Prescribing errors on medical wards and the impact of clinical pharmacists

Objectives To assess the incidence of prescribing errors, predict patient outcome from clinical pharmacists' recommendations made in response to identified prescribing errors, and evaluate the influence of clinical pharmacists on recommendation implementation. Method Clinical pharmacy activities were conducted on two wards, one of which had an existing clinical pharmacy service (intervention ward) while the other did not (control ward). For the control ward, prescribing errors were documented but not followed up unless a potentially life‐threatening problem was identified. Prescribing errors were identified and recommendations made by pharmacists. A consultant physician and pharmacist conducted an independent, blinded assessment of these recommendations to predict the impact on patient outcome if implemented. Recommendations were communicated to medical staff or implemented by the pharmacist on the intervention ward only. The proportion of recommendations implemented for intervention and control group patients were recorded. Setting Two medical wards in a UK district general hospital. The study was carried out over 12 weeks. Key findings There were 740 errors recorded for 235 patients. Fourteen recommendations could not be assessed. For all recommendations, the consultant and pharmacist predicted patient outcomes with life‐saving (one consultant vs three pharmacist), major (186 vs 318), minor (328 vs 324), neutral (211 vs 85) or harmful (five vs five) impact respectively. For the intervention group, 79% of recommendations were implemented, including 81 of 92 (88%) predicted by the consultant to have major impact on patient outcomes. In the control group, only 18% of recommendations were spontaneously implemented, including only 10 of 94 (11%) recommendations predicted by the consultant to have major impact. Conclusion Ward‐based clinical pharmacists identified large numbers of prescribing errors and made clinically significant recommendations. Implementation of recommendations was predicted to improve the outcome of patient care. Further research, specifically assessing the outcome of pharmacists' recommendations on patient care, is warranted.     

Ambulatory Pharmacy Services Affiliated With Acute Care Hospitals

The extent to which hospital-based pharmacists provide ambulatory clinical pharmacy services in the United States is unknown. We evaluated pharmacists' activities in hospital-affiliated ambulatory clinics and home health services. A questionnaire was mailed to directors of pharmacy in one-half of the United States acute care general medical-surgical hospitals with 50 or more licensed beds. The survey response rate was 56% (n=1174). In 19% of hospitals, pharmacists provided patient care (nondispensing activities) in ambulatory clinics. The most common clinics with pharmacist involvement were diabetes (10% of hospitals), oncology (9%), cardiology (6%), and geriatrics, infectious disease, and pain (4% each). Nondispensing roles varied by clinic type; prescribing by protocol was performed in 57% of anticoagulation clinics and 7% of diabetes clinics. Home health care services, with pharmacists' activity extending beyond providing drugs, were offered by 28% of the hospitals. Thirty-six percent of the hospitals operated one or more outpatient pharmacies. A statistically significant association was observed between hospitals' inpatient clinical pharmacy services (as assessed by the pharmaceutical care index) and the involvement of pharmacists in both ambulatory clinics and home health care services.     

The impact of pharmacy computerised clinical decision support on prescribing,clinical and patient outcomes: a systematic review of the literature

Objectives Computerised clinical decision support systems (CDSSs) are being used increasingly to support evidence‐based decision‐making by health care professionals. This systematic review evaluated the impact of CDSSs targeting pharmacists on physician prescribing, clinical and patient outcomes. We compared the impact of CDSSs addressing safety concerns (drug interactions, contraindications, dose monitoring and adjustment) and those focusing on medicines use in line with guideline recommendations (hereafter referred to as Quality Use of Medicines, or QUM). We also examined the influence of clinical setting (institutional versus ambulatory care), system‐ or user‐initiation of CDSS, prescribing versus clinical outcomes reported and use of multi‐faceted versus single interventions on system effectiveness. Methods We searched Medline, Embase, CINAHL and PsycINFO (1990–2009) for methodologically adequate studies (experiments and strong quasi‐experiments) comparing a CDSS with usual pharmacy care. Individual study results are reported as positive trends or statistically significant results in the direction of the intentions of the CDSS being tested. Studies are aggregated and compared as the proportions of studies showing the effectiveness of the CDSS on the majority (≥ 50%) of outcomes reported in the individual study. Key findings Of 21 eligible studies, 11 addressed safety and 10 QUM issues. CDSSs addressing safety issues were more effective than CDSSs focusing on QUM (10/11 versus 4/10 studies reporting statistically significant improvements in favour of CDSSs on ≥ 50% of all outcomes reported; P= 0.01). A number of QUM studies noted the limited contact between pharmacists and physicians relating to QUM treatment recommendations. More studies demonstrated CDSS benefits on prescribing outcomes than clinical outcomes (10/10 versus 0/3 studies; P= 0.002). There were too few studies to assess the impact of system‐ versus user‐initiated CDSS, the influence of setting or multi‐faceted interventions on CDSS effectiveness. Conclusions Our study demonstrated greater effectiveness of safety‐focused compared with QUM‐focused CDSSs. Medicine safety issues are traditional areas of pharmacy activity. Without good communication between pharmacists and physicians, the full benefits of QUM‐focused CDSSs may not be realised. Developments in pharmacy‐based CDSSs need to consider these inter‐professional relationships as well as computer‐system enhancements.     

Physicians’ views on the professional roles of pharmacists in patient care in Eritrea

Objective A collaborative relationship between physicians and pharmacists is crucial in the patient oriented role of pharmacists. In order to get an optimal patient outcome, strong cooperation between pharmacists and physicians is necessary. It is evident that in patient-oriented activities of pharmacists, their roles should be appropriately perceived and welcomed by physicians. This survey, thus, aimed to explore the perception of Eritrean physicians towards the professional roles of pharmacists in patient care. Setting The study was conducted in all hospitals in Asmara. Method A self administered questionnaire was distributed to the physicians working in Asmara hospitals. The instrument contained questions to evaluate the physicians’ level of agreement using a 5-point Likert type scale. Main outcome measure Opinions of physicians on the professional role of pharmacists. Results Out of the 55 questionnaires distributed 50 were completed and returned, giving a response rate of 90.91 %. Most of the physicians accepted the reprofessionalization of pharmacy profession (88 %); majority disagreed that pharmacists are using their full potential in patient care (60 %); physicians strongly agreed or agreed that they should accept pharmacists’ recommendations on patients’ medication (96 %). Conclusions Generally the physicians appreciated the professional role of pharmacists in patient care. They agreed with the idea of re-professionalization of pharmacy into patient care. For conclusive evidence nationwide study is recommended.     

Task analysis of Air Force pharmacy practice.

The frequency with which United States Air Force pharmacists perform specific professional tasks and the pharmacists' views as to the importance of those tasks were studied. A questionnaire was prepared that asked recipients to rate each of 36 tasks selected as representing the spectrum of practice activities. There were four categories of tasks: managerial tasks, dispensing tasks, drug information tasks, and patient care tasks. Recipients rated the tasks with respect to frequency of performance and importance on separate 6-point scales. The questionnaire was mailed in May 1991 to the 225 pharmacists then serving in the Air Force worldwide. Of the 225 questionnaires, 150 usable questionnaires were returned (response rate, 67%). All the tasks in the survey were performed by at least one Air Force pharmacy officer, although the frequency of task performance varied. In particular, the frequency of many patient care tasks was low. All the tasks were perceived to have some importance, but drug information tasks were rated as being significantly more important than tasks in the other categories; patient care tasks were rated lowest in importance. The results varied with the respondents' demographic characteristics. Pharmacy officers with more years of service, more senior positions, higher rank, or an advanced degree in a field other than pharmacy tended to give responses that diverged from those of the population. A 1991 survey showed an awareness among Air Force pharmacists of the need to orient practice around patient care; however, they were not spending substantial time on patient care and tended to view it as less important than more traditional pharmacy tasks.     

Providers' Perceptions of Student Pharmacists on Inpatient General Medicine Practice Experiences

Objective. To assess health care providers’ perceptions of student pharmacists involved as members of a general medicine team.Methods. A brief, anonymous, online survey instrument was distributed to 134 health care providers at 4 major medical centers in Massachusetts who interacted with Northeastern University student pharmacists during inpatient general medicine advanced pharmacy practice experiences beginning in March 2011. The survey instrument assessed health care provider perception of student pharmacists’ involvement, preparedness, clinical skills, and therapeutic recommendations.Results. Of the 79 providers who responded, 96.2% reported that student pharmacists were prepared for medical rounds and 87.3% reported that student pharmacists were active participants in patient care. Also, 94.9% and 98.7% of providers indicated that student pharmacist recommendations were appropriate and accurate, respectively. The majority (61.8%) of providers believed that student pharmacist involvement on internal medicine teams was beneficial.Conclusions. Provider perceptions regarding student pharmacist participation on general medicine practice experiences were mostly positive.     

Pharmacists’ Expectations for Entry-level Practitioner Competency

Objective. To determine if defined subgroups of pharmacists’ have variability in their expectations for competency of entry-level practitioners.Methods. Rating scale data collected from the 2009 National Pharmacy Practice Survey were analyzed to determine to what extent pharmacists'' degree, practice setting, and experience as a preceptor were associated with the ratings they assigned to 43 competency statements for entry-level practitioners. The competency statements determine the content on the North American Pharmacist Licensure Examination (NAPLEX).Results. Pharmacists with a doctor of pharmacy (PharmD) degree rated the co mpetency statements higher in terms of criticality to entry-level practice than did those with a bachelor of science (BS) degree (p< 0.05). Pharmacists working in inpatient settings gave slightly higher ratings to the competency statements than did pharmacists working in outpatient settings, pharmacists without direct patient care responsibilities, and those in academia. However, there were no significant differences among practitioner subgroups'' criticality ratings with regard to practice setting. Preceptor pharmacists'' criticality ratings of the competency statements were not significantly different from those of non-preceptor practitioners. Conclusion. Pharmacists exhibited a fair amount of agreement in their expectations for the competence of entry-level practitioners independent of their practice sites and professional roles. As the pharmacy profession embraces patient-centered clinical practice, evaluating practicing pharmacists’ expectations for entry-level practitioners will provide useful information to the practitioners and academicians involved in training future pharmacists. Stakeholders in pharmacy education and regulation have vested interests in the alignment of the education of future practitioners with the needs of the profession.     

Family practice physicians' perceptions of the usefulness of drug therapy recommendations from clinical pharmacists

Family practice physicians' perceptions of the usefulness and clinical outcome of drug therapy recommendations made by clinical pharmacists in a family medicine clinic were determined. For 15 weeks, pharmacists in the clinic recorded all consultations in which they made recommendations about the drug therapy of specific patients. At the time of each consultation, the pharmacists gave the physician a questionnaire designed to gauge the physician's opinion of the usefulness of the consultation. Physicians who implemented the recommendations were sent a second questionnaire and asked to indicate the extent to which the clinical pharmacist influenced their decision to implement the recommendation, the effect the recommendation had on the patient's clinical status, and the usefulness of the recommendation to the patient in ways unrelated to clinical status (such as greater patient acceptance, safety, or lower cost). Five clinical pharmacists provided 59 consultations to 33 physicians. The physicians rated 51 (88%) of the consultations as very useful, and they implemented 78 (98%) of the 80 recommended actions. Of the 56 physicians who attributed their decision to implement the recommendation to their consultation with the clinical pharmacist, 43 believed that the recommendations had improved the clinical status of the patient, and 38 believed that the recommendations were useful to patients in ways unrelated to clinical status. Physicians in a family medicine residency training program had positive perceptions of the usefulness of drug therapy recommendations made by clinical pharmacists. A majority of the physicians believed that the recommendations had a positive effect on patients' clinical status.     

LGBT cultural competency,patient exposure,and curricular education among student pharmacists

BackgroundPharmacists are positioned in unique and important roles in health care in their ability to care for the lesbian, gay, bisexual, and transgender (LGBT) population. For example, pharmacists are a highly prevalent, accessible provider type, and informal surveys have shown that LGBT patients may be more comfortable asking their pharmacists sensitive medication questions rather than their primary provider.ObjectivesTo demonstrate gaps in LGBT cultural competency among student pharmacists and propose specific recommendations on the number of LGBT patient exposures and educational hours that can significantly improve LGBT cultural competency.MethodsStudent pharmacists (N = 275) at 3 universities in the United States completed a survey comprising demographics, experiential variables (i.e., number of LGBT patients and LGBT hours), and the 7-point Likert LGBT-Development of Clinical Skills Scale (LGBT-DOCSS). LGBT-DOCSS scores were stratified by 1-point increments, and experiential variable means were computed per each stratification to characterize the mean LGBT patients and hours of student pharmacists with higher scores and those with lower scores.ResultsStudent pharmacists reported low numbers of annual LGBT patients (Mean = 3.82, SD = 9.54), annual LGBT curricular hours (Mean = 0.55, SD = 0.95), and annual LGBT extracurricular hours (Mean = 2.50, SD = 15.42). They reported very high attitudinal awareness (Mean = 6.19, SD = 1.02), moderate knowledge (Mean = 5.00, SD = 1.25), and low clinical preparedness (Mean = 3.26, SD = 1.33). Student pharmacists who cared for 25 or more LGBT patients and received 10 or more LGBT total hours reported significantly higher preparedness, knowledge, and overall cultural competency.ConclusionStudent pharmacists have shortcomings in LGBT cultural competency and limited LGBT patient exposure and education. To improve LGBT cultural competency, pharmacy schools and accrediting bodies should consider ensuring that student pharmacists receive at least a total of 25 LGBT patient contacts and 10 LGBT formal education hours across their pharmacy education.     

Impact of the Pharmacy Practice Model Initiative on Clinical Pharmacy Specialist Practice

This paper describes the goals of the American Society of Health‐System Pharmacists' Pharmacy Practice Model Initiative (PPMI) and its recommendations for health‐system pharmacy practice transformation to meet future patient care needs and elevate the role of pharmacists as patient care providers. PPMI envisions a future in which pharmacists have greater responsibility for medication‐related outcomes and technicians assume greater responsibility for product‐related activities. Although the PPMI recommendations have elevated the level of practice in many settings, they also potentially affect existing clinical pharmacists, in general, and clinical pharmacy specialists, in particular. Moreover, although more consistent patient care can be achieved with an expanded team of pharmacist providers, the role of clinical pharmacy specialists must not be diminished, especially in the care of complex patients and populations. Specialist practitioners with advanced training and credentials must be available to model and train pharmacists in generalist positions, residents, and students. Indeed, specialist practitioners are often the innovators and practice leaders. Negotiation between hospitals and pharmacy schools is needed to ensure a continuing role for academic clinical pharmacists and their contributions as educators and researchers. Lessons can be applied from disciplines such as nursing and medicine, which have developed new models of care involving effective collaboration between generalists and specialists. Several different pharmacy practice models have been described to meet the PPMI goals, based on available personnel and local goals. Studies measuring the impact of these new practice models are needed.     

Assessing the structure and process for providing pharmaceutical care in Veterans Affairs medical centers.

The structure and process used in providing pharmaceutical care to ambulatory care patients at nine Veterans Affairs medical centers (VAMCs) were studied. Institutions participating in the IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) study were selected. To assess the level of pharmaceutical care services provided to ambulatory care patients, 10 critical domains were identified. Six instruments with questions related to each domain were then designed, including a clinical pharmacist survey and an outpatient pharmacist survey. Each center was assessed through three surveys and an onsite visit. The investigators used both direct observation and a consensus approach to score the level of ambulatory care pharmaceutical services provided. The clinics in which IMPROVE study patients would be seen were run by pharmacists (33%), physicians (44%), and multidisciplinary teams (22%). Of the 51 clinical pharmacists surveyed, 23 (45%) had prescribing authority via protocols, 14 (28%) had unrestricted prescribing privileges, and 14 did not have prescribing authority. The sites varied greatly in referral patterns, methods of identifying patients, and whether patient visits were scheduled or on a walk-in basis. There was a strong correlation between observed activities by clinical pharmacists and their self-reports and between observed activities by outpatient pharmacists and their self-reports. Activities reported by clinical pharmacists were moderately but not significantly correlated with consensus scores, and activities reported by outpatient pharmacists were poorly correlated with consensus scores. The structure and process for providing pharmaceutical care to ambulatory care patients at VAMCs were evaluated with surveys, direct observation, and a consensus-based scoring system.     

Using theory to predict implementation of a physician–pharmacist collaborative intervention within a practice-based research network

BackgroundStudies have demonstrated that physician/pharmacist collaboration can improve management of chronic conditions.ObjectiveThe purpose of this study was to determine whether a correlation exists between existing clinical pharmacy services within a practice-based research network (PBRN) and provider attitudes and beliefs regarding implementing a new pharmacy intervention based on the Theory of Planned Behavior (TPB).MethodsA validated survey was completed by one clinical pharmacist from each office. This instrument evaluated the current clinical pharmacy services provided in the medical office. TPB instruments were developed that measured beliefs concerning implementation of a clinical pharmacy intervention for either blood pressure or asthma. The pharmacy services and TPB surveys were then administered to physicians and pharmacists in 32 primary care offices throughout the United States.ResultsPhysicians returned 321 (35.9%) surveys, while pharmacists returned 40 (75.5%). The Cronbach's alpha coefficients generally ranged from 0.65 to 0.98. TPB subscale scores were lower in offices rated with lower pharmacy service scores, but these differences were not statistically significant. There was no correlation between clinical pharmacy service score and providers' TPB subscale scores. In both the hypertension and asthma groups, pharmacists scores were significantly higher than physicians' scores on the attitudes subscale in the multivariate analysis (P < 0.001 and P < 0.05, respectively).ConclusionsPharmacists consistently scored higher than physicians on the TPB, indicating that they felt the hypertension or asthma intervention would be more straightforward for them to implement than did physicians. There was no significant correlation between clinical pharmacy service scores and attitudes toward implementing a future physician/pharmacist collaborative intervention using the TPB. Future studies should investigate the ability of the TPB instrument to predict implementation of a similar intervention in offices of physicians never exposed to clinical pharmacy services.     

华西医院临床药师工作调研与探讨

目的:调查四川大学华西医院临床药师工作的现状,为临床药学的发展和改进提出合理化建议。方法:对该院26名临床药师发放问卷进行调查,并通过对9名受培训的学员进行访谈了解医院临床药学及培训工作的现状。结果:该院开展的临床药师工作内容有参与临床查房、单独药学查房、参与病房治疗工作、参加门诊药学服务、倾听病案讨论、参与临床个案会诊、配合医师制定用药方案、收集临床药品不良反应、为医师开设讲座等工作,在大部分临床科室有较高的接纳程度。结论:临床药学工作在该院已经有较好的开端,但要取得进一步发展,使临床药师工作重心转为直接面向患者提供药学技术服务,尚需政府相关部门重视与扶持以及药师的自身努力。     

Documenting concurrent clinical pharmacy interventions

The documentation of clinical pharmacy activities is an important issue and the authors describe a relatively simple and easily implemented method of documenting concurrent clinical pharmacy interventions. This quality assurance measure was added to the quality assurance calendar of a tertiary care medical center/teaching hospital to: (1) document to the Joint Commission on Accreditation of Healthcare Organizations that the pharmacy department is involved in direct patient care, and (2) demonstrate to hospital administrators that pharmacists are an integral and necessary component of the health care team. At least 115 of 428 (27%) documented interventions during 1988 prevented patients from suffering potentially serious side effects and adverse drug reactions. Physicians and nurses initiated consultations by contacting pharmacists, either by phone or in person, and asking them to: (1) recommend dosages for renally impaired patients; (2) monitor patients receiving medications such as aminoglycosides, digoxin, and phenytoin; (3) suggest appropriate doses for specific indications; (4) recommend a formulary drug for a specific condition; and (5) provide drug information. Pharmacists initiated consultations by contacting physicians and nurses, either by phone or in person, to clarify an order or make recommendations regarding drug therapy. Nurses, pharmacists, and physicians initiated 37%, 33%, and 30% of the clinical interventions, respectively. Most of the physician (89%) and nurse (82%) initiated interventions were requests for drug information, whereas most of the pharmacist initiated interventions were order clarifications (51%). The daily documentation of clinical pharmacy interventions demonstrated that the quality of patient care and patient outcome was improved and served as an effective method of cost-justifying pharmacist positions in this era of fiscal constraints.