Journal of Research in Pharmacy Practice

Abstract The main aim of the study was to identify the physical and chemical incompatibilities among the drugs administered intravenously to patients admitted to the Intensive Care Unit (ICU) of a 1000 bedded hospital. The study also envisaged establishing pharmaceutical guidelines for the administration of incompatible medications. Methods: This prospective cross-sectional study was conducted from January to July 2018 in the ICU after getting approval from the Hospital Ethics Committee. A total of 104 medication charts were collected, and their data were analyzed. Compatibility of the selected drug with a second drug, when given together, was then analyzed using the Micromedex health-care series, Trissel's handbook of injectable drugs, and Manufacturer's product information. The pharmaceutical intervention was performed by preparing. The drug compatibility chart of selected drugs and the same was reported to the study department. Findings: Of 104 medication charts reviewed, 66 charts had incompatibility, accounting for 90 incompatibilities. Incompatibility between two intravenous (IV) bolus drugs constituted 68.8% with pantoprazole and ondansetron (85.4%) being the most frequent combination. Incompatibility between infusion-bolus was found to be 26.6%. Meropenem (infusion) and pantoprazole (bolus) constituted 16.6%. Incompatibility between two infusions in the same IV line was found to be 4.4%. A drug compatibility chart containing 19 selected drugs was prepared and submitted to the study department for their perusal. Conclusion: The current study showed that a significant number of drug incompatibilities occur in hospitalized critically ill patients in our tertiary care hospital. These incompatibilities could generally be prevented by adhering to proper medication administration techniques like flushing the line using compatible fluid or through a multi-lumen catheter or multiple IV access.

Abstract The objectives of this study were to investigate the frequency and reasons for missing doses and impact of a pharmacist-led intervention to reduce the missed doses in intensive care units. Methods: This study was completed in two phases. In the first phase, a retrospective quality assurance audit was conducted to quantify the problem of missed doses from the pharmacist/nurse communication slip record. The frequency and potential reasons for missing dose occurrences were identified and listed, and respective solutions were finalized by a joint health-care team. In the second phase of the study, post-intervention analysis was done for a period of 1 month to check the impact of intervention. The data were recorded from pharmacy/nursing communication forms for medication, dosage form, route of administration (ROA), frequency of missed doses, and underlying reasons for missing doses. Findings: There was a substantial reduction in the number of incidences of missed doses in post-intervention phase. The number of events decreased from 190 (pre-intervention; 2 months) to 11 (post-intervention; 1 month), 389 to 87, and 133 to 12 for automatic stop order, unknown reason, and late mix medication, respectively. No missed dose event was recorded secondary to order overseen and inactive patient status in post-intervention phase. Moreover, identified reasons, ROA, frequency, and the system status were the significant predictors of missing doses. Conclusion: The findings of this study emphasized the need to introduce better documentation procedures and continuous surveillance system to decrease the number of missing doses and further improve already established drug distribution service.

Abstract Current literature indicates that the presence of clinical pharmacists in hospitals results in improved patient care, rational drug therapy, and treatment costs. This study assessed the clinical pharmacy services in the intensive care unit (ICU) of a tertiary hospital at Tabriz University of Medical Sciences, Iran. Methods: During a 9-month cross-sectional study (2014–2015), the clinical pharmacy interventions in 27 sessions and educational activities for patients and health-care professionals were randomly assessed based on the Australian guideline and standard of practice for clinical pharmacy. The interventions of clinical pharmacist were evaluated in terms of their clinical importance. Findings: In this study, a total of 832 interventions on 242 patients were performed by the clinical pharmacist, and approximately 93.6% of the interventions were approved by the attending physician. Most interventions concerned adding a new medication to a drug regimen or switching to a needed new medication. Each patient received an average of three interventions. The clinical pharmacist provided drug information to employees and medical staff in 108 of the total 832 interventions (13%). Medical residents who were surveyed indicated that the quality of education, research, and patient care was improved by the attendance of a clinical pharmacist. Conclusion: The results of this study show that the collaboration of a clinical pharmacist with the medical staff of an ICU can improve pharmacotherapy approach and increase the quality of education.

Abstract Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. Methods: A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Findings: Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. Conclusion: In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients' pharmacotherapy, and more attention should be paid to this issue.

Abstract Selenium depletion has been reported in critical illness correlates with an increase in mortality and morbidity. In this study, we aimed to access the selenium plasma levels of septic patients early at the Intensive Care Unit (ICU) admission in order to compare with reference range.
Methods: We conducted a cross-sectional study in a university affiliated hospital aiming to assess the early plasma level of selenium in ICU admitted patients. eighty patients diagnoses with sepsis were included and considered for characteristic evaluation, monitoring criteria assessment and also blood sampling. All blood sampling was performed during 48 hours of the ICU admission in order to determined the plasma Selenium level by atomic absorption method.
Findings: The mean plasma levels of selenium in male and female was 98.14 ± 23.52 and 78.1 ± 24.46 μ/L, respectively. Although selenium plasma levels was higher in the ICU male patients significantly, both had near normal range (80 μ/L).
Conclusion: In this study we found that in early admitted Iranian ICU patients in Tehran, selenium deficiency has not routinely seen but probably will happen during ICU hospitalization. Keywords: Critical ill patients, intensive care unit, Seleniu

Abstract The risk of methicillin-resistant Staphylococcus aureus infections in Intensive Care Unit (ICU) is increasing in recent years with high rate of morbidity and mortality. Therefore, in this study, we aimed to evaluate the rationale use of vancomycin in ICU patients.
Methods: A total of 200 patients who received at least 48 h intravenous vancomycin were randomly selected from ICU wards, during 9 months. Vancomycin administration and related clinical and laboratory data were gathered from patients' charts and health information system to evaluate the appropriateness of different aspects of vancomycin use during all days which vancomycin were ordered.
Findings: During the study, 15,230 ± 1216 mg (mean ± standard error of the mean [SEM]) vancomycin was administered for 200 patients in the mean period of 9.79 ± 0.64 (SEM) days of ICU stay, for prophylaxis and empiric therapy. Results showed the appropriateness of vancomycin uses were 30.5%, 9%, and 5.5% in the first 24 h, after 72 h and during the whole time of treatment, respectively. In addition, infectious consultation was the only significantly different parameter between appropriate and inappropriate vancomycin administration groups (P < 0.001).
Conclusion: Although vancomycin utilization evaluation were mentioned in previous studies, but data related to ICU patients and during all days of vancomycin therapy are limited. High prevalence of inappropriate use of vancomycin in ICU is alarming for health systems and necessitates implementation of antibiotic policies.

Abstract Objective: Concern about adverse effects of the inconsistent use of stress‑related 
mucosal damage prophylaxis in intensive care unit (ICU) is increasing. Hence, this 
study was designed to prospectively evaluate the rate of inappropriate stress ulcer 
prophylaxis (SUP) administration upon ICU admission, at ICU discharge and determine 
the adherence to American Society of Health‑System Pharmacists (ASHP) guideline 
during ICU stay.
Methods: In this study, 200 patients were randomly selected from all ICU admissions 
during 9 months. Risk factors of stress ulcer were recorded daily during ICU stay and 
appropriateness of SUP administration was assessed according to the ASHP criteria.
Findings: Of all 160 (80%) patients who received SUP, 44.4% did not have indication; 
and among 95 patients with an indication for SUP administration, 6.3% did not receive 
it upon ICU admission. Consequently, 77 (38.5%) of 200 patients received inappropriate 
prophylaxis on ICU admission. In addition, 53.5% of patients had appropriate adherence 
to ASHP guideline during all days of ICU stay (44% and 2.5% of patients received SUP 
more than 120% and <80% of appropriate SUP duration, respectively). Moreover, 81.2% 
were continued on inappropriate prophylaxis upon transfer from the ICU.
Conclusion: We concluded that although SUP administration included both 
overutilization and underutilization in this ICU, but high prevalence of SUP 
overutilization caused unnecessary hospital costs, personal monetary burden, and may 
increase adverse drug reactions. Therefore, educating physicians and cooperation of 
clinical pharmacists regarding implementing standard protocols could improve patterns 
of SUP administration.

Abstract Objective: Pharmacy‑driven medication history (MH) programs have been shown 
to reduce the number of serious or potentially life‑threatening (S/PLT) medication 
discrepancies (MDs) in many settings, but not Intensive Care Units (ICUs).
Methods: MHs were repeated over a 6‑week period. Demographics, number, and nature 
of MDs were documented. Discrepancy severity was graded using a previously published 
method. Primary outcome was the proportion of MHs containing >1 S/PLT MDs.
Findings: Sixty‑three MHs were repeated. Pharmacy MHs were less likely to 
contain ≥1 S/PLT MDs (0% vs. 50%, P < 0.001).
Conclusion: Pharmacy MHs contained fewer S/PLT MDs in this small sample. S/PLT 
MDs on admission and home medication lists were common in patients admitted to 
the medical ICU. Pharmacy‑driven medication reconciliation (MR) reduced the number 
and frequency of these discrepancies. Further research is required to improve current 
MR procedures.

Abstract Enteral feeding tube is employed for feeding of critically ill patients who are unable to eat. 
In the cases of oral medication administration to enterally fed patients, some potential 
errors could happen. We report a 53-year-old man who was admitted to intensive care 
unit (ICU) of a teaching hospital due to the post-CPR hypoxemic encephalopathy. The 
patient was intubated and underwent mechanical ventilation. A nasogastric (NG) tube 
was used as the enteral route for nutrition and administration of oral medications. Oral 
medications were crushed then dissolved in tap water and were given to the patient 
through NG tube. In present article we report several medication errors occurred during 
enterally drug administration, including errors in dosage form selection, methods of oral 
medication administration and drug interactions and incompatibility with nutrition formula. 
These errors could reduce the effects of drugs and lead to unsuccessful treatment of 
patient and also could increase the risk of potential adverse drug reactions. Potential 
leading causes of these errors include lack of drug knowledge among physicians, inadequate 
training of nurses and lack of pharmacists participation in medical settings.