Implementation of pharmacist targeted discharge prescription review in an emergency department.

BACKGROUND/PURPOSE: Little data has been published regarding emergency medicine pharmacist (EMP) review of discharge prescriptions. An internal retrospective review of a limited sample size of emergency department (ED) discharge prescriptions demonstrated a 13.6% potential intervention rate by EMPs. With this information, it was postulated that EMPs could provide a valuable service via a process of targeted review of ED discharge prescriptions that would yield intervention rates higher than the internal audit. The aim of this project was therefore to develop a real-time notification system within the electronic health record (EHR) for targeted discharge prescription review, to establish an associated EMP workflow, and to evaluate the intervention rate achieved through targeted discharge prescription review. METHODS: This was a single-center, retrospective review of the implementation of a new pharmacist-driven clinical service over a 12 week period from February 19th, 2018 to May 14th, 2018. Criteria for prescription review were determined after an internal audit by the EMPs and included an assessment of established high-alert medications. Discharge prescriptions that met the inclusion criteria were filtered into a real-time work queue in the EHR for EMP review. When necessary, EMPs discussed recommendations with prescribers, or adjusted prescriptions according to institutional pharmacist privileges. Interventions were reviewed and categorized to assess rate of intervention and the types of medication-related problems (MRPs) identified. RESULTS: EMPs reviewed 378 discharge prescriptions and a total of 158 prescriptions were identified as having at least one MRP. Of these, 70 prescriptions were intervened upon thereby resulting in an 18.5% intervention rate. The most common interventions included a change in the dose/frequency, duration/refills of the medication, and patient education. The highest number of interventions were made for anticoagulant and antiinfective agents. CONCLUSION: Utilization of a real-time notification system for prospective ED discharge prescription review is feasible. Using targeted criteria for review, pharmacists intervened on 18.5% of prescriptions reviewed. Prospective discharge prescription review by EMPs using a real-time notification system within the electronic health record identified opportunities for the pharmacist to ensure safe and optimal prescribing.

A Case of Metronidazole Injection Infiltration Without Sequelae.

Purpose: This report describes a case of metronidazole injection infiltration which contrasts the sole other case report in the literature at this time, as the patient described herein experienced mild signs and symptoms with prompt resolution and no significant sequelae. Summary: The patient experienced metronidazole injection infiltration during administration open to gravity via an 18-gauge peripheral catheter in the left brachial vein. The site was examined at bedside within approximately 30 minutes of the incident and was noted to be slightly edematous, erythemic, and painful in terms of a 5.5 × 6.6-cm area. No blanching, blister formation, induration, skin discoloration, or diminished capillary refill were observed. The event was conservatively managed in the form of catheter discontinuation and marking of the affected area with a patient skin marker, as hyaluronidase was not administered due to a product osmolarity of ~314 mOsM/L and pH of 5.8. A bedside evaluation the next morning revealed full resolution of the previously described symptoms. The patient was discharged from the facility 11 days later without further complications from the infiltration event. Conclusion: We describe a case of metronidazole injection infiltration which did not require pharmacologic or nonpharmacologic interventions and resulted in complete resolution. This case supplements the current literature by contrasting the sole other case report which resulted in profound necrosis near the intravenous access site. This case suggests metronidazole infiltrations may not require clinician alarm or treatment if events occur under circumstances similar to that which is presented.

Assessing pharmacy students' ability to accurately measure blood pressure using a blood pressure simulator arm.

OBJECTIVE: To compare student accuracy in measuring normal and high blood pressures using a simulator arm. METHODS: In this prospective, single-blind, study involving third-year pharmacy students, simulator arms were programmed with prespecified normal and high blood pressures. Students measured preset normal and high diastolic and systolic blood pressure using a crossover design. RESULTS: One hundred sixteen students completed both blood pressure measurements. There was a significant difference between the accuracy of high systolic blood pressure (HSBP) measurement and normal systolic blood pressure (NSBP) measurement (mean HSBP difference 8.4 ± 10.9 mmHg vs NSBP 3.6 ± 6.4 mmHg; p<0.001). However, there was no difference between the accuracy of high diastolic blood pressure (HDBP) measurement and normal diastolic blood pressure (NDBP) measurement (mean HDBP difference 6.8 ± 9.6 mmHg vs. mean NDBP difference 4.6 ± 4.5 mmHg; p=0.089). CONCLUSIONS: Pharmacy students may need additional instruction and experience with taking high blood pressure measurements to ensure they are able to accurately assess this important vital sign.