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.
AimsTo evaluate paracetamol dosing in paediatric patients against local1 and BNFc2 guidance following advice that toxicity can rarely occur with doses exceeding 75 mg/kg/day. Secondly to determine adherence to regular paracetamol prescriptions to establish the impact of analgesia by reviewing Wong and Baker pain assessment.3 MethodThe drug charts of all paediatric inpatients on five separate days were retrospectively reviewed to identify patients prescribed paracetamol for analgesia. The drug charts were scrutinised to determine if any doses of paracetamol prescribed potentially exceeded 75 mg/kg/day. The doses, routes, frequencies, and doses in mg/kg of paracetamol prescribed were recorded. The number of regular paracetamol doses administered was compared against the prescribed frequency and the numbers of regular doses omitted with and without documented reason were recorded. The comfort round sheets were reviewed to establish if the Wong and Baker pain assessment3 were used to assess pain and results obtained before and after the first 24 hour period of regular paracetamol treatment were recorded where available.Results75 paediatric patients prescribed paracetamol for analgesia were identified over data collection period, approximately 50% split surgical: medical. One patient had no dose frequency of paracetamol prescribed hence the data of a total of 74 paediatric patients was analysed.78% of paediatric patients were prescribed paracetamol for use when required; in surgery 40% were prescribed regular paracetamol compared with 9% in medicine.Overall, 74% of paediatric patients were prescribed paracetamol at a dose of 15 mg/kg and at a frequency of QDS in line with local guidance.1 Equally distributed across both medical and surgical wards, 11% of patients were prescribed doses of paracetamol potentially exceeding 75 mg/kg/day as no maximum frequency stated when prescribed 4–6 hourly prn. One surgical patient was prescribed 20 mg/kg QDS regularly hence exceeding the recommended 75 mg/kg/day, this was changed by the prescriber.16 paediatric patients were prescribed paracetamol as a regular medicine but 31% of these patients had one or more missed doses without any reason for omission documented on the drug charts. Patients who had omitted doses who had a corresponding Baker Wong pain score indicated little or no pain hence omission was appropriate although not adequately documented.ConclusionsThe majority of patients were prescribed paracetamol at the 15 mg/kg dose 4–6 hourly in keeping with the local guidance1 for inpatients but there was potential to administer up to 90 mg/kg/day when the prescribers did not specify a maximum frequency QDS.One surgical patient had been prescribed 20 mg/kg QDS which was an overdose in relation BNFc2 guidance indicating a training requirement for the surgical and anaesthetic teams.The pain assessment tool was not consistently being used to evaluate analgesia and missed doses of analgesia were not being recorded appropriately.A key message was issued to all teams to emphasise the ...
AimTo explore the current prescribing, dispensing and administration practice for oral prednisolone to children with acute asthma or wheeze.MethodA semi-structured telephone interview following a course of oral prednisolone. The interview questions were designed during consultation with a multidisciplinary team and explored: doses prescribed, formulations prescribed and dispensed, parent/legal guardian/patients’ experiences and perceptions of prednisolone administration and medicines manipulation and adherence. Parents/legal guardians of children aged 2–11 years and young people over 12 years with acute asthma/wheeze prescribed a short course (≤7 days) of oral prednisolone on the Children’s Assessment Unit (CAU) or in the out-patients department were eligible to consent/assent to this study. Ethical approval was granted.Results20 families completed the study. The ages of children ranged from 2–16 years (average=5 years). Specific formulation details (e.g. tablets, soluble tablets, EC tablets) were provided by prescribers in only 20% of the oral prednisolone prescriptions. There was variability in dispensing soluble versus tablet formulations across child ages; the average ages of children prescribed soluble tablets and non-soluble tablets were 4 years and 11 years respectively. 80% of oral prednisolone formulations dispensed were soluble tablets. In 40% of cases, manipulation techniques were provided by parents to improve patient acceptance of prednisolone soluble owing to its poor palatability. In addition, 2 parents discussed using coercion to improve acceptance. A high level of adherence to prednisolone was reported:95% of prednisolone courses were completed. All prescriptions were for duration of 2 or 3 days. Of the prednisolone doses recorded: 53% were in-line with trust guidance (0.5 mg/kg rounded up to the nearest 5 mg), 13% – BNFC guidance, 13% – BTS SIGN guidance and 20% (not in the guidance listed) were between 0.32 mg/kg and 0.76 mg/kg.ConclusionThere is no gold standard for prescribing, dispensing and administering prednisolone in young children, thus dosages and formulations prescribed vary widely. This study highlighted variability in dosing of prednisolone across different guidelines. There is very little information regarding the appropriateness of prescribing non-soluble versus soluble formulations for children, however tablet size should be considered when formulating medicines for children.1 Soluble prednisolone tablets were dispensed more commonly than non-soluble in this hospital setting; however, the taste of prednisolone has been described as a barrier to medicines acceptance.2 Although adherence in this cohort was high, the majority of children had received the formulation previously and palatability was described as an adherence issue during initial prescribing. Further information at the prescribing and dispensing stage is required to understand the factors influencing formulations and doses prescribed and dispensed. This research will inform larger studies investigating the suitability o...
Objective This study evolved as part of the drug cost containment initiatives within University Hospital of North Staffordshire (UHNS) and the National Health Service (NHS) as a whole. The project was initiated when analysis of the child health ePACT data from 2009 to 2010 demonstrated significant costs associated with dispensing of unlicensed medicines. The objective was to evaluate the cost of supplying unlicensed medication on FP10HP within child health at UHNS and project the financial benefit of standardising supply of these unlicensed medications by dispensing at UHNS. Methods The ePACT data for child health at UHNS April 2009 – March 2010 was reviewed to determine the quantities and cost of prescription on FP10HP. The top 50 spend from this hospital ePACT data was then evaluated to determine which drugs contributed significantly to this spend and the data further analysed to establish the detail of prescription, including quantities and net ingredient costs (NIC). These prescriptions were then costed using the current NHS price model to determine the relative price for dispensing the equivalent products at UHNS. Results The initial ePACT searches demonstrated that child health had prescribed 5 606 items on FP10HP for the financial year 2009–2010. The top 50 NIC demonstrated that the unlicensed medication melatonin, then other hypnotics, (biomelatonin) were the two highest cost drugs accounting for 212 (3.8%) of the items prescribed. Unlicensed omeprazole suspension also featured in the top 50 NIC accounting for only 17 items dispensed. The table below demonstrates the relative cost of dispensing these items at UNHS compared with FP10HP and highlights drug formulations where significant cost savings were demonstrated. Conclusion There are clear financial benefits from dispensing these unlicensed medications at UHNS pharmacy compared with supply on FP10HP, with potential annual savings of approximately £26 000. Drug Net cost FP10HP Net cost UHNS Potential saving Melatonin 3 mg SR capsules £2627.63 £291.6 £2336.02 Melatonin 3 mg capsules £8488.69 £535.6 £7953.09 Biomelatonin 3 mg cap £3571.52 £241.3 £3330.02 Melatonin 5 mg/5 ml £11010.48 £1967.71 £9042.77 Melatonin other preparations £1117.34 £374.76 £742.58 Omeprazole 10 mg/5 ml £3089.16 £173.94 £2915.22 Total saving £26319.7 In addition, hospital supply allows the pharmacy team to check unlicensed medications are only supplied when they are the only clinically acceptable option and ensure an unlicensed medication risk assessment has been completed, in concordance with the Healthcare Commission report ‘The best medicine’.1 It also allows the medicines management team to select the most suitable formulation, taking into account the manufacturer; availability, licensed status in other countries as well as cost efficiency.2 Standardisation of supply has the clinical benefit of reducing the risk of therapeutic failure or advert drug reactiondue to variance in formulation and the advantage of providing the patient with a familiar produc...
AimThis audit explores the impact of regular pharmacist intervention monitoring and feedback on paediatric and maternity wards, and how these interventions guide educational strategies aimed at improving prescribing practice.MethodA tally-chart data collection tool was designed for each ward to collect data on common errors such as omission of booking weight, vital to ensure safer prescribing of dalteparin, omission of dose/kg imperative to ensure safer paediatric prescribing, and also omission of the residing ward from the front of the chart which affects discharge times when TTOs are delayed/lost due to misdirection.The ward pharmacist recorded the incidence of these errors during each daily visit and prepared a weekly feedback report consisting of a bar graph of the results plus a comparison to the previous week. The pharmacist would also reiterate the importance of avoiding each type of error.This would also inform the topic of the ‘key prescribing message’ (a bulletin focussing on a particular type of error) explaining the correct method and the significance of avoiding errors. This was communicated to the ward teams/prescribers.ResultsPreliminary audit data is encouraging and shows that the feedback to the ward teams has had a positive impact. Many nurses and midwives were surprised at the level of errors and now better understand their significance and how they can support accurate prescribing. The senior medics have taken an interest in the audit and are keen on sharing the information with their juniors and adapting their training to ensure that further improvements are made.The data collected informed the first ‘key prescribing messages’; ‘Booking weight’ for maternity and ‘medicines reconciliation’ for paediatrics. Since these were communicated to the ward teams/prescribers the audit has found an improvement in the number of maternity prescriptions with the booking weight recorded, a reduction in the number of incorrect dalteparin prescriptions for postnatal women, as well as improved prescribing practice in paediatrics such as including dose/kg on each prescription and improved drug-history taking by the medics.ConclusionA key priority of the NHS is the prevention of medication errors.1 The positive impact of clinical pharmacist interventions on the quality of prescribing is well established2,3 as highlighted in a Department of Health study4 reviewing the frequency of errors, identifying modes of good practice to improve safety.To date this audit has shown the benefit of increasing the multidisciplinary team awareness of common errors, monitoring these each week and sharing these findings with the team. It has also shown that short, focused bulletins encouraged improvement and helped prescribers to improve their practice.ReferencesAudit Commission. A spoonful of sugar-improving medicines management in NHS hospitals2001. London: Audit Commission.Dale A, Copeland R, Barton R. Prescribing errors on medical wards and the impact of clinical pharmacists. Int J Pharm Pract2003;11:19–24.Dhillon S. Do clinical ...
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