The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure

Objective: Heart failure patients are regularly admitted to hospital and frequently use multiple medication. Besides intentional changes in pharmacotherapy, unintentional changes may occur during hospitalisation. The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure. Setting: A general teaching hospital in Tilburg, the Netherlands. Method: An open randomized intervention study was performed comparing an intervention group, with a control group receiving regular care by doctors and nurses. The clinical pharmacist discharge service consisted of review of discharge medication, communicating prescribing errors with the cardiologist, giving patients information, preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication. Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured. Main outcome measure: The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined. Results: Forty-four patients were included in the control group and 41 in the intervention group. Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39% in the intervention group (RR 0.57 (95% CI 0.37-0.88)). The percentage of medications with a discrepancy or prescription error in the control group was 14.6% and in the intervention group it was 6.1% (RR 0.42 (95% CI 0.27-0.66)). Conclusion: This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge

Understanding and promoting effective self-care during heart failure

Heart failure (HF) self-care relates to the decisions made outside clinical settings by the individual with HF to maintain life, healthy functioning, and well-being. The people who help patients most (ie, caregivers/family members) should be involved in care, and general principles of health behavior change should be used to guide support. Medicines should be prescribed with once-daily dosing, with pharmacists providing medication review and support. Pill boxes should be provided and patients’ health literacy levels assessed. Psychosocial interventions for smoking cessation should be undertaken. Regular aerobic exercise may benefit patients with mild to moderate HF and some with severe but stable HF; therefore, referral to cardiac rehabilitation should be considered. Exercise regimen must take into account patient-related factors, including functional status, comorbid conditions, and patient preferences. Intake of salt, alcohol, and fluid should be restricted, although these steps are supported by limited evidence. Patients should be educated on appropriate sources of help. They should seek help immediately for persistent chest pain, palpitations, syncope, breathlessness at rest, or a weight increase of ≥ 2 lb. Depression, if present, should be addressed with antidepressants (sertraline and citalopram), cognitive behavioral therapy, and regular exercise. HF disease management programs should be offered if available. © 2010 Springer Science+Business Media, LLC