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      Evaluation of patient care interventions and recommendations by a transitional care pharmacist

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          A “transitional care pharmacist” (TCP) was deployed within an acute care setting to identify opportunities for improved continuity of care. The provision of medication reconciliation services, drug consultation, patient counseling and planning for after-hospital care was time consuming but also fruitful, resulting in roughly nine interventions per patient. Areas with the greatest potential for morbidity reduction were the resumption of home medications during the acute stay and at discharge. Allergy identification was a key contribution at admission, as was the provision of a detailed follow-up plan at discharge. Targeting high-risk patients and spreading portions of the work to other disciplines could achieve added efficiency in this service. Results have value to hospitals implementing medication reconciliation programs.

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          Most cited references 28

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          Adverse drug events in ambulatory care.

           K Shu,  D Bates,  J F Borus (2003)
          Adverse events related to drugs occur frequently among inpatients, and many of these events are preventable. However, few data are available on adverse drug events among outpatients. We conducted a study to determine the rates, types, severity, and preventability of such events among outpatients and to identify preventive strategies. We performed a prospective cohort study, including a survey of patients and a chart review, at four adult primary care practices in Boston (two hospital-based and two community-based), involving a total of 1202 outpatients who received at least one prescription during a four-week period. Prescriptions were computerized at two of the practices and handwritten at the other two. Of the 661 patients who responded to the survey (response rate, 55 percent), 162 had adverse drug events (25 percent; 95 percent confidence interval, 20 to 29 percent), with a total of 181 events (27 per 100 patients). Twenty-four of the events (13 percent) were serious, 51 (28 percent) were ameliorable, and 20 (11 percent) were preventable. Of the 51 ameliorable events, 32 (63 percent) were attributed to the physician's failure to respond to medication-related symptoms and 19 (37 percent) to the patient's failure to inform the physician of the symptoms. The medication classes most frequently involved in adverse drug events were selective serotonin-reuptake inhibitors (10 percent), beta-blockers (9 percent), angiotensin-converting-enzyme inhibitors (8 percent), and nonsteroidal antiinflammatory agents (8 percent). On multivariate analysis, only the number of medications taken was significantly associated with adverse events. Adverse events related to drugs are common in primary care, and many are preventable or ameliorable. Monitoring for and acting on symptoms are important. Improving communication between outpatients and providers may help prevent adverse events related to drugs. Copyright 2003 Massachusetts Medical Society
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            Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.

            Pharmacist review of medication orders in the intensive care unit (ICU) has been shown to prevent errors, and pharmacist consultation has reduced drug costs. However, whether pharmacist participation in the ICU at the time of drug prescribing reduces adverse events has not been studied. To measure the effect of pharmacist participation on medical rounds in the ICU on the rate of preventable adverse drug events (ADEs) caused by ordering errors. Before-after comparison between phase 1 (baseline) and phase 2 (after intervention implemented) and phase 2 comparison with a control unit that did not receive the intervention. A medical ICU (study unit) and a coronary care unit (control unit) in a large urban teaching hospital. Seventy-five patients randomly selected from each of 3 groups: all admissions to the study unit from February 1, 1993, through July 31, 1993 (baseline) and all admissions to the study unit (postintervention) and control unit from October 1, 1994, through July 7, 1995. In addition, 50 patients were selected at random from the control unit during the baseline period. A senior pharmacist made rounds with the ICU team and remained in the ICU for consultation in the morning, and was available on call throughout the day. Preventable ADEs due to ordering (prescribing) errors and the number, type, and acceptance of interventions made by the pharmacist. Preventable ADEs were identified by review of medical records of the randomly selected patients during both preintervention and postintervention phases. Pharmacists recorded all recommendations, which were then analyzed by type and acceptance. The rate of preventable ordering ADEs decreased by 66% from 10.4 per 1000 patient-days (95% confidence interval [CI], 7-14) before the intervention to 3.5 (95% CI, 1-5; P<.001) after the intervention. In the control unit, the rate was essentially unchanged during the same time periods: 10.9 (95% CI, 6-16) and 12.4 (95% CI, 8-17) per 1000 patient-days. The pharmacist made 366 recommendations related to drug ordering, of which 362 (99%) were accepted by physicians. The presence of a pharmacist on rounds as a full member of the patient care team in a medical ICU was associated with a substantially lower rate of ADEs caused by prescribing errors. Nearly all the changes were readily accepted by physicians.
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              Systems analysis of adverse drug events. ADE Prevention Study Group.

              To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs. Systems analysis of events from a prospective cohort study. All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Errors, proximal causes, and systems failures. Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts. During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems. Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely.

                Author and article information

                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                August 2007
                August 2007
                : 3
                : 4
                : 695-703
                [1 ]Center for Outcomes Research and Education, Providence Health and Services Portland, Oregon, USA
                [2 ]Abt Associates, Durham North Carolina, USA
                [3 ]Providence Physician Division, Providence Health and Services Portland, Oregon, USA
                [4 ]Regional Clinical Pharmacy Services, Providence Health and Services Portland, Oregon, USA
                [5 ]Providence Physician Group, Providence Health and Services Portland, Oregon, USA
                [6 ]Providence Portland Medical Center, Providence Health and Services Portland, Oregon, USA
                Author notes
                Correspondence: K Bruce Bayley 5211 NE Glisan St, Portland, OR 97213, USA Tel +1 503 215 7188 Fax +1 503 215 7178
                © 2007 Dove Medical Press Limited. All rights reserved
                Original Research


                transitional care, pharmacist, medication reconciliation, patient safety


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