Authors (including presenting author) :
Si MD(1),Cheng HW(1),Ho SM(1),Ng YB(1)
Affiliation :
(1)Ward 13A, Isolation Ward, Department of Medicine & Geriatrics, United Christian Hospital
Introduction :
With the help of infusion devices, a safe and accurate medication administration can be promoted. Nevertheless, medication incidents related to infusion devices are reported from the Hospital Authority at times. 19 of the 20 SUE cases were medication errors reported in Q1 2018. Among these cases, several incidents related to intravenous therapy with wrong infusion rate or infusion line and failure to identify incorrect dosage prescription. In December 2019, a new model - Volumat MC Agilia has replaced the old model as the majority infusion pump in an isolation ward. Unfamiliarity in using medical equipment may induce medication incidents. A series of risk reduction strategies were developed and launched for nurses.
Objectives :
1.To ensure nursing staff operating the new infusion pump safely and properly 2.To achieve zero tolerance for medication error related to unfamiliarity in using the new infusion pump
Methodology :
The new intravenous infusion pump was selected for training model and was introduced to the ward. Quick reference was designed and uploaded to department’s SharePoint intranet. Briefing and demonstration sessions were provided to all nurses in the ward. Audit tool was designed for auditing nurses’ compliance & knowledge in using Volumat MC Agilia. Data was collected through observation and asking nurse. The audit was conducted in December 2019.
Result & Outcome :
All nurses in the ward were invited to participate in the audit. 16 standard criteria on the checklist were expected to be gone through. In addition, 5 of the 16 items were identified as critical items. All nurses were 100% complied with all items. The report was shared to all nurses in the unit. All nurses had positive feedback. Not only the newly graduated nurses agreed that the audit enhanced their knowledge and made them more familiar in using infusion pump, but also the senior nurses showed the audit could sustain their compliance in pump replacement process. The audit demonstrated a high compliance and knowledge in using infusion pump in a clinical setting. Nevertheless, we are zero tolerance for medication error. Refresh training and audit should be conducted regularly to keep nurses being vigilant to high risk medical equipment.
