Authors (including presenting author) :
Kwok YTA(1), Wong PMB(1)
Affiliation :
(1)Quality and Safety Division, New Territories West Cluster
Introduction :
There had been several medication incidents related to wrong intravenous (IV) fluids with potassium chloride (KCl) given to patients due to wrong item picking. A quality improvment team in Tuen Mun Hospital was formed to review the incidents and identify improvement actions.
Objectives :
(1) To minimize the risk of wrong picking of IV fluids with KCl. (2) To adopt human factors principles to provide guiding principles for better and safer storage and management of IV fluids with KCl. (3) To produce standardised storage labels of different types of IV fluids with KCl for displaying on cabinet.
Methodology :
A quality improvement team was formed in February 2019 with members from clinical departments, pharmacy, Nursing Services Division and Quality and Safety Division in Tuen Mun Hospital. Ward visits were coordinated to understand the existing situation and identify the gaps. Seven categories of guiding principles for safer management of IV fluids with KCl in organisation safety level were developed. Standardised storage labels of different types of IV fluids with KCl, with considerations of human factors elements in visibility, consistency, minimalist, typography, colour and contrast, for sticking on cabinet's shelves were developed.
Result & Outcome :
The guiding principles were shared in the Cluster Medication Safety Committee and nursing meetings. Ward managers followed the guiding principles in storing IV fluids with KCl. The standardised storage labels were piloted in several wards in March 2019 with positive feedback received. The labels were fully implemented in all clinical wards in Tuen Mun Hospital. There was no incident related to wrong IV fluids with KCl given to patients since March 2019.
