INTRODUCTION

A medication error is defined by the National Coordinating Council for

Medication Error Reporting and Prevention (NCC MERP) as “any preventable event
that may cause or lead to inappropriate medication use or patient harm.” Medication
safety is a complex responsibility that involves multiple professionals and healthcare
resources. As front-line members of the medication dispensing team, pharmacy
technicians can directly impact medication safety. Based on the involuntary incident
reporting by 120 hospitals of the Health Ministry in 2017, there was 86 incidents
reported due to the medication administration errors.

Essentially, a medication error is a failure in any step of the medication-use

process, including medication formulation and manufacturing, prescribing,
administering, or monitoring, that can potentially harm a patient. Most commonly
error is the administration error of the medication; such as, administer the wrong
dose, wrong dosage form, wrong route, wrong frequency, wrong time of day, or
wrong duration of drug therapy. Due to this, pharmacist assistants should play their
role in reducing these medication administration errors.

BACKGROUND ISSUES
Some medication administration errors may result in patient morbidity
or mortality. In a review of 91 direct observation studies, investigators estimated
median error rates of 8% to 25%, depending on the measurement strategy and
whether or not timing errors were included. Intravenous administration was prone to
have even more medication administration error, with an estimated median rate
which include timing errors ranging from 48% to 53%. One study estimated a 73%
probability of at least one error occurs during a single given intravenous medication
administration. The most common type of error was wrong time of administration,
followed by omission and wrong dose, wrong preparation, or wrong administration
rate. A review of 36 studies found that error rates ranging from 2% to 33% with
dosage errors, omission errors, and wrong medication are the most common types
of administration errors. (15)

In Malaysia, out of 1000 prescription administered in 2015, the percentage of

wrong time/frequency was 0.043%, wrong drug 0.026%, wrong dose 0.017% and
wrong route 0.017% which are relatively low. However, for 2016 only 0.0068% of
wrong time/frequency for wrong time/frequency with no reported cases for wrong
drug, wrong dose and wrong route. The main contributing factor of administration
error is lower competency level of staff (66.67%). (14)

Therefore, in order to reduce the number of administration error refresher

training on reading prescription in full, proper verification of frequency of drug dosing,
annual competency assessment, besides monitoring and nursing audit by unit
managers were conducted. The responsibilities of pharmacy technicians are limited
and must be accomplished under the direct supervision of a pharmacist. However,
the roles and responsibilities of technicians will likely expand as pharmacists shift
their time and efforts toward direct patient care. (14)

CURRENT ISSUES REGARDING THE ROLES OF PHARMACY ASSISTANTS

1. Sciences Vol. 16, No Malaysian Journal of Pharmaceutical. 1, 1–21 (2018)

2. Workforce and Career Options for Pharmacy Assistants. (December 2004)
3. Community Pharmacy Benchmarking Guidelines. Second edition. (2015)
4. Aronson JK. Medication errors: EMERGing solutions. Br J Clin Pharmacol.
2009;67(6):589-91
5. Gabriel MH, Swain M. E-Prescribing Trends in the United States. ONC Data
Brief, no.18. Washington, DC: Office of the National Coordinator for Health
Information Technology; July 2014.
6. Aronson JK. Medication errors: what they are, how they happen, and how to
avoid them. QJM. 2009;102(8):513-2
7. Seidling HM, Kaltschmidt J, Ammenwerth E, Haefeli WE. Medication safety
through e-health technology: can we close the gaps? Br J Clin Pharmacol.
2013;76(Suppl 1):i-iv
8. Beckman A, Bernsten C, Parker MG, Thorslund M, Fastbom J. The difficulty
of opening medicine containers in old age: a population-based study. Pharm
World Sci. 2005;27:393-398. doi:10.1007/s11096-005-7903-z. [PubMed]
[CrossRef] [Google Scholar]
9. Atkin PA, Finnegan TP, Ogle SJ, Shenfield GM. Functional ability of patients
to manage medication packaging: a survey of geriatric inpatients. Age Ageing.
1994;23:113-116. [PubMed] [Google Scholar]
10. Philbert D, Notenboom K, Bouvy ML, van Geffen EC. Problems experienced
by older people when opening medicine packaging [published online
September 12, 2013]. Int J Pharm Pract. doi:10.1111/ijpp.12070 [PubMed]
[CrossRef] [Google Scholar]
11. CHEAH MENG FEI (2018) Public perception of the role of pharmacists and
willingness to pay for pharmacist-provided dispensing services: A cross-
sectional pilot study in the state of Sabah, Malaysia, Malaysian Journal of
Pharmaceutical Science.
12. Pharmacy Technicians’ Attention to Problems With Opening Medicine
Packaging, J Pharm Technol. 2014 Feb; 30(1): 3–7.
13. AR Abdul Aziz PhD; Law CL; Nor Safina AM (2017) Case Study On The
Management of Medication Errors and Near Misses: Malaysia Perspective.
International Journal of Latest Engineering Research and Applications
(IJLERA) ISSN;2455-7137
14. Medication Administration Errors. (2019). Retrieved 11 December 2019, from
http://psnet.ahrq.gov/primer/medication-administration-errors
15. Doris George, Amar-Singh HSS, Azmi Hassali. (2018) ‘Medication Error
Reporting: Underreporting and Acceptability of Smartphone Application for
Reporting among Health Care Professionals in Perak, Malaysia’, Cureus,
10(6) [online].

Available at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6075636/ (Accessed: 12
December 2019)

16. Samsiah A, Othman N, Jamshed S, Hassali MA (2016) Perceptions and

Attitudes towards Medication Error Reporting in Primary Care Clinics: A
Qualitative Study in Malaysia. PLoS ONE 11(12): e0166114.
doi:10.1371/journal. pone.0166114
REFERENCES

1. Doris George, Amar-Singh HSS, Azmi Hassali. (2018)

‘Medication Error Reporting: Underreporting and
Acceptability of Smartphone Application for Reporting
among Health Care Professionals in Perak, Malaysia’,
Cureus, 10(6) [online].

Available at:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6075636/ (Accessed: 12
December 2019)

2. Medication Administration Errors. (2019). Retrieved 11 December 2019, from

http://psnet.ahrq.gov/primer/medication-administration-errors
3. Beckman A, Bernsten C, Parker MG, Thorslund M, Fastbom J. The difficulty
of opening medicine containers in old age: a population-based study. Pharm
World Sci. 2005;27:393-398. doi:10.1007/s11096-005-7903-z. [PubMed]
[CrossRef] [Google Scholar]
4. Atkin PA, Finnegan TP, Ogle SJ, Shenfield GM. Functional ability of patients
to manage medication packaging: a survey of geriatric inpatients. Age Ageing.
1994;23:113-116. [PubMed] [Google Scholar]
5. Philbert D, Notenboom K, Bouvy ML, van Geffen EC. Problems experienced
by older people when opening medicine packaging [published online
September 12, 2013]. Int J Pharm Pract. doi:10.1111/ijpp.12070 [PubMed]
[CrossRef] [Google Scholar]
6. Pharmacy Technicians’ Attention to Problems With Opening Medicine
Packaging, J Pharm Technol. 2014 Feb; 30(1): 3–7.

7. Samsiah A, Othman N, Jamshed S, Hassali MA (2016) Perceptions and

Attitudes towards Medication Error Reporting in Primary Care Clinics: A
Qualitative Study in Malaysia. PLoS ONE 11(12): e0166114.
doi:10.1371/journal. pone.0166114

8. Sciences Vol. 16, No Malaysian Journal of Pharmaceutical. 1, 1–21 (2018)

9. Workforce and Career Options for Pharmacy Assistants. (December 2004)
10. Community Pharmacy Benchmarking Guidelines. Second edition. (2015)
11. Aronson JK. Medication errors: EMERGing solutions. Br J Clin Pharmacol.
2009;67(6):589-91
12. Gabriel MH, Swain M. E-Prescribing Trends in the United States. ONC Data
Brief, no.18. Washington, DC: Office of the National Coordinator for Health
Information Technology; July 2014.
 PHD 215

PHARMACOTHERAPY OF THE CARDIOVASCULAR AND

RESPIRATORY SYSTEMS

REDUCING MEDICATION ADMINISTRATION ERROR: ROLE

OF PHARMACIST ASSISTANT

NAME NO. MATRICS

ADLAN SHAUQI BIN KHAIRUN ANUAR 2018290596
NUR IRWANA AFIERA BINTI RAZALY 2018429044
NUR IZZAH IZZATI BINTI RUSLI 2018250202
NUR MAS’DIANA BINTI IBRAHIM 2018291304
NUR SYAZRINA BINTI SAPIEI 2018290532
NOR ASYIRIN BINTI ZAINUDDIN 2018240634
NURSYAFIQAH BINTI MASROM 2018290442
NURUL ALIAH BINTI ZAINAL AZAMAN 2018428844
NURUL FARHANI BINTI JAHARI 2018294928
NURUL HUSNA BINTI ISMAIL 2018254042