Authors (including presenting author) :
Wong KL(1), Cheng MY(1), Tung CH Cora(1), Lau CK(1), Lee YW(1)
Affiliation :
Accident and Emergency Department, North District Hospital
Introduction :
Medication incidents in healthcare system is one of the hottest topics. It should be preventable. In our A&E department, there were several cases of "Nearly Miss" reported by Pharmacy Department due to mismatched patients' name in the past few years. Patient safety is jeopardized. In addition, patient privacy might be exposed to other unnecessarily. Therefore, risk management planning should be done for minimizing such medication incidents. A good practice guide on prevention of medication errors should be recommended to all staff including medical and nursing staff. It aims to enhance patient safety and facilitate staff work efficiency.
Objectives :
-To minimize the disturbance to medical staff while having consultation
-To find out the causes of giving mismatched prescription
-To enhance staff alertness of the importance of checking CID
Methodology :
-The mnemonic of the programme is "APPS" A is AE card; P is Prescription; P is Patient's identity; and S is Safety (When the data of A, P & P are showing the same patient, then patient safety can be guaranteed) -Medical staff are involved into this programme because the underlying cause found by the pre- promotion survey. 90% medical staff revealed that the main cause was due to disturbed by others while prescribing job sheet. Therefore, modified cue card was done for reminding medical staff to return back into the original patient after reviewing other patients' electrical patient record. Medical staff -led is important for improving the medication incident. Formal e-Mail was sent to all medical staff by our doctor team member. -"APPS" posters were posted in all doctor consultation rooms and EMW -"APPS" would be introduced to all staff and emphasied the importance of checking "APPS" regularly -In- house record book is available for recordering the "Nearly Miss" episodes found by our colleagues in order to undergo the root- cause analysis
Result & Outcome :
There were 2 cases reported for "Nearly miss" by Pharmacy Department and up to ten cases noted by A&E colleagues in 2018-19 . And there is no cases noted in 2019-2020 after promoted the good practice guide "APPS". For internal audit, there was only 65 % staff that would check all data of AE card, prescription and patient's identity when disposal of patient. After promotion of the "APPS", up to 90% staff would follow the good practice guide. Besides, a survey done after promotion of using "APPS" on disposal of patient in A&E. All staff showed fully understood in using "APPS". They expressed that it is memorable. And the "APPS" can facilitate work effectiveness and increase staff satisfaction, especially among the newly staff.
