Delivery of Pharmaceutical Care at Tertiary Level: From Admission to Home Care

Abstract

Pharmaceutical care is a patient-centred practice that strives to optimise patients ‘outcomes. In tertiary institutions, pharmaceutical care plays an important role in managing complex medical conditions and ensuring medication safety. Patients who attend tertiary care institutions are admitted for various reasons, and some of the conditions that warrant admissions are medication related. Patients, especially geriatrics may experience adverse reactions and drug interactions issues due to the multiple drugs that they consume. Some patients may have adherence issues that can lead to the worsening of their medical conditions. These pharmaceutical issues can be uncovered during their stay as inpatients through a thorough medication review. Pharmacists can play a role in providing knowledge and educating patients to overcome their medication-related problems. Monitoring of these problems can be undertaken through home visits by conducting home medication reviews, and other behavioural aspects of patient care, such as self-care, can be discovered.

1. Introduction

1.1 Definition

The concept of pharmaceutical care (PC) emerged in the early 90’s and has since evolved to become a recognised aspect of pharmacy practice. The philosophy of pharmaceutical care was introduced by Hepler and Strand in 1990 [1] and has been an important concept in every field of pharmacy practice in which patients are the focus. They have defined PC as ‘the responsible provision of medical therapy for the purpose of achieving definite outcomes’. The process of pharmaceutical care involves pharmacists working with other healthcare professionals to develop, implement and monitor a therapeutic plan designed to produce specific therapeutic outcomes. These functions are carried out through a comprehensive assessment of the patient’s health and drug history, devising, implementing appropriate plans of care, monitoring and evaluating the efficacy and safety of drug therapy.

The American Society of Hospital Pharmacists (ASHP), United States (US) is of the opinion that PC represents a valuable new concept representing growth in the profession beyond clinical pharmacy as often practiced. It also goes beyond pharmacists’ activities, including medication preparation and dispensing. In 1992, ASHP came out with a new definition of PC, which is an adaptation of the definition developed by Hepler and Strand. ASHP defined pharmaceutical care as ‘the direct responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life’ [2]. The principal elements of PC by this definition are not only medication therapy but also decisions not to use medication therapy. The outcomes sought from PC are cure of a patient’s disease, eradication, reduction in patients’ symptoms, arresting or slowing of a patient’s disease progression and prevention of a disease or symptoms.

The interest in the philosophy of PC is not only confined to the US where it was founded but also spread globally. While ASHP further elucidated the meaning of PC, the board of the Pharmaceutical Care Network Europe (PCNE) saw the need to redefine PC in 2013 for the purpose of having a single and certain definition in Europe. The redefinition reads ‘pharmaceutical care is the pharmacist’s contribution to the care of individuals in order to optimise medicines use and improve health outcomes’ [3].

1.2 Pharmaceutical care at tertiary level care

PC is delivered through clinical pharmacy practice at primary, secondary and tertiary levels of care. With the ASHP PC definition that includes all medication-related problems, the practice has expanded, especially when it involves patients who are hospitalised. Pharmacists at tertiary care institutions incorporate pharmaceutical care through practices that include medication history-taking, drug regimen review and monitoring and reconciliation of medications.

Patients admitted at tertiary care centres are more critical due to the presence of co-morbidities and more drug-related problems that need urgent interventions. Studies have shown that there is a high prevalence of DRPs among patients who visited the emergency department or are admitted. An average of 1.25 (+1.23) drug-related problems (DRPs) per prescription was observed in chronic kidney disease patients. The most common DRP was adverse drug reactions [4]. Patients (N = 109) admitted to the emergency department observed for a period of 6 months were identified with various DRPs of which 69.7% was due to ADR, 27.5% non-adherence, followed by subtherapeutic doses, untreated indication and overdosage (0.91%) [5]. Pharmacists in tertiary care institutions work as part of a multidisciplinary healthcare team to provide pharmaceutical care services. They also ensure that the interventions are tailored to the unique needs of the patient and ensure treatment effectiveness and patient safety. Thus, the purpose of PC is to ensure that DRPs are discovered and recognised by pharmacists, so patients receive the right care for them to achieve definite outcomes and quality of life.

2. Medication review

2.1 Introduction

Medication review processes are changing in several countries as a result of pharmacists’ increased involvement in drug history taking, medication reconciliation and medication review in their day-to-day work [6]. A medication review can be done independently or in tandem with other interventions such as medication reconciliation or personnel education. Although the clinical advantages of medication reviews, such as lowering hospital stay and mortality, have not always been demonstrated, medication management and multidisciplinary approaches have proven to be successful methods for reducing drug-related iatrogenic risks, inappropriate medication use and drug spending for elderly recipients [7].

An ageing population necessitates more medications and has a higher prevalence of multiple medical conditions. Age-related polypharmacy, which is the continuous use of five or more different medicines [8], is becoming more prevalent. There is ample proof that polypharmacy contributes to more problems with medication safety and a higher risk of adverse drug events (ADEs). The risk of drug interactions, drug toxicity, falls, delirium and non-adherence [9], as well as the possibility of readmission and mortality, have all been linked to polypharmacy [10]. The value of medication reviews by pharmacists for patients in community settings is becoming increasingly recognised through research [11]. The World Health Organisation (WHO) suggests giving patients who are taking numerous medications a medication review to lessen the risk of polypharmacy [12]. Medication reviews may lower the likelihood of polypharmacy, also known as the use of multiple medications, improper drug usage and medication costs in patients [13]. When a healthcare provider meets a patient and decides to prescribe or stop medication after going through an extensive and planned process that is supported by the patient’s records, the process is known as a medication review [14]. The plan for discontinuing inappropriate therapy and achieving medication optimisation, therefore, incorporates a medication review [15].

It has been demonstrated that implementing a medication review effort, which allows identifying many underlying risk factors and coordinating explicit measures to lessen the effects of each can lower the incidence of inpatient falls by 20–30% [12]. Falls are a common and increasing concern to older people’s both immediate and long-term health and functional independence [16]. In addition, falls are the most reported safety occurrence among adult inpatients [17]. A physical injury occurs in 30–50% of falls, and fractures happen in 1–3% of cases. Establishing effective fall prevention strategies, such as appropriate multifactorial interventions, is crucial due to the burden associated with fall injuries from both an individual and a societal standpoint. A medication review with the goal of carefully deprescribing certain medications is an essential component of a multifaceted approach to preventing falls [18].

2.2 Process

The requirement for criteria for competency has become clear as pharmacists’ adoption of medication reviews has increased [19]. The criteria were developed based on Clyne et al.’s suggestion of three degrees of review comprehensiveness: prescription review, medication review and comprehensive medication review (CMR) [20].

The common medicine dispensing procedure includes an immediate review of the medication list known as a prescription for the medication. Whenever technical and therapeutic issues with the medication list may be resolved based on the information provided in the prescriptions, such as dosage and indication, they are considered in the prescription review.

Medication reviews, which evaluate the appropriateness of a prescription and identify and address therapeutically important medication-related issues, can be observed as a different service offered to the patient. It is advised that the medication review be carried out in a multidisciplinary setting along with the patient being informed of the drug of choice findings and adjustments. Checking proper medication use, adherence and self-management forms a component of medication review.

Compared to a medication review, a comprehensive medication review (CMR) is a more comprehensive assessment. Collaboration with the attending physician and other members of the care team will be utilised to address any clinically significant issues relating to the medication or medical condition. The patient is informed of significant medication observations and modifications. CMR involves ensuring that every medication is appropriate for consumption while considering the patient’s illness and overall health. Upon CMRs, pharmacists collaborated with doctors and patients to manage medical conditions through patient education and motivational interviewing, medication adjustments and care coordination [21].

2.3 Importance

A medication review in combination with medication reconciliation, patient and professional education and transitional care is linked to a reduced chance of readmissions to the hospital [22]. Hospitalisations can have a negative impact on older patients’ prognosis. Older patients are vulnerable to problems such as delirium, falls, functional degeneration, and future confinement or readmission following hospitalisation [23]. Readmissions due to medication are common, especially in elderly patients. Optimising medication appropriateness may lower medication-related issues and the frequency of hospital readmissions.

Medication reviews performed by clinical pharmacists’ aid in the identification and prevention of medication errors and have been demonstrated to improve patient safety and reduce the risk of medication errors by up to 50% [24]. The annual incidence of preventable adverse drug events (ADEs) caused by medication errors in hospitalised patients is estimated to be 400,000 occurrences or approximately one medication error per patient each hospital day [25]. During all transitions of the hospital stay (admission, transfer of care, and discharge), the medication review process is described as verifying medication use, discovering discrepancies and resolving any medication-related difficulties [26].

Medication review by a clinical pharmacist can help older individuals with polypharmacy use their medications more effectively, especially when combined with cognitive functioning and depression screening [27]. Polypharmacy in the elderly commonly leads to medication therapy issues such as interactions, drug toxicity, falls with injury, delirium and non-adherence [9].

3. Medication reconciliation

3.1 Introduction

The report ‘To Err Is Human’ by the Institute of Medicine has highlighted medical errors as a substantial cause of patient harm [28]. The statistics on medical errors consistently present startling figures and are often alarming. A recent WHO report and Cochrane review indicate that during hospitalisation, specifically at the transition of care, a significant proportion of patients (ranging from 25 to 80%) encountered at least one medication discrepancy or experienced a failure to communicate changes in their medication regimen [29, 30]. In the context of the delivery of pharmaceutical care at the tertiary level, medication reconciliation is a pivotal measure that should be undertaken to ensure medication safety in the inpatient setting. Recently, the original concept of medication reconciliation has transformed resulting in the establishment of a patient-centred system that supports optimal medication management [31].

Medication reconciliation is a formalised and standardised process that entails cross-referencing the medications presently consumed by a patient with any newly prescribed medications at transitions of care such as admission, discharge or transfer with standard health care [32]. The primary objective of medication reconciliation is to identify and rectify any inadvertent discrepancies, omissions or duplications in medication orders, thereby fostering safe and accurate management of medications for the patient’s well-being according to the standards of medication frequency, route, dose, combination and therapeutic purpose [33].

3.2 Process

Multiple initiatives are being implemented during patient care transitions to promote medication. Extensive measures have been adopted across all healthcare providers and several international patient safety organisations to guarantee the precise and consistent transfer of medication information for patients throughout the transition of care.

Medication reconciliation plays a vital role as a key service during care transitions and has been proven with remarkable effectiveness in mitigating potential medication error risks. National Institute for Health and Care Excellence (NICE) guidelines recommended medication reconciliation to be performed within 24 hours or earlier if deemed medically necessary within the transition of care [34].

In general, medicines reconciliation comprises three primary steps (Figure 1) [29].

Figure 1.

Medication reconciliation process.

3.2.1 Creating the best possible medication history (BPMH)

At each juncture of care transitions, the identification of a patient’s pre-transition medication regimen is paramount. BPMH is a comprehensive list of the current medications that a healthcare provider obtains from various sources of information prior to the care transition to capture essential medication information [31].

To gain this information, a systematic process is employed, ensuring that no critical information is overlooked. This process involves tapping into primary sources for obtaining an accurate medication history. The main sources for obtaining a medication history may include engaging in open and effective communication with the patient or their relatives. By accessing the electronic medical record (EMR) system within the institution, a wealth of up-to-date patient data, including medication profiles may also be obtained ensuring the completeness and accuracy of the BPMH. In addition, the medication profile provided by a third party can also serve as a valuable resource in the creation of BPMH [35].

By utilising these diverse sources of information, healthcare providers can piece together a comprehensive and accurate BPMH. This facilitates the seamless transition of medication information, promotes patient safety and optimises the quality of care provided during the care transition process. This step emphasises the significance of gathering accurate and up-to-date information regarding a patient’s medication history to inform the subsequent medical decision-making process [36].

3.2.2 Comparing the BPMH with medicines prescribed on admission, at in-patient transfer or patient discharge and identifying discrepancies

During this crucial step, a comprehensive assessment is conducted for both prescribed and non-prescribed medications. Within the clinical context, two primary models, the proactive and retroactive models or a combination thereof can facilitate the medication reconciliation process [37].

In the proactive model, BPMH is established prior to formulating admission medication orders. By obtaining a comprehensive understanding of the patient’s current medication regimen, potential drug interactions, allergies and other pertinent factors, healthcare providers can proactively address any discrepancies or potential risks to patient safety [38].

On the other hand, the retroactive model involves generating admission orders before creating the BPMH. Challenges in completing a BPMH due to delays in receiving the initial medication history from the prescriber in the retroactive model of medication reconciliation were particularly prominent in the critical care setting. Possible reasons for these delays included the challenges of approaching families during high-acuity situations and the lower priority given by physicians to medication reconciliation when engaged in acute patient care [39]. While this approach differs in sequence, it still necessitates a thorough reconciliation between the BPMH and the admission orders. This reconciliation step serves as a critical mechanism for identifying any disparities, inconsistencies or omissions that may exist between the documented medication history and the prescribed medications.

Regardless of any model employed, the reconciliation process bridged between the BPMH and the admission orders to ease the identification and rectification of any discrepancies. By comparing the patient’s medication history with the prescribed medications, healthcare providers, such as pharmacists, can pinpoint potential issues such as drug interactions, duplicate therapies, incorrect dosages or the omission of crucial medications [40].

3.2.3 Reconciling discrepancies by classifying them as intentional or unintentional and by taking the appropriate action and documenting intervention

Once the discrepancies have been identified, they undergo a comprehensive and thorough analysis within the clinical context to ensure a detailed understanding of their nature and implications. This analysis allows for further classification of the discrepancies into two distinct categories: intentional and unintentional [41]. Intentional discrepancies arise from conscious decisions made by either the patient or the healthcare provider such as intentional adjustments to the medication regimen based on specific considerations. In contrast, unintentional discrepancies encompass instances where changes in the medication history occur without a conscious decision being made. These can manifest as both omission errors, where a medication is unintentionally left out or not properly documented and commission errors, where a medication is unintentionally added or administered incorrectly. Paediatric patients are a highly vulnerable population identified with unintentional discrepancies during the transition of care [42].

4. Home medication review

4.1 Introduction

4.1.1 Importance of medication management at home

Many patients are hospitalised for chronic conditions such as hypertension, diabetes, asthma, arthritis and cardiovascular diseases, especially geriatrics. As a result, they are given multiple types of medications and polypharmacy is common. There are various drug-related problems (DRPs) that can arise because of polypharmacy such as drug-drug interactions, adverse drug reactions (ADRs), medication errors and drug-food interactions, which may have a detrimental effect on medication adherence [43]. Patients may also forget to take their medications, alter the dose or frequency of their medications or discontinue their medications. Thus, inappropriate medication use among patients is a major health concern, especially among vulnerable patients such as geriatrics [44] and psychiatric patients [45]. ADRs are DRPs that are a major burden to patients, as shown by the fact it is the highest DRP found at admission [4, 5]. Therefore, to address these DRPs at home, home medication review (HMR) was first initiated in Australia [46] and followed by many other countries [45].

4.1.2 Purpose and scope of home medication review

The purpose of HMR is to assist in identifying, addressing medication-related problems and optimising medication regimens. An accredited pharmacist will conduct the medication review to help people to better understand how to manage their medicines and minimise adverse drug events [47].

4.2 Understanding home medicines review

4.2.1 Definition and objectives

HMR is a process designed to ensure that patients take their medicines correctly at home so that medications are used safely and effectively [48]. The term home medication review is also used interchangeably and has the same definition and process as HMR.

4.2.2 Healthcare professionals’ roles

An HMR is intended for the patient’s to gain maximum benefit from their medication regimen and prevent medication-related problems through a team approach. This is achieved by conducting a home visit by the healthcare professional team consisting of doctors, nurses and pharmacists and involving the carers.

HMR involves the pharmacist responsibility to assess the patient’s adherence to their medications, identify any issues related to the patient’s medication regimen and empower the patient and caregiver’s knowledge of their disease. They also make recommendations on patients’ treatment plans to the responsible health practitioner. This helps to increase the quality use of medicines and decrease adverse events.

Applying HMR to discharged patients is a vital tool to ensure that patients receive proper care and management of their medications during the transition of care. The continuum of quality use of medicines between hospitals and the community needs to be maintained [49]. In the formal process of continuity of care between the hospital and the community, a liaison pharmacist will organise an appointment post-discharge. He/she will contact the community pharmacist to engage an accredited pharmacist to carry out the HMR, as well as to arrange for the report to be sent to the general practitioner and the community pharmacist.

HMR applies to many types of conditions. The three most common types of HMR are HMR Neurology/Stroke, HMR Psychiatry and HMR Geriatrics. However, patients with other chronic conditions may also require the HMR service depending on the assessments made on them.

4.3 The HMR process

An accredited pharmacist HMR clinical process is categorised into three stages: [50].

Stage 1: Information gathering and review.

The HMR process begins with a referral from the doctor (hospital, GP or CP). The initial assessment will include the reason for referral and the patient’s medical and medication history. The pharmacist will conduct a thorough review of the patient’s medication including prescription, over-the-counter and complementary medicine.

Stage 2: Pharmacist consultation.

The pharmacist will conduct a face-to-face consultation with the patient and his/her carer. The medications will be carefully reviewed to identify any potential issues such as drug interactions, duplications, incorrect dosages or medications that are no longer necessary. The pharmacist will assess the person’s understanding of their medications, including how and when to take them, any potential side effects and the purpose of each medication.

Stage 3: HMR documentation.

This is the stage whereby the accredited pharmacist collates, generates, prepares the findings and recommends interventions. The complete report will be given to the referring doctor for his consideration to optimise prescribing, enhance patient management and optimise patient’s health.

4.4 Benefits and outcomes

The value of HMR has been shown by two studies related to older adults and underserved groups. Frail and homebound community-dwelling geriatrics were observed to be using a high number of medications and experiencing a significant number of DRPs. Recommendations to optimise medication therapy by community pharmacists can be effectively done by HMR [51]. Likewise, underserved communities in Taiwan had many issues with medications, but with pharmacists’ home visits, their knowledge of diseases improved and drug-related problems were mitigated, while drug compliance and drug storage methods were improved resulting in less drug wastage [52].

The program managing your blood pressure was implemented in a cohort of geriatric African Americans with hypertension to reduce health disparities in blood pressure control. The percentage of patients with controlled BP increased from 46.7% to 49.5%. All other parameters, including knowledge of hypertension, medication adherence and self-monitoring of BP improved significantly from baseline to post-intervention [53]. The positive effect of HMR on psychiatric patients was shown by a study in which the impact of a hospital pharmacist-led home medication review programme on 133 patients with schizophrenia. The patients showed significant improvement in medication adherence, knowledge of antipsychotic drugs and quality of life on social and family components [45].

A retrospective review of HMR cases was performed on 224 community-dwelling older people (65 years or older). Most of the pharmacists’ recommended actions during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging as the DRPs identified were 98%. In this vulnerable population, a pharmacist with appropriate training and access to the patient’s medical record can assist with improving the quality of medication use [54].

HMR has become an accepted service in many countries as pharmacist-led medicines review has been shown to improve health outcomes [45, 52, 53]. However, there are limited studies that have investigated the cost-effectiveness of HMR by accredited pharmacists. Rosli et al. evaluated the cost-effectiveness of home medication review by community pharmacists and found that it is a cost-effective option that significantly reduced HbA1c levels among T2DM patients, although it was associated with higher mean total costs per participant [55]. This suggests that home medication review programs such as HMR-CP could minimise patients’ health-related costs and burdens, thereby enhancing the quality of life and well-being. More economic analyses and cost-effectiveness studies are needed to find evidence of the economic benefits of HMR.

5. Medication-related problems (MRP)

5.1 Introduction

The pharmaceutical profession has evolved beyond traditional roles such as drug formulation and dispensing into a highly regulated profession focused on individualised and direct patient care [56]. Medication-related problems (MRP) are a common but preventable problem in healthcare. It is defined as ‘an event or circumstance related to drug therapy that actually or potentially interferes with desired health outcomes’ [57]. A medication-related problem (MRP) is a suboptimal situation in which a particular treatment regimen is likely to produce or contribute to an undesirable outcome [58].

In our daily lives, various populations simply or implicitly rely on medications to prevent and treat infections and lifelong MRPs occur in any period of drug use. They can appear after as short as an hour of medication consumption [59]. The World Health Organisation (WHO) estimates that more than half of all medicines are prescribed, dispensed or sold improperly, and more than one-half of patients do not take them correctly [60]. Previous study stipulates that pharmacists help improve drug therapy and optimise outcomes by recognising, avoiding and resolving MRPs [61]. Hospitalisations, unnecessary clinic visits and prolonged care can be caused by unresolved or latent MRPs, which not only impede clinical treatment but also increases the financial burden for patients [62]. Often, MRPs can be related to an error in drug treatment (medication error), or they can be caused by a medication side effect (adverse drug reaction) [63]. Factors such as mismanagement, population growth, poor health systems and lack of primary health care research and evaluation have limited the development of primary health care [64].

Early intervention and containment of MRPs can significantly reduce physician visits, emergency room visits, hospitalisations and healthcare costs while improving overall patient health and quality of life [65].

5.2 Medication history assessment

Upon admission to the hospital, a medication history assessment is performed to obtain and document a complete list of the patient’s medication history. This includes prescription and over-the-counter medicines, dietary supplements and traditional medicines [66]. Drug histories are often incomplete, drug strengths, frequency, dosages and forms are missing, and complementary or over-the-counter (OTC) medications are often taken out. Previous studies have shown that 10–67% of drug histories contain at least one error [67]. Incorrect medication history can lead to treatment interruptions, reintroduction of discontinued medications, inappropriate treatment and undetected drug-related problems. The continuation of these errors upon discharge can lead to adverse events due to duplication of treatment, drug interactions and discontinuation of an essential medication [68]. Additional information, such as treatment adherence and past allergy or anaphylaxis and adverse reactions, should be recorded and compared to the patient’s previous medical or hospital admission records [69].

A previous study in Malaysia found that 990 treatment discrepancies were identified in 390 patients recruited from three general medicine departments at Sarawak General Hospital. Of these, 135 (13.6%) medical errors were identified in 93 (23.8%) patients (1.45 errors per patient), most of which were due to medication omissions (79%) [70]. Similarly, it was found that the majority (83%) of 168 patients admitted to two gastrointestinal surgery wards and one geriatric ward at St. Olav’s University Hospital in Trondheim and two general internal medicine wards at Ålesund Hospital, Norway for a period of 3 months had at least one drug discrepancy in their medical history. Drug omissions accounted for 72% of the discrepancies, while dose differences accounted for the remaining 28%. A total of 9% of the disparity could have caused serious damage or inconvenience [71].

5.3 Prescribing medicines

When there is a change in care, errors in a patient’s treatment plan can occur, particularly during a hospital stay, a transfer from an emergency room to another department or intensive care unit (ICU), a transfer from an ICU or from an operating room to a ward and a transfer from the hospital to home or to another facility, such as a nursing home [68]. Previous studies found that 30%–70% were unintentional discrepancies between the medications patients were taking before admission and their prescriptions at admission [72]. In a recent study, 26.6% of these discrepancies were due to insufficient or incorrect information on primary care medication lists, including primary care referrals and medication printouts [73].

The lack of a drug with a valid indication is the most common unintentional discrepancy, and about half of these errors can go unnoticed before impacting the patient [74]. Discrepancies during discharge often arise when prescriptions are being made and discharge notes are drawn up. An Australian study found that 15% of medications that should have been continued were omitted from the discharge prescription [75]. Another study found that 12% of patients made one or more errors in the prescriptions, including accidental omissions and discontinuation of subsequent medications [76]. Patients who forgot one or more medications on their discharge report are 2.31 times more likely than usual to be hospitalised [77].

MRPs are very common in the prescribing phase, especially in the emergency department (ED) [78]. It is estimated that at least 3% of all hospital-related adverse drug reactions occur in ED as it is among the most sought department, which offers a 24-hour medical care service [79]. A previous study conducted in the ED of a United States (US) tertiary hospital found that nearly 54% of MRPs occurred during the prescribing phase [80]. Another study conducted at a tertiary hospital in India found that MRPs are present in 16.2% of ED prescriptions [81].

A review has found that incorrect dosage, frequency and strength were the most common prescribing errors [82]. A previous systematic review of 50 published studies, mainly from Iran, Saudi Arabia, Egypt and Jordan, found that the most common factors contributing to the prescribing errors in these studies were lack of knowledge, understaffing and heavy workload [83].

Previous studies have documented the rates of prescribing errors in Australia’s various acute care settings whereby insights into prescription error rates were explained when different prescribing systems (traditional and electronic) are used [84, 85, 86]. Taken together, these studies found that prescribing errors were more prominent in traditional or paper-based systems in hospitals, there were roughly about five errors per patient. Nonetheless, these mainly involve errors in the documentation such as unclear handwriting or prescriptions, missing signatures and missing routes of administration [87]. A slightly lower error rate was reported when using the standardised medical record. Some studies also found that the overall rate of typos with electronic writing systems is half of the traditional system, with about two per admission [86, 87].

5.4 Medication administration

In a previous review that looked into drug safety in critical care, it was found that medication errors varied depending on the type of system used. After excluding timing errors, they found that the rate of administration errors such as removal of therapy and incorrect dosing ranged from 5 to 8% when individualised patient delivery systems were used, and from 15to 18% when ward stock systems were in charge [88].

It was found that approximately 9% of drug administrations were associated with clinical errors (excluding timing errors) at two main teaching hospitals in New South Wales, Australia. This study also examined how the error rate changed with intrusions and disturbances during drug administration where at each occurrence, the probability of procedural and clinical errors increased by 12% and 13%, respectively [89].

Meanwhile, in an observational study involving intravenous (IV) drug administration, incorrect infusion rates accounted for 95 of the 101 major errors and bolus administration was more likely to be associated with more serious errors (23% vs. 10.6% for other IV routes). Infusion pump error rates were similar to other methods [90].

6. Self-care

6.1 Introduction

6.1.1 What is self-care?

The WHO has defined self-care as ‘the ability of individuals, families and communities to promote health, prevent disease, maintain health and cope with illness and disability with or without the support of a healthcare provider’ [91].

The practice of self-care empowers people to take charge of their health and well-being, giving them the incentive to live a healthier and happier life. It is key to preventing certain conditions and improving recovery times when total prevention fails. In every stage of life, it is an essential part of well-being [92].

Self-care involved: [92].

1. Making healthy lifestyle choices such as eating healthy food, exercising and work-life balance.

2. Avoiding unhealthy lifestyle habits such as smoking, vaping and drinking alcohol.

3. Making responsible use of prescription and non-prescription items. This includes avoiding abusing addictive substances.

4. Self-recognition of symptoms and assessing and addressing symptoms in collaboration with healthcare providers, when necessary.

5. Self-monitoring of own conditions to check for signs of deterioration or improvement and knowing when to get professional help.

6. Self-managing symptoms of disease, either alone, with carers or in partnership with healthcare professionals.

6.1.2 Importance of self-care

The importance of self-care lies in the empowerment of people to take control of their health and well-being and to improve their quality of life for the better [92]. Self-care can help certain conditions and improve recovery times when total prevention does not work. In all stages of life, it is an integral part of well-being. As people’s life expectancy continues to rise globally, there has been a proportional increase in the number of individuals living with chronic conditions [93]. This circumstance has prompted individuals to autonomously manage and seamlessly incorporate their health conditions into their daily routine [94]. To be able to manage this situation well, healthy individuals or those living with chronic conditions need to know how to conduct it. The achievement of effective self-care necessitates a proactive collaboration between consumers and healthcare providers (HCPs), including pharmacists, and is contingent upon well informed consumers and HCPs equipped with proficient communication abilities [95].

Upon discharge from the hospital, patients encounter a multitude of challenges. This transitional phase places patients at risk of unnecessary harm due to insufficient preparation before their discharge, thereby potentially giving rise to errors and compromising their well-being [96]. It is during the discharge phase that proper medication reconciliation and comprehensive education sessions between pharmacists and patients, and their caregivers should take place to prepare patients for self-care while at home.

There is the potential for substantial healthcare cost savings from enhancing the self-care options that are available to consumers. It was estimated that 10–25% of GP consultations in different European countries could be substituted by self-care, which varies from country to country, depending on the current level of self-care uptake. Further substitution of GP visits by responsible self-care could release 17.6 billion euros per year for society [97].

7. Conclusions

Collaboration between healthcare providers, including pharmacists and well informed consumers is essential when it comes to managing medical conditions at the tertiary level. This is important to ensure that patients get the best possible care starting from admission to discharge. The practice of self-care can bring significant advantages to individuals and society by relieving the burden on medical resources. Pharmacists have a crucial role to play in ensuring proper medication management and continuity of care encompassing activities such as home medicines review (HMR) and discharge planning. Maintaining a seamless continuum of quality medicine use from hospitals to the community is paramount in guaranteeing patients receive the appropriate level of care.

Conflict of interest

The authors declare no conflict of interest.