Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing

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Abstract

Objectives

Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework.

Design

Single centre, randomised controlled, two-arm trial.

Setting

Elective surgery PAC in a Brisbane-based tertiary hospital.

Participants

400 adults scheduled for elective surgery were randomised to intervention or control.

Intervention

A pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers.

Outcome measures

Primary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing.

Results

There were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29).

Conclusions

Medication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups.

Trial Registration

Registered with ANZCTR—ACTR Number ACTRN12609000426280

Related collections

Most cited references 22

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Role of computerized physician order entry systems in facilitating medication errors.

Ross Koppel, Joshua Metlay, Abigail Cohen … (2005)

Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. To identify and quantify the role of CPOE in facilitating prescription error risks. We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders. Examples of medication errors caused or exacerbated by the CPOE system. We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.

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Relationship between medication errors and adverse drug events.

David Bates, Deborah L Boyle, Martha Vliet … (1995)

To evaluate the frequency of medication errors using a multidisciplinary approach, to classify these errors by type, and to determine how often medication errors are associated with adverse drug events (ADEs) and potential ADEs. Medication errors were detected using self-report by pharmacists, nurse review of all patient charts, and review of all medication sheets. Incidents that were thought to represent ADEs or potential ADEs were identified through spontaneous reporting from nursing or pharmacy personnel, solicited reporting from nurses, and daily chart review by the study nurse. Incidents were subsequently classified by two independent reviewers as ADEs or potential ADEs. Three medical units at an urban tertiary care hospital. A cohort of 379 consecutive admissions during a 51-day period (1,704 patient-days). None. Over the study period, 10,070 medication orders were written, and 530 medications errors were identified (5.3 errors/100 orders), for a mean of 0.3 medication errors per patient-day, or 1.4 per admission. Of the medication errors, 53% involved at least one missing dose of a medication; 15% involved other dose errors, 8% frequency errors, and 5% route errors. During the same period, 25 ADEs and 35 potential ADEs were found. Of the 25 ADEs, five (20%) were associated with medication errors; all were judged preventable. Thus, five of 530 medication errors (0.9%) resulted in ADEs. Physician computer order entry could have prevented 84% of non-missing dose medication errors, 86% of potential ADEs, and 60% of preventable ADEs. Medication errors are common, although relatively few result in ADEs. However, those that do are preventable, many through physician computer order entry.

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Unintended medication discrepancies at the time of hospital admission.

S. Knowles, David Juurlink, Steven Shadowitz … (2005)

Prior studies suggest that unintended medication discrepancies that represent errors are common at the time of hospital admission. These errors are particularly worthy of attention because they are not likely to be detected by computerized physician order entry systems. We prospectively studied patients reporting the use of at least 4 regular prescription medications who were admitted to general internal medicine clinical teaching units. The primary outcome was unintended discrepancies (errors) between the physicians' admission medication orders and a comprehensive medication history obtained through interview. We also evaluated the potential seriousness of these discrepancies. All discrepancies were reviewed with the medical team to determine if they were intentional or unintentional. All unintended discrepancies were rated for their potential to cause patient harm. After screening 523 admissions, 151 patients were enrolled based on the inclusion criteria. Eighty-one patients (53.6%; 95% confidence interval, 45.7%-61.6%) had at least 1 unintended discrepancy. The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration. Medication errors at the time of hospital admission are common, and some have the potential to cause harm. Better methods of ensuring an accurate medication history at the time of hospital admission are needed.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2013

Publication date (Electronic): 11 July 2013

Volume: 3

Issue: 7

Electronic Location Identifier: e003027

Affiliations

[1 ]Department of Pharmacy, Princess Alexandra Hospital , Brisbane, Queensland, Australia

[2 ]Department of Pharmacy, Royal Brisbane and Womens Hospital , Brisbane, Queensland, Australia

[3 ]Medicines Regulation and Quality, Queensland Health , Brisbane, Queensland, Australia

[4 ]School of Pharmacy, Pharmacy Australia Centre of Excellence, The University of Queensland , Brisbane, Queensland, Australia

[5 ]Department of Anaesthetics, Princess Alexandra Hospital , Brisbane, Queensland, Australia

[6 ]School of Clinical Sciences, Queensland University of Technology (QUT) , Brisbane, Queensland, Australia

Author notes

[Correspondence to ] A R Hale; andrew_hale@ 123456health.qld.gov.au

Article

Publisher ID: bmjopen-2013-003027

DOI: 10.1136/bmjopen-2013-003027

PMC ID: 3710977

PubMed ID: 23847268

SO-VID: cf8c2fd3-1d64-4363-a656-0f8a6e129333

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

History

Date received : 11 April 2013

Date revision received : 24 May 2013

Date accepted : 31 May 2013

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Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing

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Abstract

Objectives

Design

Setting

Participants

Intervention

Outcome measures

Results

Conclusions

Trial Registration

Related collections

Herbal Medicines Journal (Herb Med J)

Most cited references 22

Role of computerized physician order entry systems in facilitating medication errors.

Relationship between medication errors and adverse drug events.

Unintended medication discrepancies at the time of hospital admission.

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Author notes

Article

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Cited by 18

Most referenced authors 275