Professional Documents
Culture Documents
Vol. 2
Next Issue:
November 2011
Announcement :
Illegible handwriting
P.2
P.3
Sharing of globally
reported medication
errors - FDA alert on
confusion between
Risperidone
(Risperdal ) &
Ropinirole (Requip )
P.4
P.4
P.4
Page 2
SC had been conducting hospital visits to different hospitals since Feb 2009 and the first
round visit of 7 clusters had been completed. During the hospital visits, MSC observed many
good practices undertaken by hospitals to enhance medication safety, some of which are effective
in tackling problems caused by similar drug packing or drug names.
LASA/ Medication Safety Notice Board
- To alert colleagues on LASA drugs and drugs with
appearance changed recently
Page 3
Sharing of potential risk found in HA hospitals
- Similar packing of 500ml dextrose IV infusion bottles : D5 vs D50
abels of various strengths and volumes of dextrose IV infusion bottles (i.e. D5, D20 and D50) supplied by a
drug company have been changing in phases since May 2010. Subsequent to the change, a number of medication incidents and near misses have been reported in hospitals recently due to mix-up of D5 and D50 preparations.
NEW packing labels 500ml Dextrose 5% vs 500ml Dextrose 50%
Recommendations:
1.
Avoid keeping both strengths (5% and 50%) with the same volume as ward stock. Review the ward stock list
and consider replacing the 500ml D50 with 20ml D50 if possible.
2.
Separate the storage of similar packing bottles at pharmacy and in ward. Place a warning labels to remind
staff to be vigilant when picking these items.
3.
Educate and alert staff the importance of medication safety related to label design and label change.
Education poster on new product labels provided by the drug company
Page 4
2.
3.
Overlapping product characteristics, such as the drug strengths, dosage forms, and dosing intervals
4.
Similarities of the container labels and carton packaging (for generic products by the same manufacturer)
Recommendations:
1.
Prescribers to write/ print the drug name clearly on the prescription/ MAR
2.
Pharmacists to confirm/ clarify the drug name with the prescribers if the prescription is not legible
3.
Pharmacy staff to physically separate the stocks of these two drugs on the shelf
4.
Pharmacists to counsel patients about the prescribed medication, make sure patient understands the
purpose of taking the medication to avoid prescribing/ dispensing incorrect medication
igh risk medications are medications that have the highest risk of causing injury when misused. Errors with
these products are not necessarily more common, but the consequences are clearly more devastating.
In order to align with the term used in overseas countries, the term High Alert Medications would be used in the
future communications instead of the term High Risk Medications.
1. Concentrated
2. Cytotoxic
electrolytes
chemotherapy
9. Narcotics/
NSAIDs
& inotropes
opioids
8. Insulins
4. Vasopressors
7.
Oral
hypoglycaemics
5. Anticoagulants
including
6. Neuromuscular
heparin
blocking agents
Q3: qod and qd are not allowed to be used in HA (refer to HA Do Not Use list)
Answers
daily
qd
qod
In the morning
Q1: mane
Abbreviation
Intended meaning
qod or qds
q.d. (daily)
Recommendations