Optimising medicines for children: considerations for clinical pharmacists

Clinical pharmacists' interventions about drug therapy problems and its acceptability by prescribers among pediatric hospitalized patients with infectious diseases in resource-limited settings

BACKGROUND

Infectious disease continues to be a major cause of death among pediatrics. Drug therapy problem (DTP) is a significant public health challenge that is highly prevalent in pediatrics, and it has an impact on the effectiveness and safety of drug therapy to a greater extent than in adults. Thus, this study aimed to determine the magnitude of DTPs, types and acceptability of pharmaceutical interventions by prescribers and its associated factors among hospitalized pediatric patients with infectious diseases at pediatric wards of Public comprehensive specialized hospitals (PCSHs).

METHODS

This multicenter crosssectional study was conducted among pediatric patients with infectious disease admitted to PCSH pediatric wards from December 01, 2023, to February 30, 2024. Cipolle's and Strand's DTP classification methods were used for the identification of DTPs. Pharmaceutical interventions and their acceptance rate by prescribers were classified according to the Pharmaceutical Care Network Europe (PCNE) 2019. Data was entered and analyzed into SPSS version 27. To identify predictors of DTP occurrence, multivariable logistic regression analysis was used. A pvalue of less than 0.05 was considered statistically significant.

RESULTS

A total of 389 pediatric patients were involved in the current study, selected from an initial sample size of 405, resulting in a response rate of 96.05%. The overall prevalence of DTPs was 56.56% which occurred in 220 pediatric hospitalized patients with infectious disease. The most commonly encountered type of pharmaceutical intervention provided was adjusting the dose of medication (25.2%), followed by patient education/counseling/adherence (23.2%), and discontinuation of medications (20.54%). The acceptance level of interventions by prescribers was high (84.0%). Medication non-compliance (43.6%), unnecessary drug therapy (16.0%), and dose too high (12.0%) were common types of DTPs. Patients with the prolonged hospital stay (6-10 days) [AOR = 2.02, 95%CI: 1.33-7.80] and more than ten days in hospital [AOR = 2.89, 95%CI: 1.90-11.23]; patients with high number of medications (≥ 5) [AOR = 4.60, 95%CI: 1.89-8.82]; those who paid for their medications [AOR = 2.19, 95%CI: 1.18, 3.31], and patients with comorbidity [AOR = 3.90, 95% CI: 1.56-8.15] were the predictors of the occurrence of DTPs.

CONCLUSION

This study finding revealed that the magnitude of DTPs was high in pediatric inpatients with infectious diseases at PCSHs. The presence of comorbidity, source of medication fee, polypharmacy, and prolonged hospital stays were factors associated with the occurrence of DTPs. The acceptance rate of interventions by the prescribers was high. Clinical pharmacists' involvement in direct patient care responsibility astutely reduces drug therapy problems and hence increases patient safety.

Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units

Adverse drug events (ADEs) are common in hospitals, affecting one in six child in-patients. Medication processes are complex systems. This study aimed to explore the work-as-done of medication safety in three English paediatric units using direct observation and semi-structured interviews. We found that a combination of the physical environment, traditional work systems and team norms were among the systemic barriers to medicines safety. The layout of wards discouraged teamworking and reinforced professional boundaries. Workspaces were inadequate, and interruptions were uncontrollable. A less experienced workforce undertook prescribing and verification while more experienced nurses undertook administration. Guidelines were inadequate, with actors muddling through together. Formal controls against ADEs included checking (of prescriptions and administration) and barcode administration systems, but these did not integrate into workflows. Families played an important part in the safe administration of medication and provision of information about their children but were isolated from other parts of the system.

'They Take the Mum Off You When You Come In': An Ethnographic Study of Parent Experiences of Medicines Safety Systems in English Hospitals

INTRODUCTION

Medication safety in healthcare settings is a persistent problem, and children may be at greater risk of harm than adults. Most existing research examining medication safety for hospitalised children is from the perspective of healthcare professionals and organisations. This study aimed to ethnographically explore parent and staff perspectives on the role of parents in medication safety in the paediatric hospital setting.

METHODS

230 h of ethnographic observation and 19 semi-structured interviews with clinical staff and parents were conducted over paediatric wards in three acute hospitals in Northern England between October 2020 and May 2022. Data was organised and coded using NVivo and analysed thematically.

RESULTS

Three main themes were identified: (1) Capacity and Capability: Parents were often assumed to be incompetent by organisational policies and managers but at the same time were co-opted to undertake medication processes to meet operational needs. Parental experience was often ignored or judged negatively. When things went wrong parents were sometimes blamed. (2) Communication: parents were seldom meaningfully involved in decisions about their children's medication or provided with appropriate information unless requested. Parental medication histories were treated with suspicion and validated against inaccurate records. (3) Agency and Autonomy: parents often wanted to participate in their child's care but were expected to be passive observers.

CONCLUSIONS

Medication safety for children is a social phenomenon involving healthcare professionals and parents. However, parents are often relegated to a passive role by healthcare staff. We posit that this represents an example of epistemic injustice in the way parents are assumed to be incompetent outsiders with no understanding of the medical care of their children, despite them offering resilience for medicines safety. We recommend further exploration of how parents contribute to resilience and safety for children in hospital and the barriers to this, and how health services can safely support increased engagement and involvement of parents in the care of their children while in hospital.

PATIENT OR PUBLIC CONTRIBUTION

Parents contributed to the analysis and interpretation of the data collection and have contributed to the preparation of the manuscript.

Medication safety with oral antitumour therapeutics in paediatrics (youngAMBORA): A mixed-methods approach towards a tailored care program

OBJECTIVE

Oral antitumour therapeutics (OAT) are increasingly used due to improvements in outcomes and their convenient application. However, complex intake regimens pose several challenges. The randomised AMBORA trial (Medication Safety With Oral Antitumour Drugs) demonstrated highly positive outcomes of a clinical pharmacological/pharmaceutical care program for adults treated with numerous OAT, but comparable concepts in paediatrics are lacking so far.

METHODS

We used a parallel mixed-methods approach to develop a tailored pharmacological/pharmaceutical care program for OAT in paediatrics (youngAMBORA). We combined a quantitative analysis of tumour entities and used OAT in a paediatric cancer centre with a qualitative survey for patients, caregivers, and healthcare professionals to identify particular demands and educational needs (e.g., application problems, side effects).

RESULTS

Leukaemia (77/315) and antimetabolites (95/151) were the most frequently observed entity and OAT, respectively. Of 22 surveyed patients, 81.8% wanted to be involved in oral medication education. Compared to caregivers, significantly more healthcare professionals graded the three most common application problems to be challenging ('Smell/taste': 32/36 vs. 23/42, p = 0.001; 'Refusal of intake': 31/36 vs. 16/42, p<0.001; 'Swallowing problems': 28/36 vs. 21/42, p = 0.011). We identified nine relevant side effects, of which two ('Skin dryness', 'Taste changes') were not included in 15 previously published core side effects of the Common Terminology Criteria of Adverse Events (CTCAE) item library.

CONCLUSION

Based on the present findings, the tailored youngAMBORA care program will include: 1) counselling sessions for classic and targeted OAT, 2) child-friendly support with drug application, and 3) systematic evaluation of 17 relevant side effects from patients' and caregivers' points of view including age-appropriate information material.

Tripled likelihood: polypharmacy increases the occurrence of drug therapy problems in hospitalized pediatric patients

Background

A drug therapy problem (DTP) is any undesirable event experienced by a patient that accompanies drug therapy, prevents the patient from achieving their desired therapeutic goals, and requires expert judgment to resolve. Pediatric populations are at a higher risk of DTP than adults due to their immature organ systems, including the liver and kidneys, which play crucial roles in drug metabolism and excretion. Most previous studies have focused on only one element of DTP. Therefore, by considering all elements of DTP, we aimed to assess the prevalence of DTP and associated factors among pediatric patients admitted to the Wolaita Sodo University Comprehensive Specialized Hospital.

Methods

An institution-based cross-sectional study was conducted among pediatric patients admitted to Wolaita Sodo University Comprehensive Specialized Hospital from 8 July 2020, to 7 July 2021. A simple random sampling technique was employed to select study participants. Cipolle's and Strand's classification method of drug therapy problems was used to identify and categorize DTP. Data were obtained by reviewing the patient's medical records using a data abstraction checklist, entered into Epi data version 4.6, and exported to SPSS version 25 for analysis. Binary logistic regression analysis was performed to identify independent predictors of DTP.

Results

Medical records of 369 pediatric patients were reviewed, and the overall prevalence of DTP was 60.2% (95% CI:55.2%, 65.2%) with a total of 281 identified DTPs. Among them, 164 (74.2%) had only one DTP. Need additional drug therapy was the most common (140 [49.8%]) DTP identified. The number of disease conditions (AOR = 2.13, 95% CI:1.16, 3.92), polypharmacy (AOR = 3.01, 95% CI:1.70, 5.32), and duration of hospital stay (AOR = 1.80, 95% CI:1.04, 3.10) were independent predictors of DTP among admitted pediatric patients.

Conclusion

The prevalence of DTP in pediatric patients in the current setting was high. The number of disease conditions, polypharmacy, and duration of hospital stay were independent predictors of DTP. Enhancements to pharmaceutical care services, optimized dosage practices, improved deprescribing by clinicians, and efficient, comprehensive diagnostic procedures have the potential to significantly reduce specific drug therapy problems in hospitalized pediatrics.

Pharmacist and child communication: A phenomenological multidisciplinary study from the perspectives of undergraduate students in pharmacy and child development

Background

The present study is an interdisciplinary study about pharmacist-child communication exploring the perceptions and observations of students studying in two different but intersecting fields, which are pharmacy and child development.

Objective

The objective of the study is to illustrate the perceptions and observations of undergraduate pharmacy and child development students about pharmacist-child communication.

Method

The study is a phenomenological study and the phenomenon analyzed is "pharmacist-child communication". Research study group was selected via criterion sampling method. The sample group consisted of 40 undergraduate pharmacy and child development students. "Demographic Information Form" was used as the data collection tool and "Focus Group Interview Guide" was prepared for focus group interview meetings. Ten open-ended questions aligned with the research objective were asked to the students in the focus group interview. The collected data were analyzed by descriptive analysis method and the experiences of these two different groups of students were explored.

Results

At the end of the study, two main themes and five sub-themes were obtained. These themes and the sub-themes are as follows: adherence to drug therapy (Sub-themes: communication strategies relevant to the cognitive development at various ages of the child, rewarding children and reinforcement of good behavior, role of the parent in pharmacist-child communication) and physical characteristics of the pharmacy/pharmacist (Sub-themes: physical characteristics of the pharmacy, physical caharacteristics of the pharmacist).

Conclusions

Each theme was illustrated in the study with comments of the students. The results showed that the observation and perceptions of the students studying in two different fields agreed with each other and those of other researchers. It is proposed that projects and practices can be developed by these two different disciplines, pharmacy and child development are two intersecting fields. As they complement each other, they could strengthen the pharmacist-child communication and as a result support the child's adherence to therapy.

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.