Authors (including presenting author) :
Wong KS(1), Lui PLP(1), Ho ML(1), Ho KKB(1)
Affiliation :
Department of Orthopaedics & Traumatology, Tseung Kwan O Hospital
Introduction :
Drug allergies can cause severe reactions, including rash, swelling, difficulty breathing, and even death. In TKOH O&T inpatient wards, minor procedures involve heightened risks due to verbal orders, absence of electronic prescribing, and urgent situations that compromise medication safety. A 2Q 2023 incident involving the administration of lignocaine to a patient with a documented allergy underscored the need for improved safety measures.
Objectives :
1. Assess risks in the drug prescribing and administration workflow for known allergy patients in minor procedure rooms. 2. Implement and promote measures to facilitate healthcare staff in identifying uncommon drug allergies.
Methodology :
Conducted between December 2023 and March 2024, the project involved a thorough internal document review across multiple departments, including Medication Safety Committee Report, Pharmacy and Quality & Safety, as well as organization guidelines. Workflow analysis employed Fishbone Diagrams and Risk Matrices to identify failure points in three O&T wards. Risk control measures were introduced, including posters with QR codes linking to the DH Drug Ingredient Search for quick ingredient checks. Training sessions were provided to improve staff awareness and confidence in identifying drug allergies. Evaluation included monitoring QR code usage, pre- and post-intervention nurse behavior surveys, and incident tracking.
Result & Outcome :
6 months after this CQI, the QR code posters had been scanned 31 times, indicating staff engagement. No drug allergy incidents were reported post-implementation, although low occurrence rates limited this metric’s reliability. Nurse behavior surveys demonstrated a significant increase in staff confidence in identifying unfamiliar drug ingredients. Nurses shifted reliance from informal sources like Google or colleagues to official hospital resources such as the CMS Drug Ingredient Search and pharmacy consultations. Limitations included convenience sampling, potential self-reporting bias, and a smaller post-survey sample size, reducing the statistical power of the results. The project successfully enhanced medication safety and nurses’ confidence and behavior in identifying drug allergies. Structured interventions, targeted training, and improved access to official resources fostered safer practices in minor procedures within TKOH O&T wards.
