Background: Pharmacist-led peri-discharge interventions reduce adverse drug events. However, evidence is lacking as to whether there is a business case to fund these non-billable interventions. To test whether such interventions could drive reductions in post-discharge health care utilization to help build a business case, we conducted a pragmatic randomized controlled trial (RCT). Methods: The PHARMacist [...]

Background: Medication errors are common, with more than half of patients estimated to have greater than or equal to one unintended medication discrepancy at hospital admission.  Medication reconciliation can identify errors. Although there has been significant investigation into the most effective logistical strategies for performing medicine reconciliation within the healthcare system, there is little investigation [...]

Background: Hospitalized patients receiving direct oral anticoagulants (DOACs) sometimes require bridging with unfractionated heparin (UFH). Monitoring UFH with anti-Xa assays has been shown to correlate with better outcomes. However, DOACs interfere with anti-Xa assays resulting in inappropriate UFH dose adjustments that can negatively impact patient care. In 2015, we deployed an electronic health record (EHR) [...]

Background: Up to 12% of hospitalized patients require high dose parenteral thiamine treatment to prevent Wernicke’s Encephalopathy, a devastating and easily preventable neurologic disorder that can lead to death. Despite the fact that it is as simple and relatively inexpensive therapy with no known side effects, high dose thiamine continues to be underutilized. Attempts to [...]

Background: Multiple safety reports were reviewed for missed doses of critical medications on admission to the inpatient rehabilitation units at a large academic medical center. It was found that providers were inconsistently or incorrectly using the admission medication reconciliation (AdmMedRec) functionality in EHR that could have prevented these errors.Many hospitals struggle with AdmMedRec due to [...]

Background: Adverse drug events are common during transitions of care and often due to patient misunderstanding of the medication regimen or non-adherence. Challenges exist that may influence the ability of new interventions to address this issue. As part of the Smart Pillbox study, a randomized controlled trial of an electronic pillbox, we explored barriers and [...]

Background: Immunosuppression regimens are highly effective at preventing rejection but carry risk of toxicity and can be complex. Clinical decision support (CDS) tools embedded in electronic health records have presented opportunity to systematically aid providers ordering such medications appropriately. However, discrepancy between a clinically-documented plan for use and provider orders may exist. Natural language processing [...]

Case Presentation: Pyroglutamic acid (5-oxoproline) is a rare cause of metabolic acidosis most often associated with sub-acute or chronic acetaminophen intake in the presence of unique risk factors. Discussion: A 25-year old female with Crohn’s disease presented with one month of worsening abdominal pain, diarrhea, and anorexia with reported 20 kg weight loss. She developed [...]

Background: Pharmacist-led peri-discharge interventions reduce adverse drug events. However, evidence is lacking as to whether there is a business case to fund these non-billable interventions. To test whether such interventions could drive reductions in post-discharge health care utilization to help build a business case, we conducted a pragmatic randomized controlled trial (RCT). Methods: The PHARMacist [...]