Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Authors (including presenting author) :
Carmen CHAN (3), Katherine M C PANG (3), W M NG (2), Winnie W K LEUNG (2), Howard WONG (1), Sandy YEUNG (1), Howard TSOI (1), S L LEE (3)
Affiliation :
(1) Department of Pharmacy, QMH (2) Q&S Department, QMH (3) Q&S Department, HKWC
Introduction :
The proper handling and safe custody of medication is one of the core principles of medication safety. For Dangerous Drugs (DD), they should be handled and administered to the patients under the Dangerous Drugs Ordinance (DDO). In the past few years, QMH Quality & Safety Department (Q&S) and Department of Pharmacy made the best endeavors to enhance DD management.
Objectives :
The objectives of the program are to enhance the proper storage and safe handling of DD to minimize the incidents of Dangerous Drug Irregularities (DDI) and DD-related incidents.
Methodology :
Staff:
QMH Q&S Department organized three series of medication safety promotional activities throughout the year in 2023. The content consisted of safety tips on DD handling, safe use of infusion devices, and an independent double-check (IDC) workshop. Two qualified nurses are required to conduct independent double-checks during DD administration. However, the most common contributing factor of the DD incidents showed the process of independent double check was not performed properly. Hence, two identical and scenario-based workshops on IDC were held in December 2023.
Equipment:
An initiative of keeping DD in smart drug cabinet was implemented in two medical admission wards in 2021/22. The benefits of using smart drug cabinet are (i) allergy check support (ii) guiding light for drug picking.
Standardization:
The standardization exercises included the labelling of DD containers with TALL man lettering, detachable key chain for holding DD keys, and stamp chops with standardized content to facilitate the documentation of the DD stock inspection and trace back checking.
Methods:
Two strategies were employed to monitor the compliance on the DD handling i.e., theme-based round in 2021/22 and surprise check in June 2023. The round and surprise check aimed to share good practices, communicate with frontline colleagues, and understand frontline needs and difficulties in DD management.
Result & Outcome :
After a series of improvement measures and regular monitoring, there is zero Dangerous Drug Irregularities (DDI) in 2023, and the DD-related incidents dropped to 3 cases in 2023. Positive feedback was collected after the implementation of the smart drug cabinet.
Conclusion
The series of quality improvement activities organized by Q&S Department in collaboration with Department of Pharmacy is effective in enhancing the safety of DD handling and minimizing the related DDI and DD-related incidents.
The way forward is to extend the implementation of smart drug cabinet to other clinical departments and new clinical block.
