On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study

Abstract

Introduction: Patients admitted to an intensive care unit (ICU) are at high risk for prescribing errors and related adverse drug events (ADEs). An effective intervention to decrease this risk, based on studies conducted mainly in North America, is on-ward participation of a clinical pharmacist in an ICU team. As the Dutch Healthcare System is organized differently and the on-ward role of hospital pharmacists in Dutch ICU teams is not well established, we conducted an intervention study to investigate whether participation of a hospital pharmacist can also be an effective approach in reducing prescribing errors and related patient harm (preventable ADEs) in this specific setting.

Methods: A prospective study compared a baseline period with an intervention period. During the intervention period, an ICU hospital pharmacist reviewed medication orders for patients admitted to the ICU, noted issues related to prescribing, formulated recommendations and discussed those during patient review meetings with the attending ICU physicians. Prescribing issues were scored as prescribing errors when consensus was reached between the ICU hospital pharmacist and ICU physicians.

Results: During the 8.5-month study period, medication orders for 1,173 patients were reviewed. The ICU hospital pharmacist made a total of 659 recommendations. During the intervention period, the rate of consensus between the ICU hospital pharmacist and ICU physicians was 74%. The incidence of prescribing errors during the intervention period was significantly lower than during the baseline period: 62.5 per 1,000 monitored patient-days versus 190.5 per 1,000 monitored patient-days, respectively (P < 0.001). Preventable ADEs (patient harm, National Coordinating Council for Medication Error Reporting and Prevention severity categories E and F) were reduced from 4.0 per 1,000 monitored patient-days during the baseline period to 1.0 per 1,000 monitored patient-days during the intervention period (P = 0.25). Per monitored patient-day, the intervention itself cost €3, but might have saved €26 to €40 by preventing ADEs.

Conclusions: On-ward participation of a hospital pharmacist in a Dutch ICU was associated with significant reductions in prescribing errors and related patient harm (preventable ADEs) at acceptable costs per monitored patient-day.

Trial registration number: ISRCTN92487665.

Figure 1

Type, incidence and severity of prescribing errors found by intensive care unit hospital pharmacists during the whole study period. Data for prescribing errors found by intensive care unit hospital pharmacists during the whole study period. The severity was scored according to The National Coordinating Council for Medication Error Reporting and Prevention Taxonomy of Medication Errors (categories B to F). The monitoring error category consists of the following types of prescribing errors: wrong dose according to therapeutic drug monitoring, wrong dose according to laboratory tests, organ function or renal replacement therapy requirements, drug-disease interaction, drug-drug interaction, pharmacologic duplications, unrecognized adverse drug reactions.

Figure 2

Type and number of recommendations by intensive care unit hospital pharmacists during whole study period. Recommendations were given during intensive care unit (ICU) patient review meeting. The results are divided into accepted (consensus) and not accepted (no consensus) recommendations. TDM, therapeutic drug monitoring.

Figure 3

Incidence of prescribing errors per 1,000 monitored patient-days, grouped by study period and severity. The severity was scored according to The National Coordinating Council for Medication Error Reporting and Prevention Taxonomy of Medication Errors (categories B to F). Intervention¹ is the first half (first 4 months) of the intervention period; Intervention² is the second half (following 4 months) of the intervention period.

Figure 4

Medication types with most prescribing errors found by intensive care unit hospital pharmacists. Medication types with most prescribing errors found during the whole study period. The results are categorized by prescribing error type. AB, antibiotics; AM/A(R)V, antimycotics and anti(retro)viral medication; AE, antiepileptics; AT, antithrombotics; RM, respiratory medication.