High-alert medications for hospitalised paediatric patients - a two-step survey among paediatric clinical expert pharmacists in Germany.

Paediatric patients are more vulnerable to be harmed by medication errors compared to adults due to pharmacokinetic and pharmacodynamic changes in their development, individual dosing calculations, and manipulation of ready to-use products intended for adult patients. According to the Institute of Safe Medication Practices, there are some "drugs that bear a heightened risk of causing significant patient harm when they are used in error"; these drugs are called high-alert medications (HAM). The two-step survey among paediatric clinical expert pharmacists presented here aimed to compile a nation-wide HAM list. To provide detailed guidance, this survey followed a drugbased approach, resulting in specific potential drug related problems (DRPs) and associated recommendations for prevention. In contrast to this approach, in the first round of the survey two drug classes were included that both were rated as HAM (i.e.chemotherapy and parenteral nutrition). Twenty single drugs were identified as HAM, 65% of which were cardiovascular or neurological drugs. The paediatric expert pharmacists mentioned in total 216 potential DRPs; in particular, they identified potential administration-related problems (28% of all DRPs), dosing-related problems (26%), and drug-choice-related problems (18%, e.g.drug confusion and drug monitoring). Moreover, they suggested 275 potential interventions to address these DRPs. Two thirds of all interventions dealt with the preparation by the hospital pharmacy, standardisation of processes (e.g.labelling), and education or training. In conclusion, this survey provided a German paediatric high-alert medication list from a paediatric pharmacist point of view. Moreover, the experts mentioned for the first time specific potential DRPs and associated interventions to guide a local multidisciplinary approach for preventing medication-related harm in children.

The prevalence of 'triple whammy' prescriptions in surgical inpatients and associated pharmacist recommendations.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are beneficial in surgical settings, they may however lead to adverse drug reactions including decreased renal function, a risk, which is exacerbated by combination with other nephrotoxics, and particularly when NSAIDs are given as part of a so-called 'Triple Whammy' (TW) with diuretics and renin-angiotensin system blockers. The objective of this study was to identify the prevalence of TW-prescriptions in a surgical inpatient setting and to document the changes in renal function after pharmacist recommendations. A prospective, observational single centre pilot study was performed using a series of eleven weekly Point-Prevalence Analyses (PPA). Adult surgical inpatients were screened for a TW-prescription by a clinical pharmacist, who made one of two recommendations on identification of a TW: for patients with eGFR > 60 ml/min/1.73m² close monitoring of renal function; for patients with eGFR ≤ 60 ml/min/1.73m² discontinuation of NSAID. A TW was identified in 18 of 317 patients (prevalence 5.7%; mean age 75 years). NSAID discontinuation was recommended for 7/18 patients (39%) and implemented for six (33%). In cases where the NSAID was de-prescribed, an improvement in renal function until the time of discharge was observed, whilst in patients with eGFR > 60 ml/min/1.73m² for whom monitoring was recommended eGFR remained stable. TW-prescriptions were found to be a potential problem in the studied group of older surgical inpatients. Clinical pharmacists are well placed to identify patients who are prescribed a TW, and to advise on the management of these patients.