An investigation of the opinions of community and hospital pharmacists and general practitioners of the management of drug therapy at the primary-secondary care interface
ABSTRACT Introduction: Drug-related problems and medication errors, many preventable, are known to make a significant contribution to morbidity and mortality. The point of transfer between primacy and secondary care provides significant opportunities for medication errors to arise, especially in the absence of structured transfer protocols. There has been limited national and international research into mechanisms to facilitate seamless transfer across the primary-secondary care interface. This study attempts to identify the current arrangements that are in place and the opinions of healthcare professionals of those arrangements. Materials & Methods: The opinions of community pharmacists, hospital pharmacists and general practitioners in relation to the current procedures in place for the admission and discharge of patients, with particular reference to drug therapy, were sought. This was done by means of self-administered, anonymous, postal questionnaires which were distributed nationwide. The data were coded and analysed in SPSS v. 16. Standard statistical parameters were calculated and statistically significant relationships were determined using ANOVA and the chi-squared test where appropriate, taking p<0.05 to be significant. Results: There is currently very little communication across the interface at the time of discharge, with 10.7% of community pharmacists reporting that they have never been contacted by a hospital to inform them of the imminent discharge of a patient, with a further 79.8% stating that they were only contacted occasionally. On the other side of the interface, hospital pharmacists reported ongoing difficulties in attempting to obtain a patient medication history on admission, with 75.5% of respondents stating that they regularly, often or always encountered these difficulties. Discussions, Conclusion: The majority of community and hospital pharmacists and general practitioners were dissatisfied with the management of drug therapy during the hospital discharge process. All three groups of healthcare professionals felt that the introduction of a structured seamless care programme linking hospitals, general practitioners and community pharmacists to be important or very important. It is intended that the results of this analysis will feed into a protocol for a pilot seamless care programme based in the community pharmacy.
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ABSTRACT: The incidence of heart failure is increasing in developed countries. In the aged population, heart failure is a common cause of hospitalization and hospital readmission, which in conjunction with post-discharge care, impose a significant cost burden. Inappropriate medication management and drug-related problems have been identified as major contributors to hospital readmissions. In order to enhance the care and clinical outcomes, and reduce treatment costs, heart failure disease management programmes (DMPs) have been developed. It is recommended that these programmes adopt a multi-disciplinary approach, and pharmacists, with their understanding and knowledge of medication management, can play a vital role in the post-discharge care of heart failure patients. The aim of this literature review was to assess the role of pharmacists in the provision of post-charge services for heart failure patients. An extensive literature search was undertaken to identify published studies and review articles evaluating the benefits of an enhanced medication management service for patients with heart failure post-discharge. Seven studies were identified evaluating 'outpatient' or 'post-discharge' pharmacy services for patients with heart failure. In three studies, services were delivered prior to discharge with either subsequent telephone or home visit follow-up. Three studies involved the role of a pharmacist in a specialist heart failure outpatient clinic. One study focused on a home-based intervention. In six of these studies, positive outcomes, such as decreases in unplanned hospital readmissions, death rates and greater compliance and medication knowledge were demonstrated. One study did not show any difference in the number of hospitalizations between intervention and control groups. The quality of evidence of the randomized controlled trials was assessed using the Jadad scoring method. None of the studies achieved a score of more than 2, out of a maximum of 5, indicating the potential for bias. The DMPs carried out by pharmacists have contributed to positive patient outcomes, which has highlighted the value of extending the traditional roles of pharmacists from the provision of professional guidance to the delivery of continuity of care through a more holistic and direct approach. This review has demonstrated the effectiveness of pharmacists' interventions to reduce the morbidity and mortality associated with heart failure. However, there is an on-going need for the development and evaluation of pharmacy services for these patients.Journal of Clinical Pharmacy and Therapeutics 09/2007; 32(4):343-52. · 2.10 Impact Factor
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ABSTRACT: The authors retrospectively evaluated anonymously submitted inpatient medical error reports from 8 institutions participating in the University HealthSystem Consortium Patient Safety Net (PSN) in 2004 in an attempt to focus patient safety efforts on problems that were most commonly associated with harm. Of the 25,300 incidents reported, 3381 (13.3%) were associated with adverse events (AEs), and 109 (0.4%) were associated with death. Although the most commonly reported categories of incidents associated with AEs were complications of procedure/treatment/test (29%), falls (17%), and medication errors (10%), the taxonomy of the PSN limited efforts to find specific errors in care that might be addressed by attempts to improve patient safety. Skin breakdown and falls were confirmed as presenting substantial risks to hospitalized patients, in that 59% of the incidents reported in the skin integrity category and 22% of falls resulted in AEs. The benefits and limitations of a voluntary reporting system are discussed.American Journal of Medical Quality 10/2009; 24(6):520-4. · 1.47 Impact Factor
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ABSTRACT: This study was designed to determine risk factors and potential harm associated with medication errors at hospital admission. Study pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651 adult medicine service inpatients with 5,701 prescription medications. Discrepancies resulting in order changes were considered errors. Logistic regression was used to analyze the association of patient demographic and clinical characteristics including patients' number of pre-admission prescription medications, pharmacies, prescribing physicians and medication changes; and presentation of medication bottles or lists. These factors were tested after controlling for patient demographics, admitting service and severity of illness. Over one-third of study patients (35.9%) experienced 309 order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful. In logistic regression analysis, patient's age > or = 65 [odds ratio (OR), 2.17; 95% confidence interval (CI), 1.09-4.30] and number of prescription medications (OR, 1.21; 95% CI, 1.14-1.29) were significantly associated with errors potentially requiring monitoring or causing harm. Presenting a medication list (OR, 0.35; 95% CI, 0.19-0.63) or bottles (OR, 0.55; 95% CI, 0.27-1.10) at admission was beneficial. Over one-third of the patients in our study had a medication error at admission, and of these patients, 85% had errors originate in their medication histories. Attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications. Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists.Journal of General Internal Medicine 02/2010; 25(5):441-7. · 3.28 Impact Factor
Community Pharmacy Services at the Primary-Secondary Care Interface
B. Duggan and S.A. Ryder
University of Dublin, Trinity College, School of Pharmacy and Pharmaceutical Sciences, Dublin 2.
Published abstract available at: http:/ / dx.doi.org/ 10.1007/ s11096-011-9602-2 International J ournal of Clinical Pharmacy 2012 Feb; 34(1):211-2. Email: firstname.lastname@example.org
Drug-related problems and medication errors, many preventable, are known to make
a significant contribution to morbidity and mortality. The point of transfer between
primary and secondary care provides opportunities for medication errors to arise,
especially in the absence of structured transfer protocols.1The 2008 government
report Building a Culture of Patient Safety2acknowledges the movement of patients
from one care setting to another and the need for integration:
“A great deal of modern healthcare is multi-disciplinary in nature and patients
frequently have to move between different healthcare providers in accessing
care. Providing patient-centred, seamless care requires robust integration
mechanisms and strong governance arrangements which ensure that patients
receive safe and high quality care where different aspects of their care are
provided across different providers”provided across different providers.
There has been limited national and international research into mechanisms to
facilitate seamless transfer across the primary-secondary care interface, with studies
primarily focused on hospital based services. Little attention has been paid to the
potential contribution of community pharmacy based services.3-6The purpose of this
research was therefore to examine current levels of communication between
community pharmacies and hospitals, to investigate the extent and nature of errors
that arise on discharge, and to explore pharmacists’ perceptions of current
procedures, with a view to future development of structured seamless care protocols.
The response rates for the community pharmacist and hospital pharmacist surveys
were 49% and 60% respectively.
Hospital pharmacists reported ongoing difficulties in attempting to obtain an accurate
patient medication history on admission, with 76% of respondents stating that they
regularly, often or always encountered these difficulties. This is reflected in their
overall satisfaction with the admission process. The majority of hospital and
community pharmacists were also dissatisfied with the discharge process (Figure 3).
Figure 3: Pharmacists’ level of satisfaction with admission and discharge processes
very dissatisfied very dissatisfieddissatisfieddissatisfiedneutral neutralsatisfied satisfiedvery satisfiedvery satisfied
A log book of all communications between a community pharmacy and hospitals were
maintained for a period of 365 working days. A retrospective review of all
prescriptions dispensed under the hospital emergency scheme in the same community
pharmacy over the course of one year was also carried out. New discharge and post-
discharge prescriptions were also compared as they were presented in the community
pharmacy. The data were coded and analysed in SPSS v. 16. Standard statistical
parameters were calculated and statistically significant relationships were determined
using ANOVA and the χ2-test where appropriate, taking p<0.05 to be significant.
(a) Hospital pharmacists’ satisfaction
(b) Hospital pharmacists’ satisfaction
(c) Community pharmacists’
satisfaction with discharge
The opinions of community pharmacists and hospital pharmacists were sought in
relation to the current procedures in place for the admission and discharge of
patients, with particular reference to drug therapy. Self-administered anonymous
postal questionnaires were sent to one third of the community pharmacies
(geographically stratified) and to all hospitals listed as part of the HSE national(geographically stratified) and to all hospitals listed as part of the HSE national
hospitals office group and 19 additional hospitals registered with the PSI.
At present there is little communication across the interface at the time of discharge,
with 11% of community pharmacists reporting that they had never been contacted by
a hospital to inform them of an imminent discharge of a patient, and a further 80%
stating that they were only contacted occasionally. Community and hospital
pharmacists identified similar reasons for communication at discharge currently.
Figure 4: Reasons for contact between hospital and community pharmacy at time of
Identified by hospital pharmacists
Identified by community pharmacists
RESULTS AND DISCUSSION
Communication log book
A total of 216 communications between the community pharmacy and hospitals were
recorded during the study period. This represents an average of 0.59 communications
a day or one communication for approximately every 15 hrs the pharmacy was open.
In absolute terms there appeared to be little difference between the number of
communications dailyfrom Monday to Thursday,
communications occurring on Friday. However, when this was compared to the
number of prescriptions originating from hospitals that were dispensed on the variousnumber of prescriptions originating from hospitals that were dispensed on the various
days of the week, far more communications were recorded on Mondays and Fridays
than might have been expected, with a much lower level being recorded for Tuesdays
and Saturdays. There was, therefore, a significant difference between the days on
which communication occurred (p=0.01, χ2-test). This may be explained by weekend
discharges with the need for additional follow-up after the weekend if prescribers
were uncontactable on Saturday, and Monday admissions.
with a higher number of
% of respondents
High Tech medicine prescribed
Medicine that is difficult to source
Particular patient groups
Particular time of day
No special circumstances
In view of the level of dissatisfaction with current admission and discharge
procedures, it is not surprising that 98% of community pharmacists and 97% of
hospital pharmacists believed introduction of a structured seamless care programme
linking hospitals, general practitioners and community pharmacists to be either
important or very important 86% of community pharmacists and 74% of hospitalimportant or very important. 86% of community pharmacists and 74% of hospital
pharmacists were in favour of hospital pharmacies having a designated pharmacist
with responsibility for facilitating seamless patient care at discharge. The lower level
of enthusiasm among hospital pharmacists may stem from concerns about the
logistics and workload impact of such an initiative.
The reason for each communication and the outcome were also recorded (Figure 1).
In 81% of cases, communication was sufficient to resolve the issue.
Figure 1: Communication between hospitals and the pharmacy
The most popular pieces of information that community pharmacists would like
hospital staff to communicate to a patient’s nominated community pharmacy on
discharge (those identified by >50% of respondents) are displayed in Table 1. The
preferred means of communication were fax (30%), a letter carried by the patient
(28%) and telephone (26%). E-mail (9%) and post (7%) were far less popular,
probably due to concerns about security and timely receipt of the information.
(a) Reasons for communication (a) Reasons for communication(b) Outcome of communication (b) Outcome of communication
Table 1: Information desired by a majority of community pharmacists at discharge
New medicines and reasons for introduction
Discontinued medicines and reasons for cessation
Discharge prescription, if any
Intended duration of therapy of prescribed medicines
Adverse drug reactions in hospital
Dressings in use at time of discharge
Use of drugs outside terms of product license
Potential drug-related problems/interactions
% of respondents
0510 15 202530
Check patient's history
Obtain information about med
Confirm stock of med
Alert to imminent discharge
Confirm discontinued med
Confirm new med
To get info and return call
Admin info provided
Current med confirmed
Dr not available at the time
New med confirmed
1.Reid M, Estacio R, Albert R. Injury and death associated with incidents reported to the patient safety net. Am J
Med Qual. 2009 Nov-Dec;24(6):520-4.
Madden D (chairperson). Building a Culture of Patient Safety: Report of the Commission on Patient Safety and
Quality Assurance. 2008. Department of Health and Children.
Beney J Bero LA Bond C Expanding the roles of outpatient pharmacists: effects on health services utilisationBeney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilisation,
costs, and patient outcomes. Cochrane Database Syst Rev. 2000;(3):CD000336.
Gleason KM, McDaniel MR, Feinglass J, Baker DW, Lindquist L, Liss D, Noskin GA. Results of the Medications At
Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors
at Hospital Admission. J Gen Intern Med. 2010 Feb 24. [Epub ahead of print]
Ponniah A, Anderson B, Shakib S, Doecke CJ, Angley M. Pharmacists' role in the post-discharge management of
patients with heart failure: a literature review. J Clin Pharm Ther. 2007 Aug;32(4):343-52.
Voirol P, Kayser SR, Chang CY, Chang QL, Youmans SL. Impact of pharmacists' interventions on the pediatric
discharge medication process. Ann Pharmacother. 2004 Oct;38(10):1597-602.
Karapinar-Çarkıt F, Borgsteede SD, Zoer J, Siegert C, van Tulder M, Egberts AC, van den Bemt PM. The effect of
the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in
Healthcare) on readmission rates in a multicultural population of internal medicine patients. BMC Health Serv Res.
2010 Feb 16;10(1):39.
The involvement of community pharmacists in seamless care is inconsistent at
present, and both community and hospital pharmacists are dissatisfied with current
arrangements. The findings of this study will feed into a protocol for a pilot
community pharmacy-based seamless care programme.
Comparison of new discharge and post-discharge prescriptions
436 prescriptions were dispensed in total accounting for 990 items. 42% of the
items were dispensed in full, therefore no further prescription was required from the
patient’s GP. 445 items required a follow up prescription to be issued. When the GP
prescriptions were presented in the pharmacy it was found that for 121 items (27%)
the follow up was incorrect. This is comparable to the error frequency found by
hospital pharmacists in medication reconciliation at admission.4
Figure 2: Nature of errors on follow up prescriptions
% of communications
% of communications
010 203040 5060
Incorrect duration of therapy
Incorrect item prescribed
Drug inappropriately continued
New therapy not continued
Incorrect dose prescribed
% of errors
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