Authors (including presenting author) :
Wong BPK (1), Chan KKY (1), Yeung SSY (1), Mok SSM (1), Li CHY (1), Chu MH (1), Ko WK (1), Tsoi HHY (1), Wong VKC (1), Chan ACY (1), Wong HSY (1)
Affiliation :
1Department of Pharmacy, Queen Mary Hospital
Introduction :
Challenge in medication safety has been increasing over recent years due to upsurge in introduction of new drugs, higher complexity in drug treatment and frequent staff turnover. Medication safety initiatives through risk mitigation measures including information technology and staff education were commenced to boost up medication safety culture among pharmacy staff.
Objectives :
(1) To mitigate the risk in dispensing errors, especially on High Alert Medications (HAM) and look-alike sound-alike (LASA) medications
(2) To enhance safe inventory management through streamlining inventory processes
(3) To raise staff awareness in medication safety
Methodology :
To mitigate the risk in dispensing errors in pharmacy, review of drug location was performed in May 2024. Over 10 pairs of LASA medications were physically relocated. Shelf labelling and drug location code of LASA and HAM were revised to improve visual alertness. As staff education, incident sharing and promulgation of medication safety posters to all pharmacists and dispensers were performed. Afterwards, a short quiz consisting of 10 questions were also given to staff to assess their medication safety knowledge. Furthermore, for drug replenishment, a daily replenishment list and labels containing the drug code, drug description (with Tall-Man labeling), unique QR code, and drug location were generated. These labels were affixed to drug boxes delivered to the working store. The electronic barcode matching system was utilized to verify the identity of drugs being replenished.
Result & Outcome :
The number of medication incidents and near misses in pharmacy were compared before (December 2023 to May 2024) and after (June to November 2024) implementation of these medication safety initiatives. There was a 62.5% reduction in medication incidents and near misses involving pharmacy after the implementation. Regarding medication safety awareness among pharmacy staff, an overall average score of 8.6 out of 10 questions was achieved in medication safety quiz (n=55). For drug replenishment using matching system, 33 medication errors were detected and prevented from August 2023 to November 2024.
After implementation of risk mitigation measures including utilizing information technology and staff education, medication safety in pharmacy was enhanced with significant reduction in medication incidents and near misses.
