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