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Background: The medication lists in pre-admission clinic (PAC) questionnaires completed by patients prior to surgery are often inaccurate, potentially leading to medication errors during hospitalization. Studies have shown pharmacists are more accurate when obtaining a medication history and transcribing prescription orders, thereby reducing errors. Objective: To evaluate the impact of a PeRiopErative and Prescribing (PREP) pharmacist on postoperative medication management. Methods: A randomized prospective interventional study enrolled elective surgery patients at high risk for medication misadventure to receive PREP pharmacy service or usual care (control group). A best possible medication history (BPMH) was obtained by the PREP pharmacist and was available to surgical staff on admission. The PREP pharmacist also prepared discharge prescriptions for their patients. The primary outcomes for the study were accuracy of BPMH and discharge prescriptions compared to usual care. The study was powered to 80% with 2-tailed significance α of .05. Results: The medication history in the PREP pharmacist group had fewer errors than the control group: 9% (5/53) versus 96% (49/51; P < .001). Discharge prescriptions prepared by the PREP pharmacist had fewer errors than control group: 25% versus 78% ( P < .001). Significantly, more PREP pharmacist patients received a discharge summary with a complete medication list: 75% versus 33% ( P = .001). Inpatient prescribing was more accurate in the PREP pharmacist patients: 0.64 versus 1.31 errors per patient ( P = .047). Conclusion: Inclusion of the PREP pharmacist role in the elective surgery multidisciplinary team improved the accuracy of medication histories, inpatient prescribing, and discharge prescriptions for patients at high risk of medication misadventure.

Background Prescribers at a 400-bed metropolitan teaching hospital applied for approval to prescribe restricted antimicrobials using Guidance DS® (GDS), an electronic antimicrobial approval system (EAAS). The implementation of Cerner Millennium® (CM), a computerised physician order entry system (CPOE), necessitated a new but cumbersome workflow for prescribers. This prompted an evaluation of the value of a stand-alone EAAS, which has no interface with a CPOE, for antimicrobial stewardship. Aim This study compares the performance of an EAAS and CPOE, used alone and in combination, for surveillance of restricted antimicrobials and compliance with antimicrobial restriction policy. Method General medical and surgical patients prescribed restricted antimicrobials over three defined periods were retrospectively recruited; period one (P1) used GDS plus National Inpatient Medication Chart, period two (P2), GDS plus CM, and period three (P3), CM alone. For each period, 100 medical and 100 surgical restricted antimicrobial orders were collected. Data collection included prescribing date, indication, approvals obtained, and time to approval. Surveillance rate and compliance was compared. Results The introduction of CM improved surveillance from 10.5% (P1) to 65% (P2) and 100% (P3) via a CM reporting module (p < 0.0001). Compliance improved from 6% (P1), to 55% (P2) and 76% (P3) (p < 0.0001). Documentation of a clear/complete indication improved from 10% (P1) to 56.5% (P2) and 76.5% (P3) (p < 0.0001). Approvals obtained within 24 h of prescribing improved from 61.9% (P1), to 96.9% (P2), and 100% (P3). Conclusion Cerner Millennium®, with customisation, optimises surveillance and significantly improves compliance with policy, negating the need for a stand-alone EAAS.

Background Our health service is introducing an electronic medication management system (eMMs). Obtaining baseline data on the work patterns of pharmacists will allow assessment of the impact of the eMMs on pharmacists' work patterns. Aim To quantify the time clinical pharmacists spend on various activities over their working day prior to the implementation of an eMMs. Method During this continuous observational time-and-motion study (23 November to 17 December 2009), clinical pharmacists assigned to general medical and surgical wards were shadowed by two independent observers over their entire working days. A customised Access application was used to log times and calculate average times spent on each activity. Other data collected included time from admission to interview and opportunities for medication chart review. Results 9 pharmacists were observed for 265.3 hours over 30 separate pharmacist observation days. Clinical activities (56% of total time) included professional communication (20%), medication chart review (9.6%), medication history interview (9.5%), clinical review (9.1%), providing information to patients/carers (5.5%), ascertaining discharge drugs required (1.6%), and obtaining drug information (0.5%). Non-clinical activities (44% of total time) included social activities/breaks (13%), meetings (6.9%), ordering/distribution (6.6%), discharge dispensing (6.3%), walking between wards/pharmacy (5.2%), looking for something (3.1%), and other activities (2.8%). On an average day, each pharmacist reviewed 21 of a possible 38 medication charts (55%), spent 20 minutes on clinical interventions and completed 4.5 medication history interviews. Average time from admission to interview was 67 hours. 18% of pharmacists' time was taken up with discharge/transfer of patients. Most patients 130/141 (93%) at discharge did not require further medication history clarification. Conclusion This study provides baseline data for comparison of the impact of the eMMs on pharmacist workflow.

Aim: To describe the implementation of pharmacist-initiated e-script transcription service (PETS) in a teaching hospital; to validate the service through process indicators; and to explore the views of stakeholders. Method: Following an initial trial, PETS was implemented in 7 medical and surgical units at Frankston Hospital. Data were collected on activities and discharge prescription errors. Stakeholders' satisfaction was measured using a Likert scale based survey and group interviews. Transcripts of group interviews were analysed by informal word-based techniques, noting words or synonyms used repeatedly to discover themes. Results: During the implementation phase (8 to 29 February 2008), a daily average of 15 prescriptions (112 items) were prepared by the PETS pharmacist, i.e 30 to 60% of weekday discharge prescriptions. The discharge prescription error/ amendment rate was 0.06 per patient. 163 respondents (92%) were satisfied or very satisfied with PETS. As a result of 3 group interviews of 10 doctors, 10 nurses and 10 pharmacists, several areas for enhancement were identified and implemented. Conclusion: PETS has transitioned from trial to mainstream service, facilitating the discharge process and improving continuity of care.

Aim: To evaluate a pharmacist-initiated e-script transcription service for discharged patients. Method: A sequential prospective study of 2 groups of 40 eligible medical patients recruited from the neurology and respiratory wards. Pre-implementation of the service, baseline data were collected from 40 consecutive medical patients. After the new service was implemented and allowing for a 2 week run-in period, data were collected from a further 40 consecutive medical patients. The outcome indicators were the time taken to discharge patients and the number of prescribing errors. Results: The pharmacist-initiated e-script transcription service was successfully implemented. The discharge process was faster with the time taken from decision to discharge to actual discharge decreased by 34% (p = 0.02). The time spent by dispensing pharmacists in clarifying and amending discharge prescriptions decreased from 9.5 to 1.5 minutes per patient. The time spent by doctors in preparing discharge prescriptions fell from 15 to 2 minutes per patient. There were also fewer prescribing errors – number of errors decreased from 0.83 to 0.1 per patient (p = 0.0005) and from 0.0962 to 0.0137 per item (p = 0.011). Conclusion: Combining a prescribing role with the medication safety elements of electronic prescribing and medication reconciliation has resulted in significant improvements in the quality, accuracy and timeliness of discharge prescriptions. The centralised discharge transcription service is transferable to a wide variety of health settings. The principles of workforce substitution and process change is important as the health system struggles to meet ever increasing demands. J Pharm Pract Res 2009; 39: 39-42.

Aim To assess the impact of increased time spent on clinical pharmacy activities in an Australian hospital. Method During the control period, a pharmacist provided both clinical services and discharge dispensing to a 30-bed medical ward and a 15-bed surgical ward. In the test period, the same pharmacist provided only clinical services to the medical ward. The number and type of clinical interventions for patients in the medical ward were compared for the two periods. Results The number of patients discharged, mean length of stay and total number of discharge drug orders were similar in the control and test periods (96 vs 97, 6.4 vs 7.0, 635 vs 633 respectively). The profile, type and complexity of patients in both groups were also similar. In the test period, clinical interventions increased by 57%, the time from admission to first pharmacist interview was reduced from 3.51 (SD 4.10) to 1.28 (SD 1.30) days (p < 0.005), clinical interventions were resolved earlier at pharmacist admission interviews (50% vs 28%, p < 0.001) and inpatient pharmacist rounds (28% vs 2%), resulting in fewer clinical interventions (19% vs 71%, p < 0.001) at discharge. The commonest types of clinical interventions were drugs not prescribed when clinically indicated and prescribing of incorrect doses or strength. Conclusion An improved pharmacist-to -bed ratio resulted in patients receiving correct drug therapies earlier in their inpatient stay. Fewer clinical interventions encountered at discharge facilitated the dispensing process.

Background Gastric antral vascular ectasia (GAVE) accounts for 4% of non-variceal gastrointestinal bleeding. Argon Plasma Coagulation, an endoscopic therapy, is the treatment of choice, followed by medications and surgery. There is limited evidence for drug therapies, such as corticosteroids, hormones, tranexamic acid, thalidomide and octreotide, to treat GAVE. Aim To describe a case of octreotide use in GAVE. Clinical details A 78-year-old female with repeat gastrointestinal bleeds required frequent hospitalisation for investigations and blood and iron transfusions. She was eventually diagnosed with GAVE but multiple endoscopic treatments were ineffective. She was unsuitable for surgery because of her advanced age and comorbidities. She was initiated on octreotide 200 micrograms 3 times daily with ongoing maintenance on 100 micrograms 3 times daily. Outcome Prior to initiation of octreotide (June 2011 to May 2012), the patient was transfused with 53 units of blood, 5.9 g of iron and spent 151 days in hospital. Post initiation of octreotide (June 2012 to April 2013), she only required 13 units of blood, 1.9 g of iron and spent 38 days in hospital. Conclusion Successful use of octreotide in this patient with GAVE contributes to the limited available evidence.

Aim To demonstrate quantitatively the range and extent of a clinical pharmacist's activities that can be delegated to pharmacy technicians without compromising patient care. Method All activities undertaken by the clinical pharmacist were evaluated and reassigned to the technicians if they met strict criteria. A job description for the technician was developed and approved by management and staff pharmacists. Data were collected and assessed prospectively for three staffing models: original model (1 pharmacist:30 beds, no technician); initial model (1 pharmacist:45 beds, 1 technician); and revised model (1 pharmacist:40 beds, 1 technician). The following key performance indicators were collected by clinical pharmacists before and after implementing the new models: number of clinical interventions recorded; number of medication history interviews completed; time lapsed after admission before a medication history interview is completed; and a surrogate indicator of pharmacy workload. Results The initial model showed a negative outcome in all areas and resulted in the model being revised. The revised model demonstrated that there was no negative difference in the key performance indicators compared with the original model. Conclusion Ward pharmacy technicians can assist pharmacists in achieving optimum patient care and quality use of medicines.

Background: Serious and life-threatening adverse drug events are often attributed to intravenous medication administration errors. Although smart infusion pumps are increasingly being adopted by hospitals to prevent such errors, data are lacking on their effectiveness in clinical practice. Aim: To measure and characterise intravenous medication administration errors and their clinical significance before and after the implementation of smart infusion pumps. Method: In the pre-intervention period, an independent observer over 41 working days recorded the prescribing and administration details of infusions administered via the IMED Gemini Volumetric Infusion Pumps. 20 months after the introduction of the smart pumps - Alaris GP Volumetric Pump with Guardrails software - a repeat audit was conducted over 27 working days. Only infusions containing drugs that were to be incorporated into Guardrails (the medication-error-prevention software of the Alaris GP pump) were evaluated. The clinical significance of the identified errors was evaluated by 2 independent assessors (pharmacist and doctor) and rated as 'low', 'moderate', 'high' or 'extreme'. Results: In the pre-intervention period, 76 infusions (n = 432, 18%) had one or more errors compared to 25 infusions (n = 266, 9.4%) following the introduction of the smart pumps. Of the 165 infusions administered using Guardrails, only 6 infusions with errors (3.6%) were identified. When drugs were infused with the Alaris GP pumps without Guardrails, the number of errors post-intervention when compared with errors in the pre-intervention period were not statistically significant (p = 0.8). When Alaris GP pumps with Guardrails were used there were no errors of 'extreme' clinical significance and only 1 error of 'high' clinical significance compared to the pre-intervention period where 1 'extreme' and 30 errors with 'high' clinical significance were identified. Conclusion: Alaris GP pumps with Guardrails resulted in significant reductions in the number and clinical significance of intravenous medication administration errors.