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Background 49% of adverse drug events are due to ordering and prescribing errors. Pharmacists play a key role in providing drug information to other caregivers to reduce adverse events and improve patient safety. Purpose Analysis of pharmacists’ interventions during drug order validation after implementation of standardised drug information in a computerised physician order entry system (CPOE). To evaluate its added value and further information needs. Material and methods Integration of structured and standardised drug information in a CPOE system and on the hospital’s intranet was performed in a 500 bed regional hospital. Implementation of systematic drug order validation prior to dispensing by trained hospital pharmacists was studied in a retrospective analysis of pharmacists’ interventions. Results To guide prescribing, we translated existing predefined drug orders in our CPOE as part of a preliminary clinical decision support system. These schemes comprised multiple drugs in relation to specific procedures or diagnosis (eg, postoperative pain protocols) and schemes for intravenous (IV) drug administration (including correct infusion bag and duration of administration). In addition, drug specific information concerning crushing of oral dosage forms, schemes for IV drugs, antibiotic monographs and leaflets for new formulary drugs were made available on the hospital’s intranet. Prior to drug dispensing, the pharmacist performs a systematic drug order validation, with the aid of the integrated drug information. The pharmacist checks, among other items, correct drug dosing and administration modalities, drug therapy in relation to known drug allergies and contraindicated drug interactions (eg, meropenem–valproate, low molecular weight heparin (LMWH) at the same time as novel anticoagulants (NOAC)). Over a 4 month period, 119 pharmacists’ interventions were registered. Most common reasons for intervention were adjustment of drug dose or frequency (31%), drug prescribed for which an allergy was documented in the medical record (21%), adjustment of IV drug administration (16%), duplicate therapy (16%) and LMWH–NOAC interaction (8%). Overall acceptance rate of pharmacist advice was 88%. Conclusion Integration of standardised drug information in existing computerised systems in combination with patient tailored advice by the hospital pharmacist improves the quality and safety of drug orders and administrations for hospitalised patients. Analysis of pharmacists’ interventions provides valuable information to continuously improve our drug information service. References and/or acknowledgements Kaushal R. Arch Int Med2003;163:1409–16. No conflict of interest

Background Crushing tablets is an important risk factor for medicines administration errors in patients with swallowing problems and feeding tubes. Information regarding patients requiring crushed medicines does not routinely reach the hospital pharmacist. Measures to improve crushing practice may consist of introducing guidelines, training nurses or giving pharmacy advice. Purpose To describe an integrated multifaceted approach using an audit and feedback strategy to improve crushing practice on hospital wards in a 500-bed general hospital. Materials and methods After baseline assessments, the following interventions to do with prescribing, administration and training were gradually introduced: mention ‘to crush’ on drug prescriptions order tube feeding using a specific order form a pharmacist provides an information form listing the substitutions and discusses the situation with the caregivers involved audit: retrospective analysis of prescriptions to identify the most commonly crushed drugs introduction of oral syringes and disintegration testing for commonly crushed tablets (dispersible defined as disintegration within one minute in 20 ml cold water) standardise working instructions feedback: educational sessions and poster. Results Pre-intervention questionnaires and disguised observations revealed that nurses’ knowledge regarding correct crushing is limited. We analysed 160 prescriptions mentioning ‘to crush’ for 104 patients (20 on tube feeding). A total of 601 drugs had to be crushed. Proton pump inhibitors and aspirin were among the most commonly prescribed drugs. 18% of prescribed drugs were substituted because of enteric coating (43%), modified-release formulation (25%) or availability of a more suitable alternative (e.g. liquids or dispersible tablets, 32%). 318 recommendations were given and accepted, including two related to hazardous substances. Pharmacists sometimes propose different alternatives for the same drug and patient. We introduced the syringe method (dispersing the tablet in a syringe filled with water) as a closed system for administration of hazardous drugs and dispersible tablets. Commonly crushed tablets such as alprazolam and trazodone were found to disintegrate easily. Crushability, alternatives and recommendations for the 20 most commonly crushed drugs in our hospital were summarised on a poster. Provision of this practice-orientated information and patient-tailored advice can encounter the lack of knowledge of other caregivers. Conclusions Patients in need of crushed medicines may benefit from a medicines review by a pharmacist. Audit and feedback provide relevant information to other caregivers to prescribe and administer medicines correctly and safety. To evaluate and sustain the impact of our interventions, the clinical pharmacist, as a member of the nutrition support team, will regularly review the drug treatment of patients on enteral tube feeding during their ward visits. No conflict of interest.