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Year : 2015  |  Volume : 6  |  Issue : 2  |  Page : 33-37

Identification of drug-related problems and pharmacist's interventions in asthmatic patients at a private tertiary care facility-Pakistan


1 Department of Pharmacy Services, Northwest General Hospital and Research Center, Peshawar, Pakistan
2 Department of Medicines and Allied, Northwest General Hospital and Research Center, Peshawar, Pakistan

Date of Web Publication21-Apr-2015

Correspondence Address:
Aziz Ullah Khan
Department of Pharmacy Services, Northwest General Hospital and Research Center, Sector A3, Phase V, Hayatabad, Peshawar
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2045-080X.155511

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  Abstract 

Background: Drug-related problems (DRPs) potentially contribute to morbidity, mortality and financial indicators. There is increasing evidence that participation and interventions of clinical pharmacists in health care have a positive influence on clinical practice.
Objectives: The main focus of this study was to identify DRPs, evaluate clinical pharmacy services and document pharmacist's interventions.
Materials and Methods: A 3 months prospective observational study from October, 2014 to January, 2015 was carried out on 80 asthmatic patients admitted to pulmonology unit at Northwest general hospital and research center, Peshawar, Pakistan. The drug therapy details of the patients were collected from inpatient treatment charts using a predesigned questionnaire. The DRPs were identified, and clinical interventions made by pharmacists were documented.
Results: A total of 37 patients (61.25%) presenting 91 DRPs were identified, including potential drug-drug interactions 39 (48.75%), drug selection 27 (33.75%), drug use process 12 (15%), drug monitoring 5 (6.25%), adverse drug reactions 5 (6.25%) and dosing 3 (3.75%). Clinical interventions documented by pharmacist were drug information response 21 (26.25%), patient education and counseling 14 (17.5%), change/clarify medication order 11 (13.5%), proper storage and cost effectiveness 10 (12.5%), medication error/brand duplication 7 (8.75%), change of drug/dosage 3 (3.75%), dose calculation in special population 3 (3.75%) and discharge plan 2 (2.5%). Of 91 interventions, the pharmacists contacted the consultants for 24 (30%) interventions, postgraduate medical officers/registrars 34 (42.5%), nursing staff 21 (26.25%) and the patients/attendant 12 (15%). 15 (18.75%) interventions were approved by concerned prescribers.
Conclusion: To minimize the risks of DRPs and prevent their occurrence, drug therapy requires pharmacist's timely and effective interventions at all levels.

Keywords: Asthma, drug-related problems, pharmacist interventions


How to cite this article:
Khan AU, Ali I, Zafar R, Khalil A. Identification of drug-related problems and pharmacist's interventions in asthmatic patients at a private tertiary care facility-Pakistan. Arch Pharma Pract 2015;6:33-7

How to cite this URL:
Khan AU, Ali I, Zafar R, Khalil A. Identification of drug-related problems and pharmacist's interventions in asthmatic patients at a private tertiary care facility-Pakistan. Arch Pharma Pract [serial online] 2015 [cited 2019 Jul 16];6:33-7. Available from: http://www.archivepp.com/text.asp?2015/6/2/33/155511


  Introduction Top


Clinical pharmacy is an area of pharmacy concerned with the science and practice of rational medication use. It is a health science discipline in which pharmacists provide patient care optimizing medication therapy and promoting health and disease prevention. [1] A drug-related problem (DRP) is an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes. [2] DRPs include medication errors (involving an error in the process of prescribing, dispensing, or administering a drug, whether there are adverse consequences or not) and adverse drug reactions (any response to a drug which is noxious and unintended, and which occurs at doses normally used in humans for prophylaxis, diagnosis or therapy of disease, or for the modification of physiological function). [3]

Drug-related problems are common in hospitalized patients and can interfere with the achievements of desired therapeutic outcomes. [4] These problems can potentially have an impact on desired health outcomes. [5] There is increasing evidence that participation and interventions of clinical pharmacists in health care have a positive influence on clinical practice. [6] In a number of studies, clinical pharmacists have shown to reduce DRPs in the inpatient settings. In one study, 277 clinical interventions were reported by pharmacists, with 332 DRPs identified and 91.8% recommendations made. [7] Another study reported that the incidence of DRPs was found to be much higher than quoted as an average in developed countries. [8] Some publications have evaluated the impact of drug errors identified or intercepted by emergency department pharmacist. [9],[10],[11] and inpatient medical and surgical ward. [12],[13]

Over the last decades, pharmacists have seen their potential competencies broadened beyond the traditional dispensing role. [14] An intervention is defined as any action taken into account by a clinical pharmacist resulting in a change in patient's therapeutic management. [15] The effect of pharmacist-delivered services has been reported for asthma management previously. [16] The aim of this study is, therefore, to highlight the role of clinical pharmacy services on DRPs and assess drug therapy interventions by pharmacist in patients with asthma in a tertiary care facility.


  Materials and methods Top


A prospective observational study was conducted for over a period of 3 months from October, 2014 to January, 2015 in medicines and allied ward (pulmonology unit) of Northwest General Hospital and research Centre Peshawar, Pakistan. Ethical clearance of the study was obtained from hospital's ethics committee so as to allow data collection. Patients of all ages with or without co-morbidities, admitted to the medical ward for asthma and ready to give consent were included only while those from Intensive care units and oncology were excluded. Identification of DRPs was assessed by reviewing and analyzing all medication orders, administration sheets, laboratory and diagnostic test results and pathophysiological status. The registration numbers of patients were noted in order to review the computerized file through the hospital management information system software, interview the patients and retrieve the necessary information for the study.

A standard questionnaire was used in this study which constituted of:

  • Patient's demographic characteristics, including age, sex, and medical history
  • The drugs administered to the patient during the hospitalization period: Drug name, indication, dose, schedule, duration, and monitoring
  • The type of DRPs and pharmacist's interventions; revived using Pharmaceutical Care Network Europe classification (DRP registration form V.6.2).


The patient's drug therapy was routinely monitored. The DRPs were identified, discussed, intervened and documented.


  Results Top


During the period of 3 months, a total of 80 cases of asthma patients were followed and assessed for DRPs. Of which 37 patients (46.5%) had DRPs. Total number of drugs received by patients was 513. Majority of the patients were seen with the age between 65 and 82 years (61.25%), out of which 52 (65%) were male and 28 (35%) female. The number of drugs in the prescriptions ranged from 3 to 9 with the mean value of 6.41. The demographic and clinical features of patients with asthma are vivid from [Table 1].
Table 1: Demographic and clinical features of asthmatic patients (n=80)

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In 80 cases, 91 DRPs were identified, including potential drug-drug interactions 39 (48.75%), followed by drug selection 27 (33.75%), drug use process 12 (15%), drug monitoring 5 (6.25%), adverse drug reaction 6 (6.25%) and dosing 3 (3.75%), as summarized in [Table 2].
Table 2: DRPs identified in asthmatic patients (n=80)

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A total of 91 clinical interventions were documented by pharmacist; drug information response 21 (26.25%), patient education and counseling 14 (17.5%), clarify medication order 11 (13.75%), proper storage and cost-effectiveness 10 (12.5%), medication error/brand duplication 7 (8.75%), need for drug monitoring 5 (6.25%), change of drug/dosage 3 (3.75%), dose calculation in special population 3 (3.75%), discharge plan 2 (2.5%) and interventions approved by prescriber 15 (18.75%) as shown in [Table 3].
Table 3: Types of clinical interventions documented by a pharmacist (n=80)

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Of 91 interventions, the pharmacist contacted the prescribers for 24 (30%) interventions, postgraduate medical officers/registrars 34 (42.5%), nursing staff 21 (26.25%) and the patients/attendants 12 (15%).


  Discussions Top


Among 80 patients followed during the study period, 37 patients required pharmacist's interventions in their drug therapy. The remaining 43 patients had no DRPs. The incidence of DRPs was higher in patients aged between 65 and 82 years (61.25%). A high number of DRPs resulted from potential drug interactions (48.75%). A study conducted by Ismail et al. showed (45%) potential drug-drug interactions (pDDIs) at pulmonology ward in a tertiary care hospital at Peshawar, Pakistan. [17] This study showed that drug-drug interaction is a common drug therapy problem in both government and private hospitals. Micromedex® Drug interaction V. 1.52.3 by Truven Health Analytics Inc., 2012 was used for detecting pDDIs.

The second documented DRP after pDDIs was drug selection (33.75%), which comprised of cost effective alternative (17.5%), inappropriate drug selection (8.75%), too many drugs for an indication (5%) and no indication for drugs (2.5%). This was observed previously in a study in which drug use without indication accounted for highest. [18]

Avoidable adverse drug reactions are the serious consequences of inappropriate drug selection. In present study, adverse drug reactions accounted for (6.25%) DRPs accounted for drug use process was (15%), which included drug administered at inappropriate time and wrong rout of administration; that is, in current study, some patients took (Budesonide/Formoterol) Rota caps (special capsules that contain the medication in a very fine powder form that is effectively delivered into the lungs when inhaled through a special device named revolizer.) with water instead of using it with revolizer. This was due to lack of patient education and training of nursing staff.

Drug related problems accounted for drug monitoring was (6.25%), out of which narrow therapeutic drug 5 while 3.75% for dosing (over dosage 1, sub-therapeutic dosage 2). Drug information response accounted for 26.25%. The information was both telephonic and face to face. The percentage of intervention approved by prescriber and patient education and counseling was 17.5 each. 13.75% patients received clarification regarding medication order. The clarification or advice was regarding confusion about prescription reading, adequate time and rout of administration. The percentage of medication errors and the brand duplication was 8.75%. Either two drugs with same generic with or without same route of administration were prescribed.

Other recommendations made in present study were proper storage and cost-effectiveness (12.5%), drug monitoring (6.25%), change of drug/dosage and dose calculation in special population (3.75%) each and discharge plan (2.5%).

For interventions, the pharmacists mostly contacted the postgraduate medical officers/registrars (42.5%). The reason behind the pharmacists contacting the postgraduate trainees frequently was because of their availability at ward for most of the time. The percentage of the concerned prescribers being contacted for interventions was (30%). This may be due to their busy schedule in an outpatient department. This was, followed by nursing staff (26.25%). The patients/attendants being contacted for interventions were (15%). This data are almost consistent with the study carried out by Ganachari et al. [19]

The major findings in this study indicate the need of clinical pharmacy services to be implemented in wards so as to prevent DRPs, improve treatment outcomes and enhance patient's quality of life.





In conclusion, procedures for identification of, and intervention on, actual and potential DRPs, may contribute to diminishing drug-related morbidity and mortality. To avoid negative effects of drug treatment and need for additional medical care, drug treatment must be individualized with implementation of clinical pharmacy services in wards. This study suggests that clinical pharmacists can effectively identify and prevent clinically significant DRPs.

 
  References Top

1.
American College of Clinical Pharmacy. Definition of Clinical Pharmacy. Available from: . [Last accessed on 2015 Feb 01].  Back to cited text no. 1
    
2.
Pharmaceutical Care Network Europe. PCNE Working group on drug-related problems. Available from: . [Last accessed on 2015 Feb 01].  Back to cited text no. 2
    
3.
van den Bemt PM, Egberts TC, de Jong-van den Berg LT, Brouwers JR. Drug-related problems in hospitalised patients. Drug Saf 2000;22:321-33.  Back to cited text no. 3
    
4.
Reddel H. Rational prescribing for ongoing management of asthma in adults. Aust Prescr 2012;35:43-6.  Back to cited text no. 4
    
5.
Akici A, Oktay S. Rational pharmacotherapy and pharmacovigilance. Curr Drug Saf 2007;2:65-9.  Back to cited text no. 5
    
6.
Ali I, Khan AU, Zafar R. Pharmacotherapy analysis of patients admitted in medical ward: A case report. Can J Appl Sci 2014;3:90-3.  Back to cited text no. 6
    
7.
Richardson TE, O′Reilly CL, Chen TF. Drug-related problems and the clinical role of pharmacists in inpatient mental health: An insight into practice in Australia. Int J Clin Pharm 2014;36:1077-86.  Back to cited text no. 7
    
8.
Ramesh M, Madaki S, Parthasarathi G, Kumar J. Assessment of drug-related problems and clinical pharmacists′ interventions in an Indian teaching hospital. 2003.  Back to cited text no. 8
    
9.
Patanwala AE, Sanders AB, Thomas MC, Acquisto NM, Weant KA, Baker SN, et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Ann Emerg Med 2012;59:369-73.  Back to cited text no. 9
    
10.
Rothschild JM, Churchill W, Erickson A, Munz K, Schuur JD, Salzberg CA, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med 2010;55:513-21.  Back to cited text no. 10
    
11.
Vasileff HM, Whitten LE, Pink JA, Goldsworthy SJ, Angley MT. The effect on medication errors of pharmacists charting medication in an emergency department. Pharm World Sci 2009;31:373-9.  Back to cited text no. 11
    
12.
Franklin BD, Reynolds M, Shebl NA, Burnett S, Jacklin A. Prescribing errors in hospital inpatients: A three-centre study of their prevalence, types and causes. Postgrad Med J 2011;87:739-45.  Back to cited text no. 12
    
13.
Tully MP, Buchan IE. Prescribing errors during hospital inpatient care: Factors influencing identification by pharmacists. Pharm World Sci 2009;31:682-8.  Back to cited text no. 13
    
14.
Beney J, Bero L, Bond CM. Expanding the roles of outpatient pharmacists: Effects on health services utilisation, costs, and patient outcomes. Cochrane Libr 2000;2:CD000336.  Back to cited text no. 14
    
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Mangasuli S, Rao P. Clinical interventions: A preliminary survey in a South Indian teaching hospital. Indian J Pharmacol 2006;38:361.  Back to cited text no. 15
  Medknow Journal  
16.
Saini B, Filipovska J, Bosnic-Anticevich S, Taylor S, Krass I, Armour C. An evaluation of a community pharmacy-based rural asthma management service. Aust J Rural Health 2008;16:100-8.  Back to cited text no. 16
    
17.
Ismail M, Iqbal Z, Khattak MB, Khan MI, Arsalan H, Javaid A, et al. Prevalence, types and predictors of potential drug-drug interactions in pulmonolgy ward of a tertiary care hospital. Afr J Pharm Pharmacol 2011;5:1303-9.  Back to cited text no. 17
    
18.
Alagiriswami B, Ramesh M, Parthasarathi G, Basavanagowdappa H. A study of clinical pharmacist initiated changes in drug therapy in a teaching hospital. Indian J Pharm Pract 2009;2:36-45.  Back to cited text no. 18
    
19.
Ganachari M, Shashikala C, Fibin M. Assessment of drug therapy interventions by clinical pharmacist in a tertiary care hospital. Indian J Pharm Pract 2010;3:22-8.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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