Strive to reduce Prescription Errors in General Out-Patient Clinic to enhance Patient Safety

Abstract Description

Authors (including presenting author) :

Wong MK(1), Leung LM(1), Ng KM(1), Ng YS(1)

Affiliation :

(1)Department of Family Medicine and Primary Health Care, NTWC, Hospital Authority

Introduction :

Prescription errors could cause significant impact on patient clinical outcomes. Amendment of prescription errors will cause inconvenience to patients and have negative impact to both doctor consultation and pharmacy dispensing process in General Out-Patient Clinic (GOPC).

Objectives :

To identify cases of prescription errors through pharmacy reminders and reporting.

To review and analyze the root causes of these errors.

To implement measures to enhance medication management and patient safety.

Methodology :

This is a quality improvement project involving cases of prescription errors reviewed in Tin Shui Wai Health Centre (Tin Shui Road) from 1/3/2024-31/12/2024. Pharmacy identified the errors, reminded individual doctor and reported to clinic.

Result & Outcome :

From 1/3/2024-31/8/2024, there were 103 cases of prescription errors. The main issues included wrong duration at 34% (35/103), wrong dosage at 22.3% (23/103), and wrong instructions at 13.5% (14/103). Other errors included wrong or unnecessary drugs (9.7%), therapeutic duplication and contraindications (5.8% each), wrong frequency (2.9%), and minor errors such as wrong patient, route, drug form, unlicensed indication and drug allergy (1% each).

The cases involved included various categories of medical professionals: Basic Trainees accounted for 51.5% (53/103), Service Doctors represented 12.6% (13/103), newly recruited Service Doctors comprised 10.7% (11/103), Locums made up 9.7% (10/103), Associate Consultants represented 9.7% (10/103), Higher Trainees accounted for 3.9% (4/103), and Consultants contributed 1.9% (2/103).

Review of prescription errors identified key causes: mistaken clicks or system issues (52.4%), inadequate training (28.2%), communication gaps (14.6%), drug formulary unfamiliarity (2.9%), and workflow inefficiencies (1.9%). Doctors had received feedback and agreed for improvement. Preventive measures included using Departmental Drug Sets, checking available drugs, and maintaining updated prescription records from Emergency Department visits or hospitalizations. Additional steps involved verifying patient identities, double-checking printed prescriptions, and sharing drug formulary information with trainees. Clinic suggested exploring enhancements to the Medical Order Entry system to reduce mistaken clicks and minimize errors. Department Drug Subcommittee Bulletin also proposed measures to address the identified problems and causes.

From 1/9/2024-31/12/2024, 54 cases of prescription errors reminded our doctors. Majority were related to mistaken clicks or system issues.

Conclusion

Newly recruited doctors often lack adequate training and safety awareness. This project established a “speak up” culture, provided staff training, and fostered open communication to enhance risk awareness and competency. By identifying trends in prescription errors, clinics can implement targeted strategies to improve the prescribing process, enhancing patient safety while promoting continuous quality improvement.