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November 2017
Medication Safety Bulletin
The Medication Safety Bulletin (MSB) is published by the Medication Safety Committee HAHO (MSC) biannually (May and Nov) as an educational
publication to share issues related to medication safety. Please refer to the HA Risk Alert (HARA) for sharing of medication incident cases reported in HA.
Inside this issue:
Update of Medication Safety Guidelines issued by MSC
Neuroleptic malignant syndrome: a rare adverse drug reaction
Risk of hepatitis B reactivation
Hong Kong West Cluster Sharing on Continuous Quality Improvements on Near Miss
his year’s Medication Safety Forum would be held on 6 December 2017 (Wednesday) at Lecture
Theatre, HA Building. With the theme Near Miss Management – Reporting, sharing and learning,
we wish to promote the culture of Near Miss Management on reporting (at department level), sharing (at
hospital level) and learning (at staff level). Similar to previous years, continuous improvement measures in
medication safety would also be shared by staff from various hospitals. We hope you would enjoy the time
sharing and learning together!
Update of Medication Safety Guidelines issued by MSC
he MSC has recently reviewed and updated the following HA Guidelines, with endorsement by the Drug
Management Committee (DMC).
1. The HA Guideline on Look-Alike Sound-Alike Medications is a new guideline formulated from
the Safety Solutions on Look-Alike Sound Alike Medications, which aims to suggest measures to
mitigate risks associated with look-alike sound-alike medications (LASA).
2. The Safety Solutions on High Alert Medications (previously known as Safety Solutions on High Risk
Medications) suggests updated potential risks and possible system improvement strategies regarding
high alert medications. This document serves to supplement guidelines and recommendations issued by
the MSC.
The descriptions of the 9 categories of high alert medications are also updated as follows:
HA List of High Risk Medications (2010)
HA List of High Alert Medications (2017)
Concentrated electrolytes
Concentrated electrolytes
Cytotoxic chemotherapy
Chemotherapeutic agents (parenteral and oral)
Drugs commonly associated with drug allergies
e.g. penicillin, aspirin, NSAIDs
Drugs commonly associated with drug allergies
(e.g. penicillin, aspirin, NSAIDs)
Vasopressors and inotropes
Vasopressors and inotropes
Anticoagulants including heparin
Anticoagulants (parenteral and oral)
Neuromuscular blocking agents
(e.g. atracurium, pancuronium)
Neuromuscular blocking agents
(e.g. atracurium, rocuronium)
Oral hypoglycaemics
Oral hypoglycaemics
Narcotics (e.g. fentanyl)/opioids
Narcotics (e.g. fentanyl) and opioids
Guidelines and recommendations issued by the MSC can be accessed in HA intranet via below links:
Via hadf.home - http://hadf.home/Document-Form-and-Publication/Documents-and-Forms
Via cpo.home - http://portal.home/sites/cpo/committees/msc/guidelines/default.aspx
Online version of this Bulletin is available in HA intranet website (ha.home)
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Medication Safety Bulletin Vol.15
Neuroleptic malignant syndrome: a rare adverse drug reaction
euroleptic malignant syndrome (NMS) is a rare adverse reaction to
antipsychotic agents and, less commonly, to dopamine antagonists.
It leads to autonomic dysfunction and can be fatal if not recognised
The incidence of NMS is estimated at 0.01%–0.02% of patients
treated. Signs and symptoms of NMS include severe elevation of body
temperature, muscle rigidity, sudden change in mental status, and a
depressed level of consciousness.
The syndrome is more commonly associated with traditional antipsychotics such as haloperidol, fluphenazine and chlorpromazine; but it can
also occur with newer, non-traditional antipsychotics such as quetiapine,
risperidone and olanzapine.
Several clinical, systemic, and metabolic factors have been correlated
with the incidence of NMS, including agitation, dehydration, restraint, preexisting abnormalities of CNS dopamine activity or receptor function, and
iron deficiency. Nearly all case series of NMS patients have reported physical
exhaustion and dehydration prior to the onset of NMS. Elevated
environmental temperature has been proposed as a contributing factor in
some series.
Healthcare professionals should be familiarised with the clinical Elevated body temperature is one
features of NMS and vigilant in detecting early signs. Primary management of of significant symptoms for early
NMS lies in prevention through conservative use of antipsychotics, reduction recognition of NMS
of risk factors, early diagnosis, prompt discontinuation of offending
medications, and medical management. Although the onset of NMS can occur at any time during exposure to an
implicated drug, most cases arise when the drug is first started or when the dosage is increased or the drug is
rapidly titrated. It is prudent to verify with patients for any previous reactions to these drugs before prescribing,
dispensing and administration.
Any history of extrapyramidal symptoms should be investigated and documented in the patient record.
Healthcare professionals are also encouraged to report any adverse events caused by drugs to HA (via AIRS) and
Department of Health (via ADR Reporting webpage www.drugoffice.gov.hk/adr.html).
ADR Online Reporting
Drug Office, Department of Health
ADR Reporting Template
Available in AIRS
Page 3
Risk of hepatitis B reactivation
n 2016, the US Food and Drug Administration (FDA) issued a drug safety alert regarding the risk of
hepatitis B virus (HBV) reactivation in any patient who has a current or previous infection with HBV
and is treated with certain direct-acting antivirals (DAAs) for hepatitis C virus.
List of Direct-Acting Antivirals (DAAs)
*Not registered in Hong Kong
Brand name
Viekira Pak
Viekira Pak XR*
Active ingredient (s)
Sofosbuvir and Velpatasvir
Ledipasvir and Sofosbuvir
Dasabuvir, Ombitasvir, Paritaprevir and Ritonavir
Dasabuvir, Ombitasvir, Paritaprevir and Ritonavir
Ombitasvir and Paritaprevir and Rtonavir
Elbasvir and Grazoprevir
FDA would require a Boxed Warning, the most prominent warning, about the risk of HBV
reactivation to be added to the drug labels of these DAAs directing healthcare professionals to screen and
monitor for HBV in all patients receiving DAA treatment.
FDA also advised that healthcare professionals should screen all patients for evidence of current or
prior HBV infection before starting treatment with DAAs, and monitor patients using blood tests for HBV
flare-ups or reactivation during treatment and post-treatment follow-up.
In Hong Kong, approximately 10% of the population is serologically positive for hepatitis B virus
surface antigen (HBsAg) and another 40% has a previous history of hepatitis B infection, positive for
hepatitis B surface antibody (anti-HBs), hepatitis B core antibodies (anti-HBc), or both.
Apart from DAAs, hepatitis B reactivation can also occur in patients with hepatitis B infection
receiving immunosuppressive therapy (e.g. chemotherapy, steroid), and can potentially lead to significant
flare with liver failure and mortality. Current evidence showed that pre-emptive use of antiviral drugs
could reduce the risk of HBV reactivation and its related hepatitis flares. The risk of HBV reactivation varies
with different immunosuppressive agents.
In Hospital Authority, there are two guidelines available to healthcare professionals, as reference in
the pre-emtive use of nucleos(t)ide analogues in patients with Hepatitis B infection.
Clinicians should exercise their clinical judgment in the management of each individual patient.
Explanation and informed decision to patients are also important.
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Medication Safety Bulletin Vol.15
Hong Kong West Cluster
Sharing on Continuous Quality Improvements on Near Miss
ong Kong West Cluster has the following initiatives to promote medication safety
and learning from near miss:
1. Quality Reminder
In collaboration with Quality & Safety
Department to promulgate medication
safety messages for doctors, nurses and
2. Medication Safety Posters
To provide information to enhance
medication safety on wards
Safe Use on Insulin Pen Devices
Use of abbreviations in Prescriptions
3. Drug Information Tables
Oxycodone preparations available in QMH
To help nurses and pharmacists to avoid
mixing up of medications with similar drug
names and multiple dosage forms
4. Medication Safety Pearls
To raise awareness of Pharmacy staff for
near misses of medication
Insulin preparations available in QMH
Comparison table of Influenza Vaccines
This Bulletin is prepared by the Chief Pharmacist’s Office, HAHO
Sharing of near miss in picking
intravenous dangerous drugs