Michelle Condren

Clinical Practice Guidelines From the Cystic Fibrosis Foundation for Preschoolers With Cystic Fibrosis

Cystic fibrosis (CF) clinical care guidelines exist for the care of infants up to age 2 years and for individuals ≥6 years of age. An important gap exists for preschool children between the ages of 2 and 5 years. This period marks a time of growth and development that is critical to achieve optimal nutritional status and maintain lung health. Given that disease often progresses in a clinically silent manner, objective and sensitive tools that detect and track early disease are important in this age group. Several challenges exist that may impede the delivery of care for these children, including adherence to therapies. A multidisciplinary committee was convened by the CF Foundation to develop comprehensive evidence-based and consensus recommendations for the care of preschool children, ages 2 to 5 years, with CF. This document includes recommendations in the following areas: routine surveillance for pulmonary disease, therapeutics, and nutritional and gastrointestinal care.

Prescribing Errors in a Pediatric Clinic

Objective: This project was completed to determine the frequency and type of prescribing errors occuring in a pediatric clinic. Study design: Records for all patient encounters in the pediatric acute care clinic from February through April 2007 were reviewed. Prescriptions entered into the electronic medical records (EMR) were reviewed the day after they were written. Results: A total of 3523 records containing 1802 new prescriptions were reviewed. Prescribing errors were found in 175 prescriptions (9.7%). The most common type of error was an incomplete prescription (42%), followed by dosing errors (34%). Anti-infectives were most commonly written in error followed by anti-inflammatories. Conclusions: Prescribing errors were commonly identified in a pediatric clinic utilizing electronic medical records. Incomplete prescriptions and dosing errors were the most commonly occurring errors. Recognizing the types of errors has been beneficial for developing educational programs intended to decrease prescribing errors and recommending improvements to the EMR system and its utilization.

Influence of a Systems-Based Approach to Prescribing Errors in a Pediatric Resident Clinic

OBJECTIVE To measure the difference in prescribing error rates between 2 clinics, 1 with a system in place to reduce errors and 1 with no such system; to determine variables that affect the likelihood of prescription errors. METHODS This was a retrospective study at 2 university-based general pediatric clinics utilizing the same electronic medical record (EMR) system. Clinic 1 employed pharmacists who provided daily prescription review, provider feedback and education, and EMR customization to decrease errors. Clinic 2 had no systems in place for reducing prescribing errors. Prescriptions written by resident physicians over 2 months were identified and reviewed. RESULTS A total of 1361 prescriptions were reviewed, 40.7% from clinic 1 and 59.3% from clinic 2. Errors were found in 201 prescriptions (14.8%). Clinics 1 and 2 had error rates of 11% and 17.5%, respectively (P = .0012). The odds of a prescription error at clinic 2 were 1.7 times the odds of a prescription error at clinic 1. Logistic regression identified clinic, nonpediatric resident, liquid dose forms, and younger patient age as significant predictors of prescription errors. Half of the errors could have been prevented with consistent use of a custom medication list within the EMR. CONCLUSIONS We found 37% fewer prescribing errors in a clinic with systems in place for prescribing error detection and prevention. Pediatric clinics should explore systematic procedures for identifying, resolving, and providing education about prescribing errors to reduce patient risk.

Evaluation of Oral Medication Delivery Devices Provided by Community Pharmacies

Oral liquids remain common medication dosage forms used for patients who have difficulty swallowing. However, liquids require a delivery device and thus have been linked to medication administration errors. This study identified medication delivery devices available at pharmacies. Delivery devices were obtained from area pharmacies and analyzed for units of measurement, abbreviations, and largest/smallest measurable volume. A total of 58 devices were collected from 22 pharmacies. All devices were marked with mL, and 79% were additionally marked in teaspoons. The 5-mL syringe was the only device dispensed at 14% of locations. Other devices included the dosing spoon, dropper, and cup. The largest measurable volume was 30 mL, whereas the smallest was 0.01 mL, with significant variability among devices. A more consistent approach in prescribing units of measurement is needed. Prescribing in milliliters is an optimal choice because of the accessibility of measuring devices containing this measurement.

Frequency of prescribing errors by medical residents in various training programs.

Objectives Medication errors are hazardous and costly. Children are at increased risk for medication errors because of weight-based dosing, limited FDA indications, and human calculation errors. The aim of this study is to determine the frequency and type of resident prescribing errors in a pediatric clinic and further compare error rates of residents in different training programs. Methods Resident prescription error data from a pediatric clinic was collected for 5 months. Upon detection of an error, residents were notified/given feedback regarding the type of error, ways to remedy errors, and future prevention methods. Data were categorized based on medication involved, error type, and resident training program. Results The review included 2941 prescriptions, with the overall resident prescribing error rate being 5.88%. The pediatric resident error rate was 4%. Family medicine, internal medicine, and medicine/pediatrics had error rates of 11%, 8%, and 7%, respectively. The prescribing error rate showed a statistically significant difference with pediatrics compared with family medicine, internal medicine, and medicine/pediatrics (P < 0.0005, P = 0.013, and P = 0.03, respectively). The most common medication error type was overdose, followed by unclear quantity. Among the medication classes, topical agents and antimicrobials were among the top prescribed. Conclusions Numerous types of medication errors occur in a pediatric clinic. Prescribing errors take place among all medical trainees; however, medication error rates in the pediatric population may vary among resident specialty. Identifying the cause of prescribing errors will allow institutions to create educational programs tailored for safe medication use in children as well as systemwide changes for error reduction.

Insulin Edema in a Patient With Cystic Fibrosis–Related Diabetes

Insulin edema is a rare complication of insulin therapy primarily seen with newly diagnosed or uncontrolled diabetes (1–3). Patients at risk are those who are beginning insulin treatment, underweight, or increasing their insulin dose either in the normal course of the disease or after diabetic ketoacidosis (1,4). The prevalence of insulin edema is unknown; a review of the literature revealed few case reports of insulin edema and no reports of insulin edema in a patient with cystic fibrosis–related diabetes (CFRD). This case report illustrates the effects of insulin edema in a 23-year-old female patient who was diagnosed with CFRD at the age of 16 years. The patient presented to the pediatric endocrine clinic at the age of 16 years with an HbA1c of 9.8%. She …

Communication Strategies for Empowering and Protecting Children

Communication with children and adolescents is an area that requires special attention. It is our job as health care professionals to ensure that the information being relayed is provided at a level that can be understood, to ensure patient safety as well as keep a child or adolescent engaged in their own medical care and decision making. This article discusses the importance of communication with children, adolescents, and their caregivers. It focuses on the overall importance of health literacy in communicating health care information to both caregivers and their children. Included are points to consider when communicating at different developmental stages, as well as strategies to help establish rapport. Lastly, the importance of technology and how it can help facilitate communication with this population is introduced.

Evaluation of Medication-related Self-care Skills in Patients With Cystic Fibrosis.

BACKGROUND: As the life expectancy of patients with cystic fibrosis (CF) increases, the focus on ensuring success with medication therapies is increasingly important. The ability of patients to autonomously manage medications and related therapies is poorly described in the literature. OBJECTIVE: The goal of this project was to assess the level of medication-related knowledge and self-care skills in patients with CF. METHODS: This project took place in a Cystic Fibrosis Foundation accredited affiliate center. Eighty-nine patients between the ages of 6 and 60 were eligible to participate based on inclusion and exclusion criteria. Pharmacists administered a 16-item questionnaire and detailed medication history during clinic visits from January through May 2014. RESULTS: Forty-five patients 6 to 41 years old participated in the study. The skills most often performed independently were preparing nebulizer treatments (85%) and telling someone if they feel their medicines are causing a problem (89%). Skills least often performed were carrying a medication list (82%) and bringing a medication list to appointments (76%). In respondents 21 years of age and older, less than 75% of respondents were involved with obtaining financial resources, maintaining equipment, carrying a medication list, or rinsing their mouth after using inhaled medicines. Participants were able to provide drug name, dose, and frequency of use for pancreatic enzymes and azithromycin 37% and 24% of the time, respectively. CONCLUSIONS: In the population surveyed, many medication-related skills had not been acquired by early adulthood. Assessing and providing education for medication-related self-care skills at all ages are needed.

Appropriateness of oral medication delivery devices available in community pharmacies

OBJECTIVES To identify the proportion of prescribed liquid medications that can be properly administered with devices available at local community pharmacies. METHODS Prescriptions written over a 2-month time frame in a pediatric clinic were analyzed and compared with measuring devices available at community pharmacies within a 5-mile radius. Devices from the pharmacies were compared with the prescriptions to determine if they were acceptable and/or optimal to measure the dose as prescribed. Data collected for each prescription included items such as presence of markings on the device at the prescribed dose, if the units of measurement matched the device, if acceptable to measure the prescribed volume with the available device, optimal syringe volume, and if the pharmacy had an optimal device for the prescribed volume. RESULTS Among the 11 different devices collected from the pharmacies, 5 different types were found. Over the 2 months of prescription data analyzed, 557 prescriptions were written, with 158 (28%) being liquids requiring a medication delivery device for administration. When comparing the 5 unique devices to 158 prescriptions independently, it was found that 9%, 30%, 53%, and 92%, respectively, for the 1-mL, 3-mL, 5-mL, and 10-mL devices were acceptable to measure the volume prescribed. The 5-mL syringe was optimal in only 21% of prescriptions analyzed, and the 10-mL syringe and spoon were found to be the most optimal device for the prescriptions analyzed. Of the 5 pharmacies reviewed, all prescriptions could be optimally measured with the use of devices that they had available 49% of the time (range 22% to 78%). CONCLUSION Oral medication delivery devices are imperative for safe and effective oral liquid medication use. Understanding optimal and acceptable devices would allow pharmacists to tailor patient-specific education and would allow direction when stocking oral delivery devices in the community pharmacy.

Treatment Options and Considerations for Intestinal Helminthic Infections

Objective: To review the literature regarding the epidemiology and treatment of intestinal helminthic infections. Data Sources: A literature search of MEDLINE (1946-January 2014), EMBASE (1980-January 2014), International Pharmaceutical Abstracts (1970-January 2014), and the Cochrane Library (1996-January 2014) was performed using the following terms: intestinal, helminthic, humans, United States, and individual drug names (albendazole, ivermectin, mebendazole, nitazoxanide, praziquantel, pyrantel pamoate). Secondary and tertiary references were obtained by reviewing related articles. Study Selection and Data Extraction: All English-language articles identified from the data sources and clinical studies using anthelmintic agents were included. Data Synthesis: The 2011 removal and continued absence of mebendazole from the market has left limited options for helminth infections. For hookworm, albendazole has a 72% cure rate compared to 32% for pyrantel pamoate. Albendazole, ivermectin, and nitazoxanide appear to be effective for Ascaris with cure rates of 88%, 100%, and 91%, respectively. Both albendazole and pyrantel pamoate have been evaluated for pinworm with cure rates of 94.1% and 96.3%, respectively. Combination therapy with ivermectin and albendazole produces cure rates of 38% to 80% for whipworm. For Strongyloides stercoralis, ivermectin cure rates are 93.1% to 96.8% compared with 63.3% for albendazole. Praziquantel is effective for intestinal trematode infections with cure rates of 97% to 100% while its efficacy against tapeworm ranges from 75% to 85%. Conclusions: Albendazole is the drug of choice for hookworm, Ascaris lumbricoides, and pinworm. In combination with ivermectin, it is the first-line agent for whipworm. Ivermectin is preferred for Strongyloides stercoralis, and praziquantel is effective against most nematodes and trematodes.