Pharmacy interventions can reduce clinical errors - Part I of findings from ISMP survey

A 79-year-old hospitalized woman accidentally received seven doses of the oral hypoglycemic, glyburide, which was intended for another patient. A nurse took a verbal order for glyburide 10 mg orally BID for a diabetic patient and correctly transcribed it onto an order form. But the order form was stamped using an addressograph plate for the 79-year-old woman, not the intended patient. Pharmacy received a copy of the order and dispensed the medication. Because the 79-year-old woman was not diabetic, she eventually developed symptoms of hypoglycemia necessitating transfer to ICU. At that time, her blood glucose level was 10 mg/dL. Fortunately, the patient recovered without permanent harm.

To prevent such errors, some pharmacies forbid dispensing insulin or oral hypoglycemic drugs unless the pharmacist confirms that the patient has diabetes, is on TPN and not tolerating the glucose load, or has some other therapeutic reason for the medication. But here's the catch. If there's no reliable way to obtain this information in a timely manner through routine mechanisms, the pharmacist must specifically seek out this information and intervene if the therapy does not appear to be indicated. While clinical activities such as this can help lay the foundation for safe medication therapy, our survey findings suggest that pharmacists face serious barriers when attempting to perform this service or level of care.

In our survey, lack of technology support, inadequate staffing, and an inefficient documentation process were cited as the most frequent barriers to pharmacy interventions. (See page three for a table with results related to the barriers and facilitators of pharmacy interventions.) Regardless of hospital size, only about a quarter of respondents felt that proper technology was in place to aid clinical decision-making. Just 16% of all respondents felt they had adequate staffing levels to carry out pharmacy interventions. Hospitals with less than 100 beds reported the least problems with staffing adequacy to perform interventions. Only 30% of all respondents felt that pharmacists had sufficient clinical intervention skills, but specialty hospitals and hospitals with pharmacy residency programs reported a higher level of satisfaction with the clinical skills of pharmacists than general hospitals or hospitals without pharmacy residency programs.

Overall, just 31% of respondents reported that pharmacists were highly motivated to perform interventions. Interestingly, hospitals without physician or pharmacy residency programs reported a higher level of staff motivation for intervention activities than hospitals with training programs. Likewise, specialty hospitals and smaller hospitals under 300 beds reported considerably higher levels of motivation to perform interventions than general hospitals and larger hospitals over 300 beds (as much as a 29% difference). Specialty hospitals also reported higher satisfaction with staffing levels and pharmacists' skills. Little difference was noted between hospitals of varying type, size, or training programs on the issue of supportive leadership and culture, with just 32% of all pharmacists reporting that such factors are present to facilitate clinical pharmacy interventions in their hospitals.

The least likely barrier to pharmacy interventions was lack of access to information, with 70% of all respondents reporting easy access to drug information and 55% reporting easy access to patient information. Hospitals with physician and pharmacy training programs reported easier access to drug information than hospitals without training programs. The largest hospitals reported the lowest satisfaction with access to patient information.

Despite these barriers, our survey findings also clearly show that pharmacy interventions have a strong foothold in healthcare and are well received by the medical staff as a whole. In our next issue, we will discuss the findings related to the types of clinical pharmacy intervention services currently performed in hospitals and how the information is documented and used to reduce the risk of error.

Pharmacy interventions - Part II from ISMP survey

Intervention types: According to respondents, the most common routine interventions performed in the pharmacy included assuring orders were complete (89%), allergy checking (87%), and dose verification (86%). Targeted pharmacy interventions performed in patient care units were reported less frequently, with the most common categories including antimicrobial therapy (31%), renal dosing (30%), and monitoring of special populations such as pediatrics (29%). Larger hospitals and hospitals with physician and pharmacy training programs were more likely to perform these targeted interventions. Overall, the least common categories for interventions included anticoagulation and narcotics/pain control.

Communication: Half of all respondents communicated at least 80% of interventions directly to prescribers, and about a third of all respondents said that pharmacists communicated interventions directly to prescribers more than 90% of the time. Hospitals with physician training programs were more likely to communicate interventions directly to physicians. About 19% reported that all interventions were communicated directly to prescribers vs. 7% in hospitals without training, and 40% reported that most (90%) interventions were reported directly to prescribers vs. 23% in hospitals without training.

Physician acceptance: Ninety four percent of respondents felt that the medical staff, as a whole, responded well to pharmacists' interventions. In fact, about a third reported that physicians accepted more than 95% of recommendations, and only 10% reported that physicians accepted less than 80% of pharmacy recommendations. Hospitals with physician or pharmacy training programs reported even higher levels of medical staff acceptance of interventions. Little difference was noted between hospitals of varying size or type.

Documentation: About three-quarters of respondents documented pharmacy interventions, and of those, only 61% felt that it was detailed enough to guide improvement. Larger hospitals documented interventions more frequently than hospitals under 100 beds. Paper (33%) and the pharmacy computer (44%) were the most common vehicles for documenting the interventions. Only 3% of hospitals use Personal Digital Assistants (PDAs).

Use of interventions: Just two thirds of respondents reported that pharmacy interventions had been presented to committees/staff for the purpose of improving the prescribing process. Even less (44%) used pharmacy interventions to plan and carry out medical staff education. Likewise, only two thirds of hospitals reported using pharmacy interventions to improve the prescribing process in the past year. Hospitals with more than 100 beds and those with physician training programs used intervention information more often to improve the prescribing process than hospitals with 100 beds or less and those without physician training programs. Likewise, larger hospitals and those with pharmacy and physician training programs provided prescriber education based on information learned from interventions more frequently than smaller hospitals and those without training programs.

Overall, our survey findings clearly suggest that vital, clinical pharmacy activities occur everyday in hospitals. Yet hospitals of all types, sizes, and teaching affiliations are struggling in some way to perform pharmacy interventions effectively and use the information to improve the prescribing process and reduce the risk of errors. For example, while smaller hospitals reported fewer barriers to performing interventions, they also reported less success using the information to provide educational programs and improve the prescribing the process. While hospitals without training programs reported higher staff motivation to perform interventions, they were less likely to perform some of the more targeted, clinical interventions. While larger hospitals were able to use intervention information more frequently to improve the prescribing process, they also reported the most significant barriers to accessing crucial patient information. Regardless of size, type, or teaching affiliation, one thing stands out clearly - hospitals are missing out on a virtual gold mine of information that can lead to reduced errors. Take the time to review your pharmacy intervention program and maximize its capacity to reduce medication errors. The complete two-part series on pharmacy interventions and associated tables with findings appear on our web site.