David Terry

Solid oral forms availability in children: a cost saving investigation

AIM To assess the suitability and potential cost savings, from both the hospital and community perspective, of prescribed oral liquid medicine substitution with acceptable solid forms for children over 2 years. METHOD Oral liquid medicines dispensed from a paediatric hospital (UK) in 1 week were assessed by screening for existence of the solid form alternative and evaluating the acceptability of the available solid form, firstly related to the prescribed dose and secondly to acceptable size depending on the childs age. Costs were calculated based on providing treatment for 28 days or prescribed duration for short term treatments. RESULTS Over 90% (440/476) of liquid formulations were available as a marketed solid form. Considering dosage acceptability (maximum of 10% deviation from prescribed dosage or 0% for narrow therapeutic range drugs, maximum tablet divisions into quarters) 80% of liquids could be substituted with a solid form. The main limitation for liquid substitution would be solid form size. However, two-thirds of prescribed liquids could have been substituted with a suitable solid form for dosage and size, with estimated savings being of £5K and £8K in 1 week, respectively based on hospital and community costs, corresponding to a projected annual saving of £238K and £410K (single institution). CONCLUSION Whilst not all children over 2 years will be able to swallow tablets, drug cost savings if oral liquid formulations were substituted with suitable solid dosage forms would be considerable. Given the numerous advantages of solid forms compared with liquids, this study may provide a theoretical basis for investing in supporting children to swallow tablets/capsules.

Clinical significance of medication reconciliation in children admitted to a UK pediatric hospital: observational study of neurosurgical patients.

BackgroundIn December 2007, the National Institute for Health and Clinical Excellence and the National Patient Safety Agency in the UK (NICE-NPSA) published guidance that recommends all adults admitted to hospital receive medication reconciliation, usually by pharmacy staff. A costing and report tool was provided indicating a resource requirement of £12.9 million for England per year. Pediatric patients are excluded from this guidance.ObjectiveTo determine the clinical significance of medication reconciliation in children on admission to hospital.MethodsA prospective observational study included pediatric patients admitted to a neurosurgical ward at Birmingham Children’s Hospital, Birmingham, England, between September 2006 and March 2007. Medication reconciliation was conducted by a pharmacist after the admission of each of 100 consecutive eligible patients aged 4 months to 16 years. The clinical significance of prescribing disparities between pre-admission medications and initial admission medication orders was determined by an expert multidisciplinary panel and quantified using an analog scale. The main outcome measure was the clinical significance of unintentional variations between hospital admission medication orders and physician-prescribed pre-admission medication for repeat (continuing) medications.ResultsInitial admission medication orders for children differed from prescribed pre-admission medication in 39% of cases. Half of all resulting prescribing variations in this setting had the potential to cause moderate or severe discomfort or clinical deterioration. These results mirror findings for adults.ConclusionsThe introduction of medication reconciliation in children on admission to hospital has the potential to reduce discomfort or clinical deterioration by reducing unintentional changes to repeat prescribed medication. Consequently, there is no justification for the omission of children from the NICE-NPSA guidance concerning medication reconciliation in hospitals, and costing tools should include pediatric patients.

An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital

Aims To determine the incidence of unintended medication discrepancies in paediatric patients at the time of hospital admission; evaluate the process of medicines reconciliation; assess the benefit of medicines reconciliation in preventing clinical harm. Method A 5 month prospective multisite study. Pharmacists at four English hospitals conducted admission medicines reconciliation in children using a standardised data collection form. A discrepancy was defined as a difference between the patients preadmission medication (PAM), compared with the initial admission medication orders written by the hospital doctor. The discrepancies were classified into intentional and unintentional discrepancies. The unintentional discrepancies were assessed for potential clinical harm by a team of healthcare professionals, which included doctors, pharmacists and nurses. Results Medicines reconciliation was conducted in 244 children admitted to hospital. 45% (109/244) of the children had at least one unintentional medication discrepancy between the PAM and admission medication order. The overall results indicated that 32% (78/244) of patients had at least one clinically significant unintentional medication discrepancy with potential to cause moderate 20% (50/244) or severe 11% (28/244) harm. No single source of information provided all the relevant details of a patients medication history. Parents/carers provided the most accurate details of a patients medication history in 81% of cases. Conclusions This study demonstrates that in the absence of medicines reconciliation, children admitted to hospitals across England are at risk of harm from unintended medication discrepancies at the transition of care from the community to hospital. No single source of information provided a reliable medication history.

Parents and carers of patients who had liver transplants: opinions and experiences of medication issues

Purpose Birmingham Childrens Hospital in the UK provides family centred care for post-transplant medication (PTM) management. Nevertheless, PTM is often considered a burden for patients, and can be difficult to manage. This study was designed to identify the main medication issues encountered by children and their parents in order to find suitable means to improve their care management. Method Anonymised multifactorial, cross-sectional, single-site survey. Parents of children transplanted from January 2011 were recruited following two strategies: (1) self-completion of questionnaire at the outpatient department over a period of 4 weeks during May 2013, (2) telephone completion by random selection of 30 parents. Results were analysed using MS Excel 2010. Results 37 parents were recruited. Medication supply problems concerned 12 (32.4%) parents. 30 (81.1%) parents declared having almost run out of medicines, but no children missed an immunosuppressant dose. 9 (24.3%) parents experienced medication-administration problems, and 14 (37.8%) blood test issues. 14 (37.8%) parents felt they had an inadequate knowledge of side effects. However, 30 (81.1%) parents thought that their training was excellent or very good, and 36 (97.5%) that the written information provided was comprehensible and accurate. Among proposed improvements, parents’ preferences were for an online learning tool (OLT), an explanatory comic book (CB) for children and pharmaceutical consultations (PC). Conclusions To our knowledge, this study is the most comprehensive published audit concerning the care process of PTM. Although parents seemed particularly satisfied by the current training and written information, many experienced issues linked to PTM management. Based on parents’ preferences, a working party is currently considering service development options (OLT, CB, PC).

Prescribing for children at the interfaces of care

Prescribing for children at the primary–secondary/tertiary care interface is more complex than that for adults. Children often need unlicensed medicines and there may be issues over who will prescribe such items. There may also be issues in obtaining unlicensed medicines (specials) from community pharmacists. This article reviews the current arrangements in England relating to prescribing for children at the interfaces of care and describes the following: prescribing responsibility, shared-care arrangements, medication continuity on admission and discharge from hospital, unlicensed medicines, continuing-care medication arrangements and highlights potential service changes to maintain access to medicines for children.

Children/young people taking long-term medication: a survey of community pharmacists' experiences in England

To determine whether community pharmacists undertake medication reviews with children/their carers and to identify the type of medication‐related experiences presented to them when a child is taking long‐term medication.

Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors

Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation’s ‘black box’ principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.

Dosage form preference consultation study in children and young adults: paving the way for patient-centred and patient-informed dosage form development

Objectives The current study aims to evaluate dosage form preferences in children and young adults together with identifying the key pragmatic dosage form characteristics that would enable appropriate formulation of orally disintegrating tablets (ODTs). Methods International, multisite, cross-sectional questionnaire of children and young adults aged from 6 to 18 years. Eligibility was based on age, ability to communicate and previous experience in taking medications. The study was carried out at three locations: the UK, Saudi Arabia and Jordan. The questionnaire instrument was designed for participant self-completion under supervision of the study team. Results 104 questionnaires were completed by the study cohort (n=120, response rate 87%). Results showed that ODTs were the most preferred oral dosage forms (58%) followed by liquids (20%), tablets (12%) and capsules (11%). The preferred colours were pink or white while the preferred size was small (<8 mm) with a round shape. With regard to flavour, strawberry was the most preferred (30.8%), while orange was the least preferred (5.8%). The results also showed that the most important physical characteristics of ODTs were disintegration time followed by taste, size and flavour, respectively. Conclusions The results of our study support the WHO’s claim for a shift of paradigm from liquid towards ODTs dosage forms for drug administration to young children older than 6 years. Data from this study will also equip formulators to prioritise development of key physical/performance attributes within the delivery system.

MEDICATION REVIEW OF CHILDREN ON LONG TERM MEDICATIONS: A REVIEW OF THE LITERATURE

Introduction Children on long term medication may be under the care of more than one medical team including the patients GP. Children on chronic medication should be supported and their medications reviewed, especially in cases of polypharmacy. Medicines Use Reviews (MURs) were introduced into the pharmacy contract in 2005. The service was designed for community pharmacists to review patients on long term medication. The service specified that MURs were done on patients who can give consent and cannot be conducted with a parent or carer. Hence the service may be inaccessible to paediatric patients. This review aims to find studies that identify medication review services in primary care that cater for children on long term medication. Methods A literature search was conducted on 6th June 2015 using the keywords, (“Medication” or “review” or “Medication Review” or “Medicines use review” or “Medication use review” or “New Medicine Service”) AND (“community pharmacy” OR “community pharmacist” OR “primary care” OR “General practice” OR “GP” OR “community paediatrician” OR “community pediatrician” OR “community nurse”). Bibliographic databases used were AMED, British Nursing Index, CINAHL, EMBASE, HMIC, MEDLINE, PsycINFO and Health Business Elite. Inclusion criteria were: paediatric specific medication review in primary care, for example by either a GP, community paediatrician, community nurse or community pharmacist. Exclusion criteria were studies of medication review in adults/unclear patient age and secondary care medication reviews. Results From the 417 articles, 6 relevant articles were found after abstract and full text review. 235 articles were excluded after title and abstract review (11 did not have full text in English); 96 were adult or non-age specified medication review/MUR/New Medicine Service studies; 63 referred to observational, evaluative studies of interventions in adults; 6 were non-paediatric specific systematic reviews and 17 were protocols, commentaries, news, and letters. The 6 relevant articles consisted of 1 literature review (published 2004), 3 research articles and 1 published protocol. The literature review[1] recommended that childrens long term medication should be reviewed. The published protocol stated that the NMS minimum age for inclusion in the trial was for children aged over 13 years of age. The four studies were related to psychiatrists reviewing paediatric mental health patients in the USA, a pharmacist using Drug Related Problem to review patients in GP practices in Australia, a UK study based on an information prescription concept by providing children dispensed medications in community pharmacy with signposting them to health information and one GP practice based study observing pharmaceutical care issues in children and adults. Conclusion The results show that there are currently no known studies on medication use reviews specific to children, whereas in adults, published evaluations are available. The terms of the MUR policy restrict childrens access to the service and so more studies are necessary to determine whether children could benefit from such access.

The potential for pharmacists to manage children attending emergency departments

Aim There have been concerns about maintaining appropriate clinical staff levels in Emergency Departments in England.1 The aim of this study was to determine if Emergency Department attendees aged from 0–16 years could be managed by community pharmacists or hospital independent prescriber pharmacists with or without further advanced clinical practice training. Method A prospective, 48 site, cross-sectional, observational study of patients attending Emergency Departments (ED) in England, UK was conducted. Pharmacists at each site collected up to 400 admissions and paediatric patients were included in the data collection. The pharmacist independent prescribers (one for each site) were asked to identify patient attendance at their Emergency Department, record anonymised details of the cases—age, weight, presenting complaint, clinical grouping (e.g. medicine, orthopaedics), and categorise each presentation into one of four possible categories: CP, Community Pharmacist, cases which could be managed by a community pharmacist outside an ED setting; IP—cases that could be managed at ED by a hospital pharmacist with independent prescriber status; IPT, Independent Prescriber Pharmacist with additional training—cases which could be managed at ED by a hospital pharmacist independent prescriber with additional clinical training; and MT, Medical Team only—cases that were unsuitable for the pharmacist to manage. An Impact Index was calculated for the two most frequent clinical groupings using the formula: Impact index=percentage of the total workload of the clinical grouping multiplied by the percentage ability of pharmacists to manage that clinical group. Results 1623 out of 18,229 (9%) attendees, from 45 of the 48 sites, were children aged from 0 to 16 years of age (median 8 yrs, range 0–16), 749 were female and 874 were male. Of the 1623 admissions, 9% of the cases were judged to be suitable for clinical management by a community pharmacist (CP), 4% suitable for a hospital pharmacist independent prescriber (IP), 32% suitable for a hospital independent pharmacist prescriber with additional training (IPT); and the remaining 55% were only suitable for the Medical Team (MT). The most frequent clinical groups and impact index for the attendees were General Medicine=10.78 and orthopaedics=10.60. Conclusion Paediatric patients attending Emergency Departments were judged by pharmacists to be suitable for management outside a hospital setting in approximately 1 in 11 cases, and by hospital independent prescriber pharmacists in 4 in 10 cases. With further training, it was found that the total proportion of cases that could be managed by a pharmacist was 45%. The greatest impact for pharmacist management occurs in general medicine and orthopaedics.