CT-334: Medication Error Prevention Through Pharmacist-Led Interventions in the Emergency Department of a Tertiary Care Hospital in Karachi, Pakistan

The aim of this study was to estimate the near-misses to prevent medication error reporting by emergency department (ED) pharmacists in a tertiary care hospital in Karachi, Pakistan. Retrospective chart review was done on near-misses reported by ED pharmacists at Aga Khan University Hospital. These interventions were documented by ED pharmacists from January to December 2019, and were then analyzed on Microsoft Excel and categorized for potential of harm if there was no intervention. A total of 3,205 pharmacist interventions were reviewed during the study period. About 92% (n = 2,947) of the interventions were found to be moderately to very significant. Significant interventions were mostly initiated by pharmacists aged >60 years, 20.1% (n = 593). Most interventions were related to a wrong drug/mnemonic picked by a physician for medication order entry, 12% (n = 396), followed by incomplete/unclear order, 10% (n = 307). Data analysis showed that the highest number of interventions were due to the drug category of antibiotics, 27% (n = 862), followed by PPI/H2-antagonist/GI protective agents, 19% (n = 619). The most frequent intervention type was therapeutic interchange, 744 (23%), followed by dose adjustment/therapeutic drug monitoring and renal dose adjustments: 539 (17%) and 521 (16%), respectively. The overall average time consumed per intervention was 12 minutes. Our study shows that ED pharmacists play a pivotal role in reducing preventable medication errors, which ultimately lead to decreased health care costs and patient hospital length of stay.