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Original Investigation
May 28, 2007

Pharmacist Medication Assessments in a Surgical Preadmission Clinic

Author Affiliations

Author Affiliations: Inpatient Pharmacy Department (Ms Kwan, Drs Fernandes and Nagge, and Mr Wong) and Surgical Preadmission Clinic (Ms Hurn), Toronto General Hospital; Inpatient Pharmacy Department, Toronto Western Hospital (Mr Huh), and Department of Biostatistics, Princess Margaret Hospital (Mr Pond), University Health Network; Leslie Dan Faculty of Pharmacy (Drs Fernandes and Bajcar), University of Toronto, Toronto, Ontario. Ms Hurn is now with the Endoscopy, Cystoscopy, Medical Day Unit, Thalassemia and Sickle Cell Program, Toronto General Hospital. Dr Nagge is now with the Centre for Family Medicine, School of Pharmacy, University of Waterloo, Waterloo, Ontario.

Arch Intern Med. 2007;167(10):1034-1040. doi:10.1001/archinte.167.10.1034

Background  In the hospital setting, postoperative admission is a key vulnerable moment when patients are at increased risk of medication discrepancies. This study measures the reduction of medication discrepancies associated with a combined intervention of structured pharmacist medication history interviews with assessments in a surgical preadmission clinic and a postoperative medication order form.

Methods  In the Surgical Pharmacist in Preadmission Clinic Evaluation (SPPACE) study, patients who had a preadmission clinic appointment before undergoing surgical procedures were eligible for inclusion. Patients were excluded if they were scheduled for discharge the same day as their surgery. Eligible patients were randomly assigned to the intervention arm (structured pharmacist medication history interview with assessment and generation of a postoperative medication order form) or to the standard care arm (nurse-conducted medication histories and surgeon-generated medication orders). The primary end point was the number of patients with at least 1 postoperative medication discrepancy related to home medications.

Results  Between April 19, 2005, and June 3, 2005, a total of 464 patients were enrolled in the study, of which 227 and 237 patients were randomized to the intervention and standard care arms, respectively. In the intervention arm, 41 (20.3%) of 202 patients had at least 1 postoperative medication discrepancy related to home medications, compared with 86 (40.2%) of 214 patients in the standard care arm (P<.001). In the intervention arm, 26 (12.9%) of 202 patients had at least 1 postoperative medication discrepancy with the potential to cause possible or probable harm, compared with 64 (29.9%) of 214 patients in the standard care arm (P<.001). These were mostly omissions of reordering home medications.

Conclusion  A combined intervention of pharmacist medication assessments and a postoperative medication order form can reduce postoperative medication discrepancies related to home medications.