T his is the official journal of the Postgraduate Medical Volume 12 Number 1 . 2013 P E Education Society of Hospital Ipoh (Pertubuhan R A Pendidikan Perubatan Lepas Ijazah Hospital Ipoh) K PMJ M and the Clinical Research Centre Perak (CRC PERAK MEDICAL JOURNAL E D Perak), Hospital Raja Permaisuri Bainun. The recent I C A formerly known as Medical Practice Hospital Ipoh change in name reflects the wider coverage and L J representation of the journal for the region. O U R P N erak Medical Journal is a registered journal with A L an International Standard Serial Number (ISSN) issued by the National Library of Malaysia. All articles published, including editorials and letters, represent the views of the authors and not necessarily those of the Editorial Board or of the Ministry of Health. “ Research is to see what everybody else has seen, and to think wh“at nobody else has thought. Albert Szent-Gyorgyi (1893–1986) Hungarian Physiologist Won the Nobel Prize for Medicine 1937 Credited with discovering vitamin C Editorial 1 Interventional Research 4 Observational Research 14 Diagnostic Studies 69 Systematic and Literature Reviews 72 Case Reports and Case Series 75 V o l Other Research 86 u m Investigator Initiated Research 104 e 1 2 Industry Sponsored Research 139 N u m b e HOSPITAL IPOH r 1 • 2 0 1 3 DESKTOP SYSTEMS Tel: (05) 291 1830 Fax: (05) 292 1830 http://www.dts-web.com Email: [email protected] A Publication of the PGMES Hospital Ipoh & CRC Perak ISSN 1394-8474 Perak Medical Journal POSTGRADUATE MEDICAL EDUCATION SOCIETY INSTRUCTIONS TO AUTHORS OF HOSPITAL IPOH (PGMES) (formerly known as Medical Practice Hospital Ipoh) HOSPITAL IPOH Papers should be sent to: ABSTRACT The official journal of the Postgraduate Medical Education Society of Hospital Ipoh (Pertubuhan Pendidikan Perubatan THE EDITOR Research or scientific article should generally include a Lepas Ijazah Hospital Ipoh) and the Clinical Research Centre Perak Medical Journal structured abstract of about 250-500 words. This should be Perak (CRC Perak), Hospital Raja Permaisuri Bainun. The (formerly known as Medical Practice Hospital Ipoh) concisely written under the following headings: recent change in name reflects the wider coverage and Clinical Research Centre Perak, • Study Title representation of the journal for the region. OFFICE BEARERS FOR 2012/2013 4th Floor, Ambulatory Care Centre, • Authors and affliated Institutions Hospital Raja Permaisuri Bainun Ipoh, 30990 Ipoh. • Introduction and Objectives 2013 EDITORIAL COMMITTEE President Dato' Dr Krishnan Chandran Tel: 605-2085138, Fax: 605-2425477 • Methodology Email: [email protected], [email protected] • Results Editor Vice-President Dato’ Dr Amar-Singh HSS Dato’ Dr Amar-Singh HSS • Conclusion They should be prepared according to the Uniform • Keywords (3-5 keywords) Editorial Board Secretary Requirements for Manuscripts Submitted to Biomedical • NMRR ID (all research to be conducted and all abstracts Dr Sharon Linus Lojikip Dr Brian Cheong Mun Keong Journals1. submitted must be registered with the National Medical Lim Wei Yin Ooi Qing Xi Assistant Secretary Research Register2 (https://www.nmrr.gov.my) Nor Aizura Zulkifli Dr Sree Kantan Nayar GENERAL POINTS Lina Hashim Treasurer The journal is interdisciplinary and inter-profesional. PRINTING Dr Lionel Chia Dr Noor Khatijah Nurani It is intended to provide an avenue for all categories of Any manuscript that includes colour prints will incur an Sivanesan Seevagan medical staff in the region of Perak and wider afield, additional cost in printing. The editorial board will consider Dr Arvinder Singh Harbaksh Singh Committee Members Dr Netia Jeganathan Dato’ Dr Mukudan Krishnan to publish research work carried out. It also serves as a such articles but may request the authors to pay the additional Suria Junus Dato’ Dr Hj. Wahinuddin Sulaiman forum to discuss clinical and epidemiological issue of costs. Abdul Haq Nurhaizan Dr Akbar Ali Hatim Ali interest and relevance. Research article, reviews, clinical Kalpana Devi Balagangatharan Dr Rosalind Simon practice and opinions (including dissenting views) are all REFERENCES Advisors Auditors welcome. • References should be written in accordance with the Dr Raja Lope Ahmad Raja Ariffin Dato’ Dr Norain Karim Vancouver agreement1 and be cited numerical in the order Director Raja Permaisuri Bainun Hospital, Ipoh Perak Dr Ker Hong Bee • All material submitted for publication is assumed to be listed. Dato' Dr Hjh. Nordiyanah Hj. Hassan The Postgraduate Medical Education Society of Hospital Ipoh was submitted exclusively to the journal unless otherwise • All authors should be listed unless there are more than 6, in Director of Medical & Health Services, Perak State first conceived in 1991. It received official status with its registration stated. which case the remainder should be stated as et al. in 1993. Over the years Postgraduate Medical Education Society of • All authors must give their written consent to • Example: Ibrahim ES, Wong SP. Childhood drowning in Perak Medical Journal is a registered journal with an Hospital Ipoh has been active in promoting postgraduate medical publication. the Perak River, Public Health J 1995; 34:123-125. International Standard Serial Number (ISSN) issued by the education and the development of facilities for such activities. This • All manuscript must be submitted in electronic form, National Library of Malaysia. All articles published, including journal, the Perak Medical Journal, is one such activity. produced on Microsoft Word, emailed to the Editorial SPECIAL NOTE TO AUTHORS editorials and letters, represent the views of the authors and not necessarily those of the Editorial Board or of the Ministry CLINICAL RESEARCH CENTRE (CRC) PERAK Board ([email protected], [email protected]) The editorial board will gladly assist all new authors and of Health. • Number the pages, top right. those who feel "uncertain" in improving on the manuscript RAJA PERMAISURI BAINUN HOSPITAL • Define all abbreviations. quality before publication. The editorial board retains All manuscripts submitted to the journal should be in • The journal encourages the use of 95% confidence the right to style and if necessary may shorten material accordance with the "Instructions To Authors" (printed on the intervals where appropriate statistical analysis permits. accepted for publication. Perak Medical Journal (formerly last page of the journal) and submitted to the address listed • Give the name, address, telephone, fax number and known as Medical Practice Hospital Ipoh) is registered with below. CRC Perak Team Dato’ Dr Amar-Singh HSS (Head) e-mail address of the author to whom correspondence the National Library of Malaysia and has an international Editorial Address: Lina Hashim (Administrator) should be sent. standard serial number (ISSN) i.e. it can be cited. The Editor Dr Sharon Linus Lojikip • Authors may be requested to produce the raw data on Perak Medical Journal Lim Wei Yin which the manuscript is based. COMMENTS (formerly known as Medical Practice Hospital Ipoh) Ooi Qing Xi • Manuscripts received will be acknowledged. Those not Perak Medical Journal (formerly known as Medical Practice Clinical Research Centre Perak, Nor Aizura Zulkifli 4th Floor, Ambulatory Care Center, Dr Lionel Chia accepted for publication will not be returned. Hospital Ipoh) is published once a year. All articles published Raja Permaisuri Bainun Hospital Sivanesan Seevagan including editorials, reviews, letters and book reviews and 30990 Ipoh, Perak Dr Arvinder Singh Harbaksh Singh AUTHORSHIP CREDIT they represent the opinion of the authors and not necessarily Tel: +605-2085138, Fax: +605-2425477 Dr Netia Jeganarthan Authorship credit shall be granted only if one is involved those of the Postgraduate Medical Education Society Of Farahanim Jamil in ALL of the following1: Hospital Ipoh. We are grateful to the Director-General, Ministry of Health Suria Junus 1. “Substantial contributions to conception & design, Malaysia for permission to publish the articles in this issue of Abdul Haq Nurhaizan Perak Medical Journal. Kalpana Devi Balagangatharan or acquisition of data, or analysis and interpretation REFERENCE Punitha Somasundram of data 1. Uniform Requirements for Manuscripts Submitted to Raja Permaisuri Bainun Hospital is proud of its postgraduate 2. Drafting the article or revising it critically for important Biomedical Journals: Writing and Editing for Biomedical activities. It was the first Malaysian government hospital to start a medical journal as well as set up a computer centre Members intellectual content Publication-Publication Ethics, Sponsorship, Authorship Datin Dr Ranjit Kaur Praim Singh for postgraduate purposes. 3. Final approval of the version to be published and Accountability, Updated April 2010, International Dr Jeyaseelan P Nachiappan 4. All 3 conditions should be met for assigning Committee of Medical Journal Editors (accessed from Dr V Paranthaman Doris George Visuvasam authorship.”1 www.icmje.org, 15th Nov 2010). Dato’ Dr Suarn Singh Jasmit Singh 2. Circulars from the Director General of Ministry of Health Dr Japaraj Robert Peter Individuals who do not qualify for authorship but have Malaysia: NIH Guidelines on Conducting Research in the Dr Philip Rajan Devashayam contributed to parts of study shall be included in the Ministry of Health, dated 05 September 2007 (accessed The Clinical Research Centre Perak (CRC Perak), Raja Permaisuri Acknowledgements section. from www.nmrr.gov.my) Bainun Hospital officially began functioning in March 2001. CRC EDITORIAL BOARD 2013 Perak is housed at Ambulatory Care Centre since 2006. Perak Medical Journal 12 1 2013 Volume Number • formerly known as Medical Practice Hospital Ipoh EDITORIAL 1 Addressing the Emotional Side When Things Go Wrong Amar-Singh HSS ABSTRACTS OF INTERVENTIONAL RESEARCH DERMATOLOGY 4 Reducing The Complication Rate Post Cryotherapy In A Dermatology Clinic Of A Regional Referral Hospital Tick-Sheng Ang, Esther-Anuradha Supramanian, Mohd Yuszely, Norhayati I NEPHROLOGY 5 Improving Haemodialysis Patients’ and Their Caregivers’ Knowledge on Prescribed Medications Noorsyamsidar Ahmad Sidi, Siew-Choo Pan, Ngah-Ling Eng, Engchi Cheow, Nor-Ashiqin Aiman Roslan, Cheiw-Yoke Tee PHARMACY 6 Improving Prescription Practices in Ministry of Health Primary Care Clinics: A Randomised Community Trial Wei-Yin Lim, Li-Meng Ng, Selva-Rani John Jasudass, Siti-Nur Umi Aminah Zainal Bahri, Amar-Singh HSS, Paranthaman-Vengadasalam, Lina-Hashim, Ranjit-Kaur Praim Singh, Asmah-Zainal Abidin, Afida-Nor Abu Hussain 7 To Reduce Medication Administration Error Through Enteral Feeding Tube in ICU Ward of a Specialist Hospital Chew-Beng Ng, Sing-Chian Tan, Ummi-Khadijah Bani, Suhaida Mustafa, Junaidah Ariffin PAEDIATRICS 8 Improving Knowledge on Antiepileptic Drug Among Children with Epilepsy and Their Parents in a Regional Referral Hospital Norafizah-Mohd Latiff, Noor-Aznita Ahmad, Kamalia-Tarkip, Salena-Md Isa, Nor-Azura Razali, Amar-Singh HSS, Wei- Yin Lim, Siti-Aishah S, Sok-Yee Lee, Norshazila-Julia Mohd Shafie 9 Improving Knowledge, Practice, Acceptance and Satisfaction of Kangaroo Mother Care Among Parents and Health Care Professionals Zanatulain Jamaluddin, Siti-Aniyam Suder, Bahariza-Lina Barozah, Idayu-Azlina Mohd Zaidi, Kim-Kea Khoo, Lina Hashim, Amar-Singh HSS, Arvinder-Singh Harbaksh Singh, Lionel Chia, Haymalatha Rajagam 10 Improving The Management of Prolonged Neonatal Jaundice in an Administrative Region, Malaysia Inthira-Sankari, Hui-Siu Tan, Amar-Singh HSS, May-Luu Yeong, Pui-San Tan, Ai-Yuin Leow, Ranjit-Kaur Praim Singh , Marina Kamaruddin, Asmah Zainal Abidin, Fatimahtuz Zahrah, Hasmawati Harun, Muzafaliazara Muaazan, Ruhaiza Rani 11 Safety and Immunogenicity of a Tetravalent Dengue Vaccine in Healthy Children Aged 2–11 Years in Malaysia: A Randomized, Placebo Controlled, Phase III Study Amar-Singh HSS, Mia-Tuang Koh, Kah-Kee Tan, Lee-Gaik Chan, Lynn-Zhou, Alain-Bouckenooghe, Denis-Crevat, Yanee-Hutagalung PUBLIC HEALTH 12 Improving Adherence to Anti-Diabetic Medication Therapy and Glycaemic Control among Diabetic Patients in a Government Health Clinic Subashini Ambigapathy, Zainul-Ikhwan Khusairi, Norwani Razali, Mohamad-Shahrizal Razali, Maznah Idris, Zhen- Khim Ang, Zin-Yi Teh, Sumathi Moorthi, Nordiahles Mohd. Zain, Peremah Copusamay PSYCHIATRY 13 The Impact of Home Medication Review (HMR) Programme for Patients Diagnosed with Schizophrenia: A Psychiatric Hospital’s Experience Yee-Mun Tan, Chee-Ping Chong, Yee-Chuang Cheah OBSERVATIONAL RESEARCH ANAESTHESIA & CRITICAL CARE 14 Awareness and Barriers Towards Standard Precaution Policies among Healthcare Workers in a District Specialist Hospital Hartini Abdul Rahman 15 Outcome of Acupuncture Treatment in a Malaysian Pain Clinic Kavita M. Bhojwani, Lee-Choo Yeoh A Publication of the PGMES & CRC Perak • ISSN 1394-8474 i PERAK MEDICAL JOURNAL • Volume 12 Number 1 2013 EMERGENCY AND TRAUMA CARE 16 Patient Satisfaction on Emergency Medical Services In a Malaysian Regional Referral Hospital Wai-Mun Chung, Ramzuzaman Ismail, Azma-Haryaty Ahmad, Rashidi Ahmad, Qing-Xi Ooi, Wei-Yin Lim, Adi Osman, Rishya Manikam, Nor-Aizura Zulkifli CLINICAL RESEARCH PERSPECTIVE 17 Attitudes, Barriers and Facilitators to The Conduct of Research: A Cross-Sectional Study Among Specialists in Government Hospitals in Perak Lei-Choo Teh, Mun-Pung Choy, Prema Muninathan, G. R. Letchuman Ramanathan 18 Public Awareness and Attitude towards Participation in Clinical Trials Sharon-Linus Lojikip, Amar-Singh HSS, Teck-Hock Toh, Ling Yap GERIATRIC 19 Innovation Pilot Study: Acute Geriatric Unit – Provision of Acute Elderly Care in Hospital with Limited Geriatrician Input Kee-Huat Chuah, Hang-Cheng Ong, Mun-Pung Choy, Chong-Hong Lim, Wee-Kooi Cheah MEDICINE 20 Ability of Newly Qualified Medical Officers to Use Self-Inflating Resuscitation Bag Rahizal-Othman, Nurakma-Arippin, Julaina-Jamal, Norainaa-Arifin, Khairunnisak-Azman, Sok-Yee Lee, Norshazila- Julia, Kalpana-Devi Balaganatharan, Eng-Lai Chew, Amar-Singh HSS 21 Factors Associated with Advanced Breast and Cervical Cancer in Larut, Matang and Selama District, Perak, 2010- 2011: A Retrospective Review Subashini Ambigapathy, Amutha Balu, Kallaivani Pachayappan, Sumathi Morti 22 Readmission Rate of Unstable Angina (UA) and Non-ST Elevation Myocardial Infarction (NSTEMI) in a District Specialist Hospital, Malaysia Nur-Hazlizat Hashim, Nur-Husniyah Sulaiman, Yean-Foong Yee, Zye-Wei Chiam, Nik-Afzan-Iftitah Mohd Nor, Siew- Hong Ling 23 The Use of Self-Monitoring Blood Glucose (SMBG) and Its Relationship with Glycaemic Control in Insulin-Treated Type 2 Diabetic Patient Wern-Jing Ding, Min-Choo Wong, Li-Yun Chong, Pui-Chin Kong, Aridza Amran, Soraya Rezuan OPHTHALMOLOGY 24 Macular Hole Surgery in Perak, Malaysia: A Retrospective Review Hong-Kee Ng, Lieh-Bin Ong OTORHINOLARYNGOLOGY 25 A Review of Daycare Tonsillectomies at a Regional Referral Hospital in Malaysia Zabrina-Marnel Samarakkody, Philip Rajan, Gurdeep-Singh Mahinder Singh 26 Clinical and Polysomnographic Data of Positional Sleep Apnea and Its Predictors Busarakum Teerapraipruk, Naricha Chirakalwasan, Rosalind Simon, Prakobkiat Hirunwiwatkul, Nattapong Jaimchariyatam, Tayard Desudchit, Natamon Charakorn6, Chaisiri Wanlapakorn, Supaporn Krittanupong, Nirun Intarut 27 Comparison of Polysomnographic and Clinical Presentations and Predictors for Cardiovascular-Related Diseases Between Non-Obese and Obese Obstructive Sleep Apnea Among Asians Naricha Chirakalwasan, Busarakum Teerapraipruk, Rosalind Simon, Prakobkiat Hirunwiwatkul, Nattapong Jaimchariyatam, Tayard Desudchit, Natamon Charakorn, Chaisiri Wanlapakorn 28 Severity of Obstructive Sleep Apnea in Patients with and without Cardiovascular-Related Diseases Rosalind Simon, Naricha Chirakalwasan, Busarakum Teerapraipruk, Prakobkiat Hirunwiwatkul, Nattapong Jaimchariyatam, Tayard Desudchit , Natamon Charakorn, Chaisiri Wanlapakorn, Supaporn Krittanupong, Nirun Intarut NEPHROLOGY 29 Comparison of Methods for Estimating Glomerular Filtration Rate in Intensive Care Patients with Unstable Kidney Function Yen-Ping Ng, Chee-Ping Chong, As-Niza Abdul Shukor, Indralingam Vaithalingam, G. R. Letchuman Ramanathan 30 Epidemiology and Outcome Among Continous Ambulatory Peritoneal Dialysis Patients Requiring Hospital Admissions in a Regional Referral Hospital, Malaysia Sridhar Ramanaidu, Meena Nithianandan, Yee-Yan Lee, Chek-Loong Loh 31 Infective Outcome of Haemodialysis Patients with Cuffed Dialysis Catheters (CDC) Insertion Yee-Yan Lee, Sridhar Ramanaidu, Chek-Loong Loh ii A Publication of the PGMES Ipoh Hospital & CRC Perak • ISSN 1394-8474 PERAK MEDICAL JOURNAL • Volume 12 Number 1 2013 NURSING 32 Compliance to Infection Prevention Guidelines with Appropriate Use of Personal Protective Equipment by Nurses at the Maternity Ward of a District Hospital Puvaneswari Tharumalingam 33 Critical Care Nurses’ Pain Assessment and Management Practices in a Regional Referral Hospital Devanandhini Krisnan, Kit-Weng Foong, Sze-Shir Foo, Nitthya Sukumar 34 Evaluation of Satisfaction for Nurses on Implementation of Unit Dose in a Regional Referral Hospital, Malaysia Lai-Yee Chan, Sze-Min Yeap, Villiam Surenvran 35 Knowledge and Attitude of Paediatric Nurses on the Appropriate Management of Fever in Young Children in the Ward Setting Hafizah Mohd Radzuan, Norfazila Jalil, Nor-Shafura Ahmad, Tasnim Ahmad Dali, Intan-Diana Mat Akob, Norazizo Abd Rahman, Lina Hashim, Sivanesan Seevagan, Jeyaseelan P. Nachiappan, Amar-Singh HSS, Norshazila-Julia Mohd Shafie 36 Knowledge of Insulin and Injection Technique among Nurses in a District Specialist Hospital Xin-Yi Beh, Ee-Siew Lai, Hui-Sheng Yeoh, Zi-Yi Ch’ng, Norulsaffia Ahmad 37 Nurses’ Knowledge and Practice in Preventing Perioperative Hypothermia Mei-Hong Ong 38 Nurses’ Knowledge Regarding Complementary and Alternative Medicine Therapy Norazian Adnan 39 Nurses’ understanding, Perception and Acceptance of Organ Donation from a Brain Dead Patient at a Regional Referral Hospital Nagaletchumi Arumugam 40 Paediatric Nurses’ Perceptions of Medication Errors in a Regional Referral Hospital Hooi-Beng Lee PHARMACY 41 Antibiotic Prescribing Pattern and Adherence to Malaysia National Antibiotic Guideline in a District Hospital Low-Yong Chia, Chit-Yee Chee, Yi-Lyn Yean, Huey-Ling Ng 42 Appropriateness of Adult Parenteral Nutrition Usage in Specialist Hospital Wan-Ning Ng, Wai-Han Wong, Nur-Sri Mohd Azmi, Nirmala-Devi Supramaniam, Li-Yin Ch’ng 43 Comparing Medication Documentation Discrepancies by Prescribers in a Regional Referral Hospital, Malaysia Sze-Ni Khoo, Lan-Sim Chew, Wei-Yin Lim, Sue-Anne Chia, Ee-Lin Chew 44 Describing the use of Medicine and Identification of Potentially Inappropriate Medicine among Elderly Patients Admitted to a Specialist Hospital Mun-Pung Choy, Ee-Siew Lai, Norulsaffia Ahmad, Kee-Huat Chuah, Hang-Cheng Ong, Soon-Chai Low, Wee-Kooi Cheah 45 Evaluation of Vancomycin Dosage Guideline in Neonates in a Specialist Hospital Sing-Chian Tan, Chew-Beng Ng, Aida-Noordina Ahmad Rahim, Nur-Afera Abdul Ghani, Sudharma Sherng-Yhau Na, Saiful-Rijal Muhammad 46 Evaluation of Knowledge on Colclean Solution And Bowel Preparation At a Specialist Hospital Shea-Jiun Choo, Kah-Keet Foo, Seraphina Jun-Ling Tan, Jie-Yun Lee, Bee-Chee Lee, Ramasamy Umasangar 47 Knowledge, Attitude and Practice of Vitamin Supplementation among Adult Patients in a District Specialist Hospital Kamariah-Shamsinar Kamarul Bahari, Yee-Han Ng, Pei-Yun Loo, Suraya Rahman 48 Multi-Source Feedback Programme for Evaluation of Provisionally Registered Pharmacists: A Multi-Centre Study in Malaysia Doris-George Visuvasam, Nurfadilla-Ferdaos, Mun-Pung Choy 49 Patient Satisfaction Survey on Extemporaneous Syrup Preparation for Paediatric Patients in the Outpatient Pharmacy of a Regional Referral Hospital in Perak Siti-Nur-Sharida Abdul Kadir, Siti-Aisyah Mohamed Nasir, Sharon-Min–Yang Hui, Nabilah Zainuddin, Naemah Mat Idris 50 Perceptions towards Generic Medicines among Medical Specialists and Consultants at a District Specialist Hospital in Malaysia: A Qualitative Insight Zhi-Yen Wong, Mohamed-Azmi Hassali, Abdul-Haniff Mohamad Yahaya, Fahad Saleem 51 Polymyxin Prescribing Pattern in a Regional Referral Hospital in Malaysia Ros-Sakinah Kamaludin, Kah-Shuen Thong, Chiew-Ang Khor, Hong-Bee Ker 52 Prevalence of Prescribing Error with Manual Prescribing System at a Regional Referral Hospital in Malaysia Chee-Tao Chang, Nalini Krishnasamy, Harveen-Kaur Olikh, Nurizzati Kamaruddin 53 Safety and Effectiveness of Tenofovir Disoproxil Fumarate (TDF) in HIV-Infected Patients in a Regional Referral Hospital, Malaysia Wei-Yee Ng, Ming-Hui Liew, Atiqah-Akmal Azil, Chiew-Ang Khor, Kean-Yau Woo, Hong-Bee Ker A Publication of the PGMES Ipoh Hospital & CRC Perak • ISSN 1394-8474 iii PERAK MEDICAL JOURNAL • Volume 12 Number 1 2013 54 Therapeutic Drug Monitoring of Vancomycin in Patients with End Stage Renal Failure (ESRF) Doris-George, Arvinder-Jeet-Kaur, Chung-Wei Chai, Wai-Yin Yong PAEDIATRICS 55 Ability of Healthcare Professionals to Perform Heel Prick in Neonates Wei-Yin Lim, Amar-Singh HSS, Pue-Siah Chin, Lionel Chia, Fatimah-Jusoh, Norhaslin-Mad Yusoff, Normazia Dolah, Sithra-Devi Subramaniam, Haymalatha Rajagam 56 Ability of Paediatric Hospital Staff to Perform an Intraosseous Insertion at a Regional Referral Hospital Khairul Wardah Abd Razak, Nazimah Ahmad, Noradibah Shamsul Bahri, Ruhayati Tukas Abdullah, Siti Fatimah Sahid, Kogillavani Arumugam 57 Do Paediatric Healthcare Professionals Handle Chemotherapeutic Drugs Appropriately? Jeyarani Palani, Nagalatchumi Marathaiveran, Nurkhairiah Mohd Nor, Jenuthanirani Shanmuganathan, Siti-Niza Othman, Halimah Md Isa, Nor-Aizura Zulkifli, Arvinder-Singh Harbaksh Singh, Amar-Singh HSS, Norshaliza-Julia Mohd Shafie 58 Healthcare Professionals Responsiveness to NICU Monitor Alarms in a Regional Referral hospital Jagdish Kaur, Rossaslinda Zuhari, Nurul-Nadiya Shahidan, Wan Aziani Wan Ahmad, Nor-Aizura Zulkifli, Amar-Singh HSS, Arvinder-Singh HS, Noor-Khatijah Nurani, Haymalatha Rajagam 59 Routine Management of Neonatal Jaundice in Term Neonates in Malaysian Special Care Nurseries Qing-Xi Ooi, Siti-Afifah Mohd Sarib, Normi Mohd Sharif, Siti-Zuridah Yahaya, Fadilah Arsad, Amar-Singh HSS, Haymalatha Rajagam PUBLIC HEALTH 60 Do Calorie Intake and Physical Activity Affect the Body Mass Index in Primary School-Going Children? Qing-Xi Ooi, Lionel-Dick-Hua Chia, Nafizah Omar, Azlinawati Aziz, Nur-Liyana Roslan, Siti-Sakinah Lokman, Noor-Aini Mat Ghani, Amar-Singh HSS, Bee-Sim Chua, Norshazila Julia 61 Global Childhood Unintentional Injury Study: Multi-Site Surveillance Data Siran-He, Jeffrey-C Lunnen, Prasanthi-Puvanachandra, Amar-Singh HSS, Nukhba-Zia, Adnan-A Hyder 62 How Do Parents Manage Fever in Their Young Children? Siti-Noor Amisah, Faziah Abdul Rahman, Nur-Zalifa Isaac, Norhidayah Abdul Rahman, Norazlina Ali, Lina Hashim, Karen Leong, Amar-Singh HSS, Sok-Yee Lee, Norshazila-Julia Mohd Shafie 63 Initiation of Breastfeeding and Its Practices among Multipara Mothers in Maternal and Child Health Clinics Siti-Hadhiroh Ali 64 Knowledge, Attitudes and Practice of Effective Family Planning Methods among High Risk Mothers Attending Health Clinics for Antenatal Check-Ups Sivakamasundari Ratnam 65 Why Are Parents Reluctant to Immunise Their Child? Norhabibah Rahmat, Nurul-Aisyah Mustafa, Fatimah-Sham Mohd Yusof, Rohana Abd Rahman, Suriram Itam, Chin- Hwa Chan, Wei-Yin Lim, Netia Jeganathan, Amar-Singh HSS, Norshazila-Julia Mohd Shafie PSYCHIATRY 66 Admission Trends of Patients with Mental Illnesses at a Psychiatric Regional Referral Hospital (2008 - 2010) Fatimah Sain RHEUMATOLOGY 67 Chronic Pain with Anxiety and Depression: A Comparison Between Patients Attending Multidisciplinary Pain and Rheumatology Clinic Wahinuddin Sulaiman, Norhasniza Mohamed Zanyuin, Kin-Kheong Mah, Kavita M. Bhojwani 68 Patient Satisfaction with Follow-Up Monitoring Care at The Rheumatology Outpatient Clinic Ping-Seung Ong, Wahinuddin Sulaiman, Salwa Hanim DIAGNOSTIC STUDIES 69 Comparing Point of Care Devices for International Normalised Ratio Testing with Standard Laboratory Methods at a Hospital Based Anticoagulation Clinic Doris-George Visuvasam, Wai-Keng Foong, Choy-Yuen Choo, Huzaini P 70 Evaluating 8-Item Morisky Medication Adherence Scale and Pill Count as Measures of Medication Adherence and Investigating the Feasibility of Routine Medication Return by Patients Siew-Hong Ling, Wei-Yin Lim, Yi-Jie Hu, Li-Yuan Lee, Hui-Li Lin, Noor-Azrina Sanik, Nurul-Zuhanis Mohamed, Yean- Foong Yee 71 Validation of Malay Version of Montreal Cognitive Assessment in Patients with Cognitive Impairment Wooi-Kooi Cheah, Hoon-Lang Teh, Diana-Huang, Mun-Pung Choy , Alan Ch’ng, Ewe-Eow Teh, Irene Looi iv A Publication of the PGMES Ipoh Hospital & CRC Perak • ISSN 1394-8474 PERAK MEDICAL JOURNAL • Volume 12 Number 1 2013 SYSTEMATIC AND LITERATURE REVIEWS OTORHINOLARYNGOLOGY 72 Body Stuffing and The Otolaryngologist? Philip Rajan, Aidayanti Daud 73 Changing Trends in Oesophageal Endoscopy: A Systematic Review of Transnasal Oesophagoscopy Junainah-Sabirin, Maharita-Abd Rahman, Philip Rajan 74 Management of Otitis Media with Effusion in Children: A Systematic Review Zulkiflee Salahuddin, Philip Rajan, Sobani Din, Nik-Khairulddin Nik Yusoff, Jaclyn Pei-Lee Teoh, Siti-Sabzah Mohd Hashim, Asma Abdullah, Norizzati-Bukhary Ismail Bukhary, Mazapuspavina Md Yasin, Roza Sarimin, Mohd- Aminuddin Mohd Yusof, Hafeza Ahmad, Rafidah Mazlan, Shahrom Ab Rahman, Juliana Samsudin, Suhaidie Manan CASE REPORTS AND CASE SERIES DERMATOLOGY 75 Hydroa vacciniforme Like Cutaneous T Cell Lymphoma: A Rare Variant Tick-Sheng Ang, Jyh-Jong Tang, Norain Karim 76 Trigeminal Trophic Syndrome: A Case Report and Literature Review Jyh-Jong Tang, Norain Karim, Esther-Anuradha Supramanian EMERGENCY & TRAUMA 77 High Pressure Injection Injuries: A Case Series Azma-Haryaty Ahmad, Adi Osman, Abdul-Kursi Abdul Latif, Wai-Mun Chung 78 Therapeutic Hypothermia Post Cardiac Arrest Adi Osman, Abdul-Kursi Abdul Latif, Ramzuzaman Ismail, Azma-Haryaty Ahmad, Asri-Rangga Abdullah, Kit-Weng Foong NEPHROLOGY 79 Bilateral Visual Loss Due to Lupus Retinitis in a Patient with Systemic Lupus Erythematosus and Antiphospholipid Syndrome Yee-Yan Lee, Sridhar Ramanaidu, Chek-Loong Loh, Hong-Kee Ng 80 Severe Symptomatic Hypocalcaemia and Hypokalaemia Caused by Oral Sodium Phosphate Solution (Fleet®) in a Haemodialysis Patient with Tertiary Hyperparathyroidism Sridhar Ramanaidu, Yee-Yan Lee, Chek-Loong Loh OTORHINOLARYNGOLOGY 81 An Arrow Foreign Body Involving Parotid Gland, Maxillary Sinus And Tip Off Nose Suhana, Thevagi M, Lina LC, Avatar Singh 82 The Child with Suspected Hearing Loss: A Case Report Philip Rajan 83 Transient Vocal Cord Palsy due to Infection Mimicking Malignancy Kai-Jun Tey 84 Unusual Foreign Bodies of the Head and Neck: A Retrospective Case Series Aidayanti Daud, Philip Rajan, Harvinder-Singh Dalip Singh, Gurdeep-Singh Mahinder Singh 85 Unusual of Parotid Gland Presenting as Sialolithiasis: Case Report and Literature Review Sridhar Sivapatha-Sundaram Sreetharan, Philip Rajan OTHER RESEARCH INVESTIGATOR INITIATED RESEARCH INDUSTRY SPONSORED RESEARCH A Publication of the PGMES Ipoh Hospital & CRC Perak • ISSN 1394-8474 v PERAK MEDICAL JOURNAL • Volume 12 Number 1 2013 EDITORIAL ADDRESSING THE EMOTIONAL SIDE WHEN THINGS GO WRONG (HEALTHCARE PROVIDER VIEW) Amar-Singh HSS Senior Consultant Paediatrician (Community) & Head Paediatric Department, Raja Permaisuri Bainun Hospital, Ipoh, Perak. Head Clinical Research Centre (CRC) Perak, Perak. Editorial Note: This paper was presented at the Malaysian Society for Quality in Health (MSQH) Conference 3–4 September 2013, Putrajaya, Malaysia. INTRODUCTION of anger and a need for restitution come into force. Some will likely experience these at a later date when they have left the Medical errors are a painful but real and common part of hospital, or if instigated by relatives and friends. any health practice or environment. Patients and the family are devastated when it happens, especially when the errors Throughout the process it is important the medical are serious. The response of health administrators is often professionals not look to protecting themselves as much negative and punitive. The possibility (and a growing culture) as supporting the patient and family. Attentive listening of litigation only makes things worse. As such many healthcare is a vital task that allows the patient and family to express professions attempt to avoid or run away from errors by their fears, confusion and frustration. There is no need to ‘covering up’ (hiding them) or displacing responsibility to push for an immediate reconciliation or try to placate the junior staff. person(s). It is important to avoid some phrases/words and sentiments like “I understand what you are going through”, There is only one mature and responsible approach to medical “this is God’s will (takdir Tuhan) and you have to accept it” errors and that is to take joint responsibility as a team of or “don’t worry, everything will be alright”. These opinions healthcare professional for the medical error, disclose it to the are unrealistic, not true and paternalistic. They harm more patient and family, support the patient as best we can, assist than they help. A real attitude of empathy, a willingness to the professional who made the error and work to prevent it support with honesty about what has happened is the best from happening again. healing approach. Constantly assess their needs with a view to offering professional support, if necessary. There may be DISCLOSING MEDICAL ERROR AND SUPPORTING THE a need to offer a clear idea of the process of inquiry into the PATIENT & FAMILY incident. Even to the extent of involving the patient or family in the investigation of the incident. Disclosure of a medical error to patient or family is extremely difficult. It should not be left to the junior most staff but An important area to recognise in supporting patients and be done by the senior most person available. It should be families is that they may feel vulnerable as, in most situations, done promptly and honestly. Healthcare professionals must the patient will need continued care with the same healthcare take responsibility and apologise, when appropriate. There professionals and system that ‘harmed’ them. Rebuilding trust is no easy way to do it but training and experience help is an integral issue in continued support. considerably. It is unethical not to disclose an error. IMPROVING DISCLOSURE – A VEHICLE FOR HEALING One common ‘failure’ is a reluctance to engage other members of the family. In the local cultural context, where grandparents That disclosure can be a healing activity is poorly recognised and siblings are important decision makers in a person’s or by healthcare professionals. Well conducted disclosure is child’s life, it is important to be open to meeting a group of a powerful vehicle for healing for the patient, family and relatives when communicating a medical error. This can be professional. It strengthens the therapeutic bond between daunting but, in my experience, is usually rewarding. However the family and the healthcare professional. In the forefront our primary responsibility must be to the adult patient or of such work has been the Medically Induced Trauma Support both parents of a child, and they must always be informed first. In our ‘feudal society’ men often do not give sufficient Services (MITSS, see their website). In their mission statement respect to their wife’s views or needs in this situation. For they state “To Support Healing and Restore Hope to patients, children, neither the father nor mother can take precedence families, and clinicians following adverse medical events”. in disclosure of a medical error. A cope component of disclosure is effective communicating. Disclosure is not a ‘one-off’ activity. It requires repeated Investigations of medical errors often reveal a breakdown in explanations and clarifications as patients and family come communication among hospital staff. The lack of information to terms with the incident. It requires us dealing with the and adequate communication after such an event further emotional crisis that families go through. Initially the patient compounds it and leads to demands for compensation or and family are focused on the damage – how much has the legal proceedings. error affected the patient. They want information on what we are going to do medically to repair the damage. As the A review of the literature prior to 2005 by Mazor et al showed shock and confusion wears off then more intense emotions that there were very few research publications on disclosure A Publication of the PGMES Ipoh Hospital & CRC Perak • ISSN 1394-8474 1 EDITORIAL PERAK MEDICAL JOURNAL • Volume 12 Number 1 2013 of medical errors to patients and families. Few studies have CASE STUDIES – A GOOD AND BAD EXAMPLES considered the disclosure process, the consequences of disclosure, or the relationship between the two. These were presented at the conference. Case studies were not included in the written document to protect the identity A large survey of clinicians by Gallagher et al (2006) showed of patients and medical staff. that there was wide variation regarding what information physicians would disclose in the situation of a medical error. THE “SECOND VICTIM” – HEALTH PROFESSIONALS 56% would choose statements that mentioned the adverse NEED HELP TOO event but not the error, while 42% would explicitly state that an error occurred. Some physicians disclosed little information. Often, in dealing with medical errors, the needs of the medical professionals are overlooked. Doctors, pharmacists and nurses Work by Gallagher and his research team shows that clinicians struggle considerably after being involved in a medical error, can be supported to disclose errors to patients/families. The especially if it is preventable. Often there is the element of work is summarised below: guilt and failure, a loss of confidence in abilities and decision making, and persistent memories with flashbacks. Some feel (http://www.greenwall.org/scholar-profile.php?id=8) like abandoning their careers and a few have been known to take their own lives. Hence the term “second victim” has been 1. How do patients want doctors to respond to used to describe this. medical errors? patients want clinicians to: A large survey by Waterman et al of more than 3,000 clinicians • Disclose the error showed that the majority had been involved in a medical error, with 57% of them being severe errors. Only 18% of the • Take responsibility for the error and apologize physicians had received education or training on disclosing errors to patients. 90% expressed that hospitals and health • Tell them what caused the error and what will be done to care organizations did not adequately support them in coping prevent similar errors in the future with stress associated with medical errors. 61% reported increased anxiety about future errors, 44% loss of confidence, 2. How do doctors actually respond to medical 42% sleeping difficulties, 42% reduced job satisfaction, and errors? 13% harm to their reputation. • When an error occurs doctors often do not say explicitly that The problem is often exacerbated or compounded by a poor an error had occurred or why or how similar errors would be response of managers and the lack of support from peers prevented in the future and the system. Managers often tend to quickly apportion blame or adopt a one-sided view of an error making it difficult • Hence clinicians support disclosure of errors in theory but in for healthcare professionals. A high profile error with media practice typically provide much less disclosure than patients coverage often ends up as a trial by media rather than a would like good hard look at the real facts. Doctors, nurses and other health professionals in Malaysia work daily in suboptimal 3. wHat are tHe barriers to pHysician disclosure of environments with suboptimal resources. When an error errors? occurs, the medical system and the public/media tend to blame the individual rather than the system. Both the media • Lack of confidence in their ability to carry out these difficult and the health system need to differentiate and respond conversations differently to errors that are unavoidable, system related, unintentional, due to a lack of training or knowledge, and • Lack of institutional support medical negligence. The comments above are not meant to detract from errors committed by uncaring professionals (true • Shame or embarrassment medical negligence). Or those are as a result of a failed medical school training that produces incompetent individuals. Both • Note that what was not a major factor is fear of malpractice are not uncommon occurrences. However the reality is that or lack of moral courage many errors are committed in difficult situations, with staff under pressure, working in limited environments. 4. How can disclosure of medical errors be increased? Doctors, pharmacists and nurses require routine support after a medical error occurs. This includes support on: • Strengthening institutional support for physician disclosure of errors • how to conduct a meaningful disclosure conversation • Developing partnerships among health care institutions and • on-going support after the event and during the investigation state officials to encourage physicians to disclose errors, while addressing physician concerns about disclosure • legal support if necessary 2 A Publication of the PGMES Ipoh Hospital & CRC Perak • ISSN 1394-8474 PERAK MEDICAL JOURNAL • Volume 12 Number 1 2013 EDITORIAL • allowing for ‘story telling’ or a debrief after an error with a 11. Wears R.L., et al.: Human error in medicine: Promise & compassionate senior colleague is vital pitfalls, part 1. Ann Emerg Med 36:58–60, Jul. 2000. There should be a clear policy in all health organisations on 12. WHO. Patient Safety Workshop: Learning From Error. how to support healthcare professionals after a medical error World Health Organization 2008. WHO/IER/PSP/2008.09 (see ‘Medically Induced Trauma Support Services’ fro ideas). Note about the Author: “Only when health care institutions commit resources to Dato’ Dr Amar-Singh HSS, Cert Theology (Aust, Hons), MBBS (Mal), MRCP patients, physicians, and other involved hospital staff can (UK), FRCP (Glasg), MSc Community Paediatrics (Ldn, dist.), is a Senior all those negatively affected by medical errors receive the Consultant Paediatrician (Community) and the Head of the Paediatric Department at HRP Ipoh Hospital, Malaysia. He is also the Head of the support they need”.Waterman et al 2007 Clinical Research Centre at Perak. He has a long standing interest in children with disability, family self-help groups, NGOs, child abuse, adolescent ACKNOWLEDGEMENT counselling, disadvantaged/marginalised children & the development of services for children. He has an active practise supporting and working with parents, children, NGOs as well as supporting governmental agencies. He I want to thank Dr Jeyaseelan Nachiappan and Dr Khoo Kim is very active in research and postgraduate paediatric training. With his Kea, Consultant Paediatricians and colleagues, who read this wife, he is also offers spiritual direction and counselling. He is the current document and offered valuable suggestions for improvement. president of the Nation Early Childhood Intervention Council. SOME USEFUL REFERENCES/SITES: 1. Bernhard B. Medical errors leave devastating impact on families, professionals. St. Louis Post-Dispatch. http://www. stltoday.com/lifestyles/health-med-fit/health/medical- errors-leave-devastating-impact-on-families-professionals/ article_0cb6f031-fbc6-5b8f-bed9-610163dbf2f8.html 2. Carr S. Disclosure and Apology: What’s Missing? Medically Induced Trauma Support Services. http://www.mitss.org/ MITSS_WhatsMissing 3. Edwin A.K. Non-Disclosure of Medical Errors an Egregious Violation of Ethical Principles. Ghana Medical Journal. March 2009 Volume 43 Number 1. 4. Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006 Aug 14- 28;166(15):1585-93. 5. Gallagher TH. Disclosing Medical Errors to Patients: Bringing physician practice closer to patient needs. http://www. greenwall.org/scholar-profile.php?id=8 6. Healing the Healer Film 7. https://www.rmf.harvard.edu/Clinician-Resources/ Video/2010/Healing-the-Healer 8. Kenney LK. Addressing the Emotional Side When Things Go Wrong. Medically Induced Trauma Support Services Inc. 9th Annual Maryland Patient Safety Conference, April 5, 2013. 9. Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med. 2004 Aug 9-23;164(15):1690-7. 10. Waterman, Garbutt, Hazel, et al. The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada. The Joint Commission Journal on Quality and Patient Safety. August 2007 Volume 33 Number 8. A Publication of the PGMES Ipoh Hospital & CRC Perak • ISSN 1394-8474 3