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SELF-ASSESSMENT GUIDE FOR MEDICATION SAFETY Background This assessment guide has been compiled in conjunction with the Report on Drug Administration Procedures and Practices in Public Hospitals 2005 (DAR) in order to improve the safety of patients receiving medicines. It focuses on the ten key areas that significantly influence safe medication use. Core distinguishing characteristics are classified as either mandatory or otherwise as recommended practices. Users should score their hospital’s progress on the recommended characteristic as A) Fully implemented in all areas, B) Fully implemented in some areas, C) Partially implemented in some or all areas, D) Not implemented or E) Not applicable Ten Key Areas 1. Drug Allergy 2. Patient Identification in Medication Administration 3. Charting of Medication Administration Record (MAR) 4. Handling of High Risk Medications 5. Specific High Risk Medications 6. IV Infusion Devices 7. Look-alike and Sound-alike Medications 8. Drug Replenishment and Storage 9. Drug Re-packaging and Re-labeling 10. Prescription Practices using the Medication Order Entry (MOE) System

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(1) Drug Allergy Allergic reactions to medications can range from mild skin reactions such as maculopapular rash to life-threatening anaphylaxis causing laryngeal oedema, bronchospasm, or hypotension. Although drug allergy is a rare cause of death, it may contribute significantly to patient morbidity. Healthcare professionals have a pivotal role in preventing recurrence of drug-induced allergic reactions in susceptible patients. All healthcare providers should be aware of the importance of drug allergy history documentation.

Cases

Preoperative prophylaxis amoxycillin was prescribed and taken by a patient

an hour prior to the surgery at home. During routine pre-operation checking,

the patient alerted the nursing staff of a prior allergy to amoxicillin and

ampicillin.

An inpatient with a documented allergy history to prochlorperazine was

prescribed and administered with the drug. The patient received a total of

two doses. Both doctor and nursing staff were unaware of the patient’s drug

allergy history despite a red “Drug allergy” label being fixed onto the drug

cardex.

An unknown allergy history was noted in the current medication

administration record (MAR) of a patient. However, the patient developed

skin rash over the chest wall and back after four doses of co-trimoxazole

(Septrin®) were administered.

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Action Status

A Fully implemented in all areas

B Fully implemented in some areas

C Partially implemented in some or all areas

D Not implemented

E Not applicable

Core Characteristics

Strategies for maintaining accurate and consistent allergy documentations to ensure patient safety and quality patient care

For Medical Staff DAR Mandatory 1. Patients’ drug allergy histories are always assessed in

each encounter and documented in medical chart /record, MAR/prescription and clinical management system (CMS). (see Figure 1) Patients without drug allergy are recorded as “No Known Drug Allergy (NKDA)” in both the MOE and manual system.

4.4b

Yes No

Mandatory 2. Allergies are listed and made clearly visible on all pages of MARs for drug administration and dispensing.

Yes No

Mandatory 3. Prescribers re-check, verify and amend the drug allergy of patient and ensure that any allergy alerts generated by the system will be relevant at the time of prescribing.

4.4b

Yes No

For Pharmacy Staff DAR Mandatory 4. Prior to dispensing medicines, pharmacy staff check

medication(s) ordered against the patient’s current allergy history for drugs to which patients may be allergic (including cross allergies). (see Figure 2)

Yes No

Mandatory 5. Medicines are not dispensed if the section for entering Drug Allergy information in the MAR/prescription is left blank (patient allergy is a compulsory field).

Yes No

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Strategies for maintaining accurate and consistent allergy documentations to ensure patient safety and quality patient care

For Nursing Staff DAR Mandatory 6. Medicines are not administered if the section for

entering Drug Allergy information in the MAR/prescription is left blank (patient allergies is a compulsory field).

Yes No

Recommended 7. Patients’ drug allergy status (prominent signs, coloured record, drug allergy alert bands etc) are made readily distinguishable and easily reviewed by doctors and nurses during the drug prescribing and administration. (see Figure 3)

A B C D E

Recommended 8. For patients who have an allergy, ensure allergy alert wrist bands are worn. In settings where these allergy bracelets are not used, there is a drug allergy notification policy.

A B C D E

For Medical, Pharmacy and Nursing Staff DAR Recommended 9. Patients/carers are educated and instructed to share the

drug allergy information with all their healthcare providers in all encounters to prevent recurrence of allergic drug reactions.

A B C D E

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Guideline on Handling Problems on Using the CMS Drug Allergy Module

Objective: To provide a safe and consistent method to handle dubious medication allergic history. General recommendation on communication with patient: Patient should be informed of the safety problem if the allergy information is not specific. Patient should be advised to obtain more specific and reliable medication allergy information

from relevant source and update us when it is available. The communication should be documented in the clinical notes.

Problem Information should be entered in/as:- Unknown drug NKDA Only drug class is known (e.g. anti-TB, antibiotics)

Enter as free text in drug allergy module

The allergen is outside the database, English name available

Enter as free text in drug allergy module

The allergen is outside our database and only Chinese name is known

Enter as free text in drug allergy module with English phonetic.

Deletion of drug allergy record 1. Drug allergy is denied by patient/carer:

The absence of drug allergy should be re-verified, preferably from all possible sources as far as practically possible e.g. from patient’s relatives, medical records. Inform patient on the deletion and the possible implication. Document in CMS of the communication and the action you have taken to ascertain the absence of drug allergy.

2. Patient is already on the medication he/she was allegedly allergic to: Ascertain drug compliance. Delete the allergy record.

Figure 1. Sample of Guideline on Handling Problems on Using the CMS Drug Allergy Module

Source: PMH CMS Sub-Committee. Used with permission.

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Figure 2. Sample of drug allergy reference chart depicting drugs of the same class for possible cross sensitivity

considerations. Source: TKOH pharmacy. Used with permission.

8

Figure 3. Sample of coloured card attached to MAR for ease of drug allergy identification

Source: TKO pharmacy. Used with permission.

9

Cases

Two patients with same names but different surname consulted the same

doctor at GOPD. The prescription of patient A was dispensed to patient B

as the pharmacy staff was not aware of the wrong patient named. The

incident was discovered when the patient A came to the pharmacy to collect

her drug.

Two nurses gave medication to a patient. They ensured the right drug, right

dose, right time and right route to be given, but did not check the patient’s

name against the MAR form. The medication was left unattended and given

by another nurse without checking patient.

(2) Patient Identification in Medication Administration

Patient identification remains a challenge in hospitals because of the number of complex interventions that occur to patients during the hospital stay from labellling of specimen, reading/filing laboratory report, drug prescription and administration to performing investigation/procedure. These interventions occur in a variety of locations and are provided by a team of staff who work in shifts. Hospitals generally rely on standardised wristbands containing the patient’s name and other identifying information such as hospital number or HKID for correct patient identification. All prescriptions, doctor’s order or entry should only be made on a chart with patient’s label or identity.

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Action Status




D Not implemented

E Not applicable


Strategies are implemented to prevent patient misidentifications

For Medical Staff DAR Mandatory 1. Doctors do not prescribe on MAR/prescription without

the patient’s gum label affixed or patient’s particulars. 4.4a

Yes No

Mandatory 2. Correct patient identification is always ensured before prescribing medicines.

Yes No

For Nursing Staff DAR Mandatory 3. Patients are required to wear identity bracelets

throughout the hospital stay. In settings where identification bracelets are not used, there is a patient identification policy.

Yes No

For Medical and Nursing Staff DAR Mandatory 4. A match between the patient and the intended

service/treatment is always ensured.

Yes No

For Pharmacy and Nursing Staff DAR Mandatory 5. Two core patient identifiers are used before

administration and dispensing of medicines to patients. (see Figure 4) (The “numbered ticket” issued by the pharmacy outpatient for medications pick-up can be considered as a piece of core patient identifier)

Yes No

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Figure 4. Nursing Standards for Patient Care – Patient Identification

Source: COC(N) Paper 4/2004. Used with permission.

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(3) Charting of Medication Administration Record (MAR) MAR is a document detailing the entire in-patient medicine administration process. It is used by medical, nursing and pharmacy staff for prescribing, medication administration and dispensing, respectively.

Cases

A nurse omitted one dose of Slow K (prescribed as one tablet, BD) at 8pm for the patient. The dose was omitted because the nurse did not notice the doctor's prescription as BD but just focused on the administration time written by the colleague, which was wrongly assigned as daily at the time of administration. Seven doses of Cloxacillin 500mg through nasogastric tube scheduled for 17:15 were omitted The doctor's prescription was Cloxacillin 500mg QID; however, responsible nurse documented at the time schedule as 07:30, 12:15, and 20:30 only and omitted 17:15 dose on the time schedule. Nurses failed to check and verify the prescription by two nurses according to departmental guideline.

During ward round, it was noticed that a MAR with nitrofurantoin prescribed went missing. Afterwards, it was found that the MAR form was filed as inactive since the double cross on Date Off box (in fact part of the Dr’s signature) on the nitrofurantoin prescription was misinterpreted as being cancelled.

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Action Status




D Not implemented

E Not applicable


Standardised Medication Administration Record (MAR) are used to minimise the risk of error

For Drug and Therapeutic Committee DAR Recommended 1. All inpatient units of same hospital/cluster use the same

MAR format to guide and document medicine administration.

A B C D E

For Medical Staff DAR Recommended 2. Full text or the list of standard, HA-wide approved

drug names and abbreviations in the Report on Drug Administration Procedures and Practices are used in prescribing.

4.14 4.19

A B C D E

Recommended 3. Cancellation and discontinuation of medicines are signed and dated. A diagonal line through the drug name and/or a slanted double-line across the administration section corresponding to the “discontinued” medication on the MAR is being used to alert nursing staff to minimise the risk of continuous administration.

4.26

A B C D E

For Nursing Staff DAR Recommended 4. For each medicine administration, nurses always refer

to the prescribed directions (especially frequency and time of administration) by the doctor on the MAR.

A B C D E

Mandatory 5. The MARs are signed by the administering nurse after the medicine has been taken by the patient to avoid duplicating dose administration. If the administration of a medication is checked by a second nurse, she/he has also signed the MARs.

4.1124.113

Yes No

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Standardised Medication Administration Record (MAR) are used to minimise the risk of error

Mandatory 6. Medicine that is not taken by patients due to refusal, wastage or lack of availability or other reason is recorded.

4.114

Yes No

Recommended 7. Standardised time schedule for medicine administration is established and consistently used throughout the unit/hospital to ensure a more evenly distributed dosing interval after the consideration of the daily hospital routine and patient’s activities.

4.20

A B C D E

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(4) Handling of High Risk Medications Medicine in aqueous solution injected by an IV route usually produces a rapid therapeutic effect. It is therefore especially important for the right drug in the right dose to be delivered to the right patient at the right time by the right route. A mistake involving the wrong drug or dose via the IV route will produce a more rapid and potentially more serious and sustained undesirable therapeutic response to the patient than other routes. Some form of dilution / reconstitution / mixing of parenteral medication may be necessary immediately prior to its administration. These activities include the calculation and selection of doses, the withdrawal of volumes from containers, the preparation of injections from vials/ampoules of dry powder (reconstitution), the addition of parenteral medicines to IV solutions, and the preparation of complex admixtures. The activities associated with this are fundamental in ensuring the correct medicine is administered to the patient. Misidentification of drug syringes or ampoules is an important cause of medication errors in high risk medications. Ampoules are often removed from their original packaging and stored in alternative containers or on procedure trays until needed. They may then be inadvertently mixed up, resulting in selection of an incorrect drug, especially if the label styles are similar and the drug names contain similar words or character strings. Hazardous practices like pre-preparing unlabelled syringes in anticipation of being used, increase the likelihood that an incorrect product to be administered to patients.

Case

A 10ml solution of sodium chloride 0.9% was drawn into a syringe, with the intention for subsequent flushing of peripheral line for an ICU patient receiving blood transfusion. This syringe of normal saline was then put on the bedside without any label. Later, another 10ml syringe of 20mEq of undiluted potassium chloride to be added into 100ml dextrose 5% infusion was also drawn for the patient, but the KCl was not added to dextrose 5% solution immediately. The syringe of KCl was labeled and placed into a kidney dish on the bedside table. When the patient had finished blood transfusion, a nursing staff mistakenly took the 10ml syringe of KCl from the kidney dish on the bedside table and flushed the peripheral line assuming that it was normal saline.

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Action Status




D Not implemented

E Not applicable


Patient safety policies and procedures are implemented when prescribing, dispensing and administering high risk medications.

For Drug and Therapeutic Committee DAR Recommended 1. A list of high risk medications used in the hospital is

established and communicated to all practitioners who prescribe, dispense, and administer these medicines.

A B C D E

Recommended 2. For some commonly used IV infusions, standardised concentrations or dilution reference tables are used to minimise calculations. (see Figure 5 & Figure 6)

4.105

A B C D E

Recommended 3. Current protocols, guidelines, dosage range and maximum dose limits for high-risk medications are established, which are readily accessible and used when these medicines are prescribed, dispensed, and administered.

A B C D E

Recommended 4. Standard pre-printed order forms (e.g. for IV infusion, insulin and chemotherapy administration) are routinely used for administration of high risk medications that clearly spell out details e.g. drip concentrations and dosing protocols etc.

A B C D E

For Pharmacy Staff DAR Recommended 5. A list of IV preparations that “Must require further

dilutions” is prepared, promulgated to all staff and displayed in wards.

A B C D E

For Medical and Nursing Staff DAR Mandatory 6. Syringes containing parenteral medications, if not used

immediately, are properly identified with names and strengths of the medicines. Any unidentified medication found is discarded and is not given to patient.

4.108

Yes No

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Patient safety policies and procedures are implemented when prescribing, dispensing and administering high risk medications.

Recommended 7. When a high risk IV medication is prescribed, the prescription order is independently checked by 2 nurses to ensure that the order has been correctly interpreted and that the drug, dose calculations, preparations, route and mode of administration are accurate.

4.104

A B C D E

For Medical, Pharmacy and Nursing Staff DAR Recommended 8. An independent check for all calculations,

measurements and route of administration is carried out for high risk medications e.g. medicines for pediatric patients, when infusion requires a dose in mg/kg/min, for insulin infusion, chemotherapy and setting of infusion pump rates.

A B C D E

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Figure 5. Sample of Guidelines on Preparing Drug for Intra-venous Administration

Source: Department of Medicine and Therapeutics, PWH. Used with permission.

20

Tseung Kwan O Hospital (TKOH)

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Figure 6. Sample of Standard Dilution of Drug for Intravenous Infusion

Source: ICU, TKOH. Used with permission.

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(5) Specific High Risk Medications While most medicines have a wide margin of safety, a few of them have a high risk of causing injury when they are misused. The consequence of errors in administering these “high risk medications” could be devastating. Potassium chloride, potassium phosphate >0.9%, heparin, warfarin, insulin, lignocaine, magnesium, muscle relaxants, chemotherapeutic agents, narcotics, adrenergic agents, theophylline and immunoglobulin are all considered high-risk medications. Healthcare professionals should take extra care when prescribing, dispensing and administering these medications. Cancer chemotherapy - the consequence of errors involving cytotoxic chemotherapy can be devastating because these drugs typically have narrow therapeutic ranges. In addition, cancer chemotherapy usually involves complex regimen.

Case

A patient developed signs of toxicity including severe vomiting and deafness after receiving 190mg of cisplatin instead of 31mg as prescribed. Nurses wrongly transcribed the dose of cisplatin for another drug (etoposide) from a standardized preprinted treatment protocol onto the infusion sheet. The overdose was not noted.

Concentrated Potassium chloride (KCl ) - if potassium is injected too rapidly (ie.. at a rate exceeding 10mmol of KCl infusion per hour) or in too high concentration (e.g. 40mmol), it may cause cardiac arrest, thus potassium chloride should never be given as an IV push. Direct injection of concentrated KCl has occurred over the years with serious consequence. Concentrated KCl and heparin or other IV solutions are often mistaken for one another when presented in pre-filled unlablled syringes which are not used immediately.

Cases

A patient with a history of postural hypotension was found to have a low serum potassium and a 50mmol of iv potassium chloride was prescribed in an undiluted form instead of the normal diluted form to be injected slowly.

25

In another case, a night nurse mistakenly administered 20mmol of undiluted potassium chloride instead of diluting the drug in 100ml normal saline. The infusion lasted over an hour in accordance to the prescription.

Insulin - insulin is the most frequently reported medicine associated with medication incidents in HA hospitals. Medication incidents usually involved wrong dosage form of the same preparation of insulin being prescribed or dispensed i.e. vial instead of penfill and vice versa. Mix-ups have occurred because of sound and look-alike names (e.g Mixtard® and Monotard®). Overdoses have occurred when “U” is used as an abbreviation for “units” in orders and mistaken for an “O” resulting in a 10-fold overdose e.g. 40 units instead of 4 units. Figures 7a and 7b. Packaging of Mixtard® and Monotard® preparations

Case

Subcutaneous Protaphane HM 8 units in the evening was mistakenly prescribed as 80 units in MAR. The dosage was administered according as prescribed in MAR to the patient. The patient’s fasting blood sugar overnight was 1.9 mmol/L.

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Action Status




D Not implemented

E Not applicable


Strategies are undertaken to minimise errors in prescribing, dispensing and administering specific high risk medications.

Chemotherapy For Medical Staff DAR

Recommended 1. The mg/m2 or mg/kg parameters are included by prescribers with all chemotherapy prescription for dose calculation verification. The route of administration, the duration therapy and the patient’s current body surface area or body weight are specified in the prescription order. Choose E (Not Applicable) if chemotherapy is not prescribed in the hospital

A B C D E

Recommended 2. Approved preprint chemotherapy order forms are used. (see Figure 8a and Figure 8b) Choose E (Not Applicable )if chemotherapy is not prescribed in the hospital

A B C D E

For Pharmacy and Nursing Staff DAR Recommended 3. Nursing and pharmacy staff independently verify the

prescriber’s calculated dose against the protocol for chemotherapy before dispensing and administrating the drug. Choose E (Not Applicable) if chemotherapy is not prescribed in the hospital

A B C D E

Concentrated KCl For Drug and Therapeutic Committee DAR

Mandatory 4. Vials of concentrated forms of KCl that require dilution before IV use are not kept as floor stock on any patient care units.(except in critical care units)

4.131

Yes No

27


Strategies are undertaken to minimise errors in prescribing, dispensing and administering specific high risk medications.

Recommended 5. Commercially prepared, prediluted KCl solutions are used whenever available.

A B C D E

Insulin For Drug and Therapeutic Committee DAR

Recommended 6. “Units” are used for prescribing instead of “U”.

A B C D E

Recommended 7. Standard Insulin Administration Record (“Insulin Administration / Blood Glucose Monitoring Form” and “Intravenous Insulin Administration Form (DKI or IV insulin pump)” forms/protocols are routinely used. (see Figure 9)

4.7

A B C D E

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Figure 8a. Sample of Prescription for Chemotherapy

Source: Department of Medicine and Department of Pharmacy, PYNEH. Used with permission.

30

Figure 8b. Sample of Chemotherapy Prescription Sheet

Source: Department of Oncology and Department of Pharmacy, PMH. Used with permission.

31

Figure 9. Sample of Protocol for Peri-operative Management of Insulin Requiring Diabetic Patients

Source: Department of Medicine and Geriatrics, PMH. Used with permission.

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(6) IV Infusion Devices One of the most frequent causes of serious medication errors during IV drug administration is the misuse of infusion pumps/devices. This is often associated with improper flow rate settings or inaccurate connection of tubing lines.

Case

Cloxacillin 1g diluted in 10ml of water for injection was injected into a patient’s arterial line instead of the venous line in ICU. The patient had an arterial line on her left arm as well as a central venous line for haemodynamic monitoring and IV therapy. Two nurses checked the drug and dosage together and the one who was a trainee in ICU was asked to inject the drug into the peripheral line without the other nurse identifying the correct line with her. The trainee injected the cloxacillin into the arterial line as she was unaware that medications should not be injected via an arterial line.

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Action Status




D Not implemented

E Not applicable


Strategies are undertaken to minimise errors in using medications that are administered as IV infusions

For Nursing Staff DAR Mandatory 1. Tubings, syringes and stopcocks for IV medicine

administration are not used for other purpose other than those specified.

Yes No

Mandatory 2. Administration set, tubing, stopcock, syringe or injection being connected to a cannula or administration system are luer-locked to avoid inadvertent disconnection and to minimise the risks of haemorrhage, air embolism and contamination of IV system.

Yes No

Mandatory 3. Tubing lines are physically traced back carefully by hand to the site of insertion before medicines or feeds are administered.

4.109

Yes No

Mandatory 4. If there is more than one IV line, labels with different colours are used on tubings to distinguish different IV lines.

4.109

Yes No

Recommended 5. A second nurse always independently verifies the correct drug name, concentration, rate of infusion and line attachment for high risk medications.

A B C D E

Recommended 6. The types of syringe/infusion pumps used in the hospital are limited to a minimum.

4.110

A B C D E

Recommended 7. Use infusion pumps with anti free-flow device mechanism.

A B C D E

Mandatory 8. All electronic infusion control devices undergo regular and proper maintenance and are documented.

Yes No

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(7) Look-alike and Sound-alike Medications Confusion over the similarity of names of medications, either written or spoken is compounded by illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labelling, and incorrect selection of a similar name from a computerised drug list. Indecipherable or unclear prescriptions may delay the administration of medications as clarifications are required which could at the very least decrease the efficiency of the healthcare system. At worst, a misread prescription can lead to patient harm, loss of patient’s trust and decrease productivity.

Case Isosorbide dinitrate (Isordil ®) 5mg tds was prescribed to a patient but pharmacy staff misread the drug name and glibenclamide (Daonil ®) 5mg tds was dispensed. The patient was admitted to hospital for 2 days due to suspected cause of hypoglycaemic coma.

Figure 10. Poorly written prescription for Isordil seen as Daonil

The pairs of drugs most commonly involved in “wrong drug’ in HA are:

Pair of Drugs

Hydralazine and Hydroxyzine

Mixtard and Monotard

Clonazepam and Lorazepam

Amlodipine and Amiloride

Cefuroxime and Cefotaxime

Losec and Lasix

Enoxaparin and Fraxiparine (nadroparin)

Chlorpropramide and Chlorpromazine

Enalapril and Lisinopril

Daonil and Isordil

Qunidine bisulphate and Quinine sulphate

Zadine and Zaditen

Figure 11. Similar Looking Drug Name

35

The pair of drugs most commonly involved in “wrong formulation” in HA are:

Pair of Drugs

Benadryl elixir (diphenhydramine HCl)

and Benadryl expectorant (diphenhydramine HCl, ammonium Cl and sodium citrate)

Doloxene (dextropropoxyphene HCl)

and Doloxene Co (dextropropoxyphene HCl, aspirin and caffeine)

Epilium Chrono (slow-release file-coated) and Epilim EC (enteric-coated)

Sinemet 25/100, Sinemet 25/250 and Sinemet 50/200 CR (controlled release)

Tegretol 200 and Tegretol 200 CR (controlled release)

Figure 12. Packaging of Epilium products

Figure 13. Packaging of Sinemet products

Figure 14. Packaging of Tegretol

36

Action Status




D Not implemented

E Not applicable

E Not applicable


Strategies for minimising errors with drug products that have similar manufacturer/packaging and/or drug names that look and/or sound alike

For Drug and Therapeutic Committee DAR Recommended 1. Normally generic names are used for prescribing.

However, for medicines with similar names, a list of agreed names is compiled by the DTC and used in prescribing.

A B C D E

For Pharmacy Staff DAR Recommended 2. A list of look-alike or sound-alike medications is

compiled and distributed to medical, nursing and pharmacy staff to heighten their awareness.

A B C D E

For Pharmacy and Nursing Staff DAR Mandatory 3. The label is always READ before drug dispensing by

pharmacy staff and before drug administration by nursing staff to avoid confirmation bias.

Confirmation bias is the tendency to identify items by confirming portions of information that are familiar, while missing whatever bits of disconfirming evidence that may be present. The more similarities, the more likely confirmation bias will occur.

Yes No

Recommended 4. Products with look-alike or sound-alike drug names / packaging are stored separately (i.e. not adjacent to one another) and not alphabetically.

A B C D E

Recommended 5. Additional alert labels or other label enhancements (e.g. marking the distinguishing information on the product label) are placed to alert pharmacy and nursing staff when using products with similar appearance.

A B C D E

37


Strategies for minimising errors with drug products that have similar manufacturer/packaging and/or drug names that look and/or sound alike

For Medical, Pharmacy and Nursing Staff DAR Mandatory 6. If the name of the drug is unfamiliar, it is checked from

a suitable reference source. More generally, there is awareness in that there may be some new names which are unfamiliar, but perceived as alphabetically similar to established names, and extra care is employed to ensure the correct medicine is selected.

Yes No

Recommended 7. All healthcare professionals involved in medicine administration have received regular information and education regarding new medicines or revised drug dosing, especially on look-alike or sound-alike medications.

A B C D E

Recommended 8. The packages and labels of drugs are examined regularly for potential risk of look-alike / sound-alike confusion with that of the existing drugs list. The pharmacy department is informed of the potential risk which in turn collect the information and feedback to the Chief Pharmacist’s Office.

A B C D E

38

(8) Drug Replenishment and Storage Drug replenishment includes replenishment of stocks to wards and to drug shelves / automated dispensing machines in the pharmacy. It also includes replenishment of re-packed drugs, drugs from the ward return and medications not picked up by patients. All replenishment should be governed by a proper checking and recording mechanism to ensure appropriate storage and utilization of stocks and to facilitate tracing of drug records.

Cases

Metoprolol 50mg tablets were found in a stock container labelled for metoclopramide (Maxolon® ) 10mg tab. The top three-quarters of the stock container was filled with metoprolol 50mg and the bottom quarter of the bottle was filled metoclopramide 10mg. The incident was discovered when a dispenser intended to dispense metoclopramide in the evening shift.

Ten boxes of amlodipine (Norvasc®) 5mg (30's per box) were mistakenly placed in the storage bin labelled with amlodipine 10mg. A patient with a prescription of 42 tablets of amlodipine 10mg was eventually dispensed with 32 tablets of amlodipine 10mg from the storage bin and 10 tablets of amlodipine 5mg from amongst the 10 misplaced boxes of amlodipine 5mg. The mistake went undetected upon drug issue in the morning and the misplacement of amlodipine 5mg tablets was discovered only later in the afternoon.

39

Action Status




D Not implemented

E Not applicable


Strategies are implemented to ensure safekeeping of medicines

For Pharmacy Staff DAR Mandatory 1. Expiry dates of the products are checked before

dispensing. Items with shortest shelf life are placed in the front and are used first.

Yes No

Recommended 2. For replenishment of drug stock to the storage shelf, original containers are used.

A B C D E

Recommended 3. If stock containers are used, items for replenishment are not mixed with the old stock of the same product. Each stock container shows the name, strength, batch and expiry date of the product.

A B C D E

Recommended 4. For refilling of containers for pre-packs, the whole pre-pack tray is replaced rather than by topping up.

A B C D E

Recommended 5. Before returning surplus pre-packs back to storage tray/bin, the name, strength, dosage form, pre-pack size are checked against the pre-pack tray/bin. The expiry dates of the pre-packs are also checked.

A B C D E

Recommended 6. Returns from wards are properly identified, checked if suitable for use and are not refilled to the stock bottle.

A B C D E

For Nursing Staff DAR Recommended 7. Expiry dates of the products are checked before

medicine administration. Items with shortest shelf life are placed in the front and are used first.

A B C D E

40


Strategies are implemented to ensure safekeeping of medicines

Recommended 8. A list of ward stock to be held in the wards is carefully selected for each unit considering the case mix of each patient care unit, staff expertise and familiarity with specific medications.

4.74 4.74b A B C D E

Recommended 9. Nurses regularly inspect designated medicine storage areas and drug trolleys in patient care units to assure that no unapproved medicines are stocked, and to assure that all stocked medications have not expired.

A B C D E

Recommended 10. Discontinued patient-specific medications are removed from patient supplies in a timely manner (e.g. upon the patient’s discharge, discontinuation of the drug) to prevent accidental administration.

A B C D E

41

Cases

Pre-packed bags of metoprolol 50mg tablets were found to be mixed with metoclopramide 10mg tablets during the process of pre-packaging procedures.

A couples of paracetamol tablets were found in a pre-pack labelled as Triact.

A patient found a pre-pack bag of 56 tablets of metoprolol (Betaloc®) 50mg mixed with anhydrous theophylline (Nuelin SR®)

200mg.

(9) Drug Re-packaging and Re-labeling Re-packaging of medications into smaller packs of appropriate quantities from bulk supply obtained from manufacturers may be required to facilitate the dispensing service. In order to enable proper identification of drugs, all medicines should be in clearly labeled packages.

42

Action Status




D Not implemented

E Not applicable


The quality and identity of medicines at the time of use is ensured after re-packaging and re-labeling

For Pharmacy Staff DAR Mandatory 1. All medicines repackaged for dispensing to patients by

wards/units are labeled with drug name, strength, instruction for use (if appropriate), batch number, expiry date and any special storage requirements.

4.68

Yes No

Mandatory 2. Proper documentation of the process is in place which forms an essential part of the quality assurance system whereby tracing of batch history is possible.

(Documentation includes drug name, manufacturer name, batch number, quantity, expiry date of each starting materials for repackaging, date and quantity prepared are recorded on the worksheet. A sample label is affixed to the logbook/worksheet.)

Yes No

Mandatory 3. Only one item is repackaged at one time and only the materials required for repackaging are placed at the designated area.

Yes No

Mandatory 4. All pre-printed labels generated for repackages are accounted for.

Yes No

Recommended 5. Repackaging is performed according to the standard operation procedure in a designated area within the pharmacy department with appropriate lighting and minimal distraction to ensure the quality of the final product.

4.66 4.67 A B C D E

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While electronic prescriptions improve legibility and remove the ambiguity of orders, it has been recognised that certain risks are associated with prescribing electronically:

• The ease of repeating previous orders also means unnecessary or inappropriate orders are more likely to be repeated;

• Selecting from a list using a point-and-click interface carries the

inherent risk that an item neighbouring the intended one is selected by mistake;

• The prescriber may customarily ignore all system-generated alerts if he

encounters a few that are superfluous.

(10) Prescription Practices using the Medication Order Entry (MOE) System MOE is a computer-based system for ordering medications and sending prescriptions directly to the pharmacy to ensure standardised, legible and complete orders. Errors associated with transcription, missing data such as dose, route, and frequency of administration, or miscommunication with other healthcare professionals are eliminated. The MOE system also incorporates relevant drug information such as clinical decision support, which may reduce medication-related errors. Currently the MOE system is available for out-patient, home leave and discharge prescriptions and the elimination of handwritten prescriptions in both inpatient and out-patient settings is a universal goal.

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Action Status




D Not implemented

E Not applicable


The potential risk in the use of MOE is mitigated through good prescribing practice.

For Medical Staff DAR Recommended 1. After retrieving a patient’s case from MOE, the

patient’s identity displayed on screen is verbally verified with the patient.

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Recommended 2. Special attention is paid to patients with multiple attendances as these patients may be using medication prescribed from other specialties (or a different clinic). The patient’s MOE prescribing history (within the same hospital, or across affiliated hospitals, depending on MOE system settings) is reviewed irrespective of the original prescribing specialty. ePR is consulted for an integrated view of the patient’s medication history.

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Recommended 3. The use of “Select All” feature to repeat orders from the Drug History window is avoided. The genuine medication need of the patient is evaluated, individual drug items are selected accordingly, and the dosage of each is reviewed.

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Recommended 4. When searching for drugs, more characters are entered to avoid having to select from a list of similar drug names e.g. typing “CARB” gives 8 drug names beginning with “carb”, typing “CARBAM” gives “carbamazepine” alone, and typing “CARBIM” gives “carbimazole” alone.

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The potential risk in the use of MOE is mitigated through good prescribing practice.

Recommended 5. After selecting a drug, the therapeutic class of the drug is automatically shown in the “Therapeutic Class(es)” field. This field is used to confirm that the intended drug has been chosen.

Further confirmation can be sought by checking the “Common Dosage” field for usual dosages of the drug, and by reading the drug monograph which may be obtained by pressing the “i” button.

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Recommended 6. Drug sets are used for (i) combination regimens; (ii) dosages that are usual in practice but are not

listed under “common dosage”; (iii) dosages that vary with the patient’s body

surface area.

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Recommended 7. “Drug on hand” alerts are noted, and the dosage and prescribed duration of the drug in question is reviewed, to prevent the dispensing of extra supplies of the drug, and to avoid the risk of the patient taking the same dose twice.

It should be noted that “drug on hand” alerts are designed to only check for drugs with the same name and route. For drugs that can be given through different routes, human scrutiny is still required to avoid prescribing the same drug twice.

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Recommended 8. The patient’s allergy records and alert information are regularly reviewed to ensure that any allergy alerts generated by the system will remain valid for the patient.

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