Authors (including presenting author) :
Lee WY(1), Wong PM(1), Lam PK(1), Chang YY(2), Sheh PW(2), Tam YY(2)
Affiliation :
(1)Quality and Safety Division, New Territories West Cluster, (2)Department of Paediatrics and Adolescent Medicine, Tuen Mun Hospital
Introduction :
We encourage mothers to continue breastfeeding while their sick babies are hospitalized. Therefore, it is common to have mothers bringing in EBM in bottles for their babies in ward. However, there were incidents of giving EBM to wrong babies as some hand-written labels may not be clear to staff who helped to feed the babies. In order to ensure correct patient identification, a verification system with the use of QR code scanning system (the system) was developed and piloted in two paediatrics wards of TMH in 2018. Staff survey was conducted. Staff commented that the process of generating EBM labels, which required scanning of 4 barcodes from patient’s wristband and medical record, was clumsy. Besides, the barcode printed on label was often found faded after reheat of EBM. As an interim measure, staff stuck the label on a paper form and tied on the EBM bottle with a rubber band. Before reheating, staff would apply a transparent plastic bag on the EBM bottle to avoid fading. Nevertheless, 22% of staff were not satisfied with the system and urged for an enhancement.
Objectives :
To enhance the usability and sustainability of the system and to smoothen the workflow of EBM administration in order to enhance patient safety.
Methodology :
The system was enhanced in June 2020 to fulfil the wards’ operational needs. Waterproof label was used. EBM collection date and time can be written on the labels directly and immersed in water together with the bottle. The label can be easily removed from the bottle without trace. The software was also modified to streamline the workflow (e.g. number of barcode scanning to generate labels are reduced from 4 to 2). The hardware is also upgraded with larger label printer. The font size of the instruction on the label are more readable. The entire workflow of generating label, reheating EBM and checking patient identity is simplified and improved.
Result & Outcome :
There was no reported incident of administration of EBM to wrong infants since the implementation. A satisfaction survey was conducted in August 2020 and 79 returns received. 94% of staff are satisfied with the system and agreed the enhanced system is simple and easy to use. 96% agreed the information on the new label is clear and organized.
