Despite the important role of clinical pharmacy services, patients receiving drug therapy may still experience unintended harm or injury as a result of medication errors or from ADRs.
Medication errors and adverse drug reaction reporting
Despite the
important role of clinical pharmacy services, patients receiving drug therapy
may still experience unintended harm or injury as a result of medication errors
or from ADRs. Adverse events (from any cause) occur in around 10% of all
hospital admissions and medication errors account for one-quarter of all the
incidents that threaten patient safety. A study commis-sioned by the General
Medical Council identified a mean prescribing error rate of 8.9 per 100
medication orders.
Contributing to the
avoidance or resolution of adverse medication events is an important part of
any hospital pharmacist’s clinical duties. This requires a multisystem
approach, often incorporated into a hospital’s clinical risk management
strategy. Important lessons can be learned from analysis of medication-related
incidents and from near-misses (that is, those that do not develop sufficiently
to result in patient harm or are detected prior to patient harm). Chapter 12
considers these issues in fur-ther detail.
Even when the prescribed
and administered treatment is correct and no errors have occurred, a small
proportion of patients can still suffer from ADRs. Clinical pharmacists have an
important role to play in the detection and management of ADRs and, more
recently, directly reporting ADRs to the Committee on Safety of Medicines via
the Yellow Card scheme. Their involvement can help to increase the number of
ADR reports made, particu-larly those involving serious reaction. However, even
in hospitals with formal ADR schemes, gross underreporting of reactions still
remains a major problem.
Taking a medication
history from patients and prescribing on admission have traditionally been done
by junior doctors, but published work suggests that pharmacists are able to
take more accurate medication histories than medical staff. The crucial role of
clinical pharmacists in undertaking medicines reconciliation for patients on
admission to hospital has been endorsed by the National Institute for Health
and Clinical Excellence (NICE) and the National Patient Safety Agency. The
guidance recognised the increased risk of morbidity, mortality and economic
burden to health services caused by medication errors and noted that errors
occur most commonly on transfer between care settings, particularly at the time
of admission, with unintentional variances of up to 70%. It recommended that
pharmacists should be involved in medicines reconciliation as soon as possible
after hospital admission, noting this is a cost-effective interven-tion.
Reconciliation was defined as:
· collecting
information on medication history (prior to admission) using the most recent
and accurate sources of information to create a full and current list of
medicines
·
checking or verifying this list against the current
prescription chart in the hospital, ensuring any discrepancies are accounted
for and acted on appropriately
·
communicating through appropriate documentation any changes,
omissions or discrepancies.
With the increasing
use of information technology, access to patients’ sum-mary care record from
their general practitioner surgery offers a timely and accurate method for
obtaining this important information. The pharmacist can also question patients
on concordance with prescribed treatment, check their own medicines to ensure
suitability for reuse in hospital of POD and self-medication schemes and help
to identify whether or not an admission is due to prescribing errors or ADRs.
Pharmacy technicians are increasingly involved in supporting these roles. This
is discussed further later in the chapter.
A report
commissioned by NICE included economic evaluation modelling of several
different methods of medicines reconciliation and stated that: ‘in terms of
effectiveness, the pharmacist-led reconciliation intervention is pre-dicted to
prevent the most medication errors. This reduction is shown to reduce costs
associated with errors by £3002 [per 1000 prescription orders] compared to the
baseline scenario’.
For planned admissions
to hospital (for example, elective surgery), the medication history-taking role
can be moved to an earlier stage in the patient care process. Preadmission
clinics have traditionally been used to assess patients’ suitability for
surgery, but are also increasingly used to make other preparations for
admission. Clinical pharmacists can work alongside medical and nursing staff,
to help ensure that full and accurate details of medication are recorded and
that either patients bring their own medication with them on admission or that
medicines not routinely stocked by the hospital pharmacy can be ordered in
advance. For patients on clearly defined treatment pathways, early discharge
planning and advance preparation of discharge medication can also help to reduce
delayed dis-charges and this can also involve pharmacists prescribing the
discharge medication.
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