Ensuring

Medication
Safety through
Pharmacy
Interventions
Normita D. Leyesa, RPh, MSc
Sheryll Ann Q. Limson, RPh
 • Introduction
• Medication Pathway
• Current Status of Medication Safety
• Incidence of Medication Errors (ME)
• Definition and Classification of Medication Errors
• Definition and Key Elements in Adverse Drug Events
Outline (ADE) Management
• Patients’ Problems with Medications
• Ways to Decrease Risk and Improve Patients' Safety
• Pharmaceutical Drug Interactions
• Types of Drug Interactions
• Practices that increase Patients Risk of Drug
Interactions
• Impact of Drug Interactions and Remedial Actions
 The pharmacist's
responsibility goes beyond
dispensing and as such
management of adverse
drug events, prevention of
medication errors and drug
interactions are her vital
roles.

Introduction Objective

To assist in the formulation of

pharmacy interventions to
ensure proper drug usage
and achieve medication
safety.
What can go
wrong?
Medication
Pathway
The
Medication
Pathway
DOCTOR - PRESCRIBING • Lack of awareness of best practice
recommendations
• Failure to alter drug therapy in the face of altered
physiology such as renal or liver impairment
• Disregard for a patient’s history of allergy to the
same medication class
• Prescription of the wrong drug name, wrong dose
form or abbreviation
• Incorrect dosage or frequency calculations
• Illegible writing
• Inadequate monitoring or follow-up
• Discontinuity of pre-hospital and post-hospital
medications
• Transcription duplications and omissions
• Poor communication with the patient &/or other
members of the health team
PHARMACIST - DISPENSING
• Failure to understand doctors
prescription (especially if
handwritten)

• Dispenses wrong drug

• Wrong patient

• Poor patient counseling

• Poor communication with the patient

and prescribing doctor
 • Most detrimental errors are related to diagnosis, prescription
and the use of medicines.

Current Status
• Adverse Event is one of the 10 leading causes of death and
of Medication disability in the world.
Safety
• 4 in 10 patients are harmed in primary and outpatient health
care.

• Up to 80% of harm is preventable.

• Investments in reducing patient harm can lead to significant

financial savings, and more importantly better patient
outcomes.

World Health Organization, 2019

 • More than 2.2 million people required
Current Status hospitalization due to serious reactions
to medications
of Medication
Safety
• 106,000 of these patients died due to
ADRs of properly prescribed and
administered prescriptions

• ADRs: number 4 killer in US

Journal of American Medical Association (JAMA)

Current Status • Only 24% of 545 responding hospitals
of Medication had deployed pharmacists in patient
Safety care units

• In the Philippines???

ASHP: A Survey of Pharmacy Practice in Hospital Settings

 • Rate of 1 per patient per day

Incidence of • 44,000 to 98,000 deaths yearly in US

Medication
• Costs 17-29 billion dollars in a year
Errors
• Eighth leading cause of death, higher than motorcycle vehicle
accidents, breast cancer, and AIDS

• 7,000 hospital in-patient deaths and 770,000 injuries yearly

1. Kohn L, et al. To err is human: building a safer health system. National Academy Press, Washington, DC: Committee on Quality of Health
Care in America, Institute of Medicine, 1999
2. Weingart SN, et al. Epidemiology of medical error. West J Med 2000: 172 (6): 390-393
 • Becoming more common, despite of
Incidence of better drugs
Medication
Errors • 500% increase in medication-related
deaths in England and Wales for the
past 10 years
 • In the Southeast Asian countries, the
wrong dose was the most common type of
Incidence of error -12% and 72%
Medication
Errors • Most frequently reported class of drugs
related to Medication Errors
antibiotics
opioids
corticosteroids
muscle relaxants

1. Medication Errors in the Southeast Asian Countries: A Systematic Review Shahrzad Salmasi, Tahir Mehmood Khan, Yet Hoi Hong, Long
Chiau Ming, Tin Wui Wong
 Any preventable event that may cause
MEDICATION or lead to inappropriate medication use or
ERRORS patient harm while the medication
is in the control of the health care profess
ional, patient or consumer
 Dose
Dose Omission
CLASSIFICATION Improper Dose
OF Wrong strength and concentration
MEDICATION Wrong duration
ERRORS
Drug
Wrong drug administered
Drug used without indication
Inappropriate use of drug
Wrong dosage form
Expired or deteriorated drug
CLASSIFICATION Patient
OF Wrong patient
MEDICATION
ERRORS
Procedure
Wrong technique in compounding
Wrong route of administration
Wrong rate of administration
Wrong time of administration
ADVERSE Medical occurrence temporally
DRUG associated with the use of a medicinal
EVENTS (ADE) product, but not necessarily causally
related
 A. Detection

KEY
The pharmacist must always be on the watch
ELEMENTS for :
IN ADE • Prescribing errors
MANAGEMENT • Prescribing omissions
• Transcribing errors
• Dispensing errors
• Administration errors
• Adverse drug reactions
 B. Monitoring
KEY
ELEMENTS C. Assessment
IN ADE D. Treatment
MANAGEMENT E. Documentation
D. Reporting
F. Prevention
 • May attempt to manage their illnesses themselves
without seeing doctors and pharmacists
Patients’
• May be taking complementary medicines, such as
Problems with herbal preparations, vitamins and minerals without
informing health care workers
Medications
• Sometimes take other people’s medicines

• If they do see a doctor or pharmacist:

• Are inadequately counseled
• Do not accept advice as given
• Forget, get confused
 • One third take all their medicines; one third take
some of their medicines; one third take none
Patients’
Problems with • Ninety per cent make some mistakes with their
Medications medicines

• Often see multiple health care workers (doctors,

pharmacists, nurses, alternative health
practitioners) without telling one about the others
Ways to
Decrease Drug Information Services
Risk and • Answer requests and inquiries on drug and
drug-related problems
Improve
Patients' Management of Adverse Drug Events
• Creation of ADR Monitoring Network
Safety
PHARMACEUTICAL

DRUG
INTERACTIONS
An interaction occur
when It is important to take note, that
as chemical agents, drugs are
pharmacokinetics also affected by other
and substances (i.e. chemicals in
pharmacodynamic of food, herbal products, etc.)

a drug is changed.
Drug-Drug Interactions
Drug-Food/Herb Interactions
Metabolic Drug Interactions
Drug-Laboratory Test Interactions

Types of Drug Interactions

 Pharmacologic drug interactions:

Drug - Drug
A. Pharmacokinetic drug interactions
Interactions

B. Pharmacodynamic drug
interactions
 Interaction occurs due to any of the
following mechanisms:
Drug - Drug
Interactions A. Interacting drugs have similar and
opposing pharmacologic actions
Pharmacodynamic
B. Interactions Between Drugs with
drug interactions
Opposing Pharmacologic Effects
C. Duplication
 Interaction occurs due to any of the
following mechanisms:
Drug - Drug
Interactions A. Interacting drugs have similar and
opposing pharmacologic actions
Pharmacodynamic
drug interactions
Drug A + Drug B = X (interaction)

X = Additive effect (1+1=2)

Drug - Drug
Interactions ACE inhibitors + NSAIDs =
hyperkalemia
Pharmacodynamic
drug interactions

Additive effect Aspirin + Warfarin =

(1+1=2)
bleeding
 Interaction occurs due to any of the
following mechanisms:
Drug - Drug
Interactions A. Interacting drugs have similar and
opposing pharmacologic actions
Pharmacodynamic
drug interactions
Drug A + Drug B = X (interaction)

X = Synergism effect (1+1=>2)

Drug - Drug
Interactions Opioid + Benzodiazepine =
exaggerated effect
Pharmacodynamic
drug interactions

Synergism effect
(1+1=>2)
 Interaction occurs due to any of the
following mechanisms:
Drug - Drug
Interactions A. Interacting drugs have similar and
opposing pharmacologic actions
Pharmacodynamic
drug interactions
Drug A + Drug B = X (interaction)

X = Potentiation effect (1+0=2)

Drug - Drug
Interactions Digoxin + Diuretic =
hypokalemia (inc toxicity of digoxin)
Pharmacodynamic
drug interactions

Potentiation effect Favorable Interaction:

(1+0=2)
Promethazine + Meperidine
Aspirin + Codeine
 Interaction occurs due to any of the
following mechanisms:
Drug - Drug
Interactions
B. Interactions Between Drugs with
Opposing Pharmacologic Effects
Pharmacodynamic
drug interactions

Antagonistic Effect (1+1=<2)

 Chemical antagonism
 Physiological antagonism
 Pharmacological antagonism
 Interaction occurs due to any of the
following mechanisms:
Drug - Drug
Interactions
C. Duplication (1+1=2)

Pharmacodynamic
drug interactions
What effect should be expected in a
patient taking Amlodipine and
Simvastatin?

A. Nephrotoxicity
B. Bleeding
C. Rhabdomyolysis
D. Hypotension
What effect should be expected in a
patient taking Clopidogrel and
Omeprazole?

A. Diminish efficacy of Clopidogrel

B. Bleeding
C. Hypomagnesemia
D. Gastric irritation
What effect should be expected in a
patient taking Calcium carbonate
and Ferrous sulfate ?

A. Diminish efficacy of Ferrous

sulfate
B. Diminish efficacy of Calcium
carbonate
C. Hypercalcemia
 Nutrients or Chemicals in Food/Herbal
supplements + Drug =
Drug – Altered Effect or ADR
Food/Herb (little or no data available)
Interactions
Reasons why less/no data is available:
1) False security
Interactions overlooked due to a belief
….“medicinal plants are safe”
2) Variability of Composition
(both Qualitative and Quantitative)
 Variability of Composition is due to:
• seasonal difference
Drug – • soil type
Food/Herb
• climactic changes
Interactions
• existence of different varieties or
chemical races within the same plant
species;

different species of the same genus

may exhibit opposite actions
 Counter interactions can even occur

Drug –
Example:
Food/Herb
Interactions GINSENG
Panax ginseng increases Prothrombin
time
Panax guinquifolium
decreases Prothrombin time
What effect should be expected in a patient
taking Ciprofloxacin with Milk?

A. Hypertension
B. Reduces level of Ciprofloxacin in the
blood
C. Gastric irritation
D. Hypotension
What effect should be expected in a patient
taking Atorvastatin with Grapefruit?

A. Nephrotoxicity
B. Bleeding
C. Rhabdomyolysis
D. Hypotension
 Lab test reagent + Drug =
Drug-Lab Test Overestimation or Underestimation of
Interactions Results

Example:
Psychotropic drugs in plasma results
to overestimation of cholesterol or
other blood lipids
 Interaction involving alteration of
Cytochrome P450 enzyme activity
Metabolic Cytochrome P450 – very large family of haemoprotein that are
Drug characterized by their enzymatic activity and their role in the metabolism
of a large number of drugs.
Interactions
Most important enzymes:
CYP1A2, CYP2C9, CYO2D6, CYP2E1, CYP3A4

Effect :
• Enzyme induction and/or Enzyme Inhibition
• Substrate – drugs metabolized by the enzyme
that may induce or inhibit their activity.
Practices that Increase
Risk of Interaction

1. Self-medication
2. Visiting several doctors
3. Non-adherence to Regimen
4. Polypharmacy
5. Drug abuse and misuse
Impact of Drug
Interaction

1. Failure of Treatment
2. Harmful Adverse Event
3. Toxicity
4. Beneficial Effect
 1. Major
• Life-threatening or permanent
Classification damage
of Drug
Interaction Avoid combination:
Risk of the interaction
outweighs the benefit
 2. Moderate
• Deterioration of patient's status,
treatment is required
Classification
of Drug Usually Avoid
Interaction combination:
Use it only under special
circumstances
 3. Minor
• Bothersome or little effect

Classification
Minimize risk:
of Drug
Assess risk and consider an
Interaction alternative drug, take step to
circumvent the interaction risk
and/or institute a monitoring
plan
Remedial Action

1 2 3
Change of drug Adjust the interval Adjust the dose of
of administration one drug
between 2 drugs
Systematic Approach in Ensuring Medication Safety

Form Review Review Review

Form a team Review all Review the physical Review the
documentation: environment manufacturer's labeling
written or electronic and packaging of the
prescription, product(s) involved
data entry,
logs,
policies and procedure
Systematic Approach in Ensuring Medication Safety

Interview the staff involved Determine contributing Develop an action plan of Communicate the results Measure the effectiveness
in the incident factors and root causes preventive strategies for within the organization of the implemented action
using the ISMP AROC each identified root cause plan over time
document
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