Clinical Impact of Pharmaceutical Care Services in Pediatric and Neonatal Intensive Care Unit Amanda Li Clinical Pharmacist Queen Mary Hospital
Patient Safety Error pattern unique to the specialty 3 times more at risk for error than adults 1 Immature organs are more sensitive to interventions Impact on growth or other permanent impairment Kaushal R et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285:2114-20
Medication Safety Medication incidents are not uncommon Sniiders C et al 2009 27.3% (N=4846) incidents are medication related Battles JB et al 1998 29% are medication related
80% of the medication incidence occurred during medication ordering Unintended prescription discrepancies - inappropriate dosage - inappropriate drug - inappropriate rate Kaushal R et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285:2114-20
Clinical Pharmacist pharmacists have detected 2-fold more drug related problems than non-pharmacists 1 A ward-based pharmacist could have intercepted 94% of medication incidence in paediatric in-patient setting 2. 1. Shobha P et al. Pharmacists versus Nonpharmacists in Adverse Drug Event Detection: A meta-analysis and systemic review. American Journal of Health-System Pharmacy 2007; 64(8): 842-849 2. Kaushal R et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285:2114-20.
Drug Related Problems (DRP) Definition Events or circumstances involving drug therapy that actually or potentially interferes with desired health outcomes Could be sub-therapeutically use of drugs, an unpreventable side effect, or an Adverse Drug Event (ADEs) Strand LM et al. Drug-related problems: their structure and function. DICP 1990; 24(11): 1093-7
DRP-Registration Form V5.01 (PCNE Classification) Strand LM, Morley PC, Cipolle RJ, Ramsey R, Lamsam GD. Drug-related problems: their structure and function. DICP 1990;24(11):1093-7
Pharmaceutical Care Services Pediatric Clinical Pharmacist attached at PNICU Follow ward rounds Timely prescription verification Individual patient monitoring Identification of DRP Provide pharmaceutical interventions
Pharmaceutical Interventions Propagate safe & evidence-based drug therapy through collaborative care - prescriber level - patient level - drug level Bed side precautions, on site education
Pharmaceutical Interventions Level Drug Patient Scope therapeutic drug monitoring formulation assess drug compliance counsel on medications Prescriber manage health believes participate to implement & monitor a drug therapy suggest for modification or optimization
Drug Selection DDX: Acinobacter Pneumonia (d29, 31+5, 1.19kg) Augmentin 35mg IV Q8H Unasyn 60mg IV Q8H
Dose Selection DDX: ESBL E Coli Meningitis Meropenem 50mg IV Q8H (2.5kg infant) Meropenem 100mg IV Q8H
Drug Use Process DDX: Post liver transplant d2 No immunosuppresent on prescription! (6kg child) Methylprednisolone 18mg IV Q6H
Service Outcome May 2011- Mar 2012 others Provision of information regarding previous drug history Provision of information regarding administration/ reconstitution Others Streamline antibiotic choice Adjustment in route of administration (IV <-> PO) Drug discontinuation due to contraindication Drug discontinuation due to inactive indication 10.1% Identification/ avoidance of adverse drug reactions Identification/ avoidance of drug interaction or drug incompatibility Laboratory test recommended for drug monitoring 15.1% Drug recommendation to indication Drug recommendation to better alternatives Other dosage adjustment recommendations Dosage adjustment to convenient pack size Dosage adjustment with pharmacokinetic profiles Dosage adjustment with hepatic failure Dosage adjustment with renal failure Dosage adjustment with BW and clinical condition N= 100 Types of Drug Related Problems (DRP) 13.1% 19% 0 4 8 12 16
Outcome of Intervention Acceptance: 93% Compare to the centralized pharmaceutical services 100 50 7.5 more DRP found 0 Pediatric Clin Pharm Centralized Clin Pharm
Unintended Prescription Discrepancies From May 2011-Mar 2012 Inappropriate Dosing Frequency 19% Wrong Drug Identity 15% N= 26 Inappropriate dosage Selection 66% More than 10 fold under or overdose 11.5% (N=3)
10 fold error Benzylpenicillin 350,000unit IV Q12H -> 35,000unit IV Q12H (0.35kg premature infant; dosage: 100,000unit/kg/dose) Phenytoin 5mg IV Q12H -> 65mg IV Q12H (13kg child; dosage: 5mg/kg/dose) Ranitidine 10mg IV Q8H -> 1mg IV Q8H (1mg neonate; dosage: 1mg/kg/dose)
Summary Ward-based pharmaceutical services is more successful in prescription monitoring - 11.5% prescription are 10 fold error More effective in identification of DRP Pharmaceutical interventions yield satisfactory acceptance Promote drug therapy optimization with maximum safety
Let s support the sick child Questions and Comments