Tina's International APPE at NTUH: Pediatric ICU

For the next 3 weeks, I will be at the pediatric ICU in the Children’s Hospital at NTUH. The Children’s Hospital consists of 700 beds, with ~300-400 of the beds being for the pediatric population. Due to spacing issues, women’s health (primarily breast/ovarian cancer patients and gynecology) is located at the Children’s Hospital as well. All children are treated in this hospital unless they are undergoing transplantation or are on the orthopedic service (mainly because this is a relatively small subset of the pediatric population), in which they will be treated in the main hospital.

My first day was more of an orientation. Since this is my first pediatric rotation, my preceptors wanted me to be more familiar with the pediatric population so I spent part of my day reading the pediatric sections in Koda Kimble’s “Applied Therapeutics.” At NTUH, they use many of the resources that we reference to such as DiPiro’s “Pharmacology” and Lexi-Comp’s “Pediatric and Neonatal Dosage Handbook.”

From what I’ve heard it seems like medication dispensing is similar throughout the different pharmacy services. All of the pharmacists dispense and verify the medications. There is also no automation so this can prove to be a labor-intensive process in comparison to the United States. However, the inpatient pharmacy does have an automatic chemo dispenser which allows for a safe and closed system when working with chemotherapy.

Only NTUH patients can use outpatient pharmacy to fill their medications. The pharmacy does not use telephone refills and the wait time is around 20-30 minutes. After the doctor enters the prescription into the computer via CPOE, the prescription is then printed out. In order to save time, the medication order is not verified first before it is filled. Instead the pharmacist will dispense and verify the medication before giving it to the patient. I will explain a little later how this is different in the inpatient pharmacy. Also, as opposed to the US who fill their medications in vials, in Taiwan they either use individual clear plastic bags or use blister packs that are already pre-packaged. No patient information is placed on the medication. The medication is then placed in another bag with the patient’s name on it. As you can imagine, this could lead to medication errors if the incorrect medication is placed in the patient’s bag. Another interesting aspect about the outpatient pharmacy is that the pharmacists teach patients how to reconstitute medications into liquid solutions using water. This is very prevalent in the pediatrics population. This is mainly done to help save time. However, if for whatever reason the adult is unable to reconstitute the medication (for example a grandparent who may have dexterity issues), then the pharmacist will do it in the pharmacy.

The inpatient pharmacy also utilized CPOE. Like the US, the medication orders are verified first (as opposed to in the outpatient pharmacy). The medications are organized by alphabetical order by the brand name. In Taiwan, only one company is allowed to manufacture each drug so there is no confusion in terms of the brand name. Medication cassettes are also used to deliver medications to the wards. These cassettes are restocked and brought up to the floors once a day. All of the medications are pre packaged as a daily dose instead of a unit dose. Each cassette does have a divider available if the medication needs to be dosed more than once a day. When speaking with my preceptor, she acknowledged that one of the downfalls with their medication dispensing system is that they currently do not use a barcoding system. This can definitely lead to medication errors. She explained that this was partially because it is difficult to barcode all of the medications when the drugs are purchased from many countries. However, this is an area that NTUH’s pharmacy is working on to implement to help ensure quality assurance.