Hospital develops unit-based pharmacist program

The switch results in 90%+ success rate

Computerized physician order entry (CPOE) may be one way to curb medication errors. The reality, however, is that most health care centers have not implemented such a program — and may never will. CPOE systems are expensive, and some professionals fear the technology will be outdated during the time it takes to install the system and teach staff to use it.

Instead, some hospitals are looking for other methods to decrease medication errors. John T. Mather Memorial Hospital in Port Jefferson, Long Island, NY, took the challenge and developed a system in which a clinical pharmacist works with staff on each patient-care unit and enters the medication orders directly from the patient’s chart.

The unit-specific pharmacist program, which began in March 2001, has been the success that organizers had hoped. Pharmacist interventions continue to increase, 43% over the year 2002, says Olga Larios, MS, RPh, director of pharmacy. Nurses and physicians now consider pharmacists a trusted component of the patient care process.

In addition, the pharmacists have implemented a pharmacist-initiated intravenous (IV) to oral (PO) medication switch, which has had a success rate of more than 90%. This is quite an improvement from the 36% that researchers from Harvard Medical School recently reported using their CPOE system.

"On the outside, we are all in favor of CPOE," Larios says. "However, it’s a huge monetary investment and it’s not without its problem. We feel this program is a viable alternative to the CPOE that so few hospitals are utilizing right now."

Get everyone on board

The idea began in late 2000 as a response to the country’s heightened awareness of medication errors, Larios says "Our administrative staff said it would like a response from our hospital. We thought about it and came up with this plan."

The program started as a pilot in a small area of the hospital to see how physicians and staff would receive it. After a few months, the medical board saw the validity of the program and agreed to add a full-time pharmacy staff member. "It took about six months from the early start of the program until we were in full swing," Larios says.

The 248-bed hospital has two main floors. The program involves having one pharmacist on each floor all day long. One floor, for example, has an intensive care step-down unit, a coronary care unit, a telemetry area, and a medical-surgical patient care area.

"Instead of physician order entry, we have pharmacist order entry of medications and laboratory orders," explains Jeffrey Santorello, MS, MLS, RPh, a clinical pharmacist who helped develop the program. "That pharmacist has access to laboratory data, nursing personnel, and medical personnel. We interact closely by the patient bedside with medication orders and questions that would pertain to medicine."

The program was not easy to start, Larios says. "You have to gain the respect and have the physician staff, in particular, know that you have the knowledge."

John T. Mather Memorial Hospital is not a teaching facility and therefore does not have residents and interns. "We deal strictly with an attending staff, which makes the hurdle a little more difficult in the beginning," she says. "However, we overcame it and quickly came to our present level [of trust]."

The pharmacy services department has a core of two or three pharmacists that it uses to work on the two floors. "Some pharmacists aren’t comfortable being on the floor, and others are. We try to rotate the ones who are whenever we can," Santorello says. Three other pharmacists also are available to fill in on the floors when needed.

The floor-based pharmacists also got approval from the medical board and the pharmacy and therapeutics (P&T) committee to switch some medications from IV to PO without first getting physician approval. The pharmacists make the change directly on the chart, with the physician signing the change the next day.

In the beginning, pharmacy services evaluated how much money it thought it would save using one or two drugs, Santorello says. This part of the program continued once the department proved the switch was a cost-saving measure and that it could be done with the cooperation and the trust of the doctors.

Initially, the pharmacists started with about four medications, which were 100% bioavailable, and gradually increased the number over the years, Larios says. The nursing staff seemed to buy into the program quickly. They now give the clinical pharmacists the names of patients who need to have their medications switched from IV to PO.

The nursing staff even asked the pharmacists to expand the medication list to include five or six medications. In the last P&T committee, physicians asked if other medications could be added to the list, too. "It was an interesting source for the recommendation," she says.

Now the pharmacists have more than 10 medications that they are able to change from IV to PO according to protocol without contacting the physician. "Very rarely — maybe one or two cases a year, we have a physician who wants to keep the patient on IV another day," Larios says. The success rate of the switch has been up to 97%.

The program is unique in that the pharmacists don’t call the physicians for most of the IV switches, Santorello says. "The clinical pharmacist does it automatically with permission from the pharmacy and therapeutics committee and the medical board. It is interesting that major hospitals don’t have this program in effect, where the pharmacist goes from IV to PO when certain criteria are met."

The Harvard CPOE study found that physicians were hesitant to make the switch for certain patients, such as those in the intensive care unit (ICU). Having a pharmacist on the unit tends to bypass that problem, Santorello says. "[By seeing all the patients on the floor], we are able to monitor their drug therapy. If the patient is on total parental nutrition or is in the ICU or coronary care unit, we would be hesitant to make the change." Instead of spending time on the more questionable switches, the pharmacists instead go right to the ones they can change automatically, Santorello says.

The trust that allows physicians to feel comfortable with pharmacists making that change didn’t happen overnight, he adds. "It was something that we developed."

Overall, the pharmacist presence at the bedside makes the program a success, he says. "Pharmacists being on the floor make this happen."

When he was first on the floor, nurses didn’t really know how to approach him with questions. That has changed. "Nurses now depend on me for drug information and for problems involving patient medication. I feel I am part of the nursing team."