Background Closed Loop Medication Management System (CLMMS) is an end‐to‐end medication delivery system comprising seamless interfaces, independent verification processes and information feedback to improve safety and quality. Aim Following implementation of a CLMMS at an academic medical centre in Singapore, this study was conducted to identify any safety issues and areas for quality improvement. Method A direct observational study was conducted in the wards, inpatient pharmacy and unit‐dose satellite pharmacy. The numbers and types of medication errors in prescribing, supply and administration were observed and recorded to calculate the error rate. Events that have the potential to cause errors were also observed. Results The prescribing error rate was 1.3% and the most common prescribing error was dose error. Supply error rate was 0.7% in which labelling error occurred most frequently. Workflow issues were the most common occurrences that could potentially cause prescribing and supply errors. The administration error rate was 7.3%, and wrong drug preparation technique was most commonly seen. Improper procedure in the use of personal digital assistant was the most common event that could potentially lead to an administration error. Conclusion This study was instrumental in identifying important medication safety gaps in order to improve the inpatient CLMMS. Although a failure mode and effects analysis was performed prior to implementation of the system, unintended error types may still be introduced. Hence a post‐implementation audit is necessary to address such issues to ensure that the CLMMS objective of improving medication safety is achieved.

BackgroundMelioidosis is a problem in the developing tropical regions of Southeast Asia and Northern Australia where the the Gram negative saprophytic bacillus Burkholderia pseudomallei is endemic with the risk of fulminant septicaemia. While diabetes mellitus is a well-established risk factor for melioidiosis, little is known if specific hypoglycemic agents may differentially influence the susceptibility and clinical course of infection with B. pseudomallei (Bp).Methodology/Principal FindingsIn this cohort study, patients with pre-existing diabetes and melioidosis were retrospectively studied. Outcome measures: mortality, length of stay and development of complications (namely hypotension, intubation, renal failure and septicaemia) were studied in relation to prior diabetic treatment regimen. Peripheral blood mononuclear cells (PBMC) from diabetic patients and healthy PBMC primed with metformin, glyburide and insulin were stimulated with purified Bp antigens in vitro. Immune response and specific immune pathway mediators were studied to relate to the clinical findings mechanistically. Of 74 subjects, 44 (57.9%) had sulphonylurea-containing diabetic regimens. Patient receiving sulphonylureas had more severe septic complications (47.7% versus 16.7% p = 0.006), in particular, hypotension requiring intropes (p = 0.005). There was also a trend towards increased mortality in sulphonylurea-users (15.9% versus 3.3% p = 0.08). In-vitro, glyburide suppressed inflammatory cytokine production in a dose-dependent manner. An effect of the drug was the induction of IL-1R-associated kinase-M at the level of mRNA transcription.Conclusion/SignificanceSulphonylurea treatment results in suppression of host inflammatory response and may put patients at higher risk for adverse outcomes in melioidosis.

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Background: Antimicrobial resistance (AMR) has negatively impacted patient outcomes and increased healthcare costs. AMS includes all activities and policies to promote judicious use of antimicrobials. Pharmacists are key players in AMS models worldwide. However, there is a research gap in the impact of pharmacists' roles as antimicrobial stewards in Malaysia and their potential of role expansion. This study aims to qualitatively explore hospital pharmacists' perspectives on the issue of AMR, the impact they made during implementation of AMS strategies and their visions in role expansion.Methods and materials: Individual, semi-structured interviews were conducted with 16 public hospital pharmacists involved in AMS activities from 13 hospitals in Kuala Lumpur and Selangor from March to July 2018. These audio-taped interviews were transcribed verbatim and imported into NVivo software version 10.0 (QSR). Thematic analysis method was used to identify themes from the qualitative data until theme saturation was reached.Results: The results demonstrated that the respondents have good understandings on the issue of AMR and its impact. They felt injudicious prescribing is one of the main causative factors of AMR. This is further fueled by the lack of public awareness in AMR and the culture of demanding for antimicrobials from healthcare professionals. The involvement of pharmacists was seen as impactful in improving healthcare professionals' compliance towards principles of good antimicrobial therapy as well as reducing the use of broad-spectrum antimicrobials. The respondents also recognised that their involvement in AMS strategies helped to portray a better professional image of pharmacists. Currently, most pharmacists involved in AMS strategies are ward pharmacists. The respondents envisioned more hospital pharmacists from other units such as inpatient and outpatient pharmacy to be involved and to incorporate AMS principles into their daily practices. Some respondents aspire to take up the role of leading the AMS team, however others disagreed as pharmacists lack the priviledge to diagnose. Conclusion:Public hospital pharmacists have good understandings on the issue of AMR and view themselves as playing impactful roles in AMS team. For future study, views of pharmacists from other regions of the country, private sector, non-ward based pharmacists as well as community pharmacists should be included.