After searching MEDLINE to identify common causes of epoetin alfa resistance, the authors from the Renal Risk Reduction Centre at St Paul’s Hospital, Saskatoon, Saskatchewan, developed an algorithm to guide the investigation and management of suspected epoetin alfa resistance. After discussion with nurses and physicians in the renal unit, the algorithm was modified. The algorithm (Figure 1) was designed for use by physicians, pharmacists, and nurses involved in the management of patients on chronic dialysis.

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INTRODUCTION

Marketed in the last decade, epoetin alfa (Eprex, Janssen-Ortho Inc., Toronto, Ontario) has improved the quality of life of patients with anemia associated with chronic renal disease. This anemia is primarily the result of inadequate erythropoietin production and other factors such as iron deficiency. Anemia causes cardiac ischemia and left ventricular hypertrophy, both of which predispose patients with chronic renal disease to cardiac morbidity. Most patients on chronic dialysis require administration of epoetin alfa for the optimal management and prevention of anemia.

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The limitations of this study included the small sample size (59 patients) and the short duration (data collection over 1 month). In addition, the principal investigator was not blind­ed. Conversely, all data were reported by means of standard forms that required complete information, which we believe limited the amount of bias introduced. In addition, for each patient, the technician who completed the research to create the preliminary medication list also interviewed the patient. Although this might have created bias in favour of the technician, both the technician and the pharmacist began their interviews with the same information available to them. Moreover, this procedure mimics what actually happens in the emergency department, where the technicians routinely carry out the research to establish the preliminary medication list. Another notable limitation was the daily timeframe of the study: only patients who presented to the emergency depart­ment during daytime hours were included, whereas Safer Healthcare Now! audits typically include multiple hospital units and are not limited to daytime shifts.

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To the authors’ knowledge, this study is the first random­ized trial directly comparing medication histories obtained by pharmacists with those obtained by pharmacy technicians. Previous studies have examined medication reconciliation and the role of the pharmacy technician in both preoperative and hemodialysis clinics and have obtained favourable results. However, the role of the pharmacy technician in the emergency department, although increasing in popularity, is not as well studied. The results obtained here confirm the hypothesis that in the emergency department, well-trained pharmacy technicians can obtain a BPMH with as much accuracy and completeness as pharmacists.

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An unintentional discrepancy is defined by Safer Healthcare Now! as a medication error that can lead to one or more adverse drug events. The national average for unintentional discrepancies per patient for December 2008 was 0.54, as reported in the March 2009 quarterly report for medication reconciliation. In the current study, the pharmacists had a mean of 0.25 (SD 0.54) unintentional discrepancies per patient, and the techni­cians had a mean of 0.24 (SD 0.68) unintentional discrepancies per patient. For both groups, the value was significantly lower than the national average for unintentional discrepancies per patient (for pharmacists, t = -4.03, df = 58, p < 0.001, -2 = 0.22; for technicians, t = -3.43, df = 58, p = 0.001, -2 = 0.17).

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Of 120 patients identified during December 2008 as being eligible for inclusion, 60 were enrolled and 60 were assigned to not participate. Thirty of the enrolled patients were interviewed first by the pharmacist, and 30 patients were inter­viewed first by the technician. One of the patients interviewed was excluded from the analysis because both the patient and the patient’s spouse had severe cognitive dysfunction and confusion and were unable to provide the necessary information. For other patients who were either unable to communicate or who had cognitive dysfunction, information was gathered from caregivers or family members. A total of 59 patients were included in the final analysis (Table 1).

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This study was a prospective comparison of current medication histories obtained by pharmacy technicians and by pharmacists in the emergency department at The Moncton Hospital, a 400-bed community hospital. The emergency department at this institution is a combined adult and pediatric care facility that is designated as a level II trauma centre, with about 55 000 visits annually. During December 2008, patients presenting to the emergency department were enrolled to be interviewed 2 times, once by a pharmacist and once by a technician. Patient recruitment took place on weekdays during daytime hours (0830 to 1700). Patients were eligible for inclusion if they were being admitted to hospital from the emergency department or if a member of the health care team asked a pharmacist for a medication history. Patients were excluded if they had been transferred from a nursing home or other hospital or if a medication history had been initiated by a health care professional other than a pharmacist. Three pharmacists and 2 technicians participated in the study.
The pharmacy technicians were trained to obtain a BPMH by means of a 4-step process adapted from the medication reconciliation education and certification program described by Small and others. First, an interactive learning and education session was provided, during which background information was reviewed and tips for success when obtaining a BPMH were outlined. During this session, the technicians were given a BPMH interview guide, adapted with permission from an existing interview guide, which outlined appropriate probing questions. The technicians were expected to use this guide for each interview that they completed.  Third, each technician participated in several practice interviews, during which he or she interviewed a patient after a pharmacist had done so; the histories obtained by pharmacist and technician were compared, and discrepan­cies were reviewed and discussed. Finally, each technician underwent a competency assessment, during which he or she interviewed a standardized patient and received detailed feed­back from the assessor. This training program and related tools were also offered to the 3 pharmacists assigned to the emergency department.

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