Introduction
In the contemporary times, there have been increased emphases on patient centered care in which all care providers are supposed to ensure that the safety of the patients is prioritized. This is achieved through a collaborative care in which all the health professionals ensure that care delivery does not endanger the lives of the patients. As such, clinical pharmacists play a critical role in prevention of adverse drug reactions (ADRs) by being involved in timely interventions. According to Suyagh, Farah and Farha (2015), ADRs are leading causes of patient related morbidity and mortality; thus, interventions aimed at reducing the adverse effects are paramount in any treatment process. The involvement of the clinical pharmacists enhances the safety of patients. It is worth noting that the clinical pharmacists are trained in therapeutics to provide comprehensive drug management to patients. Bearing in mind the critical role played by the clinical pharmacists, the following paper presents a research on interventions carried out by pharmacists. The research exemplifies the critical role of patients in enhancing safety of the patients.
Background of Clinical Pharmacy Interventions
Clinical pharmacy is a broad term that is used to describe function performed by pharmacist in the health care setting. This broad definition is not limited to any function. In the U.S., the department of health and human services defines the term as, “Functions performed by pharmacists on behalf of the patient to identify, resolve and prevent drug-related problems” (Gillespie 15). The definition mainly focuses on optimization of drug therapy but does not provide specific context in which the pharmacists should practice. Thus, based on the definition, it signifies that clinical pharmacist can work at hospital setting or community setting to provide the various functions.
The clinical pharmacists are involved in the care process by being involved in various activities. They provide consistent process of patient care that promotes effectiveness, safety, and appropriateness of drug use. They consult with physicians and care providers to implement medication plans that can be used to meet the overall requirements of a patient. Also, the clinical pharmacist apply their knowledge and experience of the clinical use of medicines, such as dosing, drug interactions, dosage and administering of drugs in order to ensure that patients receive the right medication.
There are many studies that have established cases of inappropriate interventions in the healthcare centers, which result in adverse drug events. As such, health care systems have been under immense pressure to ensure that inaccuracies that relate to medication are reduced. Kuo, Touchette and Marinac (2013) emphasized that in the process of any treatment, there is the need to ensure that there are no errors in the medication that may adversely affect the lives of the patients. However, past studies have shown that in the course of interventions, there are inaccuracies that occur especially in the use of drugs. The errors are associated with the physicians prescribing the wrong medication, omission of medication, the wrong frequency of drugs of inappropriate route of administering the drugs. Besides, there are transcription errors. These inaccuracies are not intentional and hence, the increasing need for involvement of clinical pharmacists in the review of medication in order to stop undesired outcomes (Reis et al. 2013). The Institute of Medicine (IOM) pointed out that the mitigation of drug errors is a top priority and there is need for concerted effort to ensure that patients are accorded quality care. The institute went further to denote the cost implications that result from medications errors.
Reports on errors are normally related to the drugs products given to the patients, procedures used and the systems. According to Gillespie (2012), drug errors are not limited to specific stages of treatment; instead, they can occur at any step of the process of using the drug such as in the prescription, administering and documentation. The major areas of intervention for clinical pharmacists include consultation, drug selection, administration route, frequency of the medication, missing medication, therapeutic duplication, and transcription errors (Lakshmi, James & Kirthivasan 2013). In the past, pharmacists’ roles were predominantly dispensation of medications in health care settings. The pharmacist did not work closely with the other medical professionals. However, in the modern times, this has changed and clinical pharmacists are involved in mainstream provision of health care. Lakshmi, James and Kirthivasan (2013) pointed out that pharmacists collaborate with other health professionals to ensure patient centered care in the hospitals. In addition to ensuring that medicines are obtained and dispensed by application of the highest possible standards, many pharmacists have also diversified to alternative areas of care provision. For example, pharmacists are involved in different clinical interventions. This implies that the pharmacists work closely with physicians. A pharmacist intervention entails corrective actions taken in order to enhance the management of patients. Due to the nature of training in pharmacology, pharmaceutics, pharmatherapy, clinical pharmacist are placed at a better position to offer suggestions to the other care providers on the possible care process for the patients (Kuo, Touchette & Marinac 2013). This helps in enhancing the outcome of the patient. For example, in avoiding undesired drug interactions for patients with co-morbidities.
As argued by Kuo, Touchette and Marinac (2013), the process of medication use is a dynamic process in which caution should be exercised to ensure that the right drugs are given to the patients. The dynamics entail ensuring that there are no adverse drug interactions, right route for medication is used and that other pharmacological factors are considered. Clinical pharmacists have the essential professional training which enables them to understand the critical factors related to drugs.
The appropriate use of mediations entails health processes in which the patients receive the right mediation for their clinical need. This is normally provided in the correct dosage, appropriate period of time and in the right route of administration (Lakshmi, James & Kirthivasan 2013). As such pharmacists are concerned with appropriate medication, application of the right dosage as per the requirement of the patient, appropriate pharmacotherapy, right indication, administration, treatment duration, monitoring and ensuring that patients adhere to the treatment (Gallagher et al. 2014). These processes are important in the avoidance of adverse drug-to-drug reactions. When used correctly, medications serve as the best therapeutic resources. However, irrational use of drugs is a great public health issue which has a negative effect on clinical care process. It is estimated that medical errors can lead to usage of up to 70% of the funds allocated for normal medication (Kuo Touchette & Marinac 2013).
In 1999, IOM published the report To err is human: building a safer health system, which showed that the care advanced to patients was not safe and that there were cases of deaths happening due to inappropriate medications. Hence, the report called for rational use of medication and pointed out to the importance of inter-professional collaboration. In addition, in 2012, the World Health Organization (WHO) estimated that over 50% of all medications are inappropriately sold, prescribed and dispensed. The errors are not limited to the outpatient activities but also include the in-patient care. IOM recognized that pharmacists are essential resource in the safe medication use; the body noted that involvement of the professionals on ward rounds improves the medication safety. Also, they added that physician-pharmacist-patient collaboration is important.
Miranda et al. (2012) stipulated that the primary task of the pharmacist is to ensure that there is safe and effective use of medicines; this is achieved by collaborating with their professionals and patients. This is a shift from the traditional role in which pharmacists were relegated to the final stages of the patients stay in the hospital, i.e. dispensation of drugs. However, with the increased need for patient centered care, studies have pointed to the importance of pharmacists in ensuring safety and good outcome in the care of patient. As a result, medication review in different stages of treatment has been found to lead to reduction in the inappropriate drug prescriptions. Besides, clinical pharmacists are involved in provision of care for patients with diseases such as hypertension and diabetes.
As emphasized by Gillespie (2012), medication errors can occur at any stage of care delivery. As such, inclusion of the clinical pharmacists in the different stages of care delivery assists in the promotion of better medical use by making sure that patients obtain appropriate pharmacotherapy; hence, reducing the risks of poor outcomes. For example, in the clinical pharmacy intervention, the pharmacists are involved in the review of medication which helps in the identification and prevention of drug therapy problems and other negative outcomes associated with poor use of drugs such as increased hospital stay and costs. Therefore, clinical pharmacists are specially trained in therapeutics; hence, they are involved in the provision of comprehensive drug management to the patients in the various settings in the hospital and at community level. Even though there are many studies that have focused on the role of pharmacists in the care process, most of them have mainly been aligned to outpatient care, very few have focused on clinical pharmacist intervention in the inpatient setting. Thus, the current study is based on the need to investigate the clinical pharmacist interventions in the inpatient setting.
Objectives
Bearing in mind the implications of errors, there is the need for inter-professional collaboration in the provision of healthcare; this is in line with Gillespie (2012) sentiments that clinical pharmacists are integral in different stages of healthcare delivery. This serves as the basis of pharmacy interventions and upholding the standards of pharmatherapy. Therefore, the aim of this study was to analyze the role clinical pharmacists interventions performed in male and female surgical and male and female orthopedic wards. Thus, the objectives were
- To establish the correlations between clinical pharmacists and patients co-morbidities.
- To establish the major interventions of clinical pharmacists.
- To determine the major medications categories the clinical pharmacists are involved.
Statistical Analysis
The clinical pharmacist interventions were tabulated and graphical representations generated by use of excel spreadsheets to establish clear depiction of the major intervention and medication category. The data presented was only for the interventions and there was no control study; hence, statistical test were not conducted.
Results
In the endeavor to establish clinical pharmacist intervention, data was collected from male and female surgical and male and female orthopedic wards. The key areas of investigation were based on the earlier stated three objectives, i.e. The correlation between clinical pharmacist and patients co morbidities, The major interventions category of clinical pharmacist, and The major medications category.
The study period was from 5th of January until 16th May 2016, the researcher reviewed the clinical pharmacist interventions in various medication and intervention categories. The intervention categories included consultation, inappropriate drug selection, inappropriate route of administration, inappropriate dose, inappropriate frequency, incomplete order, missing medication, therapeutic duplication, and transcription errors. On the other hand, the medication categories were anti-coagulants/ anti-platelets, anti-hypertensive, anti-infective, gastrointestinal agents/ PPIs, NSAIDS/Analgesic, Oral anti-diabetic/ insulin, supplements, others (alkalinizing agent, asthmatic medication, Benign prostate hypertrophy, Corticosteroids, immunosuppressant, urinary incontinence medication, osteoporosis medication and thyroid medication. The clinical pharmacist interventions focused on the patients aged between 14 and 84 years. The hospitalization duration for the patients varied. It is worth noting that some of the patients had co-morbidities while other did not. Also, the age gap ensured that comprehensive results that can be generalized to different age groups could be used. In total, there clinical pharmacist were involved in 98 intervention for the short duration of the study.
The correlation between clinical pharmacist and patients co morbidities
The number of interventions for patients with co-morbidities was 39 while the patients without co-morbidities were 59. In relation to case in brief, the interaction between the pharmacist and the patient entailed correction, recommendation, and contacting the doctor or the patient to ascertain the use of the medication. For example, in a case brief involving order Victoza 18u daily, the pharmacist contacted the patient and confirmed the prescription to be 1.8mg daily. Also, the interventions entailed stopping some of the drugs, for example, in a patient who had Ht 190/100, chronic cough and a new order of Celebrex 200mg, the pharmacist recommended the patient to stop of NSAID. In other instances, the pharmacist contacted the doctor in order to ensure appropriate dosage. For example, on discharge reconciliation resume medication Exforge 320/10 Aspirin 81mg and Lextonil 3mg For 1 Month, the pharmacist intervention entailed recommendation to reduce duration of Lexatonil 3mg and added the resume medication. It is worth noting that the interventions were not limited to patients with co-morbidities only, it also included the patients without. In fact, the cases of patients without co-morbidities were more. Table 1 below and the chart present the summary of the interventions undertaken by clinical pharmacist in relation to patients with and without co-morbidities.
Table 1: Clinical Pharmacists’ Interventions.
The Major Interventions Category of Clinical Pharmacist
The interventions by the clinical pharmacist took place in different stages of patient care process. The major intervention categories included consultation, inappropriate drug selection, inappropriate route, and inappropriate dose among other inaccuracies. Table 2 below is a summary of the major intervention categories that were reviewed and the subsequent graphical representation of the interventions. From the review it was established that list cases of errors are encountered in the categories of inappropriate route, incomplete order and mission medication in which each accounted for 1 case. The major areas of concern where the clinical pharmacists intervened included therapeutic duplication, inappropriate dose and consultation which accounted for 26.6%, 24.5% and 18.4% respectively.
Table 2: Major Intervention Categories.
Medication Categories
During the intervention process, the pharmacists were involved in different medication categories. From the 98 reviews, the major medication category of intervention entailed the use of NSAIDS/analgesic which accounted for 36.7% interventions. This was followed by use of anti-ineffective which accounted for 24.5% cases. Table 2 is a summary the major medications categories and the number of clinical pharmacist interventions.
Discussion
The involvement of the clinical pharmacists in the different stages of treatment is the most appropriate way to ensure safety and minimize medical errors. According to Khalili et al. (2011), myriad of studies have supported the fact that pharmacotherapy monitoring can help in the reduction of medication inaccuracies. In the current study, it was established that clinical pharmacists have a role to play right from the consultation to the discharge of patients. This qualifies the findings by Gellespie (2012) who noted that clinical pharmacy interventions should not be limited to specific stages of medications. Thus, it is worth noting that all stages in the treatment play a critical role in enhancing the safety of the patients. The following section discusses the implications of the results obtained from the pharmacists’ interventions.
An error in medication is an important variable that can be used to gauge the safety of services provided to the patients. It is therefore important to determine the areas that are prone to errors and hence, involve the right professionals to solve the problems. In the cases of errors that relate to drug dosage, clinical pharmacists are best placed to intervene. This is achievable by ensuring that they are engaged in the review of medication for patients and constant consultation with the physicians. For instance, studies have pointed out the essentiality of clinical pharmacists interventions in the improvement of the outcomes of the patients.
According to Khalili et al. (2011), medication related issues are prevalent; statistics show that errors are reported from 1.5 to 35% of the doses to patients who are hospitalized. Khalili et al. (2011) added that the errors are responsible for undesired health outcomes such as morbidity and mortality of approximately 6.5% of the admissions in hospitals. Up to 75% of the errors reported can be prevented if appropriate measures are taken. For example, through the involvement of professionals to review the medications before the patients use them. In this context, the professionals are the clinical pharmacists. The clinical pharmaceutical interventions allow multiple layer of patient protection which can help to reduce errors in the care of the patients.
The interventions are normally achieved by engaging the clinical pharmacists in the ward rounds, in interviewing the patients, counseling the patients during the discharge and follow up; both for the in patients and outpatients. These essential roles relate to the findings by Alassaad et al. (2014) who noted that clinical pharmacists are responsible for the therapeutic drug monitoring, review of the patients’ medical records and educating the other healthcare professionals about drug interactions and adverse effects. Thus, it can be inferred that participation of the clinical pharmacists in the entire medication process from consultation, dispensing, to administration helps in the reduction of mistakes and hence, benefits the patients.
As established from the results, the major categories of interventions associated with drug errors included therapeutic duplication, inappropriate dose and consultation. The therapeutic duplication and inappropriate dose relate to prescription errors which in the previous studies have been noted as points of inaccuracies. Altavela, Jones and Ritter (2008) found out that prescription errors are major causes of adverse drug events; therefore, the interventions in the two categories qualify the importance of the clinical pharmacists in enhancing the safety of patients in the care process. Clinical pharmacists have a great role in the prevention, detection and solving clinical errors. This is confirmed by their involvement in all categories of intervention. It is important to note is that pharmacists’ intervention in the consultation accounted for 18.4% a pointer of the changing roles of pharmacists in clinical activities from just dispensation of drugs to processes that traditionally were a preserve for the physicians.
A critical analysis of the findings shows that clinical pharmacists play a great role in the early detection and resolution of wrong prescription. For example, the 98 interventions performed both for patients with and without co-morbidities is an attestation of the benefits of involving pharmacists in the clinical activities. In each stage there was a happening that required the intervention of the pharmacists. The average rate of pharmacists’ intervention in the current study was 10.5%; this relates to findings by Bulk et al. (2007) which pointed to an error rate of approximately 15% in their study. Also, the frequency of the inappropriate frequency of medication in the study is 10.2% which compares to past in-depth studies such as those by Tully and Buchan (2009) that reported a mean rate of 10.5%.
The rate signifies the important role of the professionals when they collaborate with the physicians, patients and other care givers. For example, correction of wrong doses and adjustment, which are experienced in different clinical settings. Also, the pharmacists were involved in intervention to suspend inappropriate medication. These findings relate to earlier studies that showed that wrong medication and inappropriate therapeutic being common areas where the services of pharmacist are imperative.
Drugs for relieving pain, i.e. analgesia are commonly used in the inpatient care; however, most of the time, the drugs are inappropriately used in cases of patients with co-morbidities. This predisposes the patients to serious problems. This is so, bearing in mind that the analgesic drugs are used concurrently with other mediations and hence cases of adverse drug reaction are very high. Therefore, the high percentage of intervention that relate to the NSAIDS/analgesics in which the clinical pharmacists intervened.
Pharmacists play an imperative role in ensuring that patients adhere to prescription medication. Besides various studies show that 50-80% of patients have at least a discrepancy at the time of admission or discharge (Altavela, Jones & Ritter 2008). However, the incomplete or missing medication accounted for 1% contrary to the high percentage by the earlier studies. Nevertheless, this does not disqualify the need for pharmacists’ intervention. In fact, the interventions in various categories show that there is the need for health professionals with knowledge and expertise of pharmacology during the admission and discharge of patients in order to provide medical reconciliation where necessary. This critical role is denoted by the number of interventions carried out during consultation and correction of drugs at the time of discharge. Lakshmi, James and Kirthivasan (2013) stated that the aim of pharmacist interventions in the reconciliation of medication is to ensure that medication and doses are appropriate, verification of whether the right medication is used for the medical issue at hand.
As noted by Bladh et al. (2011), medication discrepancies such as omitted medication, out of date dosages and drugs that are non active are common inaccuracies that relate to drug use. The inaccuracies result due to poor communication or lack of collaboration between the physicians, nurses, and the pharmacists. In fact, Buck et al. (2007) stated that poor inter professional collaboration is the major source of errors and adverse drug effects. These cases are normally reported in hospitalized patients and have negative effect on morbidity, increase the cost of hospitalization and sometimes can lead to mortalities. With the current emphasis on the safety of the patients, there is increased need to avoid discrepancies in the care delivery process and thus, the requirement for pharmacists to review medication for the patients at every stage of care delivery.
Existence of co-morbidity is a predictor of increased morbidity and mortality (Khalili et al. 2011). As such, there is the need for care to be taken when providing medication for patients with co-morbidities. It is estimated that half of patients with chronic diseases usually have co-morbidities. This is exacerbated by the age factor. It is worth noting that the current study included diverse age groups. Even though there was no categorization of data based on the age group, there were 39 case briefs of co-morbidities that could be associated with the senior citizen involved in the review. In relation, to clinical pharmacists’ intervention for the patients with co-morbidities, there were 39 cases which required the involvement of the pharmacists. The intervention processes entailed contacting the patient to confirm the dosage, contacting the doctor to inquire about the medication and sometimes recommendation to stop the medication, reduce or refill the medication. Other intervention processes included the referral of the patients to specialists for example, hypertensive patients with ACS on anticoagulant and arbcs/ccbs but no blockers were referred to cardiologist.
Conclusion
The paper has established that drug safety is paramount in all processes of clinical pharmacists’ intervention. For instance, the analysis of the data showed the value attained when clinical pharmacists are involved in the treatment of the patients in the male and female surgical and male and female orthopedic wards. The interventions in the 98 case briefs pointed to the critical role of the clinical pharmacists in medical interventions; hence, promoting the safety of the patients. In summary, the critical areas of pharmacist’s intervention were in therapeutic duplication, use of inappropriate dose and in the consultation. In relation to drug medication category, it was established that the NSAIDS/analgesics accounted for the highest percentage followed by anti-infective. Therefore, the findings point to the essentiality of clinical pharmacists’ intervention and the need for physicians to involve the pharmacists in categories where there are high likelihoods of errors.
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