Authors (including presenting author) :
Shek MK (1), Lui WK (1), Ng YB (1)
Affiliation :
(1) Medical and Geriatric, United Christian Hospital
Introduction :
Medication errors are major problem for patient safety. Inpatient Medication Entry (IPMOE) has been proved to reduce medication error significantly in term of prescribing, transcribing and administration. However, residual or emerging risks remains including human risk-factor such as dependency on system, new workflow and at-risk behaviors. A better knowledge of the respective risk factors as well as the type of errors and causes are necessary to avoid medication errors. Although hospital accreditation was suspended meanwhile, quality and risk management programs could be continued and worked together to achieve organizational goals and quality outcomes. A new approach of risk identifications and reducing program was initiated in Acute Medicine Ward 9B, in 2017-18.
Objectives :
1. Identify and reduce human risk factors in medication error
2. Learn from risks to prevent errors
3. Increase commitment of staff in medication safety
Methodology :
EQuIP5 Risk Classification Guide from Australian Council on Healthcare Standards (ACHS) was adopted in process. Annually data of medication risks encountered in ward were classified according to EQulP5. Sharing of findings and suggestion provided to all nursing staffs and collaborated with Clinical Teachers of ward for fortified intervention to preceptees.
Result & Outcome :
Findings
In 2018, medication related behaviors or risks of staffs encountered including: 1 Double order of drugs by A&E and ward physician, 2 Erroneous dosage instruction entry in free text of IPMOE by physicians, were classified into 152.1-Prescription error; 3 Erroneous medication custom frequency rule setting of IPMOE by nurses were classified into 152.2- Administration error; 4 Failure to correlate the medications effect to current patient situation by nurses, 5 Slow-releases type medications erroneously cut or crushed by nurses due to not familiarized with slow-releases mechanism were classified into 152.3- Improper administration; nurses be not sensitive to non-oral/injection type allergic history such as antiseptic or dressing material allergies were classified into 152.10- Other. All risks are related to human factors and custom rules manipulation of IPMOE. No actual harm was resulted to patients. Outcomes
1. Preceptees all agree classification of complex medication error scenarios into different risk categories promotes better grasp and understanding the underlying root causes for them. 2. Duplication of same error were not noted among same staffs after counseling 3. Sustained risk identification and promotion of safe practices was affirmed.
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