Vol 6 Issue 2 December 2014 “Medication Safety Is Everyone’s Responsibility” A Medication Safety Newsletter by the Pharmaceutical Services Division, Ministry of Health Malaysia This newsletter is for circulation to healthcare providers only Fixing the antics By Dr. Rizah Mazzuin Razali Geriatrician, Kuala Lumpur Hospital Another usual day at the ward and my geriatrician- colleague was with me doing rounds together with my medical officer and intern. We saw Pak cik MS who was an elderly man with multiple comorbidities (well, all our patients are elderly with multiple comorbidities!) who is unable to ambulate because of his low back pain that could have been attributed by his previous fall five years ago which resulted in a fractured spine. He was given regular Paracetamol or in-short, PCM as analgesia. The PCM does seem to help but it wasn’t enough to control the pain as to allow him to mobilize better. For the past few months, he has been dependent on his equally elderly wife who has triple vessel coronary disease to assist him in most of his bADLs (Basic activities of daily living). As such, we were quite desperate to get him up on his feet again and we deliberated on what would be the next best medication to alleviate the pain and at the same time, avoiding complications. It took us about 10 minutes before we finally made a decision. As I turned to look at my MO and intern, they looked amazed (perhaps not so much in a positive way?) at how long it took for us to make a decision of initiating another medication. Many of us take for granted when it comes to prescribing medications for patients. We like to think that we are doing our patients favours, however, what may then transpire is, with the lack of knowledge and poor judgement, they are exposed to harmful consequences especially the vulnerable elderly patients. And I am not just referring to highly toxic drugs like chemotherapy or Dabigatran, which has no antidote…I am referring to the usual simple medications like Calcium lactate, L-thyroxine, Amitriptyline… A geriatrician shares her experience…… >> Page 3 Speaking of Amitriptyline, I have once encountered a patient in a clinic who was broken by good intentions of her doctors but subsequently rebuilt herself. She was a 79- year-old lady, who looked good and well for her age. As we began to talk, I realized that this lady had gone through a period of difficulties, thanks to what is called as prescription cascade. She has been treated by a physician for dyspepsia and was given several types of medications that unfortunately did not help much.
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Vol 6 Issue 2
December 2014
“Medication Safety Is Everyone’s Responsibility”
A Medication Safety Newsletter by the Pharmaceutical
Services Division, Ministry of Health Malaysia
This newsletter is for circulation
to healthcare providers only
Fixing the antics By Dr. Rizah Mazzuin RazaliGeriatrician, Kuala Lumpur Hospital
Another usual day at the ward and my geriatrician-
colleague was with me doing rounds together with
my medical officer and intern. We saw Pak cik MS
who was an elderly man with multiple comorbidities
(well, all our patients are elderly with multiple
comorbidities!) who is unable to ambulate because
of his low back pain that could have been attributed
by his previous fall five years ago which resulted in
a fractured spine. He was given regular
Paracetamol or in-short, PCM as analgesia. The
PCM does seem to help but it wasn’t enough to
control the pain as to allow him to mobilize better.
For the past few months, he has been dependent
on his equally elderly wife who has triple vessel
coronary disease to assist him in most of his
bADLs (Basic activities of daily living). As such, we
were quite desperate to get him up on his feet
again and we deliberated on what would be the
next best medication to alleviate the pain and at
the same time, avoiding complications. It took us
about 10 minutes before we finally made a
decision. As I turned to look at my MO and intern,
they looked amazed (perhaps not so much in a
positive way?) at how long it took for us to make a
decision of initiating another medication.
Many of us take for granted when it comes to
prescribing medications for patients. We like to
think that we are doing our patients favours,
however, what may then transpire is, with the lack
of knowledge and poor judgement, they are
exposed to harmful consequences especially the
vulnerable elderly patients. And I am not just
referring to highly toxic drugs like chemotherapy or
Dabigatran, which has no antidote…I am referring
to the usual simple medications like Calcium
lactate, L-thyroxine, Amitriptyline…
A geriatrician shares her experience……
>> Page 3
Speaking of Amitriptyline,
I have once encountered a
patient in a clinic who was
broken by good intentions of
her doctors but subsequently
rebuilt herself. She was a 79-
year-old lady, who looked good
and well for her age. As we
began to talk, I realized that
this lady had gone through a
period of difficulties, thanks to
what is called as prescription
cascade. She has been treated
by a physician for dyspepsia
and was given several types of
medications that unfortunately
did not help much.
NOTE
Page 2
AdvisorsYBhg. Dato’ Eisah A. RahmanDr. Salmah Binti Bahri
For enquiries kindly contact:
Medication Safety Section,Pharmaceutical Services Division, Ministry of Health Malaysia,P.O. Box 924, Jalan Sultan,46790 Petaling Jaya, Selangor.Tel: +603-78413200 / 3320Fax: +603-79682222 / 2268E-mail: [email protected]
Materials published in this newsletter may be reproduced with permission.
The Pharmaceutical Services Division (PSD) shall not be liable for any loss or damage caused by the use of any information obtained from this newsletter
Editorial MembersChe Pun Binti BujangWan Mohaina Binti Wan MohammadJohn C.P. ChangFaridah Binti Md. YusofSubasyini a/p SivasupramaniamTea Ming HuiErik Tan Xi YiYen Sze WheyOng Su HuaJuliana Binti Nazlim Lim
Medication Safety Newsletter Vol 6 Issue 2 December 2014
Editor’sEditor’sEditorial Board
High-Tech Pill Will Text When Swallowed
1) Proteus Digital Health has developed a pill which enables the caregivers and doctors to get alerts the momentpatients swallow their medications.
2) This system is already available for over-the-counter sale in a pilot program in the United Kingdom.3) It is intended for the growing number of aging people and is expected to be most in demand among those
recently discharged from a hospital stay who may face particular challenges adhering to a new medicationregimen.
• Each of the ‘texting pills’contains a tiny metal sensor,the size of a grain of sand, thatemits a signal when it gets wetin the stomach. It then passesharmlessly through the body.
• The pill’s signal is picked upby a patch on the arm, whichtransmits the message bywireless Bluetooth technologyto the patient’s mobile phone.
• The phone then texts thepatient’s contacts – such as aloved-one and their doctor ornurse – telling them it has beentaken.
Page 3Medication Safety Newsletter Vol 6 Issue 2 December 2014
Are we doing it right??
Lack of information on the drugs side-effects and
identifying patients at risk are common causes of
elderly hospitalization. When prescribing medications
to the elderly, age and frailty are major determinants
for severe adverse drug reactions1. Hélène Peyriere
et al2 in her prospective study found that significant
hospital admissions among elderly secondary to
adverse drug reactions were actually avoidable. Cost
of care from iatrogenicities is expensive3, but to subject
patients to poor quality of life is even more! So, take
time to think thoroughly before you take that pen and
scribble down the prescription for your elderly patient.
So the questions now are: Does she need the
Amitriptyline in the first place? Does the possible side-
effects including dizziness were considered before she
was given the medication? Was the GP aware that
she developed dizziness as a side-effect of
Amitriptyline and that Prochloperazine can induce
postural hypotension especially in elderly?
After several visits, the persistent symptoms with
absence of significant physical examinations and
OGDS findings, she was deemed to be somewhat
anxious and was prescribed Amitriptyline. She was
then discharged from the clinic to be followed up at
outpatient department. After a few days, she developed
severe dizziness, especially in the morning. She
sought treatment from a GP who then prescribed her
Prochloperazine. The dizziness seems to become less
initially but several days later, the dizziness recurred
and got worse especially when she stood up to walk.
The story became tragic as she had a fall from the
dizziness and fractured her hip. She then underwent
hip surgery and was warded for weeks as she was
confused and contracted nosocomial infection. The
prolonged hospital stay had caused her to be
depressed and withdrawn. She became weak and
malnourished as she refused to eat, functionally
declined and became bed bound. The marked
deterioration of her condition has led her daughter
have her condition re-examined. She was given
Mirtazepine and was rehabilitated over a period of 14
months. At last, the robust lady recovered from the
complications and had become totally independent.
Reference
1) Graziano Onder et al, Adverse Drug Reactions as Cause of Hospital
Admissions: Results from the Italian Group of Pharmacoepidemiology in the
Elderly (GIFA), Journal of the American Geriatrics Society, December 2002,
vol 50, Issue 12, 1962–68,
2) Hélène Peyriere et al, Adverse Drug Events Associated with Hospital
Admission, The Annals of Pharmacotherapy, January 2003, vol. 37 no. 1 5-
11
3) Patrick Haentjens et al, The Economic Cost of Hip Fractures Among
Elderly Women : A One-Year, Prospective, Observational Cohort Study with
Matched-Pair Analysis, J Bone Joint Surg Am, 2001 Apr 01;83(4):493-493
>> from front page
Home Medication Review
The transformation of pharmacyservices over the years hasbroadened the scope ofpharmacists from being responsiblefor the supply of medicines to amore patient-centred care.Pharmacists involvement in patientcare has contributed towardsimproving health and economicoutcomes, enhancing quality of life,minimizing the incidence ofmedicines-related adverse eventsand reducing morbidity andmortality rates.
Home Medication Review (HMR)was introduced by the Ministry ofHealth in 2006. This service, whichfocuses mainly on stroke,psychiatric and geriatric patients,provides a platform for thehealthcare providers in managingchronic patients with complicatedpharmacotherapy issues. Patientswith these illnesses usually havedeteriorated functionalities and tendto encounter difficulties whenmanaging medications bythemselves.
The Geriatric Department, HospitalKuala Lumpur started home visitservices involving doctors, nurses,physiotherapists and occupationaltherapists since 2006. In 2009,pharmacists were also involved inthe geriatric multidisciplinary team.The pharmacist’s role is to identifymedication related problems (MRP),perform medication reconciliationsand educate patients and/orcaregivers on the Quality Use ofMedicines (QUM). Throughthorough medication reviewsconducted by pharmacists, drugtreatment received by patients canbe optimized.
By Hadijah Mohd Taib, Rosmaliah Alias & Jacqueline Wong Hui YiPharmacists, Kuala Lumpur Hospital
Ho
me
Vis
it P
roce
ss
Pre Visit – Identify case Visit day- Reconcile medications Post Visit – Discussion on MRP
Examples of the medication related problems being identified are overstocking of medications due to multiplefollow up at various facilities, non-adherence to the medications prescribed and inadequate medicationsupply due to defaulted follow up. An adverse drug reaction (ADR) case was also encountered, where the
patient was found to be dehydrated and required readmission for further management.
Figure 1: Medication related problem chart*MMAS- Modified Morisky Adherence Scale (International medication adherence assessment tool)**DFIT – Dose, Frequency, Indication, Time (medication administration knowledge assessment tool)
All medication related problems (MRP)detected during home visits are discussed atthe Geriatric Multidisciplinary Meeting (MDM)every Monday. Appropriate pharmaceuticalcare interventions will be recommended anddiscussed with the geriatricians to ensurebetter therapeutic outcomes in the overallmanagement of the patients. Hence, HomeMedication Review helps to improve healthoutcomes by emphasizing appropriate, safe,judicious and quality use of medicines.
Re-labelling medications and educate patient.
The Medication Safety Section, Pharmaceutical Services
Division welcomes contributions by readers.
Please address your articles, reports, pictures etc. together
Use of Tall Man lettering to reduce the confusionbetween similar drug names. Tall Man (uppercase)letters are used within a drug name to highlight itsprimary dissimilarities and help to differentiate look-alike names.1 Studies have shown that Tall Manlettering can draw the attention to the highlightingsections of the drug names making them less prone tomix-ups.2,3
Page 5Medication Safety Newsletter Vol 6 Issue 2 December 2014
Drug names confusion remains one of the main causesof medication errors and near misses. In most cases,the mix-ups are due to look-alike or sound-alike drugnames (LASA).
Table shows some examples of confusing drug namesreported to the Medication Error Reporting System.
Intended Drug Confused With
amoxycillin cloxacillin
benzathine penicillin benzylpenicillin
BRUFEN BACLOFEN
carbamazepine chlorpromazine
carbamazepine carbimazole
cefuroxime cefotaxime
clozapine olanzapine
daunorubicin doxorubicin
flupentixol inj fluphenazine inj
glibenclamide gliclazide
gliclazide glipizide
hydroxychloroquine hydrochlorothiazide
lithium carbonate calcium carbonate
MAXITROL MAXIDEX EYE DROP
mefenamic acid tranexamic acid
methyldopa MADOPAR
streptokinase streptomycin
sulperazone cefoperazone
valsartan VASTAREL
Use additional warning labels for LASA medicines.These labels can be placed on storage bins, medicationtrolleys or emergency trolleys.
Identify medicines based on their names andstrength and not by their appearance or location.
Identify all LASA medicines in your organization andensure staff have the access to the information.
Include topics on confusing drug names inCME/CPE/CNE.
Encourage patients and their caregivers to askwhenever a medication vary from what is usuallytaken.
1. Institute for Safe Medication Practices (ISMP) Survey on tall man lettering to reduce drug nameconfusion. ISMP Med Saf Alert! 2008;13(10):4.2. Filik R, Purdy K, Gale A, Gerrett D. Drug name confusion: Evaluating the effectiveness of capital (‘Tall Man’) letters using eye movement data. Social Sci Med. 2004;59(12):2597–2601. 3. Filik R, Purdy K, Gale A, Gerrett D. Labeling of medicines and patient safety: Evaluating methods of reducing drug name confusion. Hum Factors. 2006;48(1):39–47. 4. Guide on Handling Look Alike Sound Alike Medications, 2012. Pharmaceutical Servives Division.
Recommendations:
References:
Drug NamesConfusion
The use of multiple medications or duplicativemedications may increase the risk for drug-drug anddrug-disease interactions, mix-ups and the potentialfor side effects.
Elderly patients often present themselves with multipleco-morbidities. It is not uncommon for elderly patientsto be treated concurrently for hypertension, ischemicheart disease, diabetes, osteoporosis, urinary tractproblems, gastrointestinal diseases.
mEDICINES& THE ELDERLY
By Yen Sze Whey
Administrator, Quality & Patient Safety, Subang Jaya Medical Center
How then, do we mitigate the risks of multiplemedications in the context of an elderly patient withcomorbidities?
Principles to manage medications safely inelderly patients:
Prevention: Avoid prescribing for minor, non-specific or self-
limiting complaints. Only prescribe when there is good evidence of
likely efficacy as well as a strong need for themedication.
Regular medication review An accurate drug history is essential for patients
on multiple medicines. This is best achieved when
the medication review is done in the patient’s
home. Alternatively, ask the patient to bring in all
their medicines (prescribed and non-prescribed).
A review includes assessing appropriateness and
ongoing need for therapy, adverse effects and
interactions, the dosage regimen and
formulations, and also compliance.
Non-pharmacological approaches Use lifestyle measures whenever possible either
as an adjunct or instead of medications.
Communication Talk with the patients about their concerns,
expectations, difficulties in using the medications
and their ability to follow the medication regimen.
Discuss changes to the medication regimen with
the patient’s other health care providers.
Simplify Reduce the regimen to essential drugs. Consider
fewest possible dosage intervals and dose
reduction where appropriate. Limit use of optional,
Training on MERS Online for StateMedication Safety Liaison Officers atComputer Lab, National PharmaceuticalControl Bureau on 8 April 2014.
A Medication Safety Course was held inBentong Hospital, Pahang on 18 April2014.
A talk on Medication Safety was held at SriKota Specialist Medical Centre on 27 August2014 in conjunction with the Safety MonthCampaign at the hospital.
The Kedah Pharmaceutical Services Division, MOH incollaboration with Malaysian Pharmaceutical Society,Kedah-Perlis Branch had organized a Medication SafetySeminar 2014 in Hotel Star City, Alor Setar on 8 June 2014.
The Root Cause Analysis Workshop 2014 was organized bythe Pharmaceutical Services Division, Ministry of Healthfrom 12 to 14 August 2014 in Concorde Inn, KLIA Sepang.
The Pharmaceutical Services Division, Penang State HealthDepartment had organized a Medication Safety Seminarwith the theme Considerations to Special Populations inPenang Hospital on 17 May 2014.