Basic Medication

Safety Module
(Part I)
Pharmacy Services Program, MOH

Medication Safety Committee 2023

Disclaimer: Only for learning purpose for MOH healthcare staff Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Basic Medication Safety for Pharmacist

01. Introduction to Medication Safety Program in Malaysia

02. Type of Errors

03. Governments Initiatives to Improve Quality of Medication Safety

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Learning Objectives

01. Better understanding on safe practices in handling medications.

02. Increase awareness on the importance of safe medication practice.

03. Increase awareness on the importance of medication error reporting.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
PHARMACY PRACTICE & DEVELOPMENT DIVISION, MINISTRY OF HEALTH (2023)
Ministry of Health Malaysia
01.
Introduction to
Medication
Safety
Program in
Malaysia

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Any preventable event that may cause or
Definition
lead to inappropriate medication use or patient
harm while the medication is in the control of
the healthcare professional, patient or
consumer.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Impact of Medication Error
Impact on Patient
health status of patients Financial Implication
magnitude of overdose prolong hospital stays
damage as result of Financial & increase health
omission Implication care expenses
estimated to cost
Impact on billions of dollars
Patient annually
Medication additional medical
Error management
legal fees & out-of-
court settlements

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 What is Patient Safety?
• A discipline in the health care sector that applies safety science methods toward the goal
of achieving a trustworthy system of health care delivery.
• Aims to prevent and reduce risks, errors and harm that occur to patients during
provision of health care A fundamental component of quality essential health services.
• clear policies, leadership capacity, data to drive safety improvements, skilled health care
professionals and effective involvement of patients in their care are all needed to ensure
successful implementation.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Malaysia Patient Safety Goals (MPSG)
Goal No. 3 : Medication Safety “Medication
Without Harm”
Number of Medication Error Related To Severe
Harm Or Death ,Target : Zero cases
(Hospital & Clinic)

Additional data collection :

• Total Number of Medication Error
• Total Number of Near Miss Medication Error
• Total No. of Admission and/or Clinic Visit

Goal No. 6 : Correct Patient Identification

Number of Incidents Caused by Wrong
Patient Identification (detected by incident
investigation)
13 Goals 7 Goals (Hospital)
Zero Cases

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
Goals In Malaysian Patient Safety Goals 2.0

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Medication Safety Technical Working Group (TWG)
LOREM IPSUM
Malaysian Patient Safety Council MOH

Malaysian Patient Safety Goals

MOH
(MPSG) Steering Committee
 Chairman: Director of Pharmacy Practice and
Development Division
 Members: Doctors, pharmacists, pharmacy
Medication Safety Technical Working MOH assistants, nursing & medical assistants from various
Group (TWG) division
 Roles & Responsibilities:
 To closely monitor the performance of
Patient Safety Committee/ medication safety.
MOH
Medication Safety Committee
 To plan strategies and facilitate remedial actions
to improve performance.
 To effectively and efficiently promote and
disseminate information on medication safety.
Patient Safety Committee/ State/ Health Facilities
Medication Safety Committee  To make recommendations regarding
amendments to specific goal, indicator and 10
target .
02.
Type of errors

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Medication Use Process
Error can happen in any of the steps

Diagnosi
s of Prescribing Dispensing Administering Monitoring Outcome
patient • Data Entry
• Filling
• Labelling
• Counterchecking
• Dispensing
Prescribing Dispensing Administering Monitoring

● ● ● Wrong dose
Wrong dose Wrong dose ● Wrong
● ● ● Wrong drug
Wrong drug Wrong drug time/Omission
● ● ● Wrong route
Wrong Wrong route ● Wrong patient
● ● Wrong
route/form Wrong time
● Allergy ● Wrong patient time/omitted
● ● ● Wrong patient
Interaction Incorrect
● Incorrect
labelling
labelling

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Types of Error
TYPES DEFINITION

1) Prescribing Error Incorrect drug product selection (based on indication,

contraindication, known allergies, existing drug therapy, and
other factor), dose, dosage form, quantity, route,
concentration, rate of administration, or instruction for use of
a drug product ordered or authorized by physician (or other
legitimate prescriber); illegible prescription or medication
orders that lead to errors that reach the patient.

2) Omission Error The failure to administer an ordered dose to a patient

before the next scheduled dose or failure to prescribe a
drug product that is indicated for the patient . The failure
to administer an ordered dose excludes patient’s refusal and
clinical decision or other valid reason not to administer.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 TYPES DEFINITION

3) Wrong Time Error Administration of medication outside a predefined time interval

from its scheduled administration time.(this interval should be
established by each individual healthcare facility)

4) Unauthorised Error Dispensing or administration to the patient of medication not

authorised by a legitimate prescriber.

5) Dose Error Dispensing or administration to the patient of a dose that is

greater than or less than the amount ordered by the prescriber
or administration of duplicate doses to the patient.

6) Dosage-form Error Dispensing or administration to the patient of a drug product in a

different dosage form than that ordered by the prescriber.

7) Drug-preparation Drug product incorrectly formulated or manipulated before

error administration.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 TYPES DEFINITION

8) Administration- Inappropriate procedure or improper technique in the

technique error. administration of a drug other that wrong route.

9) Route of Use of wrong route of administration of the correct drug.

administration error

10) Deteriorated drug Dispensing or administration of a drug that has expired or for
error which the physical or chemical dosage-form integrity has been
compromised.

11) Monitoring error Failure to review a prescribed regimen for appropriateness and
detection of problems, or failure to use appropriate clinical or
laboratory data for adequate assessment of patient response to
prescribed therapy.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 TYPES DEFINITION

12) Compliance error Inappropriate patient behaviour regarding adherence to a

prescribed education regimen.

13) Other medication Any medication error that does not fall into one of the above
error predefined categories.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 How To Reduce The Risk Of Medication Error?
YOUR ROLE AS HEALTHCARE PRACTITIONER

Use Remember Practice Take complete Caution on

generic 5R double medication High Alert
names checking histories Medication

Tailor Use Be familiar Encourage Communicate Report and

prescribing for memory with the patients to clearly learn from
individual aids medications be actively errors
patients you involved
prescribe

E !
R E
F
03.
Government Initiatives to
Improve Quality of
Medication Safety

REPORTING & LEARNING POLICY & GUIDELINES EDUCATION, TRAINING &

DEVELOPEMENT INFORMATION DISSEMINATION

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
03.
Government Initiatives to
Improve Quality of
Medication Safety

REPORTING & LEARNING

Strengthening MERS And POLICY & GUIDELINES EDUCATION, TRAINING &

Managing A Database Of DEVELOPEMENT INFORMATION DISSEMINATION
Medication Error Reports
Received From Healthcare
Facilities Nationwide

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 MERS Objective

To obtain information on the To improve

occurrence of ME To learn and share PATIENT SAFETY Outcome analysis
experience on ME
from MERS

 Medication error
related harm
 Near miss
 Actual error
 Case review
 Drug-related problem
To analyse the To minimize the (HAM, LASA,
ME report reoccurrence of such Polypharmacy)
errors.  Recommendation of
key priorities areas
 MERS Background
Launching of MERS

• Appointment of state verifier

2017
Develop
2009
• Verification by state verifier
MERS MERS Online • Migration of MERS server
Online www.mers.moh.gov.my https://mers.pharmacy.gov.my
2011

2013

2018 till now

Changes in MERS:
1) Shorten workflow from 3 steps to 2
steps for near misses (Cat A&B)
2) Qreport function added to the JKN
viewer (role)
 Medication Error Reporting System (MERS)
MERS Online

http://mers.pharmacy.gov.my
All healthcare professional either in government or private sectors
Medication Error Reporting System (MERS)
https://mers.pharmacy.gov.my/
● Steps to report ME & Incident Reporting

1. Go to https://mers.pharmacy.gov.my

2. Log in username and password

3. Click on Menu [Create ME Report]

4. Choose either own facility or on behalf

5. Complete the reporting form which consists of 6
parts
6. Click SUBMIT once all the tabs are completely
filled
Medication Safety Committee 2023
Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Medication Error Reporting System (MERS)
https://mers.pharmacy.gov.my/
● Complete the reporting form which consists of 6 parts

Part B : Location and Part C : Patient’s

Part A: Error details
Error Outcome Particulars

● Date of event ● Location of facility ● Patient’s

● Time of event ● Location of event particulars: age,
● Description of error ● In which process did the error gender and
● Contributing Factor occur diagnosis.
● Category made the ● Did the error reach the patient?
initial error ● Was the incorrect medication,
● Category also dose or dosage form
involved in the error administered to or taken by the
● Category detected the patient?
error ● Error Outcome Category
● Recommendation/ ● Describe the direct result on the
Remedial action taken patient
Medication Safety Committee 2023
Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Medication Error Reporting System (MERS)
https://mers.pharmacy.gov.my/
● Complete the reporting form which consists of 6 parts

Part F : Reporter’s
Part D : Product Details Part E : Attachment
Details

● Generic Name ± Brand ● Relevant materials

● Reporter’s particulars
Name such as product label,
copy of prescription/ eg. name, profession,
● Dosage Form
order facility, address, email
● Dose, Frequency,
● Attachment for error and contact number
Duration, Route
● Is the error involved description.
similar packaging? ● Attachment for
*if yes, fill in details of recommendations/
Manufacturer, Strength or Root Cause Analysis
concentration, type and (RCA)
size of container
Medication Safety Committee 2023
Pharmacy Practice and Development Division
Ministry of Health Malaysia
03.
Government Initiatives to
Improve Quality of
Medication Safety

POLICY & GUIDELINES

DEVELOPMENT
Planning Strategies,
REPORTING & LEARNING EDUCATION, TRAINING &
Initiatives, Prioritize Action INFORMATION DISSEMINATION
And Develop Policy For
System Improvements To
Encourage Safe Medication
Practices.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Policy Implementation
• (Pharmacy Information System)
 A complete and comprehensive system that integrates pharmacy related services with the objectives to
gear toward pharmacy excellent care.
 Enhance patient safety measure by increasing access to patient medication records, improved
pharmacy workflow and substantially reduce the risk of medication errors.
 The decision support system (MIMs gateway) helps to improve the quality of checking along the
medication management process.
• Medication Safety Self-Assessment (MSSA)
 Criteria checklist for medication safety evaluation has been
establish to guide the healthcare facilities on the improvement of
medication safe practice.
Medication Safety Committee 2023
Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Policy Implementation
• KPI (Key Performance Indicator)
KPI for Director of Pharmacy Practice & Development Division.
All MOH health facilities must ACHIEVED full compliance ≥80% in medication
safety self-assessment criteria (MSSA)
MSSA Achievement (%) Target (%) KPI = Number of health facilities
120.0 achieving full compliance ≥80% for
92.9 98.4 99.0 99.5 MSSA out of the total number of
100.0 facilities that have been
80.0 90 90 identified to carry out
60.0 80 80 MSSA.
40.0
20.0
0.0
2019 2020 2021 2022
Disclaimer: Only for learning purpose for MOH healthcare staff

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
9 Medication
Safety Practice
Guidelines
03.
Government Initiatives to
Improve Quality of
Medication Safety

EDUCATION, TRAINING &

INFORMATION DISSEMINATION
Strengthening And Monitoring
REPORTING & LEARNING POLICY & GUIDELINES Medication Safety Activities Through
DEVELOPEMENT Briefings, Talks, Trainings, Campaigns,
Exhibitions And Publications, Radio
Talks And Others.

Medication Safety Committee 2023

Pharmacy Practice and Development Division
Ministry of Health Malaysia
 Education, Training &
Information Dissemination

1 Newsletters 8 Medication
Safety Alerts 5 Training
Modules
4 Education
Videos
8 31
Videos

32
Posters

33
A4 Infografik

34
Posters

35
Mouse Pad

36
Prescribing Notes

37
Fridge Magnet

38
Exhibition

39
Seminars

40
Newsletter – Medication Safety Alert

41
42
 THANK YOU
Acknowledgement:
1. Cawangan Penjagaan Farmaseutikal,
BAPF
2. JK Induk Keselamatan Pengubatan
2023/24

External Reviewers
1. Dr. Norkasihan Ibrahim (Deputy
Dean, Faculty of Pharmacy, UiTM)

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Medication Safety Committee 2023

Pharmacy Practice and Development Division
PHARMACY PRACTICE & DEVELOPMENT DIVISION, MINISTRY OF HEALTH (2023) Ministry of Health Malaysia