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WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

Geethu et al. World Journal of Pharmacy and Pharmaceutical Sciences


SJIF Impact Factor 6.041

Volume 5, Issue 8, 819-828 Research Article ISSN 2278 – 4357

ASSESSMENT OF THE IMPACT OF CLINICAL PHARMACIST


INTERVENTION IN PAEDIATRIC PATIENT CARE–A PROSPECTIVE
STUDY

Geethu C.*1, Anjali George1, Unnimaya Premkumar1, Apollo James2,


Dr. Haja Sheriff S.3 and Dr. Sivakumar T.4

1
Pharm D Interns, Department of Pharmacy Practice, Nandha College of Pharmacy, Erode,
Tamil Nadu.
2
Asst. Professor, Department of Pharmacy Practice, Nandha College of Pharmacy, Erode,
Tamil Nadu.
3
Head of Department of Pharmacy Practice, Nandha College of Pharmacy, Erode, Tamil
Nadu.
4
Principal, Nandha College of Pharmacy, Erode, Tamil Nadu.

Article Received on
ABSTRACT
24 May 2016, Background: Pediatrics, are not small adults and the most vulnerable
Revised on 13 June 2016,
Accepted on 03 July 2016 group to medication errors as they possess a unique set of risks
DOI: 10.20959/wjpps20168-7306 predominantly due to wide variation in physical and pharmacokinetic
parameters which requires appropriate medication regimen,
administration and pharmaceutical care. Medication errors may
*Corresponding Author
Geethu C. increase the length of stay at hospital, expense, mortality and
Pharm D Interns, morbidity. Aim: The goal is to identify the drug related problems and
Department of Pharmacy assess the impact of clinical pharmacist intervention to improve the
Practice, Nandha College
medication adherence in pediatric population through patient
of Pharmacy, Erode
counselling. Materials and Methods: A prospective observational and
Tamil Nadu.
interventional study was carried out in pediatric inpatient department
of a tertiary care hospital using well-designed proforma including Morisky Medication
Adherence scale from January to May, 2016. Results: There was gradual decrease in drug
related problems from the month of January (70%) to May (17.5%). Also the medication
adherence improved as the percentage of low score 48.6% reduced to 22.3% after
counselling. Inconvenience in sticking to treatment plan was a major obstacle during

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treatment plan. Conclusion Unit based pediatric clinical pharmacist are recommended to
overcome the significant gaps in pediatric pharmaceutical care through tactical approach.

KEYWORDS: Pediatrics, medication adherence, medication errors, clinical pharmacist.

INTRODUCTION
Pediatrics can be defined as a branch of medicine dealing with the development, diseases, and
disorders of children. The International Committee of Harmonization (2000) has suggested
the classification as: Preterm newborn infants, Term newborn infants (0-27 days), Infants and
toddlers (28 days- 23 months), Children (2-11 years), Adolescents (12-16/18 years).[1]

Pediatrics, the most vulnerable group to medication errors possess a unique set of risks
predominantly due to wide variation in physical and pharmacokinetic parameters which
requires appropriate medication regimen, administration and pharmaceutical care.[2]

Children are not small adults therefore patient details such as age, weight, surface area need
to be accurate to ensure appropriate dosing.[1] Medication errors are broadly defined as
incidents in which an error has occurred somewhere in the medication process, regardless of
whether any harm occurred to the patient.[3] Medication errors occurs during prescription,
transcription, administration and dispensing. Medication errors may increase the length of
stay at hospital, expense, mortality [6.5%] and morbidity.[4] The recent evidence from U.S
indicated, potentially harmful medication administration errors may be 3 times higher in
paediatric population than adults.[5] A cohort study conducted in USA shows that the
prevalence of DRPs considered clinically important was 79.7% out of which therapeutic
duplications is 54.6%, dose form optimisation is 29.7% and inappropriate uncoordinated care
is 25.3%.[6]

Medication error may also occur due to the lack of familiarity of prescribers with paediatric
dosing guidelines and also limited information on various drug formulations, safety and
efficacy of medicines in paediatrics.[1] Frequently reported errors are due to the poor
pharmacological background of physicians, poor communication between the different
healthcare providers and increased physician work load, fatigue and stress.[7] Drug
interactions are broadly classified as mild, moderate and severe. WHO defines patient
medication adherence as „the degree to which the person‟s behaviour corresponds with the
agreed recommendations from a health care provider‟ while non-adherence occurs when

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Geethu et al. World Journal of Pharmacy and Pharmaceutical Sciences

patient cannot follow the prescribers advice.[8,9] Direct method includes the estimation of the
concentration of drug in the blood, urine or by using any biological markers in blood. The
second, indirect method includes patient questionnaire, self-reports, pill counts, rate of
prescription refills, patient clinical response, electronic medication monitors.[10-12] Patient
counselling refers to the process of providing information, advice and assistance to help
patients use their medications appropriate orally, visually or by providing leaflets/pictures.
The purpose of the study is to identify the drug related problems in pediatric inpatient
department of the hospital and to assess the impact of clinical pharmacist intervention to
improve the medication adherence in pediatric population through patient counselling.

MATERIALS AND METHOD


A prospective observational and interventional study was carried out in 300 pediatric patients
in an inpatient department of a tertiary care hospital to identify the drug related problems
using a well designed data collection form consisting of patient‟s demographics, past
medication and medical history, present medical and medication details, drug interaction
determined, patient counseling method and Morisky medication adherence questionnaire. It
consists of four items that have dichotomous response categories with yes or no answers. The
rationale behind this was “the drug errors of omission could occur in any or all of these ways:
forgetting, carelessness, stopping the drug when feeling better or starting the drug when
condition becomes worse”. The total scale has a score range of 0-8. Low adherence (<6),
medium adherence (6-8), high adherence(=8).[12] The patients included in our study were
inpatients of age group 3-15 years who were followed from the date of admission to
discharge, in the meantime their general medication adherence is checked, then on discharge
the patient/parents is counselled and were asked to report during their review visit to score
their medication adherence for the second time or a self-report is obtained through a
telephone call. Critically ill and psychiatric patients were excluded from our study. The
adherence scores were documented and also reason for non-adherence were found among
patients with medium and low score. The obtained data were entered into Microsoft Excel
sheet and analyzed.

RESULTS AND DISCUSSION


Pediatrics are the group of population who are highly prone to the medication errors as they
are not small adults and vary in all pharmacokinetic and pharmacodynamics characteristics.[1]
In all aspects of pharmacokinetics they are different which arises the necessity of specific
dose calculation for each patient.

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A clinical pharmacist intervention is any relevant changes made by the pharmacist to improve
the patient care. Articles of Navneet et al. and Sabry et al., supports the role and importance
of clinical pharmacist in pediatric patients.[2,7] Always double checking can avoid many
errors. A prescription by a physician can be interpreted by the clinical pharmacist and
suggestions given accordingly can prevent many adverse events, reactions and dose related
problems.

In our study period of 5 months, we have collected 300 pediatric cases between the age of 3-
15 years, whose case files were followed up and necessary interventions were made. We have
collected cases from the general pediatric wards of various departments as shown in(Table 1).
Out of 300 cases, 58% were males while 42% were females.

The legibility of the prescription was evaluated from the case files as most of them cannot be
read properly. This illegibility of the drugs can cause misunderstanding of the pharmacists
while dispensing drugs or nursing staff during administration or even mistaken by the patient/
caretakers. The prescription was checked for errors in dose, frequency, route and drug
interactions.

The rate of drug related problems and drug interaction for every month, from January to May
were monitored and illustrated as in (Table 2). The gradual decrease in the drug related
problems shows the importance of clinical pharmacist intervention. The drug interaction can
be managed by adjusting the time gap between the administration of the drugs, by proper
enquiry of the list of drugs taken and then prescribe for the current problem, if needed the
dose can be adjusted and also by educating the patient about the need to take medicines on
time.[16]

The drug related problems were classified into prescription error, transcription error,
dispensing error and administration error, depicted in (Figure 1). The results clearly shows a
high rate of prescription errors which occurs on the account of physicians.[1]

Transcription error occurs when the order of the physician is wrongly rewritten by the junior
medical officers or nursing staffs. Transcription error occurs in various manners like a
simple spelling mistake or incorrect dose or even difference in the word heard.[7]

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A less number of dispensing error was noted, but it can also cause a great impact on the
health of the patient if not checked before administration. Even mortality can occur if the
dispensed drugs are erroneous.

The administering errors that is wrong route of administration of medications or variations in


the time of administration of drugs, omission of required frequency. The variations in the
time of administration of drugs effects the time required for the execution of the therapeutic
outcome and also the next frequency to be given.[14]

On analyzing the results, the effect of clinical pharmacist intervention is significant in


reducing the drug related problems and irrational prescription (Figure 2). In our study, we
also checked the choice of formulation of the drug usually given to the children as it
influence the medication adherence (Figure 3). Children prefer sweet syrups rather than
tablets and capsules which are difficult to swallow, sometimes they do not know how to take
it.These contributes for poor adherence.

Patient counselling is a vital part of patient care in which they are taught about the medicines,
its use and need to be on regular medication. To improve patient understanding and
adherence we can use many counselling aids like leaflets, pictorials besides oral counseling
(Table 3). It was found that pictograms and leaflets are more effective than oral counselling.
The general patient medication adherence was checked before counselling (Table 4). The
scores were documented and were counselled during discharge and were again interviewed
during review visit. By using Morisky Medication Adherence scale, we again checked the
adherence and compare it with the initial score (Figure 4). Also adherence was checked by
using pill count and self-report method. But these method are not reliable. From our results,
its clear that there is a significant reduction in the percentage low score group while high
score percentage does not vary much.

Besides checking the adherence scores, 196 patients with medium and low scores were
interviewed about the obstacles faced in adhering to the treatment regimen (Figure 5).
Children find it difficult to use inhalers and many drugs at a time.[15,16]

Table.1 Diseases based on department


DEPARTMENT CASES PERCENTAGE
CARDIOLOGY 18 6.1%
RESPIRATORY 74 25%

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NEPHROLOGY 18 6.1%
DERMATOLOGY 16 5.4%
ENDOCRINOLOGY 14 4.7%
GENERAL MEDICINE 88 29.7%
ONCOLOGY 18 6.1%
CNS 24 8.1%
BLOOD DISORDER 18 6.1%
OTHERS 8 2.7%

Table 2: Drug related Problems


Drug Related Problems JANUARY FEBRUARY MARCH APRIL MAY
110 136 42 36 24
Illegibility (25.9%) (22.9%) (30.4%) (23.7%) (29.3%)

30 102 18 26 14
Dose (7.1%) (17.2%) (13%) (17.1%) (17.1%)

214 48 6 8 10
Frequency (50.5%) (8.1%) (4.3%) (5.3%) (12.2%)

8 14 0 12 12
Route (1.9%) (2.35%) (7.9%) (14.6%)

10 18 2 2
Severe drug interaction (2.4%) (3.03%) (1.4%) (1.3%) 0

Moderate drug 36 212 66 54 14


interaction (8.5%) (35.7%) (47.8%) (35.5%) (17.1%)

Mild drug interaction 16 64 4 14 10


(3.8%) (10.8%) (2.9%) (9.2%) (12.2%)

Table 3: Patient Counselling Aids


PATIENT COUNSELLING METHODS NO OF PATIENTS
Oral 296(100%)

Pictorial+Oral 26(8.7%)

Leaflet+Oral 16(5.4%)

Table 4: Patient Medication Adherence Method


MEDICATION ADHERENCE METHOD NO OF PATIENTS
Questionnaire 244(82.4%)

Self Report+Questionnaire 64(21.6%)

Pill Count+Questionnaire 6(2%)

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Figure 1: Drug related Errors

Figure 2: Impact of Clinical Pharmacist Intervention

Figure 3: Various Drug Formulations Given during Discharge

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Figure 4: Comparison of Morisky Medication Adherence Scale Scores

Figure 5: Obstacles faced during Medication Adherence

CONCLUSION
Pediatrics are not small adults due to their pharmacokinetics and pharmacodynamics
characteristics difference. Hence dose calculation, selection of formulation, frequency of
administration is a matter of great concern.

In pediatrics patients, counselling is very useful in improving medication adherence so as to


improve the therapeutic outcomes, reduce hospital readmission and increase patient safety
and to reduce economic burden. One of the major obstacles in adhering to the treatment plan
was inconvenience in taking medications like formulation given to the patient and the
frequency of drugs to be taken. Keeping in contact with the patients through modern
technologies even after the discharge help them to adhere with the medications which
enhance successful completion of the course and thus preventing recurrence of disease.

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Among the patient counselling aids used like oral, pictorial representation and leaflets, we
found that pictograms are more effective as it provides a better understanding of patients
about the devices they use for treatment like inhalers.

Consulting patients while designing treatment plan will help to improve the medication
adherence thus improve patient satisfaction. This enables them to avoids the difficulty in
carrying medications with them, frequent drug administration and also to overcome the
problem of forgetfulness. The results of the study demonstrates the importance of clinical
pharmacist in every step of patient care. Unit based pediatric clinical pharmacists are
recommended to reduce the drug related problems through routine ward round participation,
double check the prescription and also drug administration. Well-equipped clinical
pharmacist are required to overcome the challenges in the pediatric pharmaceutical care that
exist. Development of a strategic approach is needed to increase the work force and collective
capacities to provide pediatric clinical pharmacy services for all children.

ACKNOWELEDGEMENT
We are great full to all people who have supported to complete this study including our
guide, Department of pharmacy practice, principal, hospital authorities and patients enrolled.

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