Medication Safety

Pharmacist/ Mariyyah Madkhali

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 Information contact of Medication
Safety officer
 Extension: 6012 or 7164 (Temporary)

 Email: Mariyyahm@moh.gov.sa

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 OUTLINE

1.Introduction

2.Medication safety report

3.Common mistakes of medication safety report

4.Adverse drug reaction

5.Drug Quality

6.High Alert medication

7.Look Alike –Sound Alike medication

8.Hazardous medication
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Introduction

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 Medication Safety
 The main objective of medication safety is to decrease
risk of patient harm.

 All faculty members (physicians, pharmacists, and nurses)

should report of medication error in the Medication Safety
report survey of the Eradah Complex and Mental health.

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 Medication Safety report link

 https://www.surveymonkey.com/r/JNPLFNX

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 Statistic of Medication Error

No. of Error March 2021 April 2021 May 2021

286 218 464

Pharmacy unit 195 193 424

Nurse unit 91 25 40

Physician unit 0 0 0

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Medication safety
report

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Medication safety report

I thank Reem,
Dr.Ban, Howeda,
&
Dr. Ali

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 1- No abbreviations.
2- Name of medication.
3-The dose of medication.
4-What was the error.

The good example: The doctor prescribed mirtazapine 30mg

2 tab/day , I said to him the maximum dose of mirtazapine is
45mg/day but the doctor refused to corrected the dose and
said this dose advised by consultant I can't change it .

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National Coordination Centre Medication Error Reporting Programmed
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Index for Categorizing Medication Errors

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Medication Safety Officer
Responsibility

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Common mistakes of
medication safety
report

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NAME OF EMPLOYEE

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Error not relate to medication error

Examples:

1. The patient refused his medications.

2. The patient take off his Id band.

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Wrong in drug dosing frequency

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Wrong in drug dosing frequency

Quetiapine Xr 200 mg
( long acting)
Once daily

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Additional treatments

Olanzapine 5 mg
without notes
from Doctors
(specialist or
consultant)

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Wrong drug

The drug desired was

lithium 450 mg bid and
prepared drug was
thiamine tablet .

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Drug interaction

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Duplication therapy

Duplication of
Quetiapine 200
mg

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 Prescription incomplete

Examples:

1. Patient age not available.

2. Patient body weight not available .

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Increase maximum dose of medication

Maximum dose
per day of
Flupenthixol
depo 20 mg is 60
mg /2-4 weeks

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 Adverse Drug Reaction

WHO definition: An adverse reaction is any response to a

drug that is noxious and unintended, and that occurs at
doses normally used in humans for prophylaxis, diagnosis
or therapy of disease.

It can cause patient harm, but not necessary preventable.

https://www.surveymonkey.com/r/B2CSG6J

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 Drug Quality

Drug quality report:

The Pharmacovigilance Electronic
Reporting Service is an online
Saudi Food and Drug spontaneous reporting system for
Authority website. adverse events and pharmaceutical
products defects to facilitate the
Electronic services. reporting for  health care
professionals and the public.​
Saudi Vigilance
System

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 Drug Quality report link

 http://ade.sfda.gov.sa/

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 High Alert medication

 High alert medications are drugs that can cause harm to

the patient when taking by mistake.
 Double check should be documented in the medication
administration sheet.
 Labeling with high alert label (Red).
 Keep it in separate location.

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 Look alike-Sound alike medication

Comparison/ Look alike medication Sound alike medication

similarities
Definition They have similar look They have similar sound or
with other medication or pronunciation to other
similar color, spelling , medication may causing
shape or packaging which mistake.
leading to mistake.

1. Physical separation
2. Use Tall-Man lettering or Tallman lettering
3. Use alert sticker (light blue)

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 Hazardous medication

Hazardous medications are drugs which causes a

significant risk to a healthcare workers characteristic by:
1. Teratogenic,
2. Mutagenic,
3. Carcinogenic,
4. Reproductive toxicity potentials,
5. Acute or chronic toxicity to an organ or system.

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 References
1. National coordination council for Medication Error Reporting and Prevention: Also available
at http://www.nccmerp.org/.
2. https://www.fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm
3. Addressing Medication Errors in Hospitals: California Health care foundation. Also Available
at http://www.chcf.org Accessed on September 2008.
4. The Institute of Safe Medication Practices. Available at http://www.ismp.org.
5. Patient safety workshop ‐Learning from Error. WHO publications document.
6. Preventing Medication Errors. Zellmer W. A. Am.J. Hosp Pharm 1990;47:1755 ‐6
7. ASHP guidelines on preventing Medication Error in hospitals. Also available at
www.ashp.org.
8. USP Medication Errors reporting Programm. Also available at www.usp.org.
9. World Alliance for patient safety. WHO draft guidelines for adverse event reporting and
learning systems WHO Publications document 2005
10.https://portal.cbahi.gov.sa/Library/Assets/SERF-094834.pdf

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 Acknowledgments
 All faculty members especially who work in
pharmacy department.
 Dr. Abeer for explaining and helping.
 Dr. Nora, Dr. Nada, Dr. Hesham, Dr. Saed, Dr.
Aseel, Dr. Ban, Dr.Dalal, Dr. Dhafer, Dr.Khalid.
 Reem, Howeda, Nouf, Shuaa, Juman, Amal,
Dana

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No diagnosis written

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