Case study: Spotting the error

hospital pharmacist medication chart

Why it’s imperative that pharmacists should be involved at both hospital admission and discharge

This month the SHPA spoke out in support of hospital pharmacists, following reports of understaffing, workload pressure and looming industrial action in the ACT.

The SHPA highlighted that pharmacist-to-patient ratios matter, with SHPA Chief Executive Kristin Michaels saying the key Standard of Practice stipulates 30 as the maximum number of patients per hospital pharmacist.

Victorian community pharmacy proprietor Jarrod McMaugh says he recently encountered a situation that highlighted just how important it is for hospital pharmacist numbers to be adequate.

The situation relates to a patient of his who had been admitted to hospital.

Jarrod McMaugh says pharmacists should be involved at admission and discharge.
Jarrod McMaugh says pharmacists should be involved at admission and discharge.

“The person in question is a long-term client who utilises a dose administration aid. We have long-term records of medication use and changes not always visible on dispense records,” explains Mr McMaugh.

“Planned admission didn’t include a pharmacist. [There was a] nurse administrator and medical officer who produced/signed off on chart.

“Error started here – the person had been taking pantoprazole for reflux for a number of years. Brand name is Sozol. Charted as SOTOLOL. No history of arrhythmia. Pharmacy department provided medication as charted.

“At time of expected discharge, the error was detected. A community pharmacist [McMaugh’s colleague] questioned the indication and the circumstances that led to this medication being used.

“Discharge was cancelled until impact of medication error was assessed and measures were taken to address any injury.”

Mr McMaugh says the hospital in this case did not have direct pharmacist input until discharge.

“At the time of admission, a pharmacists’ expertise in medication could have identified the charted error,” he says.

If the patient had not been using a dose administration pack, there would have not been a discussion between Mr McMaugh’s community pharmacist colleague and the hospital pharmacist.

“In other words, they would have gone home [with the] error not identified.

“The time between discharge and review by their GP may have been soon after discharge, or it may have been weeks. While they would have caught it, the error could have been prevented.

“This case highlights the need for pharmacists to be present in hospital in sufficient numbers to provide clinical input at admission, throughout treatment and at discharge.

“Hospital admission and discharge need a pharmacist’s expertise to address medication errors.

“Pharmacist’s role at admission and discharge should not be an afterthought or a luxury. It is critical to prevent and address medication error.”

He says the patient was put at significant risk when the hospital didn’t utilise the expertise they had at hand in the form of a pharmacist.

This is one instance of medication error causing hospitalisation – or in this case, an extension of stay.

There are an estimated 230,000 medication-related hospital admissions occurring per year. This suggests an annual cost of medication-related admissions of AU$1.2 billion.

Pharmacists should be key to addressing this, but underutilisation contributes to more errors, says Mr McMaugh.

He calls for not only hospital pharmacists to be involved at admission and discharge, but also the patient’s primary care team (GP and community pharmacist).

“Funding needs to facilitate better admission, discharge and communication,” he says.

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