Pharmacist provided medicines reconciliation within 24 hours of admission and on discharge: A randomised controlled pilot study

Background: The UK government currently recommends that all patients receive medicines reconciliation (MR) from a member of the pharmacy team within 24 hours of admission and subsequent discharge. The cost-effectiveness of this intervention is unknown. A pilot study to inform the design of a future randomised controlled trial to determine effectiveness and cost-effectiveness of a pharmacist delivered service was undertaken. Method: Patients were recruited seven days a week from five adult medical wards in one hospital over a 9 month period and randomised using an automated system to intervention (MR within 24 hours of admission and at discharge) or usual care which may include MR (control). Recruitment and retention rates were determined. Length of stay(LOS), quality of life (EQ-5D-3L), unintentional discrepancies(UDs) and emergency re-admission(ER) within 3 months were tested as outcome measures. The feasibility of identifying and measuring intervention associated resources was determined. Result: 200 patients were randomised to either intervention or control. Groups were comparable at baseline.95(99%) of patients in the intervention received MR within 24 hours, whilst 62(60.8%) of control patients received MRat some point during admission. The intervention resolved 250 of the 255 UDs identifed at admission. Only 2 UDs were identifed in the intervention group at discharge compared with 268 in the control. The median LOS was 94 hours in the intervention arm and 118 hours in the control, with ER rates of 17.9% and 26.7%,respectively. Assuming 5% loss to follow up 1120 patients (560 in each arm) are required to detect a 6% reduction in 3 month ER rates. Conclusions: The results suggest that changes in outcome measures resulting from MR within 24 hours were in the appropriate direction and readmission within 3 months is the most appropriate primary outcome measure. A future study to determine cost-effectiveness of the intervention is feasible and warranted

Pharmacist's review and outcomes:Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

PurposeThe purpose was to describe clinical pharmacist interventions across a range of critical care units (CCUs) throughout the United Kingdom, to identify CCU medication error rate and prescription optimization, and to identify the type and impact of each intervention in the prevention of harm and improvement of patient therapy.Materials and methodsA prospective observational study was undertaken in 21 UK CCUs from November 5 to 18, 2012. A data collection web portal was designed where the specialist critical care pharmacist reported all interventions at their site. Each intervention was classified as medication error, optimization, or consult. In addition, a clinical impact scale was used to code the interventions. Interventions were scored as low impact, moderate impact, high impact, and life saving. The final coding was moderated by blinded independent multidisciplinary trialists.ResultsA total of 20 517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. This resulted in an overall intervention rate of 16.1%: 6.8% were classified as medication errors, 8.3% optimizations, and 1.0% consults. The interventions were classified as low impact (34.0%), moderate impact (46.7%), and high impact (19.3%); and 1 case was life saving. Almost three quarters of interventions were to optimize the effectiveness of and improve safety of pharmacotherapy.ConclusionsThis observational study demonstrated that both medication error resolution and pharmacist-led optimization rates were substantial. Almost 1 in 6 prescriptions required an intervention from the clinical pharmacist. The error rate was slightly lower than an earlier UK prescribing error study (EQUIP). Two thirds of the interventions were of moderate to high impact