Multifaceted approach to medication use policy development: the restriction of meperidine.

As institutions continue to expand their drug policy development efforts in order to improve care and reduce cost, the use of multifaceted approaches offer several benefits. Population data on drug use support the need for policy action. The use of institutional outcomes data in conjunction with published evidence augments the process, and the consensus approach to guideline development engenders medical staff support. Such efforts, however, require significant dedication of human resources. Institutions with limited personnel to allocate to drug policy activities may consider increasing the depth of their efforts (using a multifaceted approach) while limiting the breadth of their efforts (only attempting one or two major targets per year, and doing them well).

Economic evaluations of clinical pharmacy services--1988-1995. The Publications Committee of the American College of Clinical Pharmacy.

The objectives of this effort were to summarize and critique original economic assessments of clinical pharmacy services published from 1988-1995, and to make recommendations for future work in this area. A literature search was conducted to identify articles that were than blinded and randomly assigned to reviewers to confirm inclusion, abstract information, and assess the quality of study design. The 104 articles fell into four main categories based on type of service described: disease state management (4%), general pharmacotherapeutic monitoring (36%), pharmacokinetic monitoring services (13%), and targeted drug programs (47%). Articles were categorized by type of evaluation; 35% were considered outcome analyses, 32% outcome descriptions, and 18% full economic analyses. A majority (89%) of the studies reviewed described positive financial benefits from the clinical services evaluated; however, many (68%) did not include the input costs of providing the clinical service as part of the evaluation. Studies that were well conducted were most likely to demonstrate positive results. Commonly, results were expressed as net savings or costs avoided for a given time period or per patient. Seven studies expressed results as a benefit:cost ratio (these ranged from 1.08:1 to 75.84:1, mean 16.70:1). Overall this body of literature contains a wealth of information pertinent to the value of the clinical practice of pharmacy. Future economic evaluations of clinical pharmacy services should incorporate sound study design and evaluate practice in alternative settings.

Work redesign and role restructuring in a pharmacy department with pharmacist assistants.

A new staffing model for decentralized pharmacists and support staff at a university hospital is described. A new technical support position--the pharmacist assistant--was created, and activities were reallocated among the pharmacists, pharmacist assistants, and pharmacy technicians according to the recommendations of two total quality management teams. Pharmacist assistants were to perform many of the drug distribution and record-keeping functions previously performed by pharmacists. The activities marked for reallocation accounted for about 50% of pharmacist time in the existing staffing model; they would not be performed by experienced pharmacy technicians who received brief training to be pharmacist assistants. Nine pharmacists and nine technicians tested the new staffing model on four patient care units over a four-week period. The reassignment of pharmacist tasks to pharmacist assistants theoretically gave pilot-unit pharmacists more time for providing and documenting patient-specific clinical activities and an additional 12 hours a week to participate in such global patient care activities as critical-pathway and quality improvement meetings. By the end of the study, the pharmacist assistants demonstrated that they could perform the reassigned activities; however, the pharmacists were not yet confident in the assistants' ability to do so. A pilot study of a new decentralized pharmacy staffing model demonstrated that technical support personnel can perform many distributive and record-keeping activities traditionally performed by decentralized pharmacists.

What should a pharmacy manager do when a serious medication error occurs? A panel discussion.

Questions related to medication errors were discussed by a panel of hospital department managers. When a serious medication error occurs, the manager has a responsibility to help the employee, the patient, and the patient's family cope with its effects, as well as a responsibility to prevent such errors from recurring. The difficulty of dealing with medication errors may be compounded when the legal system and the news media get involved. Therefore, a system for handling a serious error should be in place before that error occurs. It is also necessary to decide whether to use medication error reports in the employee evaluation process; this could make employees reluctant to report their errors. Ultimately, pharmacy managers are responsible for medication errors that occur, and repercussions have varied from nothing to reprimands to termination. Past errors, if they are reported, can be used to improve the system in which they occurred and to educate other health-care professionals. Therefore, pharmacists need to cooperate with other health-care professionals in documenting medication error reports. A national reporting system is needed so that medication error information can be shared on a large scale without placing the people involved in legal jeopardy. Sharing information about medication errors is necessary to prevent future occurrences; mechanisms are needed to facilitate such sharing.

Time and cost requirements for decentralized pharmacist activities.

Time and cost requirements for pharmaceutical services in patient-care areas at a 548-bed university hospital were studied. The study was conducted in 1987 and 1988 to (1) define the clinical and distributive activities of decentralized pharmacists, (2) develop time standards for each activity, (3) determine whether the time requirements of decentralized pharmacists depend on the type of patient involved, (4) determine the actual costs of decentralized pharmacist services for various types of patient, and (5) compare costs with reimbursement for clinical pharmacy services. Time standards were established based on data from seven patient categories representing a cross section of the institution's patients. The mean frequency of each activity and the total time and cost per patient day for all activities were determined. Pharmacist time spent daily in each patient-service category ranged from 2.3 hr for low-intensity medical care to 20.8 hr for trauma-burn intensive care. Decentralized pharmacists spent approximately 50% of their time on clinical activities in all patient-service categories. The daily cost per patient day for clinical activities was lowest for low-intensity medical care and highest for adult intensive care. The institution's daily charge for clinical activities ($10/admission and $10/day) exceeded the cost of clinical services during the study period. The decentralized pharmacist time requirement per patient day, and thus the costs of delivering pharmaceutical services, varied by patient-service category. The provision of clinical services generated a profit. A pharmacy workload analysis system that can identify costs and correlate them with patient types can be valuable in hospital pharmacy management.

Quantifying unused orders for as-needed medications.

Nonuse of as-needed (p.r.n.) medication orders in a university hospital was quantified. A total of 882 patient charts for the last six months of 1984 were reviewed (seven randomly selected patients per month from each of 21 medical-surgical services). Orders for p.r.n. medications were quantified by therapeutic category and by whether the order was written on admission. Use or nonuse of orders was determined from pharmacy records of doses administered. Of 7735 p.r.n. orders, 4793 (62%) were unused. By therapeutic category, antacids were the least prescribed p.r.n. medications but also had the highest rate of nonuse. In every therapeutic category, the rate of unused orders was higher for orders written on the day of admission than for subsequent orders. By patient's medical-surgical service, the percentages of p.r.n. orders unused ranged from 50% for renal transplant patients to 81% for ophthalmology patients. Nonuse of p.r.n. medications in all therapeutic categories decreased as length of stay increased; the overall rate of nonuse was 80% for patients hospitalized for two days or less. Reduction of the number of p.r.n. orders written but not used should begin in two areas: orders written on day of admission, and orders for patients with short hospital stays.

Recording schedule II drug use in a decentralized drug distribution system.

A decentralized system for Schedule II controlled substance distribution and accounting that does not rely on proof-of-use sheets is described. Controlled substances are kept in a vault in the central pharmacy; technicians assigned to work in the controlled substances vault are responsible for monitoring, ordering, and storing these medications. The narcotic vault technicians also prepare narcotic boxes that are used by technicians in patient-care areas to transport and issue Schedule Ii substances to nursing units. Twice during each morning and evening shift, technicians in patient-care areas visit each nursing station, replenish the unit's stock of Schedule II medications, and document on a narcotic use form all doses that have been administered since the last technician visit. Nurses leave small cards preprinted with patients' names and room information in the narcotic drawers to alert technicians to administered doses of Schedule II substances; the technicians are responsible for reconciling medications missing from the drawers with doses recorded in patients' medication administration records as being administered. Periodic audits are performed to ensure that actual inventories and the recorded information are correct. The decentralized system for distribution and accounting of Schedule II substances has been successful in increasing the flexibility of inventories on individual nursing units and ensuring maximal pharmacy department control over the dispensation of these medications.