Interdisciplinary medication decision making by pharmacists in pediatric hospital settings: An ethnographic study
Introduction
Children are more vulnerable than adults to experiencing medication errors for a range of reasons: Their body organs are not as mature as those of adults, and therefore pharmacodynamics and pharmacokinetics of medications are different. Problems can occur with having to prescribe on a kilogram weight basis. Off-label use can cause concerns as many medications are not tested in pediatric populations.1 Children are not as verbally confident as adults, and are therefore less able to describe symptoms that may be medication-related. However, this verbal confidence depends on the children's age, as well as their past experiences with medications and illness, self-esteem, and resilience.2
Medication safety is predicated on clear and precise communication between health professionals. Communication problems between clinicians about children's medications are very concerning.3 An audit comprising 2753 medication incidents in an Australian pediatric hospital, for example, found inadequate verbal communication between staff occurred in 34% of cases. In incidents that happened when children were transferred between clinical areas, a further 29% of incidents were documentation errors through misreading or not reading medication orders, and 22% involved not following policies and procedures.4
Previous research has shown the important role played by pharmacists in managing children's medications. Studies of pharmacists working in pediatric intensive care units (PICUs) demonstrate substantial reductions in prescribing errors.5 In a retrospective review of pharmacy interventions resulting in medication changes in a PICU over an 11-year period, 27,773 interventions were initiated by pharmacists for 10,963 admissions, most frequently dosing changes (52.3%) and appropriate choice of medication (21.4%).5 In a prospective study contrasting medication error (ME) rates before and after appointing a clinical pharmacist in a PICU, serious medication errors decreased from 29 per 1000 patient days before the intervention to 6 per 1000 patient days after the intervention (p < 0.01).6
Importantly, the pharmacists' role has developed over time from a focus on correcting medication orders to increased participation in medication decision making,7 including complex decision making in treating hospitalized children.5 Prior research has also identified pharmacists' expanding role in medication information provision and education.8, 9 Pharmacists have been described as “hubs of advice” (p. 1) and their contribution to complex medication decision making noted.10
Interdisciplinary collaboration in medication decisions has been advocated as fundamental to pediatric patient-centered care. Research has focused on communication between hospital doctors and pharmacists rather than pharmacists' interactions with health professionals of different disciplines.10 In an Australian prospective study of an evidence-based model to reduce medication errors in hospitalized children, multidisciplinary communication was considered an intrinsic component of a safe prescribing guideline.11, 12 There is a lack of information however about how pharmacists participate in inter-professional medication decisions, in particular, their input into complex and unusual medication issues.8 Such complex decisions include: off-label prescribing, which involves medications prescribed outside the scope of usual therapeutic practice, in the absence of protocols or when guidelines are ambiguous, when strict adherence to administrative protocols may compromise patient safety, or when patients on a plethora of medications require review. These scenarios may involve protracted deliberation for the interdisciplinary team before gaining collaborative consensus.
In this study, interdisciplinary medication decision making was defined as interactions of pharmacists with clinicians of other disciplines with the outcome of changes in medication treatment. The aim of this paper is to describe the role of pediatric clinical pharmacists in interdisciplinary medication decisions.
Section snippets
Overview
The study used an ethnographic design13 to explore communication between pharmacists, nurses and doctors about medication decisions in a major Australian pediatric teaching hospital. There are a number of defining characteristics relating to ethnography. Research involving an ethnographic approach is undertaken in a natural setting, and it requires close, face-to-face interactions with participants.14 This approach provides an accurate understanding of participant perspectives, behaviors and
Results
In all, 200 h of audio-taped observations were undertaken. Semi-structured interviews were conducted with three pharmacists, seven doctors, and 11 nurses. In addition, 59 nurses and 15 pharmacists participated in focus groups. Seven focus groups were conducted altogether. Pharmacists ranged in age from 24 to 37 years of age. Three had Bachelor of Pharmacy degrees, and three pharmacists held Masters in Clinical Pharmacy degrees, with clinical experience ranging from three months to 14.25 years.
Discussion
In this ethnographic study, new and comprehensive knowledge has been generated about the content of pharmacists' interdisciplinary role in medication decisions. Pharmacists were integral to medication decision making, which included complex medication decision making, involving off-label prescribing, clarifying administration issues when protocols were absent or ambiguous, mediating administration conundrums between patient safety and inflexible protocol adherence, and maintaining heightened
Conclusions
In the settings investigated within this study, hospital pharmacists demonstrated a pivotal role in making interdisciplinary pediatric medication decisions, particularly complex decisions. Their information and advice was valued highly and actively sought by doctors and nurses. Further descriptive research into the interdisciplinary roles of pediatric hospital pharmacists is required.
Funding
This work was supported by the Australia Research Council, Discovery Project Grant Scheme [grant number DP130100221]. The funding source had no role in the conduct of the study.
Competing interests
There are no competing interests in relation to this work.
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