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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