There are 7,000 deaths each year in the USA due to medication errors (Morrow-Frost 2006). Emergency Departments (ED) have the highest rate of preventable adverse drug events in hospitals (Cobaugh and Schneider 2005). Tam et al (2005) found that 10-97% of medication regimens written up by ED doctors were inaccurate. Additionally 31% of patients admitted to ED were found to have potentially serious drug interactions (31).

Pharmacy intervention in the ED at Lismore Base Hospital (LBH) indentified that 39% of high risk patients had at least one error on the medication list written up by the ED doctor.

As a result of this project, Pharmacists now see high risk patients in ED, continue to review their medicines during their hospital journey and ensure patients understand how to take their medicines at discharge.

To ensure the accuracy of charted medications for patients over 65 years on four or more medications admitted through the ED at LBH.

Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions (Joint Commission 2008). The literature indicates that most patients admitted to hospital have at least one medicine missing on their chart (Tam et al 2005). Inaccurate lists of medication can result in worsening of the patients' condition, as well as complicate the diagnosis and treatment of patients in hospital.

A snapshot audit was undertaken over a period of 2 weeks to gauge the extent of omitted or incorrect medications charted for patients over 65 years on four or more medications admitted through the ED at LBH. Of the 18 patients reviewed as part of the audit, 50% had an omitted or incorrect medication on the medication list written up by the ED doctor.

Tam et al (2005) found that 10-97% of medication regimens written up by ED doctors were inaccurate. Pharmacist generated medication lists were more complete than those written up by other health professionals (Nester et al 2002).

This project links to Strategic Direction 2: Creating better experiences for people using health services. It focuses on ensuring the accuracy and safety of medications at the start of the patient hospital journey through appropriate clinician engagement, information management across the acute community interface, and consultation with patients and carers.

The project team was headed by the General Manager, and included the Medical Director of ED, the NUM of ED, Director of Pharmacy and the pharmacy graduate. This support from Executive level allowed timely decision making and implementation of change strategies.

Following review of the literature and the results of the snapshot audit, the project team identified that placement of pharmacy resources in the ED was the most likely successful strategy. The team met to agree project details and to monitor progress and outcomes.

The graduate pharmacist was located in the ED and integrated into the ED team with the support of the Medical Director and NUM of ED.

Patients who were over 65 and on four or more medicines were the target group for the project.

Information about the patients’ medication was obtained from the GP, the community pharmacist, the patient and carer as well as viewing the medicines brought in by the ambulance driver. The pharmacist wrote the correct list of medications on the front of the medication chart and details about missing medicines were communicated to the doctor verbally or via the patient’s notes. Information about the patient’s compliance problems, drug interactions or medication-related reasons for admission was also provided to the doctor to facilitate diagnosis and treatment.

One hundred and seventy six patients were reviewed by the pharmacy graduate during the four month project. It took 101 graduate pharmacist hours to complete the reviews with an average time of 34 minutes per patient.

Their average age of patients reviewed was 76 years.

Sixty nine patients (68%) had at least one omitted or incorrect medication on the medication list written up by the ED doctor. The total number of missed or incorrect medications for these patients was 118 with an average of 1.7 medications per patient.

Figure 1.  Describes the types and frequency of omitted or incorrect medication on the medication list written up in ED. The major groups of omitted or incorrect medications were : oral analgesics 16%, medications for heart rhythm disorders 14%, complementary therapies 13%, antiplatlet & anticoagulant medication 10%, respiratory medications 9%, eye medications 8%, antibiotics 8% and angina medication 8%.

 Figure 1

When potential Severity Assessment Code (SAC) ratings were allocated to the 69 occasions where one or more medications were missed, 53 (77%) were rated SAC 2 and 16 (23%) were rated SAC 3. These potentially adverse patient outcomes could have increased length of stay, increased the care and/ or increased the number of investigations required. All have higher cost implications for the health service. Increasing the length of stay also increases the chance that the older patient would lose some functionality, making it more difficult for them to manage their own care in the community.

After discussion with ED, ward doctors and pharmacy staff, pharmacists now see patients in ED to obtain an accurate medication list, follow the patients on the wards by reviewing their medication and attending physician rounds and counsel patients at discharge to ensure they understand their medication. The advantages of this model are: continuity of pharmaceutical care through the hospital journey, improved learning and hence retention for the pharmacists and physicians save time by having a pharmacist available for information and advice. Registrars on the wards particularly appreciated having information about the patients medicines at admission, because it helped them to provide useful information about medication changes to the GP at discharge.

Medication and associated errors are ubiquitous to all health care settings. Ensuring accuracy and safety of medications at the start of the patient hospital journey is a pivotal strategy to reduce these errors. Pharmacist-conducted medication histories have been reported to save an average of $7million per year per hospital and reduce mortality rates by 128 deaths per year per hospital, compared with hospitals that do not use this service (Nester and La Donna 2002).

The improved clinical care of patients and financial savings would fund further pharmacist positions. The improved job satisfaction and the experience of being part of the medical team would improve retention of clinical pharmacists in the hospital service, making extensions of this service feasible (Muir and Bortoletto 2007).

• Nester TM, LaDonna SH. "Effectiveness of a pharmacist-acquired medication history in promoting patient safety". American Journal of Health System Pharmacists 2002, Vol 59, Pages 2221-5.
• Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R and Etchells EE "Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review" Canadian Medical Association Journal, 2005, Vol 173, No 5.
• The Joint Commission. National patient safety goals. Washington DC: The Commission: 2007. Available from  www.jointcommission.org
• The Australian Council for Safety and Quality in Healthcare (2002) The Second National Report on Patient Safety; Improving Medication Safety 2002.
• Morrow-Frost C., Nurses knowledge of commonly used drugs: a clinical audit. Emergency Nurse, Mar 2006, 13, 10.
• Career and Technical Education, pg. 32.
• Cobaugh DJ and Schneider SM. Medication in the emergency department: Why are we placing patients at risk? Am J Health-Syst Pharm. 2005; 62:1832-3.
• Muir P, Bortoletto D Burnout among Australian Hospital Pharmacists Pharmacy Practice and Research 2007 Vol 37 No 2 Pages 187-189.