Abstract
Background: While drug-related problems (DRPs) have been recognized as a major concern in pediatric wards, the role of hospital pharmacy in improving medication safety has been rarely studied. Objectives: To investigate the frequency, nature, and severity of DRPs and associated pharmacist interventions (PIs). Methods: This is a prospective study carried out using direct observation over a year (2019-2020) in 3 pediatric wards (pediatric emergency department (PED), pediatric intensive care unit (PICU), and neonatal intensive care unit (NICU) in Jazan, Saudi Arabia. A validated data reporting form was developed to include comprehensive clinical data about the prescribed medications, characteristics of patients, and PIs upon DRPs. Clinical significance of DRPs was evaluated by an expert panel, which comprised a clinical pharmacist, a pediatrician, and an internist. Data analysis was conducted using SPSS V26. Results: The overall incidence of DRPs was 6.6%. The highest rate of DRPs 15.2% was detected in the pediatric ICU. Of the 596 DRPs detected, 10.2% were inappropriate drug choice, 5.2% were rated major DRPs, and one-third 33.2% were related to the digestive system and metabolism. Dosing problems were the most predominant DRPs across the included wards. A higher proportion of clinically major and moderate DRPs were detected in pediatric ED. Telephone-delivered interventions [OR: 1.72: 95%CI: 0.78-2.57: P = .001], too high dose [OR: 2.64: 95%CI: 1.33-4.56: P = .01], and major DRPs [OR: 3.21: 95%CI: 2.15-6.42: P = .04] were significant predictors for acceptance of PIs. Conclusion: DRPs are common in Saudi pediatric wards and many of these incidents were clinically major and moderate. Telephone-delivered interventions, too high dose, and major DRPs were major predictors for physician acceptance of PIs.
Keywords: Drug-related problems, pharmacist, pediatric
Key Messages
-
- Hospital pharmacists play major role in the prevention and management of drug-related problems of pediatric in critical care settings in Saudi hospitals.
- A national approach should be implemented to enhance interprofessional collaborative clinical practice in pediatric.
Introduction
Drug-related problems (DRPs) are a growing concern in hospitals, especially in pediatric settings. 1 Addressing DRPs has a priority, owing to the complexity of today’s drug therapy, which consequently makes appropriate drug prescribing increasingly challenging. 2 This complexity proliferates in pediatric wards, in which off-label use of medicines, limited number of adopted pediatric formulations on the market, and the need to redesign adults’ dosage forms are all common.3-5 Pharmacists have a major role in preventing DRPs in pediatric wards. 6 There is a scarcity in clinical trials on pediatrics and low number of validated pediatric doses. Thus, the roles of pharmacists have expanded to include designing new forms. 7
Sonia Prot-Labarthe et al. 6 have shown that in a pediatric wards, clinical pharmacists have the ability to detect and correct DRPs in pediatric wards. Another study indicated that hospital pharmacists could perform significant interventions on medication errors. 8 Kaushal et al. 9 reported a higher rate of DRPs in pediatric intensive care unit (PICU), compared to adults and that pharmacist interventions could decrease the proportion of clinically significant DRPs. In this regard, 3 key factors were determined by Fortescue et al. 10 to reduce DRPs in pediatric inpatients; implementation of electronic prescribing system, pharmacist interventions, and the advanced communication among pharmacists, physicians, and nurses.
In Saudi Arabia, DRPs are common in different wards.11-13 Rashed et al. 14 reported a relatively high incidence 51.1% of DRP in pediatric wards, and wrong dose was the most common DRP. More than a quarter 27.0% of errors were clinically moderate and most of them 80.3% were preventable. A lower incidence of DRP was found in Honk Kong 21.0% 15 and the UK 39.4% 14 pediatric wards. Therefore, our study aimed to investigate wheather hospital pharmacist interventions lead to less DRPs and whether pharmacist interventions reduce the severity of DRPs in pediatric units or not.
Aims
Our study aimed to: (1) investigate the effect of hospital pharmacist interventions on the incidence of DRPs; and (2) evaluate the determinants of physicians’ acceptance of pharmacist interruptions in the pediatric wards of a Saudi hospital.
Methods
Study Design
This was a prospective study conducted in a tertiary care central hospital in Jazan, Saudi Arabia. The research team was trained to observe and document DRPs and provide interventions to clinicians of pediatric wards (pediatric emergency department [PED], PICU, neonate intensive care unit [NICU]) over a year from January 2019 to January 2020. The major outcomes of this study were the frequency, nature and severity of drug-related incidents encountered in the pediatric inpatient population at the abovementioned divisions. The secondary outcomes were the nature of pharmacist intervention (PI), its acceptance by the respondents (physicians, nurses, patients/patient representative), and estimated impact as evaluated by a multidisciplinary committee. Patients aged between 1 day and 18 years were included. Those with length of stay less than 24 h were excluded. The study was approved by the IRB Centre of the Hospital.
Definitions
A DRP was defined as “an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes.” 16 DRPs are categorized into 6 main groups and 12 subcategories (Table 1). The main categories are wrong drug choice, wrong dose, adverse drug reaction, interaction, wrong drug use, and others.
Table 1.
Classification and Examples of DRPs.
| Category | Definition | Example |
|---|---|---|
| 1. Drug choice | One or more drugs are missing according to established national/international guidelines. Deviations from guidelines that are based on the patient’s individual treatment goals and risk factors are not considered to be DRPs. | Statins after a myocardial infarction. |
| 1a. Need for additional drug | Aspirin after a cerebral stroke. | |
| Calcium supplements when using corticosteroids. | ||
| 1b. Unnecessary drug | A drug that is seen as unnecessary if the indication is no longer present, with lack of discontinuation or double prescription of 2 or more drugs from the same therapeutic group. | Antibiotic treatment finalized. |
| Ibuprofen and diclofenac concomitantly. | ||
| 1c. Inappropriate drug choice | Not given reason for deviation from concordance between drug and diagnosis/indication or absolute/relative contraindication because of for example age or comorbidity. Deviations that are based on the patient’s individual treatment goal and risk factors are not considered to be DRPs. | NSAIDs with reduced renal function |
| Broad-spectred antibiotic for simple infection. | ||
| 2. Wrong dose | Suboptimal dosing (including dosing time and formulation) according to established national/international guidelines. Deviations that are based on the patient’s individual treatment goal and risk factors are not considered to be DRPs. | Too low paracetamol dose in relation to symptom-giving arthritis. |
| 2a. Too high/2b. Too low/2c. Sub-optimal dosing scheme/2d. Sub-optimal formulation | Nitrates given without nitrate-free period. | |
| 3. Adverse drug reaction | Any noxious, unintended, and undesired effect of a drug, which occurs at doses in humans for prophylaxis, diagnosis, or therapy | Rash with use of penicillin. |
| 4. Interaction | An interaction is occurring when the effect of a drug is changed by the presence of another drug, food, drink. or some environmental chemical agent. Drug combinations with intended overall effect are not considered to be DRPs. | - Furosemide and digitalis (increased effect/toxicity of digitalis with hypokalemia). |
| 5. Drug use | Patients’ real drug use deviate from the doctor’s prescription with respect to type of drug, dose, or scheme. It is a prerequisite that prescriptions are based on a common understanding (concordance) between prescriber and patient (exception: patient with dementia, emergency situation, etc.). Problems with logistics are not considered to be DRPs. | The patient/patient family had taken a wrong drug or dose or to the wrong time. Crushing of slow release tablet or opening of capsule. |
| 5a Drugs administered by health personnel | ||
| 5b Drugs administered by the patient | ||
| 6. Other | Monitoring with respect to effect and toxicity of drugs is not done or does not adhere to guidelines | Clinical examination, eg, blood pressure, weight with heart failure. Blood tests, eg, regular counting of Hbc with clozapine treatment. X-ray |
| 6a Need for/lack of monitoring of effect and toxicity of drugs | ||
| 6b Lack of or unclear documentation of the drug chart/prescription | — | Drug chart/prescription lacks information about drug strength or formulation, as well as instructions for use (dosing scheme etc.). |
| 6c. Others | In general therapy discussions that include several problems and do not belong in any other category | Discussions on appropriate drug therapy for individual patients, eg, change dose or add a new drug. |
Note. DRP = drug-related-problem; Hbc = hemoglobin c.
Piloting
A preliminary small study was carried out to assess understandability, practicality, and time prior to performing the research. Piloting was carried out in the pediatric wards for 2 days per each ward. As a result of the test, several changes to the data reporting technique were performed; for instance; the nature of the study was changed to prospective instead of the initially planned retrospective nature to ensure reliability of the findings.
Data collection
Data was collected by a research team, comprising 3 pharmacists who were responsible for observing medications prescribed for pediatric patients. Those pharmacists were given training on drug-related problems detection and patient safety concepts by a consultant clinical pharmacist (MHA). Each research pharmacist (MMT, MAT, MAN, MHM) recorded DRPs and their pharmacist interventions in different shifts (day and night) using a standardized data collection e-form, which included information about patient demographics, medical and medication histories, prescription details, lab results, nature, and types of pharmacist-led interventions. Firstly, they identified the DRP and then followed up the response to their recommendation.
Validation of data collection e-form was carried out by the main investigators (MMT and MHA) and 2 independent assessors (MAT and MAN), who reviewed regularly against the adopted operational definitions and confimed by a third member (MHM) if discrepancy presented. Those not matching the criteria were removed. The British National Formula (BNF) for children Version 76 was the main reference for researchers and for the assessors. Further, the seriousness of DRPs was rated by a committee comprising two clinical pharmacist and a medication safety officer. A robust approach for evaluating the responses of the experts was adopted. 17 All DRPs detected were presented to the experts. They were then asked to evaluate seriousness on a 10-points scale from 0 (harmless) to 10 (lethal) and the mean score across all judges was used as an index of seriousness. Categorization of clinical significance was taken from the literature: a score of <3 was considered a minor DRP, a score between 3 and 7 was a moderate DRP, and a score of more than 7 rated as a major DRP. We used the Kappa statistic to measure the inter-rater reliability of the committee members. The internal consistency between the judges in this study was good (kappa value = 0.74).
Data management and analysis
Data obtained were firstly coded and entered into an Excel sheet for management and then into the Statistical Package for Social Science (SPSS) software Version 26 for analysis. Statistical significance was considered at p-value<0.05 (with a confidence limit at 95%). Descriptive data are demonstrated as frquency (n) and percentages (%).
Statistical tests of data, such as Chi-Square, multivariable logistic regression, inter-rater reliability, and multi-collinearity test were conducted using SPSS V26. A P value of less than .05 was considered statistically significant. Descriptive data are demonstrated as percentages (%), while regression findings are presented as odds ratio (OR).
Results
Of the 1127 patients included in this study (Table 2), 292 (25.9%) had 596 DRPs, more than half of them were females (56.5%), and the mean age was 2.3 years. The overall incidence of DRPs was 6.6%. The highest rate of DRPs 15.2% was detected in the PICU. Of the 596 DRPs detected, 10.2% were inappropriate drug choice, 5.2% were rated major DRPs, and more than one-third 33.2% were related to the digestive system and metabolism (Table 3). This resulted in 596 pharmacist interventions, of which 33.7% were dose adjustment and 81.0% were accepted (Table 4). Three significant predictors were identified for acceptance of pharmacist interventions; telephone-delivered interventions [OR: 1.72: 95%CI: 0.78-2.57: P = .001], too high dose [OR: 2.64: 95%CI: 1.33-4.56: P = .01], and major DRPs [OR: 3.21: 95%CI: 2.15-6.42: P = .04].
Table 2.
Characteristics of Patients and Rates of DRPs.
| Code | Items | PED | NICU | PICU | Total |
|---|---|---|---|---|---|
| A | No. of patients admitted | 817 | 235 | 75 | 1127 |
| B | No. of prescriptions | 1835 | 797 | 369 | 3001 |
| C | No. of medication orders prescribed | 4863 | 3165 | 952 | 8980 |
| D | No. of patients with DRPs | 128 (43.8%) | 101 (34.6%) | 63 (21.6) | 292 (100.0%) |
| E | No. of DRPs | 236 (39.6%) | 215 (36.1%) | 145 (24.3%) | 596 (100.0%) |
| F | Incidence of DRPs [F = E/C × 100] | 4.9% | 6.8% | 15.2% | 6.6% |
| G | DRPs per patient [G = E/A] | 0.3 | 0.9 | 1.9 | 0.5 |
| H | DRPs per prescription [H = E/B] | 0.1 | 0.3 | 0.4 | 0.2 |
| J | Medication order per patient [J = C/A] | 5.9 | 13.5 | 12.7 | 8.0 |
| K | No. of females with DRPs | 74 (57.8%) | 67 (66.3%) | 24 (38.1%) | 165 (56.5%) |
| L | Median age [min-max] years | 4.3 y [0 d-18 y] | 12 d [0-21 d] | 2.6 y [3 d-18 y] | 2.3 y [0-18 y] |
| M | Median weight [min-max] kilogram | 10.5 kg [3.3-67] | 4.1 kg [3.5-4.9] | 7.8 kg [3.4-66] | 7.5 kg [3.3-67] |
| N | Length of stay (days) | 1.4 d [1-5] | 23 d [8-64] | 18 d [6-43] | 14.1 d [1-64] |
Note. DRP = drug-related problem; PED = pediatric emergency department; PICU = pediatric intensive care unit; NICU = neonatal intensive care unit.
Table 3.
Drug-Related-Problems Identified (n = 596).
| PED n(%) | NICU n(%) | PICU n(%) | Total n(%) | |
|---|---|---|---|---|
| Types of DRPs | ||||
| Missing drug | 22 (9.3) | 19 (8.8) | 11 (7.6) | 52 (8.7) |
| Unnecessary drug | 24 (10.2) | 14 (6.5) | 9 (6.2) | 47 (7.9) |
| Inappropriate drug choice | 36 (15.3) | 13 (6.0) | 12 (8.3) | 61 (10.2) |
| Too high dose | 27 (11.4) | 43 (20.0) | 29 (20.0) | 99 (16.6) |
| Too low dose | 18 (7.6) | 9 (4.2) | 6 (4.1) | 33 (5.5) |
| Sub-optimal dosing | 11 (4.7) | 8 (3.7) | 3 (2.1) | 22 (3.7) |
| Sub-optimal formulation | 9 (3.8) | 5 (2.3) | 5 (3.44) | 19 (3.2) |
| Adverse drug reaction (ADR) | 13 (5.5) | 29 (13.5) | 22 (15.2) | 64 (10.7) |
| Drug-drug interaction | 21 (8.9) | 41 (19.1) | 11 (7.6) | 73 (12.2) |
| Inappropriate drug use (drugs administered by health personnel) | 16 (6.8) | 11 (5.11) | 19 (13.1) | 46 (7.7) |
| Inappropriate drug use (drugs administered by the patient/family) | 29 (12.3) | 9 (4.2) | 0 (0.0) | 38 (6.4) |
| Need for/lack of monitoring of effect and toxicity of drugs | 4 (1.7) | 13 (6.0) | 14 (9.7) | 31 (5.2) |
| Lack of or unclear documentation of the drug chart/prescription | 6 (2.5) | 0 (0.0) | 3 (2.1) | 9 (1.5) |
| Others | 0 (0.0) | 1 (0.5) | 1 (0.7) | 2 (0.3) |
| Clinical severity of DRPs | ||||
| Minor | 149 (63.1) | 172 (80.0) | 99 (68.3) | 420 (70.5) |
| Moderate | 71 (30.1) | 36 (16.7) | 38 (26.2) | 145 (24.3) |
| Major | 16 (6.8) | 7 (3.3) | 8 (5.5) | 31 (5.2) |
| ATC classification | ||||
| Digestive system and metabolism | 64 (27.1) | 73 (34.0) | 61 (42.1) | 198 (33.2) |
| Cardiovascular system | 29 (12.3) | 43 (20.0) | 26 (17.9) | 98 (16.4) |
| Anti-infective | 73 (30.9) | 56 (26.0) | 36 (24.8) | 165 (27.7) |
| Nervous system | 8 (3.4) | 23 (10.7) | 7 (4.8) | 38 (6.4) |
| Miscellaneous | 62 (26.3) | 20 (9.3) | 15 (10.3) | 97 (16.3) |
| Route of administration | ||||
| Parenteral | 187 (79.2) | 196 (91.2) | 136 (93.8) | 519 (87.1) |
| Oral | 37 (15.7) | 12 (5.6) | 0 (0.0) | 49 (8.2) |
| Other | 12 (5.1) | 7 (3.3) | 9 (6.2) | 28 (4.7) |
Note. ATC = anatomical therapeutic chemical; DRP = drug-related problem; NA = not-applicable; PED = pediatric emergency department; PICU = pediatric intensive care unit; NICU = neonatal intensive care unit.
Table 4.
Pharmacist Interventions (n = 596).
| PED (%) | NICU (%) | PICU (%) | Total (%) | |
|---|---|---|---|---|
| Types of interventions carried out | ||||
| Drug discontinuation | 64 (27.1) | 14 (6.5) | 9 (6.2) | 87 (14.6) |
| Addition of new drug | 23 (9.7) | 19 (8.8) | 11 (7.6) | 53 (8.9) |
| Dose adjustment | 73 (30.9) | 86 (40) | 42 (29.0) | 201 (33.7) |
| Drug switch | 34 (14.4) | 53 (24.7) | 63 (43.4) | 150 (25.2) |
| Route of administration change | 23 (9.7) | 7 (3.3) | 8 (5.5) | 38 (6.4) |
| Drug monitoring | 19 (8.1) | 36 (16.7) | 12 (8.3) | 67 (11.2) |
| Intervention outcomes | ||||
| Accepted without modifications | 61 (25.8) | 55 (25.6) | 32 (22.1) | 148 (24.8) |
| Accepted with modifications | 112 (47.5) | 123 (57.2) | 83 (57.2) | 318 (53.4) |
| Refused | 52 (22.0) | 31 (14.4) | 26 (17.9) | 109 (18.3) |
| Not applicable data | 11 (4.7) | 6 (2.8) | 4 (2.8) | 21 (3.52) |
| Rate of acceptance (among applicable) | 173 (76.9) | 178 (85.2) | 115 (81.6) | 466 (81.0) |
| Intervention respondent N (%) | ||||
| Physician | 193 (54.5) | 133 (52.2) | 99 (68.3) | 425 (52.8) |
| Nurse | 96 (27.1) | 85 (33.3) | 65 (44.8) | 246 (30.6) |
| Intern | 54 (15.3) | 34 (13.3) | 32 (22.0) | 120 (14.9) |
| Patient/patient family | 11 (3.1) | 3 (1.2) | 0 (0.0) | 14 (1.7) |
| Modes of carrying out the intervention N (%) | ||||
| Verbal | 69 (29.2) | 47 (21.9) | 35 (24.1) | 151 (16.8) |
| Telephone | 141 (59.7) | 117 (54.4) | 86 (59.3) | 344 (51.0) |
| Note in patient chart | 23 (9.7) | 29 (13.5) | 13 (8.9) | 65 (10.9) |
| 0 (0.0) | 14 (6.5) | 4 (2.8) | 18 (3.0) | |
| Social media (ie, WhatsApp) | 3 (1.3) | 8 (3.7) | 7 (15.6) | 18 (3.0) |
Note. DRP = drug-related problem; PED = pediatric emergency department; PICU = pediatric intensive care unit; NICU = neonatal intensive care unit.
There was a significant difference in the nature of identified DRPs across pediatric wards. Inappropriate drug choice 15.3%, too high dose 11.4%, and unnecessary prescribed drug 10.2% were the most common DRPs in the pediatric emergency department (ED). While drug interaction and adverse drug reaction accounted for 19.1% and 13.5% of DRPs in the neonatal ICU, respectively. In the pediatric ICU, inappropriate drug use (wrong administration) accounted for 13.1% of DRPs. Interestingly, identified DRPs in the pediatric ED were more clinically serious compared to those identified in other wards. There were no significant differences in anatomical therapeutic chemical (ATC) classification and route of administration across pediatric wards.
While all wards seemed to have high rates of dose adjustment intervention, drug discontinuation, drug monitoring, and drug switch have shown to be significantly higher in pediatric ED, neonatal ICU, and pediatric ICU, respectively. The intervention outcomes were similar across the pediatric wards, with the pediatric ED 76.9% has the lowest acceptance rate. Across the included pediatric wards, the majority of intervention respondents were physicians 52.8% and nurses 30.6%. While most of the interventions were delivered verbally 51.0% or by telephone 16.8%, several interventions were conducted using social media applications, such as WhatsApp 3.0%.
Discussion
The value of this study is praiseworthy due to the number of the sample included, period of the study, the operational definitions adopted, and the outcomes (DRPs incidence, nature, severity, and pharmacist interventions). Apart from the study by Sonia Prot-Labarthe et al. 6 with 270 patients followed and 996 DRPs identified in 4 different pediatric wards across Europe. Other pediatric studies document only fragments of data with ambiguous data collection methods.9,18,19
The sophisticated definitions of DRPs used in this study, including both prescriber and patient faults may well have contributed to the high DRPs incidence 6.6% in our study. Additionally, the research team in this study was properly trained on direct prospective observation of DRPs; this may be an indirect reason for the high incidence of DRPs in our study compared to the literature that adopted staff-reported DRP forms, questionnaires, or personal notes for documenting DRPs. This may lead to poor-quality documentation due to missing data. Thus, they cannot demonstrate a reliable rate of DRPs, because the methods used in these studies are subjected to biased behaviors leading to under estimation of DRPs.
The highest rate of DRPs was reported in pediatric ICU 15.2%, then neonatal ICU 6.8% and pediatric ED 4.9%. This wide variation in rates of DRPs could be attributed to different pathologies, length of stay periods, and the low number of pharmacists in pediatric ICU compared to other wards, Furthermore, many of the DRPs in pediatric ICU were identified based on verbal medical orders, rather than written or electronically prescribed medication orders. A previous systemic review study suggested a higher rate of drug-related errors in the pediatric ICU compared to the neonatal ICU. 20 In Saudi Arabia, many DRPs were found clinically serious. 11 Further, it was found that pharmacists can reduce DRPs in Saudi hospitals. 12 Further research investigating the impact of pharmacist presence on the rate of DRPs in pediatric ICU is endorsed.
Overall, dosing DRPs were the most predominant incidents reported across the included pediatric wards. Then, inappropriate drug choice, drug-drug interaction, and adverse drug reaction DRPs made up more than one-thirds of the DRPs detected at the 3 wards. Consequently, the most frequent pharmacist interventions were “dosing adjustment,” “drug switch,” and “drug discontinuation.” These findings are consistent with previous a previous study conducted in pediatric wards and emergency departments.14,21,22 Failure in the treatment could be the outcome of sup-optimal dosing or toxicity due to high dosing, both of which could lead to increased mortality. One of the plausible explanations for this finding is that the dosing process for pediatric patients requires fractional dosing, weight-based dosing calculations, and decimal use. This might confuse physicians, pharmacists, and nurses as well. Thus, we believe that this is an important topic requiring further investigation. Interestingly, we found a higher rate of inappropriate drug choice in pediatric ED compared to other wards. Overcrowding, lack of knowledge and inexperience staff might have caused the high rate of inappropriate drug choice in the ED.
Higher proportions of moderate and major DRPs were found in paediatric ED compared to other wards. Similar findings were seen in many studies reported DRPs and medication errors in emergency departments.23-25 The etiology of these DRPs in the ED is multifactorial; 26 (1) absence of pharmacist double checks on medication orders, (2) high rate of verbal orders, (3) emergent nature of services provided, (4) overcrowding, and (5) understaffing of personnel. Furthermore, The Institute of Medicine (IOM) has suggested that this is significantly due to the lack of experience among the staff members working in EDs on the needs of pediatrics and that there is a scarcity of clinical information available on the medication safety of paediatrics. 27 Digestive system and metabolism, and anti-infective were the most common ATC classes documented in our study. This is consistent with previous studies carried out in pediatric settings.6,28 This may orientate pharmacists to analyze prescriptions and common DRPs-related pathologies.
A high rate of acceptance for pharmacist interventions was recorded in our study and significant predictors for acceptance of pharmacist interventions were; interventions delivered by phone, major DRPs, and too high dose DRPs. 29 Our findings regarding the rate of acceptance was partially consistent with a previous multicentric study conducted in France. 30 In contrast to our findings, Bedouch et al. found a considerable association between acceptance of interventions and specific therapeutic drug classes. 29 Respondents were more likely to accept pharmacist interventions when they delivered via telephone, because this way preserves privacy and avoids embarrassment in front of colleagues, especially for junior doctors and nurses.
Limitations
This study has several limitations. First, we could not be able to completely avoid the impact of Hawthorn effect on our findings, because it was impractical to disguise the purposes of the study, because the news about the research preceded the data collection. Second, we were unable to measure the effect of missing data on the study’s findings. Third, the study was conducted in a single hospital. Thus, the results may be difficult to generalize to other hospitals, particularly those where different electronic systems and tools are operated, and where the pharmacists have been more integrated in clinical duties. Fourth, the present study contains no information on the characteristics of prescribers and pharmacists. A previous study reported a significant association between physician’s status (resident vs specialist) and acceptance. 31 In addition, the research team could not determine whether an intervention was proposed to the initial responsible for the DRP or to another respondent.
Nevertheless, this study demonstrates high-quality evidence of the frequency, nature, and clinical significance of DRPs across 3 pediatric settings. Furthermore, it utilizes valid and holistic operational definitions and assessment techniques. This can be used as a national reference to improve understandability of DRPs in pediatric settings and to implement corrective actions, such as clinical decision support system (CDSS), educational interventions, and workshops to improve cooperation between healthcare professionals.
Conclusion
DRPs are common in pediatric wards in Saudi Arabia. A high proportion of DRPs detected in pediatric ED were clinically major and moderate. A national approach should be implemented to improve pharmacist interventions and to enhance interprofessional collaborative clinical practice in pediatrics.
Acknowledgments
We would like to thank pharmacists, nurses and physicians in the central hospital of Jazan region for their collaboration in this research.
Footnotes
Author Contributions: MHA and MMT contributed to the study conceptualization and design. All authors contributed in developing and piloting the study tool. MMT, MAT, MAN, and MHM collected data and made the interventions. Data analysis was performed by MHA and all authors contributed in the intrpretation. All authors participated in drafting and reviewing the manuscript. MHA and MMT approved the final manuscript.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval: The study was approved by the IRB Centre of King Fahd Central Hospital.
Consent to Participate: All participants gave a verbal consent form showing their willingness to participate.
ORCID iD: Mohammed H. Abutaleb 
https://orcid.org/0000-0002-5300-5900
Data Availability: Data are available upon reasonable request from the corresponding author.
References
- 1. Krähenbühl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J, Krähenbühl S. Drug-related problems in hospitals: a review of the recent literature. Drug Saf. 2007;30(5):379-407. [DOI] [PubMed] [Google Scholar]
- 2. Abdel-Qader DH, Ismael NS, Al Meslamani AZ, et al. The role of clinical pharmacy in preventing prescribing errors in the emergency department of a governmental hospital in Jordan: a pre-post study. Hosp Pharm. Published online July 25, 2020. doi: 10.1177/0018578720942231 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Wong ICK, Ghaleb MA, Franklin BD, Barber N. Incidence and nature of dosing errors in paediatric medications: a systematic review. Drug Saf. 2004;27(9):661-670. [DOI] [PubMed] [Google Scholar]
- 4. Ghaleb MA, Barber N, Dean Franklin B, Wong ICK. What constitutes a prescribing error in paediatrics? Qual Saf Health Care. 2005;14(5):352-357. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Egunsola O, Ali S, Al-Dossari DS, Alnajrani RH. A Retrospective Study of Pediatric Medication Errors in Saudi Arabia. Hosp Pharm. Published online October 16, 2019. doi:10.1177/0018578719882318 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Prot-Labarthe S, Di Paolo ER, Lavoie A, et al. Pediatric drug-related problems: a multicenter study in four French-speaking countries. Int J Clin Pharm. 2013;35(2):251-259. [DOI] [PubMed] [Google Scholar]
- 7. Wang JK, Herzog NS, Kaushal R, Park C, Mochizuki C, Weingarten SR. Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry. Pediatrics. 2007;119(1):e77-e85. [DOI] [PubMed] [Google Scholar]
- 8. Krupicka MI, Bratton SL, Sonnenthal K, Goldstein B. Impact of a pediatric clinical pharmacist in the pediatric intensive care unit. Crit Care Med. 2002;30(4):919-921. [DOI] [PubMed] [Google Scholar]
- 9. Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Unit-based clinical pharmacists’ prevention of serious medication errors in pediatric inpatients. Am J Heal Pharm. 2008;65(13):1254-1260. [DOI] [PubMed] [Google Scholar]
- 10. Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111(4):722-729. [DOI] [PubMed] [Google Scholar]
- 11. Alomi Y, Al-Shaibani A, Alfaisal G, Alasmi N. Clinical outcomes of drug-related problems in Saudi Arabia: patients’ and healthcare providers’ perspective. J Pharm Pract Community Med. 2018;4:77-82. [Google Scholar]
- 12. Babelghaith SD, Wajid S, Alrabiah Z, et al. Drug-related problems and pharmacist intervention at a general hospital in the Jazan region, Saudi Arabia. Risk Manag Healthc Policy. 2020;13:373-378. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Al-Arifi M, Abu-Hashem H, Al-Meziny M, Said R, Aljadhey H. Emergency department visits and admissions due to drug related problems at Riyadh military hospital (RMH), Saudi Arabia. Saudi Pharm J. 2014;22(1):17–25. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Rashed AN, Neubert A, Tomlin S, et al. Epidemiology and potential associated risk factors of drug-related problems in hospitalised children in the United Kingdom and Saudi Arabia. Eur J Clin Pharmacol. 2012;68:1657-1666. doi: 10.1007/s00228-012-1302-x [DOI] [PubMed] [Google Scholar]
- 15. Rashed AN, Wilton L, Lo CCH, Kwong BYS, Leung S, Wong ICK. Epidemiology and potential risk factors of drug-related problems in Hong Kong paediatric wards. Br J Clin Pharmacol. 2014;77(5):873-879. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Lampert ML, Kraehenbuehl S, Hug BL. Drug-related problems: evaluation of a classification system in the daily practice of a Swiss University Hospital. Pharm World Sci. 2008;30(6):768-776. [DOI] [PubMed] [Google Scholar]
- 17. Knudsen P, Herborg H, Mortensen AR, Knudsen M, Hellebek A. Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. Qual Saf Health Care. 2007;16(4):291-296. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Moffett BS, Mott AR, Nelson DP, Gurwitch KD. Medication dosing and renal insufficiency in a pediatric cardiac intensive care unit: impact of pharmacist consultation. Pediatr Cardiol. 2008;29(4):744-748. [DOI] [PubMed] [Google Scholar]
- 19. Sanghera N, Chan P-Y, Khaki ZF, et al. Interventions of hospital pharmacists in improving drug therapy in children: a systematic literature review. Drug Saf. 2006;29(11):1031-1047. [DOI] [PubMed] [Google Scholar]
- 20. Alghamdi AA, Keers RN, Sutherland A, Ashcroft DM. Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review. Drug Saf. 2019;42(12):1423-1436. doi: 10.1007/s40264-019-00856-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Prot-Labarthe S, Lavoie A, Bourdon O, et al. Pilot study about pharmaceutical care implantation in a general paediatric unit in a French hospital. France-Québec collaboration and comparison. Arch Pediatr. 2007;14(4):345-353. [DOI] [PubMed] [Google Scholar]
- 22. Birarra MK, Heye TB, Shibeshi W. Assessment of drug-related problems in pediatric ward of Zewditu Memorial Referral Hospital, Addis Ababa, Ethiopia. Int J Clin Pharm. 2017;39(5):1039-1046. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Abdel-Qader DH, Al Meslamani AZ, El-Shara’ AA, et al. Investigating prescribing errors in the emergency department of a large governmental hospital in Jordan. J Pharm Heal Serv Res. 2020;11(4):375-382. [Google Scholar]
- 24. Ibrahim OM, Ibrahim RM, Meslamani AZ Al, Mazrouei N Al. Role of telepharmacy in pharmacist counselling to coronavirus disease 2019 patients and medication dispensing errors. J Telemed Telecare. Published online October 15, 2020. doi:10.1177/1357633X20964347 [DOI] [PubMed] [Google Scholar]
- 25. Fordyce J, Blank F, Pekow P, et al. Errors in a busy emergency department. Ann Emerg Med. 2003;42:324-333. [DOI] [PubMed] [Google Scholar]
- 26. Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med. 2014;6:45-55. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Davies F. Emergency care for children: growing pains. Emerg Med J. 2009;26(3):231. Accessed October 16, 2020. https://emj.bmj.com/content/26/3/231 (accessed October 16, 2020). [Google Scholar]
- 28. Chisholm MA, Pittman DG, Longley JM, Mullis SR. Implementation of pharmaceutical care in acute medical cardiovascular patients. Hosp Pharm. 1995;30(7):572-574, 577-578. [PubMed] [Google Scholar]
- 29. Bedouch P, Sylvoz N, Charpiat B, et al. Trends in pharmacists’ medication order review in French hospitals from 2006 to 2009: analysis of pharmacists’ interventions from the Act-IP© website observatory. J Clin Pharm Ther. 2015;40(1):32-40. [DOI] [PubMed] [Google Scholar]
- 30. Zaal RJ, den Haak EW, Andrinopoulou ER, van Gelder T, Vulto AG, van den Bemt PMLA. Physicians’ acceptance of pharmacists’ interventions in daily hospital practice. Int J Clin Pharm. 2020;42(1):141-149. doi: 10.1007/s11096-020-00970-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Bedouch P, Tessier A, Baudrant M, et al. Computerized physician order entry system combined with on-ward pharmacist: analysis of pharmacists’ interventions. J Eval Clin Pract. 2012;18(4):911-918. [DOI] [PubMed] [Google Scholar]