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Research Paper
International Journal of
Pharmacy Practice
International Journal of Pharmacy Practice 2014, 22, pp. 216–222

Clinical benefits and economic impact of post-surgical care

provided by pharmacists in a Canadian hospital
Heather L. Nevillea, Bernadette Chevaliera, Chris Daleyb, Lisa Nodwella, Claudia Hardinga, Anne Hiltza,
Tammy MacDonaldc, Chris Skedgeld, Neil J. MacKinnone and Kathryn Slaytera,f
a
Pharmacy Services, bMulti-Organ Transplant Program, cInfection Control, dAtlantic Clinical Cancer Research Unit, Capital Health, Halifax, NS, Canada,
e
James L Winkle College of Pharmacy, Cincinnati, OH, USA and fFaculties of Medicine and Health Professions, Dalhousie University, Halifax, NS,
Canada

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Keywords
adverse drug events; clinical interventions;
medicines management; patient safety;
cost avoidance
Correspondence
Ms Heather L. Neville, Drug Utilization
Pharmacist/Pharmacy Research Coordinator,
Pharmacy Services, Capital Health, Victoria
General, Room 2043, 1276 South Park Street,
Halifax, NS, Canada B3H 2Y9.
E-mail: heather.neville@cdha.nshealth.ca
Received July 27, 2012
Accepted June 19, 2013
doi: 10.1111/ijpp.12058
Abstract
Objective Clinical pharmacists improve the quality of patient care by reducing
adverse drug events (ADEs), length of stay and mortality. This impact is currently
not well described in surgery. The objective was to evaluate clinical and economic
outcomes after clinical pharmacist services were added to two general surgical wards
in an adult hospital.
Methods This was a prospective, observational study. All clinical interventions to
resolve drug therapy problems were documented and assessed for severity, value and
the probability of preventing an ADE. Cost avoidance was calculated using two
methods: by avoiding additional days in hospital (CA$3593/ADE) or additional
hospital costs ($7215/ADE). Two clinical pharmacy specialists and the surgical
care pharmacist independently categorized the interventions; disagreements were
resolved by consensus.
Key findings The pharmacists made 1097 interventions in 6 months with a 98%
acceptance rate by surgical staff. Half of the interventions were rated significant for
severity (561, 51.1%) and value (559, 51.0%). One-quarter of the interventions had a
40% or greater probability of preventing an ADE (270, 24.6%). Cost avoidance was
estimated to be $0.68–1.36 million or $617–1239 per intervention. Pharmacists
avoided an additional 867 days in the hospital for surgical patients.
Conclusion The pharmacist’s role in the management of the drug therapy needs of
the post-surgical patient has the potential to improve clinical and patient outcomes
and avoid healthcare costs. The inclusion of clinical pharmacists in surgical wards
may result in $7 in savings for every $1 invested.

Introduction
The pharmacists’ role in optimizing the ‘efficiency, effective-
ness, and safety of drug therapy’ has expanded over time to
provide more direct patient care in the acute care setting.[1,2]
Clinical pharmacists resolve drug therapy problems, attend
rounds, take medication histories and counsel patients. Com-
pelling research has demonstrated that interventions (drug
therapy recommendations) made by clinical pharmacists are
associated with improved quality of care and reductions
in adverse drug events (ADEs), medication errors, hospital
length of stay (LOS) and mortality rates, as well as having
produced cost savings and cost avoidance.[1–4] The median
benefit/cost ratio for clinical pharmacy services in hospitals
was estimated to be 4.89:1, indicating a positive return on
investment.[5]
The benefits and cost avoidance of a clinical pharmacist on
a surgical service are not yet well described. Published litera-
ture suggests pharmacists in a surgical preadmission clinic
can reduce medication errors and improve documentation of
drug allergies and drug interactions.[6–8] Limited services,
such as weekly chart reviews[9] and health provider educa-
tion,[10] have also decreased medication errors and produced
cost savings. Pharmacist-managed antimicrobial prophylaxis

© 2013 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2014, 22, pp. 216–222
Heather L. Neville et al.
programmes for surgical patients have been associated with
decreased mortality rates, LOS and healthcare costs.[11] In one
study, critical care pharmacists attending medical rounds
reduced ADEs by 66% with a 1 year cost avoidance of
US$270 000.[12]
Drug therapy by pharmacists in collaboration with the
healthcare team may be particularly critical in surgery. Sur-
geons spend a large proportion of their time in the operating
room, making it difficult to address the patient’s immediate
drug therapy needs related to medication errors,[13] adverse
events[14,15] and post-surgical complications.[16] This presents
challenges to ward staff and may lead to adverse outcomes.[16]
Prior to our study, clinical pharmacy services were provided to
many inpatient populations in our institution, but not to sur-
gical patients. In 2008, two clinical pharmacist positions were
assigned to a large general surgery population where it was felt
that antimicrobial use could be optimized and drug costs
better managed. The primary objectives were to measure the
quality of care provided and the potential economic impact of
clinical pharmacy services on two general surgical wards by
documenting and categorizing all interventions for severity of
drug therapy problems, the value or importance of the inter-
ventions, cost savings and cost avoidance.
Methods
This study was a prospective, uncontrolled, observational
study conducted in a 950 bed Canadian adult tertiary care
hospital. The 6 month data-collection period was 1 Decem-
ber 2008 to 31 May 2009. All patients admitted to a 23-bed
general surgical ward and a 24-bed gastrointestinal/general
surgical ward were included. The Research Ethics Board
approved this study on 4 November 2008.
Prior to practising on the wards, pharmacists received
training on best practices for medication management of sur-
gical patients in our institution. Clinical services were pro-
vided to post-operative patients on weekdays from 06.30 to
14.30. The pharmacists actively participated in patient care
rounds with the surgeons and nurses, in addition to obtaining
medication histories, conducting medication reconciliation
and counselling patients. Pharmacists practised within their
scope of practice according to published Canadian clinical
pharmacy standards.[17,18]
Interventions
Pharmacists documented all interventions on new forms
developed for the study, including the acceptance rate, the
type of drug therapy problem, the severity of the problem, the
value of the intervention and the probability that the inter-
vention avoided an ADE. Patient-specific data were not rec-
orded. Cost avoidance was calculated for interventions if the
prescriber accepted the recommendation; if the severity was
© 2013 Royal Pharmaceutical Society
217
significant, serious or potentially lethal; and if it was an inpa-
tient intervention. Interventions made at discharge were
excluded. For patients with multiple interventions, only the
intervention with the highest probability value was included
in the analysis.
An ADE was defined as the harm caused by the use of a
drug[19] and the harm from the absence of a drug to include
identified untreated indications. Drug therapy problems were
assigned Hepler and Strand[20] categories and rated for sever-
ity and value.[21] Severity categories were potentially lethal,
serious, significant, minor and no error. The value (or impor-
tance) of the intervention was defined as extremely signifi-
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cant, very significant, significant, somewhat significant, no
significance and of adverse significance.[21] The pharmacist
used their professional judgement and the literature to assign
a probability of an ADE occurring if no intervention took
place, according to a published scale.[22] The probability
values were zero, 0.01, 0.1, 0.4 and 0.6.[22] In our study, a
score of 1 was assigned if an ADE was already occurring
which necessitated the intervention (e.g. patient experiencing
post-operative pain and not receiving adequate analgesics).
Costs
Cost avoidance was based on the actual cost of preventable
ADEs published in a US study,[23] which has been utilized
in other research to measure a pharmacist’s economic
impact.[12,22,24] Two methods were used to calculate avoided
cost: additional LOS and total cost of an ADE. Patients stayed
an additional 4.6 days if they experienced a preventable
ADE.[23] The LOS was multiplied by CA$781, the average cost
per day on the two general surgical wards in 2008, for a total
cost of $3592.60 (low cost). For the high cost, a preventable
ADE was US$4685 in 1993 for hospital charges (pharmacy,
laboratory and surgical costs) and additional LOS depending
on the type of care (intensive, intermediate or routine).[23]
The figure was updated to 2008 using a factor of 1.54 from
the US consumer price index for medical care services, or
CA$7214.90. Costs were not adjusted to achieve purchasing
power parity as this may not apply to healthcare costs in dispar-
ate systems such as those of Canada and the USA.[25] It may also
inflate costs, as the purchasing power parity was 1.21 ($1.21 in
Canada theoretically purchased the same basket of healthcare
goods as $1 in the USA). The economic evaluation was under-
taken from the institutional perspective.
A benefit/cost ratio was determined based on the instit-
ution’s pharmacist salary at the top pay scale in 2008 plus
15% benefits. Cost savings were calculated when pharmacists
recommended therapy that was less costly than the original
by determining the difference in daily cost, multiplied by the
number of days of therapy. Actual hospital drug costs in 2008
were used. By convention, route-of-administration changes
from intravenous to oral therapy were calculated for 48 h.
International Journal of Pharmacy Practice 2014, 22, pp. 216–222
218 Post-surgical clinical pharmacy services

Table 1 Examples of agreed ratings for clinical interventions by surgical care pharmacists

Probability
Drug therapy problem Clinical intervention Example of Severity[21] Value[21] of avoiding ADE[22]

Patient has signs of sepsis Recommend starting Drug therapy required, potentially Potentially Extremely 0.6
(decreased blood pressure, broad-spectrum intravenous life-threatening consequences lethal significant
increased WBC, fever, antibiotic
tachycardia) and not
receiving antibiotics
Both dalteparin and warfarin Discontinue dalteparin Duplicate drug therapy with Serious Significant 0.4
prescribed on discharge, serious consequences
patient has INR in
therapeutic range

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Patient has increased pain Recommend adding regular doses Patient symptomatic, not Significant Significant 1
after surgery of oral acetaminophen receiving adequate drug
(paracetamol) and ibuprofen treatment
Medication prescribed at Recommend different medication Patient ordered drug on discharge Minor Somewhat 0.1
discharge but not covered from same class that is covered not covered by drug insurance significant
by patient’s insurance by insurance

ADE, adverse drug event; INR, international normalized ratio; PO, oral; WBC, white blood cell.

Box 1 Clinical interventions assigned standard (Box 1) and actual clinical interventions were reviewed and
values for severity, value and probability of discussed (Table 1).
avoiding an adverse drug event
Clinical Severity[21] Value[21] Probability[22] Analysis
intervention
All data were entered into Microsoft Excel for descriptive
Step down Minor Somewhat 0.1 summary statistics. The kappa statistic for inter-rater reliabil-
from significant ity was calculated for the initial ratings from the two review-
intravenous to ers.[26] Correlations were analysed in SPSS (version 15.0;
the oral route SPSS, Chicago, IL, USA). A post hoc sensitivity analysis was
Changing the Minor Somewhat 0.1 conducted to explore the robustness of the cost-avoidance
discharge significant estimates.
prescription to
a proton-pump
inhibitor Results
covered by the The surgery wards received 201 days of clinical pharmacy ser-
patient’s drug vices. Pharmacists made 1097 interventions (mean 5.4 per
insurance day) for 66.4% of all patients (446/672; mean 1.6 interven-
Drug cost No error No 0 tions per patient) of which 1075 (98%) were accepted by
savings only significance the surgeons. Drug therapy problem categories are listed
in Table 2, and severity, value and probability ratings are
depicted in Figure 1. The independent reviewers disagreed
with only one intervention made by the surgical care pharma-
During the study each intervention was removed of iden- cists. A patient was prescribed oral cloxacillin and experi-
tifying data and independently reviewed and scored for enced gastrointestinal discomfort. The pharmacist suggested
severity, value and probability by two clinical pharmacy spe- taking the cloxacillin with food, which would have decreased
cialists. Their ratings were compared to the surgical care drug absorption, and the reviewers felt the antibiotic should
pharmacist’s coding and were considered in agreement if all have been changed instead.
three values were within one unit of each other. The mode
was taken as the final value. Consensus was obtained for
Ratings consensus
interventions that had values greater than one unit different
from the other. At the beginning of the data-collection Initial ratings assigned by the two reviewers were identical:
period pharmacists were provided instruction in the rating 59% of the time for severity, 57% for value and 48% for prob-
scheme to encourage consistency. Standard interventions ability. Kappa statistics were 0.33, 0.28 and 0.29, respectively,

© 2013 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2014, 22, pp. 216–222
Heather L. Neville et al. 219

Table 2 Drug therapy problems identified by surgical care pharmacists indicating poor inter-rater reliability.[26] Using the a priori
over 6 months definition of agreement being the same or within one unit of
Drug therapy problem Number (%) the other reviewer, agreement increased to 96, 95 and 82%,
1. Untreated indication 144 (13)
respectively.
2. Drug use without indication 83 (8)
Costs
3. Improper drug selection 99 (9)
4. Sub-therapeutic dosage 103 (9) Drug cost savings of CA$19 790 resulted from intravenous-
5. Potentially excessive dose 88 (8) to-oral step-down therapy and the use of patient’s own medi-
6. Failure to receive drug 247 (23)
cations for drugs not stocked by the hospital. Cost avoidance
7. Adverse drug reaction 17 (2)
8. Drug interaction 10 (1)
ranged from CA$676 990 (low cost) to $1 359 576 (high cost)
9. Inappropriate route 209 (19) and 866.8 days in hospital were avoided (Table 3). For all
patients admitted to surgery, CA$1518–3048 in costs and 1.94

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10. Drug allergy 10 (1)
11. Other* 87 (8) days were avoided per patient. Each clinical intervention
Total 1097 avoided CA$617–1239. The highest annual salary including
*Other were clarifying home medication orders, solving discharge pre- benefits for a pharmacist in 2008 was CA$95 060, which
scription issues and making changes to total parenteral nutrition orders. resulted in a benefit/cost ratio range of 7:1–14:1.

Figure 1 Severity, value and probability ratings of clinical interventions, n = 1097.

Table 3 Additional days of hospitalization and costs avoided for eligible clinical interventions* (Canadian dollars)

Number of Days avoided Costs avoided Costs avoided

Probability interventions (days) (low) (high)

Unit value of one ADE avoided 4.6 $3592.60 $7214.90

1 135 621 $485 001.00 $974 011.50
0.6 34 93.8 $73 289.04 $147 183.96
0.4 69 126.96 $99 155.76 $199 131.24
0.1 54 24.84 $19 400.04 $38 960.46
0.01 4 0.184 $143.72 $288.60
Total 296 866.8 $676 989.56 $1 359 575.76

ADE, adverse drug event.

*Eligible interventions were recommendations accepted by the prescriber; rated significant, serious or potentially lethal in severity; inpatient interven-
tions; and if the patient had multiple interventions, only the one with the highest probability value was included.

© 2013 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2014, 22, pp. 216–222
220
Table 4 Sensitivity analysis for additional days of hospitalization and costs avoided for clinical interventions (Canadian dollars)
Number of
Probability interventions
Unit value of one ADE avoided
1 135
0.6 34
0.4 69
0.1 54
0.01 4 0.14
Total 296
ADE, adverse drug event.
Sensitivity analysis
Variation in cost estimates was explored by replacing the mode
for probability with the lowest probability value assigned by
the two reviewers. Cost avoidance decreased by 52% to
CA$324 017 (low cost) and $650 712 (high cost) with a corre-
sponding drop in the benefit/cost ratio to 3:1–7:1. Additional
LOS was replaced with a more conservative 3.4 days from a
2005–2006 US study published in 2012 (Table 4).[27]
Discussion
Surgical care pharmacists performed 1097 clinical interven-
tions over 6 months, resolving drug therapy problems such as
the failure to receive drug, inappropriate route of administra-
tion and untreated indication. Estimates for cost avoidance
were CA$0.68–1.36 million and 867 days avoided in hospital.
For every dollar spent on a pharmacist’s salary,$7 was avoided.
Our study provides evidence that clinical pharmacists
make significant and valuable contributions to the care of
surgical patients in Canadian hospitals. Prospective data col-
lection over 6 months provided an extensive database of clini-
cal pharmacy interventions from which to estimate their
economic value. We applied a consistent framework for
assessing severity, value and probability of avoiding ADEs by
using previously published scales. Common interventions
were standardized and two clinical pharmacy specialists not
involved in the care of the surgical patients rated the interven-
tions independently.
The study had an observational, uncontrolled single-
centre design, which limits its generalizability to other insti-
tutions. Resource constraints and the lack of a comparable
general surgical service did not allow for a retrospective
matching of patients on a service without a clinical pharma-
cist. In addition, conducting a before-and-after study was not
practical as it would have meant delaying the start date.
The methodology used for rating interventions was
obtained from published literature but not validated.Pharma-
cists used their professional judgement in rating interven-
tions, which may be subject to bias and affect internal validity.
© 2013 Royal Pharmaceutical Society
Post-surgical clinical pharmacy services
Days avoided Costs avoided
(days) (low)
3.4 $2 655.40
459 $358 479.00
69.36 $54 170.16
93.84 $73 289.04
18.36 $14 339.16
$106.22
640.7 $500 383.58
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Inclusion of a physician evaluator may have provided a com-
plementary perspective.[28,29] In addition, one of the surgical
care pharmacists and the two evaluators were investigators in
the study, which could be a source of bias. The impact of other
healthcare providers who may have intervened in the absence
of a pharmacist was not measured. The cost-avoidance meth-
odology has been replicated in US studies,[12,22,24] but may not
be generalizable to Canada.[25] Additional costs due to phar-
macist recommendations to start drug therapy or request
laboratory levels were not included in the study and it is
unknown how these costs might influence the economic
estimates.
Our study is comparable to other research with similar
methodology. Kopp et al.[24] evaluated 129 interventions by a
0.5 full-time-equivalent (FTE) pharmacist in a surgical inten-
sive care unit setting. The authors used the same costs of an
ADE from 1993 updated to 2004. Based on data published in
the report, each intervention would avoid US$1596–2174
(separate calculations by two evaluators), higher than our
estimation of CA$617–1233.[24] Olson et al.[30] also used 1993
costs updated to 2001 for interventions made for hospital
inpatients. However, pharmacists only documented interven-
tions that were serious or very serious and most likely to have
prevented ADEs resulting in patient harm and increased
costs. The authors calculated US$1801 avoided per interven-
tion.[30] Finally, Lee et al.[28] found that each inpatient inter-
vention in 1999 produced US$1057 in cost avoidance when a
pharmacist and a physician reviewed and assigned probabil-
ities of avoiding an ADE.
The literature also contains examples of cost avoidance
for pharmacists’ interventions with lower estimates.[22,31,32]
Nesbit et al.[22] reported 4959 interventions in haematology/
oncology, intensive care unit and general medicine beds over
a period of 1 year by three FTE pharmacists. They developed
their own method for calculating the probability of avoiding
an ADE (replicated in this study), used the 1993 cost updated
to the year 2000 and concluded that each intervention
avoided US$98 in costs. Likewise, Mutnick et al.[32] estimated
US$34 per intervention, based on 4648 interventions, using
diagnosis-related group data to estimate changes in LOS. The
International Journal of Pharmacy Practice 2014, 22, pp. 216–222
Heather L. Neville et al. 221

higher estimate in our study may be due a probability of 1
(full cost avoidance) assigned to interventions where patients
were actually experiencing ADEs. The varied results are also
likely due to differences in methodology, hospital setting,
patient population and time period. The conservative
benefit/cost ratio of 7:1 falls within the ranges published in a
recent review.[5] Benefit/cost ratios of clinical pharmacy ser-
vices were reported to range from 3:1 to 35:1 for hospitals
only and a pooled median benefit/cost ratio was 4.8:1 for all
practice sites.[5]
Practically, cost avoidance implies that hospitals can treat
more patients, reduce waiting times and improve patient flow
This study provides information that may support the expan-
sion of clinical pharmacy services to more surgical patient
populations. Further research on patient outcomes such as
LOS, rehospitalization rates and patient satisfaction would
provide additional evidence of a surgical care pharmacist’s
impact on quality of care. The inclusion of clinical pharma-
cists in surgical wards may result in CA$7 in savings for every
$1 invested.
Declarations

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to reduce hospital stays and rehospitalizations.[1–4] Specific to
this patient population, our study indicates that pharmacists
provide much needed post-surgical direct patient care. In
many Canadian hospitals, clinical pharmacy services dedi-
cated to surgical programmes appear to be underdeveloped.
Only 62% of hospitals reported having a clinical programme
in general surgery in a 2009–2010 national survey, compared
to over 80% in geriatric, transplant and adult critical care.[33]
This study resulted in permanent funding of two clinical
pharmacist positions in our institution.
Our research suggests that excess LOS due to ADEs may be
a better method to estimate costs across disparate health
systems and currencies. Individual hospitals can multiply
LOS by the local cost for one day’s stay. Estimates from US
studies range from 1.2 to 4.6 days[23,27,34–37] and in European
countries from 2.3 to 3.5 days.[38,39] Canadian data are limited
to all adverse events (not just drug-related) where excess LOS
has been estimated at 6.0 days.[15] More research is needed to
standardize cost-avoidance methods to improve consistency
in pharmacy practice evaluation.
Conclusions
Clinical pharmacy services on surgical wards have the poten-
tial to improve patient outcomes and avoid healthcare costs.
Conflict of interest
The Author(s) declare(s) that they have no conflicts of inter-
est to disclose.
Funding
This work was supported by a Canadian Society of Hospital
Pharmacists Research and Education Foundation grant.
Acknowledgements
We wish to thank surgery pharmacists Sophie Poirier and
Brent Hawrylak and the surgery health service manager
Sandra Westhaver for their support of the project. We also
wish to acknowledge Amanda Jacques and Pawlina Dexter,
pharmacy students, for their assistance with the research.
Authors’ contributions
All authors have made substantial contributions to conception
and design, acquisition of data, or analysis and interpretation
of data; all have drafted or revised the article critically; and all
have given final approval of the version to be published.

References 4. Bond CA et al. Interrelationships interventions. Int J Pharm Pract 2001;

1. De Rijdt T et al. Economic effects of
clinical pharmacy interventions: a lit-
erature review. Am J Health Syst Pharm
2008; 65: 1161–1172.
2. Kaboli PJ et al. Clinical pharmacists
and inpatient medical care: a systematic
review. Arch Intern Med 2006; 166: 955–
964.
3. Bond CA, Raehl CL. Clinical pharmacy
services, pharmacy staffing, and hospi-
tal mortality rates. Pharmacotherapy
2007; 27: 481–493.
among mortality rates, drug costs,
total cost of care, and length of
stay in United States hospitals:
summary and recommendations for
clinical pharmacy services and staff-
ing. Pharmacotherapy 2001; 21: 129–
141.
5. Perez A et al. ACCP: economic evalu-
ations of clinical pharmacy services:
2001–2005. Pharmacotherapy 2008; 28:
285e–323e.
6. Harris L et al. Effect of pharmaceuti-
cal pre-assessment on post-operative
9(Suppl.): R32–R32.
7. Hick HL et al. The impact of the phar-
macist on an elective general surgery
pre-admission clinic. Pharm World Sci
2001; 23: 65–69.
8. Kwan Y et al. Pharmacist medication
assessments in a surgical preadmission
clinic. Arch Intern Med 2007; 167:
1034–1040.
9. Buck TC et al. The effects of introduc-
ing a clinical pharmacist on ortho-
paedic wards in Denmark. Pharm
World Sci 2007; 29: 12–18.

© 2013 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2014, 22, pp. 216–222
222
10. Weiner BK et al. Towards the reduction
of medication errors in orthopedics
and spinal surgery: outcomes using a
pharmacist-led approach. Spine (Phila
Pa 1976) 2008; 33: 104–107.
11. Bond CA, Raehl CL. Clinical and
economic outcomes of pharmacist-
managed antimicrobial prophylaxis in
surgical patients. Am J Health Syst
Pharm 2007; 64: 1935–1942.
12. Leape LL et al. Pharmacist participa-
tion on physician rounds and adverse
drug events in the intensive care unit.
JAMA 1999; 282: 267–270.
13. Thompson CA. Surgical units have
high potential for harmful medication
errors, USP says. Am J Health Syst
Pharm 2007; 64: 917–920.
14. de Vries EN et al. The incidence and
nature of in-hospital adverse events: a
systematic review. Qual Saf Health Care
2008; 17: 216–223.
15. Baker GR et al. The Canadian adverse
events study: the incidence of adverse
events among hospital patients in
Canada. CMAJ 2004; 170: 1678–1686.
16. Bratzler DW, Hunt DR. The surgical
infection prevention and surgical care
improvement projects: national initia-
tives to improve outcomes for patients
having surgery. Clin Infect Dis 2006; 43:
322–330.
17. Canadian Society of Hospital Pharma-
cists (CSHP). CSHP 2015 – a Practice
Excellence Initiative for Pharmacists
in Hospitals and Related Healthcare
Settings. 2011. http://www.cshp.ca/
programs/cshp2015/docs/CSHP2015
GoalsandObjectivesStatusReport
May2011.pdf (accessed 26 July 2012).
18. Canadian Society of Hospital Pharma-
cists. Professional Hospital Pharmacy
Practice: Standards. Ottawa, ON: Cana-
dian Society of Hospital Pharmacists,
2003.
19. Nebeker JR et al. Clarifying adverse
drug events: a clinician’s guide to
© 2013 Royal Pharmaceutical Society
terminology, documentation, and re-
porting. Ann Intern Med 2004; 140:
795–801.
20. Hepler CD, Strand LM. Opportunities
and responsibilities in pharmaceutical
care. Am J Hosp Pharm 1990; 47: 533–
543.
21. Overhage JM, Lukes A. Practical,
reliable, comprehensive method for
characterizing pharmacists’ clinical
activities. Am J Health Syst Pharm 1999;
56: 2444–2450.
22. Nesbit TW et al. Implementation and
pharmacoeconomic analysis of a clini-
cal staff pharmacist practice model. Am
J Health Syst Pharm 2001; 58: 784–
790.
23. Bates DW et al. The costs of adverse
drug events in hospitalized patients.
JAMA 1997; 277: 307–311.
24. Kopp BJ et al. Cost implications of and
potential adverse events prevented by
interventions of a critical care pharma-
cist. Am J Health Syst Pharm 2007; 64:
2483–2487.
25. Deber R, Swan B. Canadian health
expenditures: where do we really
stand internationally? CMAJ 1999; 160:
1730–1734.
26. Gordis L. Epidemiology, 2nd edn.
Philadephia, PA: W.B. Saunders
Company, 2000: 308.
27. Hug BL et al. The costs of adverse drug
events in community hospitals. Jt
Comm J Qual Patient Saf 2012; 38: 120–
126.
28. Lee AJ et al. Clinical and economic out-
comes of pharmacist recommenda-
tions in a veterans affairs medical
center. Am J Health Syst Pharm 2002;
59: 2070–2077.
29. Bosma L et al. Evaluation of pharma-
cist clinical interventions in a Dutch
hospital setting. Pharm World Sci 2008;
30: 31–38.
30. Olson LM et al. Evaluation of phar-
macists’ interventions at a university
International Journal of Pharmacy Practice 2014, 22, pp. 216–222
Post-surgical clinical pharmacy services
teaching hospital. Can J Hosp Pharm
2005; 58: 20–25.
31. Dooley MJ et al. A prospective
multicentre study of pharmacist initi-
ated changes to drug therapy and
patient management in acute care gov-
ernment funded hospitals. Br J Clin
Pharmacol 2004; 57: 513–521.
32. Mutnick AH et al. Cost savings and
avoidance from clinical interventions.
Am J Health Syst Pharm 1997; 54: 392–
396.
Downloaded from https://academic.oup.com/ijpp/article/22/3/216/6101894 by guest on 03 February 2022
33. Hospital Pharmacy in Canada Edi-
torial Board. Hospital Pharmacy in
Canada 2009/2010 Report. 2010. www
.lillyhospitalsurvey.ca/hpc2/content/
2010_report/2009_2010_full_E.pdf
(accessed 26 July 2012).
34. Classen DC et al. Adverse drug events
in hospitalized patients. Excess length
of stay, extra costs, and attributable
mortality. JAMA 1997; 277: 301–306.
35. Kucukarslan SN et al. Pharmacists on
rounding teams reduce preventable
adverse drug events in hospital general
medicine units. Arch Intern Med 2003;
163: 2014–2018.
36. Senst BL et al. Practical approach to
determining costs and frequency of
adverse drug events in a health care
network. Am J Health Syst Pharm 2001;
58: 1126–1132.
37. Terceros Y et al. Impact of a pharmacy
resident on hospital length of stay and
drug-related costs. Ann Pharmacother
2007; 41: 742–748.
38. Dormann H et al. Incidence and costs
of adverse drug reactions during hospi-
talisation: computerised monitoring
versus stimulated spontaneous report-
ing. Drug Saf. 2000; 22: 161–168.
39. Vargas E et al. Effect of adverse drug
reactions on length of stay in surgical
intensive care units. Crit Care Med
2003; 31: 694–698.