By Carolyn M. Clancy, MD

Preventing medication errors, which account for nearly 20% of adverse events overall and affect about 4% of all hospital stays, has become a high-profile goal among national and international patient safety advocates, healthcare organizations, and healthcare providers (IOM, 2000).

Today, significant progress is underway in hospitals to comply with national patient safety goals set by the Joint Commission to reduce the risk of medication-related errors. Requirements include labeling all medications, flagging drugs whose names look or sound alike, and standardizing and limiting the number of drug concentrations used (Joint Commission 2007).

While this effort moves forward, momentum is also building to reduce medication errors in an especially high-risk environment — hospital emergency departments (EDs). Hospital EDs had the highest rate of preventable adverse events in the clinical environments studied by the Institute of Medicine, with a potential of 3.8 million annual events thought to be preventable, according to the 2006 IOM report, Preventing Medication Errors.

Even though medication errors occur in both inpatient and outpatient settings, the complex nature and fast pace of hospital EDs can increase their likelihood.

For example, both physician and nursing staff care for many patients in a short timeframe in the midst of multiple interruptions — a situation that has intensified with hospital ED overcrowding and boarding (Liu, Hobgood, & Brice, 2003). In addition, rapid clinical decisionmaking that is required in EDs demands that medication orders be given verbally, increasing the risk of misinterpretation. And finally, patients' medical information, including current medications and drug allergies information, are often incomplete, not up-to-date, or unavailable.

The Role of the Emergency Pharmacist
To help reduce the risk of drug-related errors in emergency care settings, a small but growing number of hospitals are employing pharmacists in their EDs. Seventy-nine hospitals said they used an emergency pharmacist in 2006, compared to 49 in 2004 (Strykowski, 2006).

Like a pharmacist working in other departments in the hospital, an emergency pharmacist, also referred to as an ED clinical pharmacy specialist or EPh, reviews medication orders, dispenses drugs, and provides education to patients. But in contrast to a traditional pharmacist, an emergency pharmacist is an active participant in clinical consultations before drugs are ordered and administered, thereby reducing the likelihood that medication errors will occur.

The emergency pharmacist's range of responsibilities varies according to the hospital and its resources; however, an emergency pharmacist at an academic medical center with a Level 1 trauma center is generally responsible for (Fairbanks, et al., 2004):

Clinical consultation: Attending rounds in the ED and providing information to nurses and physicians about their patients, such as dosage recommendations for patients with renal impairment, toxicology information, and alternative regimen recommendations.

Patient education: Identifying patients with complex medication lists, assessing for potential problems, and talking to patients to ensure they understand how to follow their drug regimens.

Screening orders: Reviewing written orders, focusing on allergies, drug interactions, indications, and dosages.

Dispensing medications: Obtaining medications from the ED's automated dispensing system, if available, or from the hospital's central pharmacy.

Preparing medications: Preparing medications for use in emergency situations.

Resuscitation response: Preparing and recommending medications for trauma alerts, cardiac arrests and "near arrests," and retrieving medications not available in the emergency cart.

Staff education: Contributing to the education of medical students, pharmacy residents, emergency medicine residents, and nursing staff.

From Theory to Practice
Organizations that have hired full-time emergency pharmacists report significant cost savings, fewer medication errors, shorter lengths of stay, and overall improvements in quality of care.

In 2000, Daniel Hays, PharmD, a pharmacist at Strong Memorial Hospital, the teaching hospital for the University of Rochester Medical Center, Rochester, New York, volunteered to work in the ED in addition to covering his responsibilities as a staff pharmacist. After one month, the hospital's department of pharmacy services realized that the addition of his presence in the ED yielded cost savings through appropriate selection of medications, reduction in medication errors, and more efficient patient throughput (Fairbanks, et al., 2004).

Shortly after, Dr. Hays was asked to work full time in the hospital's ED. Data collected in the ED over 14 randomly selected days during the emergency pharmacist's phase-in period revealed a cost savings of approximately $589 per day.

The emergency pharmacist position at Strong Memorial Hospital has spurred ongoing improvements in cost savings and error reduction. For example, reducing the use of some costly medications, such as intravenous azithromycin, in favor of less costly but effective oral medications, has contributed to cost savings of more than $100,000 over two years. During that 2-year period, 19 medical errors were reported to the hospital's voluntary reporting system, but none of them occurred while Dr. Hays was on duty.

Based on this evidence, the hospital added a second emergency pharmacist position in 2005 and established a residency program to train ED pharmacy specialists.

Following completion of an emergency care pharmacy residency at Los Angeles County Medical Center, Jill Hara, PharmD, developed a job description for an ED pharmacist position and proposed it to two hospitals (Hara, 2007). Six months later, medication errors at Huntington Hospital, Pasadena, California, the organization Dr. Hara joined as its first ED clinical pharmacist, had dropped by 50%.

Today, the 525-bed hospital is planning to expand its emergency pharmacy coverage to a 24-hour basis. It also is establishing an ED residency training program this year.

Staff Acceptance — A Critical Component
As the cost and patient safety evidence supporting the use of emergency pharmacists accumulates, hospitals deciding whether to add a full-time pharmacist to their ED also must grapple with another important consideration — staff acceptance.

To address this issue, researchers at the University of Rochester's Department of Emergency Medicine, led by Rollin (Terry) Fairbanks, MD, MS, developed a 26-item survey to test general perceptions and obtain specific feedback about the role of the emergency pharmacist (Hildebrand, et al., 2007). The survey was administered to 91 of 182 randomly selected eligible staff members, including ED nurses, attending physicians, medical residents, fellows, nurse practitioners, and physician assistants.

Nearly half (47%) said the most important contribution made by the emergency pharmacist to medication safety was being available for consults; more than one-third (36%) said attending medical and trauma resuscitation was most important. And nearly two-thirds (64%) of respondents said they had consulted the emergency pharmacist either once or multiple times per shift over the course of their previous five working shifts.

A significant majority (85%) of ED personnel said emergency pharmacists should check high-risk medications before they are used, and 75% said rarely used medications should also be reviewed. More than one-third (40%) said all urgent medication orders should be checked by the emergency pharmacist before administration.

Spreading the Word
Two new initiatives seek to assist pharmacists and hospitals in obtaining support for and implementing emergency pharmacist programs.

The first, spurred by Dr. Fairbanks' research and launched at the June 2007 meeting of the American Society of Health-System Pharmacists (ASHP), will connect teams of ED pharmacists with pharmacists interested in developing these programs (ASHP, 2007). Twenty pharmacists, including one international participant (Dublin, Ireland), were chosen to take part in the 6-month program, which will focus on the patient care impact of emergency pharmacists. Participants will:

• develop a job description for an ED pharmacist program,
  
  
• identify strategies for obtaining program support from hospital leaders and staff,
  
  
• develop a plan for imple-menting the program, and
  
  
• devise methods for moni-toring and quality assurance once a program is established.

A list of the participating organizations and more information about the emergency pharmacist mentoring program is available at: www.emergencypharmacist.org

This Web site also contains all of the components of the second initiative, a toolkit to help hospitals implement an ED pharmacist program (Emergency Pharmacist Research Center, 2007). Created by Dr. Fairbanks, whose work in this area is supported by a grant from the Agency for Healthcare Research and Quality (AHRQ), the toolkit includes:

• A sample job description for an ED pharmacist, which can be downloaded and adapted.
  
  
• Three slide presentations that can be downloaded and adapted for use within an institution describing:
  • Justification for the EPh role
    
    
  • The role of the EPh
    
    
  • EPh implementation
• Slide presentations describing the tools for developing and measuring the effectiveness of an EPh program.
  
  
• A summary of sessions at the ASHP 2007 meeting using audience response system to assess and rank barriers to implementations and proposed solutions.
  
  
• A list of relevant literature pertaining to emergency pharmacists and patient safety.

AHRQ is extremely pleased with ASHP's efforts to spread awareness of the role of emergency pharmacists and to spur adoption of these tools. We encourage organizations to take full advantage of them.

All of us who are working to improve healthcare quality realize that reducing medication errors demands a systems approach with buy-in from individuals working in varied clinical, administrative, and financial capacities. As the evidence of the cost and quality benefits of emergency pharmacists grows, we must work together to implement more of these important safety-enhancing programs.

References

American Society for Health-System Pharmacists (ASHP). (2007, June 25). Mentoring program for emergency department pharmacists launched. www.ashp.org/s_ashp/article_press.asp?CID=168&DID=2023&id=20921 (Accessed July 18, 2007).

The Emergency Pharmacist Research Center Web site, University of Rochester Department of Medicine, funded under Contract No. 1 U18 HS015818. www.emergencypharmacist.org (Accessed July 18, 2007).

Fairbanks, R. J., Hays, D. P., Webster, D. F., et al. (2004). Clinical pharmacy services in an emergency department. American Journal of Health System Pharmacists, 61(9), 934-937.

Hara, J. (2007, March 9). A day in the life of an emergency department pharmacist. Pharmacy Practice Perspective.

Hildebrand, J. M., Fairbanks, R. J., Kolstee, K. E., et al. (2007). Medical and nursing staff highly value clinical pharmacists in the ED. Presented at 2007 Society of Academic Emergency Medicine Meeting. Academic Emergency Medicine, 14(5), Supp 1:200-1.

Institute of Medicine (IOM). (2000). To err is human: Building a safer health system. L. T. Kohn, J. M. Corrigan, M. S. Donaldson, (Eds.). Washington, DC: National Academy Press.

Institute of Medicine (IOM). Committee on Identifying and Preventing Medication Errors. (2006). Preventing medication errors: Quality chasm series. Washington, DC: National Academy Press.

The Joint Commission. (2007). National Patient Safety Goals. Facts about the 2007 National Patient Safety Goals. www.jointcommission.org/PatientSafety/
NationalPatientSafetyGoals/07_npsg_facts

Liu, S., Hobgood, C., Brice, J. H. (2003). Impact of critical bed status on emergency department patient flow and overcrowding. Academic Emergency Medicine, 10(4), 382-385.

Strykowski, J. (2007, February 2). Promoting safe medication use in the ED. Highlights of the 2006 American Society of Health-System Pharmacists Midyear Clinical Meeting. www.medscape.com/viewarticle/550899 (Accessed July 18, 2007).