Adverse events: past and future

Neil Johnson; Myrella T. Roy

doi:10.1503/cmaj.1040721

Published evidence abounds on the role of hospital pharmacists in preventing adverse drug events and improving patient outcomes within hospitals.1^,2^,3 However, as the study by Alan Forster and colleagues4 demonstrates, many of the adverse medication-related events that patients experience occur outside the practice setting of hospital pharmacists.

The Canadian Society of Hospital Pharmacists promotes more seamless approaches to patient care and enhanced sharing of clinical information among hospital and community physicians and pharmacists. Use of a comprehensive electronic health record across multiple care jurisdictions can improve information flow and appropriate prescribing and monitoring of medications. Furthermore, many hospital pharmacists and physicians have implemented discharge prescription and communication tools (known variously as prescription/discharge notes form, discharge prescription form, pharmacy discharge letter and pharmacy discharge summary5^,6^,7) to enhance transfer of patient information to their primary care colleagues.

We hope that the evidence of the positive impact of hospital pharmacists1^,2^,3 will prompt implementation of similar models of interdisciplinary care in the broader health care community to improve patient outcomes and enhance the safety of our system.

Neil Johnson President Myrella T. Roy Executive Director Canadian Society of Hospital Pharmacists Ottawa, Ont.

Footnotes

Competing interests: None declared.

References

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Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285(16):2114-20.
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Forster AJ, Asmis TR, Clark HD, Al Saied G, Code CC, Caughey SC, et al. Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. CMAJ 2004;170(8):1235-40.
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Zwicker LA, MacKinnon NJ. Documentation requirements for seamless care. MacKinnon NJ, editor. In: Seamless care: a pharmacist's guide to continuous care programs. Ottawa: Canadian Pharmacists Association; 2003. p. 73-86.
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