Effectiveness of a Pharmacist-Acquired Medication History in Promoting Patient Safety

Tina M. Nester, Ladonna S. Hale


Am J Health Syst Pharm. 2002;59(22) 

In This Article


Accurately documenting a patient's home medications and allergies at the time of admission improves the efficiency and quality of patient care and helps prevent medical errors. Pharmacists are especially suited to conducting medication history interviews, as they are more familiar with drug names, characteristics, effects, dosage forms, and administration than other health care personnel. Pharmacists can readily identify inconsistencies and mistakes in patients' self-reported medication histories. Pharmacists have the expertise and experience to scrutinize questionable drug orders and optimize a patient's drug therapy through clinical interventions.

An incomplete or inaccurate medication history may lead to interrupted and inappropriate drug therapy during hospitalization and affect patient safety. Potential drug interactions and treatment duplications may result from prescribers being unaware of patients' complete list of home medications. For example, a pharmacist discovered that an epileptic patient in the study group had no admission orders for his condition. Another patient was taking clonidine at home, but the drug was missing from the patient's medication history.

A complete allergy history is also important for patient safety. Pharmacists are especially sensitive to the importance of distinguishing between allergies and intolerances and identifying the types of reactions that occurred. They are also better at correcting and resolving discrepancies in previously documented allergy information. In this pilot study, the pharmacist was able to identify important allergy information. One patient's chart listed "no known drug allergies" (NKDA), but the patient reported an allergy to morphine with subsequent itching to the pharmacist who interviewed him. Another patient's chart listed NKDA, but the patient stated he was allergic to ampicillin with subsequent itching. A third patient's chart reported an allergy to aspirin, but the patient was already taking and tolerating daily aspirin. Using pharmacists to interview patients and record medication history expedited the entry of allergy information in the hospital's computer system and prevented delays in drug dispensing.

Another important part of a medication history is the patient's use of nonprescription medications and herbal preparations. Even if these products are not continued during hospitalization or are only used occasionally, they can have significant interactions and adverse effects.[7] In our study, patients were more likely to mention their use of these products during the medication history interview when specifically prompted by the pharmacist.

The descriptive time-management data indicate that pharmacist-conducted medication histories are not time-consuming considering the substantial benefits for patients and time saved for nurses. Although not measured, it is conceivable that pharmacist time spent interviewing patients and documenting medication history reduces the time required of dispensing pharmacists to clarify incomplete orders and reconcile admission orders. By eliminating the duplication of time and effort, it may be possible for some institutions to implement this service without additional pharmacist staffing. However, more rigorous evaluation of the impact of this service on actual nursing and pharmacist workflow is necessary to determine the effect this service would have on the number of nursing and pharmacy staff.

Implementing a 24-hour hospital-wide pharmacy service would be difficult for most institutions. A partial service might be more practical, but several models could be explored. A pharmacist could work in the emergency room or admissions area during certain hours to conduct medication histories as patients are admitted to the hospital. Floors with decentralized pharmacy services could add medication history interviews to the other clinical services already offered. Targeting the service to certain populations with more drug-related complications, such as the elderly and patients admitted for adverse drug reactions, may make the service more efficient.

Although there is evidence in the biomedical literature that pharmacist-conducted medication histories are more accurate, save money, and increase patient safety, this service is not widely implemented in U.S. hospitals.[2,3,4,5,6] We encountered no resistance from physicians or nursing staff during our study. On the contrary, the nursing staff strongly supported the prospect of pharmacists' role and expertise in conducting medication history interviews.

Any redistribution of duties has potential problems. If nurses feel that pharmacists' desire to provide this service stemmed from the belief that nurses were doing it inadequately, they might feel alienated or insulted. Maintaining good nursing-pharmacy relations is important for the success of both departments. Therefore, we presented our pilot study as a means of relieving nurses to perform other direct patient care activities and improve efficiency for both departments. This approach proved successful.

The results of this study were presented to the pharmacy and therapeutics committee. The project received wide support from physicians who also admitted frustration with ordering medications on the basis of patient history and receiving questions from pharmacists for clarifications. They recognized the project's positive effect on patient safety.

Despite strong support from nurses, physicians, and pharmacists, our hospital has not yet instituted this clinical service. We first attempted to add this service one year ago, but our efforts were curtailed due to major personnel and budget changes occurring at that time. We are now revising our clinical pharmacy services and planning the implementation of this service. We will begin on a limited basis, targeting patients with complicated histories, and will expand the service if it is found feasible by upper management. Some of the logistic and budgetary hurdles we face may explain why many other hospital pharmacies cannot spare pharmacists for conducting medication history interviews.