Perception of Pharmacists About the High-Risk/Alert Medications in Saudi Arabia

Objectives: To demonstrate the perception of pharmacists about the High-Risk/ Alert medications in Saudi Arabia. Methods: It analyzes a cross-sectional survey that discussed the perception of pharmacists about High-Risk/Alert medications in Saudi Arabia. The survey consisted of respondents’ demographic information about pharmacists and The Perception of High-Risk/Alert Medications, barriers, which factors may Discourage you from implementing High-Risk/Alert medications, and recommendations/suggestions for facilitating the implementation of High-Risk/Alert medicines. The 5-point Likert response scale system was used with closed-ended questions.


INTRODUCTION
Medical errors contributed to the significant the 3 rd cause of death in the United States of America. [1] The drug-related disorder consists of medication errors, adverse drug reactions, drug poisoning, medication non-compliance, drug without indication, and indications without medication. [2,3] Drug-related problems implicate a high economic burden on the healthcare system locally and internationally. [4][5][6] Various quality management tools assess the reasons for drug-related issues, emphasizing medication errors. For instance, root causes analysis and fish boon analysis. [7] Multiple causes of medication errors occur, such as poor clinical knowledge, unawareness of healthcare facility policy and procedures, and using non-electronic prescribing and dispensing medication. [8][9][10][11] Besides, properly poor perception or attitude toward medication errors. Again, it could be some barriers to implementing an appropriate system of medicine problem prevention. [8][9][10][11] The various types of medications contributed to the error. One of the serious drugs is called High-Risk/Alert medication. [12,13] The mistake of those medications might cause hazardous consequences to patients and the healthcare system. Few studies discussed the perception or barriers to High-Risk/Alert medication system development. [14][15][16] The current research with cross-sectional about pharmacist perception of high risks medication in Saudi Arabia

METHODS
It analyzes a cross-sectional survey that discussed perception of pharmacists about the high-Risk/Alert medications in Saudi Arabia. It self-reported an electronic survey of the pharmacist, including pharmacists from internship to consultant, pharmacist specialties, and Saudi Arabia. All nonpharmacist or students, non-completed, nonqualified surveys will be excluded from the study. The survey consisted of respondents' demographic information about pharmacists and The Perception of High-Risk/Alert Medications, barriers, which factors may Discourage you from implementing High-Risk/ Alert medications, and recommendations/ suggestions for facilitating the implementation of High-Risk/Alert medicines. The 5-point Likert response scale system was used with closed-ended questions. According to the previous litterateur with an unlimited population size, the sample was calculated as a cross-sectional study, with a confidence level of 95% with a z score of 1.96 and a margin of error of 5%, a population percentage of 50%, and drop-out rate 10%. As a result, the sample size will equal 380-420 with a power of study of 80%. [17][18][19] The response rate required for the calculated sample size is at least 60-70 % and above. [19,20] The survey was distributed through social media of what's applications and telegram groups of pharmacists. The reminder message had been sent every 1-2 weeks. The survey was validated through the revision of expert reviewers and pilot testing. Besides, various tests of the reliability of McDonald's ω, Cronbach alpha, Gutmann's λ2, and Gutmann's λ6 were done with the study. The data analysis of the Pharmacist's perception of High-Risk/Alert Medications is done through the survey monkey system. Besides, the statistical package of social sciences (SPSS), Jeffery's Amazing Statistics Program (JASP), and Microsoft Excel sheet version 16. It included a description and frequency analysis, good of fitness analysis, correlation analysis. Besides, inferential analysis of factors affecting the perception of pharmacists about the high-Risk/Alert medications and linear regression. The STROBE (Strengthening the reporting of observational studies in epidemiology statement: guidelines for reporting observational studies) guided the reporting of the current study. [21,22]

RESULTS
A total number of 442 pharmacists responded to the questionnaire. Of them, more than one-third responded from the Central region (183 (40.40%)), and one Quarter responded from the Western part (119 (26.92%)), with statistically significant differences between the provinces (p=0.000). Most of the responders were from MOH Hospitals (157 (35.36%)), with a statistically significant difference between working sites (p=0.000). Males responded more than females (264 (59.59%)) versus 179 (40.41%)), with statistically significant differences between all levels (p=0.000). Most of the responders were in the age group of 24-30 years (266 (59.91%)) and 31-35 years (78 (17.57%)), with statistically significant differences between all age groups (p=0.000). Most of the pharmacists were staff pharmacists (323 (72.75%)) and pharmacy supervisors (56 (12.61%)), with statistically significant differences between all levels (p=0.000). Most of the responders held Bachelor in pharmacy (1214 (48.20%)), and Pharm D (193 (43.47%)). Most pharmacists had a work experience of 1-3 years (125 (28.28%%)) and >1 year (99 (22.40%)), with a statistically significant difference between years of experience (p=0.000). Most pharmacists works at inpatient pharmacy (110 ((26.76%)) and outpatient (88 ((21.41%)) with statistically significant differences between all levels (p=0.000). There was a strong positive correlation between age (years) and years of experience based on Kendall's tau_b (0.744) and Spearman's rho (0.827) correlation coefficients, with a statistically significant difference between the two factors (p<0.000). There was a medium negative correlation between age (years) and current positions based on Kendall's tau_b (0.429) and Spearman's rho (0.474) correlation coefficients, with a statistically significant difference between them (p<0.000). There was a medium positive correlation between the site of work and current practice area based on Kendall's tau_b (0.322) and Spearman's rho (0.404), with a statistically significant difference between the two factors (p<0.000). There was a medium negative correlation between the site of work and years of experience based on Kendall's tau_b (0.323) and Spearman's rho (0.407), with a statistically significant difference between the two factors (p<0.000) (Tables 1 and 2). The average score of perception of pharmacists about High-Risk/Alert medications was (3.88). The element "Staff compliance with protocols, guidelines and order sets related to high-alert medications is required" obtained the highest score (4.38). The pharmacists believe that Standard protocols, order sets, and orders express IV and neuraxial high-alert medication infusions/doses are highly recommended (4.36). In contrast, the lowest score was obtained for the element "The High-Risk/ Alert medications system should be optional and paid " (3.26). The score for the element "I think there is under-working in High-Risk/ Alert medications in the healthcare institutions " was (3.46) with a statistically significant difference between the responses (p<0.000). All aspects of the perception of pharmacists about High-Risk/Alert medications were statistically significant between responses (p<0.000) ( Table 3). The average score for the element "Factors Discourage you to implement High-Risk/Alert medications" was (3.36). The highest score from the component "The High-Risk/Alert medications are of a serious nature" was (3.92). The score for the element "Lack of Periodic training of pharmacy staff about High-Risk/Alert medications " was (3.83), and "Low level of clinical knowledge of High-Risk/ Alert medications "was (3.70). In contrast, low scores were obtained for the elements "The High-Risk/Alert medications sciences is too trivial to work " (2.13), "Consider it the doctor's responsibility " (2.71), and "Lack of confidence in discussing the High-Risk/Alert medications with the physician" (3.15), with statistically significant difference between the responses (p<0.000). All responses about aspects of perception of Factors that affected Factors Discourage you from implementing High-Risk/Alert medications were statistically significant (p<0.000) ( Table 4). The most recommendations/suggestions for facilitating the implementation of High-Risk/Alert medications were the Implementation of an electronic high-alert medications system 385(88.30%), setup up the therapeutic protocol or guidelines for High-Risk/Alert medications 347 (79.59%), and standardizing the prescribing, preparation, dispensing and administration of High-Risk/Alert drugs 345 (79.13%) ( Table 5). The score for single-test reliability analysis of McDonald's ω was 0.900, Cronbach's α was 0.903, Gutmann's was λ2, 0.913, Gutmann's λ6 was 0.939, and Greater Lower Bound was 0.965 with statistically significant (p<0.05).

Factors affecting the perception of pharmacists about High-Risk/Alert medications
Factors affecting the perception were analyzed. We adjusted the significant values using the independent samples Kruskal-Wallis test and

Answered question 444
Skipped question 0   the Bonferroni correction for multiple tests. perception of pharmacists about the high-Risk/Alert medications location, worksite, age (years), gender, experience, position held, and practice area in a pharmacy career. All seven factors did not affect the perception of pharmacists about High-Risk/Alert medications with non-statistically significant differences between regions (p>0.05) ( Table  6). The relationship between the perception of High-Risk/Alert medicines, such as location, worksite, age (years), gender, years of experience, position held, and practice area in a pharmacy career. The multiple regression analysis considered perception as the dependent variable and factors affecting it as an expletory variable. There was a weak relationship (R=0.119 with p=0.584) between the perception of High-Risk/Alert medications and their factors. All seven factors were nonsignificant differences in the relationship (p>0.05). The bootstrap model was also confirmed ( Table 7).

Factors affecting the Factors barriers may Discourage the implementation of High-Risk/Alert medications
Factors affecting the barriers that may Discourage the implementation of High-Risk/Alert medications were analyzed. We adjusted the significant values using the independent samples Kruskal-Wallis test and the Bonferroni correction for multiple tests. The factors that might affect barriers that may Discourage the implementation of High-Risk/ Alert medications include location, worksite, age (years), gender, years of experience, position held, and practice area in a pharmacy career. All seven factors did not affect the perception of pharmacists about barriers that may Discourage the implementation of High-Risk/Alert medications with nonstatistically significant differences between regions (p>0.05) ( Table 6). The relationship between the barriers may Discourage the implementation of High-Risk/Alert medicines. Factors affecting it include location, worksite, age (years), gender, years of experience, position held, and practice area in a pharmacy career. The multiple regression analysis considered factors of the passing of barriers that may Discourage the implementation of High-Risk/ Alert medications as the dependent variable and factors affecting it as an expletory variable. There was a weak relationship (R=0.096 with p=0.820) between the factors barriers that may Discourage the implementation of High-Risk/ Alert medications and the factors involving it. All seven factors were non-significant differences in the relationship (p>0.05). The bootstrap model was also confirmed (Table 7).

DISCUSSION
The High-Risk/Alert medication might have implicated serious adverse effects or severe consequences if a mistake occurred. That leads to poor clinical outcome and increase the unnecessary and additional cost of pharmacy services and the healthcare system. [23,24] Therefore, the perception of High-Risk/Alert medication might affect the foundations of plucky procedures at healthcare facilities. If their lousy perception of the healthcare provider's emphasis on the pharmacy staff, that's probably would ignorance might have happened and progress to severe drug misadventures. Besides, sometimes various barriers might prevent the development and implementation of High-Risk/Alert medication if the pharmacist or higher administration does not correct or remove the obstacles that lead to harmful and severe drug-related conditions.
The current investigation, with the excellent number of responders and high reliability of the survey, will explore the pharmacist's perception of High-Risk/Alert medication. which better than previous in the sample size and reliability analysis. [14][15][16] The study's findings showed that the pharmacist's perception of High-Risk/Alert medications is acceptable. The pharmacist believes the pharmacy staff should ensure compliance with order sets of High-Risk/Alert medicines. Besides, the High-Risk/ Alert medication dosing protocol of parental administration is recommended. That means the pharmacists are ready to implement all High-Risk/Alert medications and related policies and procedures. In contrast, the pharmacist disagreed that high risk should be optional, or healthcare administrators did not implement the high risk or not enough at healthcare organizations. That means the pharmacists fully support the higher administration to implement a High-Risk/Alert medication system and help them perform well and reduce the incidence of mistakes of highrisk/alert medications. [10,25] Thus, there is no previous investigation to compare with the current findings. The findings showed that the significant barrier to preventing a High-Risk/Alert medication system at pharmacy practice was a lack of regular education and training about the program. [26] Besides, there was a low level of clinical knowledge of High-Risk/Alert medications, which was a part of inadequate education and training or an unavailable of high caliber and expert pharmacists at their institutions. [26] Therefore, the pharmacist believes High-Risk/Alert medication is serious and part of the pharmacist's job and responsibility to prevent any medication errors. [10,25] Thus, there is no previous investigation to compare with the current findings. The findings showed the high demand for electronic prescriptions of High-Risk/Alert medications, establishing the therapeutic protocol of High-Risk/Alert medicines. Therefore, besides standardized prescribing, preparation, and dispensing of High-Risk/Alert drugs, it those excellent to start implementing High-Risk/Alert medication in pharmacy services. In addition, various publications suggested standardized total parental nutrition for neonates, pediatrics, and adults. [27][28][29] Moreover, some authors recommended standardized emergency medications or electrolytes as physician orders and converted them to electronic physician orders. [30][31][32] Thus, there is no previous investigation to compare with the current findings. Various factors, including location, working site, age, gender, position held, and many years

CONCLUSION
The pharmacist's perception of High-Risk/ Alert medications was beneficial and supportive for improving high-quality performance. The pharmacist believes there is a high demand for standardized protocols for prescription, preparation, and administration stages of drug orders. Besides, the High-Risk/ Alert medication is under-working of some High-Risk/Alert medications. The pharmacist lacks periodic education and training about High-Risk/Alert medications and lacks clinical background knowledge. Therefore, the electronic prescription of High-Risk/Alert drugs and electronic therapeutic protocol or guidelines of High-Risk/Alert medicines are highly recommended for implementation in pharmacy practice in Saudi Arabia.