Page 29 - Q BULLETIN, Ministry of Health Malaysia, VOLUME 1, NO. 31 (SUPPLEMENT 1), JAN-DEC 2022

Q Bulletin, Volume 1, No. 31 (Supplement 1), Jan - Dec 2022
11 National QA Convention, 4 – 6 October 2022
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Increasing the Percentage of Paediatric Thalassemia Patients on Iron Chelation Therapy
with Serum Ferritin Below 1000mcg/L in Hospital Tengku Ampuan Afzan (HTAA)

Nurul Amira Z , Khairul Naim ZA , Nur Wahida JK ,Lee YL , Tan YS , Siti Sarah I 1
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1 Hospital Tengku Ampuan Afzan (HTAA), Pahang
2 Bahagian Perkhidmatan Farmasi, Jabatan Kesihatan Negeri Pahang, Pahang
SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:
Serum ferritin level is targeted below 1000mcg/L to prevent iron overload complications. Unfortunately, one
paediatric patient died due to iron overload complications in HTAA, whose serum ferritin was 4295.6mcg/L.
Therefore, this study is necessary to prevent iron overload complications and death.

KEY MEASURES FOR IMPROVEMENT:
The key indicator for improvement is the percentage of paediatric patients on iron chelation therapy with a
serum ferritin below 1000mcg/L. The standard is 75%.

PROCESS OF GATHERING INFORMATION:
A quality improvement study was conducted in 2019 using a universal sampling of 38 patients and eight
pharmacists. Data to identify contributing factors was collected by using audit forms and validated
questionnaires. Re-evaluation was done in two cycles in 2020.

ANALYSIS AND INTERPRETATION:
The pre-remedial study showed that only 16% of paediatric patients on iron chelators had serum ferritin
below 1000 mcg/L. The ABNA was 59%. The contributing factors were inadequate counselling (n=38), poor
compliance with medications (n=26), and poor compliance with diet restrictions (n=22).

STRATEGIES FOR CHANGE:
A detailed counselling checklist and an all-inclusive counselling flipchart were prepared. More pharmacists
were allocated during clinic sessions, bedside teaching was organised, and the counselling review form was
reconstructed. The importance of compliance was emphasised during counselling. Patients were registered in
pharmacy value-added service for a medication refill. Comprehensive counselling in managing side effects and
correct administration techniques was delivered. Information on the food label, high iron-content food, food
that increases iron absorption, and proper cookware was highlighted.

EFFECT OF CHANGE:
The percentage increased from 16% to 32%, then improved to 39%. The ABNA was reduced from 59% to 43%
and 36%. Adequate counselling was delivered to all patients. Successful delivery of information regarding
medications and diet restrictions helps patients understand the importance of compliance. Patients’ compliance
with medications improved, and patients’ compliance with diet restrictions enhanced as well.

THE NEXT STEP:
We plan to develop a module to establish a Medication Therapy Adherence Clinic for Paediatric Thalassemia.

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