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Q Bulletin, Volume 1, No. 32 (Supplement 1), Jan - Dec 202412th National QA Convention, 8 %u2013 10 October 2024PP-22Reducing Near-Miss Medication Filling Error in Health Clinics in Federal Territory ofKuala Lumpur & Putrajaya Health Department (JKWPKL&P)Min Wei C1, Ahmad Faiz MR2, Norsyazana AH3, Siti Juwahir J4, Nurul Najwa MI5, Jia Xin N6, RevathyK7, Segeran2, Norfarhana M, Nor Sohaila AJ5, Nazirah Z8, Maisarah A91Pharmacy Department, Hospital Rehabilitasi Cheras2Pharmacy Services Division, Federal Territory of Kuala Lumpur & Putrajaya Health Department3Pharmacy Department, Putrajaya Presint 9 Health Clinic, Kuala Lumpur4Pharmacy Department, Bandar Tun Razak Health Clinic, Kuala Lumpur5Pharmacy Department, Tanglin Health Clinic, Kuala Lumpur6Pharmacy Department, Setapak Health Clinic, Kuala Lumpur7Pharmacy Department, Jinjang Health Clinic, Kuala Lumpur8Titiwangsa Health Of ice, Federal Territory of Kuala Lumpur & Putrajaya Health Department9 Pharmacy Department, Putrajaya HospitalSELECTION OF OPPORTUNITIES FOR IMPROVEMENT:Near-miss medication errors had been increasing from 538 incidences in 2019 to 1,791 incidences in 2021in all healthcare facilities under Federal Territory of Kuala Lumpur & Putrajaya Health Department(JKWPKL&P). 42% of medication errors were contributed by medication filling in pharmacy.KEY MEASURES FOR IMPROVEMENT:The indicator used was the percentage of near-miss medication filling error detected from the totalnumber of medications filled. 0.01% was set as standard based on consensus during the quality committeemeeting.PROCESS OF GATHERING INFORMATION:A quality improvement study was conducted in five health clinics, sampled from five districts. A surveywas conducted among pharmacy personnels in all health clinics to identify contributing factors for fillingerror. Pharmacy staff performing medication filling were observed to evaluate adherence to goodpractices. Number of near-miss medication filling errors was collected for two months from monthlystatistics for every cycle.ANALYSIS AND INTERPRETATION:Pre-remedial study detected 147 filling errors from 224,939 medications filled (0.065%). Findings fromsurvey and observation reported that contributing factors include look-alike, sound-alike (LASA)medications (61.1%), new/inexperienced staff (43.3%), fatigue/careless (35.3%), unsystematic medicationarrangement (30.9%) and no counter-checking before sticking labels (16.9%).STRATEGIES FOR CHANGE:In cycle 1, we systematically rearranged medication bin: colour-coded bin for internal, external and fridgemedications; using pharmacology system and colour-coded; %u201cMedication Error of The Month%u201d highlight;Medication Safety Corner graphical improvisation with monthly briefing and first-hand filling errornotification via chatgroup. In cycle 2, we revamped the filling procedure using %u201cShopping Asing, TampalAsing%u201d (SATA) concept with good practices for labelling and medication top-up. In cycle 3, we enhancedSATA procedure by adding prescription transcription counter-checking and promoted SATA through theSATA DASH game.EFFECT OF CHANGE:Medication filling error reduced from 0.065% to 0.034% in cycle 1, then 0.009% and finally to 0.006% incycle 3. Achievable benefit not achieved reduced from 0.055% to 0.024% in cycle 1, then -0.001% andfinally reached -0.004% in cycle 3.73 | Page