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Farmacia Hospitalaria

versión On-line ISSN 2171-8695versión impresa ISSN 1130-6343

Farm Hosp. vol.42 no.5 Toledo sep./oct. 2018 


Hospital Pharmacy and Critical Care Medicine: a necessary alliance

María Cruz Martín-Delgado1  , Miguel Ángel Calleja-Hernández2 

1President of Spanish Society of Intensive and Critical Medicine and Coronary Units (SEMICYUC). Critical Care Unit, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain.

2President of the Spanish Society of Hospital Pharmacy (SEFH). Hospital Pharmacy Unit, Hospital Universitario Virgen Macarena, Seville, Spain.

Critical Care Medicine represents one of the main components of modern healthcare systems. Its objective is to offer critical patients health care adapted to their needs, with good quality, and in the safest way possible, ensuring that it is adequate, sustainable, ethical, and respects patient autonomy1.

Pharmacotherapy in critical patients is complex, and characterized by polymedication and high-risk drugs with intravenous administration, with frequent modifications. Besides, changes in distribution volumes will determine pharmacokinetics and pharmacodynamics. Therefore, given the severity and complexity of critical patients, there is a higher risk of suffering harm due to adverse events and medication errors2. It is worth highlighting that the multicenter study SYREC “Safety and Risk in Critical Patients”, developed in Spain, showed a 62% likelihood of suffering at least one incident associated with safety, just by being hospitalized in a Intensive Care Unit (ICU); the most frequent were drug-related, and 90% of all incidents were classified as avoidable or potentially avoidable3. Moreover, in a post hoc analysis, it was observed that there was a 22% risk of suffering a medication error while hospitalized in a ICU (IQR: 8%, 50%). The conclusion of said study was that 16% of medication errors will harm the patient, and 82% of these are avoidable4.

In the setting of the multiple institutional initiatives for promoting safety patient, a great number of Scientific Societies have adopted the Declaration of Vienna, which confirms the commitment by professionals involved in critical patient care for an improvement in quality and safety of care5. The World Health Organization (WHO) has implemented in 2017 the third challenge on Patient Safety: Safe Medication, with the objective to reduce by 50% those avoidable severe damages associated with drug-related adverse events within the next 5 years6.

There is strong evidence supporting a multidisciplinary approach in ICUs in order to achieve quality care. In this sense, the review by Donovan et al. underlines the importance of each professional that can be a member of the ICU team7.

According to the Society of Critical Care Medicine (SCCM), ideal critical care includes a multidisciplinary team, and it is recommended to include a Pharmacist (Grade C of Recommendation)8. Different studies have shown the benefits of the presence of a Pharmacist in the ICU, in terms of a reduction in prescription errors and adverse events9,10, reduction in hospital stay, reduction in drug-related costs (lower use of anaesthetics and antimicrobial agents)11, detection of drug-related errors, and sorting out questions by nurses and physicians1. There are have been experiences in our country demonstrating that the presence of a Pharmacist in the ICU allows to detect areas for improvement and determine protocols to guarantee patient safety and the efficacy of pharmacological treatments, with a high rate of acceptance of these interventions by the rest of Intensive Care professionals12. However, regardless of the evidence supporting the presence of a Pharmacist in the ICU, the truth is that in Spain there has been a low presence of the Pharmacist in said hospital units.

An international study based on a study to describe the activities conducted by Pharmacists in ICUs reached the conclusion that the Pharmacist is involved in a wide variety of activities: more than half of Pharmacists took part in medical visit rounds, and a small percentage was involved in the preparation of intravenous agents and parenteral nutrition13. The positioning document prepared jointly by the SCCM and the American College of Clinical Pharmacy, with the objective to define the scope of action of Pharmacists in ICUs, lists the activities that could or should be conducted by them14, as well as their responsibilities5:

- Prescription validation (indication, dose, way of administration, formulation, drug-drug and drug-food interactions, allergies, etc.) in order to maximize cost-benefit, review of the pharmacotherapeutical record, and interview with patients and relatives / caregivers to obtain the most accurate information possible.

- Detection, evaluation and report of adverse effects.

- Management of parenteral and enteral nutritional support.

- Drug monitoring to optimize the therapy.

- Scientific-technical information about medications, compatibilities and stabilities.

- Development and implementation of protocols and guidelines regarding medication.

- Pharmacotherapeutical training for other team members.

- Collaboration with physicians and nurses in research projects.

- Minimizing drug-related costs.

Clinical Practice Guidelines have recently been published, dealing with the safe use of medication in ICUs15. These guidelines review the strategies that improve safety throughout the medication process (prescription, distribution, administration and monitoring), and the future areas for research in the critical patient setting. The safe use of medication, with the objective to reduce avoidable adverse events, requires a multimodal strategy, where the profile of the Pharmacist integrated in the multidisciplinary team will offer additional value. For this aim, collaborative strategies are necessary, where different disciplines and specialties will work proactively as a team, identifying the risks and offering the best patient care.

In this setting, a Collaboration Agreement has been signed between the Spanish Society of Intensive and Critical Medicine and Coronary Units (SEMICYUC) and the Spanish Society of Hospital Pharmacy (SEFH), which will be the setting for the development of common projects. Said agreement determines collaboration scenarios in the training and research areas, in the processes for guaranteeing professional quality, as well as in the patient care setting. This collaboration will allow to promote the safe use of medication in the critical patient, to implement recommendations and clinical practice guidelines, to delve into the epidemiology of drug-related errors and adverse events, to develop projects on pharmacogenetics, pharmaco-dynamics and pharmacoeconomics, and to promote specific competences through continuous training.


World Federation of Societies of Intensive and Critical Care Medicine, Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, European Society of Intensive Care Medicine, Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias, Société de Réanimation de Langue Française. Santander Statement: Intensive Care Medicine. Patientcentered care for the critically ill (Monografía en internet) Santander, 11 de junio de 2012 (citado 1/06/2018). Disponible en: ]

Johansen ET, Stine MH, Ann SM, Lars MY. Effects of implementing a clinical pharmacist service in a mixed Norwegian ICU. Eur J Hosp Pharm. 2016;23(4):197-202. DOI: 10.1136/ejhpharm-2015-000751 [ Links ]

Merino P, Álvarez J, Cruz Martín M, Alonso Á, Gutiérrez I. Adverse events in Spanish intensive care units: the SYREC study. Int J Qual Health Care. 2012;24(2):105-13. DOI: 10.1093/intqhc/mzr083 [ Links ]

Merino P, Martin MC, Alonso A, Guitierrez I, Alvarez J, Becerril F. Errores de medicación en los servicios de Medicina Intensiva españoles. Med Intensiva. 2013;37(6):391-9. DOI: 10.1016/j.medin.2012.11.002 [ Links ]

Moreno RP, Rhodes A, Donchin Y, European Society of Intensive Care. Patient safety in intensive care medicine: the Declaration of Vienna. Intensive Care Med. 2009;35(10):1667-72. DOI: 10.1007/s00134-009-1621-2 [ Links ]

World Health Organization. Medication Without Harm-Global Patient Safety Challenge on Medication Safety (Monografía en internet). Geneva: World Health Organization, 2017. Licence: CC BY-NC-SA 3.0 IGO (citado 1/06/2018). Disponible en:;jsessionid=E03C4B92B0 4568ADBF7A2A4235D597BE?sequence=1Links ]

Donovan AL, Aldrich JM, Gross AK, Barchas DM, Thornton KC, Schell-Chaple HM, et al. Interprofessional Care and Teamwork in the ICU. Crit Care Med. 2018;46(6):980-90. DOI: 10.1097/CCM.0000000000003067 [ Links ]

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Klopotowska JE, Kuiper R, van Kan HJ, de Pont AC, Dijkgraaf MG, Lie-A-Huen L, et al. On-ward participation of a hospital pharmacist in a Dutch intensive care unit reduces prescribing errors and related patient harm: an intervention study. Crit Care. 2010;14(5):R174. DOI: 10.1186/cc9278 [ Links ]

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Franco Sereno MT, Pérez Serrano R, Ortiz Díaz-Miguel R, Espinosa González MC, Abdel-Hadi Álvarez H, Ambrós Checa A, et al. Pharmacist Adscription To Intensive Care: Generating Synergies. Med Intensiva. (pendiente de publicación, aceptado marzo 2018). DOI: 10.1016/j.medin.2018.02.006 [ Links ]

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Kane-Gill SL, Dasta JF, Buckley MS, Devabhakthuni S, Liu M, Cohen H, et al. Clinical Practice Guideline: Safe Medication Use in the ICU. Crit Care Med. 2017 Sep;45(9):e877-e915. DOI: 10.1097/CCM.0000000000002533 [ Links ]

Received: July 17, 2018; Accepted: August 02, 2018

Autor para correspondencia. Correo electrónico: (María Cruz Martín-Delgado.).

Conflict of interests No conflict of interests.

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