ADMINISTRATION AND MONITORING OF DRUG USAGE

Categories of Drug-Related Problems

1.

Medication Errors
use or cause harm to the patient while the medication is in the control of a health care professional or the patient.

- Any preventable event leading to inappropriate medication 2. Adverse Drug Events

Categories of Drug-Related Problems

1. Medication Errors
1.1 Dose 1.1.1 Dose omission 1.1.2 Improper dose 1.1.3 Wrong strength or concentration 1.1.4 Wrong duration

Categories of Drug-Related Problems

1. Medication Errors
1.2 Drug 1.2.1. wrong drug was administered 1.2.2. drug use without indication 1.2.3. inappropriate use of drug 1.2.4. wrong dosage form 1.2.5. expired or deteriorated drug 1.3 Patient 1.3.1. wrong patient

Categories of Drug-Related Problems

1. Medication Errors
1.4. Procedure 1.4.1 wrong technique in compounding 1.4.2 wrong route of administration 1.4.3 wrong rate-too fast or too slow 1.4.4 wrong time of administration 1.4.5 wrong monitoring

Categories of Drug-Related Problems

2. Adverse Drug Events may be due to: 1. ADR 2. Patients reaction to drugs

Pharmacist responsibilities:

Carry out appropriate order Correct an appropriate order Monitor and report patients response to the prescribed pharmacologic intervention

MEDICATION SAFETY THROUGH PHARMACY INTERVENTIONS

Drug Information Services Management of Adverse Drug Events Admission Drug Histories Drug Protocol Management

MEDICATION SAFETY THROUGH PHARMACY INTERVENTIONS A. Drug Information Services

Should provide support to the Pharmacy and Therapeutics Committee for drug information and evaluation. Should take an active role in hospital formulary formulation and training

MEDICATION SAFETY THROUGH PHARMACY INTERVENTIONS B. Management of Adverse Drug Events (ADE)
Drug therapy monitoring is a process which includes all functions necessary to ensure appropriate, safe, effective and economical drug therapy for the patient

Key Elements in ADE Management

Detection Monitoring Assessment and correlation Treatment Documentation Reporting Prevention

Key Elements in ADE Management

Detection

The pharmacist must at all times be on the watch for:

Prescribing errors Prescribing omissions Transcribing errors Dispensing errors Administration errors ADE others

Key Elements in ADE Management

Documentation

It is important that all contributions to patients well being be followed by documentation by the respective providers involved in health care.

MEDICATION SAFETY THROUGH PHARMACY INTERVENTIONS C. Admission Drug Histories

- done by medical residents & nurses.

- there is benefit if a pharmacist joins the Medical Admission Team

1. Intervention by pharmacist regarding reuse of medicines brought in by patients. 2. Support from pharmacist to physicians prescribing for older patients and for antibiotic prescribing.

C. Admission Drug Histories

3. Advice regarding administration 4. Allergy status of patients 5. Patient counseling 6. Cost of medications

MEDICATION SAFETY THROUGH PHARMACY INTERVENTIONS D. Drug Protocol Management

Important for standardization of treatment in hospitals Pharmacist should take part in the formulation of each protocol.

HEALTH CARE DELIVERY SYSTEM

Members of the Healthcare Team

1. Patient the focal point of our service 2. Physician prescribes drug therapy after diagnosis 3. Pharmacist manages drug therapy 4. Nurse performs direct bedside care 5. Medical technologist does clinical tests to aid diagnosis 6. Dietitian manages patients nutritional requirements 7. Others

Pharmacy Health Care Objectives

Extend pharmaceutical care focused on achieving positive patient outcomes through drug therapy

Provides services that foster the efficacy, safety and cost effectiveness of drug use

Pharmacy Health Care Objectives

Contribute to programs and services that emphasize the health needs of the public and the prevention of disease Promote pharmacy as an essential component of the health care team

Hospital Drug Administration System

Physicians order Transcription of orders by pharmacist Dispensing of medication orders by pharmacist Delivery of medications to nursing units Checking of dispensed drugs by the pharmacist Preparation of unit doses by the pharmacist endorsement of medications by the pharmacist to nurses Administration of drugs by nurses Documentation by pharmacist & nurse

Major Functions of Clinical Pharmacist

Ensure rational drug therapy Transcribes doctors orders Monitor drug therapy Provides drug information

Major Functions of Clinical Pharmacist

Participates in management of emergency medical care Provides patient education and medical counseling Monitor narcotic usage and floor stocks Monitor patients response to prescribe pharmacologic interventions

Appendix B: Examples of Serious Adverse Drug Reactions (table)

DRUG INTERACTIONS

DRUG INTERACTIONS

Drug-drug interactions are changes in a drugs effects caused by another drug when taken at the same time

Types of Drug-Drug Interactions:

1. Duplication 2. Antagonism 3. Alteration of Pharmacokinetic actions ADME

Types of Drug-Drug Interactions

Duplication refers to the potentiation of effect when 2 drugs with the same active ingredient or with the same action are taken at the same time.

Types of Drug-Drug Interactions

Duplication Cause: 1. Patients taking Rx drug together with a selfprescribing OTC drugs or herbal preparations. 2. Patient may be taking two different brands of the same drug which are prescribed separately by two doctors for different reasons

Types of Drug-Drug Interactions

Duplication Example:

Taking cold remedy with: Phenylpropanolamine HCl & Paracetamol combination with an antipyretic preparation containing Paracetamol.

Types of Drug-Drug Interactions:

Antagonism refers to the reduction of efficacy when two drugs with opposing actions are taken together.

Types of Drug-Drug Interactions

Antagonism Examples: 1. NSAIDS - may cause the body to retain fluids and salts. Together with diuretic may result in reduced efficacy of diuretics.

2. Propranolol is a beta blocker opposing the action of Albuterol which is a beta-adrenergic stimulant

Types of Drug-Drug Interactions:

Alteration of Pharmacokinetic Actions (ADME) a second drug may increase or decrease the rate at which the body absorbs, distributes, metabolizes or excretes a first drug.

Types of Drug-Drug Interactions

Alteration of Pharmacokinetic Actions (ADME) A. Absorption: Change in gastric pH

Example:

A weakly basic drug - rate of absorption is lowered by ascorbic acid

Types of Drug-Drug Interactions

Alteration of Pharmacokinetic Actions (ADME) B. Distribution

Example:

A plasma protein binding - displaced in the presence of a second drug

Types of Drug-Drug Interactions

Alteration of Pharmacokinetic Actions (ADME) C. Metabolism: Enzyme Induction

Example:
Phenobarbital - increases the rate at which warfarin (anticoagulant) is inactivated. Pharmacist - advise for the increase dose of warfarin if the drug should be taken together. - However, the dose of warfarin should be reduced once phenobarbital is discontinued to avoid risk of bleeding.

Types of Drug-Drug Interactions

Alteration of Pharmacokinetic Actions (ADME) C. Metabolism: Enzyme Inhibition

Example:

Cimetidine, ciprofloxacin and erythromycin decreases rate of metabolism of theophylline thus prolonged activity.

Types of Drug-Drug Interactions

Alteration of Pharmacokinetic Actions (ADME) Excretion: Change in urinary pH

Example:

Large doses of Vitamin C supplements - increases urines acidity resulting to: increased rate of excretion of basic drug like pseudo-ephedrine and decrease rate of excretion of acidic drugs like aspirin

PHARMACY INTERVENTIONS TO PREVENT DRUG-DRUG INTERACTIONS

Drug history taking - during admission For patients being manage by several doctors - keep each doctor informed about all other possible medications being prescribed.

PHARMACY INTERVENTIONS TO PREVENT DRUG-DRUG INTERACTIONS

Check possible drug interactions - adjust doses or dosing intervals and discuss this with doctors and patient. Instruct patient to report unusual symptoms - related to the use of the drugs.

DRUG-MEDICINAL HERBS INTERACTIONS

Dietary supplements or food supplements - most commonly used alternative therapy, includes: medicinal herbs or herbal drugs - used for health benefits nutraceuticals - natural substances that includes: certain herbs, such products as cholesterol-lowering margarines, psyllium-fortified products (dietary supplements & regulated as food) - therapeutic claims: not scientifically studied & evaluated by the BFAD

Medicinal herbs & nutraceuticals regulated as food accepted & used for chronic illnesses &/or for the promotion of health & well-being.

Dietary supplements

natural, assumed safe to use, has no side effects & has no dose limitations. in the market, no assurance of safety, efficacy & purity that drugs have not considered as drugs, patients do not divulge their use of such supplements to the doctors &/or pharmacists during drug history taking potent causes of medication errors. contain vitamins, minerals, amino acids & other constituents that may interact with drugs taken by the patient.

Interactions

may intensify or reduce the efficacy of a drug or cause a serious side effect. avoided by consulting the doctor before taking supplements

Some Possible Drug-Medicinal Herb Interactions (table)

DRUG-FOOD INTERACTIONS

May result in any of the following: Delayed/reduced absorption of the food nutrients or the drug Enzyme inhibition or induction resulting in delayed or hastened drug elimination Reduced plasma concentration of the food nutrient or the drug resulting in decreased therapeutic effect Increased or decreased action of the medication or inactivation of the medication

Pharmacist should give proper advice, to avoid the potential adverse drug reaction on whether to: eliminate the interacting food altogether adjust the time of intake

Examples of food that should not be taken with drugs as a general rule:

alcohol - increases the risk of liver damage, increase drowsiness &/or sedation, or cause nausea. Caffeine - a CNS stimulant, alters the action of many drugs affecting the CNS depending on whether the drug is sympathetic or parasympathetic. Grapefruit - causes enzyme induction whereby the biotransformation of some drugs are hastened. Depending on the resulting metabolite, more of the drug may enter the bloodstream at a shorter period time, or more of the drug will be eliminated faster.

Examples of food that should not be taken with drugs as a general rule:

Milk - dairy product or any product containing Ca, Fe, Mg, Al and other heavy metals (like antacids & multivitamins), forms a chelate with the drug rendering both the drug & the heavy metal non-usable by the body. Drug that causes gastric irritation - patients are advised to take the medication together with milk or crackers or with a full stomach. Antibiotics - almost always taken with an empty stomach unless the patient complains of gastric irritation.

Table for Drug Groups, Food, Result & Recommendation

DRUG-DISEASE INTERACTIONS
Refer to following: Worsening of a disease because of a drug Alteration of the effect of a drug because of a disease Manifestation of side effects because of interaction between the drug & a disease other than the one for which the drug is being taken

Because drugs can affect diseases other than the one being treated: People should tell their doctor or pharmacist all of the diseases they have Drugs they are taking for such a disease At high risk, elderly patients & people with diabetes, hypertension, glaucoma, insomnia, poor bladder control

DRUG-DISEASE INTERACTIONS ARE CAUSED BY THE FOLLOWING:

PHYSIOLOGICAL CHANGES IN THE ELDERLY amount of body water while the amount of fat tissue Drugs that dissolve in water - reach higher concentrations & drugs that dissolve in fat - accumulate more amount of acetylcholine in the body with age resulting in the older patients decreased tolerance to drugs with anticholinergic effects KIDNEY IMPAIRMENT For the elderly - kidneys are less able to excrete drugs into the urine - resulting in the prolonged stay of the drugs in the body - thus prolonging its effect

DRUG-DISEASE INTERACTIONS ARE CAUSED BY THE FOLLOWING:

LIVER IMPAIRMENT decreases metabolism of many drugs Drugs stay in the body much longer than normal, prolonging its effect ALTERED DRUG RESPONSE Older people, more sensitive to the effects of many drugs. Drugs cause more dramatic effects to elder DIFFICULTY IN COMPLIANCE Not following doctors instructions; not taking the prescribed drug, taking too little or taking too much Risky & life-threatening

PHARMACISTS, TO AVOID SERIOUS OVERDOSAGE AND/OR TO REDUCE THE RISKS OF SIDE EFFECTS: Should take note of plasma levels of the drugs Make necessary adjustments in either the size of dose or the dosing interval

Drugs with Increased Risk for Older Patients (table) Appendix H: DO NOT USE LIST (table)

PHARMACY INTERVENTION SAMPLES

1. PRESCRIBING ERROR INAPPROPRIATE DRUG Humulin R was ordered but the: patient is using Humalog Order was changed to Humalog KCl Elixir was ordered to a pregnant woman Order was changed to Potassium Chloride Solution INAPPROPRIATE DOSE Co-amoxyclav sus 312.5 mg/5mL TID was ordered to a 13 Kg patient, Dose was changed to Co-amoxyclav 457 mg/5mL, 3 mL BID Codeine syrup 30mL BID was ordered, Recommended dose is 15mL BID

PHARMACY INTERVENTION SAMPLES

1. PRESCRIBING ERROR

INAPPROPRIATE ROUTE Ketoprofen (Orudis IV) was ordered as IV push Ketoprofen is given as IM or IV drip only

INAPPROPRIATE DOSAGE FORM

Esomeprazole (Nexium) tab ( a delayed-release capsule) 40mg OD was ordered per ngt (nasogastric feeding tube) but it should not be crushed or chewed Drug was changed to Sucralfate (Iselpin) tablet 1 g one tab TID per ngt

PHARMACY INTERVENTION SAMPLES

1. PRESCRIBING ERROR

INAPPROPRIATE DURATION Azithromycin tab 500mg OD for 5 days was ordered Recommended duration of treatment is for 3 days only IV INCOMPATIBLE Cisplatin is incompatible with D5W Nasal drip in D5W was given after the cisplatin drip instead of simultaneous infusion

PHARMACY INTERVENTION SAMPLES

2. PRESCRIBING OMISSION

INCOMPLETE DOSE There is an order of Ambroxol syr 15 mg/5mL BID, Dose was not specified INCOMPLETE DIRECTIONS There is an order of Digoxin 0.25 mg OD, but the route of administration is not indicated.

PHARMACY INTERVENTION SAMPLES

2. PRESCRIBING OMISSION DURATION NOT SPECIFIED There is an order of Cefaclor cap 500 mg po TID as take home medication but duration of treatment was not specified. VAGUE ORDER There is order to shift Citicholine to per orem, same dose & frequency. The patient is on Citicholine 1g IV q 8 hrs and its oral preparation is Citicholine drops 100 mg/mL. Dose must be verified.

PHARMACY INTERVENTION SAMPLES

2. PRESCRIBING OMISSION INCOMPLETE/NO TAKE HOME MEDICATIONS Patient is going home but his present antibiotic Coamoxyclavtab 625 mg TID was not ordered to be continued and up to when.
3. DRUG THERAPY MONITORING THERAPEUTIC DUPLICATION Patient is on Rebamipide (for gastroduodenal ulcers)100 mg TID but there is a new order of Famotidine (treat ulcers in the stomach and intestines) tablet 20 mg po BID Famotidine was not given and the order was held

PHARMACY INTERVENTION SAMPLES

3. DRUG THERAPY MONITORING ANTIMICROBIAL MONITORING Patient is on Netilmycin ampoule 150mg IV Drip OD and is on its 5th day, Drug was discontinued as recommended by the pharmacist. PHARMACOKINETIC MONITORING Milk of Magnesia suspension (antacid & laxative, avoided with kidney disease) was ordered for a patient with Acute Renal Failure and increased BUN/Crea Drug was changed to Lactulose liquid (for chronic constipation, safe to use).

PHARMACY INTERVENTION SAMPLES

3. DRUG THERAPY MONITORING ALTERNATE ROUTE RECOMMENDED Patient is in Vitamin K amp 10mg IM OD and an IV Fluid was started on the 3rd day, Route was changed to IV as recommended by pharmacist. DRUG-DRUG INTERACTION SIGNIFICANT Warfarin is given together with Metronidazole, Anticoagulant effect of Warfarin is enhanced and may lead to hemorrhage, thus timing of medication was separated.

PHARMACY INTERVENTION SAMPLES

3. DRUG THERAPY MONITORING ALLERGY NOT NOTED Patient is allergic to Penicillin, but there was an order of Amoxycillin Antibiotic was changed to Cephalexin FLUID RESTRICTION NOT NOTED A patient with Congestive Heart Failure has an order of D5W250mL + 400mg Dopamine at 10 mcg/kg/min, Concentration of Dopamine was changed to D5W100mL + 400mg Dopamine to restrict the fluid of the patient as suggested by the pharmacist.

PHARMACY INTERVENTION SAMPLES

3. DRUG THERAPY MONITORING DOSE ADJUSTMENT BASED FROM LABORATORY RESULTS (BUN/Crea, K, Na, etc) Initial dose of Cefepime vial (for nosocomial pneumonia) is 1g IV q 8hrs, but the latest BUN/Creatinine result is 35mL/min (moderate impairment) Dose was adjusted to 1g IV q12hrs as suggested by the pharmacist. RECOMMEND CHANGE IN FREQUENCY Patient is still on Nalbuphine ampoule 10mg IV q4hrs on his 3rd post op day, patient is no longer experiencing pain as much, Frequency was decreased to pm (Post Meridiem "after midday" )

PHARMACY INTERVENTION SAMPLES

3. DRUG THERAPY MONITORING REVISION IN THERAPY DUE TO DIET CHANGE Patient is on Ranitidine ampoule IV q8 hrs but his diet was changed from NPO to soft, Drug was discontinued

DRUG-FOOD INTERACTIONS

PHARMACY INTERVENTION SAMPLES

4.TRANSCRIBING ERROR INAPPROPRIATE DRUG Trimipramine (Surmontil) tab was transcribed instead of Imipramine (Tofranil) INAPPROPRIATE STRENGTH Pentoxifylline drip in NSS 20mL was transcribed instead of Pentoxifylline amp in NSS 200mL INAPPROPRIATE FORM Furosemide tablet was transcribed instead of ampoule

PHARMACY INTERVENTION SAMPLES

5. DISPENSING ERROR INAPPROPRIATE DRUG Terbutaline sulfate ER 2.5mg was dispensed instead of Felodipine ER INAPPROPRIATE STRENGTH Heparin 5000u/mL was dispensed instead of 100u/mL Metoprolol tab 50mg was dispensed instead of 100mg INAPPROPRIATE FORM Vitamins B1, B6, B12 amp was dispensed instead of tablet

PHARMACY INTERVENTION SAMPLES

6. ADMINISTRATION ERROR (in units without clinical pharmacist) INAPPROPRIATE DRUG Dexamethasone 1mg, Neomycin sulfate 3,500 iu, Polymyxin B sulfate 6000 u (Maxitrol) eyedrops was requested and administered instead of Dexamethasone (Maxidex) eyedrops INAPPROPRIATE FORM Morphine plain tab was requested and administered instead of long acting MST continus tab. (morphine sulphate, an

opioid) painkiller.

PHARMACY INTERVENTION SAMPLES

6. ADMINISTRATION ERROR (in units without clinical pharmacist) INAPROPRIATE STRENGTH 1g/10mL was given instead of 2 mL of Meropenem 1g/20 mL Fluconazole vial 200mg IV was given instead of 100 mg 7. DOCUMENTATION ERROR Amlodipine tab 5mg OD to start and was documented as given but was not actually given

PHARMACY INTERVENTION SAMPLES

7. MISCELLANEOUS Non formulary medications Recommend cost-effective medications Not available/out of stock medications

TAXONOMY OF MEDICATION ERRORS

Classification of Medication Errors
NO ERROR 1.1 Category A

Circumstances or events that have the capacity to cause error ERROR, NO HARM Harm - defined as death, or temporary or permanent impairment of body functions/structure requiring intervention. Intervention include: monitoring the patients condition change in therapy, or active medical or surgical treatment.

TAXONOMY OF MEDICATION ERRORS

Classification of Medication Errors
1.2 Category B An error occurred but the medication did not reach the patient

1.3 Category C An error occurred but the medication reached the patient 1.31 Medication reaches the patient and is administered 1.32 Medication reaches the patient but not administered

TAXONOMY OF MEDICATION ERRORS

Classification of Medication Errors
1.4 Category D An error occurred that resulted in the need for increased patient monitoring, but no patient harm. 1.5 Category E An error occurred that resulted in need for treatment or intervention and caused temporary patient harm

TAXONOMY OF MEDICATION ERRORS

Classification of Medication Errors
1.6 Category F An error occurred that resulted in initial or prolonged hospitalization and caused temporary patient harm 1.7 Category G An error occurred that resulted in permanent patient harm

TAXONOMY OF MEDICATION ERRORS

Classification of Medication Errors
1.8 Category H An error occurred that resulted in a near-death event (e.g. Anaphylaxis, cardiac arrest). 1.9 Category I An error occurred that resulted in patients death.