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Shaukat Khanum Memorial Cancer Hospital and Research Center

Pharmacy Newsletter

JCI Special Edition

Volume VIII, Issue # 1, 2018

The Team

Shahbaz Ahmad Khan, Saba Mazhar, Ehsan Elahi, Rehan Khan Niazi, Mariam Fatima, Faiqa

Malik, Adeel Siddiqui ,Irfan Raza, Salman Azeem, Murryam Khalid, Saba Ashraf ,Eman Tahir,

Salbia Shereen

Co-Editors:

Ghulam Mujtaba, Sidrah Andleeb, Omar Akhlaq Bhutta

Editor-in-Chief:

Muhammad Tahir Aziz

Following medications are approved by P&TC:

1. Pilocarpine eye drops: Approved as regular formulary item

2. Sirolimus Tab: Approved for one patient / year for max. 3 years

treatment

3. Vasopressin Inj: Approved as regular formulary item

4. Prosure powder: Restricted by service (nutritionist only) – max. one

month prescription for malnourished and cachectic patients

5. Zolidronic Acid: Approved as regular formulary item

6. Sitagliptin & Combination: Approved as regular formulary item

Following medications are deleted from formulary list.

1. Pamidronate Inj - Cost effective alternative Zoledronic acid.

2. Procainamide Inj: Due to unavailability.

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Document what you do, and do what you document. Yes! We are ready for the big one. In context of

measures taken to prepare for Joint Commission International Accreditation (JCIA) at SKMCH we

have improved our attention to detail and through rigorous rounds of tracers, managers and

supervisors have developed the eye that sees room for improvement and the vision that sets sky as the

limit. Education, education and education. Daily evening meetings, tutorials and discussions, have

improved the concept of patient safety and hence staff has become more comprehensive in their work

to ensure it. Departments have come closer and communication gaps have been minimized. Not that

all of this has been a walk in the garden; discussions, disagreements, conflicts that seemed un-

resolving at times and emotional outbursts - we have had our fair share of twist in the tail.

At SKMCH we learn to empathize with our patients irrespective of their ability to pay, deciding

preference only on the basis of medical need – equity. With the standards of quality our policies

define for patient care and thankless efforts put in from top to bottom of our institutional hierarchy,

we are very hopeful to achieve this international certification. As we see the official countdown to the

mega day, we stand strong, we stand confident, we stand together and irrespective of the outcome, our

strife for excellence will keep moving ahead. Fingers crossed for the milestone!

Drug recall is the process of removing a drug from the market if it presents a threat to the safety of

consumer including product adulteration, gross fraud or deception of consumers, and/or are subject to

legal action under other aspects of FDA’s compliance policy. SKMCH has a comprehensive drug

recall policy. Recently, we dealt with phenobarbitone tablet recall, based on customer complaint of

lack of efficacy proven through zero serum drug levels post 1 month of continued use. Cough

suppressant Sancos syrup has been recalled from market in Pakistan under orders of drug regulatory

authority of Pakistan (DRAP). Pharmacy department SKMCH conducted a thorough review of

inventory to ensure that the product is not available in stock and the recall notice is saved as official

record.

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108%

77%

45% 38% 26% 20%

0%

50%

100%

2015 2016 2017P

erc

en

tage

Years

Meropenem DDD SKMCH, 2015 - 2017

DDD/1000Patientsdays

DDD/100Patientadmissions

8 %

6%

3% 2.8% 2.2% 1.4%

0%

5%

10%

2015 2016 2017

Pe

rce

nta

ge

Years

Linezolid DDD SKMCH, 2015 - 2017

DDD/1000Patients days

DDD/100 Patientadmissions

25% 21% 18%

8.8% 7.1% 8.2%

0%

25%

50%

2015 2016 2017

Pe

rce

nta

ge

Years

Colistin DDD SKMCH, 2015 - 2017

DDD/1000Patients days

DDD/100Patientadmissions

70%

50%

26% 24.6% 17.3% 11.8%

0%20%40%60%80%

100%

2015 2016 2017

Per

cen

tage

Years

Vancomycin DDD SKMCH, 2015 - 2017

DDD/1000Patientsdays

DDD/100Patientadmissions

67.6 72.4 64.47 70 87.5

92.86

32.3 27.5

35.52 30

12.52 7.14 0

20

40

60

80

100

2011 2013 2014 2015 2016 2017

%ag

e

Years

Drug utilization review of restricted antibiotics SKMCH (2011 – 2017)

Rational

irrational

11910 13266

16859

20350

0

5000

10000

15000

20000

25000

2014 2015 2016 2017Tota

l In

terv

en

tio

ns

Years

SKMCH Pharmacy Clinical Interventions – Year wise

0

1000

2000

3000

Sep,08 Oct,11

Feb,17

Nu

mb

ers

Months

Pharmacy Clinical Interventions Trend (PDCA - 2008-18)

Total-Accepted

Total-Rejected

Physcian Delinquency

Total Interventions

ASP is a coordinated approach towards

appropriate use of antibiotics – probably the only

tool the world has today against the ever emerging

resistant microorganisms. The program was

implemented in SKMCH&RC Lahore in 2011

headed by pharmacy and therapeutic committee

(P&TC). Effectiveness review of ASP is

carried out through anti-biogram review,

defined daily dose (DDD) and drug utilization

review (DUR) results. DDD is the assumed

average maintenance dose per day for a drug used

for its main indication in adults. It provides a

measure of exposure or therapeutic intensity in a

defined population, allowing comparisons across

various time periods and population groups.

Presented in the graphs here, is a comparison for

DDD of restricted antibiotics 2015 through 2017.

Results show a steady decrease in usage trend.

ASP implementation also provides pharmaco-

economic benefit. For instance SKMCH saved

PKR 2.2 million approximately solely through

vancomycin restriction.

Drug utilization review of restricted antibiotics

shows a promising trend towards compliance with accepted guidelines of antibiotic use.

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0.70% 3%

7.40%

3.70%

9.60%

0%

5%

10%

15%

20%

25%

30%

%ag

e

Clinical outcome

ADRs by clinical outcome, SKMCH, 2017

250

2

Errors with harm Data SKMCH, 2017

Total Reports

Errors withharm

11 11

9 8 8

7 6

5 5 4 4

0

2

4

6

8

10

12

Nu

mb

er

Drugs

Most Commonly Reported ADRs SKMCH&RC 2017

8.8

16.8

3.6 2 3.2 2

30

2.8 1.6 2 1.2 0.8 4

0 0.8 1.6

%ag

e

Type of error

ME/NM - Top Errors SKMCH, 2017

Patient safety is part of the ethos of SKMCH. We have always been educated to report gaps for

improvement with no blame culture while analyzing reports; we blame the system to improve it, not

the person! Patient’s therapy is monitored in terms of response of drug therapy and adverse effects are

noted in patient’s medical record. Pharmacy evaluates the reported adverse drug reactions (ADRs)

and adverse event (medication errors and near miss) reports for possible action. For the year 2017,

hospital reported a total of 135 ADRs. The graph below shows the categories of serious ADRs

reported. Most common reported ADRs were nephrotoxicity with cisplatin – A type A ADR

(extended pharmacologic effect), and allergic reactions with

dacarbazine – A type B reaction (bizarre, not an extended

pharmacologic effect). Root cause analysis is carried out on

serious ADRs to identify any possible practice gaps.

Reporting culture for medication errors (ME) and near misses

(NM) has positively increased in the past one year - an

encouraging sign of improved patient safety. Corrective and

preventive actions are taken wherever required for reported

errors and near miss reports with validation through quality

and patient safety department QPSD.

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Department of pharmacy SKMCH works on strategies to improve safety of high alert and LASA medications.

We have adopted uniform stacking plan across the hospital with colour codes – “Red” for high alert drugs and

“Yellow” for LASA drugs.

Department of pharmacy SKMCH conducts yearly

review of high alert and look-alike-sound-alike

(LASA) drugs list based on adverse event reports.

The updated list for the year 2018 has a number of

additions. Colistimethate sodium injection has been

added in high alert list due to 2 reported errors of

dosing in 2017 ( 1 due to wrong transcription by

pharmacist and the other due to wrong dose

prescribed on manual prescription form). Octreotide

injection and calcitonin injection are strong look

alikes and led to 3 near miss reports in the year

2017, based on which these have been added in

SKMCH’s LASA list. By policy, all LASA are

dealt as high alert drugs and go through double

check before dispensing and administration.

Controlled drugs and concentrated electrolytes

listed below are part of high alert list

Alprazolam Bromazepam Clonazepam Diazepam Lorazepam

Tramadol Midazolam Phenobarbital Chloral hydrate Buprenorphine

Potassium Chloride Injection 1meq/ml Magnesium Sulfate Injection 50%

LOOK ALIKE SOUND ALIKE