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: mers@moh.gov.my

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.

Source: http://www.telegraph.co.uk/health/healthnews/10279007/The-pill-that-can-text-from-inside-the-body.html

By Tea Ming Hui Pharmacist, Sultanah Nora Ismail Hospital, Batu Pahat

What’s

New??

Our focus on Geriatrics is timely because Malaysian demographic profile is inching towards

older population where the above 60 years now stands at around 10% and expected to touch

15% by 2030. Rising living standard and health awareness with better healthcare have enabled

Malaysians to enjoy longer life. However, with life extension it also means having to endure

higher incidence of degenerative and other diseases requiring more medical attention and

medications, often lead to polypharmacy as well.

In the U.S., for example, 13% of the population are above 65 years but consume 30% of the

prescription medications. Over 46% of elderly patients hospitalised are taking at least 7

medications, and one can expect similar situation in Malaysia. More medications can result in

increasing risks of drug interactions that may lead to more complex drug regimens and medical

complications, serious enough for the US Department of Health and Human Services to

designate polypharmacy a principal medication issue in its Healthy People Report 2000.

Despite specialised need and care of older patients, healthcare providers and medical facilities

are still geared mainly towards mainstream younger population. It is timely we be reminded that

older persons today are living longer and want to stay active, healthy and independent. The last

they want is to suffer from medical and medicines mismanagement from callous attitude towards

their fragile body.

Dr. Rizah Mazzuin Razali, a geriatrician in Kuala Lumpur Hospital, in her article “Fixing the

antic”, shares her experience with a 79 year-old patient exemplifies situations that older people

could face as they seek medical attention for their endless aches and pain. This could have

been prevented earlier if geriatric conditions were given more attention especially with large

numbers of healthcare providers being churned out of our institutions, the younger practitioners

need to be reminded of special needs of such patients they would increasingly encounter.

To address situations where elderly patients often suffer from multiple co-morbidities that

require multiple and duplicative medicines, pharmacist Yen Sze Whey reminds us of simple yet

effective ways of ensuring care and minimising medication errors. Home Medication Review by

a multi-disciplinary team undertaken by the Ministry is another effort to optimise medication

therapy in geriatric patients, more importantly to ensure they do not become innocent victims of

malfunctioning system and neglect. Do take note of the "High-Tech" Pill that can be welcoming

to both patients and caregivers.

Finally, the Medication Safety Newsletter Editorial members would like to wish all our readers

“Happy New Year”. Hope you all enjoy reading this issue.

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

Medication Related Problem (MRP)

(A) Management of medication

Stock

Storage

Administration

How?

Who?

(B) Use of medication

Polypharmacy

Adherence MMAS*

Knowledge DFIT*

ADR

Page 4 Medication Safety Newsletter Vol 6 Issue 2 December 2014

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

with your name, profession and address to mers@moh.gov.my

Dehydration is common in the elderly when their body does not

have enough water and other fluids to function normally. One of

the reasons may be due to the medications they are taking. A

diuretic may cause the patient to urinate more water while some

antihypertensive medications and cardiac drugs can compound the

effects of dehydration and blood pressure.

Take adequate amount of fluids.

Eat healthy, high-water-content

foods such as fruit, vegetables and

soups.

If you have mobility issues, keep a

water bottle next to your bed or

your favourite chair.

If you have a chronic medical

condition, such as congestive heart

failure, consult your doctor on the

daily fluid allowance.

Check that urine color is light and

adequate output. Look out for the

symptoms of dehydration.

You can help your patients by

giving the following advice(s):

Extreme thirst

Lack of sweating

Low blood pressure

Irritability and confusion

Very dry mouth, skin and mucous

membranes

Little or no urination

Rapid heartbeat

Fever

Symptoms for SEVERE dehydration:

Dry, sticky mouth

Sleepiness or tiredness

Thirst

Decreased urine

Headache

Lightheadedness

Symptoms for MILD dehydration:

Dehydration & Elderly

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,

trivial and placebo medications.

Page 6 Medication Safety Newsletter Vol 6 Issue 2 December 2014

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.

Medicat i on Safety