2444 Am J Health-Syst Pharm Vol 56 Dec 1 1999 Reports Clinical activities Practical, reliable, comprehensive method for characterizing pharmacists’ clinical activities J. MARC O VERHAGE AND ANITA LUKES Abstract: A method for rat- ing the value of pharmacists’ clinical services was studied. An instrument was devel- oped to measure the severity of medication errors and the value of pharmacists’ clinical interventions. Pharmacists at a hospital pharmacy depart- ment used the instrument at the time they made an inter- vention. A single pharmacist reviewed and adjusted the scores assigned by the phar- macist who made the inter- vention. An expert panel consisting of two clinical J. MARC OVERHAGE, M.D., PH.D., is Scientist, Regenstrief Institute for Health Care, and Assistant Professor of Medicine, Indiana University School of Medicine, Indianapolis. ANITA LUKES, PH ARM.D., is Clinical Pharmacist, Pharmacy Department, Wishard Memorial Hospital, Indianapolis. Address reprint requests to Dr. Overhage at the Regenstrief Institute for Health Care, 1001 West 10th Street, RHC 5th Floor, Indianapolis, IN 46202, or to marc@falcon.iupui.edu. The assistance of the following is acknowledged: Bonnie Finn, Pharm.D., and David Rudy, M.D., for rating the pharmacists’ interventions; Denise Haines and Michael Murray, Pharm.D., for their comments on the manuscript; and John Gaebler, M.D., for helping develop the scales. Supported by grants R01-HS07763 and R01-HS07719 from the Agency for Health Care Policy and Research. Copyright © 1999, American Society of Health-System Phar- macists, Inc. All rights reserved. 1079-2082/99/1201-2444$06.00. pharmacists and two physi- cians also scored all the inter- ventions using the same instrument. All rankings were compared using κ (kappa) and weighted κ statistics, and symmetry tests were applied to examine whether specific raters consistently rated high- er or lower than other raters. Data were extracted from the pharmacy department’s inter- vention database to rate 300 interventions. Agreement between the rat- ers was substantial, both overall and for each dimen- sion individually. However, the physicians rated severity of error and value of service lower than their pharmacist counterparts. The study indi- cated that severity of error and value of service are clear- ly related, but not linearly. Services can be identified as high value even when there are no prescribing errors. Pharmacists found the instru- ment usable and practical. A literature-based instru- ment for simultaneously as- sessing the severity of errors in medication orders and the value of pharmacists’ inter- ventions was constructed, tested in a hospital, and de- termined to be reliable. Index terms: Administra- tion; Documentation; Errors, medication; Interventions; Pharmaceutical services; Pharmacists, hospital; Phar- macy, institutional, hospital; Records Am J Health-Syst Pharm. 1999; 56:2444-50 he role of pharmacists in health care delivery continues to evolve beyond dispensing and di- rectly related activities. 1,2 There are several rea- sons for characterizing pharmacists’ clinical activities, including obtaining additional resources, 3 justifying the cost of providing the services, 4 obtaining reim- bursement, identifying systematic problems in care processes, and measuring the impact of organizational and process changes both internal and external to the pharmacy. To serve these different needs, the method used to characterize pharmacists’ clinical activities must be practical and valid and must capture all rele- vant aspects of clinical activities. If a consistent method is adopted for use by many institutions, our ability to compare information will be greatly enhanced. Many of the methods already in use for characterizing phar- macists’ interventions do not fulfill these require- ments. Most methods described in the literature are practical, but few 5 are valid or address the value of clinical activities beyond interventions in medication errors. Furthermore, only one method discussed in the literature has been applied to several studies. Prescribing errors are frequent and costly, as docu- mented in a number of studies in various settings. 6-9 Some prescribing errors result in adverse drug events, which are the most common type of adverse events experienced by patients in hospitals. 10 Pharmacists iden- tify and prevent many prescribing errors. Errors not prevented can adversely affect care processes, increase costs, and produce suboptimal therapeutic effects. 11-16 The literature on pharmacists’ cognitive services focuses on the classification of errors, which are identified with scales reflecting the type of error (e.g., dosage error, timing error), the underlying reasons the error occurred, and the potential for harm to the patient. 8,9,17,18 In addition to preventing prescribing errors, phar- macists provide cognitive services, including therapeu- tic drug monitoring, drug-use review, physician educa- tion, and (in some settings) disease management. 19-21 These cognitive services do not derive from prescribing errors and may need to be valued separately. To create a method for characterizing pharmacists’ clinical services that is practical and valid and that measures the value of pharmacists’ services, we re- T