Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge

Background Medication discrepancies may occur at transitions in care and negatively impact patient outcomes. Objective To determine if involving clinical pharmacists in hospital care, medication reconciliation and discharge medication plan communication can reduce medication discrepancies with a prospective, randomized, blinded, controlled trial. Setting A large, tertiary care, academic medical center. Method The intervention consisted of clinical pharmacist medication reconciliation, patient education and improved communication of the discharge medication plan, as devised by the hospital physician and care team, to primary care physicians and community pharmacists. Medication discrepancies were identified by blinded research pharmacists who reviewed primary care physician and pharmacy records at discharge through 90 days post-discharge to create 30- and 90-day medication lists. Main outcome measure Rate of medication discrepancies compared across groups. Results A total of 592 subjects from internal medicine, family medicine, cardiology and orthopedic services were evaluated for this study. Clinically important medication discrepancies in the primary care physician record were different between groups 30 days after hospital discharge following a clinical pharmacist’s intervention. The mean number of medication discrepancies per patient for the enhanced group being nearly half the number in the control group. However, this effect did not persist to 90 days post-discharge and did not extend to community pharmacy records. Conclusion The present study demonstrates the involvement of pharmacists in hospital care, medication reconciliation and discharge medication plan communication may affect the quality of the outpatient medical record.     

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation

ObjectivesTo describe the types and causes of medication discrepancies in the electronic medical record identified by pharmacist medication reconciliation during outpatient medical visits and to identify patient characteristics associated with the presence of discrepancies.DesignObservational case series study.SettingIndigent primary care clinic in Pittsburgh, PA, from April 2009 to May 2010.Patients219 adults presenting for follow-up medical visits and self-reporting medication use.InterventionMedication reconciliation as part of patient interview and concurrent chart review.Main outcome measuresFrequency, types, and reasons for medication discrepancies and demographic variables, patient knowledge, and adherence.ResultsOf 219 patients interviewed, 162 (74%) had at least one discrepancy. The most common type of discrepancy was an incorrect medication documented on the chart. The most common reasons included over-the-counter (OTC) use of medications and patients not reporting use of medications. The presence of one or more medication discrepancies was associated with the use of three or more medications. Patient factors such as gender, age, and race were not associated with discrepancies. Patients able to recall the strength for more than 75% of their medications had fewer discrepancies, while knowledge of the medication name, indication, or regimen had no association with discrepancies.ConclusionPharmacists play a critical role in identifying discrepancies between charted medication lists and self-reported medication use, independent of adherence. Inaccuracies in charted medications are frequent and often are related to use of OTC therapies and lack of communication and documentation during physician office visits. Knowledge of patient-related variables and other reasons for discrepancies may be useful in identifying patients at greatest risk for discrepancies and interventions to prevent and resolve them.     

临床药师干预对老年科患者用药合理性的效果分析

目的:探讨临床药师干预对老年患者用药合理性的作用。方法:采用回顾性分析的方法,随机抽取南京大学医学院附属鼓楼医院老年科2016年1至3月出院的100例患者作为对照组,抽取2017年1至3月出院的100例患者作为干预组。对2组患者的不合理医嘱、住院期间用药种类、处方金额和个体化给药情况进行对比分析。结果:经临床药师干预后,干预组总不合理医嘱率、用药种类、注射剂种类、处方金额均较对照组均明显降低,差异有统计学意义(χ~2=28. 19, t=5. 12、5.68、8.94, P <0.01);干预组进行个体化给药的例次明显高于对照组,差异有统计学意义(χ~2=15.99, P <0.01)。结论:临床药师干预对提高老年科患者用药合理性具有重要意义。     

Evaluation of medication reconciliation in an ambulatory setting before and after pharmacist intervention

ObjectivesTo determine the accuracy of medication reconciliation in an internal medicine clinic and to evaluate pharmacist interventions targeted at improving the accuracy of medication reconciliation.DesignProspective case series.SettingMemphis, TN, from October 2007 to March 2008.Patients180 adults attending an internal medicine appointment.InterventionOn patient arrival, a nurse completed the medication reconciliation form. In Phase 1 of the study, a pharmacist randomly selected and reviewed a patient's medication reconciliation form, interviewed the patient, and verified information if indicated. A total of 90 forms were reviewed and compared to determine baseline medication reconciliation accuracy. Education interventions were held with the medical and nursing staff, targeting areas for improvement. In Phase 2 of the study, 90 additional medication reconciliation forms were reviewed in the same manner. Phase 1 and Phase 2 results were compared to evaluate differences in accuracy after the pharmacist's education interventions.Main outcome measuresAccuracy of medication reconciliation forms and number of potentially significant errors at baseline and after pharmacist interventions.ResultsIn Phase 1, 14.4% of medication reconciliation forms were correct. The remaining forms contained 190 potentially significant errors. After the education interventions, 18.9% of medication reconciliation forms were correct and the others contained 139 potentially significant errors.ConclusionMedication reconciliation accuracy is poor. Although education interventions showed a trend toward improvement, continued education training for staff and patients is needed in addition to other interventions to optimize this process and prevent medication errors.     

临床药师开展药物重整的药学服务实践

目的:为临床药师开展药物重整的药学实践提供参考。方法:探讨临床药师在实践工作中如何通过掌握用药史,及引入诺氏评估量表进行不良反应分析为切入点实现药物重整的药学服务实践。结果和结论:临床药师在药物重整工作中扮演着重要的角色。在临床实践中,临床药师获取精确的用药清单,加强专业知识地学习,借助一些适当的工具,才能实现药物重整。     

Encouraging comprehensive and consistent pharmacist education for provision of contraception

Objectives

To initiate a call to action for community pharmacists and key stakeholders to encourage comprehensive and consistent education and certification for contraception services, especially in states where laws have been enacted for pharmacist prescribing of hormonal contraceptives.

The role of clinical pharmacist to improve medication administration through enteral feeding tubes by nurses

Background As a common practice, medications are given in addition to nutrients through enteral catheters especially in critically ill patients. Nurses are primarily responsible to administer medications in this manner. The correct drug delivery via enteral tubes requires special skills. Objective This study was designed to evaluate effectiveness of clinical pharmacist-led educational program in progressing nurses' knowledge and practice regarding medications delivery via enteral catheters. Setting This study has been performed in two teaching hospital affiliated to Tehran University of Medical Sciences. Methods This is a case-control, interventional study. At first, a knowledge and practice questionnaire regarding drug administration trough enteral feeding tube by intensivist nurses was prepared. This questionnaire was filled by each nurse at pre-intervention phase of the study. Then, the clinical pharmacists provided educational programs including preparing evidence-based booklet and classes for case group nurses. Nurses in case and control groups were evaluated again after 3?months. At pre- and post-intervention phases nurses were observed regarding their practice to administer drugs via enteral tubes as well. Main outcomes Mean scores of knowledge and practice questions as well as percent of nurses with correct answers were compared between pre- and post-intervention phases in case and control groups. Results The mean scores of knowledge and practice questions significantly increased in the case group but decreased or remained unchanged in the control group. In contrast to control group, the percent of nurses with correct answers to each domain of knowledge and practice questions increased significantly in the case group. Conclusion This study showed that nurses did not have sufficient baseline knowledge about rules of drug administration via enteral feeding tubes; however, integrated educational program by clinical pharmacists that focus on promoting correct administration of drugs via enteral feeding catheters significantly improved knowledge and practice of nurses. A theory-practice gap was found in this study that may be related to the authority of physicians not nurses in ordering rules for medication administration through enteral catheters.     

Educational campaign for proper medication disposal

ObjectivesTo assess the effect of an educational intervention on pharmacists' attitudes and knowledge about medication disposal.MethodsIn September 2005, a survey was mailed to 488 registered pharmacists serving as experiential education preceptors to Massachusetts College of Pharmacy and Health Sciences students in 27 states throughout the country. Mailing of this presurvey occurred 2 months before an educational intervention. An identical postsurvey was mailed to the 223 respondents to the presurvey 3 months after the intervention. The main outcome measure was change in pharmacist attitudes and knowledge about medication disposal after educational intervention.Results158 pharmacists (32% response rate) completed the pre- and postsurveys. Before the intervention, 47% of pharmacists perceived inappropriate medication disposal to be an environmental problem compared with 57% after the intervention (P = 0.03). Similarly, when asked about medication disposal, 10% correctly indicated that patients could arrange for hazardous waste pick up compared with 20% postintervention (P< 0.01). Conversely, 19% incorrectly indicated that patients should wash medications down the sink compared with 5.6% postintervention (P< 0.01).ConclusionA brief educational intervention is effective at changing pharmacists' attitudes and knowledge of inappropriate and environmentally unsafe medication disposal practices. Pharmacists receiving the educational intervention were more likely to report that they would recommend appropriate methods of medication disposal. Further educational efforts are necessary for improving pharmacists' knowledge regarding safe medication disposal practices.     

Reengineering a pharmacist intervention program.

At the beginning of a period of rapid growth in clinical pharmacy services in our integrated health system, we realized that there was no mechanism to address how pharmacist interventions were processed, evaluated, and followed up. Interventions were inconsistently documented, and the documentation served no more purpose than to record workload statistics. There was little assessment of the value or quality of interventions, no peer review, and no reporting of aggregate data to improve system-related problems. How are others handling the documentation and assessment of pharmacist interventions?     

Effect of pharmacist intervention on improving antidepressant medication adherence and depression symptomology: A systematic review and meta-analysis

Background

Depression is a widespread disease with effective pharmacological treatments, but low medication adherence. Pharmacists play a key role in supporting medication adherence in patients with depression given their accessibility to patients.