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Pharmacy practice
Objectives To describe and quantify the clinical and logistic activities of a resident pharmacist in a paediatric
intensive care unit (PICU) and to identify the key areas for improvements in training.
Methods A prospective quasi-experimental cross-sectional study was conducted in an 11-bed PICU over a 3-month
period. Pharmacist recommendations (clinical interventions) were made on patient care during the validation stage
of medical orders. All interventions performed were recorded in a database and included the following information:
reason for the intervention, clinical significance and acceptance by the physician. A record was also kept of the
number of interventions per patient-day and the number of drugs whose profiles for dispensing from an automatic
cabinet automatic dispensing system (ADS) were modified.
Results There were 40 interventions (13% recommendations issued in the absence of error, 59% concerned drug
safety issues, 20% related to efficacy and 8% to the indication), of which 72.5% were classified as significant or very
significant; 95% were accepted by the physician. There were 4.0 interventions per 100 patient-days. No single drug
was involved in more than 5% of interventions. The profiles of 16.6% of the drugs included in the ADS were modified.
Conclusions The action of the pharmacist enabled prevention of prescription errors of critically ill paediatric patients.
It is necessary to broaden and systematise clinical training in this discipline in order to identify a larger number of
negative outcomes associated with medications.
Introduction to promote integration with the rest of than adults to medication errors, as has been
In recent years pharmaceutical practice the care team’. The resident thus had to demonstrated in a number of studies.4 5
has become orientated towards achieving take on the responsibility of ensuring that Furthermore, patients admitted to paediatric
therapeutic results and a rational use of drugs. treatments administered to patients were intensive care units (PICUs) are characterised
In order to further develop these activities both appropriate and effective.2 In order to by certain pharmacokinetic peculiarities due
in the complexity of the hospital setting, achieve these objectives, the Spanish Society to disturbances in one or more of their vital
pharmacists need to become directly involved of Hospital Pharmacy drew up strategic organs.6 Intensive care units are particularly
in patient care through incorporation into training directives which described the susceptible to medication errors.7 This fact
the care team in different hospital units. In need to equip fourth-year residents with makes them ideal areas for implementing
1999 the National Specialties Commission a systematic methodology and specific new strategies related to clinical activities
in Spain added a fourth year to the hospital measurement variables to be able to structure (pharmacotherapeutic follow-up) and also
pharmacists’ training programme established their work and thus contribute positively to to optimise distribution systems in order
by Royal Decree 2708/82 on 15 October.1 a patient’s pharmacotherapeutic strategy in to improve safety in hospitals and reduce
The objective of this fourth year of residency each type of hospital unit such as oncology, medication errors.8
was ‘to perform the specific duties of the the surgical specialties, infectious diseases The aim of this study is to describe and
pharmacist in contact with patients and units and paediatrics.3 quantify the clinical and logistic activities
As with the adult population, the later of a resident pharmacist in a PICU. We also
development of clinical pharmacy as a identify the key areas for improvements in
specialty in Spain compared with other training.
countries has meant that few studies have
focused on the integral role of the pharmacist Methods
in paediatrics, and there is no specific This prospective cross-sectional study
training schedule for residents that defines was performed in the 11-bed PICU of our
1
Hospital Pharmacy, Gregorio Marañón University the abilities to be acquired. In addition, the hospital in Madrid, Spain over a 3-month
General Hospital, Madrid, Spain continuous developmental changes in the rotation in the unit (from 1 October to 31
2
Pediatric Intensive Care Unit, Gregorio Marañón paediatric population and the immaturity December 2009). Logistic activities and
University General Hospital, Madrid, Spain of their physiological systems lead to clinical interventions made by a resident
Correspondence to Lara Echarri-Martínez, different care needs from those of adults and pharmacist during a paediatric pharmacist’s
Hospital Pharmacy, Hospital General Universitario a distinct therapeutic approach with regard rotation in the PICU were included. A
Gregorio Marañón, Servicio de Farmacia, to drugs, pharmaceutical forms, excipients clinical specialist pharmacist in the Central
c/Dr Esquerdo 46, Madrid 28007, Spain; and administration techniques. These Pharmacy provided support to the resident
larott@hotmail.com peculiarities make children more vulnerable but only activities and recommendations
Pharmacy practice
made by the resident were included. analysis of the data gathered in the MS Access The number of interventions per patient-
Attendance in the unit was from Monday database was performed using MS Excel. day was used as the indicator of activity,
to Friday, 08:00 to 15:00 h. Activities The design concept of the database which was calculated using data from Farhos
performed outside this time period were was based on the methodology of two Unidosis™ (a database used in the pharmacy
excluded because after 15:00 h the resident high-impact studies on the development Department). This indicator shows the
works in the Central Pharmacy. of recording systems for pharmacists’ number of physician orders validated and
The requirement for informed consent interventions.10 11 The following measurement the number of patients admitted during the
was waived because the participation of variables were included: negative outcomes study period (patient-days were defined as
the pharmacist integrated into the unit was associated with medication (NOM) detected active prescriptions per occupied bed).
considered by all the team in the department and reason for the intervention and clinical
as part of the routine work of the PICU, and significance, acceptance of intervention and
the rest of the health workforce is required drug involved in the intervention.
Logistic activities
The main medication store, which was
to preserve the confidentiality and use data
only for purpose of scientific publication.
Negative outcomes associated with already implemented before this study in the
medication (NOM) detected PICU, was the Pyxis automatic dispensing
The NOMs were classified into six system (ADS) which was linked via an
Clinical activities categories (box 1). In addition, NOMs were interface to the prescription profile of the
After the first morning session and full defined as avoided (if the medication error patient. In this way, the dispensing system
ward round in the intensive care unit, the could have caused harm but the drug was received the information of the medical
medical staff prescribed patient treatment not administered to the patient) or real (if the prescription in real time. This function of the
electronically using the Visual Limes drug involved in the medication error was system linked to the patient profile provided
Prescriplant programme. The pharmacist then administered to the patient and led to the an additional control, allowing access only
validated the physicians’ orders. Validation corresponding repercussions). to medications prescribed and validated
focused on confirmation of the correct dose by the pharmacy department. However,
of the drug according to the weight and Reason for the intervention and clinical drugs were categorised into different profiles
height of the child, the suitability of the significance (groups 1 and 2) according to the therapeutic
drug prescribed and its indication, the dose The recommendation made by the group to which they belonged and their
adjustments recommended in the literature pharmacist to the responsible physician use in the unit. Drugs included in group
according to the characteristics of the patient, was recorded. The different motives for 1 required an electronic prescription and
the absence of contraindications and clinically intervention are listed in table 1, together with validation by the pharmacist in order for
significant interactions, and the proposal of the clinical significance of each of the motives nurses to be able to access the drug. Those in
alternative drugs for those not included in the based on a slightly modified Overhage scale.11 group 2, for urgent treatment or for nursing
hospital’s pharmacotherapeutic guidelines, Acceptance of the intervention care (PRN, as needed) could be accessed by
recommending available equivalents. If The prescribing physician’s acceptance of the nurse without prior prescription by the
clarification was required, the pharmacist the recommendation issued was evaluated physician or validation by the pharmacist.
wrote a note appended to the electronic over the following 24 h and was classified The resident updated and reviewed
prescription or contacted the responsible as accepted, not accepted or not evaluable drugs included in the dispensing system
physician by telephone. (when it was not possible to assess based on a drug list updated in July
All interventions were recorded in acceptance due to transfer of the patient to 2009 and supplied by the dispensing
a Microsoft Access database designed in another hospital ward); these events were and logistics service of the pharmacy
the Pharmacy Department to quantify excluded from the analysis. department. In an initial phase, the drug
and evaluate the activity of the pharmacists in profiles were reviewed with the head of
each clinical unit; the database had been Drug involved in the intervention the nursing staff in the unit and another
validated by pharmacists with various levels Both the trade name and the active substance experienced nurse in order to identify
of specialization, observing an acceptable were recorded. Drugs were included whether discrepancies between the established
degree of concordance.9 Clinical interventions or not they appeared in the hospital’s profile of each of the drugs in the ADS
were defined as those recommendations pharmacotherapeutic guidelines. and its actual use in the PICU. In a second
issued when a prescription error was
detected and interventions in which the Box 1 Classification of negative outcomes associated with medication (NOMs) according to the Third
additional information provided on the use Consensus of Granada (2007)
of a drug may have avoided a medication Necessity
error. The resolution of consultations made Untreated health problem: the patient has a health problem as a consequence of not receiving the m edicine
by the health professionals of the unit that he needs
about drug dosage and administration and Effect of unnecessary medicine: the patient has a health problem as a consequence of receiving a m
edicine
clarification of incomplete physicians’ orders that he does not need
Pharmacy practice
phase, the drugs for which consensus with Teaching activity provide specific training programmes in this
the nursing staff was not reached in the Training needs were detected in discipline and the activities normally carried
first phase were evaluated based on drug both theoretical aspects (difficulty out by pharmacists in our hospital.
consumption during the year 2009 in comprehending the morning sessions of
order to determine the need for availability the care team or nursing activities related Results
in the unit. In these cases, data on drug to drug administration) and practical
consumption in 2009 were obtained from
Clinical activities
aspects (prescription validation and Forty pharmaceutical interventions
Farhos Gestión (a database used in the difficulties related to the identification and were performed, representing about four
pharmacy department) for those medicinal categorisation of NOMs). These aspects interventions per 100 patient-days.
products included in the Pyxis ADS on the were assessed by a process of self-evaluation,
unit and that contained the same active periodic meetings with the head of the NOM detected
substance; the products with the highest PICU and head of teaching, and comparison The profile of the interventions was as
level of consumption during the previous with the schedules from countries that follows (figure 1): recommendations
year were selected and those that could
lead to confusion were withdrawn, thus
also reducing the likelihood of expiry of
the medication. The profiles of some drugs
were modified based on this information
and the inventory of the ADS in the unit
was updated. As a variable of the principal
objective, the number of drugs whose
profiles were modified was recorded.
The relationship with the nursing team
has facilitated the detection of problems
related to the request, receipt and storage
of drugs not held in the automatic store;
these activities were defined as secondary
objectives of the resident’s rotation. Figure 1 Stratification of the interventions by type of drug-related negative outcome.
Pharmacy practice
Pharmacy practice
Logistic activities difficult owing to the numerous factors Furthermore, the use of the electronic
Results of the primary objective that affect the methodology of studies prescription in 100% of cases avoided
Forty-eight of the 289 medicinal products (such as the number and type of patients illegibility of the physicians’ orders, and
held in the ADS underwent changes seen, number and level of specialisations the category ‘clarification of physician’s
to their prescription profile or were of the pharmacists involved and system for orders’ was therefore used to refer only
removed from the dispensary cabinet. recording interventions) and also to the fact to those cases in which information was
These modifications were based on stock/ that the results are presented using different requested because the validator considered
consumption management criteria or safety types of activity indicators. Studies at a that the nursing staff could misinterpret the
issues to avoid possible confusion with other national level in the adult population have prescription, giving rise to an error of drug
drugs commonly used in the unit (table 3). reported numbers of interventions that administration. In addition, the overlap
vary between 0.70 and 3.2 per 100 patient- of this study with the initiation of the
Results of the secondary objectives days.12 13 The study by Izco et al14 specified pharmacokinetics service in our Pharmacy
Improvements were made at two levels. a dedication of 5 h per day to the review Department made it impossible to include
The first involved improvements in the of admitted patients and recorded a total the consultations and reports issued by this
drug circuits (there had been many reports of 3.23 interventions per 100 patient-days. service as interventions; in some studies,
of incidents in the receipt of requests for Some international studies have reported these interventions have represented a
enteral nutrition) and review of the expiry higher levels of intervention in an adult high percentage of all the interventions
dates of drugs not held in the ADS of the population, with ranges from 1.2 to 11.5 recorded.16
unit. The second involved information interventions per 100 patient-days.15 16 No With regard to the distribution of drug-
management: recommendations Spanish studies in a paediatric population related problems, the results are similar to
on the choice of various pharmacy- have quantified the activity indicators those of the study performed in Argentina
prepared formulations, resolution of using interventions per 100 patient-days. by Fontana et al18 in which 52.5% of the
doubts concerning the use of electronic In the USA, Folli and colleagues described problems were related to drug safety, 32.5%
prescriptions, detection of deficiencies in interventions in various paediatric areas in to efficacy and 15% to indication. As in
the prescription system and potentiation of two hospitals,17 reporting figures of 1.35– our study, those authors found the highest
its use in accordance with hospital policy. 1.77 interventions per 100 patient-days; in number of interventions to be related to
that study, the PICUs had the highest risk of safety issues. The majority of interventions
Areas for improvement in medication errors due to the wide range of are therefore related to the detection of
teaching weights and heights of the patients admitted errors of prescription that constitute an
After the pharmacist’s rotation in the to the units and to the large number of drugs absolute overdose of drugs, a common
unit it was considered necessary to used. event in paediatric units and intensive care
present proposals to improve the clinical This variability in reported intervention units. Although requests for information
rotation (table 4). levels may also be due to the fact that in are the most common source of
some studies the recorded interventions interventions in some studies,19 overdosage
Discussion included drug consultations and the continues to be one of the most frequent
Forty pharmaceutical interventions clarification of physicians’ orders due to reasons for pharmacist intervention.4
were performed, representing about 4.0 illegibility. In our study, consultations on
20 21
Our data support those of other
interventions per 100 patient-days. The drug administration (mostly intravenous) authors who report a significant number
number of interventions observed in similar were recorded but they were quantified of prescriptions with doses two, three or
studies varies and comparisons are often separately from the interventions. up to 10 times the dose recommended in
children.22 23
Although there was no single active
Table 3 Results of logistic activities
substance that accounted for the majority
Drug profile of these interventions, it must be realised
Drugs predefined as URGENT + PRN GROUP (group 2) (n = 88) that our database did not group the drugs
Number of drugs modified 3 involved into the therapeutic groups to
Drugs withdrawn* Percentage of drugs modified in this 3.4% which they belong. The study by Folli et
group
Number of drugs modified 15
al17 found that the majority of potentially
Drugs categorised as ‘e’† Percentage of drugs modified in this 17.05% serious or fatal errors occurred with
group antibiotics, theophyllines, digoxin and fluid
Drugs predefined with profile of PRESCRIPTION ONLY (group 1) (n = 201) therapy. Furthermore, studies undertaken
Number of drugs modified 4 in adult intensive care units highlight
Drugs withdrawn Percentage of drugs modified in this 1.99% certain therapeutic groups as the source of
group
the majority of interventions.24 Analysis
Drugs categorised as ‘e’(a) Number of drugs modified 24
of these data would be useful in order to
Percentage of drugs modified in this 11.94%
group identify prescription patterns and common
Drugs categorised as ‘e’ to avoid medication errors despite not being high (n = 0) errors that require correction through
consumption or very urgent medicinal products pharmacist intervention.
Number of drugs 2 The rate of acceptance by physicians
Percentage of drugs modified in this group 0.99% in our study (95%) was similar to that
*Withdrawn drugs from the automatic dispensing system (ADS) may be prescribed by the physician. To of other studies which have reported
include these drugs in the ADS, a pharmacist check is required. acceptance rates of 91–99%, and no
†
These are high-consumption or urgent medicinal products that must always be available in the automatic inappropriate interventions were
dispenser.
detected.14 25–27
Pharmacy practice
With respect to the results of the logistic initial programme in those hospitals that team depends directly on the usefulness that
activities, it was difficult to compare findings have not yet implemented this activity in the pharmacist demonstrates through these
as no publications have quantified the a highly specialised unit such as a PICU.32 33 activities, making it essential to broaden the
duties undertaken by that the pharmacist to Our level of understanding of paediatrics study to include pharmacoeconomic issues
optimise the ADS, although evaluations of and the complexity of these patients makes (differences in the costs of treatment after
the impact of the introduction of automatic it difficult to identify a large number of the pharmacist’s intervention) to quantify
cabinets and of the electronic prescription true NOMs, leading to the need for more the economic saving, which could lead to an
system on the reduction in medication errors detailed pharmacotherapeutic patient increase in the number of pharmacists who
have been performed.28 29 monitoring. could transfer their activities to the clinical
The principal limitation of our study setting.
is that the data correspond to the activity Conclusions
of a single resident pharmacist whose The integration of a fourth-year resident Acknowledgements The authors are very
dedication was not completely uniform into the multidisciplinary team in the PICU grateful to all the staff of the intensive care unit
over the 3 months of the rotation and facilitates the detection of drug-related for their enthusiastic cooperation. They thank all
whose training in general paediatrics was problems and enables the pharmacotherapy the staff physicians and residents of the unit for
performed in parallel with her training of critically ill paediatric patients to be the explanations received and for their teaching
in paediatric intensive care. Although optimised. Furthermore, the close relationship and give particular thanks to the nursing staff for
the English-speaking countries have with the nursing staff and acquisition of their unreserved collaboration.
developed specific training schedules,30 31 it additional information about the problems Contributors LE-M was the lead author and
is necessary for each country to design their faced by health professionals in the unit each wrote the final version of the manuscript. She
own schedules according to pharmacist day has facilitated resolution of events and designed the study, working with the other
availability and level of integration into the the identification of areas for improvement authors to define the variables, and also carried
care team, with adaptation to each hospital. in the processes related to the request, receipt out the overall statistical analysis of the data.
Our contribution to the improvement in and optimisation of use of drugs. However, CMF-L, SM-R and IG-L helped to design the study,
training could give rise to the creation of an the integration of the pharmacist into the care defined the variables and checked the statistical
Pharmacy practice
analyses, and critically reviewed the text. JL-H 10. Panel de consenso. Tercer consenso de 22. Koren G, Haslam RH. Pediatric medication
Granada sobre Problemas Relacionados con errors: predicting and preventing tenfold disasters.
and MS-S reviewed the final text.
Medicamentos (PRM) y Resultados Negativos J Clin Pharmacol 1994;34:1043–5.
Ethics approval Ethics approval was obtained asociados a la Medicación (RNM). Ars Pharm 23. Koren G, Barzilay Z, Greenwald M. Tenfold
from the paediatric intensive care unit. 2007;48:5–17. errors in administration of drug doses: a
11. Overhage JM, Lukes A. Practical, reliable, neglected iatrogenic disease in pediatrics. Pediatrics
Provenance and peer review Not comprehensive method for characterizing 1986;77:848–9.
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Pharm 1999;56:2444–50. A, et al. Clinical and economic impact of the
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Eur J Hosp Pharm 2012 19: 416-422 originally published online July 6,
2012
doi: 10.1136/ejhpharm-2011-000032
These include:
References This article cites 30 articles, 8 of which you can access for free at:
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Notes