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The Impact-full Role of Hospital
Pharmacists in the Profession
Moving Forward
Amrahi Buang
Deputy Director (Professional)
University Malaya Medical Centre
MPS Seminar - Amrahi - 23.5.15
1
The Role of the Pharmacist in a
Health Care system
4.3 Hospital pharmacy
Hospitals and other institutions and facilities, such as outpatient
clinics, drug-dependency treatment facilities, poison control
centres, drug information centres, and long-term care facilities,
may be operated by the government or privately. While many of
the pharmacist’s activities in such facilities may be similar to those
performed by community pharmacists, they differ in a number of
ways. Additionally, the hospital or institutional pharmacist:
• has more opportunity to interact closely with the prescriber and,
therefore, to promote the rational prescribing and use of drugs;
• in larger hospital and institutional pharmacies, is usually one of
several pharmacists, and thus has a greater opportunity to interact
with others, to specialize and to gain greater expertise;
MPS Seminar - Amrahi - 23.5.15
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The Role of the Pharmacist in a
Health Care system
• having access to medical records, is in a position to influence the
selection of drugs and dosage regimens, to monitor patient
compliance and therapeutic response to drugs, and to recognize
and report adverse drug reactions;
• can more easily than the community pharmacist assess and
monitor patterns of drug usage and thus recommend changes
where necessary;
• serves as a member of policy-making committees, including
those concerned with drug selection, the use of antibiotics, and
hospital infections (Drug and Therapeutics Committee) and
thereby influences the preparation and composition of an
essential-drug list or formulary;
MPS Seminar - Amrahi - 23.5.15
3
The Role of the Pharmacist in a
Health Care system
• is in a better position to educate other health professionals
about the rational use of drugs;
• more easily participates in studies to determine the
beneficial or adverse effects of drugs, and is involved in the
analysis of drugs in body fluids;
• can control hospital manufacture and procurement of
drugs to ensure the supply of high-quality products;
• takes part in the planning and implementation of clinical
trials.
MPS Seminar - Amrahi - 23.5.15
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In 2011, FIP and WHO adopted an updated
version of Good Pharmacy Practice
entitled "Joint FIP/WHO guidelines on
good pharmacy practice: standards for
quality of pharmacy services“.
GPP are organised around 4 major roles for
pharmacists
Role 1: Prepare, obtain, store, secure,
distribute, administer, dispense and dispose
of medical products
Role 2: Provide effective medication therapy
management
Role 3: Maintain and improve professional
performance
Role 4: Contribute to improve effectiveness
of the health-care system and public health
MPS Seminar - Amrahi - 23.5.15
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SCOPE OF SERVICES
Non-Clinical
Clinical
 Pharmacy logistics
 Dispensing of drugs
 Preparation of sterile &
non-sterile drugs
 Drug information service
 Medication counseling
 Pharmacy ward rounds
 Clinical pharmacokinetic
service
 Specialised services
 CDR
 PN
80s
MPS Seminar - Amrahi - 23.5.15
90s
New Millennium
7
2010
2015
Pharmacy Leadership
 Provide leadership to steer the pharmacy department
in line with hospital’s mission and vision
 Leader in all matters concerning medicines
management and use
 Formulating policies and procedures
 Sit in powerful decision making committees
 Provision of excellent facilities
 Optimising resources
 Healthcare technology
MPS Seminar - Amrahi - 23.5.15
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COMMITTEES
1.
2.
3.
4.
5.
6.
Drug & Therapeutics
Medication safety
Medical Advisory
Medical Ethics
Drug Technical Evaluation
Infection Control & Antibiotics
MPS Seminar - Amrahi - 23.5.15
7.
8.
Risk Management
Quality Management System &
Accreditation
9. Occupational Safety, Health &
Environment
10. Credentialing & Privileging
11. PharmUMMC
9
Healthcare Technology
 Pharmacy Information System
 Closed Loop system
MPS Seminar - Amrahi - 23.5.15
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Pharmacy Integrated System
(PIS)
 Integrate all activities in
pharmacy
 Patient medical record
(PMR)
 Clinical screening
 Dispensing label
 Inventory control
 References - eBNF
MPS Seminar - Amrahi - 23.5.15
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Farmasi Pesakit Luar
(Outpatient Pharmacy)
Stor Farmasi
(Pharmacy Store)
Sistem Bersepadu
PIS
Integrated System
Kedai PharmUMMC
(Retail Pharmacy)
Pusat Maklumat Ubat-ubaatan
(Drug Information Centre)
Pengeluaran
(Production)
MPS Seminar - Amrahi - 23.5.15
Farmasi Pesakit Dalam
(Inpatient Pharmacy)
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Pharmacy Integrated System (PIS)
IMPACT
 Dispensing
 Reduction of potential
medication errors
Enhancement of
patient safety
MPS Seminar - Amrahi - 23.5.15
Quality
Assurance
13
The METRO
26 June 2006
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Closed Loop Medication
Management System
PCMC Journey & Milestones
Closed Loop
Medication
Administrati
on System
Advance CPOE
Medication
Reconciliation
Bar Coded
Medication
Administration
(BCMA)
Barcoded Unit
Dose System
Go-Live – Fully
Integrated PIS,
Unit Dose
System, CPOE, eMAR, CDSS
2007
MPS Seminar - Amrahi - 23.5.15
2008
2011
2011
15
2012
2012
Closed Loop Medication
Management System in
PCMC
Closed Loop Medication Management System
is a system that is designed
 to feed data and outcomes from the various medication
processes back into the system that will support future
improvements and changes providing patient care
 to eliminate gaps in information
 to smoothen handovers, reduce handoffs
 to minimise healthcare professionals interventions
 to automate the repetitive tasks
MPS Seminar - Amrahi - 23.5.15
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Closed Loop Medication
Management System in PCMC
PATIENT INFO
 Name: Mary Jones
 Age: 67
 Problem: Congestive Heart
Failure
 Medications: Digoxin
 Allergies: No Known Allergies
ASSESS
Doctor
ADMINISTER
ORDER
THIS
Nurse
Doctor
DISPENSE
(Verification)
Pharmacist
MPS Seminar - Amrahi - 23.5.15
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Healthcare Technologies in PCMC
Computerized physician order entry (CPOE)
Clinical Decision Support System (CDSS)
Pharmacy Information System (PIS)
Pharmacy Unit Dose System (UDDDS)
Electronic medication administration record (eMAR) integrated with CPOE and pharmacy
system
Bedside Bar-Code Medication Administration
(BCMA)
MPS Seminar - Amrahi - 23.5.15
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Pharmacy Logistics




Quality, safety and efficacy of medicines
Availability of medicines at all times
Accountability
Proper storage – cytotoxic drugs, cold chain items,
dangerous drugs, psychotropic
 Proper transportation of medicines
 Expired items
 Proper disposal
MPS Seminar - Amrahi - 23.5.15
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Alarm for power failure
 Monitoring panel for cold room
 Electrical trip --> security will call Pharmacist oncall
who will check coldchain items
 Thermoguard for all chillers & freezers
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Cold chain item monitoring
 Logtag
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Outpatient Dispensing






24 hour service
Main and satellite pharmacies
Acceptable patient waiting time
Supply of long term medications
Medication Therapy Adherence Clinic (MTAC)
Use of high technology
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PROCESS
Model of Good Care - Dispensing
•Screening
•Keying-in
•Packing
IMPACT
• Systematic framework
• Promote medication
safety
• Catch near misses
• Prevent error
•Checking
•Dispensing
MPS Seminar - Amrahi - 23.5.15
Enhancement of
patient safety
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HUMANWARE
Pharmacy Preceptorship Program
•
•
•
•
CPD program
Train → verification → re-verification
Dispensing process
Keying-in & packing process
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HUMANWARE
Pharmacy Preceptorship Program
IMPACT
• Address competency of
staff
• Competency profiling
Enhancement of
patient safety &
care
MPS Seminar - Amrahi - 23.5.15
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PharmCARE
Counter service
Medication counseling
By-Post
Drive-Thru
MPS Seminar - Amrahi - 23.5.15
SERVICE DELIVERY
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PharmCARE
SERVICE DELIVERY
IMPACT
•
•
•
“PharmCARE is the most efficient
and friendliest in the hospital..”
MPS Seminar - Amrahi - 23.5.15
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Promote medication safety
Medication counseling
sessions
Total number of PharmCARE
patients:
 Counter: 2440/month
 Drive-thru: 120/mth
 By-Post: 60/mth
Enhancement of
patient safety &
care
Berita Harian
11 September 2008
Berita Harian July 2007
MPS Seminar - Amrahi - 23.5.15
Harian Metro 14 May 2010
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Pharmaceutical Manufacturing
 Non-sterile
 Sterile – special speciality
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Sterile Complex
 Inventory control includes referring to expiry dates & cold chain
document
 Model of Good Care for aseptic dispensing as framework
 Use PPEs in sterile complex & general lab
MPS Seminar - Amrahi - 23.5.15
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RECONSTITUTION OF CYTOTOXIC DRUGS
Protocols
(from
wards/cli
nics) sent
to
Inpatient
Pharmac
y
• Protocols are
checked
• Prescriber
confirmation on
whether to
proceed with
chemotherapy is
obtained
For tracking
purposes,
worksheet
is initialed
by
pharmacy
assistant
Protocols
sent to
Sterile
Complex
via the
passthrough
hatch
Products
sent out
from the
clean
room via
the passthrough
hatch
Products
are
attached
Labelling with purple
Packagin
of
cytotoxic
g of
products
stickers- and
products
MPS Seminar
Amrahi - 23.5.15
other
anxillary
labels
Protocols inserted
into individual
plastic folders
•
Reconstitu
tion is in
accordanc
e with
written
standard
operating
procedure
s
• Using
aseptic
technique
The
product is
placed into
a clear,
impervious
plastic bag
& heat
sealed
Generati
on of
workshe
ets &
product
labels
Reconstit
ution of
cytotoxic
drugs by
trained
and
validated
personnel
Products
placed
into
opaque
bags
• Doses are
calculated to
reconfirm
• Labels are
computergenerated
The
identity,
strength,
quantity &
expiry date
of the
materials
are checked
by
pharmacy
assistant
• Bags
labeled with
name,
ward,
storage
condition,
expiry &
warnings
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• Intrathecal
products in
green bags;
Crosschecking
of
protocol
with
generate
d labels
Crosschecking
of
materials
with the
reconstitu
tion label
Finished
products
sent out
from
Sterile
Complex
Labels &
worksheets are
checked by
pharmacist
Trays are
sent in one
by one
• Products
given a
final check
by
pharmacis
t
• Protocol
is initialed
Details
entered
into the
cytotoxi
c
product
register
Items
sent to
the
cytotoxic
clean
rooms
via passthrough
hatch
Products
stored at
Inpatien
t
Pharmac
y
• Patient’s name
• Ward
• Name, strength
& quantity of
products
• Batch number
Each tray
contains
equipment
& material
for one
cytotoxic
product
Products
are placed
in
designated
bins
awaiting
collection
Packing
of raw
materials
, diluents
&
syringes
PREPARATION OF TPN
BAXA M 24
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HIGH TECHNOLOGY EQUIPMENT
BAXA MM12
IV STATION
Laminar Flow Hood
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Clinical Pharmacy Services
 Collaborative work with doctors, nurses and other
allied healthcare professionals
 Ward pharmacists
 Specialised areas
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PAU KIEW BING
LAU CHEE LAN
FARAH WAHEEDA
TAJARUDIN
LOONG LY SIA
YIN MEI KUAN
KONG SHUE HONG
GHAN SHEAH LIN
LAI YIN KEY
NUR JANNAH BINTI
AZMAN
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Our team - 11 Clinical
Pharmacists
MPS Seminar - Amrahi - 23.5.15
SARAH ANNE
ROBERT
LYDIA GAN LAY YEN
Introduction
Wards that we cover:
 Adult Medical Wards 1-6
• Intensive wards
 General Intensive Care Unit (GICU), Coronary Care
Unit (CCU), Cardiac Rehabilitation Ward (CRW),
Bone Marrow Transplant (BMT) ward, Neonatal
Intensive Unit (NICU)
• Orthopaedic wards (male & female), Surgical wards 1-
8, Psychiatric wards (male & female)
• Also receive referrals from other wards for
counseling, Therapeutic Drug Monitoring (TDM)
and other services
MPS Seminar - Amrahi - 23.5.15
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CLINICAL PHARMACY SERVICES
OTHERS:
1. Neuro team meeting
2. Multi-disciplinary patient
management programme
3. Training/ education
4. Clinical practice pathways
5. Patient’s own drug (POD)
6. Ward Check
7. Infectious control committee,
UKMMC
8. Publications
9. Research projects
10. Counseling week (annually)
CORE SERVICES:
A) PATIENT MONITORING
B) VERIFICATION
C) ANSWERING QUERIES FROM
DOCTORS/ NURSES
D) PATIENT COUNSELLING
E) THERAPEUTIC DRUG
MONITORING
F) CLINICS
Services accredited by ISO 9001:2000
Quality Objective:
80% of patients in primary wards with Clinical Pharmacists are to be monitored
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3.
TRAINING/EDUCATION
3.1 CONTINUOUS NURSES’ EDUCATION (CNE)
• Hold CNE sessions for nurses from time to time
• Topics usually relevant to nurses such as Insulin Therapy, High
alert medications, Drug Administrations and Dilution, TDM etc
MPS Seminar - Amrahi - 23.5.15
Provision of Clinical Pharmacy Service
July 2010 – Dec 2010 – Preparation work
•Recruitment of clinical pharmacists
•Hospital demographic study
•Survey to selected consultants
•Policy and SOP related to clinical pharmacy
Year 2011 – Stroke Interest Group
Member in SIG to set up allied health
support to stroke cases.
Year 2011
Monash Student attachment
MOA agreement for yearly pharmacy
student attachment
Dec 2010 – Pilot service
• Review prescription for in-patients
admitted under 1 consultant
March 2011 – Coverage of 1 ward
• Expanded service to cover inpatients admitted / transferred in to 1
Medical / Surgical ward
Jan 2012 – Coverage of 2 wards
Expanded service to cover in-patients
admitted / transferred in to 2 Medical /
Surgical wards
2014
Year 2012 – 2013 – Clinical initiatives & Publications
•Reconstitution and Administration Guideline for Injectable
Anti-infectives
•Understanding Tuberculosis and Your Treatment
•Guideline for dilution and administration of IV Pantoprazole
•Guideline for dilution and administration of IV Amiodarone
Introduction of Pharmacy
Referral Form to all wards.
2015
Expansion to Oncology
& Critical Care areas
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Antibiotic Stewardship Activities
 Conducted 6 months survey on reasons for prescribing carbapenems in inpatients
 Survey results summarized in write-up that was circulated in-house
 Poster was accepted for presentation at 15th Asia Pacific Congress of
Clinical Microbiology and Infection
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
MPS Seminar - Amrahi - 23.5.15
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SERVICES RENDERED
 Ambulatory Drug Distribution
 OUT-PATIENT
 EMERGENCY / TRAUMA
 Unit Dose Drug Distribution for inpatients
 Clinical Pharmacy Services








 Intensive Care (ICU, CCU, SICU, Neuro
ICU)
 Medical
 Pain Management
 Hematology
 RESEARCH
 DRUG USE EVALUATIONS / REVIEWS
 Drug counseling
 In-patient / Discharges
 Out-patient
 Medication Adherence Programme
 DIABETES
 WARFARIN
MPS Seminar
Amrahi(Chronic
- 23.5.15 Kidney Disease)
 -CKD
Total Parenteral Nutrition
IV Admixtures
Cytotoxic Drug Reconstitution
Pharmaceutical / Galenicals
Radiopharmacy
Therapeutic Drug Monitoring
Dissemination of Drug Information
Investigational Drug Services
 Procurement of Drugs &
Disposables
 Store & Inventory for
Pharmaceuticals and Disposables
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ACHIEVEMENTS @ FARMASI MAKMAL
PENDISPENSAN ASEPTIK
•Counseling for Cancer Patients
RADIOFARMASI
•PREPARATIONS
•Diagnostic
•Treatment
•QUALITY CONTROL
•COUNSELING
•PUPIL TRAINING
•SAMARIUM THERAPY
PEMONITORAN DRUG TERAPEUTIK
•Steroid
•Best Lab 2007
•Best Lab Runner-up 2015
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ACHIEVEMENTS @ FARMASI PESAKIT DALAM
FARMASI
SATELIT
FARMASI
KLINIKAL
• Unit Dose Drug Distribution
• COMING SOON: In-patient Prescription On Line
System (i-POLS) under simulation……..
•Critical Care : ICU, CCU, SICU,Neuro-ICU
•Hematology
•Pain Management
•Medical
•HUSM Formulary On-Line / Mobile
•Develop/implementing 5 Counselling
Modules for CKD-MAP@Nephrology
KAJIAN & •Co-ordination of Investigational Drug
Services
MAKLUMAT
DRUG
•Multicentered Sponsor-Initiated Clinical
Studies
•Local Studies
•Drug Use Evaluations/Reviews
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Drug Information Services





Pharmacy bulletin & newsletters
Drug formulary – hard copy and on-line
Secretariat to Drugs & Therapeutics committee
Samples
Clinical trials
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Improving Management of Allergy Documentation
 Allergy screening
service provided by
Pharmacists
 Issuing of Drug
Allergy Card to patients
 Documentation in
hospital HIS system
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Screening of Medications for Enteral Tube Feeding
 Development of in-house reference database
on suitability to crush medications for patients
on tube feeding
 Screening of suitability by Pharmacists
 Provision of administration guide to nurses to
educate on correct administration method
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Development of In-House Reference Guidelines
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Development of In-House Reference Guidelines
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Development of In-House Patient Education Materials
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Development of In-House Patient Education Materials
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Publication of In-House Pharmacy Bulletin
 Platform for sharing of information & alerts on
medication safety, updates on policies,
amendments to hospital drug formulary
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Medication Safety





On-line incident reporting system
Root cause analysis
Patient safety solutions
Reporting of Medication Errors (ME)
Reporting of Adversed Drug Reactions (ADR)
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Improving Safety of High Risk Medications
 Dedicated shelf for identified
High Risk Medications
 Labelling of each ampoule &
vial to alert users to double
check
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Increasing Awareness of Look-Alike
Sound-Alike (LASA) Drugs
 Increase awareness
of LASA drugs via
posters, drug container
colour coding, bulletin
article
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
Transportation
 Special container for fridge
items
 Controlled drugs use locked
luggage
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Colour-coded syringes.
 Morphine and Epidural Cocktail
look alike could lead to possible
handling errors as both syringes
are prepared by the Sterile Unit,
and normally ordered for the
same indication ie ‘pain’.
Therefore an initiative to colourcode the stoppers and labels
were initiated. Combi Blue and
Combi Red Stoppers were
purchased as below. Apart from
that, Preparation of PCA
Morphine and Epidural Cocktail
done different days to avoid
confusion.
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Screening
 Detects prescribing errors
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Packing
 Alerts for packers – LASA, multiple strength, different
dosage forms/preparations
 Separate oral & IV preparations
 Separate LASA & multiple strength
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Checking
 Compare Rx with medication &
labels
 Record near misses to study causes
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Dispensing
 Two patient identifiers
 Provide verbal instructions
 Partition between dispensing
counter and the rest of pharmacy
area functions to minimize
distractions of staff
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Separation/segregation
Improvement on separation and
segregation on LASA (Looks Alike and
Sound Alike) medication in the pharmacy
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DifferentiationUse techniques
such as boldface
or color codes
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1.13 High alert labels and date of opened labels
 These high alert labels help to alert nurses regarding
drugs with high hazard levels if administered wrongly.
Labels of ‘date of opening’ helps to reduce
administration of expired drugs.
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PATIENT SAFETY SOLUTIONS
 Look-alike/sound-alike drugs (LASA)
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1.7 Use of ‘Tall Man
Letters’ and Alert
Labels for Lookalike or Sound-Alike
medications
Previous Selection errors had
occurred before for this drug as
AKURIT and AKURIT-4 soundalike. So the Outpatient
Pharmacy took the initiatives to
utilise ‘Tall Man Letters’ in
medication labelling and also by
adding additional labels to alert
pharmacy assistants about the
difference strengths available for
certain selected drugs. ( As
Shown)
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Tallman lettering
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Example of Tallman lettering on label
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Improvement in resuscitation and anesthetic
box supply
Before
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After
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Guidelines on the handling GTN on the wards
Step 1
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Step 3
Step 2
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Step 4
Coloured boxes for storing HCE
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Continuous Improvement Activities
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Putting red tag at patient
notes for allergic sign for
patient who allergic to any
medication
Allergy Sticker
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Tablet Cutter
Tablet Crusher
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Medication nurse serving medications
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Oral Medication Syringe
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SOP Prescribing and SOP Administration
 Registered 2012
 Collaboration between
Clinician, Pharmacy and
Nursing
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Medication Error Reporting
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Adverse Drug Reaction Reporting
• Malaysia ADR
Advisory Committee
(MADRAC)
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Pharmacy Automation
 Automated Dispensing Cabinet
 Automated Dispensing robot
 Automated IV station
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Usage of Automated Dispensing Cabinets in Wards
 12 automated dispensing cabinets used hospital-wide including
medical, surgical, paediatric, critical care wards
 Improve in inpatient medication supply efficiency
 Secured & orderly storage of medications in cabinets,
accessed by authorized nurses & pharmacy staffs only
 Nurses remove medications only after medication order is
reviewed by Pharmacy
The proposal and recommendations contained herewith remain the sole property of Sunway Group. Any unauthorized duplication or content use without consent of authority from Sunway Group, is deemed as breach of copyright.
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Pharmself24 automated dispensing unit
Tuanku Mizan Military Hospital
Kuala Lumpur
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Thank You
Special thanks to MPS Hospital Pharmacy Chapter for
sharing their experiences and achievements
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