Epidemiology and potential associated risk factors of drug-related problems in hospitalised children in the United Kingdom and Saudi Arabia

Pharmaceutical interventions for drug-related problems in the neonatal intensive care unit: incidence, types, and acceptability

Background: Drug-related problems (DRPs) are widespread in hospitalized neonates, but studies on the prevalence of DRPs in this population are limited. The presence of clinical pharmacists on multidisciplinary teams helps prevent and reduce DRPs. Aim: This investigation aimed to identify and classify the incidence of DRPs in the neonatal intensive care unit (NICU), to determine the determining factors associated with DRPs and to document clinical pharmacists' interventions, outcomes, acceptance rates and clinical significance. Method: A prospective descriptive hospital study was conducted from August to November 2023 at the NICU of Children's University Hospital, Assiut University, Egypt. DRPs were classified using the Pharmaceutical Care Network of Europe (PCNE) classification V9.1. Results: Three hundred sixteen neonates were included in the study, with a mean gestational age of 34 ± 4 weeks and a mean birth weight of 2.03 ± 0.85 kg. A total of 1723 DRPs occurred among 283 neonates (89.6%), an average of 5.5 ± 5.1 DRPs per patient. The main types were treatment effectiveness (P1) (799, 46.4%), followed by others (P3) (469, 27.2%), and treatment safety (P2) (455, 26.4%). The leading causes were dose selection (C3) (1264, 61.9%) and "other domain" (C9) (543, 26.6%). Of the 2149 interventions introduced by pharmacists, 98.8% were accepted and 93% were accepted, and fully implemented. As a result, 92% of the DRPs were resolved. Both length of hospital stay and number of medications were significantly associated with DRPs. Conclusion: DRPs are common in the NICU; this study demonstrated the crucial role of clinical pharmacists in identifying and resolving DRPs.

Assessment of clinical pharmacist interventions using a web-based application in a Saudi Arabian Tertiary Hospital

Objectives

Medication-related problems are a top concern of clinical pharmacists. Medication-related problems can cause patient harm and increase the number of visits, hospital admissions, and length of hospital stay. The objective was to assess clinical pharmacy medication-related problem-related interventions in a tertiary care setting.

Methods

A retrospective cohort study was conducted at King Fahad Armed Forces Hospital in Jeddah (Saudi Arabia) between June 2021 and June 2022. The data were extracted monthly from a new web-based Microsoft Excel application documenting medication-related problems during any stage of the medication use process.

Results

A total of 5310 medication-related problem-related interventions in 1494 patients were performed. The departments associated with the highest frequency of medication-related problem-related interventions were the critical care unit (26.9%), intensive care unit (23.8%), anticoagulation clinic (17.1%), medical ward (11.3%), and nephrology unit (6.8%). The most common type of medication-related problem-related interventions included inappropriate dosage regimens (25.6%), monitoring drug effect or therapeutic drug monitoring (24.4%), requirement of additional drug therapy (21.9%), and inappropriate drug selection (14.1%). The proposed interventions were accepted by physicians in 97% of the incidents. The most frequent medication classes associated with medication-related problem-related interventions were cardiovascular agents (47.6%), antimicrobial agents (27.2%), and nutrition and blood substitute agents (11.4%). The most frequent medication groups associated with medication-related problem-related interventions were anticoagulants (25.6%) and antibiotics (25.2%).

Conclusions

The current findings characterize the medication-related problem-related interventions addressed in clinical pharmacy at a tertiary care setting. The high rate of physician acceptance emphasizes the integral patient safety role of clinical pharmacy services.

Root cause analysis of medication errors of the most frequently involved active substances in paediatric patients

BACKGROUND

Use of medicinal products in paediatric patients is identified as a risk factor for the occurrence of medication errors.

OBJECTIVES

To describe and identify root causes of medication errors in children and adolescents spontaneously reported to Agency for Medicinal Products and Medical Devices of Croatia (Agency).

METHOD

Agency's adverse drug reaction database was searched by using the Standardised MedDRA Query: medication errors (Broad) with data lock point set at 30th June 2022. Cases in which medication errors occurred in patients up to 18 years of age were analysed according to the patients' age group and gender, reporter's qualification, seriousness, reported preferred terms and active substances. For the first 30 most frequently reported active substances, an in-depth analysis was performed to identify the root cause of medication errors.

RESULTS

Altogether, 6254 reports were spontaneously reported to the Agency, out of which 1947 (31 %) contained at least one preferred term belonging to Standardised MedDRA Query medication errors. More than half of patients experiencing medication errors belonged to the age group 2-11 years (66 %) and male gender (53 %). The most frequently reported ME PTs included accidental exposure to product by a child (64 %) and accidental overdose (17 %). Medication error root causes for the first 30 most frequently involved active substances included misinterpretation of prescribed dosage due to a very small volume resulting in salbutamol overdose; replacing millilitre and milligram units resulting in paracetamol solution overdose; interchange between medicinal products due to primary package similarities resulting in cholecalciferol overdose and interchange between oral solution and syrup resulting in valproate overdose.

CONCLUSIONS

Healthcare professionals should counsel caregivers about the importance of keeping medicinal products out of children's reach and provide detailed instructions on how to appropriately use medicinal products.

Medication Safety Gaps in English Pediatric Inpatient Units: An Exploration Using Work Domain Analysis

OBJECTIVES

Medication is a common cause of preventable medical harm in pediatric inpatients. This study aimed to examine the sociotechnical system surrounding pediatric medicines management, to identify potential gaps in this system and how these might contribute to adverse drug events (ADEs).

METHODS

An exploratory prospective qualitative study in pediatric wards in three hospitals in the north of England was conducted between October 2020 and May 2022. Analysis included a documentary analysis of 72 policies and procedures and analysis of field notes from 60 hours of participant observation. The cognitive work analysis prompt framework was used to generate a work domain analysis (WDA) and identify potential contributory factors to ADEs.

RESULTS

The WDA identified 2 functional purposes, 7 value/priority measures, 6 purpose-related functions, 11 object-related processes and 14 objects. Structured means-ends connections supported identification of 3 potential contributory factors-resource limitations, cognitive demands, and adaptation of processes. The lack of resources (equipment, materials, knowledge, and experience) created an environment where distractions and interruptions were unavoidable. Families helped provide practical support in medicines administration but were largely unacknowledged at an organizational level. There was a lack of teamwork with regards to medication with different professionals responsible for different parts of the system. Mandated safety checks on medicines were frequently omitted because of limited resources and perceived redundancy. Interventions to support adherence to safety policies were also often bypassed because they created more work.

CONCLUSIONS

The WDA has provided insights into the complex system of medication safety for children in hospital and has facilitated the identification of potential contributory factors to ADEs. We therefore advocate (in priority order) for processes to involve parents in the care of their children in hospital, development of skill-mix interventions to ensure appropriate expertise is available where it is needed, and modified checking procedures to permit staff to use their skills and judgment effectively and efficiently.

Impact of clinical pharmacist-led intervention for drug-related problems in neonatal intensive care unit a randomized controlled trial

Introduction: Drug-related problems (DRPs) incidence is higher in neonatal intensive care units (NICUs), compared to other pediatric wards due to aspects like off-label medications, pharmacokinetic/dynamic variability, or organ dysfunction/immaturity. This study aimed to determine whether and to what extent a clinical pharmacist intervention improves medication safety and prevents DRPs [medication errors (MEs), adverse drug reactions (ADRs), drug-drug interactions (DDIs)]. Methods: A prospective, randomized, double blind, controlled study in NICU-admitted neonates was conducted. NICU patients were randomly assigned to the intervention (clinical pharmacist-led) (IG) or control group (standard care such as clinical diagnosis, pharmacotherapy) (CG). The clinical pharmacist was involved in the IG to identify-prevent-intervene MEs, or identify and monitor ADRs and DDIs. The primary outcome was the number of neonates who developed at least one DRP compared with those seen across IG and CG. Secondary outcomes included length of hospital stay, total number of drugs or DRP type. Results: Neonates were randomly assigned to CG (n = 52) or IG (n = 48). In total, 45%, 42%, and 16% of patients had at least 1 MEs, ADRs, and clinically significant DDIs, respectively. The number of patients with at least 1 ME was 28 (53%) and 17 (35%) in the CG and IG (p>0.05). The median (range) number of ME was higher in CG [1 (0-7)] than in IG [0 (0-4)] (p = 0.003). Applying regression analysis, the CG had 2.849 times more MEs than the IG (p<0.001). Furthermore, the number of patients (CG to IG) with at least one detected ADR or clinical DDI was 19 (36%) to 23 (47%) (p>0.05) and 4 (7%) to 12 (25%), respectively (p = 0.028). Conclusion: Clinical pharmacist availability to systematically and standardized identify, prevent and resolve DRPs among NICU patients is effective. Daily detailed clinical pharmacist observations and interventions enables prevention and monitoring of DRPs. Clinical Trial Registration ClinicalTrials.gov, identifier NCT04899960.

Pharmacist-Led Interventions to Reduce Drug-Related Problems in Prescribing for Pediatric Outpatients in a Developing Country: A Randomized Controlled Trial

OBJECTIVE

To evaluate a pharmacist-led intervention's effectiveness in reducing drug-related problems (DRPs ( related to prescriptions for pediatric outpatients.

METHODS

We conducted a randomized controlled trial. We recruited and randomly assigned 31 physicians to control or intervention groups. We collected 775 prescriptions (375 from the control group and 400 from the intervention group) at the start. For 3 weeks, intervention physicians received additional information and meetings with pharmacists in addition to the usual practices of the hospital. We then collected prescriptions at the end of the study. We classified DRPs, based on reliable references (Supplemental Table S1) at baseline and endpoint (a week after the intervention). The primary outcome was the proportion of prescriptions with DRPs, and secondary outcomes were the proportions of prescriptions with specific DRP types.

RESULTS

The influence of the intervention on general DRPs and specific DRPs was the study's main finding. The pharmacist-led intervention helped reduce the prescriptions with DRPs proportion in the intervention group to 41.0%, compared with 49.3% in the control group (p < 0.05). The DRPs proportion related to the timing of administration relative to meals, unlike the other DRP types, increased in the control group (from 31.7% to 34.9%) and decreased in the intervention group (from 31.3% to 25.3%), with a significant difference between the 2 groups at endpoint (p < 0.01). Patients aged >2 to ≤6 years (OR, 1.871; 95% CI, 1.340-2.613) and receiving ≥5 drugs (OR, 5.037; 95% CI, 2.472-10.261) were at greater risk of experiencing DRPs related to prescribing.

CONCLUSIONS

A pharmacist-led intervention improved DRP occurrence related to physicians' prescribing. Pharmacists could be involved in in-depth research with physicians in the prescribing process to provide tailored interventions.

Drug-Related Problems of Children With Chronic Diseases in a Chinese Primary Health Care Institution: A Cross-Sectional Study

Introduction: Drug-related problems (DRPs) refer to events or circumstances involving drug therapy that actually or potentially interfere with desired health outcomes. DRPs might be severe for children with chronic diseases managed at primary health care institutions, but the relevant research is scarce.

Objective: In this cross-sectional study, we aimed to explore the prevalence, types, causes, and influencing factors of DRPs in children with chronic diseases in a Chinese primary health care institution.

Methods: We recruited children with chronic diseases who visited the pediatric outpatient department in a primary health care institution from July 1 to 12 October 2021. Clinical pharmacists identified DRPs through medication therapy reviews, classified the types and causes of DRPs, and distinguished the manifested DRPs that affected the outcome and potential DRPs that were going to affect the outcome.

Results: A total of 188 children with chronic diseases was included, and 584 DRPs were identified in 89.89% of participants. The most common type of DRPs was “treatment effectiveness” (a manifested problem or potential problem with the effect of the pharmacotherapy; 83.56%), of which 67.29% were potential DRPs. The second common type was “treatment safety” (patient suffers or could suffer from an adverse drug event; 14.21%), of which 89.16% were potential DRPs. The most common cause of DRPs was related to the process of use (42.24%), such as “patient uses/takes less drug than prescribed or does not take the drug at all,” “patient stores drug inappropriately,” and “patient administers/uses the drug in a wrong way.” The second common cause was related to the process of dispensing (29.83%), such as “necessary information not provided or incorrect advice provided” and “prescribed drug is not available.” The third common cause was related to the process of prescribing (26.21%), such as “drug dose is too low” and “no or incomplete drug treatment despite an existing indication.” The number of combined medications was an influencing factor for the frequency of DRPs (p &lt; 0.05).

Conclusion: This cross-sectional study showed that the current situation regarding DRPs among children with chronic diseases managed in the primary health care institution was serious. The types of DRPs were mainly related to treatment effectiveness, and improper usage of medications was one of the main causes of DRPs. The number of combined drugs was the influencing factor for the frequency of DRPs. In the future, pharmacists should consider formulating pharmaceutical intervention strategies for this specific group according to the characteristics of DRPs.

Hospital Pharmacists Interventions to Drug-Related Problems at Tertiary Critical Care Pediatric Settings in Jazan, Saudi Arabia

Background: While drug-related problems (DRPs) have been recognized as a major concern in pediatric wards, the role of hospital pharmacy in improving medication safety has been rarely studied. Objectives: To investigate the frequency, nature, and severity of DRPs and associated pharmacist interventions (PIs). Methods: This is a prospective study carried out using direct observation over a year (2019-2020) in 3 pediatric wards (pediatric emergency department (PED), pediatric intensive care unit (PICU), and neonatal intensive care unit (NICU) in Jazan, Saudi Arabia. A validated data reporting form was developed to include comprehensive clinical data about the prescribed medications, characteristics of patients, and PIs upon DRPs. Clinical significance of DRPs was evaluated by an expert panel, which comprised a clinical pharmacist, a pediatrician, and an internist. Data analysis was conducted using SPSS V26. Results: The overall incidence of DRPs was 6.6%. The highest rate of DRPs 15.2% was detected in the pediatric ICU. Of the 596 DRPs detected, 10.2% were inappropriate drug choice, 5.2% were rated major DRPs, and one-third 33.2% were related to the digestive system and metabolism. Dosing problems were the most predominant DRPs across the included wards. A higher proportion of clinically major and moderate DRPs were detected in pediatric ED. Telephone-delivered interventions [OR: 1.72: 95%CI: 0.78-2.57: P = .001], too high dose [OR: 2.64: 95%CI: 1.33-4.56: P = .01], and major DRPs [OR: 3.21: 95%CI: 2.15-6.42: P = .04] were significant predictors for acceptance of PIs. Conclusion: DRPs are common in Saudi pediatric wards and many of these incidents were clinically major and moderate. Telephone-delivered interventions, too high dose, and major DRPs were major predictors for physician acceptance of PIs.

Systematic review of the prevalence and nature of drug‐related problems in paediatric patients

What is known and objective

Methods

Results

What is new and conclusion

Expert Consensus on a List of Inappropriate Prescribing after Prescription Review in Pediatric Units in Abidjan, Côte d'Ivoire

Introduction

Inappropriate prescribing (IP) includes inappropriate prescription and omission of prescription. IP can adversely affect the quality of health care in pediatric units. A list of IP taking into account frequently encountered drug-related problems (DRPs) can be useful to optimize prescriptions in pediatrics. The aim of this study was to validate by expert consensus a list of IP after a prescription review in pediatric units in Abidjan.

Materials and Methods

A list of IPs was developed from a prescription review of inpatients and outpatients aged 1 month to 15 years and followed in pediatric units at teaching hospitals of Abidjan during 16 months. A two-round Delphi method was used to validate a qualitative list of IPs by experts according to their level of agreement on a six-point Likert scale of 0–5 (0, no opinion; 5, strongly agree). Only propositions obtaining the agreement (rating 4 or 5) of >70% of experts who gave a non-zero rating for the first round and 80% for the second round were retained.

Results

A qualitative list of 54 IPs was drawn up from 267 DRPs detected after prescription review of 4,992 prescription lines for 881 patients. Our panel comprised 22 pediatricians (96%) and one clinical pharmacist (4%). Mean agreement ratings were 4.43/5 (95% CI 4.39–4.48) and 4.6/5 (95% CI 4.56–4.64), respectively, during the first Delphi round and the second (p<0.001). At the end of the first round, all items submitted (54) were retained, including 13 items that had been reworded. In the second round, 20 experts participated and two IPs (4%) were not retained for the final list. This list comprised 52 IPs (44 inappropriate prescriptions and eight omissions of prescription).

Conclusion

The list of IP validated in this study should help in the detection of DRPs and optimize prescriptions in pediatric units in Côte d’Ivoire.

Drug-related problems and its determinant among hospitalized neonates with sepsis at Jimma University Medical Center, Ethiopia: a prospective observational study

BACKGROUND

Neonatal populations are quite susceptible to drug-related problems (DRPs) because of clinical heterogeneity and clinical practice trends. However, studies reporting DRPs in the neonatal population are quite limited.

OBJECTIVE

This study aimed to assess the magnitude and types of DRPs and determinant factors among neonates admitted with neonatal sepsis at the Neonatal Intensive Care Unit (NICU) of the Jimma University Medical Center (JUMC), Ethiopia.

METHODS

A hospital-based prospective observational study was conducted involving 201 neonates with sepsis admitted to the NICU from May to August 30, 2018. DRPs were classified using Cipolle's classification method. Statistical Package for Social Science Version 22 was employed for data analysis. Logistical regression was carried out to determine the determinants of DRPs. A p-value < 0.05 was considered to be statistically significant.

RESULTS

Of 201 neonates with sepsis included in this study, 125 (62.2%) were males and the median age of the neonate was 5 days. The mean (±standard deviation) number of medications taking during their hospital stay was 2.6 ± 0.7. DRPs were identified in 98 neonates, at a rate of 48.8% (95% CI, 41.7-55.9). Dose too high (42, 35.8%) and need additional drug therapy (40, 34.1%) were the commonly identified DRPs. Taking antibiotics plus other medications (Adjusted Odds Ratio (AOR) =5.2, 95%CI [1.2-22.0], p = 0.02) was a determinant factor for the occurrence of DRPs.

CONCLUSION

The burdens of DRPs occurrence were high in hospitalized neonates with sepsis. The most common DRPs identified were dose too high and need additional drug therapy. Combined use of other medicines with antibiotics was a predictor of DRP occurrence. The innovative way to tackle the occurrence of DRPs, such as the incorporation of clinical pharmacy service provider into the neonatal care team, which will prevent, detect and/or minimize the occurrence of DRPs, is highly recommended.

Drug-related problems in Ethiopian public healthcare settings: Systematic review and meta-analysis

Identification and prevention of drug-related problems have become the central role of patient-centered pharmacy practitioners. After the initiation of patient-oriented pharmacy service, many studies evaluating magnitude of drug-related problems at facility level in Ethiopia have been conducted, though the extent of the problem at a national level remains unknown. Hence, this systematic review and meta-analysis is undertaken with the aim of quantifying the prevalence of drug-related problems in Ethiopian public healthcare settings using Cipolle/Strand classification system. Electronic databases were searched including PubMed, EMBASE, Web of Science, MEDLINE and HINARI, Google Scholar and ResearchGate for both published and unpublished works. Data on study characteristics and outcomes were extracted using the format developed on Microsoft Excel. The primary measure was the pooled prevalence of drug-related problems. The meta-analysis was conducted using OpenMeta[Analyst].A total of 17 studies were included in this systematic review and meta-analysis. The pooled prevalence of drug-related problems of patients who experienced at least one drug-related problem during their therapy was found to be 69.4% (95% confidence interval: 61.5-77.4). The most frequently reported types of drug-related problems were "need for additional drug and "noncompliance," together accounting for more than half of the drug-related problems. The most frequently reported factors associated with drug-related problems were patients' age, polypharmacy, comorbidities and the number days of hospital stay.The prevalence of drug-related problems in Ethiopian public healthcare settings was found to be high. Inconsistent reporting of drug-related problems was observed across the studies. It is imperative to design and implement interventions aimed at reducing drug-related problems. Responsible stakeholders should adopt uniform drug-related problem classification approach to ensure uniform reporting of drug-related problems in Ethiopian healthcare settings.

Drug-Related Problems in Prescribing for Pediatric Outpatients in Vietnam

BACKGROUND

Our study was conducted to determine the prevalence of drug-related problems (DRPs) in outpatient prescriptions, the impact of DRPs on treatment efficacy, safety, and cost, and the determinants of DRPs in prescribing for pediatric outpatients in Vietnam.

METHODS

A retrospective cross-sectional study was conducted on pediatric outpatients at a pediatric hospital in Can Tho, Vietnam. DRPs were classified according to the Pharmaceutical Care Network Europe classification (PCNE) of 2020. The study determined prevalence of DRPs and their impacts on efficacy, safety, and cost. Multivariate regression was used to identify the determinants of DRPs.

RESULTS

The study included 4339 patients (mean age 4.3, 55.8% male), with a total of 3994 DRPs, averaging 0.92 DRP/prescription. The proportion of prescriptions with at least one DRP was 65.7%. DRPs included inappropriate drug selection (35.6%), wrong time of dosing relative to meals (35.6%), inappropriate dosage form (9.3%), inappropriate indication (7.1%), and drug-drug interactions (0.3%). The consensus of experts was average when evaluating each aspect of efficiency reduction, safety reduction, and treatment cost increase, with Fleiss' coefficients of 0.558, 0.511, and 0.541, respectively (p < 0.001). Regarding prescriptions, 50.1% were assessed as reducing safety. The figures for increased costs and decreased treatment effectiveness were 29.0% and 23.9%, respectively. Patients who were ≤2 years old were more likely to have DRPs than patients aged 2 to 6 years old (OR = 0.696; 95% CI = 0.599-0.809) and patients aged over 6 years old (OR = 0.801; 95% CI = 0.672-0.955). Patients who had respiratory system disease were more likely to have DRPs than patients suffering from other diseases (OR = 0.715; 95% CI = 0.607-0.843). Patients with comorbidities were less likely to have DRPs than patients with no comorbidities (OR = 1.421; 95% CI = 1.219-1.655). Patients prescribed ≥5 drugs were more likely to have DRPs than patients who took fewer drugs (OR = 3.677; 95% CI = 2.907-4.650).

CONCLUSION

The proportion of prescriptions in at least one DRP was quite high. Further studies should evaluate clinical significance and appropriate interventions, such as providing drug information and consulting doctors about DRPs.

Establishing dose bands for commonly prescribed oral medications for children in the UK: Results of a Delphi study

OBJECTIVE

To establish weight-based dose bands for commonly used oral medicines, given in liquid forms, for children in the UK that could be used for prescribing and administering accurate and safe drug doses.

METHODS

A list of commonly prescribed, oral liquid medications was established from the medication dispensing database of four UK hospitals and a primary care database. The evidence base of currently used dose regimens for each drug was identified from paediatric reference books, summary of product characteristics and the literature. Then, weight-based dose bands were developed and a modified Delphi process was used to achieve healthcare professional consensus about the suggested dose bands for each drug.

RESULTS

Forty-six experts in paediatric medicines participated in the Delphi process (mean years of experience 17.3 ± 9.4 [standard deviation]) and assessed 45 oral liquid drugs in total. Four categories of weight-based dose bands were established: drugs with two dose bands (17.8%, 8/45), drugs with three dose bands (64.4%, 29/45), drugs with four dose bands (15.6%, 7/45) and drugs with five dose bands (2.2%, 1/45). The 46 participants reached consensus on all the suggested dose bands for 53.3% (24/45) of the drugs. Consensus was reached in the first round of the Delphi process for 91.7% (22/24) of the drugs and after two rounds for two drugs. No agreement was achieved on any of the suggested dose bands for 26.7% (12/45) of the drugs.

CONCLUSION

This study provides healthcare professionals with a set of recommended weight-based dose bands for commonly prescribed oral liquid drugs for children. These bands could establish the basis for change in clinical practice to reduce dosing errors and improve healthcare for children.

Drug-related problem and its predictors among pediatric patients with infectious diseases admitted to Jimma University Medical Center, Southwest Ethiopia: Prospective observational study

Background

Drug-related problem is any event involving drug therapy that may interfere in a patient's desired clinical outcome. It has been pointed out that hospitalized pediatric patients are particularly prone to drug-related problems. Thus, this study aimed to assess drug-related problems and its predictors among pediatric patients diagnosed with infectious diseases admitted to Jimma University Medical Center, Southwest Ethiopia.

Methodology

A prospective observational study was conducted among pediatric patients with infectious diseases admitted to the Jimma University Medical Center. Drug-related problems were classified based on Cipolle, Morley, and Strand's drug-related problems classification method. The patient's specific data were collected using a structured questionnaire. Data were entered into Epi data version 4.0.2 and then exported to statistical software package version 21.0 for analysis. To identify predictors of drug-related problems occurrence, multiple stepwise backward logistic regression analysis was done. Statistical significance was considered at a p-value < 0.05.

Results

Of the total 304 participants, 226 (74.3%) of them had at least one drug-related problem during their hospital stay. A total of 356 drug-related problems were identified among 226 patients. Anti-infective medication was the major class of drug involved in drug-related problems. Noncompliance (28.65%) and dose too low (27.53%) were the most common type of drug-related problems identified. Presence of disease comorbidity (adjusted odds ratio = 3.39, 95% confidence interval = 1.89-6.08), polypharmacy (adjusted odds ratio = 3.16, 95% confidence interval = 1.61-6.20), and more than 6 days stay in hospital (adjusted odds ratio = 3.37, 95% confidence interval = 1.71-6.64) were independent predictors for the occurrence of drug-related problems..

Conclusion

Drug-related problems were high among pediatric patients with infectious disease in the study setting. The presence of comorbidity, polypharmacy, and prolonged hospital stay were predictors of drug-related problems in this finding. Therefore, to prevent these problems, the collaboration of clinical pharmacists, pediatricians, and other health care professionals is needed during the provision of pharmaceutical care.

Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis

INTRODUCTION

The risk of medication errors is high in paediatric inpatient settings. However, estimates of the prevalence of medication errors have not accounted for heterogeneity across studies in error identification methods and definitions, nor contextual differences across wards and the use of electronic or paper medication charts.

OBJECTIVE

Our aim was to conduct a systematic review and meta-analysis to provide separate estimates of the prevalence of medication errors among paediatric inpatients, depending on hospital ward and the use of electronic or paper medication charts, that address differences in error identification methods and definitions.

METHODS

We systematically searched five databases to identify studies published between January 2000 and December 2018 that assessed medication error rates by medication chart audit, direct observation or a combination of methods.

RESULTS

We identified 71 studies, 19 involved paediatric wards using electronic charts. Most studies assessed prescribing errors with few studies assessing administration errors. Estimates varied by ward type. Studies of paediatric wards using electronic charts generally reported a reduced error prevalence compared to those using paper, although there were some inconsistencies. Error detection methods impacted the rate of administration errors in studies of multiple wards, however, no other difference was found. Definition of medication error did not have a consistent impact on reported error rates.

CONCLUSIONS

Medication errors are a frequent occurrence in paediatric inpatient settings, particularly in intensive care wards and emergency departments. Hospitals using electronic charts tended to have a lower rate of medication errors compared to those using paper charts. Future research employing controlled designs is needed to determine the true impact of electronic charts and other interventions on medication errors and associated harm among hospitalized children.

Risk factors for drug-related problems in a general hospital: A large prospective cohort

OBJECTIVE

To identify risk factors for potential Drug-Related Problems (DRP) at admission in hospitalized patients.

METHODOLOGY

Prospective cohort study conducted in adults patients hospitalized (May 2016 to May 2018) in a general tertiary care hospital in Brazil. Potential DRP were detected by daily review of 100% of electronic medication orders by hospital pharmacists and classified by the Pharmaceutical Care Network Europe classification system (PCNE version 6.2). For the identification of risk factors of potential DRP, backward stepwise logistic regression was used to identify the set of independent predictors among over 120 variables collected in the initial 48 hours after admission in a training set consisting of 2/3 of the study population. The model was validated in the remaining sample.

RESULTS

The study population consisted of 1686 patients aged 52.0+/- 18.3 years-old, 51.4% females, with a median length of stay of 3.24 days, and 4.5% in-hospital mortality. The cumulative incidence of potential DRP was 14.5%. Admission for elective surgery and main diagnosis of disease of the circulatory system were associated with reduced risk of DRP (OR 0.41 and 0.57, respectively, p<0.05). The independent risk factors of DRP are heart rate ≥ 80 bpm (OR 1.41, p = 0.05), prescription of more than seven drugs in day 2 (OR 1.63, p = 0.05), prescription in day 1 of drugs of the Anatomical Therapeutic Chemical Code (ATC) class A (alimentary tract and metabolism, OR 2.24, p = 0.003), prescription in day 2 of two or more ATC class A drugs (OR = 3.52, p<0.001), and in day 1 of ATC class J drugs (antiinfectives for systemic use, OR 1.97, p = 0.001). In the validation set, the c-statistic of the predictive model was 0.65, the sensitivity was 56.1% and the specificity was 65.2%.

CONCLUSION

This study identified seven independent risk factors of potential DRP in patients hospitalized in a general hospital that have fair predictive performance for utilization in clinical practice.

Drug-related problems in a general paediatric ward of a tertiary care hospital in Malaysia

Background Drug-related problems are relatively common among hospitalised patients and may be detrimental to patients and even increase healthcare costs. Characterising drug-related problems allows remedial actions to be in place to minimise the frequency and ensure higher medication safety for the patients involved. Currently, the incidence of drug-related problems among hospitalised paediatric patients in Malaysia is unknown. Objective To determine the incidence, types and intervention acceptance, as well as the risk factors associated with drug-related problems in a Malaysian general paediatric ward. Setting General paediatric ward in Universiti Kebangsaan Malaysia Medical Centre. Method A cross-sectional observational study was conducted from March to May 2019. Data were collected from patients' medical charts, clinical notes and medical records for problem identification based on the modified Pharmaceutical Care Network Europe (PCNE) classification V 8.02. The incidence, types, causes and intervention acceptance as well as the risk factors were assessed. Main outcome measure Drug-related problems based on the modified PCNE classification V 8.02. Results In total, 225 paediatric patients with a total of 694 prescriptions were included in this study. The incidence of drug-related problems was 52.9% (198 prescriptions with problems in 119 patients). The main types of problems were treatment safety (68 prescriptions, 34.3%), incomplete prescription (56 prescriptions, 28.3%) and un-optimised drug treatment (35 prescriptions, 17.7%). The main causes for the problems were necessary information not provided (n = 63, 30.1%), inappropriate dose selection (n = 47, 22.5%) and medication served without a valid prescription (n = 40, 19.1%). Of the 143 interventions proposed to prescribers by the pharmacist, 117 (81.8%) were accepted. The number of prescriptions was found to be the only risk factor associated with DRPs (odds ratio, 1.91; 95% confidence interval, 1.54-2.38; p < 0.001). Conclusion The frequency of drug-related problems among general paediatric ward patients is high and with each increase in prescription a patient received, the risk of a DRP doubles.

Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC)

Classifying harm associated with a medication error can be time consuming and labour intensive and limited studies undertake this step. There is no standardised process, and few studies that report harm assessment provide adequate methods to allow for study replication. Studies typically mention that a clinical review panel classified patient harm and provide a reference to a classification tool. Moreover, in many studies it is unclear whether potential or actual harm was classified as studies refer only to ‘error severity’. The tools used to categorise the severity of patient harm vary widely across studies and few have been assessed for inter-rater reliability and criterion validity. In this paper, we describe the systematic process we undertook to synthesise the defining elements and strengths, while mitigating the limitations, of existing harm classification tools to derive the Harm Associated with Medication Error Classification (HAMEC). This new tool provides a harm classification for use across clinical and research settings. The provision of an explicit process for its application and guiding category descriptors are designed to reduce the risk of misclassification and produce results that are comparable across studies. As the World Health Organisation embarks on its international safety challenge of reducing medication-related harm by 50%, accompanying methodological advances are required to measure progress.

A Scoping Review of Medications Studied in Pediatric Polypharmacy Research

PURPOSE

The purpose of this study is to describe medications most commonly studied in pediatric polypharmacy research by pharmacologic classes and disease using a scoping review methodology.

METHODS

A search of electronic databases was conducted in July 2019 that included Ovid Medline, PubMed, Elsevier Embase, and EBSCO CINAHL. Primary observational studies were selected if they evaluated polypharmacy as an aim, outcome, predictor, or covariate in children 0-21 years of age. Studies not differentiating between adults and children or those not written in English were excluded. Study characteristics, pharmacologic categories, medication classes, and medications were extracted from the included studies.

RESULTS

The search identified 8790 titles and after de-duplicating and full-text screening, 414 studies were extracted for the primary data. Regarding global pharmacologic categories, central nervous system (CNS) agents were most studied (n = 185, 44.9%). The most reported pharmacologic category was the anticonvulsants (n = 250, 60.4%), with valproic acid (n = 129), carbamazepine (n = 123), phenobarbital (n = 87), and phenytoin (n = 83) being the medications most commonly studied. In studies that reported medication classes (n = 105), serotonin reuptake inhibitors (n = 32, 30.5%), CNS stimulants (n = 30, 28.6%), and mood stabilizers (n = 27, 25.7%) were the most studied medication classes.

CONCLUSION

While characterizing the literature on pediatric polypharmacy in terms of the types of medication studied, we further identified substantive gaps within this literature outside of epilepsy and psychiatric disorders. Medications frequently identified in use of polypharmacy for treatment of epilepsy and psychiatric disorders reveal opportunities for enhanced medication management in pediatric patients.

DRUG-RELATED PROBLEMS IN CARDIAC NEONATES UNDER INTENSIVE CARE

Objective:

To determine the frequency and nature of the Drug Related Problems (DRP) in neonates with cardiac diseases admitted to an Intensive Care Unit.

Methods:

This prospective cross-sectional study was developed at the Neonatal Intensive Care Unit (NICU) of a teaching maternity hospital in Brazil from January 2014 to December 2016. All neonates diagnosed with any heart disease (congenital heart disease, cardiomyopathy, arrhythmias, etc.) and who were admitted to the NICU for more than 24 hours with at least one prescribed drug were included in the study. Demographic and clinical data were collected from the records of the institution’s clinical pharmacy service. DRP and their respective interventions were independently reviewed and classified by two pharmacists. DRP classification was performed through the Pharmaceutical Care Network Europe v6.2 system.

Results:

122 neonates were included in the study. The frequency of neonates exposed to DRP was 76.4% (confidence interval of 95% [95%CI] 65.9–82.0), with a mean of 3.2±3.8 cases/patient. In total, 390 DRP were identified, of which 49.0% were related to “treatment effectiveness”, 46.7% to “adverse reactions” and 1.0% to “treatment costs”. The medicines most involved in DRP were Vancomycin (10.2%; n=46), Meropenem (8.0%; n=36) and Furosemide (7.1%; n=32). Pharmacists performed 331 interventions, of which 92.1% were accepted by physicians and nurses.

Conclusions:

The study showed that DRP are very frequent in patients with cardiac diseases hospitalized in the NICU, predominating problems related to the effectiveness and safety of the drug treatment.

Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

BACKGROUND

Problems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety.

METHODS

Nine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted.

RESULTS

In all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8-29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7-13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9-13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4-23). Administration technique errors represented 53% (IQR 52.7-67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1-46) of prescribed medication; 70.3% (Range 50-78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors.

CONCLUSIONS

Children are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.

Epidemiology of Preventable Drug-Related Problems (DRPs) Among Hospitalized Children at KAMC-Jeddah: a Single-Institution Observation Study

Aim

Drug-related problems (DRPs) "are the unwanted effects of drugs that potentially lead to a harmful outcome" thereby requiring considerable attention. Hospitalized pediatric patients, in particular, represent a population at risk of DRPs. The epidemiology of preventable DRPs among children in Saudi Arabia remains scarce, which thus poses distinct challenges to all healthcare professionals. We aim to characterize preventable DRPs among hospitalized children at KAMC-Jeddah.

Methods

A prospective observational study of children (≤15 years) admitted to pediatric units (excluding cancer units) at KAMC-Jeddah over a 3-month period (May 29 to August 30, 2016) is carried out to determine the incidence of preventable DRPs and investigate the possible associated factors (gender, age, admission location, type of admission, and number of medications).

Results

A total of 319 DRPs were identified among 235 patients, of which 280 DRPs (87.8%, 280/319) were deemed preventable. The majority of preventable DRPs were related to dose selection (78%, 219/280). None of the preventable DRPs were life threatening or fatal, and the majority were assessed as moderate in severity (94.3%, 264/280). There was no significant difference between DRP incidences with age mean 3.5 (P=0.389), gender mean (P=0.436), and weight mean 13.47 (P=0.323). Younger children (age ≤2years) admitted to PICU were more likely to have DRP (OR 4.44, 95% CI, 1.87 to 10.52, P=0.00001). Scheduled admissions were 2.89 times more likely to be exposed to DRP compared to transferred admissions (OR 2.8, 95% CI, 1.83 to 4.70, P=0.005). Additionally, DRP incidences increased proportionally to the number of medications.

Conclusion

Our data suggest that establishing appropriate prevention strategies towards improvement and safety in medicine use among this vulnerable patient population is a high priority.

What causes prescribing errors in children? Scoping review

OBJECTIVES

(1) Systematically assemble, analyse and synthesise published evidence on causes of prescribing error in children. (2) Present results to a multidisciplinary group of paediatric prescribing stakeholders to validate findings and establish how causative factors lead to errors in practice.

DESIGN

Scoping review using Arksey and O'Malley's framework, including stakeholder consultation; qualitative evidence synthesis.

METHODS

We followed the six scoping review stages. (1) Research question-the research question was 'What is known about causes of prescribing error in children?' (2) Search strategy-we searched MEDLINE, EMBASE, CINAHL (from inception to February 2018), grey literature and reference lists of included studies. (3) Article selection-all published evidence contributing information on the causes of prescribing error in children was eligible for inclusion. We included review articles as secondary evidence to broaden understanding. (4) Charting data-results were collated in a custom data charting form. (5) Reporting results-we summarised article characteristics, extracted causal evidence and thematically synthesised findings. (6) Stakeholder consultation-results were presented to a multidisciplinary focus group of six prescribing stakeholders to establish validity, relevance and mechanisms by which causes lead to errors in practice.

RESULTS

68 articles were included. We identified six main causes of prescribing errors: children's fundamental differences led to individualised dosing and calculations; off-licence prescribing; medication formulations; communication with children; and experience working with children. Primary evidence clarifying causes was lacking.

CONCLUSIONS

Specific factors complicate prescribing for children and increase risk of errors. Primary research is needed to confirm and elaborate these causes of error. In the meantime, this review uses existing evidence to make provisional paediatric-specific recommendations for policy, practice and education.

Risk assessment of patient factors and medications for drug-related problems from a prospective longitudinal study of newborns admitted to a neonatal intensive care unit in Brazil

OBJECTIVE

To identify patient factors and medications associated with the occurrence of drug-related problems (DRPs) in neonates admitted to neonatal intensive care units (NICUs).

DESIGN

Prospective, longitudinal study.

SETTING

NICU of a teaching hospital in Brazil.

PARTICIPANTS

Data were collected from the records of the clinical pharmacy service of all neonates admitted between April 2014 and January 2017, excluding neonates with length of stay in the NICU <24 hours or without prescribed drugs.

PRIMARY OUTCOME MEASURES

Occurrence of one or more DRP (conditions interfering in the patient's pharmacotherapy with potential undesired clinical outcomes).

RESULTS

The study observed 600 neonates who had a median length of stay in the NICU of 13 days (range 2-278 days). DRPs were identified in most neonates (60.5%). In a multivariate logistic regression model, the factors independently associated with DRP were gestational age (adjusted OR (AOR) 0.85, 95% CI 0.81 to 0.89), 5 min Apgar <7 (AOR 1.74, 95% CI 1.00 to 3.13), neurological disease (AOR 2.49, 95% CI 1.09 to 5.69), renal disease (AOR 5.75, 95% CI 1.85 to 17.8) and cardiac disease (AOR 2.36, 95% CI 1.31 to 4.24). The medications with greater risk for DRP were amphotericin B (AOR 4.80), meropenem (AOR 4.09), alprostadil (AOR 3.38), vancomycin (AOR 3.34), ciprofloxacin (AOR 3.03), gentamicin (AOR 2.43), cefepime (AOR 1.88), amikacin (AOR 1.82) and omeprazole (AOR 1.66). These medicines represented one-third of all prescribed drugs.

CONCLUSIONS

Gestational age, 5 min Apgar <7, and neurological, cardiac and renal diseases are risk factors for DRP in NICUs. Alprostadil, omeprazole and several anti-infectives were associated with greater risk of DRP.

The Prevalence of Dose Errors Among Paediatric Patients in Hospital Wards with and without Health Information Technology: A Systematic Review and Meta-Analysis

INTRODUCTION

The risk of dose errors is high in paediatric inpatient settings. Computerized provider order entry (CPOE) systems with clinical decision support (CDS) may assist in reducing the risk of dosing errors. Although a frequent type of medication error, the prevalence of dose errors is not well described. Dosing error rates in hospitals with or without CPOE have not been compared.

OBJECTIVE

Our aim was to conduct a systematic review assessing the prevalence and impact of dose errors in paediatric wards with and without CPOE and/or CDS.

METHODS

We systematically searched five databases to identify studies published between January 2000 and December 2017 that assessed dose error rates by medication chart audit or direct observation.

RESULTS

We identified 39 studies, nine of which involved paediatric wards using CPOE with or without CDS. Studies of paediatric wards using paper medication charts reported approximately 8-25% of patients experiencing a dose error, and approximately 2-6% of medication orders and approximately 3-8% of dose administrations contained a dose error, with estimates varying by ward type. The nine studies of paediatric wards using CPOE reported approximately 22% of patients experiencing a dose error, and approximately 1-6% of medication orders and approximately 3-8% of dose administrations contained a dose error. Few studies provided data for individual wards. The severity and prevalence of harm associated with dose errors was rarely assessed and showed inconsistent results.

CONCLUSIONS

Dose errors occur in approximately 1 in 20 medication orders. Hospitals using CPOE with or without CDS had a lower rate of dose errors compared with those using paper charts. However, few pre/post studies have been conducted and none reported a significant reduction in dose error rates associated with the introduction of CPOE. Future research employing controlled designs is needed to determine the true impact of CPOE on dosing errors among children, and any associated patient harm.

Impact of the e-prescribing system on the incidence and nature of drug-related problems in children in a Saudi hospital

OBJECTIVES

To determine the impact of a computerised physician order entry (CPOE) system on the drug-related problems' (DRPs) incidence and characteristics in hospitalised children in a Saudi hospital, and to compare DRPs incidence pre-/post-CPOE implementation.

METHODS

An observational study. DRPs were identified by pharmacists, reviewing children's (0-14 years) medical records on CPOE system, in paediatric wards and/or attending emergency department. DRPs preventability and severity were assessed.

RESULTS

A total of 657 paediatric patients were included, with 235 (35.8%) experienced 328 DRPs, majority were preventable (99.7%, 327). Difference in DRP incidence pre- and post-CPOE implementation (44.8% versus 35.8%, P < 0.01) was significant.

CONCLUSION

The CPOE system has significantly reduced DRPs incidence in children in the study hospital.

Drug related problems in the neonatal intensive care unit: incidence, characterization and clinical relevance

BACKGROUND

Any event involving drug therapy that may interfere in a patient's desired clinical outcome is called a drug related problem (DRP). DRP are very common in intensive therapy, however, little is known about DRP in the Neonatal Intensive Care Unit (NICU). The purpose of this study was to determine the incidence of DRPs in NICU patients and to characterize DRPs according to type, cause and corresponding pharmaceutical conducts.

METHODS

Prospective observational study conducted in the NICU at a teaching hospital in Brazil from January 2014 to November 2016. The data were collected from the records of the clinical pharmacy service, excluding neonates admitted for less than 24 h and those who had no drugs prescribed. DRPs were classified according to the Pharmaceutical Care Network Europe system and evaluated for relevance-safety.

RESULTS

Six hundred neonates were included in the study, with mean gestational age of 31.9 ± 4.1 weeks and mean birth weight of 1779 ± 885 g. The incidence of DRPs in the NICU was 6.8% patient-days (95%CI 6.2-7.3%) and affected 59.8% of neonates (95% CI 55.8-63.8%). Sub-optimal effect (52.8%) and inappropriate dose selection (39.75%) were the most common problem and cause, respectively. Anti-infectives was the medication class most involved in DRPs. More than one-third of neonates were exposed to DRP of significant or high safety-relevance. Most of the pharmaceutical interventions were related with drug prescription, with over 90% acceptance by attending physicians.

CONCLUSION

DRP are common in NICU, predominating problems of sub-optimal treatment, mainly due to inappropriate dose selection.

The Responsibility of Clinical Pharmacists for the Safety of Medication Use in Hospitalized Children: A Middle Eastern Experience

Objective:

We aimed to detect and report the frequency of occurrence of drug-related problems (DRPs) in a Middle Eastern University Children's Hospital (Isfahan, Iran) and classify them in terms of their nature and cause to clarify the responsibility of clinical pharmacists for the safe utilization of medications in hospitalized children.

Methods:

In this cross-sectional study which was carried out in Imam Hossein Children's University Hospital affiliated with Isfahan University of Medical Sciences (Isfahan, Iran) from September 2017 to May 2018, DRPs during the hospitalization of pediatric patients in three medical wards, the pediatric intensive care unit, and two neonatal intensive care units were detected and identified concurrently with the treatment process using Pharmaceutical Care Network of Europe data gathering form for DRPs v. 8.01. All cases were verified and validated in a professional focus group before documentation.

Findings:

We detected 427 DRPs in 201 out of 250 randomly included hospitalized children in which 86% of them were directly reported by the hospital's clinical pharmacist. The highest frequency of DRPs (47.3%) was observed in the age range of 1 month–2 years. Safety of treatment was the most frequently reported as the nature of the problem (43.5%), followed by effectiveness issues (36.8%). The most frequent cause of DRPs was dose selection issues (34.2%), followed by drug-type selection (25.5%), and unavailability of appropriate dosage forms (13.6%). Ninety-eight interventions were proposed by the clinical pharmacist, in which 59.2% of them were accepted.

Conclusion:

This study confirms the necessity for the active role of clinical pharmacists before, during, and after drug therapy in hospitalized pediatric patients for the safety and proper utilization of drugs in this vulnerable population.

Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries

BACKGROUND

Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries.

METHODS

A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included.

RESULTS

Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5-16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists' interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists' recommendations.

CONCLUSIONS

Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.

Medication audit and feedback by a clinical pharmacist decrease medication errors at the PICU: An interrupted time series analysis

OBJECTIVE

Medication errors (MEs) are one of the most frequently occurring types of adverse events in hospitalized patients and potentially more harmful in children than in adults. To increase medication safety, we studied the effect of structured medication audit and feedback by a clinical pharmacist as part of the multidisciplinary team, on MEs in critically ill children.

METHOD

We performed an interrupted time series analysis with 6 preintervention and 6 postintervention data collection points, in a tertiary pediatric intensive care unit. We included intensive care patients admitted during July to December 2013 (preintervention) and July to December 2014 (postintervention). The primary endpoint was the prevalence of MEs per 100 prescriptions. We reviewed the clinical records of the patients and the incident reporting system for MEs. If an ME was suspected, a pediatrician-intensivist and a clinical pharmacist determined causality and preventability. They classified MEs as harmful according to the National Coordinating Council for Medication Error Reporting and Prevention categories.

RESULTS

We included 254 patients in the preintervention period and 230 patients in the postintervention period. We identified 153 MEs in the preintervention period, corresponding with 2.27 per 100 prescriptions, and 90 MEs in the postintervention period, corresponding with 1.71 per 100 prescriptions. Autoregressive integrated moving average analyses revealed a significant change in slopes between the preintervention and postintervention periods (β = -.21; 95% CI, -0.41 to -0.02; P = .04). We did not observe a significant decrease immediately after the start of the intervention (β = -.61; 95% CI, -1.31 to 0.08; P = .07).

CONCLUSION

The implementation of a structured medication audit, followed by feedback by a clinical pharmacist as part of the multidisciplinary team, resulted in a significant reduction of MEs in a tertiary pediatric intensive care unit.

Risk factors for adverse drug reactions in pediatric inpatients: A cohort study

Purpose

The present study aims to identify the risk factors for adverse drug reactions (ADR) in pediatric inpatients.

Methods

A prospective cohort study in one general pediatric ward in a hospital in Northeast Brazil was conducted in two stages: the first stage was conducted between August 17^th and November 6^th, 2015, and the second one between March 1^st and August 25^th, 2016. We included children aged 0–14 years 11 months hospitalized with a minimum stay of 48 hours. Observed outcomes were the ADR occurrence and the time until the first ADR observed. In the univariate analysis, the time to the first ADR was compared among groups using a log-rank test. For the multivariate analysis, the Cox regression model was used.

Results

A total of 173 children (208 admissions) and 66 ADR classified as “definite” and “probable” were identified. The incidence rate was 3/100 patient days. The gastro-intestinal system disorders were the main ADR observed (28.8%). In addition, 22.7% of the ADR were related to antibacterials for systemic use and 15.2% to general anesthesia. Prior history of ADR of the child [hazard ratio (HR) 2.44; 95% confidence interval (CI) 1.19–5.00], the use of meglumine antimonate (HR 4.98; 95% CI 1.21–20.54), antibacterial for systemic use (HR 2.75; 95% CI 1.08–6.98) and antiepileptic drugs (HR 3.84; 95% CI 1.40–10.56) were identified risk factors for ADR.

Conclusions

We identified as risk factors the prior history of ADR of the child and the use of meglumine antimonate, antibacterial for systemic use and antiepileptic drugs.

Assessment of drug-related problems in pediatric ward of Zewditu Memorial Referral Hospital, Addis Ababa, Ethiopia

Background Although medications play a vital role in the cure, palliation, and inhibition of disease, they also expose patients to drug-related problems (DRPs). DRPs are common in hospitalized patients. Specifically, pediatrics population are easily affected by DRPs, as dynamic and kinetic behaviors of drugs in this population are usually different than  in adults. Objectives To assess the prevalence of DRPs and associated factors in a pediatric setting in Ethiopia. Setting Pediatric ward of Zewditu Memorial Referral Hospital, Addis Abbeba, Ethiopia. Methods A cross-sectional study was conducted on 285 randomly selected patients. Data were obtained through review of physician medication orders and patient files. The prevalence and type of DRPs were studied and documented using the Pharmaceutical Care Network Europe Foundation classification system. The results were summarized using descriptive statistics including frequency, mean, and standard deviation. To identify the independent predicators of DRPs, logistic regression analysis was run and a P value ≤0.05 was considered as statistically significant. Main outcome measure DRPs, types of DRPs, drugs that are frequently involved in DRPs, and factors associated with DRPs. Main outcome measure Number of DRPs. Results Of the 1055 medication orders reviewed, a total of 106 DRPs were identified in 90 patients. This gives an overall rate of drug-related problems of 31.57%. The most frequently identified DRPs were dosing problems, with dose too low being 34.9% and dose too high being 7.5%. This was followed by drug-drug interactions (38.67%) and adverse drug reactions (8.49%). The number of prescribed drugs (AOR 2.3, 95% CI 1.3-4.3, P = 0.007) and total number of disease conditions (AOR 4.8, 95% CI 1.9, 12.1, P = 0.001) were potential risk factors for occurrence of DRPs. Conclusion The present study demonstrated that DRPs were common at the pediatric ward of Zewditu Memorial Referral Hospital and that it needs great attention. The most frequently identified DRPs were dosing problems, followed by drug-drug interactions and adverse drug reaction. Poly-pharmacy and number of disease conditions have been identified as important risk factors for occurrence of DRPs. The investigators recommend establishing a system for reporting DRPs in the pediatric ward of the hospital as it may facilitate appropriate measures for prospective interventions, such as training the healthcare team, as well as detail precautions to be followed by the practitioners. In addition to this, improving communication between the healthcare team members such as physicians, pharmacists, nurses, and other healthcare workers in the hospital is recommended.

Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to improve patient outcomes. Protocol for an observational study

INTRODUCTION

Medicines optimisation is a key role for hospital pharmacists, but with ever-increasing demands on services there is a need to increase efficiency while maintaining patient safety. The aim of this study is to develop a prognostic model, the Medicines Optimisation Assessment Tool (MOAT), which can be used to target patients most in need of pharmacists' input while in hospital.

METHODS AND ANALYSIS

The MOAT will be developed following recommendations of the Prognosis Research Strategy partnership. Using a cohort study we will prospectively include 1500 adult patients from the medical wards of two UK hospitals. Data on medication-related problems (MRPs) experienced by study patients will be collected by pharmacists at the study sites as part of their routine daily clinical assessment of patients. Data on potential risk factors such as polypharmacy, renal impairment and the use of 'high risk' medicines will be collected retrospectively from the information departments at the study sites, laboratory reporting systems and patient medical records. Multivariable logistic regression models will then be used to determine the relationship between potential risk factors and the study outcome of preventable MRPs that are at least moderate in severity. Bootstrapping will be used to adjust the MOAT for optimism, and predictive performance will be assessed using calibration and discrimination. A simplified scoring system will also be developed, which will be assessed for sensitivity and specificity.

ETHICS AND DISSEMINATION

This study has been approved by the Proportionate Review Service Sub-Committee of the National Health Service Research Ethics Committee Wales REC 7 (16/WA/0016) and the Health Research Authority (project ID 197298). We plan to disseminate the results via presentations at relevant patient/public, professional, academic and scientific meetings and conferences, and will submit findings for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02582463.

Investigating the Relative Significance of Drug-Related Problem Categories

The aim of the review was to investigate whether an assessment of clinical significance can be related to specific drug-related problems (DRPs) and hence may assist in prioritizing individual categories of DRP categorization systems. The literature search using Google Scholar was performed for the period 1990 to 2013 and comprised primary research studies of clinical pharmacy interventions including DRP and clinical significance assessments. Two reviewers assessed the titles, abstracts, and full-text papers individually, and inclusion was determined by consensus. A total of 27 unique publications were included in the review. They had been conducted in 14 different countries and reported a large range of DRPs (71-5948). Five existing DRP categorisation systems were frequently used, and two methods employed to assess clinical significance were frequently reported. The present review could not establish a consistent relation between the DRP categories and the level of clinical significance. However, the categories "ADR" and possibly "Drug interaction" were often associated with an assessed high clinical significance, albeit they were infrequently identified in the studies. Hence, clinical significance assessments do not seem to be useful in prioritizing individual DRPs in the DRP categorization systems. Consequently, it may be necessary to reconsider our current approach for evaluating DRPs.

Risk factors for adverse drug reactions in pediatric inpatients: a systematic review

BACKGROUND

The main objective of the present systematic review is to identify potential risk factors for adverse drug reactions (ADRs) through prospective cohort studies in pediatric inpatients.

METHODS

The data search was done in the following electronic databases PubMed/MEDLINE; Scopus; LILACS and Web of Science from the earliest record until 31 May 2015. Two reviewers independently screened each study and one of them assessed the methodological quality according to the Newcastle-Ottawa scale for cohort studies. The data extraction was conducted according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative for cohort studies.

RESULTS

The only risk factor observed in all studies was the increase in the number of prescription drugs. However, other factors were identified, such as the increase in the length of stay or the number of low- or high-risk drugs prescribed, use of general anesthesia and oncological diagnosis. The cumulative incidence of ADR was 16.4% (95% confidence interval: 15.6 to 17.2). The main professional responsible for ADR identification was the pharmacist and the dominant category among the ADRs were gastrointestinal disorders. In addition, analgesics, antibacterial agents and corticosteroids were the drug classes commonly associated with ADRs. The methodology used in this study was tried to homogenize the data extracted; however, this was not sufficient to correct the discrepancies so it was not possible to perform a meta-analysis.

CONCLUSIONS

The increase in the number of prescription drugs was the main risk factor in this population. However, additional studies are required to identify the risk factors for ADRs in pediatric inpatients.

Relation between safe use of medicines and Clinical Pharmacy Services at Pediatric Intensive Care Units

Objective:

Clinical Pharmacy Services (CPS) are considered standard of care and is endorsed by the Joint Commission International, the American Academy of Pediatrics, and the American College of Clinical Pharmacy. In Brazil, single experiences have been discreetly arising and the importance of these services to children and adolescents care has led to interesting results, but certainly are under reported. This short report aims to discuss the effect of implementing a bedside CPS at a Brazilian Pediatric Intensive Care Unit (PICU).

Methods:

This is a cross-sectional study conducted in a 12 bed PICU community hospital, from Campo Largo/Brazil. Subjects with<18 years old admitted to PICU were included for descriptive analysis if received a CPS intervention.

Results:

Of 53 patients accompanied, we detected 141 preventable drug-related problems (DRPs) which were solved within clinicians (89% acceptance of all interventions). The most common interventions performed to improve drug therapy included: preventing incompatible intravenous solutions (21%) and a composite of inadequate doses (17% due to low, high and non-optimized doses). Among the top ten medications associated with DRPs, five were antimicrobials. By analyzing the correlation between DRPs and PICU length of stay, we found that 74% of all variations on length of stay were associated with the number of DRPs.

Conclusions:

Adverse drug reactions due to avoidable DRPs can be prevented by CPS in a multifaceted collaboration with other health care professionals, who should attempt to use active and evidence-based strategies to reduce morbidity related to medications.

Tools for Assessing Potential Significance of Pharmacist Interventions: A Systematic Review

INTRODUCTION

Assessing the significance of pharmacist interventions (PIs) is essential to demonstrate the added value of pharmacists. Methods and tools for assessing the potential significance of PIs are diverse and their properties are questionable.

OBJECTIVES

We aimed to systematically review the tools available to assess the potential significance of PIs.

METHODS

We conducted a systematic search for English- or French-language publications from 1986 to 2013 in PubMed, PsycINFO, PASCAL, and CINAHL. Studies were screened by two independent reviewers based on inclusion/exclusion criteria and were abstracted for content, structure of tools, and validation process.

RESULTS

Of 873 citations screened, 82 distinct tools were identified from 133 studies. While clinical aspects were often defined quite clearly, terminology regarding humanistic, economic, and process-related aspects of PIs was omitted, incomplete, or ambiguous in most tools. The probabilities of consequences of PIs/drug-related problems were evaluated in 20/82 tools. Few tools simultaneously measured economic, clinical, humanistic, and process-related variables. Structure of the tools varied from an implicit, mono-dimensional tool to an explicit, multi-dimensional algorithm. Validation processes were diverse in terms of quantification and number of raters, rating method, and psychometric parameters. Of 133 identified studies, there was limited evidence of validity (8/133, 6.0%), inter-rater reliability (49/133, 36.8%), and intra-rater reliability (2/133, 1.5%).

CONCLUSIONS

The majority of tools focused primarily on assessing clinical aspects and failed to detect comprehensive impacts. The heterogeneity of tools and assessment processes hindered our ability to synthesize the results of evaluations. Limited results for their validity and reliability cast doubt on the credibility of this methodology for justification of the value of PIs. Recommendations for development of tools with optimal theoretical, pragmatic, and psychometric properties are proposed.

Relation between safe use of medicines and Clinical Pharmacy Services at Pediatric Intensive Care Units

OBJECTIVE

Clinical Pharmacy Services (CPS) are considered standard of care and they are endorsed by the Joint Commission International, the American Academy of Pediatrics, and the American College of Clinical Pharmacy. In Brazil, single experiences have been discreetly arising and the importance of these services to children and adolescents care has led to interesting results, but certainly are under reported. This short report aims to discuss the effect of implementing a bedside CPS at a Brazilian Pediatric Intensive Care Unit (PICU).

METHODS

This is a cross-sectional study conducted in a 12 bed PICU community hospital, from Campo Largo/Brazil. Subjects with<18 years old admitted to PICU were included for descriptive analysis if received a CPS intervention.

RESULTS

Of 53 patients accompanied, we detected 141 preventable drug-related problems (DRPs) which were solved within clinicians (89% acceptance of all interventions). The most common interventions performed to improve drug therapy included: preventing incompatible intravenous solutions (21%) and a composite of inadequate doses (17% due to low, high and non-optimized doses). Among the top ten medications associated with DRPs, five were antimicrobials. By analyzing the correlation between DRPs and PICU length of stay, we found that 74% of all variations on length of stay were associated with the number of DRPs.

CONCLUSIONS

Adverse drug reactions due to avoidable DRPs can be prevented by CPS in a multifaceted collaboration with other health care professionals, who should attempt to use active and evidence-based strategies to reduce morbidity related to medications.

Epidemiology of medication-related problems in children with kidney disease

BACKGROUND

Medication-related problems (MRPs) are the undesirable effects of pharmacotherapy that can potentially lead to harm. The epidemiology of MRPs in paediatric renal patients is unknown. We aimed to characterise MRPs in this population at two tertiary care hospitals in the UK.

METHODS

Prescription charts for children (≤18 years) were reviewed to identify MRPs, and characterised using a specific proforma with a standard operational definition. MRP predictors were evaluated by logistic regression and severity was assessed using a validated scale.

RESULTS

Two hundred and sixty-seven MRPs were identified from 266 prescription chart reviews. The incidence was 51.2 % (203 MRPs, 166 charts; 95 % CI 43.2-60.6 %) of hospitalised patients and 32 % (64 MRPs, 100 charts; 95 % CI 22.9-41.1 %) in outpatients. The number of prescribed medications was the only independent predictor during inpatient treatment (OR 1.06, 95 % CI 1.02-1.10, p = 0.002) with no significant predictors identified at outpatient clinics. The severity level of the MRPs was minor: 53.9 %, (144 out of 267); or moderate: 46.1 %, (123 out of 267). Sub-optimal drug effect was the predominant MRP (inpatient: 68 %; outpatient: 39 %). Prescribing error and patients' medicine-taking behaviour were the main contributory factors. The majority of the MRPs in the inpatient setting were resolved.

CONCLUSION

Many factors are associated with MRPs in children; the associations are cumulative and interdependent. Investment in preventive strategies and extending the support from the acute health care setting into the community are invaluable for optimising pharmacotherapy.

Epidemiology and potential risk factors of drug-related problems in Hong Kong paediatric wards

AIMS

A drug-related problem (DRP) is ‘an event or circumstance involving drug therapy that actually or potentially interferes with the desired health outcome’. The extent and characteristics of DRPs in children in Hong Kong are unknown. The aim of this study was to determine the epidemiology of and identify riskf actors for DRPs in hospitalized children in Hong Kong.

METHODS

This was a prospective cohort study in children aged 0–18 years who were admitted to a medical ward, paediatric intensive care unit or neonatal intensive care unit of seven Hong Kong hospitals, during a 3 month period. Patients’ charts, medical records and laboratory data were reviewed daily to identify DRPs; their preventability and severity were assessed. Logistic regression was used to analyse potential risk factors associated with the incidence of DRPs.

RESULTS

Three hundred and twenty-nine children (median age, 2 years; interquartile range, 0 months to 9 years) were included. In total, 82 DRPs were experienced by 69 patients. The overall incidence of DRPs was 21.0% (95% confidence interval, 16.7–25.8%). The incidence was higher in neonatal and paediatric intensive care units than medical wards. Dosing problems were the most frequently reported DRPs (n = 35; 42.7%), followed by drug choice problems (n = 19; 23.2%) and adverse drug reactions (n = 11; 13.4%). Sixty-seven (81.7%) DRP cases were assessed as preventable, 42 (51.2%) as minor and 40 (48.8%) as moderate. The number of prescribed drugs and ‘certain infectious and parasitic diseases’ were potential risk factors for occurrence of DRPs.

CONCLUSIONS

Drug-related problems were common in hospitalized children in this study in Hong Kong; the most frequent were dosing and drug choice problems, and the majority of them were preventable. Polypharmacy and ‘certain infectious and parasitic diseases’ were potential risk factors.

Admissions for drug-related problems at the Emergency Department of a University Hospital in the Kingdom of Saudi Arabia

Background and Aim:

Medication Errors can result in drug-related problems (DRPs). Insight into the frequency, type, and severity of DRPs could help reduce their incidence. The aim of the present study was to estimate the prevalence of admissions as a result of DRPs at the Emergency Department (ED) of a university hospital in the Kingdom of Saudi Arabia.

Materials and Methods:

Files of suspected cases of DRPs reporting to ED in the year 2012 were scrutinized. Suspicion arose from the hospital record system based on Diagnosis Code Numbers (ICD-9-CM, Professional 2010) and from triggers, such as some drugs, laboratory tests, and signs and symptoms pointing to DRPs.

Results:

Of 5574 admissions, 253 (4.5%) were DRPs and were categorized as: Overdose toxicity and side effects of drugs 50 (19.8%), drug-interactions 29 (11.5%), accidental and suicidal drug ingestions 26 (10.3%), drug abuse 18 (7.1%), drug allergy 10 (4%), super-infections 8 (3.2%), and noncompliance to treatment 112 (44.3%). About 70% of DRPs were preventable; 67 (26.5%) required hospital admission for 7-102 days and 10 (4%) died.

Conclusions:

Noncompliance to treatment, overdose toxicity, drug interactions, and drug abuse are important causes of hospital admissions as a result of DRPs. Awareness of prescribers to the problem and their education would help to prevent them and improve patient care.

Development of an Aggregated System for Classifying Causes of Drug-Related Problems

Background: More than 20 different types of classification systems for drug-related problems (DRPs) and their causes have been developed. Classification is necessary to describe and assess clinical, organizational, and economic impacts of DRPs through documentation of collected data. However, many researchers have judged classification systems incomplete when describing their data, and have modified them or developed their own. This variability between systems has made study comparisons difficult. Objectives: To perform a category-by-category comparison of the content of selected DRP classification systems to construct an aggregated cause-of-DRP classification system containing the content of all systems. Method: DRP classification systems were identified after a literature review, with 7 chosen based on their use in varied health care settings, geographical diversity, frequency of use, and method of development. These systems were critically analyzed, and the content of each category was compared and aggregated where appropriate. A hierarchy of categories was constructed to include all content from all systems. Any modifications that previous studies may have made to the 7 systems were also cross-referenced to ensure that no concepts were missing from the newly aggregated system. Clinical examples to optimize application, and instructions for when or when not to use categories, were developed. Interrater agreement for classification of the causes of DRPs from 10 medication reviews was performed between 3 clinical pharmacists and the authors’ gold standard. Results: We found variation in developmental methods, category descriptions, number and types of categories, and validation methods between the 7 selected systems, together with intermingling of categories identified as causes of DRPs with DRPs themselves. A hierarchical classification system was constructed consisting of 9 cause-of-DRP categories, 33 subcategories, and 58 sub-subcategories, for which interrater agreements were 82.5%, 74.6%, and 58.8%, respectively. Conclusion: An aggregated classification system was constructed through a unique and transparent developmental process that may provide the most comprehensive description of causes of DRPs to date. This may facilitate teaching of pharmaceutical care, comparisons of clinical practice, and measurement of the effectiveness of pharmaceutical care interventions.

Impact of medication and psychological behaviour assessment by community pharmacists in type 2 diabetes mellitus patients after hospital stay

BACKGROUND

Drug related problem (DRPs) is a key factor which will affect the outcome of therapy and safety.

OBJECTIVE

To assess the DRPs in type 2 diabetes mellitus (T2DM) patients and psychological aspects of patients by community pharmacists to observe the rate of DRP.

METHODS

Prospective randomized controlled intervention study involved T2DM patients and conducted in two community pharmacies at Kanpur from January 2012 to December 2012. The assessment of DRPs was based on the PCNE. Changes in glycosylated hemoglobin (HBA1c), low density lipoproteins (LDL), blood pressure(BP), foot examinations, changes medical and medication utilization were studied. Using as control group, received usual care, and interventional group provided, intervened with use of the standard treatment guidelines (STG). Researcher provided the knowledge to community pharmacists and patients. Baseline and interventional data were collected at 0,3,6,9 and 12 months.

RESULTS

Over the 12 month study, participants' average HBA1C reduced from 8.9% at initial visit to 7.5%. During this time, the eye examination rate was raised from 31% to 48%, and the foot examination rate was raised from 35% to 50%.

CONCLUSION

The intervention of pharmacists showed little influence on any of the intermediate health outcomes in T2DM.

Drug-related problems found in children attending an emergency department in Saudi Arabia and in the United Kingdom

BACKGROUND

No published studies investigating drug-related problems (DRPs) in children visiting emergency department (ED) in either the Kingdom of Saudi Arabia (KSA) or the United Kingdom (UK) were identified.

OBJECTIVE

To determine the frequency and characteristics of DRPs in paediatric patients attending ED in the KSA and the UK.

METHOD

An observational study. DRPs were identified by a researcher, reviewing the medical records of children attending the ED during a three-month period in KSA and a 1 month period in UK; severity and preventability of the DRPs were assessed. Incidence of DRPs overall and in each country was calculated.

RESULTS

A total of 253 patients (KSA n = 143, UK n = 110) were included. Fifty-five patients (22%; 55/253), experienced 69 DRPs. 2% (5/253) of the patients attended the ED due to DRPs. Overall incidence was 21.7% (95% CI, 16.8-27.3). 78% (54/69) of the DRPs were assessed as preventable; 33% (23/69) as of moderate severity.

CONCLUSION

DRPs were common in paediatric patients attending EDs; the majority were preventable. Further study is needed to investigate the impact of mild and moderate DRPs on paediatric patients' health and also to improve the care provided to minimise the occurrence of preventable DRPs.