When pharmacists have the final say on drug orders


At the University of Wisconsin Hospital and Clinics, pharmacists can veto physicians' drug orders if they are inappropriate



When pharmacists have the final say on drug orders

Veto power over inappropriate drug orders is a dream for many hospital pharmacists. At the University of Wisconsin Hospital and Clinics, it is reality.

"Between 96% and 97% of our scripts are written by trainees and fellows," explained Lee Vermeulen, director of Wisconsin's Center for Drug Policy. "We wanted clinical pharmacists to have authority over their prescribing because pharmacists generally know more about drugs. House staff just are not qualified to make the decision on high-risk medications. We're helping our attending physicians solve a problem."

Attending physicians agree. The hospital's pharmacy and therapeutics committee has voted to expand what began as a trial program in the trauma unit in the mid-1990s to the entire hospital.

Pharmacist oversight of all anti-infective orders should begin this summer. Other product categories will be added later, Vermeulen said.

"It's not uncommon for pharmacists to review scripts written by residents," said Carla Frye, scientific affairs associate at ASHP. But it is less common to give pharmacists veto power over drug orders—even orders from physicians in training. The key is that this is not a blind change to a physician order," said Frye. "It is a carefully thought-out system that has been approved by the P&T committee."

It is also a system that is evolving. The program began in 1996, when pharmacists started checking trauma center orders for albumen, sedatives, anti-infectives, potassium chloride, and other specific product categories. The current pharmacist review will eventually be replaced by an automated review as part of a planned computerized physician order entry (CPOE) system.

If a physician orders vancomycin without serum creatinine lev- els, for example, CPOE will reject the order the same way a pharmacist rejects it under the current manual review system.

"We're building those decision trees right now," Vermeulen said. "CPOE will make the same kinds of guideline decisions that pharmacists make today, but faster."

CPOE review will also ease the load on the facility's 90-some clinical pharmacists who are overseeing orders for 450 beds and 90 specialty clinics. There are about 1,200 faculty physicians on staff.

Formulary and practice guidelines are key to pharmacist review of drug orders. If the order meets guidelines, Vermeulen said, it is filled. If it violates guidelines, a pharmacist stops the order and contacts the house staff who wrote it.

That's when the negotiations begin. The physician either agrees that the order is inappropriate and changes it, or explains why the guidelines do not fit the specific case.

"Everyone is aware that guidelines don't fit every occurrence and every patient," Vermeulen said. "Guidelines have to be dynamic if they are going to be effective."

But convincing the pharmacist to allow an exception is a tough sell, he added. That's because the pharmacist has to document and justify every guideline exception.

But pharmacy's veto authority is not absolute. If the house staffer is adamant, the dispute is kicked up to the attending physician. However, while that supervising physician can override pharmacy objections, it almost never happens, Vermeulen said. The reason is simple: The attending must detail the reasons for overriding the pharmacy veto. The written justification then becomes part of the physician's personal accreditation file. Too many guideline violations could have a negative impact on the next accreditation or privileging review.

"In most teaching hospitals, attending physicians will not accept responsibility for prescribing by their house staff," Vermeulen explained. "There is no incentive for them to bird-dog their trainees. We're giving them that incentive."

Giving attending physicians final authority keeps the hospital within the collaborative practice guidelines published by the American College of Physicians-American Society of Internal Medicine earlier this year.

"The Institute of Medicine has documented medication errors as an area needing significant improvements," said William Hall, M.D., president of ACP-ASIM. "We have no doubt that greater collaboration between physicians and pharmacists will improve patient results."

ACP-ASIM insists that physicians should have the final word on drug orders. That's fine with Vermeulen. Requiring physicians to document decisions that run counter to pharmacy recommendations is solid insurance that it won't happen often.

"There is very little basis for argument," Vermeulen explained. "The medical staff has already approved all of the guidelines that pharmacists are applying. We have had a string of very supportive medical directors over the years."

Medical support has already helped the hospital pharmacy open its own mail-order refill service for kidney transplant patients. Other specialty mail operations are in the works for hospice, oncology, and HIV/AIDS. Pharmacists are also working as outpatient case managers for Wisconsin's managed care operation.

Vermeulen sees the ACP-ASIM position paper as a gateway to expanding pharmacy practice, not a barrier. "We are wonderfully underrestricted by ACP standards in most practice settings," he explained. "For 95% of pharmacists, this is an open door to expand clinical activities. For everyone else, it's an incentive to explore new directions."

Fred Gebhart


Fred Gebhart. When pharmacists have the final say on drug orders.

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