drug and poison information services pharmacy …
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DRUG AND POISON INFORMATION SERVICES PHARMACY DEPARTMENT, HOSPITAL TELUK INTAN, TEL:05-6298400 EXT:8474
P H A R M A C Y B U L L E T I N
DISEMBER 2017
LOCKER4U 2
ADVERSE DRUG REACTIONS RE-
3
MEDICATION ER-ROR REPORT
4
LIST OF ANIMAL ORIGIN
MEDICATIONS 5
LIST OF COLD CHAIN
MEDICATIONS 6
Inside this issue:
Locker4U is the latest value-added service
available in our hospital since March 2017.
This service allows customers to collect their
medications at any time without having to
wait their turn at the counter. This promotes
faster and more effective supply of medi-
cines.
The ultimate goals of this new service are to
reduce patient’s waiting time, reduce conges-
tion of patients at the Out-patient Pharmacy
(OPP) and offer a more flexible way of collect-
ing medicines.
Each locker will be shared by 4 patients
according to the following table:
Page 2
Registration Criterias:
A. Patient
Obey and understand the treatment of
medicines.
Understand how to take and use
medicines.
Able to comply with the service’s rules
and regulations. Responsible for lockers and keys
provided.
Stable
B. Medicines
Dosage forms are tablet / capsule and
syrup instead of an extemporaneous
preparation (commercial syrup only).
Not inhaler dosage form and
psychotropic drugs.
Not sensitive to temperature and
humidity changes (such as insulin and
topical preparation).
C. Prescription
Number of drugs on each prescription: 4
types of medicines and above.
Follow up period: 2 months and above.
First time drug supplied should be at the
pharmacy counter.
Have the next doctor's appointment date
(except dialysis patients).
D. Others
The supply of GTN drugs to patients is
done at the pharmacy counter during
office hours only
LOCKER
CODE
DATE OF MEDICINES
COLLECTION
A First Week (1st - 5th day)
B Second Week (8 - 12th day)
C Third Week (15th - 19th day)
D Fourth Week (22 - 27th day)
Total Number of Locker = 72
Each Locker has 4 keys =
(A, B, C, D)
Number of patients can be
registered;
72 x 4 = 288 patients
Location = Out-patient
Pharmacy Corridor
(Facing Recording Office)
Inside view
Front view (facing OPP corridor)
Back side view (facing OPP waiting area)
Page 3
Health professionals play an important role in the safety of medicines by
reporting any encountered adverse drug reaction (ADR) during the care of a
patient. From January to Disember 2017, Hospital Teluk Intan has submitted
a total of 131 ADR reports to the National ADR Centre (severe (N = 11),
moderate (N = 53), mild (N = 67). As shown in Figure 1 , the three most
common pharmacological groups that caused ADR are anti-infectives (N = 49),
analgesics (N = 19), and NSAIDs (N = 18).
Majority of the ADR cases were reported by the hospital pharmacists
(N = 105). Malays have the most ADR cases reported (N = 76), followed by
Indians and Chineses. Most of the patients are adults aged 18-65 years old.
There were 16 reports for pediatrics aged below 12 years old and 25 reports
for elderly patients above 65 years old.
Examples of adverse reactions caused by the top three drugs:
1. Diclofenac Sodium: Itchiness, rashes, pruritus, sweating and hot, body
numbness, shortness of breath, hypotension, angioedema and bronchospasm.
Therefore, special precautions must be taken especially in asthmatics patient
in view of the risk of fatal bronchospasm.
2. Metoclopramide: Chest tightness, shortness of breath, sweating, and
extrapyramidal effects (spasms, rigidity and muscle contraction). It is noted
that about 1%-25% patient will likely get acute dystonia and it is dose and age
related. The risk increases in paediatrics, patient younger than 30 years old
and elderly (beers criteria).
3. Isoniazid: Multiple vasculitis (rashes), itchiness and derange liver function
test. Hence, it is contraindicated in patients with acute liver disease and
special precautions must be taken in patient with liver or renal impairment.
Figure 1
‘Medication Error Reporting System’ requires a collective effort
from various parties and a change in the way we manage
medication errors. We need to be able to discuss errors openly,
encourage reporting of errors and maintain a culture that is
non-punitive and blamelessness. With this, healthcare
providers will be able to learn from the errors.
Table 1 shows the list of Classification of Medication Error
Severity:
From January to Disember 2017, Hospital Teluk Intan has
reported a total of 216 medication errors (ME) to the
Medication Safety Centre. The most common severity of
medication error is under category B (N = 149). The second
most reported is category C, with a total of 11 reports. MEs
under categories D, F, and H are reported 1 each.
There are 4 reports that need to be highlighted for our concern:
1. Medication Error Category D
An in-patient was prescribed with Tablet Frusemide 80mg OD.
However, the drug was wrongly served by a staff nurse as
Tablet Frusemide 80mg BD. The incident occurred because
the responsible staff nurse had lack of experience and had
misunderstood the house officer’s handwritten instruction
which looked like BD instead of OD. The error was detected by
the pharmacist and the staff nurse was informed about it.
Tablet Frusemide was continued as 80mg OD.
2. Medication Error Category D
Expired Amoxicillin capsule 250mg tds (8/2017) was given to
patient at mini pharmacy on 18/11/2017. Patient's mother
claimed her child’s fever/condition did not improve and no-
ticed the expired antibiotic after 3rd dose taken and came to
the main outpatient pharmacy on 20/11/2017. The incident
occurred because of failure of pharmacist in adhering to work
procedure by checking the medication before dispensing. The
expired medication was retrieved and replaced with Amoxicillin
250mg with expiry date Feb 2020. Patient was advised to seek
doctor’s attention if patient had not improved after taking the
medication.
3. Medication Error Category F
An in-patient was administered with IV Vancomycin 750mg TDS
on 23/8/17. Based on the Therapeutic Drug Monitoring (TDM)
analysis, it was suggested to withhold the second and third
doses (8pm and 4am) and to start a new regime of IV
Vancomycin 750mg BD on 24/8/2017 at 12noon. Re-sampling
of blood was planned on 25/8/17 at 11.30pm. Although the
ward was informed, no sample was received till 4/9/2017. By
then, patient had developed Acute Kidney Injury (AKI)
secondary to Vancomycin toxicity. TDM level on 4/9/2017 was
>50 mcg/ml. The incident occurred because the responsible
house officer had lack of experience and failed to adhere to
work procedure. The error was detected by the specialist and
medical officer during ward round and the patient was admitted
for further monitoring and then was discharged on
1/10/2017.
4. Medication Error Category H
A patient under the follow-up at the Orthopaedic Clinic of
Hospital Seri Manjung was admitted to Hospital Teluk Intan for
an elective operation. On 13/3/2017, patient was induced with
general anaesthesia. After repositioning to prone, anaesthesia
medical officer (MO) then proceeded to administer intravenous
(IV) drugs prepared by orthopaedic house officer (HO). The
drugs are IV Cefuroxime 3g (diluted in 20cc) and IV Vancomycin
2g (diluted in 40cc). Patient was administered with test dose
prior to the full dose. The last 500mg dose of IV Vancomycin
was withheld until the patient is repositioned to supine position.
After repositioned, anaesthesia MO noted hypotension (BP:
66/30), end tidal CO2 started dropping to 21, then to lowest
19. However, patient did not respond to IV Ephedrine 6mg.
Manual bagging was initiated when the SPO2 desaturated until
81%. The anaesthesia specialist had suspected patient
developed an anaphylactic shock secondary to drug
(Vancomycin or Cefuroxime). Patient was then given IV
Adrenaline 1:10000 1cc; BP had picked up to 136/68, end
tidal CO2 had picked up to 40. Patient was also given IV
Hydrocortisone 100mg STAT, IV Rantidine 50mg STAT, and IV
Chlorpheniramine 10mg STAT. Patient was also noted to have
bilateral earlobe swellings. No rashes, no rhonchi, no vocal
cord oedema was noted. Upon clarification, the Vancomycin
was actually intended for local instead of IV administration.
Procedure was finally abandoned and the patient was admitted
to ICU for close monitoring.
Category Code
NO ERROR
Potential error, circumstances/events have
potential to cause incident A
ERROR, NO HARM
Actual Error – did not reach patient B
Actual Error – caused no harm C
Additional monitoring required – caused no harm D
ERROR, HARM
Treatment / intervention required – caused
temporary harm E
Initial/ prolonged hospitalization – caused
temporary harm F
Caused permanent harm G
Near death event H
ERROR, DEATH
Death I
Page 4
Page 5
BOVINE
PORCINE:
HORSE SERUM
No. Medicines
1. Acitretin 10mg capsule
2. Amoxycillin 250mg capsule
3. Amoxicillin 500mg capsule
4. Celecoxib 200mg capsule
5. Cephalexin monohydrate 250mg capsule
6. Clindamycin 300mg capsule
7. Cloxacillin 500mg capsule
8. Cloxacillin 250mg capsule
9. Cyclosporine 25mg capsule
10. Cyclosporine 100mg capsule
11. Doxycycline 100mg capsule
12. Duloxetine 30mg capsule
13. Duloxetine 60mg capsule
14. Dutasteride 0.5mg capsule
15. Essentialle phospholipid capsule
16. Gabapentin 300mg capsule
17. Gemfibrozil 300mg capsule
18. Heparin sodium 1000 IU/ml Injection
No. Medicines
19. Heparin sodium 5000 IU/ml Injection
20. Heparin sodium 10 IU/ml in NaCl 0.9% w/v Injection
21. Hydroxyure 500mg capsule
22. Itraconazole 100mg capsule
23. Mefenamic acid 250mg capsule
24. Mycophenolate mofetil 500mg capsule
25. Omeprazole 20mg capsule
26. Phenytoin sodium 100mg capsule
27. Phenytoin sodium 300mg capsule
28. Pregabalin 150mg capsule
29. Rifampicin 150mg capsule
30. Rifampicin 300mg capsule
31. Thalidomide 50mg capsule
32. Tramadol 50mg capsule
33. Tranexamic acid 25omg capsule
34. Ursodeoxycholic acid 250mg capsule
35. Zidovudine 100mg capsule
No. Medicines
1. Pancreatin 150mg capsule
2. Enoxaparine sodium 40mg Injection
3. Enoxaparine sodium 60mg Injection
4. Hospira Vancomycin 500mg Injection
5. Tinzaparin Na 4500 Anti-Xa Injection (0.45ml)
6. Tinzaparin Na 10000 Anti-Xa Injection (0.5ml)
7. Cobra Antivenin Injection
8. Malayan Pit Viper Antivenin Injection
No. Medicines
1. King Cobra Antivenin Injection
2. Green Pit Viper Antivenin Injection
3. Polyvalent Snake Antivenin Injection Reference: Products’ leaflet
Temp (-10 OC)
Temp (2 — 8 OC)
Page 6
No. Medicine
1. Gemeprost 1mg pessary
No. Medicines
1. Adalimumab 40 mg (Humira)
2. Alfacalcidol 2 mcg/ml Inj (One-Alpha)
3. Alprostadil 500mcg Inj
4. Amphotericin B 50mg
5. Anidulafungin 100 mg Inj
6. Antihepatitis B Immunoglobulin 100IU
7. Antitetanus toxoid (ATT)
8. Antivenin – Cobra
9. Antivenin – Green Pit Viper
10. Antivenin – Hematopolyvalent
11. Antivenin – King Cobra
12. Antivenin – Malayan Pit Viper
13. Antivenin – Neuropolyvalent
14. Antivenin – Polyvalent
15. Antivenin – Sea snake
16. Atracurium 25mg/2.5ml
17. Beclomethasone dipropionate/ Formoterol
fumarate dehydrate (Foster)
18. Beractant 25mg/ml (Survanta)
19. BCG Vaccine 0.5mg
20. Bisacodyl 10mg suppository (Dulcolax)
21. Bupivacaine Heavy 0.5%
22. Carbaprost 250 mcg (Hembate)
23. Carbitotocin 100 mcg/Inj
24. Caspofungin 50mg Inj
25. Chloramphenicol ear drop
26. Chloramphenicol eye drop
27. Denosumab 60mg (Prolia)
28. Desmopressin 4mcg/ml Inj
29. Dinoprostone 3mg (Prostin E2)
30. Epoetin Alfa 2000IU
31. Erythropoietin Beta 2000IU
32. Factor VIII
33. Filgrastim 30MU (Neupogen)
34. Flupentixol 20mg
35. Glucagon Inj
No. Medicines
36. Hepatitis B 10 µg (Paediatric)
37. Hepatitis B 20 µg (Adult)
38. Influenza vaccine
39. Isoprenaline 0.2mg Inj
40. Insulin – Actrapid 1000 IU (Vial)
41. Insulin – Insulatard 1000 IU (Vial)
42. Insulin – Mixtard 300 IU (Penfill)
43. Insulin – Insugen Rapid 300 IU (Penfill)
44. Insulin – Insugen Basal 300 IU (Penfill)
45. Insulin – Insugen Combo 300 IU (Penfill)
46. Interferon Alfa 2β- Inj
47. Latanaprost 0.005% Eye drop
48. Lopinavir 80mg/ml Ritonavir 20mg/ml oral
solution (Kaletra)
49. Octreotide 0.1mg Inj
50. Oxytocin 10IU Inj
51. Palivizumab 100mg (Synargis)
52. Paracetamol 125 mg suppository
53. Pneumococcal Conjugated Vaccine
(Synflorix)
54. Pneumococcal Conjugated Vaccine
(Prevenar)
55. Profasi 5000 IU (Pregnyl/Pubergen)
56. Rabies Vaccine
57. Replenine –VF 500 (Factor 9)
58. Risperidone 25mg Inj
59. Rhogam 1500 IU
60. Rocuronium Bromide 50mg/ml
61. Streptokinase 150000 IU
62. Suxanethonium 100mg (Scoline) Inj
63 Synacten 250 mcg Inj
64. Syntometrine Inj
65. Tetanus Immunoglobulin
66. Tuberculine 1.5ml Inj
67. Varicella Zoster Immunoglobulin
68. Zuclophentixol 200mg (Clopixol)
Reference : 1. Products’ leaflet
2. Stor Integrasi