention. Reports were generated and extracted into a database for data analysis, data graphing, and final-report generation.

CONCLUSION

Implementation of an automated tool derived from the EMR and developed by clinical and IT staff allowed decentralized clinical pharmacists' activities to be captured electronically and reported quarterly and annually. Weighted metrics enabled the quantification of pharmacists' clinical activities.

Effects of clinical decision support on initial dosing and monitoring of tobramycin and amikacin

PURPOSE

The impact of clinical decision support (CDS) on initial doses and intervals and pharmacokinetic outcomes of amikacin and tobramycin therapy was evaluated.

METHODS

A complex CDS advisor to provide guidance on initial dosing and monitoring of aminoglycoside orders, using both traditional-dosing and extended-interval-dosing strategies, was integrated into a computerized prescriber-order-entry (CPOE) system and compared with a control group whose aminoglycoside orders were closely monitored by pharmacists. The primary outcome measured was an initial dose within 10% of a dose calculated to be adherent to published dose guidelines. Secondary outcomes included a guideline-adherent interval, trough and peak concentrations in goal range, and rate of nephrotoxicity.

RESULTS

Of 216 patients studied, 97 were prescribed amikacin and 119 were prescribed tobramycin. The number of orders with initial doses consistent with reference standards increased from 40% in the preadvisor group to 80% in the postadvisor group (p < 0.001). Selection of the correct initial interval based on renal function increased from 63% to 87% (p < 0.001). The changes in the initial dosing and interval resulted in an increase of trough concentrations at goal (59% in the preadvisor group versus 89% in the postadvisor group, p = 0.0004). There was no significant difference in peak concentrations in the goal range or rate of nephrotoxicity.

CONCLUSION

An advisor for aminoglycoside dosing and monitoring integrated into a CPOE system significantly improved selection of initial doses and intervals and resulted in an improvement in the rate of trough serum drug concentrations at goal compared with standard provider dosing.

Community pharmacy services in the United Arab Emirates

OBJECTIVES

To identify the type and frequency of services provided through community pharmacies in the United Arab Emirates (UAE).

METHODS

A survey was conducted using an anonymous questionnaire distributed by hand to 700 community pharmacies. Items included information about the pharmacists and pharmacies, type of products sold, type and extent of enhanced services provided and perceived barriers to providing these services.

KEY FINDINGS

Most pharmacies provided a wide range of medicinal and non-medicinal products. The frequency with which services were provided was assessed on a scale of 1 (never) to 5 (always). Enhanced professional services were not provided to a large extent in most pharmacies. Fewer than one-third (29%) reported they always supplied printed information to patients (mean = 3.37, 95% confidence interval = 3.23-3.52); fewer than one-third (28%) counselled patients on a regular basis (3.25, 3.09-3.40); nearly two-thirds (62%) reported monitoring patients' adherence to therapy at least sometimes (2.96, 2.81-3.10). Most pharmacies (92%) in the UAE did not routinely keep patient records (2.09, 1.96-2.32). While just over a quarter of respondents claimed that they always reported medication errors (27%) and adverse drug reactions (28%), these activities were not often performed in around 40% of pharmacies.

CONCLUSIONS

This is the first study to explore the type and extent of professional services provided through community pharmacies in the UAE and provides baseline data critical to inform the development of strategies to improve the quality of community pharmacy services.

Oral Anti-Cancer Agents in the Community Setting: A Survey of Pharmacists in Newfoundland and Labrador

Background:

Over the past decade, there has been a sharp rise in the approval of orally administered anti-cancer agents for disease control. The increase in the use of oral anti-cancer agents (OAAs) raises concerns that community pharmacists may not have the training to safely dispense these agents and provide effective patient care. In order to identify the needs of community pharmacists with respect to oral anti-cancer therapy, a survey was conducted in the province of Newfoundland and Labrador.

Methods:

A structured electronic mailing strategy was used. Standardized data collection forms with a cover letter were electronically mailed to 560 practising pharmacists. Survey items included questions related to demographic information, practice setting, current knowledge related to cancer therapy, education needs, access to resources, patient education, patient and pharmacist safety and required elements of an OAA prescription.

Results:

The response rate was 39%. Only 9.6% of respondents felt that they had received adequate oncology education at the undergraduate level and approximately 31% had attended a continuing education event related to oncology in the past 2 years. Just 17% of respondents stated that they used protective equipment when dispensing OAAs. Only 28% of the pharmacists who responded were familiar with the common doses of OAAs and approximately 25% felt comfortable educating patients on these medications.

Conclusions:

A substantial portion of community pharmacists in Newfoundland and Labrador do not have a solid understanding of oral anti-cancer therapy. These educational gaps must be addressed to ensure patient safety as well as the safe handling and dispensing of OAAs by community pharmacists.

Development and implementation of a method for characterizing clinical pharmacy interventions and medication use in a cancer center

PURPOSE

Develop and implement a method to characterize clinical pharmacy activities and the associated medication use in a comprehensive cancer center. A standard characterization of clinical pharmacy services facilitates benchmarking and informs continuous development.

METHODS

A set of quantifiable parameters to describe clinical pharmacy activities and the associated medication use was proposed and validated by peer review. For implementation, clinical pharmacy interventions for six clinical pharmacy services at the King Hussein Cancer Center in 2008 were prospectively documented and the numbers of patients and medications dispensed for the same period were obtained from the admission office and pharmacy database respectively.

RESULTS

The method comprised four main aspects: (1) number of interventions, (2) type of interventions, (3) number of doses dispensed, and (4) the NNI which is the number of doses dispensed for one intervention to occur. A total of 8552 interventions were recorded for 37,784 patient days. Interventions were highest in the pediatric oncology and ICU with 2612 (31%) and 1867 (22%) respectively, followed by medical oncology 1563 (18%), BMT 998 (12%), palliative care 792 (9%), and surgery 720 (8%). Interventions per 1000 patient days were: ICU 555, pediatric oncology 326, BMT 319, palliative care 244, medical oncology 137, and surgery 83. Main intervention categories for all services: therapeutic 3055 (36%), safety 2195 (26%), quality assurance 2376 (28%), and education-information 925 (10%). The number of doses dispensed per 1000 patient days was: BMT 19,404, palliative care 17,272, ICU 12,290, medical oncology 13,182, pediatric oncology 12,093, and surgery 8976. Finally, NNI was as follows: ICU 22, pediatric oncology 39, BMT 60, palliative care 71, medical oncology 96, and surgery 109.

CONCLUSION

A method for characterizing clinical pharmacy interventions and medication use was developed and used to compare different oncology clinical pharmacy services. Further work is warranted to refine and validate the parameters proposed.

Comparison of hospital admission medication lists with primary care physician and outpatient pharmacy lists

PURPOSE

Medication reconciliation is a process to reduce errors and harm associated with loss of medication information as the patient enters and moves through the healthcare system. This study examines medication list accuracy upon hospital admission.

DESIGN

This prospective study enrolled 75 English-speaking medical and surgical patients (18 years of age or older) who were taking prescription medications. The study took place at a rural, tertiary teaching hospital in the northeastern United States. Data collection occurred from November 2006 to March 2009.

METHODS

Nursing admission team medication lists were reconciled with primary care physician (PCP) and outpatient pharmacy (OP) lists. Outcome measures were accuracy of medication history generated by admission nurses (ANs) compared with PCP and OP lists, and identification of factors influencing probability of accurate medication list generation by ANs. The Generalized Estimating Equations modeling approach was used to compare AN, OP, and PCP medication list accuracy. Additionally, sex and age were analyzed as covariates and included in the model.

FINDINGS

Forty-five males and 30 females (N= 75) with a mean age of 60 years (SD 15) participated. Fifty-seven subjects (76%) used over-the-counter or herbal medications, but the AN recorded only 31 (41%) cases. Patients received outpatient care from 1 to 12 providers. Forty patients (67%) obtained medications from one pharmacy, 22 (29%) from two, and 3 (4%) from three pharmacies. OP medication lists were completely accurate more often than PCP but not AN lists (19/75 [25%] OP vs. 6/75 [8%] PCP vs. 14/75 [19%] AN; 95% confidence interval [CI] of the difference [0.07, 0.50]). No difference between AN and PCP list accuracy was found. Completely accurate AN lists were more than twice as likely with male and younger patients (95% CI of the difference [1.07, 6.22] and [0.94, 0.99], respectively).

CONCLUSIONS

Like other studies, this study showed admission medication reconciliation lists are often inaccurate. Our results suggest that verification of admission medication lists with outpatient provider lists may improve accuracy. Patients, with guidance from outpatient care providers, should assume accountability for maintaining accurate medication lists. A secure, universal, interactive electronic medical record may be a future solution for organizing and sharing medication data between providers.

CLINICAL RELEVANCE

Medication reconciliation upon inpatient admission remains a high-volume and high-acuity problem. We found that not only hospital medication lists, but source lists, including those maintained by the patient, the PCP, and the OP, are vastly inaccurate.

Clinical pharmacy consultations provided by American and Kenyan pharmacy students during an acute care advanced pharmacy practice experience

OBJECTIVE

To compare the clinical consultations provided by American and Kenyan pharmacy students in an acute care setting in a developing country.

METHODS

The documented pharmacy consultation recommendations made by American and Kenyan pharmacy students during patient care rounds on an advanced pharmacy practice experience at a referral hospital in Kenya were reviewed and classified according to type of intervention and therapeutic area.

RESULTS

The Kenyan students documented more interventions than American students (16.7 vs. 12.0 interventions/day) and provided significantly more consultations regarding human immunodeficiency virus (HIV) and antibiotics. The top area of consultations provided by American students was cardiovascular diseases.

CONCLUSIONS

American and Kenyan pharmacy students successfully providing clinical pharmacy consultations in a resource-constrained, acute-care practice setting suggests an important role for pharmacy students in the reconciliation of prescriber orders with medication administration records and in providing drug information.