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Pharmacology+&+Pharmacy,+2014,+5,+577‐587+
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Impact'of'a'Clinical'Pharmacist'in'the'
General'Hospital:'An'Egyptian'Trial'
Nirmeen'A.'Sabry,'Maggie'M.'Abbassi
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Abstract'
Medication' review' aims' at' optimizing' the'impact' of' medications' while' minimizing' their' related'
problems.'Drug‐related'problems'have'never'been'properly'addressed'in'Egyptian'hospitals.'The'
purpose' of' this'paper'is' to' record' and' compare' the'prevalence' and' types' of'medication'related'
problems,'the'interventions'provided'by' the'clinical'pharmacists'and'how'physicians'responded'
along'with'making'recommendations'for'error'prevention.'This'prospective'study'was'conducted'
between'June'2012'and'December'2012,'at'an'Egyptian'general'hospital.'Five'trained'pharmacists'
recorded'patient‐specific'medication'related'recommendations'and'completed'quality‐of‐care'in‐
terventions.'The'average'number'of'audited'doses'was'81%'of'those'prescribed.'The'most'preva‐
lent'medication'problem'was'prescribing'errors'followed'by'administration'errors.'A'total'of'20'
patients'experienced'adverse'drug'events.'The'greatest'error'rates'across'the'seven'months'were'
observed' in' the' ICU' and' cardiology' units.' Numbers' of' interventions' offered' by' the' pharmacists'
ranged' from' 241,' to' 519' per' month.' Nurses' accepted' all' the' interventions' introduced' by' the'
pharmacists' aimed' at' reducing' administration' errors' while' physicians’' resistance' rates' had' an'
average'of'21%.'This'study'showed'a'positive'influence'of'the'pharmacist‐led'medication're view'
in'reducing'potential'drug‐related'problems'in'an'Egyptian'secondary'care'where'the'hospital'un‐
der'study'implemented'new' measures'to' minimize' drug' related'problems'according' to' the' find‐
ings'of'the'trained'pharmacists.'
'
Keywords'
Egypt,'Medication'Review,'Intervention,'Drug'Related'Problems'
1.'Introduction'
Patient safety is a main goal in any treatment protocol. Drugs are not licensed worldwide until they are proven to
*
Corresponding author.
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be safe and efficacious. However, drug related problems (DRPs) represent a worldwide concern. A DRP can be
defined as “A circumstance that involves a patient’s drug treatment that actually, or potentially, interferes with
the achievement of an optimal outcome” [1]. This can include any stage of drug use starting from the prescribing
process, all through dispensing, administration and then possible adverse events. The frequency of DRPs is
ranging in the literature from 1.7% to 59% according to definitions of problems studied and the setting in which
the study was conducted [2]. It is being documented that, DRPs are one of the reasons for increasing the length
of hospital stays and overall treatment costs [2]. A Danish medication report found that, 8.7% of medication er-
rors can result in death [3]. The interest in DRPs was greatly stimulated by the report of the Institute of Medicine
“To err is human” [4], which emphasized the fact that, even though errors are inevitable yet, they can be mini-
mized to build a safer healthcare system.
Although medication review process is a routine pharmacy practice in many countries in Europe and the
United States for more than 30 years now, this practice is recently introduced and is developing in the Middle
East countries including Egypt.
Only few studies were done in Egyptian hospitals to identify DRPs and were performed on a small scale in-
side one unit of a hospital: Intensive care unit, pediatric intensive care unit and in an obstetric emergency ward
[5]-[7]. Even though, DRPs have been studied worldwide, extrapolating international solutions to local settings
might not always be applicable. One of the main reasons for the lack of monitoring DRPs in Egyptian hospitals
is that, clinical pharmacy practice in Egyptian hospitals has been only recently introduced and implemented in
only few of the hospitals.
Increasing interest in implementing this practice has recently stemmed after the Egyptian Ministry of Health
mandated that, all hospitals must implement clinical pharmacy practices before July 2013. An important reason
for the delay in implementing a significant role for the pharmacists within Egyptian hospitals is the physician’s
resistance to pharmacist’s role.
With the implementation of this practice in several hospitals in Egypt, the aim of this study arouse, which was
recording, and comparing the prevalence, and types of medication related problems, the interventions provided
by the clinical pharmacists and how physicians responded in one of the trial Egyptian hospitals along with mak-
ing recommendations for error prevention, emphasizing the role of clinical pharmacists in an Egyptian setting.
2.'Methods'and'Materials'
This work was conducted after an approval and permission from the Ethics Committee of the Faculty of Phar-
macy, Cairo University. Authors have no conflicts of interest with regard to the data produced. A cross-sectional
evaluation of medication review improvement service was conducted in a private Egyptian general hospital (150
beds) of multiple specialties. All the patients admitted to the hospital were subjected to a thorough medication
review process during their hospital stay. This service was part of a bigger quality improvement project that was
designed for all the hospital services. Before applying this service, the pharmacist’s role was limited to receiving
physicians’ orders, screening it for medication availability and dispensing the medications. The first step in
launching the service was a careful selection and recruitment of clinical pharmacists to carry out the medication
review process. The selected pharmacists were trained to review patient files, identify DRPs, communicate with
other healthcare professions and document valid data. The training process was done by the principle investiga-
tor who has already received her training in one of the teaching hospitals in the United Kingdom, over a period
of 4 years.
2.1.'Data'Collection'
The characteristics of the hospital and wards are presented in Table 1. Because this was a service evaluation, no
sample size was decided. Instead, a 7 month period was selected starting from the June 2012 which was the first
month of launching the service. During this period all the reviewing pharmacists were requested to review as
many patients as they can and to record any identified problems together with any suggested interventions. All
the reviewed patients were considered the study sample size and the percentages of patients reviewed were cal-
culated.
Patient data collection sheet was specially designed to include all the patients’ relevant data including demo-
graphics, reason(s) of hospital admission, co-morbidities, prescribed medication during hospital stay, and all the
relevant biochemical data done during the hospital stay.
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Table 1. Characteristics of hospital and wards being studied.
Hospital type
Private
Beds
150
Inpatient prescribing
Paper based and computer based
Discharge prescribing
Paper
based and computer based
Number of Wards
8 general wards served by 15 specialty +
3 criti
cal areas
Pharmacist availability on
ward
5 clinical pharmacists working 6 days/week,
9 am
-3 pm shift
Pharmacists documented details of DRPs identified, the number of doses administered (or omitted) to the pa-
tient in the hospital before the problem was identified, together with any proposed intervention(s) to correct the
problem and the response to the proposed interventions. DRPs were detected through both file review and clini-
cal round attendance. The outcome measures were the rates and types of DRPs, the types and frequencies of
recommendations proposed by pharmacists and the number of the recommendations, which were accepted or
implemented by the treating physicians.
A carefully designed DRPs list was specially created to be used in the hospital as a guidance to record all the
identified problems in a structured way. The problems were mutually exclusive and included: indication with no
prescribed medication [8], medications with no valid indication [8], overdose: accidental or intentional use of a
drug or medicine in an amount that is higher than is normally used [8] [9], underdose: accidental or intentional
use of a drug or medicine in an amount that is less than is normally used [8] [9], drug-drug interaction (Using
online Lexi-interact
®
): occurring whenever the effects of one drug are modified in or on the body by the prior or
concurrent administration of another pharmacologically active substance. Only those interactions required dose
modification, changing schedules, or avoiding combination were recorded [8] [9], adverse drug events: any ad-
verse, noxious or harmful event associated with the use of a drug in humans, whether or not considered drug re-
lated, as defined by The United States Food and Drug Administration (FDA) [10].
Lack of therapeutic drug monitoring (TDM) and/or resultant need of adjustment of drug doses, drug duplica-
tion: the use of multiple agents from the same chemical family or therapeutic class [9], contraindication: a con-
dition or factor that serves as a reason to withhold a certain medical treatment, therapeutic failure when the ex-
pected drug effects do not occur following a prescribed pharmacological treatment, including any clinical event
that could be related to a low prescribed dose [9]. Also, nursing administration problems were recorded. This
was defined as any deviation from the physician’s medication order as written on the patient’s chart [11], in-
cluding timing problems, missing doses as observed from the administration sheet and after confirming with the
nurse, an extra dose as observed from the quantities of unit doses remaining in the patient’s tray, or wrong infu-
sion flow rate. Finally, prescribing errors adopted from Anderson 2003 [9] and described as drug repetition, un-
clear writing (abbreviation, concentration, frequency), wrong interpretation of the culture and sensitivity, in-
complete PRN medication order, wrong dose, dosage form, or wrong route of administration, and wrong timing
of medication administration were also documented and corrected whenever it was possible.
2.2.'Interventions'
Intervention was defined as “any kind of measure taken by the pharmacy staff members to solve a detected
drug-related problem” [9]. All the interventions recorded were proposed by the clinical pharmacy team on the
level of the prescriber or on the level of nurses. None were done on the level of patients or drug. On the pre-
scriber level, the prescribers were either informed only, intervention proposed, approved by prescriber, or inter-
vention proposed, but not approved by prescriber.
2.3.'Data'Analysis'
Prevalence of medication problems, breakdown by specialty, interventions done by the pharmacists and rate of
resistance to pharmacist interventions were calculated. Ninety five percent confidence intervals (95% CI) were
calculated when possible. Prevalence of medication problems was calculated as number of error doses as a frac-
tion of total audited doses. Percentage of problems per specialty was calculated as number of error doses per
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specialty as a fraction of total error doses for this month. Interventions done by the pharmacists per specialty
were counted; the resistance rate was calculated as the number of times the intervention was refused by the phy-
sician or if the physician could not be reached as a fraction of the total number of interventions per specialty. In
case of accepting the intervention, the doses taken or missed before the error was corrected were also counted.
Although demographic data (gender, weight, height) were collected for the accuracy of medication review
process, demographic data were not included in the analysis process as the aim was service focused rather than
patient focused.
3.'Results'
3.1.'Frequencies'and'Types'of'Medication'Problems'
Because of the nature of the hospital and being a general hospital, it was inaccurate to describe the identified
problems per patient due to major variability in the number of medications prescribed for each patient. Instead,
the problems were recorded based on the total dispensed doses. The number of medications taken by patients
ranged from 1 to 20 during the seven months. The total numbers of prescribed doses in the hospital were 52887,
48412, 48317, 52359, 44896, 44541 and 49622 for the seven months period starting in June, respectively, in 11
wards including surgical and intensive care units (ICUs). Total audited doses by the pharmacists were 43072
(81%), 33096 (68%), 36509 (76%), 37129 (71%), 35866 (80%), 43240 (97%), and 48749 (98%) with an aver-
age rate of 81%.
The number of doses found to have problems were 1197 (2.8% (2.6 to 2.9)), 856 (2.6% (2.4 to 2.8)), 624 (1.7%
(1.6 to 1.8)), 1248 (3.4% (3.2 to 3.6)), 1489 (4.2%( 4 to 4.4)), 1473 (3.4% (3.2 to 3.6)) and 902 (1.9% (1.7 to 2))
for the seven consecutive months respectively with an average rate of 2.8%.
The average percentages of each problem over the seven months are shown in Figure 1. The most prevalent
medication problem in the seven months was prescribing errors followed by administration errors. Medication
Figure 1. Average incidence of different identified medication problems in sev-
en months period.
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overdose was the third reported problem especially in patients with renal impairment who were not subjected to
dose adjustment according to their kidney function. The 95% confidence intervals are shown in Table 2.
During the study period, a total of 20 (92 doses) patients experienced adverse drug events. One of them only
was recorded as allergic and the rest were non-allergic events. Thirteen (70 doses) of the recorded events were
described as serious events according to the FDA definitions [12]. These events resulted in death or serious
events, and required urgent intervention including ICU admission, discontinuing medication, treatment change,
or extra monitoring. Due to confidentiality issues, it was quite difficult to obtain total death cases recorded in the
hospital during the evaluation period, which in turn made it difficult to calculate the medication related mortalities.
3.2.'Interventions'by'Pharmacists'
Pharmacists were requested to intervene whenever a problem was identified. The interventions permitted by the
hospital authorities were either informing the nurse for any administration problems or the physician for all
other types of problems. Total numbers of interventions offered by the pharmacists were 241, 278, 183, 421, 388,
519 and 405 for the seven months with resistance rates 21% (16% to 27%), 33% (27% to 39%), 31% (25% to
Table 2. Percentage of doses of each type of problem from total error doses per month (95% confidence interval).
Types of
Identified
Problems (%)
June July August September October November December
Administration
Errors
7.9% 14.6% 16.0% 29.3% 21.8% 28.4% 23.8%
(6.4% - 9.6%) (12.3% - 17.2%)
(13.3% - 19.2%)
(26.8% -32.0%)
(19.7% - 24.0%)
(26.1%
-
50.8%)
(21.1%
-
26.8%)
Adverse Drug
Reaction
2.8% 0.5% 0.8% 0.8% 0.1% 2.3% 0.9%
(2.0% - 4.0%) (0.1% - 1.3%) (0.3% - 2.0%) (0.4% - 1.5%) N/A (1.6% - 3.2%) (0.4% - 1.8%)
Contra
Indication
3.1% 2.2% 3.8% 1.0% 0.8% 3.3% 5.0%
(2.2% - 4.3%) (1.4% - 3.5%) (2.5% - 5.8%) (0.6% - 1.8%) (0.4% - 1.4%) (2.4% - 4.3%) (3.7% - 6.7%)
Drug-Drug
Interaction
0.3% 0.5% 0.8% 0.4% 0.0% 0.2% 0.6%
(0.1% - 0.9%) (0.1% - 1.3%) (0.3% - 2.0%) (0.1% -1.0%) N/A (0.1% - 0.6%) (0.2% - 1.4%)
Duplication
4.1% 0.8% 0.3% 0.7% 0.3% 0.6% 1.9%
(3.1% - 5.4%) (0.4% - 1.8%) (0.1% - 1.3%) (0.4% - 1.4%) (0.1% - 0.8%) (0.3% - 1.2%) (1.1% - 3.1%)
Indication No
Medication
11.5% 10.4% 10.4% 6.5% 4.1% 8.3% 8.6%
(9.7% - 13.4%) (8.5% - 12.7%) (8.2% - 13.1%) (5.2% - 8.0%) (3.2% - 5.3%) (6.9% - 9.8%) (6.9% - 10.7%)
Lack of
Therapeutic
Drug Monitoring
0.2% 0.7% 1.9% 0.2% 0.6% 0.2% 0.2%
(0.0% - 0.7%) (0.3% - 1.6%) (1.0% - 3.4%) (0.1% - 0.8%) (0.3% - 1.2%) (0.1% - 0.6%) (0.0% - 0.9%)
Medication No
Indication
1.2% 0.4% 0.6% 0.7% 0.9% 1.6% 3.2%
(0.7% - 2.0%) (0.1% - 1.1%) (0.2% - 1.7%) (0.4% - 1.4%) (0.5% - 1.5%) (1.0% - 2.4%) (2.2% - 4.6%)
Medication
Overdose
12.0% 19.4% 20.0% 19.3% 9.9% 12.0% 15.3%
(10.2% - 14.0%) (16.8% - 22.2%)
(17.0% - 23.4%)
(17.2% - 21.6%)
(8.4% - 11.5%)
(10.4%
-
13.8%)
(13.0%
-
17.9%)
Medication
Underdose
9.2% 7.0% 7.5% 6.7% 9.3% 13.0% 15.0%
(7.6% - 11.0%) (5.4% - 9.0%) (5.6% - 10.0%) (5.4% - 8.2%) (7.9% - 11.0%)
(11.4%
-
14.9%)
(12.7% -17.5%)
Wrong
Combination
N/A 1.3% 2.1% 1.0% 2.9% 1.3% 0.0%
N/A (0.7% - 0.7%) (1.2% - 3.6%) (0.6% - 1.8%) (2.1% - 3.9%) (0.8% - 2.0%) N/A
Wrong
Interpretation
of Culture’s
N/A 1.2% N/A 1.0% N/A 0.5% 1.1%
N/A (0.6% - 2.2%) N/A (0.5% - 1.7%) N/A (0.2% - 1.0%) (0.6% - 2.1%)
Prescribing
Errors
47.7% 41.1% 35.6% 32.3% 48.8% 27.7% 23.6%
(44.8% - 50.6%) (37.8% - 44.5%)
(31.8% - 39.5%)
(29.7% - 35.0%)
(46.2% - 51.3%)
(25.4% -30.1%)
(20.9%
-
26.6%)
Therapeutic
Failure
0.1% N/A N/A N/A N/A 0.4% 0.2%
(0.0% - 0.5%) N/A N/A N/A N/A (0.2% - 0.9%) (0.0% - 0.9%)
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39%), 16% (12% to 20%), 15% (12% to 19%), 21% (18% to 25%) and 20% (16% to 24%) respectively with an
average resistance or rejection of the proposed intervention of 21%. When it comes to the response of the
healthcare provider, the nurses always complied with the pharmacist recommendations while the resistance al-
ways came from physicians. Antibiotic, sedative/analgesic agents, cardiovascular, and gastrointestinal agents
were the most common classes of medications in which dosing interventions were performed.
The number of problem doses per specialty was counted and the error rates were calculated. The average error
rate per specialty is shown in Figure 2. The greatest error rates across the seven months were observed in the
ICU units (average of 22%) and cardiology units (average of 22%). Internal medicine and surgery showed also
high rates of problems (average of 10% and 9% respectively) compared to other specialties.
The breakdown of interventions per specialty and the resistance rates per specialty are shown in Table 3. The
reported interventions were counted per medication problem not per dose. The 95% confidence intervals were
too wide and not statistically meaningful due to the low number of observations when broken down by month
and specialty. Cardiology, ICU and internal medicine specialties had the highest number of interventions. Re-
sistance rates were relatively high in these specialties as well as in surgery ward. Even though resistance by
physicians to pharmacist interventions seemed to decrease across the study period or did not change for most of
the specialties, it appeared to increase in the Internal medicine and ICU departments.
4.'Discussion'
This study is the first study to describe the role of clinical pharmacists as a hospital improvement service in de-
tecting, avoiding, and correcting DRPs in an Egyptian general hospital for a period of seven months. This study
records the pharmacists’ interventions in the secondary care setting and the measures taken by the hospital as a
result of the pharmacists’ review. Pharmacists were effectively able to intervene and correct all audited adminis-
tration errors while physicians especially consultants were more resistant to interventions.
The percentage of doses reviewed increased along the study except for August and September. Ramadan—the
fasting month—came during this period and could be the reason behind this decline, where the daily working
hours decreased from 6 hours daily to four hours only. The pharmacists were capable of auditing 98% of all the
prescribed doses in the hospital by the seventh month. The majority of DRPs in this study were avoidable as
previously documented [13]. Seventy doses only were behind serious events all over the study period.
Critical care areas had the highest percentage of recorded DRPs. This could be attributed to the presence of
Figure 2. Medication problems incidence per specialty averaged over a pe-
riod of seven months (ICU: Intensive Care Units, Obs & Gyn: Obstetrics and
Gynecology, ENT: Ear, nose and throat).
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Table 3. Number of interventions done by pharmacists per specialty per month, number of doses affected by positive inter-
ventions and resistance rate to pharmacist interventions divided by specialty.
Specialty June July August September October November December
Cardiology
Number of interventions 45 62 41 44 79 129 98
Number of affected doses 104 160 93 151 279 217 158
Resistance rate 33% 31% 24% 18% 23% 31% 23%
Hepatology
Number of interventions 10 14 5 18 11 36 24
Number of affected doses 67 22 17 103 49 111 47
Resistance rate 20% 50% 0% 17% 0% 11% 21%
ICU
Number of interventions 73 58 58 219 87 99 85
Number of affected doses 267 65 109 526 259 163 88
Resistance rate 14% 29% 43% 16% 14% 16% 28%
Internal Medicine
Number of interventions 44 36 18 32 26 69 27
Number of affected doses 136 76 32 63 97 146 41
Resistance rate 16% 33% 33% 16% 15% 20% 30%
Nephrology
Number of interventions 5 8 3 9 15 8 5
Number of affected doses 3 8 0 43 47 13 15
Resistance rate 60% 50% 8% 0% 20% 25% 40%
Neurology
Number of interventions 7 21 13 8 20 22 21
Number of affected doses 2 70 25 35 69 61 38
Resistance rate 71% 14% 23% 25% 10% 23% 29%
Obstetrics and
Gynecology
Number of interventions 12 6 7 19 42 36 32
Number of affected doses 65 12 4 54 76 61 43
Resistance rate 0% 50% 71% 21% 14% 6% 13%
Oncology
Number of interventions 8 18 4 6 6 2 2
Number of affected doses 48 34 22 22 19 3 10
Resistance rate 0% 39% 25% 0% 0% 0% 0%
Opthalmology
Number of interventions 3 0 0 1 0 1 0
Number of affected doses 9 0 0 2 0 0 0
Orthopedics
Number of interventions 15 18 6 21 19 35 36
Number of affected doses 43 30 7 59 87 119 62
Resistance rate 13% 50%
33% 24% 26% 20% 3%
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Continued
Pediatrics
Number of interventions 3 0 6 7 28 28 28
Number of affected doses 1 0 41 34 78 64 55
Resistance rate 67% 0 17% 14% 4% 11% 7%
Surgery
Number of interventions 9 29 14 33 35 39 32
Number of affected doses 27 74 64 152 121 60 56
Resistance rate 44% 28% 7% 12% 20% 31% 16%
Urology
Number of interventions 6 8 4 4 16 11 15
Number of affected doses 28 16 13 17 36 29 25
Resistance rate 0% 25% 25% 0% 6% 18% 7%
ENT
Number of interventions 1 0 0 0 4 4 0
Number of affected doses 0 0 0 0 14 21 N/A
Resistance rate N/A N/A N/A N/A N/A N/A N/A
Average
Interventions/Patient
1.76 2 1.71 2.72 2.77 2.47 2.37
substantial patient safety challenges because of the fast-pace, complex problems, and the urgent high-risk deci-
sion-making by physicians with varying levels of critical care training, often with incomplete data [14]. Fur-
thermore, critically ill patients may be particularly vulnerable to iatrogenic injury because of the severity and in-
stability of their illness and their frequent need for high-risk interventions and medications [15]. Literature pro-
vides evidence that, pharmacist involvement improves patient safety [16] [17], where the presence of clinical
pharmacists in pediatric ICU decreased serious medication problems by 79% [18], and in adult ICU preventable
adverse drug events were decreased by 66% [19].
Prescribing errors were the most frequently reported problems, possibly due to poor pharmacological back-
ground of the physicians, poor communication between the different healthcare providers and increased physi-
cian workload, fatigue and stress for physicians as reported in other studies [20]. These factors accounted for
medication problems in other studies especially in the Middle East [21] [22]. As a result, a pharmacologically
oriented physicians’ training program was developed, and delivered and communication skills course for
healthcare professionals was tailored to be delivered.
Drug administration is crucial in the medication management process since the possibilities of correcting er-
rors at this stage are limited [23] [24]. Nursing drug administration errors were observed to be the second high-
est problem in this study, being mainly attributed to the large numbers of patients under the nurse’s care where
the ratio was 1:10, increasing both the work-load and the stress level. This nurse to patient ratio is much higher
than those reported in other countries [25]. Nursing skills and training are other factors linked to such errors; the
hospital had two nursing levels based on their educational background, the head nurses who work in morning
shifts only, are university graduates and not in charge of patients. The second level is the charge nurses, who
were graduates of two year nursing technical schools. All the administration errors could have been easily
avoided by proper training of the nurses. Hence, a focused nursing training program was proposed by the phar-
macy team to be routinely delivered to overcome the educational factor. Although nurses were encouraged to
report administration errors; however, one deterring factor is the fear of losing their jobs or being subjected to
disciplinary actions [22] [26], creating the need for constructive strategies to minimize such fears [27].
In the current study, investigators demonstrated how simple nurse instruction by pharmacists can lead to the
correction of a substantial percentage of DRPs. The pharmacists’ interventions, however, increased over the
study period, probably due to the increase in the total number of audited doses and the increased experience of
the pharmacists. The average resistance rate to pharmacist interventions was 21% compared to only 1% in one
US study [19], and 20.8% in a French study [28]. Consultants could be more resistant to pharmacist interven-
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tions as was earlier demonstrated that physicians’ age negatively correlated with attitude towards pharmacists’
interventions [29] [30].
Medication problems may occur throughout the entire drug distribution system, from prescribing to adminis-
tration [2]. Although, human errors are impossible to eliminate, the goal is to bring medication problems down
to a minimum. Exploring the reasons behind these problems, and implementing efficient systems are the key
processes to minimize human error. However, there has to be a system to stop carelessness and violations that
are intentional rather than a human or system error in pursuit of patient safety [31]. To ensure patient safety,
surveys of DRPs are indispensible since appropriate recommendations are dependent on the setting and back-
ground culture.
Additional contributing factors to DRPs could be miscommunications such as illegible medication orders,
look-alike drug names, confusion of brand and generic names [32], interruptions or distractions during prescrib-
ing, dispensing and administration [33] [34] and the absence of extra checking procedures to further recover
problems [35]. As a result of these findings, the pharmacy department in the hospital created a look-alike sound-
alike list. Also, a generic name prescribing policy was developed, as well as a reconciliation policy. In addition,
medication auditing systems were started along with physician and nursing training programs including a phar-
macology-oriented physicians’ training program and a communication skills course for healthcare and a phar-
macy and therapeutic committee (PTC) was created to be responsible for reporting, and discussing all the identi-
fied DRPs in the hospital under study.
Increasing the number of nurses could have minimized the number of administration errors. However, due to
financial constraints, the nurse workload was quite difficult to be solved, but a focused nursing training program
was proposed by the pharmacy team to be routinely delivered to overcome the educational factor. Nurses were
also, encouraged to report administration errors.
Nevertheless, it should be noted that this was a single center study, pharmacists identifying DRPs worked 6
days per week for one morning shift only and there was no possibility of auditing all the doses nor of imple-
menting a quality assurance system where medication orders could be re-checked for missed problems due to
the limited number of pharmacists. A post discharge follow-up was also not possible. In addition, there was no
possibility of comparing DRP’s before and after implementation of the pharmacist medication review system
due to the preceding lack of reporting DRP’s by the hospital. Studies in other Egyptian hospitals need to be per-
formed to further address drug related problems with interventions focusing actual outcomes, including quality
of life, cost, morbidity and mortality, to address post-discharge follow-up and to record the impact of the medi-
cation review process on discharge process, on the primary care services the patient will be receiving, and on the
estimate cost savings due to pharmacists interventions.
5.'Conclusion'
In conclusion, medication errors or problems within the Egyptian hospital were found common among hospita-
lized patients. The most common issues were prescribing errors, administration errors and over doses. Factors
associated with an increased risk of such problems were physicians’ resistance, shortage of nursing staff, and
renal impairment. Clinical pharmacists trained in pharmacotherapy could help to detect problems/errors and re-
duce their effects, thus improving the quality of prescription, and patient’s safety.
Disclosure'Statement'
The authors have no conflict of interest to report.
Acknowledgments'
The authors would like to thank the all the pharmacy team in the study site for the technical support.
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