Optimizing pharmacists' detection of prescribing errors: Comparison of on-ward and central pharmacy services.

WHAT IS KNOWN AND OBJECTIVE: Prescribing errors are the leading cause of adverse drug events in hospitalized patients. Pharmaceutical validation, defined as the review of drug orders by a pharmacist, associated with clinical decision support (CDS) systems, significantly reduces these errors and adverse drug events. In Belgium, because clinical pharmacy services have limited public financial support, most pharmaceutical validations are performed at the central pharmacy instead of on-ward, by hospital pharmacists doing dispensing activities. In that context, we aimed at evaluating whether the strategy of CDS-guided central validation was the most appropriate method to improve the quality and safety of medicines' use compared to an on-ward pharmaceutical validation. METHODS: Our retrospective observational study was conducted in a Belgian tertiary care hospital, in 2018-2019. Data were extracted from our validation software and pharmacists' charts. The outcomes of the study were the number of pharmaceutical interventions due to the detection of prescribing errors, reasons for interventions, their acceptance rate and their potential clinical impact (according to two blinded experts) in the central pharmacy and on-ward validation groups. RESULTS AND DISCUSSION: Despite the use of the same CDS, a pharmaceutical intervention following the detection of a prescribing error was made for 2.9% (20/698) of central group patients and 13.3% (93/701) of on-ward patients (χ2  = 49.97, p < 0.001). Interventions made at the central pharmacy (n = 20) mostly relied on CDS-alerts (i.e. drug-drug interaction [25%] or overdosing [20%]) while interventions made on-ward (n = 93) were also for pharmacotherapy optimization (i.e. no valid indication [25%] or inappropriate drug's choice [11%]). The on-ward validation group showed a higher acceptance rate compared to the central group (84% and 65%, respectively [Fisher's test, p = 0.053]). Proportions of interventions with significant or very significant clinical impact were similar between the two groups but as fewer interventions were made centrally, a significant proportion of errors were probably not detected by the central validation. WHAT IS NEW AND CONCLUSION: On-ward pharmaceutical validation leads to a higher rate of prescribing error detection. Pharmaceutical interventions made by on-ward pharmacists are also better accepted and more relevant, going further than CDS-alerts.

Correction to: Development of a tool for benchmarking of clinical pharmacy activities.

In the original publication of an article, the corresponding author name has been swapped. Now the correct name has been published in this correction.

Development of a tool for benchmarking of clinical pharmacy activities.

Background Initiatives are needed to promote and evaluate clinical pharmacy. In this context, benchmarking could be useful. Objective To develop and validate a benchmarking tool for clinical pharmacy activities. Setting Six Belgian hospitals. Method A narrative literature review and two focus groups were performed to identify (1) clinical pharmacy benchmarking projects, (2) clinical pharmacy activities with a proven positive impact on the quality of care for patients, (3) quality indicators and (4) contextual factors to be included in the tool. Next, a Delphi survey and a test of the tool in practice led to content validation and usability of the benchmarking tool. Main Outcome Measure To identify quality indicators and contextual factors to be included in the tool. Results Three Delphi rounds were required (rounds 1-2: 9 participants, round 3: 8 participants). Ten quality indicators and 36 relevant contextual factors were selected. These 10 quality indicators represent 6 clinical pharmacy activities that demonstrated to improve patient outcomes: medication reconciliation at admission, patient monitoring, information provided to the health care team, patient education, discharge and transfer medication counselling, and adverse drug reaction monitoring. To collect the information needed to compose the quality indicators and to benchmark, the tool consists of three data collection instruments. An instruction manual accompanies the tool. Conclusion We have developed and validated a benchmarking tool, designed to identify and promote clinical pharmacy activities that demonstrated to improve patient outcomes. Future perspectives include the use of the tool on a national scale to identify the most efficient practices and their enablers and barriers.

Successful sublingual cobalamin treatment in a child with short-bowel syndrome.

Vitamin B12 (B12) is essential for deoxyribonucleic acid synthesis, to maintain normal hematologic and neurologic functions. Studies suggest that cobalamin deficiency in children is more common than previously recognized. Main causes are decreased intake, abnormal absorption, and inborn errors of metabolism. The classic treatment for cobalamin deficiency is intramuscular administration of B12. There are no data concerning the use of alternative routes of cobalamin administration in children. This report shares the experience of sublingual administration of B12 to a patient with short-bowel syndrome and B12 malabsorption. We report the case of successful treatment of cobalamin deficiency by sublingual administration in a 9-year-old patient who had undergone intestinal resection and jejunum-colon, with anastomosis of 32 cm of residual small intestine and absence of distal jejunum and ileocecal junction. We determined a B12 deficiency because low serum cobalamin levels (<200 pg/mL) were shown in 2 consecutive tests (130 pg/mL and 170 pg/mL). The patient presented with neither clinical nor hematological manifestations. He received sublingual cobalamin preparation, 1000-mcg sublingual nuggets per day for 1 month. Normalization of serum cobalamin was obtained (790 pg/mL) after 1 month of treatment. The sublingual route of administration not only improved the quality of life of this patient by avoiding monthly painful injections but also reduced the cost of treatment and the number of hospital visits.

Pediatric drug-related problems: a multicenter study in four French-speaking countries.

BACKGROUND: Pediatric intensive care patients represent a population at high risk for drug-related problems. There are few studies that compare the activity of clinical pharmacists between countries. OBJECTIVE: To describe the drug-related problems identified and interventions by four pharmacists in a pediatric cardiac and intensive care unit. SETTING: Four pediatric centers in France, Quebec, Switzerland and Belgium. METHOD: This was a six-month multicenter, descriptive and prospective study conducted from August 1, 2009 to January 31, 2010. Drug-related problems and clinical interventions were compiled from four pediatric centers in France, Quebec, Switzerland and Belgium. Data on patients, drugs, intervention, documentation, approval and estimated impact were compiled. MAIN OUTCOME MEASURE: Number and type of drug-related problems encountered in a large pediatric inpatient population. RESULTS: A total of 996 interventions were recorded: 238 (24 %) in France, 278 (28 %) in Quebec, 351 (35 %) in Switzerland and 129 (13 %) in Belgium. These interventions targeted 270 patients (median 21 months old, 53 % male): 88 (33 %) in France, 56 (21 %) in Quebec, 57 (21 %) in Switzerland and 69 (26 %) in Belgium. The main drug-related problems were inappropriate administration technique (29 %), untreated indication (25 %) and supra-therapeutic dose (11 %). The pharmacists' interventions were mostly optimizing the mode of administration (22 %), dose adjustment (20 %) and therapeutic monitoring (16 %). The two major drug classes that led to interventions were anti-infectives for systemic use (23 %) and digestive system and metabolism drugs (22 %). Interventions mainly involved residents and all clinical staff (21 %). Among the 878 (88 %) proposed interventions requiring physician approval, 860 (98 %) were accepted. CONCLUSION: This descriptive study illustrates drug-related problems and the ability of clinical pharmacists to identify and resolve them in pediatric intensive care units in four French-speaking countries.