Aim To identify whether a novel model of hospital based pharmaceutical care using a medical team based pharmacist provides benefits for patients and health care resources.
Setting Medical unit of a district general hospital.
Design Pilot study, open, using retrospective controls, three-month periods.
Outcome measures Intervention monitoring, errors, omissions and alterations on discharge prescriptions, reuse of patients' own drugs.
Results Increase in number of interventions by pharmacist from 114 to 237; shift in grade of doctor with whom interventions discussed from junior to senior (p<0.001); increase in interventions made prospectively from 26% to 54% (p<0.001); reduction in errors, omissions and alterations of discharge prescriptions (TTOs) from 32% to 8% (p<0.0001) and increase in the reuse of patients' own drugs in TTOs from 5% to 18% (p<0.001).
Conclusion Pharmacists can facilitate improved prescribing and medicines management by working closely with the medical team. This model provides a safer system, improvements in pharmaceutical care and better resource utilisation.
Traditional United Kingdom clinical pharmacy services in hospital utilise a designated pharmacist for each ward making scheduled visits to provide pharmaceutical care. Pharmaceutical care has been defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life.1 It has also been described as a collaborative process that aims to prevent or identify and solve medication problems. Doctors and pharmacists have complementary and supportive responsibilities in this process.2
In practice, clinical pharmacists in hospitals undertake prescription monitoring, working to ensure that prescribing and use of drugs is safe, effective and cost-effective.3 Any medication problems encountered are investigated by talking to the patient, nurse and/or doctor and making reference to the patient's medical notes where necessary. If the pharmacist considers that the patient's drug therapy may be causing harm or could be improved, this will be discussed with the prescriber and appropriate action instituted. In most centres this will be documented as a clinical intervention or contribution.
The pharmacist will also provide advice on medication to patients, nursing and medical staff. Some pharmacists attend consultant ward rounds. However, on most ward rounds, the pharmacist works in relative isolation without accompanying nurses or doctors. Prescription monitoring tends to be retrospective as the pharmacist has not been part of the decision making process of choosing individual drug therapy. The pharmacist will need to contact the doctor to confirm or amend drug charts after the prescription has been written and the patient may have already received the medicine. Pharmacist rounds may not always coincide with junior doctor rounds when medication related issues can be addressed at convenient or appropriate times for both doctor and pharmacist.
Analysis of clinical pharmacy interventions has demonstrated that pharmacists have an important role in improving patient care and advice is generally accepted by prescribers.4–7 The Crown report8,9 considered alternatives to the traditional roles of doctors in the prescribing process. The recommendations outline a number of situations where both nurses and pharmacists could extend their professional responsibilities in this area. For the clinical pharmacist these opportunities can facilitate the pharmacist becoming further accepted into the health care team as a dependent prescriber. Inclusion of pharmacists in consultant teams should give greater scope for them to contribute actively rather than intervene in the daily monitoring and prescribing of drugs.
Over the past five to 10 years, there has been considerable pressure in the UK to decrease junior doctors' working hours. A possible way of doing this is to transfer some tasks to other health care professionals, including nurses and pharmacists. A potential role that could be transferred to pharmacists is that of prescribing discharge medication. At present, junior house officers write most inpatient drug charts and discharge prescriptions. In addition to the considerable workload that this entails, these individuals are the least experienced of the medical team and may have limited knowledge of drugs and therapeutics. By accompanying junior doctors on their daily ward rounds, the pharmacist may be better able to contribute to patient care. Errors in discharge prescriptions have been reported in at least one study.10 These are often detected by dispensary staff as the writing of discharge prescriptions may not always coincide with the ward pharmacist visit. Using the pharmacist to write discharge prescriptions on a daily junior doctor round may help decrease prescribing errors and provide a safer system.
Reuse of patients' own drugs has been found to save money by decreasing dispensary workload as well as preventing unnecessary duplication of supplies that may confuse some patients.11–13 If the discharge prescription is discussed with the patient before it is dispensed, concordance is more likely to be realised as the patient will have more opportunity to question the need for certain medicines or ask about medicines not prescribed. Examination of the patient's own drugs at this point will allow the pharmacist to determine suitability for reuse and also to advise the patient about discontinued medicines. Closer liaison with the patient's nurse on a daily ward round is more likely to highlight certain pharmaceutical needs such as large print labels or medication reminder charts needed on discharge.
Aim The aim of this study was to test whether a team-based pharmacist could improve pharmaceutical care by facilitating prescribing and liasing more closely with patients. This in turn should help to reduce junior doctor workload and use staff resources more effectively.
The study was carried out over two separate three-month periods. During the control period (July to September, 1996), a traditional visiting clinical pharmacy service to review prescribing and provide advice was in place. All discharge prescriptions (TTOs) were written by junior doctors and clinically screened, with reference to the inpatient treatment chart, by a pharmacist either on the ward or in the pharmacy prior to dispensing. There was limited reuse of patients' own drugs, which was existing hospital practice.
During the study period (February to April, 1997) one clinical pharmacist was attached to a consultant medical team. This pharmacist attended the morning working ward round led by a senior house officer or registrar each day for a 22-bed medical ward. This enabled the pharmacist to contribute and participate actively in prescribing and management decisions. Additionally the pharmacist wrote TTOs for patients scheduled for discharge which were clinically validated by the doctor prior to dispensing.
For the first month of the study, pharmacist written discharge prescriptions were also clinically validated by a second pharmacist. Where appropriate, discharge medication was discussed with patients at the time of writing the prescriptions so that the pharmacist could provide medication counselling, assess which of the patient's own drugs were suitable for reuse and advise patients about any discontinued medicines.
The impact of this new model was evaluated by analysis of three activities: clinical interventions, TTO provision and the re-use of patients' own drugs.
Clinical interventions A standard data collection form was used to collect clinical intervention data conforming to widely accepted guidelines.14 These were collected by all pharmacists providing clinical services for medical, surgical and care of the elderly wards during the control period and by the designated pharmacist only in the study period. In addition to clinical details, process data were collected, including the pharmacist's identity, grade of doctor and whether the intervention was prospective (before prescribing) or retrospective (after the medicine had been prescribed).
TTO provision All TTOs in both arms of the study were checked by a pharmacist against the inpatient chart before dispensing and any prescribing errors, omissions and/ or alterations recorded. Any reuse of patients' own drugs and the location for the clinical validation (ie, ward or pharmacy) were also noted.
Patients' own drugs The number of items on each TTO was recorded together with the number of items of patients' own drugs suitable for reuse.
All data were analysed on Epi Info Vs 6 database.
During the control period, 556 interventions were recorded by eight pharmacists, 437 (78 per cent) of which were related to medical patients. There was no difference in the nature of interventions, the grade of doctor with whom the intervention was discussed, and whether the intervention was prospective or retrospective, between the study pharmacist and other pharmacists during the control period. Subsequent analysis is based on the activities of the team-based pharmacist.
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The nature of clinical interventions is outlined in Table 2. In addition to a doubling in the number of interventions there were increases in intervention of a multiple nature, ie, those which involved a number of problems and/or causes, and also patient counselling sessions.
Examination of the interventions showed that overall 56 interventions (49 per cent) in the control period compared with 131 (55 per cent) in the study period resulted in medication being started or stopped and 25 interventions (22 per cent) in the control period compared with 30 (13 per cent) in the study period resulted in dose alterations being made.
Table 2: Nature of interventions for study pharmacist |
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| Intervention | Control (n=104) | Study (n=237) |
| Adverse drug reaction | 4 (4%) | 6 (3%) |
| Drug history | 5 (4%) | 16 (7%) |
| Dosage regimen | 27 (24%) | 35 (15%) |
| Drug selection | 18 (16%) | 42 (18%) |
| Duration | 16 (14%) | 21 (9%) |
| Illegal or incomplete | 1 (1%) | 0 (0%) |
| Interaction | 8 (7%) | 2 (1%) |
| IV administration | 0 (1%) | 1 (<1%) |
| Multiple | 7 (6%) | 54 (23%) |
| Non-formulary | 6 (5%) | 4 (2%) |
| Other | 1 (1%) | 0 (0%) |
| Patient counselling | 8 (7%) | 36 (15%) |
| Patient monitoring | 9 (8%) | 15 (6%) |
| Therapeutic drug monitoring | 4 (4%) | 4 (2%) |
| Unclear | 0 (0%) | 1 (<1%) |
The acuity shifts, as shown in Table 3, must be viewed in tandem with the fact that during the study period there were almost twice as many interventions in total for the study pharmacist.
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During the study period, there was a highly significant increase in the number of interventions made prospectively compared with those made retrospectively (chi-squared, P<0.00001, odds ratio 3.29, confidence interval 1.95–5.56) (Table 4).
Table 4: Time of intervention with respect to prescribing |
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| Intervention | Control (n=114) | Study (n=237) |
| Prospective | 30 (26%) | 128 (54%) |
| Retrospective | 84 (74%) | 109 (46%) |
One hundred and eighty-seven discharge prescriptions were available for analysis during the control period from a total of 587 prescriptions written. Of these, 80 per cent were written by junior house officers and 76 per cent were clinically validated by pharmacists in the dispensary. Errors or omissions were found in 57 (30 per cent) of the sample. These could be classified as clinical (12, 6 per cent), illegal (3, 2 per cent), transcription (21, 11 per cent), unclear (4, 2 per cent) and multiple (17, 9 per cent).
During the study period, 102 discharge prescriptions were written by the pharmacist during or immediately after the morning junior doctor rounds of which 94 (92 per cent) were validated by the doctor, with no errors omissions or alterations documented. Every discharge prescription prepared by the pharmacist in the study period was clinically validated by the doctor on the ward. All the alterations on pharmacist written discharge prescriptions were either additions arising from new medication being prescribed or existing medication being stopped after it had been written. Comparison of number of errors and omissions or alterations per discharge prescription is shown in Table 5. This difference is highly significant (Kruskal-Wallis H-test, p<0.0001).
A total of 805 items were prescribed on the 187 control period discharge prescriptions of which 41 items (5 per cent) were patients' own drugs suitable for reuse. Of the 102 prescriptions written during the study period, there were 465 items of which 82 items (18 per cent) were suitable for reuse. Again this difference is highly significant (Kruskal-Wallis H-test, p<0.001).
Table 5: Errors, omissions and alterations on discharge prescriptions |
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| Number of errors per prescription | Control (n=187) Doctor written |
Study (n=102) Pharmacist written |
| None | 128 (68%) | 94 (92%) |
| One | 36 (19%) | 8 (8%) |
| Two | 11 (6%) | 0 (0%) |
| Three | 6 (3%) | 0 (0%) |
| Four | 3 (2%) | 0 (0%) |
| Five | 2 (1%) | 0 (0%) |
| Nine | 1 (1%) | 0 (0%) |
The aim of this study was to test whether a team-based pharmacist would improve pharmaceutical care of patients and reduce junior doctor workload. The results from the intervention data suggest that, by working closely with the doctors, the pharmacist can have a major impact on prescribing, as both the number and complexity of interventions increased during the study period. The pharmacist was able to provide a more active role in the prescribing and management of drugs. This was confirmed by an increase in number of prospective interventions during the study period supported by a corresponding increase in the number of drugs being started or stopped. The increase in number and complexity of interventions, rather than any major change in acuity, supports the hypothesis that the pharmacist had more opportunity to contribute to patient care because more knowledge about patients was gained by sharing with all members of the multidisciplinary team than by individual pharmacist rounds. There was, however, some change in the nature of interventions with the new model, in particular an increase in provision of medication counselling for patients. This was partly because the study pharmacist was able to spend more time per patient but also because preparation of the discharge prescription by the pharmacist allowed more opportunity for discussion of take-home medicines and greater scope for reuse of patients' own drugs.
All the intervention data in this work are self-reported which leads to potential bias from the observer. However, comparison with control period intervention data for all pharmacists working at the hospital, not just the study pharmacist, showed that the study pharmacist appeared to intervene in the same manner as the whole group during this period. This suggests that the change was due to the new method of working rather than some pre-existing factor associated with the study pharmacist, thus confirming that the intervention results support a more proactive role for the pharmacist by incorporation into the team.
A further source of potential bias is that the study has sequential control and study periods, a situation which was unavoidable. Ideally the same periods a year apart should have been used but due to practical constraints of working in a "real" environment this was not possible. However, the changes in the interventions to a more active prospective nature suggest the change is pharmacist rather than doctor influenced. The consultant team involved and the patient mix remained the same and this should have reduced this source of bias.
It was proposed that some errors in discharge prescriptions would occur with the new model as pharmacists have little experience in writing prescriptions and doctors may fail to detect errors during clinical validation. As a safeguard, a second pharmacist check was used for the first month of the study period to validate clinically discharge prescriptions written by the study pharmacist. The results indicate that despite these reservations there was a dramatic improvement in reduction of errors on TTOs, by reversing the usual roles of the pharmacist and doctor.
It has been suggested that dispensary pharmacists may not detect as many errors on discharge prescriptions as ward pharmacists.15. In this new model there was a dramatic shift in where the clinical validation took place from the dispensary to the ward.
This study only considered intervention outcomes defined as changes in prescribing and medication counselling which improved by incorporating the pharmacist into the team. Work in the United States has demonstrated that clinical pharmacy interventions can also be associated with favourable patient outcomes in terms of length of stay, cost avoidance issues and savings in drug expenditure.16–18 Although the results of these studies are not directly comparable with our work owing to differences in health care systems and care delivery, the principles of pharmacist contributions are similar as the potential adverse patient events avoided are the same. It is reasonable, therefore, to suggest that similar types of benefit are likely to accrue in UK hospitals, although the economic value will be different.
Our results did not show appreciable cost savings by reuse of patients' own drugs as the number of items reused for TTOs remained low even in the study period.
Although not objectively measured, there is no doubt that junior doctors' workload was reduced by the pharmacist taking on responsibility for writing the discharge prescription. This occurred in two ways. Although the time taken to write TTOs was not measured in this study this transfer of workload consequently saves medical time. If the assumption is made that it takes one minute to write a prescription line on a TTO and it also takes 30 seconds to carry out the overall clinical validating, then, in this study, approximately seven hours of junior medical staff time would have been saved. The second, which is more difficult to quantify, is the time lost rectifying errors and omissions. In the control phase almost one in three discharge prescriptions written by doctors (32 per cent) required referral back, due to at least one error or omission. Although unknown, the time taken by this must be considerable. In addition, elimination of this number of referrals and changes has significant benefits for pharmacy workload, should reduce delays for patients waiting for discharge medicines and decrease the "hassle" factor for nurses. Finally and importantly, it should improve patient safety, as although the pharmacy screening system is highly effective, the more errors or omissions that do occur the more likely are some errors to remain undetected, potentially leading to patient misadventure.
Benefits to pharmacists included being able to discuss drug therapy at the point of prescribing with more senior members of the medical team at regular, appropriate and convenient times. This helped to improve working relationships and avoided the pharmacist being perceived as criticising drug therapy through retrospective prescription monitoring. All discharge prescriptions written by the study pharmacist were prepared during morning rounds, often 24 hours ahead of planned discharge. If this were implemented throughout the hospital, it would be much easier to control workload in the dispensary, reducing delays in dispensing and consequently discharge of patients.
This study demonstrates that pharmacists contribute more frequently to prescribing and management of medicines by working closely with the medical team. The increased provision of medication advice to patients together with decreased prescribing errors on discharge prescriptions provide a safer system and improvements in pharmaceutical care of patients.
Acknowledgments Funding for the project was provided through South Thames department of postgraduate medical and dental education regional task force on junior doctors' hours.
Thanks go to Dr H. Alban-Davies (consultant, general medicine) and Dr K. Dhatariya (registrar) for supporting the project, and to Mrs M. A. Keating (chief pharmacist), Ms E. Wyatt (secretary) and pharmacy staff at Joyce Green hospital.
Susan Boorman is clinical services pharmacist at Joyce Green Hospital, Dartford, Kent DA1 5PL. Chris Cairns was director of the pharmacy academic practice unit at St George's Hospital, London. He is now director of pharmacy and dietetics at University Hospital, Lewisham. Correspondence to Miss Boorman