This document summarizes the role of clinical pharmacists and information technology in enhancing patient safety in medication use at Hoan My Sai Gon Hospital. It discusses how clinical pharmacists monitor medication administration, adverse drug reactions, and therapeutic drug monitoring. It also explains how the hospital utilizes an information technology system to reduce medication errors by checking for drug interactions, maximum doses, and dispensing errors. The results shown indicate increases in clinical pharmacist involvement and a 100% reduction in contraindicated drug interactions after implementing the IT system.

1. "Enhancing safety for patients
in using medication at Hoan My Sai Gon Hospital:
The role of clinical pharmacists and information technology
Nguyen Thi Thu Ba, Pharm., Msc.
Head of Pharmacy Department –HMSG Hospital
Quy Nhon, 9/2023

2. 15-17 August 2023
Speaker’s introduction
Nguyen Thi Thu Ba, Pharm., MSc.
Summary of the training process:
1979-1984: Graduated as a Pharmacist. Ho Chi Minh City University of Medicine and
Pharmacy
1993-1994: Graduated from Level 1 Specialization, majoring in Hospital Pharmacy and
Pharmacy Management at Hanoi Pharmacy University
1999-2001: Specialization in Clinical Pharmacy, Master in Biomedical Sciences at Rangueil
University, Toulouse III, France.
Work experiences:
1984-1999: 15 years of teaching at the Department of Pharmacy, Central Medical School No.2
Ministry of Health, now Danang University of Medical Technology and Pharmacy
1999-2000: Resident Pharmacist in Clinical Pharmacy at the Pharmacy Department of
Montauban Hospital, France.
11/2001 - 2/2021: 19 years: Head of Pharmacy Department of Hoan My Da Nang Hospital,
concurrently 10 years as Pharmaceutical Manager of Hoan My Medical Group.
3/2021 to present: Head of Pharmacy Department of Hoan My Saigon Hospital
Scientific research and quality improvement topics:
23 scientific research projects and 8 quality improving projects have been reported, including
1 report at the ACCP 2013
1 report at the APSIC (Asia-Pacific infectious disease conference) 2019
1 project received the Excellence Award from the Asia Hospital Management Association in the
Philippines in 2017

3. Outline
1
2
3
4
5
Medication errors- a major patient risk
The role of clinical pharmacists in promoting
patient safety in medication use
Applying information technology to
improve patient safety
Results
Conclusion

4. World Patient Safety Day 17.12.2022. WHO office on Quality of Care and Patient Safety (Athens, Greece)
1. Bloodborne Pathogens
2. Catheter-Associated Uninary Tract
Infection (CAUTI)
3. Diagnostic Errors
4. Hacked Medical Devices
5. Healthcarre-Associated Venous
Thromboembolism
6. Hospital-Acquired Pneumonia
7. Medication Errors
8. Methicillin-resistant Staphylococcus
aureus (MRSA)
9. Post-discharge Adverse Events
10. Sepsis
Top 10 patient safety risks in hospitals
WHO-2022
in Europe:
The Rate of ME ranges from
0.3% to 9.1% in prescription
In USA: 25%
In HMSG Hospital: < 0.5%

5. Take a look at some of medication errors that cause serious harm to patients, even
death…
In Vietnam
In March 2018, a district medical
center of Tien Giang Province
mistakenly prescribed
Misoproston (abortion pills) to
three pregnant women instead of
Miprotone (an embryo-nourishing
pills).
In foreign countries
50-year-old women, accidental
administration of epinephrine
instead of midazolam during
colonoscopyinprep
Gado A, Accidental IV administration of epinephrine instead of
midazolam at colonoscopy. Alexandria J of Med. 2016;62(1)
In 2016, 5 adult patients
unintentionally received insulin
(Humalog U-100) instead of the
influenza vaccine at a public
school clinic in Missouri
Drugs Ther Perspect. 2016. 32: 439-
doi:10.1007/s40267-016-0333-2
In July 2023, an 85-year-old
woman with a 20-year history of
hypertension was admitted to
the National Hospital of
Endocrine after accidentally
taking a hypoglycemic medicine.
Hypoglycemia, seizure, drowsy,
consciousness disorders

6. 2. The urgent need to reduce medication errors in hospitals to prevent patient and second victim harm [White paper]. European Collaborative Action On Medication Errors
and Traceability (ECAMET); 2022 (https://eaasm.eu/wp-content/uploads/ECAMET-White-Paper-Call-to-Action-March-2022-v2.pdf, accessed 5 August 2022)
Medication
Errors
(ME)
most common
ME in dispensing:
wrong patient,
wrong drug,
wrong dosage form
1.6% to 2.1% (2)
ME in prescribing:
wrong dose,
wrong quantity,
drug interaction
0.3% to 9.1% (2)
ME in administration:
Wrong patient,
Wrong drug,
Wrong dose,
Wrong route,
Wrong time
8%-25% (1)
1. Patient Safety Network, 2018

7. Hoan My Sai Gon Hospital:
❖ OPD: 1700 – 2000 prescriptions/day
❖ IPD: 400 medication orders/day
Big problems:
HOW WE CAN
• Avoid and prevent harm to patients
• Protect reputation and brand of hospital
• Protect medical staff from legal errors
rate of ME:
0,1% - 0,37%

9. The role of clinical pharmacists in enhancing
patient safety in medication use at HMSGH
OUTPATIEN
T
INPATIENT
DOSE
DRUG
INTERACTIONS
CONTRAINDICATION
The most
common
medication
errors
Dose adjustments
and drugs utilization
in specific groups
2022-2023: Our GOALS
1. Check: 100% medication orders and prescriptions
2. Control to keep the rate of ME: less than 0.5% of total prescriptions.
3. Prevent: 100% ME from prescribing, dispensing, administrating from
reaching to patients

10. The role of clinical pharmacist in monitoring and intervention medication administration
Pharmacists in clinical departments:
- diagnostic meeting
- monitoring the efficacy and safety of
medication treatments in specific groups of
patients: renal/liver failures
- evaluating, choosing alternative drugs for
patients with ADR.
Dose adjustment
ADR
Specific groups
serious illness patients
with polypharmacy

11. The role of clinical pharmacist in monitoring medication use
Vancomycin Therapeutic Drug Monitoring
🡪 Giving advices on dose adjustments
Monitoring and evaluation ADR
🡪 Finding patient’s medical history or
previous drugs hypersensitivity reactions

12. How can we achieve our SMART GOALS with just only 3 clinical pharmacists?
Check and alert
duplicated drugs in
prescriptions
Check and alert
contraindicated
drug interactions
Check and alert
daily maximum
dose or maximum
quantity for a
period of a
prescription
Check and prevent
errors in dose unit
and delivery unit
Signs to identify high
risk and fall-risk
medication
Suppling patient
info on label of
each medicine
Training and Performing professional
pharmacy staff to be able to:
- Validate prescriptions, MO
- Diagnosic and give
recommendations to select
medicines
- TDM, ADR, monitoring medication
use in clinical services
Our Strategy = Active Roles of Pharmacists + Information Technology

13. Dispensing
Insurance payment
Prescribing
Administering
3
4
1
2
ME
Applying information technology to improve patient safety

14. ▪ Importing ADR reports easily.
▪ Distributing informations to responsible staffs and
hospital administrators.
▪ Sending ADR reports to National DI & ADR Centre.
Applying information technology to improve patient safety

15. Continuing medical education to improve knowledge
and skills of all medical staff

16. E-learning program will be used to train new health
workers, including doctors, nurses, and pharmacists.
Applying information technology to improve patient safety

17. This document is strictly private and confidential
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In daily clinical practice, we have applied IT in
alerting and blocking overlapped
prescriptions of same active ingredients
❑ Database already in operation
❑ Constantly updating the
medication list
❑ IT alert and block
overlapped prescriptions of
same active ingredients

18. This document is strictly private and confidential
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Setting up an alert and blocking system to prevent the prescription of
contraindicated drug combinations according to MOH regulation.
❑ 131 contraindicated drug-drug
interactions
❑ 1/2022: Set up the alert system
❑ 28/2/2023: Officially operated
❑ Clinical pharmacists supply Database ❑ IT: alert & blocking system

19. This document is strictly private and confidential
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2. The display of the contraindicated drug interactions alert in one or >two prescriptions

20. This document is strictly private and confidential
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3. Installing maximum doses for the system to alert and preventing
doctors prescribing over maximum doses
❑ 358 brand names and
generics in total
❑ Including maximum single
dose, daily dose, dose
frequency, and dose
duration
❑ Operated since 28/02/2023

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3. The display of maximum dose alert and blocking system
❑ Alert and blocking system
for maximum doses:
- single dose,
- daily dose,
- dose frequency,
- dose of a therapy duration
❑ Effectively operated since
28/02/2023

22. This document is strictly private and confidential
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4. Setting up database for preventing errors in dose unit and dispensing unit of
multidose drug products in electronic medical records/prescriptions
Default unit of dose on HIS
The prescriber can alter appropriately
Name Ingredient
Dispensing
unit
Dose
Unit
Mixtard 30 Flexpen
100 UI/ mL, 3 mL
Combined Insulin
rapid/retard 30/70
Pen IU
Mixtard 30 HM 100 UI/
mL, 10 mL
Combined Insulin
rapid/retard 30/70
Vial IU
NovoMix 30 Flexpen
100 UI/ mL, 3 mL
Combined Insulin
rapid/retard 30/70
Pen IU
Ryzodex Flextouch
100 UI/ mL, 3 mL
Insulin aspart
+Insulin degludec
Pen IU
Ganfort (0,3 mg + 5
mg)/ mL, 3 mL
Bimatoprost +
Timolol
Vial
Drop
Dermovate Cream
0,05%, 15g
Clobetazol
Probionate
Tube Time
Symbicort
Turbuhaler 160 mcg
+ 4,5mcg (60 dose)
Budenoside +
Formoterol
Symbicort
Turbuhaler 160 mcg
+ 4,5mcg (60 dose)
Budenos
ide + Formoterol
Vial Pump

23. Tất cả thông tin trong tài liệu này được bảo mật
5. Solutions to reduce ME in dispensing medication
1. Preparing and dispensing drugs: developing the medication
double-checking processes
2. Hospital Information System (HIS): Allowing to show drug
information such as: drug name, strength, manufacturers, lot,
expired date on drugs dispensing notes

24. 5.1. Developing the medication double-checking processes
Guideline for
implementation and
management of
high risk medication

25. This document is strictly private and confidential
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Inpatient
5.2. Showing drug information such as: drug name, strength, labeller – country on goods
transfer note
Outpatient

26. 178
thuốc
57 ca 7 khoa
LS
6. Monitoring nurses administrating medicines on patients
“6 rights” of medication use:
1. The right patient:
2. The right drug
3. The right dose
4. The right route of administration
5. The right time
6. The right document
Auditing the 6 right of medication use

27. 7. Help to identify and manage utilization high risk and falling
risk medications
Pharmacists:
Update the database of
formulary
HIS
1
2
IT system help to
Bold names of high-risk medications
Italicize name of falling risk medications

28. This document is strictly private and confidential
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Solutions to prevent wrong route:
❑Drugs which have one route of administration
❖ IV infusion→ “IV infusion”
❖ Subcutaneous injection → “Subcutaneous injection”
❖ Intramuscular injection→ “Intramuscular injection”
❖ IV bolus→ “IV bolus”
❖ Intradermal injection→ “Intradermal injection”
❑ Various routes of administration: IV, IM,
SC, ID → “Injection”
❑ Various routes of administration : IV, IM,
SC, ID, IV Infusion → “parenteral route ”
❑ Concentrated solution: Adding “Dilute
before injecting”

29. Tất cả thông tin trong tài liệu này được bảo mật
To reduce ME in administrating drugs on
patients
The high-risk medications are bolded in
medication chart notes

30. Results
Enhancing Patient Safety in Using Medication at
Hoan My Sai Gon Hospital
Updated in July 2023

31. Tất cả thông tin trong tài liệu này được bảo mật
Increasing number of cases of diagnostic meetings, ADR reports, AB monitoring on patients by pharmacists
138 cases
82
90
113
121
106 111
0
20
40
60
80
100
120
140
Tháng
1
Tháng
2
Tháng
3
Tháng
4
Tháng
5
Tháng
6
Số ca KSƯTQLSD đã giám sát 6 tháng đầu năm 2023
3 9 13 16 20 13
4.1%
12.2%
17.6%
21.6%
27.0%
17.6%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
0
5
10
15
20
25
T 1 T 2 T 3 T 4 T 5 T 6
The number of ADR reports in the first half of 2023
Số lượng Tỷ lệ
%
74 cases
52
27
33 32
27
35
0
10
20
30
40
50
60
Tháng 1 Tháng 2 Tháng 3 Tháng 4 Tháng 5 Tháng 6
Số ca Hội chẩn theo từng tháng
15 14 12 7 17 11 13 8 16 9 6 10
11%
10%
9%
5%
12%
8%
9%
6%
12%
7%
4%
7%
0%
2%
4%
6%
8%
10%
12%
14%
0
2
4
6
8
10
12
14
16
18
Tháng 01 Tháng 02 Tháng 03 Tháng 04 Tháng 05 Tháng 06 Tháng 07 Tháng 08 Tháng 09 Tháng 10 Tháng 11 Tháng 12
The number of ADR reports monthly in 2022
Số lượng Tỷ lệ
Quantity %
Quantity

32. Tất cả thông tin trong tài liệu này được bảo mật
Increasing the number of cases of TDM of vancomycin and dose adjustment
7
3
7
2
4
8
0
2
4
6
8
10
Tháng
1
Tháng
2
Tháng
3
Tháng
4
Tháng
5
Tháng
6
The number of Vancomycin TDM
cases in the first half of 2023
1
3
5
1 1 1
2
1 1
0
2
4
6
01-22
02-22
03-22
04-22
05-22
06-22
07-22
08-22
09-22
10-22
11-22
12-22
The number of Vancomycin TDM cases
between 04 – 06/2022
16 cases
31 cases

33. Tất cả thông tin trong tài liệu này được bảo mật

34. Tất cả thông tin trong tài liệu này được bảo mật
Up to 100% reduction in contraindicated drug interactions
1 1 11 3 3 2 2 1 2
0.004%
0.003%
0.036%
0.009%
0.009%
0.006%
0.006%
0.003%
0.007%
0.000%
0.010%
0.020%
0.030%
0.040%
0
2
4
6
8
10
12
ME cases Percentage (%)
Before After
6/2022 7/2022 8/2022 9/2022 10/2022 11/2022 12/2022 01-07/2023
Percentages
of reduction
of ME
73% 73% 82% 82% 91% 100% 82% 100%

35. Tất cả thông tin trong tài liệu này được bảo mật
Dropping importantly the amount of refusing insurance payout
due to medication errors in prescribing

36. Tất cả thông tin trong tài liệu này được bảo mật
Conclusion
Pharmacists
play an
important
role in
enhancing
patient safety
Information
technology is
quite essential
to support and
improve
patient safety
Doctors and
nurses have
always
played key
roles in
reducing ME
Continue to
find strategies
to prevent ME
and promote
patient safety