A total of 42 (80.8%) respondents claimed that they were Tympanometry results show that all (100%) had Type A
exposed to noise disturbance in their daily working bilaterally. Audiometric results show that 7.7% (n=4) of
environment. Two contract dental officers did not dental staff experienced noise induced hearing
respond to the questionnaire. A total of 8 respondents impairment as shown in figure 5.2. All respondents stated
declared that there noise did not cause any disturbance at that they did not use any personal protective equipment
work. The respondents involved were 1 clerk, 2 dental such as ear plug or ear muffs for noise exposure during
surgery assistants who worked mostly at the registration their work.
counter, 2 dental nurses, 1 dental technologist and 1
driver.
Table 5.2: Category of dental staffs with Hearing Impairment and associated risk factors
Category Impairment Age Duration PMH Part Past job Hobby
of service time experience Watching
TV
job Sports
Dental Officer Right - Normal 24 1 Nil Nil Nil Cooking
Left - Mild SNHL Fishing
Dental Surgery Right - Mild SNHL 41 3 Nil Nil Hospital
attendant
Assistant Left - Normal
Attendant 1 Right - Normal 42 10 Nil Nil Glass
Left – Mild NIHL manufacturing
factory
Attendant 2 Left – Normal 27 1 Nil Nil Heavy vehicle
Right - Mild NIHL driver
No drivers, dental nurses, dental technologists or clerks Further research was carried out in all dental clinics in
had any noise induced hearing impairment while 1 Kota Tinggi district to assess noise produced by dental
dentist, 1 dental surgery assistant and 2 attendants equipment in daily working environment of various staff
experienced unilateral or bilateral hearing impairment. categories. Results of this study for the dental surgery,
Two dental attendants' hearing impairment may be partly dental laboratory and mobile dental squad ambient noise
contributed to past job experience (Table 5. 2). found at all test sites were between 55.5-72.9dBA.
Initial assessment of noise levels among compressors Risk analysis using likelihood and severity in qualitative
used in Kota Tinggi clinic demonstrated that noise levels matrix method results in a medium to high risk noise
of Compressor A and B placed inside the room were 95.7 hazard in the dental surgery, dental laboratory and mobile
and 86 dBA respectively; 89.7 and 83 dBA respectively dental squad (range 90.9 to 102.1 dBA).
when placed outside the room.
Table 2.5: Risk assessment summary in dental surgery
Issue Severity Likelihood Issue Risk
Assessment
Compressor 3 5 15 High
High speed handpiece 2 3 6 Medium
Low speed handpiece 2 3 6 Medium
Ultrasonic scaler 3 5 15 High
High volume suction 2 3 6 Medium
49
Risk analysis using likelihood and severity in qualitative method10 results in a risk matrix as shown in Table 2.5 in
the dental surgery, Table 2.6 in the dental laboratory and Table 2.7 in the mobile dental squads respectively. Dental
surgery showed the highest risk area of noise exposure among risk assessment matrix compared to dental laboratory
and dental mobile squads.
Table 2.6: Risk assessment summary in dental laboratory
Issue Impact Likelihood Issue
Assessment
Laboratory handpiece 2 3 6 Medium
Lathe wheel 2 6 Medium
Model trimmer 2
2 3
Fume cupboard 2 3 6 Medium
Dust extractor 3 6 Medium
6 Medium
3
Table 2.7: Risk assessment summary in mobile dental squads
Issue Impact Likelihood Issue
3 Assessment
Compressor 2 3 6 Medium
3 6 Medium
High speed handpiece 2 3
3 6 Medium
Low speed handpiece 2
6 Medium
Ultrasonic scaler 2
High volume suction 2 6 Medium
Mean Mean Category of staffs
sound exposure
Equipment Facility level time daily Dental Dental Attendant
(dB) officer Surgery
Compressor Kota Tinggi (hours) Assistant
Main Dental 88.3 8
High speed vv v
handpiece Clinic 92.2 3
Bandar 89.1 3½ -- -
Ultrasonic Tenggara 87.6 3 1/2
scaler Dental Clinic -- -
Bandar Mas 85.7 1 1/2 -- v
Dental Clinic
Sening Dental 90.9 10min v v v Table 2.8:
Clinic Prevalence of noise induced hearing
Kota Tinggi 88.9 1jam
Main Dental 94.3 30 min - - - impairment among dental personnel
Clinic - - - in Dental Surgery.
Bandar 90.9 1 1/2
Tenggara -- v
Dental Clinic 99.7 30min
Bandar Mas vv v
Dental Clinic 102.1 40 min
101.5 40 min -v -
Sening Dental
Clinic -- -
Kota Tinggi -- v
Main Dental
Clinic
Bandar
Tenggara
Dental Clinic
Bandar Mas
Dental clinic
Sening Dental
Clinic
50
The study also found that the three category of staff References
suffered hearing impairment were working in high noise . Act 514 Occupational Safety And Health Act 1994
area (Kota Tinggi Main Dental Clinic, Sening dental [Reprint 2002]
Clinic) and with high noise equipment such as
compressor, high speed handpiece and Ultrasonic 2. Leggat PA, Kedjarune U, Smith DR. Occupational
scaler(Table 2.8). health problems in modern dentistry: a review. Ind
Health. 2007 Oct;45(5):611-21.
6. Discussion 3.http://www.dosh.gov.my/doshV2/phocadownload/Re
Hearing impairment of two dental surgery assistants gulations/AKJ/pua0001y1989s0005.pdf accessed at
(DSA) may be attributable to past job experience. One 13:51 7 May 2011
attendant worked in a glass factory with exposure to loud 4. Noise and hearing loss - Noise, Regardless of Source,
noise for about 14 years before joining the dental Can Lead To Hearing Loss Henry P. CIH Robert E.
services. He has been working in the dental clinics for 4 Sheriff; Shotwell Courtesy of Atlantic Environmental,
years. Another attendant worked as a heavy vehicle driver Inc. Jan. 1, 2002
and claimed that he was exposed to loud noise during his 5. Szymanska J. Work-related noise hazards in the dental
5 years of service before joining the dental services. surgery.AnnAgric Environ Med 2000 (7): 67-69
Exposure to noise level at 90dBA is quite common in the 6.European Heart Journal, published online Nov. 23
dental environment. Although the duration of exposure 7. Virkkunen H, Kauppinen T, Tenkanen L Long-term
does not reach the permissible exposure limit, dental effect of occupational noise on the risk of coronary heart
personnel experienced distraction and annoyance during disease. Scand J Work Environ Health. 2005
the exposure. Aug;31(4):291-9.8. C.E. Wilson T.K. Vaidyanathan W.R.
Cinotti S.M. Cohen S.J. Wang.Hearing-damage Risk and
7. Conclusion Communication Interference in Dental Practice Journal
Hazard from noise in dental working environment cannot of Dental Research, Vol. 69, No. 2, 489-493 (1990)
be underestimated. Hearing problems can occur due to 9.Bali N, Acharya S, Anup N, An assessment of the effect
dental field noise due to prolong exposure. Hence, proper of sound produced in a dental clinic on the hearing of
monitoring and Hearing Conservation programme is dentists. Oral Health Prev Dent. 2007;5(3):187-9110.
required for early detection and management of these Guidelines for hazard identification, risk assessment and
cases. Dental staffs working in high noise area above risk control. Department of occupational safety and
90dBA are advised to wear ear plugs. Regular medical health, Ministry of Human Resources, Malaysia. 2008
surveillance of staff exposed to high level of noise must
be complied as per Factories and Machinery (Noise
Exposure) Regulation 1989. This can ensure early
detection and management of the patient hence
preventing hearing impairment among the dental staffs.
8. Acknowledgements
The authors expressed their gratitude to Kota Tinggi
District Dental Officer, Kota Tinggi Senior Health
Officer, Director of Sultan Ismail Hospital, staff of ORL
Clinic Sultan Ismail Hospital and all dental personnel in
Kota Tinggi districts who had contributed to the conduct
of this study.
51
Prescription Intervention and Prescribing 11
Errors Detected by Inpatient Volume 10
Pharmacy Unit in Hospital Segamat 2012
Mohd Syahrizam bin Ta'at, Lau Kok Hou
Hospital Segamat
Introduction: Prescribing errors primary occur due to 1,400 prescribing errors per 1,000 admissions, 0.61 – 53
inadequate knowledge, failure to recognize, important percent prescribing errors per 1,000 orders, and 1.5 – 9.9
patient information or drug information. Medication percent prescribing errors per 100 opportunities for errors
prescribing errors are one recognized contributor to the 2. Other studies had identified and documented problems
overall problem of medication errors and have a high associated with prescribing errors. The extent of such
potential to result in adverse patient consequences errors varied from 2.6% to 15.4% or estimated as 2.87 to
Objectives: To determine the extent of prescribing errors 4.9 per 1000 medication orders3. An audit on this study
detected by inpatient pharmacy unit in Hospital Segamat, found that 2.6% of the prescriptions required active
to identify factors associated with medication prescribing pharmacist intervention to resolve a prescribing error4.
errors and to identify and document the types of Medication prescribing errors are one recognized
prescription intervention and its outcome contributor to the overall problem of medication errors
Method: A descriptive cross sectional analysis within 6 and have a high potential to result in adverse patient
week study duration in in-patient department of Hospital consequences5. Timothy S. L et al reported that 20% of
Segamat. prescribing errors made by physicians resulted in serious
Result and discussion: A total of 39 confirmed errors were incidents, compared with 6% for other causes of
evaluated for a likely related factor that was associated medication errors. Understanding of the type and
with the error. The most common types of medication frequency of, and risk factors associated with, medication
prescribing errors detected were drug therapy 48.15%; prescribing errors would allow closer monitoring of
dosage form related 12.81%; patient characteristic factor patients and medications associated with higher risk for
related 7.69%; inexperience personal 5.12% and serious errors, thereby limiting potential harm to
miscellaneous factor related 17.94%. The most common patients6.
medications involved were antimicrobials (17 errors, Studies on the types of prescribing errors in Malaysia
43.7%), cardiovascular agents (3 errors, 7.69%), appeared limited in the literature. Therefore, the present
gastrointestinal agents (3 errors, 7.69%), mineral/vitamin study was conducted to evaluate the extent of prescription
(5 errors, 12.82%) and diuretics (3 errors, 7.69 %). 2 error detected as well as to identify the types of
errors were rated as A potentially serious; 6 errors were prescribing errors. In this study prescribing errors was
rated as (potentially significant); and 31 were rated as monitored from inpatient unit with the aim of producing a
problem orders. By services, 23.09% occurred in surgical classification of errors based on the potential effects of
services, 51.28%by medical services, 2.56% in errors. Besides that, this study aim is to identify and
anaesthatic service, 5.12% in obstetric-gynecologic document the types of pharmacist intervention and its
service, and 12.28% in orthopedic service. Most outcome on problematic prescriptions.
intervention done by phone 82% and countersign 18%.
2) LITERATURE REVIEW
Conclusion: The results demonstrate a risk to patients for
adverse consequences from prescribing errors, if 2.1 BACKGROUND
undetected, and identification of specific associated risk
factors related to error also achieved. The UK, USA and the World Health Organization have
1) 1) INTRODUCTION identified that priority should be given to enhanced
patient safety in healthcare. Medication error has been
In the UK, potentially serious error occur between 1 in shown to be one of the most common forms of medical
1000 and 1 in 10000 prescription, but fortunately most are error and it is associated with significant medical harm7.
identified by staff1. Prescribing errors primary occur due For example, in the UK, 4.5% - 5% of admissions to
to inadequate knowledge, failure to recognise, important secondary care have resulted from preventable drug-
patient information or drug information. Medication related morbidity preventable harm from medicines
errors have been shown to increase length of hospital stay could cost more than £750 million pounds per year in
and medical cost1. England7.
Across various studies, the rates have been found to be In our country, one of the main missions of the healthcare
providers is to facilitate patients make the best use of
medications and attempt to ensure patient safety 2,8.
52
Medication safety is one of the major components in 2.3.3Administration Errors
patient safety but unfortunately medication errors do A drug administration error may be defined as a
occur and often go undetected. Some medication errors discrepancy between the drug therapy received by the
may result in serious patient morbidity and mortality, thus patient and the drug therapy intended by the prescriber11.
we need to further strengthen the current system with a Drug administration is associated with one of the highest
mechanism to monitor and make recommendations for risk areas in nursing practice. The “five rights” have long
remedial actions when errors occur and are reported8. been the basis for nurse education on drug administration
giving the right dose of the right drug to the right patient at
2.2 MEDICATION ERROR the right time by the right route11. Drug administration
A medication error is any avoidable event that may cause errors largely involve errors of omission where
or lead to inappropriate medication use or patient harm administration is omitted due to a variety of factors such
while the medication is in the control of the healthcare as wrong patient, lack of stock. Other types of drug
professional, patient or consumer. Such an event may be administration errors include wrong administration
related to professional practices, healthcare products, technique, administration of expired drugs and wrong
procedures and systems including prescribing, order preparation administered8.
communication, product labelling, packaging and
nomenclature, compounding, dispensing, distribution, 2.4 FACTOR RELATED TO MEDICATION
administration, education, monitoring and use9,10. PRESCRIBING ERROR
Medication errors may be committed by both
inexperienced and experienced personnel like doctors, The problems and sources of prescribing errors are
pharmacists, dentists and other healthcare providers, multidisciplinary and multi-factorial. The action of one
patients, manufacturers, caregivers and others10. individual alone is rarely the solitary cause of a
medication error or incident, rather a variety of
2.3 TYPES OF MEDICATION ERROR contributing factors combine to cause incidents13 :
Medication errors can be broadly classified as
prescribing, dispensing or drug administration errors. 2.4.1 Patient characteristic-related:
Adverse outcomes can be related to lack of knowledge or
2.3.1 Prescribing Errors skill6,13. Even the apparently simple act of transcribing
previous medications and collecting information as part
Prescribing errors may be defined as an incorrect drug of the medication history requires a knowledge of
selection for a patient, be it the dose, the strength, the pharmacotherapy as well as adequate information about
route, the quantity, the indication, the contraindications8. the patient's clinical condition13. Equally, the choice of
This definition can be further expanded to include failure dose requires information about the patient's clinical
to comply with legal requirements for prescription status and immediate verification of the appropriateness
writing11. The prescriber must specify the information of treatment. Prescribers frequently failed to make
which the pharmacist needs to dispense the drug in the necessary adjustments in the drug therapy of patients with
correct dosage and form and the directions the patient well-recognized disease or physiological factors known
needs to take it safely. A study undertaken in the hospital to alter drug action or disposition6. The most common of
setting found an error rate of 4 errors per 1000 medication these factors were those that affected the renal
orders. Of the errors with potential for adverse patient elimination of drugs advanced age and renal
effects, drug allergies accounted for 12.1%, wrong drug impairment14. Failure to consider the effect of patient
name, dosage form or abbreviation for 11.4% incorrect disease state and physiological status on drug disposition
dosage calculations for 11.1% and incorrect dosage is well recognized as a risk factor for drug toxicity1,14.
frequency for 10.8%11. Allergy, same class prescribing medications, or classes of
medications, to which the patient had a documented
2.3.2 Dispensing Errors allergy occurred frequently6. Many patients are placed at
Dispensing errors are errors that occur at any stage during risk for hypersensitivity reactions due to an inadequate
the dispensing process from the receipt of a prescription provision of timely information regarding allergy history
in the pharmacy through to the supply of a dispensed or the failure to recognize the components of combination
product to the patient11. Studies in the USA have products. Likewise, inappropriate concurrent drug
estimated that dispensing errors occur at a rate of 1- therapies were frequent, both drug-drug interactions and
24%13. Dispensing errors may undermine the patient's duplicative therapies15.
confidence in the pharmacist and increase the likelihood
of litigation procedures. These errors include the 2.4.2 Dosage form-related :
selection of the wrong strength/product. This occurs This problem involves both an apparent lack of
primarily when two or more drugs have a similar knowledge and a lack of appreciation of the important
appearance or similar name (look-a-like/sound-a-like distinguishing properties of different dosage forms
errors)11. The use of computerised labelling has led to the available for certain medications5,6. With an ever-
emergence of transposition and typing errors which are increasing variety of dosage forms and the increasing
among the most common causes of dispensing error12. clinical importance of their unique drug delivery
Other potential dispensing errors include wrong dose, properties, it is likely we will continue to encounter these
wrong drug, and wrong patient8. types of errors. Wrong dosage form for intended use,
wrong frequency for dose form and wrong dosage form
for route prescribed also lead to prescribing error6.
53
2.4.3 Nomenclature related : 3) JUSTIFICATION OF STUDY
The nomenclature such as adding a suffix to an
established brand name was used to identify dosage This study is being conducted because any study related
formulations by manufacturers is often confusing and to prescribing error in hospital Segamat is not done yet
increases the risk for errors6. Error in prescribing might and at the same time to create awareness regarding to
be due to similarities in drug brand names or prescribing errors are particular concern associated with a
pharmaceutical names. Application of abbreviations for higher risk for serious consequences and results in patient
medication frequency and for route also contributed to injury, increased health care costs and liability claims.
nomenclature related to prescribing error6,13. Based on this situation, a result from this study is believed
to create awareness among all prescriber regarding to the
2.4.4 Calculations/unit expression-related : impact of prescribing errors.
Miscalculation of medication doses, wrong decimal point
placement (10-fold errors), incorrect expression of unit of 4) OBLECTIVESANDAIMS OF THE STUDY.
measurement or concentration, or an incorrect
medication administration rate is usual factor lead to Objectives:
error6. Calculation errors, as might be expected in 1. To determine the extent of prescribing errors detected
previous studies were demonstrated significant by inpatient pharmacy unit in hospital segamat.
deficiency in the ability of prescribers to correctly - To determine frequency and type of prescribing errors
calculate drug dosages13. that occurs in hospital Segamat medical prescription.
2. To identify factors associated with medication
2.4.5 Inexperienced prescriber prescribing errors.
Prescriber personal experienced in this course. Medical 3. To identify and document the types of prescription
graduates themselves feel unprepared to prescribe shortly intervention and its outcome.
after graduation, emphasising the need to ensure
sufficient education in prescribing skills6. Organisational 5) METHODOLOGY
factors such as inadequate training, low perceived
importance of prescribing, a hierarchical medical team, 5.1 Study design
and an absence of self awareness of errors also
contributed to these errors. Inappropriate prescribing A sample of medication order written by prescriber in
most often derives from a wrong medical decision, Hospital Segamat will be used for descriptive cross
because of lack of knowledge or inadequate training16. sectional analysis within 6 week study duration. In this
Junior doctors often work in stressful circumstances that type of research study, the entire sample will be taken as
are perceived as routine by experienced doctors16. sample size during the duration of study, selected, and
from these individuals, data are collected to help answer
2.5 PRESCRIPTION INTERVENTION research questions of interest and objectives. This module
will use the term cross-sectional study to refer to this
Many studies had recognized and documented problems particular research design and the term error form to refer
associated with prescribing errors. The degree of such to the data collection form that is used to collect data
errors varied from 2.6% to 15.4% or estimated as 2.87 to prescription that received in in patient unit of Hospital
4.9 per 1000 medication orders3,4. An audit on Segamat.
pharmacies found that 2.6% of the prescriptions required
active pharmacist intervention to resolve a prescribing 5.2 Study setting and population
error6. Another study conducted in outpatient pharmacies
found that approximately 4 per 100 dispensed The setting was in Hospital Segamat. Medication order
prescriptions had problems and required pharmacists will be review from all wards in Hospital Segamat which
intervention. In 44% of the intervention, the outcome was are paedratic ward, MOPD, physiatric ward, obstetrics
a change in drug, strength or directions of drug use4. and gynaecology ward, intensive care unit and surgical
Most prescription interventions by pharmacists have a unit.
limited potential for medical harm although it may be
inappropriate in some instances as mentioned18. 5.3 Inclusion & Exclusion Criteria
However, it should be noted that a small number of
detected prescribing errors have a major potential for Inclusion Criteria:
medical harm if not corrected and hence, the importance 1. Orders for medications were presented by prescriber
of pharmacist interventions is not overemphasized18,19. for admission in their ward at Hospital Segamat.
The ultimate goal for combining the unique knowledge 2. New medication order and patient newly diagnosed
and competencies of both medical and pharmaceutical within the study duration.
professionals is to achieve optimal therapeutic outcomes
and quality of life for the patient. Therefore, both Exclusion Criteria:
professions have a definite role to play and should work 1. Medication they prescribe is sample medication
hand in hand towards achieving this common goal19. 2. Medication is not available in hospital formula list
3. Patient own medication.
54
During 6 week duration showed 44 samples taken. From potentially produce serious toxic reactions or inadequate
the total sample taken 5 samples was excluded due to drug therapy for a serious illness.
is not available in hospital formula list such as Aceprin 6. A medication order was written illegibly or in such a
instead of Cardiprin, Tablet Xarelto 10mg ON, manner as to result in an error that could produce serious
Ketonazole Cream, IV Ertromycin 100mg QID, Syrup toxic reactions or inadequate therapy for a serious illness.
Appeton 10ml once daily. 7. Duplicate therapy with potential for serious toxic
reactions was prescribed.
5.4 Data collection
5.5.1.3. Potentially Significant
Data will be collected within 6 week observational study
in inpatient unit of Hospital Segamat. Prescription will be 1. The dose ordered of a medication with a low
screening by pharmacist in patient. The following data therapeutic index was 1.5 to 4 times the normal dose, with
will be collected for each confirmed order error detected potential toxic reactions because of the high dose.
in the study period: patient case number, classification of 2. The dose ordered of any medication was five times or
the prescribing physician, ward involved, and type of greater than normal, with potential for adverse effects
error, patient specific information and intervention because of the high dose.
documentation. Pharmacists routinely used all available 3. The dose ordered was inadequate to produce
information sources to evaluate all medication orders for therapeutic effects.
appropriateness. 4. The wrong route of administration was ordered, with
potential for increased adverse effects or inadequate
5.5 Data analysis therapy.
5. The wrong medication was ordered for a nonsevere
Prescription errors by definition from guidelines on illness and/or there was a potential for side effects from
medication error reporting is incorrect drug product the drug.
selection (based on indications, contraindications, known 6. A medication order was written illegibly or in such a
allergies, existing drug therapy, and other factors), dose, manner as to result in an error producing adverse effects
dosage form, quantity, route of administration, or inadequate therapy.
concentration, rate of administration, or instructions for 7. Duplicate therapy was prescribed with a potential for
use of a drug product ordered or authorized by physician additive toxic reactions.
(or other legitimate prescriber); illegible prescriptions or
medication orders that lead to errors. 5.5.1.4. Problem Orders
1. Duplicate therapy was prescribed without potential for
5.5.1 Potential severity classification for order errors increased adverse effects.
2. The order lacked specific drug, dose, dosage strength,
5.5.1.1. Potentially Fatal or Severe formulation, route, or frequency information.
3. The wrong route was ordered without potential for
1. The dose ordered for a medication with a low toxic reactions or therapeutic failure.
therapeutic index was greater than 10 times the normal 4. An errant order was written that was unlikely to be
dose. carried out given the nature of drug, dosage forms, route
2. A dose was ordered for a medication with a very low ordered, missing information, etc.
therapeutic index that would potentially result in
pharmacologic effects or serum concentrations Adapted from Folli et al.
associated with severe or fatal toxic reactions.
3. A drug was ordered that had the potential to produce a 5.5.2 Classification of factors related to medication
severe or life-threatening reaction in the patient (ie, prescribing errors
anaphylaxis).
4. The dose of a lifesaving drug or drug being used for a 1. Patient characteristic-related:
severe illness was too low for the patient being treated. · Patient pathological, physiological status
· Allergy, same class
5.5.1.2. Potentially Serious · History taking
· No indication
1. The dose ordered for a medication with a low · Wrong patient
therapeutic index was 4 to 10 times the normal dose. · Allergy, related class
2. A dose was ordered for a medication with a very low · Contraindications
therapeutic index that would potentially result in serious
toxic reactions. 2. Drug therapy factor-related
3. The dose ordered for a drug used for a serious illness · Therapeutics/toxicity-related dose frequency
was too low for the patient.
4. The wrong medication was ordered, with potential error
serious toxic reactions or inadequate therapy for a serious · Duplicative therapy
illness. · Wrong drug prescribed, same drug class
5. A route was ordered for a medication that could · Failure to adjust for route of administration error
· Unusual/atypical route for drug/therapy
· Toxicity-related treatment duration error
· Failure to appreciate combination components
55
· (not allergies) A total of 39 prescribing errors, 9 errors (23.09%)
· Wrong drug prescribed, "linked" therapies occurred in patients cared for by surgical services, 20
· Significant drug interaction (51.28%) occurred in patients cared for by medical
· Therapeutics-related treatment duration errors services, 1 (2.56%) in anaesthatic service patients, 2
(5.12%) in obstetric-gynecologic service patients, and 5
3. Dosage form-related : (12.28%) in orthopedic service patients.
· Wrong dosage form prescribed for intended use
· Wrong frequency for dose form prescribed Most intervention was done by using telephone with 32
· Wrong dosage form for route prescribed interventions (82.05%) and by countersign, 7
interventions (17.94%). One intervention which doctor
4. Nomenclature related : insist to continue current prescribed dose due to own
· Brand name lacking special dosage form suffix reason. Other interventions, doctor agree to pharmacist
· Generic drug with failure to specify special recommendation.
· dosage form
· Soundalike drug prescribed, similar dose Table 1 Types of Medication Errors Detected
· Soundalike drug prescribed, dissimilar dose
· Abbreviations for frequency Types of error No. of total error % of total error
· Abbreviations for route
Duplicate therapy 6 15.38
5. Calculations/unit expression-related :
· Calculation error Wrong dose 5 12.28
· Decimal point error
· Unit of measure Incomplete dose 2 5.12
· Rate expression
6. Inexperienced prescriber Overdose 4 10.25
· Prescriber personal experienced in this course
Inappropriate therapy 2 5.12
6. RESULT
A total of 44 confirmed medication prescribing errors Wrong dosage form 1 2.56
were detected and averted by the pharmacy prescribing
error prevention program during the 6 week study period. Wrong frequency 4 10.25
A total of 39 confirmed errors were evaluated for a likely
related factor that was associated with the error. The Pathological patient status 3 7.69
characteristics and likely related factors for these 39
errors constitute the data for the study. Unit of measure 2 5.12
Characteristics of Prescribing Errors Wrong spelling 1 2.56
The most common types of medication prescribing errors
detected among the 39 total during the study period were Incomplete regime 2 5.12
drug therapy, including duplicate therapy (6 errors,
15.38%), overdoses (4 errors, 10.25%) and wrong doses No signature 7 17.94
(5 errors, 12.28%); dosage form related including wrong
frequency ( 4 errors, 10.25%), wrong dosage form (1 Total error 39 100
errors, 2.56%); patient characteristic factor related
including pathological patient status (3 errors, 7.69%); Figure 2. Factors Related to Error Detected
inexperience personal related including imcomplete
regime ( 2 errors, 5.12%) and miscellaneous factor
related such as no signature (7 errors, 17.94%). Table 6
lists the number of each error type detected and averted
for errors included in the study database.
The most common medications involved in the 39
prescribing errors were antimicrobials (17 errors,
43.7%), cardiovascular agents (3 errors, 7.69%),
gastrointestinal agents (3 errors, 7.69%), mineral/vitamin
(5 errors, 12.82%) and diuretics (3 errors, 7.69 %).
Error rates varied among medication groups of 39 errors,
2 (5.12%) were rated as A potentially serious; 6 errors
(15.38%) were rated as potentially significant; and 31
(79.48%) were rated as problem orders.
56
Table 2 Medication Classes Involved in Errors 7. DISCUSSION
Types of error No. of total error % of total error Medication errors are an all too common occurrence in
Antimicrobial 17 43.58 the provision of modern health care and one of the many
Cardiovascular 3 7.69 "hazards of hospitalization." The problem is both
Gastrointestinal 3 7.69 multidisciplinary and multifactorial in nature and results
Analgesic 1 2.56 in patient injury and increased health care costs and
Mineral/vitamin 5 12.82 liability claims. Most studies of medication errors have
Antiemetic 2 5.12 primarily evaluated the dispensing and administration of
Antidiabetic 1 2.56 drugs, without addressing physician prescribing errors.
Mucolytic 1 2.56 Errors of physician prescribing are of particular concern;
Diuretic 3 7.69 as such errors have been associated with a higher risk for
Antidiarrhea 1 2.56 serious consequences than errors from other sources. The
Nebulizer 2 5.12 results of this study further document and define the
Total 39 100 problem of medication prescribing errors and the
potential risk such errors pose to patients.
Table 3. Potential Severity Classification for Order Errors
The potential severity of the detected errors varied
Classification of severity No. of total error % of total error considerably, from potentially severe, to having minor
clinical consequences, to having negligible patient
Potentially fatal or severe 0 0.00 impact. Many of the errors classified as "problems" with
low potential for patient impact were incomplete or
Potentially serious 2 5.12 ambiguous orders or orders considered unlikely to be
carried out. This study confirms the importance of
Potentially significant 6 15.38 standard checks within healthcare systems in reducing
the risk for medication errors, specifically, the
Problem orders 31 79.48 importance of the review of medication orders by
pharmacists. Similarly, the standard "double-checking"
Total 39 100.00 of physician prescribing and pharmacy dispensing
activities by nurses is most likely an important risk-
Table 4. Order Errors by Prescribing Service reducing function. Compliance with these standard
checks in health care settings should be emphasized and
Service No. of total error % of total error monitored. The limitation, elimination, or circumvention
of these functions would be expected to result in an
Medical 20 51.28 increased risk of errant orders being carried out.
Surgical 9 23.07 Specific factors and factor groups associated with errors
varied among the medication classes involved in the
Anaesthatic 1 2.56 error. Patient characteristics and drug therapy
(polypharmacy, overdose, underdose drug interaction)
Obstetrics/gynecology 2 5.12 were the most common factors for antimicrobials
(43.58%), cardiovascular agent (7.69%) and
Paedratics 0 0.00 gastrointestinal agents (7.69%).
Orthopedic 5 12.28
Psychiatric 2 5.12
Table 5. Prescription Intervention Medical officer had a significantly greater error rate than
other physicians. Experience and knowledge are
Form of intervention No. of total intervention % of total intervention important factors in physician performance that correlate
to error to occur. Continuation of the monitoring program
By phone 32 82.05 will allow the following up of individual prescribers
through their training to confirm a reduction of error rates
By SMS 0 0.00 with years of training.
By personal 0 0.00 Medication errors occurred more frequently in patients
being cared for by medical and surgical services than by
By countersign 7 17.94 other services. The specific reasons for this higher error
rate in medical and surgical services are unclear but may
be related to the limited time or less emphasis during
training programs. Additional studies are required to
confirm this finding and to determine underlying reasons
for the greater error rate.
The findings of this study have important implications for
the functional design, risk-management and quality-
57
assurance procedures, educational priorities, and Malaysian Journal of Pharmacy; 1(3):86-90.
performance evaluation within health care systems. 5. Timothy S. L, Laurie L. B, Karen D Janet C P, Vickey M
Improved quality of care is expected to follow the G (1990). Medication Prescribing Errors in a Teaching
implementation of procedural and educational initiatives Hospital. JAMA, vol; 263, page: 2329-2334.
specifically designed to address identified problems in 6. Timothy S. Lesar, PharmD; Laurie Briceland, PharmD;
the provision of medical care. Procedures for provision of Daniel S. Stein, MD (1997). Factors Related to Errors in
care should be designed to provide appropriate Medication Prescribing. JAMA, vol : 277:312-317.
concurrent risk management and quality-assurance 7. Sara Garfield, Nick Barber1, Paul Walley, Alan
activities. As a result of this study, an ongoing monitoring Willson and Lina Eliasson (2009). Quality of medication
program of prescribing errors was implemented in the use in primary care - mapping the problem, working to a
study hospital as part of the hospital's quality-assurance solution: a systematic review of the literature. BMC
program. All detected errors are concurrently evaluated, Medicine, vol 7:50, pg: 1-8.
summarized, and recorded. Potential causes of errors are 8. Guidelines on medication error reporting (2009).
identified and solutions developed. The impact of Pharmaceutical Services Division, Ministry of Health
providing such feedback on specific errors to individual Malaysia. First edition.
prescribers, and general information on common errors to 9. American Society of Hospital Pharmacists (ASHP)
prescribers as a group, will be evaluated through Report (2003) – ASHP guidelines on preventing
continued monitoring of error rates within the institution. medication errors in hospitals. Am J Hosp Pharm vol ;
The knowledge of how and why errors occur will 50:305-314.
hopefully reduce the hazards of hospitalization. 10. The National Coordinating Council for Medication
Error Reporting and Prevention (2005).
8. LIMITATION 11. DJP Williams (2007). Medication errors. J R Coll
Physicians Edinb vol: 37:343–346.
Lack of the pharmacist was routinely in charged in 12. Suriya J, Jacob E, Shalaka I, Sethi A, Danushan S and
inpatient department as to check and counterchecking, Robert C (2007). Prescription Errors and the Impact of
review on computerized checking of dosage, allergy, Computerized Prescription Order Entry System in a
duplicate therapy, and drug interaction in prescription Community-based Hospital. American Journal of
orders, thus limiting potential variability in error Therapeutics 14, 336–340.
detection ability. Duration of study as 6 week is not 13. Giampaolo P. Velo, Pietro Minuz1 (2009).
enough to collect sample data as for more significant Medication errors: prescribing faults and prescription
result will be achieve. errors. British Journal of Clinical Pharmacology, vol 67:6
/ 624–628.
9. CONCLUSION 14. Marlene R Miller, Karen A Robinson, Lisa H
Lubomski, Michael L Rinke, Peter J Pronovost(2007).
44 prescribing errors were detected during a six week Medication errors in paediatric care: a systematic review
duration study in a Hospital Segamat. The results of epidemiology and an evaluation of evidence
demonstrate a risk to patients for adverse consequences supporting reduction strategy recommendations. Qual
from prescribing errors, if undetected, and identification Saf Health Care; 16:116–126.
of specific associated risk factors related to error was 15. J.K. Aronson (2009). Medication errors: what they
detetected. The study confirms the importance of checks are, how they happen, and how to avoid them. Q J Med,
within health care systems in reducing risks to patients vol: 102: page: 513–521.
from errors. Health care institutions and physician 16. Sarah R, Christine B, Helen R, Sian T, & Mary Joan M
training programs should implement procedural, (2008). What is the scale of prescribing errors committed
monitoring, and educational programs designed to limit by junior doctors? A systematic review. British Journal of
patient risk for adverse consequences from prescribing Clinical Pharmacology, vol 67:6 / 629–640.
errors. Further study can be done to give more significant 17. Joanna E K, Rob K, Hendrikus J, Anne-C, Marcel G
result and as a monitoring measure for prevention of D, Loraine L, Margreeth B V, Susanne M S (2010). On-
prescribing error in heatlhcare institution. ward participation of a hospital pharmacist in a Dutch
intensive care unit reduces prescribing errors and related
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22. Dellemin C A, Noor S I, Mohamed I M I (2004). 24. Michael L. Rinke, Margaret Moon, John S. Clark,
Medication errors among geriatrics at the outpatient MS, Shawna Mudd, MSN, and Marlene R. Miller (2008).
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Medications At Transitions and Clinical Handoffs
59
A Pilot Study To Assess Patient's Knowledge, 12
Metered-dose Inhaler (mdi) Techniques And
Compliance To Treatment After Medication Volume 10
Therapy Adherence Clinic (mtac) Asthma.
Low Y.B.1, Tan W.L.1, Patricia Lim M.H.1, Yeo L.P.1 2012
1Hospital Sultanah Aminah, Johor Bahru (HSAJB)
Summary Besides, a study conducted by Thaper12 showed that a
high level of morbidity experienced by asthmatics may be
A high level of morbidity among asthmatics may be associated with a poor patient's knowledge of the disease
associated with poor patient's knowledge of the disease process and medication use, while Wilson et. al.13 studies
and the use of inhalers, which may contribute to high showed that asthmatic patients have poor understanding
asthma prevalence in Malaysia (4.1 – 13.8%). To address of the use of inhaler. Both Hilton et.al.14 and Lai et. al.15
this problem, a cross-sectional observational prospective reported that most of the asthmatic patients have poor
study with the Before-and-After-Design was conducted self-management on their disease and this may then
by recruiting asthmatic adults in MTAC Asthma HSAJB associated with their poor quality of life.
from 1 March 2011 to 31 May 2011 using convenience
sampling method. A significant improvement in mean Since a high morbidity trend among asthmatic patients
patient's score for knowledge of disease has been shown may be associated with the poor patient's knowledge
after counseling. Morisky Scale for compliance has been about the disease itself and the medications use, thus each
shown to be significantly improved from 34% to 75% of the factors stated above is amenable to asthma
after counseling. education for this population. 2, 3, 4, 11 Therefore, this
study aimed to assess the effectiveness of AEP (MTAC
Key Words Asthma) for asthmatic patients in outpatient clinic setting
Hospital Sultanah Aminah Johor Bahru (HSAJB) by
pilot study; knowledge; Metered-dose Inhaler (MDI) evaluating the knowledge of asthma, their MDI
techniques; compliance to treatment; Asthma Education techniques and their compliance to asthma management
Program (AEP); MTACAsthma. who followed up in MTAC Asthma HSAJB from 1 March
2011 to 31 May 2011.
Introduction Materials and Methods
Asthma is a chronic inflammatory disorder of the airways Study Population
that causes significant morbidity and mortality
globally.1, 10 It affects 5 – 6% of the world population This study was carried out from 1 March 2011 until 31
which involves about 300 million individuals.1, 5 May 2011. MTAC Asthma HSAJB opens every
Besides, the latest asthma prevalence in Malaysia is 4.1 – Wednesday from 8am until 1pm. All adult patients aged
13.8%, which shows an increasing trend.6 more than 18 years old who were followed up in MTAC
Asthma during the study period were recruited using
There are two main components involved in asthma convenience sampling method.
management, which are pharmacological therapy and
Asthma Education Program (AEP).1 Pharmacological Forty two patients aged more than 18 years old, who
therapy for asthmatic patients are reliever medications attended the MTAC Asthma during the study period, were
and controller medications. The former is normally recruited using convenience sampling method. Then, the
indicated for acute attacks, while the latter is normally eligible participants were selected by applying inclusion-
indicated for prevention and to improve lung functions. exclusion criteria, which were thirty-nine patients. One
patient was excluded due to the first visit to MTAC
AEP is an education program which aim to increase Asthma, while two patients were excluded because they
patient's knowledge about asthma therapy in order to could not come for retesting. All participants were then
maintain optimal asthma control in asthmatic patients.1, been asked for verbal consent to take part in this study.
2 Several global studies have been designed to evaluate The questionnaire (data collection form) was completed
the impact of patient education to asthma control.2, 3, 4, during a one-to-one interview session without time limit.
11 These studies have identified some factors which Patients would then be asked to come back after one
contribute to poor asthma control in this population. month for retesting and seven patients were excluded
Gibson et. al. reported that asthmatic patients always since they have been lost of follow up for retesting after
deny that they are having a chronic condition of asthma one month. Figure 1 has shown an overview of the study
and thus they just use the medications when necessary.11 procedure.
60
Data Source Definition of MDI Technique
This study would only take one encounter for each patient The eight steps of standard MDI technique mentioned in
who have completed the first month retesting process the questionnaire in this study was obtained from GINA
after their first clinic visit during the study period guideline.1 Subjects would be asked to demonstrate the
regardless of how many times clinic visits were made MDI technique during test-and-retesting, while
after that. The Before-and-After-Design was used in the researchers would make a tick if patients have followed
study with the subjects serving as their own control. the proper step mentioned.
There were two data collection sheet completed by each
patient after interviewed by different researchers for test- Definition of Patient's Compliance to Medications
and-retest purpose without time limit. The questionnaire
or the data collection form in this study was adapted and In this study, patient's compliance to medications was
modified from other similar studies by Prabhakaran et. evaluated by using the Morisky Scale. Subjects have to
al.4 and Robin at. al.9 answered four questions with the answer of YES (1 mark)
and NO (0 mark). The table 1 showed the Morisky Scale.
An assumption has been made in which this study would
only record all information given by the patients, hence Based on the Morisky Scale, patient's compliance was
all patients were assumed to be honest during the assumed to be good in this study if their score was 0, 1 and
interview session. 2. For those patients who got their score as 3 or 4, their
compliance was assumed to be poor.
Inclusion-exclusion Criteria
Results
All adult asthmatic patients aged more than 18 years old
prescribed only on the MDI were selected. In addition, the During the three months study period, 32 eligible patients
selected subjects must have regularly followed up at were included and 56.3% of them were male patients.
MTAC Asthma HSAJB with at least two or more visits in Most patients were within the age range of 20 to 80 years
past twelve months. old for both genders. Generally, most patients have an
average of 22 years history of asthma. About 62.5% of
On the other hands, subjects with first visit to MTAC them have taken 2 medications to control their asthma.
Asthma were excluded from this study. Besides, patients One-third of the asthmatic patients have the secondary
with language and understanding problems were education level (Figure 2). Besides, about 59.4% of the
excluded since they could not answer the questionnaire. asthmatic patients in this study claimed that they were
This study also excluded those patients who could not non-smokers (Figure 3), while more than half of the
come for retesting after one month. Patients who were patients admitted that they have attended asthma group
using MDI with the aid of aero-chamber were excluded counseling previously (Figure 4). Patient demographic
from this study. characteristics have been summarized in Table 2.
Data Analysis In this study, the mean score of patients' knowledge of
disease and medication was significantly increased from
The collected data was analyzed by using Statistical 20.31 to 23.72 after counseling. Mostly patients
Package for the Social Sciences version 17.0. The data for recognized about five factors that contribute to their
continuous variable was summarized as mean with asthma attack, which were not significantly different
standard deviation (means ± SD) with the p-value was before and after counseling. Approximately half of them
obtained from Paired Samples T-test. For categorical did not know that they were using a reliever medication,
variable, the data was summarized as percentage and the but after counseling half of them knew that Ventolin was
respective p-value was obtained from Pearson Chi- their reliever, while one-third of them claimed that
Square Test. All data analyzed was presented in the form Berodual could relieve their asthma (Table 3).
of bar chart and table.
In this study, Morisky Scale has been used to assess the
Definition ofAsthma Education Program (AEP) impact of MTAC Asthma on patient's compliance to
medications. Before given counseling, approximately
This study reviewed the effectiveness of AEP in MTAC one-third of the patients have poor compliance to
Asthma HSAJB by evaluating patients' knowledge of the medicines, while only 9.4% of them were reported to be
disease and medication use. There were five related compliant to medicines. However, a statistically
questions have been asked during the interview session significant increase has been reported in which 75% of
and patients would choose the scale among one (strongly the patients claimed that they were compliant to the
disagree), two (disagree), three (neutral), four (agree) and therapy after counseling have been given (Table 4).
five (strongly agree). Patients who chosen agree and
strongly agree would be assumed as knowledgeable, During the one-to-one interview session, all subjects have
while those who chosen neutral, disagree and strongly been asked to demonstrate their MDI techniques. After
disagree would be considered as not knowledgeable. counseling have been given based on the eight steps listed
in the GINA guideline1, their MDI techniques would be
assessed after one month retest interview. In this study, a
61
significantly increase has been shown in most of the asthma therapy, while one-third of them has poor
steps. However, only half the patients remembered to compliance or not compliant to therapy at all. The non-
prime their MDI before use and to clean their MDI once a compliance rate of around 50% has been reported in this
week although the counseling has been given to them study with the regular preventive therapy. After they
(Table 5). attended the MTAC Asthma, there was a significant
improvement on patient's compliance to the therapy in
In this study, before counseling has been given, one-third which 75% of the subjects have satisfactory compliance
of the patients claimed that they usually have less than rate to the therapy. This might be associated with the
two asthma attacks per month, while 25% of the patients benefit of AEP in which patients were more
complained that they have three to four asthma attacks per knowledgeable about their disease and the treatment
month. When these subjects came back after one month being used, thus they have the awareness to be more
for the retest purpose, about 70.8% of them have compliant to the asthma therapy. Besides, a significant
infrequent asthma attack in this one month period of time. improvement in patient's compliance might be associated
This was a statistically significant improve in asthmatic with the short one month retest period since they were
patients' quality of life (Table 6). given medical attention by health care professional.
Discussion In this study, all subjects have been assessed their MDI
techniques based on the eight steps listed in GINA
Based on the Malaysia Clinical Practice Guideline6 2002, guideline.1 The proper use of the inhaler, especially the
the latest asthma prevalence in Malaysia was 13.8% anti-inflammatory agents or the preventer inhalers, with
indicating that more Malaysians are suffering from appropriate dose schedule was important to achieve the
asthma. On the average, patients have been suffered from benefits of these medications.13 Similar to the result
asthma attacks for more than 20 years. Within this reported by Maria et. al.21, only 22% and 28% of the
population, about 62.5% of them have 2 medications to subjects in this study have prime the MDI or wait for one
control their asthma, which were reliever and preventer. minute between puffs and clean the mouthpiece once a
week. Maria et. al.21 found that about 66% to 84% of the
This study result was consistent with the result from other asthmatic patients had difficulty in using MDI and
studies4, 15, 17, which showed that there was a associated with the poorly control of asthma. After the
significant increase in patients' knowledge of asthma subjects have been followed up at MTAC Asthma, it was
score. A complete counseling session given during found that there was a significant improvement on
MTAC Asthma has successfully improved patient's patients' MDI techniques, especially all patients would
knowledge of disease process of asthma. Since patients shake and remove the cap before using MDI and hold
were more understand about their disease, this may lead breath for ten seconds after taking one puff. However,
them to be more effective in controlling their disease almost half of the patients in this study did not prime the
condition besides they would be more compliant to inhaler or clean the mouthpiece once a week even though
medications. Thus, as suggested by Meenu and Sonal20, counseling was given one month before retest. This result
information about the basic pathophysiology of asthma is was consistent with the result found by one group of
the foundation of patient education. authors in Brazil in which they found that ten days after
the first explanation of MDI technique, only 48.4% of the
Besides, number of factors causing asthma attacks patients performed the inhaler technique correctly.21
recognized by study subjects before and after MTAC This result may indicate that patients tends to always
Asthma was not significant different. This may be claim that they knew how to use the MDI and the health
associated with the chronic condition of most of the care professional believed it to be true and therefore do
subjects in this study. Since most of them have an average not test them. Hence, regular assessment of MDI
of about 20 years of asthma condition, they might clearly technique was necessary to ensure that patients gain the
understand the factors which may trigger their biggest benefit from the pharmacotherapy.
exacerbation of asthma. As suggested by Meenu and
Sonal20, patient education on possible allergens and On the other hand, the impact of MTAC Asthma has
triggers might help the asthmatic patients to be more significantly reduced patients' asthma attack in this study.
effectively control their asthma exacerbation by using Most of the patients claimed that they have three to four
environment control strategies. It was not surprising attacks per month or less than two attacks per month
when this study reported that almost half of the patients before they followed up at MTAC Asthma. After
could not recognize their reliever medication. When counseling has been given, 70.8% of the subjects reported
subjects have been given an explanation about reliever infrequent asthma attack within this one month study
medication during the interview session, there was a period. This might be due to patients who were more
significant improvement on patients' knowledge of knowledgeable about their disease and management
reliever medication. which may then associated with their better compliance
and improved MDI technique. This study result similar to
Similarly to those the result reported by Maiman et. al.18 other studies that shown that AEP improved patient's
and Scherer and Bruce19, patient's compliance with the functional status and quality of life.16, 17, 18
therapeutic regimes for chronic disease was generally
low. In this study, before counseling has been given, only This study has several limitations. A short term follow up
9.4% of the subjects claimed that they were compliant to period might make the subjects felt that they gained more
62
medical attention from health care professional and thus NMJ. 1999. Current Outpatient Management of Asthma
bias might be existed and associated to high level of Shows Poor Compliance with International Consensus
patient's compliance and less asthma attacks. Besides, Guidelines. CHEST, 116: 1638 – 1645.
subjects were not randomly selected might be subjected 8. Marianne HS and Olle L. 2004. Drug compliance and
to bias because convenience sampling method has been identity: reasons for non-compliance – Experience of
used in this study. Questionnaire or the data collection medication from persons with asthma/allergy. Patient
form in this study was adapted and modified from other Education and Counseling, 3 – 9.
similar studies by Prabhakaran et. al.4 and Robin at. al.9, 9. Robin G, Gloria D, & David P (2008). Perceptions,
but was not validated in our own setting. The small impact and management of asthma in South Africa: a
sample size might be affecting the result of this study patient questionnaire study. Primary Care Respiratory
which might not represent the impact of MTAC Asthma Journal, 17 (4): 212-216.
in all government hospital in Malaysia. 10. GINA. Gobal strategy for asthma management and
prevention. National Heart,Lung and Blood Institute;
Conclusion 2002. Report no: NIH 02-3659.
11. Gibson P, Powell H, Coughlan J, et al. Limited
With the increasing trend of asthma prevalence, this study (information only) patient education programs for adults
showed that with post-intervention, there were with asthma. Cochrane Library, 2004.
significant improvement in the patient's knowledge of 12. Thapar A. Educating asthmatic patients in primary
asthma and medications, self-reported compliance to care: a pilot study of small group education. Family
treatment regimen, MDI technique and frequency of Practice 1994; 11:39-43.
asthma attacks. Overall patients' health outcomes can be 13. Wilson SR, Scamagas P, German DF, et al. A
further improved. The findings of this study may suggest controlled trial of two forms of self-management
a well-structured AEP consists of MTAC Asthma and education for adults with asthma. Am J Med 1993;
asthma group counseling. Regular assessment of patient's 94:564-76.
MDI technique may ensure them gain more benefit from 14. Hilton S, Sibbald B, Anderson H, Freeling P.
the treatment. Controlled evaluation of the effects of patient's education
on asthma morbidity in general practice. Lancet 1986;
References 4:26-9.
15. Lai CKW, Guia TS, Kim YY, et al. Asthma control in
1. [GINA] Global Initiative for Asthma. 2010. Pocket the Asia-Pacific region: The Asthma Insights and Reality
Guide for Asthma Management and Prevention (for in Asia-Pacific Study. J Allergy Clin Immunol 2002;
adults and children older than 5 years). Canada: GINA. 111:263-8
2. Franks TJ, Burton DL and Simpson MD. 2005. 16. Yoon R, McKenzie DK, Bauman A, Miles DA.
Patient medication knowledge and adherence to asthma Controlled trial evaluation of an asthma education
pharmacotherapy: a pilot study in rural Australia. program for adults. Thorax 1993; 48:1110-6.
Therapeutics and Clinical Risk Management, 1 (1): 33 – 17. Abdulwadud O, Abramson M, Forbes A, James A,
38. Walter EH. Evaluation of a randomized controlled trial of
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Evaluating health education in asthma – developing the 54:493-500.
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Royal Society of Medicine, 75: 625 – 630. (1979). Education for self-treatment by adult asthmatics.
4. Prabhakaran L, Lim G, Ablsheganaden J, Chee CBE JAMA; 241:1919-21.
and Choo YM. 2006. Impact of an asthma education 19. Scherer YK, Bruce S (2001). Knowledge, attitudes,
program on patients' knowledge, inhaler technique and and self-efficacy and compliance with medical regimen,
compliance to treatment. Singapore Medicine Journal, 47 number of emergency department visits, and
(3): 225 – 231. hospitalizations in adults with asthma. Heart Lung;
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education Patient Education and Counseling, 26: 81 – 86. 20. Meenu S & Sonal K (2006).Adherence issues in
6. Ministry of Health Malaysia, Malaysian Thoracic asthma. Indian Pediatrics, 43; 1050-1055.
Society, Academy of Medicine of Malaysia. 2002. 21. Maria L, Andrea C, Erica F, Elcio V & Marcos C
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63
A Study of The Effect of Home Water 13
Filtration Systems On Fluoride Content of Volume 10
Drinking Water in Johor
Loh KH*, Yaacob H**, Adnan N***, Omar S****, Jamaludin M****. 2012
*Pejabat Kesihatan Pergigian Daerah Johor Bahru,
**Pejabat Kesihatan Pergigian Daerah Ledang,
***Pejabat Kesihatan Pergigian Daerah Pontian,
****Pejabat Timbalan Pengarah Kesihatan Negeri (Pergigian), Negeri Johor
ABSTRACT purchasing bottled water and filtration systems are at a
Introduction: With the general population concerned with high.2 This poses a challenge to the maintenance and
polluted water, tendencies toward purchasing bottled expansion of our water fluoridation programme, as
water and filtration systems are at a high. This poses a questions are being raised as to whether fluoride content
challenge to the water fluoridation programme as in public water supplies is affected by these filters.
questions are being raised as to whether fluoride content
in public water supplies is affected by these filters. 2. LITERATURE REVIEW
Objectives: To compare fluoride content of drinking 2.1 Types of Domestic Water Filtration Systems
water before and after passing through various water Domestic water treatment systems include water
filtration devices, and also to compare fluoride content conditioners and softeners and water filters. These
differences between various water filtration devices. systems fall into two basic categories: point of entry
Methodology: A total of 49 water filters were included in (POE) and point-of-use (POU). Point-of-entry water
this study. Fluoride levels were analyzed using the Hach's treatment systems treat all of the water entering and being
colorimeter. Statistical analysis was done using SPSS used in the home. Point-of-use water treatment systems,
software. All procedures were computed to within the on the other hand, treats part of the water in the home
95% confidence level. Results: Of the 49 filters, 29 were water distribution system, usually at one faucet. The
carbon activated (CA), 11 reverse osmosis (RO) and 9 water is typically only used for drinking and cooking.
using other technologies. Fluoride levels before and after Reverse osmosis, distillation and activated carbon
filtration through CA systems were not significantly filtration are examples of POU water treatment systems.
different (p>0.05); while those through RO and other
systems were significantly different (p<0.05). Fluoride Carbon Filtration Systems is a pour-through carafe which
levels between different filtration systems were found to most often resembles a water pitcher or large jug and use
be significantly different (p<0.05), with CA systems activated charcoal (CA) as the filtering medium. Gravity
being significantly higher than RO and others. pulls the water through the activated carbon filter,
Conclusions: The use of carbon activated water filtration removing chlorine, lead and mercury, as well as
systems has no effect on fluoride levels in drinking water. pesticides.3,4
Water filtration systems using Reverse Osmosis and other
technologies significantly lower fluoride levels of Reverse Osmosis (RO) Systems uses pressure to force
drinking water. Optimally fluoridated drinking water water molecules first, through a microscopic membrane
when subjected to home water filtration systems that or screen, and then through a cellophane membrane that
reduce fluoride significantly may not offer the same screens out even smaller pollutants from the water. They
caries preventive effect. greatly improve the taste of water by removing infiltrates,
lead and some pesticides, and natural minerals.5
1. INTRODUCTION
Water fluoridation remains the most cost-effective, Distillation is a process that removes contaminants from
equitable and safe means to provide protection from water. It heats up the water to boiling point, traps the
dental caries in a community. However, according to the rising steam, and uses a fan or other cooling device to
U.S. Environmental Protection Agency (EPA), condense the vapour back to its original form, minus
approximately one in eight Americans is exposed to everything else.6
potentially harmful microbes, pesticides, lead, or
radioactive radon whenever they drink a glass of tap Water softeners use a cation-exchange resin, regenerated
water or take a shower.1 With the general population with sodium chloride or potassium chloride, to reduce the
concerned with polluted water, tendencies toward amount of hardness (calcium, magnesium) in the water.
The hardness ions in the water are replaced with sodium
or potassium ions. Ion-exchange water softeners
64
simultaneously remove radium and barium while The efficiency of removal of lead (Pb) and other elements
removing water hardness.4,6 While being effective in from natural drinking waters using a bench-top water
eliminating metals, they can raise, however, the level of filter system was evaluated by Gulson et al.16 It was
sodium in the water. shown that elements unaffected by filtration were Al, Si,
Na, Fe, Cl and F. Water conditioners and softeners have
2.2 Popularity and Reasons for Using Domestic Water been shown to have little or no effect on fluoride.12,17,18
Filtration Systems
The sale of home water treatment units is expanding. The 2.4 Role of Relevant Agencies in Domestic Water
January 1999 National Consumer Water Quality Survey Filtration Systems Usage
indicates that 38% of adults reported using a household As far as the removal of contaminants, the National
water treatment device, a 28% increase since 1995. Forty- Sanitation Foundation (NSF), provides certification of
seven percent of respondents stated they would be more contaminant removal for water purification systems. The
likely to buy a house with a water treatment device if they label of the filter should specify NSF certification for the
were in the market for a new home.7 contaminants that are removed.3 Glass emphasized the
importance of dentists asking patients about their
A study in Pahang found that almost 50% of households drinking water, in order to make recommendations on
surveyed had one or more forms of household water whether fluoride supplementation was needed.3
filters in place and another 44% which had not, planned to Petrowski stated the purpose of water quality agencies
to do so.8 The purpose of installing these filtration and their roles. Instructions on purchasing and
devices were solely for health reasons and for better maintaining a system were also discussed and reference
quality water. numbers of different companies for additional
information on their products were provided.4
2.3 Effect of Home Water Filtration Systems on Fluoride 2.5 Proper Usage of Water Filters and Filtered Water
Content Water that has passed through a domestic filter should be
The ability of the different water filtration systems to treated as a perishable foodstuff and kept in refrigerated
remove fluoride from tap water has been studied. There is conditions. This water should be consumed within 24
strong evidence that systems such as those based on RO hours. The manufacturer's instructions for the filter
and distillation removed a substantial amount of equipment should be followed at all times.19
fluoride2,3,9 but tests of those based on activated carbon
have given contradictory results. Some reports have 3. RATIONALE
demonstrated a reduction in fluoride levels with use of With growing affluence coupled with smart marketing
carbon filters,2,3,8,9 while another study found no strategies, the sale of home water treatment units is fast
reduction.12-15 It has been suggested that the design of expanding. In the quest for increased coverage of our
the carbon filter may be a factor affecting fluoride fluoridation programme, there is also a need to look into
removal.2 Therefore, each carbon filter should be whether the intended population is benefiting from
assessed individually. fluoride in drinking water.
Removal of fluoride from water is a difficult water
treatment action.13 Most POU treatment systems for There are pockets of population in Johor who do not have
homes that are installed for use by single faucets use access to optimally-adjusted fluoridated water supplies.
activated carbon filtration, which will not remove the This study also helps to monitor consistency of fluoride
fluoride ion. The ability of other treatment systems such levels in fluoridated areas; hence, evaluating the quality
as reverse osmosis, ion exchange, or distillation systems control of the water fluoridation programme in the state.
to reduce fluoride levels vary in their effectiveness to
reduce fluoride
A study by Robinson et al12, in which water was passed Scientific evidence on the impact of different types of
through softeners and a conditioner, tested for fluoride devices on fluoride content will enable healthcare
concentration using a specific ion metering device. It professionals to educate patients on the possible removal
revealed no alteration in levels when compared with of fluoride by some water treatment systems and to
controls. Similar experiments of filtered water provide advice on the most suitable types of devices to
demonstrated highly significant amounts of fluoride ion purchase. This is to ensure that the benefits of fluoridated
were removed. In one filter tested, 90% of the fluoride water actually reach the population. With more studies
content was lost in the filtration process. like these being done, the Oral Health Division, Ministry
of Health, will be better positioned to work with related
The study by Prabhakar et al15 showed that the systems agencies in the certification of contaminants and minerals
based on reverse osmosis, viz, reverse osmosis system removal by each system.
and Reviva (R) showed maximum reduction in fluoride
levels, the former proving to be more effective than the 4. OBJECTIVE
latter; followed by distillation and the activated carbon 4.1 General Objective
system, with the least reduction being brought about by The objective of this study is to determine the effect of
candle filter. The amount of fluoride removed by the various home water filtration systems on fluoride content
purification system varied between the system and from in drinking water in Johor.
one source of water to the other.
65
4.2 Specific Objectives bottles were rinsed twice with distilled water to remove
4.2.1 To compare fluoride content of drinking water any fluoride residue.
before and after passing through water filtration devices.
4.2.2 To compare the difference in fluoride content of At the start of experimentation, water samples were
drinking water between water filtration devices. collected after running the water for 5 minutes.
Unfiltered water samples were collected from a second
5. METHODOLOGY tap (in same room) receiving the same main supply.
5.1 Sampling
Three districts in Johor were selected for the study; 5.2 FluorideAnalysis
namely, Johor Bahru representing an urban population The samples were brought back to the clinics, where
and with almost 100% fluoridation coverage, Muar with fluoride readings were taken. Fluoride content was
an equal mix of urban and rural population and about 90% analyzed using Hach's colorimeter. Each sample of water
fluoridated and lastly, Mersing with a mostly rural was measured twice and the recorded measurement
population and only half of which receiving fluoridated being the average of the two readings. Fluoride levels are
water. expressed as ppm F.
Water samples were collected from households using 5.3 Data Management
Water Filtration Systems (WFS), identified from an Data were entered into a dummy table and the SPSS
earlier study through systematic randomized sampling. software. Statistical analysis of effect of different types
Sampling of water was carried out over three consecutive of water filtration devices on fluoride level was done
days by trained personnel in each district. Standard using SPSS. Wilcoxon Signed-Rank test was used to
plastic bottles (100 ml) were used for collection of water compare fluoride content of drinking water before and
samples, one for control i.e. before water passed through after passing through various WFS. Mann Whitney tests
water filtration device and another for test i.e. after were used to compare difference in fluoride content of
passing through device. Each bottle was labeled drinking water between various WFS. All procedures
accordingly before collection of sample, with date, time, were computed to within 95% confidence level.
name of personnel and address of residence. Reused
6. RESULTS
A total of 49 water filters were selected from a pool of 115 filters in Johor Bahru, Muar and Mersing, as shown in TABLE
1 and TABLE 2a and 2b below.
TABLE 1 : Types of Water Filtration Systems Used by Selected Households in Johor
Frequency Percent Valid Percent Cumulative
Percent
Activated Carbon 83 72.2 72.2
20.0 72.2
Reverse Osmosis 23 20.0 92.2
7.8 100.0
Others 9 7.8 100.0
Total 115 100.0
Of the 49 filters, twenty-nine were activated carbon, 11 reverse osmosis, and 9 'Others'. Results showed that fluoride
levels before and after filtration with CA systems were not significantly different (p>0.05). Comparisons for RO systems
showed significant differences (p<0.05), similarly with WFS using other technologies (p<0.05). Refer to TABLE 2a and
2b.
TABLE 2a : Compare F level before and after filtration
Types of n Day 1 Day 2 Day 3
water Median F Median F *P value Median Median F *P value Median F Median F *P value
filter (Compare F Level Level (Compare Level Level (Compare
Level Level After before and Before After before and
Before After before and Before Filtration after Filtration Filtration after
filtration) filtration)
Filtration Filtration after filtration) Filtration 0.45 0.40
0.636 0.037
Activated 29 0.40 0.40 0.366 0.40 0.40 0.40 0.10
carbon 11 0.40 0.15 0.011 0.40 0.10 0.007 0.003
Reverse 0.40 0.35 0.005 0.40 0.30 0.40 0.30
Osmosis 9 0.006 0.008
Others
Total 49
*Wilcoxon Signed Rank Test
66
TABLE 2b : Compare F level before and after filtration (Overall)
Types of water n Overall
filter
Median F Level Median F Level *P value
Before Filtration After Filtration (Compare before and after
Activated carbon 29 0.43 0.43 filtration)
Reverse Osmosis 11 0.40 0.11 0.152
Others 0.40 0.30
Total 9 0.005
49
0.003
TABLE 3 shows comparison between various types of WFS, where significant differences (p<0.05) were obtained.
Filtered water from CAsystems had higher fluoride levels than those from RO systems and WFS using other technologies
(p<0.05). However, test results from RO and systems using other technologies were not significantly different (p>0.05).
TABLE 3: Compare types of filter Day 1 Day 2 P value Overall
0.001 <0.001 Day 3 <0.001
Types of water filter <0.001
0.001 <0.001 <0.001
Activated carbon versus Reverse 0.295 0.046 0.001 0.154
Osmosis <0.001 <0.001 0.007 <0.001
Activated carbon versus Others <0.001
Reverse Osmosis versus Others
All three types
* Mann-Whitney Test
7. DISCUSSION from water samples. This further strengthens evidence
The study was set up to investigate the effect of home found in other studies.2,3,9,15
WFS on fluoride levels in drinking water in Johor. This
study used tap water from the homes as distinct from It has been recognized that the water source used is of
laboratory fabricated deionised samples in an earlier critical importance.21 This study sampled tap water
paper.2,12 Most studies had used findings of the effect of from public water supplies and has the disadvantage of
WFS on fluoride levels to advise against unnecessary being less well controlled for other water constituents, but
prescription of fluoride supplements.10,13-15 This may provide a better reflection of the effects of filtration
study serves to identify effect of commonly-used WFS on in 'real-life' use. It may be suggested that complexation of
fluoride level and to address concerns in relation to the fluoride with high levels of aluminium and iron in
maintenance and expansion of our fluoridation unfiltered water will render some free fluoride ions still
programme. unavailable for detection.
Findings of this study showed that activated carbon (CA)
had no significant effect on fluoride level in drinking Readings taken over three consecutive days showed
water. Previous tests based on CA systems have given consistent fluoride readings before filtration, which
contradictory results. This finding concurs with results comply to the range of 0.4-0.6 ppm F (Quality Assurance
reported in several studies12-15 but is in contrast to Programme, MOH). This reflects on the well-controlled
others.2,3,8,9 It has been suggested that the design of the dosing of fluoride in public waters in the districts
carbon filter may be a factor affecting fluoride removal.2 concerned. Hach's colorimeter was used in this study, as
Variation in fluoride reductions by WFS is also dependent opposed to ion-specific electrode in other studies, due to
on differing pressure lines and regular maintenance of cost factor. However, stringent measures were taken to
equipment may also influence its efficacy in fluoride ensure accuracy and consistency in sampling and
reduction.3 analysis. Dental Surgery Assistants involved in routine
fluoride analysis were re-trained and calibrated prior to
For the purpose of analysis, this study had grouped CA the study by a senior technician from the supplier
filters using ion-exchange technology together with those company. All colorimeters used were serviced and
using distillation as 'WFS using other technologies'. They calibrated shortly before the sampling exercise.
were found to reduce fluoride content significantly but to
a lesser degree than reverse osmosis (RO). Astandard CA 8. CONCLUSION
system does not remove fluoride. A more complex The results of the study showed that the use of carbon
filtration system, which employs an ion exchange activated water filtration systems has no effect on fluoride
technology, adding potassium ions to the water can levels in drinking water. Water filtration systems using
remove 40-60% fluoride.20 Fluoride content of water Reverse Osmosis and other technologies significantly
filtered through WFS using RO was significantly reduced lower fluoride levels of drinking water. Optimally
in this study, with most filters totally removing fluoride fluoridated drinking water when subjected to home water
67
filtration systems that reduce fluoride significantly may 9. Brown MD, Aaron G. The effect of point-of-use
not offer the same caries preventive effect. water conditioning systems on community fluoridated
water. Pediatr Dent 1991;13:35–8.[Medline]
9. RECOMMENDATIONS 10. Ong YS, Williams B, Holt R. The effect of
Based on the findings in this and related studies, several domestic water filters on water fluoride content. B. Dent J
recommendations are proposed. The Oral Health 1996;181:59–63.
Division at district/state/MOH level may play a more 11. Tate W H, Synder R, Montgomery E H, Chan J
active role in the following: T. Impact of source of drinking water on fluoride
9.1 Work with local water agencies in educating and supplementation. J Paediatrics 1990; 117:419-421.
reassuring the public on quality of public water supplies. Robinson SN
9.2 Advise patients on suitable water filtration systems to 12. , Davies EH, Williams B. Domestic water
use and that some systems (using reverse osmosis and treatment appliances and the fluoride ion. Br Dent J.
distillation) will reduce the benefits of fluoride in 1991Aug 10-24;171(3-4):91-3.
drinking water. Buzalaf MA
9.3 Work with water quality agencies in certification of 13. , Levy FM, Rodrigues MH, Bastos JR. Effect of
contaminant removal for water filtration systems. domestic water filters on water fluoride content and level
Authorities need to ensure instructions on maintaining a of the public water supply in Bauru, Brazil. J Dent Child
system after purchase are provided and reference (Chic). 2003 Sep-Dec;70(3):226-30.
numbers of different companies for additional 14. Hideki Konno, Tsutomu Sato, Takatoshi
information on their products were provided. Neither Hollow-Fibre Membrane Filters nor Activated
Charcoal Filters Remove Fluoride from Fluoridated Tap
ACKNOWLEDGEMENT Water. JCDA www.cda-adc.ca/jcda June 2008, Vol. 74,
Many thanks to the team of dental surgery assistants who No.5
carried out water sampling and fluoride analysis. The Prabhakar AR
cooperation of the District Dental Officers and the dental 15. , Raju OS, Kurthukoti AJ, Vishwas TD. The
personnel who gave permission for their water filtration effect of water purification systems on fluoride content of
systems to be tested is acknowledged. Not forgetting the drinking water. J Indian Soc Pedod Prev Dent. 2008 Jan-
effort and expertise of Ms Wong Bau Li of Arachem Sdn Mar;26(1):6-11.
Bhd, who assisted in training of the sampling team. Last Gulson BL
but not least, our appreciation to Dr Tan Ee Hong, for her 16. , Sheehan A, Giblin AM, Chiaradia M, Conradt
role in literature search and data analysis. B The efficiency of removal of lead and other elements
from domestic drinking waters using a bench-top water
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Child 2000;67:350–4.[Medline] anions and cations. Iowa Dent J 1983; 69:37-39.
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recommendations for fluoride supplementation. J Dent water.com/UK/region/en_gb/content/FAQ/FAQ_00005
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5. Sharp D. A clean drink of water. Health 20.
Magazine, September, 1995, p 88 21. Personal communication. M.L. Wakeling,
6. Water Health Series: Filtration Facts. Boots Company Ltd
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68
14
Traumatic Abdominal Wall Hernia : Volume 10
A Johor Case Report
YJ Lee1; TT Yew1; AC Chan2 2012
1 Department of Radiology, Hospital Sultan Ismail, Taman Mount Austin,
81100 Johor Bahru, Johor, Malaysia.
2 Department of Surgery, Hospital Sultan Ismail, Taman Mount Austin,
81100 Johor Bahru, Johor, Malaysia.
Corresponding author: wall hernia that was initially thought to be an abdominal
wall haematoma, and was treated non-operatively. The
Dr Lee Yeong Ji, patient developed symptoms of bowel obstruction four
Department of Radiology, days later and urgent CT was performed followed by
Hospital Sultan Ismail, Taman MountAustin, immediate laparotomy.
Jalan Persiaran Mutiara Emas Utama,
81100 Johor Bahru, Johor, Malaysia CASE REPORT
Phone: +607-3565000 ext. 2611 A 21-year-old male was brought to casualty department 3
Fax: +607-3565034 days after a road traffic accident. His motocycle handle
Email: [email protected] bar had impaled over the right side of his abdomen. Prior
to admission, he presented himself to a local hospital for
Short title: traumatic abdominal hernia right abdominal swelling and was treated for abdominal
hematoma. However he later complained of generalized
SUMMARY abdominal pain, vomiting, shortness of breath and chest
pain which subsequently brought him to our casualty
Most reported cases of traumatic abdominal wall department.
herniation result from blunt impact particularly handlebar On examination, he was tachypnoeic, tachycardic and
injuries. The diagnosis is often made on physical febrile. There was crepitus felt over the chest wall and
examination or abdominal computed tomography (CT). right flank. His abdomen was distended with tenderness
We report a 22-year-old man with anterior abdominal over right iliac fossa region. A 4 x 5cm swelling was
wall swelling following blunt handle bar injury to the palpated over right anterior abdomen. There were no
abdomen. This patient was initially thought to have an other injuries.
abdominal wall haematoma. However he developed A CT scan of the thorax, abdomen and pelvis revealed an
symptoms of abdominal pain and vomiting 4 days later. anterior abdominal wall defect (5cm wide and 7cm
An urgent CT was performed which confirmed the caudocranial diameter) just lateral to the right rectus
diagnosis of traumatic abdominal hernia. abdominis muscle at right iliac fossa region. There was
Intraoperatively, the herniated small bowel loops were herniation of small bowels loops through the wall defect
gangrenous with multiple perforations leading to bowel with evidence of rupture of herniated bowel segment
contents contamination in the abdomen, chest and neck (Figure 1). There was also extensive subcutaneous
region. This case highlights the need for a high index of emphysema involving the right abdomen, thorax and
suspicion for traumatic herniation in patients who sustain neck (Figure 2). Other solid organs were unremarkable.
low-velocity blunt abdominal wall trauma. No free fluid per abdomen or pneumoperitoneum.
Keywords: handlebar injury, blunt, traumatic, abdominal, Emergency exploratory laparatomy was performed on
hernia the same day. A large full thickness defect found in the
anterior wall abdominal muscle (6cm x 8cm) from right
INTRODUCTION iliac fossa to right hypochondriac region, with herniation
Traumatic herniation of the abdominal wall is a rare of strangulated small bowels. A 40cm length of small
occurrence following blunt abdominal trauma with only bowel was gangrenous and perforated at 45cm from the
about 50 reports worldwide1. Most herniations are ileocaecal junction, leading to bowel contents
diagnosed at presentation by physical examination or on contamination in the abdominal wall, chest wall, neck
abdominal computed tomography (CT), which mostly and inguinal region. There was also a mesenteric
proceeded to immediate laparotomy and repair because hematoma noted the right lower pelvic region. A bowel
of the high incidence of associated intra-abdominal resection-anastomosis was done and the defect was
injury. We report a case of traumatic anterior abdominal repaired. The patient's recovery was uneventful and was
discharged on the 24th day postoperatively.
69
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Jurnal Kesihatan Johor Volume 10 2012
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