Jurnal Kesihatan Johor Volume 10 2012

A total of 42 (80.8%) respondents claimed that they were Tympanometry results show that all (100%) had Type Aexposed to noise disturbance in their daily working bilaterally. Audiometric results show that 7.7% (n=4) ofenvironment. Two contract dental officers did not dental staff experienced noise induced hearingrespond to the questionnaire. A total of 8 respondents impairment as shown in figure 5.2. All respondents stateddeclared that there noise did not cause any disturbance at that they did not use any personal protective equipmentwork. The respondents involved were 1 clerk, 2 dental such as ear plug or ear muffs for noise exposure duringsurgery assistants who worked mostly at the registration their work.counter, 2 dental nurses, 1 dental technologist and 1driver.Table 5.2: Category of dental staffs with Hearing Impairment and associated risk factorsCategory Impairment Age Duration PMH Part Past job Hobby of service time experience Watching TV job SportsDental Officer Right - Normal 24 1 Nil Nil Nil Cooking Left - Mild SNHL FishingDental Surgery Right - Mild SNHL 41 3 Nil Nil Hospital attendantAssistant Left - NormalAttendant 1 Right - Normal 42 10 Nil Nil Glass Left – Mild NIHL manufacturing factoryAttendant 2 Left – Normal 27 1 Nil Nil Heavy vehicle Right - Mild NIHL driverNo drivers, dental nurses, dental technologists or clerks Further research was carried out in all dental clinics inhad any noise induced hearing impairment while 1 Kota Tinggi district to assess noise produced by dentaldentist, 1 dental surgery assistant and 2 attendants equipment in daily working environment of various staffexperienced 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 noisecontributed 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 qualitativeused in Kota Tinggi clinic demonstrated that noise levels matrix method results in a medium to high risk noiseof Compressor A and B placed inside the room were 95.7 hazard in the dental surgery, dental laboratory and mobileand 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 surgeryIssue Severity Likelihood Issue Risk AssessmentCompressor 3 5 15 HighHigh speed handpiece 2 3 6 MediumLow speed handpiece 2 3 6 MediumUltrasonic scaler 3 5 15 HighHigh 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 inthe dental surgery, Table 2.6 in the dental laboratory and Table 2.7 in the mobile dental squads respectively. Dentalsurgery showed the highest risk area of noise exposure among risk assessment matrix compared to dental laboratoryand dental mobile squads.Table 2.6: Risk assessment summary in dental laboratoryIssue Impact Likelihood Issue AssessmentLaboratory handpiece 2 3 6 MediumLathe wheel 2 6 MediumModel trimmer 2 2 3Fume cupboard 2 3 6 MediumDust extractor 3 6 Medium 6 Medium 3Table 2.7: Risk assessment summary in mobile dental squadsIssue Impact Likelihood Issue 3 AssessmentCompressor 2 3 6 Medium 3 6 MediumHigh speed handpiece 2 3 3 6 MediumLow speed handpiece 2 6 MediumUltrasonic scaler 2High volume suction 2 6 Medium Mean Mean Category of staffs sound exposureEquipment Facility level time daily Dental Dental Attendant (dB) officer SurgeryCompressor Kota Tinggi (hours) Assistant Main Dental 88.3 8High 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 Referencessuffered hearing impairment were working in high noise . Act 514 Occupational Safety And Health Act 1994area (Kota Tinggi Main Dental Clinic, Sening dental [Reprint 2002]Clinic) and with high noise equipment such ascompressor, high speed handpiece and Ultrasonic 2. Leggat PA, Kedjarune U, Smith DR. Occupationalscaler(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/ReHearing 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 2011attendant 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, 2002and claimed that he was exposed to loud noise during his 5. Szymanska J. Work-related noise hazards in the dental5 years of service before joining the dental services. surgery.AnnAgric Environ Med 2000 (7): 67-69Exposure to noise level at 90dBA is quite common in the 6.European Heart Journal, published online Nov. 23dental environment. Although the duration of exposure 7. Virkkunen H, Kauppinen T, Tenkanen L Long-termdoes not reach the permissible exposure limit, dental effect of occupational noise on the risk of coronary heartpersonnel experienced distraction and annoyance during disease. Scand J Work Environ Health. 2005the 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 and7. Conclusion Communication Interference in Dental Practice JournalHazard 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 effectdental field noise due to prolong exposure. Hence, proper of sound produced in a dental clinic on the hearing ofmonitoring 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 andcases. Dental staffs working in high noise area above risk control. Department of occupational safety and90dBA are advised to wear ear plugs. Regular medical health, Ministry of Human Resources, Malaysia. 2008surveillance of staff exposed to high level of noise mustbe complied as per Factories and Machinery (NoiseExposure) Regulation 1989. This can ensure earlydetection and management of the patient hencepreventing hearing impairment among the dental staffs.8. AcknowledgementsThe authors expressed their gratitude to Kota TinggiDistrict Dental Officer, Kota Tinggi Senior HealthOfficer, Director of Sultan Ismail Hospital, staff of ORLClinic Sultan Ismail Hospital and all dental personnel inKota Tinggi districts who had contributed to the conductof 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 SegamatIntroduction: Prescribing errors primary occur due to 1,400 prescribing errors per 1,000 admissions, 0.61 – 53inadequate knowledge, failure to recognize, important percent prescribing errors per 1,000 orders, and 1.5 – 9.9patient information or drug information. Medication percent prescribing errors per 100 opportunities for errorsprescribing errors are one recognized contributor to the 2. Other studies had identified and documented problemsoverall problem of medication errors and have a high associated with prescribing errors. The extent of suchpotential to result in adverse patient consequences errors varied from 2.6% to 15.4% or estimated as 2.87 toObjectives: To determine the extent of prescribing errors 4.9 per 1000 medication orders3. An audit on this studydetected by inpatient pharmacy unit in Hospital Segamat, found that 2.6% of the prescriptions required activeto 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 recognizedprescription intervention and its outcome contributor to the overall problem of medication errorsMethod: A descriptive cross sectional analysis within 6 and have a high potential to result in adverse patientweek study duration in in-patient department of Hospital consequences5. Timothy S. L et al reported that 20% ofSegamat. prescribing errors made by physicians resulted in seriousResult and discussion: A total of 39 confirmed errors were incidents, compared with 6% for other causes ofevaluated for a likely related factor that was associated medication errors. Understanding of the type andwith the error. The most common types of medication frequency of, and risk factors associated with, medicationprescribing errors detected were drug therapy 48.15%; prescribing errors would allow closer monitoring ofdosage form related 12.81%; patient characteristic factor patients and medications associated with higher risk forrelated 7.69%; inexperience personal 5.12% and serious errors, thereby limiting potential harm tomiscellaneous factor related 17.94%. The most common patients6.medications involved were antimicrobials (17 errors, Studies on the types of prescribing errors in Malaysia43.7%), cardiovascular agents (3 errors, 7.69%), appeared limited in the literature. Therefore, the presentgastrointestinal 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 oferrors were rated as A potentially serious; 6 errors were prescribing errors. In this study prescribing errors wasrated as (potentially significant); and 31 were rated as monitored from inpatient unit with the aim of producing aproblem orders. By services, 23.09% occurred in surgical classification of errors based on the potential effects ofservices, 51.28%by medical services, 2.56% in errors. Besides that, this study aim is to identify andanaesthatic service, 5.12% in obstetric-gynecologic document the types of pharmacist intervention and itsservice, and 12.28% in orthopedic service. Most outcome on problematic prescriptions.intervention done by phone 82% and countersign 18%. 2) LITERATURE REVIEWConclusion: The results demonstrate a risk to patients foradverse consequences from prescribing errors, if 2.1 BACKGROUNDundetected, and identification of specific associated riskfactors related to error also achieved. The UK, USA and the World Health Organization have1) 1) INTRODUCTION identified that priority should be given to enhanced patient safety in healthcare. Medication error has beenIn the UK, potentially serious error occur between 1 in shown to be one of the most common forms of medical1000 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 toto inadequate knowledge, failure to recognise, important secondary care have resulted from preventable drug-patient information or drug information. Medication related morbidity preventable harm from medicineserrors have been shown to increase length of hospital stay could cost more than £750 million pounds per year inand 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 Errorspatient safety but unfortunately medication errors do A drug administration error may be defined as aoccur and often go undetected. Some medication errors discrepancy between the drug therapy received by themay 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 highestmechanism to monitor and make recommendations for risk areas in nursing practice. The “five rights” have longremedial 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 at2.2 MEDICATION ERROR the right time by the right route11. Drug administrationA medication error is any avoidable event that may cause errors largely involve errors of omission whereor lead to inappropriate medication use or patient harm administration is omitted due to a variety of factors suchwhile the medication is in the control of the healthcare as wrong patient, lack of stock. Other types of drugprofessional, patient or consumer. Such an event may be administration errors include wrong administrationrelated to professional practices, healthcare products, technique, administration of expired drugs and wrongprocedures and systems including prescribing, order preparation administered8.communication, product labelling, packaging andnomenclature, compounding, dispensing, distribution, 2.4 FACTOR RELATED TO MEDICATIONadministration, education, monitoring and use9,10. PRESCRIBING ERRORMedication errors may be committed by bothinexperienced and experienced personnel like doctors, The problems and sources of prescribing errors arepharmacists, dentists and other healthcare providers, multidisciplinary and multi-factorial. The action of onepatients, manufacturers, caregivers and others10. individual alone is rarely the solitary cause of a medication error or incident, rather a variety of2.3 TYPES OF MEDICATION ERROR contributing factors combine to cause incidents13 :Medication errors can be broadly classified asprescribing, dispensing or drug administration errors. 2.4.1 Patient characteristic-related: Adverse outcomes can be related to lack of knowledge or2.3.1 Prescribing Errors skill6,13. Even the apparently simple act of transcribing previous medications and collecting information as partPrescribing errors may be defined as an incorrect drug of the medication history requires a knowledge ofselection for a patient, be it the dose, the strength, the pharmacotherapy as well as adequate information aboutroute, the quantity, the indication, the contraindications8. the patient's clinical condition13. Equally, the choice ofThis definition can be further expanded to include failure dose requires information about the patient's clinicalto comply with legal requirements for prescription status and immediate verification of the appropriatenesswriting11. The prescriber must specify the information of treatment. Prescribers frequently failed to makewhich the pharmacist needs to dispense the drug in the necessary adjustments in the drug therapy of patients withcorrect dosage and form and the directions the patient well-recognized disease or physiological factors knownneeds to take it safely. A study undertaken in the hospital to alter drug action or disposition6. The most common ofsetting found an error rate of 4 errors per 1000 medication these factors were those that affected the renalorders. Of the errors with potential for adverse patient elimination of drugs advanced age and renaleffects, drug allergies accounted for 12.1%, wrong drug impairment14. Failure to consider the effect of patientname, dosage form or abbreviation for 11.4% incorrect disease state and physiological status on drug dispositiondosage 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 documented2.3.2 Dispensing Errors allergy occurred frequently6. Many patients are placed atDispensing errors are errors that occur at any stage during risk for hypersensitivity reactions due to an inadequatethe dispensing process from the receipt of a prescription provision of timely information regarding allergy historyin the pharmacy through to the supply of a dispensed or the failure to recognize the components of combinationproduct to the patient11. Studies in the USA have products. Likewise, inappropriate concurrent drugestimated that dispensing errors occur at a rate of 1- therapies were frequent, both drug-drug interactions and24%13. Dispensing errors may undermine the patient's duplicative therapies15.confidence in the pharmacist and increase the likelihoodof 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 ofprimarily when two or more drugs have a similar knowledge and a lack of appreciation of the importantappearance or similar name (look-a-like/sound-a-like distinguishing properties of different dosage formserrors)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 increasingamong the most common causes of dispensing error12. clinical importance of their unique drug deliveryOther potential dispensing errors include wrong dose, properties, it is likely we will continue to encounter thesewrong 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 STUDYThe nomenclature such as adding a suffix to anestablished brand name was used to identify dosage This study is being conducted because any study relatedformulations by manufacturers is often confusing and to prescribing error in hospital Segamat is not done yetincreases the risk for errors6. Error in prescribing might and at the same time to create awareness regarding tobe due to similarities in drug brand names or prescribing errors are particular concern associated with apharmaceutical names. Application of abbreviations for higher risk for serious consequences and results in patientmedication 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 the2.4.4 Calculations/unit expression-related : impact of prescribing errors.Miscalculation of medication doses, wrong decimal pointplacement (10-fold errors), incorrect expression of unit of 4) OBLECTIVESANDAIMS OF THE STUDY.measurement or concentration, or an incorrectmedication administration rate is usual factor lead to Objectives:error6. Calculation errors, as might be expected in 1. To determine the extent of prescribing errors detectedprevious 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 errorscalculate drug dosages13. that occurs in hospital Segamat medical prescription. 2. To identify factors associated with medication2.4.5 Inexperienced prescriber prescribing errors.Prescriber personal experienced in this course. Medical 3. To identify and document the types of prescriptiongraduates themselves feel unprepared to prescribe shortly intervention and its outcome.after graduation, emphasising the need to ensuresufficient education in prescribing skills6. Organisational 5) METHODOLOGYfactors such as inadequate training, low perceivedimportance of prescribing, a hierarchical medical team, 5.1 Study designand an absence of self awareness of errors alsocontributed to these errors. Inappropriate prescribing A sample of medication order written by prescriber inmost often derives from a wrong medical decision, Hospital Segamat will be used for descriptive crossbecause of lack of knowledge or inadequate training16. sectional analysis within 6 week study duration. In thisJunior doctors often work in stressful circumstances that type of research study, the entire sample will be taken asare perceived as routine by experienced doctors16. sample size during the duration of study, selected, and from these individuals, data are collected to help answer2.5 PRESCRIPTION INTERVENTION research questions of interest and objectives. This module will use the term cross-sectional study to refer to thisMany studies had recognized and documented problems particular research design and the term error form to referassociated with prescribing errors. The degree of such to the data collection form that is used to collect dataerrors varied from 2.6% to 15.4% or estimated as 2.87 to prescription that received in in patient unit of Hospital4.9 per 1000 medication orders3,4. An audit on Segamat.pharmacies found that 2.6% of the prescriptions requiredactive pharmacist intervention to resolve a prescribing 5.2 Study setting and populationerror6. Another study conducted in outpatient pharmaciesfound that approximately 4 per 100 dispensed The setting was in Hospital Segamat. Medication orderprescriptions had problems and required pharmacists will be review from all wards in Hospital Segamat whichintervention. In 44% of the intervention, the outcome was are paedratic ward, MOPD, physiatric ward, obstetricsa change in drug, strength or directions of drug use4. and gynaecology ward, intensive care unit and surgicalMost prescription interventions by pharmacists have a unit.limited potential for medical harm although it may beinappropriate in some instances as mentioned18. 5.3 Inclusion & Exclusion CriteriaHowever, it should be noted that a small number ofdetected 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 prescriberof 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 diagnosedand competencies of both medical and pharmaceutical within the study duration.professionals is to achieve optimal therapeutic outcomesand 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 medicationhand 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 inadequatethe 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 ainstead of Cardiprin, Tablet Xarelto 10mg ON, manner as to result in an error that could produce seriousKetonazole 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 SignificantData will be collected within 6 week observational studyin inpatient unit of Hospital Segamat. Prescription will be 1. The dose ordered of a medication with a lowscreening by pharmacist in patient. The following data therapeutic index was 1.5 to 4 times the normal dose, withwill 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 orthe prescribing physician, ward involved, and type of greater than normal, with potential for adverse effectserror, patient specific information and intervention because of the high dose.documentation. Pharmacists routinely used all available 3. The dose ordered was inadequate to produceinformation 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 inadequate5.5 Data analysis therapy. 5. The wrong medication was ordered for a nonseverePrescription errors by definition from guidelines on illness and/or there was a potential for side effects frommedication error reporting is incorrect drug product the drug.selection (based on indications, contraindications, known 6. A medication order was written illegibly or in such aallergies, existing drug therapy, and other factors), dose, manner as to result in an error producing adverse effectsdosage form, quantity, route of administration, or inadequate therapy.concentration, rate of administration, or instructions for 7. Duplicate therapy was prescribed with a potential foruse of a drug product ordered or authorized by physician additive toxic reactions.(or other legitimate prescriber); illegible prescriptions ormedication orders that lead to errors. 5.5.1.4. Problem Orders 1. Duplicate therapy was prescribed without potential for5.5.1 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 for1. 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 bedose. carried out given the nature of drug, dosage forms, route2. A dose was ordered for a medication with a very low ordered, missing information, etc.therapeutic index that would potentially result inpharmacologic 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 medicationsevere or life-threatening reaction in the patient (ie, prescribing errorsanaphylaxis).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 class5.5.1.2. Potentially Serious · History taking · No indication1. The dose ordered for a medication with a low · Wrong patienttherapeutic index was 4 to 10 times the normal dose. · Allergy, related class2. A dose was ordered for a medication with a very low · Contraindicationstherapeutic index that would potentially result in serioustoxic reactions. 2. Drug therapy factor-related3. The dose ordered for a drug used for a serious illness · Therapeutics/toxicity-related dose frequencywas too low for the patient.4. The wrong medication was ordered, with potential errorserious toxic reactions or inadequate therapy for a serious · Duplicative therapyillness. · Wrong drug prescribed, same drug class5. 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 5.126. RESULTA total of 44 confirmed medication prescribing errors Wrong dosage form 1 2.56were detected and averted by the pharmacy prescribingerror prevention program during the 6 week study period. Wrong frequency 4 10.25A total of 39 confirmed errors were evaluated for a likelyrelated factor that was associated with the error. The Pathological patient status 3 7.69characteristics and likely related factors for these 39errors constitute the data for the study. Unit of measure 2 5.12Characteristics of Prescribing Errors Wrong spelling 1 2.56The most common types of medication prescribing errorsdetected among the 39 total during the study period were Incomplete regime 2 5.12drug 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 wrongfrequency ( 4 errors, 10.25%), wrong dosage form (1 Total error 39 100errors, 2.56%); patient characteristic factor relatedincluding pathological patient status (3 errors, 7.69%); Figure 2. Factors Related to Error Detectedinexperience personal related including imcompleteregime ( 2 errors, 5.12%) and miscellaneous factorrelated such as no signature (7 errors, 17.94%). Table 6lists the number of each error type detected and avertedfor errors included in the study database.The most common medications involved in the 39prescribing 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 inAntimicrobial 17 43.58 the provision of modern health care and one of the manyCardiovascular 3 7.69 \"hazards of hospitalization.\" The problem is bothGastrointestinal 3 7.69 multidisciplinary and multifactorial in nature and resultsAnalgesic 1 2.56 in patient injury and increased health care costs andMineral/vitamin 5 12.82 liability claims. Most studies of medication errors haveAntiemetic 2 5.12 primarily evaluated the dispensing and administration ofAntidiabetic 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 forAntidiarrhea 1 2.56 serious consequences than errors from other sources. TheNebulizer 2 5.12 results of this study further document and define theTotal 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 variedClassification of severity No. of total error % of total error considerably, from potentially severe, to having minor clinical consequences, to having negligible patientPotentially fatal or severe 0 0.00 impact. Many of the errors classified as \"problems\" with low potential for patient impact were incomplete orPotentially serious 2 5.12 ambiguous orders or orders considered unlikely to be carried out. This study confirms the importance ofPotentially significant 6 15.38 standard checks within healthcare systems in reducing the risk for medication errors, specifically, theProblem 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 anMedical 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 theAnaesthatic 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%) andPaedratics 0 0.00 gastrointestinal agents (7.69%).Orthopedic 5 12.28Psychiatric 2 5.12Table 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 programBy phone 32 82.05 will allow the following up of individual prescribers through their training to confirm a reduction of error ratesBy 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 byBy 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 MImproved quality of care is expected to follow the G (1990). Medication Prescribing Errors in a Teachingimplementation 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 incare 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, Alanactivities. As a result of this study, an ongoing monitoring Willson and Lina Eliasson (2009). Quality of medicationprogram of prescribing errors was implemented in the use in primary care - mapping the problem, working to astudy hospital as part of the hospital's quality-assurance solution: a systematic review of the literature. BMCprogram. 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 Healthproviding 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 preventingcontinued 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 andinpatient department as to check and counterchecking, Robert C (2007). Prescription Errors and the Impact ofreview on computerized checking of dosage, allergy, Computerized Prescription Order Entry System in aduplicate therapy, and drug interaction in prescription Community-based Hospital. American Journal oforders, 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 prescriptionresult 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 reviewduration study in a Hospital Segamat. The results of epidemiology and an evaluation of evidencedemonstrate a risk to patients for adverse consequences supporting reduction strategy recommendations. Qualfrom 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 theydetetected. 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 Mtraining programs should implement procedural, (2008). What is the scale of prescribing errors committedmonitoring, and educational programs designed to limit by junior doctors? A systematic review. British Journal ofpatient 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 Gresult 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 related10. REFERENCES patient harm: an intervention study. Critical Care 2010, 14:R174 pg 2-11.1. S. A. Ridley, S. A. Booth, C. M. Thompson (2004).Prescription errors in UK critical care units. Anaesthesia, 18. Ghazal Vessal (2010). Detection of prescription errorsvol: 59, pages 1193–1200. by a unit-based clinical pharmacist in a nephrology ward.2. Angie S. G (2008). Prescribing Errors. California Pharm World Sci (2010) 32:59–65.Journal of Health-System Pharmacy. Page 5-15. 19. Bambi L. Taylor, Steven M. Selbst, and Andrea E.C.3. Kuan M N, Chua S S, Mohamed N R (2002). Shah (2005), PrescriptionWriting Errors in the PediatricNoncompliance with Prescription Writing Requirements Emergency Department. Pediatric Emergency Care,and Prescribing Errors in an Outpatient Department. Volume 21: 12, pg 822-827.Malaysian Journal of Pharmacy, vol; 1(2), page: 45-50. 20. B Dean (2002). Learning from prescribing errors.4. Chua Siew Siang, Kuan Mun Ni, Mohamed Noor bin Qual Saf Health Care, vol;11, page: 258–260.Ramli(2003). Outpatient Prescription Intervention 21. Christina E. S, David N, Robert P, and Peter A. 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baylor university medical center in preparation for (MATCH) Study: An Analysis of Medicationimplementation of a computerized physician order entry Reconciliation Errors and Risk Factors at Hospitalsystem. BUMC proceedings, vol; 17:357–361. Admission. J Gen Intern Med 25(5):441–7.22. 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).pharmacy in a teaching hospital in Kelantan. Malaysian Prescribing Errors in a Pediatric Emergency Department.Journal of Medical Sciences, Vol. 11, No. 2, July 2004 Pediatric Emergency Care, Volume 24:1, pg 1-8.(52-58). 25. Ronald G. N, FIiopna R, Susan L, Iain K. C (1989). A23. Kristine M. G, Molly R. M, Joseph F David W. B, Lee classification of prescription errors. Journal of the RoyalL, David L and Gary A. N (2010). Results of the College of General Practitioners, vol: 39, page: 110-112.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 beA high level of morbidity among asthmatics may be associated with a poor patient's knowledge of the diseaseassociated with poor patient's knowledge of the disease process and medication use, while Wilson et. al.13 studiesand the use of inhalers, which may contribute to high showed that asthmatic patients have poor understandingasthma prevalence in Malaysia (4.1 – 13.8%). To address of the use of inhaler. Both Hilton et.al.14 and Lai et. al.15this problem, a cross-sectional observational prospective reported that most of the asthmatic patients have poorstudy with the Before-and-After-Design was conducted self-management on their disease and this may thenby recruiting asthmatic adults in MTAC Asthma HSAJB associated with their poor quality of life.from 1 March 2011 to 31 May 2011 using conveniencesampling method. A significant improvement in mean Since a high morbidity trend among asthmatic patientspatient's score for knowledge of disease has been shown may be associated with the poor patient's knowledgeafter counseling. Morisky Scale for compliance has been about the disease itself and the medications use, thus eachshown to be significantly improved from 34% to 75% of the factors stated above is amenable to asthmaafter counseling. education for this population. 2, 3, 4, 11 Therefore, this study aimed to assess the effectiveness of AEP (MTACKey Words Asthma) for asthmatic patients in outpatient clinic setting Hospital Sultanah Aminah Johor Bahru (HSAJB) bypilot study; knowledge; Metered-dose Inhaler (MDI) evaluating the knowledge of asthma, their MDItechniques; compliance to treatment; Asthma Education techniques and their compliance to asthma managementProgram (AEP); MTACAsthma. who followed up in MTAC Asthma HSAJB from 1 March 2011 to 31 May 2011.Introduction Materials and MethodsAsthma is a chronic inflammatory disorder of the airways Study Populationthat causes significant morbidity and mortalityglobally.1, 10 It affects 5 – 6% of the world population This study was carried out from 1 March 2011 until 31which involves about 300 million individuals.1, 5 May 2011. MTAC Asthma HSAJB opens everyBesides, the latest asthma prevalence in Malaysia is 4.1 – Wednesday from 8am until 1pm. All adult patients aged13.8%, which shows an increasing trend.6 more than 18 years old who were followed up in MTAC Asthma during the study period were recruited usingThere are two main components involved in asthma convenience sampling method.management, which are pharmacological therapy andAsthma Education Program (AEP).1 Pharmacological Forty two patients aged more than 18 years old, whotherapy for asthmatic patients are reliever medications attended the MTAC Asthma during the study period, wereand controller medications. The former is normally recruited using convenience sampling method. Then, theindicated 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 MTACAEP is an education program which aim to increase Asthma, while two patients were excluded because theypatient's knowledge about asthma therapy in order to could not come for retesting. All participants were thenmaintain 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 completedthe 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 onecontribute to poor asthma control in this population. month for retesting and seven patients were excludedGibson et. al. reported that asthmatic patients always since they have been lost of follow up for retesting afterdeny that they are having a chronic condition of asthma one month. Figure 1 has shown an overview of the studyand thus they just use the medications when necessary.11 procedure. 60

Data Source Definition of MDI TechniqueThis study would only take one encounter for each patient The eight steps of standard MDI technique mentioned inwho have completed the first month retesting process the questionnaire in this study was obtained from GINAafter their first clinic visit during the study period guideline.1 Subjects would be asked to demonstrate theregardless of how many times clinic visits were made MDI technique during test-and-retesting, whileafter that. The Before-and-After-Design was used in the researchers would make a tick if patients have followedstudy with the subjects serving as their own control. the proper step mentioned.There were two data collection sheet completed by eachpatient after interviewed by different researchers for test- Definition of Patient's Compliance to Medicationsand-retest purpose without time limit. The questionnaireor the data collection form in this study was adapted and In this study, patient's compliance to medications wasmodified from other similar studies by Prabhakaran et. evaluated by using the Morisky Scale. Subjects have toal.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 wouldonly record all information given by the patients, hence Based on the Morisky Scale, patient's compliance wasall patients were assumed to be honest during the assumed to be good in this study if their score was 0, 1 andinterview session. 2. For those patients who got their score as 3 or 4, their compliance was assumed to be poor.Inclusion-exclusion Criteria ResultsAll adult asthmatic patients aged more than 18 years oldprescribed only on the MDI were selected. In addition, the During the three months study period, 32 eligible patientsselected 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 yearspast twelve months. old for both genders. Generally, most patients have an average of 22 years history of asthma. About 62.5% ofOn 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 secondarywith language and understanding problems were education level (Figure 2). Besides, about 59.4% of theexcluded since they could not answer the questionnaire. asthmatic patients in this study claimed that they wereThis study also excluded those patients who could not non-smokers (Figure 3), while more than half of thecome for retesting after one month. Patients who were patients admitted that they have attended asthma groupusing MDI with the aid of aero-chamber were excluded counseling previously (Figure 4). Patient demographicfrom 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 fromThe collected data was analyzed by using Statistical 20.31 to 23.72 after counseling. Mostly patientsPackage for the Social Sciences version 17.0. The data for recognized about five factors that contribute to theircontinuous variable was summarized as mean with asthma attack, which were not significantly differentstandard deviation (means ± SD) with the p-value was before and after counseling. Approximately half of themobtained 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 wasrespective p-value was obtained from Pearson Chi- their reliever, while one-third of them claimed thatSquare 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 theDefinition ofAsthma Education Program (AEP) impact of MTAC Asthma on patient's compliance to medications. Before given counseling, approximatelyThis study reviewed the effectiveness of AEP in MTAC one-third of the patients have poor compliance toAsthma HSAJB by evaluating patients' knowledge of the medicines, while only 9.4% of them were reported to bedisease and medication use. There were five related compliant to medicines. However, a statisticallyquestions have been asked during the interview session significant increase has been reported in which 75% ofand patients would choose the scale among one (strongly the patients claimed that they were compliant to thedisagree), two (disagree), three (neutral), four (agree) and therapy after counseling have been given (Table 4).five (strongly agree). Patients who chosen agree andstrongly agree would be assumed as knowledgeable, During the one-to-one interview session, all subjects havewhile those who chosen neutral, disagree and strongly been asked to demonstrate their MDI techniques. Afterdisagree 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 poorsteps. 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 thisweek 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 inIn this study, before counseling has been given, one-third which 75% of the subjects have satisfactory complianceof the patients claimed that they usually have less than rate to the therapy. This might be associated with thetwo asthma attacks per month, while 25% of the patients benefit of AEP in which patients were morecomplained that they have three to four asthma attacks per knowledgeable about their disease and the treatmentmonth. When these subjects came back after one month being used, thus they have the awareness to be morefor the retest purpose, about 70.8% of them have compliant to the asthma therapy. Besides, a significantinfrequent asthma attack in this one month period of time. improvement in patient's compliance might be associatedThis was a statistically significant improve in asthmatic with the short one month retest period since they werepatients' 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 GINABased on the Malaysia Clinical Practice Guideline6 2002, guideline.1 The proper use of the inhaler, especially thethe latest asthma prevalence in Malaysia was 13.8% anti-inflammatory agents or the preventer inhalers, withindicating that more Malaysians are suffering from appropriate dose schedule was important to achieve theasthma. On the average, patients have been suffered from benefits of these medications.13 Similar to the resultasthma attacks for more than 20 years. Within this reported by Maria et. al.21, only 22% and 28% of thepopulation, about 62.5% of them have 2 medications to subjects in this study have prime the MDI or wait for onecontrol 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 theThis study result was consistent with the result from other asthmatic patients had difficulty in using MDI andstudies4, 15, 17, which showed that there was a associated with the poorly control of asthma. After thesignificant increase in patients' knowledge of asthma subjects have been followed up at MTAC Asthma, it wasscore. A complete counseling session given during found that there was a significant improvement onMTAC Asthma has successfully improved patient's patients' MDI techniques, especially all patients wouldknowledge of disease process of asthma. Since patients shake and remove the cap before using MDI and holdwere 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 thecondition besides they would be more compliant to inhaler or clean the mouthpiece once a week even thoughmedications. Thus, as suggested by Meenu and Sonal20, counseling was given one month before retest. This resultinformation about the basic pathophysiology of asthma is was consistent with the result found by one group ofthe 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 theBesides, number of factors causing asthma attacks patients performed the inhaler technique correctly.21recognized by study subjects before and after MTAC This result may indicate that patients tends to alwaysAsthma was not significant different. This may be claim that they knew how to use the MDI and the healthassociated with the chronic condition of most of the care professional believed it to be true and therefore dosubjects in this study. Since most of them have an average not test them. Hence, regular assessment of MDIof about 20 years of asthma condition, they might clearly technique was necessary to ensure that patients gain theunderstand the factors which may trigger their biggest benefit from the pharmacotherapy.exacerbation of asthma. As suggested by Meenu andSonal20, patient education on possible allergens and On the other hand, the impact of MTAC Asthma hastriggers 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 fourenvironment control strategies. It was not surprising attacks per month or less than two attacks per monthwhen this study reported that almost half of the patients before they followed up at MTAC Asthma. Aftercould not recognize their reliever medication. When counseling has been given, 70.8% of the subjects reportedsubjects have been given an explanation about reliever infrequent asthma attack within this one month studymedication during the interview session, there was a period. This might be due to patients who were moresignificant improvement on patients' knowledge of knowledgeable about their disease and managementreliever medication. which may then associated with their better compliance and improved MDI technique. This study result similar toSimilarly to those the result reported by Maiman et. al.18 other studies that shown that AEP improved patient'sand Scherer and Bruce19, patient's compliance with the functional status and quality of life.16, 17, 18therapeutic regimes for chronic disease was generallylow. In this study, before counseling has been given, only This study has several limitations. A short term follow up9.4% 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 Asthmabias might be existed and associated to high level of Shows Poor Compliance with International Consensuspatient'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 andto bias because convenience sampling method has been identity: reasons for non-compliance – Experience ofused in this study. Questionnaire or the data collection medication from persons with asthma/allergy. Patientform 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: asample size might be affecting the result of this study patient questionnaire study. Primary Care Respiratorywhich 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. LimitedWith the increasing trend of asthma prevalence, this study (information only) patient education programs for adultsshowed 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 primaryasthma and medications, self-reported compliance to care: a pilot study of small group education. Familytreatment 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. Afurther improved. The findings of this study may suggest controlled trial of two forms of self-managementa 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 in1. [GINA] Global Initiative for Asthma. 2010. Pocket the Asia-Pacific region: The Asthma Insights and RealityGuide for Asthma Management and Prevention (for in Asia-Pacific Study. J Allergy Clin Immunol 2002;adults and children older than 5 years). Canada: GINA. 111:263-82. 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 educationpharmacotherapy: 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 of3. Sean H, Bonnie S, Anderson AR and Paul F. 1982. adult asthma education in a hospital setting. Thorax 1999;Evaluating health education in asthma – developing the 54:493-500.methodology: primary communication. Journal of the 18. Maiman LA, Green LW, Gibson G, MacKenzie EJRoyal 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;5. Martyn RP. 1995. Asthma: lessons from patient 30:250-7.education Patient Education and Counseling, 26: 81 – 86. 20. Meenu S & Sonal K (2006).Adherence issues in6. 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 CClinical Practice Guidelines for Management of Adult (2009). Knowledge of and technique for using inhalationAsthma. Kuala Lumpur: CPG. devices among patients and COPD patients. J Bras7. David MT, Thomas EA, William JC and Vincent Pneumol, 35 (9); 824-831. 63

A Study of The Effect of Home Water 13Filtration Systems On Fluoride Content of Volume 10 Drinking Water in JohorLoh 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 JohorABSTRACT purchasing bottled water and filtration systems are at aIntroduction: With the general population concerned with high.2 This poses a challenge to the maintenance andpolluted water, tendencies toward purchasing bottled expansion of our water fluoridation programme, aswater and filtration systems are at a high. This poses a questions are being raised as to whether fluoride contentchallenge to the water fluoridation programme as in public water supplies is affected by these filters.questions are being raised as to whether fluoride contentin public water supplies is affected by these filters. 2. LITERATURE REVIEWObjectives: To compare fluoride content of drinking 2.1 Types of Domestic Water Filtration Systemswater before and after passing through various water Domestic water treatment systems include waterfiltration devices, and also to compare fluoride content conditioners and softeners and water filters. Thesedifferences between various water filtration devices. systems fall into two basic categories: point of entryMethodology: A total of 49 water filters were included in (POE) and point-of-use (POU). Point-of-entry waterthis study. Fluoride levels were analyzed using the Hach's treatment systems treat all of the water entering and beingcolorimeter. 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 home95% confidence level. Results: Of the 49 filters, 29 were water distribution system, usually at one faucet. Thecarbon 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 carbonfiltration through CA systems were not significantly filtration are examples of POU water treatment systems.different (p>0.05); while those through RO and othersystems were significantly different (p<0.05). Fluoride Carbon Filtration Systems is a pour-through carafe whichlevels between different filtration systems were found to most often resembles a water pitcher or large jug and usebe significantly different (p<0.05), with CA systems activated charcoal (CA) as the filtering medium. Gravitybeing 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 assystems has no effect on fluoride levels in drinking water. pesticides.3,4Water filtration systems using Reverse Osmosis and othertechnologies significantly lower fluoride levels of Reverse Osmosis (RO) Systems uses pressure to forcedrinking water. Optimally fluoridated drinking water water molecules first, through a microscopic membranewhen subjected to home water filtration systems that or screen, and then through a cellophane membrane thatreduce fluoride significantly may not offer the same screens out even smaller pollutants from the water. Theycaries preventive effect. greatly improve the taste of water by removing infiltrates, lead and some pesticides, and natural minerals.51. INTRODUCTIONWater fluoridation remains the most cost-effective, Distillation is a process that removes contaminants fromequitable and safe means to provide protection from water. It heats up the water to boiling point, traps thedental caries in a community. However, according to the rising steam, and uses a fan or other cooling device toU.S. Environmental Protection Agency (EPA), condense the vapour back to its original form, minusapproximately one in eight Americans is exposed to everything else.6potentially harmful microbes, pesticides, lead, orradioactive radon whenever they drink a glass of tap Water softeners use a cation-exchange resin, regeneratedwater or take a shower.1 With the general population with sodium chloride or potassium chloride, to reduce theconcerned 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 elementsremoving water hardness.4,6 While being effective in from natural drinking waters using a bench-top watereliminating metals, they can raise, however, the level of filter system was evaluated by Gulson et al.16 It wassodium in the water. shown that elements unaffected by filtration were Al, Si, Na, Fe, Cl and F. Water conditioners and softeners have2.2 Popularity and Reasons for Using Domestic Water been shown to have little or no effect on fluoride.12,17,18Filtration SystemsThe sale of home water treatment units is expanding. The 2.4 Role of Relevant Agencies in Domestic WaterJanuary 1999 National Consumer Water Quality Survey Filtration Systems Usageindicates that 38% of adults reported using a household As far as the removal of contaminants, the Nationalwater treatment device, a 28% increase since 1995. Forty- Sanitation Foundation (NSF), provides certification ofseven percent of respondents stated they would be more contaminant removal for water purification systems. Thelikely to buy a house with a water treatment device if they label of the filter should specify NSF certification for thewere in the market for a new home.7 contaminants that are removed.3 Glass emphasized the importance of dentists asking patients about theirA study in Pahang found that almost 50% of households drinking water, in order to make recommendations onsurveyed had one or more forms of household water whether fluoride supplementation was needed.3filters in place and another 44% which had not, planned to Petrowski stated the purpose of water quality agenciesto do so.8 The purpose of installing these filtration and their roles. Instructions on purchasing anddevices were solely for health reasons and for better maintaining a system were also discussed and referencequality water. numbers of different companies for additional information on their products were provided.42.3 Effect of Home Water Filtration Systems on Fluoride 2.5 Proper Usage of Water Filters and Filtered WaterContent Water that has passed through a domestic filter should beThe ability of the different water filtration systems to treated as a perishable foodstuff and kept in refrigeratedremove fluoride from tap water has been studied. There is conditions. This water should be consumed within 24strong evidence that systems such as those based on RO hours. The manufacturer's instructions for the filterand distillation removed a substantial amount of equipment should be followed at all times.19fluoride2,3,9 but tests of those based on activated carbonhave given contradictory results. Some reports have 3. RATIONALEdemonstrated a reduction in fluoride levels with use of With growing affluence coupled with smart marketingcarbon filters,2,3,8,9 while another study found no strategies, the sale of home water treatment units is fastreduction.12-15 It has been suggested that the design of expanding. In the quest for increased coverage of ourthe carbon filter may be a factor affecting fluoride fluoridation programme, there is also a need to look intoremoval.2 Therefore, each carbon filter should be whether the intended population is benefiting fromassessed individually. fluoride in drinking water.Removal of fluoride from water is a difficult watertreatment action.13 Most POU treatment systems for There are pockets of population in Johor who do not havehomes 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 fluoridefluoride ion. The ability of other treatment systems such levels in fluoridated areas; hence, evaluating the qualityas reverse osmosis, ion exchange, or distillation systems control of the water fluoridation programme in the state.to reduce fluoride levels vary in their effectiveness toreduce fluorideA study by Robinson et al12, in which water was passed Scientific evidence on the impact of different types ofthrough softeners and a conditioner, tested for fluoride devices on fluoride content will enable healthcareconcentration using a specific ion metering device. It professionals to educate patients on the possible removalrevealed no alteration in levels when compared with of fluoride by some water treatment systems and tocontrols. Similar experiments of filtered water provide advice on the most suitable types of devices todemonstrated highly significant amounts of fluoride ion purchase. This is to ensure that the benefits of fluoridatedwere removed. In one filter tested, 90% of the fluoride water actually reach the population. With more studiescontent was lost in the filtration process. like these being done, the Oral Health Division, Ministry of Health, will be better positioned to work with relatedThe study by Prabhakar et al15 showed that the systems agencies in the certification of contaminants and mineralsbased on reverse osmosis, viz, reverse osmosis system removal by each system.and Reviva (R) showed maximum reduction in fluoridelevels, the former proving to be more effective than the 4. OBJECTIVElatter; followed by distillation and the activated carbon 4.1 General Objectivesystem, with the least reduction being brought about by The objective of this study is to determine the effect ofcandle filter. The amount of fluoride removed by the various home water filtration systems on fluoride contentpurification 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 remove4.2.1 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 weredrinking water between water filtration devices. collected after running the water for 5 minutes. Unfiltered water samples were collected from a second5. METHODOLOGY tap (in same room) receiving the same main supply.5.1 SamplingThree districts in Johor were selected for the study; 5.2 FluorideAnalysisnamely, Johor Bahru representing an urban population The samples were brought back to the clinics, whereand with almost 100% fluoridation coverage, Muar with fluoride readings were taken. Fluoride content wasan equal mix of urban and rural population and about 90% analyzed using Hach's colorimeter. Each sample of waterfluoridated and lastly, Mersing with a mostly rural was measured twice and the recorded measurementpopulation and only half of which receiving fluoridated being the average of the two readings. Fluoride levels arewater. expressed as ppm F.Water samples were collected from households using 5.3 Data ManagementWater Filtration Systems (WFS), identified from an Data were entered into a dummy table and the SPSSearlier study through systematic randomized sampling. software. Statistical analysis of effect of different typesSampling of water was carried out over three consecutive of water filtration devices on fluoride level was donedays by trained personnel in each district. Standard using SPSS. Wilcoxon Signed-Rank test was used toplastic bottles (100 ml) were used for collection of water compare fluoride content of drinking water before andsamples, one for control i.e. before water passed through after passing through various WFS. Mann Whitney testswater filtration device and another for test i.e. after were used to compare difference in fluoride content ofpassing through device. Each bottle was labeled drinking water between various WFS. All proceduresaccordingly before collection of sample, with date, time, were computed to within 95% confidence level.name of personnel and address of residence. Reused6. RESULTSA total of 49 water filters were selected from a pool of 115 filters in Johor Bahru, Muar and Mersing, as shown in TABLE1 and TABLE 2a and 2b below.TABLE 1 : Types of Water Filtration Systems Used by Selected Households in Johor Frequency Percent Valid Percent Cumulative PercentActivated Carbon 83 72.2 72.2 20.0 72.2Reverse Osmosis 23 20.0 92.2 7.8 100.0Others 9 7.8 100.0Total 115 100.0Of the 49 filters, twenty-nine were activated carbon, 11 reverse osmosis, and 9 'Others'. Results showed that fluoridelevels before and after filtration with CA systems were not significantly different (p>0.05). Comparisons for RO systemsshowed significant differences (p<0.05), similarly with WFS using other technologies (p<0.05). Refer to TABLE 2a and2b.TABLE 2a : Compare F level before and after filtrationTypes of n Day 1 Day 2 Day 3water Median F Median F *P value Median Median F *P value Median F Median F *P valuefilter (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 0.037Activated 29 0.40 0.40 0.366 0.40 0.40 0.40 0.10carbon 11 0.40 0.15 0.011 0.40 0.10 0.007 0.003Reverse 0.40 0.35 0.005 0.40 0.30 0.40 0.30Osmosis 9 0.006 0.008OthersTotal 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 afterActivated carbon 29 0.43 0.43 filtration)Reverse Osmosis 11 0.40 0.11 0.152Others 0.40 0.30Total 9 0.005 49 0.003TABLE 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 Test7. DISCUSSION from water samples. This further strengthens evidenceThe study was set up to investigate the effect of home found in other studies.2,3,9,15WFS on fluoride levels in drinking water in Johor. Thisstudy used tap water from the homes as distinct from It has been recognized that the water source used is oflaboratory fabricated deionised samples in an earlier critical importance.21 This study sampled tap waterpaper.2,12 Most studies had used findings of the effect of from public water supplies and has the disadvantage ofWFS on fluoride levels to advise against unnecessary being less well controlled for other water constituents, butprescription of fluoride supplements.10,13-15 This may provide a better reflection of the effects of filtrationstudy serves to identify effect of commonly-used WFS on in 'real-life' use. It may be suggested that complexation offluoride level and to address concerns in relation to the fluoride with high levels of aluminium and iron inmaintenance and expansion of our fluoridation unfiltered water will render some free fluoride ions stillprogramme. 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 showedwater. Previous tests based on CA systems have given consistent fluoride readings before filtration, whichcontradictory results. This finding concurs with results comply to the range of 0.4-0.6 ppm F (Quality Assurancereported in several studies12-15 but is in contrast to Programme, MOH). This reflects on the well-controlledothers.2,3,8,9 It has been suggested that the design of the dosing of fluoride in public waters in the districtscarbon filter may be a factor affecting fluoride removal.2 concerned. Hach's colorimeter was used in this study, asVariation in fluoride reductions by WFS is also dependent opposed to ion-specific electrode in other studies, due toon differing pressure lines and regular maintenance of cost factor. However, stringent measures were taken toequipment may also influence its efficacy in fluoride ensure accuracy and consistency in sampling andreduction.3 analysis. Dental Surgery Assistants involved in routine fluoride analysis were re-trained and calibrated prior toFor the purpose of analysis, this study had grouped CA the study by a senior technician from the supplierfilters using ion-exchange technology together with those company. All colorimeters used were serviced andusing distillation as 'WFS using other technologies'. They calibrated shortly before the sampling exercise.were found to reduce fluoride content significantly but toa lesser degree than reverse osmosis (RO). Astandard CA 8. CONCLUSIONsystem does not remove fluoride. A more complex The results of the study showed that the use of carbonfiltration system, which employs an ion exchange activated water filtration systems has no effect on fluoridetechnology, adding potassium ions to the water can levels in drinking water. Water filtration systems usingremove 40-60% fluoride.20 Fluoride content of water Reverse Osmosis and other technologies significantlyfiltered through WFS using RO was significantly reduced lower fluoride levels of drinking water. Optimallyin 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-usenot 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 ofBased on the findings in this and related studies, several domestic water filters on water fluoride content. B. Dent Jrecommendations 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 Jactive role in the following: T. Impact of source of drinking water on fluoride9.1 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 SN9.2 Advise patients on suitable water filtration systems to 12. , Davies EH, Williams B. Domestic wateruse 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 MA9.3 Work with water quality agencies in certification of 13. , Levy FM, Rodrigues MH, Bastos JR. Effect ofcontaminant removal for water filtration systems. domestic water filters on water fluoride content and levelAuthorities need to ensure instructions on maintaining a of the public water supply in Bauru, Brazil. J Dent Childsystem 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, Takatoshiinformation on their products were provided. Neither Hollow-Fibre Membrane Filters nor Activated Charcoal Filters Remove Fluoride from Fluoridated TapACKNOWLEDGEMENT Water. JCDA www.cda-adc.ca/jcda June 2008, Vol. 74,Many thanks to the team of dental surgery assistants who No.5carried out water sampling and fluoride analysis. The Prabhakar ARcooperation of the District Dental Officers and the dental 15. , Raju OS, Kurthukoti AJ, Vishwas TD. Thepersonnel who gave permission for their water filtration effect of water purification systems on fluoride content ofsystems 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 BLbut not least, our appreciation to Dr Tan Ee Hong, for her 16. , Sheehan A, Giblin AM, Chiaradia M, Conradtrole in literature search and data analysis. B The efficiency of removal of lead and other elements from domestic drinking waters using a bench-top waterREFERENCES filter system. Sci Total Environ. 1997 Apr 1;196(3):205-http://www.epa.gov/safewater/dwh/contams.html 16.1. Accessed 16 June 2008 17. Groman K W, Nazif M M, Zullo T. The effects2. Jobson MD, Grimm SE 3rd, Banks K, Henley G. of water conditioning on fluoride concentration. J DentThe effects of water filtration systems on fluoride: Child 1980; 47:21-23.Washington, D.C. Metropolitan Area. ASDC J Dent 18. Full C A, Wefel J S. Water softener influence onChild 2000;67:350–4.[Medline] anions and cations. Iowa Dent J 1983; 69:37-39.3. Glass RG. Water purification systems and http://www.thames-recommendations for fluoride supplementation. J Dent water.com/UK/region/en_gb/content/FAQ/FAQ_00005Child 1991;58:405–8. 8.jsp4. Petrowski, E.M.: Cleansing the Water. Home 19. Accessed 12 June 2008Mechanix, 98(38):36, June 1996 http://www.waterfiltercomparisons.com.au/faqs/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 Ltdwww.epa.gov September 2005http://www.ada.org/public/topics/documents/art_water_ LKH/26.09.2011home.pdf7. Accessed 12 June 20088. Lopez I, Asmani AR, Kwan GL. Effect ofHousehold Water Filters on the Fluoride Level in FilteredWater. A Compendium of Abstracts 2006, oral healthDivision, Ministry of Health 2007; 88 68

14Traumatic Abdominal Wall Hernia : Volume 10 A Johor Case ReportYJ Lee1; TT Yew1; AC Chan2 20121 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. TheDr Lee Yeong Ji, patient developed symptoms of bowel obstruction fourDepartment of Radiology, days later and urgent CT was performed followed byHospital Sultan Ismail, Taman MountAustin, immediate laparotomy.Jalan Persiaran Mutiara Emas Utama,81100 Johor Bahru, Johor, Malaysia CASE REPORTPhone: +607-3565000 ext. 2611 A 21-year-old male was brought to casualty department 3Fax: +607-3565034 days after a road traffic accident. His motocycle handleEmail: [email protected] bar had impaled over the right side of his abdomen. Prior to admission, he presented himself to a local hospital forShort title: traumatic abdominal hernia right abdominal swelling and was treated for abdominal hematoma. However he later complained of generalizedSUMMARY abdominal pain, vomiting, shortness of breath and chest pain which subsequently brought him to our casualtyMost reported cases of traumatic abdominal wall department.herniation result from blunt impact particularly handlebar On examination, he was tachypnoeic, tachycardic andinjuries. The diagnosis is often made on physical febrile. There was crepitus felt over the chest wall andexamination or abdominal computed tomography (CT). right flank. His abdomen was distended with tendernessWe report a 22-year-old man with anterior abdominal over right iliac fossa region. A 4 x 5cm swelling waswall swelling following blunt handle bar injury to the palpated over right anterior abdomen. There were noabdomen. 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 ansymptoms of abdominal pain and vomiting 4 days later. anterior abdominal wall defect (5cm wide and 7cmAn urgent CT was performed which confirmed the caudocranial diameter) just lateral to the right rectusdiagnosis of traumatic abdominal hernia. abdominis muscle at right iliac fossa region. There wasIntraoperatively, the herniated small bowel loops were herniation of small bowels loops through the wall defectgangrenous with multiple perforations leading to bowel with evidence of rupture of herniated bowel segmentcontents contamination in the abdomen, chest and neck (Figure 1). There was also extensive subcutaneousregion. This case highlights the need for a high index of emphysema involving the right abdomen, thorax andsuspicion 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 onhernia the same day. A large full thickness defect found in the anterior wall abdominal muscle (6cm x 8cm) from rightINTRODUCTION iliac fossa to right hypochondriac region, with herniationTraumatic herniation of the abdominal wall is a rare of strangulated small bowels. A 40cm length of smalloccurrence following blunt abdominal trauma with only bowel was gangrenous and perforated at 45cm from theabout 50 reports worldwide1. Most herniations are ileocaecal junction, leading to bowel contentsdiagnosed at presentation by physical examination or on contamination in the abdominal wall, chest wall, neckabdominal computed tomography (CT), which mostly and inguinal region. There was also a mesentericproceeded to immediate laparotomy and repair because hematoma noted the right lower pelvic region. A bowelof the high incidence of associated intra-abdominal resection-anastomosis was done and the defect wasinjury. We report a case of traumatic anterior abdominal repaired. The patient's recovery was uneventful and was discharged on the 24th day postoperatively. 69