Breaking the safety barrier: Risk factors for unjustified non-acceptance of pharmaceutical interventions in the PICU and their association with mortality

Background: While pharmaceutical interventions (PIs) serve as safety barriers in Pediatric Intensive Care Units (PICU), their effectiveness relies on acceptance by the multidisciplinary team. Objective: Therefore, this study sought to identify factors associated with the acceptance and refusal of PIs in a PICU, with focus on identifying risk factors for non-acceptance PIs and their association with mortality. Methods: A retrospective analytical study was conducted in a PICU. Zero-Inflated Negative Binomial (ZINB) and standard Negative Binomial (NB) regression models were applied to determine independent predictors of total PIs, accepted PIs (PIa), and Non-Accepted PIs ('PIna)-stratified into Justified (PInaJ) and Unjustified (PInaUJ) refusals. Conclusion: Pharmacotherapeutic risk reflects process complexity and surgical status, not severity. The PInaUJ-mortality link signals team dysfunction during deterioration, supporting risk-based screening and mandatory refusal justification in prescribing systems.