Authors (including presenting author) :
CHAN Joyce(2), Tam YY(1), SHEH Karen (1), CHANG Vivian(1), HUANG Jay(2), WONG Bonnie(2)
Affiliation :
(1) Department of Paediatrics & Adolescent Medicine, Tuen Mun Hospital, (2) Quality & Safety Division, New Territories West Cluster
Introduction :
Ensuring correct breast milk administration was brought to concern as there was incident reported in February 2018. The incident was investigated and major contributing factor was identified that staff noncompliance with standard patient identification process. Continue reinforcement in the department was conducted while risk of human error could still not be eliminated. Moreover, the separation of the mother and infant in a hospital increases the risk of breast milk misadministration and, in the ward environment, infant cannot participant in the identification process, use of QR code system can be an adjunct safeguard measure for correct breast milk administration.
Objectives :
Use of QR code system for breast milk administration to enhance correct patient identification
Methodology :
A milk bottle verification program was developed using QR codes system on the milk label for mothers of infants labeling the milk bottle and verifying against patients’ wristbands before administration. Staff consultation and system testing before implementation were conducted. Milk labels with unique QR code containing patient’s identities were generated during admission then are given to parents for affixing the milk bottles. Staff will confirm the milk label with QR code affixing on the milk container before receiving and storage. Before breast milk administration, a bedside double check by nurses and QR code verification for correct patient identification are performed. Error message will be shown to alert nurses when the information is not matched. The verification process must be restarted to achieve correct patient identification. Once the verification has succeeded, a verification label is generated for documentation.
Result & Outcome :
The milk bottle verification program is rolled out since December 2018. 4 identical training sessions were arranged and 64 staff were trained before implementation. Staff survey was conducted and 91 survey forms were received. 5 out of 91 survey forms were excluded due to incompleteness of survey forms. The survey result showed 86% staff agreed that the system is simple and easy to use, and 91 % staff expressed that the information (such as on-screen messages and next step) which provided by the system is clear and easy to understand. 83% staff are satisfied with the system. Incident related to patient misidentification during expressed breast milk administration was monitored from December 2018 to April 2019. No incident was reported. In addition, a compliance audit was conducted after the program was implemented for a month. The compliance rate of all critical items showed 100%.
