Patients with leukemia often transition between inpatient and outpatient settings, which may interrupt attention to medication reconciliation. A group at the Taussig Cancer Institute at the Cleveland Clinic in Ohio sought to explore the prevalence of medication discrepancies at an outpatient leukemia clinic and whether a dedicated oncology pharmacist could minimize medical errors and improve patient care.
Between November 2017 and March 2018, an oncology-trained pharmacist saw all patients discharged from the inpatient leukemia service within five business days. The pharmacist assessed patients for drug-related adverse events, correct regimens and doses, adherence, and concerns about access. The pharmacist also performed medication reconciliation to identify discrepancies and opportunities for medication-related interventions, including avoidance of drug interactions, dose adjustments, and therapeutic drug monitoring. When an intervention was necessary, the pharmacist recommended it to the licensed medical provider, categorizing interventions as:
- serious: drug interactions likely to reduce efficacy or worsen toxicity of chemotherapy, management of anticoagulation with thrombocytopenia, and management of antimicrobials in neutropenia
- not serious: therapeutic drug monitoring for antifungals, management of chemotherapy-induced nausea and vomiting, discontinuation of herbal products and other non-essential agents, and application for grants to minimize out-of-pocket costs
Seventy-six patients participated in visits (33% more than once). A total of 173 medication discrepancies were identified and corrected, which the authors noted was an extremely high rate. Sixty-three (36%) of the discrepancies required additional intervention, of which 22 (35%) were considered serious. In addition, the pharmacist provided medication education and adherence counseling during 93 visits (87%). Thirty-three drug interactions were identified, five of which were considered serious.
The study authors, led by Madeline Waldron, PharmD, of the Department of Hematology and Medical Oncology at the Cleveland Clinic, collected patient data on age, marital status, diagnosis, treatment type, and disease status, then evaluated associations with medication discrepancies.
According to the results, male patients were more likely to have discrepancies if they were newly diagnosed, compared to patients who had relapsed or refractory disease. Female patients were significantly more likely to need intervention if they were single or younger. The research team did not find evidence that any other factors predicted medication discrepancies or a need for interventions.
The authors concluded that a dedicated oncology-trained pharmacist can implement meaningful clinical interventions to help patients with leukemia improve outcomes and safety.