Effect of critical care pharmacist's intervention on medication errors: A systematic review and meta-analysis of observational studies

doi:10.1016/j.jcrc.2015.06.018

Journal of Critical Care

Volume 30, Issue 5, October 2015, Pages 1101-1106

https://doi.org/10.1016/j.jcrc.2015.06.018 Get rights and content

Abstract

Pharmacists are integral members of the multidisciplinary team for critically ill patients. Multiple nonrandomized controlled studies have evaluated the outcomes of pharmacist interventions in the intensive care unit (ICU). This systematic review focuses on controlled clinical trials evaluating the effect of pharmacist intervention on medication errors (MEs) in ICU settings. Two independent reviewers searched Medline, Embase, and Cochrane databases. The inclusion criteria were nonrandomized controlled studies that evaluated the effect of pharmacist services vs no intervention on ME rates in ICU settings. Four studies were included in the meta-analysis. Results suggest that pharmacist intervention has no significant contribution to reducing general MEs, although pharmacist intervention may significantly reduce preventable adverse drug events and prescribing errors. This meta-analysis highlights the need for high-quality studies to examine the effect of the critical care pharmacist.

Section snippets

Background

Over the past 3 decades, the role of the critical care pharmacist has expanded in the intensive care unit (ICU) from traditional dispensing responsibilities to active members of multidisciplinary teams [1]. Pharmacists play an important daily role in ICU patient care by assisting physicians and other health care providers with pharmacotherapy decision making and monitoring, ultimately improving medication safety [2].

Medication errors (MEs) and adverse drug events (ADEs) occur at high rates in

Scope

A systematic review of published works following the methods specified in the Cochrane Handbook for Reviews on Interventions [16] and the Meta-analysis of Observational Studies in Epidemiology guidelines was conducted (Supplementary material 1) [17].

Searching

Studies were identified by electronically searching the MEDLINE and EMBASE databases and the Cochrane Database until August 2014. The following keywords were used in combination for the following medical subject headings and text words: “critical

Results

The electronic search identified 741 potentially relevant articles. After initial screening and full-text review, 8 articles were identified (Fig. 1), including 4 studies reporting monitored patient-days [6], [11], [12], [13] and 4 studies that did not [7], [8], [9], [10]. The 8 included publications contained 3 CBA studies [10], [11], [12] and 5 HCSs [6], [7], [8], [9], [13] (Table 1, Table 2).

Summary of main findings

The critical care arena provides good examples of pharmacist efforts in reducing MEs including ADEs [1]. In this systematic review of 8 ICU observational studies, we performed quantitative meta-analysis for 4 studies clearly reporting monitored patient-days (involving 535 ME events among 10585 patient-days) and qualitative analysis for the rest. The present quantitative meta-analysis did not show a significant association between pharmacist intervention and reduction in general MEs. However,

Conclusion

The present systematic review and meta-analysis did not demonstrate a significant beneficial effect of the intervention on general MEs. However, the pooled analysis supported the role of pharmacists in reducing preventable ADEs and prescribing errors. Future high-quality studies that examine the effect of a critical care pharmacist are warranted. Specifically, carefully designed and conducted observational studies that clearly define the study population and total number of medication orders,

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Cited by (48)

Effectiveness of nonpharmacological interventions to prevent adverse events in the intensive care unit: A review of systematic reviews
2023, Australian Critical Care
Citation Excerpt :
The number of patients in the eligible studies ranged from 45432 to 336933 and was not reported or unknown in nine (24.3%) reviews. The included reviews covered 11 different AEs: ventilator-associated pneumonia (VAP) (11 SRs),33–43 delirium (six SRs),29,44–48 physical function deterioration (five SRs),32,49–52 reintubation (four SRs),53–56 medication error (three SRs),31,57,58 artificial airway occlusion or hospital-acquired pneumonia (two SRs),59,60 healthcare-associated infections (HAIs; two SRs),61,62 pressure injury (two SRs),30,63 and tube displacement or tube occlusion (two SRs).27,28,54 The total number of interventions evaluated was 27, and VAP was the most frequent AE studied with seven NPIs.
Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence.
The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit.
A review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study’s quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events.
Thirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion.
Some nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.
Effect of participation of typical clinical pharmacists in patient medication in ICUs with different approaches: An investigation and case analysis
2023, Heliyon
To investigate and study the impact on patient recovery of pharmacists’ participation in the medication guidance and intervention of patients in intensive care units (ICUs).
We analyzed the drug use and typical cases of patients in the ICU of our hospital during clinical pharmacists' consultations or active monitoring from July 2019 to December 2020. This study included a total of 292 cases, which were distributed in the following eight areas: drug adjustment based on patients with hepatic and renal insufficiency,optimisation of treatment regimens based on drug interaction, identification and intervention based on adverse drug reactions, selection of blood purification methods based on drug intoxication, infusion access adjustment based on drug compatibility, drug adjustment based on genetic testing, antibiotic dose adjustment based on pharmacokinetics/pharmacodynamics (PK/PD) and others. The main observation indexes included consultation opinion efficiency rates and acceptance rates. The acceptance rate is calculated according to the acceptance of the clinical pharmacist's opinion by the competent doctor (fully accepted, partially accepted, not accepted). Calculate the efficiency rate according to the effect of the intervention measures. Definition of effectiveness: improvement of therapeutic effect of drugs; Avoid the occurrence of potential adverse drug reactions; Avoid the occurrence of potential drug compatibility reaction (for example, adjust the infusion sequence to avoid turbidity and sedimentation in the infusion pathway).
The results showed that clinical pharmacists participated in 292 cases of consultation or active monitoring of patients in the hospital's ICU based mainly on specific patient medications, drug interactions, adverse drug reactions, blood purification therapy, drug compatibility/venous infusion pathways, blood drug concentrations/drug–gene monitoring, drug PK/PD, etc. The doctor in charge acceptance rate of the consultation advice was 88.46% (completely accepted by 59.3%, partially accepted by 30.8%), and the effective rate of the consultation was 80.2%.
Based on different purposes of intervention, the acceptance rate and efficiency rate were different. The efficiency rate with complete acceptance was significantly higher than that with partial acceptance or non-acceptance. The intervention opinions proposed by a comprehensive team in which pharmacists participate are of great help to patients and can reduce adverse reactions and medication risks. The higher the acceptance rate of their opinions, the higher the effective rate.
An international perspective on the frequency, perception of utility, and quality of interprofessional rounds practices in intensive care units
2020, Journal of Critical Care
Citation Excerpt :
For example, Krishnan et al. reported a respiratory therapist-led weaning protocol was associated with similar outcomes compared to individualized case discussions, making rounds more efficient [20]. On the other hand, pharmacist-led interventions may decrease drug-related incidents [21], making rounds safer. Another interesting finding is the infrequent participation of physiotherapists on rounds, in spite of guidelines pushing the adoption of early mobility [22].
To describe international variation in interprofessional rounds in intensive care units (ICUs).
Survey of ICU clinicians on their practices and perceptions of rounds using societal mailing lists and social media.
Out of 2402 respondents, 1752 (72.8%) use rounds. Teams are mostly composed of intensivists, nurses and medical trainees. The majority of rounds (57.5%) last >2 h, and North Americans report the highest rates of rounds allowing family attendance (92.4%). Shorter rounds (1–2 h, OR 0.67, 0.52–0.86, p < 0.01; <1 h, OR 0.72, 0.53–0.97, p = 0.03), and strategies such as designating a person for writing (OR 0.73, 0.57–0.95, p = 0.01), and designating a person to assist other patients (OR 0.75, 0.57–0.98, p = 0.04) are associated with a lower perception of negative outcomes. Using daily goals during rounds is associated with a higher perception of positive outcomes (OR 1.85, 1.17–2.90, p < 0.01).
Three-quarters of respondents perform rounds, and models of rounds are heterogeneous, creating challenges for future studies on improving rounds. Respondents reporting better outcomes also experience shorter rounds, and adopt strategies such as discussion of daily goals, and designation individuals for writing or assisting other patients during rounds.
Nationwide current situation of hospital pharmacists in intensive care units
2019, Farmacia Hospitalaria
To describe the current situation of the hospital pharmacist in intensive care units and their activity in care, in teaching and in research.
Multicenter and prospective study through a survey disseminated by the Spanish Society of Hospital Pharmacy, which consisted of several sections: personal and hospital's data, hospital's characteristics, pharmacist's involvement in intensive care units and teaching.
A number of 58 completed surveys were obtained. The number of pharmacists involved in intensive care units was 1 in 77.6% of cases, assisting an average of 30.8 beds (5-70). Experience of pharmacists in the intensive care unit was 5 years on average (2 months-25 years). Visitor's pass assistance and shift changes were between “never” by 36.2% to “daily” by 22.4%. Out of respondents, 93.1% reported a part-time intensive care unit involvement. Regarding activities undertaken, between 40-60% of pharmacists manage narcotics, teaching at intensive care unit, conciliation and safety. Between 60-80%, pharmacists cover clinical nutrition, notarization, optimization of pharmacokinetics and antibiotics; and 84.5% perform pharmacotherapy follow-up. Out of the surveyed pharmacists, 77.6% have specialized medical training, rotating intensive care unit residents in 86% of cases.
Most of the surveyed hospitals have one part-time pharmacist in these units. In order to improve the quality of pharmaceutical care of critically ill patients, it would be necessary to extend the involvement in time and staff, regarding the current situation, and a greater number of hospitals should include pharmacists in hospital intensive care units.
Describir la situación actual del farmacéutico de hospital en las unidades de cuidados intensivos, su actividad asistencial, docente e investigadora.
Estudio multicéntrico, prospectivo mediante encuesta difundida por la Sociedad Española de Farmacia Hospitalaria, la cual constaba de varios apartados: datos personales y del hospital, características del hospital, implicación del farmacéutico en la unidad de cuidados intensivos y docencia.
Se obtuvieron 58 encuestas completadas. El número de farmacéuticos implicados en unidades de cuidados intensivos era 1 en el 77,6% de los casos, atendiendo una media de 30,8 camas (5-70). La experiencia en la unidad de cuidados intensivos del farmacéutico fue de 5 años de mediana (2 meses-25 años). La asistencia al pase de visita o cambios de guardia fue entre “nunca” en un 36,2% a “diariamente” en un 22,4%. El 93,1% de los encuestados reportaron dedicación a tiempo parcial en la unidad de cuidados intensivos. Respecto a actividades desarrolladas, entre el 40-60% gestiona estupefacientes, docencia en unidad de cuidados intensivos, conciliación y seguridad; entre el 60-80% abarca nutrición clínica, protocolización, optimización de antibióticos y farmacocinética, y un 84,5% realizan seguimiento farmacoterapéutico. Un 77,6% cuenta con formación sanitaria especializada, rotando los residentes en la unidad de cuidados intensivos en un 86% de los casos.
La mayor parte de los hospitales encuestados cuenta con un solo farmacéutico a tiempo parcial en estas unidades. Con objeto de mejorar la calidad de la atención farmacéutica del paciente crítico sería necesario ampliar la dedicación en tiempo y personal respecto a la situación actual y que más centros incluyan al farmacéutico en las unidades de cuidados intensivos hospitalarias.
Drug-drug interactions and pharmacists’ interventions among psychiatric patients in outpatient clinics of a teaching hospital in Saudi Arabia
2019, Saudi Pharmaceutical Journal
Citation Excerpt :
Although the above-indicated values that are undoubtedly below the acceptable standard, the role of pharmacists in avoiding medication errors has to be appreciated. A systematic review of pertinent publications revealed that pharmacists’ interventions could significantly decrease the occurrence of preventable adverse drug events and errors of prescribers (Wang et al., 2015). In another study that investigated the impact of pharmacists’ interventions on reducing the rate of DDIs among psychiatric patients in Germany, the rate of interactions was reduced by 78% when pharmacists intervened (Hahn et al., 2013).
Lack of recognition of labeled drug-drug interactions (DDIs) is a type of medication error of particular relevance to the treatment of psychiatric patients. Pharmacists are in a position to detect and address potential DDIs.
This study aimed to explore pharmacists’ role in the identification and management of DDIs among psychiatric patients in psychiatric outpatient clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia.
This study was a retrospective, cross-sectional medical chart review of patients visiting outpatient psychiatric clinics. It utilized medical records of patients who were taking any psychotropic medications and were prescribed at least one additional drug. The hospital Computerized Physician Order Entry system was used to identify DDIs and determine the pharmacists’ interventions. The Beers criteria were applied to detect inappropriate prescribing among older patients.
On average, the pharmacists intervened in 12 out of 213 (5.6%) cases of major or moderate DDIs. Older age, higher number of prescription medications, the severity of DDIs, and the utilization of lithium and anticoagulants were positively associated with the pharmacist undertaking an action.
Future studies should explore the prevalence rate of harmful DDIs among psychiatric patients on a large scale and examine the effectiveness of different pharmacy policies in the detection and management of DDIs.
Patient prioritization for pharmaceutical care in hospital: A systematic review of assessment tools
2019, Research in Social and Administrative Pharmacy
Citation Excerpt :
Clinical pharmacy services can be defined as the pharmacist led services that contribute actively to patient care in order to optimize drug therapy outcomes, these might include but are not limited to patient education, adjustment or monitoring of medication and reviews of medication charts.11,12 There is evidence to suggest that clinical pharmacy services improve patient safety12,13 and that clinical pharmacists are major contributors to the identification, rectification, and prevention of DRPs14 which can decrease the length of hospital stays.12 Ideally, each hospital pharmacy would have the resources to provide comprehensive clinical pharmacy services to every patient based on their needs.15
Clinical pharmacy services improve patient safety, outcomes, and care quality; however, UK clinical pharmacy services face limited resources, insufficient capacity, and patients who present with increasingly complex medication regimes and morbidities. These indicate a need for the prioritization of pharmacy services. Several prioritization tools have been developed; however, there has been no comprehensive review of such tools to date.
A systematic review was conducted to provide a structured overview and description of existing assessment tools with a focus on study quality, themes, tool validity, risk factors, and high-risk drug classes.
Systematic searches for English-language publications (from 1990 to September 2017) were conducted in Embase, Medline, Scopus, International Pharmaceutical Abstracts, and Web of Science. Papers in the inpatient setting and in which the tool users were pharmacists or pharmacy technicians were included. Data on each study (e.g. aim and design) and the structure of tools (e.g. risk factors) from each included study were extracted by 2 independent reviewers. A descriptive analysis was conducted to summarize these tools along with a thematic analysis of study findings. The quality of each paper was assessed using the Hawker method.
Nineteen studies involving 17 risk assessment tools were included. Most tools were developed in Europe (76.5%) and published in the last 5 years (82%). Most tools (88%) were designed to identify patients at greatest risk of adverse drug reactions, adverse drug events, or medication errors and to guide appropriate pharmaceutical care. Ten out of 17 tools (59%) were validated. None showed a measurable impact on prescription errors or adverse drug events. Keys themes identified from the studies were the positive impact of risk assessment tools on both patient care and provision of pharmacy services as well as the limitations of risk assessment tools.
Current assessment tools are heterogeneous in their content, targeting diverse patient groups and clinical settings making generalization difficult. However, an underlying theme of all studies was that tools appear to achieve their aim in directing pharmaceutical care to where it is needed most which might provide reassurance and incentive for greater adoption and development of tools across clinical pharmacy services. However, further research is required to measure objectively the impact of tools on patient outcomes and on workforce efficiency so that comparisons can be made between tools.

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Clinical PotpourriEffect of critical care pharmacist's intervention on medication errors: A systematic review and meta-analysis of observational studies

Abstract

Section snippets

Background

Scope

Searching

Results

Summary of main findings

Conclusion

Chest

J Crit Care

The impact of critical care pharmacists on enhancing patient outcomes

Intensive Care Med

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care

Crit Care Med

Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units

Crit Care Med

Clinical review: medication errors in critical care: review

Crit Care

On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study

Crit Care

Reducing prescribing errors in the paediatric intensive care unit: an experience from Egypt

Acta Paediatr

Educational strategy to reduce medication errors in a neonatal intensive care unit