title: Interdisciplinary medication decision making by pharmacists in pediatric hospital settings: An ethnographic study.
abstract: Children are particularly vulnerable to experiencing medication incidents in hospitals. Making sound medication decisions is therefore of paramount importance. Prior research has principally described pharmacists' role in reducing medication errors. There is a dearth of information about pharmacists' interactions with pediatric hospital staff across disciplines in resolving medication issues. The aim of this study was to examine interdisciplinary medication decision making by pharmacists in pediatric hospital settings.
  
  
  
  An ethnographic design was undertaken comprising observations, semi-structured interviews and focus groups. Audio-recorded data were analyzed thematically.
  
  
  
  The study was conducted in three wards of an Australian pediatric tertiary teaching hospital, comprising general surgical, gastroenterology, endocrinology, neurology, adolescent and rehabilitation settings.
  
  
  
  Pharmacists, registered nurses and doctors were recruited from diverse clinical wards following information sessions.
  
  
  
  Pharmacists were central to complex pediatric medication decision making, intervening about dosage, administration, drug interactions and authorities. Pharmacists proactively contacted doctors and nurses about prescribing issues; conversely, staff routinely approached pharmacists for medication advice. Pharmacists were perceived as medication experts, their extensive knowledge valued in resolving complex issues: when off-label medications were prescribed, when protocols were absent or ambiguous, where tension existed between protocol adherence and patient safety, and where patients on multiple medications were at risk of medication error. Pharmacists had strong relationships with doctors and nurses, which had a bearing on pharmacists' input in interventions. Furthermore, pharmacists identified prescribing errors through strategies, such as case note review and medication reconciliation, although the lack of emergency department pharmacists and limited after-hours staffing posed challenges to both strategies.
  
  
  
  Pharmacists made a substantial and highly valued contribution to pediatric inter-professional medication decision making. These results provide new knowledge that informs theoretical developments of pharmacists' role in decision making.
authors.affiliation: Department of Nursing, The University of Melbourne, 161 Barry Street, Parkville, VIC, 3052, Australia. Electronic address: mimi7@westnet.com.au.
authors.forename: Ellie
authors.initials: E
authors.lastname: Rosenfeld
authors.affiliation: Department of Nursing, The University of Melbourne, 161 Barry Street, Parkville, VIC, 3052, Australia; The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia. Electronic address: Sharon.Kinney@rch.org.au.
authors.forename: Sharon
authors.initials: S
authors.lastname: Kinney
authors.affiliation: Department of Nursing, The University of Melbourne, 161 Barry Street, Parkville, VIC, 3052, Australia. Electronic address: cj_weiner@hotmail.com.
authors.forename: Carlye
authors.initials: C
authors.lastname: Weiner
authors.affiliation: Department of Nursing, The University of Melbourne, 161 Barry Street, Parkville, VIC, 3052, Australia; The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia; Murdoch Childrens Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia. Electronic address: fiona.newall@rch.org.au.
authors.forename: Fiona
authors.initials: F
authors.lastname: Newall
authors.affiliation: Monash University, School of Nursing and Midwifery, Room 323, 35 Rainforest Walk, Wellington Road, Clayton, VIC, 3168, Australia. Electronic address: allison.williams@monash.edu.
authors.forename: Allison
authors.initials: A
authors.lastname: Williams
authors.affiliation: Murdoch Childrens Research Institute, 50 Flemington Road, Parkville, VIC, 3052, Australia; Clinical Pharmacology Unit, Department of Medicine, Royal Children's Hospital, 3 West Clinical Offices, 50 Flemington Road, Parkville, VIC, 3052, Australia. Electronic address: noel.cranswick@rch.org.au.
authors.forename: Noel
authors.initials: N
authors.lastname: Cranswick
authors.affiliation: University College London, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, United Kingdom. Electronic address: i.wong@ucl.ac.uk.
authors.forename: Ian
authors.initials: I
authors.lastname: Wong
authors.affiliation: Department of Nursing, The University of Melbourne, 161 Barry Street, Parkville, VIC, 3052, Australia. Electronic address: elleranne@hotmail.com.
authors.forename: Narelle
authors.initials: N
authors.lastname: Borrott
authors.affiliation: Deakin University, Faculty of Health, School of Nursing and Midwifery, 221 Burwood Highway, Burwood, VIC, 3125, Australia; The Royal Melbourne Hospital, Department of Medicine, Royal Parade, Parkville, VIC, 3052, Australia; Department of Nursing, The University of Melbourne, 161 Barry Street, Parkville, VIC, 3052, Australia. Electronic address: emanias@deakin.edu.au.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Manias
mesh_terms: D000328:Adult; D000368:Aged; D001315:Australia; D003657:Decision Making; D011307:Drug Prescriptions; D017144:Focus Groups; D006776:Hospitals, Pediatric; D006784:Hospitals, Teaching; D006801:Humans; D007400:Interprofessional Relations; D008875:Middle Aged; D009741:Nursing Staff, Hospital; D010595:Pharmacists; D010607:Pharmacy Service, Hospital; D010820:Physicians; D055815:Young Adult
keywords: Decision-making; Ethnography; Interdisciplinary; Medication; Pediatrics; Pharmacist