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Managing the Medication Use Process Medication Safety Anna Lee Senior Pharmacist Hospital Authority

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... and Sound-alike Medications. Drug Replenishment and Storage ... Prescription Practices using the Medication Order Entry (MOE) System. Risk Management Framework ... – PowerPoint PPT presentation

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Title: Managing the Medication Use Process Medication Safety Anna Lee Senior Pharmacist Hospital Authority


1
Managing the Medication Use Process-Medication
SafetyAnna LeeSenior PharmacistHospital
Authority
2
The Structure of the Health Care Service in Hong
Kong
Hong Kong Government
Secretary for Health, Welfare and Food (SHWF)
Private Sector licensing practice standards
  • Public Sector

formulate policies monitor performance
Department of Health
  • Private Hospitals
  • Private Practice

Hospital Authority of Hong Kong
3
The Department of Health (DH) -- Hong Kong
Special Administrative Region
  • The health adviser of the Government
  • To execute health legislation and policy
  • Major services areas include-
  • health education
  • occupational health
  • student health
  • surveillance, prevention, and control of
    communicable diseases and non-communicable
    diseases

4
In HK Public funding financed primarily through
tax revenues
5
Provisions of Public Health Care Services by 7
Hospital Clusters of the HA
(42) Public Hospitals (46) Specialist
Outpatient Clinics (74) General Outpatient
Clinics
6
Risk Management Framework
  • Policy Strategies

Information Safety Culture (Bottom up)
Standards (Top down)
Specific Priority Areas
Corporate RM Capabilities
Risk Register
7
MIRP - Mechanism
  • Hospital level
  • standardised forms
  • voluntary basis
  • Hospital Drug Committee
  • review cases periodically
  • identify underlying causes
  • recommend appropriate measures to Hospital Chief
    Executives
  • report statistical data case reports to Head
    Office quarterly

8
MIRP - Mechanism (cont)
  • Head Office level
  • monitor overall trend
  • recommend appropriate corporate measures
  • MIRP bulletin
  • statistical information
  • cases studies

9
MIRP - Severity Index (0-6)
  • 0Near miss/preventative measures only
  • (incident stopped before reaching the patient)
  • 1Incident occurred that did not result in injury
  • 2Incident occurred, increase monitoring required
    with no change in vital signs
  • 3 Temporary morbidity, permanent injury not
    expected
  • (temporary injury with change in vital signs)
  • 4Significant morbidity/change in vital signs
    requiring/necessitating emergency treatment
  • (require antidote/emergency treatment or
    transfer to a high level of care)
  • 5Permanent disability expected (sustained
    permanent injury)
  • 6Death

10
MIRP Reported Incidents
11
MIRP Distribution of Incidents
12
MIRP Incidents by Error Type
13
MIRP Underlying Causes
14
MIRP Top 10 drugs
15
MIRP - Actions
  • Report on drug adminstration procedures
    practices updated
  • MIRP bulletins
  • Guidelines on high alert medications e.g. conc
    KCl, Insulin, parenteral adminstration
  • Education seminars at hospitals
  • Orientation for new staff
  • Posters and calendars-tips
  • Review mechanism
  • Website at CPO.home

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22
Incident occurs
1. Manage the incident. 2. Grade the incident 3.
Report incident through AIRS
Staff action
1. Manage the incident through routine
procedures 2. Report within 48 hours
Green incident?
1. Management action needed 2. Report within 24
hours
Yellow incident?
1. Urgent management action needed 2. Report
immediately
Red incident?
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Flowchart for the management of all incidents
Incident occurs
1. Manage the incident. 2. Grade the incident
(outcome and risk). 3. Investigate/analyse the
incident. 4. Update incident report through AIRS
Management action
No investigation required. Monitor trends through
AIRS
Green incident?
Basic investigation Consider mini RCA Monitor
trends through AIRS
Yellow incident?
Full investigation Mini or full RCA (full if
red/red) Monitor trends through AIRS
Red incident?
31
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32
Risk Management Framework
  • Policy Strategies

Information Safety Culture (Bottom up)
Standards (Top down)
Specific Priority Areas
Corporate RM Capabilities
Risk Register
33
The Self Assessment Guide (SMS)
34
SMS - Ten Key Areas
  • Drug Allergy
  • Patient Identification in Drug Administration
  • Charting of Medication Administration Record
    (MAR)
  • Handling of High Risk Medications
  • Specific High Risk Medications
  • IV Infusion Devices
  • Look-alike and Sound-alike Medications
  • Drug Replenishment and Storage
  • Drug Re-packaging and Re-labeling
  • Prescription Practices using the Medication Order
    Entry (MOE) System

35
Risk Management Framework
  • Policy Strategies

Information Safety Culture (Bottom up)
Standards (Top down)
Specific Priority Areas
Corporate RM Capabilities
Risk Register
36
The 2005 Report (DAR)
37
Standard 29 A system is in place in the
hospital to ensure safe and cost effective
practices related to the medication use process
38
Annual Plan Target 06/07
  • To develop strategy to reduce medication
    incidents associated with high risk medications
  • Action items
  • High concentration electrolytes
  • Standardise dilution table for high risk IV
    medications
  • Sharing session on medication incidents

39
Annual Plan 07/08
  • Lookalike, Sound-alike medications
  • High concentration electrolytes
  • Medication reconciliation??
  • Feasibility study on in-patient CPOE

40
Challenges Ahead
  • Analysis / benchmarking of data
  • Dissemination / sharing of information
  • Fair blame / just culture
  • Monitoring of compliance to recommendations and
    standards
  • Limited negotiation power with multinational drug
    companies
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