12 things pharmacists want hospitalists to know

From better communications to extra vigilance to high-risk decisions, veteran pharmacists outline areas for improvement.

May 9, 2017|The Hospitalist

Thomas R. Collins

It’s hard to rank anything in hospital medicine much higher than making sure patients receive the medications they need. When mistakes happen, the care is less than optimal, and, in the worst cases, there can be disastrous consequences. Yet, the pharmacy process – involving interplay between hospitalists and pharmacists – can sometimes be clunky and inefficient, even in the age of electronic health records (EHRs).

The Hospitalist surveyed a half-dozen experts, who touched on the need for extra vigilance, areas at high risk for miscues, ways to refine communications and, ultimately, how to improve the care of patients. The following are tips and helpful hints for front-line hospitalists caring for hospitalized patients.

1. Avoid assumptions and shortcuts when reviewing a patient’s home medication list.

“As the saying goes, ‘garbage in, garbage out.’ This applies to completing a comprehensive medication review for a patient at the time of admission to the hospital, to ensure the patient is started on the right medications,” said Lisa Kroon, PharmD, chair of the department of clinical pharmacy at the University of California, San Francisco.

Even though EHRs are becoming more connected, they don’t provide all the details. Just because a medication is on the medication list doesn’t mean patients are actually taking it. They also might be taking it differently than prescribed, Dr. Kroon said. Patients and caregivers should be asked what medications they’re actually taking, as well as the strength of the tablet, how many at a time and how often, and at what time of the day they are taking them.

The EHR “is often more of a record of which medications have been ordered by a provider at some point,” she notes.

Doug Humber, PharmD, clinical professor of pharmacy at the University of California, San Diego, said hospitalists should be sure to ask patients about over-the-counter drugs, herbals, and nutraceuticals.

“Some of those medications may interact with prescribed medication in the hospital,” he said. “The most complete data that we have on a patient’s medication list coming in clearly sets [us] up for success, in terms of making medication therapy safer for the patients while they’re here.”

Dr. Kroon encourages hospitalists to conduct a complete medication review, which helps determine what should be continued at discharge.

“Sometimes, not all medications a patient was taking at home need to be restarted, such as vitamins or supplements, so avoid just entering, ‘Restart all home meds,’ ” she said.

2. Pay close attention to adjustments based on liver and kidney function.

“A hospitalist may take a more hands-off approach and just make the assumption that their medications are dose-adjusted appropriately, and I think that might be a bad assumption. [Don’t assume] that things are just automatically going to be adjusted,” Dr. Humber said.

Mohamed Jalloh, PharmD, a pharmacist and a spokesman for the American Pharmacists Association, concurs. He said that most mistakes are related to “kidney [or] liver adjustments.”

That said, hospitalists also need to be cognizant of adjustments for reasons that aren’t kidney or liver related.

“It is well known that patients with renal and hepatic disease often require dosage adjustments for optimal therapeutic response, but patients with other characteristics and conditions also may require dosage adjustments due to variations in pharmacokinetics and pharmacodynamics,” said Erika Thomas, MBA, RPh,, a pharmacist and director of the Inpatient Care Practitioners section of the American Society of Health-System Pharmacists. “Patients who are obese, elderly, neonatal, pediatric, and those with other comorbidities also may require dosage adjustment.”

Drug-drug interactions might call for unique dosage adjustments, too, she adds.

3. Carefully choose drug-information sources.

Dr. Jalloh said that one of the roots of inappropriate dosing is simply “a lack of time and money to look at credible resources.” Free drug-information apps might not have the extensive information needed to make all the right decisions, such as adjustments for organ function, he said. More comprehensive apps are expensive, he admits, and sometimes even those apps contain gaps.

“Hospitalists can contact drug-information centers that answer complex clinical questions about drugs if they do not have the time to explore themselves,” he said.

Creighton University, Omaha, Neb., for example, has such a center that has been nationally recognized.

4. Carefully review patients’ medications when they transfer from different levels of care.

Certain medications are started in the ICU that may not need to be continued on the non-ICU floor or at discharge, said MacKenzie Clark, PharmD, program pharmacist at the University of California, San Francisco. One example is quetiapine, which is used in the ICU for delirium.