Practice and Perception of Pharmacist Intervention Documentation in Saudi Arabia

Yousef Ahmed Alomi*, BSc. Pharm, MSc. Clin Pharm, BCPS, BCNSP, DiBA, CDE, Critical Care Clinical Pharmacists, TPN Clinical Pharmacist, Freelancer Business Planner, Content Editor and Data Analyst, Riyadh, Saudi Arabia. Elaf Mohamad Faraj, Director of Pharmaceutical Services, Fakeeh Care Services, Jeddah, Saudi Arabia. Asma Al-Dosari, Pharm D, College of Pharmacy, Prince Nora University, Riyadh, Saudi Arabia. Asmaa Al-Fifi, Pharm D, College of Pharmacy, Prince Nora University, Riyadh, Saudi Arabia. Razan Al-Dossari, Pharm D, College of Pharmacy, Prince Nora University, Riyadh, Saudi Arabia. Haya Fahad bin Omar, Pharm D, College of Pharmacy, Prince Nora University, Riyadh, Saudi Arabia. Huda Al-Jaziri, Pharm D, College of Pharmacy, Prince Nora University, Riyadh, Saudi Arabia.


INTRODUCTION
In the hospital setting, there is a need to document the interventions provided for continuity and productivity of the hospital. The hospital must document the medications provided to make a permanent record. This is an important part of communication between all healthcare providers including pharmacists to continue medical care based on the level of care provided. However, the pharmacist documentation system can measure the workload and ensure accountability necessary for medico-legal reasons, take responsibility for the pharmacist's role in direct patient care improving the quality of care. 1 Moreover, another systematic review in an inpatient setting of the ICU showed that preventable ADRs decreased by 66%, another study that focused on antibiotic choice, dosing and drug administrations showed a mean of cost-saving of 400$. 2 Another study was conducted to evaluate a school-wide, webbased clinical intervention system to document types and impact of pharmacy students through clinical activities during the advanced pharmacy practice experiences. All pharmacy students were trained to document interventions appropriately. Over a period of 3 years of data collection, approximately 15,393 interventions were documented. More than 5000 interventions were documented as having a long-term impact and about 4000 were documented as having an immediate impact on cost.. In this study, students documented prevention of about 4222 potential ADRs and more 1000 medication errors in the general medical setting. All interventions prevented potential ADRs, which our study also demonstrated with the use of manual method. 3 All these studies show that documentation of the intervention by the pharmacist will benefit the healthcare system in terms of cost avoidance and clinical impact and will provide a better outcome for patients in terms of prevention of medication errors and ADRs. However, the practice of pharmacist intervention documentation has not been discussed in the previous studies. Another various local studies showed the pharmacist in- Alomi YA, et al.: Practice and Perception of Pharmacist Intervention in Saudi Arabia tervention documentations at healthcare institutions in Saudi Arabia. 4-7 Various international and a few local studies conducted on practice of pharmacist intervention documentation discuss the practice and perception of pharmacist intervention documentation. [8][9][10][11][12][13][14][15][16] Therefore, in this study, we aimed to investigate the practice and perceptions of pharmacist intervention documentation in the KSA.

METHODS
This is a 4-month cross-sectional self-administered survey of documentation of pharmacist intervention. It consists of two parts: the first part collects demographic information and the second part comprises of a questionnaire with a total of 18 questions. The domains included policies and procedures, types of data through pharmacist intervention, documentation of clinical impact and cost avoidance, analysis of pharmacist intervention and the barrier of pharmacist intervention documentation. All kinds of pharmacist professionals were included in this survey. We used a 5-point Likert response scale system to obtain responses. There were open and close-ended questions. The survey was prepared in an electronic format and was distributed through the social media (What-sApp and other social media) to more than 1000 pharmacist professionals across the Kingdom of Saudi Arabia (KSA). The data were obtained through the Survey Monkey system. Three methods of validation were used in this study. More than two authors reviewed the survey independently and the pilot study was started. The survey data was corrected accordingly. Cronbach's alpha test value for internal validity was calculated. This survey is types which is exempted from the international guidelines of institutional review boards (IRB). 17

RESULTS
A total of 128 pharmacists responded to the questionnaire. Of them, 106 (82.81%) were Saudi and 22 (17.19%) were non-Saudi pharmacists. The majority of the responders were in the age group of 25-34 years and 35-44 years (44.53% and 25.00%, respectively). Most of the responders had obtained their Bachelor of Science in Pharmacy degree (40 (31.25%)) and Diploma in Pharmacy (33 (25.78%)) and the majority of the pharmacists (112 (87.50%)) had not obtained their accreditation from the Board of Pharmaceutical Specialties. The majority of the responders (77 (60.16%), 44 (20.47%) and 39 (31.20%)) had more than 6 years of experience in pharmacy, clinical pharmacy and pharmacy administration, respectively (Tables 1 and 2). Most of pharmacists were working at hospitals with ≥600 bed capacity (23 (17.97%)) and at Medical City (22 (17.19%)) with the majority of the hospitals having accreditation by the CBAHI (84 (73.04%)) and Joint Commotion USA (68 (59.13%)) ( Table  1). Most of the pharmacist-reported intervention items was "a brief description of the intervention" (94.49%), "date of intervention" (93.75%) and "pharmacist's name/identification" (93.70%), whereas the least-reported items of pharmacist intervention was "the effect of cost-saving" (45.57%), "time spent for intervention" (51.61%) and "drug therapeutic classification" (65.73%). The highest practice-related manual documentation was "the date of intervention" (46.88%), "classification of intervention" (44.09%) and "place where intervention was made. " However, the highest electronic documentation was for statements "a brief description of intervention" (69.29%), "medication name" (66.41%) and "reason for making the intervention" (65.35%) ( Table 3). Most of the documentation related to clinical impact and cost avoidance was for "general pharmacist intervention" (75.78%), "adverse drug reaction" (72.66%) and "drug quality reporting" (72.22%). The most clinical impact and cost avoidance documentations for adults and pediatrics interventions was (72.66%), (56.25%) respectively. While with neonates, the highest compliance of clinical impact and cost avoidance documentation was related to "drug information inquiries" (42.97%) ( Table 4). The majority of the pharma-cist had a good perception of documentation of pharmacist intervention (98 (76.56%)) and getting benefit from the intervention documentation (84 (66.67%)) ( Table 5). Most of the barriers that prevent pharmacist intervention documentation was lack of time 98 (76.56%) followed by "there is no system for pharmacist intervention" (43 (33.59%)) and "the analysis of pharmacist intervention does not exist" (41 (32.03%)) ( Table  6). Cronbach's alpha value was 0.925.

DISCUSSION
Over the past few years, the pharmaceutical care services has been expanded at all healthcare institutions in the KSA. The pharmacist practice has transformed through the last decades, from primarily focusing on medications dispensing to patient care. 18, 19 However, the evaluation of the pharmacy strategic plan shows that the plan has not been fully implemented. 20 Moreover, the documentation impact of pharmacists toward patient care has not yet reached an optimal level. That has related to the documentation of pharmacist work and interpretation. 4,5,7 This study focused on the practice and perception of pharmacist intervention documentation at healthcare services in the KSA. Our findings showed that most of the pharmacist intervention was straightforward information for instance date of intervention or patients name and description of medications intervention, whereas most of the important information is cost saving or time spent for intervention, which was poorly documented. 13 The economic impact or workload calculation are critical elements of documentation to the higher healthcare administration. Moreover, half of the pharmacist's intervention documentation was manual even during the initiation of New Saudi Vision 2030. [21][22][23] The computerized method of pharmacist intervention documentation is highly recommended, which should be implemented at hospital settings to improve the pharmacist intervention documentation. 9,24,25 Our findings showed that reporting of cost avoidance due to documentation was related to general pharmacist intervention, ADRs, or drug quality reporting systems, which is excellent. However, most of the documentation which was inadequate was related to medication errors or poisoning incidence. These two elements have a very high impact on clinical outcomes and prevention of additional unnecessary economic burden on the healthcare system. In addition, most patients from pharmacist intervention were adults, despite pediatric or neonatal populations had very high potential required of pharmacist intervention documentations. Assuring of essential elements of intervention documentation is crucial in the pharmacy practice with an emphasis on specific population is necessary. Despite the fact that there was no fair practice of pharmacist intervention, most of the pharmacists were willing to document their intervention. A pharmacist should revise the attitude and position to correct pharmacist intervention documentation pattern quickly. Our results show multiple reasons for an inadequate documentation of pharmacist intervention such as lack of time and high amount of workload prevent the pharmacist from documenting the intervention. This will lead to a high performance indicator in reality without the evidence of work and the healthcare provider will misjudge that the pharmacist performance was poor. The other barriers to the process of documentation are policies and procedures and pharmacist does not know how and to when and where to document. However, on some occasions there are documentation systems. There was not any analysis of pharmacist intervention documentation presented to the pharmacy staff. Moreover, the pharmacist intervention pattern not reporting to higher administration or utilized the reports for healthcare professionals awareness of pharmacist's intervention documentation. As a result, the pharmacist will get into depression and are easily discouraged to document in the future. The pharmacist intervention documentation practice should be reviewed and some education and training about its improvement should be provided to the pharmacists. 26 The lack of local resources, short duration of the study and the small sample size might be

Answered question 125
Skipped question 3