The contribution of patient interviews to the identification of drug‐related problems in home medication review

What is known and Objective: To determine to what extent patient interviews contribute to the identification of drug‐related problems (DRPs) in home medication reviews, in terms of number, type and clinical relevance. Methods: We performed a cross‐sectional study within the intervention arm of a randomized controlled trial. Patients were recruited from 10 Dutch community pharmacies. Patients were eligible if they were home‐dwelling, aged 65 years and over and used five or more different drugs, including at least one cardiovascular or antidiabetic drug. The community pharmacist interviewed the patient at home about the medicines and identified potential DRPs in combination with medication and clinical records. This medication review was assessed and modified by an independent pharmacist reviewers’ panel. Outcomes were the number and type of DRPs and recommendations and percentage of clinical relevant DRPs. Clinical relevance of DRPs was assessed by DRPs assigned a high priority, DRPs followed by recommendations for drug change and DRPs followed by implemented recommendations for drug change. Results: A total of 1565 potential DRPs and recommendations (10 per patient).were identified for 155 patients (median age, 76 years; 54% women). Fifty‐eight per cent of all recommendations involved a drug change; 27% of all DRPs were identified during patient interviews and 74% from medication and clinical records. Compared to DRPs identified from patient medication and clinical records, DRPs identified during patient interviews were more frequently assigned a high priority (OR = 1·8 [1·4–2·2]), were more frequently associated with recommendations for drug change (OR = 2·4 [1·9–3·1]) and were implemented recommendations for drug change (OR = 2·8 [2·1–3·7]). What is new and Conclusion: This study shows that more than a quarter of all DRPs were identified during patient interviews. DRPs identified during patient interviews were more frequently assigned a higher clinical relevance.     

A retrospective study of drug‐related problems in Australian aged care homes: medication reviews involving pharmacists and general practitioners

Background Drug‐related problems (DRPs) in Australian aged care homes have been studied previously. However, little is known about the acceptance and implementation of pharmacists' recommendations by general practitioners (GPs) to resolve DRPs. Objectives The primary objective of this study was to investigate the number and nature of DRPs identified by accredited clinical pharmacists. The secondary objective was to study the GP acceptance and implementation of pharmacist recommendations to resolve DRPs. Methods This was a retrospective study of 500 randomly selected, de‐identified medication reviews performed by 10 accredited clinical pharmacists over 6 months across 62 aged care homes. The DRPs identified by pharmacists were subsequently classified by the drugs involved, types of problem (indication, effectiveness and safety) and medical diagnoses of the patient. GP written feedback on the medication review reports determined implementation of pharmacists' recommendations to resolve the DRPs. Results A total of 1433 DRPs were identified in 480 of the 500 residents. Potential DRPs were frequently classified as risk of adverse drug reactions, need for additional monitoring and inappropriate choice of a drug. Alimentary, cardiovascular, central nervous system and respiratory drugs were most frequently implicated, accounting for more than 75% of the DRPs. GPs' acceptance and implementation of pharmacists recommendations were 72.5% (95% CI; 70.2, 74.8) and 58.1% (95% CI; 55.5, 60.6), respectively. Conclusions Over 96% of the residents had potential DRPs identified by pharmacists. GP acceptance of pharmacists' recommendations was independent of the drug category, but not independent of the disease category.     

Potential adverse drug events in an indigent and homeless geriatric population.

OBJECTIVE: To identify potential adverse drug events (ADEs) in a geriatric ambulatory population using the modified Beers criteria. METHODS: This is a cross-sectional study of an indigent and homeless geriatric population served by a network of six primary healthcare clinics with clinical pharmacy services. Medical records of patients > or = 65 years old visiting the clinics between December 1999 and April 2000 were retrospectively reviewed by a clinical pharmacist. Medications meeting the modfied Beers criteria were evaluated for the most common drug classes involved, severity potential, and dose or disease state restrictions. Following the identification of medications meeting Beers criteria, the pharmacist left a written recommendation regarding use of alternative drugs or doses in the medical record. Physician acceptance of pharmacy recommendations was also evaluated. RESULTS: Medical records of 146 patients (71.9% women, average age 72.6 +/- 6.7 y) were reviewed. Overall, 52 patients (35.6%) had 70 medications with the potential for causing an ADE based on the modified Beers criteria The most commonly identified medication classes were narcotic analgesics (20.0%), antihypertensives (20.0%), and antihistamines (14.3%). Fifteen of these medications (21.4%) had a high severity potential. Identified medications met the following modified Beers criteria: 41.4% were inappropriate in a specific disease state, 38.6% were inappropriate for the elderly, 10.0% exceeded maximum dosage guidelines, and 10.0% were inappropriate for both the elerly and the patients disease state. Approximately 60% of pharmacy recommendations were accepted by physicians. CONCLUSIONS: The modified Beers criteria are a useful tool for reviewing medical records to identify potential ADEs in an ambulatory geriatric population.     

Comprehensive medication therapy management: identifying and resolving drug-related issues in a community pharmacy

OBJECTIVE: The aim of this study was to characterize comprehensive medication therapy management (MTM) involving a community pharmacy and local physicians by describing the drug-related issues encountered, identifying which medication types were associated with these issues, and listing the actions taken by physicians and pharmacists to address them. METHODS: In the MTM program studied, community pharmacists and physicians worked together to manage the drug therapy of ambulatory Iowa Medicaid recipients dispensed > or =4 medications for chronic conditions by a community pharmacy. After initial assessment, pharmacists made written recommendations to the patient's physician, and the physicians subsequently responded. Data were extracted from pharmacy records for patients who made > or =1 visit during the first 2 years of the program. Collected data included patient demographics, number of chronic conditions and medications at enrollment, type and number of drug-related issues, medication category, pharmacist recommendations, and physician acceptance of recommendations. RESULTS: Data were gathered for 150 patients. The mean (SD) age was 54.4 (19.4) years and 74.0% were female. They were taking a mean (SD) of 9.3 (4.6) medications and had a mean (SD) of 6.1 (3.1) medical conditions at enrollment. A total of 886 drug-related issues were classified into 7 categories: inappropriate adherence (25.9%), needs additional therapy (22.0%), wrong drug (13.2%), unnecessary drug therapy (12.9%), adverse drug reaction (11.1%), dose too low (9.7%), and dose too high (5.3%). Overall, physicians accepted 313 (47.4%) of the 659 recommendations to alter drug therapy made by pharmacists, with the highest rates of agreement to stop or change a medication (50.3% and 50.0%, respectively) and the lowest rate of agreement to start a new medication (41.7%). CONCLUSION: The MTM program showed that drug therapy for ambulatory patients taking multiple medications to treat chronic conditions can be improved through collaboration between physicians and community pharmacists.     

Are interventions recommended by pharmacists during Home Medicines Review evidence‐based?

Introduction Over the past decade medication review services have been implemented in many countries, including Australia, UK and USA. Although, the attitudes and barriers to the implementation of evidence‐based medicine have been investigated, the extent to which medication review recommendations are evidence‐based is not known. Objective To determine (1) the extent to which pharmacist's recommendations during medication review services were consistent with the evidence‐based guides at the time of the review; and (2) the nature and extent of drug‐related problems (DRPs) and the actions recommended by pharmacists to resolve DRPs. Method A retrospective review of Home Medicines Review cases performed on 224 community‐dwelling older people (65 years or older). The chi‐squared test for categorical variables was used to compare the proportion of recommendations that were evidence‐based and recommendations for which no evidence could be identified in the most common Australian information sources. DRPs and the actions recommended to resolve the DRPs were classified according to previously employed criteria. Results Pharmacists made a total of 1114 therapeutic recommendations to general practitioners, of which 964 required supporting pharmacotherapeutic evidence. The majority (94%) of the pharmacists' recommendations were in accordance with the evidence‐based guides, as compared with the recommendations for which no evidence could be identified (P < 0.001). Pharmacists reported that 98% of the patients had at least one problem with use of their medication detected. Conclusion The majority of the actions recommended by pharmacists during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging, as highlighted by the DRPs identified in 98% of our patients. A suitably trained pharmacist, with full access to the patient, medical record and supporting resources, can help to improve the quality use of medicines in this at‐risk population.     

The impact of medication therapy management in older oncology patients

Purpose

This project aimed to identify common drug-related problems (DRP) among elderly cancer patients, to determine the effectiveness of medication therapy management (MTM) service in resolving DRP, to determine the clinical significance of pharmacist interventions, and to determine patients’ satisfaction level of MTM service.

Method

Elderly cancer patients (age ≥65) who were at least on one chronic medication would be eligible for the MTM service. Any DRP that was detected would be recorded and steps to resolve it were taken. Pre- and post-service patient satisfaction surveys (PSS) were conducted before and after MTM. All interventions performed by MTM pharmacists were subjected to independent evaluation by a panel of three judges.

Results

One hundred eighteen patients received at least one session of MTM. We identified and attempted to resolve 361 DRPs, and the most common DRPs were drug interactions (117 cases, 32.4 %), adverse effects (114 cases, 31.6 %), and non-adherence (48 cases, 13.3 %). Forty-four interventions were performed by pharmacists and forty cases (91 %) were accepted by physicians. Almost two third of these interventions were deemed significant (or higher) by the judges. Seventy-two patients completed PSS. There was statistically significant improvement in patients’ satisfaction level after the service was provided.

Conclusion

MTM is an important platform in identifying and managing DRPs. Patients are generally satisfied with MTM services.     

Pharmaceutical care for HIV patients on directly observed therapy

BACKGROUND: Inner-city patients infected with HIV can be a challenging group to treat. Homelessness, mental illness, substance abuse, and hepatitis C infection may serve as barriers to effective treatment. A multidisciplinary team including the pharmacist can impact upon the delivery of care to the inner-city HIV patient population. OBJECTIVE: To describe the implementation and provision of pharmaceutical care to inner-city patients taking directly observed therapy (DOT), as well as drug-related problems (DRPs) and their respective outcomes. METHODS: Pharmaceutical care, including the prospective identification and management of DRPs, was provided by a clinical pharmacist. RESULTS: Fifty-seven patients were followed over a 14-month period. Overall, 149 DRPs were identified and >95% were resolved. Those included (1) adverse effects (n = 56; gastrointestinal, central nervous system effects, allergies, laboratory abnormalities), (2) drug interactions (n = 32), (3) drugs indicated for comorbidities (n = 24; safety in pregnancy, tuberculosis, Pneumocystis carinii pneumonia prophylaxis, oral candidiasis, herpes zoster, nutritional supplements), (4) adherence issues (n = 20; altering timing of medication, changing formulation, decreasing pill burden), (5) drugs no longer indicated (n = 10; opportunistic infection prophylaxis, treatment of primary infection), and (6) dosage adjustment (n = 7) for weight and renal insufficiency. CONCLUSIONS: In the provision of pharmaceutical care to HIV-infected patients on DOT, an HIV pharmacist significantly contributed to antiretroviral selection, monitoring of drug therapy, and managing DRPs. An HIV pharmacist can assist in promoting patient adherence and improved outcomes in this setting.     

Drug-related problems on hospital admission: relationship to medication information transfer

BACKGROUND: Patients with end-stage renal disease (ESRD) are at risk for drug-related problems (DRPs), especially on hospital admission. OBJECTIVE: To identify and characterize the DRPs experienced by patients with ESRD on admission and investigate how these DRPs could be related to gaps in medication information transfer. METHODS: Patients with ESRD admitted to the hospital were prospectively identified and clinically assessed by a pharmacist to identify and categorize DRPs on admission. Each DRP was evaluated to determine whether it could have been caused by a gap in medication information transfer. For DRPs caused in this manner, the interface in the information transfer process where the gap may have occurred was determined. RESULTS: A total of 199 DRPs were identified in 47 patients with ESRD over a 12 week period. Ninety-two percent of patients had at least one DRP on admission, with an average of 4.2 +/- 2.2 DRPs per patient. The most common DRP identified was indication for drug therapy--patient requires drug but is not receiving it (51.3%). Of the total DRPs, 130 (65%) were related to gaps in medication information transfer, with 21.5% occurring between the inpatient hospital and the ambulatory clinic pharmacists and 17.7% between the admitting physician and the patient. CONCLUSIONS: Results of this study demonstrate that, in patients with ESRD, DRPs on admission are frequently related to gaps in medication information transfer between healthcare professionals and also between healthcare providers and patients. Improved communication is required at medication information transfer interfaces to prevent these DRPs.     

Computerized physician order entry system combined with on-ward pharmacist: analysis of pharmacists' interventions

Rationale, aims and objectives To analyse pharmacists' interventions in a setting where a computerized physician order entry system (CPOE) is in use and a pharmacist works on the ward. Method A prospective cohort study was conducted in seven wards of a French teaching hospital using CPOE along with the presence of a full‐time on‐ward pharmacy resident. We documented the characteristics of pharmacists' interventions communicated to physicians during the medication order validation process whenever a drug‐related problem was identified. Independent predictors of the physician's acceptance of the pharmacist's intervention were assessed using multiple logistic regression analysis. Results The 448 pharmacists' interventions concerned: non‐conformity to guidelines or contraindications (22%), too high doses (19%), drug interactions (15%) and improper administration (15%). The interventions consisted of changes in drug choice (41%), dose adjustment (23%), drug monitoring (19%) and optimization of administration (17%). Interventions were communicated via the CPOE in 57% of cases and 43% orally. The rate of physicians' acceptance was 79.2%. In multivariate analysis, acceptance was significantly associated with the physician's status [higher for residents vs. seniors: OR = 7.23, CI 95 (2.37–22.10), P < 0.01], method of communication [higher for oral vs. computer communication: OR = 12.5, CI 95 (4.16–37.57), P < 0.01] and type of recommendation [higher for drug monitoring vs. drug choice recommendations: OR = 10.32, CI 95 (3.20–33.29), P < 0.01]. Conclusions When a clinical pharmacist is present on a ward in which a CPOE is in use, the pharmacists' interventions are well accepted by physicians. Specific predictors of the acceptance by physicians emerge, but further research as to the impact of CPOE on pharmacist–physician communication is needed.     

Characteristics of pharmaceutical opinions written in a Quebec community pharmacy.

OBJECTIVE: To describe the characteristics of pharmaceutical opinions written in a community pharmacy and to estimate the possible effects of these opinions on patient drug profiles. DESIGN: Retrospective survey. SETTING: The community pharmacy where these opinions were written is located in a rural area of the province of Quebec. Only health-related items are sold and no merchandise is displayed in this pharmacy. PARTICIPANTS: Ten pharmacists worked at this pharmacy during the period of the study. INTERVENTION: Pharmacists were paid when they sent advice to a patient or a physician about the patient's drug profile or about the therapeutic value of a prescribed treatment. This survey included recommendations made from 1978 to 1983. A sample of 600 opinions was drawn at random from a total of 1992 opinions that had been written at the site of the study. MAIN OUTCOME MEASURE: The impact of each opinion was assessed by analyzing patient drug profiles for three months after the opinion was written to determine if the recipient had followed the pharmacist's recommendation. RESULTS: Pharmacists, on their own initiative, sent 97.9 percent of the opinions. Only 1.7 percent of the opinions were requested by patients and 0.4 percent by physicians. Most opinions were addressed to patients (86.7 percent) rather than to physicians (13.3 percent). Almost four of five recommendations sent to patients were about compliance (45.1 percent) or were suggestions for improving the therapeutic effect of a medication or replacing a drug with nondrug treatment (33.4 percent). The three most common recommendations sent to prescribers were to replace one drug with another (25 percent), to change the dose or dosing schedule of a drug (16.3 percent), and to discontinue drug treatment (16.3 percent). Chemical stability, underuse or overuse of a medication, and adverse effects were the most frequent causes of recommendations sent to patients. Adverse effects, interactions, and the underuse of a medication were the most frequent reasons for recommendations sent to physicians. The proportion of recommendations that were implemented was 77.7 percent for patients and 58.1 percent for physicians. CONCLUSIONS: The pharmaceutical opinion seemed to be a good means of communicating with patients and prescribers on a wide variety of problems encountered in a community pharmacy. It allowed pharmacists to be paid for their expertise even if a drug was not dispensed. Also, the pharmaceutical opinion could compensate for the loss of income when the pharmacist recommended replacing a prescribed medicine with nondrug treatment.     

Darbepoetin alfa administration to achieve and maintain target hemoglobin levels for 1 year in patients with chronic kidney disease

OBJECTIVE: To assess the efficacy and safety of every-other-week darbepoetin alfa therapy in treating anemia and maintaining hemoglobin levels for 1 year in patients with chronic kidney disease (CKD) who were not undergoing dialysis and who had not previously received erythropolesis-stimulating proteins (ESPs). PATIENTS AND METHODS: This multicenter 52-week study (evaluation period, weeks 20-32), a subanalysis of the Simplify the Treatment of Anemia with Aranesp study, enrolled patients with CKD who were not receiving dialysis (creatinine clearance < or =70 mL/min or estimated glomerular filtration rate [GFR] < or =60 mL/min). Patients evaluated in this analysis were not receiving ESPs, had hemoglobin concentrations less than 11 g/dL, and had transferrin saturation of 20% or higher during screening. Patients Initiated every-other-week darbepoetin alfa therapy at 0.75 microg/kg, with the dose subsequently titrated to maintain hemoglobin levels not to exceed 12 g/dL. The first study participant was enrolled on February 4, 2002, and the last participant completed the study on March 31, 2004. RESULTS: The analysis included 911 patients (mean [SD] age, 66.4 [14.2] years; 54.3% female; 55.3% white). The least squares mean evaluation hemoglobin concentration was 11.54 g/dL (95% confidence interval, 11.47-11.61 g/dL), and the change from baseline was 1.6 g/dL (95% confidence interval, 1.5-1.7 g/dL). The mean (SD) every-other-week darbepoetin alfa dose during evaluation was 44.5 (33.7) microg. Iron supplementation was administered to 573 patients (62.9%) during the study. Darbepoetin alfa was well tolerated throughout the study period. CONCLUSION: Darbepoetin alfa initiated every other week safely and effectively treated anemia and maintained hemoglobin for 1 year in patients with CKD who were not undergoing dialysis and who were not receiving prior ESP therapy.     

A multi-intervention approach on drug therapy can lead to a more appropriate drug use in the elderly. LIMM-Landskrona Integrated Medicines Management

Rationale, aims and objectives  To evaluate if an integrated medicines management can lead to a more appropriate drug use in elderly inpatients.
Method  The study was an intervention study at a department of internal medicine in southern Sweden. During the intervention period pharmacists took part in the daily work at the wards. Systematic interventions aiming to identify, solve and prevent drug-related problems (DRPs) were performed during the patient's hospital stay by multidisciplinary teams consisting of physicians, nurses and pharmacists. DRPs identified by the pharmacist were put forward to the care team and discussed. Medication Appropriateness Index (MAI) was used to evaluate the appropriateness in the patients' drug treatment at admission, discharge and 2 weeks after discharge. In total 43 patients were included, 28 patients in the intervention group and 25 patients in the group which was used as control.
Results  For the intervention group there was a significant decrease in the number of inappropriate drugs compared with the control group ( P  = 0.049). Indication, duration and expenses were the MAI-dimensions with most inappropriate ratings, and the drugs with most inappropriate ratings were anxiolytics, hypnotics and sedatives.
Conclusion  This kind of systematic approach on drug therapy can result in a more appropriate drug use in the elderly.     

Investigation of the prevalence of CKD in 13,383 Chinese hospitalised adult patients

BACKGROUND: There is an increase prevalence of chronic kidney disease (CKD)worldwide. However, the exact incidence of CKD in China is still uncertain. In this cross-sectional study, we retrospectively investigated the prevalence and distribution of CKD in Chinese hospitalised adult patients. METHODS: Totally, 13,383 adults patients who were hospitalised at our hospital were included in this study. They included 6215 males and 7168 females. Patients' gender, age, blood pressure, serum creatinine, blood urea nitrogen, uric acid, triglyceride, total cholesterol, albumin, hemoglobin, hemotocrit, urine protein, and history of hypertension, diabetes, and smoking were investigated. CKD was defined as eGFR<60 ML/ MIN PER 1.73 m(2) and/or proteinuria, GFR was estimated by using of the simplified MDRD equation. RESULTS: The prevalence rate of CKD was 14.82% in our group, which was respectively distributed from 1 to stage 5 at the following percentage, 3.33% (stage 1), 2.49% ( stage 2), 7.07% (stage 3), 1.08% (stage 4), and 0.86% (stage 5). Elderly patients (age >65 y) accounted for 53.07%, which had a higher CKD prevalence (29.47%) than middle and young-aged patients (9.49%). It was noted that 39.06% patients at stage 1-3 were undiagnosed with CKD during their hospitalization. The common etiology for CKD was hypertension (29.49%), diabetes (11.64%) and primary glomerulonephritis (4.39%). Hypertension, diabetes and ages were main associated factors for CKD. CONCLUSIONS: CKD is a very common disease among the hospitalised patients in China. With the increasing of aging population, elderly people will be the highest risk group for CKD. More strategies have to be made for its early detection and prevention.     

Physicians' recommendations for patients who undergo noncardiac surgery

OBJECTIVE: To investigate how consulting physicians attempt to modify perioperative cardiac risk for patients who undergo noncardiac surgery by comparing the preoperative cardiac recommendations of consulting physicians in 2 university centres. DESIGN: Retrospective cross-sectional analysis. SETTING: Five hospitals affiliated with 2 Canadian universities. PATIENTS: Three hundred and eight preoperative consultations were evaluated in 297 patients who were 40 years of age or older and scheduled for noncardiac surgery. OUTCOME MEASURES: Cardiac drug recommendations at the preoperative consultation [corrected]; overall recommendations and practice variation between the 2 centres. RESULTS: The greatest changes in drug management suggested by consultants were the initiation of nitrates in 13% of the patients and a decrease in acetylsalicylic acid administration from 27% to 17%. Centre A physicians recommended adding an angiotensin-converting enzyme inhibitor 11% of the time, whereas centre B physicians recommended such an inhibitor in only 1% of the patients (p = 0.001). In patients taking acetylsalicylic acid at the preoperative consultation, Centres A and B physicians recommended withholding the drug 47% and 22% of the time, respectively (p = 0.03). These differences persisted between the 2 centres after controlling for physician estimates of risk. CONCLUSIONS: Consultants frequently recommended perioperative changes in the use of cardiac medications, and there were differences in practice patterns between the 2 centres. These differences may be affecting patient outcomes and highlight the need for randomized clinical trials to determine the impact of perioperative drug administration on bleeding, myocardial infarction and death.     

Diffusion of pharmacist interventions within the framework of clinical pharmacy activity in the clinical ward

BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors. OBJECTIVES: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance. METHODS: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital. RESULTS: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01). CONCLUSION: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.     

Drug-related problems in medical wards with a computerized physician order entry system

Objective:  Identification and estimation, by clinical pharmacists participating in routine medical rounds, of drug-related problems (DRPs), arising despite the use of a computerized physician order entry (CPOE) system.
Methods:  An 18-month prospective study of DRPs through a CPOE was conducted by seven clinical pharmacists participating in ward activity. DRPs were identified by two independent pharmacists using a structured order review (French Society of Clinical Pharmacy instrument).
Results:  A total of 29 016 medication orders relating to 8152 patients were analysed, and 2669 DRPs, involving 1564 patients (56% female; mean age 72·6 years), were identified representing 33 DRPs per 100 admissions. The most commonly identified DRPs were non-conformity to guidelines or contra-indication (29·5%), improper administration (19·6%), drug interaction (16·7%) and overdosage (12·8%). There were 429 different drugs associated with these DRPs. Cardiovascular drugs were the most frequently implicated (22·2%), followed by antibiotics/anti-infectives (13·3%) and analgesics/antiinflammatory drugs (11·3%). Different types of DRPs were closely associated with specific classes of drugs.
Conclusions:  Drug-related problems are common even after implementation of CPOE. In this context, routine participation of clinical pharmacists in clinical medical rounds may facilitate identification of DRPs. Pharmacists should be able to enhance patient safety through such involvement.     

An analysis of clinical pharmacist interventions in an intensive care unit.

In a 6-month study period, 170 pharmacist interventions in an intensive care unit (ICU) were analysed. Of the interventions, 68.8% were solicited and 31.2% were initiated by the pharmacists. The majority of the interventions were initiated by specialists (69.4%) followed by the medical officers (15.9%) and nurses (9.4%). Most of the interventions occurred during the grand rounds (75.9%), followed by ward visits (12.9%) and communication through the satellite pharmacy (10.5%). The most frequent type of intervention made was for indication or therapeutic efficacy followed by general product information, drug regimen, laboratory assessment, disease state, pharmaceutical availability and adverse drug reaction or side effect. It was also found that 83.7% of pharmacists' suggestions were accepted, 6.4% were accepted with changes, and 9.9% were not accepted. The majority of the interventions were made by direct verbal communications followed by telephone and written communications. In conclusion the study indicates that pharmacist therapeutic recommendations form an important integral element of patient care in an ICU.     

Impact of a pediatric clinical pharmacist in the pediatric intensive care unit

OBJECTIVE: To study the impact of a clinical pharmacist in a pediatric intensive care unit. The goals of the study were to determine the type and quantity of patient care interventions recommended by a clinical pharmacist and to specifically examine cost savings (or loss) that resulted from clinical pharmacist recommendations. DESIGN: A prospective case series. SETTING: Ten-bed pediatric intensive care unit in a university-affiliated children's hospital. PATIENTS: All patients admitted to the pediatric intensive care unit during the study period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the 24-wk study period, the pediatric clinical pharmacist documented all interventions that occurred during her shift. She rounded with the pediatric intensive care unit team approximately two times a week and reviewed medication lists daily. Drug acquisition costs were used to calculate drug cost savings. Demographic information was collected on all the patients in the pediatric intensive care unit during the study period. There were 35 recommendations per 100 patient days. The most common interventions were dosage changes (28%), drug information (26%), and miscellaneous information (22%). The average time spent per day by the clinical pharmacist in the pediatric intensive care unit was 0.73 hrs or 0.02 full-time equivalent. The total cost direct savings for the study period was $1,977. Extrapolated to direct cost savings per year, the total amount saved was $9,135/year or 0.15 full-time equivalent. Indirect savings from educational activities, avoidance of medication errors, and optimization of medical therapies represent an additional nonquantifiable amount. CONCLUSION: We conclude that a clinical pharmacist is an important and cost-effective member of the pediatric intensive care unit team.