Table 3 Description of outcomes of pharmacist interventions

AbuRuz et al. [33]

▪ Total DRPs: 1062 (517 control, 545 intervention)

▪ Reduction in DRPs in the intervention group at discharge was significantly higher than in the control group [MD − 2.63 (− 1.3 to − 3.94); P < 0.0001]

NR

▪ Unnecessary drug therapy (11.2% vs 7.7%)

▪ Untreated condition (10.8% vs 8.1%), need for additional/combination therapy (7.2% vs 10.3%), and need of more effective drug (6.9% vs 6.1%)

▪ Efficacy-related issues (16.6% vs 21.3%), efficacy drug interaction issue (1% vs 0.9%), and safety drug interaction issue (7.2% vs 5.7%)

▪ Low (1.5% vs 4.0%) or high dose (7.2% vs 6.6%)

▪ Safety-related issues (20.5% vs 20.0%), drug is contraindicated (2.1% vs 1.5%)

▪ The patient is at high risk for developing adverse drug reaction and requires prophylaxis or intervention (3.5% vs 5.3%) or allergic reaction or undesirable effect (0.6% vs 0.9%)

▪ Inappropriate knowledge about medications or diseases (14.7% vs 13.21%)

▪ Inappropriate medicine adherence (8.1% vs 7.52%)

▪ Need for additional/more frequent drug monitoring (20.7% vs 19.45%)

NR

90%

6 months

Bansal et al. [38]

None

NR

▪ Medicines optimization: 186

▪ Peri‐operative drug management: 234

420

NR

12 months

Chen et al. [39]

▪ Irrational use of PPI (64.11% vs 31.55%; P < 0.001)

NR

▪ Medication unindicated: 20.2% vs 11.2%, P = 0.018

▪ Composition ratios of unindicated drugs (63 vs 26), unsuitable drug selection (71 vs 8), and unsuitable drug formulation (37 vs 12): P < 0.05

▪ Repeated administration (6 vs 2), inappropriate usage and dosage (27 vs 17), and incompatibility (0 vs 0) were nonsignificant: P > 0.05

NR

Not reported

Not reported

Falconer et al. [40]

NR

NR

▪ Number of new or changed medications (3.7 ± 1.2 vs 4.2 ± 1.8; P = 0.003)

▪ Number of stopped medications (1.2 ± 1.5 vs 1.5 ± 1.9; P = 0.09)

▪ Antihypertensive medications were decreased or stopped (44.7% vs 85.4%; P < 0.001)

▪ Antidiabetic medications were decreased or stopped (65.9% vs. 66.7%; P = 0.43)

▪ Discrepancies among the final medication list (28.5% vs 20.0%; P = 0.59)

NR

77%

30 days

Fitzpatrick et al. [28]

▪ Prescriptions with ≥ 1 prescribing difference: 38.8% patient

NR

Pre-intervention group

▪ Postoperative thromboprophylaxis prescribed: 22.5% of patients (18.75% of patients were given aspirin as thromboprophylaxis despite (BMI) > 30 (classified as at increased VTE risk and should be prescribed alternative thromboprophylaxis)

▪ NSAID prescription despite caution, contraindication, or existing NSAID prescription: 15%

▪ QT-prolonging medication despite a borderline or prolonged QTc on preoperative ECG: 6.3%

▪ 115

NR

9 days

Hale et al. [34]

NR

NR

▪ Medication omission (31.5% vs 1.2%, P < 0.001)

▪ Prescribing errors involving selection of drug, dose, or frequency (6.3% vs 0.2%, P < 0.001)

Orders with at least one component of the prescription missing, incorrect, or unclear (43% vs 23%, P < 0.001)

▪ NR

NR

Hospital duration

Han et al. [41]

None

NR

▪ Prior-to-admission corrections: Adding missing medications (93%), removing old medications (52%), updating missing or incorrect medication details (48%), removing duplicate medications (5%)

▪ Pharmacist interventions pre-op: Dose change (16%), taper (13%), other interventions (12%), monitoring (10%)

▪ Pharmacist interventions post-op: New medication counselling (100%), admin instruction change (85%), hold medication until follow-up (78%), agent change (66%), discontinue medication (60%)

▪ Prior-to-admission corrections: 61 patients (90%) in the intervention group. The pharmacist made a median of four corrections per patient

▪ Pre-op interventions: Median of 13 interventions per patient in the preoperative clinic consultation

NR

NR

Kwan et al. [35]

Number of patients with at least one postoperative medication discrepancy: intervention: 86/214 (40.2%) vs 41/202 (20.3%), P < 0.001 (odds ratio, 0.38; 95% confidence interval, 0.24–0.59)

Causing discomfort and/or clinical deterioration

▪ Probable (20% vs 33.8%)

▪ Possible (38.3% vs 32.5%)

▪ Unlikely (41.7% vs 33.7%)

▪ Drug omission (36.7% vs 46.5%), incorrect or omitted dose (8.3% vs 8.9%), drug formulation (1.7% vs 5.7%) and frequency (0% vs 4.5%), and inappropriate route (5% vs 1.3%)

▪ Orders requesting pharmacy to clarify medications (no medication orders or incomplete medication orders written) (6.7% vs 17.8%) or illegible order (0% vs 0.6%)

▪ No indication (1.7% vs 3.8%)

▪ Slow to restart (15.0% vs 3.2%) or too fast to restart drug therapy (1.7% vs 0.6%)

▪ Drug interactions (5% vs 1.9%)

▪ Omission of drug name (3.3% vs 1.3%) or misspelled drug name (1.7% vs 0.6%)

▪ Therapeutic duplication (5% vs 0.6%)

▪ Allergy or intolerance (0% vs 0.6%)

▪ Miscellaneous (8.3% vs 1.9%)

▪ NR

NR

Hospital duration

Léguillon et al. [29]

▪ Number of PIPs: − 2.46 PIPs (95% CI: − 2.63; − 2.24), P < 0.001

▪ Number of overall PIMs: − 1.13 [− 1.27; − 0.98], P < 0.001

▪ -Number of overall PPOs (omission/underuse): − 1.35 [− 1.52; − 1.18] < 0.001

▪ Number of patients with one or more PIPs at hospital discharge: 95% vs 29%, P < 0.001

No patient in the intervention group had three or more PIPs at hospital discharge, compared to 61% in the control group (P < 0.001)

N/A

▪ N/A

▪ N/A

N/A

Not reported

Luo et al. [30]

▪ NR

NR

▪ No indication (82.41% vs 72.78%), P = 0.023

▪ Inappropriate choice of acid suppressant (2.32% vs 0%), P = 0.046, dose (14.35% vs 7.10%), P = 0.025, and route (61.11% vs 37.27), P < 0.001

▪ Repeated medication (1.39% vs 0%), P > 0.05

▪ Unnecessary replacement of drugs (25.93% vs 10.06%), P < 0.001

▪ Unnecessary prolonged duration of prophylaxis (65.28% vs 37.87%), P < 0.001

▪ NR

NR

Hospital duration

Marotti et al. [25]

NR

NR

Control group vs. pharmacist taking history vs. pharmacist prescribing (means)

▪ Doses missed during inpatient stay (3.21 vs 3.30 vs 1.07; P < 0.001)

▪ Medications charted at an incorrect dose: 0.48 vs 0.12 vs 0.02, P < 0.001

▪ Medications charted at an incorrect frequency: 0.29 vs 0.07 vs 0.015, P < 0.001

▪ NR

N/A

Hospital duration

Nguyen et al. [27]

▪ Proportion of patients ≥ 1 med error [96% vs 9%, P < 0.001]

▪ Preadmission errors/patient [5.25 vs 0.21, P < 0.001]

▪ Proportion of discharge prescriptions with ≥ 1 error [78% vs 25%, P < 0.001]

▪ Time to charting the first regular home medication [21 h vs 16.8 h, P = 0.605]

▪ Quality of inpatient charting (errors per patient) [1.31 vs 0.64, P = 0.047]

▪ Proportion of patients who received a discharge summary with a completed medication list [33% vs 75%, P = 0.002]

Preadmission: Low-risk errors (46.4% vs 72.7%), moderate high, and extreme error (53.6% vs 27.3%)

Discharge: Moderate error (44.2% vs 44.4%)

▪ Omission: Preadmission (2.84 vs 0.21), inpatient (1.12 vs 0.66), discharge (1.38 vs 0.92)

▪ Incorrect medication listed: Preadmission (0.55 vs 0), inpatient (0.04 vs 0.04), discharge (0.27 vs 0.06)

▪ Incorrect strength: Preadmission (0.65 vs 0), inpatient (0.04 vs 0), discharge (0.08 vs 0.03)

▪ Incorrect frequency: Preadmission (0.53 vs 0), inpatient (0.02 vs 0.04), discharge (0.14 vs 0.03)

▪ Incorrect dose: Preadmission (0.39 vs 0), inpatient (0.06 vs 0), discharge (0.11 vs 0.17)

▪ Incorrect dosage form: Preadmission (0.18 vs 0), inpatient (0.04 vs 0), discharge (0.14 vs 0.03)

▪ Incorrect instructions: Preadmission (0.12 vs 0), inpatient (0 vs 0.02), discharge (0.05 vs 0.03)

NR

NR

Hospital duration

SUREPIL Study Group [26]

Mean number of preventable ADE: incidence of 3.84% (2.49 to 5.91%) vs 2.74% (1.65 to 4.57%), P = 0.324

Incidence rate ratio of 0.71 (95% CI (0.37–1.39)

NR

▪ NR

880

NR

Hospital duration

Van Prooyen et al. [36]

NA

NR

▪ Interventions: Anti-HTN adjustment, discontinue (non-insulin injectable, NSAIDs, loop diuretics, oral diabetic), insulin dose adjustment

▪ The prescription at discharge: Extended-release medication 19.3% reduction, P = 0.0005. Capsules unable to be opened P = 0.27. Noncrushable tablets 7 (4.2%) vs 1 (1.2%), P = 0.27. Enteric- or film-coated tablets: 2 (1.2%) vs 3(3.5%), P = 0.34. NSAIDs: 15 (9%) vs 3 (3.5%), P = 0.11, and loop diuretics: taking at baseline 13 (7.8%) vs 10 (11.8%), P = 0.30, continued at discharge: 6 (46.2%) vs 2 (20%), P = 0.38

130

85.40%

30 days

Yang et al. [42]

None

NR

▪ Change in drug treatment (n = 396)

▪ Dose adjustment (n = 61)

▪ Discontinuation of a drug (n = 121)

▪ Order entry error (n = 34)

630

97.10%

30 days

Zhang et al. [37]

▪ Inappropriate PPI use (48.9% vs. 22.7%; P < 0.001)

▪ Unindicated PPIs prescriptions (32.2% vs 14.2%; P < 0.001)

▪ Inappropriate PPI daily dose (782 vs 96, P < 0.001), duration (611 vs 45, P < 0.001), and route of administration (223 vs 89, P < 0.001)

NR

▪ Starting new therapy (n = 15)

▪ Discontinuation of inappropriate therapy (n = 136)

▪ Dose adjustment (n = 78), change route (n = 124)

▪ Inappropriate PPI daily dose (782 vs 96, P < 0.001), duration (611 vs 45, P < 0.001), and route of administration (223 vs 89, P < 0.001) between the pre- and post-intervention groups

356

88%

Hospital duration