This document summarizes the evolution and current state of emergency medicine clinical pharmacists internationally. It describes how their role has expanded from medication distribution to active clinical roles on multidisciplinary teams. Studies show emergency medicine pharmacists can reduce medication errors, mortality, readmissions, and improve time to appropriate treatments. While initially confined to North America, their benefits are now reported internationally. More evidence is still needed on reducing adverse drug events, but existing data shows emergency medicine pharmacists improve patient outcomes and reduce costs.

1. 1Coralic Z, Hayes BD. Emerg Med J Month 2017 Vol 0 No 0
Emergency medicine pharmacists on an
international scale
Zlatan Coralic,1
Bryan D Hayes2
Emergency Medicine (EM) clinical phar-
macy services in the USA were first
described in the literature in the 1970s.
Initially, the role was confined mainly to
medication distribution, but has evolved
significantly into clinical practice while
the number of EM pharmacists has steadily
increased.1
Inclusion of clinical pharma-
cists in EM has been supported by
the American Society of Health-System
Pharmacists, Agency for Healthcare
Research and Quality (AHRQ), American
College of Medical Toxicology; and most
recently, the American College of Emer-
gency Physicians.2
This support is due to decades of
bedside practice and evidence of benefit.
The contribution of clinical pharmacists
on multidisciplinary teams has been shown
to reduce patient mortality,3
hospital read-
missions4
and medication errors.5
Further,
EM clinical pharmacists have demon-
strated improvement in time-sensitive
therapies in the ED, such as reductions
in time to administration of antibiotics
in sepsis,6
analgesics in trauma,7
sedatives
and analgesics after rapid sequence intu-
bation,8
and thrombolytic therapy in acute
ischaemic stroke.9
The daily responsibilities of EM clin-
ical pharmacists are broad and may differ
slightly between institutions. Most EM
pharmacists support the ED team with
bedside medication procurement and
provision of patient-specific pharmaco-
therapy recommendations (eg, selection of
appropriate antibiotics, review of cultures
and follow-up after discharge, assis-
tance with medication history gathering,
high-risk medication evaluation, drug
information and toxicology consulta-
tion, participation in code or trauma
response).10
The studies by De Winter et al
(Belgium)11
and Perez-Moreno et al (Spain)
add to the expanding literature regarding
the potential benefit of pharmacists in
the ED. Perez-Moreno et al evaluated the
clinical relevance of EM pharmacist inter-
ventions.12
The study was carried out in
a large and busy 74-bed Spanish ED. For
2984 patients, EM pharmacists evaluated
drug therapy orders by ED physicians and
reconciled patients’ home medications,
ensuring they were continued (or omitted)
during the patients’ ED stay or subsequent
hospitalisation. As in a similar multicentre
study5
carried out in four US EDs, there
was a concerning rate of medication
errors. Most of the errors were considered
severe and most EM pharmacists’ inter-
ventions clinically relevant. While it is
reassuring that there were no ‘potentially
lethal’ mistakes, the number of errors
is an alarming figure. As the sample size
was limited to day hours (08:00–15:00),
it is possible that the cohort was not large
enough to detect potentially lethal medi-
cation errors. Or, perhaps devastating
medication errors are more likely to occur
in the afterhours where the census, acuity
and demand on clinicians may be higher
with less resources in the department. The
authors used the best available tools to
evaluate severity of errors and their clin-
ical significance; however, no perfect tool
exists for such an evaluation and some
categorisations are prone to subjectivity.
The authors represent a multidisciplinary
team of clinical pharmacists and EM
physicians, which may limit some of the
bias that is inherent in such study designs.
This study certainly highlights the fact that
medication errors in EM are a universal
problem and supports the idea that EM
pharmacists can help prevent these.
The WHO, the Joint Commission, and
AHRQ stress the importance of accurate
medication reconciliation. Briefly, medi-
cation reconciliation is a complex process
involving collection of a patient's accu-
rate medication history, evaluation of
medication-related contribution(s) to the
presenting problem, and appropriate reor-
dering (or omission) of home medications
during hospitalisation and at discharge.
Medication reconciliation is a univer-
sally challenging problem in medicine and
remains a great source of error and patient
harm. The precise account of medications,
as a patient moves through the healthcare
setting, remains a major patient safety goal.
Medication reconciliation is labour-in-
tensive, and an accurate medication list
on a complex patient may take up to an
hour (eg, calling pharmacies or primary
care providers, requesting records from
previous healthcare settings). Emergency
care nurses and physicians are often the
primary resources for the collection of
medication histories. Not surprisingly,
medication data collection in a complex
environment such as the ED has been
found to be error prone. Pharmacists
can obtain a more complete and accurate
medication history,13
but are also limited
by similar time constraints, especially
when working clinically in the ED where
higher acuity patients take precedence.
Recognising this, De Winter et al
employed a novel and pragmatic approach
in attempting to derive a clinical decision
rule identifying patients at risk for medi-
cation discrepancies during the medication
reconciliation process.11
Their results are
promising, offering a decision rule with a
74% positive predictive value. One down-
side is that the prediction model takes
into account 13 parameters which may
overwhelm bedside clinicians. As such, the
utility of the decision rule would be limited
in paper-based institutions. However, all
13 points can be programmed and easily
extracted from computerised order entry
systems. Their decision rule has the potential
to decrease workload, improve throughput
and optimise medication reconciliation for
EM pharmacists and all staff involved in
medication history gathering. With further
validation and streamlining, this tool could
become a standard for practice among EM
pharmacists.
Perhaps the biggest critique against
having EM clinical pharmacists is the cost.
Pharmacists are an expensive resource
and institutions may be concerned about
whether the cost justifies the benefit.
However, multiple studies have demon-
strated significant cost avoidance with
pharmacist presence in the ED, ranging
between $1–$1.7 million saved per
year14 15
–—well beyond what is needed
to support a pharmacist's salary. These
savings were associated with adherence
to evidence-based and institutional guide-
lines, reduction in medication errors,
timely institution of drug therapy, and use
of cost-effective drugs and treatment.
An additional area for further study
is EM pharmacists’ effect on reduction
of adverse drug events. The majority of
data to date show that EM pharmacists
reduce medication errors; however, less
is known about the reduction of adverse
drug events. An AHRQ-supported study
of 11 250 patients concluded that there
1
Clinical Pharmacist, Emergency Medicine, University of
California San Francisco, San Francisco, California, USA
2
Clinical Pharmacist, Emergency Medicine and
Toxicology, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts, USA
Correspondence to Dr Bryan D Hayes, Clinical
Pharmacist, Emergency Medicine and Toxicology,
Massachusetts General Hospital Harvard Medical
School, Boston, Massachusetts 02114, USA; ​
bryanhayes13@​gmail.​com
Commentary
EMJ Online First, published on May 13, 2017 as 10.1136/emermed-2016-206470
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2. 2 Coralic Z, Hayes BD. Emerg Med J Month 2017 Vol 0 No 0
Commentary
was no difference in adverse drug events
when an EM pharmacist was present
in the ED.16
However, EM pharma-
cists were present for half of the shifts
and introduced education and changes
that may have affected practice when
they were not there. As this study was
published only in abstract form, caution
should be taken in sweeping conclusions.
EM pharmacist effect on reduction of
adverse drug events certainly merits
further rigorous study.
Much of the data regarding EM clinical
pharmacists are limited to literature stem-
ming from the USA and Canada, though
the benefits of EM clinical pharmacists are
not unique to North America. Reports of
similar safety advantages from France,17
Qatar,18
the UK and Australia10
have been
published.
Medication errors are the most
common errors in medicine. Many medi-
cation errors will not result in patient
harm; however, those that do can be
devastating to patients, their families and
all staff involved in their care.19
EM clin-
ical pharmacists are the first system-based
intervention that has proven over and
over again, from state to state, and from
country to country to reduce medication
errors in the ED at a favourable cost to the
patient and the institution. Enough signifi-
cant literature now exists that the time has
come to change the question we are asking
from ‘what is an EM clinical pharmacist?'
to ‘how do we implement one?’
Contributor Both authors contributed to the
development and writing of the manuscript.
Competing interests None declared.
Provenance and peer review Commissioned;
internally peer reviewed.
© Article author(s) (or their employer(s) unless
otherwise stated in the text of the article) 2017.All
rights reserved. No commercial use is permitted unless
otherwise expressly granted.
To cite Coralic Z, Hayes BD.Emerg Med J Published
Online First: [please include Day Month Year].
doi:10.1136/emermed-2016-206470
Received 19 December 2016
Revised 24 January 2017
Accepted 15 February 2017
►► http://​dx.​doi.​org/​10.​1136/​emermed-​2015-​204726
►► http://​dx.​doi.​org/​10.​1136/​emermed-​2016-​205804
Emerg Med J 2017;0:1–2.
doi:10.1136/emermed-2016-206470
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3. international scale
Emergency medicine pharmacists on an
Zlatan Coralic and Bryan D Hayes
published online May 13, 2017Emerg Med J
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