Page 57 - 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
th
11 National QA Convention, 4 – 6 October 2022
PP-19

Reducing the Percentage of Inappropriate Tramadol Prescribing in the Emergency &
Trauma Department (ETD) of Hospital Tuanku Ampuan Najihah (HTAN)

Ser YT , Pang SF , Amril A , Nurfatin MM , Wan CX , Siti AR 2
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1 Pharmacy Department, Hospital Tuanku Ampuan Najihah, Negeri Sembilan
2 Emergency and Trauma Department (ETD), Hospital Tuanku Ampuan Najihah, Negeri Sembilan
SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:
Tramadol usage in ETD HTAN increased by 45.7% from 2018 to 2020. Tramadol is considered a safe analgesic
but is also associated with common and serious side effects. A verification study showed that 76.6% of tramadol
prescribing in ETD HTAN was inappropriate.

KEY MEASURES FOR IMPROVEMENT:
The indicator was the percentage of the total number of tramadol prescriptions not following ETD pain
management guidelines with a standard of 20% based on the consensus in pharmacy and ETD department
meetings. Inappropriate tramadol prescribing in ETD was defined as tramadol prescribed in ETD not in
accordance with the Pain Management in ETD Guideline.

PROCESS OF GATHERING INFORMATION:
A cross-sectional study was conducted using universal sampling in an Emergency Pharmacy. A data collection
form was used to collect data from ETD prescriptions, while an online questionnaire was distributed to doctors
and pharmacists.

ANALYSIS AND INTERPRETATION:
The pre-remedial study (October to December 2020) showed inappropriate tramadol prescribing rate was
76.6%. The achievable benefit not achieved (ABNA) gap was 56.6%. The main causes were not following
ETD pain management guidelines among doctors and pharmacists (100%), common prescribing practice
among doctors in ETD (86.7%), lack of intervention by pharmacists (77.8%) and low awareness of ETD pain
management guidelines among doctors and pharmacists (48.3%).

STRATEGIES FOR CHANGE:
The strategies were the establishment of ETD Pain Management Quick Note, online continuous medical
education (CME), and focus group discussions with the Head of ETD for standardising the prescribing practice
among doctors according to the guideline.

EFFECT OF CHANGE:
The post-remedial study (September 2021-February 2022) revealed a reduction of inappropriate tramadol
prescribing from 76.6% to 18.5%, with ABNA reduced to 0%.

THE NEXT STEP:
We plan to expand the study to ETD in other cluster hospitals. Besides, continuous monitoring and education
under the orientation module will be carried out.

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