Difficulties experienced during preparation and administration of oral drugs

'Working outside the box'-an interview study regarding manipulation of medicines with registered nurses and pharmacists at a Swedish paediatric hospital

AIM

Studies on frequencies of manipulated medicines in paediatric care are common, but there is little knowledge of experiences of pharmacists and registered nurses in this area. The aim of this study was to explore registered nurses' and pharmacists' reasoning in the manipulation of medicines to paediatric inpatients.

METHODS

Semistructured interviews with twelve registered nurses and seven pharmacists were performed at a Swedish paediatric university hospital. The interviews were transcribed verbatim and analysed using content analysis.

RESULTS

Four major categories emerged from the analysis of the interviews: medicines management, knowledge, consulting others and organisation. Medicines management involved the process of drug handling, which is prescribing, reconstitution or manipulation and administration. Knowledge concerned both the knowledge base and how healthcare personnel seek information. Consulting others involved colleagues, registered nurses and pharmacists, between registered nurses, pharmacists and physicians and between registered nurses, pharmacists and caregivers. Organisation covered documentation, time and working environment.

CONCLUSION

Both pharmacists and registered nurses stated that manipulation of medicines to paediatric patients was often necessary but felt unsafe due to lack of supporting guidelines. Pharmacists were natural members of the ward team, contributing with specific knowledge about medicines and formulations.

Chronic Medication Use and Factors Associated With Polypharmacy Among Outpatient Pediatric Patients

OBJECTIVE

This study aimed to determine the prevalence and predictors of chronic polypharmacy among pediatric patients in an outpatient setting.

METHODS

We conducted a review of medications dispensed to patients from an outpatient pediatric facility during a 12-month period. Patients who received chronic medications (≥30 days' supply), which contained at least 1 active pharmaceutical ingredient were included in the study. Descriptive analysis was used to determine prevalence of polypharmacy while predictive factors for polypharmacy were evaluated using logistic regression.

RESULTS

Our study included 3920 patients (median age, 9.9 years; IQR, 9.4) and 16,401 medications. The median number of chronic medications used among our study cohort was 2.0 (IQR, 1) with polypharmacy identified in 309 (7.9%) patients. Predictors for polypharmacy were age and the use of certain therapeutic class of medications. Patients 12 to <19 years old (OR, 6.95; 95% CI, 4.1-10.1) were more likely to require ≥5 concurrent medications compared with patients younger than 2 years of age. Use of calcium supplements (OR, 21.2; 95% CI, 11.3-39.6), Vitamin D analogues (OR, 14.3; 95% CI, 8.0-25.8), and systemic glucocorticoids (OR, 18.8; 95% CI, 10.7-33.2) were also highly associated with polypharmacy.

CONCLUSIONS

Adolescents and children with chronic medical conditions who require prolonged systemic glucocorticoids, calcium, and Vitamin D supplements are at higher risk of incurring long-term polypharmacy. This subgroup of pediatric patients may be more vulnerable to the occurrence of negative outcomes resulting from the use of multiple chronic medications.

Tea Tree Oil Nanoemulsion-Based Hydrogel Vehicle for Enhancing Topical Delivery of Neomycin

The present investigation aims to improve the antimicrobial influence of certain antibacterial drugs, namely, neomycin (NEO), exploiting the benefits of natural oils such as tea tree oil (TTO). Therefore, a distinctive nanolipid formulation, namely, a nanoemulsion (NE), was developed using a Central Composite Factorial Design (CCD) approach depending on the amount of TTO and tween 80 as surfactant. The optimized NEO-NE formula exhibiting minimum globular size and maximum in vitro release was selected. For efficient topical delivery, NEO-NE was incorporated into a pre-formulated hydrogel. The developed NEO-NE-hydrogel was characterized by its physical characteristics such as pH, viscosity, and spreadability. Next, it was tested for stability under different conditions for 3 months. Ultimately, an irritation test was conducted followed by an antibacterial examination. The preparation demonstrated acceptable properties to be successfully applied topically. It showed non-significant changes in stability in both conditions up to 3 months storage when compared to a fresh preparation. It exhibited no irritation when applied on hairless animal skin. Finally, TTO revealed a good inhibition for the bacterial growth that could improve the influence of NEO antibacterial activity, indicating the efficiency of NE containing NEO prepared with TTO to be a promising antibacterial nanocarrier.

Medication administration and anxiety: an observational study with nursing students

BACKGROUND AND AIM

Medication administration errors represent a topic of great scientific interest. Medication administration is considered by nursing students a complex process during which it is easy to make mistakes; therefore, institutional measures have been adopted in order to reduce medication errors. However, it remains a critical issue in nursing practice for which several causes have been identified, including environmental factors and individual knowledge. Mistakes can be made by nurses and especially by students who must cope with additional causal factors including anxiety management. The aim was to investigate state anxiety levels among nursing students when it comes to medication administration.

RESEARCH DESIGN AND METHODS

An observational study involving a convenience sample of 150 nursing students from a Northern Italy University has been conducted; they were asked to complete a questionnaire to measure the levels of state anxiety in relation to medication administration.   Results. There were no particularly high levels of state anxiety among students associated with medication administration; however, state anxiety levels were slightly higher in third-year students than in second-year students, and this is most likely due to the growing complexity of the medication administration process compared to the lack of experience.   Conclusions. Although the results don't show statistically significant data, the effectiveness of nursing education plays a crucial role in reducing medication errors, which is why it is essential to provide suitable tools for the professionals of the future and invest in clinical simulations.

Inpatient Observation After Transition From Intravenous to Oral Antibiotics

OBJECTIVES

Children hospitalized with infections are commonly transitioned from intravenous (IV) to enteral (per os [PO]) antibiotics before discharge, after which they may be observed in the hospital to ensure tolerance of PO therapy and continued clinical improvement. We sought to describe the frequency and predictors of in-hospital observation after transition from IV to PO antibiotics in children admitted for skin and soft tissue infections (SSTIs).

METHODS

We conducted a retrospective cohort study of children with SSTIs discharged between January 1, 2016, and June 30, 2018, using the Pediatric Health Information System database. Children were classified as observed if hospitalized ≥1 day after transitioning from IV to PO antibiotics. We calculated the proportion of observed patients and used logistic regression with random intercepts to identify predictors of in-hospital observation.

RESULTS

Overall, 15% (558 of 3704) of hospitalizations for SSTIs included observation for ≥1 hospital day after the transition from IV to PO antibiotics. The proportion of children observed differed significantly between hospitals (range of 4%-27%; P < .001). Observation after transition to PO antibiotics was less common in older children (adjusted odds ratio [aOR] = 0.69; 95% confidence interval [CI] 0.52-0.90; P = .045). Children initially prescribed vancomycin (aOR = 1.36; 95% CI 1.03-1.79; P = .032) or with infections located on the neck (aOR = 1.72; 95% CI 1.32-2.24; P < .001) were more likely to be observed.

CONCLUSIONS

Children hospitalized for SSTIs are frequently observed after transitioning from IV to PO antibiotics, and there is substantial variability in the observation rate between hospitals. Specific factors predict in-hospital observation and should be investigated as part of future studies aimed at improving the care of children hospitalized with SSTIs.

The difficulties experienced during the preparation and administration of oral drugs by parents at home: a cross-sectional study from Palestine

BACKGROUND

Failure to properly administer drugs to children at home may cause adverse events, which makes it a challenging job for parents or caregivers. The main goal of this study was to investigate the problems and difficulties that parents or caregivers faced when administering oral drugs to their children at home.

METHODS

A cross-sectional study was conducted using a questionnaire consisting of 'yes/no' and multiple-response questions to assess parents' experiences and problems with administering medication to their children at home. Data was collected from parents who visited primary health care centres in Nablus. Descriptive analysis was conducted to describe the characteristics of the sample.

RESULTS

We interviewed 420 parents. 91.9% of the parents used drugs without prescription from a doctor, and the most commonly used non-prescription medicines were antipyretics (n=386, 100%), influenza drugs (n=142, 36.8%), cough drugs (n=109, 28.2%) and antibiotics (n= 102, 26.4%). The study showed that 21.7% of parents used teaspoon and 7.1% used tablespoon in administering liquid medications to their children. When the children refused taking liquid medications, almost two-thirds of the parents (65.7%) insisted their children take them, 21.5% mixed it with juice, 5.2% mixed it with food and 4.7% mixed it with milk. 12.4% of the parents reported that they gave drugs in doses higher than prescribed by the doctor to treat their children more quickly. Also, our study revealed that 80.5% of the parents gave medications at incorrect intervals.

CONCLUSIONS

This study has shown that there is a proportion of caregivers or parents who administer oral drugs to their children incorrectly, which may involve giving them at the wrong intervals or doses, using incorrect instruments, or mixing them with food, juice or milk. The development of educational programs that will provide parents with education about medication administration is therefore recommended.

Comparative Stability of Oral Vitamin K Liquids Stored in Refrigerated Amber Plastic Syringes

Background: Compounded vitamin K oral liquids may be useful in some patient populations, or when an appropriate solid dosage form is not available. While vitamin K oral liquid is typically prepared with sterile water for injection (SWFI), other compounding agents may be more palatable. Objective: To evaluate stability of compounded vitamin K liquids in SWFI, Ora-Sweet, simple syrup, cherry syrup, and SyrPalta stored in amber plastic oral syringes. Methods: Five types of compounded vitamin K liquids were prepared in triplicate-Ora-Sweet, simple syrup, cherry syrup, SyrPalta, and SWFI without flavoring; aliquoted into amber plastic oral syringes; and stored in a laboratory refrigerator (4.9°C to 5.4°C). On study days, 3 syringes from each batch were removed, diluted to assay concentration, and compared with a freshly prepared US Pharmacopeia reference solution. The samples and reference were analyzed using a previously validated high-performance liquid chromatography-ultraviolet method. Product stability was defined as 90% to 110% labeled amount. Results were further compared using a 2-way ANOVA (analysis of variance; P = .05) with post hoc Tukey's correction for multiple comparisons. Results: Vitamin K in SWFI, SyrPalta, and cherry syrup was stable for 21 days, 7 days, and 24 hours, respectively, under refrigeration in amber plastic oral syringes. Vitamin K in Ora-Sweet and simple syrup demonstrated high within-day variability and low potency. Statistically significant differences were detected between the SWFI formulation and all other vehicles. Conclusion: Vitamin K in SWFI is appropriate for longer-term storage of unit-dosed vitamin K; however, SyrPalta and cherry syrup may be used for short-term storage or immediate administration of vitamin K.

Hydrocortisone Granules Are Bioequivalent When Sprinkled Onto Food or Given Directly on the Tongue

Background

Immediate-release hydrocortisone granules in capsules for opening in pediatric-appropriate doses have recently been licensed for children with adrenal insufficiency. This study evaluated the bioavailability of hydrocortisone granules administered as sprinkles onto soft food and yogurt compared with direct administration to the back of the tongue.

Methods

Randomized, 3-period crossover study in 18 dexamethasone-suppressed healthy men. In each period, the fasted participants received 5 mg hydrocortisone granules either directly to the back of the tongue or sprinkled onto soft food (applesauce), or yogurt, followed by 240 mL of water. Serum cortisol was measured by liquid chromatography tandem mass spectometry.

Results

The cortisol geometric mean maximum concentration (C_max) and area under the curve (AUC) for direct administration, sprinkles onto yogurt, and sprinkles onto soft food were: C_max 428, 426, 427 nmol/L and AUC_0-inf 859, 886, 844 h × nmol/L, and AUC_0-t 853, 882, 838 h × nmol/L respectively. The 90% CI for the ratios of C_max, AUC_0-inf and AUC_0-t for administration with soft food or yogurt to direct administration were well within the bioequivalent range, 80% to 125%. Median time to Cmax (T_max) was similar between methods of administration: 0.63 hours administered directly, 0.75 hours on soft food and 0.75 hours on yogurt. No adverse events occurred during the study.

Conclusions

Hydrocortisone granules administered as sprinkles onto soft food or yogurt but not mixed with these foods are bioequivalent to those administered directly to the back of the tongue. Carers, parents, or patients may choose to administer hydrocortisone granules either directly or sprinkled onto soft food or yogurt.

Assessment of the preparation and administration of oral medications to institutionalized children

OBJECTIVE

to evaluate the preparation and administration of oral medications to institutionalized children by nursing professionals.

METHOD

quantitative study, developed from August to September 2016, in a shelter in Fortaleza, Ceará. 323 observations of preparation and administration of oral drugs were carried out. Interview and non-participant direct observation of the process of drug administration were performed, whose data were analyzed through descriptive statistics.

RESULTS

Of the 29 actions of preparation and administration of the drugs, ten were considered satisfactory. Sanitizing of hands before touching the pills occurred in only 5.2% of the observations and cleansing of the bottle for liquid drugs was performed in 23.8%. The actions "check the right child"; "checking medication with the prescription", and "check the right dose" obtained percentages below 15%.

CONCLUSION

measures recommended by the literature for the administration of medication were not, in their clear majority, followed, making specific training and protocols necessary.