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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 5  |  Page : 235-236

Prevention is better than cure: The vital role of the clinical pharmacist in the pediatric intensive care unit to prevent medication errors

1 Department of Pharmacy Services, Children's Hospital of Philadelphia, Philadelphia, PA, USA
2 Department of Anesthesiology and Critical care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA

Date of Submission07-Aug-2020
Date of Acceptance17-Aug-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Vijay Srinivasan
Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_110_20

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How to cite this article:
Blowey B, Resendiz KV, Grachen A, Srinivasan V. Prevention is better than cure: The vital role of the clinical pharmacist in the pediatric intensive care unit to prevent medication errors. J Pediatr Crit Care 2020;7:235-6

How to cite this URL:
Blowey B, Resendiz KV, Grachen A, Srinivasan V. Prevention is better than cure: The vital role of the clinical pharmacist in the pediatric intensive care unit to prevent medication errors. J Pediatr Crit Care [serial online] 2020 [cited 2021 Mar 4];7:235-6. Available from: http://www.jpcc.org.in/text.asp?2020/7/5/235/295012

Critically ill children require numerous medications during their management in the pediatric intensive care unit (PICU). In the United States, published data show that one error occurs for every five doses of medication administered.[1] In addition, pediatric patients are three times more likely to be involved in a medication error event than adult patients.[2] These errors occur even in the setting of processes already in place to improve medication safety, including unit dose dispensing, pharmacy compounding, automation, and computerized physician order entry (CPOE).[1] The clinical pharmacist plays a vital role in the PICU to optimize drug therapy, perform pharmacokinetic evaluations, mitigate adverse drug events, and support medication error prevention. The integration of a clinical pharmacist into patient care has been shown to not only reduce costs but also prevent errors, especially when available to round with the multidisciplinary intensive care unit team.[3],[4] More recently, the involvement of clinical pharmacists during cardiopulmonary resuscitation is strongly encouraged to improve the process of care in a high-stress event in the PICU.[5] As pharmacologic agents and biologics become more complex due to drug development and novel therapeutic interactions, the clinical pharmacist assumes even greater importance to prevent medication errors, optimize patient care, and promote financial stewardship of limited resources in the PICU.

This prospective observational study conducted by Loni et al.[6] in the PICU of a secondary level hospital in Karnataka highlights that medication errors are quite common, with errors occurring during a quarter of observed patient days. Medication errors occurred in different steps of prescribing, transcribing, dispensing, and administering medications for critically ill children. Importantly, the study emphasizes the key role played by the clinical pharmacist to identify medication errors in different stages and to provide appropriate recommendations to optimize medication therapy in the PICU. The most common type of medication error found in this study was prescription errors (59%), with the most common prescription error being error related to dosage (76% of all prescription errors). This is not unexpected given the differences in pediatric pharmacokinetics and pharmacodynamics that affect drug response in critically ill children, the lack of commercially available pediatric formulations, and the complexity of weight-based dosing that spans multiple ages and developmental stages in children.[2] The study also classified medication errors using the National Coordination Committee for Medication Error Reporting and Prevention Index Severity Classification, with most errors falling in Category B (61%-the error did not reach the patient), followed by Category C (34%-the error reached the patient but did not cause harm). These findings support that the integration of a clinical pharmacist with extensive training in pediatric pharmacology is essential to provide optimized and safe care to this vulnerable population. Interestingly, when a pharmacist intervened, recommendations were accepted at a rate of 92%, suggesting that the incorporation of a clinical pharmacist into this type of clinical setting is well-received. The findings of this study are similar to a landmark adult study that observed that the presence of a pharmacist on rounds as a full member of the patient care team in a medical intensive care unit (ICU) was associated with a substantially lower rate of medication errors caused by prescribing errors.[3]

This prospective study is unique in its description of medical errors in the context of the health-care setting with limited access to technologies to improve medication safety such as CPOE, barcode-assisted medication administration, and new generation infusion devices with smart pump technology. This is a common scenario and this study provides further support that a clinical pharmacist can have a profound impact on the amount and outcomes of medical errors that occur within a pediatric ICU setting. A limitation of this study is that only medication errors identified by the pharmacist were included for evaluation, potentially resulting in bias with underreporting of the true rate of medication errors. In addition, the inclusion of a historical cohort group, would have allowed for a more accurate evaluation of the true impact of a clinical pharmacist on enhancing medication safety. Additional information regarding the timing of pharmacist intervention in relation to when errors occurred in the medication utilization process would be helpful to ensure the best deployment of the pharmacist to match documented needs. It also remains unclear how often verbal orders to prescribe medications were utilized as this is often an important source of medication error.[7]

This study demonstrates that clinical pharmacists add high value to patient care and outcomes outside the drug dispensing process. Such involvement can result in practice changes that improve medication safety such as standardization of administration times, medication dilutions, and infusion rates; identification of interactions; and estimation of drug clearance and disposition. Increased involvement of clinical pharmacy services can provide ways to prevent medication errors and optimize overall patient care. In particular, the presence of the pharmacist on bedside rounds with the clinical team in the PICU serves as an immediate resource to optimize drug therapy and prevent medication errors. Limited access to in-house pharmacy resources or lack of qualified pharmacists is barriers to the delivery of high-quality care in the PICU. In the absence of a clinical pharmacist on site, alternative strategies and modalities to consult a clinical pharmacist for complex drug information questions either via telehealth or as an on-call service can mitigate dosing and medication selection errors for all providers in the PICU setting. Regardless of whether a clinical pharmacist is available in real time or not, we recommend dedicated pediatric-trained pharmacist involvement in quality improvement, guideline development, and policy implementation for improving therapeutics in the PICU. In the context of having a dedicated pediatric-trained pharmacist for the optimal care of critically ill children, the old adage of prevention is better than cure rings true…

  References Top

Mansur JM. Medication safety systems and the important role of pharmacists. Drugs Aging 2016;33:213-21.  Back to cited text no. 1
Eiland LS, Benner K, Gumpper KF, Heigham MK, Meyers R, Pham K, et al. ASHP-PPAG guidelines for providing pediatric pharmacy services in hospitals and health systems. J Pediatr Pharmacol Ther 2018;23:177-91.  Back to cited text no. 2
Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267-70.  Back to cited text no. 3
Folli HL, Poole RL, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987;79:718-22.  Back to cited text no. 4
Johnson PN, Mitchell-Van Steele A, Nguyen AL, Stoffella S, Whitmore JM; Advocacy Committee for the Pediatric Pharmacy Advocacy Group. Pediatric pharmacists' participation in cardiopulmonary resuscitation events. J Pediatr Pharmacol Ther 2018;23:502-6.  Back to cited text no. 5
Loni R, Charki S, Kulkarni T, Kamle M, Bidari L. Utility of a clinical pharmacist in the paediatric intensive care unit to identify and prevent medication errors. J of Pedtr Care 2020;7:249-54.  Back to cited text no. 6
Shastay A. Despite technology, verbal orders persist, read back is not widespread, and errors continue. Home Healthc Now 2019;37:230-3.  Back to cited text no. 7


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