Pharmacist's Role in Improving Medication Safety for Patients in an Allogeneic Hematopoietic Cell Transplant Ambulatory Clinic.

BACKGROUND Patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT), supported by complex drug regimens, are vulnerable to drug therapy problems (DTPs) at interfaces of care after discharge from hospital and may benefit from timely pharmacy interventions and education. OBJECTIVE To determine the effect on medication safety of, as well as potential barriers to, incorporating a pharmacist in the multidisciplinary team of an allo-HCT clinic. METHODS Two pharmacists rotated to attend the allo-HCT clinic of a tertiary care, university-affiliated cancer centre between January and June 2010 (coverage for 1 of 3 clinic days per week). For every patient who was seen by a pharmacist, all discharge medications were reconciled from the inpatient ward to the clinic. The pharmacists' primary task was to perform medication reconciliation and to identify and resolve DTPs. The pharmacists also provided medication education to patients and pharmacy consultations to clinic staff. Working with the outpatient pharmacy, the pharmacists helped to clarify prescriptions and drug coverage issues. Medication discrepancies identified and interventions performed by the pharmacists were recorded and were later graded for clinical significance by a panel of clinicians. Patient and staff satisfaction surveys were conducted at random during the study period. Barriers to the flow of patient care and other operational issues were documented. RESULTS The 2 pharmacists saw a total of 35 patients over 100 visits. They identified a total of 50 medication discrepancies involving 17 (49%) of the patients and 70 DTPs involving 23 (66%) of the patients. Thirty-one of the 70 DTPs resulted directly from a medication discrepancy. Twenty (95%) of the 21 unintentional medication discrepancies and 7 (70%) of the 10 undocumented intentional medication discrepancies were graded as clinically significant or moderately significant. Satisfaction surveys completed by patients and clinic staff yielded positive responses supporting pharmacists' participation. CONCLUSIONS Pharmacists working as part of the multidisciplinary team identified and resolved medication discrepancies, thereby improving medication safety at the allo-HCT clinic.