Ian Coombes

Background: Evidence suggests that some medical emergencies in hospital are associated with preventable medication errors or adverse reactions. Aim: The purpose of this case series was to investigate and describe the proportion of Medical Emergency Response Team ( MERT ) activations that are medication‐related, the degree of preventability and underlying contributing factors. Method: This retrospective case series included a review of MERT activations collected from an Australian tertiary hospital by two separate multidisciplinary teams. Initial review by the research team identified those that were potentially medication‐related; these cases were then reviewed by an expert panel to determine the degree of causation and preventability and to identify errors within the medication management cycle and their underlying factors. The main outcome measures were the proportion of preventable medication‐related MERT activations. The secondary outcome included descriptions of medications, medication errors in the context of the medication management cycle and consideration of factors underlying the errors including pharmacy review contributing to these activations. Results: Fifteen per cent (17/117) of MERT activations reviewed were medication‐related, and 65% (11/17) of those were deemed preventable. The omission of medications due to errors in prescribing, administration, pharmacy review or supply stage was the main contributor to preventable medication‐related MERT activations (7/11, 64%). Cardiovascular medications, predominantly metoprolol, were most implicated in preventable medication‐related MERT activations. Conclusions: Medication adverse events due to potentially error‐prone steps in medication management processes are a common cause of inpatient MERT activations, presenting a considerable preventable burden to patients and healthcare resources.

Background: Transition of care (TOC) is a high-risk period for medication errors as patients move between multiple health care professionals, settings, and changing medication regimens. Ineffective communication systems further increase the likelihood of medication harm and hospital readmission. A TOC service with tailored, patient-specific support may help reduce these risks. Cardiovascular medicines significantly contribute to medication harm, and patients recovering from acute myocardial infarction (AMI) or cardiothoracic surgery (CS) are vulnerable due to complex regimens and frequent medication changes. Pharmacists, as medication experts embedded within cardiology teams, are well positioned to support these high-risk patients, facilitate safer transitions from hospital to home, and provide coordinated postdischarge follow-up. Objective: This study aims to evaluate the impact of a pharmacist-led interdisciplinary TOC service on reducing medication harm for cardiology patients post-AMI or CS. Methods: The study will be conducted in two phases: phase 1—intervention development will combine scoping review findings with stakeholder input to design an evidence-based, cocreated, culturally relevant intervention, underpinned by implementation science. A risk prediction model will be developed and validated to identify AMI/CS patients at high risk of medication-related unplanned readmission within 30 days. Phase 2: the RECARD (Reduce Hospital Readmissions for High-Risk Cardiology Patients) trial will use a pre-post design across 3 Australian tertiary hospitals (2 metropolitan and 1 regional) to compare a retrospective usual care patient cohort (referred to as “pre”) with a different prospective patient cohort (referred to as “post”) that includes both usual care and intervention AMI/CS patients receiving the TOC service. Only high-risk poststudy patients will receive the intervention TOC service, consisting of an individualized bundle of TOC activities to optimize medication management, while the remaining poststudy patients will receive usual care. A unique feature of the service is its capacity for hospital clinicians to conduct postdischarge home visits for patients needing additional support. The primary outcome for this study is medication-related 30-day hospital readmission. The analysis will consist of multivariable logistic regression. An economic analysis will be conducted to evaluate the costs associated with the intervention and medication-related readmissions. A comprehensive process evaluation will be conducted using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to enable learnings from the trial to inform sustainable improvements in this field. A patient survey will be administered at the end of the trial to assess patient experience and elicit patient preferences using a discrete choice experiment. Results: The predata are currently being collected for patients discharged from the 3 hospital sites during the 12-month prestudy period. The postdata intervention began on December 10, 2025. As of May 27, 2026, a total of 343 patients have been recruited at the 3 study sites. Conclusions: The findings of this study will inform future implementation of a sustainable cardiac TOC model within the Australian health care setting.

The trial has been prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12625000617460). This work was supported by the Emergency Medicine Foundation (EMF) throug...

Acute coronary syndrome is a major global disease burden with high morbidity and mortality. This study aims to assess the impact of clinical pharmacy interventions on improving the quality use of medicines and drug-related problems in acute coronary syndrome patients. An open, prospective, controlled, nonrandomised clinical trial was conducted at the Teaching Hospital, Peradeniya, Sri Lanka. Consenting patients were recruited and divided into control and intervention groups. Medication history, medication adherence and drug-related problems were assessed. The intervention group received clinical pharmacy interventions for six months. Improvements in medication adherence, discharge medication appropriateness, reduction of hospital readmissions for six months, and responses from the healthcare team’s awareness and perception on clinical pharmacy services were recorded. Both groups (control – 180 patients, intervention – 185 patients) showed poor medication adherence at baseline. Medication adherence improved significantly after 6-months post-discharge in the intervention group compared to the control group (49.3% vs 18.8%). The clinical pharmacists successfully identified drug-related problems and provided suggestions for resolving them. The treating team accepted the majority (60%) of these suggestions. Discharge medication appropriateness in the intervention group was significantly higher compared to the control group. There was no significant difference in hospital readmissions related to cardiovascular disorders between the groups. Most doctors and nurses were aware of clinical pharmacists but none of them had previously worked with one. Clinical pharmacist-led interventions significantly improved medication adherence and appropriateness, underscoring the added value of clinical pharmacists in a multidisciplinary healthcare team. While most doctors and nurses were aware of clinical pharmacists, none of them had prior experience working with them, emphasising an opportunity to foster greater multidisciplinary integration for improved health outcomes. Overall findings highlight the potential role of clinical pharmacists in enhancing good patient outcomes and improving real-world patient care.

This case highlights how a cascade of diagnoses and prescriptions from multiple prescribers can lead to extreme polypharmacy, multiple compounding adverse effects and serious sequelae.

Background Clinical pharmacists perform activities to optimise medicines use and prevent patient harm. Historically, clinical pharmacy quality indicators have measured individual activities not linked to patient outcomes. Aim To determine the proportion of patients who receive a pharmaceutical care bundle (PCB) (consisting of a medication history, medication review, discharge medication list and medicines information on the discharge summary) as well as investigate the relationship between delivery of this PCB and patient outcomes. Method Pharmaceutical care bundle activities were defined within state-wide (Queensland, Australia) clinical information systems and datasets were linked. An observational study using routinely recorded data was performed at ten participating sites for adult patients who had a non-same day hospital stay. The association between extent of PCB delivery and three patient outcomes were investigated: length of stay (LOS), unplanned readmission, and mortality. Results In total 283,813 patient hospital stays were evaluated. The delivery of the PCB occurred in 26.9% of patients at the ten participating hospital sites, ranging from 0.6 to 61.2% across sites. Patients with a longer LOS were more likely to receive delivery of the complete PCB (P < 0.001). There was no correlation between PCB and hospital standardised mortality ratio (r = 0.03, p = 0.93). Higher rates of delivery of the PCB were associated with lower rates of unplanned readmission within 30 days (r = − 0.993, p < 0.001). Conclusion A complete PCB was delivered to 26.9% of patients and was associated with a significantly lower rate of unplanned readmission within 30 days.

The University of Queensland's institutional repository, UQ eSpace, aims to create global visibility and accessibility of UQ’s scholarly research.

Introduction Clinical pharmacy services often involve multifaceted pharmacist-led interventions. However, current pharmacy practice models vary across different countries. Despite the documented benefits of clinical pharmacy services, the characteristics of pharmacist-led interventions in different countries have not yet been adequately explored and described. Therefore, this protocol outlines the methodology for a proposed scoping review aiming to investigate various types of multifaceted pharmacist-led interventions and the outcomes used to evaluate their effectiveness within secondary care settings. Additionally, the scoping review will map the current evidence surrounding the characteristics of interventions and outcomes reported across various countries of socioeconomic status. Methods and analysis The scoping review will be conducted according to the JBI Methodology for Scoping Reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews. We will systematically search the following electronic databases: MEDLINE (Ovid), CINAHL (EbscoHost), Embase (embase.com), Scopus (scopus.com), Cochrane Library (cochranelibrary.com) and APA PsycInfo (Ovid). Additionally, the reference lists of identified reviews and included full texts will be searched for relevant papers. Grey literature sources, such as International Pharmaceutical Abstracts and the International Pharmaceutical Federation (FIP) website, will be searched. We will include primary studies published in the English language from January 2013 to December 2023, involving secondary care multifaceted pharmacist-led interventions. Two independent reviewers will screen studies against eligibility criteria and use a piloted data extraction form to extract relevant information. We will extract relevant data, complete a tabular summary from each included publication and analyse it. Ethics and dissemination Ethical approval is not required as we will be using data from publicly available literature sources. Findings will be disseminated in publications and presentations with relevant stakeholders. We aim to map available evidence across the breadth of studies that have reported multifaceted pharmacist-led interventions and their outcomes.

Background Clinical pharmacists perform patient-centred activities to optimise medicines use and prevent harm. Historically, clinical pharmacy quality indicators have measured an individual activity and are not linked to patient outcomes. Aim To determine the proportion of patients for which bundled pharmaceutical care activities are performed and to investigate associations between patient outcomes and delivery of pharmaceutical care bundles (PCB). Methods Medication history, medication review, discharge medication list and medicines information on the discharge summary were defined within relevant state-wide clinical information systems. Routinely recorded data was extracted at ten participating sites for adult patients who had a non-same day separation. Associations between extent of delivery of all activities as a PCB and 3 patient outcomes were investigated. Results In total 283,813 hospital stays were evaluated. Delivery of the PCB occurred in 26.9% of patients (range 0.6% to 61.2% at participating sites). Patients with a longer length of stay were more likely to receive delivery of the complete PCB (P<0.001). There was no association between bed:clinical pharmacist FTE ratio and delivery of the PCB (r=-0.183, p=0.64) and there was no correlation between PCB and hospital standardised mortality ratio (r=-0.03, p=0.93). Higher rates of delivery of the PCB were associated with lower rates of unplanned readmission within 30 days (r=-0.993, p<0.001). Conclusion Delivery of a PCB consisting of medication history, medication review, discharge medication list and medicines information on the discharge summary was provided to 26.9% of patients. It was associated with lower rates of unplanned readmission within 30 days.

Context: Medical interns (interns) find prescribing challenging and many report lacking readiness when commencing work. Errors in prescribing puts patients’ safety at risk. Yet error rates remain high, despite education, supervision and pharmacists’ contributions. Feedback on prescribing may improve performance. Yet, work-based prescribing feedback practices focus on rectifying errors. We aimed to explore if prescribing can be improved using a theory-informed feedback intervention. Methods: In this pre-post study, we designed and implemented a constructivist-theory informed prescribing feedback intervention, informed by Feedback-Mark 2 Theory. Interns commencing internal medicine terms in two Australian teaching hospitals were invited to engage in the feedback intervention. Their prescribing was evaluated by comparing errors per medication order of at least 30 orders per intern. Pre/baseline (weeks 1–3) were compared with post intervention (weeks 8–9). Interns’ baseline prescribing audit findings were analysed and discussed at individualised feedback sessions. These sessions were with a clinical pharmacologist (Site 1) and a pharmacist educator (Site 2). Results: Eighty eight intern’s prescribing over five 10-week terms was analysed from two hospitals. The frequency of prescribing errors significantly reduced at both sites after the intervention, across all five terms (p < 0.001).There were initially 1598 errors in 2750 orders (median [IQR] 0.48 [0.35–0.67] errors per order) and after the intervention 1113 errors in 2694 orders (median [IQR] 0.30 [0.17–0.50] errors per order). Conclusion: Our findings suggest interns’ prescribing practices may improve as a result of constructivist -theory learner centred, informed feedback with an agreed plan. This novel intervention, contributed, to a reduction in interns’ prescribing errors. This study suggests new strategies for improving prescribing safety should include the design and implementation of theory-informed feedback interventions.