12 things pharmacists want hospitalists to know

From better communications to extra vigilance to high-risk decisions, veteran pharmacists outline areas for improvement.


It’s hard to rank anything in hospital medicine much higher than making sure patients receive the medications they need. When mistakes happen, the care is less than optimal, and, in the worst cases, there can be disastrous consequences. Yet, the pharmacy process – involving interplay between hospitalists and pharmacists – can sometimes be clunky and inefficient, even in the age of electronic health records (EHRs).

The Hospitalist surveyed a half-dozen experts, who touched on the need for extra vigilance, areas at high risk for miscues, ways to refine communications and, ultimately, how to improve the care of patients. The following are tips and helpful hints for front-line hospitalists caring for hospitalized patients.

1. Avoid assumptions and shortcuts when reviewing a patient’s home medication list.

“As the saying goes, ‘garbage in, garbage out.’ This applies to completing a comprehensive medication review for a patient at the time of admission to the hospital, to ensure the patient is started on the right medications,” said Lisa Kroon, PharmD, chair of the department of clinical pharmacy at the University of California, San Francisco.

Dr. Lisa Kroon

Dr. Lisa Kroon

Even though EHRs are becoming more connected, they don’t provide all the details. Just because a medication is on the medication list doesn’t mean patients are actually taking it. They also might be taking it differently than prescribed, Dr. Kroon said. Patients and caregivers should be asked what medications they’re actually taking, as well as the strength of the tablet, how many at a time and how often, and at what time of the day they are taking them.

The EHR “is often more of a record of which medications have been ordered by a provider at some point,” she notes.

Doug Humber, PharmD, clinical professor of pharmacy at the University of California, San Diego, said hospitalists should be sure to ask patients about over-the-counter drugs, herbals, and nutraceuticals.

Dr. Doug Humber

Dr. Doug Humber

“Some of those medications may interact with prescribed medication in the hospital,” he said. “The most complete data that we have on a patient’s medication list coming in clearly sets [us] up for success, in terms of making medication therapy safer for the patients while they’re here.”

Dr. Kroon encourages hospitalists to conduct a complete medication review, which helps determine what should be continued at discharge.

“Sometimes, not all medications a patient was taking at home need to be restarted, such as vitamins or supplements, so avoid just entering, ‘Restart all home meds,’ ” she said.

2. Pay close attention to adjustments based on liver and kidney function.

“A hospitalist may take a more hands-off approach and just make the assumption that their medications are dose-adjusted appropriately, and I think that might be a bad assumption. [Don’t assume] that things are just automatically going to be adjusted,” Dr. Humber said.

Dr. Jalloh Mohamed

Dr. Jalloh Mohamed

Mohamed Jalloh, PharmD, a pharmacist and a spokesman for the American Pharmacists Association, concurs. He said that most mistakes are related to “kidney [or] liver adjustments.”

That said, hospitalists also need to be cognizant of adjustments for reasons that aren’t kidney or liver related.

“It is well known that patients with renal and hepatic disease often require dosage adjustments for optimal therapeutic response, but patients with other characteristics and conditions also may require dosage adjustments due to variations in pharmacokinetics and pharmacodynamics,” said Erika Thomas, MBA, RPh,, a pharmacist and director of the Inpatient Care Practitioners section of the American Society of Health-System Pharmacists. “Patients who are obese, elderly, neonatal, pediatric, and those with other comorbidities also may require dosage adjustment.”

Drug-drug interactions might call for unique dosage adjustments, too, she adds.

3. Carefully choose drug-information sources.

Dr. Erika Thomas

Dr. Erika Thomas

Dr. Jalloh said that one of the roots of inappropriate dosing is simply “a lack of time and money to look at credible resources.” Free drug-information apps might not have the extensive information needed to make all the right decisions, such as adjustments for organ function, he said. More comprehensive apps are expensive, he admits, and sometimes even those apps contain gaps.

“Hospitalists can contact drug-information centers that answer complex clinical questions about drugs if they do not have the time to explore themselves,” he said.

Creighton University, Omaha, Neb., for example, has such a center that has been nationally recognized.

4. Carefully review patients’ medications when they transfer from different levels of care.

Certain medications are started in the ICU that may not need to be continued on the non-ICU floor or at discharge, said MacKenzie Clark, PharmD, program pharmacist at the University of California, San Francisco. One example is quetiapine, which is used in the ICU for delirium.

“Unfortunately, we are seeing patients erroneously continued on this [medication] on the floor. Some are even discharged on this [med],” Clark said, adding that a specific order set can be developed that has a 72-hour automatic stop date for all orders for quetiapine when used specifically for delirium.

“[The order set] can help reduce the chance that it be continued unnecessarily when a patient transfers out of the ICU,” she explains.

Another class of medication that is often initiated in the ICU is proton pump inhibitors for stress ulcer prophylaxis. Continuing these on the floor or at discharge, Clark said, should be carefully considered to avoid unnecessary use and potential adverse effects.

5. Seek opportunities to change from intravenous to oral medications – it could mean big savings.

Intravenous medications usually are more expensive than oral formulations. They also increase the risk of infection. Those are two good reasons to switch patients from IV to oral (PO) as early as possible.

“We find that physicians often don’t know how much drugs cost,” said Marilyn Stebbins, PharmD, vice chair of clinical innovation at University of California, San Francisco.

A common example, she said, is IV acetaminophen, the cost of which skyrocketed in 2014. Institutions can save significant dollars by limiting use of IV acetaminophen outside the perioperative area to patients unable to tolerate oral medications. For patients who are candidates for IV acetaminophen, consider setting an automatic expiration of the order at 24 hours.

Hospitalists can help reduce the drug budget by supporting IV-to-PO programs, in which pharmacists can automatically change an IV medication to PO formulation after verifying a patient is able to tolerate orals.

6. Consider a patient’s health insurance coverage when prescribing a drug at discharge.

“Don’t start the fancy drug that the patient can’t continue at home,” said Ian Jenkins, MD, SFHM, a hospitalist and health sciences clinical professor at the University of California, San Diego, and member of the UCSD pharmacy and therapeutics committee. “New anticoagulants are a great example. We run outpatient claims against their insurance before starting anything, as a policy to avoid this.”

7. Tell the pharmacist what you’re thinking.

Dr. Jenkins uses a case of sepsis as an example:

“If you make it clear that’s what’s happening, you can get a stat loading-dose infused and meet [The Joint Commission] goals for management and improve care, rather than just routine antibiotic starts,” he said.

Dr. Ian Jenkins

Dr. Ian Jenkins

Another example is anticoagulants:

“Why are you starting the anticoagulant? Recommendations could differ if it’s for acute PE (pulmonary embolism) versus just bridging, which pharmacists these days might catch as overtreatment,” he said. “Keep [the pharmacy] posted about upcoming changes, so they can do discharge planning and anticipate things like glucose management changes with steroid-dose fluctuations.”

8. Beware chronic medications that are not on the hospital formulary.

Your hospital likely has a formulary for chronic medications, such as ACE inhibitors, angiotensin receptor blockers, and statins, which might be different than what the patient was taking at home. So, changes might need to be made, Dr. Clark.

“Pharmacists can assist in this,” she said. “Often, a ‘therapeutic interchange program’ can be established whereby a pharmacist can automatically change the medication to a therapeutically equivalent one and ensure the appropriate dose conversion.”

At discharge, the reverse process is required.

“Be sure you are not discharging the patient on the hospital formulary drug [e.g., ramipril] ... when they already have lisinopril in their medicine cabinet at home,” Clark said. “This can lead to confusion by the patient about which medication to take and result in unintended duplicate drug therapy or worse. A patient may not take either medication because they aren’t sure just what to take.”

9. Don’t hesitate to rely on pharmacists’ expertise.

“To ensure that patients enter and leave the hospital on the right medications and [that they are] taken at the right dose and time, do not forget to enlist your pharmacists to provide support during care transitions,” Dr. Stebbins said.

Dr. Humber said pharmacists are “uniquely qualified” to be medication experts in a facility, and that “kind of experience and that type of expertise to the care of the hospitalized patient is paramount.”

Dr. Thomas said that pharmacists can save hospitalists time.

“Check with your pharmacist on available decision-support tools, available infusion devices, institutional medication-related protocols, and medications within a drug class.”Additionally, encourage pharmacists to join you for rounds, if they’re not already doing so. Dr. Humber also said hospitalists should consider more one-on-one communications, noting that it’s always better to chat “face to face than it is over the phone or with a text message. Things can certainly get misinterpreted.”

10. Consider asking a pharmacist for advice on how to administer complicated regimens.

“Drugs can be administered in a variety of ways, including nasogastric, sublingual, oral, rectal, IV infusion, epidural, intra-arterial, topical, extracorporeal, and intrathecal,” Dr. Thomas said. “Not all drug formulations can be administered by all routes for a variety of reasons. Pharmacists can assist in determining the safest and most effective route of administration for drug formulations.”

11. Not all patients need broad-spectrum antibiotics for a prolonged period of time.

According to the Centers for Disease Control and Prevention, 20%-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate, Dr. Kroon said.

“Specifying the dose, duration, and indication for all courses of antibiotics helps promote the appropriate use of antibiotics,” she noted.

Pharmacists play a large role in antibiotic dosing based on therapeutic levels, such as with vancomycin or on organ function, as with renal dose-adjustments; and in identifying drug-drug interactions that occur frequently with antibiotics, such as with the separation of quinolones from many supplements.

12. When ordering medications, a complete and legible signature is required.

With new computerized physician order entry ordering, it seems intuitive that what a physician orders is what they want, Dr. Kroon said. But, if medication orders are not completely clear, errors can arise at steps in the medication management process, such as when a pharmacist verifies and approves the medication order or at medication administration by a nurse. To avoid errors, she suggests that every medication order have the drug name, dose, route, and frequency. She also suggested that all “PRN” – as needed – orders need an indication and additional specificity if there are multiple medications.

For pain medications, an example might be: “Tylenol 1,000 mg PO q8h prn mild pain; Norco 5-325mg, 1 tab PO q4h prn moderate pain; oxycodone 5mg PO q4h prn severe pain.” This, Dr. Kroon explains, allows nurses to know when a specific medication should be administered to a patient. “Writing complete orders alleviates unnecessary paging to the ordering providers and ensures the timely administration of medications to patients,” she said.

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