MINUTES OF PHARMACY & THERAPEUTIC COMMITTE MEETING 04/2023
KPJ BANDAR MAHARANI SPECIALIST HOSPITAL
DATE : 30.11.2023 (Thursday)
TIME : 1.30 -2.30 pm
VENUE : Board Room, Level 4, KPJ Bandar Maharani Specialist Hospital
Present:
Dr. Ruhaila Abdul Rahim(Dr.RAR)
En Prathaban Sevaraman (PS)
Dr. Norfaizal Abd Latiff (Dr.NFAL)
Dr. Wong Jia Jia (Dr.WJJ)
Dr. Norhayati Che Soh (Dr.NHCS)
Dr. Md Mujait Kasman (Dr.MMK)
Dr. Abu Bakar Mohd Supaat (Dr.ABS)
Dr. Maizatul Rahman Selamat
(Dr.MRS)
Dr Siti Rasidah bt Ibrahim (DSRI)
Pn. Siti Nor Fazira Saleh (SNFS)
Pn. Norfaizah Bachok (NFB)
Pn. Ruzyanah Amir (RA)
Nursyafiqah Moideen (NSM)
Pn. Siti Suhailee Binti Merjuki
Absent with apology
Dr. Tan Wei Jing (Dr.TWJ)
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Consultant Physician & Rheumatology cum Chairman
Chief Executive Officer
Consultant Physician, cum Chairman of Hospital
Infection and Antibiotic Control Committee (HIACC)
Consultant Paediatrician cum Head of Paediatric
Consultant O&G cum Head of Obstetrics And
Gynecologist
Consultant Orthopaedic cum Chairman of Mortality and
Morbidity Review Committee (MMRC)
Consultant Anaesthetist cum Head of Anaesthetist
Consultant General Surgeon cum Chairman of Surgical
& Medical Intervention Committee
Medical Officer In Charge
Chief Nursing Officer
Chief Pharmacist cum Secretary of Committee
Laboratory Manager
Pharmacist
Infection Control Nurse
Consultant Orthopaedic cum Chairman of Peer Review
Ethics Committee, Head of Orthopaedic
 ACTIO
NO MATTER DISCUSS N BY

1 OPENING REMARKS
Welcoming remark by Chairman to all present Info

1.1 CONFIRMATION OF PREVIOUS MINUTES

Minutes of previous meeting held on 26.9.2023 were taken as read and confirmed as true record Info
with no amendment.
RA proposed to confirm the minutes, seconded by DR.NHCS

MATTERS ARISING

OP & IP KCIS medication label processes– Average time to print medication’s label is ranging NFB
from more than a minute just to print out 2-3 labels. IT Services yet to resolve this problem.

Dr WJJ suggested to come out with a monthly statistic on KCIS problem to be settled by IT and
to be presented on next PTC meeting

2 2.1 Updates on SLOW MOVING & SHORT EXPIRY ITEMS – As at 15.11.2023

No Drug Expiry Qty UOM Info

Item Code
1 51002069 Micardis 80/12.5mg tab Jan-24 1 Tab
2 51002762 Probitor 20mg Tab Mar-24 93 Tab
3 51002725 Janumet XR 100/1000mg tab Mar-24 28 Tab
4 51200795 Arixtra 2.5mg/0.5mg Inj Mar-24 34 Inj
5 51200073 Epilim 400 mg Inj Mar-24 3 Inj
6 21002174 Neulin SR 125mg tab (Theophylline) Mar-24 156 Tab
51200659 Durotocin Inj 100mcg/ml Apr-24 3
7 Inj
8 51201042 Zithromax 500mg/5ml Inj Apr-24 2 Inj
9 51760004 Dormicum 7.5mg tab (Midazolam) Apr-24 86 Tab
10 51002263 Bisoprolol 2.5mg tab (Bisohexal) May-24 2x100 Tab
11 51001880 Janumet 50/500mg tab Jun-24 141 Tab
12 51000474 Tenormin 50mg tab Jun-24 9x28+23 Tab
13 51002180 GTN 500mcg tab (Myonit) Jun-24 6x30 Bot
51650456 Physiogel A1 Cream Jun-24 6
14 Bot
51650628 Supirocin Ointment Jun-24
15 3 Ea
16 51001144 Zocor 40mg tab Jul-24 168 Tab
17 51200224 P-trovite Inj Jul-24 4 Inj
18 51002390 Twynsta 40/10mg tab Aug-24 1x30 Tab
19 51002142 Coveram 5/5mg tab Aug-24 1x30 Tab

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 20 51002515 Cozaar XQ 5/50mg tab Aug-24 3x3+11 Tab
21 51002717 Rosuvastatin 20mg tab Sep-24 79 Tab
22 51002069 Micardis 80/12.5mg tab Sep-24 5 Tab
23 51002388 Twynsta 80/10mg tab Sep-24 16 Tab
24 51201285 Kisan 10 mg Inj Sep-24 9 Inj
25 51000195 Janumet 50/1000mg tab Oct-24 277 Tab
26 51002725 Janumet XR 100/1000mg tab Oct-24 112 Tab
27 51002999 Jardiance Duo 5/500mg tab Dec-24 4 Tab
28 51002999 Jardiance Duo 5/500mg tab Dec-25 120 Tab
Resolutions:
Drug evaluation form will be issued to extremely slow moving & non-life saving item.
Consultant/ Medical Officer has to give cooperation to prescribe the medication if applicable.

2.2 Updates on Formulary Addition / Deletion

2.2.1 New Formulary Addition Request 15 September – 15 November 2023

No Drug Indication Requester NFB

1 CRESPINE GEL ONE DEGENERATIVE CARTILAGE DR SHAHRUN

2ML INJ + PRP NAWAL

2.2.2 Formulary Deletion / Upon request item only

1. NIL

Resolutions:
All new formulary addition/ deletion/upon request only medication above has been approved by
the committee.

3.1 Statistic of Medication Error Analysis – Dispensing / Administration Error (2015-

3 Info
2023)- as at 15 November 2023

2015 2016 2017 2018 2019 2020 2021 2022 2023

Medication Error 1 1 5 1 1 0 1 1 1

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 • On 10th November 2023, Doctor prescribed Patient own medication :
1. T. Entresto 100 mg ON PRN
2. T. Entresto 200mg OD PRN
3. T.Plavix 75mg OD PRN
• However, there is no indication for PRN order and staff nurse administered the
medications to patient without notice the PRN on the manual medication chart and on
the label
• This was classified as Administration error under Nursing Services

Resolutions:

CORRECTIVE ACTION:

1) Prescriber
All PRN orders should have the indication for PRN – This is to be fulfilled by the prescriber
No verbal withhold of medication to the Staff Nurse in the ward as they might be forgotten. All withhold
medication should be written clearly in the patient’s case note for everyone reference.

2) Pharmacy Staff
Pharmacy staff has to ensure all PRN orders prescribed with the indication on the manual medication
chart/ in the Inpatient KCIS before proceeding to prepare the label.

3) Staff Nurses
Medication with Incomplete PRN instruction (no indication on the label/ in the medication chart/ Inpatient
KCIS) should not be administered to the patient until they got confirmation from the prescriber.
Info
3.2 Adverse Drug Reaction (ADR) Report January to November 2023
Reported
Report Drug Patient Treatment Patient
NO MRN Reported By
Occurred Involved Reaction/ ordered Outcome
symptoms

Piriton inj
&
Pethidine Fully
1 13.01.2023 62958 Urticarial Dexameth Dr Firdaus
50mg inj Recovered
asone inj
given

Sulfasalazi
Itchiness & Withhold Fully
2 24.02.2023 77271 ne 500mg Dr Ruhaila
rashes the drug Recovered
tab

Generalised Hydrocorti
Cravit body rashes sone inj & Fully
3 13.03.2023 77684 Dr Ruhaila
750mg tab and itchiness Piriton inj Recovered
+ urticarial given

Developed
facial flushing Hydrocorti
Ciprobay Fully
4 17.03.2023 62978 during Iv sone inj Dr Ruhaila
400mg inj Recovered
Ciprobay given
infusion

Skin rashes
Rocephin Fully
5 31.03.2023 3554 on abdomen No record Nursyafiqah
1gm inj Recovered
& back

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 Reported
Report Patient Treatment Patient Reported
NO MRN Drug Involved
Occurred Reaction/ ordered Outcome By
symptoms

Prochloperazine IM
Bena syrup,
injection & Oculogyric Fully
6 04.05.2023 79393 Iv fluids Dr Yia
Metoclopramide Crisis Recovered
given
10mg tab

Hydrocortis
Rashes at both
7 16.06.2023 Omnipaque Inj one 100mg Recovering Dr Nasazli
cheek
inj
Fully
8 5.7.2023 81265 Rocephin 1gm inj Swollen eyes IV Piriton Dr Rahman
recovered

Dyskinesia-
unable to open
Bena syrup
mouth fully
15ml stat , Fully
9 9.7.2023 35444 Metoclopramide Inj and Dr Ruhaila
Dormicum recovered
generalised
5mg inj Stat
body cramp &
restless

Urticarial after Piriton tab,

Fully
10 12.7.2023 Arcoxia 90mg tab 1 day of prednisolon Dr Yia
recovered
Arcoxia dose e tab

Immediately
felt uneasy, Stop Fully
11 30.07.2023 22207 Metoclopramide inj Dr Yia
anxious, medication recovering
agitated

Throat
Stop Fully
12 19.9.2023 80665 Bioflor capsule tightness, Dr Yia
medication Recovered
burning & pain

Redness & Withold

itchy rashes drug, IV Fully
13 23.10.23 56580 Augmentin Dr Ruhaila
bilateral hands Piriton recovered
& back given

IV
Skin rashes &
Hydrocortis Fully
14 30.10.2023 Jan-27 Dynastat itchiness at Dr Tan
one & IV recovered
both thighs
Piriton stat

Developed
localized
Remove
swelling &
branula, IV Fully
15 16.11.2023 82596 Iomeron rashes at Dr Ruhaila
Hydrocortis recovered
branula site
one given
after contrast
injection

Note: Total ADR reported from January to November 2023 were 15 cases

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 Resolution:

ADR report: All consultant encourage to report all ADR if it is occurred in our Hospital. ADR
Form is assessable at ward level or in the Quality document folder or can directly get the hard
copy form at Pharmacy Services.

4 IPSG 3 and KCEA (Know, Check, Explain and Ask) Audit Q3/2023 Info

4.1 IPSG 3 Audit Q3/2023 (audit result)

4.2 KCEA Audit Q3/2023 (Outpatient & Inpatient)

GRAPH 1 : KCEA AUDIT Q3/2023 (OUTPATIENT)

150
100 91
100 84 81

50
10 19
0 9
0
KNOW CHECK EXPLAIN ASK

SC PC NC

GRAPH 2 : KCEA AUDIT Q3/2023 (INPATIENT)

100 91 90 87
83
80
60
40
17 13
20 9 10
0
KNOW CHECK EXPLAIN ASK

SC PC NC

Resolutions:

Both, IPSG & KCEA Audit targets audit were achieved for Q3/2023. To continue monitoring the
compliance towards IPSG3 & to prevent medication errors from occurring in our hospital.
5 Info

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 ANALYSIS AND INTERPRETATION OF ANTIBIOTIC USAGE & RESISTANT
(based on antibiogram report) July to September 2023 (Q3/2023)

2500
2031
2000

1500
1189
1000
691 489
414
500 324
206 170 130
51 35 25 22 18 11 5 3 1
0

5.1 Cefuroxime inj, Ceftriaxone inj, Tazocin Inj, Unasyn Inj, & Amoxicilin + Clavulanic Inj
were the top 5 highest of antibiotic usage in Q3/2023
5.2 Total specimen registered: 1366 specimens
Total positive growth= 284 specimens (20.79%)
5.3 Cephalosporin use VS Resistant in Cephalosporin for Escherichia Coli (E.Coli) &
Klebsiella Pneumoniae : Cephalosporin use (Cefuroxime / ceftriaxone) in this hospital for the
treatment of E.Coli is acceptable while for Klebsiella Pneumonia, it has to be based on Culture
& Sensitivity result since the resistant were 22.1% (more than 20% Resistant).

5.4 Cephalosporin use Vs the selection of ESBL-Producing Enterobacteriaceae

( ESBL – producing E.Coli, ESBL-producing Klebsiella Pneumoniae, ESBL-producing
Enterobacter species & other ESBL- producing Enterobacteriaceae): Cephalosporin use in
this hospital towards the selection of ESBL-Producing Enterobacteriaceae (ESBL– producing
E.Coli, ESBL-producing Enterobacter species & other ESBL- producing Enterobacteriaceae
still need to be monitored since all alert organism cases detected/ isolated was not originated
from our hospital. But it is good for the Consultant to strictly use Rocephin (Ceftriaxone) as the
first line if it is really indicated.

5.5 Quinolones use VS Resistant Quinolones for E.Coli, Klebsiella pneumonia &
pseudomonas Aeruginosa :
5.5.1 Quinolones use in this hospital towards the treatment of E.Coli as the first line treatment
was not accepted since the Resistant towards Ecoli was 29.6% in Q3/2023.
5.5.2 Quinolones (ciprofloxacin) used in the treatment of Klebsiella is also not recommended
since the resistant towards Klebsiella was 16.3% in Q3/2023 and treatment should be based
on Culture & sensitivity result.Quinolones can be used as the first line treatment for
Pseudomonas since the resistant was around 3% Q3/2023.

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 Quinolones (moxifloxacin) use in the treatment of E.Coli, Klebsiella and pseudomonas has to
be further investigated since the number of samples is only 1-3 samples per quarter.
5.5.3 Quinolones use Vs the selection of MRSA: Quinolones use in this hospital
towards the selection of MRSA still need to be monitored since MRSA cases detected/ isolated
was not originated from our hospital
5.6 Carbapenems use Vs Resistant Carbapenems for Pseudomonas Auroginosa &
Acinetobactor baumanii : Carbapenem used in this hospital (Q3/ 2023) for the treatment of
Pesudomonas & Acinetobactor as the first line treatment are recommended and acceptable
since the % of resistant towards Carbapenem for both Pseudomonas was 3% and
Acinetobactor was Zero%
5.7 Carbapenems use Vs the selection of CRE and Stenotrophomonas maltophilia: We
cannot conclude the Carbapenem use in this hospital with the selection of CRE &
Stenotrophomonas maltophilia
5.8 Ampicillin-sulbactam (Unasyn) use Vs Resistant in Acinetobactor baumanii: Unasyn
used in this hospital towards the treatment of Acinetobactor Baumanii for Q3/2023 is
acceptable since the % of resistant was 0%
5.9 Ampicillin-sulbactam (Unasyn) use versus the selection of MDR Acinetobacter
species & MDR Acinetobactor baumanii: We cannot conclude the Unaysn use in this
hospital with the selection of MDR Acinetobacter species & MDR Acinetobactor baumanii

Conclusion/ Resolution
• The top 5 Antibiotic Used In Q3 20223 : Zinacef inj, Rocephin inj, Amoxicilin +
Clavulanic Inj, Unasyn Inj & Tazocin Inj
• Cephalosporin use (Cefuroxime / ceftriaxone) in this hospital for the treatment of
E.Coli is acceptable while for Klebsiella Pneumonia to be used based on C&S results
• Ceftriaxone used in this hospital may leads to significant increase in ESBL E.Coli
isolates/ ESBL Klebsiella isolates in the general population
• Quinolones (Ciprofloxacin) use in the treatment of Klebsiella is NOT
recommended while it is acceptable to be used as first line for Pseudomonas
(Ciprofloxacin)
• More data/ samples needed for Moxifloxacin Resistant and sensitivity report in
order to conclude the recommendation treatment towards E.Coli, Klebsiella and
Pseudomonas.
• Overall Antibiotic Usage and Resistance (Q3/2023) pattern in KPJMSH is still
acceptable

Info

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 6 Use of Dangerous Drugs @ psychotropic Drugs and Poison update

6.1 Psychotropic Drugs maximum duration that can be supplied to patient according to
prescriber
Doctor Maximum Duration of psychotropic can be
dispensed/ supplied to Patient (Outpatient / TTA)

1 Medical Officer 3-7 days

2 Psychiatrist Consultant No limit

3 Other Consultants 30 days

6.2 Updates for Import Permit Items as at 15.11.2023

Qty
Permit
Approve Requester-
No Item Expiry Consultant
Remarks
d for
date
Purchase
1 Acyclovir 3% eye ointment 14.4.2024 10 tube Dr Fadzlina
Sodium Bicarbonate 650 50 000
2 17.04.2024 Dr Yia
mg tab tab
3 Thiamine injection 6.6.2024 20 x 6's Dr Yia

4 Dantrolene 20mg inj 13.9.2024 60 vials Dr Abu

Lugol's oral solution 100
5 13.9.2024 10 bottles Dr Ruhaila
ml
10 x300’s
8 Hydroxyzine 25mg tab 14.9.2024 Dr Yia
tab
9 Diltiazem Hcl 2% ointment 21.02.2024 200 tubes Dr Ang
Phenobarbitone 200
10 8.2.2024 100 vials Dr Wong
mg/ml inj
Nitrofurantoin 100 mg tab
11 18.12.2023 1500 tabs Dr Norfaizal MAL19984749ACRZ
(Niftran)
Suxamethonium chloride
12 18.12.2023 200 vials Dr Abu MAL06061674ARZ
100 mg/2ml inj
13 Tuberculin PPD 0.1 ml Inj 17.3.2024 100 vials Dr Ruhaila
100
14 Lignocaine 10% spray 2.2.2024 Dr Tahir valid 3 months
bottles

Resolution:
All Doctors have to follow the maximum duration of prescription for Psychotropic supply
to patients. Psychotropic drugs are prohibited for Courier Delivery.

All import permit items will be monitored by Pharmacists and reporting on the ADR
related to the use of Import permit item has to be done by the Consultant if they
encountered it occur to patient.

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 7 Analysis of Prescription Percentage & Leakages Jan to October 2023

Prescription %
100 81 86.3 81.2
77 76 80.5 80.1 77.4 80.5 79.5
80
60
40
20
0

The prescription percentage by month in 2023 were more than 70%.

Resolutions:
All Consultant have to support Hospital Drug Formulary and prescribed the medication &
advice the patient to purchase/ to get their medication in our hospital.

8 Statistic on Pharmacy Intervention Jan to Oct 2023

There were total of 66 Pharmacy interventions recorded from January to October 2023.

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 8.1 Incomplete Prescription

Total number of interventions for incomplete prescription were 66 cases.

Number of Incomplete Frequency, duration were the top 2 highest interventions that Pharmacy
Staff found on Doctor’s order (Outpatient prescription & inpatient prescriptions from January to
October 2023)

8.2 Inappropriate Regimen

Total number of interventions recorded Zero case in 2023.

Resolution:

Consultant & Medical Officer need to be extra careful when entering medication in KCIS or
writing on the manual prescription. Pharmacy staff have to call Consultant or Medical officer in
order to have the complete frequency/ duration/ dosage of treatment for patient.

In view of wrong Medication been entered to the wrong patient MRN, recorded Zero case for
this quarter

9 Other matters

9.1 Inpatient Kcis (IP KCIS) Utilisation Statistic January to Oct 2023.
Info

Data presented was a 10 months analysis of IP KCIS usage vs manual prescription

(medication chart) in our hospital.

Resolution:

All Consultant and Medical Officers are fully encourage to use IP KCIS 100% (except for POM-
Own medication) in order to avoid Pharmacy staff to transcribe the prescription into KCIS. This
is a requirement under MSQH 6th Standard.

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 9.0 Other Matters –
9.1 IP KCIS ordering – Problem in medication ordering
1) PRN DOSE IP KCIS –
Prescriber should write the indication on the medication chart / IP KCIS

Resolution: All Consultants and Medical Officer has to key in the indications (IP KCIS order)
for PRN order as this is to indicate when the PRN medications should be administered.

9.2 Paxlovid tablet (Usage report)

1. August 2022 – 31st Dec 2022- total 18 patients

2. Jan to May 2023- total 20 patients been prescribed
with paxlovid tablet
3. June to November 2023 – 10 patients only
Balance at Pharmacy = 10 boxes (short exp: feb/2024)

Resolution: To follow the current flow of prescribing for Paxlovid tablet.

9.3 Long Term Medications – Under PMCare

Long term medication for patient under GL PMCare will only be supplied once approved
/confirmed with Business Office staff

The meeting adjourned at 230PM.

Prepared By Approved By

Original has been signed Original has been signed

………………………… ………………………….
Pn Norfaizah Bt Bachok Dr. Ruhaila bt Abd Rahim
Secretary of P&T Committee Chairman of P&T Committee

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