Clinical pharmacy services, pharmacist staffing, and drug costs in United States hospitals

Economic impact of clinical pharmacist interventions in a general tertiary hospital in Qatar

BACKGROUND

With an increasingly strained health system budgets, healthcare services need to continually demonstrate evidence of economic benefits. This study sought to evaluate the economic impact of interventions initiated by clinical pharmacists in an adult general tertiary hospital.

METHODS

A retrospective review of clinical pharmacist interventions was carried out throughout follow-up durations in March 2018, July/August 2018, and January 2019 in Hamad General Hospital (HGH) at Hamad Medical Corporation (HMC) in Qatar. The study included clinical pharmacy interventions data of patients admitted to the internal medicine, critical care, and emergency wards. Included interventions were documented by clinical pharmacists or clinical pharmacy specialists, and approved by physicians. Interventions by non-clinical pharmacists or with missing data were excluded. Adopting the perspective of HMC, we calculated the total economic benefit, which is the sum of the cost savings and the cost avoidance associated with the interventions. Cost savings was defined as the reduced cost of therapy associated with therapy changes minus the cost of intervention and cost avoidance was the cost avoided by eliminating the occurrence of adverse drug events (ADEs). Sensitivity analyses were performed to assess the robustness of results against uncertainties.

RESULTS

A total of 852 interventions, based on 340 patients, were included. The analysis projected an annual total benefit of QAR 2,267,036 (USD 621,106) based on a negative cost-savings of QAR-175,139 (USD-47,983) and a positive cost avoidance of QAR741,898 (USD203,260) over the 3-month follow-up period. The uncertainty analysis demonstrated the robustness of outcomes, including a 100% probability of positive economic benefit.

CONCLUSIONS

The clinical pharmacist intervention was associated with an increased cost of resource use, which was overtaken by the cost avoidance generated. The pharmacy intervention, therefore, is an overall economically beneficial practice in HGH, reducing ADEs with considerable consequential positive economic savings.

Relationship between the number of hospital pharmacists and hospital pharmaceutical expenditure: a macro-level panel data model of fixed effects with individual and time

BACKGROUND

The rapid increase in pharmaceutical expenditure (PE) has been a main problem of global healthcare reform for decades. Previous studies demonstrated that pharmacists play an indispensable role in controlling PE, but macro-research evidence is scarce. Exploring the role of pharmacists from a macro-perspective is essential for pharmacy source allocation with an advantage of extensive applicability over regions. This study aimed to explore the relationship between the number of hospital pharmacists and hospital PE and to provide a macro-perspective evidence to curb the increasing PE and decline unnecessary medications.

METHODS

Data were extracted from China Health Statistics Yearbook from 2011 to 2018. A panel dataset with 31 provinces from 2010 to 2017 was constructed. Amongst them, 'Number of hospital pharmacists per 1 million of population' (HLPT) was selected as an independent variable, 'Per visit of hospital outpatient pharmaceutical expenditure' (OTPE) and 'Per capita of hospital inpatient pharmaceutical expenditure' (ITPE) were selected as dependent variables, and 'Number of hospital physicians per 1 million of population' (HLPN) and 'Drug price index' (DPI) were applied as control variables. Fixed-effect panel data analysis was performed to evaluate the relationship between the number of hospital pharmacists and hospital PE.

RESULTS

HLPT had a significant and negative relationships with OTPE (β₁ = - 0.0893, p = 0.0132) and ITPE (β₁ = - 4.924, p < 0.001). Considering the control variables, the significant and negative relationships with HLPT and OTPE remained unchanged (β₁ = - 0.141, p < 0.001; β₁ = - 4.771, p < 0.001, respectively), indicating that an increase in hospital pharmacist per 1 million of population led to a decrease of ¥474 million ($67.4 million) OTPE and ¥902 million ($128 million) ITPE in 2017. Overall, in 2017, an increase of 1 hospital pharmacist led to a decrease of approximately ¥1 million ($142 thousands) hospital PE nationwide.

CONCLUSION

This study confirmed the negative relationship between hospital pharmacists and hospital PE, indicating that hospital pharmacists might play a significant role in controlling PE. Pharmacists were encouraged to participate in more drug-therapy-related activities, such as medication reconciliation.

Contracted Drug Information Services: Comparison of Utilization with Local Hospital Pharmacists

In recent years, pharmacy management companies have begun to contract with drug information centers to provide centralized services for participating institutions. This study compared the utilization of drug information services by contracting pharmacists with local hospital pharmacists. All drug information questions from contract pharmacists during 1993 to 1995 were compared with those from local hospital pharmacists utilizing the drug information center. A total of 997 and 1,835 questions were received from contract and local pharmacists, respectively, with the types of information requests being similar for pharmacotherapeutic questions and differing (p < 0.001) for requests for product information and a reference or monograph. Complex responses were required more frequently (p < 0.05) for contracting pharmacists (13%) than for local pharmacists (10%) and took longer to complete. Contract pharmacists more frequently received a response by fax or mail than local pharmacists. Provision of drug information services for a contracting group of pharmacists may present different demands for the types of drug information responses than those from local hospital pharmacists.

Problems, interventions, and their outcomes during the routine work of hospital pharmacists in Bosnia and Herzegovina

Background In the last 30 years, activities of hospital pharmacists have gone through significant changes. Pharmacists are increasingly involved in patient care. Objectives To explore drug-related and logistic problems, interventions, and their outcomes during routine everyday work of hospital pharmacists. Setting Institute for physical medicine and rehabilitation, Banja Luka, Bosnia and Herzegovina. Methods In the period of January 2013-October 2015 a prospective observational study was performed. Medical doctors, nurses, therapists, and patients addressed pharmacists, face-to-face or by telephone, with drug-related problems (DRPs) and/or logistic issues. Main outcome measure Type of DRP or logistic issue, intervention, outcome, initiator and time spent for solving the problem were documented for each consultation. Results Out of 1515 interventions, 48.8% were aimed at solving DRPs. The most common DRPs were the recommendation of a drug or dose and need for additional information about drugs. Drug price and supply were the most prevalent logistic issues. DRPs were more frequently initiated by medical doctors and required more time to solve the problem compared to logistic issues (Mann-Whitney U test, p ≤ 0.001, respectively). The acceptance rate of interventions to solve DRPs (83.7%) was lower compared to logistic issues (95.2%; p ≤ 0.001). Conclusions Hospital pharmacists were faced with an approximately equal number of DRPs and logistic issues during their routine everyday work. The overall acceptance rate of pharmacists' interventions was high, and the results of our study indicate that there is a need for more involvement of hospital pharmacists in Bosnia and Herzegovina in clinical activities. Impact on practice.

The role of the pharmacist in the intensive care unit

As our health care system has begun to place more emphasis on the provision of direct patient care activities and adherence to clinical guidelines, the profession of pharmacy has adapted to provide services, and practitioners, that meet these demands. Two areas of the hospital where pharmacy services are in high demand are the intensive care units and the emergency department; 2 dynamic environments that place a premium on providing appropriate medication therapy in a timely manner. The pharmacists working in these areas can provide a wide range of services that can expedite the arrival of medications and improve adherence to clinical practice guidelines and patient outcomes. In addition to processing medication orders and coordinating the arrival of medications, these pharmacists can also assist with therapeutic drug monitoring (vancomycin, aminoglycosides, and warfarin), medication dosing, renal dosing, and responding to medical emergencies (stroke, code blue, therapeutic hypothermia, rapid sequence intubation, etc). Critical care pharmacists also play an active role on hospital committees, in the education of staff, students, and residents (pharmacy and medical), and in the implementation of new institutional policies and protocols.

Analysis of clinical pharmacist interventions in a tertiary teaching hospital in Brazil

Objective:

To analyze the clinical pharmacist interventions performed during the review of prescription orders of the Adult Intensive Care, Cardiologic Intensive Care, and Clinical Cardiology Units of a large tertiary teaching hospital in Brazil.

Methods:

The analysis took place daily with the following parameters: dose, rate of administration, presentation and/or dosage form, presence of inappropriate/unnecessary drugs, necessity of additional medication, more proper alternative therapies, presence of relevant drug interactions, inconsistencies in prescription orders, physical-chemical incompatibilities/solution stability. From this evaluation, the drug therapy problems were classified, as well as the resulting clinical interventions.

Results:

During the study, a total of 6,438 drug orders were assessed and 933 interventions were performed. The most prevalent drug therapy problems involved ranitidine (28.44%), enoxaparin (13.76%), and meropenem (8.26%). The acceptability of the interventions was 76.32%. The most common problem found was related to dose, representing 46.73% of the total.

Conclusion:

Our study showed that up to 14.6% of the prescriptions reviewed had some drug therapy problem and the pharmacist interventions have promoted positive changes in seven to ten of these prescriptions.

Clinical pharmacist impact on care, length of stay, and cost in pediatric cystic fibrosis (CF) patients

BACKGROUND

Cystic fibrosis (CF) patients are often treated with aminoglycoside (AG) antibiotics during infective pulmonary exacerbations. Achieving pharmacokinetic and pharmacodynamic (PK/PD) targets to improve outcomes and counteract resistance is paramount.

PURPOSE

The primary objective was to compare the number of pediatric CF patients achieving AG PK/PD targets when a clinical pharmacist (CP) managed therapeutic drug monitoring (TDM) compared with usual care (UC).

METHODS

A retrospective cohort study was conducted on the records of 40 CF patients that received AGs and ≥2 serum samples between 1/2007 and 5/2009. Chi-square and Student's t-test were used to analyze nominal and continuous variables, respectively.

RESULTS

Twenty-nine patients with 52 courses of AGs were included the CP group, and 22 patients with 42 courses were included the UC group. Ninety-eight percent of patients in the CP group reached AG PK/PD targets compared with 71% in the UC group, P < 0.001. Patients in the CP group reached the AG PK/PD target in a mean of 1.9 ± 0.8 days compared with 4.8 ± 3.4 days in the UC group, P < 0.0001. The average LOS in the CP group was 9 ± 5 days compared with 12 ± 7.5 days in the UC group, P = 0.033. The mean number of levels per patient was 2.7 in the CP group compared with 5.2 (range of 2-20) in the UC group, P < 0.001. Resource utilization associated with drug levels, dosing adjustments and LOS were $26,549, $14,069, and $1,680,000 in the CP group as compared with $40,683, $27,812, and $1,940,000, respectively, in the UC group.

CONCLUSION

CP managed TDM resulted in a significantly higher percentage of pediatric CF patients achieving AG PK/PD targets 3 days sooner with an average LOS that was 3 days shorter. CP managed TDM resulted in significantly fewer dosage adjustments, drug levels, and cost associated with serum sampling, drug wastage, and LOS.

Use of a general level framework to facilitate performance improvement in hospital pharmacists in Singapore

OBJECTIVE

To evaluate the acceptability and validity of an adapted version of the General Level Framework (GLF) as a tool to facilitate and evaluate performance development in general pharmacist practitioners (those with less than 3 years of experience) in a Singapore hospital.

METHOD

Observational evaluations during daily clinical activities were prospectively recorded for 35 pharmacists using the GLF at 2 time points over an average of 9 months. Feedback was provided to the pharmacists and then individualized learning plans were formulated.

RESULTS

Pharmacists' mean competency cluster scores improved in all 3 clusters, and significant improvement was seen in all but 8 of the 63 behavioral descriptors (p ≤ 0.05). Nonsignificant improvements were attributed to the highest level of performance having been attained upon initial evaluation. Feedback indicated that the GLF process was a positive experience, prompting reflection on practice and culminating in needs-based learning and ultimately improved patient care.

CONCLUSIONS

The General Level Framework was an acceptable tool for the facilitation and evaluation of performance development in general pharmacist practitioners in a Singapore hospital.

Implementation and progress of clinical pharmacy in the rational medication use in a large tertiary hospital

ABSTRACT Objective: To show developments and contributions of a clinical pharmacy service in safety and rational use of medications in a large tertiary hospital. Methods: Clinical pharmacists were responsible for all issues using medications at the hospital. In the beginning this professional was responsible for analyzing medical prescriptions, horizontal visits, and to set up protocols. Afterwards, other activities were designated such as monitoring for drug safety, participating in committees and managed routines. If problems were found, the pharmacist reported them for the physician and, after intervention, registered the management on the prescription or in medical records. The data collected were presented as reports to medical managers. Results: There was an increase of clinical pharmacist employed in 2010, reaching 22 individuals. Interventions types also increased from 1,706 in 2003 to 30,727 in 2010. The adhesion observed in medical team in 2003 was 93.4%, reaching 99.5% of adhesion in 2010. Conclusion: Clinical pharmacy service shows a positive impact when it comes to performed interventions. It also promotes a rational use of medicines and increase patient safety. Pharmacists were included and their importance confirmed within the multidisciplinary team and in the process of patient safety.

Pharmacists' perceptions of the impact of care they provide

Limitations on health care resources necessitate careful focus on activities that lead to the greatest improvement in patient outcomes. Despite the importance of aligning pharmacists’ time with activities deriving the most impact, there is a paucity of literature on the correlations between pharmacists’ perceptions of the impact of their activities, how they actually spend their time and how these align with published evidence of impacts on patient outcomes.

[Security in medication use process: state-of-play report in 21 hospital pharmacies in Aquitaine (France)]

BACKGROUND

Failures may occur in each part of the medication use process. This study aimed to evaluate the barriers existing in hospital pharmacies in order to prevent medication errors and to help institutions to make improvement actions.

METHODS

Within the framework of the SECURIMED project, risk assessment visit (interviews, observations, analysis of adverse event scenario by professionals...) were conducted in volunteer hospital pharmacies. A restitution meeting, after visit in each pharmacy permitted exchanges between visitors and professionals on barriers and weaknesses and then on solutions to reduce identified risks.

RESULTS

Twenty-one hospital pharmacies participated. Despite presence of safeguards in some pharmacies, many weaknesses were retrieved (multiplicity of process, lack of resources...) and clinical pharmacy was not enough developed.

CONCLUSION

This project has led to an overview of the situation in Aquitaine, and created a regional dynamic to improve the medication system safety.

The Rate and Costs Attributable to Intravenous Patient-Controlled Analgesia Errors

Purpose

To estimate the rates and costs of intravenous patient-controlled analgesia (IV PCA) errors from the hospital or integrated health system perspective.

Methods

This study used a cost-accounting methodology to estimate the costs attributable to IV PCA errors in the United States. Data for the study were obtained from the MEDMARX and Manufacturer and User Facility Device Experience (MAUDE) datasets, published literature, and expert opinions. MEDMARX is a voluntary, anonymous, medication-error-reporting database owned and operated by the United States Pharmacopeia. MAUDE is a mandatory, device-error-reporting database maintained by the US Food and Drug Administration. Levels of care rendered as a result of the IV PCA errors were estimated by applying clinical assumptions (validated by an expert advisory panel) to each of the 7 error consequences considered in this analysis. Variable and opportunity costs (2006 values) were considered, including medication, laboratory, lost revenue, and labor. The corresponding costs were applied to the error consequences to derive the estimated mean cost for each error cause. The numbers of errors documented in each dataset and the published literature were used to extrapolate the rate of IV PCA errors annually.

Results

The average cost per error event was $733 in the MEDMARX dataset and $552 in the MAUDE dataset. Harmful IV PCA errors were 120 to 250 times more costly than nonharmful errors. The annual error rates were estimated as 407 IV PCA-related errors and 17 device-related errors per 10,000 people within the United States. Conclusion: Analysis of 2 datasets, MEDMARX and MAUDE, revealed that IV PCA medication- and device-related errors are costly to hospitals and integrated health systems and represent a significant burden on the US health system. This study provided a novel approach to estimating the associated costs of undesired IV PCA-related events. Additional research is needed to validate the methodology (as applied to this area) and results.

Clinical and economic outcomes of pharmacist-managed antimicrobial prophylaxis in surgical patients

PURPOSE

The associations between pharmacist-managed antimicrobial prophylaxis in Medicare patients who had surgical codes indicative of the need for antimicrobial prophylaxis and the major health care outcomes of death rate, length of stay, Medicare charges, drug charges, laboratory charges, and complications were explored.

METHODS

Pharmacist management of antimicrobial prophylaxis was evaluated in 242,704 Medicare patients from 860 [corrected] hospitals.

RESULTS

Patients who developed a surgical-site infection (SSI) had a 331.58% increased risk of death compared with patients who did not develop an SSI (chi2 = 743.471; df = 1; p < 0.0001; odds ratio [OR], 3.62; 95% confidence interval [CI], 3.28-3.99). Patients who developed an SSI also had a 167.16% increase in length of stay, 136.49% increase in total Medicare charges, 245.96% increase in drug charges, and 187.14% increase in laboratory charges. In hospitals without pharmacist-managed antimicrobial prophylaxis, death rates were 52.06% higher (105 excess deaths; p < 0.0001; OR, 1.54; 95% CI, 1.46-1.63), length of stay was 10.21% higher (167,941 excess patient days, p < 0.0001), mean +/- S.D. total Medicare charges were 3.10% higher ($980 +/- $1,109 more per patient) ($182,113,400 excess total Medicare charges, p < 0.0001), mean +/- S.D. drug charges were 7.24% higher ($292 +/- $492 more per patient) ($54,262,360 excess drug charges, p = 0.005), mean +/- S.D. laboratory charges were 2.72% higher ($74 +/- $151 more per patient) ($13,751,420 excess laboratory charges, p = 0.0056), and SSIs were 34.30% higher (chi2 = 95.48; df = 1; p < 0.0001; OR, 1.52; 95% CI, 1.40-1.66).

CONCLUSION

The provision of pharmacist-managed antimicrobial prophylaxis was associated with significant improvement in clinical and economic outcomes for Medicare patients with a surgical code indicative of the need for antimicrobial prophylaxis.

Polymedicine and aging. Enhancing older adult care through advanced practitioners. GNPs and elder care pharmacists can help provide optimal pharmaceutical care

Approximately one third of all drugs prescribed in the United States are considered unnecessary. Polymedicine, polypharmacy, medication nonadherence, and adverse drug reactions are among the top five causes of acute care hospitalizations in persons older than age 65. These conditions significantly increase health care costs and will continue to do so at an alarming rate as America's population ages. Although medications are an important factor in improving and maintaining the quality of life for older adults, polymedicine places them at risk of an acute care admission for medication-related problems and other complications. This article reviews polymedicine and common medication errors, explores the depth of the problem in aging clients, and advocates for the use of gerontological nurse practitioners as advanced practice nurses and specialty-trained elder care pharmacists as active members of the interdisciplinary health care team.

Clinical Pharmacy Services, Pharmacy Staffing, and Hospital Mortality Rates

OBJECTIVE

To determine if hospital-based clinical pharmacy services and pharmacy staffing continue to be associated with mortality rates.

METHODS

A database was constructed from 1998 MedPAR, American Hospital Association's Annual Survey of Hospitals, and National Clinical Pharmacy Services databases, consisting of data from 2,836,991 patients in 885 hospitals. Data from hospitals that had 14 clinical pharmacy services were compared with data from hospitals that did not have these services; levels of hospital pharmacist staffing were also compared. A multiple regression analysis, controlling for severity of illness, was used.

RESULTS

Seven clinical pharmacy services were associated with reduced mortality rates: pharmacist-provided drug use evaluation (4491 reduced deaths, p=0.016), pharmacist-provided in-service education (10,660 reduced deaths, p=0.037), pharmacist-provided adverse drug reaction management (14,518 reduced deaths, p=0.012), pharmacist-provided drug protocol management (18,401 reduced deaths, p=0.017), pharmacist participation on the cardiopulmonary resuscitation team (12,880 reduced deaths, p=0.009), pharmacist participation on medical rounds (11,093 reduced deaths, p=0.021), and pharmacist-provided admission drug histories (3988 reduced deaths, p=0.001). Two staffing variables, number of pharmacy administrators/100 occupied beds (p=0.037) and number of clinical pharmacists/100 occupied beds (p=0.023), were also associated with reduced mortality rates.

CONCLUSION

The number of clinical pharmacy services and staffing variables associated with reduced mortality rates increased from two in 1989 to nine in 1998. The impact of clinical pharmacy on mortality rates mandates consideration of a core set of clinical pharmacy services to be offered in United States hospitals. These results have important implications for health care in general, as well as for our profession and discipline.

Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals

Adverse drug reactions (ADRs) were examined in 1,960,059 hospitalized Medicare patients in 584 United States hospitals in 1998. A database was constructed from the MedPAR database and the National Clinical Pharmacy Services survey. The 584 hospitals were selected because they provided specific information on 14 clinical pharmacy services and on pharmacy staffing; they also had functional ADR reporting systems. The study population consisted of 35,193 Medicare patients who experienced an ADR (rate of 1.8%). Of the 14 clinical pharmacy services, 12 were associated with reduced ADR rates. The most significant reductions occurred in hospitals offering pharmacist-provided admission drug histories (odds ratio [OR] 1.864, 95% confidence interval [CI] 1.765-1.968), drug protocol management (OR 1.365, 95% CI 1.335-1.395), and ADR management (OR 1.360, 95% CI 1.328-1.392). Multivariate analysis, performed to further evaluate these findings, showed that nine variables were associated with ADR rate: pharmacist-provided in-service education (slope -0.469, p=0.018), drug information (slope -0.488, p=0.005), ADR management (slope -0.424, p=0.021), drug protocol management (slope -0.732, p=0.002), participation on the total parenteral nutrition team (slope 0.384, p=0.04), participation on the cardiopulmonary resuscitation team (slope -0.506, p=0.008), medical round participation (slope -0.422, p=0.037), admission drug histories (slope -0.712, p=0.008), and increased clinical pharmacist staffing (slope -4.345, p=0.009). As clinical pharmacist staffing increased from the 20th to the 100th percentile (from 0.93+/-0.77/100 to 5.16+/-4.11/100 occupied beds), ADRs decreased by 47.88%. In hospitals without pharmacist-provided ADR management, the following increases were noted: mean number of ADRs/100 admissions by 34.90% (OR 1.360, 95% CI 1.328-1.392), length of stay 13.64% (Mann-Whitney U test [U]=11047367, p=0.017), death rate 53.64% (OR 1.574, 95% CI 1.423-1.731), total Medicare charges 6.88% (U=111298871, p=0.018), and drug charges 8.16% (U=108979074, p<0.001). Patients in hospitals without pharmacist-provided ADR management had an excess of 4266 ADRs, 443 deaths, 85,554 patient-days, $11,745,342 in total Medicare charges, and $1,857,744 in drug charges. The implications of these findings are significant for our health care system, especially considering that the study population represented 15.55% of 12,261,737 Medicare patients and 5.71% of the 34,345,436 patients admitted to all U.S. hospitals.

Clinical and Economic Outcomes of Pharmacist-Managed Antiepileptic Drug Therapy

This study explores the associations between pharmacist-managed antiepileptic drug therapy in hospitalized Medicare patients and diagnoses indicating the need for these drugs. It also explores the following major heath care outcomes: death rate, hospital length of stay (LOS), Medicare charges, drug charges, laboratory charges, complications, and adverse drug reactions. Data were drawn from the 1998 MedPAR and 1998 National Clinical Pharmacy Services databases. Pharmacist-managed antiepileptic drug therapy was evaluated in a study population of 9380 Medicare patients with diagnosed epilepsy or seizure disorders treated in 794 United States hospitals. This population was derived from the 38,311 hospitalized Medicare patients with epilepsy or seizure disorders (MedPAR). In hospitals without pharmacist-managed antiepileptic drug therapy, death rates were 120.61% higher, with 374 excess deaths (chi(2)=5.983, df=1, p=0.014, odds ratio [OR]=1.553, 95% confidence interval [CI] 1.102-2.189). Hospital LOS was 14.68% higher, with 8069 patient-days (Mann-Whitney U test [U]=3833132, p=0.0009); total Medicare charges were 11.19% higher, with 14,372,550 dollars in excess total charges (U=3644199, p=0.0003); per-patient drug charges were $115 +/- $92 higher (p=NS); laboratory charges were 32.24% higher, with 5,664,970 dollars in excess charges; and aspiration pneumonia rate was 54.61% higher (chi(2)=5.848, df=1, p=0.015, OR=1.233, 95% CI 1.081-1.901). Although the frequencies of other complications and adverse effects were higher, these differences were not statistically significant compared with hospitals with pharmacist-managed antiepileptic drug therapy. Clinical and economic outcomes were improved among hospitalized Medicare patients whose antiepileptic drug therapy was managed by pharmacists.

Clinical and economic outcomes of pharmacist-managed aminoglycoside or vancomycin therapy

PURPOSE

The associations between pharmacist-managed aminoglycoside or vancomycin therapy for hospitalized Medicare patients who had diagnoses indicating probable treatment with these antibiotics and the major health care outcomes of death rate, length of stay, Medicare charges, hearing loss, and renal impairment were explored.

METHODS

Pharmacist management of drug therapy was evaluated in a study population composed of 199,082 Medicare patients treated in 961 hospitals.

RESULTS

In hospitals that did not have pharmacist-managed aminoglycoside or vancomycin therapy, death rates were 6.71% higher (1,048 excess deaths [chi(2) (1) = 43.801, p < 0.0001]), length of stay was 12.28% higher (131,660 excess patient days [U = 4.701 x 10(9), p < 0.0001]), total Medicare charges were 6.30% higher (140,745,924 US dollars in excess total Medicare charges [U = 4.864 x 10(9), p < 0.0001]), drug charges were 8.15% higher (34,769,250 US dollars in excess drug charges [U = 4.785 x 10(9), p < 0.0001]), laboratory charges were 7.80% higher (22,530,474 US dollars in excess laboratory charges [U = 4.860 x 10(9), p < 0.0001]), hearing loss was 46.42% higher (134 more patients with hearing loss [chi(2) = 54.423, df = 1, p < 0.0001]), renal impairment was 33.95% higher (2,801 more patients with renal impairment [chi(2) = 118.13, df = 1, p < 0.0001]), and the death rate in patients who developed complications was 10.15% higher (231 excess deaths [chi(2) = 22.345, df = 1, p < 0.0001]) than in hospitals with pharmacists managing these drugs.

CONCLUSION

The presence of pharmacist-managed aminoglycoside or vancomycin therapy was associated with significant improvement in health care and economic outcomes for Medicare patients who received these drugs.

Pharmacist-provided anticoagulation management in United States hospitals: death rates, length of stay, Medicare charges, bleeding complications, and transfusions

We explored the associations between pharmacist-provided anticoagulation management in hospitalized Medicare patients and several major heath care outcomes: death rate, length of stay, Medicare charges, bleeding complications, and transfusions. Using the 1995 National Clinical Pharmacy Services database and the 1995 Medicare database for hospitals, data were retrieved for 717,396 Medicare patients treated in 955 hospitals for conditions requiring anticoagulant therapy. In hospitals without pharmacist-provided heparin management, death rates were 11.41% higher (chi2 (1) = 122.84, p<0.0001), length of stay was 10.05% higher (Mann-Whitney U test = 40039529342, p<0.0001), Medicare charges were 6.60% higher (U = 41004749266, p<0.0001), bleeding complications were 3.1% higher (chi2 (1) = 10.996, p=0.0009) and the transfusion rate for bleeding complications was 5.47% higher (chi2 (1) = 11.24, p=0.0008) than in hospitals with pharmacist-provided heparin management. In hospitals without pharmacist-provided warfarin management, death rates were 6.20% higher (chi2 (1) = 19.20, p<0.0001), length of stay was 5.86% higher (U = 25730993838, p<0.0001), Medicare charges were 2.16% higher (U = 259955112970, p<0.0001), bleeding complications were 8.09% higher (chi2 (1) = 49.259, p<0.0001), and the transfusion rate for bleeding complications was 22.49% higher (chi2 (1) = 78.68, p<0.0001). Study hospitals without pharmacist-provided heparin management had 4664 more deaths, 494,855 more patient-days, 145 more patients with bleeding complications, and $651,274,844 more in patient charges; 9784 more units of whole blood were used in patients requiring transfusions for bleeding complications. Hospitals without pharmacist-provided warfarin management had 2786 more deaths, 316,589 more patient-days, 429 more patients with bleeding complications, and $234,275,490 more in patient charges; 8991 more units of whole blood were used in patients requiring transfusions for bleeding complications. The implications of these findings are significant for the health care system, especially considering that the study population represents 28.25% of hospitalized Medicare patients who should receive anticoagulants, and that total Medicare admissions represent 35.02% of total admissions to United States hospitals.

Evidence-Based Core Clinical Pharmacy Services in United States Hospitals in 2020: Services and Staffing

We developed a model for the provision of clinical pharmacy services in United States hospitals in 2020. Data were obtained from four National Clinical Pharmacy Services database surveys (1989, 1992, 1995, and 1998) and from the American Health-System Association's 2000 Abridged Guide to the Health Care Field. Staffing data from 1998 indicated that 45,734 pharmacist and 43,836 pharmacy technician full-time equivalent (FTE) staff were employed in U.S. hospitals; 17,325 pharmacist FTEs (38%) were devoted to providing clinical pharmacy services. To provide 14 specific clinical pharmacy services for 100% of U.S. inpatients in 2020, 37,814 new FTEs would be needed. For a more realistic manpower projection, using an evidence-based approach, a set of five core clinical pharmacy services were selected based on favorable associations with major health care outcomes (mortality rate, drug costs, total cost of care, length of hospital stay, and medication errors). The core set of services were drug information, adverse drug reaction management, drug protocol management, medical rounds, and admission drug histories. Implementing these core clinical pharmacy services for 100% of inpatients in 2020 would require 14,508 additional pharmacist FTEs. Based on the current deployment of clinical pharmacists and the services they perform in U.S. hospitals, change is needed to improve health care outcomes and reduce costs. The average U.S. hospital (based on an average daily census of 108.97 +/- 169.45 patients) would need to add a maximum of 3.32 pharmacist FTEs to provide these core clinical services (if they were not provided already by the hospital). Using this evidence-based approach, the five selected core clinical pharmacy services could be provided with only modest increases in clinical pharmacist staffing.

Estimating the cost of the Medicare Pharmacist Services Coverage Act of 2001

BACKGROUND

In recent years considerable attention has focused on pharmacists' professional evolution toward patient care-oriented practice. The Pharmacist Provider Coalition (PPC), established in 2000, seeks recognition and payment for pharmacists' patient care services. Concerted effort by the PPC on this issue resulted in the introduction of the Medicare Pharmacist Services Coverage Act of 2001, which would have amended Title XVIII of the Social Security Act to create new types of covered services under Medicare and recognize pharmacist practitioners as providers. However, the legislation was not passed by the 107th Congress.

STUDY OBJECTIVES

The PPC engaged The Moran Company to measure the potential net cost to the United States government of the Medicare Pharmacist Services Coverage Act of 2001, and to perform this measurement in a manner that is consistent with the cost-projection methods used by the Congressional Budget Office (CBO).

DESIGN

The model is anchored to the 10-year projection of revenues and spending within the federal government developed annually by the CBO. It examines the anticipated magnitude and cost of patient care services with respect to chronic disease and pharmaceutical therapy management, in both facility and nonfacility settings.

RESULTS

The methodology yields a final cost estimate of 427 million dollars in 2004, the first year of implementation, and a 10-year estimate of 13 billion dollars.

CONCLUSIONS

Recognition of pharmacists as providers of selected drug therapy management services under Medicare will have a considerable financial impact. It is instructive, however, to view the 10-year cost estimate of 13 billion dollars for pharmaceutical therapy management in light of the CBO's projected 1.5 trillion dollars estimate, over the same time frame, for drug spending among the Medicare population.

Evidence of the economic benefit of clinical pharmacy services: 1996-2000

We sought to summarize and assess original evaluations of the economic impact of clinical pharmacy services published from 1996-2000, and to provide recommendations and methodologic considerations for future research. A systematic literature search was conducted to identify articles that were then blinded and randomly assigned to reviewers who confirmed inclusion and abstracted key information. Results were compared with those of a similar review of literature published from 1988-1995. In the 59 included articles, the studies were conducted across a variety of practice sites that consisted of hospitals (52%), community pharmacies and clinics (41%), health maintenance organizations (3%), and long-term or intermediate care facilities (3%). They focused on a broad range of clinical pharmacy services such as general pharmacotherapeutic monitoring (47%), target drug programs (20%), disease management programs (10%), and patient education or cognitive services (10%). Compared with the studies of the previous review, a greater proportion of evaluations were conducted in community pharmacies or clinics, and the types of services evaluated tended to be more comprehensive rather than specialized. Articles were categorized by type of evaluation: 36% were considered outcome analyses, 24% full economic analyses, 17% outcome descriptions, 15% cost and outcome descriptions, and 8% cost analyses. Compared with the studies of the previous review, a greater proportion of studies in the current review used more rigorous study designs. Most studies reported positive financial benefits of the clinical pharmacy service evaluated. In 16 studies, a benefit:cost ratio was reported by the authors or was able to be calculated by the reviewers (these ranged from 1.7:1-17.0:1, median 4.68:1). The body of literature from this 5-year period provides continued evidence of the economic benefit of clinical pharmacy services. Although the quality of study design has improved, whenever possible, future evaluations of this type should incorporate methodologies that will further enhance the strength of evidence of this literature and the conclusions that may be drawn from it.

The critical care pharmacist: an essential intensive care practitioner

Clinical pharmacy services in the critical care setting have expanded dramatically and include assisting physicians in pharmacotherapy decision making, providing pharmacokinetic consultations, monitoring patients for drug efficacy and safety, providing drug information, and offering medical education to physicians, nurses, and patients. Measurable clinical effects of these services include reduced drug errors and adverse drug events, decreased morbidity and mortality rates, and a positive pharmacoeconomic impact by decreasing overall health care costs.

Clinical pharmacist staffing in United States hospitals

We evaluated hospital demographics (census regions, size, teaching affiliation, hospital ownership, hospital pharmacy director's degree, pharmacist location within the hospital) and clinical pharmacist staffing/occupied bed in United States hospitals. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field and the 1992 National Clinical Pharmacy Services database. Simple statistical tests and multiple regression analysis were employed. The study population consisted of 1391 hospitals that reported information on clinical pharmacist staffing. The mean number of clinical pharmacists/100 occupied beds was 0.51 +/- 0.18. Factors associated with increased clinical pharmacist staffing were west north central region (slope = 0.0029439, p = 0.002), Pacific region (slope = 0.0032089, p = 0.004), affiliation with pharmacy teaching hospitals (slope = 0.0025330, p = 0.0001), teaching hospitals (slope = 0.0028122, p = 0.001), federal government ownership (slope = 0.0029697, p = 0.012), directors with Pharm.D. degrees (slope = 0.0335020, p = 0.002), directors with M.S. Pharmacy degrees (slope = 0.0028622, p = 0.003), pharmacists in a decentralized location (slope = 0.0035393, p = 0.0001), and pharmacy technician staffing (slope = 0.0517713, p = 0.0001). Statistically significant associations between demographic variables and decreased clinical pharmacist staffing/occupied bed were mid-Atlantic region (slope = -0.0028237, p = 0.002), small size (slope = -0.0028894, p = 0.001), pharmacy directors with B.S. degrees (slope = -0.0019271, p = 0.023), and pharmacy administrator staffing (slope = -0.0184513, p = 0.042). The R2 for this multiple regression analysis was 28.31% and adjusted R2 was 24.83%. Increased pharmacy technician staffing had the greatest association (slope = 0.0517713) with increased clinical pharmacist staffing. Significant differences were observed between clinical pharmacist staffing and hospital demographic factors. It appears that one of the most effective ways to increase clinical pharmacist staffing is to increase pharmacy technician staffing (slope). These findings will help future researchers determine specific reasons why some types of hospitals have higher and some lower levels of clinical pharmacist staffing.

Effect of telephone follow-up on the physical well-being dimension of quality of life in patients with cancer

OBJECTIVE

To evaluate the effect of telephone follow-up on the physical well-being dimension of health-related quality of life in patients with cancer.

DESIGN

Randomized, controlled trial.

SETTING

Public teaching hospital.

PATIENTS

One hundred fifty patients with cancer who were discharged to home from the hospital.

INTERVENTION

Patients received a telephone follow-up call 48-72 hours after discharge. Information was solicited regarding drug-related (and other) problems. Problems were addressed, and advice and support were given.

MEASUREMENTS AND MAIN RESULTS

Analysis of variance revealed no differences in the physical well-being dimension of health-related quality of life between patients who received telephone follow-up and a control group who did not. Sixty-eight percent of the follow-up group and 40% of the control group (p = 0.007) reported having had at least one contact with a health professional.

CONCLUSION

One possible explanation for the lack of effect of the intervention is that high-risk patients in the control group received a similar intervention from other health care professionals. We suggest that telephone follow-up be coordinated among health professionals.

Cost-benefit analysis of the detection of prescribing errors by hospital pharmacy staff

OBJECTIVE

Prescribing errors are a major cause of iatrogenic patient morbidity and therefore interventions aimed at preventing the adverse outcomes of these errors are likely to result in cost reduction. However, it is unclear whether the costs associated with these preventive measures are outweighed by the cost reductions (benefits). Therefore, a study was set up to analyse costs and benefits of detecting prescribing errors by hospital pharmacy staff.

DESIGN

During 5 consecutive days in two Dutch hospitals in February 2000 all medication orders, in which prescribing errors were detected, were analysed. A cost-benefit analysis was performed, based on direct medical costs only. The benefit-to-cost ratio was calculated by taking into account the net time hospital pharmacy staff needed for the prevention of the error (this included potential time saving for nursing staff, when an error was prevented by hospital pharmacy staff instead of nursing staff), as well as taking into account the possible consequences of the prescribing error (were the error not prevented).

RESULTS

A total of 3540 orders, of which 351 contained prescribing errors (9.9%), were analysed. During the 1-week period investigated, time-investment of the pharmacy staff had net costs of EUR285 (2000 values). During the same period estimated benefits related to this investment were EUR9867. The finding of higher benefits than costs was robust in sensitivity analysis.

CONCLUSIONS

From this study it can be concluded that prevention of prescribing errors by hospital pharmacy staff results in higher benefits than the costs related to the net time investment.

Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals

The direct relationships and associations among clinical pharmacy services, pharmacist staffing, and medication errors in United States hospitals were evaluated. A database was constructed from the 1992 National Clinical Pharmacy Services database. Both simple and multiple regression analyses were employed to determine relationships and associations. A total of 429,827 medication errors were evaluated from 1081 hospitals (study population). Medication errors occurred in 5.22% of patients admitted to these hospitals each year. Hospitals experienced a medication error every 22.04 hours (every 19.13 admissions). These findings suggest that at minimum, 90,895 patients annually were harmed by medication errors in our nation's general medical-surgical hospitals. Factors associated with increased medication errors/occupied bed/year were drug-use evaluation (slope = 0.0023476, p=0.006), increased staffing of hospital pharmacy administrators/occupied bed (slope = 29.1972932, p<0.001), and increased staffing of dispensing pharmacists/occupied bed (slope = 19.3784148, p<0.001). Factors associated with decreased medication errors/occupied bed/year were presence of a drug information service (slope = -0.1279301, p<0.001), pharmacist-provided adverse drug reaction management (slope = -0.3409332, p<0.001), pharmacist-provided drug protocol management (slope = -0.3981472, p=0.013), pharmacist participation on medical rounds (slope = -0.6974303, p<0.001), pharmacist-provided admission histories (slope = -1.6021493, p<0.001), and increased staffing of clinical pharmacists/occupied bed (slope = -9.5483813, p<0.001). As staffing increased for clinical pharmacists/occupied bed from the 10th percentile to the 90th percentile, medication errors decreased from 700.98 +/- 601.42 to 245.09 +/- 197.38/hospital/year, a decrease of 286%. Specific increases or decreases in yearly medication errors associated with these clinical pharmacy services in the 1081 study hospitals were drug-use evaluation (21,372 more medication errors), drug information services (26,738 fewer medication errors), adverse drug reaction management (44,803 fewer medication errors), drug protocol management (90,019 fewer medication errors), medical round participation (42,859 fewer medication errors), and medication admission histories (17,638 fewer medication errors). Overall, clinical pharmacy services and hospital pharmacy staffing variables were associated with medication error rates. The results of this study should help hospitals reduce the number of medication errors that occur each year.

Medication errors in United States hospitals

This study evaluated hospital demographics, staffing, pharmacy variables, health care outcomes measures (severity of illness-adjusted mortality rates, drug costs, total cost of care, and length of stay) and medication errors. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field, the 1992 National Clinical Pharmacy Services database, and 1992 mortality data from the Health Care Financing Administration. Simple statistical tests and a severity of illness-adjusted multiple regression analysis were employed. The study population consisted of 1116 hospitals that reported information on medication errors and 913 hospitals that reported information on medication errors that adversely affected patient care outcomes. We evaluated factors associated with the 430,586 medication errors and 17,338 medication errors that adversely affected patient care outcomes. Medication errors occurred in 5.07% of the patients admitted each year to these hospitals. Each hospital experienced a medication error every 22.7 hours (every 19.73 admissions). Medication errors that adversely affected patient care outcomes occurred in 0.25% of all patients admitted to these hospitals/year. Each hospital experienced a medication error that adversely affected patient care outcomes every 19.23 days (or every 401 admissions). The following factors were associated with increased medication errors/occupied bed/year: lack of pharmacy teaching affiliation (slope = 0.8875, p=0.0416), centralized pharmacists (slope = 1.0942, p=0.0001), number of registered nurses/occupied bed (slope = 1.624, p=0.032), number of registered pharmacists/occupied bed (slope = 25.0573, p=0.0001), hospital mortality rate (slope = 2.8017, p=0.0192), and total cost of care/occupied bed/year (slope = 0.01432, p=0.0091). Factors associated with decreased medication errors were location in the Mid-Atlantic census region (slope = -1.5182, p=0.03), affiliation with a pharmacy teaching program (slope = -1.0252, p=0.0349), decentralized pharmacists (slope = -0.9843, p=0.0037), and number of medical residents/occupied bed (slope = -1.478, p=0.0014). There was a 45% decrease in medication errors (1.81-fold decrease) in hospitals that had decentralized pharmacists, compared with hospitals that had centralized pharmacists. In addition, there was a 94% decrease in medication errors that adversely affected patient care outcomes (16.88-fold decrease) in hospitals that had decentralized pharmacists compared with hospitals that had only centralized pharmacists. Based on previous field studies and our findings in 1116 hospitals, it appears that one of the most effective ways to prevent or reduce medication errors is to decentralize pharmacists to patient care areas. The results of this study should help hospitals reduce the number of medication errors that occur each year.

Pharmacists' Assessment of Dispensing Errors: Risk Factors, Practice Sites, Professional Functions, and Satisfaction

Certain demographic, practice, staffing, and pharmacist satisfaction variables may contribute to dispensing errors. A survey was randomly mailed to 7298 (50%) Texas pharmacists, of which 2862 were returned (39% response rate). Responders were 2437 pharmacists who indicated that they were in practice. Of these, 535 (23%) reported no risk to patients for dispensing errors and 793 (34%) reported at least one patient/week was at risk for such an error. There was a positive relationship between number of prescription orders filled/hour and the estimated risk of dispensing errors (r(s)=0.285, p<0.001). Pharmacists practicing in mail service pharmacies (risk score = 1.85 +/- 1.32), traditional chain store pharmacies (1.66 +/- 1.18), and hospital pharmacies (1.61 +/- 1.09) reported a higher risk than other groups. Pharmacists practicing in independent community pharmacies (0.75 +/- 0.84), home health care (0.83 +/- 0.99), grocery chain store pharmacies (1.30 +/- 0.96), and mass merchandise chain store pharmacies (1.30 +/- 1.08) reported a lower risk (H=260, df=8, p<0.001). Nine job satisfaction variables were strongly associated with the risk of dispensing errors (r(s) = between -0.3 and -0.422, p<0.001), as were prescription volume, practice site, staffing, training, pharmacist functions, and professional organization membership. The results of this survey should help pharmacists and management develop specific plans for reducing the risks of dispensing errors. These data should be useful for more in-depth study of such errors.

Interrelationships among mortality rates, drug costs, total cost of care, and length of stay in United States hospitals: summary and recommendations for clinical pharmacy services and staffing

We evaluated interrelationships and associations among mortality rates, drug costs, total cost of care, and length of stay in United States hospitals. Relationships between these variables and the presence of clinical pharmacy services and pharmacy staffing also were explored. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field, the 1992 National Clinical Pharmacy Services database, and 1992 Health Care Finance Administration mortality data. A severity of illness-adjusted multiple regression analysis was employed to determine relationships and associations. Study populations ranged from 934-1029 hospitals (all hospitals for which variables could be matched). The only pharmacy variable associated with positive outcomes with all four health care outcome measures was the number of clinical pharmacists/occupied bed. That figure tended to have the greatest association (slope) with reductions in mortality rate, drug costs, and length of stay. As clinical pharmacist staffing levels increased from the tenth percentile (0.34/100 occupied beds) to the ninetieth percentile (3.23/100 occupied beds), hospital deaths declined from 113/1000 to 64/1000 admissions (43% decline). This resulted in a reduction of 395 deaths/hospital/year when clinical pharmacist staffing went from the tenth to the ninetieth percentile. This translated into a reduction of 1.09 deaths/day/hospital having clinical pharmacy staffing between these staffing levels, or 320 dollars of pharmacist salary cost/death averted. Three hospital pharmacy variables were associated with reduced length of stay in 1024 hospitals: drug protocol management (slope -1.30, p=0.008), pharmacist participation on medical rounds (slope -1.71, p<0.001), and number of clinical pharmacists/occupied bed (slope -26.59, p<0.001). As drug costs/occupied bed/year increased, severity of illness-adjusted mortality rates decreased (slope -38609852, R(2) 8.2%, p<0.0001). As the total cost of care/occupied bed/year increased, those same mortality rates decreased (slope -5846720642, R(2) 14.9%, p<0.0001). Seventeen clinical pharmacy services were associated with improvements in the four variables.

Clinical pharmacy services, pharmacy staffing, and the total cost of care in United States hospitals

This study evaluated direct relationships and associations among clinical pharmacy services, pharmacist staffing, and total cost of care in United States hospitals. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field and the 1992 National Clinical Pharmacy Services Database. A multiple regression analysis, controlling for severity of illness, was employed to determine the relationships and associations. The study population consisted of 1016 hospitals. Six clinical pharmacy services were associated with lower total cost of care: drug use evaluation (p=0.001), drug information (p=0.003), adverse drug reaction monitoring (p=0.008), drug protocol management (p=0.001), medical rounds participation (p=0.0001), and admission drug histories (p=0.017). Two services were associated with higher total cost of care: total parenteral nutrition (TPN) team participation (p=0.001) and clinical research (p=0.0001). Total costs of care/hospital/year were lower when any of six clinical pharmacy services were present: drug use evaluation $1,119,810.18 (total $1,005,589,541.64 for the 898 hospitals offering the service), drug information $5,226,128.22 (total $1,212,461,747.04 for the 232 hospitals offering the service), adverse drug reporting monitoring $1,610,841.02 (total $1,101,815, 257.68 for the 684 hospitals offering the service), drug protocol management $1,729,608.41 (total $614,010,985.55 for the 355 hospitals offering the service), medical rounds participation $7,979,720.45 (total $1,212,917,508.41 for the 152 hospitals offering the service), and admission drug histories $6,964,145.17 (total $208,924,355.10 for the 30 hospitals offering the service). Clinical research $9,558,788.01 (total $1,013,231,529.06 for the 106 hospitals offering the service) and TPN team participation $3,211,355.12 (total $1,027,633,638.43 for the 320 hospitals offering the service) were associated with higher total costs of care. As staffing increased for hospital pharmacy administrators (p=0.0001) and clinical pharmacists (p=0.007), total cost of care decreased. As staffing increased for dispensing pharmacists, total cost of care increased (p=0.006). Based on this total cost of care model, optimal hospital pharmacy administrator staffing was 2.01/100 occupied beds. Staffing for dispensing pharmacists should be as low as possible, and definitely fewer than 5.11/100 occupied beds. Staffing for clinical pharmacists should be as high as possible, but definitely more than 1.11/100 occupied beds. The results of this study suggest that increased staffing levels of clinical pharmacists and pharmacy administrators, as well as some clinical pharmacy services, were associated with reduced total cost of care in United States hospitals.

Drug-related problems in hospitalised patients

Drug-related problems include medication errors (involving an error in the process of prescribing, dispensing, or administering a drug, whether there are adverse consequences or not) and adverse drug reactions (any response to a drug which is noxious and unintended, and which occurs at doses normally used in humans for prophylaxis, diagnosis or therapy of disease, or for the modification of physiological function). Furthermore, adverse drug events can be defined as an injury--whether or not causally-related to the use of a drug. Drug-related problems are relatively common in hospitalised patients and can result in patient morbidity and mortality, and increased costs. In order to get an overview of studies on drug-related problems in hospitalised patients, with specific attention to the incidence of drug-related problems and their costs, to the possibilities of prevention and to the effect of these interventions, we performed a literature search. Incidences of medication errors reported in studies vary widely. The range of reported incidences of adverse drug reactions is even wider. These wide ranges can be largely explained by the different study methods and definitions used. Problems related to drug therapy may be averted by preventive interventions. Several possibilities for prevention exist, especially for the prevention of medication errors. Prescribing, transcription and interpretation errors can be reduced by using computerised physician order entry. Together with the use of automated dispensing systems and bar-code technology, this will aid in the reduction of both dispensing and administration errors. Education of nursing staff involved in the process of drug distribution is another important measure for preventing medication errors. Finally, the introduction of systems for the early detection of adverse drug reactions may help to reduce problems related to drug therapy. Identifying risk factors that contribute to the development of adverse drug reactions, may aid in the prevention of these reactions.