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11/7/2003

Preventable Adverse Events Decline When Pharmacist Joins General Medicine Rounds

Cheryl Thompson

Seventy-eight percent fewer preventable adverse drug events (ADEs) occurred among patients in a hospital’s general medicine unit when a pharmacist participated in weekday medical rounds, researchers recently reported in the Archives of Internal Medicine.1

The findings from the three-month study at Henry Ford Hospital in Detroit, Michigan, build on the landmark results reported in 1999 by Lucian L. Leape and colleagues,2 who studied a pharmacist’s participation on medical rounds in an intensive care unit (ICU) at Massachusetts General Hospital in Boston. Partial funding for the Boston study came from the ASHP Research and Education Foundation.

That earlier study, conducted in phases from 1993 through 1995, found that the rate of ADEs caused by prescribing errors decreased by 72% when a pharmacist made rounds with the patient care team, spent the rest of the morning in the ICU, and was on call for the unit’s staff the rest of the day.

At Henry Ford, two preventable ADEs occurred among the 86 patients whose medical rounds team included a pharmacist who also documented pharmacotherapy history and provided discharge counseling. Nine preventable ADEs arose among a comparable group of 79 general medicine patients who received standard care, which included computer-aided reviews for basic drug interactions and duplication of therapy.

The researchers extrapolated these results to cover a uniform period and calculated that pharmacists’ participation in general medicine rounds led to 5.7 preventable ADEs per 1000 hospital days—20.8 fewer events than on the unit with standard care.

Lead author Susan N. Kucukarslan, manager of the pharmacy department’s Center for Drug Use Analysis and Information, said Leape’s article propelled her to study how pharmacists on medical rounds at her hospital affected patient care.

As at many teaching institutions, Henry Ford has had to decrease services in response to cuts in Medicare payments instituted by the Balanced Budget Act of 1997, Kucukarslan said.

“One of the reasons why we did the study [in 2000] was just to assess the impact that the cuts in services could have on patient care,” she said.

The research at Massachusetts General focused on patient care in the ICU “because those are very critically ill patients,” Kucukarslan said. “But from what I’ve observed here in the general practice units, we also have very ill patients with multiple comorbidities and complex medication regimens. . . . I thought it would be interesting to see if we could find the same sort of impact on preventable adverse drug events that Leape did” but not in a unit devoted to the critically ill.

So Kucukarslan spearheaded a study that would as much as possible emulate the design of the study by Leape’s group without disrupting existing services at Henry Ford. The most important differences in design were the lack of baseline data and randomization to care unit in the Henry Ford study. Also, the Henry Ford study did not restrict participation in medical rounds to “an experienced senior pharmacist.” Pharmacists at the hospital, Kucukarslan said, rotate through the rounding teams.

Leape found that pharmacist participation in ICU medical rounds decreased the incidence of preventable ADEs to 3.5 per 1000 hospital days. The Henry Ford group attributed its slightly higher ADE incidence of 5.7, despite the lack of patients considered critically ill, to possible differences in how the two research teams interpreted the identical definitions of preventable ADEs and the potential for drug reactions in ICU patients to resemble deteriorations in health status.

By joining the general medicine team in its daily rounds, a pharmacist hears information about patients—such as their history, origin, problems with therapy compliance, and comments spoken by a physician during the physical examination—that might not be documented in detail in the medical record but would be useful to know, Kucukarslan said.

“If you’re going to have systems that work, you need to get the right people in the right places,” she said. “And that’s why I believe . . . that pharmacists belong on the rounding team, so they can be there at the right time to help make the right decisions for the patient.”

In addition to proving her point about pharmacists adding value to general medicine rounds, Kucukarslan said having the study findings in print was valuable for the pharmacy department’s communications with hospital administration.

“What we hope to show in this particular paper is that we do make a difference, even on the rounding team,” she said.

Kimberly K. Scarsi, a clinical pharmacist at Northwestern Memorial Hospital in Chicago, Illinois, said proof of pharmacists’ contributions to patient care has definitely made a difference for her pharmacy department.

A few months before the Henry Ford group started collecting data, Scarsi and colleagues3 investigated the ability of a pharmacist on daily general medicine rounds to decrease the frequency of medication errors and their duration once identified. The number of errors decreased by about half through the pharmacist’s daily participation in rounds, and those errors that did occur were caught earlier than in a comparable group for which a pharmacist participated only in rounds with the admitting team from the previous evening.

“Since the study, we’ve added an additional six rounding positions, and that was to an already existing five or six,” Scarsi said.

Several physicians, after hearing of the study’s results, asked if they, too, could have a pharmacist accompany them on daily medical rounds, she said. But the size of Northwestern Memorial—600 beds—makes it difficult to provide a pharmacist everywhere requested, she explained.

Scarsi said the study’s results were “used as part of a set of data that developed a patient safety team, which now includes three pharmacists, as well as three to four nurses, that are solely dedicated full-time to various patient safety aspects.” The pharmacists, she said, “are dedicated to the medication safety aspect of it.”

Kucukarslan said pharmacists’ participation in medical rounds at Henry Ford is not as regular as it was during the study. Whether a pharmacist participates in rounds nowadays depends on the patient care area involved and how he or she decides to allocate time on the unit, she said. In the general practice units, for example, each of the five pharmacists who practice there care for 30–40 patients apiece, up from the typical 15 patients in 1999.

“They don’t have the luxury of rounding as they did in the past,” Kucukarslan said, although pharmacists still regularly participate in medical rounds on the nephrology, infectious diseases, and cardiology units.

1. Kucukarslan SN, Peters M, Mlynarek M et al. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003; 163:2014-8.

2. Leape LL, Cullen DJ, Clapp M et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 282:267-70.

3. Scarsi KK, Fotis MA, Noskin GA. Pharmacist participation in medical rounds reduces medication errors. Am J Health-Syst Pharm. 2002; 59:2089-92.