Published on October 7, 2017
1. The cost-saving effect and prevention of medication errors by clinical pharmacist intervention in a nephrology unit SHARAD CHAND, Pharm D (Intern) Rajiv Gandhi university of health sciences Preceptor: Mr. Arun J , M pharm. Department of Pharmacy Practice TVM College of Pharmacy. Author :- Chen et al. Medicine (2017) 96:34
2. Background • The definition of adverse drug events (ADEs) is any injuries to a patient resulting from medication use, including any harm or loss of function. Medication errors refer to any mistakes occurring during the medication use process such as prescription, transcription, dispensing, administration, or monitoring, regardless of whether an injury occurred or whether the potential for injury was present.ADEs in hospitalized patients will result in longer hospital stays and extra medical costs, even though they are sometimes preventable.
3. INTRODUCTION • Preventable ADEs could be related to medication errors and are avoidable by many methods such as pharmacist intervention.In several studies, clinical pharmacists’ participation in hospital was shown to prevent medication errors, to reduce preventable ADEs, and to save costs. Medication errors may be more common among patients with chronic kidney disease and those on dialysis because of altered pharmacokinetics, high susceptibility to medication toxicity, multiple comorbidities, and polypharmacy. Studies also have shown that clinical pharmacists’ contributions helped to identify drug-related problems and to prevent medication errors, and may have reduced medication costs in end-stage renal disease patients.
4. Study Objective • The purpose of this retrospective study was to evaluate the differences before and after a clinical pharmacist was deployed in the nephrology ward. The primary endpoint was to evaluate the cost-saving effect after the clinical pharmacist’s participation.
5. Methods Study Design • Retrospective • Interventional ( order modification, TDM, Suggestion, Medical reconciliation). • Pre and post analysis(Cost saving and cost avoidance). • Uni-center Research and Analysis • Ethical clearance was waived as it is a part of daily work. • Chi square test.(p=0.5). • Cost saving and cost avoidance, probaility of ADE on absence of pharmacist. • Benifit./cost ratio.
6. Methods Inclusion Criteria • All nephrology patients , of all age group, gender & Severity. Exclusion Criteria • Out patient . • Non Renal patients.
7. Methods Study Population • 824 in 2012 (preintervention), and 1977 in 2013 (postintervention). • The numbers of active recommendation were 40 in 2012, and 253 in 2013.
8. Intervention Order modification. Therapeutic drug monitoring. Suggestion. Medical reconciliation.
9. Assessment • Pharmacist interventions in medication orders were classified into 4 groups: order modification, therapeutic drug monitoring, key in error, and violation of National Health Insurance (NHI) or NTUH regulations. • The numbers and types of pharmacist interventions in 2012 were compared with those in 2013.
10. Study Outcomes discontinuing unnecessary medications (order modifications of duration or quantity, no medication indication, and inappropriate medication combination), switching medications from intravenous form to oral form. correcting dosage or frequency were assumed that medication costs could be saved in these areas.
11. Statistical Analysis • Confidence Interval 95% • P value 0.5. • Chi square test.
12. Results • The total numbers of pharmacist interventions in medication orders were 824 in 2012 (pre), and 1977 in 2013 (post). The numbers of active recommendation were 40 in 2012, and 253 in 2013. The estimated cost savings in 2012 and 2013 were NT$52,072 and NT$144,138, respectively. The estimated cost avoidances of preventable ADEs in 2012 and 2013 were NT$3,383,700 and NT$7,342,200, respectively. The benefit/cost ratio increased from 4.29 to 9.36, and average admission days decreased by 2 days after the on-ward deployment of a clinical pharmacist.
13. Discussion • The number of pharmacist interventions in medication orders greatly increased after the on-ward deployment of a clinical pharmacist, which resulted in a significant cost benefit, fewer admission days, and probably fewer ADEs. There were obviously more interventions about medication duration or quantity, suggestions of more appropriate medications, and the detection of ADEs after the clinical pharmacist’s participation. On the basis of these interventions, the preventable ADEs significantly increased from 338 to 734. The benefit/cost ratio doubled after the on-ward deployment of a clinical pharmacist.
14. Author’s Conclusions • The number of pharmacist’s interventions increased dramatically after her on-ward deployment. This service could reduce medication errors, preventable ADEs, and costs of both medications and potential ADEs.
15. Article Critique
16. Title The cost-savingeffect and prevention of medication errors by clinicalpharmacist intervention in a nephrologyunit • Un-biased • Overall, reflective of the study question and study outcome • The title doesn’t reflect the study design.
17. Abstract • Not well structured • Background • Methods • Results • Conclusions • Are not structured, it would had been better if structured abstract was presented. • Study rationale was well developed , Abstract is well reflecting the article.
18. Introduction and Background Good • The role of pharmacist is clearly mentioned. • The statistical relevance in data is demonastrated. Could Be Better If it addressed the current clinical need of the study.
19. Study Design Good • Appropriate time frame (2012 – 2013) • Utilized all the patient in nephrology wards. • No ethical issues. • No conflict of interest. Could Be Better • If the study had used definitive tool to asses the medication error and ADE.
20. Study Population Good • Informed consent • Characteristics evenly distributed among treatment groups Could Be Better • If it would had deployed in multi hospital ( Multi- centred).
21. Intervention and Assessment Good • Definite guidelines are used. Could Be Better • No any standard end points are there for the comparisons.
22. Statistical Analysis Good • Appropriate test is used. • Widely acceptable CI. • Power of test is high. Could Be Better • ---
23. Results Good • Result was measured in term of the cost . • Cost benefit ratio was mentioned. • No of hospital admission also clearly mentioned. Could Be Better • It would had better if the pharmaco-economic measures were utilized Viz- QALY.
24. Discussion and Conclusion Good • Primary and Secondary conclusions were valid and supported by the presented data • Discussion is comprehensive and establishes study value Could Be Better • No limitations are identified
25. Overall Impression • Study was ethical, appropriately conducted, and produced useful results. • The study clearly demonstrated the role of pharmacists in wards. • Need for a reassessment of such study in other places and hospital also.
26. Study Applications • This study may aid in the widening of the role of the pharmacists in the hospital setup. • This study may be applied to conclude that ADE & Medication errors are decreased by the active participation and intervention by pharmacist.
28. References • Chia-Chi Chen, Fei-Yuan Hsiao, Li-Jiuan Shen,, Chien-Chih Wu, et. al , The cost-saving effect and prevention of medication errors by clinical pharmacist intervention in a nephrology unit, Medicine journal of quality improvement study, Medicine (2017) 96:34. • Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 1995;274:29–34. • Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc 2014;89:1116–25. • Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997;277:307–11.