A time and motion study of pharmacists and pharmacy technicians obtaining admission medication histories

Using pharmacists to obtain admission medication histories (AMHs) reduces medication errors by 70% to 83% and resultant adverse drug events (ADEs) by 15%.^1-3 Dissemination of this practice has been limited by several factors, including clinician practice models, staff availability, confusion in provider roles and accountability, and absence of standardized best practices.^4-5 This paper assesses one of these barriers: the high cost of utilizing pharmacists. Third-person observer time and motion analysis shows that pharmacists require 46 and 92 minutes to obtain AMHs from medical and geriatric patients,⁶ respectively, resulting in pharmacist costs of $44 to $88 per patient, based on 2015 US Bureau of Labor Statistics (BLS) hourly wage data for pharmacists ($57.34).⁷

Pharmacist-supervised pharmacy technicians (PSPTs) achieve AMH accuracy comparable to pharmacists,^8-9 but their hourly wages are only 26% of pharmacists’.⁷ We conducted a third-person observer time and motion study¹⁰ to compare the amount of time and labor cost necessary for pharmacists and PSPTs to obtain AMHs for patients at high risk for ADEs.

This study originated as part of a randomized, controlled trial conducted during January-February 2014 at Cedars-Sinai Medical Center (CSMC), an 896-bed, university-affiliated, not-for-profit hospital.⁹ Pharmacy staff included pharmacists, PGY-1 pharmacy residents, and pharmacy technicians, each of whom received standardized didactic and experiential training (Appendix 1).

The pharmacists’ AMH and general pharmacy experience ranged from <1 to 3 years and <1 to 5 years, respectively. For PSPTs, AMH and general pharmacy experience ranged from <1 to 2 years and 1 to 17 years, respectively. Three additional pharmacists were involved in supervising PSPTs, and their experience fell within the aforementioned ranges, except for one pharmacist with general pharmacy experience of 16 years. The CSMC Institutional Review Board approved this study with oral consent from pharmacy staff.

For the trial, pharmacists and PSPTs obtained AMHs from 185 patients identified as high-risk for ADEs in the CSMC Emergency Department (ED). Patients were randomized into each arm using RANDI2 software¹¹ if they met one of the trial inclusion criteria, accessed via electronic health record (EHR) (Appendix 2). For several days during this trial, a trained research nurse shadowed pharmacists and PSPTs to record tasks performed, as well as the actual time, including start and end times, dedicated to each task.

After excluding AMHs with incomplete data, we calculated mean AMH times and component task times (Table). We compared mean times for pharmacists and PSPTs using two sample t tests (Table). We calculated mean times of tasks across only AMHs that required the task, mean times of tasks across all AMHs studied, regardless of whether the AMH required the task or not (assigning 0 minutes for the task if it was not required), and percent mean time of task per patient for providers combined (Table).

We calculated Pearson product-moment correlation estimates between AMH time and these continuous variables: patient age; total number of EHR medications; number of chronic EHR medications; years of provider AMH experience; and years of provider general pharmacy experience. Using two sample t tests, we also checked for associations between AMH time and the following categorical variables: sex; presence of a patient-provided medication list; caregiver availability; and altered mental status, as determined by review of the ED physician’s note. Caregiver availability was defined as the availability of a family member, caregiver, or medication administration record (MAR) for patients residing at a skilled nursing facility (SNF). The rationale for combining these variables is that SNF nurses are the primary caregivers responsible for administering medications, and the MAR is reflective of their actions.

After reviewing our initial data, we decided to increase our sample size from 20 to 30 complete AMHs. Because the trial had concluded, we selected 10 additional patients who met trial criteria and who would already have an AMH obtained by pharmacy staff for operational reasons. The only difference with the second set of patients (n = 10) is that we did not randomize patients into each arm, but chose to focus on AMHs obtained by PSPTs, as there is a greater need in the literature to study PSPTs. After finalizing data collection, the aforementioned analyses were conducted on the complete data set.

Lastly, we estimated the mean labor cost for pharmacists and PSPTs to obtain an AMH by using 2015 US BLS hourly wage data for pharmacists ($57.34) and pharmacy technicians ($15.23).⁷ The cost for a pharmacist-obtained AMH was calculated by multiplying the measured mean time a pharmacist needed to obtain an AMH by $57.34 per hour. The cost for a PSPT-obtained AMH was the sum of the PSPT’s measured mean time to obtain an AMH multiplied by $15.23 per hour and the measured mean pharmacist supervisory time multiplied by $57.34 per hour.