Authors (including presenting author) :
Si MD(1), Cheng HW(1), Ho SM(1), Ng SW(1), Ng YB(1), Tang SK(1)
Affiliation :
(1)Department of Medicine & Geriatrics, United Christian Hospital
Introduction :
Nowadays, most of patients admitted to hospital will receive intravenous therapy. With the help of infusion devices, a safe and accurate medication administration can be promoted. Nevertheless, medication incidents related to infusion devices are reported from the Hospital Authority at times. According to the 50th issue of "HA Risk Alert", 19 of the 20 SUE cases were medication errors reported in Q1 2018. Among these cases, several errors related to intravenous therapy with incorrect infusion rate or incorrect infusion line and failure to identify incorrect dosage prescription. In 2016, Nursing Services Division (NSD) had already introduced "Pointing and Calling" concept and adopted it for checking high risk medications in UCH. In order to structuralize the perspective of "Pointing and Calling" closer to the isolation ward practice, an enhancement program was developed and launched for nurses as part of nursing quality improvement.
Objectives :
1. To ensure nursing staff operating the infusion pump safely and properly by using "Pointing and Calling" 2. To minimize medication incidents due to unfamiliarity in using infusion pump
Methodology :
Hospira Plum XL was the specified model and has been unified in the isolation ward. Quick reference was designed and uploaded to department’s SharePoint intranet. Briefing and demonstration sessions were provided to all nurses in the isolation ward. Audit tool was designed for auditing nurses’ compliance in "Pointing and Calling" & knowledge in using Hospira Plum XL. All 18 standard criteria on the checklist were expected to be gone through during each audit. In addition, 5 of the 18 items were identified as critical items which were using “Pointing and Calling” concept. Data was collected through observation and asking nurse. The audit was conducted in December 2018.
Result & Outcome :
All nurses in isolation ward were invited to participate in the audit. All nurses were 100% complied with all items. The audit found that "Pointing and Calling" was overused in every step of action resulting in over checking. The report was shared to all nurses in the isolation unit. All nurses had positive feedback. Not only the newly graduated nurses agreed that the audit enhanced their knowledge and made them more familiar in using infusion pump, but also the senior nurses showed the audit could sustain their compliance. To conclude that the audit demonstrated a high compliance and knowledge in using infusion pump in a clinical setting. Nevertheless, one mistake could be life-threatening. Refresh training and audit should be conducted regularly to keep nurses being vigilant to high risk medical equipment.
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