Pharmacy Bulletin

V O L U M E 7 ( I S S U E 3 / 2 0 1 1 ) H O S P I T A L T A I P I N G

INSIDE THIS ISSUE:

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Ward Pharmacy Service Update: Progress of 5S in Pharmacy Department Summary of ADR reports (Jan-Jun 2011) Pharmacy Gala Night 2011 Fabulous Purple

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the cist in Pharma hy?? W ward? o? o you d What d

Ward Pharmacy Service

The Ward Pharmacy Service was established in Hospital Taiping almost 5 years ago. However, some hospital staff are still not aware that there are full-time pharmacists based in many wards, and of their roles in the wards. Currently, Taiping Hospital has 8 full-time ward pharmacists, covering ICU, 5 medical wards and both surgical wards. This number will be increased when more pharmacists are available in the hospital. Some Statistics of Clinical Activities by Ward Pharmacists (January-June 2011) Drug information queries answered in the wards: 1867 (mostly on dosage, adverse drug reactions, and drug availability) Interventions made: 3583 (mostly for incomplete or inappropriate drug regimens, polypharmacy, drug administration errors, and therapeutic drug monitoring (TDM)). Medication history taken: 3495 patients Bedside counseling: 2111 sessions Bedside discharge dispensing: 1520 patients Cardio Rehab group counseling: 10 sessions (April-June 2011) - See page 3 for more on this service -

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EDITORIAL BOARD
Advisors: Pn. Narimah Md. Yusoff Pn. S. Nirmala Devi Chief Editors: Rema Panickar Sun Gaik Peng Editors: Cheng Shuh Yi Goh Ee Jye Khairunnisa N. Jeevanandan Leong Meng Fai Teh Xin Yi Toi Wai Hong
ur me y o welco and We a ck feedb ions: st sugge yahoo.com tin@ bulle pharm

UPDATE:

Progress of 5S in the Pharmacy Department

The 5S system has been implemented at Farmasi Klinik Pakar, Farmasi Bekalan Wad and Stor Integrasi. The work is still in-progress for all these three places. Through this system, drugs available in Hospital Taiping are now arranged alphabetically according to their pharmacological group, such as anti-infective, cardiovascular, analgesic, psychiatry, ear drops, eye drops, etc. This will help reduce errors in the process of dispensing medication. - See Page 4 for more information -

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Carbapenem Audit in the Intensive Care Unit (ICU) of Hospital Taiping

by N. Jeevanandan, Teoh Kai Lin, Nazedah bt. Ain@ Ibrahim, Ng Chew Beng

ABSTRACT
Data of monthly antibiotic usage showed an increased usage of carbapenems in the Intensive Care Unit (ICU) from January to September 2010. Thus, this study was conducted to audit the carbapenem usage in ICU, Hospital Taiping (HTPG). Method: This was a prospective, observational study on the use of carbapenems in the ICU of Taiping Hospital over 3 months (November 2010-January 2011). Patients started on IV carbapenems (either Meropenem or Imipenem+Cilastin) during the study period were identified and followed-up by pharmacists. documented in the data collection form. Results: From a total of 50 cases enrolled in the study, 82% of carbapenem prescribers were specialists, and the remaining 18% of the cases were started by medical officers. The mean duration of treatment with carbapenems was 5.95 1.4 days. The main reasons for starting carbapenems were not responding to previous antibiotics (24 cases; 48%), and treatment for severe infection as indicated in the National Antibiotics Guidelines 2008 (13 cases; 28%). In 90% of the cases, carbapenems were prescribed empirically. Culture and sensitivity (C&S) tests were conducted prior to initiation of carbapenems in 41 over 45 of the empiric cases. However, it was noted that more than 20% of the C&S results were not traced, which is not optimal practice. De-escalation was only carried out in 12 empirically-treated cases. Conclusion: This study showed that empiric use of carbapenems was common in the ICU. Main reasons for initiating carbapenems were patients not responding to previous antibiotics and treatment for severe infection. Septic workout was done before initiating carbapenems in most of the empiric cases, but tracing of C&S results needs to be improved. All relevant information was retrieved and

Summary of Medication Error Reports in Hospital Taiping (Jan-June 2011)

A total of 157 medication error reports were received by the Pharmacy Department Drug and Poison Infor mation Service between January to June this year. All these reports were submitted by pharmacists. The table below summarises the different types of errors reported.
Type of Medication Error Prescribing Error No. of reports 76

Some examples of errors reported

T. Dexamethasone was mistakenly prescribed as 1g stat when the intended dose was 1mg stat. T. Glibenclamide 60mg BD was prescribed while it should have been T. Gliclazide 60mg BD. T. Aspirin and T. Cardiprin were prescribed for the same patient when both are indicated for the same purpose (antiplatelet). Doctor prescribed Normal Saline eye drops, but hypertonic saline 3% eye drops was dispensed. C. Amoxycillin 500mg TDS was wrongly filled with C. Cloxacillin 500mg TDS. T. Methotrexate 12.5mg weekly was wrongly labelled as T. Methotrexate 12.5mg OD. Doctor prescribed T. Hydrochlorothiazide 125mg OD (intended dose was 12.5mg OD) and this dose was served by staff nurse. Error was noted by MO. Patient was monitored and did not suffer any adverse reaction of overdose. Doctor prescribed T. Daflon 1g TDS x 3/7, 1g BD x 3/7, 1g OD x 3/7 but staff nurse served the patient 1g TDS for 4 days. 5 tablets of T. Warfarin 1mg were prepared by student nurse to serve a patient but patient was on 3mg OD. Error detected before serving. During routine ward check, pharmacist found 1 ampoule of IV Tramadol 50mg mixed with 10 ampoules of IV Vitamin K 10mg (lookalike labels).

Interventions made
-Reinforce importance of prescription screening by pharmacists - Continuing nurse and house officer education sessions

Filling or Dispensing Error

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- Reinforce counterchecking of medication and labels - Implement 5S (standardised arrangement of medication)

Administration Error

28

- Counterchecking of drug supply and administration by ward pharmacists. - Continuing nurse education sessions

Others 2

15

- Alert notice put up to inform nurses of look-alike drugs

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Eight hours a day just to monitor medication-related issues in one ward - sounds like a breeze doesnt it? But talk to any full-time ward pharmacist and 90% will tell you that these hours are just packed. Lets join a Taiping Ward Pharmacist on a typical day:

Activities in the ward:

Screen medication prescriptions of each pa-

tient, ensuring appropriate drugs, doses and timing. Read through patient case notes to ensure optimal treatment. Document full medication history of every patient admitted (CP1). Follow specialists on ward rounds to better understand the treatment plans, provide more patient-specific recommendations, highlight any medication-related problems, suggest changes, provide drug information, etc.
Counsel patients at their bedside, for example

At Ward Supply / Satellite Pharmacy

Charting of the medication to be supplied

for every patient in the ward.

Ensure any changes in the ward medication

are updated at Ward Supply.

Inform staff nurses of any special instruc-

patients with inhalers, on drugs with special instructions, or with poor understanding of their medication. Check the ward medication trolley to ensure patients medications are placed and labeled correctly. Monthly ward check on drugs to reduce incidence of storing expired drugs or overstocking in the wards.

tions for drug administration or storage.

More ward activities:

Counselling of patients as necessary Bedside discharge dispensing, where the ward pharmacist checks the pa-

tients prescription before discharge, packs the medication and supplies it to the patient or family members in the ward with counselling. Provide medication list/ reminder card to patients who need it. Prepare SPUB for patients who wish to collect their medication at other locations. Remove any discontinued medication with the patients permission. Clerking cases in the patient monitoring form (CP2), to help identify problems or better understand the case. Complete daily statistics record (CP3) and other paperwork.

Other duties:
Besides the daily routine, our ward pharmacists are also involved in the Cardio Rehabilitation Programme twice a week, performing medication reconciliation when patients are moved to other wards or hospitals, training of ProvisionallyRegistered Pharmacists (PRPs), conducting briefings for house officers, conducting education (CME) sessions for the ward nurses, attending medical department grand rounds, attending stroke rounds with a multidisciplinary team, conducting journal club discussions, clinical case presentations, annual research projects, and attending weekly CME/ CPD sessions at the pharmacy department.

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S BEFORE 5

Improvements AFTER 5S

Medication Returns Box

SPUB Counter

BEWARE of Look-alike Medications!!

IV Ceftriaxone 1g and IV Cefotaxime (500mg / 1g)

IV Vitamin K (1mg / 10mg) and IV Tramadol 50mg

T. Cetirizine 10mg and T. Loratadine 10mg

T. Amlodipine 5mg and 10mg

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The first half of 2011 saw a total of 104 adverse drug reaction (ADR) reports being submitted to the Drug and Poisons Information Service (DIS). 99% of these reports were prepared by pharmacists, while one was submitted by a medical officer. Other reports may have been submitted directly to MADRAC without going through the pharmacy department. The table below shows the 15 drugs with the most number of ADR reports this year. Adverse Drug Reaction Reports Jan-June 2011
No.
1 2

Drug Name
T. Isoniazid C. Rifampicin

Total no. of reports

8 8

Reaction (no. of cases if more than 1)

Elevated AST-(4) Elevated AST-(3) Rigors, SOB, nausea & fever Swelling over orbital region(2) Elevated AST-(3) Rashes-(2) Dry mouth Burning headache Elevated AST-(2) Generalized skin rashes, itchiness and swollen-(2) Pedal edema Vomiting Facial swelling Shortness of breath-(2) Rashes & itchiness Rashes, itchiness Elevated ALT(2) Elevated ALT Lethargy & weakness Choking sensation Elevated ALT(2) Eye swelling(2) Gastric pain Burning sensation over arm Lethargy & weakness Acute interstitial nephritis Cough Body rashes & itchiness (3) Lethargy & weakness Lethargy & weakness Dropping of platelet Skin redness Skin redness

T. Aspirin

4 5 6 7

T. Pyrazinamide T. Erythromycin T. Varenicline IV Cefoperazone

7 5 4 4

Skin redness Acute interstitial nephritis Nausea & dizziness Rashes over inguinal area Skin redness

Constipation Sore lips

8 9

T. Ethambutol T. Allopurinol

4 3

10 11 12

T. Amlodipine IV Ceftriaxone T. Diclofenac Sodium IV Diclofenac Sodium T. Hydrochlorothiazide Polyvalent snake antivenom injection

3 3 3

Headache Body swelling & itchiness Bilateral periorbital swelling Swollen eyes Facial puffiness Shaking of limbs

GIT discomfort & diarrhea Eye swelling & tears Headache, SOB, tearing

13 14 15

3 3 3

Acute interstitial nephritis SOB, abdominal cramps

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Pharmacy Gala Night 2011 Fabulous Purple

s rimah Pn. Na speech

The Stocking Dance

This year, Pharmacy Night was held at SSL Traders Hotel on 23rd July, with the theme Fabulous Purple. Dinner began at 8:35pm with an opening speech by the organizing committee head, Puan. Nirmala. This was followed by a welcome speech by the Head of our Pharmacy Department, Puan. Narimah, who then conducted the opening ceremony. Those who attended included pharmacists, pharmacy assistants, attendants and other staff of the pharmacy department, as well as students undergoing training here. Several ex-staff members also took the trouble to attend the function and add to the cheer. After enjoying the buffet dinner, entertainment was provided by some of our students, with an impressive solo song, and a Bollywood-style group dance. Our pharmacy assistants had the crowd in stitches with their unique and creative Stocking Dance. It was easy to guess which pair of legs belonged to Madam Marleythe ones that jumped highest! The organizers also prepared some table games, including a crossword puzzle, find-the-words puzzle, and collecting items on a list. Most of the games were related to the pharmacy department or drugs. The King and Queen of the Night were Encik Haji Sofian (pharmacy assistant) and Cik Nasyidah (student) respectively, who were judged the best-dressed on that night. Those who did not fulfill the purple theme were punished! The men had to perform push ups while women did a catwalk. However, Encik Renganathan managed to escape with the help of a handy tongkat and good acting skills! The evening was interspersed with lucky draws, ensuring every guest went home with a gift. The happiest moment for three of our pharmacists came near the end of the night, with the grand prizes of microwave-oven and DVD player going to the three young men, Encik Izzat, Encik Majid, and Mr. Toi. Kudos to the organizing committee on hosting a successful, enjoyable event!

Bollywood

Dance

Table games..a team effort!

Lucky Dra w prize galore s

Punishm ent for the non-purp les!