Minutes of meeting no. 4 of the Network for the Prevention of Medication Errors held on 18 November 2009

21 May 2010


The meeting was held on Wednesday 18 November 2009 at the Danish Medicines Agency.



  1. Welcome and 'news update', Danish Medicines Agency
  2. Status of the High-Risk Medicines Working Group
  3. The Shared Medication Record, Troels Asger Hansen, Danish Medicines Agency
  4. Quality assurance of procedures in clinical pharmacy and experiences with the Shared Medication Record, Lene Stenbek, Hospital Pharmacy at Næstved Hospital
  5. Quality control of hospital operational procedures, Anne Mette Dons, Danish National Board of Health
  6. New sources of error from the implementation of electronic prescribing, Annemarie Hellebek, Danish Society for Patient Safety
  7. Any other business
    Next meeting – Wednesday 14 April 2010.



Re item 1. Welcome
Marie Melskens welcomed the attendants and gave an account of the development in the area at the Danish Medicines Agency since the last meeting (presentation in Danish is attached).
Kim Peder Dalhof expressed his wish to be informed of the OBS announcements that the Danish Medicines Agency dispatches and mentioned the possibility of cooperation between the Danish Poison Control Hotline and the Danish Medicines Agency in the area of abuse and overdoses.
Annemarie Hellebek and Lene Stenbek recommended to consider the criteria for sending out OBS announcements from the Danish Medicines Agency. Annemarie Hellebek expressed a wish to receive a central list of the most frequent mix-ups based on a review of the reports made to the Danish Patient Safety Database.
Bente Dam explained that Amgros is considering the layout of the packaging as part of their procurement policy.

Re item 2. Status of the High-Risk Medicines Working Group
Marie Melskens reported on the status of the working group by noting that a first draft of a memo on the group's work was being prepared. The working group has agreed on a definition and a list of high-risk medicines, and will, among its initiatives, propose that a risk scoring system be developed to ensure that the list is continuously updated. Annemarie Hellebek added that the process had gone well and that there had been an important discussion on the choice of the term "high-risk medicines", which must be seen from the perspective of frequency. Frequency may be difficult to determine for adverse incidents, and another term will therefore be considered.

Re item 3. Focus on the Shared Medication Record
Troels Asger Hansen explained the basis for the Shared Medication Record, where the Danish Medicines Agency is supplier to Digital Health in Denmark (see attached presentation prepared under the Shared Medication Record programme, Connected Digital Health in Denmark, presentation is in Danish only). A general introduction to the Shared Medication Record is available in Danish on the website of Connected Digital Health in Denmark http://sdsd.dk/Det_goer_vi/Faelles_Medicinkort.aspx).
Anne Mette Dons pointed out that the applied definition of the Shared Medication Record lacked precision in regard to the fact that the last doctor to examine the patient was expected to have a total overview of the patient's current medication record. A general practitioner, however, cannot be accountable for the prescriptions made by a specialist.
Annemarie Hellebek mentioned the need for medical secretaries to have access to the Shared Medication Record in order to print from the electronic medication card. Anne Mette Dons explained that this would be made possible by classifying medical secretaries as technical support.
In order for the Shared Medication Record to be a success, it was generally felt that the system should be flexible, in particular with respect to dosage. There should be a clearly visible indication in the system when the dose is adjusted up or down, especially with respect to anti-coagulants and insulin products. In addition, it must appear clearly if the specified dose is 'weekly'. There was also a wish that 'three times a day' instead be specified as 'morning, noon, evening or night', as this would ease transition between sectors. This specification of time of dose may turn out to be a problem in connection with the dose 'once a day'.
Furthermore, it should be unanimously agreed whether the dose is specified in international units or in mg/μg. The Danish National Board of Health agreed to investigate this further.
For further information about the Shared Medication Record, please contact Send an email.

Re item 4. Quality assurance of procedures in clinical pharmacy and experiences with the Shared Medication Record
Lene Stenbek first went through the experiences gathered from the Shared Medication Record so far, and explained how Region Zealand had implemented it in its electronic prescribing system OPUS (see presentation, in Danish only).
Problems have been identified with the dose specification between medicinal products, as the dose varies between units and mg. The OPUS system is updated in such a way that during back orders, the doctor may only order substitution products at the same time as products in back order are removed from the medicine rooms. Finally, Lene Stenbek spoke about quality assurance of hospitals' procedures.


Re items 5 and 6
Since the meeting approached the hour, these two items were postponed to the next meeting.

Re item 7. Any other business
Re a) Next meeting will be held Wednesday 14 April 2010, where 'Quality assurance of procedures of medicine handling' will also be on the agenda.
Finally, several of the attendants proposed topics for discussion at the next network meeting.


Amgros I/S: Bente Dam
Association of Danish Pharmacies: Mette Gram Hansen
Danish Drug Information: Christianna Marinakis,
Danish Society for Patient Safety: Annemarie Hellebek
Association of Hospital Pharmacies in Denmark: Lene Stenbek
Danish Nurses’ Organization: Janne Due Sommerset,
Danish Poison Control Hotline: Kim Peder Dalhoff
Institute for Rational Pharmacotherapy: Marianne Møller
Danish Medical Association: Geert Amstrup
Danish Association of the Pharmaceutical Industry: Helen Shennan, Marie Lund,
The Danish Medicines Agency: Lene Havsteen, Lone Stengelshøj Olsen, Marie Melskens
Pharmadanmark: Helle Byg Armandi, Sonja Paltoft
Pharmakon: Charlotte Rossing
National Board of Health: Anne Mette Dons, Marianne Søeborg Nielsen


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