Risk Factors Associated with the Requirement for Pharmaceutical Intervention in the Hospital Setting: A Systematic Review of the Literature

BACKGROUND A number of methods exist for the risk assessment of hospital inpatients to determine the likelihood of patients experiencing drug-related problems (DRPs), including manual review of a patient's medication (medication reviews) and more complex electronic assessment using decision support alerts in electronic prescribing systems. A systematic review was conducted to determine the evidence base for potential risks associated with adult hospital inpatients that could not only lead to medication-related issues but might also be directly associated with pharmacist intervention. OBJECTIVES The aims were to perform a systematic review of the literature in order to (1) identify all measurable risk factors associated with adult hospital inpatients that potentially lead to a pharmaceutical intervention; (2) critically evaluate the quality of the identified research; and (3) further subcategorise potential risk factors, so that pharmaceutical services may be targeted to patients "at risk" by identifying potential risk factors in a patient's electronic hospital record. METHODS A systematic review, conducted in June 2013, searched ten medical literature databases for all papers identifying risks leading to pharmacist interventions or DRPs, adverse drug events (ADEs), adverse drug reactions, drug errors (where not included in the definition of an ADE), and medication-related problems. The search identified 7720 titles, from which 120 papers were sourced. A hand search of a further 11 journals was also performed. No date restrictions were imposed. All primary research and literature reviews were included. Summary articles were excluded with the exception of literature reviews. The inclusion of search outputs was validated by a third party pharmacy research graduate. RESULTS From the 7720 titles, 38 publications met the inclusion criteria for the review. The ten most frequently reported risk factors associated with medication-related issues that may potentially lead to a hospital pharmaceutical intervention are as follows (ranked in descending order of frequency): prescription of certain drugs or classes of drugs, polypharmacy, elderly patients (defined as over 65 years), female gender, poor renal function, the presence of multiple comorbidities, length of patient stay, history of drug allergy or sensitivity, patient compliance issues, and poor liver function. The ten classes of drugs most frequently reported to be associated with medication-related issues leading to a hospital pharmaceutical intervention are as follows (ranked in descending order of frequency): intravenous antimicrobials, thrombolytics/anticoagulants, cardiovascular agents, central nervous system agents, corticosteroids, diuretics, chemotherapy, insulin/hypoglycaemics, opiates, and anti-epileptics. CONCLUSION Review of the literature identified 38 papers, from which the ten most frequently reported risk factors linked with factors that are potentially associated with hospital pharmaceutical interventions (all definitions included) were identified. No papers were identified that demonstrated a direct causal relationship between a potential risk factor and hospital pharmaceutical interventions. All of the potential risk factors associated with problems with the use of medicines can be identified from patient records on admission to hospital. These risk factors may be used to identify patients at risk, with a view to targeting pharmaceutical intervention in order to minimise risks of problems with medicines and improve efficiency of clinical pharmacy services.