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Herzig M, Eisenhofer S, Ruschkowski M, Neubert A, Bertsche A, Bertsche T, Neininger MP. Authorized or Off-Label Use? A Structured Analysis of Summaries of Product Characteristics with Regard to Authorization in Pediatrics. Pharmaceut Med 2024; 38:205-216. [PMID: 38555544 PMCID: PMC11101375 DOI: 10.1007/s40290-024-00519-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 04/02/2024]
Abstract
PURPOSE The Summary of Product Characteristics (SmPC) is required to provide unambiguous information on the authorized use of a medicinal product. Therefore, we performed a structured analysis of the information provided for pediatric patients in current SmPCs. METHODS In the German SmPC of the medicinal products of 452 active substances, we analyzed for each of the listed indications whether information on pediatric use was available in Sects. 4.1-4.4 of the SmPC and, if so, whether it was unambiguous. Information was considered unambiguous if it indicated an exact age- or weight-related specification. The analysis also considered the type of marketing authorization and the date of marketing authorization, either before or after the Pediatric Regulation 2007 came into force. RESULTS Among the 30,354 identified indications in 8464 SmPCs, unambiguous information was found for 72.4% (21,974/30,354) of the indications. Of these, 45.4% (9967/21,974) disclosed a contraindication for the entire population under 18 years of age. The proportion of unambiguous information was higher for medicinal products with centralized marketing authorization (86.5% [1449/1676]) than for those with a national one (71.6% [20,525/28,678]; p < 0.001). A higher proportion of unambiguous information was found for the marketing authorization period 2007-2021 compared with 1996-2006 (1996-2006: 63.8% [7466/11,694]; 2007-2021: 82.1% [12,349/15,040]; p < 0.001). CONCLUSION For about a quarter of all indications, no or only ambiguous information was available for pediatric patients. The measures initiated in recent years to increase pediatric-specific information in SmPCs should be intensified in order to improve drug safety in children and adolescents.
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Affiliation(s)
- Markus Herzig
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University, and Drug Safety Center, Leipzig University and University Hospital, Bruederstrasse 32, 04103, Leipzig, Germany
| | - Simone Eisenhofer
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University, and Drug Safety Center, Leipzig University and University Hospital, Bruederstrasse 32, 04103, Leipzig, Germany
| | - Meike Ruschkowski
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University, and Drug Safety Center, Leipzig University and University Hospital, Bruederstrasse 32, 04103, Leipzig, Germany
| | - Antje Neubert
- Department of Pediatric and Adolescent Medicine, University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany
| | - Astrid Bertsche
- Division of Neuropediatrics, University Hospital for Children and Adolescents, Ferdinand-Sauerbruch-Str. 1, 17475, Greifswald, Germany
| | - Thilo Bertsche
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University, and Drug Safety Center, Leipzig University and University Hospital, Bruederstrasse 32, 04103, Leipzig, Germany.
| | - Martina Patrizia Neininger
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University, and Drug Safety Center, Leipzig University and University Hospital, Bruederstrasse 32, 04103, Leipzig, Germany
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de Barros Fernandes T, Ramos SF, Leitzke LRF, Júnior RGA, de Araújo JM, de Souza Júnior AS, da Silva ARO, Heineck I, de França Fonteles MM, Bracken LE, Peak M, de Lyra Junior DP, Osorio-de-Castro CGS, Lima EC. Use of antimicrobials in pediatric wards of five Brazilian hospitals. BMC Pediatr 2024; 24:177. [PMID: 38481225 PMCID: PMC10936065 DOI: 10.1186/s12887-024-04655-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
The use of antimicrobials (AMs) in pediatric infections is common practice and use may be inappropriate leading to antimicrobial resistance. Off-label AM use is also common in this group and can result in drug-related problems. There is lack of DUR data in Brazil and in Latin America, specially for AM pediatric use. The aim of this study was to describe the utilization of AMs in hospitalized children in five hospitals in Brazil. We conducted an observational study of the utilization of AMs in pediatric wards in hospitals in the states of Ceará (CE), Sergipe (SE), Rio de Janeiro (RJ), Rio Grande do Sul (RS) and the Federal District (DF). Data derived from patient medical records and prescriptions were collected over a six-month period in each hospital. The number of AMs used by each patient was recorded, and AM use was assessed using Days of therapy (DOT) and Length of therapy (LOT) per 1000 patient days according to different patient characteristics. Off-label (OL) use was described according to age. The study analyzed data from 1020 patients. The sex and age distributions were similar across the five hospitals. However, differences were found for comorbidities, history of ICU admission and length of hospital stay. The most common diseases were respiratory tract infections. There were wide variations in DOT/1000PD (278-517) and LOT/1000PD (265-390). AM utilization was highest in the hospital in SE. The consumption of second-generation penicillins and cephalosporins was high. The prevalence of OL use of AMs was higher for patients in the RJ hospital, in infants, in patients who underwent prolonged hospital stays, and in patients who used multiple AMs. The AM that showed the highest prevalence of OL use was azithromycin, in both oral and parenteral formulations. Overall AM use was high and showed differences in each setting, possibly influenced by local characteristics and by prescribing standards adopted by pediatricians.
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Affiliation(s)
- Thais de Barros Fernandes
- Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, 21041-210, Brazil.
| | - Sheila Feitosa Ramos
- Center for Biological and Health Sciences, Federal University of Western Bahia, Barreiras, Brazil
| | - Luísa Rodrigues Furtado Leitzke
- Postgraduate Program in Pharmaceutical Services, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | | | - Isabela Heineck
- Postgraduate Program in Pharmaceutical Services, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Louise E Bracken
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Divaldo Pereira de Lyra Junior
- Health Sciences Graduate Program, Social Pharmacy Teaching and Research Laboratory (LEPFS), Federal University of Sergipe, São Cristóvão, Brazil
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Neubert A, Toni I, König, […] J, S. Urschitz M, Rascher W. A Complex Intervention to Prevent Medication-Related Hospital Admissions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:425-431. [PMID: 37278031 PMCID: PMC10478767 DOI: 10.3238/arztebl.m2023.0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 11/28/2022] [Accepted: 05/08/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Children are often treated off-label and are at a disadvantage in pharmacotherapy. The aim of this study was to implement and evaluate a quality assurance measure (PaedPharm) for pediatric pharmacotherapy whose purpose is to reduce medication-related hospitalizations among children and adolescents. METHODS PaedPharm consisted of the digital pediatric drug information system PaedAMIS, pediatric pharmaceutical quality circles (PaedZirk), and an adverse drug event (ADE) reporting system (PaedReport). The intervention was implemented in a cluster-randomized trial (DRKS 00013924) in 12 regions, with a pediatric and adolescent medicine clinic in each and a total of 152 surrounding private practitioners, in 6 sequences over 8 quarters. In addition to the proportion of ADE-related hospital admissions (primary endpoint), comprehensive process evaluation included other endpoints such as coverage, user acceptance, and relevance to practice. RESULTS 41 829 inpatient admissions were recorded, of which 5101 were patients of physicians who participated in our study. 4.1% of admissions were ADE-related under control conditions, and 3.1% under intervention conditions (95% CI: [2.3; 5.9] and [1.8; 4.5], respectively). A model-based comparison yielded an intervention effect of 0.73 (population-based odds ratio; [0.39; 1.37]; p = 0.33). PaedAMIS achieved moderate user acceptance and PaedZirk achieved high user acceptance. CONCLUSION The introduction of PaedPharm was associated with a decrease in medication-related hospitalizations that did not reach statistical significance. The process evaluation revealed broad acceptance of the intervention in outpatient pediatrics and adolescent medicine.
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Affiliation(s)
- Antje Neubert
- Department of Pediatric and Adolescent Medicine, University Hospital Erlangen
| | - Irmgard Toni
- *Other authors were involved in this publication and are listed in the citation and at the end of the article where their affiliations are also located
- Department of Pediatric and Adolescent Medicine, University Hospital Erlangen
| | - Jochem König, […]
- *Other authors were involved in this publication and are listed in the citation and at the end of the article where their affiliations are also located
- Institute for Medical Biometry, Epidemiology and Information Technology, University Medicine of the Johannes Gutenberg University of Mainz
| | - Michael S. Urschitz
- *These authors share last authorship
- Institute for Medical Biometry, Epidemiology and Information Technology, University Medicine of the Johannes Gutenberg University of Mainz
| | - Wolfgang Rascher
- *These authors share last authorship
- Department of Pediatric and Adolescent Medicine, University Hospital Erlangen
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Leitzen S, Dubrall D, Toni I, Stingl J, Christ P, Köberle U, Schmid M, Neubert A, Sachs B. Adverse Drug Reactions in Children: Comparison of Reports Collected in a Pharmacovigilance Project Versus Spontaneously Collected ADR Reports. Paediatr Drugs 2023; 25:203-215. [PMID: 36369590 PMCID: PMC9931796 DOI: 10.1007/s40272-022-00540-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Adverse drug reactions (ADRs) and medication errors in children may result from a lack of appropriate drugs, dosages, and pharmaceutical forms. In addition, children may respond differently to drugs than adults. Reporting of ADRs in the pediatric population is therefore of importance in order to increase the amount of safety data. However, different methodological approaches are used to collect ADRs. OBJECTIVE The aim of the present study was to analyze whether there were differences in the ADRs collected in the KiDSafe project (845 ADR reports) compared with the spontaneous ADR reports sent to EudraVigilance (697 reports) in the same time period. The strengths and limitations of these two different approaches should be discussed. METHODS The same inclusion criteria were applied for the systematically collected ADRs in the KiDSafe project and the spontaneous reports from EudraVigilance, and only reports of ADRs coded with hospitalization were considered. In both datasets, the number of reports (related to number of hospitals), their documentation quality (VigiGrade), causal relationship (World Health Organization-Uppsala Monitoring Centre [WHO-UMC] criteria), most frequently reported drugs and ADRs, demographical parameters of the patients, reported medical histories, and the seriousness of ADR reports were analyzed descriptively. The results of the two analyses were compared. RESULTS There was considerable underreporting of ADRs via the spontaneous reports (0.4 reports per hospital; 697/1902) compared with 70.4 reports per hospital (845/12) in the systematically collected KiDSafe reports. Documentation quality assessment yielded similar results in both datasets. Among the 10 most frequently reported drugs, anticonvulsants such as levetiracetam (6.6%), valproic acid (5.6%), oxcarbazepine (3.6%), and lamotrigine (3.4%) were mainly reported in the KiDSafe reports, while in the EudraVigilance reports, mite allergen extract (4.4%) and allergens (3.6%) were preferentially reported. Seizures were the most frequently reported clinically specific ADRs in the KiDSafe reports, whereas anaphylactic reactions and urticaria were prominent in the spontaneous reports from EudraVigilance. Notably, the proportion of reports referring to medication errors and other medication safety related issues were more prominent in KiDSafe than in the spontaneous reports (27.8% vs. 12.6% and 46.0% vs. 29.0%, respectively). CONCLUSION In general, reports from both data sources contributed to the identification of ADRs and dedicated issues related to drug therapy. However, these differed by nature and strength of the signal, likely due to the characteristics of the individual method. A combined approach could likely compensate for limitations inherent to the single approaches, but will most likely only be applied to dedicated pharmacovigilance topics or research objectives.
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Affiliation(s)
- Sarah Leitzen
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany ,Department of Physics, Chemistry and Pharmacy, University of Southern Denmark, Odense, Denmark ,Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Diana Dubrall
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany. .,Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany.
| | - Irmgard Toni
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Julia Stingl
- Institute of Clinical Pharmacology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Patrick Christ
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany ,Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Ursula Köberle
- Drug Commission of the German Medical Association, Berlin, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Bernhardt Sachs
- Research Division, Federal Institute for Drugs and Medical Devices, Bonn, Germany ,Department for Dermatology and Allergy, University Hospital Aachen, Aachen, Germany
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Stevens L, Perry KE, Moide I, Kaemala F, Nankinga J, Innes AL, Mogaba I. Leveraging Experience From Active TB Drug-Safety Monitoring and Management for Monitoring Active Antiretroviral Toxicity. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00595. [PMID: 35487562 PMCID: PMC9053160 DOI: 10.9745/ghsp-d-21-00595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/25/2022] [Indexed: 11/15/2022]
Abstract
Systems established for active drug safety monitoring and management of drug-resistant TB should be leveraged to ensure comprehensive surveillance for active toxicity monitoring during scale-up of newer antiretroviral regimens.
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Affiliation(s)
- Lisa Stevens
- FHI 360 Asia Pacific Regional Office, Bangkok, Thailand.
| | - Kelly E Perry
- FHI 360 Asia Pacific Regional Office, Bangkok, Thailand
| | - Iakuna Moide
- FHI 360 Papua New Guinea Office, Port Moresby, Papua New Guinea
| | - Francil Kaemala
- FHI 360 Papua New Guinea Office, Port Moresby, Papua New Guinea
| | | | | | - Ignatius Mogaba
- FHI 360 Papua New Guinea Office, Port Moresby, Papua New Guinea
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Aung AK, Walker S, Khu YL, Tang MJ, Lee JI, Graudins LV. Adverse drug reaction management in hospital settings: review on practice variations, quality indicators and education focus. Eur J Clin Pharmacol 2022; 78:781-791. [PMID: 35171316 PMCID: PMC9005418 DOI: 10.1007/s00228-022-03287-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/31/2022] [Indexed: 11/28/2022]
Abstract
Purpose Adverse drug reactions (ADRs) contribute significantly to healthcare burden. However, they are largely preventable through appropriate management processes. This narrative review aims to identify the quality indicators that should be considered for routine monitoring of processes within hospital ADR management systems. It also examines the potential reasons behind variation in ADR management practices amongst HCPs, and explores possible solutions, focusing on targeted education programmes, to improve both the quality and quantity indicators of ADR management processes. Methods A comprehensive literature review was conducted to explore relevant themes and topics concerning ADR management, quality indicators and educational interventions. Results Substantial variability exists in ADR management amongst healthcare professionals (HCPs) with regard to reporting rates, characteristics of ADRs reported, quality of assessment, completeness of reports and, most importantly, risk communication practices. These variable practices not only threaten patient safety but also undermine pharmacovigilance processes. To date, quality indicators to monitor ADR management practices within hospital settings remain ill-defined. Furthermore, evidence behind effective interventions, especially in the form of targeted education strategies, to improve the quality of ADR management remains limited. Conclusions The focus of ADR management in hospitals should be to promote patient safety through comprehensive assessment, risk communication and safe prescribing. There is a need to develop a system to define, measure and monitor the quality of ADR management. Educational strategies may help improve the quality of ADR management processes.
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Affiliation(s)
- Ar Kar Aung
- Department of General Medicine, Alfred Hospital, Melbourne, Australia. .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Steven Walker
- Department of Pharmacy, Alfred Hospital, Melbourne, Australia
| | - Yin Li Khu
- Department of General Medicine, Alfred Hospital, Melbourne, Australia
| | - Mei Jie Tang
- Department of General Medicine, Alfred Hospital, Melbourne, Australia
| | - Jennifer I Lee
- Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, USA.,Quality Improvement Academy, Weill Cornell Medicine, New York, USA
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Leitzen S, Kayser C, Weißmann K, Sachs B. Arzneimittelnebenwirkungen und Medikationsfehler bei Kindern. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01382-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Zusammenfassung
Hintergrund
Kinder sind einem höheren Risiko für Nebenwirkungen (NW) und Medikationsfehler (MF) als Erwachsene ausgesetzt, auch weil es häufig an geeigneten Dosierungsempfehlungen, Arzneiformen und adäquaten Applikationsformen mangelt.
Material und Methode
Kurze Literaturübersicht und Auswertung von Spontanberichten aus der Datenbank EudraVigilance bezüglich NW zu Kindern zwischen 2000 und 2019 sowie einer Datensammlung zu MF bei Kindern zwischen 2014 und 2020 in Deutschland.
Ergebnisse
MPH als zentral wirksames Sympathomimetikum wird zur Behandlung der Aufmerksamkeitsdefizit‑/Hyperaktivitätsstörung (ADHS) eingesetzt.
Im Bewertungszeitraum 2014–2020 wurden dem Bundesinstitut für Arzneimittel und Medizinprodukte 151 MF direkt gemeldet. Häufig gemeldet wurden nicht korrekt durchgeführte Zubereitungen von Arzneimitteln, wie z. B. bei antibiotischen Trockensäften, die zu fehlerhaften Dosierungen führten.
Schlussfolgerung
Zudem sollten andere Informationsquellen (z. B. Dosierungsdatenbanken) intensiv genutzt werden, zum einen, um bereits vorhandene Informationen im klinischen und im ambulanten Setting besser umzusetzen, zum anderen, um die Kenntnisse zu Anwendungsrisiken bei Kindern zu verbessern. Diesbezüglich sollte die Meldebereitschaft der Ärzte- und Apothekerschaft zu NW und MF weiter erhöht werden.
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da Costa Lima E, de Barros Fernandes T, Freitas A, de Lima Sias JF, Land MGP, Aires MT, Bracken L, Peak M. Translation, transcultural adaptation and validation to Brazilian Portuguese of tools for adverse drug reaction assessment in children. BMC Med Res Methodol 2021; 21:141. [PMID: 34238235 PMCID: PMC8265060 DOI: 10.1186/s12874-021-01315-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/10/2021] [Indexed: 01/16/2023] Open
Abstract
Background Children are more vulnerable to adverse drug reactions (ADRs) due to complex changes in the body during the growth process and lack specific pharmacoepidemiologic studies. Causality and Avoidability assessment of ADRs are relevant to clinical guidelines development and pharmacovigilance. This study aimed to translate and transcultural adapt two new tools—Liverpool Causality Assessment Tool (LCAT) and the Liverpool Avoidability Assessment Tool (LAAT)—to Brazilian-Portuguese and evaluate the psychometric properties of these tools to analyse ADRs in Brazilian children. Methods The validation of the cross-cultural adaptation of tools was obtained by the functional (conceptual, semantic, operational, and measurement) equivalence between the original and translated versions of each instrument. The translated version of LCAT and LAAT was applied to assessing the twenty-six case reports of suspected adverse drug reactions in a Brazilian teaching paediatric hospital. The inter-rater reliability (a pharmacist and a physician) was evaluated using Cronbach’s alpha. The exact agreement percentages (%EA) and extreme disagreement (%ED) were computed. Overall Kappa index was calculated with a 95% confidence interval. Results There was a need to modify some terms translated into Portuguese for semantic and conceptual equivalence. The Cronbach’s alpha coefficient values obtained were 0.95 and 0.85, and the weighted Kappa (95% confidence interval) were 0.82 (0.67–0.97) and 0.68 (0.45–0.91) for LCAT and LAAT, respectively. The Brazilian-Portuguese versions of the LCAT and LAAT showed reliable and valid tools for the diagnosis and follow-up of ADRs in children. Conclusion The methodological approach allowed the translation, transcultural adaptation, and validation to Brazilian-Portuguese of two easy and quick to perform tools for causality and avoidability of ADRs in children by a multidisciplinary expert specialist committee, including the authors of original tools. We believe these versions may be applied by professionals (patient safety teams) and researchers in Brazil in groups or by a single reviewer. Trial registration This study was evaluated and approved by the Research Ethics Committee (Instituto de Pediatria e Puericultura Martagão Gesteira – Federal University of Rio de Janeiro – Number: 3.264.238. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01315-9.
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Affiliation(s)
| | | | - Adair Freitas
- Instituto de Puericultura e Pediatria Martagão Gesteira- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Marcelo Gerardin Poirot Land
- Instituto de Puericultura e Pediatria Martagão Gesteira- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana Tschoepke Aires
- Instituto de Puericultura e Pediatria Martagão Gesteira- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Louise Bracken
- Paediatric Medicines Research Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Prevalence and Nature of Medication Errors and Preventable Adverse Drug Events in Paediatric and Neonatal Intensive Care Settings: A Systematic Review. Drug Saf 2020; 42:1423-1436. [PMID: 31410745 PMCID: PMC6858386 DOI: 10.1007/s40264-019-00856-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Children admitted to paediatric and neonatal intensive care units may be at high risk from medication errors and preventable adverse drug events. OBJECTIVE The objective of this systematic review was to review empirical studies examining the prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care units. DATA SOURCES Seven electronic databases were searched between January 2000 and March 2019. STUDY SELECTION Quantitative studies that examined medication errors/preventable adverse drug events using direct observation, medication chart review, or a mixture of methods in children ≤ 18 years of age admitted to paediatric or neonatal intensive care units were included. DATA EXTRACTION Data on study design, detection method used, rates and types of medication errors/preventable adverse drug events, and medication classes involved were extracted. RESULTS Thirty-five unique studies were identified for inclusion. In paediatric intensive care units, the median rate of medication errors was 14.6 per 100 medication orders (interquartile range 5.7-48.8%, n = 3) and between 6.4 and 9.1 per 1000 patient-days (n = 2). In neonatal intensive care units, medication error rates ranged from 4 to 35.1 per 1000 patient-days (n = 2) and from 5.5 to 77.9 per 100 medication orders (n = 2). In both settings, prescribing and medication administration errors were found to be the most common medication errors, with dosing errors the most frequently reported error subtype. Preventable adverse drug event rates were reported in three paediatric intensive care unit studies as 2.3 per 100 patients (n = 1) and 21-29 per 1000 patient-days (n = 2). In neonatal intensive care units, preventable adverse drug event rates from three studies were 0.86 per 1000 doses (n = 1) and 0.47-14.38 per 1000 patient-days (n = 2). Anti-infective agents were commonly involved with medication errors/preventable adverse drug events in both settings. CONCLUSIONS Medication errors occur frequently in critically ill children admitted to paediatric and neonatal intensive care units and may lead to patient harm. Important targets such as dosing errors and anti-infective medications were identified to guide the development of remedial interventions.
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Mouton JP, Mehta U, Rossiter DP, Maartens G, Cohen K. Interrater agreement of two adverse drug reaction causality assessment methods: A randomised comparison of the Liverpool Adverse Drug Reaction Causality Assessment Tool and the World Health Organization-Uppsala Monitoring Centre system. PLoS One 2017; 12:e0172830. [PMID: 28235001 PMCID: PMC5325562 DOI: 10.1371/journal.pone.0172830] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 02/10/2017] [Indexed: 12/03/2022] Open
Abstract
Introduction A new method to assess causality of suspected adverse drug reactions, the Liverpool Adverse Drug Reaction Causality Assessment Tool (LCAT), showed high interrater agreement when used by its developers. Our aim was to compare the interrater agreement achieved by LCAT to that achieved by another causality assessment method, the World Health Organization-Uppsala Monitoring Centre system for standardised case causality assessment (WHO-UMC system), in our setting. Methods Four raters independently assessed adverse drug reaction causality of 48 drug-event pairs, identified during a hospital-based survey. A randomised design ensured that no washout period was required between assessments with the two methods. We compared the methods’ interrater agreement by calculating agreement proportions, kappa statistics, and the intraclass correlation coefficient. We identified potentially problematic questions in the LCAT by comparing raters’ responses to individual questions. Results Overall unweighted kappa was 0.61 (95% CI 0.43 to 0.80) on the WHO-UMC system and 0.27 (95% CI 0.074 to 0.46) on the LCAT. Pairwise unweighted Cohen kappa ranged from 0.33 to 1.0 on the WHO-UMC system and from 0.094 to 0.71 on the LCAT. The intraclass correlation coefficient was 0.86 (95% CI 0.74 to 0.92) on the WHO-UMC system and 0.61 (95% CI 0.39 to 0.77) on the LCAT. Two LCAT questions were identified as significant points of disagreement. Discussion We were unable to replicate the high interrater agreement achieved by the LCAT developers and instead found its interrater agreement to be lower than that achieved when using the WHO-UMC system. We identified potential reasons for this and recommend priority areas for improving the LCAT.
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Affiliation(s)
- Johannes P. Mouton
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ushma Mehta
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Dawn P. Rossiter
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
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Bracken LE, Nunn AJ, Kirkham JJ, Peak M, Arnott J, Smyth RL, Pirmohamed M, Turner MA. Development of the Liverpool Adverse Drug Reaction Avoidability Assessment Tool. PLoS One 2017; 12:e0169393. [PMID: 28046035 PMCID: PMC5207751 DOI: 10.1371/journal.pone.0169393] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 12/13/2016] [Indexed: 11/27/2022] Open
Abstract
Aim To develop and test a new tool to assess the avoidability of adverse drug reactions that is suitable for use in paediatrics but which is also applicable to a variety of other settings. Methods The study involved multiple phases. Preliminary work involved using the Hallas scale and a modification of the existing Hallas scale, to assess two different sets of adverse drug reaction (ADR) case reports. Phase 1 defined, modified and refined a new tool using multidisciplinary teams. Phase 2 involved the assessment of 50 ADR case reports from a prospective study of paediatric inpatients by individual assessors. Phase 3 compared assessments with the new tool for individuals and groups in comparison to the ‘gold standard’ (the avoidability outcome set by a panel of senior investigators: an experienced clinical pharmacologist, paediatrician and pharmacist). Main Outcome Measures Inter-rater reliability (IRR), measure of disagreement and utilization of avoidability categories. Results Preliminary work—Pilot phase: results for the original Hallas cases were fair and pairwise kappa scores ranged from 0.21 to 0.36. Results for the modified Hallas cases were poor, pairwise kappa scores ranged from 0.06 to 0.16. Phase 1: on initial use of the new tool, agreement between the two multidisciplinary groups was found on 13/20 cases with a kappa score of 0.29 (95% CI -0.04 to 0.62). Phase 2: the assessment of 50 ADR case reports by six individual reviewers yielded pairwise kappa scores ranging from poor to good 0.12 to 0.75 and percentage exact agreement (%EA) ranged from 52–90%. Phase 3: Percentage exact agreement ranged from 35–70%. Overall, individuals had better agreement with the ‘gold standard’. Conclusion Avoidability assessment is feasible but needs careful attention to methods. The Liverpool ADR avoidability assessment tool showed mixed IRR. We have developed and validated a method for assessing the avoidability of ADRs that is transparent, more objective than previous methods and that can be used by individuals or groups.
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Affiliation(s)
- Louise E. Bracken
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- * E-mail:
| | - Anthony J. Nunn
- Department of Women’s & Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jamie J. Kirkham
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Matthew Peak
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- School of Health, University of Central Lancashire, Preston, United Kingdom
| | - Janine Arnott
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- School of Health, University of Central Lancashire, Preston, Lancashire, United Kingdom
| | - Rosalind L. Smyth
- Institute of Child Health, University College London, London, United Kingdom
| | - Munir Pirmohamed
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Mark A. Turner
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
- Department of Women’s & Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom
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Gupta SK, Kumar KD. An assessment of reported adverse drug reactions in a Tertiary Care Hospital in South India: A retrospective cross-sectional study. Int J Pharm Investig 2017; 7:193-197. [PMID: 29692979 PMCID: PMC5903024 DOI: 10.4103/jphi.jphi_81_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective: The primary objective of this study was to assess the causality of ADRs using World Health Organization-Uppsala Monitoring Centre (WHO–UMC), Naranjo and Liverpool ADR Causality Assessment Tool (LCAT). Other primary objective was to assess the agreement between the WHO-UMC criterion, Naranjo algorithm and LCAT. The secondary objective was to assess the reported adverse drug reactions in a tertiary care hospital in South India. Materials and Methods: This was a cross-sectional retrospective study. All the ADRs which were reported by the Pharmacovigilance Unit between July 2016 and March 2017 were assessed. Causality assessment was performed by two well-trained independent pharmacologists by applying the three methods–WHO, Naranjo and LCAT. Concurrence between the two algorithms was compared using the Cohen's weighted kappa statistic. Results: Causality assessment of adverse reactions according to Naranjo criteria shows that 81% cases were of probable type, 9.5% cases were possible and 9.5% cases were unlikely. Causality assessment of adverse reactions according to WHO-UMC criteria shows that 85.7% cases were of probable type, 4.8% cases were possible, 4.8% cases were unlikely and 4.8% cases were definite. Causality assessment of adverse reactions according to Liverpool criteria shows that 61.9% cases were of probable type, 4.8% cases were possible and 33.3% cases were definite. Cohen's kappa test shows that negative and poor concurrence was seen between WHO and Naranjo causality comparison (κ = −0.161). Positive but poor concurrence based on kappa values was seen between Liverpool and Naranjo's causality comparison (κ = 0.133). Negative and poor concurrence based on kappa values was seen between WHO and Liverpool causality comparison (κ = −0.161). Conclusion: The most frequent causality category observed by the WHO-UMC criteria, Naranjo as well as the Liverpool algorithm was “Probable.” Full concurrence was not found between any of two scales of causality assessment.
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Affiliation(s)
- Sandeep Kumar Gupta
- Department of Pharmacology, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - K Deva Kumar
- Department of Pharmacology, Dhanalakshmi Srinivasan Medical College and Hospital, Perambalur, Tamil Nadu, India
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Wimmer S, Neubert A, Rascher W. The Safety of Drug Therapy in Children. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:781-7. [PMID: 26806565 PMCID: PMC4671328 DOI: 10.3238/arztebl.2015.0781] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/16/2015] [Accepted: 07/16/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND 1.7% of children taking medication on an outpatient basis in Germany have at least one adverse drug reaction (ADR). The corresponding figure for hospitalized children is estimated at 10% . METHODS This review is based on pertinent literature retrieved by a selective search in PubMed. RESULTS According to reports submitted to the Drug Commission of the German Medical Association (Arzneimittelkommission der deutschen Ärzteschaft, AkdÄ), serious ADRs can arise, for example, after the administration of dimenhydrinate, α-adrenergic nose drops, enemas containing phosphate, ACE inhibitors, angiotensin-2-receptor antagonists (sartans), and methylphenidate. The causes of ADRs include overdoses, drug administration despite contraindications, and inadequate monitoring of long-term treatment. Errors can also be made in communication, labeling, and drug administration. The risk of ADRs is especially high in off-label use. Computerized physician order entry systems, individual packaging and labeling of single doses, and the use of bar codes for patient and drug identification can help prevent such errors. CONCLUSION The process of drug administration should be optimized through suitable interventions and electronic support, with due consideration of local circumstances. Clinical trials on children should be encouraged as a means of improving drug safety, and additional financial incentives should be created for trials concerning drugs that are off-patent. Physicians and pharmacists should take care to report adverse reactions as they are required to do by professional code, particularly in the case of new drugs, off-label use, or medication errors. A recognized national standard for dosing that can be implemented in computerized physician order entry systems is needed so that evidence-based pediatric dosages can be calculated.
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Affiliation(s)
- Stefan Wimmer
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen
| | - Antje Neubert
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen
| | - Wolfgang Rascher
- Department of Paediatrics and Adolescent Medicine, Universitätsklinikum Erlangen
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