[Re: https://www.hifa.org/dgroups-rss/introduction-gracia-didas-tanzania-safe... ]
Dear Neil,
Thank you very much for your thoughtful email. I appreciate your insightful explanation of patient safety and the safe and effective use of medicines and I fully agree that medication safety extends beyond preventing administration errors at the bedside. Rational prescribing, appropriate medicine selection, and understanding the system factors that contribute to errors are all essential components of ensuring safe, high-quality patient care.
One example from my experience involved a patient who attended our hospital for his routine monthly medication refill. He had been receiving long-term treatment for hypertension and was prescribed a regimen that included a combined drug therapy of losartan 50 mg, hydrochlorothiazide 12.5 mg, and bendroflumethiazide 5 mg.
During our medication review, we identified that the patient was receiving two thiazide diuretics concurrently. Clinically, the combined use of multiple thiazide diuretics increases the risk of hypokalemia (low serum potassium), which can impair insulin secretion and contribute to elevated blood glucose levels, and in this case the patient had indeed started developing a rise in blood glucose levels, prompting us to reassess his treatment.
So, rather than viewing this as an individual prescribing error, we worked collaboratively with the Physician to discontinue the duplicate thiazide therapy and optimize the patient's antihypertensive regimen while closely monitoring both his blood pressure and blood glucose during his follow-up clinic visits.
Therefore it is such experiences that reinforce the importance of regular medication reviews and multidisciplinary collaboration in ensuring the safe and effective use of medicines but also the need for continuous patient education because, when patients understand the purpose of their medicines and their potential side effects, they become active partners in their own care and potential medication related problems can be identified and prevented much earlier.
Above all, Patient safety is built on strong systems rather than individual vigilance alone and I believe that every patient encounter is an opportunity to reassess whether a treatment remains appropriate, safe, and effective, and to make improvements that ultimately lead to better patient outcomes.
Thank you!
Gracia Didas,
Pharmacist, Cardinal Rugambwa Hospital.
HIFA profile: Gracia Didas is a Pharmacist at Cardinal Rugambwa Hospital, Tanzania, where she is chair of patient safety. Professional interests: Pharmaceutical Services, Patient Safety (Medication Safety), Mental health advocacy. She is a HIFA Country Representative. gracydyder AT gmail.com