1. Improving medication management in the emergency department at Royal Perth Hospital Lea Dias - ED Pharmacist Barry Jenkins, Chief Pharmacist Dr Frank Sanfilippo, Population Health, UWA Stephen Witney - ED Technician

2. Background ED is under-serviced by pharmacy at RPH Significant medication safety concerns Significant continuity of care issues Funding obtained for a pharmacist and technician from Oct 05 - June 06

3. Aim Introduce a comprehensive service patient own medication bags frequent stock checks and analysis access to a clinical pharmacist during business hrs introduce an electronic drug formulary investigate the role of the pharmacist & technician Conduct a Pilot study assess the accuracy of medication history taking assess the impact of pharmacy involvement

4. Achievements Patient Own Medication Bags (POMBs) introduced and written into hospital policy Drug protocols and administration guidelines on ED intranet Service to nursing & medical staff improved Pilot study completed and analysed

5. Ongoing E-formulary trial POMBs roll-out rest of RPH Discussion with SJA. Possible use State-wide? Business case to continue the pharmacy service.

7. Pilot study summary Primary objective: To compare the accuracy of medications recorded on the medication chart against a validated medication history taken by the pharmacist for high-risk patients. Secondary objective Assess the utility of the pharmacy service in reviewing high risk patients and resolving medication related problems.

8. Method Service 1FTE clinical pharmacist, 1FTE Technician Mon-Fri 8:00am-4:30pm Sample - high risk patients Inclusion criteria admitted patients with a completed drug chart  65 years old or  5 medications Exclusion criteria nil medications pre-admission Recruitment once or twice daily ward rounds in all ED areas 9th April - 30th May 06 (period of 7 weeks)

9. Method Role of the technician Record pre-admission medication information patient’s own medications/list or WebsterPak® GP letters nursing home/pharmacy medication list previous admission at RPH discharge letters Record medications charted on admission

10. Method Role of the pharmacist Validate history with at least two sources Reconcile pre-admission medication history with charted medications Classify discrepancy as; intentional (deliberate changes) eg. withheld, new or cease drug, OR unintentional (errors) eg. drug omission, drug commission, or incorrect dose. Communicate discrepancies written in blue notes verbally with team or ward pharmacist attach Medication Action Plan to chart

11. Method

12. Introduced towards the end of the study.

13. Analysis Data analysed using SPSS Lost to follow up subjects that satisfied the selection criteria but were lost to the ward/discharged before being seen by the ED Pharmacist these subjects were not included in the results Patients not screened lack of resources did not permit all high-risk pts to be reviewed and included in the results. sub-sample of these patients to test for selection bias

14. Results

15. Results 2

16. Unintentional errors PatientsPatients Distribution of unintentional errors

17. Discussion Unintentional discrepancies (errors) mean of 2.1 per patient Intentional (deliberate) changes mean of 0.9 per patient On discharge must account for:- all errors not corrected in ED and all deliberate changes initiated in ED and all other discrepancies arising from the ward

18. Case 1: 95yo, Italian lady presents with ?pulm oedema 3 errors identified dose incorrect frusemide irbesartan charted (drug commission) gliclazide charted (drug commission) withhold gliclazide and instructions to begin an insulin infusion no history of diabetes daughter/mother medication mix up discrepancies corrected in ED

20. Case report 1: Medication Action Plan ED Pharmacist GP confirmed: no history of diabetes daughter/mother medication mix up irbesartan ceased frusemide increased discussed digoxin/clarithromycin interaction blue notes indicated withhold gliclazide, begin insulin infusion (admitting team) discrepancies corrected in ED digoxin level 3.5 Ward pharmacist follow up digoxin, allopurinol, ibuprofen

22. Case report 2: Medication Action Plan ED Pharmacist patient’s own medications brand names used on the Websterpak meds charted by admitting team ceased phenytoin add carbamazepine discrepancies corrected in ED by admitting team Ward Pharmacist to follow up liquid paraffin in ? aspiration pneumonia

24. Case report 3: Medication Action Plan ED Pharmacist GP confirmed: recent discharge from Swan Elderley Mental Health Service 1 week ago changed antidepressant to sertraline at SEMHS increased dose of sotalol at SEMHS ceased fosinopril/hydrochlorothiazide in Nov ‘05 dose of atorvastatin discrepancies corrected in ED by admitting team morning doses of venlafaxine and fosinopril had been given history obtained from a previous admission (Aug ‘05)

25. Case report 4: Medication Action Plan ED Pharmacist GP contacted 18/04/06 & confirmed: no medication changes communicated on discharge 09/03/06 patient had recommenced allopurinol, frusemide and diclofenac pantoprazole not continued Ward pharmacist warfarin counselling follow up allopurinol, diclofenac, frusemide

26. Conclusion Primary objective [To compare the accuracy of medications recorded on the medication chart against a validated medication history taken by the pharmacist for high-risk patients.] there is a high incidence of unintentional error in admission medication histories for high-risk patients Secondary Objective [Assess the utility of the pharmacy service in reviewing high risk patients and resolving medication related problems] a pharmacist/technician based pharmacy service identified, and in a third of cases, corrected, unintentional medication errors

27. Key messages Don’t rely on old information - validate it Accurate discharge letter is vital Undetected errors made on admission may go uncorrected at discharge Medical and nursing staff benefit from clinical pharmacy services A dedicated ED pharmacy service improves the medication management of admitted patients