Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Authors (including presenting author) :
Cheng KY(1), Pun KL(2), Wong KW(2), Cheung Y(1)
Affiliation :
(1)Department of Medicine and Rehabilitation, (2)Nursing Quality and Safety Committee, Tung Wah Eastern Hospital
Introduction :
In-patient medication order entry (IPMOE) has been adopted in TWEH since 2019. Despite the convenience and efficiency with the use of IPMOE over the traditional paper medication administration system, medication errors occurred occasionally. Recently, there was an increased rate of medication incident related to drug scheduling error, which raised concerns on safe drug administration.
Objectives :
1. To enhance medication safety and increase the awareness of pitfalls of using IPMOE system among nursing staff 2. To reduce medication incidents related to inappropriate drug scheduling
Methodology :
1.Request for enhancement with HAIT by setting up the new AOM schedule: After discussion with Hospital Quality and Safety Committee and HAIT, enhancement of IPMOE Auto-time assignment for Q1H, Q2H, Q3H, QID during daytime was set up and implemented among all HKEC cluster hospitals on 12 September 2023. 2.Administration of Medication (AOM) procedures audit round for nurses: AOM procedures audit round was conducted during the period of 16 November 2023 to 8 December 2023 to evaluate nurse’ compliance towards AOM procedures using IPMOE. The auditor reminded and provided feedback to nurses on areas for improvement immediately. 3. Educational Seminar on Medication Safety: Hybrid mode of Zoom Medication Safety Seminar was conducted in TWEH on 18 December 2023 by pharmacists and senior nurses. Recent medication safety issue including enhancement on medication safety, medication incident trend analysis and lessons learnt from incidents were shared at the seminar. Questionnaires were distributed to participants for evaluation at the end of the seminar.
Result & Outcome :
Result: The enhancement of the default schedule was applied to the new prescriptions since 12 September 2023. Nursing staff showed positive feedback towards the enhancement of IPMOE Auto-time assignment. Regarding to AOM procedures audit round, 20 observations were audited within all Medical and Rehabilitation wards in TWEH. The overall compliance rate was 100%. A total of 53 staffs were participated in the educational seminar. They found that the seminar was practical and able to raise their awareness of pitfalls of using IPMOE especially on drug scheduling. Conclusion: Safe drug administration is essential for patient safety. The enhancement of drug scheduling system and educational seminar can strengthen staff awareness and minimize medication errors. For continuous quality improvement, performing regular spot check on AOM procedure and custom scheduling by ward APNs are also crucial to maintain the standard of AOM.
