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American Journal of  
Chemistry and Pharmacy (AJCP)

Documenting Pharmacist Intervention: A Technology-Driven 
Solution to Overcome Challenges

Murooj Shukri1, Amna Mukhtar2, Sahar Alsharif3, Abdilahi Mohamed4

Volume 2 Issue 2, Year 2023
ISSN: 2834-0116 (Online)

DOI: https://doi.org/10.54536/ajcp.v2i2.1630
https://journals.e-palli.com/home/index.php/ajcp

Article Information ABSTRACT

Received: April 20, 2023

Accepted: May 22, 2023

Published: May 25, 2023

Clinical pharmacist conducts multiple activities governed by the best evidence for disease 
management and safe medication practices. The ASHP highlighted the importance of  
documenting and recording clinical pharmacy interventions to prevent adverse drug 
events and reduce hospital length of  stay. Our institution utilizes an in-house electronic 
documentation system (e-DS) to document clinical interventions. We aim to study the 
impact of  enhancing the e-DS. This study is a retrospective single-center descriptive 
review post-implementation of  in-house e-DS enhancements. Data were collected between 
September 2017 and December 2019 for documented interventions by clinical pharmacists 
for admitted patients. Fields for analysis include clinical interventions, expected outcomes 
of  interventions, cycle time for documentation, and drug cost. Outcomes measures include 
several documented interventions, preventing medication errors/adverse drug events, time-
saving and cost avoidance. Descriptive analysis will be performed for categorical variables. 
The study showed an increased number of  documented interventions for preventing 
medication errors/adverse drug events, time-saving, and cost avoidance, with an average 
time-saving of  20 minutes per 10 interventions and estimated cost avoidance of  20 000 
SAR per month. Study limitations include a lack of  interface with EHR and non-feasibility 
to estimate indirect cost. Investment in documentation system optimization to reduce 
medication errors/adverse drug events, time-saving and cost avoidance.

Keywords
Clinical Interventions, 
Documentation System, 
Clinical Pharmacy

1 Medication Safety Officer, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia 
2 Medication Safety/Clinical Support Pharmacy, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
3 Pharmacy Automation and Support, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
4 Clinical Pharmacy Specialist, King Faisal Specialist Hospital and Research Center, Madina, Saudi Arabia
* Corresponding author’s e-mail: mshukry@kfshrc.edu.sa

INTRODUCTION
Clinical pharmacist conducts multiple activities governed 
by the best evidence for disease management and safe 
medication practices with other providers to optimize 
patient outcomes (Pharmacy, 2014). Their interventions 
must be documented directly in the patient’s medical 
record or equivalent retrievable documentation system. 
According to Kim Y. et al., a pharmacist intervention may 
be defined as an act or action that prevents medication 
therapy problems and optimize drug therapy for 
individual patients in cooperation with other healthcare 
professionals (Kim & Schepers, 2003). 
Documentation of  clinical activities is an integral part 
of  efficient healthcare delivery, particularly to the clinical 
pharmacist (Pharmacists, 1996). This documentation 
can also be used as a metric system to justify clinical 
pharmacists’ productivity and demonstrate their integral 
role in multidisciplinary healthcare teams.

LITERATURE REVIEW
The ASHP highlights the importance of  documenting and 
recording clinical pharmacist interventions (Pharmacists, 
1996). Interventions by clinical pharmacists in a hospital 
setting prevent adverse drug events, reduce hospital 
length of  stay and mortality rate, and provide a significant 
economic benefit to healthcare systems (Gallagher et 
al., 2014; Kim & Schepers, 2003; Samp et al., 2014). 
Documentation is a vital key performance indicator to 
demonstrate the impact of  clinical pharmacy services. 
It is also important to improve communication among 

healthcare providers to optimize medication management 
plan for a patient (Hamblin et al., 2012). As Catania et al. 
mentions, these data can be used to cost-justify the need 
for additional clinical pharmacists in a practice setting 
(Catania & Catania, 1988; Kim & Schepers, 2003). Over 
the years, hospitals have faced challenges in simplifying, 
optimizing, and promoting clinical interventions 
documentation and interpretation. 
In the past, clinical pharmacists used to document limited 
interventions as handwritten notes to physicians or 
pharmacist progress notes, usually filed with the patient’s 
medical chart. Over the years, many enhancements 
have been introduced to improve documentation and 
information utilization (Claus et al., 2012). This has been 
established since replacing the manual with computerized 
databases and electronic health records (Kim & Schepers, 
2003). Another important aspect of  implementing 
electronic documentation is reducing the variation and 
lack of  standardization of  pharmacist intervention 
documentation to improve patient care. Al-Jedai A. et al. 
highlighted a big variation in the consistency of  hospital 
pharmacists’ documentation and data collection between 
50% to 72% in various countries (Al-Jedai & Nurgat, 
2012).
Kim Y. et al. reported limited evidence in the literature 
regarding the types of  pharmacy intervention 
documentation collection systems and the quality, 
quantity, and utilization of  the collected information 
(Kim & Schepers, 2003).
Many pharmacy intervention reporting systems, from 

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paper to electronic, are used in pharmacy practice settings. 
Although hospital administrative personnel admit that 
current systems demand equipment or software costs, 
the support was minimal. As a result, pharmacies tend to 
self-enhance their systems or use commercially available 
systems that meet their needs (Kim & Schepers, 2003).
At our institution, clinical pharmacists have utilized a 
secured in-house electronic Documentation System 
(e-DS) since 2010 to capture the clinical pharmacist 
intervention documentation. The initial version of  the 
e-DS had many challenges and limitations. This study 
aims to enhance and measure the improvement of  e-DS 
clinical pharmacist intervention documentation.

MATERIALS AND METHOD
This retrospective single-center descriptive study of  
clinical pharmacists documented interventions post e-DS 
enhancements. Data were collected between September 
2017 and Dec 2019 for auditing and evaluation purposes. 
The enchantments were implemented in 3 phases; 
September 2017, January 2018, and September 2018, 
respectively. In order to evaluate the impact of  our 
enhancements, data was collected from September 2017 
to 2018. All the end-users were surveyed through multiple 
formats, and feedback for program feature enhancement 
testing was deliberated. Additional data was collected for 
another 12 months to measure users’ experiences (January 
to December 2019). Some of  the Outcomes we looked 
into were several documented interventions, preventing 
medication errors/adverse drug events, time-saving and 
cost avoidance. The data was collected from secondary 
and tertiary sources (Annette Clarkson, 2008; Australia, 
2018; Pharmacists, 1996; Pharmacy, 2014; project, 2016).
Data to be collected on the secured in-house e-DS 
for analysis include clinical interventions, types of  
interventions, cycle time for documentation, and 
intravenous (IV) to oral (PO) conversion drug cost 
avoidance. Outcomes analyzed from the e-DS generated 
reports that include several documented interventions, 
prevented medication errors/adverse drug events, time-
saving, and cost avoidance  (Annette Clarkson, 2008; 

Australia, 2018; Gin, 2013; Guidance, 2013; Hospitals, 
2008; Pharmacists, 1996; Pharmacy, 2014; project, 2016) 
Descriptive analysis is performed for categorical variables 
on Microsoft Excel 2016. A time-saving Calculator for 
estimating the cycle time. This study was approved by the 
Institutional Review Board (IRB) of  King Faisal Specialist 
Hospital and Research Center.
The pharmacy automation and informatics team supports 
the in-house e-DS enhancements through a series of  
efforts to optimize clinical pharmacist documentation. 
Some enhancements included: standardizing the 
intervention classification and field categories per 
recent literature in international evidence see appendix 
1(Australia, 2018). improving layout usability and enabling 
remote accessibility from smart devices. The latter was 
established through hospital-secured access to ensure 
information confidentiality. A downtime contingency 
plan was designed and reflected in the department’s 
policy to avoid data loss and ensure its integrity.

RESULTS
Investment in enhancing clinical pharmacist 
documentation system optimized interventions 
documentation that was reflected through an increased 
number of  documented interventions for preventing 
medication errors/adverse drug events, time-saving and 
cost avoidance by 56% with a monthly average of  4,600 
interventions. The average time saving is 20 minutes per 
10 interventions. The estimated cost avoidance from 
converting IV to PO formulations is approximate ~ 27 000 
SAR per month. The number of  prevented medication 
errors/adverse drug events interventions accounted for 
34,847 (50%), while the top type of  interventions per the 
expected outcomes was related to enhancing therapeutic 
effect 49,050 (71%) of  total interventions. The level 
of  significance of  the documented interventions (7% 
minor, 66% moderate versus 27% severe) is illustrated in 
figure 1. The top categories of  document intervention 
per the DOCUMENT standardized categorization were 
Monitoring 52% followed by Drug Selection 18% then 
Undertreated 10% categories refer to figure 2.

Figure 1: Illustrating the Level of  Significance of  the Documented Interventions.

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DISCUSSION
Documenting clinical pharmacist interventions is 
essential to quantify the impact on patients’ outcomes and 
justify the workload and the value of  the provided clinical 
pharmacy services. Haslett et al. stated that documented 
pharmacist interventions had prevented 27% of  
potentially serious adverse drug events in a tertiary-care 
medical center/teaching hospital (Al-Jedai & Nurgat, 
2012; Kim & Schepers, 2003). Also, hospital pharmacy 
directors acknowledge that documenting clinical 
pharmacist interventions is useful in demonstrating 
individual and organizational competency (Kim & 
Schepers, 2003). In the same survey, almost 40% of  the 
pharmacy directors commented that the most common 
opinion was pharmacist time challenge or unfriendliness 
of  available comprehensive documentation systems. The 
survey universally affirmed that those systems are vital 
to a clinical pharmacist’s responsibility. Those systems 
supported the communications of  clinical pharmacists’ 
actions with other healthcare providers and reflected 
clinical pharmacy services’ importance. While many 
pharmacies continued to document their interventions 
manually, others invested in computerized options. 
The latter provided the advantages of  providing more 
comprehensive information and user-friendliness 
compared to the manual.
Furthermore, the report highlighted that the available 
systems were challenged with providing real cost savings 
or clinical outcome information. The main reason for the 
administrative reluctance to invest in obtaining software, 
equipment, and maintenance is the cost which may reach 
$5000. Accordingly, there have not been enough solutions 
to overcome all the problems. However, a step forward 
has been taken to utilize personal digital assistants (PDA) 
for clinical pharmacist intervention documentation 
systems (Kim & Schepers, 2003).
Over the past years, our institution has used various 
methods to document clinical pharmacy interventions, 
starting with manual documentation on a paper-based 
form in 2008. The form includes clinical pharmacists, 
patient information, and drug-related problems (Al-
Jedai & Nurgat, 2012). This manual method had many 

challenges: loss of  documentation, time & paper 
consumption, inaccessibility, lack of  data security and 
integrity, and difficulty in collecting and interpreting data 
timely. Accordingly, to overcome these challenges, an in-
house build of  an electronic documentation system (e-
DS) for capturing clinical interventions was implemented 
in 2012. The e-DS captured interventions performed 
by clinical pharmacists; however, there were unresolved 
shortcomings associated with the system. For example, 
no user interface on the hospital server, which limited the 
clinical pharmacist’s access remotely, an unfriendly data 
entry layout that resulted in long documentation time, 
and a lack of  data standardization to obtain meaningful 
information and timely report. Accordingly, an attempt 
to improve the e-DS was completed by releasing a new 
enhanced system version. The enhancement project was 
implemented over 3 phases; September 2017, January 
2018, and September 2018. To evaluate the impact of  those 
enhancements, data was collected from September 2017 
to 2018. Each phase included a cycle of  (implementing 
modification according to end-user feedback, education 
for the clinical pharmacists about the new features, 
and a testing period). Further data were collected for 
additional 12 months to evaluate sustainability (January 
to December 2019).

Implemented Enhancements on the e-DS Updated 
Version
Standardization
Upon searching for the most comprehensive, standardized, 
and the closest to meet our clinical pharmacists’ needs, 
we selected DOCUMENT MRP and recommendation 
classification codes provided by Guidelines for 
Pharmacists Performing Clinical Interventions by the 
Pharmaceutical Society of  Australia (Australia, 2018). 
The selected categorization was further customized to 
meet the unfulfilled needs, see Table 1. Customizations 
were added to capture some of  the clinical pharmacist’s 
productivity data (for example, drug shortage issues, 
reviewing of  Non-Formulary Medication or Off-label 
medication use requests). Another customization was 
deleting some categories. For example, medication 

Figure 2: Illustrate the type of  document intervention per the DOCUMENT MRP standardized categorization.

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education provided to a patient is documented directly 
on the patient’s EHR. Also, the conversion from IV 
to PO category was removed to EHR as part of  the 
enhancement to minimize entry duplication and improve 
communication with other healthcare providers. The 
latter was part of  another plan to establish clinical 
pharmacist standardized notes for certain services on 
EHR. This standardization helped minimize the Drug 
Related Problem from 20 major categories and 107 
subcategories to 8 categories and 37 subcategories in the 
updated version (Australia, 2018).

Usability
The initial e-DS version layout took a long time for 
clinical pharmacists to document their interventions 
timely. Human factor engineering was considered while 
implementing the layout enhancements. This included: 
automated popups for the user and the dates, the option 
to manually change the intervention date where available 
to allow retrospective data entry, and an in-build calendar 
for date selection used to prevent non-standardized date 
format. Also, a dropdown list for the inpatient units was 
added to limit discrepancies in the unit’s name to be 
extracted accurately in the report for workload purposes. 
The most impactful enhancements were allowing multiple 

interventions to be documented per patient daily on the 
same page instead of  multiple pages for each intervention, 
see figure 3. Additionally, activating the Tab button to move 
quickly between fields and the automatic fill option using 
the first letter/category code to minimize typing time. 
Furthermore, intervention categories and subcategories 
were popping up in separate windows by double clicking 
instead of  a long dropdown list to select from. For accurate 
referencing of  comments, the free text box for it per patient 
was moved to be next to each medication intervention. 
These enhancements resulted in an almost 45% reduction 
in the time needed for documentation, see Figure 3.  

Accessibility & Security
Accessibility was a major challenge for clinical pharmacists 
to document their interventions timely. Users needed to 
access the e-DS from his/her personal desktop computer 
using their authorized access (Pharmacy, 2014). The 
targeted enhancement was to upload the electronic 
documentation system to a secure web page within the 
institution network (hospital server). This maintained 
patient confidential information and provided users 
with remote access to e-DS from the inpatient unit’s 
workstation computers, computers on wheels (COW), 
tablets, or mobile devices. 

Table 1: Customized DOCUMENT Medication-Related Problem (MRP) and recommendation categorization codes
D: Drug Selection
D1 Duplication
D2 Drug interaction
D3 Inappropriate drug
D4 Inappropriate dosage form/ route
D5 Contraindications apparent
D6 No indication apparent
D7 Drug shortage issue
D8 TPN initiation
D9 TPN follow up
O: Over or underdose
O1 Prescribed dose too high
O2 Prescribed dose too low
O3 Incorrect or unclear dosing
O4 Incorrect/Inappropriate renal dosing
C: Compliance
C1 Need: to hold/ resume or renewal reminder
C2 Difficulty reaching physician/ nurse
C3 Non-compliance with policy/ guidelines/ protocol
C4 Need to review of  policy/ guidelines/ protocol
C5 Need to review chemotherapy protocol
C6 Review Non-Formulary Medication Request 
C7 Review of  Off-label medication use request 
U: Undertreated
U1 Condition undertreated
U2 Condition untreated

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Table 2: Customized DOCUMENT MRP and recommendation categorization codes per intervention expected 
outcome
ADR/Medication error prevented
D: Drug Selection
D2 Drug interaction
D3 Inappropriate drug
D4 Inappropriate dosage form/ route
D5 Contraindications apparent
O: Over or underdose
O1 Prescribed dose too high
O2 Prescribed dose too low
O3 Incorrect or unclear dosing
O4 Incorrect/Inappropriate renal dosing
U: Undertreated
U1 Condition undertreated
U2 Condition untreated
U3 Preventative therapy required
M: Monitoring
M3 Allergy/demographics missing
T: Toxicity or adverse reaction
T1 Toxicity, allergic reaction or adverse effect present
ADR/Medication error prevented/ Enhanced Therapeutic Effect
M: Monitoring
M1 TDM/laboratory/microbiology monitoring
M2 Non-laboratory monitoring
Cost Saving/ ADR or Med Error prevented
D: Drug Selection
D1 Duplication
D6 No indication apparent
Cost Saving/ ADR or Med Error prevented/ Enhance Therapeutic Effect

U3 Preventative therapy required
U4 need for therapeutic alternative
M: Monitoring
M1 TDM/laboratory/microbiology monitoring
M2 Non-laboratory monitoring
M3 Allergy/demographics missing
M4 Chart Review
E: Education or information
E1 Patient requests pharmacy related information
E2 Physician requests pharmacy related information
E3 Nurse requests pharmacy related information
E4 Pharmacist requests pharmacy related information
E6 Inservice/competency conducted
N: Not classifiable
NO
T: Toxicity or adverse reaction
T1 Toxicity, allergic reaction or adverse effect present

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U: Undertreated
U4 need for therapeutic alternative
Cost Saving/ Enhance Therapeutic Effect
D: Drug Selection
D7 Drug shortage issue
Enhance Therapeutic Effect
D: Drug Selection
D8 TPN initiation
D9 TPN follow up
C: Compliance
C1 Need: to hold/ resume or renewal reminder
C3 Non-compliance with policy/ guidelines/ protocol
C4 Need to review of  policy/ guidelines/ protocol
C5 Need to review chemotherapy protocol
C6 Review form A
C7 Review form B
M: Monitoring
M4 Chart Review
E: Education or information
E1 Patient requests pharmacy related information
E2 Physician requests pharmacy related information
E3 Nurse requests pharmacy related information
E4 Pharmacist requests pharmacy related information
E6 Inservice/competency conducted

Before:

Reports from the updated e-DS version became easily 
and timely retrieved with meaningful information: 
the number of  interventions per period/inpatient 
units or pharmacist, top categories of  interventions, 
top intervened medications, and cost avoidance per 
medication. These reports were utilized for workload/ 
productivity purposes. Also, it can be shared with 
Pharmacy and Therapeutic (P&T) or drug utilization 
committees, quality improvement committees, pharmacy 
management, and hospital management to support the 
positive impact of  the clinical pharmacists to optimize 
patients’ outcomes and to prevent harm (Kim & Schepers, 
2003). Other meaningful fields reported in the literature 

were not added to the updated e-DS version; for example, 
the level of  intervention significance and acceptance 
response rate, considering the allotted documentation 
time versus the number of  priority fields to be completed.
Our study findings showed a gradual improvement in 
documented interventions after each enhancement, 
especially with the testing, education, and immediate 
feedback from the end users. Additionally, there is a 
direct correlation between the number of  documented 
interventions, the number of  clinical pharmacists on 
duty, and the inpatient census for that period. Regardless, 
documented interventions were easily doubled over the 
sustainability period. 

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Table 3: Number of  documented interventions per DOCUMENT (MRP) and recommendation categorization 
codes for the studied period
DOCUMENT MRP and recommendation categorization Number of  interventions (%)
D: Drug Selection 11,389 (18%)
O: Over or underdose 4,857 (8%)
C: Compliance 4,591 (7%)
U: Undertreated 6,471 (10%)
M: Monitoring 33,692 (52%)
E: Education or information 3,024 (5%)
N: Not classifiable 327 (1%)
T: Toxicity or adverse reaction 174 (0.3%)
Total 64,525

Our analysis reflected the successful documentation of  
the well-established therapeutic drug monitoring service, 
as it was ranked the top among reported categories 
with 52% of  all documented interventions. The lowest 
reported category was toxicity or adverse reaction (0.3%). 
This is explained by the parallel hospital safety reporting 

system that requires staff  to use for such incidents. This 
duplication can be modified in the future. Supporting 
the successful selection of  the customized standardized 
categorization, we noticed that an insignificant 
percentage (1%) of  interventions were not classifiable. 
See Table 3. 

Figure 3: Usability and accessibility enhancements on the eDS layout

After:

To identify the impact of  the expected outcome, we 
replicated published studies with similar intervention 
categories and significance levels (Campbell, 2011). 
Accordingly, the top reported types of  interventions 
per expected outcomes were invested in enhancing 

therapeutic effect and (adverse Drug Reaction (ADR)/
medication error prevention with 49% and 26%, 
respectively, as shown in Table 4. Our study demonstrated 
that the majority of  clinical pharmacist interventions 
were impactful per the level of  significance. These results 

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support the huge value of  the clinical pharmacist in 
medication management.
As the hospital administration highly appreciates the 
cost-saving initiatives, focused efforts were directed to 
establish the intravenous (IV) to oral (PO) conversion 
service. It describes converting intravenous therapy to 
an alternative oral formulation as clinically applicable 
(Craig & Andes, 1995; Cyriac & James, 2014). Based 
on Craig and Andes’s review, the mean duration of  IV 
therapy before converting ranged from 2 to 8 days (Craig 

& Andes, 1995; Paladino et al., 1991). Accordingly, this 
study utilized 8-days of  therapy to demonstrate the 
cost saving. Our service launched with ten medications, 
primarily antimicrobials, that have impactful cost savings. 
Later, the list was expanded to seventeen medications 
once the service was stabilized, see appendix VI. Over 
the sustainability period, we identified that the top five 
cost-saving medications were responsible for 93%, 
listed in order: levetiracetam, omeprazole, voriconazole, 
fluconazole, and acetaminophen; see Table 5. 

Table 5: IV to PO Conversion Medication List
Medication IV Dose Equivalent Oral 

Dose
IV to Oral 
Conversion Ratio

Frequency

Acetaminophen 650 mg 650 mg 1:1 Continue same
Ciprofloxacin 200 mg 250 mg 1:1.25 Continue same

400 mg 500 mg 
750mg 

Clindamycin 300mg 300mg NA Continue same
600 mg 450 or 600 mg 

Cyclosporine* 25 mg 30mg to 45mg 1:1.2 to 1.8 Continue same
Dexamethasone 1-10mg 1-10mg 1:1 Continue same
Doxycycline 100 mg 100 mg 1:1 Continue same
Fluconazole 200 mg 200 mg 1:1 Continue same

400 mg 400 mg
800 mg 800 mg

Folic Acid 1mg 1mg 1:1 Continue same
Levetiracetam 250 mg 250 mg 1:1 Continue same
Levothyroxine 50 mcg 100 mcg 1:2 Continue same
Levofloxacin 500mg 500mg 1:1 Continue same

750mg 750mg 
Linezolid 600 mg 600 mg 1:1 Continue same
Metronidazole 250 mg 250 mg 1:1 Continue same

500 mg 500 mg 
500 mg 500 mg 

Mycophenolate 
mofetil*

500mg 500mg 1:1 Continue same

Omeprazole 40 mg 40 mg 1:1 Continue same
Rifampin 600 mg 600 mg 1:1 Continue same

Table 4: Number of  documented interventions per intervention expected outcome for the studied period
Intervention expected outcome Number of  interventions
Enhance Therapeutic Effect 33,887 
ADR/Medication error prevented 17,692 
ADR/Medication error prevented/ Enhanced Therapeutic Effect 13,657 
Cost Saving/ ADR or Med Error prevented  2,308 
Cost Saving/ ADR or Med Error prevented/ Enhance Therapeutic Effect 1,190 
Cost Saving/ Enhance Therapeutic Effect 316
Cost Saving 127
Total 69,177 

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Although clindamycin IV to PO conversion shows 
negative direct cost-saving, the indirect cost of  
hospitalization, sterile medication preparation by 
pharmacy, administration by nurse, and associated risk of  
line infection outweigh that value.
The main challenge with the updated e-DS version was 
that it was not integrated with EHR. This prevented 
accessibility by other healthcare providers to the clinical 
pharmacist interventions that support the medication 
management plan. In addition, this limit the generation 
of  clinical outcome data (e.g., length of  hospital stay, 
readmission, and mortality rate). Furthermore, the 
hospital-invested billing system cannot capture the 
monetary value of  the clinical pharmacist services.

Tacrolimus* 1mg 3mg or 4mg 1:3 to 4 Twice daily
Thiamine 50-100mg 50-100mg 1:1 Continue same
TMP/SMZ 5-20 ml 1 SS tab =5ml IV 1:1 Continue same

5ml IV= 400mg 
SMX + 80mg 
TMP

1 DS tab=10ml IV
2DS tabs=20ml IV

Voriconazole 200 mg q12h 200 mg q12h 1:1 Continue same
Valproic Acid 250 mg Q8H 250 mg Q8H 1:1 IV valproate sodium 

given at same total 
daily dose/same 
frequency as oral 
products. However, 
daily doses >250 mg 
should be divided.

Table 6: IV to PO Conversion Cost Avoidance (SAR) 
during the sustainability period, ranked from highest to 
lowest.
Drug Name 8-days Cost Saving (SAR)
Levetiracetam 131,828
Omeprazole 92,624
Voriconazole 83,920
Fluconazole 10,288
Acetaminophen 9,152
Valproic acid 6,120
Ciprofloxacin 5,344
Acyclovir 3,348
Doxycycline 2,840
levothyroxine 2,366
Levofloxacin 1,896
Rifampin 1,472
Metronidazole 432
TMP/SMZ 233.36
Dexamethasone 157.6
Linezolid 80
Clindamycin -28,184
Total 323917

CONCLUSION
Technology investments to improve the clinical pharmacist’s 
intervention documentation helped enhance the process 
and provide meaningful data to show the value of  the 
clinical pharmacist in providing direct patient care. Many 
technological enhancements were implemented, including 
standardized intervention categorization, enhanced 
database usability and accessibility, and building reports. 
This is positively reflected in the number of  documented 
interventions, preventing medication errors/adverse drug 
events, time-saving and cost avoidance.
The next step is to propose integrating the clinical 
pharmacist intervention documentation on the EHR 
to allow visibility to other healthcare providers, translate 
interventions into clinical outcomes, and plan for the 
clinical pharmacist services’ billing system.
 
Acknowledgments
The authors are grateful to the King Faisal Specialist 
Hospital and Research Center for their continuous support 
throughout the research.

Funding
This research received no specific grant from funding 
agencies in the public, commercial, or not-for-profit 
sectors. All authors declare no relevant conflicts of  interest 
or financial relationships. 
This project was presented as a poster at the 3rd 
International Saudi Health Informatics Conference on 
17th-21st November 2018. Riyadh, Saudi Arabia; 11th 
Medication Safety Conference 2018, Abu Dhabi, UAE; 
Saudi International Pharmaceutical Annual SIPHA 
meeting 2020-Virtual. 

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Sommi, R.W. . (2011). Medications Most Commonly 
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Documented by Pharmacy Students Psychiatric 
Medications Number of  Interventions All Other 
Medications Number of  Interventions Risperidone 
25 Lisinopril 11 Divalproex 11 Warfarin 11 Lithium 
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