ED-based pharmacists make a big dent in medication errors
Gather data to make the case for on-site pharmacists, guide program development
Medication errors have long been one of the more difficult safety challenges facing hospitals, but they are particularly vexing in young patients. "You would think that you would order a medication as a physician and the risks of you making a mistake would be fairly low, but in pediatrics it is fairly complex because every child weighs a different amount, and all of the 12-hour medications are based upon [a child’s] weight," explains Rustin Morse, MD, the chief quality officer and vice president of quality at Children’s Medical Center (CMC) in Dallas, TX. Morse, who is also a practicing emergency physician at CMC, adds that prescribing becomes even more complex when young patients have multiple underlying diseases and are taking multiple medications.
The result of all these factors combined is that hospital-based medication errors are three times more likely to occur in pediatric patients than in adult patients, according to research.1 And the emergency setting is hardly immune to such problems, with its fast pace and pressure-cooker atmosphere. However, hospital administrators do not need to settle for such dismal statistics. For instance, by integrating specially trained pharmacists into the workflow of the ED, CMC has been able to bring medication errors from an average of 8% down to less than 1%.
In fact, the intervention works so well that today CMC has 10 full-time pharmacists working in the ED. The pharmacists are available to providers 24/7, and they review every medication ordered in real time to ensure that errors are caught before a medication reaches a patient. And hospital administrators see no reason why such an approach can’t work equally well for other large pediatric EDs.
The idea of having pharmacists present in the ED was first seriously considered at CMC in 2001, explains Brenda Darling, RpH, PharmD, the organization’s clinical pharmacy manager. "At the time, Children’s had a lot of pharmacists in other areas of the hospital like the NICU [neonatal intensive care unit] and all the different specialty floors but we did not have any pharmacy presence at all in the ED," she says.
The problem with this arrangement was that by the time medication orders made it from the ED to the hospital’s central pharmacy for review, it was often too late to prevent an error from reaching a patient. "The nurse would have already pulled the drug [from an automatic dispenser] and given it to the patient prior to the order being reviewed by a pharmacist," explains Darling.
Recognizing that there were opportunities for improvement in the medication error rate, investigators from the pharmacy department spent some time in the ED observing medication orders and noting the different types of errors that would occur. "We brought the information back and presented it to both the pharmacy department and the emergency management department and it was determined that yes, a pharmacy presence was needed in the ED." (Also see: "Study: Emergency providers still prescribing codeine for children, despite evidence of potentially harmful effects," p. 94.)
At this point, pharmacy representatives huddled with ED leaders to map out how to add pharmacists into the workflow of the ED. "From the beginning, our service was designed to be purely clinical, very hands on, and very integrated," says Darling. "It was not pharmacy-driven. It was truly the medical director of the ED who presented the idea to the board and said that we needed pharmacists in the ED 24 hours a day, seven days a week."
Make pharmacists part of the team
With the model now fully implemented, the pharmacist is engaged right from the inception of a case, notes Darling. "If we get a telephone call, indicating that we have a critical care patient coming, then the pharmacist will get information on the mechanism of the injury, the estimated age of the patient, and then [he or she] will start thinking what medications are needed back in the critical care room," she says.
While pharmacists are part of the care team for all of the critical care patients who come through the ED, the ED-based pharmacists are also available to provide guidance to providers on medication issues, and, at times, nurses call on the pharmacists to speak with patients or families about their medications, especially in cases in which a complicated regimen is involved, observes Darling. "We also make recommendations to providers when they are looking at treatment options or when they are looking at what labs need to be ordered on a patient," says Darling
In addition to these responsibilities, Darling notes that a pharmacist reviews all medications ordered in the ED and all prescriptions written as part of a discharge instruction from the ED.
Don’t tolerate pushback
The pharmacist’s active role in caring for patients in the ED takes some providers who are not used to this type of model by surprise, at least initially. "I came from an organization that did not have robust pharmacy involvement in the ED so it was an eye-opening experience to come to Children’s here in Dallas and see how this interaction plays out. It was incredibly comforting as well," recalls Morse, who has been working at CMC for two years.
"We are a large academic medical center, so we have residents who provide care, and sometimes residents make mistakes when they are prescribing medicines, either as a prescription or internally here in the hospital," adds Morse. "And frankly, despite practicing for well over 15 years, I too make errors in ordering medications, so the benefit of having a pharmacist review every single order in real time, and every prescription before it leaves our organization is tremendously helpful from a patient safety standpoint."
Further, Morse stresses that on-site pharmacists do much more than just review medication orders. "They are actually reviewing patient charts, reviewing their past histories, and reviewing medications patients have received in the past, as well as their allergies," he says. "They are a fundamental and integral part of our team where they fully know the patient’s history as well as any other provider on the team, and they are playing a role in looking at [the case] from the perspective of the medications and interactions."
Stephanie Weightman, RpH, PharmD, BCPS, an emergency services clinical pharmacist, observes that while she hasn’t experienced any pushback from providers, she acknowledges that it is not unusual for new residents to be caught slightly off-guard when she approaches them and starts asking questions about a case. "Throughout the rotation, they start to realize how valuable we can be and how we are here to help," she says. "By the end of their rotation they are always very grateful, and it is a really nice transition to see."
Morse adds that pushback would never be tolerated by the organization. "From an ED perspective, patient safety is our top priority, and health care is a team sport," he says. "If someone ever has a concern about the safety of a patient and is performing their role to intervene to make sure we are providing high quality, safe care, that is fully supported by the organization."
In Morse’s experience, input from the on-site pharmacists has not only always been welcome, but also generally acted upon. "I would say probably 75%-90% of the time, their intervention results in a change in the medication order," he says.
Nurture a trusting relationship
The on-site pharmacists can, in fact, add value in a multitude of ways. For instance, Morse recalls one recent discussion with Darling about intravenous fluids he had ordered for a patient. "She asked if I was sure that I wanted the IV fluids, and did it have to be the [specific IV fluids] that I ordered," he says, noting that he gave her a puzzled look at the question. Darling then explained that there was a national shortage of the IV fluids, and suggested an alternative that would be equally efficacious for the patient, notes Morse.
In another case, Morse recalls that a pharmacist asked whether he would like to order a pain medication for a critically ill patient who was being sedated for a procedure. "He thought it might be a good idea to have a pain medication on board, and frankly, I had not thought of it from that perspective. It was an excellent suggestion, and I added a pain medication for that patient," says Morse.
In other cases, pharmacists have pointed out cases in which medications can be given orally rather than via IV, resulting in less expense without compromising efficacy, and they have commonly recommended dosing strategies for antibiotics that are more palatable for patients, but still effective, adds Morse.
"We also sometimes suggest better or more narrow antibiotic therapies to help maintain antimicrobial stewardship, and to help decrease potential resistance out in the community," says Weightman. "We have helped to tailor medications to optimize intubation in critically ill patients, and also to optimize vasopressure therapy for patients who may have low blood pressure."
For pediatrics, being on site in the ED offers important advantages, stresses Darling. "When we look at a medication order, we consider a patient’s age, their gender, and we also look at the weight," she says. However, in cases in which pharmacists may question a patient’s weight, they have the ability walk right over to the patient’s room and physically look at the patient and have a discussion in real time with the patient’s providers. "[The model] ED enables us to have very open dialog and trust with the providers and our nursing staff," adds Darling.
Morse concurs, noting that it makes a difference that the pharmacists are working side-by-side with the providers every day. Further, he states that while there is a cost to staffing an ED with specially trained pharmacists around the clock, the gains in patient safety are very important.
"I would much rather have a pediatric pharmacist who only specializes in looking at pediatric medications review my prescriptions prior to discharge than hope that a pharmacist at a local pharmacy will be familiar with how we dose immunosuppressants in a child with cancer," says Morse. "The safety aspects of this far outweigh the costs, and, therefore, it gives us great comfort in knowing that we are doing everything we can to keep our patients safe."
Visit other programs
For others interested in implementing a pharmacy program similar to what CMC has in place in the ED, Darling stresses that it is important to first gather data regarding when and why medication errors occur so you can effectively make your case to higher-ups. "You really need to be aware of the needs of your department before you can design your program, and it needs to be multidisciplinary because medicine is multidisciplinary," she says. "You can’t forget that your customer is not only the patient, but also [medical professionals from] the other departments that you work with."
Darling also advises ED and pharmacy leaders to visit hospitals that already have on-site pharmacists in the ED. "We have spoken with pharmacists who work in the ED at a lot of other hospitals, and we have also had them come visit us to observe how we do our practice," she says. "We are very open to answering questions, sharing what has worked well for us, and what has not worked well."
- Kaushal R, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-2120.
- Brenda Darling, RpH, PharmD, Clinical Pharmacy Manager, Children’s Medical Center, Dallas, TX. Phone:
- Rustin Morse, MD, Chief Quality Officer, Vice President of Quality, and Emergency Physician, Children’s Medical Center, Dallas, TX. E-mail: email@example.com.
- Stephanie Weightman, RpH, PharmD, BCPS, Clinical Pharmacist, Emergency Services, Children’s Medical Center, Dallas, TX. E-mail: stephanie.weightman@