Multifaceted pharmacist-led interventions in secondary care settings between countries of various income levels: a scoping review protocol.

INTRODUCTION: Clinical pharmacy services often involve multifaceted pharmacist-led interventions. However, current pharmacy practice models vary across different countries. Despite the documented benefits of clinical pharmacy services, the characteristics of pharmacist-led interventions in different countries have not yet been adequately explored and described. Therefore, this protocol outlines the methodology for a proposed scoping review aiming to investigate various types of multifaceted pharmacist-led interventions and the outcomes used to evaluate their effectiveness within secondary care settings. Additionally, the scoping review will map the current evidence surrounding the characteristics of interventions and outcomes reported across various countries of socioeconomic status. METHODS AND ANALYSIS: The scoping review will be conducted according to the JBI Methodology for Scoping Reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews. We will systematically search the following electronic databases: MEDLINE (Ovid), CINAHL (EbscoHost), Embase (embase.com), Scopus (scopus.com), Cochrane Library (cochranelibrary.com) and APA PsycInfo (Ovid). Additionally, the reference lists of identified reviews and included full texts will be searched for relevant papers. Grey literature sources, such as International Pharmaceutical Abstracts and the International Pharmaceutical Federation (FIP) website, will be searched. We will include primary studies published in the English language from January 2013 to December 2023, involving secondary care multifaceted pharmacist-led interventions. Two independent reviewers will screen studies against eligibility criteria and use a piloted data extraction form to extract relevant information. We will extract relevant data, complete a tabular summary from each included publication and analyse it. ETHICS AND DISSEMINATION: Ethical approval is not required as we will be using data from publicly available literature sources. Findings will be disseminated in publications and presentations with relevant stakeholders. We aim to map available evidence across the breadth of studies that have reported multifaceted pharmacist-led interventions and their outcomes.

Unplanned rehospitalisation due to medication harm following an Acute Myocardial Infarction.

Introduction The contribution of medication harm to rehospitalisation and adverse patient outcomes after an acute myocardial infarction (AMI) needs exploration. Rehospitalisation is costly to both patients and the healthcare facility. Following an AMI, patients are at risk of medication harm as they are often older, have multiple comorbidities and polypharmacy. This study aimed to quantify and evaluate medication harm causing unplanned rehospitalisation after an AMI. Methods This was a retrospective cohort study of patients discharged from a quaternary hospital post-AMI. All rehospitalisations within 18 months were identified using medical record review and coding data. The primary outcome measure was medication harm rehospitalisation. Preventability, causality and severity assessments of medication harm were conducted. Results A total of 1564 patients experienced an AMI and 415 (26.5%) were rehospitalised. Eighty-nine patients (5.7% of total population; 6.0% of those discharged) experienced a total of 101 medication harm events. Those with medication harm were older (p=0.007) and had higher rates of heart failure (p=0.005), chronic kidney disease (CKD) (p=0.046), chronic obstructive pulmonary disease (COPD) (p=0.037) and a prior history of ischaemic heart disease (p=0.005). Gastrointestinal (GI) bleeding, acute kidney injury (AKI) and hypotension were the most common medication harm events. Forty percent of events were avoidable and 84% were classed as 'serious'. Furosemide, antiplatelets and angiotensin-converting enzyme inhibitors (ACEi) were the most commonly implicated medications. The median time to medication harm rehospitalisation was 79 days (interquartile range [IQR]: 16-200 days). Conclusion Medication harm causes unplanned rehospitalisation in 5.7% of all AMI patients (1 in 17 patients; 6.0% of those discharged). The majority of harm was serious and occurred within the first 200 days of discharge. This study highlights that measures to attenuate the risk of medication harm rehospitalisation are essential, including post-discharge medication management.

Impact of a clinical pharmacist on optimising the quality use of medicines according to the acute coronary syndrome (ACS) secondary prevention guidelines and medication adherence following discharge in patients with ACS in Sri Lanka: a prospective non-randomised controlled trial study protocol.

OBJECTIVES: Ensuring quality use of medicines (QUM) through clinical pharmacy services can improve therapeutic outcomes of patients diagnosed with acute coronary syndrome (ACS). The major objective of this study is to demonstrate the added value of a clinical pharmacist to the medical and nursing team providing care to patients with ACS on the continuation of quality use of the patients' medicine after discharge. STUDY DESIGN: This protocol outlines a prospective, non-blinded, non-randomised, controlled interventional study. STUDY SETTING: The study will be conducted at the professorial medical wards of a tertiary care teaching hospital in Sri Lanka. PARTICIPANTS: Sample size will be 746 patients in both control and intervention arms. Patients diagnosed with ACS who are 18 years old or above and expected to visit the hospital for their routine clinic follow-ups after discharge will be recruited and randomised 1:1 to either the intervention group or the control group. Patients who are diagnosed and suffering from psychological disorders will be excluded from this study. INTERVENTIONS: The planned interventions that will be delivered at discharge include review and optimisation of medications, assessing patient adherence and providing discharge medication counselling. Data will be collected at recruitment, 1 month, 3 months and 6 months' time intervals in both groups. Improvement of patients' medication adherence, reduction of hospital readmissions, reduction of drug-related problems, the attitude of doctors and nurses towards clinical pharmacy services and the cost-effectiveness of the clinical pharmacy services will be the major outcomes of this study. ETHICS AND DISSEMINATION: Ethical approval for this study has been obtained from the ethics review committee, Faculty of Medicine, University of Peradeniya (2019/EC/26) and the trial is registered at the Sri Lanka Clinical Trials Registry. The results of this study will be disseminated via conference proceedings, journal publications and thesis presentations. TRIAL REGISTRATION NUMBER: SLCTR/2019/039.

Reducing Medical Admissions into Hospital through Optimising Medicines (REMAIN HOME) Study: protocol for a stepped-wedge, cluster-randomised trial.

INTRODUCTION: A model of general practitioner (GP) and pharmacist collaboration in primary care may be an effective strategy to reduce medication-related problems and provide better support to patients after discharge. The aim of this study is to investigate whether a model of structured pharmacist and GP care reduces hospital readmissions in high-risk patients. METHODS AND ANALYSIS: This protocol details a stepped-wedge, cluster-randomised trial that will recruit participants over 9 months with a 12-month follow-up. There will be 14 clusters each representing a different general practice medical centre. A total of 2240 participants will be recruited from hospital who attend an enrolled medical centre, take five or more long-term medicines or whose reason for admission was related to heart failure or chronic obstructive pulmonary disease.The intervention is a multifaceted service, involving a pharmacist integrated into a medical centre to assist patients after hospitalisation. Participants will meet with the practice pharmacist and their GP after discharge to review and reconcile their medicines and discuss changes made in hospital. The pharmacist will follow-up with the participant and liaise with other health professionals involved in the participant's care. The control will be usual care, which usually involves a patient self-organising a visit to their GP after hospital discharge.The primary outcome is the rate of unplanned, all-cause hospital readmissions over 12 months, which will be analysed using a mixed effects Poisson regression model with a random effect for cluster and a fixed effect to account for any temporal trend. A cost analysis will be undertaken to compare the healthcare costs associated with the intervention to those of usual care. ETHICS AND DISSEMINATION: The study has received ethical approval (HREC/16/QRBW/410). The study findings will be disseminated through peer-reviewed publications, conferences and reports to key stakeholders. TRIAL REGISTRATION NUMBER: ACTRN12616001627448.

An evaluation framework for non-medical prescribing research.

Without robust and credible evidence for the benefits in health outcomes of non-medical prescribing, widespread implementation will be challenging. Our aim is to develop a consistent evaluation framework that could be applied to non-medical prescribing research. An informal collaboration was initiated in 2008 by a group of pharmacists from Australia and New Zealand to assist in information sharing, pilot design, methodologies and evaluation for pharmacist prescribing. Different pilots used different models, methodologies and evaluation. It was agreed that the development of a consistent evaluation framework to be applied to future research on non-medical prescribing was required. The framework would help to align the outcomes of different research pilots and enable the comparison of endpoints to determine the effectiveness of a non-medical prescribing intervention.

Pilot of a National Inpatient Medication Chart in Australia: improving prescribing safety and enabling prescribing training.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Prescribing errors are common and are caused by multiple factors. Standard medication charts have been recommended by British and Australian Health services. A study of a standard medication chart in five hospitals in one state of Australia significantly reduced prescribing errors. WHAT THIS STUDY ADDS: A standard medication chart developed in one area can be adopted through a collaborative process and successfully implemented across a diverse country resulting in similar reductions in prescribing errors. Three of the four stages of the prescribing process (information gathering, decision making and communication of instructions) can be improved by the use of an improved standard medication chart. The introduction of a standard medication chart has enabled development of standard prescribing education programmes. AIMS: To establish whether a standard national inpatient medication chart (NIMC) could be implemented across a range of sites in Australia and reduce frequency of prescribing errors and improve the completion of adverse drug reaction (ADR) and warfarin documentation. METHODS: A medication chart, which had previously been implemented in one state, was piloted in 22 public hospitals across Australia. Prospective before and after observational audits of prescribing errors were undertaken by trained nurse and pharmacist teams. The introduction of the chart was accompanied by local education of prescribers and presentation of baseline audit findings. RESULTS After the introduction of the NIMC, prescribing errors decreased by almost one-third, from 6383 errors in 15,557 orders, a median (range) of 3 (0-48) per patient to 4293 in 15,416 orders, 2 (0-45) per patient (Wilcoxon Rank Sum test, P < 0.001). The documentation of drugs causing previous ADRs increased significantly from 81.9% to 88.9% of drugs (χ(2) test, P < 0.001). The documentation of the indication for warfarin increased from 12.1 to 34.3% (χ(2) test, P= 0.001) and the documentation of target INR increased from 10.8 to 70.0% (χ(2) test, P < 0.001) after implementation of the chart. CONCLUSIONS: National implementation of a standard medication chart is possible. Similar reduction in the rate of prescribing errors can be achieved in multiple sites across one country. The consequent benefits for patient care and training of staff could be significant.

Safe medication practice: attitudes of medical students about to begin their intern year.

OBJECTIVES: Interns are expected to prescribe effectively and safely. This study aimed to assess medical students' perceptions of their readiness to prescribe, associated risks and outcome if involved in an error, as well as their perceptions of available support. METHODS: We carried out a survey of 101 students prior to their intern year using a structured questionnaire. An indication of agreement with 21 closed statements was sought. Thematic clusters were identified by factor analysis. RESULTS: Most students (84) felt they would be able to prescribe for most simple complaints and complete discharge prescriptions (81). In high-risk situations, fewer students felt comfortable with prescribing: only 54 felt sufficiently confident to prescribe warfarin and 66 felt confident enough to order i.v. fluids. Many felt support such as guidelines was available (87) and that, if in doubt, they could clarify instructions and seek advice. Students were aware of errors occurring within the medication system; however, most (99) believed that the medicines they prescribed would be safely administered. There was a mixed perception of medication errors: 40 felt that their prescribing errors would not be dealt with constructively and 79 indicated that a culture existed at their hospitals where clinicians would be blamed if they made a prescribing error. CONCLUSIONS: At the end of medical school education and prior to assuming responsibility for prescribing, students felt unprepared and perceived that negative outcomes would result if they were involved in errors. These findings indicate that much more work is needed to prepare doctors to prescribe safely, improve the safety of prescribing systems and address the issue of blame.

Why do interns make prescribing errors? A qualitative study.

OBJECTIVE: To identify and analyse factors underlying intern prescribing errors to inform development of specific medication-safety interventions. DESIGN: A prospective qualitative study that involved face-to-face interviews and human-factor analysis. SETTING: A tertiary referral teaching hospital, Brisbane, Queensland, February-June, 2004. PARTICIPANTS: Fourteen intern prescribers involved in 21 errors. METHOD: A structured questionnaire was used to identify factors causing the errors. Transcripts were analysed on the basis of human-error theory to identify underlying themes. MAIN OUTCOME MEASURES: Factors underlying prescribing errors. RESULTS: Errors were multifactorial, with a median of 4 (range, 2-5) different types of performance-influencing factors per error. Lack of drug knowledge was not the single causative factor in any incident. The factors in new-prescribing errors included team, individual, patient and task factors. Factors associated with errors in represcribing were environment, task and number of weeks into the term. Defences against error, such as other clinicians and guidelines, were porous, and supervision was inadequate or not tailored to the patient, task, intern or environment. Factors were underpinned by an underlying culture in which prescribing is seen as a repetitive low-risk chore. CONCLUSION: To reduce the risk of prescribing errors, a range of strategies addressing patient, task, individual, team and environment factors must be introduced.