Effectiveness of a pharmacist-acquired medication history in an emergency department

1. Medication discrepancies associated with the intervention. The following definition of medication discrepancy has been adopted for the present study: “Any patient medication-related statement regarding medication consumed at home, made during admission to the emergency service.” Discrepancies will be prospectively identified. The main result will lie in identifying patients having at least one discrepancy regarding the medication being taken at home, then recording it and communicating it.
Medication discrepancies may be associated with drugs, medication brand-name, dose, duration, frequency, formulation, administration route, resumption of appropriate medication, illegible medical orders/prescriptions.
Identifying the type of discrepancy: Detecting the presence of some of the following events:
1.1. Omission (not ordering medication which a patient has been taking before admission)
1.2. Therapeutic duplicity (receiving more than one similar medication for the same indication)
1.3. Slowness in resuming therapy (selecting one of the following categories: before 6 hours, 6-12 hours, 12-24 hours or more than 24 hours after being admitted)
1.4. Therapy instituted too soon (i.e. treatment being reinitiated without taking frequency of taking a prescribed drug at home into account: before 6 hours, 6-12 hours, 12-24 hours or more than 24 hours)
2. Prescription discrepancies
2.1. Inconsistency or omission of some type of the following information: medication brand-name, dose, frequency, administration route or illegible orders
2.2. Prescription omission (when a patient has been given medication which has not been prescribed)
2.3. Medications lacking indication (medication administered without any indication, not associated with a diagnosis or consuming unneeded medication)
2.4. Allergies and interactions (these should be classified according to the following categories: higher (interaction could affect a patient’s life or cause permanent damage must be suspended immediately), moderate (when this does not put a patient’s life at imminent risk but could complicate his/her general state and lead to reversible damage), lower (not affecting a patient’s clinical condition but could involve adjusting the dose), none (interaction is present but documentation is lacking regarding the clinical effect), others (some of those which are not described in this protocol but which could be of clinical interest).
Number of discrepancies per category. Describing events which could arise: omission, therapeutic duplicity, slowness in resuming therapy, therapy instituted too soon, prescription discrepancies, prescription omission, medication lacking indication, allergies, interactions, other events.

Classifying and evaluating discrepancy safety: Involuntary medication discrepancies which may cause damage are defined as, “An incident potentially leading to a medication-related lesion.” The potential to cause damage has been used to measure medication safety and its reduction as an action to reduce real medical administration records (RAM). Discrepancy risk has been defined in three classes (according to Cornish et al.):
1. Class 1 (those probably not causing clinical deterioration or nuisance)
2. Class 2 (those having the potential to cause moderate nuisance or clinical deterioration)
3. Class 3 (those having the potential to cause serious discomfort for a patient or significant clinical deterioration)

Characterising the population seeking help from emergency services will involve recording date regarding chronological age in years, gender, socioeconomic strata, number of prior hospitalisations, number of morbidities, type of co-morbidity, how many medications are being taken, the type of medication and interventions made by the pharmacist.

Characterizing and evaluating reconciliation will involve evaluating the opportunity and suitability of pharmaceutical action. The number of interventions made by a pharmacist will be measured, as will the medication history’s level of acceptance and average time spent on MedRec in hours.