Implementation and safety evaluation of autoverification for select low-risk, high-volume medications in the emergency department.

PURPOSE: Use of autoverification has decreased in many emergency departments (EDs) with the expansion of emergency medicine (EM) pharmacists. Few studies have evaluated ways to prioritize verification of medications. Here we describe a process to design, implement, and measure the safety of autoverification of low-risk, high-volume medications. SUMMARY: A 3-month retrospective review of medications ordered and administered in the ED generated a list of medications to be considered for autoverification. Concurrently, a novel risk stratification tool was created to identify low-risk medications. Taking these together, medications that were high volume and low risk were considered potentially autoverified medications (PAMs). To evaluate the safety of PAMs, a retrospective review of the ED medication orders placed before implementation of autoverification was performed. A total of 7,433 medication orders were reviewed. Of these, 3,057 orders (41%) were identified as PAMs. EM pharmacists verified 2,982 (97.5%) of the orders without changes. Of the remaining 93 orders that were modified or discontinued and met autoverification criteria, only 2 (0.07%) were identified as potentially inappropriate for autoverification. CONCLUSION: Low-risk, high-volume medications can be safely autoverified in the ED by using a systematic approach to order selection. Using these methods can provide large decreases in verification volume, close to 41%, without compromising patient safety.

A call to action: Maximizing the pharmacy technician role through certifications.

The continued advancement of pharmacy practice demands highly skilled and knowledgeable pharmacy technicians to enhance the services provided. As technician responsibilities continue to evolve to include more advanced roles, the need for standardized technician training and certification is essential to advance the profession of pharmacy technicians and pharmacy practice. With only 45% of states requiring technician certification, great variation exists in the education and training competencies required for technicians practicing in the health system setting. While the gap in certified pharmacy technician workforce is significant, the advancing skills demanded of our technician workforce underscore the need for national standardization of technician certification requirements in the health system setting. Pharmacists, health systems, and legislators must commit to advancing the profession of pharmacy and advocate for a uniform, certified technician workforce as a professional standard.

Implementation and Impact of Pharmacist-Initiated Home Medication Ordering in an Emergency Department Observation Unit.

PURPOSE: To design and evaluate the accuracy and efficiency of a medication reconciliation workflow incorporating pharmacist home medication ordering. METHODS: Designed and implemented an admission medication reconciliation workflow that expanded the pharmacists' role to include an initial ordering of home medications. Performed a prospective, pre-post cohort analysis comparing preimplementation accuracy and efficiency data from inpatient medicine and cardiology patients to postimplementation accuracy and efficiency data from our emergency department observation unit. Accuracy for the preimplementation group was defined by the number of unintentional discrepancies identified by pharmacists between the prescriber admission orders and the reconciled home medication lists. Accuracy for the postimplementation group was defined by the prescriber acceptance of pharmacist-ordered home medications. Efficiency was measured by pharmacist time to complete the admission medication reconciliation process. RESULTS: Prescribers accepted 98% of home medication orders placed by pharmacists, which correlated with a significant decrease in the occurrence of home medication orders containing a medication-related problem or discrepancy (46.4% vs 1.3%, P < .0001). The mean pharmacist time spent completing medication reconciliation per admission decreased from 64 to 23 minutes (P < .0001). CONCLUSION: Implementation of an admission process that incorporates pharmacist ordering of home medications increased prescribing accuracy and efficiency.

Emergency department discharge prescription interventions by emergency medicine pharmacists.

STUDY OBJECTIVE: We determine the rate and details of interventions associated with emergency medicine pharmacist review of discharge prescriptions for patients discharged from the emergency department (ED). Additionally, we evaluate care providers' satisfaction with such services provided by emergency medicine pharmacists. METHODS: This was a prospective observational study in the ED of an academic medical center that serves both adult and pediatric patients. Details of emergency medicine pharmacist interventions on discharge prescriptions were compiled with a standardized form. Interventions were categorized as error prevention or optimization of therapy. The staff of the ED was surveyed related to the influence and satisfaction of this new emergency medicine pharmacist-provided service. RESULTS: The 674 discharge prescriptions reviewed by emergency medicine pharmacists during the study period included 602 (89.3%) for adult patients and 72 (10.7%) for pediatric patients. Emergency medicine pharmacists intervened on 68 prescriptions, resulting in an intervention rate of 10.1% (95% confidence interval [CI] 8.0% to 12.7%). The intervention rate was 8.5% (95% CI 6.4% to 11.1%) for adult prescriptions and 23.6% for pediatric prescriptions (95% CI 14.7% to 35.3%) (difference 15.1%; 95% CI 5.1% to 25.2%). There were a similar number of interventions categorized as error prevention and optimization of medication therapy, 37 (54%) and 31 (46%), respectively. More than 95% of survey respondents believed that the new pharmacist services improved patient safety, optimized medication regimens, and improved patient satisfaction. CONCLUSION: Emergency medicine pharmacist review of discharge prescriptions for discharged ED patients has the potential to significantly improve patient care associated with suboptimal prescriptions and is highly valued by ED care providers.

Evaluating and classifying pharmacists' quality interventions in the emergency department.

PURPOSE: The results of an evaluation of the impact of pharmacists' medication-related interventions on quality of care in the emergency department (ED) setting are reported. METHODS: Using data from a previously published observational study of medication errors intercepted by ED pharmacists at four academic medical centers, trained reviewers retrospectively analyzed 130 additional pharmacist interventions (those not categorized as medication errors in the primary study) over a specified four-month period to identify "quality interventions" (QIs), defined as those that (1) prevented misuse, underuse, or overuse of medications or (2) improved adherence to quality standards or evidence-based medicine (EBM) standards. The study included an evaluation of the medication classes associated with QIs and the acceptance of pharmacist-recommended QIs. RESULTS: The reviewers identified a total of 91 pharmacist QIs at the four sites during the study period (2.3 QIs per 100 patients or about 1 QI per 100 medication orders). About 45% of the identified QIs improved adherence with EBM or national quality standards; other QIs prevented medication underuse (34%), misuse (14%), or overuse (6%). Pharmacists' QIs most often pertained to antiinfective agents (39%), cardiovascular agents (13%), and anticoagulants and thrombolytics (12%). The overall rate of acceptance of pharmacists' QIs was 93.4%. CONCLUSION: A secondary analysis of data from a previously published study at four medical centers indicated that ED pharmacists often recommend interventions that improve the quality of medication use and adherence to EBM and national quality standards.

Medication errors recovered by emergency department pharmacists.

STUDY OBJECTIVE: We assess the impact of emergency department (ED) pharmacists on reducing potentially harmful medication errors. METHODS: We conducted this observational study in 4 academic EDs. Trained pharmacy residents observed a convenience sample of ED pharmacists' activities. The primary outcome was medication errors recovered by pharmacists, including errors intercepted before reaching the patient (near miss or potential adverse drug event), caught after reaching the patient but before causing harm (mitigated adverse drug event), or caught after some harm but before further or worsening harm (ameliorated adverse drug event). Pairs of physician and pharmacist reviewers confirmed recovered medication errors and assessed their potential for harm. Observers were unblinded and clinical outcomes were not evaluated. RESULTS: We conducted 226 observation sessions spanning 787 hours and observed pharmacists reviewing 17,320 medications ordered or administered to 6,471 patients. We identified 504 recovered medication errors, or 7.8 per 100 patients and 2.9 per 100 medications. Most of the recovered medication errors were intercepted potential adverse drug events (90.3%), with fewer mitigated adverse drug events (3.9%) and ameliorated adverse drug events (0.2%). The potential severities of the recovered errors were most often serious (47.8%) or significant (36.2%). The most common medication classes associated with recovered medication errors were antimicrobial agents (32.1%), central nervous system agents (16.2%), and anticoagulant and thrombolytic agents (14.1%). The most common error types were dosing errors, drug omission, and wrong frequency errors. CONCLUSION: ED pharmacists can identify and prevent potentially harmful medication errors. Controlled trials are necessary to determine the net costs and benefits of ED pharmacist staffing on safety, quality, and costs, especially important considerations for smaller EDs and pharmacy departments.