Minneapolis Hospitals Use AHRQ Research to Help Reduce Medication Errors in Emergency Departments

Two Minneapolis-area hospitals are putting into practice the findings of AHRQ-sponsored research suggesting that clinical pharmacy services can reduce medication errors in emergency departments. Mercy Hospital and Unity Hospital, with support from their parent organization, Allina Hospitals and Clinics, have instituted a program of dedicated pharmacist coverage for emergency department (ED) patients. This innovative staffing structure ensures timely pharmacist consultation, attendance at trauma care and resuscitation, and review of medication orders—all in the interest of patient safety.

The research that inspired this emergency pharmacist experiment was funded under AHRQ's "Partnerships in Implementing Patient Safety" grant program. In 2005, Rollin J. Fairbanks, MD, MS, and his colleagues in emergency medicine at the University of Rochester Medical Center in New York, conducted a series of interviews with ED staff members. They learned which pharmacist services ED staff already found helpful and gathered ideas about how an existing dedicated ED pharmacist program might be optimized for patient safety.

Based on these findings, the hospital refined and expanded a program that gave the clinical pharmacist an enhanced and more visible role in the ED. The pharmacist's administrative responsibilities were minimized, so that attention could be focused on maintaining surveillance of medication orders, responding to critical situations, and being available for clinical consultations.

Jill Strykowski, MS, RPh, Pharmacy Director of Mercy and Unity's joint program, learned of Fairbanks' research at the American Society of Health-System Pharmacists' 2006 clinical meeting. She wanted to see if the program could be adapted to small community hospitals. At that time, 271-bed Mercy and 220-bed Unity Hospital had just acquired a new electronic medical records (EMR) system, including a computer-based provider order entry system for medications and laboratory tests. Hospital physicians felt the need for pharmacists' help with the new system—in particular the process of medication reconciliation in the ED. This situation made it easy for Strykowski to pose the idea to Allina's corporate management. Both hospitals' programs were implemented in 2007; Unity's began in April and Mercy's in June.

The program in place at both Mercy and Unity hospitals is designed for maximum efficiency, consistent with quality. A total of four pharmacists are involved in the program, two at each hospital. Each pharmacist works a 70-hour, seven-day week every other week, on a late afternoon/evening shift (2:30 p.m. to 12:30 a.m.) aligned to the hours of greatest ED demand. In this way, the program achieves optimal coverage, and the pharmacists have an off-duty week to balance a very long work week.

The new EMR system makes it possible for pharmacists to shift their work locations within the hospital as needed. "Their queue of medication orders follows them electronically," explains Strykowski. "They can also participate easily in emergency codes in the ED, so that critically ill patients have a ready resource for accurate drug dispensation," she adds.

In its first year of operation, clinicians at both hospitals welcomed the service enthusiastically, according to Strykowski. Moreover, she reports, a recent survey of emergency clinical staff at Mercy and Unity indicates that their level of satisfaction with pharmacy services has nearly doubled since the emergency pharmacist program was instituted. Cost savings are being measured that can be ascribed to the pharmacists' active presence in the ED. Notably, the hospital's reimbursement rates have also increased, because the hospitals now meet Medicare's "core measures" for adherence to quality standards for care of pneumonia, acute myocardial infarction, and heart failure.

Strykowski's next step is to document the program's effect on the efficiency and quality of emergency care. Early data points toward an annual savings of as much as $300,000 to $500,000. Strykowski also speculates that a proposed Joint Commission standard requiring prospective review of all ED medication orders will confirm the need for dedicated emergency pharmacists.

Meanwhile, Fairbanks' team in Rochester is continuing its research program, with the goal of demonstrating that the presence of the emergency pharmacist has had an impact on patient outcomes. They are hoping to show a reduction in "closed-loop errors"—instances where emergency staff fail to follow up on medication orders. And "the next frontier of our research will be to demonstrate that the program is cost-effective for the hospital that adopts it," Fairbanks adds.