Miss Ting Su Rong 24/6/2013

Medication errors Causes significant Pattern of brings significant Any stage, from delay to the delivery adverse but prescribing, of medications to Prescribing Error preventable drug dispensing to patients due to events to administering1,2 need to contact in patients1 prescribers. Sibu , Outpatient Setting

Ting Su Rong Pharmacist, Sibu Hospital, Introduction

4 A prescription needs to have : Main aim: To determine the pattern of prescribing error in Sibu Hospital, patient’s name and ID number outpatient setting. Objectives: drug regimen (dose, frequency, administration and duration) determine the prevalence of prescribing error in the outpatient setting prescriber’s signature and chop

drugs written in generic names compare error rate in manual versus electronic teleprimary care (TPC) prescribing drug names not abbreviated

for children less than 12 years old, their age scrutinize the prevalance of prescribing error in and weight High Alert Medications (HAMs) Source: MOH Drug Formulary 2009

Outpatient pharmacy Methodology prescriptions (Jun-Sep 2011) Methodology New Owing scripts prescriptions

• This study was conducted retrospectively Meet inclusion EXCLUDED • Registered under the National Medical criteria New scripts from: Research Register: 10757, exempted from Yes No Medical (MOPD) ethical approval. Scripts from: Surgical (SOPD) Prescribing Error(s) EXCLUDED Eye Prescriptions from visiting clinics Ear, Nose, and Throat (ENT) HIV clinic Yes No and (O&G) Psychiatric clinic Emergency and Trauma (ETD) Other healthcare institutions / SPUB Data collection Data collection Orthopaedic (Ortho)form 1 formWeekend 2 prescriptions from E & T Paediatric (Paed) Discharge and inpatient prescriptions received Data analysis using during ‘extended hours’ shift Staff Clinic SPSS & Microsoft Office Owing scripts Excel

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Data Collection Form 1

Data Collection Form 2

Clinic No. of drugs Total number o f Clinic No. of drugs Total number of prescription prescription

Adult Paed TPC ETD 1-4 √ X 5-9

≥10 MOPD 1-4 ENT 1-4 5-9 5-9 ≥10 ≥10 PAED 1-4 STAFF 1-4 5-9 5-9

≥10 ≥10

Table 6.1: Characteristics of study samples

Types of Manual TPC prescriptions Total prescriptions prescriptions Results and discussions: prescription No of prescription 17,140 (90.9%) 1,709 (9.1%) 18,849 (%)

Obj 1: Prevalence of prescribing error

Prevalence of prescribing errors Total no. of errors detected 6576 in this study is Prescription without error (35%) 21825. 12273 Prescription with one or (65%) more error

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0.87% 0.99% Unacceptable 2.39% 5.13% 0.26% Staff brand name 0.43% Unknown 0.36% Unacceptable4.06% medication abbreviation0.15% 0.66% Paed Paed0.49% Staff Unacceptable Unknown 0.56% 5.75% brand name 0.46% Clinic stamp MOPD Ortho SOPD 16.32% MOPD 22.71% 30.88% 15.63% 3.96% 10.56% Eye 0.84% Ortho 1.43% 21.15% ENT 8.96%SOPD 2.03% 10.48% Total no. of 0.81% O&G 0.46% 2.35% errors detected E&T 37.33% 0.05% in this study is 30.91% ENT Eye 0.30% 9.29% 0.89% 21825. Unacceptable E&T abbreviation O&G 45.39% 4.71% Figure 6.1: Prevalence of prescribing errors Figure 6.2: Percentage of occurrence of unacceptable medication abbreviation and (according to type of prescribing error). brand name according to different clinics.

E&T Paediatric clinic Unknown 0.39% Without Specialist body 16.56% HO weight 25.20% With 5.86% body weight 22.98%

With Without body MO body 57.85% weight weight 77.02% 94.14%

Figure 6.3: Percentage of paediatric prescriptions without body weight between E&T department and Paediatric department. Figure 6.4: Prevalence of prescribing error (according to designation of prescriber).

Table 6.2: Correlation between number of medication per prescription and number of • Causes7? prescribing errors per prescription.  increased number of medications per prescription  fatigue Number of medication  in a hurry Mean ± SD F P value  incomplete knowledge of the medication per prescription  incomplete knowledge of the patient

1-4 0.96±0.90 • Interventions7?  TPC 5-9 0.98±0.98 14.72 <0.05a  eliminate dangerous abbreviations ≥10 1.17±0.88  generic name  written protocols for HAMs Note:aPost Hoc Test showed the significance lies between <10 items and ≥ 10 items. p<0.05 indicates significant. SD: standard deviation

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60.0 Obj 2: TPC prescribing 49.8 50.4 Error rate in manual 50.0 error rate48.8 = 21.1 ± 2.9 % 47.7 TPC prescribing showed SIGNIFICANT vs 40.0 REDUCTIONManual prescribing in prescribing errors

electronic teleprimary care (TPC) prescribing comparederror to manual rate = 49.2 prescribing, ± 1.2 % p<0.05 TPC error rate 30.0

25.1 Manual Errorrate (%) 21.0 20.1 error rate 20.0 18.3

10.0

0.0 June July August September Month Figure 6.5: Error rate in manual versus electronic teleprimary care (TPC) prescribing in both MOPD and paediatric clinic.

Table 6.3: Prevalence of different types of prescribing error in manual & TPC prescriptions in both MOPD and paediatric clinic. Table 6.4: Error rate of prescriptions in category of incorrect/inappropriate/inadequate regimen among MOPD and paediatric Clinic

Type of error Error ratea (%)

Manual TPC P value

Incorrect/inappropriate/

inadequate regimen

Drug 37.8±7.3 38.6±3.8 0.843

Dose 38.9±12.2 34.8±5.2 0.552

Frequency 12.8±5.9 15.1±4.5 0.552

Duration 10.6±9.3 11.6±4.6 0.854

% is defined as percentage of error out of total prescribing error in respective MOPD and paediatric clinic. p<0.05 indicates significant.

Our study: - 0Obj.21% of 3: medication Prevalance errors were of related prescribing to HAMs error - Mostly due to unacceptablein medications HAMs abbreviation & brand name

• Errors should be continuously monitored after 12 Types of prescribing error Example introduction of the system so that prescribers 10 Unacceptable10 abbreviation MTX instead of methotrexate can be appropriately trained and other 9 6-MP instead of 6-mercaptopurine appropriate preventive measures can be 8 implemented in the future to minimize the Unacceptable brand name Casodex instead of bicalutamide 5 6 occurrence of prescribing errors . 5 DF118 instead of dihydrocodeine 4

error of Number 2 2 Potential confusion and communication breakdowns3

0 Antithrombotic Chemo Insulin Opiate Figure 6.9: Prevalence of prescribing error in HAMs

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Prevalance of prescribing error in Conclusions:

HAMs • Most common prescribing error in Sibu Hospital: Unacceptable brand name & abbreviations

Monitoring a group of drugs classified as HAMs is one • Other prescribing error (clinic stamp & body weight) 8 approach to decrease medication errors • Introduction of e-prescribing (TPC) – modifications? • Pharmacist’s role  doctors

All health care professionals should be aware of • Communication to  prescribing errors drugs classified as HAMs • Improve patient’s safety and quality of services

Limitations References:

Retrospective study - No OPD / home-based 1. Garbutt JM, Gabrielle H, Jeffe DB, Dunagan WC, Fraser VJ. Safe medication prescribing: Training and experience of medical students and housestaff at a large teaching hospital. cards available Academic Medicine 2005; 80: 594-9. 2. Cassidy N, Duggan E, Williams DJP, Tracey JA. The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland. Clinical Toxicology 2011; 49: 485-91. Polypharmacy (under multiple clinic follow-ups) 3. Dean B., Schachter M., Vincent C., Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance quality and safety in Healthcare 2002; 11: 340-4. 4. Ministry of Health Drug Formulary. Pharmaceutical Services Division. Ministry of Health Malaysia 2009. p .iv-v. Some errors had been intervened at the point of 5. Guideline of safe use of High Alert Medications. Pharmaceutical Services Division. Ministry of Health Malaysia 2011. screening 6. Westbrook, J.I., Reckmann, M., Ling, L., Runciman, W.B., Bukre, R., Connie, L., et al. (2012) Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study, PLoS Medicine, 9(1): 1-11. Teaching hospital with Provisionally Registered 7. Angie S. Graham, FCSHP. Prescribing errors. CJHP 2008; 05-15. nd 8. Cohen MR, Smetzer JL, Thuohy NR, Kilo CM. High-alert medications: Safeguarding Pharmacist - detection missed for 2 time against errors. Medication errors. American Pharmaceutical Association 2006; 2: 317-411.

Limited knowledge and experience

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