ijlpr 2022; doi 10.22376/ijpbs/lpr.2022.12.1.

P88-94

International Journal of Life science and Pharma Research

ISSN 2250-0480

Pharmacy for better health

Research Article

The Impact Of Clinical Pharmacists' Interventions On Drug-Related Problems At

The Military Hospital, Omdurman, Sudan

Nada Rashad Farrag Eltaib1, Najla Idriss Abdurhman Ahmed1, Hala Mahamed Elnasif1, Ashraf N. Abdalla 2,3 *
,
Yosra Alhindi4* and Sahar Elashmony5,6*
1
School of Pharmacy, Ahfad University for women, Omdurman 167, Sudan
2
Department of Pharmacology and Toxicology, Faculty of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia
3
Department of Pharmacology and Toxicology, Medicinal and Aromatic plants research institute, National center for research, Khartoum 2404,
Sudan
4
Department of Pharmacology and toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia
5
Department of Clinical Pharmacy, Faculty of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia
6
Medical Pharmacology Department, Faculty of Medicine, Cairo University, Cairo, Egypt

Abstract: Clinical pharmacists can help to identify, solve and prevent drug-related problems (DRPs) through appropriate
interventions. The objective of this retrospective study was to identify DRPs, their causes and to evaluate how the clinical
pharmacists' interventions can impact on them in the medicine department at the Military Hospital, Omdurman, Sudan. A total of 100
files belonging to patients admitted between September 2018- March 2019 were analyzed in this study according to specific criteria,
of which 170 Clinical pharmacists' Intervention (CPIs) were made, and 152 DRPs were identified. The most common DRP found was
untreated indication (not prescribed drug but clear indication) accounting for 32.9% (n=50) of total studied cases, followed by sub-
therapeutic dose 14.5% (n=22), and drug interactions 12.5% (n=19). Interventions were made by clinical pharmacists based on the
type of DRP. The acceptance of intervening pharmacist suggestions was found to be 57.6% (n=98), the remaining 41.8% (n=71) of
interventions were not accepted. The study highlighted that the participation of clinical pharmacists in the medical ward had a positive
impact on optimization of drug therapy by reducing drug-related problems.

Keywords: Clinical pharmacist, Drug-related problems, acceptance, Clinical pharmacists' Intervention.

*Corresponding Author Received On 8 November, 2021

Yosra Alhindi , Department of Pharmacology and toxicology, Revised On 20 December, 2021

Faculty of Medicine, Umm Al-Qura University, Makkah Accepted On 30 December, 2021
21955, Saudi Arabia Published On 10 January, 2022

Funding This study has not received any external funding.

Citation Nada Rashad Farrag Eltaib, Najla Idriss Abdurhman Ahmed, Hala Mahamed Elnasif, Ashraf N. Abdalla, Yosra Alhindi and Sahar
Elashmony , The Impact Of Clinical Pharmacists' Interventions On Drug-Related Problems At The Military Hospital, Omdurman,
Sudan.(2022).Int. J. Life Sci. Pharma Res.12(1), P88-94 http://dx.doi.org/10.22376/ijpbs/lpr.2022.12.1.P88-94

This article is under the CC BY- NC-ND Licence (https://creativecommons.org/licenses/by-nc-nd/4.0)

Copyright @ International Journal of Life Science and Pharma Research, available at www.ijlpr.com

Int J Life Sci Pharma Res., Volume12., No 1 (January) 2022, pp P88-94

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1. INTRODUCTION doctors perceive and the obstacles that face them in

implementing clinical pharmacy in hospitals. One study
Previously, the concepts of clinical pharmacy were showed that the roles that were perceived by the majority of
announced as “hot new trends” in the 1960s by pharmacy pharmacists as part of their tasks in hospitals in Sudan were
educators as a type of pharmacy practice, which is concerned identifying drug-related problems (100%, n= 51), providing
with patients rather than drug1. Recently, clinical pharmacy is drug-related information to healthcare workers by (96%, n=
considered as a health science discipline in which pharmacists 47), and educating patients about their medicines (96%, n=
provide patient care that optimizes medication therapy and 48) 11.Another study found that doctors and nurses had a
promotes health, wellness, and disease prevention 2. Clinical good acceptance of clinical pharmacists' interventions
pharmacy was introduced in Sudan in 2001 as a subject in the compared to senior doctors. Also, they found that the main
Universities undergraduate pharmacy curriculum. obstacle the clinical pharmacist faced was their limited
Postgraduate clinical pharmacy education was started in number, lack of support from health authorities, lack of job
2004 as a “2-year” master program. Thereafter, postgraduate descriptions, lack of specific area in the patients’ files for
clinical pharmacy education expanded further, as several their intervention, and low salaries12. However, more studies
pharmacists started master degrees in clinical pharmacy in the field are needed to evaluate the impact of CPIs in
programs. Unfortunately, the unavailability of suitable decreasing the DRPs.The main aim of the present study was
facilities, absence of resources, and unavailability of well- to evaluate the impact of clinical pharmacists' interventions
trained clinical pharmacists all challenge the progress of on drug-related problems in the medicine department at the
clinical pharmacy education in Sudan 3.The role of Clinical military hospital, Omdurman, Sudan. Moreover,
pharmacists is to assess the status of the patient’s health determination of the percentage of DRPs identified by clinical
problems and determine whether the prescribed medications pharmacists (adverse reactions, drug choice problem, dosing
optimally meet the patient’s needs and goals of care. problem, drug use problem, and interactions) in the basis of
Moreover, evaluate the appropriateness and effectiveness of pharmaceutical care network Europe foundation (PCNE)
the patient’s medications. In addition to recognition of version 5.01. Also, identification of the frequency of
untreated health problems that could be improved or interventions suggested by the clinical pharmacists at drug
resolved with appropriate medication therapy, following the level, and at prescriber level. Assessment of interventions
patient’s progress to determine the effects of the patient’s suggested by clinical pharmacists whether correct or not
medications on his/ her health. Clinical pharmacists also according to references. Finally, investigation of the outcome
consult with the patient’s physicians and other health care of clinical pharmacists' interventions whether DRPs are
providers in selecting the medication therapy that best meets solved or not solved.
the patients’ needs and contribute effectively to the overall
therapy goals. They also advise the patient on how to best 1. METHODS
take his or her medications, support the health care team’s
efforts to educate the patient on other important steps to 2.1 Study Design, duration and settings
improve or maintain health, such as exercise, diet, and
preventive steps like immunization 4. A cornerstone of The present manuscript is a retrospective study, which was
clinical pharmacy is the identification, solving and prevention done in Medicine department at military hospital,
of drug-related problems (DRPs). DRP is defined as an ‘event Omdurman. The study duration was seven months from
or circumstance involving a patient’s drug treatment that September 2018- March 2019.
actually, or potentially, interferes with the achievement of an
optimal therapeutic outcome 5. An actual problem has 2.2 Study Population, sample size and sample method
resulted in clinical manifestations (e.g. a drug-related rash, an
adverse drug reaction), or therapy failure due to incorrect We checked files of patients admitted to the medicine
dosage. A potential problem is not manifested, but if left department at the military hospital, Omdurman. We included
unresolved, it may lead to drug-related harm to the patient 6. files of patients admitted to the medicine department with
Categorization of DRPs can serve as a focus for developing a clinical pharmacists' interventions at the military hospital,
system for pharmacists to contribute significantly to positive Omdurman from September 2018- March 2019. We
patients’ outcomes.Several research groups and organizations excluded files of patients admitted to the medicine
have developed their own systems for the classification of department without clinical pharmacists' intervention at the
DRPs; including the Pharmaceutical Care Network Europe 5, military hospital, Omdurman. One Hundred and seventy
The American Society of Health-System Pharmacists 7 are clinical pharmacists' interventions were collected from
perhaps the most well-known and used among pharmacists hundreds of patients admitted to the medicine department at
8
.According to the classification scheme of the PCNEF military hospital, Omdurman. The sample was convenient,
version 5.01, five types of DRP exist including: ADRs, drug non-random sampling.
choice problem, dosing problem, drug use problem and
interactions on which this study is based on. Clinical 2.3 Data collection
pharmacists can help to identify and resolve DRPs through
appropriate interventions 9. Examples of CPIs include advising Data were collected using a checklist composed of three
patients of drug information and instructions for use or parts: (drug related problems, clinical pharmacist
changing the drug prescription, dosage, formulation or interventions and the outcome of the intervention) based on
regimen. In addition, if needed, CPs can also provide the classification scheme of the Pharmaceutical Care
medication counselling and education for patients regarding Network Europe Foundation (PCNEF) version 5.01. The CPI
ADR presentations and drug interactions 10. In Sudan, many were evaluated according to online references (Medscape,
studies were done to assess the role of CPs, the self- drugs.com, and ACCP guidelines 2017). Data were collected
perception of CPs regarding their roles in hospitals, how retrospectively from patients’ files (including lab reports,

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nephrology unit reports and medication profile). 3.3 Limitations of the Study
The sampling was convenient. Moreover, Due to time
2. STATISTICAL ANALYSIS
restrictions, rounds were not attended. Also, the study is a
uni-center study and hence it lacks the representation of the
Variables were: Type of DRPs, Type of clinical pharmacists'
impact of CPIs in other hospitals and this is due to that in
intervention at drug level, Approval of clinical pharmacists'
some hospitals clinical pharmacists were not available, lack of
intervention by prescribers, Status of CPI according to
cooperation of some CPs and poor documentation of CPI
references (whether correct or incorrect), status of the
because they were verbally suggested during rounds.
outcome of CPI (whether solved or not solved). Data were
analyzed using a statistical package for social science (SPSS) 3.4 Strength of the study
version 16 and Excel 2010. Frequency and percentage were
calculated and presented by pie, bar, and column charts. Many studies were done to assess the role CPs, the self-
perception of CPs regarding their roles in hospitals, however
3.1 Ethical Clearance more studies in the field are needed to evaluate the impact of
clinical pharmacist interventions in decreasing DRPs. The
Joint ethical clearance was granted from the Ahfad University sample size of the study was hundred files of patients taken
and the Military hospital (No. MsMH/2390). A consent was from seven month which is helpful to achieve better results.
received from all study participants following the guidelines Open ended options in addition to the listed items were
outlined in the Declaration of Helsinki. Patients’ medical included in the data collection.
information and reports were kept confidential. 3. RESULTS
Among 100 patient's files analyzed during the study period,
3.2 Expected Outcome
170 CPIs were determined and a total of 152 DRPs were
identified in 93 patient's files, where each problem may have
It is expected to find out a positive impact of CPIs which can
one intervention or more. The most common DRP found
help in achieving better therapeutic outcomes and improved
was untreated indication (not prescribed drug but clear
patient care.
indication) accounting for 32.9% (n= 50) out of 152 DRPs
(Figure 1).

Fig 1: Type of Drug-related problems (y-axis) identified by CPs (n=152) in percentage: x-axis.

Interventions were made by clinical pharmacists based on the type of DRP. Most frequent intervention was starting a new drug
31.8% (n= 54), which was done for untreated indications, where no drug prescribed but clear indication (Figure 2).

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Fig.2 : Type of clinical pharmacists' intervention (x-axis) at drug level (n=170) shown in percentage: y-axis.

The acceptance of intervening pharmacists’ suggestions were found to be 57.6% (n= 98), on the other hand 41.8% were not
accepted (Figure 3).

Fig 3: Percentage of approved clinical pharmacists' intervention at prescriber level (n=170).

Interventions provided by clinical pharmacists were mostly correct 87.1% (n= 148). Incorrect interventions were 12.9% (n= 22)
and they were all fortunately rejected showing the awareness and knowledge of physicians (Figure 4).

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Fig 4:Percentage status of CPI according to references (n=170)

Out of 152 DRPs, 66.4% (n= 101) were solved by interventions suggested by clinical pharmacists, while 32.9% were not solved
(Figure 5).

Fig 5: Percentage status of the CPI outcome (n=152)

4. DISCUSSION enzyme inhibitors like ceftriaxone and sodium valproate

interact with warfarin leading to massive bleeding. Improper
Our main aim of the study was to evaluate the impact of drug selection (inappropriate drug) was mostly observed in
clinical pharmacists' interventions on drug related problems patients who may develop stress induced ulcer during the
in the medicine department at military hospital, Omdurman. hospitalization period and in the treatment of pneumonia
Also, to determine the percentage of DRPs identified by whether hospital (HAP) or community acquired (CAP) e.g.
clinical pharmacists. Our results showed that the most for CAP, CPs suggested (clarithromycin + ceftriaxone)
common DRP found was untreated indication (not instead of (clarithromycin + ceftazidim), while
prescribed drug but clear indication). Agents not prescribed contraindications mostly occurred among drugs administered
mostly were supplements (vitaferrol, iron supplement, for patients with heart, liver and renal problems like
potassium chloride, etc.), and antibiotics e.g., doxycycline diclofenac Na, meanntim hydrochloride and vancomycin,
after malaria course. This was followed by sub-therapeutic respectively. The occurrences of other problems included
dosage, and then drug interactions which may be due to lack inappropriate duplication of therapeutic group or active
of physician’s knowledge about the pharmacokinetic and ingredient e.g., lisinopril and captopril, and amlo 10mg and
pharmacodynamics properties of the drug 13 also poly- amlodipine 5mg, respectively. Inappropriate duplication was
pharmacy and the combination of various drug classes might followed by long duration of treatment that was common in
have contributed to the high prevalence of drug interactions the course of antibiotics. These were followed by drug
14.
Most of these interactions were pharmacokinetic overdose and then ADR’s, which may be due to age factor,
interactions that led to change or cessation of drugs e.g. poly-pharmacy, drug administration with narrow index,

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decreased renal elimination and the use of oral anticoagulants Around 66.4% of DRPs were solved by interventions
and diuretics 15. Other minor problems were drug without suggested by clinical pharmacist, this observation is in
indication (no clear indication for drug use) and no consistency to a study by Muhammad Umair Khan, et al.
administration of drug, which occurred for one patient only, (2014) which showed CPI were successful in solving DRPs 18.
where the patient received no slow potassium tablets By observation, ADRs, no administration of the drug and
although it was prescribed. There was no DRP attributed to drug without indication were completely solved. Other
short duration of treatment and wrong drug administration problems that have been mostly solved were untreated
during the study. This finding is in contrast to A. indications (no drug prescribed but clear indication), sub
Chandrakanth1, et al (2013), and Javedh Shareef, et al (2014) therapeutic dose and interactions. This result was achieved
where drug interaction was the most DRP 14,15. Interventions by analyzing laboratory reports, nephrology unit reports and
were made by clinical pharmacists based on the type of DRP. physician replaying notes. Problems were solved due to the
The most frequent intervention was starting a new drug, effectiveness of clinical pharmacist interventions and
which was done for untreated indications, where no drug cooperation of physicians with clinical pharmacists. A
prescribed but clear indication. This observation coincides previous hospital based observational cross-sectional study
with the study conducted by Al-Hajje AH , Atoui F, Awada S performed during 2015- 2016 in Spain, showed that the
, et al, (2012) where addition was (31%) 16. Drug involvement of clinical pharmacists in the multi-disciplinary
discontinuation (drug stopped) was due to drug without teams facilitated the detection and solution of DRPs, which
indication, inappropriate duplication, long duration of included many disease categories, mainly allergy, renal
treatment, and improper drug selection, ADR, drug impairment, obesity and polypharmacy 19. It was observed
interactions, and contraindications. The last three problems that all correct and approved interventions contributed in
also contributed to the change of drug by for example, solving problems except one was missed, where the clinical
changing pantoprazole to H2 blocker (ranitidine) as pharmacist suggested adding potassium supplement or diet
prophylaxis for stress ulcer was mostly observed to avoid rich in potassium for a hypokalemic patient because of insulin
incidence of infection by clostridium difficile. Dosage change therapy. The outcome of this intervention was not
was done for sub therapeutic dose, ADRs, and drug determined because the patient's potassium level of the next
overdose as well. Other interventions include change of days was not documented. On the other hand, around 32.9
usage instructions that were specifically frequency change for % of problems were not solved, this was due to the rejection
lactulose and antibiotics. This besides some files included of interventions by some prescribers and hence no change in
monitoring, counselling and reviewing of medications. drug therapy occurred. One problem was not solved due to
According to ACCP guidelines 17, Medscape and drugs.com, ineffective CPI where the clinical pharmacist recommended
interventions provided by clinical pharmacists were mostly to stop metformin for a diabetic patient that has renal
correct 87.1%, revealing the awareness, knowledge and problem without changing it to the other proper medication.
impact of clinical pharmacists in optimization of drug therapy. In a previous study at the general Hospital in the Jazan
For incorrect interventions it was about 12.9% and they region, Saudi Arabia in 2016, only 17.5% of the clinical
were all fortunately rejected showing the awareness and pharmacists interventions were rejected, compared with
knowledge of physicians. The acceptance of intervening 29.7% rejections in 2017 20.
pharmacists’ suggestions was found to be 57.6%, this finding
is similar to a study by Shareef J, et al (2016) where 58% of 5. CONCLUSION
interventions were accepted 15. A study by Javedh Shareef, et The present study highlighted that the participation of clinical
al. (2014) also showed high acceptance of CPIs 96.21% 15. All pharmacists in the medical ward had a positive impact in
of the accepted interventions led to change in drug therapy, optimization of drug therapy by reducing drug related
this was observed from the next day medication profile. problems. Furthermore, the well acceptance of interventions
Mostly accepted interventions where dosage change and drug by physicians can infer that clinical pharmacists' interventions
change, and this may be due to the fact that most physicians were highly relevant. Interventions were mostly correct,
believe that clinical pharmacists possess more knowledge which indicates the awareness, knowledge and positive
about dosing and drug interactions. One documentation was impact of clinical pharmacists in achieving better patient care
missed, where the clinical pharmacist suggested adding a that can lead to improved quality of care and drug therapy.
potassium supplement or diet rich in potassium for a Therefore, clinical pharmacy services could contribute to a
hypokalemic patient because of insulin therapy, no document rationalization of drug therapy and may eventually lead to
shows whether this suggestion was approved or not. The more medication safety.
remaining of the interventions were not accepted which may
be due to the guidelines used by physicians differ from those 6. LIST OF ABBREVIATIONS
used by clinical pharmacists. At the military hospital,
ACCP : American College of Clinical Pharmacy
physicians are using British guidelines while clinical
CPs : Clinical Pharmacists
pharmacists are using American guidelines. Another reason is
CPI : Clinical pharmacists' Intervention
the intervention may be correct but without proper
DRPs : Drug Related Problems
references to strengthen the suggestions provided. Another
PCNE : Pharmaceutical Care Network Europe Foundation
reason may be the suggestions provided were thought to be
insignificant by the physicians. Moreover, the effect of 7. AUTHOR CONTRIBUTIONS STATEMENT
medical representatives in promoting one product rather
than other. For example, physicians were preferring using Nada Rashad Farrag Eltaib, Najla Idriss Abdurhman Ahmed
Pantodac. It is known that (pantoprazole) for stress ulcers as and Hala Mahamed Elnasif are responsible for the study
prophylactic while clinical pharmacists were always suggesting research conception and design concept, Data acquisition,
H2 blocker to prevent the incidence of infections by Drafting of the manuscript, Critical revision of the
colistrediun difficil followed by treatment with pantoprazole. manuscript, Administrative, technical, or material support

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and Approval of the final manuscript. Ashraf Nabeel Abdalla, 9. CONFLICT OF INTEREST
Yosra Zakariyya Y. Alhindi and Sahar Mohy A. Elashmony The authors declare that there are no conflicts of interests.
were responsible for the Statistical analysis, Data analysis and
interpretation and Supervision. 10. DATA AND MATERIALS AVAILABILITY
8. FUNDING
All data associated with this study are present in the paper.
This study has not received any external funding.

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