Convince doctors to prescribe less number of drugs which will reduce medication errors-Jacqueline Surugue


 PHSP Second International Conference Proceedings-III

Convince doctors to prescribe less number
of drugs which will reduce medication
errors -
Jacqueline Surugue

Attitude to declare medical errors and aptitude
to prevent is more important

KARACHI: Ms. Jacqueline Surugue Chief of Pharmacy Department Centre Hospital from France has suggested that the doctors should be convinced to prescribe less number of drugs which will reduce the medication errors. She also laid emphasis on safe procurement procedures, adequate labeling which is clear, easy to read, bar coding and appropriate inner as well as outer packaging of drugs. She was delivering a keynote address at the recently held International conference organized by Pakistan Society of Health-System Pharmacists here on October 14, 2017. The topic of her presentation was “Current Technological Advancements and Practices in Pharmacy Services”.

Talking about patient safety- a drive for change Ms. Jacqueline said that today one out of ten patients in the hospital get harm. Infection is a big problem and the total cost of medical errors is reported to be forty two billion US$. Almost 15% of hospital budget is spent on treating safety accidents. She further stated that one out of two medical errors should be avoided. Deaths due to medication errors are more as compared to deaths by traffic accidents in France and it accounts for the third leading cause of death in United States after heart attacks and cancer.  Attitude to declare and aptitude to prevent medical error is more important. She emphasized the importance of creating awareness among hospital doctors, technicians, nurses and Director, Managers the leaders should be informed. These errors take place due to dysfunction in medication workflow management. All healthcare professionals are involved in medication errors starting from prescription, transcription, dispensing and administration of drugs. It is important that we should initiate a reporting system. There should be no punitive reporting system. We should try to improve quality and safety of drugs being used.

Dr. Musadik Malik along with Mr. Latif Sheikh and Jacqueline Surugue chairing a session during
the Second Int. Conference of Pakistan Health-System Pharmacists held
at Karachi on October 14th, 2017.

Continuing Ms. Jacqueline Surugue said that proven errors and near misses should all be reported, in fact the latter is more important.  For one serious accidents there are six hundred near misses, thirty minor damages and ten minor injuries. Medical errors is sometimes confused with side effects of drugs. Administration of penicillin to someone who is allergic to Penicillin is an error but allergy is side effect which comes under Pharmacovigilance. If one drug is prescribed it is ok, two will result in interaction but if the patient is taking three of more drugs, there is no way to go. She also referred to fifteen major drug interactions. She highlighted the importance of Computer Physician Order Entry system in hospitals and also talked about unit dose dispensing, storage of drugs. We should have SOPs for risky situations, conceptual injectable drugs. She also talked about secure drug administration, checking identity of patient before giving drugs. Errors could also be related to route of administration of drugs. She was of the view that every injectable preparation should be prepared by pharmacy.  Medication errors should never happen in case of anticoagulants, injection potassium chloride, injectable solutions, insulin, anesthetic drugs, in intensive care, with delivery devices, plastic vials.

High risk drugs, Ms. Jacqueline Surugue pointed out should have red labels. Analyze medical errors collectively. Educate doctors, medical students, staff nurses, care assistants, managers, administration staff, pharmacy students as well as patients. Make available relevant information protocols, SOPs, Data bank, drug lists and all this is not easy but time consuming. Create a good faith, non-punitive environment and don’t be ashamed of medical errors. Declare your medication errors as well as potential errors. You should not be blamed for this. Remember to err is human, hence there should be no shame, no blame. Advocate the safety culture. She laid stress on vigilance, concentrating, and critical thinking. Stay aware, be watchful, and be vigilant. Do not disturb when drug is being prepared in the ward. Help those who have made medication errors. WHO has now come up with an initiative of 50% harm reduction due to medications in the next five years? She also suggested that we should celebrate Patient Safety Days every year.

Earlier Dr.Aslam Afghani COO of DRAP in his presentation said that it should be our mission that patients are saved. He also talked about the implementation of drug regulatory framework. We are working on this.  With the help head of US FDA we have organized lot of training programmes to ensure compliance with international regulations. CDL will soon be the first WHO pre-qualified laboratory in Pakistan on which we are currently working. It will be the first public sector laboratory to be accredited by WHO. Audit is going on as regards National Regulatory Agency. Dr.Aslam further stated that we have multiple training programmes which covers pre-registration, registration and post registration. We have initiated Drug bar coding, post marketing surveillance, Pharmacovigilance and promoting rational prescribing. Clinical trials and bioequivalence studies are being performed, Adverse Drug Reactions reporting system is being introduced. Rules have been framed to cover Medical devices, orphan drugs, and neutraceuticals.  In the days to come lot of fields will be available for pharmacists including dispensing. New and emerging sciences needs to be included in the curriculum of pharmacy and in future we will need lot of professionals, he added.

Pharmacists Impact on Quality,
Safety and Cost effectiveness

Members in this panel discussion included Prof. Nadeem Qamar from NICVD, Prof. Abdul Basit form BIDE, Dr. Abdul Bari from Indus Hospital, Syed Jamal Raza from NICH, Prof. Rizwan Azmi from MMI and Wasif Shahzad. Mr. Jibran was the moderator. Participating in the discussion Prof. Nadeem Qamar said that involving pharmacists in patient care was rare and we started giving pharmacists a bigger role two and a half years ago. Private hospitals who acquired the services of pharmacists have proved their usefulness. We at the NICVD have now involved pharmacists in patient care and they are important part of the healthcare team. They are part of the round and they have helped us save lot of money. Now drug resistance is reducing. Their involvement did not increase the healthcare cost but reduced it, he added.

Prof. Jamal Raza said that pharmacists help preparing custom made dose for the patients. He also referred to the role of DRAP and pointed out that at times drug registration is delayed for too long, there are issues related to quality of drugs, many lifesaving drugs are not registered. He was of the view that we should have a system of regular inspection of drugs being used at public hospitals. It is recommended that there should be one pharmacists for fifty beds in a hospital but we at NICH had just one pharmacist and even this post was vacant for five years. We need to improve our pharmacy services. We need more and more clinical pharmacists who can help doctors and take increased responsibility which will improve patient care.

Prof.Rizwan Azmi said that pharmacists have a role in In-patient care. They help in choice of drugs and also give their feedback. They help refresh the mind of the physicians who are prescribing the drugs.  They know what they have to do but we do not allow the pharmacists to work. They need to be available in the system. It needs money to have a better systems otherwise we cannot realize the full potential of pharmacists. At times blame game is started. Pharmacists have a great role to play in in-patient and this should be recognized by the physicians as well as pharmacists. There are cultural issues and we need to change the culture. We must state what is required. Doctors should sit down and discuss and they should not be dictating. They will remain leader of the healthcare team on the front line. All these things have to be included in the curriculum. Physicians as well as Pharmacists both needs to be educated, he remarked.

Prof. Basit suggested utilizing the services of pharmacists at the primary care level. Physicians should support the pharmacists. Prof. Nadeem Qamar said that we need to change the hospital infrastructure. The concept of consultation with pharmacists does not exist in public hospitals. For everything acceptance in public hospitals comes late. We need to convince the healthcare team in public sector hospitals. Prof. Jamal Raza said that pharmacists role in primary healthcare is neglected. Family Physicians make mistakes in prescribing. At times wrong information is provided in drugs literature. It was pointed out that at present there are two hundred thirty pharmacists working in Aga Khan University Hospital and it has minimized the medical errors. Government of Sindh it was stated will soon appoint one hundred sixty five pharmacists.

Role of Drug Manufacturers
to enhance Patient Safety

The next panel discussion was on role of pharmaceutical manufactures in ensuring patient safety. The panelists included Mr. Arshad Rahim, Mr. Zahid Saeed, Dr. Kaiser Waheed, Mr.Kazim Hussain, Mr. Anis Shah and others. Mr. Saifur Rehman Khattak was the moderator. During the discussion it was pointed out that there is always room for improvement. About three hundred pharmacists are working in GSK plant alone. Safety of drugs is ensured at a highest level. Dr. Kaiser Waheed said that at present over 90% of drugs were being provided by the national pharmaceutical industry which was producing quality drugs at affordable prices. When we employ the pharmacists they do not know much about drug manufacturing and we train them. They should be trained in hospitals as well during their education. While working in the industry the pharmacists see the quality being built in the system. Experts are putting the systems in place which ensures quality of drugs.

Mr. Arshad Rahim talked about the SOPs and said that training was an integral part of the system. People are trained as adverse events are quoted by the doctors, everything is documented and remedial measures are taken. Mr. Kazmi Hussain opined that pharma industry was a major stake holder in patient safety. Our population is different and drugs could have different effects for which Pharmacovigilance should be there. As regards cost of the medications, we need to introduce health insurance scheme so that those who cannot afford are helped. Even otherwise cost of drugs in total healthcare cost is very negligible. The industry needs some profit so that it can further invest and improve the facilities. Mr.Kazim Hussain further opined that we do not compromise on quality, it is a no go area and if drug production is not economically viable, the industry will stop manufacturing it and that is why sometimes  we see shortage of essential drugs. Mr. Anis Shah said that we must make available drugs to the patient and the society should take up this responsibility. Mr. Zahid Saeed remarked that quality has a premium. Pharma industry in Pakistan is facing lot of challenges. Standards are going up for which we have to make investment. It increases the cost of production. Instruments, equipment is very costly. We have to comply with all the new regulations and upgrade our systems. These are serious issues and we need to look into them. We have problem in human resource. It was also suggested that we need to introduce industrial pharmacy and community pharmacy. We can introduce certificate course in industrial pharmacy Mr. Zahid Saeed remarked.

Patient Centric Healthcare

This was followed by another panel discussion on Patient Centric Healthcare. The panelists included Nasir Abdul Jalil, Jibran Bin Yousuf, Ms. Salwa Ahsan, and Kelum Jayasuria from Sri Lanka while Mr. Shamim Raza acted as the moderator. Mr. Jayasuria emphasized the importance of patient pharmacist engagement. A pharmacist, he said, should be good communicator and must listen to the patient. Ms. Salwa Ahsan said that we should treat the patient and refrain from under or over use of drugs. We should have a targeted approach defining clinical services. Mr. Jibran highlighted the importance of improving compliance with drug therapy. Mr. Nasir said that we must select good competent pharmacists and then train them. Our SOPs should be of international standards. Pharmacists should know who my patient is and ensure right drug at right time in right dose. We need to empower the patients in the hospitals.

Every hospital must have a Pharmacy and Therapeutics Committee. Pharmacists complain that doctors often do not listen to them. Pharmacists should develop an interaction system and have adequate knowledge. Hospital formulary should have good quality drugs. Mr. Jayasuria opined that in Sri Lakna pharmacists do not learn pharmacology but   they are just dispensing drugs. We in Sri Lanka are doing lot of training of pharmacists. Ms. Salwa said that there should be a shift from quality to safety from dispensing and we should be more focused on patient needs. We need to involve the patients in their healthcare. Mr. Jibran said formation of Pharmacy and Therapeutics Committee will be very helpful. Public hospitals do not have many drugs and we have to develop a model pharmacy service.

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