Pharmacy student contribution to direct patient care during inpatient hospital experiential rotations: a scoping review.

OBJECTIVES: The aim of this scoping review was to identify and characterise pharmacy students' contributions to extend pharmacist's direct patient care during inpatient hospital experiential rotations. METHODS: A search of PubMed, Embase and CINAHL databases from 2000 to July 2021 was conducted. Articles were included if they involved pharmacy students during experiential rotations, described student's contribution to direct patient care in the inpatient hospital setting, and reported outcomes. Included articles were categorised according to clinical pharmacy key performance indicators (cpKPIs) and non-cpKPI care activities. Students' contributions to reported outcomes were extracted and summarised. KEY FINDINGS: Thirty-six of 1182 identified articles were included which were either descriptive or quasi-experimental design. Studies reported student involvement in the delivery of single or multiple cpKPIs: medication reconciliation on admission (n = 13), pharmaceutical care (n = 13), interprofessional care rounds (n = 4), patient education during hospital stay (n = 6), medication reconciliation at discharge (n = 7) and patient education at discharge (n = 10). Eight studies reported student involvement in non-cpKPI activities, including clinical interventions (n = 5), clinical services (n = 2) and postdischarge follow-up (n = 1). Reported outcomes included service measure counts, process and clinical outcome measures. SUMMARY: This review identified the contributions of pharmacy students in the provision of a range of direct patient care services and associated outcomes during experiential rotations in the inpatient hospital setting. Students delivering care as part of the pharmacy team as 'care extenders' has the potential to expose more patients to key pharmacist activities that have been linked to demonstrated positive outcomes.

A formal medication reconciliation programme in a haemodialysis unit can identify medication discrepancies and potentially prevent adverse drug events.

BACKGROUND: Patients on haemodialysis have been identified as high-risk for medication discrepancies and adverse drug events. Medication reconciliation is an important patient safety initiative to prevent adverse drug events. The primary objective of our study was to determine the number and types of medication discrepancies and drug therapy problems (DTPs) identified in patients on haemodialysis. Our second objective was to assess the potential clinical impact and severity of all unintentional medication discrepancies identified. METHODS: Patients in an academic haemodialysis unit were interviewed to obtain a best possible medication history (BPMH) between May and August 2010. The BPMH was documented and discrepancies were identified, classified and resolved with the interprofessional team. An interprofessional panel conducted a discrepancy clinical impact assessment for potential adverse drug events. RESULTS: Two hundred and twenty-eight patients on haemodialysis were interviewed and 512 discrepancies were identified for 151 patients (3.4 discrepancies per patient). Of these, 174 (34%) were undocumented intentional discrepancies and 338 (66%) were unintentional discrepancies. The unintentional discrepancies were classified as 21% omissions, 36% commissions and 43% incorrect dose/frequency. Most drug therapy problems were related to patient taking a medication that was not indicated (25%), medication required but patient not taking (25%), patient not willing to take the medication as prescribed (28%) or incorrect dosing of a drug (20%). Overall, 6% of discrepancies were classified as clinically significant potential adverse drug events. CONCLUSION: Medication discrepancies appear to be common in patients on haemodialysis. Formal interprofessional medication reconciliation practice models are essential to identify discrepancies and prevent patients from experiencing adverse drug events.

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

BACKGROUND: Internal hospital transfer is a vulnerable time during which patients are at high risk of medication discrepancies that can result in clinically significant harm, medication errors, and adverse drug events. OBJECTIVE: To identify, characterize, and assess the clinical impact of unintentional medication discrepancies during internal hospital transfer and to investigate the influence of computerized prescriber order entry (CPOE) on medication discrepancies. METHODS: All patients transferred between 10 inpatient units at 2 tertiary care hospitals were prospectively assessed to identify discrepancies. Interfaces included transfers between (1) units that both used paper-based medication ordering systems; (2) units that both used CPOE-based systems; and (3) units that used both paper-based and CPOE-based systems (hybrid transfer). The primary endpoint was the number of patients with at least 1 unintentional medication discrepancy during internal hospital transfer. Discrepancies were identified through assessment and comparison of a best possible medication transfer list with the actual transfer orders. A multidisciplinary team of clinicians assessed the potential clinical impact and severity of unintentional discrepancies. RESULTS: Overall, 190 patients were screened and 129 patients were included. Eighty patients (62.0%) had at least 1 unintentional medication discrepancy at the time of transfer, and the most common discrepancy was medication omission (55.6%). Factors that independently increased the risk of a patient experiencing at least 1 unintentional discrepancy included lack of best possible medication history, increasing number of home medications, and increasing number of transfer medications. Forty-seven patients (36.4%) had at least 1 unintentional discrepancy with the potential to cause discomfort and/or clinical deterioration. The risk of discrepancies was present regardless of the medication-ordering system (paper, CPOE, or hybrid). CONCLUSIONS: Clinically significant medication discrepancies occur commonly during internal hospital transfer. A structured, collaborative, and clearly defined medication reconciliation process is needed to prevent internal transfer discrepancies and patient harm.

Medication reconciliation at hospital discharge: evaluating discrepancies.

BACKGROUND: Hospital discharge is an interface of care when patients are at a high risk of medication discrepancies as they transition from hospital to home. These discrepancies are important, as they may contribute to drug-related problems, medication errors, and adverse drug events. OBJECTIVE: To identify, characterize, and assess the clinical impact of unintentional medication discrepancies at hospital discharge. METHODS: All consecutive general internal medicine patients admitted for at least 72 hours to a tertiary care teaching hospital were prospectively assessed. Patients were excluded if they were discharged with verbal prescriptions; died during hospitalization; or transferred from or to a nursing home, another institution, or another unit within the same hospital. The primary endpoint was to determine the number of patients with at least one unintended medication discrepancy on hospital discharge. Medication discrepancies were assessed through comparison of a best possible medication discharge list with the actual discharge prescriptions. Secondary objectives were to characterize and assess the potential clinical impact of the unintentional discrepancies. RESULTS: From March 14, 2006, to June 2, 2006, 430 patients were screened for eligibility; 150 patients were included in the study. Overall, 106 (70.7%) patients had at least one actual or potential unintentional discrepancy. Sixty-two patients (41.3%) had at least one actual unintentional medication discrepancy at hospital discharge and 83 patients (55.3%) had at least one potential unintentional discrepancy. The most common unintentional discrepancies were an incomplete prescription requiring clarification, which could result in a patient delay in obtaining medications (49.5%), and the omission of medications (22.9%). Of the 105 unintentional discrepancies, 31(29.5%) had the potential to cause possible or probable patient discomfort and/or clinical deterioration. CONCLUSIONS: Medication discrepancies occur commonly on hospital discharge. Understanding the type and frequency of discrepancies can help clinicians better understand ways to prevent them. Structured medication reconciliation may help to prevent discharge medication discrepancies.

Pharmacist medication assessments in a surgical preadmission clinic.

BACKGROUND: In the hospital setting, postoperative admission is a key vulnerable moment when patients are at increased risk of medication discrepancies. This study measures the reduction of medication discrepancies associated with a combined intervention of structured pharmacist medication history interviews with assessments in a surgical preadmission clinic and a postoperative medication order form. METHODS: In the Surgical Pharmacist in Preadmission Clinic Evaluation (SPPACE) study, patients who had a preadmission clinic appointment before undergoing surgical procedures were eligible for inclusion. Patients were excluded if they were scheduled for discharge the same day as their surgery. Eligible patients were randomly assigned to the intervention arm (structured pharmacist medication history interview with assessment and generation of a postoperative medication order form) or to the standard care arm (nurse-conducted medication histories and surgeon-generated medication orders). The primary end point was the number of patients with at least 1 postoperative medication discrepancy related to home medications. RESULTS: Between April 19, 2005, and June 3, 2005, a total of 464 patients were enrolled in the study, of which 227 and 237 patients were randomized to the intervention and standard care arms, respectively. In the intervention arm, 41 (20.3%) of 202 patients had at least 1 postoperative medication discrepancy related to home medications, compared with 86 (40.2%) of 214 patients in the standard care arm (P<.001). In the intervention arm, 26 (12.9%) of 202 patients had at least 1 postoperative medication discrepancy with the potential to cause possible or probable harm, compared with 64 (29.9%) of 214 patients in the standard care arm (P<.001). These were mostly omissions of reordering home medications. CONCLUSION: A combined intervention of pharmacist medication assessments and a postoperative medication order form can reduce postoperative medication discrepancies related to home medications.

The EMITT study: development and evaluation of a medication information transfer tool.

BACKGROUND: Continuity of care is required as patients move from the care of one pharmacist to another. The appropriate transfer of medication information between pharmacists as well as to patients at these times is essential in order to prevent drug-related problems (DRPs). OBJECTIVE: To develop a tool to transfer medication information between various pharmacists caring for the same patients. Secondary objectives were to evaluate the tool based on utility in practice and satisfaction of pharmacists. METHODS: The project consisted of a needs assessment involving in-depth interviews with patients and pharmacists and a literature review. These data were used to develop an optimal tool for medication information transfer between pharmacists in different practice settings. The tool was evaluated in a feasibility pilot for potential utility and pharmacist satisfaction. RESULTS: The tool created called EMITT (electronic medication information transfer tool) facilitates the communication of information to outpatient pharmacists including a letter and an up-to-date list of the patient's drugs. A total of 187 medication issues were communicated within 40 transferred letters, 61 of which required active follow-up, which potentially prevented 348 DRPs if the receiver of the information acted on the information that was provided. The 3 most common issues that required follow-up were restarting a held medication (n = 13), adjustment of doses based on laboratory results (n = 11), and starting a new indicated medication in the future (n = 7). CONCLUSIONS: A tool can be created to help address the gap in communication between pharmacists when patients move between interfaces of care by evaluating the needs of healthcare professionals involved in the information transfer process. It is envisioned that the elements of our tool can be easily adapted to other institutions to improve medication information transfer.

Drug-related problems on hospital admission: relationship to medication information transfer.

BACKGROUND: Patients with end-stage renal disease (ESRD) are at risk for drug-related problems (DRPs), especially on hospital admission. OBJECTIVE: To identify and characterize the DRPs experienced by patients with ESRD on admission and investigate how these DRPs could be related to gaps in medication information transfer. METHODS: Patients with ESRD admitted to the hospital were prospectively identified and clinically assessed by a pharmacist to identify and categorize DRPs on admission. Each DRP was evaluated to determine whether it could have been caused by a gap in medication information transfer. For DRPs caused in this manner, the interface in the information transfer process where the gap may have occurred was determined. RESULTS: A total of 199 DRPs were identified in 47 patients with ESRD over a 12 week period. Ninety-two percent of patients had at least one DRP on admission, with an average of 4.2 +/- 2.2 DRPs per patient. The most common DRP identified was indication for drug therapy--patient requires drug but is not receiving it (51.3%). Of the total DRPs, 130 (65%) were related to gaps in medication information transfer, with 21.5% occurring between the inpatient hospital and the ambulatory clinic pharmacists and 17.7% between the admitting physician and the patient. CONCLUSIONS: Results of this study demonstrate that, in patients with ESRD, DRPs on admission are frequently related to gaps in medication information transfer between healthcare professionals and also between healthcare providers and patients. Improved communication is required at medication information transfer interfaces to prevent these DRPs.