The strengths of this study included random selection of patients from a representative sample of joint surgeries in an entire health region. Drug-related problems were identified by auditing the patients’ charts according to the information that would be available to a pharmacist in a prehabilitation clinic (i.e., medication history, preadmission clinic assessment, and laboratory values). In addition, to increase the validity of the results and to minimize the subjective nature of the process of identifying drug-related problems, a second pharmacist confirmed the assessment of each problem.
Audits of patient records are subject to several limitations. One disadvantage of retrospective studies is the possibility of missing patient data. In addition, the accuracy of the medication history could not be verified, the rationale for the choice of medications prescribed could not be determined, drug allergies could not be clarified, and intentional and unintentional drug omissions could not be evaluated. Because of the retrospective nature of the study, the true prevalence of drug-related problems might have been underestimated or overestimated. The only information available for audit was the patient’s medication history, the preadmission clinic assessment, and laboratory values. Thus, information gathered from the patient record was limited by what had been documented; the patient was not available to verify actual use of home medications, and management or control of disease could not necessarily be determined. In addition, the intent of the prescriber in stopping or continuing drug therapy was not always documented. Assumptions were made about drug allergies, the physician’s intent, medication history documented in the preadmission clinic, patient-reported medication history, and drug-related problems involving indications for drug therapy. More specifically, the broadest possible drug allergy or intolerance was assumed to be correct. kamagra soft tablets
Errors of medication omission were assumed to be unintentional, unless specifically indicated otherwise or unless the intention was obvious from the chart. The most comprehensive medication history documented in the chart was assumed to be the most accurate history. Finally, the method for categorizing drug-related problems in this study differed from what is traditionally employed in pharmacy practice. This categorization, modified from an evaluation of a medication error classification system, was chosen because the drug-related problems were being evaluated retrospectively, from the perspective of a hospital pharmacist at the point of order entry, with limited clinical information available. Although this perspective for assessing drug-related problems is limited, pharmacists in this situation do spend time identifying and resolving such problems as they fill prescriptions for patients who have undergone total joint arthroplasty. Only a prospective study could use a broader categorization of drug-related problems.
Despite the assumptions inherent in a retrospective approach, many drug-related problems were identified in this population of patients undergoing total joint arthroplasty. Furthermore, the problems pertinent to disease management, including potential indications for drug therapy, were considered as drug-related problems, albeit potential rather than actual. When these problems were excluded from the analysis, the total number of problems observed was still 218 (1.49 per patient), and 73% of the patients experienced at least one problem. Although a second pharmacist confirmed the categorization used in this project, there was still potential for misclassification of the drug-related problems. In addition, alternative tools for classifying drug-related problems, other than the tool used here, are available, and using one of the other tools available might have yielded different results.
In addition to obtaining patients’ medication histories, pharmacists perform a variety of tasks to prevent and resolve drug-related problems in the perioperative setting, including checking availability in hospital of medications that patients are taking at home and arranging for suitable alternatives if unavailable; recording the patient’s medication history in the chart for hospital use; writing prescriptions for discharge medications before the patient is admitted; counselling the patient about home medications, pre- and post-operative medications, and administration times; offering general health promotion activities; and communicating with the patient’s primary care physician by sending a referral form with recommendations when drug-related problems are identified.
In conclusion, many drug-related problems occur in patients undergoing total joint arthroplasty, and a great opportunity exists for pharmacists to intervene to resolve these actual and potential problems. The results of this study will be used to develop the role of the pharmacist in the preadmission and prehabilitation clinics of the Winnipeg Regional Health Authority.
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