1. Selection of opportunities for improvement (Outline for problem)
Polypharmacy error leads to adverse drug reactions, hospitalizations and death1,2.102 chronic patients/month which came to Hospital Banting Outpatient Pharmacy Department (OPD) had multiple prescriptions from different healthcare facilities or units and n=38 had polypharmacy error. There was hospitalization reported due to double dose of amlodipine taken from different facilities.

2. Key Measures for improvement
The indicator is percentage of multiple follow-ups patients with polypharmacy error. The standard is 15% based on literature and consensus in Medication Safety Meeting.

3. Process of gathering information
A cross-sectional study using purposive sampling of OPD’s multiple follow-ups patients was conducted with calculated sample size of 81. Patients that fulfilled the criteria were interviewed using validated questionnaires. The polypharmacy error’s contributing factors were identified using questionnaires to pharmacists, doctors and patients.

4. Analysis and Interpretation
43.2% of recruited patients (n=88) had polypharmacy error. The main contributing factors were inappropriate record of patients’ medications (19%),
poor doctor’s knowledge (17%), confusion of medications received from various facilities (15%), lack of explanation from pharmacist on change of hospital formulary, brand and strength of medications (12%) and no or ineffective counseling from pharmacist (12%).

5. Strategy for Change
A pocket Kad Farmasi (KF) was introduced as a tool for patients to keep multiple prescriptions which allowed proper medications’ screening by pharmacists as medication records available once patient came to the pharmacy. Others include common polypharmacy list to improve staffs’ knowledge, change of medications brand catalogue for clearer explanation to patients, compilation of extended counseling checklist for standardized and effective counseling by pharmacists, education video for patients, continuous pharmacy education (CPE) and addition of multiple follow-ups stamp for cycle 2.

6. Effects of Change
Polypharmacy error reduced to 29.5% (Cycle 1) and 19.3% (Cycle 2). ABNA reduced from 28.2% to 14.5% (Cycle 1) and 4.3% (Cycle 2). Patients are more aware to bring all medication records from 25% to 53%. Pharmacists are more alert in screening prescriptions with multiple follow-ups from 10.9% to 48%. KF’s cost (45cents/card) outweighs patients’ admission and medications wastage (RM20, 555 per year) costs. Most of users satisfied with KF (patients: 91%; pharmacists: 94%; doctors: 90.9%). Doctors’ and pharmacists’ knowledge on polypharmacy increased from 20% to 45.5% and 50% to 55% respectively. Number of counseling done at OPD increased by 180% from n=162 to n=454 and explanation regarding changes in medication brands increased from 41.8% to 76%. Patients understanding about medications increased from n=33 to n=42 scored DFIT 100%.

7. Next step
KF will be a compulsory card for chronic patients in Hospital Banting and has been expanded in Klinik Kesihatan in Kuala Langat.