Systems & Medication Errors in Healthcare Practice
Pharmaceutical (Technical Reporter) The systematic and medication errors are potential challenges in healthcare practice as under,
Systems & Medication Errors: Institutions help minimize medication errors; Foster well-trained & knowledgeable staff; Maintain favorable work environment; Institute effective policies & procedures; Patient counseling; Plays important role in reducing medication errors; Increases likelihood of compliance.
Systems Legal Requirements Policies & Procedures: Designed to protect public; Ensure knowledgeable individual involved in process; Help prevent medication errors; Policies & procedures; Establish systems to prevent medication errors; Approximately 33% of errors due to noncompliance with policies & procedures.
Systems Multiple Check Systems might include: Pharmacist reviewing physician order; Pharmacy technician preparing medication; Nurse inspecting dose from pharmacy; Patient asking questions & examining medication before taking it.
Standardized Order Forms – Medication orders easier for: Prescriber to read; Pharmacist & nurse to interpret; Chemotherapeutic agents designated as high alert; Ideal drugs to be included on standardized order form; Use for complicated drug therapies/high-risk drugs; Preprinted forms legible; Informally educate prescriber about formulary
Education & Training Education & training: reduce medication errors: Pharmacy calculations; Compounding techniques; Pharmacy abbreviations; Preparation of iv medications; Computer operation skills; Classes of medications; Generic & trade names; Forms & doses.
Computerization & Automation: Bar coding; Automated dispensing cabinets (ADCs)l Robots; Pharmacy-generated MARs & labels; Computerized physician order entry (CPOE); Decrease # of personnel involved in ordering process; Decrease medication errors in transcription process
When an Error Occurs -Inform pharmacist about any known details: Pharmacist investigates error & contacts physician; Course of action depends on details of error; Inform patient about error; Policies & procedures; Documentation; Medication error reporting form; Quality assurance review
Root Cause Analysis Examine contributing factors: Root cause analysis consists of 5 steps:; Establish team of appropriate personnel; Describe event in detail; Diagram steps that led up to error to determine root cause; Develop specific action plan; Develop outcome measures.
Pharmaceutical (Technical Reporter) Medical error and clinical mistakes are potential threats to healthcare system around the world. Major considerations are as under,
Product Labeling: Labels may emphasize manufacturer’s name or logo instead of drug name & dose; same labeling scheme, including letter size, print, background color, to associate the product with manufacturer. Makes all labels look alike; Different vial sizes of injections may be similarly labeled with concentration (mg/mL), Potassium chloride (KCl) & normal saline. Potassium chloride injection- black vial caps -overseals with warning “must be diluted”
Other Problems: Color Coding-relying on color of product packaging is not safe practice; Daunorubicin 20 mg & doxorubicin 10 mg are packaged in vials shaped similarly & have dark blue vial caps both are lyophilized powders that turn red upon reconstitution
Advertising Zyrtec oral products contain active ingredient cetirizine: Zyrtec Itchy Eye Drops; contain active ingredient ketotifen; Claritin oral products; contain loratadine as active ingredient; Claritin Eye contains ketotifen; Pepcid; Pepcid contains active ingredient famotidine; Pepcid Complete contains famotidine, calcium, magnesium hydroxide
Drug Preparation Errors; Read product labels carefully; Process one prescription at a time; Label prescriptions properly; Store drugs properly; Maintain safe work environment; Keep up with changes in medical profession
Work Environment Inadequate lighting Poorly designed work spaces: Inefficient workflow; Cluttered work spaces & stock areas; Distractions & interruptions; Improper maintenance of equipment.
Personnel Issues Scheduling of staff members; Frequency of rotating shifts; Staffing levels; Amount of supervision; Untrained, inadequately trained, or inexperienced personnel; Relying on memory instead of checking references; Performing complicated calculations without doublecheck.
Deficiencies in Drug Use Systems: Errors frequently due to defective/inadequate systems; Stocking dangerous drugs in patient care areas; Floor stock mixups; Heparin injection & normal saline flush; Potassium chloride & furosemide injections; Premixed Lidocaine in D5W500mL & D5W500mL plain bags; Automation/technology reduce medication errors
Prevention of Medication Errors: Systems /methods to help prevent medication errors; Failure mode & effects analysis (FEMA); Systems designed to prevent medication errors; Legal requirements; Policies & procedures; Multiple check systems; Standardized order forms; Education & training; Computerization & automation.
Failure Mode & Effects Analysis: Systematic evaluation of process; Predicts opportunity for errors at steps in process; Evaluates “how” & “why” instead of “who”; Each step in process; Opportunities for failure at each stage; Effects of failures on process; Root causes described; Severity, likelihood of occurrence, probability of actually identifying failure are estimated.
Criticality Index: Multiply; Severity; Likelihood of occurrence; Probability of actually identifying failure; Address first those steps with highest criticality index; Greatest potential for reducing risk for error; After making changes to process; Perform FMEA again to determine effectiveness of changes.
Pharmaceutical Review (Scientific Reporter). There are million of medication error happened around the world every year. Many of these mistakes are potentially avoidable. Our scientific research reported provided us a review report as under,
Key Terms Omission error Root Cause Analysis (RCA) are Unauthorized drug error, Wrong administration technique error, Wrong dosage form error and Wrong time error. However the major Types of Medication Errors are as under,
Prescribing Errors; Omission Errors; Wrong Time Errors; Unauthorized Drug Errors; Improper Dose Errors; Wrong Dosage Form Errors; Wrong Drug Preparation Errors; Wrong Administration Technique Errors; Deteriorated Drug Errors; Monitoring Errors; Compliance Errors.
Prescribing Errors; Prescription error occurred/ happened in specific patient’s:
Drug; dose; dosage form; route of administration; length of therapy; number of doses; administration; drug concentration; inadequate or incorrect instructions for use; illegible handwriting;
Wrong Time Errors Standardized administration times: Acceptable interval surrounding scheduled time; Medications administered outside this window; considered wrong time errors; Occasionally unavoidable; patient is away care area for test; medication is not available at time it is due.
Unauthorized Drug Errors: Administration of medication to patient without proper authorization by prescriber; Administration of medication outside established guidelines; Medication for patient given to another patient; Nurse gives medication without prescriber order; Patients “share” prescriptions; Refilling prescription that has no refills remaining; Protocols may allow flexibility-not unauthorized;
Improper Dose Errors Dose that is greater or less than prescribed dose: Can occur when additional dose is administered; delay in documenting dose; absence of documentation; Inaccurate measurement of oral liquid; Exclusions from this error type; topical applications; variances that occur from apothecary to metric conversions.
Wrong Dosage Form Errors: Doses administered as different form than ordered; Depends on state laws & facility guidelines; Dosage form changes may be acceptable; Accommodate particular patient needs; Often acceptable.
Wrong Drug Preparation Errors: Reconstituting oral suspension with incorrect volume; Using bacteriostatic saline instead of sterile water to reconstitute lyophilized powder for injection; Not activating an ADD-Vantage® IV admixture bag.
Wrong Admin Technique Errors: Examples:
Subcutaneous injection that is given too deep
Intravenous (iv) drug is allowed to infuse via gravity instead of using an iv pump
Instilling eye drops in wrong eye
Deteriorated Drug Errors: Monitoring expiration dates is very important; Drugs used past their expiration date; may have lost potency; may be less effective or ineffective; Refrigerated drugs stored at room temperature may decompose & lose efficacy; Monitoring Errors Inadequate drug therapy review Examples:
Ordering serum drug levels but not reviewing them
Not responding to level outside of therapeutic range
Not ordering drug levels when required
Prescribing antihypertensive agent & then failing to check blood pressure
Errors that cannot be placed into category examples:
Medication dispensed without adequate patient education
Determination of the incidence: Few studies provide complete evaluation of errors; Different methods used to detect errors; Various definitions of errors; Large volumes of medications dispensed;
Small percentage of errors can result in large number of medication errors: Annual # of prescriptions ~ 3.54 billion; Small % of 3.54 billion is still large number; Medication Errors are as under,
Errors occurring earlier in medication use process more likely to be detected & corrected than those occurring later in process
Many studies varying results:
error rates outpatient pharmacies reported ~12%
in hospitals ~1 error per patient per day
hospitals & skilled nursing facilities:
19% of all doses were not administered correctly
43% of errors were due to wrong time of administration
Review of Institute of Medicine: ~ 1.5 million people are harmed by medications each year; Up to 400,000 of adverse events considered preventable; Medication error studies report different error rates; How studies were performed; various techniques & definitions used; scope of study; Errors which are corrected before medications reach patient might not be accounted for necessary action.
Review of Medication Error Reporting: Medication error rates based on incident reports; Errors not always reported: Lack of knowledge to identify errors; Lack of time to document errors; Afraid of negative consequences.
Impact of Medication Errors: Outcomes; Range from no effect to long-term disability or death; Significance; Type of medication error; Health status of patient; Pharmacologic classification of drug involved; Route of drug administration, Timing of drug administration; Cost to health care system; Damage to patient’s trust in care providers; Impact on Patient: Personal and Financial Implications; Health status of patients; Magnitude of overdose; Damage as result of omission; Financial implications; Prolong hospital stays & increase health care expenses; Estimated to cost billions of dollars annually; Additional medical management; Legal fees & out-of-court settlements; Never Events-not reimbursed by Medicaid.
Loss of Trust Loss of faith in medical community: From either experience or knowledge of event; May choose to; Switch pharmacies or physicians; Hesitate to seek medical help; Seek nonconventional treatments from outside medical community.
Causes of Medication Errors: Calculation errors; Improper use of zeros & decimal points; Inappropriate use of abbreviations; Careless prescribing; Illegible handwriting; Missing information; Drug product characteristics; Compounding /drug preparation errors; Prescription labeling; Work environment & personnel issues; Deficiencies in medication use systems. Errors Committed by and population at risk: Prescribers; Pharmacists; Technicians; Nurses; Pediatric population at risk; Adult formulations be diluted/manipulated for peds; Personnel with multiple years of experience are just as likely to make mathematical errors as inexperienced.
Pharmaceutical Review (Special Reporter). A legendary of dishonest and symbolically corrupt Mr. Sajid Bashir (Retired) has surprisingly appointed principal of Lords College of Pharmacy, Industrial Estate, Kot Lakhpat, Lahore, Pakistan. His corruption, dishonesties and irregularities are internationally recognized and established. The detail is published and available online.
Unluckily, this stupid is now appointed as head of a prestigious pharmacy institution to mock the teaching quality, recruitment policy and education standard in Pakistan. He is symbolling all possible ways corruptions in pharmacy academia. He has long and terrible history of corruption, irregularities and dishonesties as under,
An amazing character revealing the fundamental factors hurting the health standards, pharmaceutical patient’s care and teaching quality in developing countries.ادویات و صحت کے نظام کو مجروح کرنیوالی حقیقی اور مثالی شخصیت۔ http://dx.doi.org/10.52182/22205187.13022021 https://pharmareview.files.wordpress.com/2021/03/28-2021-feb-13-corruption-of-dean.pdf
The corruption of dean pharmacy, university of Sargodha needs attention and appropriate investigation. جامعہ سرگودہا کے شعبہ فارمیسی کے سرپرست کی بددیانتی وبد عنوانی۔ http://dx.doi.org/10.52182/22205187.7122018 | https://pharmareview.files.wordpress.com/2018/12/12-uos-corruption.pdf |
Pharmacy council of Pakistan, pharmacy discipline and pharmacist community. پاکستان فارمیسی کونسل کی ناکامی کا سدباب اور اسکے نظام صحت پر اثراب۔ http://dx.doi.org/10.52182/22205187.07112021 | https://pharmareview.files.wordpress.com/2021/11/2021-nov-7-pcp-role-2.pdf
An ideological compliance to establish the real state of Pakistan. فکری قومی تعبیر سے عملی ملکی تعمیر کا حقیقی سفر۔ http://dx.doi.org/10.52182/22205167.25062020 | https://pharmareview.files.wordpress.com/2020/07/dr.-taha-june-25-2020.pdf
Correction of pharmaceutical teaching institution is the start point of professional growth.ادویاتی تعلیمی اداروں کی اصلاح، پیشہ فارمیس کی ترقی و خوشحالہ کا نقطہ آغاز۔ http://dx.doi.org/10.52182/22205187.13122016 | https://pharmareview.files.wordpress.com/2016/12/academic-and-admin-role.pdf
You will always be in our heart and memories تماری یادیں بسی ہیں دل میں افق کے اس پار جانے والو۔ http://dx.doi.org/10.52182/22205167.132022019 | http:/pharmareview.files.wordpress.com/2020/01/16-iqbal-and-dr.-rifat-3.pdf
Lest we forget; Muhammad Iqbal (late) and dr. Riffat ul zaman (late)شہدافارمیسی کی عظمت کو سلام۔ http://dx.doi.org/10.52182/22205187.11022019 | https://pharmareview.files.wordpress.com/2019/02/13-iqbal-and-dr.-rifat-.pdf
M. Iqbal (late) – great leader, skilled pharmacist and outstanding person. عزت مآب محمد اقبال کی عظمت کو سلام ۔ http://dx.doi.org/10.52182/22205187.27082019 | https://pharmareview.files.wordpress.com/2019/08/13-iqbal-1-1.pdf
Pharmaceutical “fact sheet” 2014-15; released by prof. Dr. Taha nazir president pharmacist federation (Pakistan ) and pharmacist alliance, PPA. پیشہ فارمیسی کا حقائق نامہ 2014-2015 | http://dx.doi.org/10.52182/22205167.25012015 | https://pharmareview.files.wordpress.com/2015/01/21-fact-sheet-2014-15.pdf
The dilemma of pharmacy profession in Pakistan; a “white paper” regarding ppa election 2014پیشہ فارمیس کا المیہ ۔ قرطاس ابیٖض۔ | http://dx.doi.org/10.52182/22205187.21072014 | https://pharmareview.files.wordpress.com/2014/08/white-paper-election-corruption-2014.pdf
Lest we forget to our legend heroes تمہاری یادیں بسیں ہیں دل میں افق کے اس پار جانے والو۔ http://dx.doi.org/10.52182/22205187.19012020 | https://pharmareview.files.wordpress.com/2021/03/15-iqbal-and-dr.-rifat.pdf
Prudential review of pharmacy teaching institutions in Pakistan. پیشہ فارمیسی کے ملکی تدریسی اداروں کا تجزیاتی جائزہ۔ http://dx.doi.org/10.52182/22205187.14062015 | https://pharmareview.files.wordpress.com/2015/06/academic-corruption-ff5.pdf
Review of evolving role and poor representation of pharmacy professional in Pakistan. ماہرین ادویات کی ناقص نمائندگی اور پیشہ ورانہ بد حالی کی وجوہات و اسباب۔ | http://dx.doi.org/10.52182/22205187.25032016 | https://pharmareview.files.wordpress.com/2016/03/poor-rep-and-bad-prof-situa-of-pharm-prof-ff.pdf
Review of dissimilar roles, responsibilities and official duties of licensing (qualified person) and employee (working) pharmacists. قانونی اور ملازم فارماسسٹ کے پیشہ ورانہ کردار کا اصولی فرق۔ http://dx.doi.org/10.52182/22205187.13032017 | https://pharmareview.files.wordpress.com/2017/03/13-difference-among-the-licensing-and-employeed-pharmacist1.pdf
The poor and illegal representation of pharmacy profession in Pakistan. پاکستان کا غیر معیاری ادویاتی نظام اور غیر اخلاقی پیشہ ورانہ نمائندگی ۔ http://dx.doi.org/10.52182/22205187.02022014 | https://pharmareview.wordpress.com/2014/02/02/poor-pharmaceutical-care-and-illegal-professional-representation-of-pharmacy-profession-in-pakistan/
Insufficient effort of the government of the punjab to improve the local health care. حکومت پنجاب کے ادویاتی قوانین اور نظام صحت کے غیر یقینی اور ادہورے اقدامات۔ | http://dx.doi.org/10.52182/22205187.03082017 | https://pharmareview.files.wordpress.com/2017/03/8-insufficient-contribution.pdf
The potential reasons of poor representation and despicable professional situation in Pakistan.ماہرین ادویات کی ناقص نمائیدگی اور پیشہ ورانہ بد حالی کی وجوہات و اسباب۔ | http://dx.doi.org/10.52182/22205187.03082017
Pharmaceutical Review (Staff Reporter). Post graduation study is very respected credential all over the world. Unluckily, a culprit Mr. Sajid Bashir has surprisingly supervised the whole class of 15 Post Graduation/ M.Phil Pharmaceutics scholars, session 2011-13 in University of Sargodha, Pakistan. Technically, it is not possible to produce a valid, conclusive and fruitful research by supervising of a single person. That is unethical, illegal and totally unacceptable in pharmacy academia.
The most verse part of this story that, the culprit Mr. Sajid Bashir is re-appointed as principal of the Lords College of Pharmacy (LCP) Lahore to continue hurting the pharmacy profession in country. The Lord institution, Pharmacy council of Pakistan and affiliated university of the Punjab has accepted and endorsed this illegal appointment.
Pharmaceutical Review (Staff Reporter). A culprit Mr. Sajid Bashir has been reappointed principal of the Lords College of Pharmacy (LCP) Lahore after his successful corruption in University of Sargodha. This innovative model of corruption and peace of crap is appointed as Principal of Lord Principal of the Lords College of Pharmacy (LCP) Lahore, Pakistan.
The seat of professor of pharmacy was advertised on November 1, 2009 in Daily Jung, bearing last date December 31, 2009, under which the said professor was selected. The criteria were also given as per guidelines of HEC Islamabad. In selection of professor, the external expert reports have key value to comply with criteria. Therefore, university did not give me access to the requested information to protect the illegal appointment. However, I obtained the reports from another source (copies attached Annexure 6). Both of the foreign reports did not support the appointment of candidate as professor in university of Sargodha as under,
Sverre Arne Sande, Professor of Pharmaceutics and Social Pharmacy, Sem Sælands vei 3 Farmasibygningen 0371 Oslo stated in his decision (conclusion) that “reports and short communications can not be considered as research publication. In this case, he (culprit Mr. Sajid Bashir) do not comply neither with the requirement for the total publications, nor with the requirement for publication during the last five years. If one or more the publication in journals of unknown status should turn out to be recognized by HEC, he will comply the requirement for number of publication during the last 5 years, but the total number will still be too low”.
Dr. Hohamed Azmi Ahmad Hassali, Associate Professor, Programme Chair, Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Penang, Malaysia (T.: +604 653 4085, F.: +604 657 0017, azmihassli@usm.my) was associate professor at that time. He can not evaluate the candidate for the appointment as professor. One step lower expert automatically disqualified to examine the credibility of a candidate of higher (professorship) position. Secondly, Dr. Hohamed Azmi has worked with candidate (Sajid Bashir) during September 2009 – November 2009 to complete a cross-sectional, observational study entitled “Association between knowledge and drug adherence in patients with hypertension in Quetta, Pakistan”. Both of them (candidate and evaluator) have published their research article in “Tropical Journal of Pharmaceutical Research” April 2011; 10(2): 125-132. This is potential conflict of interest and automatically disqualifies the appointed of expert Hohamed Azmi Ahmad Hassali as foreign exprt. His evaluation also null and vided on behalf of his explicit predefined relationship with candidate.
The administration misinterpret, concealed the facts and hided the real information. Because in methodology section of the article, it is explicitly described that the project started in September 2009 and completed November 2009 as under,
“A cross-sectional, observational study was employed as the method of data collection. Based on the prevalence of hypertension, a sample of 385 hypertensive patients was selected between the months of September 2009 and November 2009 from two tertiary care hospitals in Quetta, Pakistan, namely, Sandamen Provisional Hospital and Bolan Medical Complex Hospital. Both of these institutions carry the major population burden from all over the province of Baluchistan with a large proportion of low income patients.”
Thus, candidate started project on September 2009 and completed on November 2009; before the advertised closing date December 31, 2009 of university of Sargodha. Then was, followed by revised accepted on January 12, 2011 and finally published on April 20, 2011. The screen shots are attached in Annexure 7 and web links are as under,
Unluckily, this innovative model of corruption, good peace of dirt and icon of useless crape is engaged and hired by Lords College of Pharmacy, Lahore, Pakistan.
Pharmaceutical Review (Staff Reporter). Mr. Sajid Bashir Principal of Lord Principal of the Lords College of Pharmacy (LCP) Lahore has played major role to purchase the substandard and used machinery for University of Sargodha Pharmaceutical Laboratories. The equipment’s were purchased from VarioTech, Plot 9, Industrial Area, Saggian Bypass, Lahore under the purchase order numbers,
UOS/RC/11-412 dated 21.03.2011
UOS/RC/10-160 dated 25.05.2010
UOS/RC/11-616 dated 18.10.2011
UOS/RC/11-615 dated 18.10.2011 and
UOS/RC/11-624 dated 21.10.2011
Manufacturing license No. 000859/167 dated 12.06.2017 granted by Chairman Central Licensing Board, Government of Pakistan under the Drug Act 1976. Unluckily, the potential profitable and excellent drug manufacturing project of approximately Rs. 0.8 Billion was failed because of the corruption of aforesaid officer. The granted license was then voluntarily surrendered by University of Sargodha under letter No. UOS/PIU/1666 dated November 19, 2018 and facility was shut downed (DRAP letter dated March 13, 2019 attached). So, a strict disciplinary action against the corruption of the Dean Pharmacy, University of Sargodha is requested. The damage should be recovered from the culprit.
Finally, the HR Lords College of Pharmacy (LCP) Lahore has engaged and hired this culprit and appointed as principal to continue the spoiling the pharmacy academia in Pakistan.
Pharmaceutical Review (Staff Reporter). Current principal of Lord Principal of the Lords College of Pharmacy (LCP) located in Lahore Dr. Sajid Bashir has registered the firm M/S UOS Pharmaceutical Laboratories, University of Sargodha. He is major partner of this firm to run pharmaceutical manufacturing. Unluckily this stupid culprit has failed this drug manufacturing project worth of approximately Rs. 0.8 billion, after 18 years of its deployment; because of corruption of sitting principal of principal of Lord Principal of the Lords College of Pharmacy (LCP) located in Lahore, Pakistan.
Additionally, reference to the irregularities, blunders and corruptions reported within the University of Sargodha under letters No. 171/Pharm/ 2017 dated January 24, 2017, regarding “Explanation of Letter No. UOS/Pharm/4692 Dated 17.1.2017”. The case was taken at next level within the institution with three applications submitted in the office of the Vice-Chancellor, University of Sargodha, under VCD No. 16311 dated November 26, 2015; VCD No. 7157 dated May 19, 2015, and VCD No. 4023 dated March 15, 2016. Additionally, the letter dated November 25, 2015, Diary No. UOS/Pharm/1998, VCD No. 16311 dated 26.11.2015; letter No. nil, dated March 15, 2016 VCD and Letter No. UOS/Acad/910 dated 7.12.2016, Regarding the Appearance in Dean Committee, University of Sargodha was submitted in the office of Vice-Chancellor, University of Sargodha. The case was also filed with Higher Education Commission, confirmed by the letter No. 05-48/A&C(Affairs)/2016/7151 dated July 01, 2016, and forward the matter to the concerned University of Sargodha for comments.
Thus, we should not complaint about changing of the Form 45, 47 by the establishment during the recent election 2024 in Pakistan. We should also ignore judicial prosecution of great leader Imran Khan. W may also believe that Honorable Maryam Safdar is legitimate chief minister of the Punjab, Pakistan. The impose President Asif Ali Zardari and PM Mian Shahbaz Sharif should also be accepted in any possible manner.
However, the academic corruption, particularly in private pharmacy education should be controlled by removing the fraudulent culprits including Dr. Sajid Bashir principal of Lord Principal of the Lords College of Pharmacy (LCP) located in Lahore, Pakistan.
Pharmaceutical Review (Staff Reporter). There is a poor pharmaceutical academic standard in private education sector in Pakistan. That is confirmed by the appointed of a fraudulent person Dr. Sajid Bashir as Principal of the Lords College of Pharmacy (LCP) located in Lahore, Pakistan. This stupid culprit has cheated University of Sargodha by obtaining his evaluation report from one of the Co-Authier of his article. That is not only potential conflict of interest but also an illegal, unethical and unacceptable act. The Malaysian Associate professor report and article published is attached here for the evidence of the fraud of this stupid culprit.
Pharmaceutical Review (Staff Reporter). Lords College of Pharmacy (LCP) located at Kot Lakhpat, Lahore, Pakistan has engaged Dr. Sajid Bashir as Principal of the college. Unluckily, this man has deceived the administration of University of Sargodha successfully by obtaining his evaluation report from a Malaysian Associate professor for the appointment as professor. As per rule and academic ethics, the lower ranked person can not examine the candidate for position higher than his current appointment. So, the private education mafia and pharmaceutical regulating authorities are potentially hurting the standards in Pakistan.
