Improve patient safety and cut costs with clinical pharmacists

by Emmanuel King, MD

What if you could improve patient safety, cut costs, broaden your medical knowledge and find 20% more time in your workday?  On October 1, 2010, that is just what we can expect when clinical pharmacists move from the back room to the bedside in ten general medical units at the Hospital of the University of Pennsylvania.

As we all know, medications play an intensely complex and ever-growing role in patient care. In tertiary care hospitals, it is not uncommon for patients to take 12 to 16 medications a day.  When patients return home, one-third to one-half of them don’t take medications as prescribed, and up to one-quarter never fill prescriptions at all.  Furthermore, we all know that medication problems at discharge — such as prescription omissions and instructions that are incomplete, inaccurate, and difficult for patients to understand — are common. It’s no wonder medication issues are a major cause of readmissions.

In pilot studies, the presence of a residency-trained pharmacist as an active part of our medical team addressed all of these concerns.  Our clinical pharmacist attended daily bedside rounds, optimized inpatient medication regimens, served as a drug information resource, performed discharge medication reconciliation, and provided discharge medication education, including, in some cases, custom-made medication lists in an easier to read calendar/pictorial format for patients with limited health literacy.

The impact of our pharmacist’s presence on the team was significant.  She was able to suggest medications that the team may have overlooked or improperly prescribed and, though too early to prove long-term effects, has already anecdotally prevented some medication-related readmissions.  Meeting with patients directly revealed simple issues that could have hindered compliance, such as patients who could not take large pills due to swallowing dysfunction, or confusion due to multiple new medications.  At discharge, she prevented several errors in dosage, omissions, and even potential problems with insurance by switching patients to medications covered by their plans.  Besides these obvious benefits, she also reduced the demands on the physicians and nurses in our unit by taking on responsibilities in a much more expert and efficient manner, freeing us to focus on other aspects of patient care.

We have learned so much from having a pharmacist present, and seen that the need is really there.  Our pharmacist plays a role that up until now had been reserved for transplant or ICU services, patients widely considered to be more “complex” than general medical patients due to high-risk diagnoses and medications such as immunosuppressants..  But in fact, we have seen our general medical patients benefit just as much.  Many general medicine patients are equally complex, with medication lists that are no less long, and questions and concerns that are no less important. In fact, it can be more challenging to care for members of this population, who are frequently admitted to the hospital with undifferentiated issues, many of which overlap with their medication regimens, limited health literacy, and adherence. A clinical pharmacist can have an impact on all of these areas, and more.

Obviously, we will continue to learn and refine the role that clinical pharmacists play on our services.  But the expansion of this role is long overdue.  In the long term there will be global benefit from the enhanced role of clinical pharmacists, and I believe we are just beginning to see that potential now.

Emmanuel King is Assistant Professor of Clinical Medicine and Director of Operations, Section of Hospital Medicine at the Hospital of the University of Pennsylvania.

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