Page 61 - Q BULLETIN, Ministry of Health Malaysia, VOLUME 1, NO. 31 (SUPPLEMENT 1), JAN-DEC 2022
P. 61
Q Bulletin, Volume 1, No. 31 (Supplement 1), Jan - Dec 2022
11 National QA Convention, 4 – 6 October 2022
th
PP-23
Increasing Patient Safety through Reduction of Actual Medication Error
Teoh LH, Diu SC, Yeong PC, Tan TC
Bagan Specialist Centre, Pulau Pinang
SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:
In 2019, a total of 31 errors were reported at Bagan Specialist Centre, of which 22 were documented by
Pharmacy Services. This potential adverse drug event poses a patient safety risk if it is not averted from the
outset. The study aimed to reduce these errors in order to improve patient safety.
KEY MEASURES FOR IMPROVEMENT:
The indicator used was the number of medication errors which includes errors in labelling, medication,
strength, verification, quantity, and dose in Pharmacy Services. The target was set as 0 medication errors in the
Pharmacy Services.
PROCESS OF GATHERING INFORMATION:
Data was collected through departmental data collection and incident reports. Data were analysed and validated.
Audits were used to check on the compliance of intervention activities.
ANALYSIS AND INTERPRETATION:
Out of the 12 medication errors recorded till June 2019, the most commonly reported medication errors were
wrong verification (4 cases) and wrong medication (2 cases). Strategies were implemented in July 2019, with
monthly audits done throughout the year. The post-intervention evaluation was carried out throughout 2020
and 2021.
STRATEGIES FOR CHANGE:
Few strategies were executed targeting system improvements, such as the use of brand names followed by
their ingredients in all drug descriptions in the system. Drug descriptions for injections were revised by putting
strength, followed by the total volume of injection. In addition, the Electronic Medical Record verification
assessment and the accuracy check assessment for the Out-Patient Department were developed.
EFFECT OF CHANGE:
Medication errors had decreased following the adoption of the preventive measures taken but still occurred in
certain months due to non-compliance with verification procedures. Actual medication errors decreased from
22 cases (2019) to 19 (2020) and further to 12 (2021).
THE NEXT STEP:
For further improvement, we will focus on reducing human errors by enhancing staff competency.
57
