TABLE 1
Types of clinical pharmacy interventions
Type of clinical pharmacy intervention
Non-compliance with guidelines or existing contraindications
Inadequate drug administration
Specific information and therapy discussion
Prescribed medication dose was an overdose
Medication was prescribed without an indication or lacking documentation
Drug – drug interactions
Documentation error in patient notes
Therapeutic drug monitoring ( TDM )
Untreated indication ( need for additional medication )
Occurrence of side effects
Prescribed medication dose was an underdose
Literature research
Examples
Patient with impaired liver function but no dose adjustment prescribed
Prescription of half tablets where tablets were not splittable , thus creating the potential for dose dumping for modified-release tablets
Patient with oral thrush and cortisone inhaler spray . Information to rinse mouth or brush teeth after use of inhaler or use inhaler before food
Maximum daily dose was prescribed twice as high as recommended for amlodipine ( daily maximum dose is 10mg )
Muscle relaxants had been re-prescribed without checking for indication
Concomitant prescription of fluconazole and digoxin
Wrong transfer of home medication to inpatient medication chart
Patient with eGFR of 34 presenting with delirium ; lithium and zuclopenthixol in current prescription – advise for TDM
Patient with HFpEF but no prescription for ACE inhibitor or AT1-receptor-antagonist
Patient with oedema and headaches prescribed amlodipine
Pradaxa underdosed in patient with thrombosis under present DOAC therapy
Request of ward round doctor to check which of the patient ’ s medications could cause thrombocytopenia pharmacist made suggestions on the phone or wrote notes in the patients ’ electronic Kardex systems .
Data collection The data were collected using convenience sampling , as part as the day to day job of the hospital ’ s clinical pharmacist . The document used to record clinical pharmacy interventions originated from a French publication , 12 which was adapted for Austrian use by the “ Arbeitsgemeinschaft österreichischer Krankenhausapotheker ”. 13 The document records the pharmacist ’ s initials , date of clinical pharmacy intervention , initials of the doctor who was involved , patient gender , patient age and details of the clinical pharmacy intervention ( Table 1 ).
The number of patients reviewed for medication correctness was recorded on each day that clinical pharmacy interventions took place . Out of those interventions , the pharmacist recorded which patient records were relevant to review and the number of interventions made on that date . Non-polypharmacy patients were not included , and review did not take place when , on initial screening , no medication-related problems were found .
The clinical pharmacy interventions were rated by the pharmacist on a 6-point significance scale ( Hatoum 14 ). A number of the interventions were randomly chosen ( those having a high variety of ATC-codes and different types of interventions ) and additionally rated by four medical consultants . Each rating was carried out separately and without sharing the scores of their colleagues to minimise bias . The ratings were then evaluated , and a mean
Stereotypical and traditional role models for both medical and pharmacy staff make it difficult to widen the scope of CPS calculated for each coder , respectively .
A two-way model inter-rater reliability ( IRR ) analysis was performed for the four different consultant assessments using SPSS to determine intra-class correlation ( ICC ). This was then correlated with the pharmacist ’ s rating to decide whether it could be extrapolated to all 255 pharmacists ’ intervention ratings . Common cutoff values based on ICC ratings between 0.75 and 1.0 were deemed excellent ; good , between 0.60 and 0.74 ; fair for values between 0.40 and 0.59 ; and poor for values less than 0.40 . 15
Impact of COVID-19 on methods Due to the impact of COVID-19 and the increasing daily workload in the hospital , the data that could be collected was reduced . Due to patient isolation , the pharmacist was restricted to pharmaceutical medication review remotely and not in person on the ward rounds . This resulted in less doctor – pharmacist and nurse – pharmacist interaction .
Ethical considerations The data from this small-scale service evaluation study was collected as a part of the researcher ’ s day-to-day job as a newly employed clinical pharmacist . It is only an early analysis of her work at Tauernklinikum , Zell am See and serves as a pilot study . For this reason , ethical approval was not required .
Results Total number of interventions A total of 255 clinical pharmacy interventions
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