HIV Pharmacists Eliminate Inpatient Medication Errors

Daniel M. Keller, PhD

October 17, 2014

PHILADELPHIA — Intervention by an HIV pharmacist can quickly fix medication errors for HIV-infected patients who are hospitalized, a new study shows.

The electronic medical record system flagged some medication errors, but inpatient prescribers often get alerts "for a lot of different things," so sometimes they get ignored, said Sara Bares, MD, from the University of Nebraska Medical Center in Omaha. The dedicated pharmacist intervention was the only thing that brought the errors "down to zero."

Dr Bares, who was not a study investigator, presented the results on behalf of her colleagues during a poster session here at IDWeek 2014.

Patients with HIV are often admitted to hospital services other than infectious disease for medical or surgical conditions. A review of medical records at the University of Nebraska Medical Center for a 3-year period revealed an error rate of 35% (146 of 416 admissions) in the prescribing of antiretroviral therapy, and more than half of those errors were never corrected.

A unified electronic medical record system was therefore instituted at the center.

Although the system caught more than half of the errors, antiretroviral therapy mistakes were still common. In light of continuing errors, outpatient HIV pharmacists were consulted. These pharmacists received notification when any HIV-infected patient was admitted to the hospital, regardless of the service they were admitted to. Many of the HIV inpatients were also outpatients of the medical center, and this assistance was considered within the scope of the pharmacists' duties.

Rishi Batra, BS, and colleagues conducted a prospective review of the medical records, for a 1-year period after the implementation of the system, of all HIV-infected patients hospitalized for more than 24 hours.

"The goal was to correct the errors before patients were discharged," Dr Bares told Medscape Medical News. "If they get sent home on a wrong medication and if a regimen has significant drug interactions, that is a concern."

During the intervention period, an HIV pharmacist reconciled outpatient antiretroviral prescriptions with inpatient orders in the first 24 hours of hospitalization. The error rate fell to 16.7% of admissions (43 medication errors in 31 of 186 admissions).

Errors were 9.4 times more likely to be corrected within 24 hours after the implementation of the system than during the 3-year review period (P < .001). All errors detected during the intervention period were corrected (65.0% within 24 hours and 81.4% within 48 hours; during the review period, 31.0% were corrected within 24 hours and 55.0% were never corrected).

Table. Types of Antiretroviral Errors

Error Review Period (n = 340 errors) Intervention Period (n = 43 errors)
Omission, % 58.8 21.0
Incorrect dosing, % 12.3 16.0
Duplicate therapy, % 0.9 0.0
Incorrect scheduling, % 11.2 42.0
Incorrect therapy, % 1.8 2.3
Drug–drug interaction, % 15.0 18.0


Compared with prescriptions for coformulated drugs, the risk for error was higher with prescriptions for nucleoside reverse-transcriptase inhibitors (relative risk [RR], 3.91) and protease inhibitors (RR, 3.6). This was not the case for integrase inhibitors or non-nucleoside reverse transcriptase inhibitors.

In the past, patients with HIV were admitted to the infectious disease service, which then called in other consults, as necessary, said Rochelle Walensky, MD, from Harvard Medical School and Massachusetts General Hospital in Boston.

"We had our finger on the pulse of all prescriptions written," she told Medscape Medical News. Now, "they're getting written by people who are not used to prescribing antiretroviral therapy."

Her practice is to check her own patients and those of her colleagues who are in the hospital, often just by reviewing the medications they are being prescribed. She said studies such as this one highlight the need for such checks, either by an infectious disease physician or an HIV pharmacist.

"There are some real subtleties in what we do every day that not everybody is accustomed to," Dr Walensky noted. Standard doses of drugs are usually not a problem, but interactions between antiretrovirals and other drugs (like statins), comorbidities such as renal disease, and the temporary effect of surgical stress on drug absorption, metabolism, and excretion can require dose alterations, she explained. "Those doses really do matter when they're in house."

Mr Batra, Dr Bares, and Dr Walensky have disclosed no relevant financial relationships.

IDWeek 2104: Abstract 1557. Presented October 11, 2014.


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