Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study.

BACKGROUND: Medication-related visits to the emergency department are an important but poorly understood phenomenon. We sought to evaluate the frequency, severity and preventability of drug-related visits to the emergency department. METHODS: We performed a prospective observational study of randomly selected adults presenting to the emergency department over a 12-week period. Emergency department visits were identified as drug-related on the basis of assessment by a pharmacist research assistant and an emergency physician; discrepancies were adjudicated by 2 independent reviewers. RESULTS: Among the 1017 patients included in the study, the emergency department visit was identified as drug-related for 122 patients (12.0%, 95% confidence interval [CI] 10.1%-14.2%); of these, 83 visits (68.0%, 95% CI 59.0%-76.2%) were deemed preventable. Severity was classified as mild in 15.6% of the 122 cases, moderate in 74.6% and severe in 9.8%. The most common reasons for drug-related visits were adverse drug reactions (39.3%), nonadherence (27.9%) and use of the wrong or suboptimal drug (11.5%). The probability of admission was significantly higher among patients who had a drug-related visit than among those whose visit was not drug-related (OR 2.18, 95% CI 1.46-3.27, p < 0.001), and among those admitted, the median length of stay was longer (8.0 [interquartile range 23.5] v. 5.5 [interquartile range 10.0] days, p = 0.06). INTERPRETATION: More than 1 in 9 emergency department visits are due to drug-related adverse events, a potentially preventable problem in our health care system.

Drug-related hospitalizations in a tertiary care internal medicine service of a Canadian hospital: a prospective study.

STUDY OBJECTIVES: To determine the frequency, severity, preventability, and classification of adverse drug events resulting in hospitalization, and to identify any patient, prescriber, drug, and system factors associated with these events. DESIGN: Prospective, observational study. SETTING: Internal medicine service of a large tertiary care hospital in Canada. PATIENTS: A total of 565 consecutive adult patients admitted to the hospital during a 12-week period. MEASUREMENTS AND MAIN RESULTS: A patient's hospitalization was defined as drug related if it was directly related to one of eight predefined classifications; severity and preventability of the hospitalization were also assessed. Multivariate logistic regression analysis was used to evaluate patient, prescriber, drug, and system factors associated with drug-related hospitalizations. The frequency of drug-related hospitalization was 24.1% (95% confidence interval [CI] 20.6-27.8%), of which 72.1% (95% CI 63.7-79.4%) were deemed preventable. Severity was classified as mild, moderate, severe, and fatal in 8.1% (95% CI 4.1-14.0%), 83.8% (95% CI 76.5-89.6%), 7.4% (95% CI 3.6-13.1%), and 0.7% (95% CI 0.0-4.0%), respectively, of the hospitalizations. The most common classifications of drug-related hospitalization were adverse drug reactions (35.3% [95% CI 27.3-43.9%]), improper drug selection (17.6% [95% CI 11.6-25.1%]), and noncompliance (16.2% [95% CI 10.4-23.5%]). No independent risk factors for drug-related hospitalization were identified with regression modeling. CONCLUSION: Approximately 25% of patients in our study were hospitalized for drug-related causes; over 70% of these causes were deemed preventable. Drug-related hospitalization is a significant problem that merits further research and intervention.

Documenting drug-related problems with personal digital assistants in a multisite health system.

PURPOSE: A scalable, multiuser, personal digital assistant (PDA)-based documentation tool for pharmacist collection of data on drug-related problems (DRPs) is described. SUMMARY: A PDA-based tool for documenting DRPs and pharmacist interventions was developed with database software. Data fields were based on the pharmaceutical care model. PDA synchronization stations were configured to transmit encrypted data from three hospital sites to a central server. Pharmacists in a multisite health care organization were trained to use the documentation tool. Data were analyzed with commercially available software. Users' opinions about the tool were solicited in a survey. Twenty-eight PDAs containing a 15-field database were issued to 39 pharmacists in 31 service areas. Data were successfully transmitted from all hospital sites over the existing corporate local area network. During a two-month period, 5084 DRPs were documented; 90% of them were resolved at the time of data entry. The most frequent types of DRPs were the need to add a drug (31%) and the ordering of an unnecessary drug (15%). Most pharmacists reported that the tool was easy to use, was well integrated with the workflow, and required less than 30 minutes per day for documenting DRPs. CONCLUSION: A PDA-based documentation tool was successfully used in a multisite health care organization to collect data on DRPs and document pharmacist interventions.

The impact of a pharmacist-managed dosage form conversion service on ciprofloxacin usage at a major Canadian teaching hospital: a pre- and post-intervention study.

BACKGROUND: Despite cost containment efforts, parenteral (IV) ciprofloxacin appears to be overutilized at Vancouver General Hospital. In November 2003, the Pharmacist-managed intravenous to oral (IV-PO) Dosage Form Conversion Service was implemented, enabling autonomous pharmacist-initiated dosage form conversion for ciprofloxacin. This study evaluates characteristics of ciprofloxacin use prior to and following implementation of this conversion service. METHODS: This was a single-centre, two-phase (pre/post), unblinded study. Phase I occurred between November 12, 2002 and November 11, 2003 (365 days), and Phase II between November 12, 2003 and March 11, 2004 (120 days). All patients receiving ciprofloxacin IV during these periods were reviewed. The primary endpoint was IV:PO ciprofloxacin use ratio. Secondary endpoints were total number of ciprofloxacin doses, proportion of inappropriate IV ciprofloxacin doses, cost of therapy between phases, and estimated cost avoidance with the intervention. RESULTS: Two hundred ciprofloxacin IV treatment courses were evaluated (100 per phase). The IV:PO ciprofloxacin use ratio was 3.03 (Phase I) vs. 3.48 (Phase II). Total number of doses and ratio of IV to total doses across phases were similar (p = 0.2830). IV-PO ciprofloxacin conversion occurred in 27/100 (27%) of IV courses in Phase I and 23/100 (23%) in Phase II. Proportion of inappropriate ciprofloxacin IV doses decreased between Phases I and II (244/521 (47%) vs. 201/554 (36%) (p = 0.0005), respectively). Furthermore, the proportion of pharmacist-preventable inappropriate ciprofloxacin IV doses was reduced between Phases I and II (114/244 (47%) vs. 65/201 (32%) (p = 0.0026). Proportional cost avoidance associated with total inappropriate IV use was 7,172 Can dollars/16,517 Can dollars (43%) (in Canadian dollars) in Phase I vs. 6,012 Can dollars/17,919 Can dollars (34%) in Phase II (p = 0.001). Similarly, proportional cost avoidance associated with pharmacist-preventable inappropriate IV doses was reduced from 3,367 Can dollars/16,517 Can dollars (20%) in Phase I to 1,975 Can dollars/17,919 Can dollars (11%) in Phase II (p = 0.001). CONCLUSION: While overall utilization of ciprofloxacin remained unchanged and the proportion of IV to total doses was stable during the study period, the proportion of inappropriate IV doses and its associated costs appear to have declined subsequent to implementation of a Pharmacist-managed IV-PO Dosage Form Conversion Service. Such a program may be a beneficial adjunct in facilitating appropriate and cost-effective usage of ciprofloxacin.

Pharmacist computer skills and needs assessment survey.

BACKGROUND: To use technology effectively for the advancement of patient care, pharmacists must possess a variety of computer skills. We recently introduced a novel applied informatics program in this Canadian hospital clinical service unit to enhance the informatics skills of our members. OBJECTIVE: This study was conducted to gain a better understanding of the baseline computer skills and needs of our hospital pharmacists immediately prior to the implementation of an applied informatics program. METHODS: In May 2001, an 84-question written survey was distributed by mail to 106 practicing hospital pharmacists in our multi-site, 1500-bed, acute-adult-tertiary care Canadian teaching hospital in Vancouver, British Columbia. RESULTS: Fifty-eight surveys (55% of total) were returned within the two-week study period. The survey responses reflected the opinions of licensed BSc and PharmD hospital pharmacists with a broad range of pharmacy practice experience. Most respondents had home access to personal computers, and regularly used computers in the work environment for drug distribution, information management, and communication purposes. Few respondents reported experience with handheld computers. Software use experience varied according to application. Although patient-care information software and e-mail were commonly used, experience with spreadsheet, statistical, and presentation software was negligible. The respondents were familiar with Internet search engines, and these were reported to be the most common method of seeking clinical information online. Although many respondents rated themselves as being generally computer literate and not particularly anxious about using computers, the majority believed they required more training to reach their desired level of computer literacy. Lack of familiarity with computer-related terms was prevalent. Self-reported basic computer skill was typically at a moderate level, and varied depending on the task. Specifically, respondents rated their ability to manipulate files, use software help features, and install software as low, but rated their ability to access and navigate the Internet as high. Respondents were generally aware of what online resources were available to them and Clinical Pharmacology was the most commonly employed reference. In terms of anticipated needs, most pharmacists believed they needed to upgrade their computer skills. Medical database and Internet searching skills were identified as those in greatest need of improvement. CONCLUSIONS: Most pharmacists believed they needed to upgrade their computer skills. Medical database and Internet searching skills were identified as those in greatest need of improvement for the purposes of improving practice effectiveness.

Point of care use of a personal digital assistant for patient consultation management: experience of an intravenous resource nurse team in a major Canadian teaching hospital.

The development and integration of a personal digital assistant (PDA)-based point-of-care database into an intravenous resource nurse (IVRN) consultation service for the purposes of consultation management and service characterization are described. The IVRN team provides a consultation service 7 days a week in this 1000-bed tertiary adult care teaching hospital. No simple, reliable method for documenting IVRN patient care activity and facilitating IVRN-initiated patient follow-up evaluation was available. Implementation of a PDA database with exportability of data to statistical analysis software was undertaken in July 2001. A Palm IIIXE PDA was purchased and a three-table, 13-field database was developed using HanDBase software. During the 7-month period of data collection, the IVRN team recorded 4868 consultations for 40 patient care areas. Full analysis of service characteristics was conducted using SPSS 10.0 software. Team members adopted the new technology with few problems, and the authors now can efficiently track and analyze the services provided by their IVRN team.