Request for Emergency Department
Pharmacist Program
Institution A
<Date>
Executive Summary
Pharmacy Service, in conjunction with Medical Service is requesting 4.6 Pharmacist FTEE to
allow intensive pharmacy services in the Emergency Department 24 hours a day, 7 days a week.
The additional full time pharmacists will simultaneously allow for improved patient safety via
prospective review of ED and radiology as well as bring the Institution A into compliance with
JCAHO and other regulatory codes and regulations. We do not believe the Institution A will be
able to meet the Joint Commission standards without the implementation of this program.
Additional benefits from this proposal include:








Improving inventory/formulary regulation resulting in more effective budget
management, improved streamlining of the ED workflow, as well as assuring an increase
in patient safety within our system.
Increased effectiveness of medication reconciliation via decreasing medication
discrepancies through prospective pharmacist review in the ED where the majority of
non-elective hospital admissions occur.
Assisting in meeting Institution A established criteria goals.
Provide a medication usage information source.
Relieving ED staff of the additional burden of tasks preferentially handled by pharmacy
staff.
Expanding code blue coverage in the hospital.
Minimizing the potential for costly litigation by decreasing overall medication errors in
the ED.
Increasing patient satisfaction and decreasing overall wait times while providing the
highest quality of care for our veterans.
Through a review of published cost analysis literature analyzing the overall financial benefit of
pharmacists in the ED it is estimated that the addition of these pharmacy positions will cost at
the most approximately $100,000, however we believe that this proposal will come close to
completely offsetting the additional cost incurred with the possibility of the Institution A
realizing an overall cost savings. In addition, with the substantial increase in workload absorbed
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over the past several years without a compensatory increase in staffing, undertaking such a
sizeable workload without additional FTEE would not be feasible.
ESTIMATED COSTS
4.6 FTEE @ $104,000/FTEE annually
Benefits (estimated at 30%)
ESTIMATED SAVINGS
Savings range (see section II)
Probable financial impact on Facility
$478,400
$143,520
$586,500-863,800
(-$35,420) – 241,880
I. Background
Pharmacy Service, with cooperation, support and input from the Emergency Department (ED),
is requesting 4.6 Pharmacist FTEE to institute a comprehensive ED pharmacist program. Below
you will find a thorough analysis and justification detailing the reasons for these positions at the
Institution A and the anticipated outcomes of the program. The 4.6 Pharmacists would allow
intensive pharmacy services in the Emergency Department 24 hours a day, 7 days a week. This
document will demonstrate that we believe we can do this at little net cost to the Institution A
while significantly improving patient safety and compliance with Joint Commission and other
regulatory requirements. It is not possible for Pharmacy Service to accomplish any of these
tasks in any meaningful way without additional FTEE due to the continued increase in Pharmacy
workload in all its sections and the resultant relative shortage of current staffing levels. We do
not believe the Institution A will be able to meet the Joint Commission standards without the
implementation of this program. We are asking that the RMC take action quickly on this request
so that we can gain all the advantages of the program for optimizing patient care in the ED. The
approval of this proposal is also timely for hiring of qualified pharmacists as a number of
potential candidates will be ending their advanced clinical residencies at the end of June.
II. Cost Avoidance/Cost Savings Initiatives
The following studies evaluated the impact of pharmacy involvement in the ED. Although none
of the studies were designed to assign direct mortality data from pharmacy involvement in the
ED, they were able to quantify the number of interventions pharmacists made, evaluate which
areas the pharmacists had the greatest impact as well as calculate projected total cost savings.
In 2002 Lee et al. evaluated 600 pharmacist recommendations at a 344 bed Institution A serving
over 220,000 patient visits per year providing care to approximately 25,000 veteran patients.
Using Institution A costs, pharmacist recommendations and their clinical and economic
outcomes were evaluated. The mean cost avoidance per inpatient recommendation was
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calculated to be $1,057. The table below indicates the types of interventions and
recommendations documented and the associated average cost avoidance (1).
Type of Recommendation
Probable financial impact on Facility
Drug interaction
Prevent or manage drug allergy
Adjust dose or frequency
Untreated diagnosis
Prevent or manage adverse drug event
Drug not indicated
Duplication of therapy
Average Cost avoided per
recommendation
(-$35,420) – $241,880
$1,647
$1,375
$1,188
$1,106
$1,098
$724
$165
A study by Lada et al. looked at pharmacist interventions in a 340- bed, university-affiliated,
urban level-I trauma center for adult patients. In 2001, over 84,000 adult patients were seen in
the hospital’s 100-bed ED. The ED reported 2,150 interventions in a 4 month period with a
mean ± SD of 17.5 ± 1.43 within a 24 hour period. This extrapolates to a total of approximately
6,400 interventions per year. The most common interventions involved provision of drug
information, dosage adjustment recommendations, responses to nursing questions, formulary
interchanges, and suggestions for the initiation of drug therapy. A breakdown of the
pharmacist interventions is shown below.
Category
Drug information
Dosage adjustment
Nursing questions
Formulary interchanges
Suggest initiation of Rx
Order clarification
Change to alternative Rx
Compatibility issues
Patient information
Change route of administration
Discontinue drug therapy
Toxicology
Allergy notification
Drug therapy duplication
Drug interaction
No. Interventions
(n = 2150)
362
353
316
181
180
164
157
143
77
66
58
43
40
8
2
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Cost avoidance during the 4 month study period was determined to be $1,029,776.
Extrapolated to one year the total yearly cost avoidance totals $3,089,328. (2) It should be
noted that the data presented by Lee and Lada were based on Institution A costs and thus
provide the most accurate depiction of the impact pharmacy services may have on the
Institution A ED.
Year
1989
1990
1991
# of
interventions
9,700
15,770
15,637
# of saving
interventions
1,334
1,464
1,541
Cost savings
($)
31,041.20
54,007.09
93,561.22
Cost savings in 2007
dollars ($)
50,942.36
84,088.67
139,791.59
Ling et al. looked at pharmacist interventions in an ED at a large, urban, teaching institution
that treats over 100,000 patients annually. A satellite pharmacy was open for 8 hours daily to
support medication distribution, and a clinical pharmacist specialist was available for
consultation and code response for an additional 8 hours on weekdays. The study documented
401interventions; the total cost avoidance estimated for these interventions was $192,923. This
extrapolates to an annual cost avoidance of $463,015. The acceptance rate of pharmacist
interventions by other health care professionals was 89%. The top five interventions captured
were 1) switching from a non-formulary to a formulary preferred agent, 2) correcting a
subtherapeutic dose or frequency, 3) correcting a supratherapeutic dose or frequency, 4)
providing professional services, and 5) documenting allergies. The events most frequently
avoided were suboptimal disease management, adverse drug reactions, and drug cost
avoidance.(3) Levy conducted a separate study which reported cost savings calculated by
pharmacist interventions in an emergency department from 1989-1991. Pharmacists were
instructed to document all clinical interventions. The data was then compiled for each year and
the results are shown below.
While analyzing total cost savings, the study calculated only material costs resulting from
medication interchanges and adjunctive equipment. Additional cost benefit resulting from time
saving interventions, decreased hospital stay and avoidance of adverse events and interactions
was not taken into consideration with this study. This would likely result in a significant
underestimation of total cost benefit from having a pharmacist employed in the emergency
department. The author cited several examples where pharmacist presence in the emergency
department had a positive impact on delivery of patient care in the emergency department via
distributional, clinical, and educational services performed. The study concluded that
pharmacist presence in the emergency department improved medication ordering,
administration, and charting in addition to minimizing medication errors while saving almost
$180,000 in medication costs over the three year period (4). In current dollars this represents a
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$275,000 savings in medication costs independent of the potential improvements that could be
made to the present inventory management system.
Bates et al. assessed the resource utilization associated with an ADE (adverse drug event).
Among the 4,108 admissions to medical and surgical units analyzed, 190 ADEs were
documented, 60 of which were preventable. The ADEs were associated with a mean additional
length of stay of 2.2 days and an average increase in cost of $2,595 per event. For preventable
ADEs the associated increased length of stay was 4.6 days with an increase in cost of $4,685 (5).
Senst and colleagues performed a study in which one of the goals was to analyze data from
multiple hospital admissions and project costs of ADEs occurring after admission and resulting
in admission. Data was collected from a healthcare system comprised of a 383-bed tertiary care
facility; a 60-bed Mental Health Center, an 84-bed Children's Psychiatric unit, and a 30-bed
facility for children with disabilities. The estimated ADE rate during hospitalization was 4.2
events per 100 admissions, with a cost of $2,162 per ADE. In addition, 3.2% of admissions were
caused by ADEs, with an associated cost of $6,685 per event (6). Based on the study, 15% of
hospital ADEs and 76% of ADEs causing admission were judged preventable.
A retrospective study by Beers et al. sampled 424 randomly selected adults seeking care at a
university-affiliated 24 bed hospital ED that sees over 37,000 patients per year. Among patients
who received medications at the ED, they found a 10% rate of exposure to what were
considered clinically relevant potential ADEs. Upon reviewing patient charts, there was little
indication that physicians were aware of the potential for adverse drug reactions (7).
Data published by Leape et al., which addressed the pharmacist’s impact at the time of
prescribing, showed that the active participation of a pharmacist during clinical ICU rounds was
associated with a 66% reduction in ADEs with respect to baseline (from 10.4 to 3.5 ADEs per
1000 patient-days), with no change in the incidence of ADEs being noted in the control group.
These outcomes were achieved with a clinical pharmacist being available in the morning on
rounds and by consult thereafter (8).
Our proposal allows for an onsite pharmacist to participate in all ED admissions around the
clock, while also serving to actively process and deliver medications, control medication
inventories, and assess progress and outcomes of therapy as part of the ED team. The majority
of the studies reviewed implemented programs that provided service support for less than 24
hours, suggesting that our 24 hour program should result in further benefits relative to those
reported.
Assigning monetary value to the individual patient care contributions made by a healthcare
provider is challenging and represents a barrier in accurately determining the true fiscal impact
a pharmacist’s contributions may have on a service. Studies addressing the drug-related
morbidity costs and drug cost-avoidance are thus important in developing accurate estimations
of the dollar value of the ED pharmacist program. A model developed by Ling et al. combined
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study outcomes from both cost-avoidance and drug-related morbidity studies. Interventions
were stratified into 6 levels in an attempt to categorize the impact of each intervention. The
table below provides an example of the average cost savings of each type of intervention (3).
Unit type
Medical ICU
Surgical ICU
General Medical
General Surgical
Total avg.
Cost per
event
$3,369
$5,097
$2,738
$1,772
$2,595
Outcomes of ED Interventions by Pharmacists:
Adapted from Ling et al
Level
Cost Avoidance
Information inquiry
1a
(≤5 min)
Information inquiry
(>5 min i.e.
1b
oral/written
presentation)
Dosage adjustment,
formulary/restricted
2
medication, IV/PO
switch, therapeutic
duplication
Explanation
Category
Cost ($)
Verbal info
Drug info
26.17
Verbal info with presentation
and/or articles
Drug info
54.89
Drug cost avoidance
Drug cost
avoidance
30.35
3a
Additional
treatment
Medications, aerosolizations,
transfusions, oxygen
3b
Additional tests
Chemistry panels, CBCs, drug
concentrations etc.
3c
4a
4b
Noninvasive
procedure,
additional tests
Additional
treatment and
additional tests
Noninvasive
procedure,
additional
CT, angiography, ECG, Doppler,
EEG, ECHO, MRI, CXR, PFT etc. +
3b
3a+3b
3a + 3c
Avoidance of
additional
treatment
Avoidance of
additional
treatment
Avoidance of
additional
treatment
Avoidance of
additional
treatment
Avoidance of
additional
treatment
260.46
109.00
320.70
370.04
581.75
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4c
treatment, and
additional tests
Increased length of
stay or admission
from med. related
problem + 4b
Daily room rate + 4b
4d
Invasive procedure +
4c
Cath, MI perfusion studies, PTCA,
surgery, dialysis,
pericardiocentesis + 4c
5a
Transfer to ICU + 4c
ICU bed, art line, Swan-Ganz,
intubation, cardiac arrest + 4c
5b
5c
6
Transfer to ICU,
invasive procedure +
4c
Long term care
admission +
previous
Death
Invasive procedures + 5a
Self-explanatory
Self explanatory
Avoidance of
additional
treatment
Avoidance of
additional
treatment
Avoidance of
additional
treatment
Avoidance of
additional
treatment
Avoidance of
additional
treatment
Avoidance of
additional
treatment
3,562.79
6,437.13
6,592.03
9,466.36
11,837.5
1
100,000
Based on the model above and the cost avoidance data presented by Lada et al. (2) it can be
estimated that a pharmacist staffed ED that sees 8-9 acutely ill patients daily will realize savings
of $6,428 -$9,465 per 24 hour period relative to an ED that does not employ the service of a
clinical pharmacist. The presented range of savings was calculated by multiplying the lower and
higher average costs of an individual ADE ($400-500) by the average number of ADEs reported
daily +/- the standard deviation (17.5+/- 1.43). The value of an individual ADE was extrapolated
from the Ling et al. data. A conservative extrapolation of these numbers to our facility suggests
that a more moderate recovery of resources would likely offset the $620,000 invested into
salaries (including benefits) for 24 hour ED coverage by a pharmacist. For example, if both the
number of patients seen daily and the savings per intervention are reduced by 50%, a savings of
$586,500-863,800 is still attainable. This implies that it is beneficial from both a resource
investment and patient outcome perspective to implement such a program within the
Institution A facility.
III. Improved Patient Safety
The continuous improvement of patient care is of paramount importance, and with a majority
of patients visiting the ED receiving multiple medications, there is significant opportunity for
the introduction of medication errors into the system. We currently lack appropriate
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application of clinical pharmacy in the ED, with administered medications never being screened
for compatibility, patient allergies, drug interactions, or dosage. In its present state, the
Institution A system does not require medication orders to be placed for agents administered
by providers in the ED or in radiology. However, 2006 Joint Commission standards require a
review of all hospital orders. This ultimately means that providers in the ED and radiology will
be charged with placing orders for all medications administered. This change will also impact
the pharmacy service as the new workload associated with an increase in medication order
verification duties of the pharmacist will result in a compromise of current resources. Today’s
Pharmacist is uniquely equipped to serve as the expert in the therapeutic use of medications
while providing direct patient care. Without the proactive application of this expertise, it is not
possible to ensure optimal and safe drug therapy for our patients. Data shows that medications
are administered or prescribed in almost 80% of ED visits with three or more medications
administered or prescribed in about 30% of patient visits (9). At Institution A we estimate this
number to be approximately 40%. With such a high amount of medication usage associated
with ED encounters, numerous opportunities are available for medication errors to occur. Chin
and colleagues performed a prospective cohort study of 898 patients 65 years or older who
presented to an urban academic ED in 1995 and 1996. They reported that 3.6% of ED patients
were administered an inappropriate medication and 5.6% were prescribed an inappropriate
medication upon discharge from the ED. (10)
A study by Hafner et al. retrospectively reviewed 13,004 emergency department charts from
visits occurring between March 1 and May 31 of 1997. The researchers found 321 (2.5% of all
charts) total visits with suspected adverse drug events. Based on the Naranjo adverse drug
reaction probability scale, a method used to estimate the probability of adverse drug reactions,
217 visits (1.7% of all charts) had a score greater than 4 and were classified as probable ADEs.
Compared with the control population, the patients with ADEs were hospitalized more
frequently (OR 2.29; 95% CI 1.33 to 3.94 (11)). Although these studies looked at the overall
incidence of medication errors in their respective EDs, they did not address the potential
benefit gained through pharmacy involvement.
IV. Compliance with Joint Commission Mandates
A. EMERGENCY DEPARTMENT ORDER REVIEW
Joint Commission Medication Management (MM) Standard 4.10 (MM.4.10) requires that all
prescriptions or medication orders be reviewed prospectively for appropriateness by a
pharmacist. Our facility currently lacks a system for the review of orders placed in the ED and
in radiology, and we are thus failing to meet the minimum criteria for standard 4.10 (12). The
addition of an ED pharmacist would satisfy this standard and it would also serve to reduce the
likelihood of patient harm from occurring. In a recent case of medication mismanagement, a
patient who had presented to the ED with seizures was overdosed on phenytoin, a mistake
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made by a healthcare provider that has led to a criminal investigation of the involved parties
(13). With the reality of practitioners being held accountable for the outcomes of medication
errors, it is important that preventative measures be taken in order to protect the patients,
providers, and the healthcare system from the legal ramifications of medication misadventures.
A prospective verification system would act as a filter and quality assurance tool, preventing
medication mistakes such as the one just mentioned from occurring and is a compelling reason
to pursue the implementation of such a system. Prospective review ultimately requires
allocation of pharmacy staff to the emergency department to assure that the new goals do not
delay the administration of pharmaceutical care for all patients and especially to critical
patients whose outcomes are time dependent.
B. MEDICATION RECONCILIATION
2007 Joint Commission patient safety goals place an emphasis on medication safety, specifically
on medication reconciliation practices and safe medication use. Standard MM 3.20 requires
that medication reconciliation be completed at each point of transitional care and can be
completed by any qualified healthcare provider (12). At the Institution A approximately 90
patients on weekdays and 60 patients on weekends present to the ED, with 15-20% of
presenting patients being admitted to the facility. These 9-13 daily ED admissions reflect a
majority of our non-elective admissions to the facility. This places a significant burden on the
ED, as the ED staff is required to complete the initial medication reconciliation of all patient
visits and for patients being admitted. It is clear that the most effective point of reconciliation
is at the time of admission, and resources need be allocated for medication reconciliation
services in the ED. Studies assessing the effectiveness of the reconciliation process have
identified that pharmacists provide the highest level of effective reconciliation, reducing
medication omission errors and discrepancies upon admission and assuring that the patient
receives the appropriate medications at discharge. Scarsi et al from Northwestern Memorial
found that in the absence of pharmacist intervention, 22 percent of medication discrepancies
posed potential risk for patient harm during hospitalization, and 60 percent of the discrepancies
may have led to deleterious outcomes if continued beyond discharge (14). The most common
error was the complete omission of a medication that the patient reported taking prior to
hospitalization, as well as reports of a different dose, route or frequency of medication ordered.
Many of these medication discrepancies could be eliminated by the concomitant
implementation of a prospective medication review and an ED medication reconciliation
program, serving to significantly improve our current level of patient care.
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V. OIG /DEA Compliance, National/VISN Performance Goals and
other considerations
A. INVENTORY/FORMULARY MANAGEMENT AND SECURITY
Medication distribution within the ED is currently carried out through the use of the automated
dispensing cabinet (ADC) system, with inventory updates being completed weekly by
technicians from the pharmacy service. An audit of the actual versus expected medication
counts of floor stock items in the ED ADC system was conducted in March 2007. During this
audit, fifteen random medications were counted, recorded, and compared to the expected
inventory counts produced from the ADC report for the ED. The results showed inaccurate
counts for all agents, including refrigerated and controlled agents, as compared to the expected
inventory in the ADC log. It is unclear whether these agents were used in patient care, diverted,
disposed of or lost. The pharmacy technicians currently depend on the accuracy of the ADC
report to guide them in the restocking process. These discrepancies represent a danger to both
our patients and our healthcare system. An inaccurate count could potentially result in an
inability to deliver medications in a timely manner to critical patients if floor stocks are
unknowingly depleted, and our medical team and facility would be held accountable for
deleterious outcomes in such an instance. Moreover, failure to meet DEA and FDA
requirements associated with the physical storage, distribution, and documentation of the use
of dangerous drugs and controlled substances could result in actions being taken against our
facility.
Improvements in this system would benefit our organization by reducing the loss of inventory
resulting in more effective budget management and will assure both patient safety and security
within our system. The expansion of such management would be a component of the
described duties for the pharmacist staffing the ED.
B. PATIENT SATISFACTION
Improving the efficiency of patient care in the ED is important, and as patient wait times
increase we often lose the opportunity to serve our patients. In February 2007 there were 184
reports of patients waiting >6 hours to be seen by a provider, and 157 cases where the patient
left prior to being assessed. This does not account for the number of patients who fail to
receive the prescribed medications from the outpatient pharmacy due to an additional wait
beyond the time spent in the ED. The pharmacy wait is often in excess of 30 minutes on
weekdays and 2 hours on weekends, the latter being attributed to the fact that weekend ED
coverage is carried out by pharmacists staffing the ICU. These wait times have manifested in
complaints to patient services as well as verbally expressed dissatisfaction by the veterans of
our healthcare system. To address these wait times and thus improve patient care and
satisfaction, medication reconciliation, medication processing and medication dispensing duties
would be assigned to the pharmacist on staff in the ED. This will help to reduce time to provider
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0
contact and will expedite the processing and dispensing of prescribed agents. For patients
being admitted, this will also improve continuity of care within the pharmacy service, as
improved communication of ED management to medicine and ICU pharmacists can be
achieved.
C. TELEMETRY UNIT
The ED will soon be responsible for the management of a telemetry unit. This addition will
result in an increase in workload and the use of many drugs unfamiliar to the nursing staff,
warranting close monitoring and assessment of ordered agents by the healthcare team. The ED
pharmacist will serve to both assess and monitor the patients in this unit, working to ensure
safe medication use in this critical population of patients.
D. MEETING INSTITUTION A ESTABLISHED CRITERIA
Pharmacists staffing the ED will provide an additional resource for meeting goals that have
been established and implemented within the INSTITUTION A Healthcare System. Examples of
these goals include administration of antibiotics within 4 hours of arrival and obtaining blood
cultures prior to antibiotic administration in patients presenting with community acquired
pneumonia, appropriate and timely antibiotic utilization, management of prophylactic
antibiotic use, time to medication delivery in NSTEMI patients, and tobacco counseling in MI,
HF and CAP patients.
E. CODE BLUE COVERAGE
The ICU pharmacist is currently responsible for responding to code blue calls on all floors in the
hospital, including codes called on the first floor. The ED pharmacist’s responsibilities will
include responding to codes on the first floor. Hence, the addition of an ED pharmacist will
allow the ICU staff to focus on the acute issues in their own area, avoiding the potential
interruption of patient care in the ICU and DOU. This will also serve to improve the response
time to codes called on the lower floors of the hospital and will reduce time to administration
of critical medications supplied by the pharmacist.
VI. ACA Principles
Pharmacy Service conducts ongoing analysis of its staffing and potential for assuming new
responsibilities at Institution A. Currently our staffing in all the sections of pharmacy is highly
taxed due to growing workload. Over the past several years we have forestalled additional FTEE
for these workload increases by utilizing automation, improving operational efficiency, and
increasing the roles of students and residents in patient care areas. One example of such
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workload growth is the Ambulatory Care Pharmacy as demonstrated by the prescription
volume changes over the past 10 years. Nearly all of this has been accomplished without
additional FTEE to this section. Although we are happy with our successes thus far, we are
unable to take on such a huge additional program such as the ED pharmacist program without
additional FTEE.
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VII. Summary
Pharmacy Service believes that with an additional 4.6 Pharmacist FTEE we can attain a myriad
of successes in the areas of improved patient care and regulatory compliance. Because of the
demonstrated cost savings, the new cost to the facility will be, at most, approximately
$100,000, but we believe this program will most likely be a breakeven, or optimistically, a cost
savings proposition. These positions would represent a new commitment to our goal for the
highest quality of care for our veterans, while minimizing the financial impact on the Institution
A.
VIII. References
1) Lee AJ, Boro MS, Knapp KK, Meier JL, Korman NE. Clinical and economic outcomes of
pharmacist recommendations in a Veterans Affairs medical center. Am J Health Syst Pharm.
2002 Nov 1;59(21):2070-7.
2) Lada P, Delgado G Jr., Documentation of pharmacists' interventions in an emergency
department and associated cost avoidance. Am J Health Syst Pharm. 2007 Jan 1;64(1):638.
3) Ling JM, Mike LA, Rubin J, Abraham P, Howe A, Patka J, Vigliotti D. Documentation of
pharmacist interventions in the emergency department. Am J Health Syst Pharm. 2005 Sep
1;62(17):1793-7.
4) Levy DB. Documentation of clinical and cost-saving pharmacy interventions in the emergency
room. Hosp Pharm. 1993 Jul; 28(7):624-7, 630-4, 653.
5) Bates DW, Spell N, Cullen DJ et al. The costs of adverse drug events in hospitalized patients.
Adverse Drug Events Prevention Study Group. JAMA. 1997 Jan 2229;277(4):307-11.
6) Senst BL, Achusim LE, Genest RP et al. Practical approach to determining costs and frequency
of adverse drug events in a health care network. American Journal of Health-System Pharmacy.
2001 June; 58(12):1126-1132.
7) Beers MH, Storrie M, Lee G. Potential adverse drug interactions in the emergency room. An
issue in the quality of care. Ann Intern Med. 1990 Jan 1;112(1):61-4.
8) Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, Bates DW. Pharmacist
participation on physician rounds and adverse drug events in the intensive care unit. JAMA.
1999 Jul 21;282(3):267-70. Erratum: JAMA 2000 Mar 8;283(10):1293.
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9) McCaig, Linda F. "National Hospital Ambulatory Medical Care Survey: 2004 Emergency
Department Summary." Advanced Data from Vital and Health Statistics 372(2006):
http://www.cdc.gov/nchs/data/ad/ad372.pdf
10) Chin MH, Wang LC, Jin L et al. Appropriateness of medication selection for older persons in
an urban academic emergency department. Acad Emerg Med. 1999; 6:1232-42.
11) Hafner JW Jr, Belknap SM, Squillante MD, Bucheit KA. Adverse drug events in emergency
department patients. Ann Emerg Med. 2002 Mar;39(3):258-67.
12) http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_hap_
cah_npsgs.htm
13) Criminal Prosecution of human Error Will Likely Have Dangerous Long-term Consequences.
ISMP Medication Safety Alert. 2007 March; 12(5): 1-2.
14) Scarsi KK, Fotis MA, Noskin, GA. Pharmacist participation in medical rounds reduces
medication errors. AJHSP. 2002 Nov; 59(21):2089-2092.
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