Medication use in the emergency department: Why are we placing patients at risk?

Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis

BACKGROUND

Pharmacists have an increasing role as part of the emergency department (ED) team. However, the impact of ED-based pharmacy interventions on the quality use of medicines has not been well characterised.

OBJECTIVE

This systematic review aimed to synthesise evidence from studies examining the impact of interventions provided by pharmacists on the quality use of medicines in adults presenting to ED.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE and CINAHL. Two independent reviewers screened titles/abstracts and reviewed full texts. Studies that compared the impact of interventions provided by pharmacists with usual care in ED and reported medication-related primary outcomes were included. Cochrane Risk of Bias-2 and Newcastle-Ottawa tools were used to assess the risk of bias. Summary estimates were pooled using random-effects meta-analysis, along with sensitivity and sub-group analyses.

RESULTS

Thirty-one studies involving 13 242 participants were included. Pharmacists were predominantly involved in comprehensive medication review, advanced pharmacotherapy assessment, staff and patient education, identification of medication discrepancies and drug-related problems, medication prescribing and co-prescribing, and medication preparation and administration. The activities reduced the number of medication errors by a mean of 0.33 per patient (95% CI -0.42 to -0.23, I²=51%) and the proportion of patients with at least one error by 73% (risk ratio (RR)=0.27, 95% CI 0.19 to 0.40, I²=85.3%). The interventions were also associated with more complete and accurate medication histories, increased appropriateness of prescribed medications by 58% (RR=1.58, 95% CI 1.21 to 2.06, I²=95%) and quicker initiation of time-critical medications.

CONCLUSION

The evidence indicates improved quality use of medicines when pharmacists are included in ED care teams.

PROSPERO REGISTRATION NUMBER

CRD42020165234.

Impact of Partnered Pharmacist Medication Charting (PPMC) on Medication Discrepancies and Errors: A Pragmatic Evaluation of an Emergency Department-Based Process Redesign

Medication errors are more prevalent in settings with acutely ill patients and heavy workloads, such as in an emergency department (ED). A pragmatic, controlled study compared partnered pharmacist medication charting (PPMC) (pharmacist-documented best-possible medication history [BPMH] followed by clinical discussion between a pharmacist and medical officer to co-develop a treatment plan and chart medications) with early BPMH (pharmacist-documented BPMH followed by medical officer-led traditional medication charting) and usual care (traditional medication charting approach without a pharmacist-collected BPMH in ED). Medication discrepancies were undocumented differences between medication charts and medication reconciliation. An expert panel assessed the discrepancies' clinical significance, with 'unintentional' discrepancies deemed 'errors'. Fewer patients in the PPMC group had at least one error (3.5%; 95% confidence interval [CI]: 1.1% to 5.8%) than in the early BPMH (49.4%; 95% CI: 42.5% to 56.3%) and usual care group (61.4%; 95% CI: 56.3% to 66.7%). The number of patients who need to be treated with PPMC to prevent at least one high/extreme error was 4.6 (95% CI: 3.4 to 6.9) and 4.0 (95% CI: 3.1 to 5.3) compared to the early BPMH and usual care group, respectively. PPMC within ED, incorporating interdisciplinary discussion, reduced clinically significant errors compared to early BPMH or usual care.

Medication Safety in the Emergency Department: A Study of Serious Medication Errors Reported by 101 Hospitals From 2011 to 2020

Background: Although serious medication errors are uncommon, accounting for only 0.4% (166 of 46,568) of medication errors reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in 2020, their effects can be devastating for patients and their loved ones. Methods: We queried PA-PSRS for reports of serious events classified as medication errors that occurred in the emergency department (ED) from January 1, 2011, to December 31, 2020. We performed a descriptive analysis to identify trends among patient sex, patient age, event harm score, event day of the week, and event time of day. We also manually coded and analyzed events based on the prescribed medication(s) and medication class(es), stage of the medication-use process at which the error occurred, and medication error type. Results: We identified 250 reports of serious medication error events in PA-PSRS that occurred in the ED from 2011 to 2020. Reports more often specified that the patient was female (61.2%; 153 of 250), and patients ranged in age from 8 months to 96 years, with a median patient age of 55 years. Events were significantly more likely to occur Friday through Sunday versus Monday through Thursday (p = .0214) and in the p.m. hours versus a.m. hours, (p = .0007). The most common prescribed medications mentioned in reports were epinephrine, insulin, hydromorphone, sodium chloride, heparin, propofol, diltiazem, ketamine, and morphine. Events occurred most often at the prescribing stage of the medication-use process (42.0%; 105 of 250), and the most common medication error type was a wrong dose (42.0%; 105 of 250). Conclusion: Potential safety strategies to consider to reduce the risk of medication errors in the ED include stocking epinephrine autoinjectors, using clinical decision support at the ordering/prescribing stage of the process, and adding an emergency medicine pharmacist as part of an interdisciplinary emergency medicine team.

Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana

OBJECTIVES

This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana.

METHODS

This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes.

RESULTS

Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems.

CONCLUSIONS

This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.

The State of US Emergency Care: A Call to Action for Hospital Pharmacists

The recent publication of the Institute of Medicine/Board on Health Care Services reports on the future of emergency care in the US health system has identified the main limitations of the care provided by emergency departments (EDs). Increased development of ED pharmacy services and increased involvement of pharmacists in the ED can contribute to improvements in shortcomings identified in the report. Pharmacy training programs must take the initiative to incorporate emergency care into their curricula to meet the predicted increase in demand for ED pharmacists. Pharmacy associations, administrators, and ED practitioners must direct research on the impact of the pharmacist in the ED.

Impact of prospective verification of intravenous antibiotics in an ED

BACKGROUND

Delay in appropriate antibiotic therapy is associated with an increase in mortality and prolonged length of stay. Automatic dispensing machines decrease the delivery time of intravenous (IV) antibiotics to patients in the emergency department (ED). However, when IV antibiotics are not reviewed by pharmacists before being administered, patients are at risk for receiving inappropriate antibiotic therapy. The objective of this study was to determine if a difference exists in the time to administration of appropriate antibiotic therapy before and after implementation of prospective verification of antibiotics in the ED.

METHODS

This retrospective, institutional review board-approved preimplementation vs postimplementation study evaluated patients 18years or older who were started on IV antibiotics in the ED. Patients were excluded if pregnant, if the patient is a prisoner, if no cultures were drawn, or if the patient was transferred from an outside facility. Appropriate antibiotic therapy was based on empiric source-specific evidence-based guidelines, appropriate pharmacokinetic and pharmacodynamic properties, and microbiologic data. The primary end point was the time from ED arrival to administration of appropriate antibiotic therapy.

RESULTS

Of the 1628 evaluated, 128 patients met the inclusion criteria (64 pre vs 64 post). Patients were aged 65.2±17.0years, with most of infections being pneumonia (44%) and urinary tract infections (18%) and most patients being noncritically ill. Time to appropriate antibiotic therapy was reduced in the postgroup vs pregroup (8.1±8.6 vs 15.2±22.8hours, respectively, P=.03). In addition, appropriate empiric antibiotics were initiated more frequently after the implementation (92% post vs 66% pre; P=.0001). There was no difference in mortality or length of stay between the 2 groups.

CONCLUSION

Prompt administration of the appropriate antibiotics is imperative in patients with infections presenting to the ED. The impact of prospective verification of antibiotics by pharmacists led to significant improvement on both empiric selection of and time to appropriate antibiotic therapy.

Impact of clinical pharmacy services in a short stay unit of a hospital emergency department in Qatar

Background The presence of a clinical pharmacist in a hospital's Emergency Department (ED) is important to decrease the potential for medication errors. To our knowledge, no previous studies have been conducted to evaluate the impact of implementing clinical pharmacy services in the ED in Qatar. Objective To characterize the contributions of clinical pharmacists in a short stay unit of ED in order to implement and scale-up the service to all ED areas in the future. Methods A retrospective study conducted for 7 months in the ED of Hamad General Hospital, Qatar. The intervention recommendations were made by clinical pharmacists to the physician in charge during medical rounds. Results A total of 824 documented pharmacist recommendations were analyzed. The interventions included the following: Providing information to the physician (24.4 %) and recommending medication discontinuation (22.0 %), dose adjustment (19.3 %), medication addition (16.0 %), changes in frequency of medications (7.6 %), medication resumption (5.7 %), and patient education (5.0 %). Conclusion Clinical pharmacists in the ED studied play an important role in patient care.

Clinical pharmacist evaluation of medication inappropriateness in the emergency department of a teaching hospital in Malta

Appropriate prescribing remains an important priority in all medical areas of practice.

Objective

The objective of this study was to apply a Medication Appropriateness Index (MAI) to identify issues of inappropriate prescribing amongst patients admitted from the Emergency Department (ED).

Methods

This study was carried out at Malta's general hospital on 125 patients following a two-week pilot period on 10 patients. Patients aged 18 years and over and on medication therapy were included. Medication treatment for inappropriateness was assessed by using the MAI. Under-prescribing was also screened for.

Results

Treatment charts of 125 patients, including 697 medications, were assessed using a MAI. Overall, 115 (92%) patients had one or more medications with one or more MAI criteria rated as inappropriate, giving a total of 384 (55.1%) medications prescribed inappropriately. The mean SD MAI score per drug was 1.78 (SD=2.19). The most common medication classes with appropriateness problems were biguanides (100%), anti-arrhythmics (100%) and anti-platelets (96.8%). The most common problems involved incorrect directions (26%) and incorrect dosages (18.5%). There were 36 omitted medications with untreated indications.

Conclusions

There is considerable inappropriate prescribing which could have significant negative effects regarding patient care.

Emergency medicine pharmacy practice

Emergency medicine (EM) pharmacy practice has existed for over 30 years. In recent years, however, the specialty has grown significantly. A large number of health care systems have either a dedicated EM pharmacist or other clinical pharmacist presence in the Emergency department (ED). Over the past decade, the role of the EM pharmacist as a critical member of the health care team has expanded significantly and many innovative practices have evolved throughout the country. There is also some heterogeneity between different EM pharmacy practice sites. This article reviews the history and general concepts of EM pharmacy practice as well as illustrate some of the established benefits of an EM pharmacist.

Severity and probability of harm of medication errors intercepted by an emergency department pharmacist

Objectives

The objective of this study was to evaluate the severity and probability of harm of medication errors (MEs) intercepted by an emergency department pharmacist. The phases of the medication-use process where MEs were most likely to be intercepted were determined.

Methods

The emergency department was staffed with a full-time pharmacist during the 7-month study period. The MEs that were intercepted by the pharmacist were recorded in a database. Each ME in the database was independently scored for severity and probability of harm by two pharmacists and one physician investigator who were not involved in the data collection process.

Key findings

There were 237 ME interceptions by the pharmacist during the study period. The final classification of MEs by severity was as follows: minor (n = 42; 18%), significant (n = 160; 67%) and serious (n = 35; 15%). The final classification of MEs by probability of harm was as follows: none (n = 13; 6%), very low (n = 96; 41%), low (n = 84; 35%), medium (n = 41; 17%) and high (n = 3; 1%). Inter-rater reliability for classification was as follows: error severity (agreement = 75.5%, kappa = 0.35) and probability of harm (agreement = 76.8%, kappa = 0.42). The MEs were most likely to be intercepted during the prescribing phase of the medication-use process (n = 236; 90.1%).

Conclusions

A high proportion of MEs intercepted by the emergency department pharmacist are considered to be significant or serious. However, a smaller percentage of these errors are likely to result in patient harm.

Factors associated with medication errors in the pediatric emergency department

OBJECTIVES

To describe the prevalence, type, and factors associated with medication errors in a pediatric emergency department.

METHODS

This is a descriptive retrospective study about the treatments administered in the pediatric emergency department during a week in November 2007. We used the protocols and clinical guides at our center as pattern of reference. The errors were classified as follows: (1) prescription error: drug involved, indication, dose, and route of administration; (2) severity of the error; and (3) associated factors: triage category, age of the patient, training level of the physician, day of the week, and hour of the day.

RESULTS

In 377 of 1906 checked reports, some treatments were prescribed. A total of 92 errors (15%) were detected and all of them were prescription errors: 50 (8%) for inappropriate indication and 42 (7 %) for inadequate dose. Also, 87 were considered insignificant errors, 5 were moderate and none were severe. There was a higher rate of errors among residents with less experience. We did not find differences in the triage category neither in the age of the patient. In the weekends and holidays, we commit more errors compared in weekdays (28% vs 18 %, P=0.02). Between 24 and 8 hours, we registered more errors than between 8 and 16 and between 16 and 24 hours (32.3% vs 17.9% vs 21.2%; P=0.03).

CONCLUSIONS

Error rates in drugs administered exclusively in the emergency department are slightly higher than others evaluating house orders and emergency department treatments. The high assistance pressure during weekends and holidays and the tiredness during the night are risk factors of prescribing errors. Periodical evaluation of the prescriptions is necessary to develop the best strategies to apply every time.

Effect of emergency medicine pharmacists on medication-error reporting in an emergency department

PURPOSE

The effect of an emergency medicine (EM) clinical pharmacist on medication-error reporting in an emergency department (ED) was studied.

METHODS

The medication-error reports for patients seen at a university's ED between September 1, 2005, and February 28, 2009, were retrospectively reviewed. Errors reported before the addition of an EM pharmacist (from September 1, 2005, through February 28, 2006) were compared with those reported after the addition of two EM pharmacists (from September 1, 2008, through February 28, 2009). The severity of errors and the provider who reported the errors were characterized.

RESULTS

A total of 402 medication errors were reported over the two time periods. Pharmacy personnel captured significantly more errors than did other health care personnel (94.5% versus 5.7%, p < 0.001). The addition of two EM pharmacists resulted in 14.8 times as many medication-error reports as were made when no EM pharmacist was in the ED. More errors that actually occurred were captured with two pharmacists providing care (95.7% versus 4.3%, p < 0.001). A majority of the errors documented were ordering errors (79.8%). Of these, 73.7% were captured after the addition of two EM pharmacists. Performance (40.0%) and knowledge (27.9%) deficits were the most common contributing factors to medication errors.

CONCLUSION

During the study period after the addition of two EM pharmacists in the ED, 371 medication-error reports were completed, compared with 31 reports during the study period before the addition of the pharmacists. Pharmacy personnel reported the majority of medication errors during both study periods.

Survey of physicians regarding clinical pharmacy services in academic emergency departments

PURPOSE

The prevalence and nature of clinical pharmacy services in academic emergency departments (EDs) were studied.

METHODS

A Web-based survey instrument consisting of questions regarding clinical pharmacy services available in the ED was developed based on a review of the current literature and expert consensus. The revised instrument was sent to a representative of all emergency medicine (EM) residency programs listed in the Society for Academic Emergency Medicine residency catalog in June 2006. The survey included questions addressing characteristics of the institution and the availability and nature of various pharmacy services in the ED. EM physicians were deliberately targeted so that the results would represent the ED staff's perceptions of their use of pharmacy services. Only respondents' primary residency hospital sites were considered. Data were compiled and analyzed using descriptive statistics and 95% confidence intervals.

RESULTS

Of the 135 EM residency programs surveyed, 99 responses (73%) were received. Eight percent of institutions reported that a dedicated pharmacist was available in the ED 24 hours a day, 22% reported partial coverage in the ED, and 70% reported no coverage. Six percent reported the presence of a satellite pharmacy located in the ED that was staffed by a pharmacist. The most common clinical pharmacy services reported in EDs with pharmacy coverage were modification of inventory according to formulary status, provision of drug or toxicology information, and adverse-drug-event reporting.

CONCLUSION

A minority of respondents from academic EDs reported that clinical services are provided by a pharmacist working in the ED.

Medical and nursing staff highly value clinical pharmacists in the emergency department

Despite the potential impact that emergency pharmacist (EPh) programmes could have on medication safety and quality of care in the emergency department (ED), very few programmes exist. This descriptive survey study aimed to assess staff perceptions of an EPh programme. A random sample of medical and nursing staff in an academic medical centre ED with a dedicated EPh programme received a 26-item survey (82% return rate). 99% of respondents felt the EPh improves quality of care, 96% feel they are an integral part of the team, and 93% had consulted the EPh at least a few times during their last five shifts. Staff felt that the EPh should be available for consults, attend resuscitations, and check orders. This study reinforced the value of many specific duties of the EPh programme and found that doctors and nurses overwhelmingly favour the presence of an EPh in the ED, frequently seek their advice, and feel they improve quality of care. Staff acceptance is clearly not a barrier to implementation of this programme.

Documentation of pharmacists’ interventions in an emergency department and associated cost avoidance

PURPOSE

An analysis was conducted of pharmacist interventions and resuscitation experiences, including pharmacist participation in a hospital emergency department (ED), and the potential cost avoidance associated with the interventions made by the pharmacists.

METHODS

All pharmacists working in the ED prospectively documented the pharmacist interventions that were accepted by physicians and nursing staff and entered into a spreadsheet on a weekly basis, between September 1, 2003, and December 31, 2003. Intervention categories included the provision of drug information; recommendations for dosage adjustment, formulary interchange, initiation of medications, alternative drug therapy, discontinuation of drug therapy, changes in medication therapy due to allergy notification, drug therapy duplication prevention, or changes in the route of drug administration; questions from nursing staff; order clarifications; drug compatibility issues; patient information; toxicology; and drug interaction identification. Intervention data were analyzed and the likelihood of harm was scored; interventions were classified and analyzed by calculating average cost, probability of harm, and potential cost avoidance.

RESULTS

During the study, 2150 pharmacist interventions were documented. Pharmacists participated in the care of 1042 patients triaged to the resuscitation area of the ED. Cost avoidance during the study was determined to be 1,029,776 dollars.

CONCLUSION

The most commonly documented interventions made by pharmacists involved in the care of patients visiting the ED included provision of drug information, dosage adjustment recommendations, responses to questions from nursing staff, formulary interchanges, and suggestions regarding initiation of drug therapy. The potential cost avoidance attributable to the pharmacist interventions during the study period was over 1 million dollars.

ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2005

PURPOSE

Results of the 2005 ASHP national survey of pharmacy practice in hospital settings that pertain to dispensing and administration are presented.

METHODS

A stratified random sample of pharmacy directors at 1173 general and children's medical-surgical hospitals in the United States was surveyed by mail.

RESULTS

The response rate was 43.5%. Most hospitals had a centralized drug distribution system; however, there is evidence of growth in decentralized models compared with data from 2002. Automated dispensing cabinets were used by 72% of hospitals and robots by 15%. The percentage of doses dispensed in unit dose form increased, as did the use of two-pharmacist checks for high-risk drugs and high-risk patient groups. However, the percentage of medication preparation and dispensing quality-improvement programs declined over the past six years. Medication administration records (MARs) have become increasingly computerized over the past six years. Consequently, the use of handwritten MARs has declined substantially. Technology implemented at the administration step of the medication-use process is continuing to grow. Bar-code technology was implemented by 9.4% of hospitals, and 32.2% of hospitals had smart infusion pumps. Pharmacy hours of operation were stable, with 30% of hospitals providing around-the-clock services. About 12% of hospitals are using off-site medication order review and entry after hours. Pharmacy staffing has steadily increased over the past three years; however, hospital pharmacies reported a 5.6% vacancy rate.

CONCLUSION

Safe systems continue to be in place in most hospitals, but the adoption of new technology is changing the philosophy of medication distribution. Pharmacists are continuing to improve medication use at the dispensing and administration steps of the medication-use process.