Observational audit of pharmacist clinical intervention and continuum of care activities at Nambour General Hospital

Abstract

Introduction Medication errors on hospital admission and discharge are common, and are potentially harmful to patients.1-3 Background The role of the hospital ward pharmacist is crucial in ensuring patient safety and continuity of medication management during the hospital stay and post-discharge. Medication reconciliation at admission and discharge, patient counselling, and general monitoring of patient medication during hospital stay greatly reduces medication-related patient harm. Method To observe the type and frequency of clinical interventions and continuum of care activities provided to inpatients by pharmacists working on wards 2E (cardiac patients) and 2C (general medical patients) of Nambour General Hospital (NGH). Two auditors shadowed 2E and 2C ward pharmacists over a two week period, and recorded continuum of care activities and clinical interventions observed for each inpatient via an audit tool. Results The analysis indicated that 79% and 87% of newly admitted patients received medication history and reconciliation (MHR) services on the day of admission for wards 2E and 2C respectively, with 25% and 47% of episodes requiring pharmacist intervention. Of the discharge prescriptions reviewed, more than 50% required pharmacist intervention. The most common interventions were wrong dose/form of drug (34%) and omitted/additional therapy (25%). Conclusion Obtaining and reconciling medication history information, and preparing for patient discharge, are the predominant continuum of care activities provided by ward pharmacists on 2E and 2C of NGH. The most common interventions observed were detection of omission of a medication, and inappropriate dose of form of medication being prescribed. 1. Healthcare, A.C.o.S.a.Q.i., Second National Report On Patient Safety - Improving Medication Safety, A.C.f.S.a.Q.i.H. Care, Editor. 2002: Canberra. 2. Stowasser D, A.Y., O'Leary K, Understanding the Medicines management Pathway. Journal of Pharmacy Practice and Research, 2004. 34(4): p. 4. 3. Council, A.P.A., Guiding principles to achieve continuity in medication management, A.P.A. Council, Editor. 2005, Commonwealth of Australia 2005: Canberra. p. 55.