Authors (including presenting author) :
YANG KT(1), LAU CK(1)(2), SINN TTM(2), MAK CK(1)(2), CHAN WYM(1)(2), MAK LKK(1)(2)
Affiliation :
(1)Department of Pharmacy, Tseung Kwan O Hospital
(2)Tseung Kwan O Hospital Medication Safety Committee
Introduction :
Medication errors, commonly encountered in daily practice, could lead to significant adverse drug events and negative pharmaceutical outcomes. Pharmacists and hospital Medication Safety Committee (MSC) play a vital role in safeguarding medication safety and promoting optimal use of medications. A quality improvement project was carried out with the conjoint effort of pharmacists and MSC to raise staff awareness on medication safety.
Objectives :
1. To raise doctors, nurses and pharmacists’ awareness on medication safety through routine sharing
2. To reduce the number of prescribing errors
3. To identify common examples of drug related problems (DRPs) through analysis of pharmacists intervention on DRPs
Methodology :
Since 4Q 2018, pharmacists analyzed all problematic prescribing orders on Inpatient Medication Order Entry in each quarter to identify common DRPs and presented common examples in MSC and Drug Therapeutic Committee meetings for further promulgation to frontline medical and nursing staff.
Screensavers on CMS stations were designed to alert doctors and nurses on common DRPs and share tips of safe prescribing.
To evaluate outcome, number of prescribing errors in 1Q and 2Q 2019 was analyzed. Feedback from doctors and nurses were also collected.
Result & Outcome :
The details of medication incidents reported in AIRS from 1Q 2019 to 2Q 2019 were collected. The number of incidents related to therapeutic duplication, which was the most commonly encountered problem, significantly reduced by 76% from 1Q 2019 (N=9) to 2Q 2019 (N=2), while incidents involving prescribing errors dropped by 39% in the same period.
In addition, the number of prescribing near misses involving high risk medications such as direct oral anticoagulants, concentrated electrolytes and low molecular weight heparins dropped by 12.1% from 1Q (N=173) to 2Q 2019 (N=152). Inappropriate orders on therapeutic duplications and suboptimal renal dose adjustment were reduced by 9.3% and 23.1% respectively. The outcomes were satisfactory and revealed an increased awareness on safe prescribing.
Lastly, feedback from representing doctors and nurses attending MSC were encouraging and they supported the continuing work of the project.
The joint-discipline project effectively enhanced doctors and nurses’ awareness on medication safety. The enhanced support from pharmacists was welcomed by various departments.
