BETHESDA, MD 10 April 2013—A federally sponsored review of practices that improve patient safety encourages the adoption of clinical pharmacists' services for medication reconciliation and the prevention of adverse events.
The Agency for Healthcare Research and Quality (AHRQ)-commissioned report, Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices," names 10 practices that are "strongly encouraged" for immediate adoption and 12 that are "encouraged" for adoption. The practices that directly involve pharmacists fall into the latter category.
Lynn Eschenbacher, assistant director of clinical services at Raleigh, North Carolina-based WakeMed Health & Hospitals, said she was pleased that pharmacists' contributions were discussed in the report and would like to have seen even more emphasis on the profession's role in patient safety.
"As pharmacists, we don't always do the best job of touting and highlighting all the fabulous things we do each day," Eschenbacher said. "We contribute so greatly and are such an integral part of the team."
The report describes changes in the patient safety landscape since 2001, when the first "Making Health Care Safer" report was published.
The new report, like its predecessor, identifies evidence-based practices described in scientific literature that improve patient safety. Evidence about a practice's effectiveness and its readiness for implementation were considered during the review.
Steven P. Nelson, director of ASHP's Center on Pharmacy Practice Advancement, said the nod to clinical pharmacists' services is important, even though the recommendations did not make the top tier.
"When you look at the strongly encouraged practices, most of them are simple: Do this, and then you get an impact. And obviously where there's a more complex system, it's been more difficult to accumulate the body of literature to support the practice," he said.
Practices that are strongly encouraged for immediate adoption include implementing do-not-use lists for hazardous abbreviations, interventions to improve prophylaxis for venous thromboembolism, and proper hand hygiene.
The recommendation to use clinical pharmacists' services to prevent adverse drug events arose from an examination of data from 11 studies published during 2000–12.
The reviewers found that although many of the studies were "not methodologically strong," they generally supported the finding that pharmacists' involvement in intensive care units, especially when participating in bedside rounds, "improves medication management and/or reduces medication errors" and preventable adverse drug events.
According to the report, the data support, but less strongly, a similar role for pharmacists outside of intensive care units. The report urged that well-designed studies be conducted to better determine the magnitude of the benefit conferred by clinical pharmacists.
The report also stated that clinical pharmacists' interventions are more likely to be cost-effective if new pharmacists do not need to be added to a hospital's staff or if pharmacy technicians' roles are altered to allow pharmacists the time to interact directly with patients and physicians.
Nelson, who oversees ASHP's Pharmacy Practice Model Initiative (PPMI) activities, said the point about pharmacy technicians is an important focus of the initiative's work.
"PPMI would say that if you use technicians effectively and use technology effectively, you can extend the role of pharmacists without adding as many new pharmacists," he said.
The report's chapter on the use of clinical pharmacists to prevent adverse events was updated from the previous report. A chapter on medication reconciliation in the hospital appears for the first time in the new report and focuses on the role played by clinical pharmacists during transitions in care.
The new chapter notes that medication reconciliation is not always performed by pharmacists, and national accrediting organizations that mandate medication reconciliation do not require that the task be performed by pharmacists. But all of the evidence for the effectiveness of medication reconciliation involves pharmacists' interventions, according to the report.
The highest-rated medication reconciliation practices cited in the report included a thorough medication reconciliation at admission, electronically generated discharge prescriptions, discharge counseling by a pharmacist, communication of medication changes directly to the patient's community pharmacy, and postdischarge telephone follow-up by a pharmacist or other clinician.
The chapter concluded that pharmacist-supported medication reconciliation alone is unlikely to cut 30-day hospital readmission rates but may do so when combined with other interventions. One study cited in the report found that pharmacist-supported medication reconciliation decreased hospital use in the 12 months after discharge.
The reviewers noted that some problems found during reconciliation, such as inadvertent discontinuation of anticoagulants, cholesterol-lowering medications, osteoporosis medications, or gastric acid suppressants, "all may produce adverse clinical effects requiring hospital utilization in the long term, but not necessarily within 30 days of discharge."
The report states that it is important to address the "opportunity costs" of using clinical pharmacists, who are "in short supply at most hospitals," to perform medication reconciliation.
Specifically, the report states, "involving pharmacists in medication reconciliation, the method for which all the evidence of efficacy exists, risks taking these personnel away from other important activities related to patient safety."
Eschenbacher said that although medication reconciliation is "one of the most important things that we can do for our patients and for patient safety," it's not necessary for pharmacists to perform every step in the process.
But ideally, she said, the profession should be visionary and take ownership of the issue.
At WakeMed, she said, pharmacist-trained pharmacy technicians take medication histories in the emergency room.
"It's like any performance improvement," she said. "You have to continually check in to make sure that you're doing the right thing. And if anything gets off track, then you have to figure out what went off track" and fix it.
She said bringing pharmacy technicians into the medication history-taking process has allowed pharmacists to assume vital roles caring for patients who come into the emergency room after suffering a stroke, trauma, or cardiac arrest.
"That's three unique areas that if we were doing medication histories, we wouldn't be able to just leave the bedside and go running over to help the patients," she said.
The report was prepared for AHRQ by the RAND Southern California–Evidence-Based Practice Center and does not necessarily represent the official views of the agency, according to the document.