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By Julie Crawshaw
Including pharmacists in rounds through the intensive care unit (ICU) can reduce medication errors substantially, according to a study led by researchers at the Harvard School of Public Health (JAMA 1999; 282:267-270.) The results translated into a projected savings of $270,000 a year for Massachusetts General Hospital in Boston, where the study was conducted.
Previous studies have shown that when pharmacists review medication orders in the ICU, errors are prevented. But until now, no one had looked at whether including pharmacists at the time the drug is actually prescribed might reduce adverse events.
According to the researchers, past studies found that "the major cause of prescribing errors was physicians’ lack of essential drug and patient information at the time of ordering."
The study involved a before-after comparison in the ICU and used a coronary care unit as a control. Pharmacists made daily rounds with the residents, nurses, and attending staff, then remained in the ICU for consultations and were available on call throughout the day.
"[Success] clearly depends on the politics, the individual personality of the pharmacist and how well they communicate with the doctors and nurses. In this study, the doctors and nurses filled out a satisfaction score and they were well satisfied," says co-author David J. Cullen, MD, Chair of the Department of Anesthesiology at St. Elizabeth’s Medical Center in Boston and Professor of Anesthesiology at Tufts University School of Medicine.
During the study period, pharmacists made a total of 398 interventions, of which 366 were related to drug orders. Physicians accepted 362, or 99% of the recommendations. Nearly half were clarifications or corrections to an order. The errors found by the pharmacists included wrong doses, wrong frequencies, inappropriate choices, and duplicate therapies. In 100 instances, pharmacists provided drug use information. They recommended alternative therapies in 47 cases, and several times identified potential problems with drug interactions and allergies.
Overall, the study found that the rate of adverse drug events caused by prescribing errors was reduced by 66% during the six months pharmacists were involved. In the control unit, there was essentially no change in the rate of medication errors during the same period of time.
The authors concluded: "The participation of a pharmacist on rounds with the medical team in an ICU is a powerful means of reducing the risk of adverse drug events caused by prescribing errors." They wrote that computerized physician order entry also can significantly reduce the rate of serious medication errors. But since most hospitals do not use this technology, they say, "The incorporation of a pharmacist into the patient care team is a more feasible alternative . . . especially in units with high medication use."
Cullen also notes the practicality of a pharmacist on rounds, which on average, required three hours each day to complete. "There are clinical pharmacists at many hospitals who have a great deal of knowledge and are not used by physicians as they should be. They are not as accessible as they should be. We felt that having a pharmacist would make a difference, so the pharmacy department found ways to back and fill during the course of the study."
The study was partially funded by a grant from the American Society of Health-System Pharmacists Research and Education Foundation as part of its system changes and outcomes project on adverse drug event prevention.
"Obviously, we were pleased with the results and to some degree were expecting them," says assistant program director for research Helen Waldren.
"It was interesting that, as the author’s found, pharmacists were well accepted on the team, more so after the impression by medical staff that [pharmacists] were primarily concerned with cost in their decision making, which is a mindset projected a lot onto different departments by each other these days," she says. "It’s also noteworthy that pharmacists reported that developing interpersonal relationships helped a lot on all counts."
[Additional information is available on the AMA’s Web site at www.ama-assn.org. ASHP’s grant office can be reached through (301) 657-3000.]