Title: Managing the Medication Use Process Medication Safety Anna Lee Senior Pharmacist Hospital Authority
1Managing the Medication Use Process-Medication
SafetyAnna LeeSenior PharmacistHospital
Authority
2The Structure of the Health Care Service in Hong
Kong
Hong Kong Government
Secretary for Health, Welfare and Food (SHWF)
Private Sector licensing practice standards
formulate policies monitor performance
Department of Health
- Private Hospitals
- Private Practice
Hospital Authority of Hong Kong
3The 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
4In HK Public funding financed primarily through
tax revenues
5Provisions of Public Health Care Services by 7
Hospital Clusters of the HA
(42) Public Hospitals (46) Specialist
Outpatient Clinics (74) General Outpatient
Clinics
6Risk Management Framework
Information Safety Culture (Bottom up)
Standards (Top down)
Specific Priority Areas
Corporate RM Capabilities
Risk Register
7MIRP - 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
8MIRP - Mechanism (cont)
- Head Office level
- monitor overall trend
- recommend appropriate corporate measures
- MIRP bulletin
- statistical information
- cases studies
9MIRP - 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
10MIRP Reported Incidents
11MIRP Distribution of Incidents
12MIRP Incidents by Error Type
13MIRP Underlying Causes
14MIRP Top 10 drugs
15MIRP - 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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22Incident 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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30Flowchart 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?
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32Risk Management Framework
Information Safety Culture (Bottom up)
Standards (Top down)
Specific Priority Areas
Corporate RM Capabilities
Risk Register
33The Self Assessment Guide (SMS)
34SMS - 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
35Risk Management Framework
Information Safety Culture (Bottom up)
Standards (Top down)
Specific Priority Areas
Corporate RM Capabilities
Risk Register
36The 2005 Report (DAR)
37Standard 29 A system is in place in the
hospital to ensure safe and cost effective
practices related to the medication use process
38Annual 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
39Annual Plan 07/08
- Lookalike, Sound-alike medications
- High concentration electrolytes
- Medication reconciliation??
- Feasibility study on in-patient CPOE
40Challenges 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