From HARM to CHARM: Pharmaceutical advisor aids cardiology outpatients with medication in Atrium Hospital; the value of the pharmaceutical counselor at the cardiology office in recapitulating and guiding medication

*To Err Is History*
From the well-known report To err is human, it is known that many errors in
health care involves medication[1].
In The Netherlands it was found that medication problems are related to a large
amount of hospital admissions [2-3]. One of the problems with medication is
lack of medication overview when patient are transfered from home setting to
the hospital [4-5] and lack of medication insight by patients.

Local research: Atrium MC
In previous observational (pilot) research it was found that many medication
transfer errors occurred in the outpatients clinic * in 120 patients more than
150 medication discrepancies occurred compared to medication history from
pharmacies or lack of follow-up of medication changes by cardiologists [6].
It is necessary to make a good overview of the medication that patients use for
the doctor to make treatment decisions and to prevent introducing transfer
errors in prescriptions. Moreover, it is important that patient which
medication they use and in which dosage.

Various research has been done on this tiopic in The Netherlands for hospital
admissions [7-13]. For outpatients clinical consults there is still a lack of
data.

Intervention research: CHARM
After finishing the pilot research project, we will investigate the potential
role of the pharmaceutical consultant to make a medication overview with the
outpatient for the doctor, and checking the knowledge of the patient's
medication usage.

CHARM: pharmaceutical Consultant Helpts in outpatient cardiology unit Atrium
hospital in Reconciliation of Medication.
Medication reconciliation: verification, clarification, reconciliation and
transmission.

REFERENTIES

1. Kohn LT, Corrigan JM, Donaldson MS, red. To err is human.Washington DC:
National Academy Press; 1999.
2. Van der Hooft CS, Dieleman JP, Siemes C, et al. Adverse drug reactionrelated
hospitalisations: a population-based cohort study. Pharmacol Drug Safety
2008;17(4):365-71.
3. Leendertse AJ, Egberts AC, Stoker LJ, et al. Frequency of and risk factors
for preventable medication-related hospital admissions in the Netherlands. Arch
Int Med 2008;168(17):1890-6.
4. Conceptrichtlijn Overdracht van medicatiegegevens 2008. Utrecht: Inspectie
voor de gezondheidszorg; 2008.
www.medicatieoverdracht.nl/uploaddb/downl_object.asp?atoom=9008&VolgNr=1.
5. Medicatieverificatie bij opname en ontslag. Veiligheidsprogramma VMS Zorg;
2008. http://vmszorg.nl/Documents/Tools_Extras/Thema*s/
Medicatieverificatie/20080101_praktijkgids_medverificatie.pdf.
6. Munnecom MPM, Slikkerveer M, Kragten JA, Groothuis S, Krings AWH.
Medicatieoverzicht openbare apotheken als gouden standaard. Pilotonderzoek naar
medicatiefouten op een polikliniek cardiologie. Pharm Weekbl 2005;912-5.
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Begeleiding bij ontslag van hartfalen patienten. Pharm Weekbl Wetenschappelijk
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en P.N. Langendijk. Bijdrage farmaceutisch opnamegesprek door
apothekersassistent aan preventie van transmurale medicatiefouten. Pharm Weekbl
Wetenschappelijk Platform. 2008;2(6):127-131
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ingreep. Pharm Weekbl Wetenschappelijk Platform. 2007;1(5):105-109
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Pharm Weekbl. 2004;139:974-7.
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- to investigate the additional value of a pharmaceutical consultant at the
cardiology outpatient unit on qualtiy, safety, efficacy, patient's satisfaction
and costs compared to usual care.

Usual care (a normal cardiologist's consultation) means an interview of 10
minutes by the cardiologist, in which a medication overview is made based on
information of the patient, and usually treatment decisions are made with new
or recurrent prescriptions.

Randomised (1:1) open trial

Medication reconciliation and guidance by pharmaceutical begeleiding door
farmaceutisch consulent

Not applicable.