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A Long-Term Study of the Reduction in Drug-Related Incident Reports and the Impact on Patients by Pharmacist Intervention in the Emergency Department
2023 年 143 巻 4 号 p. 405-409
詳細
2023 年 143 巻 4 号 p. 405-409
In Japan, pharmacists have begun working in emergency departments (ED) over the last decade. However, no reports exist on the contribution of pharmacists’ activities in the ED to patient safety. We investigated whether pharmacists’ long-term duties influence the number of incident reports in the ED. Of the 862 incidents reported, 152 (17.6%) were drug-related reports. Further investigations revealed that 42 cases occurred during pharmacists’ usual working hours, four cases (9.5%) occurred when a pharmacist was present in the ED, and 38 cases (90.5%) occurred in the absence of a pharmacist in the ED. The number of incident reports was significantly reduced by pharmacists optimizing pharmacotherapy in the ED (p=0.002). There was a decrease in the degree of impact on patients through pharmacist duties compared to pharmacist absence (intercepting errors prior to patient administration: 4.8 vs. 31%; medication misadministration: 4.8 vs. 59.4%). Medical staff-associated factors and time of patient arrival at the ED did not have a significant impact on incident reports for any time. Long-term pharmacist duties in the ED can reduce the number of incident reports and contribute to safe medication care in the ED.
The need for urgent intervention is not uncommon in the emergency department (ED), despite a lack of sufficient patient information. Such urgent interventions pose risks. More often, there is insufficient time to verify and document the patient’s medical record before the drugs are used. In the United States, the benefits of pharmacists working in the ED have been reported since the 1970s; many pharmacists have reported intervention results such as performing drug-related checks in the ED to detect and correct errors early and optimize drug therapy.1–4) However, these studies were conducted for relatively short periods of time, and reports examining the benefits of long-term pharmacist interventions are lacking. In Japan, most pharmacists have started working in the ED in the last decade. The reports on pharmacists’ activities in the ED that contribute to patient safety are lacking too.
Pharmacists’ intervention in the ED for the pharmacotherapy of patients in the ED has the potential to contribute to patient safety. However, there are no reported direct and long-term results for patients of pharmacists’ intervention in various emergent drug therapies. This study, for the first time, describes the long-term intervention by a pharmacist in the ED that can reduce drug-related errors. Avoiding adverse events remains the highest priority in medicine; hence, this study is important as it presents the benefits of a pharmacist working long-term in emergency setup and documents drug-related adverse events in the ED in Japan.
This study investigated whether pharmacists could reduce the number of incident reports by performing drug-related tasks in the ED. The incident reports from January 2015 to March 2022 in the ED were analyzed, wherein one expert emergency medicine pharmacist worked in the ED between 8:30 a.m. to 5:15 p.m., Monday through Friday. In this study, we investigated the number of incident reports that entailed adverse drug events for patients. Service in the ED was not continuous but rather intermittent, and the prioritization of work in the ED was determined by the pharmacist. In particular, work was prioritized for the most urgent patients. For example, interventions were performed for the most urgent situations, such as cardiopulmonary arrest, confirming and preparing emergency medications, and consulting with physicians regarding drug therapy and toxicology services, similar to previous reports.5) The actual pharmacist’s duties in emergency medicine are shown (Table 1). All patients who came to the hospital ED during the study period were included in the analysis. Incident reports were logged by all staff working in the ED (i.e., physicians, nurses, pharmacists, radiological technologists, and clerks). Incident reports were based on the Japan National University Hospital Alliance on Patient Safety level-based patient impact classification.6) The primary outcome was the presence or absence of a pharmacist in the ED performing medication therapy-related tasks when an incident report was raised. The secondary outcome was the extent to which medical staff-related factors influenced incident reports.
| Characteristics |
|---|
| Emergency |
| Direct bedside care for emergency patients (cardiopulmonary resuscitation, trauma, stroke, sepsis, etc.) |
| Preparation and inspection when prescribing high-risk drugs |
| Addict patient care and provide recommended drug therapy information |
| Semi-Emergency |
| Consultation and confirmation of implementation of recommended drug therapy |
| Monitoring Adverse Effects During Medication |
| Propose and audit prescription medications for discharge patients |
| Non-emergency |
| Education of emergency staff |
| Medication storage and distribution |
| Training and participation in emergency response |
| Post-hospitalization pharmacotherapy follow-up |
| Preparation of drug history |
This retrospective study was conducted at the ED of the Tosei General Hospital. This analysis was approved by the Tosei General Hospital medical ethics committee (Registration Number: 1055). The need for informed consent was waived due to the retrospective study design.
Statistical AnalysisAll reports were anonymized, including patient names and reporters, years of medical experience, ED experience, and time from patient arrival at the ED, and were reviewed and approved by the hospital’s safety officers. Further, the working hours of the pharmacist in the ED were verified from the attendance book. We used Mann–Whitney U tests to compare the number of adverse drug events. The factors associated with medication errors in the ED were analyzed using ANOVA. The pharmacist’s average work time per month in the ED is described as mean±standard deviations, and quantitative data are presented as percentages, medians, and interquartile ranges (IQR). A p-value <0.05 was considered statistically significant. StatView 5.0 (SAS Institute Inc., Cary) and Statistical Package for Social Sciences (SPSS, version 25) (IBM Corp, Armonk) were used for statistical analysis.
A total of 188372 patients were admitted to the ED during the study period, and 862 incident reports were reported. Of those, 152 (17.6%) were drug-related reports, and 42 occurred during the usual pharmacists’ working hours (55 cases outside of pharmacists’ working hours 5:15 p.m. to 8:30 a.m.; 55 cases on weekends and holidays). Of the 42 incident reports, 4 occurred while the pharmacist was working in the ED, and 38 occurred in absence of a pharmacist in the ED (9.5% and 90.5%; p=0.002) (Fig. 1). In terms of the impact on the patient regarding the drug-related reports, the errors prior to administration of medications to patients in category zero occurred in two cases when the pharmacist was on duty whereas 13 cases occurred when the pharmacist was not present. The incorrect medication was administered to patients (category one or higher) in two cases while the pharmacist was on duty, but in 25 cases, the pharmacist was not present (Table 2). Furthermore, many of the reductions in incident reports of drug-related adverse events occurred when pharmacists performed pharmacological assessments and audits at the bedside when medications were used (Table 3). When incidents that occurred at night, (Monday–Friday; 5:15 p.m.–8:30 a.m.) or on holidays were compared to the incidents that occurred during the hours the pharmacist was on duty, no significant difference was observed for years of medical experience, ED experience, or time from patient arrival at the ED compared with Daytime (Fig. 2).
Results are presented as number of incidents and percentages. ED, emergency department.
| Category | Definition | Pharmacist intervention and number of incidents | % | |
|---|---|---|---|---|
| 0 | Drug error was observed but not reached in patients | (+) | 2 | 4.8 |
| (−) | 13 | 31 | ||
| 1 | No actual harm was done to the patient (the possibility of some impact cannot be ruled out) | (+) | 2 | 4.8 |
| (−) | 16 | 38 | ||
| 2 | No treatment or therapy was performed (the need for enhanced patient observation, minor changes in vital signs, or tests to confirm safety) | (+) | 0 | 0 |
| (−) | 8 | 19 | ||
| 3a | Required simple procedures or treatments (e.g., disinfection, compresses, skin stitches, administration of analgesics, etc.) | (+) | 0 | 0 |
| (−) | 1 | 2.4 | ||
| 3b | Required intensive care or treatment (e.g., advanced changes in vital signs, ventilator placement, surgery, patient hospitalization, fractures, etc.) | (+) | 0 | 0 |
| (−) | 0 | 0 | ||
| 4a | Permanent disability or sequelae, but without significant functional impairment or cosmetic problems | (+) | 0 | 0 |
| (−) | 0 | 0 | ||
| 4b | Permanent disability or sequelae, with significant functional impairment and cosmetic problems | (+) | 0 | 0 |
| (−) | 0 | 0 | ||
| 5 | Death (excluding death due to natural history of underlying disease) | (+) | 0 | 0 |
| (−) | 0 | 0 | ||
Results are presented as number of incidents and percentages.
| Incident | Before intervention | After intervention | Protocol for avoidance |
|---|---|---|---|
| Use of a drug generally indicated for a different purpose | Adrenaline | Noradrenaline | Identify drugs with similar names, such as adrenaline and noradrenaline |
| Administration of drugs from different routes | Intravenous | Intramuscular | Ensure that the recommended method of administration for the suspected disease |
| Use of contraindicated drugs | Meropenem | Tazobactam/Piperacillin | Check concomitant medications, including meropenem instructions for patients taking Valproic acid |
| Overdose of a drug requiring dose adjustment | Adrenaline 0.3 mg/time | Adrenaline 0.01 mg/kg/time | Check age, body weight, kidney function, etc., and make sure doses are appropriate |
| Administration of drugs that cannot be administered at the same time | Same routes | Another routes | Identification of IV routes, including nicardipine and tranexamic acid |
Results are presented as median and interquartile range (IQR). ED, emergency department.
In this study, we examined the incident reports on adverse drug events that occurred in the ED to determine whether a pharmacist working in the ED could reduce the number of incident reports. We found that a pharmacist working in the ED significantly reduced the frequency of drug-related incident reports (Fig. 1) and the degree of drug-related impacts on patients (Table 2) for a considerable duration of the study period. Emergency medicine workloads fluctuate; hence, it is possible that short-term studies may be less accurate for evaluating the results of pharmacist interventions, but given that the study period of the current study was long-term, this effect is likely to be minimal. This is the first analysis to document that pharmacists’ preferential intervention for emergency patients in the ED over a long period reduced the frequency of incident reports. In cases of patients with emergencies, it was thought that degree of influence could be reduced by pharmacists directly intervening in the patient’s care and performing drug-related tasks, given that high-risk drugs are used in many cases (Table 1). Compared to previous studies, our results indicated that the total number of incident reports was low during the study period.3) The major differences between previous studies and this study are that previous reports include a lack of instructions for recommended medications at the time the pharmacist checked as adverse drug events or medication errors, one facility did not have electronic medical records, and typographical errors were also included in the medication error category. However, our study only included the actual incident reports of what occurred with patients, hence, reflecting the actual occurrence of adverse drug events in Japanese EDs. Other factors could have confounded the results, such as the electronic medical record alert system that signals if a physician orders and enters a medicine that is more than twice the dose described in the package insert; drugs contraindicated in patients cannot be entered; nurses with at least 3 years of occupational experience are assigned to the ED. Moreover, boarding7–10) seldom occurs in Japan, and patients’ wait times >6 h are very rare (Fig. 2). However, such preventive systems are not always effective in emergency situations. Many errors occur when dealing with urgent patients. Time limitations make it difficult to check electronic medical records, oral orders take precedence, and manpower shortages create an environment more prone to drug-related errors. Oral orders can lead to the use of various incorrect drugs and methods of administration. For example, an expert emergency medicine pharmacist could avoid the following: misusing drugs with similar names, such as adrenaline and noradrenaline; using a wrong method of administration, such as intravenous or intramuscular infusion; using intravenous drugs that are contraindicated with oral medication; providing overdose of drugs that require dosage adjustment according to age, body weight, or renal function; or using intravenous drugs that cannot be administered via the same route (Table 3). The pharmacist’s intervention could prevent adrenaline overdose during anaphylaxis or change the antibiotic to prevent seizures. Physicians and nurses may have difficulty in questioning these oral orders because of the need to perform tests and procedures, but only a pharmacist who is familiar with the drug can question them at the bedside within the time from oral instruction to medication administration. Therefore, it is important for the pharmacist to provide drug-related interventions for emergency situations in the ED for patient safety.
The average working hours per month for a pharmacist in the ED during the study was 87.5±11.8 h. Our results suggest that the number of incident reports could be reduced further by assigning pharmacists to the ED for longer times not only during the daytime but also on weekends and at night (Figs. 1 and 2). However, pharmacists working at the ED in many hospitals are regarded as having few advantages under the current Japanese healthcare system. Thus, the results of our analysis are important for patient safety in the ED, in Japan. Our study shows that there are clear benefits of having pharmacists in the ED in Japan. Provision of emergency medical care could be safer if more pharmacists are able to work in the ED in the future.
There were two limitations of this study. First, we could not compare the incidence reports with the period when a pharmacist was not working in the ED. Also, we were not been able to investigate the number of incidents or the impact on patients when the pharmacist was absent. We also checked incident reports prior to the pharmacist’s intervention in the ED, but various factors made it difficult to provide accurate comparisons, such as number of patients, number of ambulances, number of emergency physicians, and the modifications in the electronic medical record system’s error detection function. We were unable to measure the confounding effect of educational activities that pharmacists regularly conduct in the ED, and if these may have influenced the reduction in the number of adverse drug events, and prevention of adverse drug events affecting patient outcomes.5) Second, this study was not blinded; since the focus was adverse drug events reports, it is possible that the pharmacist may have intervened aggressively to reduce the frequency of incident reports. In addition, when the pharmacist was not in the ED, the patient impact measured may have been inaccurate as queries about drug management in patients may have been answered by the on-call central pharmacy’s pharmacist. In fact, any drug therapy consultation in absence of a pharmacist could not be declined due to concerns for patient safety. Hence, the number of adverse drug events might have been higher than the number reported.
In conclusion, long-term pharmacist intervention in the ED can reduce the number of incidents and contribute to safe emergency medication care.
The authors declare no conflict of interest.
