Ward-based Clinical Pharmacists Research Articles

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

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. In 2020, apilot 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. By ateam of experienced intensive care physicians and clinical pharmacists on the basis of aconsensus principle, each pharmaceutical intervention (PI) was assigned aprobability 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. During the study period, 177pharmaceutical 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. 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.

Enhancing carbapenem antimicrobial dosing optimization: synergy of antimicrobial stewardship teams and ward-based clinical pharmacists.

Antimicrobial-product package inserts and insufficient staffing impede routine carbapenem monitoring in the inpatient setting in Japan. The collaboration between antimicrobial stewardship teams and clinical pharmacists was associated with a sustained improvement in carbapenem dosing optimization. Our findings could be of use to countries with inadequate monitoring of carbapenem antimicrobial use.

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study

ObjectiveTo understand the sociotechnical factors affecting medication safety when intensive care patients are transferred to a hospital ward. Consideration of these medication safety factors would provide a theoretical basis, on...

Anticoagulation Interventions by Pharmacists in Acute Care.

Clinical pharmacy key performance indicators (cpKPIs) relate to activities performed by pharmacists that have been shown to improve patient outcomes. Within Saskatchewan Health Authority (SHA) Regina, most cpKPIs are incorporated into the organization's clinical practice standards, which provide guidance in prioritizing care, especially for high-risk medications, including anticoagulants. To track pharmacists' interventions associated with clinical practice standards, a locally developed electronic data-capture system (known as AIM High) was implemented. To quantify and describe pharmacists' anticoagulation interventions on 16 wards with dedicated ward-based clinical pharmacists and to compare intervention rates between the cardiology and internal medicine wards to further evolve the organization's practice model. Data from the electronic data-capture system were retrospectively analyzed for a 5-year period (January 2016 to December 2020). A total of 94 201 interventions were recorded in the AIM High system (average 362 interventions per week or 26 interventions per pharmacist per week). Of these, 15 661 (16.6%) cited the anticoagulation standard (average 60 anticoagulation interventions per week or 4 anticoagulant interventions per pharmacist per week). For the cardiology and internal medicine wards, 4183 of 11 888 (35.2%) and 9034 of 54 843 (16.5%) interventions cited the anticoagulation standard, respectively. The top 4 types of anticoagulation interventions were dose changed (n = 4372 or 27.9%), drug started or restarted (n = 3867 or 24.7%), patient education (n = 3094 or 19.8%), and drug discontinued (n = 2944 or 18.8%). Dedicated ward-based clinical pharmacists were following clinical practice standards incorporating the majority of cpKPIs to complete anticoagulation interventions. The types of anticoagulation interventions evolved over time and were influenced by the patient population.

Impact of a checklist used by pharmacists on hospital antimicrobial use: a patient-level interrupted time series study

Antimicrobial misuse leading to drug resistance is a growing concern for clinicians. Improving antimicrobial stewardship programmes through development of new tools could be part of the solution. To evaluate antimicrobial use in hospitalized patients after implementation of an antimicrobial checklist for ward-based clinical pharmacists. A checklist based on quality indicators of optimal antimicrobial use was implemented to standardize hospital pharmacists' assessments of antimicrobial therapy. Antimicrobial use metrics from adults hospitalized during the control and intervention periods were assessed in an interrupted time series analysis of individual patient data. The primary endpoint was days of therapy (DOT) for all antimicrobials per 1000 days present for included patients. Secondary endpoints were the DOT of extended-spectrum antimicrobials (DOT-ES), length of therapy of all antimicrobials (LOT) and the number of pharmacist interventions. One-thousand six-hundred and nineteen patients were included: 800 and 819 in the pre- and post-checklist implementation periods, respectively. As indicated by the point estimates and their 95% confidence intervals (CIs), there were no changes in trend for DOT, DOT-ES or LOT. A change in level was not found for the DOT, while a change of -118 DOT-ES [-209,-28] and -51 LOT [-97,-4] was documented. Furthermore, pharmacists' interventions regarding antimicrobials increased by 18.7% (14.0, 23.5) and progress notes by 32.3% (27.8, 36.8). An antimicrobial checklist used by ward-based clinical pharmacists did not decrease DOT for all antimicrobials, but decreased DOT-ES and LOT upon its implementation.

Comprehensive medication reviews by ward-based pharmacists in Swedish hospitals: What does the patient have to say?

Inappropriate medication prescribing and use amongst older patients is a major patient safety and health care problem. To promote appropriate medication prescribing and use, comprehensive medication reviews (CMRs) by ward-based pharmacists, including follow-up telephone calls after hospital discharge, have been conducted in older patients in the context of a randomized controlled trial (RCT). One of the key actors in a CMR is the patient. To support the understanding of the effects of CMRs on patients' health outcomes and improve clinical practice, knowledge about the patient perspective is needed. We therefore aimed to explore older patients' experiences with, and views on, hospital-initiated CMRs and follow-up telephone calls by ward-based clinical pharmacists within an RCT. We conducted in-depth semi-structured interviews with 15 patients (66-94years) and carers from four hospitals in Sweden. Discussion topics included communication, information, decision-making, and effects on the patient. Interviews took place after discharge, were audio-recorded, transcribed verbatim, and thematically analysed using a framework approach. In general, patients' experiences and views were positive. Seven key themes were identified: (a) feeling of being taken care of and heterogenous health effects; (b) the pharmacist is competent; (c) despite the unclear role of pharmacists, their involvement is appreciated; (d) patients rely on health care professionals for decision-making; (e) importance of being informed, but receiving and retaining information is problematic; (f) time, location, and other factors influencing the effectiveness of CMRs; and (g) generic substitution is a problem. Older patients generally have positive experiences with and views on CMRs and follow-up telephone calls. However, some factors, like the unclear role of the ward-based pharmacist and problems with receiving and retaining information, may negatively impact the effectiveness of these interventions. Future initiatives on hospital-initiated CMRs by clinical pharmacists should address these negative factors and utilize the positive views.

Utilization of neonatal medication error prevention strategies: a clinical practice survey of Australian and New Zealand neonatal units.

Medication errors are common in neonatal care and can lead to significant harm. We sought to explore utilization of various medication error prevention strategies across Australian and New Zealand neonatal units (NNUs) through a clinical practice survey. An electronic survey was distributed in October 2016 to relevant staff at each of the 29 level III NNUs identified as members of the Australian and New Zealand Neonatal Network (ANZNN). The survey contained questions relating to a range of medication error prevention strategies identified from a previous systematic review on the topic. The evaluated interventions targeted different aspects of the medication-use process including prescribing, evaluation/checking of orders by clinical pharmacists, transmission, preparation and dispensing of orders, storage of medications, and medication administration. From the 20 respondents, the evidence-based strategies most commonly utilized were use of smart pumps (n = 18; 90%), and ward-based clinical pharmacists (n = 17; 85%). Interventions least commonly utilized included barcode scanning with medication administration (n = 0; 0%), electronic prescribing and clinical decision support (n = 1; 5%), and dedicated medication administration nurse (n = 2; 10%). The total number of evidence-based medication error prevention strategies utilized in each NNU ranged from 2 to 10 (median = 7), 10 of 16 strategies were utilized by less than 50% of NNUs. While evidence supports utilization of a number of medication error prevention strategies, these appear inconsistently utilized across current practice settings.

Improving Patient's Primary Medication Adherence: The Value of Pharmaceutical Counseling.

Quality of transitions of care is one of the first concerns in patient safety. Redesigning the discharge process to incorporate clinical pharmacy activities could reduce the incidence of postdischarge adverse events by improving medication adherence. The present study investigated the value of pharmacist counseling sessions on primary medication adherence after hospital discharge.This study was conducted in a 1844-bed hospital in France. It was divided in an observational period and an interventional period of 3 months each. In both periods, ward-based clinical pharmacists performed medication reconciliation and inpatient follow-up. In interventional period, initial counseling and discharge counseling sessions were added to pharmaceutical care. The primary medication adherence was assessed by calling community pharmacists 7 days after patient discharge.We compared the measure of adherence between the patients from the observational period (n = 201) and the interventional period (n = 193). The rate of patients who were adherent increased from 51.0% to 66.7% between both periods (P < 0.01). When discharge counseling was performed (n = 78), this rate rose to 79.7% (P < 0.001). The multivariate regression performed on data from both periods showed that age of at least 78 years old, and 3 or less new medications on discharge order were predictive factors of adherence. New medications ordered at discharge represented 42.0% (n = 1018/2426) of all medications on discharge order. The rate of unfilled new medications decreased from 50.2% in the observational period to 32.5% in the interventional period (P < 10−7). However, patients included in the observational period were not significantly more often readmitted or visited the emergency department than the patients who experienced discharge counseling during the interventional period (45.3% vs. 46.2%; P = 0.89).This study highlights that discharge counseling sessions are essential to improve outpatients’ primary medication adherence. We identified predictive factors of primary nonadherence in order to target the most eligible patients for discharge counseling sessions. Moreover, implementation of discharge counseling could be facilitated by using Health Information Technology to adapt human resources and select patients at risk of nonadherence.

Nationwide evaluation of day-to-day clinical pharmacists' interventions in German hospitals.

To describe and evaluate the extent and diversity of nationwide data from clinical pharmacists' interventions (PIs) in German hospitals. Retrospective analysis. The ADKA-DokuPIK German database, a national anonymous self-reported Internet-based documentation system for routine PIs as well as for medication errors reported by German hospital pharmacists. Data sets from ADKA-DokuPIK entered between January 2009 and December 2012 were analyzed descriptively. A total of 27,610 PIs were entered, mainly by ward-based clinical pharmacists (82.5%). Most of the PIs were performed on surgical wards (37.8%), followed by anesthesiology/intensive care unit/intermediate care unit and internal medicine. The most prevalent therapeutic subgroup that was the trigger for the PIs was antibacterials for systemic use (13.9%), followed by antithrombotic agents, analgesics, drugs for acid-related disorders, and agents acting on the renin-angiotensin system. About a quarter of interventions (23.4%) were performed due to inappropriate use of drugs, followed by use of a wrong dose or administration interval (22.1%), resulting in the most frequently taken actions of change of dose, change of drug, and drug stopped/paused (withheld). Altogether, the implementation rate of the PIs was 85.5%. Underlying medication errors were predominantly classified as "error, no harm" according to the National Coordinating Council for Medication Error Reporting and Prevention. For the first time in a European country, our findings show the scope of clinical pharmacist involvement in patient care in daily clinical practice and demonstrate the usefulness and importance of their proactive interventions in the prevention of hazards and risks for hospital inpatients.

Pharmacist prescribing within a UK NHS hospital trust: nature and extent of prescribing, and prevalence of errors

ObjectivesSuitably qualified pharmacists in the UK are able to prescribe all medicines. While doctors’ prescribing errors are well documented, there is little information on the rate and nature of pharmacists’...

A waste walk through clinical pharmacy: how do the ‘seven wastes’ of Lean techniques apply to the practice of clinical pharmacists†‡

This study used a 'Lean' technique, the 'waste walk' to evaluate the activities of clinical pharmacists with reference to the seven wastes described in 'Lean' including 'defects', 'unnecessary motion', 'overproduction', 'transport of products or material', 'unnecessary waiting', 'unnecessary inventory' and 'inappropriate processing'. The objectives of the study were to categorise the activities of ward-based clinical pharmacists into waste and non-waste, provide detail around what constitutes waste activity and quantify the proportion of time attributed to each category. This study was carried out in a district general hospital in the North West of England. Staff were observed using work-sampling techniques, to categorise activity into waste and non-waste, with waste activities being allocated to each of the seven wastes described earlier and subdivided into recurrent themes. Twenty different pharmacists were observed for 1 h on two separate occasions. Of 1440 observations, 342 (23.8%) were categorised as waste with 'defects' and 'unnecessary motion' accounting for the largest proportions of waste activity. Observation of clinical pharmacists' activities has identified that a significant proportion of their time could be categorised as 'waste'. There are practical steps that could be implemented in order to ensure their time is used as productively as possible. Given the challenges facing the UK National Health Service, the adoption of 'Lean' techniques provides an opportunity to improve quality and productivity while reducing costs.

GRP-101 Insulin: Improving Prescribing Safety

BackgroundInsulin has been defined as one of the highest risk medicines worldwide, [1] with a 2009 national UK audit demonstrating prescribing errors in 19.5% of in-patient insulin prescriptions. [2] The...

Ranking of healthcare programmes based on health outcome, health costs and safe delivery of care in hospital pharmacy practice

To establish a consensual and coherent ranking of healthcare programmes that involve the presence of ward-based and clinic-based clinical pharmacists, based on health outcome, health costs and safe delivery of care. This descriptive study was derived from a structured dialogue (Delphi technique) among directors of pharmacy department. We established a quantitative profile of healthcare programmes at five sites that involved the provision of ward-based and clinic-based pharmaceutical care. A summary table of evidence established a unique quality rating per inpatient (clinic-based) or outpatient (ward-based) healthcare programme. Each director rated the perceived impact of pharmaceutical care per inpatient or outpatient healthcare programme on three fields: health outcome, health costs and safe delivery of care. They agreed by consensus on the final ranking of healthcare programmes. A ranking was assigned for each of the 18 healthcare programmes for outpatient care and the 17 healthcare programmes for inpatient care involving the presence of pharmacists, based on health outcome, health costs and safe delivery of care. There was a good correlation between ranking based on data from a 2007-2008 Canadian report on hospital pharmacy practice and the ranking proposed by directors of pharmacy department. Given the often limited human and financial resources, managers should consider the best evidence available on a profession's impact to plan healthcare services within an organization. Data are few on ranking healthcare programmes in order to prioritize which healthcare programme would mostly benefit from the delivery of pharmaceutical care by ward-based and clinic-based pharmacists.

Perceived value of ward-based pharmacists from the perspective of physicians and nurses

Clinical pharmacy in a hospital setting is relatively new in Sweden. Its recent introduction at the University Hospital in Uppsala has provided an opportunity for evaluation by other relevant professionals of the integration of clinical pharmacists into the health-care team. The objectives of this descriptive study were to evaluate the perceived value of wardbased clinical pharmacists from the perspective of hospital based physicians and nurses and to identify potential advantages and disadvantages related to the new inter professional collaboration. Another objective was to evaluate the experiences of general practitioners on receiving medication reports from ward-based clinical pharmacists. Two acute internal medicine wards at the University Hospital in Uppsala, where a previously reported randomized controlled trial investigating the effects of ward based clinical pharmacists on re-visits to hospital was undertaken. Data were collected by questionnaires containing closed- and open-ended questions. The questionnaires were distributed during the nine-month study period of the randomized controlled trial by an independent researcher to 29 hospital-based physicians and 44 nurses on the study wards and to 21 general practitioners who had received two or more medication reports. Answers were analysed descriptively for the closed-ended questions and by content analysis for the open-ended questions. The main outcome measure was the physicians' and nurses' level of satisfaction with the new collaboration with clinical pharmacists, from a hospital and primary care perspective. Seventy-six percent of the hospital-based physicians and 81% of the nurses completed the questionnaire. Ninety-five percent of the physicians and 93% of the nurses were very satisfied with the collaboration. Out of the 17 general practitioners (81%) that completed the questionnaire 71% wanted to continue to receive medication reports in a similar way in the future. Increased patient safety and improvements in patients' drug therapy were the main advantages stated by all three groups of respondents. Eighteen percent of the hospital-based physicians and 21% of the nurses thought that the collaboration had been time-consuming to certain or to a high extent. The majority of the respondents, both GPs and hospital based physicians and nurses, were satisfied with the new collaboration with the ward based pharmacists and perceived that the quality of the patients' drug therapy and drug-related patient safety had increased.

Effects of pharmaceutical counselling on antimicrobial use in surgical wards: intervention study with historical control group,

The objective of this study was to assess the impact of pharmaceutical consulting on the quality of antimicrobial use in a surgical hospital department in a prospective controlled intervention study. Patients receiving pharmaceutical intervention (intervention group, IG, n = 317) were compared with a historical control group (control group, CG, n = 321). During the control period, antimicrobial use was monitored without intervention. During the subsequent intervention period, a clinical pharmacist reviewed the prescriptions and gave advice on medication. Intervention reduced the length of antimicrobial courses (IG = 10 days, CG = 11 days, incidence rate ratio for i.v. versus o.p. = 0.88, 95% confidence interval 0.84 to 0.93) and shortened i.v. administration (IG = 8 days, CG = 10 days, hazard rate = 1.76 in favour of switch from i.v. to p.o., 95% confidence interval 1.23 to 2.52). Intervention also helped to avoid useless combination therapy and reduced total costs for antimicrobials. A clinical pharmacist who reviews prescriptions can promote an increase in efficiency, for example, by shortening the course of treatment. Counselling by ward-based clinical pharmacists was shown to be effective to streamline antimicrobial therapy in surgical units and to increase drug safety.

Clinical pharmacists’ interventions in a German University Hospital

To evaluate pharmaceutical interventions by ward-based clinical pharmacists in Germany. Two ward-based clinical pharmacists working at the Departments of Stem Cell Transplantation and Intensive Care Medicine. Pharmaceutical interventions during ward rounds from December 1st 2006 to November 30th 2008 were recorded and classified according to our own system that was adopted from established classification systems. Classification of (1) cause of intervention, (2) intervention, (3) outcome of intervention and (4) initiator of intervention. Altogether 2,312 interventions were documented. Besides 520 cases of information about drugs (rational selection, occurrence of infrequent adverse events or interactions), the main interventions were recommendations for the addition, the withdrawal or the replacement of a drug (n = 907, 50.6%) and advice for the change of dosage, dosing intervals or dose adjustment according to impaired renal or liver function (n = 584, 32.6%). The vast majority of the suggested interventions (92.8%) have been accepted. The participation of a clinical pharmacist during ward rounds contributes to the optimisation of pharmacotherapy, in terms of choosing the most appropriate drug and/or the suitable dosage and may improve patient care.

Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients.

Medication errors in pediatric inpatients occur at similar rates as in adults but have 3 times the potential to cause harm. Error prevention strategies in this setting remain largely untested. The objective of this study was to classify the major types of medication errors in pediatric inpatients and to determine which strategies might most effectively prevent them. A prospective cohort study was conducted of 1020 patients who were admitted to 2 academic medical centers during a 6-week period in April and May 1999. Medication errors were characterized by subtype. Physician raters evaluated error prevention strategies and identified those that might be most effective in preventing errors. Of 10 778 medication orders reviewed, 616 contained errors. Of these, 120 (19.5%) were classified as potentially harmful, including 115 potential adverse drug events (18.7%) and 5 preventable adverse drug events (0.8%). Most errors occurred at the ordering stage (74%) and involved errors in dosing (28%), route (18%), or frequency (9%). Three interventions might have prevented most potentially harmful errors: 1) computerized physician order entry with clinical decision support systems (76%); 2) ward-based clinical pharmacists (81%); and 3) improved communication among physicians, nurses, and pharmacists (86%). Interrater reliability of error prevention strategy assignment was good (agreement: 0.92; kappa: 0.82). Of the assessed interventions, computerized physician order entry with clinical decision support systems; ward-based clinical pharmacists; and improved communication among physicians, nurses, and pharmacists had the greatest potential to reduce medication errors in pediatric inpatients. Development, implementation, and assessment of such interventions in the pediatric inpatient setting are needed.

Medication errors in the emergency department: A systems approach to minimizing risk

Adverse drug events caused by medication errors represent a common cause of patient injury in the practice of medicine. Many medication errors are preventable and hence particularly tragic when they occur, often with serious consequences. The enormous increase in the number of available drugs on the market makes it all but impossible for physicians, nurses, and pharmacists to possess the knowledge base necessary for fail-safe medication practice. Indeed, the greatest single systemic factor associated with medication errors is a deficiency in the knowledge requisite to the safe use of drugs. It is vital that physicians, nurses, and pharmacists have at their immediate disposal up-to-date drug references. Patients presenting for care in EDs are usually unfamiliar to their EPs and nurses, and the unique patient factors affecting medication response and toxicity are obscured. An appropriate history, physical examination, and diagnostic workup will assist EPs, nurses, and pharmacists in selecting the safest and most optimum therapeutic regimen for each patient. EDs deliver care "24/7" and are open when valuable information resources, such as hospital pharmacists and previously treating physicians, may not be available for consultation. A systems approach to the complex problem of medication errors will help emergency clinicians eliminate preventable adverse drug events and achieve a goal of a zero-defects system, in which medication errors are a thing of the past. New developments in information technology and the advent of electronic medical records with computerized physician order entry, ward-based clinical pharmacists, and standardized bar codes promise substantial reductions in the incidence of medication errors and adverse drug events. ED patients expect and deserve nothing less than the safest possible emergency medicine service.