Analysis of Clinical Intervention Documentation by Dispensing Pharmacists in a Teaching Hospital

Abstract

Decentralized pharmacists have a valuable role in preventing medication errors. At Mount Sinai Hospital, each pharmacist's contact with a prescriber to correct or clarify a possible prescribing error is documented on the original order. Our pharmacists are also encouraged to document interventions as part of the pharmacist intervention program. The authors undertook a blinded observational study to determine the percentage of prescriber contacts documented as pharmacist clinical interventions. This 2-month study was conducted in two nursing units with computerized physician order entry. All orders from these units were collected and evaluated for possible prescribing errors and documentation of a pharmacist's contact with a prescriber. Additionally, all pharmacist interventions documented in these units during the study period were collected and entered into the pharmacist intervention database. The percentage of all pharmacist interventions vs the number of documented prescriber contacts on original orders was then calculated. A total of 14 pharmacists were involved in the provision of pharmaceutical care to patients in the study units. During the 2-month study period, a total of 221 orders required pharmacists to contact prescribers regarding potential prescribing errors. However, only 109 (49.3%) of these were documented as clinical interventions. The findings indicate a need for improved documentation of clinical services (eg, interventions) performed by pharmacists.