One Year Evaluation of Pharmacist Medication Charting Service in a Principal Referral Women and Newborn Hospital

Abstract

Background: Accuracy of medication charts on admission to hospital has previously shown that inadvertent omission of therapy was the most common discrepancy, accounting for 40% to 60% of errors. Partnered Pharmacist Medication Charting (PPMC) has shown to reduce medicationrelated problems. Objective: The aim of this study was to evaluate the implementation of Pharmacist Medication Charting (PMC), a derivative of PPMC, in a maternity and gynecological hospital. The occurrence of medication omission identified by the pharmacists was assessed and the pharmacist interventions involving PMC analyzed. Methods: The pharmacist interventions documented from 1st July 2022 to 30th June, 2023 were evaluated using PowerBI for data and trends on the Medication-Related Problems (MRPs) identified, occurrence of PMC, common medications charted by the pharmacists and the pharmacist recommendation and action following the identification of MRPs. Results: A total of 4898 pharmacy interventions was documented in the 12-month period. Of the total interventions documented, 1321 (26.97%) were related to pharmacist medication charting. Of all the interventions related to PMC, 53.29% involved pharmacists charting medications for the continuation or initiation of over-the-counter medications, 13.32% involved pharmacist partnered charting of Prescription Only Medications and Controlled Medications with medical staff, and 33.3% were referred to a credentialled pharmacist for PMC service. With regards to action taken following interventions involving PMC, 1065 (80.62%) were resolved following PMC. Common medications charted by the pharmacists include: macrogol and docusate laxatives (288), pregnancy multivitamin containing iron, iodine and folate (169), colecalciferol (133), iron (127), asthma inhaler (99), paracetamol and ibuprofen (88), nicotine (38), calcium (29), folic acid (26), and pantoprazole (15). Conclusion: Our study demonstrated that hospital pharmacists contribute to the reduction of MRPs, and PMC enables pharmacist to address prescribing omission and conditions untreated in the hospital. This study also reflects skills enhancement in practice for clinical pharmacists and resulted in successful implementation of PMC.

Introduction

Medication-related problems (MRPs) such as adverse events, medication interactions and non-adherence are a major burden on the healthcare system. ¹ Pharmacists play an important role in reducing inappropriate prescribing and MRPs by recognizing prescribing errors, identifying incorrect doses, frequencies, allergies, duplication of therapy, and medication chart omissions.^2,3

Previous research on the accuracy of medication charts on admission to hospital had shown that inadvertent omission of therapy was the most common discrepancy, accounting for 40% to 60% of errors. ¹ Medication-related problems relating to medication omissions have also been reported in obstetrics patients.^{4 -7} A Norwegian study involving 2 maternity wards reported the need for additional medications to be 46.7% of the MRP identified. ⁴ In a study investigating the MRPs in a Women’s Health Unit in Australia, a total of 40% of MRPs were pertinent to incomplete medications charted on admission (28%), and additional medication required (12%). ⁵ A 10-year analysis of 14 085 pharmacist interventions in the study hospital showed that the identification of medicine omission constituted 1 of 3 of the most common medicine related problems requiring intervention. ⁶ In a more recent study involving 10 855 clinical interventions documented over 5 years, 24.7% of MRP identified by the pharmacists involved a condition untreated and prescribing omission of patient’s regular medications. ⁷

One strategy to reduce MRPs and prescribing errors is the implementation of Partnered Pharmacist Medication Charting (PPMC).^{8 -13} PPMC has recently been adopted across hospitals globally, and in some parts of Australia. International review reported the benefits of PPMC include increased access to healthcare services, better use of pharmacists’ skills and knowledge, and reduced physician workload.^{8 -10} In Australia, a pilot study in 2012 and a randomized controlled trial in 2016 was conducted at the Alfred Hospital in an emergency short-stay unit and general medical unit.^11,12 The model demonstrated feasibility and improved patient safety, reducing medication error rates from 78.7% to 3.7%. ¹² In 2016-17, a replication of the project was undertaken in general medical units across 7 health services. ² The outcomes of the evaluation include reduction in medication errors from 66% to 3.6%, and reduction in patient length of stay from 4.7 to 4.2 days. ² The estimated savings for each area with a PPMC pharmacist was $4725 to $9450 per day. ² A Tasmanian Hospital Emergency Department implemented a PPMC model involving pharmacist-documented best-possible medication history (BPMH) followed by a clinical discussion between the pharmacist and medical officer to co-develop a treatment plan and chart medications. ¹³ The medical officer then endorsed the medications charted before the nursing staff administered them. ¹³ The study showed that fewer patients in a PPMC group had at least 1 error (3.5%) than in the early BPMH (49.4%) and usual care groups (61.4%). ¹³ In Western Australia, PPMC was introduced at the acute medical unit, General Medicine and Nephrology at Fiona Stanley Hospital. ¹⁴ The medical officers are required to sign the order to validate the prescription. ¹⁴ This study showed PPMC reduced medication error rates per patient admission from 60.1% to 4.4%. ¹⁴

The Pharmacist Medication Charting (PMC) service was established in the study hospital in August 2020 as an adaptation alongside PPMC to further facilitate the reduction of medication errors and omissions. ¹⁵ Under the framework, credentialed pharmacists can chart medications for the continuation or initiation of over-the-counter medications during admission, and the partnered charting of Prescription Only (Schedule 4) Medications and Controlled (Schedule 8) Medications during admission with medical staff.^15,16 The prescribers are required to sign the order for Schedule 4 and Schedule 8 medications to validate the prescription due to state legislation. The PMC model was unique within Western Australia at the time of implementation.

Aim

The aim of this study was to evaluate the implementation of the PMC in tertiary maternity and gynecological hospital. Objectives were to:

1. Assess the occurrence of medication omission identified by the pharmacists

2. Analyze the pharmacist interventions involving PMC clinical service

3. Examine the common medications involved in the PMC

Method

Study Site

The 300-bed (including 100 neonatal cots) study hospital is the only tertiary maternity and gynecological hospital in Western Australia. More than 6000 births take place annually and it is the only major referral center in the state for high-risk pregnancies. The hospital also provides services to approximately 5000 women with gynecological conditions each year, including malignant and non-malignant urological problems, sexually transmitted diseases and reproductive disorders.

Implementation of Pharmacist Medication Charting (PMC)

Pharmacist Medication Charting (PMC) was implemented on the 13th of August 2020. The PMC hospital policy was endorsed by the Medicines and Therapeutics Committee, noted by Obstetrics and Gynaecology Management Committee, Postgraduate Medical Education, and the Clinical Governance Committee. ¹⁵ All pharmacists participating in pharmacist charting were required to be a registered pharmacist with 2 years of clinical pharmacy experience, completed a training with competency framework including an e-Learning package compiled by the pharmacy department (Figure 1) and supervised charting of medications using departmental assessment tool.

Figure 1.

Contents overview of self-directed learning education package.

In-patient ward areas with clinical pharmacy services were included in the implementation, areas without a clinical pharmacy service were excluded. The exclusion locations included the Emergency Center, Maternal Fetal Assessment Unit, Labor and Birth Suites, and Theaters Credentialed pharmacists chart medications for the continuation or initiation of medications that are not prescription medications, which include Schedule 2 Pharmacy Medicines or Schedule 3 Pharmacist Only Medicines and general medications that are not included in any of the Schedules to the Poison Standard during admission, which may involve varying the continuation of therapy order, in relation to appropriate dose, strength, frequency, or duration.^15,16 Credentialed pharmacists perform partnered charting of Schedule 4 Prescription Only Medicines and Schedule 8 Controlled Medicines during admission with medical staff, which requires the medical staff to sign the order to validate the prescription due to state legislation.^15,16 Appropriate medications are charted by the pharmacist in purple ink on the inpatient medication record which is utilized to administer medications. This method is a unique charting model within Western Australia.

Documentation of Pharmacist Clinical Interventions

The hospital’s pharmacists document clinical interventions daily when performing clinical pharmacy services.^6,7,17 Omission of medication is often identified during pharmacist ward round, obtaining patient’s Best Possible Medication History (BPMH) and performing medication reconciliation on admission and on discharge. The interventions are documented using a REDCap^® recording tool and the information is integrated to Microsoft Power BI^® in real-time for visual analytics and reporting.^17,18 The integration in data management and visualization of pharmacy clinical interventions has shown to be effective and feasible, allowing users to access reporting and analytics immediately with real time data. ¹⁷ A clinical intervention documentation matrix guide (including the MRP, Pharmacist Recommendations and Actions Taken classifications) used in the study hospital was created based on the Pharmaceutical Society of Australia (PSA) and the Society of Hospital Pharmacists of Australia (SHPA) models for intervention documentation. ⁷ Consistent with previous studies, a risk assessment of the potential impact of intervention was made using the SHPA model determined by the potential consequence (impact) and likelihood of occurrence happening again.^6,7 Additional codes were created to the matrix to document activities for PMC in the database under Pharmacist Recommendation as: R11—Refer to pharmacist for PIM/PPMC service, R21—pharmacist has partner charted regular medication (PPMC), R22—pharmacist has partner charted new medication (PPMC), R23—Pharmacist has continued regular OTC medication (PIM continuation), and R24—Pharmacist has initiated new OTC medication (PIM initiation). The pharmacist interventions documented from 1st July 2022 to 30th June 2023 were evaluated using PowerBI^® dashboard ¹⁷ for data and trends on the MRPs identified, occurrence of pharmacist interventions relating to PMC, common medications charted by the pharmacists and the pharmacist recommendation and action following the identification of MRPs.

Human Research Ethics approval was gained from the Women and Newborn Health Service Quality Improvement Committee (Approval number: GEKO 39703) at King Edward Memorial Hospital.

Results

A total of 4898 pharmacy interventions was documented in the 12-month period (Figure 2). The most common MRPs identified were prescribing omission of regular medications (n = 995, 20.31%), followed by condition untreated (n = 774, 15.80%). Medications involved in these MRPs of omission and untreated condition include: macrogol osmotic laxatives and docusate laxatives (207), pregnancy multivitamin (162), iron (155), colecalciferol (152), and salbutamol (85).

Figure 2.

Medication-related problem and medication involved.

Of the total interventions documented, 1321 (26.97%) were related to PMC. Pharmacist recommendations involving PMC, actions taken following pharmacist recommendations and medications involved are shown in Figure 3. Of all the interventions related to PMC, 53.29% involved pharmacists charting medications for the continuation or initiation unscheduled, Schedule 2 or Schedule 3 medications, 13.32% involved pharmacist partnered charting of Schedule 4 and Schedule 8 medications with medical staff, and 33.38% were referred to a credentialled pharmacist for PMC service. With regards to action taken following interventions involving PMC, 1065 (80.62%) were resolved following PMC. Common medications charted by the pharmacists include: macrogol osmotic laxatives and docusate laxatives (288), pregnancy multivitamin containing iron, iodine and folate (169), colecalciferol (133), iron (127), asthma inhaler (99), paracetamol and ibuprofen (88), nicotine (38), calcium (29), folic acid (26), and pantoprazole (15).

Figure 3.

Pharmacist recommendation involving pharmacist medication charting.

In the risk assessment of MRPs, 6 (0.45%) were rated as extreme risk, 340 (25.74%) as high risk, 538 (40.73%) as moderate risk, and 437 (33.08%) as low risk (Figure 4). The significance of risk assessment of MRPs involving PMC indicates the implication to the patient if the omission was not charted by the pharmacist. The obstetric wards, Ward 5 and Ward 3, documented the most interventions involving PMC (77.52%), followed by gynecology and gynecological oncology, Ward 6 (15.59%), Adult Special Care Unit (4.09%), and Mother and Baby Unit (0.23%) (Figure 4).

Figure 4.

Risk assessment of pharmacy interventions involving pharmacist medication charting.

Discussion

The MRPs and medications involved in the study is consistent with previous studies reported in obstetrics patients.^{4 -7} A total of 36.11% of MRPs identified involving omission of regular medication and medication required for patient’s condition not charted, which is comparable to 40% and 46.7% demonstrated in 2 studies involving maternal patients.^4,5 The study in Women’s Health Unit in South Australia highlighted omissions which can be reflected in the findings in this study, examples include: “patient’s asthma inhalers not charted for duration of stay” and “patient experienced significant blood loss in delivery and subsequently had a low hemoglobin level (<10 g/dL), which was currently not being treated (requires iron therapy).” ⁵ The study also reported common MRPs identified involved the use of medications in the management of identified colecalciferol deficiency, asthma, and depression. ⁵ This is consistent with this study, in which iron (8.76%), colecalciferol (8.59%), and salbutamol (4.8%) were amongst the common medications for MRPs involving prescribing omissions and condition untreated.

Pharmacists charting medications for the continuation or initiation unscheduled, Schedule 2 or Schedule 3 medications has been the common form of PMC service provided. While we were unable to compare the medications charted with other sites as this was not completed in previous studies,^{2,12 -14} the medications charted in this study reflected the medications involved in the MRPs reported in obstetrics patients.^{4 -7} Besides identifying the need for colecalciferol and iron in patients with deficiency,^19,20 pharmacists have also shown to play a vital role in identifying the need for analgesics in obstetrics patients following vaginal delivery and cesarean sections.^21,22 Meanwhile, the risk of women experiencing constipation during postpartum period is increased due to hemorrhoids, pain at the episiotomy site, effects of pregnancy hormones, iron supplement, damage to the anal sphincter or pelvic floor muscles during childbirth. ²³ Normal bowel movement is temporarily interrupted in the early postoperative period following cesarean delivery. ²⁴ The National Institute for Health and Care Excellence (NICE) (2021) guideline for cesarean birth advises that laxatives to be considered for women taking opioids, for the prevention of constipation. ²⁵ Identifying patients requiring and charting laxatives helps to manage and prevent postnatal constipation in obstetric patients.

Approximately one-fourth of pharmacist recommendations following identification of MRPs involved PMC. By utilizing the PMC service, pharmacists were able to resolve 21.74% of the total MRPS at the point of identification, resulting in rapid correction. Without the PMC service, these MRPs would await prescriber attendance to the ward for correction. This is reflected in the previous 5-year study with no PMC service for most of the study period (PMC introduced in the last 7 months of study period), pharmacists resolved the MRP identified by providing a service in 7.2% of the MRPs identified. ⁷ Pharmacist Medication Charting also provides a patient-centered medication management focus by enabling pharmacist charting medications needed for immediate administration at the point of identifying the MRPs, these included, simple analgesics and laxatives to relieve pain and constipation. The findings of this study could be used to provide site-specific, targeted education to encourage reflective learning and reduce medication omission.

A limitation of the study included the variability within individual pharmacist documentation of clinical interventions and the provision of PMC. Another limitation in the study is the absence of clinical pharmacy service in certain areas, resulting in the exclusion of admitting wards such as the Emergency Center. This limits the optimal opportunity of PPMC during patient admission which is demonstrated in previous studies.^{11 -13} A more comprehensive analysis of the PMC service to the study site would be achieved if clinical pharmacy services including PMC are provided to these areas.

Conclusion

Our study demonstrated that hospital pharmacists contribute to the identification of MRPs, and PMC enables the pharmacist to address prescribing omission and condition untreated in the hospital. This study also reflects a skill enhancement in practice for clinical pharmacists and resulted in a successful implementation of PMC in the hospital.