overseas pediatric clinical pharmacy training and …...training site university of illinois at...

OVERSEAS PEDIATRIC CLINICAL

PHARMACY TRAINING AND

PEDIATRIC CLINICAL PHARMACY SERVICE

IN PRINCESS MARGARET HOSPITAL

Candy Lau

Pharmacist

Princess Margaret Hospital

CONTENT

Overseas Training at University of Illinois at

Chicago (UIC) Medical Centre

Pediatric Clinical Pharmacy Service at Princess

Margaret Hospital

TRAINING AT UIC

2 pharmacists selected

Pediatric clinical pharmacy training

A 3-month training

General Pediatrics

Neonatal Intensive Care Unit (NICU)

Pediatric Intensive Care Unit (PICU)

TRAINING SITE

University of Illinois at

Chicago (UIC) Medical

Centre

Teaching hospital of

University of Illinois at

Chicago

34 pediatric, 12 PICU, and

55 NICU beds

TRAINING CONTENT

-DAILY ACTIVITIES

Attach with clinical

pharmacist to attend

ward round with

multidisciplinary team

Neonatologists,

pharmacists, nurse

practitioners,

respiratory therapists,

dietitian, social worker,

& registered nurses

TRAINING CONTENT

-DAILY ACTIVITIES

Case review

Review cases seen in morning round

Discuss medication treatment options, monitoring,

care plan with preceptors

TRAINING CONTENT

-WEEKLY ACTIVITY

Out-patient clinic visit

Check patient’s lab data

Interview patient

See patient with doctor

Propose intervention to doctor

Prepare patient medication list

Provide patient counseling

TRAINING CONTENT

-OTHERS

Visit to central pharmacy and aseptic suite

THINGS LEARNT

Total Parenteral Nutrition prescription Nutrition and fluid requirement of

neonates

Monitoring parameters

Conditions require modification of TPN

Therapeutic drug monitoring Different pharmacokinetics of

premature infants

Handling out of therapeutic range

Patient interviewing and

counseling

Drugs commonly used in pediatrics

Promote medication safety

Medication reconciliation

PEDIATRIC CLINICAL PHARMACY

SERVICE

Back from training……

PEDIATRIC CLINICAL PHARMACY SERVICE

Service provided since June, 2011

Serves NICU and SCBU patients

NICU: 14 beds

SCBU: 25 beds

OBJECTIVES

To improve medication safety and provide better

pharmaceutical care to the patients through pediatric

clinical pharmacy service

CLINICAL PHARMACY SERVICE

Monday to Sunday

Ward-round with doctors

Case discussion

Provide drug treatment options

Provide interventions

Clinical screening of medication orders

Evaluate medication regimen

MAR transcription checking

Drug administration checking

CLINICAL PHARMACY SERVICE

TPN consult and review

Monitoring

electrolytes, fluid balance,

triglyceride…

Individualize nutrition need

Recommendations for special medical

conditions

Review compatibility with drug

infusions

Drug information service

Literature search

Consolidate drug information

Provide up-to-date drug information to

doctors and nurses

CLINICAL PHARMACY SERVICE

Protocols and guidelines development

Retinopathy of prematurity sedation

protocol

Drug reference charts compilation

Dosage reference charts

Compatibility charts

Pharmacokinetics consult and

Therapeutic Drug Monitoring

Time of sampling

Pharmacokinetic calculations and

interpretation

CLINICAL PHARMACY SERVICE

Medication Management Service

Ensure safe storage and administration of

medications on ward

Provide advice on storage of high-risk, look-alike, sound-

alike medications

Pharmacy Intravenous Admixture Service (PIVAS)

Drug cart management

Ward stock management

WORKLOAD STATISTICS

Over the 18-month period

Medications for 18,305 patient days

reviewed

22,008 medication orders screened

4,394 TPN orders reviewed

166 pieces of drug information provided

MEDICATION INCIDENT PREVENTION

Before Clinical

Pharmacy

Service

After Clinical

Pharmacy

Service

“near miss” per 1000-

neonatal-activity-days

prevented

7 28

MEDICATION INCIDENT PREVENTION- INTERVENTIONS

352 interventions documented

28%

27% 16%

3%

17%

3% 6%

Interventions

TPN

Regimen(Dose, Freq,

Route)

Drugs to be

added/discontinued

Monitoring

Vaccination

Dilution and

Administration

Others

MEDICATION INCIDENT PREVENTION

Patient transferred in after partial resection of small bowel due to necrotizing enteral colitis

Before transfer, patient was receiving partial TPN (1/2 bag) which delivers 3mmol/kg/day of potassium.

The whole bag contains 6mmol/kg/day of potassium.

Due to fluid restriction, doctor ordered TPN with same content but less fluid and intended to give full TPN to the patient.

Double dose of potassium in new TPN

Risk of hyperkalemia

Severity Index

0: Incident occurred but stopped before reaching patient. No consequence.

1: Incident occurred (reached patient) but no injury sustained.

2: Minor injury

3: Temporary morbidity 5: Major permanent loss of function/disability

4: Significant morbidity 6: Death

If not prevented, medication incident with severity index ≥3

MEDICATION INCIDENT PREVENTION

Morphine infusion of initial dose

10mcg/kg/hr was intended to be ordered by

doctor

Dilution calculation

problem occurred,

20mcg/kg/hr was prescribed

On dosage checking,

discrepancy found before

drug was administered

Dose doubled

Increased risk of respiratory depression,

hypotension

If not prevented, medication incident with severity index ≥ 3

MEDICATION INCIDENT PREVENTION

NICU Infusion Calculator

MEDICATION INCIDENT PREVENTION

• Neonate found to have DVT

• Rare disease in neonates

• Tinzaparin chosen by doctors

Information from pharmacist

1. Tinzaparin contains benzyl alcohol not suitable for neonates

2. Enoxaparin suggested as alternative

3. Dosage regimen, administration method, monitoring plan provided to doctor

4. Method of administration and dilution of Enoxaparin from prefilled syringe provided to nurse

MEDICATION INCIDENTS

None during operation hours of clinical pharmacy

service

11 occurred during non-operation hours

9 discovered by clinical pharmacist during medication

order screening

7 dose omissions

1 transcription error

1 wrong dose

BENEFIT OF PEDIATRIC CLINICAL

PHARMACY SERVICE

Improve medication safety

Prevent prescribing errors

Prevent incompatibility of medications

Prevent drug interactions

Ensure proper administration of medications

Optimize drug treatment for patients

Minimize side effects of medications

Ensure efficacy and safety through therapeutic drug

monitoring

Improve nutrition support from TPN

Optimize drug dosage and frequency according to changing

pharmacokinetics of growing baby

Build up trustable relationship with doctors and

nurses

THANK YOU!