based on nurses feedback. In year 2013, remedial actions were car-ried out. Education program and training for nurses are held aim-ing to increase the awareness of staff in wards about importance of correct parenteral administra-tion. Dilution Guide for High Alert Medication (refer Appendix 1), Parenteral medication admini-stration & dilution guideline were distributed to all the wards (refer Appendix 2). Quick reference (a summary of dilution guideline made in small cards. Refer Ap-pendix 3) was produced and at-tached to ward’s medication trol-ley and also collaboration with nursing unit to produce a SOP for parenteral medication administra-tion. References;

1. Guideline of Medication Error Reporting, 1st Ed., 2009, Ministry of Health, Malaysia.

2. Johanna W, Marilyn R, Amanda W, et al. Errors in the administration of intravenous mediations in hospital and the role of correct procedures and nurse experience. BMJ Qual Sad 2011;20: 1027-37.

3. Wirtz V, Taxis K, Barber ND. An Observational study of intravenous medication errors in the United Kingdom and in Germany. Pharm Word Sci, 2003(3):104-11.

Parenteral medications are com-monly prescribed for patients admitted to wards. Parenteral medications may have higher risk and severity of error than other medication administration route. Non adherence to standard proto-col/guidelines may lead to medi-cation errors which may harm the patients. The possible contribut-ing factors may due to personnel factors as well as lack of informa-tion on correct and proper par-enteral medication administra-tion. This problem can be solved by optimizing the quality of per-sonnel and resources in hospital.

IV administration errors are com-mon and frequent. Types of er-rors are procedural failures (i.e. do not check patient identifica-tion, read medication label) and administration errors such as wrong route, rate, mixture, vol-ume and drug compatibility. Most common error is wrong rate error. Therefore, a quality assur-

ance study was carried out in year 2012 to determine the rates of non-adherence to guidelines and protocol of parenteral medication administration by registered nurses in hospital Labuan’s ward before and after intervention.

The result of the study showed that most frequent failure is Fail-ure of countercheck by another nursing staff during medication preparation and administration (88.2%) followed by Failure to use aseptic technique (36.1%). On the other hand, most frequent error is Wrong volume of solvent/ diluents added (73%). For exam-ple IV Augmentin (Amoxycillin plus Clavunate) should be diluted with 20ml of WFI instead of 10ml. Then the second highest is Wrong administration rate (54%). Examples are wrong IV Infusion rate and IV bolus in-jected too fast.

Remedial actions were brain-stormed among QA team and

A Quality Assurance Study on the Administration of Parenteral Medication in Hospital Labuan’s ward

Guidelines for Parenteral Medications

Appendix 3: Dilution Guide for Par-enteral Medication to be kept at ward trolley

Pharmacy department, Hospital Labuan

March 2013 Pharmacy Bulletin 1/2013

Pharmacy Bulletin

A Publication of Drug Information Service

(DIS) Pharmacy, Hospital Labuan

Advisor

Pn Soo Bee Kuan

Editor Ung Yew Jye

Any Comment, query,

recommendation kindly contact DIS

Pharmacy 087596888

Ext. 4185

Inside this issue:

Analgesics and pain relief in pregnancy & breastfeeding

2

Aliskiren 3

How to apply Benzyl Benzoate Lotion

3

Product update 4

New Drug Allergy Card

4

No.

Drug Diluents/ Dilution Route& Rate of Administration Stability & Storage Remarks

1. Acyclovir 250mg (KLOVIREKS-L)

Diluent: Reconstitute with WFI. Di luents for infusion: NS or D5. Dilution: Reconstitute with 10ml of steri le WFI. Remove calculated dose from the vial and add into electrolyte and glucose solution. Infusion concentration should be ≤ 7mg/ml.

Route: Slow IV Infusion only. Avoid rapid infusion. Rate: IV Infusion over 1 hour (prevent renal damage).

Stability: Reconstituted solution stable for 12 hours at RT, do not refrigerate. Storage: Below 25⁰C, away from light.

Should NOT be given as IM or SC. References: MOH formulary, Lexicomp, PI.

2. Amikacin 250mg, Amikacin 500mg (AMICIN ®)

Diluent: NS, D5, other electrolyte containing solution. Dilution: IV: Dilute 500mg to 100ml or 200ml of NS, D5, or other electrolyte containing solution. IM: Give undi luted.

Route: IV Infusion, IM Rate: IV: Adults and chi ldren over 30-60 minutes. Infants over 1-2 hours.

Stability: When mixed with D5 or NS, stable for 24 hours at RT (25°C) and 4 days at 4°C. Storage: Below 25°C. Protect from l ight. Do not freeze.

References: MOH formulary, Medscape, PI, Lexicomp.

Appendix 2: Reconstitution & Administration Of Parenteral Medication Guideline Hospital Labuan

Appendix 1: Dilution Guide for high alert medications

Pain during pregnancy may be due to acute conditions such as infection or injury, or secondary to underlying medical disorders such as rheumatoid arthritis. Pain related to pregnancy can also occur. Inadequate man-agement of persistent pain can result in depression and anxiety. Women should not suffer unnecessarily from pain during pregnancy and lactation. Common analgesics such as paracetamol, aspirin, non-steroidal antiinflammatory drugs (NSAIDs) and opioids are relatively safe if used appropriately. In counselling women about taking medi-cines during pregnancy it is always important to empha-sise that all couples have a background risk of 3% of having a baby with a major birth defect and around 15% of all recognised pregnan-cies end in miscarriage, re-gardless of any drug expo-sures.

Paracetamol Paracetamol is the analgesic and antipyretic drug most widely used particularly by pregnant women. Although it readily crosses the pla-centa, in therapeutic doses it does not appear to increase the risk of birth defects or adver se pregnancy out-comes. Paracetamol is con-sidered to be safe for use d u r i n g b r e a s t f e e d i n g .

Aspirin Aspirin is used to treat mild pain and fever. Overall, as-pirin is not associated with

an increased risk of congeni-tal malformations. Aspirin is generally not recommended for treatment of pain during breastfeeding because there may be significant adverse effects in infants. There is concern that aspirin can cause Reye's syndrome (sudden (acute) brain dam-age and liver function prob-lems) in infants.

NSAiDs NSAIDs including ibupro-fen, naproxen, indomethacin and diclofenac are widely used to treat mild to moder-ate pain and fever. These drugs have not been shown to increase the risk of struc-tural birth defects or other adverse outcomes such as preterm delivery or low birth weight. Use of NSAIDs af-ter 30 weeks pregnancy is contraindicated because of their potential to cause pre-mature closure of the fetal ductus arteriosus and persis-tent pulmonary hyperten-sion. High doses may also reduce perfusion of the fetal kidneys and urine output. Topical NSAIDs considered to be relatively safe in preg-nancy. NSAIDs, such as ibuprofen and diclofenac, are considered to be com-patible with breastfeeding

Opioids

Codeine and morphine, as well as drugs such as pethidine and tramadol, are used to treat moderate to severe pain. Overall, opioid analgesics have not been associated with an increase in birth defects or other ad-verse outcomes such as mis-

carriage. The main concern about these drugs is that persistent use may lead to dependence and tolerance in the mother with resultant withdrawal (neonatal absti-nence syndrome) in the neo-nate. Women with persistent pain who may require high doses of opioids during pregnancy, alternative drugs including tricyclic antide-pressants may help to con-trol persistent pain and re-duce opioid exposure. Tri-cyclic antidepressants have not been associated with an increased rate of birth de-fects or long-term neurode-velopmental effects. In breast feeding, short-term use is unlikely to pose a significant risk but long term use can be potentially dan-gerous, it may cause central nervous system depression between mother and baby. If longer-term pain relief is required, then other drugs such as NSAIDs should be considered as first-line treat-ment .

Excerpt from Aust Prescr 2011;34:8–10

Analgesics and pain relief in pregnancy and breastfeeding

Page 2

Pharmacy Bulletin

Pregnancy and Breastfeeding

Corner

What is Aliskiren

Aliskiren, a direct renin in-hibitor (DRI) is currently a new drug used for the treat-ment of hypertension. Al-iskiren, is the first known new class of orally effective, nonpeptide, low molecular weight renin inhibitor that is successfully be used for treatment of hypertension.

Mode of action Aliskiren, a renin inhibitors block this complex hormo-nal system at initial point of activation, prevent the for-mation of both Ang 1 and Ang II [2]

Monotherapy

Studies showed that the dose reposnse curve for Aliskiren in patients with mild to moderate hypertension reaches a plateau at 300mg, and no significant BP redu-cation observed at 600mg [1, 2, 4]

Comparison with other antihypertensive drug Study by Gradman et al showed that 75mg, 150mg and 300mg Aliskiren daily provided similar magnitude in reduction of daytime and

nighttime systolic and dia-stolic blood pressures to those of full dose of a cur-rently used antihypertensive agent, namely 100mg Losar-tan [3] Aliskiren 150mg provided efficacy similar to that of the AT1-receptor blocker Irbesartan 150mg and higher doses of Al-iskiren (300mg or 600mg) are more effective in BP reduction and control than Irbesartan 150mg [2]. Al-iskiren also showed superior reduction in SBP when com-pared with Ramipril 10mg (the maximum effective BP-lowering dose) [5].

Combination with other antihypertensive drug Aliskiren and ACE-inhibitors -

Aliskiren/ramipril combina-tion led to greater reduction in 24 hour ambulatory DBP compared to ramipril mono-therapy

Aliskiren and ARBs -

Aliskiren 150mg in combi-nation with Valsartan 80 provides antihypertensive efficacy similar to Aliskiren 300mg and greater than val-sartan 160mg.

Aliskiren and Diuretics - The addition of 25mg of Hydrochlorothiazide to pa-tient with mild to moderate hypertension who received 150mg of Aliskiren leads to further significant reductions in daytime systolic and dia-stolic BP.

Side effect and tolerability Aliskiren treatment showed good safety and tolerability profile in present studies [2, 3].

References

1.Parving H-H, Persson F, Lewis JB, Lewis EJ, Hollen-berg NK. Aliskiren Combined with Losartan in Type 2 Diabetes and Nephropathy (AVOID). The new England journal of medicine 2008, 358: 23. 2. Gradman AH, Schmieder RE, Lins RL, Nussberger J, Chiang YT, Bedigian MP. Aliskiren, a Novel Orally Effective Renin Inhibitor, Provides Dose-Dependent Antihypertensive Efficacy and Placebo-Like Tolerability in Hypertensive Patients. Circulation 2005, 111:1012-1018. 3. Stanton A, Jensen C, Nussberger J, Obrien E. Blood Pressure Lowering in Essential Hypertension With an Oral Renin Inhibitor, Aliskiren. Hypertension 2003, 42:1137-1143.

4. Oh BH, Mitchell J, Herron JR, Chung J, Khan M, Keefe DL. Aliskiren, an Oral Renin Inhibitor, Provides Dose-Dependent Efficacy and Sustained 24-HourBlood Pressure Control in Patients With Hypertension. J. Am. Coll. Cardiol 2007.

5. Uresin Y, Taylor AA, Kilo C, Tschöpe D, Santonas-taso M, Ibram G, Fang H, Satlin A. Efficacy and safety of the direct renin inhibitor aliskiren and ramipril alone or in combination in patients with diabetes and hypertension. Journal of the Renin- Angiotensin- Aldosterone System 2007, 8:4..

3. APPLY and rub the lotion from your neck to other parts of your whole body including leg and finger.

4. LEAVE it for 12 hours or overnight.

5. On the NEXT MORNING, apply lotion again without take

Benzyl benzoate lotion is used to treat Scabies. For child or infant, dilution of lotion is needed before apply .

Steps:

1. Use it at NIGHT.

2. Take a bath and DRY your body properly

a bath and leave it for another 12 hours.

6. Then, WASH your body properly.

7. REPEAT step 3–6 for an-other 2 times.

Aliskiren

How to apply Benzyl Benzoate Lotion

Page 3

Pharmacy Bulletin 1/2013

Introduction of New drug

Counselling Corner

Previous Packaging Current Packaging

Extended Hours Service by phar-macy at A&E is no longer in ser-

vice, starting 1st March 2013 until further notice due to low workload.

Pharmacy Staff Movement New Staff: Cik Michelle L Tan Pegawai Farmasi U41, Farmasi Klinik Pakar, Ext 983 Further study: Pn Tan Suet Yin (Pegawai Farmasi U48) Pn Kuapih @Florina (Pegawai Farmasi U48) Transferred: Cik Cheah Soong Yee (Pegawai Farmasi U44)

Tramadol HCl 50mg

New Drug Allergy Card and Drug Allegy notification sticker

Page 4

Pharmacy Bulletin

Announcements

Other Update

Old Drug Allergy Card

Product Update