RESUMO
BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent drug related problems (DRPs). OBJECTIVES: The primary objective was to make an inventory of the DRPs and resident pharmacist on-ward interventions (PIs) identified in a geriatric acute care unit using CPOE system. The secondary objective was to evaluate the physicians' acceptance of the proposed interventions. SETTING: A 26-bed geriatric ward of a 1,300-bed teaching hospital. METHOD: A 6-month descriptive study with prescription analysis and recommendations to physicians by a resident pharmacist during five half days a week. MAIN OUTCOME MEASURES: Patients' characteristics, number of prescribed drugs per patient, nature and frequency of DRPs and PIs, physicians' acceptance and drugs questioned. RESULTS: Resident pharmacist reviewed 311 patients and identified 241 DRPs. One hundred and fifty-two patients (49 %) had at least one DRP (mean ± SD age 87 ± 6 years, mean ± SD number of prescribed drugs 10.7 ± 3.4). Most frequent DRPs were: untreated indication (n = 58, 24.1 %), dose too high (n = 46, 19.1 %), improper administration (n = 31, 12.9 %) and drug interactions (n = 23, 9.5 %). The rate of physicians' acceptance was 90.0 % (7.5 % refusals, 2.5 % not assessable). DRPs related to CPOE system misuse (n = 35, 14.5 %) appeared as a worrying phenomenon (e.g., errors in selecting dosage or unit, or duplication of therapy). CONCLUSION: A resident pharmacist detected various DRPs. Most PIs were accepted. DRPs related to the misuse of the CPOE system appeared potentially dangerous and need particular attention by healthcare professionals. The description of the DRPs is an essential step for implementation of targeted clinical pharmacy services in order to optimize pharmacists' job time.
