Leveraging Pharmacist Expertise in Patient Safety

By Matt Phillion

According to the Department of Health and Human Services (HHS), one in three adverse events in hospitals involve injuries to patients resulting from medications. The impact of these adverse events is astronomical, affecting nearly 2 million hospital stays and prolonging the length of stay for these cases from 1.7 to 4.6 days.

That being said, the HHS notes that most adverse drug events are preventable. A recent study helps quantify the impact pharmacists can have in identifying medication errors at transitions of care and the impact of a method for categorizing the scale and severity of medication errors corrected by pharmacy staff during medication reconciliation at admission.

Carol Aboud, PharmD, chief pharmacy officer at McLean Hospital and a co-author of the study, highlights the expertise pharmacists bring to reviewing patient medication history records during transition of care.

“An admitting provider is able to look at the same data and not analyze it in the same way a pharmacist is able to,” she says. “Our expertise isn’t just in pharmacology. It’s also looking at dosage, or if the refills are timely, if there’s any duplication of therapies, things the provider isn’t necessarily looking for.”

An admitting provider may not want to question the dosage for a disease state that is not the primary reason for admission.

“For the pharmacist, we’re looking at the entire picture,” Aboud says.

And this goes for all institutions and medical conditions, whether it’s behavioral health, diabetes, or blood pressure. Aboud sees an opportunity to elevate awareness about what pharmacists can bring to the table when it comes to transition of care.

“There’s an opportunity there to integrate pharmacists more into that team, especially at those junctures,” she says.

There are any number of factors that can come into play for where medication reconciliation can be imperfect, Aboud notes, which is more reason to leverage the expertise of pharmacists in this space.

“In human nature, we know the right thing to do, but we don’t always do the right thing,” she says. “Organizations have limited resources and all these requirements to comply with, and so they are very careful with how they allocate these resources.”

There’s no official standard, Aboud notes, that requires a pharmacist to be present during a transition of care.

“But we know what a pharmacist would bring to that situation. A lot of people in leadership know that, but unless there is a mandate or significant return on investment that is measurable, they may not be as amenable to bringing someone in,” says Aboud. “This costs money, and I think that’s a hurdle to bringing pharmacists into this setting.”

But a focus on quality is helping to raise awareness about the benefits of such an investment.

Another challenge is the siloed nature of healthcare.

“A lot of institutions work in silos,” says Aboud. “Unless there’s measurable outcomes or metrics, change is difficult.”

The goal is to move the patient along as efficiently as possible: treat what needs to be treated and move them to the next stage.

“The industry is not always connecting things together. They will do the right thing and bring about the right outcome, but unless your patient goes to settings within the same system, there’s really not that level of continuity,” says Aboud.

A shift can’t happen overnight, Aboud notes, and requires many disciplines to be involved to make the change stick.

“It makes sense, but you have to have buy-in from physicians, nurses, hospitals,” she says. “There’s a lot on everyone’s plate when it comes to healthcare, so not every institution might see this as a must-have.”

Victoria Vargas, assistant director of pharmacy with McLean Hospital and also a co-author of the study, highlights the important role pharmacists can play specifically in the area of medication reconciliation.

“Why not take that task away from the provider and let them focus on other tasks?” she says.

It’s a matter of putting the right eyes on the right data to get the best outcomes, Aboud notes.

“Medication history is an amazing tool, but unless you’re trained to know what you’re looking for, you can’t analyze the data the way you are supposed to,” says Aboud.

Preventing perpetuation of errors

The study also offers a rating scale that can assist in generating reports to quantify the impact of transitions-of-care-pharmacy staff, and looks at how improving medication reconciliation practices, involving pharmacist expertise, and maintaining up-to-date medication history data can help prevent errors like duplicative medication errors and adverse drug interactions.

“The reason the scale is important is because, without a crystal ball or time machine, you won’t know how a medical error will affect a patient,” says Vargas. “You can look at it in different ways: is it identified in admission, is it an error corrected at discharge, does the patient go out into the community and go some time without being noticed, or is it ever going to be noticed again?”

Medication errors that go overlooked can become permanent fixtures, she notes.

“Errors perpetuate and an error can been there so long that nobody wants to question it anymore,” says Vargas. “Then it becomes accepted as fact when it was never right to begin with. It’s a lot of effort at that point to correct.”

What the rating scale does is look at how to rate and assess what the outcomes would look like should an error perpetuate.

“There’s the assumption that you identify and change medications throughout admissions, but the primary providers often don’t review medications after the initial order, so it’s very likely for errors to perpetuate,” says Vargas. “In acute care, after the initial medication reconciliation, the team is focused on the primary problem the patient faces.”

Focusing on the problem at hand can add a risk of not noticing medication changes or interactions that aren’t directly involved with the problem to be solved in the moment can enable med rec errors to continue long after the patient has left the facility.

“How do you know they have good patient follow-up?” asks Vargas. “They come to the hospitals, that’s their checkpoint, but then they go back into the community and may not have care for quite some time. Making an error here can have long-term effects.”

“We have them here, let’s focus on everything instead of just one complaint,” says Aboud. “If we do this, we have much better outcomes for the patient.”

While the patient is right there in front of you, Vargas points out, is a perfect opportunity to take a snapshot of the whole medication picture and make sure everything is as it should be. For example, at McLean Hospital, when the patient is transitioned from the ED to inpatient care, pharmacy staff use medication history from DrFirst to identify discrepancies between the prior-to-admission medications and inpatient medication orders.

“All of these things are interrelated,” she says. “You can’t look at a patient as a silo. We should be reviewing their medications and looking for things like side effects particularly during these turbulent transitions.”

And having a pharmacist in position to do so helps other providers focus on their own areas of expertise, she notes.

The industry could benefit from an openness to questions, Aboud explains.

“The mentality is that they trust their colleagues more than they should. A provider might think, ‘This was ordered by the GI specialist, that’s their area of expertise and who am I to question it?’ We have tremendous respect for our colleagues, so we don’t want to question their decisions or treatment plan. ‘I’ll stay in my lane, you’ll stay in yours, and we’ll come together to help the patient,’ but that’s where the patient can end up suffering,” she says. “If the patient is on this, there must be a reason their doctor ordered it. But we should ask: why is the patient taking this? I understand we don’t want to step on the toes of our colleagues, but if we switch from that mentality to one of treating it like a second opinion, we could get to a place where the patient benefits from that holistic view.”

Pharmacists, she says, are programmed to question, but aren’t always empowered to do so.

“We as a profession don’t have the ability to override that decision even if we know it might not be the right one. We can make a recommendation, suggest an alternative, reference papers and studies, but the ultimate decision to continue the drug or dose is the provider,” she says. “Unless the view of pharmacists as a profession changes to where they can become independent practitioners, that isn’t going to change. I can offer a suggestion but if you’re not open to it or sued to being questioned, that alternative scenario is not going to happen.”

Reaching this point requires more visibility for the role of the pharmacist, Vargas notes.

“There’s a lack of visibility and understanding of the different skills a pharmacist in a hospital setting can offer,” she says.

“In the hospital setting, the level of service a pharmacist can provide is very different with the training, education, and certification required. Many have completed a residency, are board certified, and are able to contribute to patient care in a very different way,” says Aboud.

Aboud believes changes in regulation, view, and utilization of pharmacists can go a long way to improving patient care.

“Let’s break up the silos and make it one continuous workflow,” she says. “First, make this information available to every single healthcare provider and second, recognize pharmacists as independent providers able to make independent decisions when it comes to medications.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.