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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!