On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study

Abstract

IntroductionPatients admitted to an intensive care unit (ICU) are at high risk for prescribing errors and related adverse drug events (ADEs). An effective intervention to decrease this risk, based on studies conducted mainly in North America, is on-ward participation of a clinical pharmacist in an ICU team. As the Dutch Healthcare System is organized differently and the on-ward role of hospital pharmacists in Dutch ICU teams is not well established, we conducted an intervention study to investigate whether participation of a hospital pharmacist can also be an effective approach in reducing prescribing errors and related patient harm (preventable ADEs) in this specific setting.MethodsA prospective study compared a baseline period with an intervention period. During the intervention period, an ICU hospital pharmacist reviewed medication orders for patients admitted to the ICU, noted issues related to prescribing, formulated recommendations and discussed those during patient review meetings with the attending ICU physicians. Prescribing issues were scored as prescribing errors when consensus was reached between the ICU hospital pharmacist and ICU physicians.ResultsDuring the 8.5-month study period, medication orders for 1,173 patients were reviewed. The ICU hospital pharmacist made a total of 659 recommendations. During the intervention period, the rate of consensus between the ICU hospital pharmacist and ICU physicians was 74%. The incidence of prescribing errors during the intervention period was significantly lower than during the baseline period: 62.5 per 1,000 monitored patient-days versus 190.5 per 1,000 monitored patient-days, respectively (P < 0.001). Preventable ADEs (patient harm, National Coordinating Council for Medication Error Reporting and Prevention severity categories E and F) were reduced from 4.0 per 1,000 monitored patient-days during the baseline period to 1.0 per 1,000 monitored patient-days during the intervention period (P = 0.25). Per monitored patient-day, the intervention itself cost €3, but might have saved €26 to €40 by preventing ADEs.ConclusionsOn-ward participation of a hospital pharmacist in a Dutch ICU was associated with significant reductions in prescribing errors and related patient harm (preventable ADEs) at acceptable costs per monitored patient-day.Trial registration numberISRCTN92487665

Pharmacist’s review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

“…A prospective observational study was undertaken in 21 UK CCUs from [5][6][7][8][9][10][11][12][13][14][15][16][17][18] th Nov 2012. A data collection web portal was designed where the specialist critical care pharmacist (SCCP) reported all interventions at their site.…”

“…Since the first reports of clinical pharmacist interventions in critical care in the mid-1980s [4], there has been a gradual progression from those focused on financial savings in medicine use, to reducing medication errors and more recently to the optimisation of medication therapy [5]. Clinical pharmacists have been reported to improve medicines-related patient outcomes in the use of sedation [6], antimicrobial therapy [7], therapeutic drug monitoring [8] and management of thromboembolism/ infarction [9]. Medicines optimisations by addition or adjustment of pharmacotherapy are becoming more dominant practices [10,11].…”

Do we need a pharmacist in the ICU?

“…These benefits appear generalizable since the studies have been conducted in a variety of ICUs (e.g., medical, surgical, neurosurgical, cardiac, and pediatric) using different physician staffing models (e.g., open vs closed ICU), and date back to the early 1990s [13]. The majority of the studies have been conducted in North America, but similar beneficial results have been published from studies conducted in Asia [4,8,9], the Middle East [10], and Europe [11]. Provision of drug information, clarifying and correcting medication orders, identifying drug interactions as well as actual or potential adverse drug events, and recommending alternative therapies account for greater than 90 % of ICU pharmacists' activities [3,4,8,13,14].…”

“…In fact, within the SCCM guidelines for best practice model and ICU staffing [2], pharmacist presence was considered as best practice supported by grade C evidence, the highest level of all recommendations in that document. A summary of the studies evaluating the impact of having a dedicated pharmacist in the ICU is shown in Table 1 [3][4][5][6][7][8][9][10][11][12][13][14][15]. In general, these studies show reductions in drug prescribing errors, adverse drug events, and costs, with no worsening and typically improvement in clinical outcomes such as ICU length of stay and mortality.…”

“…Despite the fact that ICU pharmacists have been demonstrated to provide cost-effective care and cost savings in many facets of care, some hospital administrators may still not (however erroneously) see the clear return on investment. Studies estimate that costs saved in terms of direct drug costs and avoidance of preventable adverse drug events compared to the pharmacist cost is a multiple of at least 4 [11,13]. Second, critical care training is not common in pharmacy training curricula, and thus the specialized training required to be a competent ICU pharmacist must be obtained either ''on the job'' or in a formal manner through a limited number of residency/ fellowship-type training programs.…”