Abstract
Objective
It has been shown that pharmacists, as members of multidisciplinary patient care teams, can decrease the number of medicine errors. The objective of the present study was to analyse pharmaceutical interventions (PI) in emergency departments, to assess their clinical relevance, the cost-effectiveness and the potential economic benefits.
Methods
We designed a 5-month observational prospective study of PI in the emergency department (ED) of a 330-bed hospital in Spain. We analysed PI made by a pharmacist during a period of 3 hours a day from Monday to Friday in the ED, and classified detected medication errors according to their relevance and severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) severity index, and whether or not the drug involved was on the High-Alert Medications Institute for Safe Medication Practices (ISMP) list. We used statistical analysis to study the relationship between the relevance of PI and age, gender, the number of interventions per patient, and whether or not the drug was on the High-Alert Medications ISMP list. We also estimated the incremental cost incurred for each PI (cost-effectiveness) and the potential economic benefits (cost-benefit).
Results
A total of 529 interventions for 390 patients (median age 72.7±8.6 years, 53.1% women) were performed during the study period, representing 1.4 interventions per patient with an acceptance rate of 84.9%. Of all potential medication errors, 112 (21.2%) were related to drugs on the High-Alert Medications ISMP list, and using the NCC MERP severity index, we found that 150 (28.3%) of those errors could cause harm. We also found a relationship between patients on high-risk medications according to the ISMP and the relevance of PI. Finally, this study showed an incremental cost for each PI of 20.23 Euros and a cost-benefit ratio of 3.46 Euros per intervention.
Conclusion
These results show that clinical pharmacist can positively identify and reduce medication errors and costs associated, considering the number of interventions observed and those of clinical relevance. Based on these results, drug safety therapy in the ED can be improved by the revision of prescriptions by a clinical pharmacist.
Keywords: accident & emergency medicine, clinical pharmacy, drug administration (others), medical errors, adverse effects
Introduction
The emergency department (ED) represents the point of connection between different levels of care (primary, specialised, and socio-health care, among others). Due to the unplanned nature of patient attendance, the ED must provide initial treatment for a broad variety of illnesses and injuries, some of which may be life threatening and require immediate attention, which means that there is a high risk of medication errors and it represents an ideal setting in which the clinical pharmacist can resolve them.1 Patanwala et al showed that in the case of 59.4% of patients with access to the ED, one or more medication errors were made.2 Some of the factors that can precipitate errors in the ED are: the high number of professionals working there; their lack of patient knowledge; the high frequency of verbal medical orders; working conditions; and the lack of pharmaceutical validation of medical orders prior to the administration of treatment.3–5 In 2010, the EVADUR study was carried out in Spain. It estimated that 12% of patients treated in the ED had at least one incident or adverse drug event associated with medication, and that 70% of these were potentially preventable.6
Emergency medicine (EM) clinical pharmacists could significantly reduce the number of medication errors that occur in the ED, by forming part of the medical team.7–10 In recent years, the role of the EM clinical pharmacist has expanded, and pharmacists are moving from remote locations to working alongside other healthcare professionals to take an active role in bedside patient care. This active role includes the selection of appropriate medication, optimal dose, provision of drug information, research and teaching activities plus administrative tasks to optimise the efficiency of care delivered to ED patients.11
The benefits of EM clinical pharmacists have been recognised internationally.12–18 In 2008, a retrospective analysis was performed by pharmacists from Durham, in the United States, and they observed that including a pharmacist in the ED reduced medication errors by 66.6%.19 In 2012, a prospective multicentre study of four EDs found that EM pharmacists detected 364 medication errors in a total of 16 446 patients during the 1000 hours of cumulative time when present in the ED, the majority due to an incorrect dosage.20 Another prospective multicentre observational study found that EM pharmacists detected 7.8 medication errors per 100 patients,18 the majority of these being dosage errors, drug omission, and wrong frequency errors. Additional prospective studies in the United States and Canada have also demonstrated that EM pharmacists intercept and significantly decrease the number of medication errors.2 21
Moreover, in the literature this strategy is beneficial in terms of cost-effectiveness. A recent study demonstrated that the presence of a pharmacist in the ED was associated with approximately US$ 320 000 in cost avoidance per year.22 Other interventions have demonstrated improvements in terms of adverse drug reactions (ADR)23 and medication appropriateness measures.24
Despite the evidence obtained, in our environment the presence of a pharmacist in the ED is far less frequent in comparison with other countries, and the majority of experiences describe only a partial dedication of the pharmacist to the ED. For this reason it is unlikely that their intervention can benefit all patients equally. In contrast, the US healthcare model accepts the integration of the pharmacist into the healthcare team, and this constant visibility improves perceptions of the pharmacists’ work by other professionals and increases confidence levels.
The objective of the present study was to evaluate the type and frequency of interventions performed by the clinical pharmacist in the ED, to analyse their potential positive impact in terms of reducing preventable medication errors, and to provide a cost-effectiveness and a cost-benefit analysis of pharmaceutical interventions in the ED.
Methods
Subjects and methodology
A prospective observational study was performed from October 2018 to March 2019 in the ED of a 330-bed hospital in Spain that serves a population of 270 000 people and receives around 116 000 visits per year, with a hospitalisation rate of 9.78% for the acute hospitalisation unit, 0.15% for the social health unit, and 0.31% for home hospitalisation. The ED attends both adult and paediatric patients, treats approximately 300 cases daily and has 59 assistance points and nine observation beds organised into different areas.
Pharmaceutical interventions (PI) were performed by the clinical pharmacist while cooperating with the ED interdisciplinary team. The pharmacist reviewed medication prescriptions and, when indicated, suggested therapeutic interventions to improve the safety or efficacy of the treatment. The pharmacist was located in the ED, as recommended in the literature25 from Monday to Friday over a 3-hour period analysing the daily medical prescriptions and recorded PI in a database for further analysis.
This study was conducted according to the principles and rules laid down in the Declaration of Helsinki26 and its subsequent amendments, and approved by the hospital’s Ethics Committee.
Data collection
A database was designed to record the PI performed over the 5 consecutive months. The pharmacist actively reviewed the medication of the patients who were going to be hospitalised, prioritising them in the following order: those being treated with high-risk medications, patients over the age of 75, and polymedicated patients. Polypharmacy is defined as the use of multiple medications by a patient. There is no consensus in the literature about the exact minimum number of medicines to define such practice, but it usually varies from five to ten. We considered polymedicated patients if they were using five or more drugs.
In our hospital, medication is prescribed using a computerised system. However, some urgent prescriptions are verbal. For each PI, sociodemographic data (patient age and gender), the type of intervention, and the drugs involved were collected.
Type of pharmaceutical interventions
The clinical pharmacist made interventions regarding medication: indication, dose modifications, frequency modifications, pharmaceutical service provisions (eg, administration information, doubts regarding posology, information to the patient or about adverse events), withdrawals, route of administration modifications, duplicities, change to an alternative drug, pharmaceutical form modifications, and interactions. The pharmacist performed reconciliation of home medications using the electronic system, and also by means of a clinical interview with the patient or the family, in cases where it was considered necessary. Medication reconciliation involves creating the most accurate list possible of all the medications a patient is taking, comparing that list against the one given in the ED, then ensuring that those necessary are administered while patients are in the ED, that doses and frequencies are correct, and that there are no interactions. In addition, the clinical pharmacist answers any queries about pharmacotherapy from the whole of the ED team. All interventions were communicated to the doctor concerned, most often verbally, but also via the electronic system. Any nonconformities found in the prescriptions were consulted in the literature prior to intervention.
We classified the PI made by the pharmacist regarding its potential to cause medicine errors. We excluded interventions to adapt the medication presentation to the ones included in the pharmacotherapeutic guide. The severity of the medicine errors, if they were detected when performing PI, was also analysed using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) severity index.27 This classification comprises nine categories (table 1).
Table 1.
Adaptation of NCC MerP index for Categorising medication errors
| Category A | No error | Circumstances or events that have the capacity to cause error. |
| Category B | An error occurred but the error did not reach the patient. | |
| Category C | No harm | An error occurred that reached the patient but did not cause patient harm. |
| Category D | An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm. | |
| Category E | Harm | An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention. |
| Category F | An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalisation. | |
| Category G | An error occurred that may have contributed to or resulted in permanent patient harm. | |
| Category H | An error occurred that required intervention necessary to sustain life. | |
| Category I | Death | An error occurred that may have contributed to or resulted in the patient’s death. |
©2001 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved.
*Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.
NCC MERP, National Coordinating Council for Medication Error Reporting and Prevention.
We also determined the pharmacotherapeutic group to which the medication belonged according to the Anatomical Therapeutic Chemical (ATC) Classification28 for each intervention and whether or not the drug involved was classified as a high-alert medication by the ISMP (box 1).29
Box 1. Categories of high-alert medications by the ISMP.
Categories of medications
Adrenergic agonists, IV (eg, epinephrine, phenylephrine, norepinephrine)
Adrenergic antagonists, IV (eg, propranolol, metoprolol, labetalol)
Anaesthetic agents, general, inhaled, and IV (eg, propofol, ketamine)
Antiarrhythmics, IV (eg, lidocaine, amiodarone)
-
Antithrombotic agents, including:
Anticoagulants (eg, warfarin, low-molecular weight heparin, unfractionated heparin)
Direct oral anticoagulants and factor Xa inhibitors (eg, dabigatran, rivaroxaban, apixaban, edoxaban, fondaparinux)
Direct thrombin inhibitors (eg, argatroban, bivalirudin)
Glycoprotein IIb/IIIa inhibitors (eg, eptifibatide)
Thrombolytics (eg, alteplase, tenecteplase)
Cardioplegic solutions
Chemotherapeutic agents, parenteral and oral
Dextrose, hypertonic, 20% or more
Dialysis solutions, peritoneal and haemodialysis
Epidural and intrathecal medications
Inotropic medications, IV (eg, digoxin, milrinone)
Insulin, subcutaneous and IV
Liposomal forms of drugs (eg, liposomal amphotericin B)
Moderate sedation agents, IV (eg, dexmedetomidine, midazolam, lorazepam)
Moderate and minimal sedation agents, oral, for children (eg, midazolam, ketamine parenteral)
Opioids
Neuromuscular blocking agents (eg, succinylcholine, rocuronium, vecuronium)
Parenteral nutrition preparations
Sodium chloride for injection, hypertonic, greater than 0.9% concentration
Sterile water for injection, inhalation, and irrigation in containers of 100 mL or more
Sulfonylurea hypoglycemics, oral (eg, chlorpropamide, glimepiride, glyburide, glipizide, tolbutamide)
Specific medications
Epinephrine, subcutaneous
Epoprostenol, IV
Hypertonic sodium chloride
Magnesium sulfate injection
Methotrexate, oral, non-oncologic use
Sodium nitroprusside for injection
Opium tincture
Oxytocin, IV
Potassium chloride for injection concentrate
Potassium phosphates injection
Promethazine injection
Vasopressin, IV and intraosseous
© Institute for Safe Medication Practices: ISMP list of high-alert medications in acute care settings, 2018. Retrieved 6 January 2020 www.ismp.org/recommendations/high-alert-medications-acute-list
ISMP, Institute for Safe Medication Practices; IV, intravenous.
Cost-effectiveness analysis of pharmaceutical interventions and cost-benefit analysis
Cost-effective and cost-benefit analyses were performed from a hospital perspective to estimate the cost effectiveness of the emergency pharmacist interventions.
Cost elements considered in the study included, particularly, the use of human resources and all are expressed in Euros (2019). In relation to human resources, it was estimated that the study intervention required a mean of 3 hours of a pharmacist per day (drug revision of all patients included and discussion with the physician). Based on discussion with the other investigators, it was agreed that 3 hours was an appropriate duration to assign for pharmacist time spent implementing the intervention. Monetary valuation of time was possible using salary data available through the 2018 collective labour agreement (Catalan Health Service). The cost per hour for the pharmacist adjusted for insurance cost, pension payments, and general overheads was 32.44€.30 Costs associated with physician review/discussion of the pharmaceutical care plan were excluded since expert guidance dictated that it would take only approximately 5 minutes to approve or reject suggested interventions.
The cost-effectiveness was estimated as the incremental cost incurred for each additional pharmaceutical intervention made (incremental cost-effectiveness ratio).
To estimate the benefit, we computed for each intervention the possible direct sanitary benefits related to the pharmacist care in the ED. This cost was obtained from aggregated national and international data. Costs avoidance were estimated considering other published data in a similar setting.22 The return of investment of the study intervention has been calculated with the cost-benefit ratio, which was defined as saved or avoided cost divided by investment.
Data analysis and statistical methods
A descriptive analysis of the main characteristics of the study sample was performed. Categorical variables were described as percentages and quantitative parameters as mean±SD. We carried out a comparative study in the case of those patients with a relevant PI (classified as harm according to the NCC MERP index)27 and recorded age, gender, the number of interventions per patient, and whether or not a medication defined as high risk according to the ISMP was involved. For the study of the association of relevant interventions and categorical variables, the Chi-square or the Fisher tests were used, and for continuous variables, the Mann–Whitney U test or the t test were used.
Interrater reliability
The classification of the severity of errors when detected were performed independently by two pharmacists to calculate the interrater reliability. The similarity between the pharmacists’ evaluation was estimated based on the number of items evaluated in an identical manner. The agreement between the two evaluators was estimated by the Kappa coefficient of concordance (linear weighting) and for which the value close to 1 corresponds with the highest degree of concordance. A Kappa value of 0.8 to 1.0 indicated nearly perfect agreement among raters, and a value of 0.6 to 0.8 indicated substantial agreement.31 32
Results
Pharmaceutical Interventions
During the period of the study, there were 40 511 patient visits to the ED. The ED pharmacist reviewed the pharmacotherapy history of 2176 patients and made PI in 390 patients (17.9%) (median age 72.7±8.6 years, 53.1% women). A total of 529 PI were performed (excluding interventions to adapt the medication presentations to bring them in line with the hospital’s pharmacotherapeutic guide) representing 1.4 interventions per patient. The acceptance rate of all interventions was 84.9%. Table 2 summarises the type of PI performed.
Table 2.
Type of PI performed (N (%)) and cost avoidance per intervention (€)
| Type of PI | Specific type of PI | N (%) | Cost avoidance per intervention (€) |
| Initiations (or restarts) of medications | 173 (32.7%) | ||
| Dose modifications | Renal impairment | 82 (15.5%) | 35.03 |
| Insufficient dosage | 44 (8.3%) | ||
| Excessive dosage | 20 (3.7%) | 70.05 | |
| Service provisions | Facilitating access to medication | 35 (6.6%) | |
| Administration information | 31 (5.9%) | ||
| Doubts about posology | 16 (3.0%) | 138.41 | |
| Information to the patient | 11 (8.5%) | ||
| Adverse events | 9 (1.7%) | ||
| Indication | 8 (1.5%) | ||
| Frequency modifications | 30 (5.6%) | 70.05 | |
| Medication withdrawal | 26 (4.9%) | 78.26 | |
| Drug modifications | 10 (1.9%) | 4.06 | |
| Duplicities | 10 (1.9%) | 40.17 | |
| Interactions | 8 (1.5%) | 40.17 | |
| Modifications of the pharmaceutical form | 8 (1.5%) | 1.42 | |
| Modifications of route | 8 (1.5%) | 70.05 |
N, number of patients; PI, pharmaceutical interventions.
The drug groups in which the pharmacist made the highest number of interventions were: 115 (21.7%) drugs that act on the nervous system (ATC code N); 101 (19.1%) anti-infectives for systemic use (J); 92 (17.4%) the cardiovascular system (C); 65 (12.3%) the blood and blood formatting organs (B); and 60 (15.4%) the alimentary tract and metabolism (A).
Severity of prescribing errors
Of the 529 PI, 485 (91.7%) were considered for having a potential to cause a medication error from 371 patients. Using the NCC MERP severity index26 we found that the majority of prescribing errors were categorised as no harm (categories B, C, and D): 335 (69.1%) and harm (categories E, F, G and H): 150 (30.9%) and no prescribing error was a cause of death (table 3).
Table 3.
Category of prescribing errors and interventions in high-alert medications (N 485 interventions)
| Category of prescribing errors using the NCC MERP severity index, n % | |
| Category A | 0 (0.0%) |
| Category B | 75 (15.5%) |
| Category C | 139 (28.7%) |
| Category D | 121 (24.9%) |
| Category E | 57 (11.8%) |
| Category F | 63 (13.0%) |
| Category G | 21 (4.3%) |
| Category H | 9 (1.9%) |
| Category I | 0 (0%) |
| PI involving a drug included in ISMP high-alert medications list, n (%) (107 (20.2%)) | |
| Low-molecular weight heparins | 31 (5.8%) |
| Oral anticoagulants | 26 (4.9%) |
| Insulin | 22 (4.1%) |
| Oral hypoglycaemic agents | 17 (3.2%) |
| Opioids | 7 (1.3%) |
| Adrenergic antagonists | 5 (0.9%) |
| Antithrombotic agents | 5 (0.9%) |
| Oral cytostatic agents | 4 (0.7%) |
| Magnesium sulfate injection | 4 (0.7%) |
| Potassium chloride | 4 (0.7%) |
| Parenteral nutrition preparations | 1 (0.2%) |
| Moderate sedation agents | 1 (0.2%) |
ISMP, Institute for Safe Medication Practices; NCC MERP, The National Coordinating Council for Medication Error Reporting and Prevention; N, number; PI, pharmaceutical interventions.
The relationship between the relevance of PI (classified as harm) and age, gender, the number of interventions per patient, and whether or not an ISMP high-risk medication was involved is summarised in table 4. We did not find any correlation between patients with relevant PI and age, gender, or the number of interventions performed, although patients with high-risk medications as defined by the ISMP were more likely to have a relevant PI.
Table 4.
Characteristics of patients with PI with potential to cause medicine errors (N 371)
| Characteristics | Patients with relevant PI (categories E, F, G, H, and I) of the NCC MERP: n (%). n=150 (38.4%) | Patients without relevant PI (categories A, B, C, and D) of the NCC MERP: n (%). n=221 (40.4%) | P-value |
| Gender | |||
| Female | 78 (52.0%) | 124 (56.1%) | 0.207 |
| Age (mean age+SD) | 72.1±8.6 years | 73.1±10.0 years | 0.329 |
| Number of interventions | 0.118 | ||
| 1 (298, 76.4%) | 117 (78,0%) | 164 (74.2%) | |
| 2 (76, 19.5%) | 25 (16.7%) | 48 (21.7%) | |
| ≥3 (16, 4.1%) | 7 (5.3%) | 9 (4.1%) | |
| High-risk medications of ISMP involved | 68 | 39 | <0.001 |
ISMP, Institute for Safe Medication Practices; NCC MERP, The National Coordinating Council for Medication Error Reporting and Prevention; N, number; PI, pharmaceutical interventions.
High-alert medications
As described in table 3, we found 112 (21.2%) interventions that involved drugs considered high-alert medications according to the classification established by the ISMP.
Interrater reliability
Interrater reliability of clinical reliability between the two pharmacists was good, with a Kappa coefficient of 0.79 (95 % CI 0.52 to 0.92). Discussion was required to reach a consensus in 27/529 (4.5%) cases.
Cost-effectiveness analysis and cost-benefit analysis
The resulting incremental cost for the pharmacist spending 3 hours a day in the ED during the 5-month period resulted in 10.705€, representing an incremental cost-effectiveness ratio of 20.23€ per intervention. Table 2 summarises the type of PI performed and also the cost avoidance for each type.
The cost avoidance (mainly related to ADE avoided) was estimated to be a medium of 69.91€ per intervention and the cost–benefit ratio was 3.46:1.
Discussion
A new model of pharmacy practice that integrates clinical pharmacists into the emergency medicine multidisciplinary team has the potential to reduce medication errors and decrease the costs, thereby improving the outcomes associated with drug therapy.
This study evaluates PI and its contribution to the reduction of medication errors. It demonstrates that the contribution of clinical pharmacists in EDs is essential in order to ensure a safe and efficient treatment, since EDs are high-risk environments in terms of the probability of the occurrence of medication errors. Moreover, we found that patients involved in the study on high-risk medications according to the ISMP were more likely to have relevant PI. The clinical impact of PI has been previously assessed in the literature, although most studies describe the type of error detected in prescriptions, but not relevance with regard to the impact on the patient’s health or costs associated.
The ED offers extended opportunities for the clinical pharmacist’s participation. Pharmacists can help with the revision of medical orders, medication therapy management, and the detection of medication errors and adverse drug events. Therefore, the health-system pharmacist’s role has evolved over time, moving from traditional medication dispensing responsibilities to involvement in direct patient care. It has been shown that pharmacists, as members of patient care teams, can reduce the number of ADR.8
In this study, the ED pharmacist was only physically present in the ED for 3 hours a day but performed a high number of interventions (considering the exclusion of interventions to adapt the medication presentation to the ones included in the pharmacotherapeutic guide). The PI per patient of 1.4 was comparable with other studies.33 A descriptive study carried out by clinical pharmacists working in the ED reported a rate of 1.6 PI per patient27 and the acceptance rate of all interventions was also similar.34
The greatest number of interventions carried out in this study were restarts of medications and occurred during medication reconciliation, followed by dose modifications and a variety of service provisions by the clinical pharmacist. The prevalence of potential drug-related problems associated with medication reconciliation found in our study was similar to the findings reported by Kent et al35 and it is of high relevance that some studies have concluded that interventions related to medication reconciliation were of higher quality.36 37 In the present study, dose-related interventions represent 27.6% of the total number of PI performed. A similar study highlighted two main types of PI, drug information (16.8%) and dosage adjustment of the medication (16.4%).38
A key finding in this study is that in a high proportion of cases the pharmacist was able to identify a medication error during consultative activities, expressed as pharmacy service provisions. In contrast to inpatient medical units, there is little patient information available in the ED. Therefore, being present in the ED may provide the pharmacist with patient information that could influence drug therapy selection.
We also found a statistical association between high-alert medications as defined by ISMP and the frequency of significant errors, as this list defines the drugs that can cause more substantial adverse drug events in patients.
Finally, we calculated a cost-benefit ratio of 3.46:1. Previous studies have evaluated the economic impact of pharmacist interventions and have reported even higher estimates of savings related to record PI in EDs.34 39 40 McMullin et al performed a prospective, randomised trial to assess the cost impact of pharmacist-initiated interventions finding that the group randomised to receive pharmacist's interventions had drug costs that were 41% lower than those in the control group.39 Ling et al during a 4-month period analysed 646 interventions made by EM clinical pharmacists and estimated a cost avoidance of $192,923,34 and Aldridge et al during a 6-month period with 9568 interventions performed by EM clinical pharmacists showed cost savings of $845,592.40
Although there is a need for a large scientific study in the European setting to assess the cost savings associated with an ED pharmacist programme and the unification of these estimations, the literature certainly suggests that emergency pharmacist programmes have the potential to be cost effective.
There are some limitations to this work that could reduce the degree to which general conclusions may be drawn from these results. First, for ethical reasons there was no control group who received no intervention. Therefore, it was not possible to calculate the exact costs savings when comparing control and intervention groups. Second, not every patient in the ED was included because the clinical pharmacist was not present all of the time. Last, a single pharmacist was involved in the interventions. However, the Kappa score was used to test interrater reliability. For these reasons, we would recommend carrying out a more extensive prospective multicentre study to further demonstrate the impact of PI in EDs.
To conclude, given the number and severity of PI performed, the intervention of the clinical pharmacist produced direct benefits for both patients and for the interdisciplinary team in the ED. The ED is an ever-changing environment and the interventions performed by the clinical pharmacist can substantially improve drug therapy safety.
What this paper adds.
What is already known on this subject
Clinical pharmacy services in emergency medicine (EM) are well established in some parts of North America, but are far less common in Europe.
The hospital EM pharmacy practice model in Europe is changing, and pharmacists are moving from remote locations to working alongside other healthcare professionals to take an active role in bedside patient care.
What this study adds
In this prospective observational study, we demonstrate that the presence of clinical pharmacists in the ED detected and resolved certain potentially serious medication errors performing 1.4 interventions per patient, representing a cost-effective contribution.
ejhpharm-2019-002067supp001.pdf (59KB, pdf)
Acknowledgments
We thank Jane Perkins for reviewing the English of the Manuscript.
Footnotes
Contributors: MM: acquisition of data, study design, analysis and interpretation of data, and drafting the manuscript. SM and MD: analysis and interpretation of data. SM, IA, MR, MD, LC: revision for intellectual content and approval of the final version.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. https://orcid.org/0000-0001-7847-1580.
Ethics statements
Patient consent for publication
Not required.
Ethics approval
Ethics Committe of Mataró Hospital. Number/ID of the approval: 2020-03
References
- 1. Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"? Acad Emerg Med 2000;7:1239–43. 10.1111/j.1553-2712.2000.tb00469.x [DOI] [PubMed] [Google Scholar]
- 2. Patanwala AE, Warholak TL, Sanders AB, et al. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med 2010;55:522–6. 10.1016/j.annemergmed.2009.12.017 [DOI] [PubMed] [Google Scholar]
- 3. García V, Marquina I, Olabarri A, et al. Negative results associated with medication in the emergency department of a hospital. Farm Hosp 2008;32:157–62. 10.1016/S2173-5085(08)70037-6 [DOI] [PubMed] [Google Scholar]
- 4. Paparella S, ENA's ED Safety Workgroup . Avoid verbal orders. J Emerg Nurs 2004;30:157–9. 10.1016/j.jen.2004.01.014 [DOI] [PubMed] [Google Scholar]
- 5. Shah MN, Clarkson L, Lerner EB, et al. An emergency medical services program to promote the health of older adults. J Am Geriatr Soc 2006;54:956–62. 10.1111/j.1532-5415.2006.00736.x [DOI] [PubMed] [Google Scholar]
- 6. Baena Parejo MI, Juanes Borrego AM, Altimiras Ruiz J, et al. Medication list assessment in Spanish hospital emergency departments. J Emerg Med 2015;48:416–23. 10.1016/j.jemermed.2014.06.063 [DOI] [PubMed] [Google Scholar]
- 7. Kopp BJ, Mrsan M, Erstad BL, et al. Cost implications of and potential adverse events prevented by interventions of a critical care pharmacist. Am J Health Syst Pharm 2007;64:2483–7. 10.2146/ajhp060674 [DOI] [PubMed] [Google Scholar]
- 8. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267–70. 10.1001/jama.282.3.267 [DOI] [PubMed] [Google Scholar]
- 9. López Palomino J, Borrero Rubio JM, Martínez Díaz MC, et al. Pharmaceutical intervention for the optimisation of outpatient drug prescription in a hospital emergency department. Farm Hosp 2003;27:166–70. [PubMed] [Google Scholar]
- 10. Patanwala AE, Hays DP, Sanders AB, et al. Severity and probability of harm of medication errors intercepted by an emergency department pharmacist. Int J Pharm Pract 2011;19:358–62. 10.1111/j.2042-7174.2011.00122.x [DOI] [PubMed] [Google Scholar]
- 11. Thomas MC, Acquisto NM, Shirk MB, et al. A national survey of emergency pharmacy practice in the United States. Am J Health Syst Pharm 2016;73:386–94. 10.2146/ajhp150321 [DOI] [PubMed] [Google Scholar]
- 12. Wanbon R, Lyder C, Villeneuve E, et al. Clinical pharmacy services in Canadian emergency departments: a national survey. Can J Hosp Pharm 2015;68:191–201. 10.4212/cjhp.v68i3.1452 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. López Martin C, Álvaro E, Agüera C, et al. Is the emergency pharmacist role accepted by emergency department staff? Eur J Clin Pharmacol 2015;17:7. [Google Scholar]
- 14. Collignon U, Oborne CA, Kostrzewski A. Pharmacy services to UK emergency departments: a descriptive study. Pharm World Sci 2010;32:90–6. 10.1007/s11096-009-9347-3 [DOI] [PubMed] [Google Scholar]
- 15. Roulet L, Asseray N, Ballereau F. Establishing a pharmacy presence in the emergency department: opportunities and challenges in the French setting. Int J Clin Pharm 2014;36:471–5. 10.1007/s11096-014-9934-9 [DOI] [PubMed] [Google Scholar]
- 16. Abdelaziz H, Al Anany R, Elmalik A, et al. Impact of clinical pharmacy services in a short stay unit of a hospital emergency department in Qatar. Int J Clin Pharm 2016;38:776–9. 10.1007/s11096-016-0290-9 [DOI] [PubMed] [Google Scholar]
- 17. Proper JS, Wong A, Plath AE, et al. Impact of clinical pharmacists in the emergency department of an Australian public hospital: a before and after study. Emerg Med Australas 2015;27:232–8. 10.1111/1742-6723.12384 [DOI] [PubMed] [Google Scholar]
- 18. Rothschild JM, Churchill W, Erickson A, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med 2010;55:513–21. 10.1016/j.annemergmed.2009.10.012 [DOI] [PubMed] [Google Scholar]
- 19. Brown JN, Barnes CL, Beasley B, et al. Effect of pharmacists on medication errors in an emergency department. Am J Health Syst Pharm 2008;65:330–3. 10.2146/ajhp070391 [DOI] [PubMed] [Google Scholar]
- 20. Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Ann Emerg Med 2012;59:369–73. 10.1016/j.annemergmed.2011.11.013 [DOI] [PubMed] [Google Scholar]
- 21. Stasiak P, Afilalo M, Castelino T, et al. Detection and correction of prescription errors by an emergency department pharmacy service. CJEM 2014;16:193–206. 10.2310/8000.2013.130975 [DOI] [PubMed] [Google Scholar]
- 22. McAllister MW, Chestnutt JG. Improved outcomes and cost savings associated with pharmacist presence in the emergency department. Hosp Pharm 2017;52:433–7. 10.1177/0018578717717395 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. O'Sullivan D, O'Mahony D, O'Connor MN, et al. Prevention of adverse drug reactions in hospitalised older patients using a software-supported structured pharmacist intervention: a cluster randomised controlled trial. Drugs Aging 2016;33:63–73. 10.1007/s40266-015-0329-y [DOI] [PubMed] [Google Scholar]
- 24. O'Sullivan D, O'Mahony D, O'Connor MN, et al. The impact of a structured pharmacist intervention on the appropriateness of prescribing in older hospitalized patients. Drugs Aging 2014;31:471–81. 10.1007/s40266-014-0172-6 [DOI] [PubMed] [Google Scholar]
- 25. Miarons M. Pharmacy preceptorship in the emergency department. Emerg Med J 2017;34:694. 10.1136/emermed-2017-206856 [DOI] [PubMed] [Google Scholar]
- 26. World Medical Association . World Medical association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013;310:2191–4. 10.1001/jama.2013.281053 [DOI] [PubMed] [Google Scholar]
- 27. National Coordinating Council for Medication Error Reporting and Prevention . About medication errors. Available: http://www.nccmerp.org/ [Accessed 1 April 2019].
- 28. WHO . The anatomical therapeutic chemical classification system with defined daily doses (ATC/DDD). World Health organization. Available: http://www.who.int/classifications/atcddd/en/ [Accessed 01 Oct 2018].
- 29. Institute for Safe Medication Practices . ISMP's list of high-alert medications. Huntingdon Valley, PA: ISMP, 2012. http://www.ismp.org/Tools/highalertmedications.pdf [Google Scholar]
- 30. Second collective work agreement from hospitals of acute centers . Health and social care centers, primary care, health mental centers of the Catalan service of health. Available: https://www.acra.cat/2n-conveni-siscat_432638.pdf [Accessed 12 Dec 2019].
- 31. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med 2012;22:276–82. 10.11613/BM.2012.031 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74. 10.2307/2529310 [DOI] [PubMed] [Google Scholar]
- 33. Pérez León M, Alonso Ramos H, González Munguía S, et al. Evaluation of the quality of scientific evidence of pharmaceutical interventions in an emergency department. Farm Hosp 2014;38:123–9. [PubMed] [Google Scholar]
- 34. Ling JM, Mike LA, Rubin J, et al. Documentation of pharmacist interventions in the emergency department. Am J Health Syst Pharm 2005;62:1793–7. 10.2146/ajhp040588 [DOI] [PubMed] [Google Scholar]
- 35. Kent AJ, Harrington L, Skinner J. Medication reconciliation by a pharmacist in the emergency department: a pilot project. Can J Hosp Pharm 2009;62:238–42. 10.4212/cjhp.v62i3.794 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. World Health Organization . Communication during patient hand-overs: the nine patient safety solutions. World Health Organization, 2007. https://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf [Google Scholar]
- 37. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care 2006;15:122–6. 10.1136/qshc.2005.015347 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38. Lada P, Delgado G. Documentation of pharmacists' interventions in an emergency department and associated cost avoidance. Am J Health Syst Pharm 2007;64:63–8. 10.2146/ajhp050213 [DOI] [PubMed] [Google Scholar]
- 39. McMullin ST, Hennenfent JA, Ritchie DJ, et al. A prospective, randomized trial to assess the cost impact of pharmacist-initiated interventions. Arch Intern Med 1999;159:2306–9. 10.1001/archinte.159.19.2306 [DOI] [PubMed] [Google Scholar]
- 40. Aldridge VE, Park HK, Bounthavong M, et al. Implementing a comprehensive, 24-hour emergency department pharmacy program. Am J Health Syst Pharm 2009;66:1943–7. 10.2146/ajhp080660 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
ejhpharm-2019-002067supp001.pdf (59KB, pdf)
Data Availability Statement
All data relevant to the study are included in the article or uploaded as supplementary information. https://orcid.org/0000-0001-7847-1580.