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Impact of a Clinical Pharmacist in the General Hospital: An Egyptian Trial

  • Faculty of Pharmacy, Cairo University, Cairo, Egypt

Abstract and Figures

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 review 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.
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Medication' review' aims' at' optimizing' the'impact' of' medications' while' minimizing' their' related'
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'
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'
der'study'implemented'new' measures'to' minimize' drug' related'problems'according' to' the' find‐
Patient safety is a main goal in any treatment protocol. Drugs are not licensed worldwide until they are proven to
Corresponding author.
be safe and efficacious. However, drug related problems (DRPs) represent a worldwide concern. A DRP can be
defined as A circumstance that involves a patients 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.
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.
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-
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.
Table 1. Characteristics of hospital and wards being studied.
Paper based and computer based
based and computer based
8 general wards served by 15 specialty +
3 criti
cal areas
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.
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.
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
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.
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.
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.
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
Problems (%)
June July August September October November December
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%)
Adverse Drug
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%)
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%)
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%)
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
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
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
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%)
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%)
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%)
(12.7% -17.5%)
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
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%)
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%)
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%)
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.
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).
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
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%
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%
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%
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%
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
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%
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%
Number of interventions 3 0 0 1 0 1 0
Number of affected doses 9 0 0 2 0 0 0
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%
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%
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%
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%
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
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-
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.
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.
The authors have no conflict of interest to report.
The authors would like to thank the all the pharmacy team in the study site for the technical support.
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... Factors influencing head nurse's appropriate management of high alert medications were time constraints, limited resources, lack of training in management and leadership, and lack of support from hospitals' management (21). Although clinical pharmacy services are not widely implemented in Egypt, one study reported that clinical pharmacists' interventions have resolved prescribing and administration errors, however 21% of the interventions were not accepted (22). Recommendations to prevent medication errors in Egypt included staff education and training, establishing a local reporting system in each hospital, environment modification, improving communication, designing a standard prescription form, drug formulary spreading to physicians, auditing an administration sheet, and adopting clinical practice guidelines (18). ...
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Background: Literature on medication safety issues such as medication errors, adverse drug events and medication safety practices in African countries are scarce compared to western countries. Objective: This review was carried out to explore medication safety challenges in four Lower Middle-Income Countries (LMIC) of Africa and recommend strategies to improve medication safety. Methods: Electronic databases such as PubMed, Science Direct, and Google Scholar were searched to locate studies related to medication safety in LMIC of Africa. Results: The results of this review suggest that a very few numbers of existing studies have investigated medication safety issues in the four LMIC. The medication safety issues reported were in the areas of prescribing, monitoring, administration, and transcribing stages. Medication-related challenges during prescribing were incorrect dose, incorrect frequency, and drug-drug interactions. In the monitoring stage, the most commonly seen errors were drug interactions and inappropriate monitoring process. During the administration stage, the most commonly observed errors were in incorrect dose and medications omission. The Incorrect dose problem was also identified during the dispensing stage. Incidences of adverse drug reactions were reported. Among the reported contributing factors to these medication safety issues were lack of training and limited resources. Conclusion: one of the challenges faced by the healthcare systems in LMIC is the medication safety issue. Most of the challenges identified can be resolved with the utilization of some available resources in these countries. This paper suggests several recommendations through which these challenges can be address.
... Prescribing errors were the most frequent MEs. This is in agreement with many studies conducted in Middle East countries [25][26][27][28][29][30][31][32][33][34][35][36] . ...
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Background: The limited evidence of the critical role of clinical pharmacists in Egyptian teaching hospitals led to the fact that critical care pharmacists' responsibilities are still focused on dispensing and drug distribution. Objective: Assess the important role of clinical pharmacy service activities in an Egyptian intensive care unit (ICU) by describing the impact of medication errors on clinical outcome of critically ill-patients with renal insufficiency. Methods: An observational retrospective cohort study was carried out over a five months period on patients admitted to ICU with estimated creatinine clearance (CrCl) less than 50 ml/min on admission and known to have chronic kidney disease (CKD). Patient records, physician orders, pharmacy and nursing notes of 69 patients were collected and reviewed by a clinical pharmacist. Medication errors were assessed. Main outcome measure was Length of ICU stay and mortality. Results: One hundred and seventeen MEs were identified; prescribing errors (58.9%), wrong administration technique (17.9%), drug-preparation errors (11.9%) and monitoring errors (11.1%). Errors in renal dose adjustment were the most frequent prescribing errors (66.7%). The length of ICU stay was positively correlated with number of medication errors per prescription (r=0.392, p=0.001) and mortality was associated with significantly higher number of medication errors (p=0.01). Only 29% of errors observed were documented in pharmacy records and 93% of documented pharmacy interventions were accepted by the physicians. Conclusion: Decreasing morbidity and mortality in critically ill Egyptian patients with renal insufficiency may be achieved through optimizing clinical pharmacy services with prescription intervention activities.
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Background: Patients' safety is one major challenge that encounters health care system today. Medication errors represent major factors endangering the patient's safety. This study aims to assess the effectiveness of interventions to limit errors and interruptions during medication administration in medical and surgical unit at Mansoura University Hospital (MUH). Methods: A quasi-experimental one group pre and post test design was used .The study has been conducted among 48 nurses assigned to administer medication to 90 patients in a working week at (MUH)in general medical units (n=2) and surgical units (n=2). Data were collected utilizing the following tools: 1) Structure Questionnaire to assess nurses' knowledge related to errors and interruption during medication administration, 2) Observational checklist to ensure the process is safe to reduce errors through using six safe practices, and determine the frequency of errors and interruption and 3) Demographic data form for collecting data related to socio-demographic data. Results: The present study revealed that: (a) the nurses' knowledge increased immediately after intervention with statistical significant difference compared to pre intervention. (b) There was improved safe practice during medication administration as evidence by decrease error after intervention than pre intervention (c) There were decrease errors and interruptions immediately after intervention with a highly statistically significant difference in comparison to pre intervention. Conclusion: This study concluded that improving nursing staff' knowledge and practice about safe medication administration is evident by decreasing frequency of the errors and interruptions nurses faced during medication administration after intervention. Recommendations: The present study recommends conducting a continuous educational program for the nursing staff, as it is necessary for reducing medication errors and interruptions to protect the patients' safety.
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Background The incidence of drug related problems (DRPs) in intensive care units (ICU) is higher compared to any other wards in the hospital, requiring a structured pathway to ensure optimum detection of DRPs. The study aimed to evaluate the impact of implementing a pharmaceutical care pathway on the detection and management of DRPs in an ICU. Methods The study was conducted in a general ICU and included three phases: tool preparation phase included the development of a core measures reference pathway and daily working scenario flow-charts, a control phase where the patient files and pharmacists' case assessment notes were retrospectively reviewed to detect the rate of DRPs before pathway implementation and a prospective phase similar to the control phase but with the implementation of the new pathway. The number and classification of DRPs and required core measures in the control and implementation phases were documented. Results Using the new pathway, the detection of unmet core measures increased from 7.3% in the control phase to 99% in the implementation phase (p-value <0.001). The prevalence of unidentified DRPs/1000 patients' service days decreased from 98.1 in the control phase to 27.08 in the implementation phase (p-value <0.001). However, there was no significant difference between the phases regarding mortality rate and length of ICU stay. Conclusions The implementation of a unified pharmaceutical care pathway improved the detection of DRPs in ICU patients.
Objectives To assess the impact of electronic prescription on the types and rates of medication errors in prescribing and dispensing phases and to formulate recommendations on the use of electronic prescriptions in Egyptian outpatient practice. Methods Medication errors and correction interventions were collected by reviewing the incident reports obtained from the outpatient pharmacy in a specialized hospital in Egypt. A data collection form was used to classify the errors. The Main outcome measures are prescribing and prescription errors, dispensing errors, error free prescriptions, pharmacy call-backs and phone calls for five months before and five months after the electronic system implementation. Results 3512 incident reports were reviewed for errors in the hand-written and electronic phases. The use of electronic system led to a minor significant 2% reduction in prescribing errors, significant 1.2% decrease in dispensing errors and significant 18.2% increase in the error free prescriptions (p < 0.05). Indication and omission prescribing errors were increased significantly (1.7%, p < 0.0001) in the electronic phase. The electronic system failed to significantly decrease some types of dispensing errors like wrong medicine and wrong dosage form. No difference was detected in the volume of communications between pharmacists and prescribers. Conclusion Electronic prescribing is able to reduce prescribing and dispensing errors associated with the use of hand-written prescriptions in the Egyptian outpatient clinic, however, more advanced and trusted systems are likely needed for more efficient effect on error rates and pharmacy workflow.
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Background Physicians’ perception of the role of the clinical pharmacist role plays a cornerstone in accepting interventions suggested by pharmacists to correct DRPs and in complying with guidelines of a pharmacist-led Antibiotic stewardship program (ASP). This study aimed at evaluating the acceptance of physicians’ to pharmacists interventions to antibiotic prescribing and the change in antibiotic consumption in Al-Haram general hospital Intensive care unit (ICU). Methods This study was performed in Al-Haram general hospital ICU from July 2014 till December 2015. Medication review of antibiotics started in Al-Haram hospital ICU in July 2014 by responsible clinical pharmacists. An on-job physician education program about antibiotics started in June 2015. Implementation of ASP started in July 2015. The antibiotic related interventions and response of physicians to interventions were recorded all along the study period. The pattern of physicians’ acceptance along with antibiotic consumption (in Daily define dose per 1000 patient-days) were reported. Results The number of accepted interventions had increased along the study. The overall antibiotic consumption increased after implementation of ASP, however the individual pattern of antibiotic prescribing changed. Conclusion The physicians in Al-Haram hospital appeared to accept the role of clinical pharmacist in correcting antibiotic-related DRPs as well as in implementing ASP.
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Background: Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. Objective: The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. Methods: We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Results: Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5-20.1%), while adverse drug events causing admission were reported in 2.8% (0.7-6.4%) of patients but it was reported that a median of 43.5% (20.0-47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0-0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8-72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5-50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge/training) and environmental factors, such as workplace distraction and high workload. Conclusion: Medication errors in the African healthcare setting are relatively common, and the impact of adverse drug events is substantial but many are preventable. This review supports the design and implementation of preventative strategies targeting the most likely contributing factors.
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Background: Patients' safety is one major challenge that encounters health care system today. Medication errors represent major factors endangering the patient's safety. This study aims to assess the effectiveness of interventions to limit errors and interruptions during medication administration in medical and surgical unit at Mansoura University Hospital (MUH). Methods: A quasi-experimental one group pre and post test design was used .The study has been conducted among 48 nurses assigned to administer medication to 90 patients in a working week at (MUH)in general medical units (n=2) and surgical units (n=2). Data were collected utilizing the following tools: 1) Structure Questionnaire to assess nurses’ knowledge related to errors and interruption during medication administration, 2) Observational checklist to ensure the process is safe to reduce errors through using six safe practices, and determine the frequency of errors and interruption and 3) Demographic data form for collecting data related to socio-demographic data. Results: The present study revealed that: (a) the nurses’ knowledge increased immediately after intervention with statistical significant difference compared to pre intervention. (b) There was improved safe practice during medication administration as evidence by decrease error after intervention than pre intervention (c) There were decrease errors and interruptions immediately after intervention with a highly statistically significant difference in comparison to pre intervention. Conclusion: This study concluded that improving nursing staff’ knowledge and practice about safe medication administration is evident by decreasing frequency of the errors and interruptions nurses faced during medication administration after intervention. Recommendations: The present study recommends conducting a continuous educational program for the nursing staff, as it is necessary for reducing medication errors and interruptions to protect the patients' safety. Keyword: Safe medication administration, medication administration error, interruption, and patient safety
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Background Medication errors are a significant global concern and can cause serious medical consequences for patients. Little is known about medication errors in Middle Eastern countries. The objectives of this systematic review were to review studies of the incidence and types of medication errors in Middle Eastern countries and to identify the main contributory factors involved. Methods A systematic review of the literature related to medication errors in Middle Eastern countries was conducted in October 2011 using the following databases: Embase, Medline, Pubmed, the British Nursing Index and the Cumulative Index to Nursing & Allied Health Literature. The search strategy included all ages and languages. Inclusion criteria were that the studies assessed or discussed the incidence of medication errors and contributory factors to medication errors during the medication treatment process in adults or in children. Results Forty-five studies from 10 of the 15 Middle Eastern countries met the inclusion criteria. Nine (20 %) studies focused on medication errors in paediatric patients. Twenty-one focused on prescribing errors, 11 measured administration errors, 12 were interventional studies and one assessed transcribing errors. Dispensing and documentation errors were inadequately evaluated. Error rates varied from 7.1 % to 90.5 % for prescribing and from 9.4 % to 80 % for administration. The most common types of prescribing errors reported were incorrect dose (with an incidence rate from 0.15 % to 34.8 % of prescriptions), wrong frequency and wrong strength. Computerised physician rder entry and clinical pharmacist input were the main interventions evaluated. Poor knowledge of medicines was identified as a contributory factor for errors by both doctors (prescribers) and nurses (when administering drugs). Most studies did not assess the clinical severity of the medication errors. Conclusion Studies related to medication errors in the Middle Eastern countries were relatively few in number and of poor quality. Educational programmes on drug therapy for doctors and nurses are urgently needed.
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Data regarding the prevalence and types of drug-related problems (DRPs) among neurology inpatients is sparse. The objective of this study was to characterise the types of DRPs seen among neurology inpatients and furthermore to study factors affecting the acceptance of clinical pharmacologists' and pharmacists' recommendations for improving drug safety. 1,263 consecutive inpatient cases in a Swiss university hospital neurology unit were assessed for the presence of DRPs over 12 months. Treating neurologists' acceptance of the resulting recommendations was also recorded. Primary outcome measures were types of DRP, recommendations made by clinical pharmacologists and number of recommendations accepted. Factors potentially associated with acceptance were studied using univariate and multivariate generalised estimating equation modelling. Twenty-nine percent of cases demonstrated one or more DRPs. DRPs were the cause of admission in 10 cases (0.8%). In total 494 DRPs were identified and 467 recommendations given, of which 62% were accepted. Factors associated with an increased likelihood of acceptance were prescriptions involving regularly administered drugs (odds ratio [OR] 2.57 95% confidence interval [CI] 1.73-3.80), adverse drug events (OR 2.5; 95% CI 1.29-5.06), known drug side-effect (OR 1.85; 95% CI 1.06-3.22), high-risk drug-drug interactions (OR 3.22; 95% CI 1.07-9.69) and interventions involving changing a drug (OR 2.71; 95% CI 1.17-6.25). Clinical pharmacologists and pharmacists can play an important role in identifying DRPs among neurology inpatients. Their recommendations for optimising medication-safety are most likely to be accepted for regular prescriptions, prescriptions associated with an adverse drug event and high-risk drug combinations.
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Introduction Medication-related problems in the ICU are an important but poorly understood phenomenon. Many patients admitted to intensive care units consume long-term medication. New drugs may be commenced during intensive care intended for the short term or longer. Patients are often cared for by several teams during hospital admission and long-term medication may inadvertently be permanently discontinued. Aim: We sought to evaluate the frequency and incidence of medication-related problems in the ICU in one of the largest teaching hospitals in Egypt. Methodology: Prospective observational study was conducted to report and record the frequency of medication related problems in the ICUs. Patients: 220 patients were reviewed during a period of one year. Those patients were prescribed 2286 medications. Results: Medication review was done for 220 ICU patients. The average length of the period the patients stayed in the hospital was around 10.396 days. The 220 recruited patients, using a total of 2286 medicines, were classified into six major categories according to the BNF 2009. Cardiovascular conditions represented the principal reason for ICU admission. Cardiovascular agents counted for the majority of the medications consumed by the participants; 2 anticoagulants and antiplatelets, nitrates and H -receptor antagonists were prescribed most frequently. About 97% of monitored patients were reported with one or more drug related problems. The problems were categorized into 13 different classes. Among the detected errors, incorrect dosing regimen represented the highest percentage (21.971%) followed by duplication and prescribing unnecessary medication representing around 12% each. Equal incidence of drugs being prescribed either in a lower dose, higher dose or had some degree of drug interaction (8.4 % each). Drugs that required therapeutic monitoring that was not done represented 7.27 % and antibiotic misuse represented 5.331 % of the total medication errors detected.
The objective of this study was to link the different types of patient drug-related problems to the pharmacists' interventions. This would lead to a description in some detail of the professional activities performed by the pharmacists during the everyday encounters in Swedish pharmacies and possibly highlight target areas for quality improvement. Design: Pharmacy staff used a self-reporting system that as much as possible would meet the requirement of an observational study. Setting: Twenty randomly selected Swedish community pharmacies. Patients: Patients with problems related to prescribed medicines, OTC-medicines and individuals asking questions without buying any medicines. Interventions: Pharmacy staff interventions with patients, doctors or nurses to solve detected problems. Results: During a 2-week study 1,465 problems were detected, generating 2,412 documented interventions. Problems were detected among 1.4% of the patients with prescriptions and 1.3-1.5% of individuals buying OTC-medicines. Persons asking questions without buying any medicines generated 20% of all registered problems. Most problems (44%) and most interventions (48%) were related to prescribed medicines. Twelve alternative types of interventions were registered. The most common intervention in relation to prescribed medicines was "improve patient's understanding of the therapy" and for OTC-medicines "select appropriate drug". Only a fraction of the patient drug-related problems are discovered and solved during the dispensing process at the pharmacies. The potential for problem detection and interventions could be 10 times higher than the present level. Conclusion: Linking the patients' drug-related problems to the pharmacists' interventions reveal three target areas for quality improvement of pharmacists cognitive services: 1. Detect and solve the majority of patients' drug-related problems. 2. Assure that the pharmacists have a good ability to correctly analyse patients drug-related problems 3. Assure that the pharmacists have both professional and communication skills so that they can perform both product and person oriented interventions.
Objective —To identify and evaluate the systems failures that underlie errors causing adverse drug events (ADEs) and potential ADEs. Design —Systems analysis of events from a prospective cohort study. Participants —All admissions to 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Main Outcome Measures —Errors, proximal causes, and systems failures. Methods —Errors were detected by interviews of those involved. Errors were classified according to proximal cause and underlying systems failure by multidisciplinary teams of physicians, nurses, pharmacists, and systems analysts. Results —During this period, 334 errors were detected as the causes of 264 preventable ADEs and potential ADEs. Sixteen major systems failures were identified as the underlying causes of the errors. The most common systems failure was in the dissemination of drug knowledge, particularly to physicians, accounting for 29% of the 334 errors. Inadequate availability of patient information, such as the results of laboratory tests, was associated with 18% of errors. Seven systems failures accounted for 78% of the errors; all could be improved by better information systems. Conclusions —Hospital personnel willingly participated in the detection and investigation of drug use errors and were able to identify underlying systems failures. The most common defects were in systems to disseminate knowledge about drugs and to make drug and patient information readily accessible at the time it is needed. Systems changes to improve dissemination and display of drug and patient data should make errors in the use of drugs less likely.(JAMA. 1995;274:35-43)
This study investigated the perspectives of newly graduated and experienced nurses concerning medication errors. This is a descriptive cross-sectional study conducted in a military education and research hospital in Turkey, which was performed between July and August 2009. Totally, 169 nurses were involved in this study: 87 were new graduates and 82 were experienced nurses. The Modified Gladstone's Scale of Medication Errors was used to collect data on rates, causes and reporting of medication errors. The two highest perceived causes of medication errors were nurse exhaustion and nurse distraction. Most medication errors were preventable errors. The reasons for error occurrence and failure to inform co-workers of medical errors were examined. Implications: Training nurses to understand the causes of medication errors and related prevention methods should be provided to newly graduated nurses, and continuous training should be provided.
kim k.s., kwon s.-h., kim j.-a. & cho s. (2011) Journal of Nursing Management 19, 346–353 Nurses’ perceptions of medication errors and their contributing factors in South Korea Aim The aim of this study was to identify Korean nurses’ perceptions of medication errors. Background Knowing nurses’ perceptions of medication errors is important in developing prevention strategies for medication errors. Methods A cross-sectional descriptive survey was conducted. A convenient snowballed sample of 220 nurses from seven hospitals was obtained. Participants were asked to identify contributing factors of medication errors, reporting and strategies to prevent medication errors. Results A total of 224 of 330 (67.9%) questionnaires were returned. Over half (63.6%) of the participants had been involved in medication errors once or more in the past month. For factors contributing to medication errors, 99 nurses (45.0%) answered ‘advanced drug preparation and administration without rechecking’. Only 13.5% of participants informed patients and their families of medication errors and 28.3% of participants submitted an incident report. Medication errors occurred most often during the day-shift. Conclusions Developing strategies to reduce nurses’ fear of punishment and supporting nurses’ attitudes in a constructive manner are needed. Implications for nursing management Effective strategies for nursing are needed, particularly during the day-shift, and during routine medication administration. In addition, non-punitive reporting systems of medication error should be established and patients should be included in reporting.
Drug administration is one of the highest risk areas of nursing practice and a matter of considerable concern for both managers and practitioners The aim of this study, earned out in a district general hospital, was to identify any common themes that underlie the occurrence and reporting of drug administration errors Data were collected from a variety of sources drug error reports, questionnaires to nurses and nurse managers, and interviews with nurses who had been involved in drug errors Several areas of particular concern emerged, including the nurses’ confusion regarding the definition of drug errors and the appropriate actions to take when they occurred, their fear of disciplinary action, their loss of clinical confidence, the variation in managerial response, and a possible lack of nurses’ mathematical skills The results from the study demonstrated that it was likely that many drug errors were not reported, for a variety of reasons It is recommended that all of these issues are addressed as a matter of urgency, for the sake of both patients and nurse practitioners