Beruflich Dokumente
Kultur Dokumente
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
treatment plan. Conclusion Unit based pediatric clinical pharmacist are recommended to
overcome the significant gaps in pediatric pharmaceutical care through tactical approach.
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
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.
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]
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.
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]
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%
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
Pictorial+Oral 26(8.7%)
Leaflet+Oral 16(5.4%)
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.
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.
REFERENCE
1. Roger walker. Clinical Pharmaceutics and Therapeutics. Third edition. Churchill
Livingston Title. 2013.
2. Navneet S et al. Interventions of hospital pharmacists in improving drug therapy in
children: a systematic literature review. Drug safety. 2006; 29(11): 1031-1047.
3. Sheena Williamson. Reporting medication errors and near miss. In: molly countenary and
Matt Griffiths. Medication safety: an essential guide. Cambridge university press, 2009;
155-172.
4. Classen DC et al. Adverse drug events in hospitalized patients. Excess length of stay,
extra costs, and attributable mortality. Journal of American Medical Association. 1997;
227: 301-306.
5. The Joint Commission. Preventing pediatric medication errors. April 2008; 39.
6. LaFleur J et al. Prevalence of Drug Related Problems and Cost – Savings opportunities in
Medicaid High Utilizers identified by A Pharmacist - Run Drug regimen Review Center.
Journal of Managed Care Pharmacy. 2006; 12(8): 677-685.